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01.01.2012 | Letter to the Editor | Ausgabe 1/2012

Neurosurgical Review 1/2012

An ideal microvascular decompression technique should be simple and safe

Zeitschrift:
Neurosurgical Review > Ausgabe 1/2012
Autor:
Jun Zhong
Wichtige Hinweise

Comments

Toshio Matsushima, Jun Masuoka, Saga, Japan
MVD is now one of the standard surgeries. But, there are still some problems which should be solved. One of them is recurrence after the MVD especially for trigeminal neuralgia. For this reason, many neurosurgeons in Japan have changed the decompression method from the interposition technique to the transposition one. The transposition technique with glue is generally utilized. However, unreliability of the fixation by the glue seems to be still one of the causes of the recurrence. Therefore, we started to try the transposition of offending arteries with the stitched sling retraction technique several years ago and reported it as one of the optional methods based on the knowledge of the anatomy this year.
The writer of this letter asked us several questions, and we are going to state our opinions answering his questions.
1. As he points out, it is difficult to perform this technique in a small surgical field. Many neurosurgeons that perform MVD prefer a small surgical field, but we perform this method in not-so small craniotomy and not-so small surgical field. In order to perform a reliable and safe surgery, we do not care much about the size of the craniotomy.
2. This method is not so complicated for surgeons who are familiar with cerebellopontine angle (CPA) surgeries. When the anatomy is well understood, we do not think complications increase. However, the operation time becomes longer by 30–60 min.
3. The offending arteries transposed by a sling are neither injured nor occluded because we do not tie silk sutures around the arteries. For further fixation, we sometimes use teflon felt and glue to fix the sutures of the sling to the tentorium.
4. We do not perform any blind operations. We perform this method in a sufficient surgical field watching the surrounding structures such as nerves, arteries, and veins.
5. This method is not a novel one for the surgeons who use the micro needle holder in the cranium. A few special long surgical instruments such as a micro needle holder are necessary especially in the MVD for trigeminal neuralgia.
6. In the surgeries of the upper portion of the CPA, the petrosal veins are very important, and we should know the anatomy of the complicated veins. After sufficient preoperative examinations of the veins by 3D CT, we first perform the dissection of the arachnoid membrane around the petrosal veins in order to be able to move the veins safely.
7. Many neurosurgeons that perform MVD make an effort not to use retractors in order to avoid compression of the cerebellum. We also agree that the MVD without any spatulas is safer. However, when this stitched sling retraction technique is performed, a wide operative field should be obtained even with retractors. We make an effort to reduce the time of use of the retractor short. Whether a retractor had better be used or not should be carefully determined based on its merits and demerits in each surgery.
8. In the cases with analogous retraction technique, a surgeon has to pay attention to the strength of the fixation for the transposition. When sufficient transposition is obtained by analogous retraction technique, the stitched sling retraction technique is not necessary.
9. Their surgery shown in Fig. 1 does not have a proper surgical field for the technique, and the petrosal vein has not been dissected. They are using only the petrosal cerebellar surface. In such a surgical field, it is very difficult and dangerous to perform the stitched sling retraction technique. We use not only the petrosal cerebellar surface but also the tentorial cerebellar surface after dissecting the arachnoid membrane around the petrosal veins.
Since the MVD was developed by Janetta PJ about 40 years ago, it has been gradually changed and improved. The MVD for trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia was used to be performed in the same craniotomy and approach. However, now each MVD is performed through a little different craniotomy and approach as we proposed. The decompression methods and techniques have also been changed. In order to minimize complications and obtain good surgical results, we think it is important to improve our surgical procedures.

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