Microvascular Decompression For Glossopharyngeal Neuralgia Research Articles

Glossopharyngeal Neuralgia.

Glossopharyngeal neuralgia (GPN) is a rare disease that must be differentiated from trigeminal neuralgia. The purpose of this article is to provide a comprehensive review of anatomy, pathophysiology, diagnostic criteria, and several options of treatment for GPN. Lessons learned through our experience of treating GPN are presented in detail, as well as cases of misdiagnosis and diagnostic pitfalls. Microvascular decompression (MVD) should be primarily considered for medically intractable GPN. Techniques employed in MVD for GPN are categorized and described. Especially, we underscore the advantages of the 'transposition' technique where insulating material is positioned 'off' the root entry zone (REZ), instead of 'on' it. We believe this 'off-the-REZ' technique can fundamentally prevent recurrence, if applicable. In addition, Gamma Knife radiosurgery can be an alternative option when a patient is ineligible for MVD, though it is categorized as a destructive procedure.

Reoperation after failed microvascular decompression for glossopharyngeal neuralgia.

Microvascular decompression (MVD) is known as a safe and effective procedure to treat glossopharyngeal neuralgia (GN). However, some patients experienced poor pain relief after MVD, for which the mechanism is not clear yet. Reviewing the intraoperative findings and postoperative effect of reoperation for patients who failed the first MVD, is helpful to figure out why the first MVD for GN failed. There were eight patients with GN who failed first MVD. The possibilities for secondary GN were eliminated by physical and radiological examination. The reoperation through the previous incision was conducted, and appropriately, treatment was provided according to the intraoperative findings. The video data and prognosis of the reoperation were retrospectively reviewed. The reasons for the invalid first MVD were analyzed. To the end of follow-up, there were 7 patients of pain-free, and one patient with occasional mild pain attacks (VAS 2). There was one patient who experienced transient hoarseness in 3months after the reoperation. We summarized the causes for failed first MVD which were omission of the offending vessel in 3 cases, inadequate decompression of the nerve root in 2 cases, and excessive decompression materials which caused iatrogenic nerve root compression in 3 cases. For patients with recurrent or failed after MVD, a thorough examination should be carried out to eliminate the possibility of secondary GN. Reoperation through the previous incision is safe and effective. The bone window should be close enough to the sigmoid sinus to aid the exposure of the nerve root. The nerve transection could be adopted if no offending vessels were found. And a multi-site decompression could be used when the vertebral artery is the offending vessel.

Letter to the Editor. Radiosurgery is a valuable alternative to microvascular decompression for glossopharyngeal neuralgia.

Letter to the Editor. Radiosurgery is a valuable alternative to microvascular decompression for glossopharyngeal neuralgia.

Efficacy and safety of microvascular decompression for glossopharyngeal neuralgia: A meta-analysis study

Objective To investigate the efficacy and safety of the microvascular decompression (MVD) for glossopharyngeal neuralgia (GN). Methods A systematic review was performed to retrieve relevant literatures up to February 2018 through PubMed, Embase and Web of Science database. The relevant literatures were screened according to the inclusion and exclusion criteria. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) was used to conduct a quality evaluation for the included literatures. The relevant data were extracted to evaluate the immediate complete remission rate post operation, long-term remission, proportion of occurrence on the left side, proportion of posterior inferior cerebellar artery (PICA) as offending vessel, proportion of a single vessel as offending vessel, operational mortality and complications. Meta-analysis was conducted by using the meta package of R software. Results A total of 12 studies involving 665 patients were enrolled. The mean STROBE score of the included literatures was 16. The immediate complete remission after operation was achieved in 553 of 665 patients and the corresponding rate was 91% (95% CI: 83%-96%, I2=82%). The long-term remission was achieved in 298 of 335 patients and the corresponding rate was 87% (95% CI: 80%-93%, I2=64%). The symptoms of 387 in 665 patients were located on the left and the proportion of occurrence on the left side was 59% (95% CI: 52%-67%, I2=67%). The PICA was found to be the offending vessel in 292 of 408 patients and the corresponding proportion was 72% (95% CI: 68%-76%, I2=0). A single vessel was found to be the offending vessel in 336 of 408 patients and the corresponding proportion was 84% (95% CI: 77%-93%, I2=82%). The funnel plot and Egger linear regression demonstrated no publication bias. The cumulative meta-analysis suggested that the rate of remission did not change with a fixed trend with the date of the publication. Sensitivity analysis and subgroup analysis provided similar results. Conclusions The results of our meta-analysis suggested that MVD is an effective and safe modality of treatment for GN with high immediate postoperative complete remission rate, high long-term complete remission rate and low relapse rate. The surgical complications of MVD are few and slight, which is worth getting promoted. Key words: Glossopharyngeal neuralgia; Meta-analysis; Microvascular decompression; Efficacy; Safety

MRI Findings and Outcomes in Patients Undergoing Microvascular Decompression for Glossopharyngeal Neuralgia

Glossopharyngeal neuralgia causes extreme paroxysmal pain in the posterior pharynx, tonsillar region, base of tongue, or deep ear, that is, the distribution of the glossopharyngeal nerve. Some cases of glossopharyngeal neuralgia are associated with neurovascular conflict, usually by the posterior inferior cerebellar artery. Such symptomatic compression occurs only in proximal, centrally myelinated portions of the glossopharyngeal nerve near the brainstem. Microvascular decompression provides effective and durable pain relief for properly selected patients with medically refractory glossopharyngeal neuralgia. The purpose of this study is to describe a tailored MRI evaluation of neurovascular conflict in glossopharyngeal neuralgia to improve candidate selection for microvascular decompression. Our team developed a glossopharyngeal neuralgia imaging and evaluation protocol including a grading system for neurovascular conflict of the glossopharyngeal nerve and applied it to evaluate candidates for microvascular decompression. Our team grades neurovascular conflict as "contact" (vessel touching nerve without intervening cerebrospinal fluid) versus "deformation" (deviation or distortion of nerve from its normal course by the offending vessel). MRIs of patients with glossopharyngeal neuralgia demonstrate proximal neurovascular conflict. Postoperative MRI demonstrates separation of the glossopharyngeal nerve from the offending vessel. A tailored glossopharyngeal neuralgia imaging evaluation protocol is presented. We believe this approach has helped improve microvascular decompression outcomes and reduce unnecessary procedures at our institution. Further research may elucidate whether clinical and imaging features, including neurovascular conflict severity, predict surgical outcome for glossopharyngeal neuralgia.

Microvascular decompression for glossopharyngeal neuralgia using intraoperative neurophysiological monitoring: Technical case report.

Background:Glossopharyngeal neuralgia (GN) is a rare functional disorder representing around 1% of cases of trigeminal neuralgia. Lancinating throat and ear pain while swallowing are the typical manifestations, and are initially treated using anticonvulsants such as carbamazepine. Medically refractory GN is treated surgically. Microvascular decompression (MVD) is reportedly effective against GN, superseding rhizotomy and tractotomy.Methods:We encountered three patients with medically refractory GN who underwent MVD using intraoperative neurophysiological monitoring (IONM). The offending vessels were the posterior inferior cerebellar arteries, which were confirmed intraoperatively via a transcondylar fossa approach to be affecting the root exit zones of the glossopharyngeal and vagus nerves. As IONM, facial motor-evoked potentials (MEPs) and brainstem auditory-evoked potentials were monitored during microsurgery in all three patients. Pharyngeal and vagal MEPs were added for two patients to avoid postoperative dysphagia.Results:GN disappeared immediately after surgery with complete preservation of hearing acuity and facial nerve function. Transient mild swallowing disturbance was observed in 1 patient without pharyngeal or vagal MEPs, whereas the remaining two patients with pharyngeal and vagal MEPs demonstrated no postoperative dysphagia.Conclusion:Although control of severe pain is expected in surgical intervention for GN, lower cranial nerves are easily damaged because of their fragility, even in MVD. IONM including pharyngeal and vagal MEPs appears very useful for avoiding postoperative sequelae during MVD for GN.

A simple bracing technique to correct kinking of arterial branches to avoid ischemic sequelae during neurovascular surgery.

Background:During microscopic procedures for neurovascular disease, we sometimes encounter kinking of arterial branches resulting in ischemic sequelae. A simple and useful technique that involves inserting a small, ball-like prosthesis made of oxidized cellulose or shredded Teflon with fibrin glue that corrects the arterial branch kinking and avoids subsequent compromise is reported.Methods:Between January and December 2014, three patients developed arterial kinking during microscopic procedures, including two in the caudal loop of the posterior inferior cerebellar artery during microvascular decompression for glossopharyngeal neuralgia and one in a branch of the middle cerebral artery (MCA) during clipping for an unruptured MCA aneurysm. Blood flow insufficiency was confirmed by microvascular Doppler ultrasonography (MDU) and indocyanine green (ICG) videoangiography. The prosthesis, which was made of shredded Teflon in two cases and oxidized cellulose in one case, was inserted into the crotch of the kinked arteries to correct the kinking of the arteries and restore the proper vascular shape and normal blood flow.Results:The small, ball-shaped prosthesis corrected the kinked arteries and maintained the proper shape, which was confirmed by ICG videoangiography and MDU during the operation and three-dimensional computerized tomography angiography postoperatively. Postoperatively, the patients did not manifest any ischemic sequelae related to the kinked arteries.Conclusion:The insertion of prostheses with fibrin glue into the crotch of a kinked artery for repair is considered a simple and useful method for correcting a kinked artery that avoids ischemic sequelae.

Microvascular decompression for glossopharyngeal neuralgia through a microasterional approach: A case series

Background:Glossopharyngeal neuralgia (GPN) is an uncommon craniofacial pain syndrome. It is characterized by a sudden onset lancinating pain usually localized in the sensory distribution of the IX cranial nerve associated with excessive vagal outflow, which leads to bradycardia, hypotension, syncope, or cardiac arrest. This study aims to review our surgical experience performing microvascular decompression (MVD) in patients with GPN.Methods:Over the last 20 years, 14 consecutive cases were diagnosed with GPN. MVD using a microasterional approach was performed in all patients. Demographic data, clinical presentation, surgical findings, clinical outcome, complications, and long-term follow-up were reviewed.Results:The median age of onset was 58.7 years. The mean time from onset of symptoms to treatment was 8.8 years. Glossopharyngeal and vagus nerve compression was from the posterior inferior cerebellar artery in eleven cases (78.5%), vertebral artery in two cases (14.2%), and choroid plexus in one case (7.1%). Postoperative mean follow-up was 26 months (3–180 months). Pain analysis demonstrated long-term pain improvement of 114 ± 27.1 months and pain remission in 13 patients (92.9%) (P = 0.0001) two complications were documented, one patient had a cerebrospinal fluid leak, and another had bacterial meningitis. There was no surgical mortality.Conclusions:GPN is a rare entity, and secondary causes should be discarded. MVD through a retractorless microasterional approach is a safe and effective technique. Our series demonstrated an excellent clinical outcome with pain remission in 92.9%.

Intraoperative neurophysiological monitoring of microvascular decompression for glossopharyngeal neuralgia.

To evaluate if adding cranial nerves (CNs) V and VI to standard intraoperative neurophysiological monitoring (IONM) of microvascular decompressions for glossopharyngeal neuralgia improve its efficacy. We reviewed all patients who received a microvascular decompression for glossopharyngeal neuralgia at our institution between January 2008 and August 2012. All received upper extremity somatosensory evoked potentials, brainstem auditory evoked potentials, and free-running electromyography of muscles innervated by ipsilateral CNs VII, IX, and X. The sample was divided into 12 patients who received additional monitoring of CNs V and VI and 15 who did not. No difference on neurotonic activity presence was found on CN V (standard IONM: 0% versus additional CNs IONM: 8.33%; p = 0.423), CN VI (never present on the additional CN patients), CN VII (standard IONM: 73.33% versus additional CNs IONM: 66.64%; p = 0.973), CN IX (standard IONM: 40.0% versus additional CNs IONM: 25.0%; p = 0.683), or CN X (standard IONM: 46.67% versus additional CNs IONM: 33.33%; p = 0.701) between groups. Additionally, no differences of brainstem auditory evoked potentials wave V's delay, and amplitude at the end of the decompression, or closing of the case were found between groups. Monitoring free-running electromyography of additional CNs V and VI does not improve the efficacy of IONM of microvascular decompressions for glossopharyngeal neuralgia.

Transcondylar Fossa (Supracondylar Transjugular Tubercle) Approach: Anatomic Basis for the Approach, Surgical Procedures, and Surgical Experience

The authors clarify the anatomic basis and the usefulness of the transcondylar fossa approach (T-C-F A), in which the posterior portion of the jugular tubercle is removed extradurally through the condylar fossa with the atlanto-occipital joint intact. The authors first performed an anatomic study to identify the area to be removed using cadaveric specimens and then applied the T-C-F A to foramen magnum surgeries. The surgeries included clipping a vertebral artery-posterior inferior cerebellar artery aneurysm in 11 cases, microvascular decompression for glossopharyngeal neuralgia in 15 cases, and removing intradural foramen magnum tumors in 17 cases. Only the condylar fossa was removed, but the approach offered very good visualization of the lateral part of the foramen magnum and sufficient working space. These surgeries were performed safely without major complications. This skull base approach is minimally invasive and is not difficult. Therefore, it can be a standard approach for accessing intradural lesions of the foramen magnum. It can be combined with the transcerebellomedullary fissure approach from the lateral side and can also be easily changed to the transcondylar approach, if necessary.

Microvascular decompression for glossopharyngeal neuralgia: a long-term retrospectic review of the Milan-Bologna experience in 31 consecutive cases

To examine surgical findings and results of microvascular decompression (MVD) for glossopharyngeal neuralgia (GN). Between 1990 and 2007, 31 consecutive patients affected by drug-resistant GN underwent MVD through a retromastoid keyhole in the supine position with the head rotated to the opposite side. A retrospective analysis was performed that paid particular attention to the relationship among surgical technique, pain control and side effects. A vascular compression of the glossopharyngeal nerve was found in all cases. Twenty-eight out of 31 patients (90.3%) were found to be pain free without medication at long-term follow-up (1-17 years, mean 7.5 years). Three patients (9.7%) were found to require medication to control pain paroxysms that were less frequent and less severe than those observed preoperatively. Two patients required repeated surgery for a drug-resistant recurrence of pain for a total of 33 MVDs. We observed no mortality and did not find any long-term surgical morbidity. Cranial nerve impairment, when observed, always resolved in the following months. MVD is a safe and effective treatment for GN in patients of all ages.

Microvascular decompression for the treatment of glossopharyngeal neuralgia

Glossopharyngeal neuralgia is a rare disorder. In this article, the condition is defined and its clinical features and diagnostic criteria are described. Treatment of this condition has changed over the years, and evolution of surgical treatment is reviewed. Microvascular decompression for glossopharyngeal neuralgia is described in detail, emphasizing special preoperative anesthetic considerations and up-to-date results and complications.