Suprafloccular approach via the petrosal fissure and venous corridors for microvascular decompression of the trigeminal nerve: technique notes and clinical outcomes

Abstract

OBJECTIVE Surgical exposure and decompression of the entire trigeminal nerve in a conventional lateral supracerebellar approach can be challenging because of blockages from the superior petrosal vein complex, cerebellum, and vestibulocochlear nerve. The authors demonstrate a novel suprafloccular approach via the petrosal fissure and venous corridors that can be used as a substitute for the conventional route used to treat trigeminal neuralgia and present a consecutive series of patients and their clinical outcomes. METHODS Preoperative and postoperative clinical data from 420 patients who underwent this modified approach at Hangzhou First People's Hospital between March 2012 and May 2014 were reviewed. The technique expands the working space by opening the petrosal fissure and dissecting adhesions between the vein of the cerebellopontine fissure and the simple lobule as needed. Via 3 surgical corridors, the entire trigeminal nerve is exposed and decompressed thoroughly with minimal retraction of the surrounding vital structures. RESULTS The medial one-third of the trigeminal nerve accounted for the majority (275 [65.5%] cases) of neurovascular conflict sites. The lateral corridor was used in 219 (52.1%) cases, the medial corridor was used in 175 (41.7%) cases, and the intermediate corridor was used in 26 (6.2%) cases. The entire trigeminal nerve in each patient was accessed directly and decompressed properly. At the end of the 24-month follow-up period, the rate of excellent results (Kondo score of T0 or T1) was stable at approximately 90.5%. No complications were related directly to petrosal vein or vestibulocochlear nerve injury. CONCLUSIONS Based on data from the large patient series, the authors found this suprafloccular approach via the petrosal fissure and venous corridors provides full exposure and decompression of the entire trigeminal nerve, a high cure rate, and a low neurovascular morbidity rate.

Resection of a Vestibular Schwannoma Using a Retrosigmoid Approach in a Patient With a High Jugular Bulb: 2-Dimensional Operative Video

“…We describe the technical nuances to safely expose the jugular bulb overlying the internal auditory canal using a high-speed drill. Because the effectiveness of using a retrosigmoid approach has been reported for pontine cavernous malformation removal 6,7 and microvascular decompression, 8 this approach was used to create an ample working field for safe drilling of the horizontal fissure of the cerebellum. The V-shaped area created by opening the horizontal fissure allowed for sufficient visualization of the facial nerve and brainstem, which contributed to the preservation of facial nerve function and the avoidance of brainstem injury and retraction injury in the cerebellar hemisphere.…”