Operative Strategies for Minimizing Hearing Loss and Other Major Complications Associated with Microvascular Decompression for Trigeminal Neuralgia

OBJECTIVE: To retrospectively assess the surgical outcomes and complication rates following microvascular decompression (MVD) for trigeminal neuralgia, using a targeted, restricted retrosigmoid approach. METHODS: During the period 1994-2009, a total of 119 patients underwent MVD for trigeminal neuralgia. A retrospective review was conducted in order to assess pain outcomes following surgery and at most recent follow-up. The intraoperative findings, Barrow Neurologic Institute (BNI) pain scores, medication usage, brainstem auditory evoked potential records, and complication rates (including postoperative hearing status) were reviewed and subsequently analyzed. RESULTS: Of the 119 patients who underwent MVD, 61 (51%) were male and 58 (49%) were female. The mean age was 60 years (range 22-86 years). Operative findings included 94 patients (79%) with arterial compression, 16 patients (13%) with isolated venous compression, 1 patient (1%) with a small arteriovenous malformation, and 8 patients (7%) with no obvious source of compression. No perioperative deaths or major complications, including hearing loss, occurred in any patients. Minor complications occurred in 9 patients (8%), including a transient trochlear nerve palsy in 1 patient, transient nystagmus in 1 patient, cerebrospinal fluid leak requiring revision in 1 patient, wound infections requiring revision in 3 patients, and wound infections requiring antibiotics alone in 3 patients. Follow-up data were available for 109 patients, of whom 88 (81%) had excellent outcomes (BNI Score I-II). Ninety-eight patients (90%) had good outcomes (BNI scores I-IIIb), 7 patients (6%) had persistent pain that was not controlled with medications (BNI Score IV), and 4 patients (4%) experienced no relief following surgery (BNI Score V). CONCLUSION: The use of a small craniectomy (<20 mm) in conjunction with a restricted retrosigmoid approach, inferolateral cerebellar retraction, and maintenance of the vestibular nerve arachnoid may minimize complications and optimize surgical outcomes associated with microvascular decompression for trigeminal neuralgia.