An Application of Combined Transpetrosal Approach With Microneurovascular Transposition in Recurrent Trigeminal Neuralgia Caused by Dolichoectatic Vertebral Artery.

Abstract

In general, the superior cerebellar artery is the most prevalent vessel that compresses the trigeminal nerve root exit zone (TGNREZ) and is responsible for trigeminal neuralgia (TGN). Nevertheless, the surgical outcome is less efficacious when the offending vessel is a dolichoectatic vertebrobasilar vessel (DVB). In addition, the potential for postprocedural adhesion and fibrosis renders recurrent TGN after prior surgery, an extremely challenging operation. We describe our surgical strategy and procedure that effectively resolved recurrent TGN in a patient whose offending vessel was a large DVB following standard microvascular decompression surgery. The size and nature of the offending DVB indicated that there was limited space for mobilization away from the TGNREZ, as evidenced by previous operative findings. Consequently, the patient's TGN may not be effectively treated by reoperating with the same standard lateral suboccipital approach. Our surgical approach comprised the creation of an expanded area to facilitate the mobilization of the DVB from the TGNREZ, as well as the untethering of the trigeminal nerve and its subsequent mobilization from the DVB using the transposition technique. A combined transpetrosal approach with microneurovascular transposition technique was selected to achieve all objectives. A case illustration with a surgical video is demonstrated.