Tentorial sling for microvascular decompression in patients with trigeminal neuralgia: a description of operative technique and clinical outcomes

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OBJECTIVE

Trigeminal neuralgia is a debilitating pain disorder most often caused by arterial compression of the trigeminal nerve, although there are other etiologies. Microvascular decompression (MVD) remains the most definitive treatment for this disorder, with cure rates reported between 60% and 80%. Traditional MVD techniques involve a retrosigmoid craniotomy with placement of an inert foreign material, such as Teflon, between the nerve and compressive vessel. Recurrence of trigeminal neuralgia after MVD has been associated with vessel migration, adhesion formation, and arterial pulsation against the Teflon abutting the nerve. Additionally, foreign materials such as Teflon have been reported to trigger inflammatory responses, resulting in recurrence of trigeminal pain. An alternative method for decompression involves the use of a sling to transpose the compressive vessel away from the nerve. Results of various sling techniques as a decompressive strategy are limited to small series and case reports. In this study, the authors present their experience utilizing a tentorial sling for MVD in patients with trigeminal neuralgia.

METHODS

Institutional review board approval was obtained in order to contact patients who underwent MVD for trigeminal neuralgia via the tentorial sling technique. Clinical outcomes were assessed utilizing the Barrow Neurological Institute (BNI) pain intensity score immediately after surgery and at the time of the study.

RESULTS

The tentorial sling technique was performed in 45 patients undergoing MVD for trigeminal neuralgia. In 41 of these patients, this procedure was their first decompressive surgery. Immediate postoperative relief of pain (BNI score I) was achieved in 80% of patients undergoing their first decompressive procedure. At last follow-up, 73% of these patients remained pain free. Three patients experienced recurrent trigeminal pain, with surgical exploration demonstrating an intact tentorial sling. The complication rate was 6.6%.

CONCLUSIONS

Transposition techniques for MVD have been described previously in small series and case reports. This study represents the largest experience in which the utilization of a tentorial sling for MVD in patients with trigeminal neuralgia is described. The technique represents a novel method for decompression of the trigeminal nerve by transposition of the offending vessel without the use of foreign material. Although the authors’ preliminary results parallel the historical cure rate, further outcome data are required to assess long-term durability of this method.

ABBREVIATIONS BNI = Barrow Neurological Institute; MVD = microvascular decompression; SCA = superior cerebellar artery.

Article Information

Correspondence Jeffrey A. Steinberg: University of California, San Diego, CA. j1steinberg@ucsd.edu.

INCLUDE WHEN CITING Published online April 20, 2018; DOI: 10.3171/2017.10.JNS17971.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

  • View in gallery

    Creation of a right-sided tentorial sling. A: View of the cerebellopontine angle, including the underside of the tentorium (Tent). The SCA is seen looping inferiorly, compressing the medial/superior aspect of the trigeminal nerve (TN). B: An initial 3-mm transverse incision is made using a 15 blade. C: Dissection is carried out in a split-thickness plane of the dura. D: Microscissors are used to cut perpendicular to the initial incision. E: A parallel cut, approximately 1.5–2 cm long, is made to complete the tentorial sling (SL). F: A view of the tentorial sling prior to wrapping around the compressive vessel. *Tentorial incision. Figure is available in color online only.

  • View in gallery

    Utilization of the tentorial sling to transpose the compressive vessel away from the nerve. A: The tentorial sling is mobilized toward the compressive vessel. B: The vessel is lifted to allow the tentorial sling to be positioned around it. C: The sling is manipulated around the vessel. D: The free edge of the sling is secured to the tentorium using a Weck clip. E: The transposed vessel is inspected to ensure no constriction of blood flow and adequate decompression of the nerve. F: Final view of the vessel repositioned away from the trigeminal nerve by the tentorial sling. The motor rootlet (MR) of the trigeminal nerve is now visible. Figure is available in color online only.

  • View in gallery

    Left: Initial view of the right trigeminal nerve demonstrating the SCA compressing the superior aspect of the trigeminal nerve root entry zone. Right: Final view after completing the tentorial sling technique for vessel transposition. The motor rootlet of the trigeminal nerve is now visible, as the nerve has been decompressed. Figure is available in color online only.

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