Kim J. Burchiel
Kim J. Burchiel
Raymond F. Sekula Jr., Edward M. Marchan, Lynn H. Fletcher, Kenneth F. Casey, and Peter J. Jannetta
Although microvascular decompression (MVD) for patients with medically refractory trigeminal neuralgia (TN) is widely accepted as the treatment of choice, other “second-tier” treatments are frequently offered to elderly patients due to concerns regarding fitness for surgery. The authors sought to determine the safety and effectiveness of MVD for TN in patients older than 75 years of age.
The authors performed a retrospective review of medical records and conducted follow-up telephone interviews with the patients. The outcome data from 25 MVD operations for TN performed in 25 patients with a mean age of 79.4 years (range 75–88 years) were compared with those of a control group of 25 younger patients with a mean age of 42.3 years (range 17–50 years) who underwent MVDs during the same 30-month period from July 2000 to December 2003.
Initial pain relief was achieved in 96% of the patients in both groups (p = 1.0). There were no operative deaths in either group. After an average follow-up period of 44 and 52 months, 78 and 72% of patients in the elderly and control groups, respectively, remained pain free without medication (p = 0.74).
Microvascular decompression is an effective treatment for elderly patients with TN. The authors' experience suggests that the rate of complications and death after MVD for TN in elderly patients is no different from the rate in younger patients.
Raymond F. Sekula Jr., Andrew M. Frederickson, Peter J. Jannetta, Sanjay Bhatia, and Matthew R. Quigley
Stereotactic radiosurgical rhizolysis using Gamma Knife surgery (GKS) is an increasingly popular treatment for medically refractory trigeminal neuralgia. Because of the increasing use of GKS for trigeminal neuralgia, clinicians are faced with the problem of choosing a subsequent treatment plan if GKS fails. This study was conducted to identify whether microvascular decompression (MVD) is a safe and effective treatment for patients who experience trigeminal neuralgia symptoms after GKS.
From their records, the authors identified 29 consecutive patients who, over a 2-year period, underwent MVD following failed GKS. During MVD, data regarding thickened arachnoid, adhesions between vessels and the trigeminal nerve, and trigeminal nerve atrophy/discoloration were noted. Outcome and complication data were also recorded.
The MVD procedure was completed in 28 patients (97%). Trigeminal nerve atrophy was noted in 14 patients (48%). A thickened arachnoid was noted in 1 patient (3%). Adhesions between vessels and the trigeminal nerve were noted in 6 patients (21%) and prevented MVD in 1 patient. At last follow-up, 15 patients (54%) reported an excellent outcome after MVD, 1 (4%) reported a good outcome, 2 (7%) reported a fair outcome, and 10 patients (36%) reported a poor outcome. After MVD, new or worsened facial numbness occurred in 6 patients (21%). Additionally, 3 patients (11%) developed new or worsened troubling dysesthesias.
Thickened arachnoid, adhesions between vessels and the trigeminal nerve, and trigeminal nerve atrophy/discoloration due to GKS did not prevent completion of MVD. An MVD is an appropriate and safe “rescue” therapy following GKS, although the risks of numbness and troubling dysesthesias appear to be higher than with MVD alone.
Case report and review of the literature
Raymond F. Sekula Jr., Michael Y. Oh, J. Brad Bellotte, and Jack E. Wilberger
✓ Chondrolipoangioma is a mesenchymoma primarily composed of cartilage, with adipose tissue and vascular elements present in lesser proportions. Chondrolipoangiomas have been reported to occur in the extremities, chest wall, oral soft tissues, mediastinum, uterus and its round ligament, seminal vesicles, and heart. In this report, the authors present an unusual case in which a chondrolipoangioma caused a brachial plexopathy. To their knowledge, a chondrolipoangioma has never been reported in the neurosurgical literature.
Parthasarathy Thirumala, Andrew M. Frederickson, Jeffrey Balzer, Donald Crammond, Miguel E. Habeych, Yue-Fang Chang, and Raymond F. Sekula Jr.
Microvascular decompression is a safe and effective procedure to treat hemifacial spasm, but the operation poses some risk to the patient’s hearing. While severe sensorineural hearing loss across all frequencies occurs at a low rate in experienced hands, a recent study suggests that as many as one-half of patients who undergo this procedure may experience ipsilateral high-frequency hearing loss (HFHL), and as many as one-quarter may experience contralateral HFHL. While it has been suggested that drill-related noise may account for this finding, this study was designed to examine the effect of a number of techniques designed to protect the vestibulocochlear nerve from operative manipulation on the incidence of HFHL.
Pure-tone audiometry was performed both preoperatively and postoperatively on 67 patients who underwent microvascular decompression for hemifacial spasm during the study period. A change of greater than 10 dB at either 4 kHz or 8 kHz was considered to be HFHL. Additionally, the authors analyzed intraoperative brainstem auditory evoked potentials from this patient cohort.
The incidence of ipsilateral HFHL in this cohort was 7.4%, while the incidence of contralateral HFHL was 4.5%. One patient (1.5%; also included in the HFHL group) experienced an ipsilateral nonserviceable hearing loss.
The reduced incidence of HFHL in this study suggests that technical modifications including performing the procedure without the use of fixed retraction may greatly reduce, but not eliminate, the occurrence of HFHL following microvascular decompression for hemifacial spasm.
Jesse D. Lawrence, Chad Tuchek, Aaron A. Cohen-Gadol, and Raymond F. Sekula Jr.
Use of the ICU during admission to a hospital is associated with a significant portion of the total health care costs for that stay. Patients undergoing microvascular decompression (MVD) for cranial neuralgias are routinely admitted postoperatively to the ICU for monitoring. The primary purpose of this study was to compare complication rates of patients with and without a postoperative ICU stay following MVD. The secondary intents were to identify predictors of complications, to analyze variables of health care resource utilization, and to estimate the cost of postoperative management.
The authors performed a retrospective comparative analysis of consecutive patients undergoing MVD at 2 institutions. A total of 199 patients without a postoperative ICU stay from Institution A and 119 patients with an ICU stay from Institution B were reviewed. Inclusion criteria included any adult (i.e., 18 years of age or older) undergoing MVD for trigeminal neuralgia, hemifacial spasm, glossopharyngeal neuralgia, or geniculate neuralgia. Patients with incomplete medical records were excluded. Medical comorbidities, intraoperative variables, complications, postoperative interventions, and variables indicating health care resource utilization were reviewed.
The study compared 190 patients without a postoperative ICU stay from Institution A with 90 patients with an ICU stay from Institution B. Seven patients without an ICU stay and 5 patients with an ICU stay experienced complications after surgery (p = 0.53). Multivariate analysis identified coronary artery disease to be a predictor of complications (p = 0.037, OR 6.23, 95% CI 1.12–34.63). Patients from Institution A without a postoperative ICU stay had a significantly shorter length of stay, by approximately 16 hours (p < 0.001), and received less postoperative imaging (p < 0.001, OR 14.39, 95% CI 7.75–26.74) and postoperative diagnostic testing (p < 0.001) than patients from Institution B with an ICU stay. Estimated cost savings in patients without an ICU stay and 1 less day of inpatient recovery was calculated as $1400 per patient.
Selective versus routine use of ICU care as well as postoperative imaging and diagnostic testing may be safe after MVD and can lead to a reduction in overall health care costs.
Edward M. Marchan, Raymond F. Sekula Jr., Peter J. Jannetta, and Matthew R. Quigley
✓Spinal glioblastomas multiforme (GBMs) are rare lesions of the central nervous system with a prognosis as poor as that of their intracranial counterpart. The authors present a case of a 50-year-old man with a GBM of the spinal cord treated with surgical removal of the mass and cordectomy after the onset of paraplegia. Six years later, the patient developed hepatitis C and received interferon therapy. Six months after the start of interferon therapy, magnetic resonance imaging revealed a right cerebellar mass pathologically consistent with a GBM. Despite aggressive treatment, the patient died 1 month later. Although intracranial dissemination of spinal GBMs has been reported, this case illustrates the longest reported interval between the occurrence of a spinal GBM and its intracranial dissemination. Thus, cordectomy should be considered as a reasonable alternative in patients with complete loss of neurological function at and below the level where they harbor a malignant spinal cord astrocytoma.
Marion A. Hughes, Ronak H. Jani, Saeed Fakhran, Yue-Fang Chang, Barton F. Branstetter IV, Parthasarathy D. Thirumala, and Raymond F. Sekula Jr.
The aim of this study was to identify preoperative imaging predictors of surgical success in patients with classic trigeminal neuralgia (cTN) undergoing microvascular decompression (MVD) via retrospective multivariate regression analysis.
All included patients met criteria for cTN and underwent preoperative MRI prior to MVD. MR images were blindly graded regarding the presence and severity (i.e., mild or severe) of neurovascular compression (NVC). All patients were contacted by telephone to determine their postoperative pain status.
A total of 79 patients were included in this study. Sixty-two patients (78.5%) were pain-free without medication following MVD. The following findings were more commonly observed with the symptomatic nerve when compared to the contralateral asymptomatic nerve: NVC (any form), arterial compression alone, NVC along the proximal trigeminal nerve, and severe NVC (p values < 0.0001). The only imaging variable that was a statistically significant predictor of being pain-free without medication following MVD was severe NVC. Patients with severe NVC were 6.36 times more likely to be pain-free following MVD compared to those without severe NVC (p = 0.007).
In patients with cTN undergoing MVD, severe NVC on preoperative MRI is a strong predictor of an excellent surgical outcome.
Raymond F. Sekula Jr., Sanjay Bhatia, Andrew M. Frederickson, Peter J. Jannetta, Matthew R. Quigley, George A. Small, and Ryan Breisinger
In this paper, the authors' goal was to determine the utility of monitoring the abnormal muscle response (AMR) or “lateral spread” during microvascular decompression surgery for hemifacial spasm.
The authors' experience with AMR as well as the data available in the English-language literature regarding resolution or persistence of AMR and the resolution or persistence of hemifacial spasm at follow-up was pooled and subjected to a meta-analysis.
The pooled OR revealed by the meta-analysis was 4.2 (95% CI 2.7–6.7). The chance of a cure if the AMR was abolished during surgery was 4.2 times greater than if the lateral spread persisted.
The AMR should be monitored routinely in the operating room, and surgical decision-making in the operating room should be augmented by the AMR.