Marc Sindou, Mohamed Mahmoudi and Andrei Brînzeu
In spite of solid anatomical and physiological arguments and the promising results of Jannetta in the 1970s, treating essential hypertension by microvascular decompression (MVD) of the brainstem has not gained acceptance as a mainstream technique. The main reason has been a lack of established selection criteria. Because of this, the authors' attempts have been limited to patients referred for MVD for hemifacial spasm (HFS) who also had hypertension likely to be related to neurovascular compression (NVC).
Of 201 patients referred for HFS, 48 (23.8%) had associated hypertension. All had high-resolution MR images that demonstrated NVC. All underwent MVD of the root exit/entry zone (REZ) of the ninth and tenth cranial nerves (CN IX-X) and adjacent ventrolateral medulla in addition to the CN VII REZ. Effects on hypertension, graded using the WHO classification, were studied up to the latest follow-up, which was 2–16 years from the time of surgery, 7 years on average. Also, effects of MVD on blood pressure (BP) according to the side of vascular compression were evaluated.
Preoperatively, hypertension was severe in all but 1 of the patients; in spite of medical treatment, 47 patients still had WHO Grade 1 or 2 hypertension, and 18 still had unstable BP. After MVD, at latest follow-up, BP had returned to normal (i.e., systolic pressure < 140 mm Hg) in 28 patients; 14 of these patients (29.10% of the whole series) were able to maintain normal BP without any antihypertensive treatment; the other 14 still required some medication to maintain their BP below 140 mm Hg (p < 0.0001). Also, at latest follow-up, BP remained unstable in only 8 of the 18 patients with instability prior to MVD (p < 0.02). Analysis according to side of compression showed that of the 30 patients with left-sided compression, 17 had their BP normalized (without medication in 11 cases), and of the 18 patients with right-sided compression, 11 had their BP normalized (without medication in 3 cases). The difference between sides was not significant.
These results argue for considering MVD for the treatment of hypertension likely to be due to NVC at the CN IX-X REZ and adjacent ventrolateral medulla. Criteria for selecting patients with hypertension alone still need to be established and could include the following indications: apparently essential hypertension, likely to be neurogenic, in patients in whom high-resolution MRI shows clear-cut images of NVC at the CN IX-X REZ and adjacent ventrolateral medulla and in whom BP cannot be controlled by medical treatment.
George Georgoulis, Andrei Brînzeu and Marc Sindou
The utility of intraoperative neuromonitoring (ION), namely the study of muscle responses to radicular stimulation, remains controversial. The authors performed a prospective study combining ventral root (VR) stimulation for mapping anatomical levels and dorsal root (DR) stimulation as physiological testing of metameric excitability. The purpose was to evaluate to what extent the intraoperative data led to modifications in the initial decisions for surgical sectioning established by the pediatric multidisciplinary team (i.e., preoperative chart), and thus estimate its practical usefulness.
Thirteen children with spastic diplegia underwent the following surgical protocol. First, a bilateral intradural approach was made to the L2–S2 VRs and DRs at the exit from or entry to their respective dural sheaths, through multilevel interlaminar enlarged openings. Second, stimulation—just above the threshold—of the VR at 2 Hz to establish topography of radicular myotome distribution, and then of the DR at 50 Hz as an excitability test of root circuitry, with independent identification of muscle responses by the physiotherapist and by electromyographic recordings. The study aimed to compare the final amounts of root sectioning—per radicular level, established after intraoperative neuromonitoring guidance—with those determined by the multidisciplinary team in the presurgical chart.
The use of ION resulted in differences in the final percentage of root sectioning for all root levels. The root levels corresponding to the upper lumbar segments were modestly excitable under DR stimulation, whereas progressively lower root levels displayed higher excitability. The difference between root levels was highly significant, as evaluated by electromyography (p = 0.00004) as well as by the physiotherapist (p = 0.00001). Modifications were decided in 11 of the 13 patients (84%), and the mean absolute difference in the percentage of sectioning quantity per radicular level was 8.4% for L-2 (p = 0.004), 6.4% for L-3 (p = 0.0004), 19.6% for L-4 (p = 0.00003), 16.5% for L-5 (p = 0.00006), and 3.2% for S-1 roots (p = 0.016). Decreases were most frequently decided for roots L-2 and L-3, whereas increases most frequently involved roots L-4 and L-5, with the largest changes in terms of percentage of sectioning.
The use of ION during dorsal rhizotomy led to modifications regarding which DRs to section and to what extent. This was especially true for L-4 and L-5 roots, which are known to be involved in antigravity and pelvic stability functions. In this series, ION contributed significantly to further adjust the patient-tailored dorsal rhizotomy procedure to the clinical presentation and the therapeutic goals of each patient.
Jacques J. Morcos, Stephan A. Munich, Tiit Mathiesen, Marc P. Sindou and Vinko V. Dolenc
Paulo Roberto Lacerda Leal, Charlotte Barbier, Marc Hermier, Miguel Angelo Souza, Gerardo Cristino-Filho and Marc Sindou
The aim of this study was to prospectively evaluate atrophic changes in trigeminal nerves (TGNs) using measurements of volume (V) and cross-sectional area (CSA) from high-resolution 3-T MR images obtained in patients with unilateral trigeminal neuralgia (TN), and to correlate these data with patient and neurovascular compression (NVC) characteristics and with clinical outcomes.
Anatomical TGN parameters (V and CSA) were obtained in 50 patients (30 women and 20 men; mean age 56.42 years, range 22–79 years) with classic TN before treatment with microvascular decompression (MVD). Parameters were compared between the symptomatic (ipsilateralTN) and asymptomatic (contralateralTN) sides of the face. Twenty normal control subjects were also included. Two independent observers blinded to the side of pain separately analyzed the images. Measurements of V (from the pons to the entrance of the nerve into Meckel's cave) and CSA (at 5 mm from the entry of the TGN into the pons) for each TGN were performed using imaging software and axial and coronal projections, respectively. These data were correlated with patient characteristics (age, duration of symptoms before MVD, side of pain, sex, and area of pain distribution), NVC characteristics (type of vessel involved in NVC, location of compression along the nerve, site of compression around the circumference of the root, and degree of compression), and clinical outcomes at the 2-year follow-up after surgery. Comparisons were made using Bonferroni's test. Interobserver variability was assessed using the Pearson correlation coefficient.
The mean V of the TGN on the ipsilateralTN (60.35 ± 21.74 mm3) was significantly smaller (p < 0.05) than those for the contralateralTN and controls (78.62 ± 24.62 mm3 and 89.09 ± 14.72 mm3, respectively). The mean CSA of the TGN on the ipsilateralTN (4.17 ± 1.74 mm2) was significantly smaller than those for the contralateralTN and controls (5.41 ± 1.89 mm2 and 5.64 ± 0.85 mm2, respectively). The ipsilateralTN with NVC Grade III (marked indentation) had a significantly smaller mean V than the ipsilateralTN with NVC Grade I (mere contact), although it was not significantly smaller than that of the ipsilateralTN with NVC Grade II (displacement or distortion of root). The ipsilateralTN with NVC Grade III had a significantly smaller mean CSA than the ipsilateralTN with NVC Grades I and II (p < 0.05). The TGN on the ipsilateralTN in cured patients had a smaller mean CSA than that on the ipsilateralTN of patients with partial pain relief or treatment failure (p < 0.05). The same finding was almost found in relation to measurements of V, but the p value was slightly higher at 0.05.
Results showed that TGN atrophy in patients with TN can be demonstrated by high-resolution imaging. These data suggest that atrophic changes in TGNs, which significantly correlated with the severity of compression and clinical outcomes, may help to predict long-term prognosis after vascular decompression.