Recurrence Of Spasm Research Articles

Robot-assisted stylomastoid foramen puncture and radiofrequency ablation for hemifacial spasm treatment: clinical outcomes and technique assessment

OBJECTIVE Stylomastoid foramen (SMF) puncture with radiofrequency ablation (RFA) is a minimally invasive therapy for hemifacial spasm (HFS) with notable therapeutic outcomes. Conventionally, this procedure is performed under CT guidance. The present study highlights the authors’ preliminary clinical experience with robot-assisted SMF puncture in 7 patients with HFS using a neurosurgical robot. METHODS Patients were secured in a skull clamp, and their heads were linked to the Sinovation neurosurgical robot’s linkage arms for precise positioning. Bone fiducial registration was conducted using the robotic pointer. Under robotic guidance, a puncture needle was positioned at the skin entry point and then advanced to the target with a surgical blade incision. On target attainment, an RFA electrode was positioned, and the ablation was performed while monitoring facial nerve function. Preoperative and postoperative spasm grading, surgical metrics, and adverse events were meticulously documented. RESULTS The puncture trajectories averaged 49.5 mm in length, and the overall operation duration was 27.3 minutes. Guided by the robotic arm, all puncture attempts were successfully achieved without any obstructions, and SMF puncture was completed in a single attempt. Following RFA, immediate spasm relief was achieved, with all patients attaining Cohen spasm grade 0. Over a mean follow-up period of 12 months (range 6–15 months), no recurrence of spasms was reported. Facial paralysis was observed in 85.7% of patients, with 6 cases classified as House-Brackmann (HB) grade II and 1 case as grade III. At the final follow-up, 1 patient remained at HB grade II, while the remaining patients improved to grade I. No other lasting or severe complications were recorded. CONCLUSIONS SMF puncture and RFA emerge as a potent and minimally invasive treatment option for HFS. The robot-assisted approach, despite necessitating additional time for head fixation and registration, notably reduces the overall puncture time, puncture attempts, and radiation exposure, thereby enhancing the puncture success rate.

Epilepsy surgery for children with epileptic spasms: A systematic review and meta-analysis with focus on predictors and outcomes.

To conduct a systematic review of the literature regarding rates and predictors of favorable seizure outcome after resective surgery for epileptic spasms (ES) in pediatric patients. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards were followed. We searched PubMed, EMBASE, and Cochrane CENTRAL for articles published on the prevalence or incidence of epileptic spasm since 1985. Abstract, full-text review, and data extraction were conducted by two independent reviewers. Meta-analysis was performed to assess overall seizure freedom rate. Subject-level analysis was performed on a subset of studies to identify prognostic indicators. A total of 21 retrospective studies (n = 531) were included. Meta-analysis of all studies demonstrated a pooled seizure freedom rate of 68.8%. Subject-level analysis on 18 studies (n = 360) demonstrated a significant association between duration of spasms and recurrence of spasms after surgery, with an estimated increased risk of 7% per additional year of spasms prior to operation. Patients who underwent resective surgery that was not a hemispherectomy (i.e., lobectomy, lesionectomy, etc.) had an increased recurrence risk of 57% compared to patients who had undergone hemispherectomy. Resective surgery results in seizure freedom for the majority of pediatric patients with epileptic spasms. Patients who undergo hemispherectomy have lower risk of recurrence than patients who undergo other types of surgical resection. Increased duration of spasms prior to surgery is associated with increased recurrence risk after surgery. PLAIN LANGUAGE SUMMARY: Children with epileptic spasms (ES) that do not respond to medications may benefit from surgical treatment. Our study reviewed existing research to understand how effective surgery is in treating ES in children and what factors predict better outcomes. Researchers followed strict guidelines to search for and analyze studies published since 1985, finding 21 studies with a total of 531 patients. They found that, on average, nearly 70% of children became seizure-free after surgery. Further individual analysis of 360 patients showed that longer duration of spasms before surgery increased the risk of spasms returning by 7% per year. Additionally, children who had less extensive surgeries, such as removal of only a specific part of the brain, had a 57% higher risk of seizure recurrence compared to those who had a hemispherectomy, which removed or disconnected half of the brain. Overall, the study concludes that surgery can often stop seizures, especially when more extensive surgery is performed and when the surgery is done sooner rather than later.

Predictors of Multi‐Vessel Identification, Outcome, and Optimal Surgical Timing for Microvascular Decompression in Hemifacial Spasm

Objectives and BackgroundHemifacial spasm (HFS) is a disabling condition that imposes significant burden upon patients. Microvascular decompression (MVD) surgery is the most effective and long-lasting treatment for HFS, but outcomes following this surgery may vary based on a variety of clinical and operative factors. A more thorough understanding of the variables that impact patient outcome after MVD surgery is needed. MethodsA systematic review and meta-analysis of Medline, Embase, and Central was conducted (n = 2108 screened; n = 86 included) with the goal of determining the impact of the following variables on outcome: duration of disease, geographic location, intraoperative use of an endoscope, and intraoperative finding of single versus multi-vessel neurovascular compression. ResultsMost cases of hemifacial spasm occur on the left side (53.9%, p < 0.001) and are more common in women than men (66.5% versus 33.5%, p < 0.0001). The offending vessel frequencies were: 40.8% anterior inferior cerebellar artery [AICA], 24.9% posterior inferior cerebellar artery [PICA], 17.2% multiple vessels, and 4.7% vertebral artery [VA]. Multiple vessel combinations involved: 26.5% PICA + AICA, 24.6% PICA + VA, 23.1% AICA + VA, and 4.7% AICA + PICA + VA. Relative to the Americas, AICA was less frequent in Europe (p = 0.005), while PICA more frequent in Europe (p = 0.009) and Asia (p < 0.0001). With endoscope assistance, frequency of multiple vessels identified was 31.7% (versus 14.7% with non-endoscopic, p = 0.005), and 27.4% for AICA (43.5% with non-endoscopic, p = 0.003). Spasm improvement was 94.1% near discharge and 96.0% at maximum follow-up. Complications occurred in 16.5% of cases, with spasm recurrence in 2.4%. Greatest frequency of spasm improvement (p < 0.0001) and lowest spasm recurrence rates (p = 0.0005) were reported in series from Asia. For every additional month of pre-operative spasm, the effect size of post-operative improvement decreased (p = 0.04). With every subsequent postoperative month, the effect size of spasm improvement increased (p = 0.0497). The frequency of spasm improvement was significantly higher in series published after 2005 (94.4% versus 97.4%, p = 0.005). ConclusionClinical outcomes following MVD for HFS have improved since 2005. Consideration should be given to earlier operation (shorter disease duration) and use of an endoscope may increase detection of multiple offending vessels. Further studies are needed to understand regional differences in culprit vessel incidence and surgical outcomes in the Americas, Europe, and Asia.

Long-term analysis of adrenocorticotropic hormone monotherapy for infantile epileptic spasms syndrome with periventricular leukomalacia

PurposeInfantile epileptic spasms syndrome (IESS) with periventricular leukomalacia (PVL) has a poor neurological prognosis. Adrenocorticotropic hormone (ACTH) and vigabatrin therapies are the recommended first-line treatments for IESS. However, ACTH monotherapy for IESS with PVL has not been studied in detail. We analysed long-term outcomes of ACTH monotherapy for IESS with PVL. MethodsWe retrospectively examined 12 patients with IESS and PVL at Saitama Children's Medical Center between January 1993 and September 2022. We evaluated seizure outcomes 3 months post-ACTH therapy and at the last visit. We also assessed electroencephalography findings and developmental outcomes. A positive response was defined as complete remission of epileptic spasms, no other seizure types, and hypsarrhythmia resolution post-ACTH therapy. ResultsThe median onset age of epileptic spasms was 7 (range: 3–14) months. The median age at initiation of ACTH therapy was 9 (7–17) months. Seven of 12 patients (58.3%) showed a positive response. The median age at the last visit was 5 years and 6 months (1 year and 5 months–22 years and 2 months). At the last visit, only 2 of 7 initial responders remained seizure-free who demonstrated normal electroencephalography findings within 1-month post-ACTH therapy. Patients with epileptic discharge in the parieto-occipital region within 1-month post-ACTH therapy showed relapse of epileptic spasms or other seizure types. ConclusionPatients having epileptic discharge in the parietal or occipital regions on electroencephalography within 1-month post-ACTH therapy may be at a high risk of epileptic spasm recurrence or other seizure types in the long term.

Factors Related to Hemifacial Spasm Recurrence in Patients Undergoing Microvascular Decompression-A Systematic Review and Meta-Analysis.

There is a lack of knowledge about the factors associated with the recurrence of hemifacial spam (HFS) following an initially successful microvascular decompression (MVD) surgery. The aim of the present study was to systematically review the pertinent literature and carry out a meta-analysis of factors linked to HFS recurrence in patients undergoing initially successful MVD treatment. An online literature search was launched on the PubMed/Medline and Scopus databases. The following data were collected: sex, age at surgery, affected side, reported improvement after surgery, presence of post-operatory facial weakness, symptom duration, offender vessels, and data obtained from intraoperative neurophysiological monitoring. Upon full-text review, eight articles were included, studying 1105 patients, of which 64 (5.7%) reported recurrence after MVD surgery for hemifacial spasm. There was a statistically significant increased incidence of HFS recurrence in patients with the persistence of lateral spread response (LSR after surgery (OR 9.44 (95% CI 1.69–52.58) p 0.01), while those patients experiencing a shorter disease duration before going to surgery were significantly less prone to experiencing disease recurrence (OR 0.11 (95% CI 0.03–0.46) p 0.002). The remaining examined factors did not result as significantly associated with the risk of recurrence. The funnel plots were largely symmetrical for each variable studied. Taken together, the results of our meta-analysis seem to suggest that short-term symptom duration is a protective factor against HFS recurrence after MVD surgery, while LSR persistence is a negative prognostic factor. Well-designed randomized controlled clinical trials with a long follow-up are expected to further explore therapeutic alternatives for HFS recurrence.

Short-term outcome of intravenous methylprednisolone pulse therapy versus oral prednisolone in patients with epileptic spasms

BackgroundInfantile spasm (IS) is an age-specific epileptic disorder of early infancy that typically presents with epileptic spasms occurring in clusters. International League Against Epilepsy (ILAE) also recommends the term “IS syndrome” for clustered spasms occurring during infancy (~ 1 year, rarely after 2 years of age) accompanied by electroencephalography (EEG) hypsarrhythmia. Older clinical studies comparing efficacy of adrenocorticotrophic hormone (ACTH) and corticosteroids preferred ACTH, but recent studies did not observe a significant difference between both nor showed better efficacy of oral prednisolone compared to intramuscular synthetic one. Participants were 53 patients with epileptic spasms divided into two groups: 26 patients treated by intravenous methylprednisolone (group A) and 27 treated by oral prednisolone (group B). Both groups were matched in age, sex, and age of spasm onset. The outcome measures were spasms cessation at 7 and 14 days and recurrence at 6 weeks after tapering, EEG improvement at 2 and 6 weeks, and frequency of side effects.ResultsWe found that both groups had similar results regarding frequency of children achieving spasms cessation at day 7 and day 14 (53.8% vs 51.9% and 38.5% vs 40.7%, p = 1.000 each), respectively. After drug tapering, there was insignificant difference between both groups regarding recurrence of spasm at 6 weeks (14.8% vs 11.5%, p = 1.000) and EEG improvement at 2 weeks (42.3% vs 33.3%, p = 0.577) with nearly similar improvement in both groups at 6 weeks (46.2% vs 48.1%, p = 1.000). With regard to adverse effects of both therapies, no difference observed between both groups.ConclusionsNo significant difference was found between oral prednisolone and intravenous methylprednisolone in treatment of epileptic spasm regarding short-term outcomes. The only advantage of intravenous therapy is decreased time to get response and the only advantage of oral therapy is its applicability at home without hospitalization. Further studies are warranted to explore the long-term outcomes.

Intraoperative neurophysiologic monitoring in microvascular decompression for hemifacial spasm

The majority of primary hemifacial spasm (HFS) patients are related to a vascular compression of the facial nerve root at its entry zone. Non-surgical treatment methods of HFS are anti-epileptic drugs and local botulinum toxin injection, but their outcomes are often not satisfactory in relieving symptoms. Microvascular decompression (MVD) is a surgical treatment method of HFS. Nowadays, intraoperative neurophysiologic monitoring is being used during MVD for two main objectives. The first and main objective is to prevent and reduce the risk of hearing impairment. Brainstem auditory evoked potentials (BAEPs) is monitored during surgery, to monitor the cranial nerve VIII and determine hearing sense preservation. Researches on BAEPs has enabled near real-time and safe monitoring, as warning indicators and advanced techniques to get results faster has been discovered. The second objective is to optimize the effectiveness of surgery. Despite the surgery, some patients had persisted symptoms or recurrence of spasm for some reasons, in few cases. The lateral spread response (LSR) monitoring is performed to guide the operator during surgery. LSR shows modest sensitivity. Nevertheless, it shows high specificity in predicting the symptom-free status after MVD. Low sensitivity precluded the use of the LSR monitoring as an exclusive solitary diagnostic modality. The disappearance of LSR during MVD appears to be not effectively in predicting long-term outcomes, but it demonstrated limited prognostic values in predicting favorable short-term outcomes. These results implements that, intraoperative monitoring of LSR during MVD can provide considerable value for investigating the adequacy of MVD before cranial bone closure.

Is the pre-operative lateral spread response on facial electromyography a valid diagnostic tool for hemifacial spasm?

The lateral spread response (LSR) on preoperative facial electromyogram (EMG) is a useful tool in evaluating patients with hemifacial spasm (HFS). There may be some instances where the LSR does not appear on the preoperative EMG, thus disrupting the diagnosis and treatment of HFS. In this study, we evaluated the patients who did not exhibit LSR on preoperative EMG but underwent microvascular decompression (MVD) for hemifacial spasm. We searched for patients who underwent MVD for HFS but had an absence of LSR on preoperative EMG between January 2016 and June 2018. Surgical outcomes were evaluated at 1, 3, and 6months after surgery. Follow-up facial EMG was performed 3months after surgery. Results were divided into two categories: (1) spasm relief within 24h of surgery and (2) spasm was observed immediately post-operation. The following parameters were analyzed when comparing between the two groups: age, sex, affected side, duration of symptoms, and offending vessel(s). A total of 306 patients underwent MVD for HFS during the study period. Among them, 13 (4.2%) patients had no LSR on preoperative EMG. Eight patients (61.5%) were female and five patients were male. The 13 patients had a mean age of 51years. All patients exhibited probable offending vessels in the root exit zone (REZ) of the facial nerve on preoperative magnetic resonance (MR) imaging that was confirmed during surgery. Seven patients were free of HFS immediately after surgery, though six patients were not. Only one (7.7%) patient had persisted symptom 6months after surgery. No patients experienced recurrence of spasm, nor exhibited abnormal waves on follow-up facial EMG. LSR on facial EMG is a valuable tool for evaluating hemifacial spasm. However, although LSR did not appear on preoperative EMG, if the patient presents with typical symptoms and the offending vessels are identified on MRI, we expect good results after MVD for HFS.

Long-term follow-up results of 550 cases of spastic torticollis treated with modified Foerster-Dandy operation

Objective To investigate the long-term efficacy and complications of modified Foerster-Dandy operation in the treatment of spasmodic torticollis (ST). Methods A total of 550 cases of ST admitted to Neurosurgery Department of China-Japan Friendship Hospital from April 2005 to April 2013 were retrospectively enrolled into this study. All patients were treated with modified Foerster-Dandy operation, in which occipitocervical posterior median approach was used without opening of occipital squama and foramen magnum. Limited laminectomy, endoscope-assisted bilateral subdural accessory nerve and C1 spinal nerve root cutting and selective partial cutting of anterior and posterior roots of C2-4 spinal nerve were conducted. The international Tsui scale was used to evaluate the efficacy post operation. We also analyzed the complications occurring following the operations. Results All patients were followed up for 60-156 months, with an average of 117.0±5.5 months. The median improvement rate of spasticity at 6 months, 12 months and the latest follow-up was 73.6% (54.7%, 86.4%), 70.2% (48.8%, 85.1%) and 73.2% (51.1%, 88.5%), respectively. The Tsui score before operation was 17.2 (13.6, 20.6). However, at 6 months, 12 months and the latest follow-up, the Tsui scores were 4.6 (2.2, 7.3), 4.9 (2.6, 8.1) and 4.3 (2.0, 7.5), respectively, which were significantly lower than those prior to operation (all P<0.05). However, 30 (5.5%) cases had neck rotation weakness, 34 (6.2%) reported shoulder shrug weakness, 32 (5.8%) had limited arms abduction, 45 (8.2%) developed long-term neck back pain and numbness, 11 (2.0%) reported neck circumference narrowing, and 62 (11.3%) suffered from dysphagia. Among them, no obvious improvement was achieved in 5 cases with neck rotation weakness and 9 cases with dysphagia. All the other complications were relieved to various degrees during the follow-up period after rehabilitation training. During the follow-up, spasm recurrence to various degrees was reported in 25 (4.5%) cases. Conclusion Modified Foerster-Dandy operation is a safe and effective surgical therapy for patients with ST. Key words: Spasmodic torticollis; Neurosurgical procedures; Treatment outcome; Postoperative complications; Foerster-Dandy operation

Endoscope-assisted retrosigmoid approach in hemifacial spasm: our experience

IntroductionThe use of surgical decompression of facial hemispasm due to the loop in the internal auditory canal is not always accepted due to the risk related to the surgical procedure. Currently a new surgical technique allows surgeons to work in safer conditions. ObjectiveTo report the results with endoscope-assisted retrosigmoid approach for facial nerve microvascular decompression in hemifacial spasm due to neurovascular conflict. The surgical technique is described. MethodsWe carried out a prospective study in a tertiary referral center observing 12 (5 male, 7 female) patients, mean age 57.5 years (range 49–71) affected by hemifacial spasm, that underwent to an endoscope assisted retrosigmoid approach for microvascular decompression. We evaluated intra-operative findings, postoperative HFS resolution and complication rates. ResultsHemifacial spasm resolution was noticed in 9/12 (75%) cases within 24h after surgery and in 12/12 (100%) subjects within 45 days. A significant (p<0.001) correlation between preoperative historical duration of hemifacial spasm and postoperative recovery timing was recorded. Only 1 patient had a complication (meningitis), which resolved after intravenous antibiotics with no sequelae. No cases of cerebrospinal fluid leak, facial palsy or hearing impairment were recorded. Hemifacial spasm recurrence was noticed in the only subject where the neurovascular conflict was due to a vein within the internal auditory canal. ConclusionsThe endoscope assisted retrosigmoid approach technique offers an optimal visualization of the neurovascular conflict thorough a minimally invasive approach, thus allowing an accurate decompression of the facial nerve with low complication rates. Due to the less invasive nature, the procedure should be considered in functional surgery of the cerebellar pontine angle as hemifacial spasm treatment, specially when the procedure is performed by an otolaryngologist.

Microvascular decompression for atypical hemifacial spasm: lessons learned from a retrospective study of 12 cases.

Typical hemifacial spasm (HFS) commonly initiates from the orbicularis oculi muscle to the orbicularis oris muscle. Atypical HFS (AHFS) is different from typical HFS, in which the spasm of muscular orbicularis oris is the primary presenting symptom. The objective of this study was to analyze the sites of compression and the effectiveness of microvascular decompression (MVD) for AHFS. The authors retrospectively analyzed the clinical data for 12 consecutive patients who underwent MVD for AHFS between July 2008 and July 2013. Postoperatively, complete remission of facial spasm was found in 10 of the 12 patients, which gradually disappeared after 2 months in 2 patients. No recurrence of spasm was observed during follow-up. Immediate postoperative facial paralysis accompanied by hearing loss occurred in 1 patient and temporary hearing loss with tinnitus in 2. All 3 patients with complications had gradual improvement during the follow-up period. The authors conclude that most cases of AHFS were caused by neurovascular compression on the posterior/rostral side of the facial nerve distal to the root entry zones. MVD is a safe treatment for AHFS, but the incidence of postoperative complications, such as facial paralysis and decrease in hearing, remains high.

Epileptic spasms: Experience with a high‐dose oral corticosteroid protocol

To audit clinical practice and assess early outcomes for infants with epileptic spasms after an agreed initial treatment protocol was adopted. We reviewed all cases of epileptic spasms diagnosed between July 2007 and June 2009 and assessed adherence to protocol, remission by day 14, spasm recurrence and side effects. The protocol required that infants be treated with high-dose oral prednisolone except those with tuberous sclerosis complex (TSC) who were treated with vigabatrin. Twenty-eight infants (age 3-14 months, 17 male) were newly diagnosed. Six (21%) had no cause identified (cryptogenic), six (21%) had TSC and 16 (57%) had other non-TSC symptomatic aetiologies. Twenty-three were treated per protocol and five were not. The proportion with remission by day 14 of treatment was 100% in the cryptogenic group (all treated per protocol), 64% in those with non-TSC symptomatic aetiologies treated per protocol, 20% in those with non-TSC symptomatic aetiologies treated not per protocol and 17% in infants with TSC (all treated per protocol). Of 17 infants who received prednisolone, two were admitted for management of febrile illness. Our experience with high-dose oral prednisolone for treatment of epileptic spasms suggests that it is effective and tolerable. The greater proportion of non-TSC symptomatic patients with timely cessation of spasms when treated by this protocol supports the use of high-dose oral prednisolone as the treatment of choice. Given the poor response of children with TSC to treatment with vigabatrin, early use of steroid therapy deserves consideration.

Microvascular decompression for hemifacial spasm: long-term outcome and prognostic factors, with emphasis on delayed cure

The postoperative course of microvascular decompression (MVD) for hemifacial spasm (HFS) is variable, and the optimal time for assessing the results is unclear. From April 1997 to October 2007, MVD for HFS was performed in 801 patients. Patients were divided into two groups (cured or failed) according to subjective patient assessments over a 3-year period. We analyzed patient characteristics and surgical findings to determine prognostic factors. Medical records were analyzed retrospectively over the 3-year follow-up period. Of the 801 patients who underwent surgery, 743 (92.8%) appeared to be cured, 70 (8.7%) had residual or recurrent spasms more than 1year after surgery, 11 (1.3%) had gradual improvement over 3years, and 1 (0.1%) had delayed improvement more than 3years after surgery. Fifty-eight patients (7.2%) had residual or recurrent spasms more than 3years after surgery, of which 19 (2.4%) had recurrence after initial relief. The mean time to spasm recurrence was 18.9months. Intraoperative resolution of the lateral spread response (LSR) after decompression (p = 0.048) and severe indentation (p = 0.038) were significant predictors of good long-term outcome after MVD for HFS. In our series, 70 patients (8.7%) had residual or recurrent spasms more than 1year after surgery, of which 12 (17.1%) improved gradually after 1year. If the surgeon can confirm intraoperative resolution of the LSR and severe indentation, reoperation can be delayed until 3years after MVD.

Automatic Implantable Cardioverter Defibrillator for the Treatment of Ventricular Fibrillation Following Coronary Artery Spasm

Coronary artery spasm is an infrequently recognized condition that causes Prinzmetal's angina and specific electrocardiographic changes. A 50-year-old man who suffered a spontaneously aborted acute inferior myocardial infarction is presented. He underwent cardiac catheterization, which initially showed a normal coronary artery. The coronary angiogram was repeated shortly after a second presentation of acute coronary syndrome and ventricular fibrillation. Coronary spasm of very proximal right coronary artery was present, which was reversed completely with intracoronary nitroglycerin. The spasm segment was first stented. Subsequently, an automatic implantable cardioverter defibrillator was inserted because of the uncertainty of future spasm recurrence. The patient was discharged with oral isosorbide dinitrate and Amlodipine. In further follow-up, the patient had two separate shocks within 4 months of implantation. Ventricular fibrillation was the trigger for the shock therapy in both occasions.

Repeat microvascular decompression for hemifacial spasm

Objective: To report our experience with repeat microvascular decompression (MVD) for hemifacial spasm (HFS) in patients who have failed their first operation. Methods: The authors describe 41 redo MVDs for...

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Objective: To describe our experience with adriamycin (ADM) selective chemical rhizotomy of facial nerves in a patient with hemifacial spasm (HFS) who refused neuro-vascular decompression surgery. This unique technique was less invasive than intracranial neuro-surgery. It was possible to perform a permanent nerve block under local anesthesia.Case report: The patient, a 73-year-old female, had difficulty opening her left eye due to HFS. After treatment with antiepileptic medicine (carbamazepine) was ineffective, the patient received selective intraneural injections of ADM under local anesthesia. One week after the surgery, the spasms had disappeared completely and slight muscle weakness was observed. No major complications were caused by this procedure and no recurrence of spasms was observed two years after the surgery.Main outcome: It is thought that recurrence of HFS should be observed after simple neurotomy due to re-growth of nerve fibers. However, this did not occur after selective ADM chemical rhizotomy of facial nerves. This method clearly differs from previously used methods of simple neurotomy because simple neurotomy does not cause severe destructive change in the facial motor nucleus.Conclusion: We conclude that selective facial nerve chemical rhizotomy with ADM under local anesthesia may be effective in treating a subgroup of patients with HFS, especially elderly patients and those in high risk groups for general anesthesia and intra cranial neuro-vascular decompression surgery.

Microvascular decompression to treat hemifacial spasm: long-term results for consecutive series of 143 patients. Samii M, Gunther T, Iaconetta G, Muehling M, Vorkapic P, Samii A. Neurosurgery 2002;50:712–719.

The treatment of hemifacial spasm may include medications, botulin toxin injections, or neurosurgical neurovascular decompression. In this study, the authors report their long-term results for 145 cases of hemifacial spasm treated with microvascular decompression procedures. Among 143 patients (62.2% female patients and 37.8% male patients; mean age, 54.5 years), 145 microvascular decompressions to treat hemifacial spasm were performed between 1980 and 1998. The onset of symptoms was typical in 95.9% of cases and atypical in 4.1%. Platysma muscle involvement was observed in 24.5% of patients, with a higher incidence among female patients (74.3%). Patients were monitored with annual questionnaires. Twenty-six patients were lost to follow-up, and 117 patients are still being followed, with an average period of 9.6 years (range, 1–17.6 years). At hospital discharge, 69 patients (59%) were spasm-free and 48 patients (41%) experienced further spasm. At 6 months, the number of spasm-free patients had increased to 108 (92.3%), whereas only 9 patients (7.7%) complained of hemifacial spasm. In follow-up (average period, 9.4 years), 106 patients were spasm-free. Seven patients experienced only temporary relief, with recurrence after 4.5 years. Two patients were spasm-free after 4 or 6 weeks, and the recurrence of spasm was observed 1 year later. Two patients were never completely spasm-free. Deafness was the main postoperative complication (8.3%), but most of those cases (66%) occurred before the routine use of intraoperative evoked potential monitoring. The authors conclude that this surgical procedure for hemifacial spasm involves low risk, is well-tolerated by elderly patients, is associated with very low recurrence rates, and is a definitive treatment for more than 90% of cases.—Nancy J. Newman

Microvascular Decompression to Treat Hemifacial Spasm: Long-term Results for a Consecutive Series of 143 Patients

The concept of neurovascular decompression for the treatment of hemifacial spasm is now widely accepted. In this study, we report our long-term results for 145 cases treated with this procedure. The results of 145 microvascular decompressions to treat hemifacial spasm (performed between 1980 and 1998) among 143 patients (62.2% female patients and 37.8% male patients; mean age, 54.5 yr) are presented. The onset of symptoms was typical in 95.9% of cases and atypical in 4.1%. Platysma muscle involvement was observed for 24.5% of patients, with a higher incidence among female patients (74.3%). Patients were monitored with annual questionnaires. Twenty-six patients were lost to follow-up monitoring, and 117 are still undergoing follow-up monitoring, with an average period of 9.6 years (range, 1-17.6 yr). At discharge, 69 patients (59%) were spasm-free and 48 patients (41%) experienced further spasm. At 6 months, the number of spasm-free patients had increased to 108 (92.3%), whereas only 9 patients (7.7%) complained of hemifacial spasm; 44 patients were spasm-free at an average time of 15 weeks. In follow-up examinations (average period, 9.4 yr), 106 patients were spasm-free. Seven patients experienced only temporary relief, with recurrence after 4.5 years. Two patients were spasm-free after 4 or 6 weeks, and the recurrence of spasm was observed 1 year later. Two patients were never completely spasm-free. Among the patients who did not undergo previous surgery elsewhere, only two experienced recurrence. Deafness was the main postoperative complication (8.3%); most of those cases (66%) occurred before the routine use of intraoperative evoked potential monitoring. Analysis of our series demonstrates that this surgical procedure involves very low risk, is well tolerated by elderly patients, is associated with very low recurrence rates, and is a definitive treatment for more than 90% of cases.

Intraoperative monitoring of facial EMG responses during microvascular decompression for hemifacial spasm. Prognostic value for long-term outcome: a study in a 33-patient series

Lateral spread responses (LSR), an electrophysiological characteristic of hemifacial spasm (HFS), can be recorded during surgery. This work aims at evaluating the prognostic value of the persistence or suppression of the LSR at the end of the microvascular decompression (MVD) procedure of the facial nerve. Thirty-three patients with HFS, which had been evolving for 5.5 years, underwent MVD with intraoperative EMG. Monitoring required the placement of a needle in the frontalis and mentalis muscles. Responses were recorded after stimulation of inferior or superior branches of the facial nerve to search for abnormal ephaptic LSR. Preoperative abnormal LSRs were present in all patients. In 23 patients, LSR disappeared with vascular decompression and was not present upon closure. Among those patients, 20 were considered clinically cured and three still presented with mild/moderate spasm at 3-month follow-up. At late follow-up, 22 patients were free of spasm. One patient had recurrence of spasm at month 10. On the contrary, 10 patients had persistent abnormal LSR upon closure. Among those, seven were cured at early follow-up (3 months on average), whereas spasm disappeared at late follow-up (12 to 36 months) in the other three patients. The prognostic value of LSR monitoring is questionable; a good clinical result may be obtained in patients who presented with persistent LSR at the end of MVD. Delayed cure strongly supports the hypothesis that HFS is not only due to the mechanical pulsations of the elongated artery against the root exit zone of the facial nerve, but also to demyelination of the nerve and/or hyperactivity of the facial motornucleus generated by the neurovascular compression.

Long-Term Follow-up of Recurrent Laryngeal Nerve Avulsion for the Treatment of Spastic Dysphonia

Long-term follow-up of 3 to 7 years is reported on 18 patients who had undergone recurrent laryngeal nerve avulsion (RLNA) for the treatment of adductor spastic dysphonia (SD). Data on neural regrowth after previous recurrent laryngeal nerve section (RLNS) are presented in 2 of these 18 patients. We introduced RLNA as a modification of standard RLNS to prevent neural regrowth to the hemiparalyzed larynx and subsequent recurrence of SD. We have treated a total of 22 patients with RLNA, and now report a 3- to 7-year follow-up on 18 of these 22 patients. Resolution of symptoms was determined by routine follow-up assessment, perceptual voice analysis, and patient self-assessment. Sixteen of 18, or 89%, had no recurrence of spasms at 3 years after RLNA as determined at routine follow-up. Two of the 16 later developed spasms after medialization laryngoplasty for treatment of weak voice persistent after the avulsion. This yielded a total of 14 of 18, or 78%, who were unanimously judged by four speech pathologists to have no recurrence of SD at the longer follow-up period of 3 to 7 years. Two of these 4 patients were judged by all four analysts to have frequent, short spasms. The other 2 were judged by two of four analysts to have seldom, short spasms. Three of 18 patients presented with recurrent SD after previous RLNS. At the time of subsequent RLNA, each patient had evidence of neural regrowth at the distal nerve stump as demonstrated by intraoperative electromyography and histologic evaluation of the distal nerve stump. One remained free of SD following RLNA, 1 was free of spasms at 4 years after revision avulsion but developed spasms after medialization laryngoplasty, and the final patient developed spasms 3.75 years after revision RLNA. Medialization laryngoplasty with Silastic silicone rubber was performed in 6 of 18, with correction of postoperative breathiness in all 6, but with recurrence of spasm in 3. Spasms resolved in 1 of these with downsizing of the implant. We conclude that RLNA represents a useful treatment in the management of SD in patients not tolerant of botulinum toxin injections.