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Re-operation for persistent hemifacial spasm after microvascular decompression with the aid of intraoperative monitoring of abnormal muscle response

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Abstract

Background and objectives

Microvascular decompression (MVD) is the only solution that can effectively control hemifacial spasm (HFS). Regarding treatment of the patients who failed the first operation, it is still controversial. We tried to evaluate the safety and efficiency of the early re-exploration for such kinds of patients.

Methods

Thirteen patients failed the first MVD and received a second MVD procedure. The spasm was not resolved at all or became even more severe after the first MVD. Abnormal muscle response (AMR) persisted during the first MVD operation or disappeared once but emerged again. The patient had a strong will to do the re-operation and was aware of the high risks of operative complications.

Results

All the 13 patients got good or excellent spasm resolution immediately after the re-operation, which involved whole-range exploration and intraoperative AMR monitoring; however, there were two cases (15.4%) of permanent facial weakness and three cases (23.0%) of transient facial weakness.

Conclusions

Our experience on early repeat MVD is whole-range exploration and intraoperative AMR monitoring; in other words, re-operation cannot rely too much on experience.

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Abbreviations

HFS:

Hemifacial spasm

MVD:

Microvascular decompression

AMR:

Abnormal muscle response

PICA:

Posterior inferior cerebellar artery

AICA:

Anterior inferior cerebellar artery

VA:

Vertebral artery

EMG:

Electromyography

RExP:

Root exit point

AS:

Attached segment

REZ:

Root exit zone

CP:

Cisternal portion

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Conflicts of interest

None.

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Authors and Affiliations

  1. Department of Neurosurgery, XinHua Hospital, Shanghai JiaoTong University School of Medicine, 1665 Kongjiang Road, Yangpu District, Shanghai, 200092, China

    Shiting Li, Wenyao Hong, Yinda Tang, Tingting Ying, Wenchuan Zhang, Xinyuan Li, Jin Zhu, Jun Zhong, Xuming Hua, Shunqing Xu, Liang Wan, Xuhui Wang, Min Yang, Yi Li & Xuesheng Zheng

Authors
  1. Shiting Li
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  2. Wenyao Hong
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  3. Yinda Tang
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  4. Tingting Ying
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  5. Wenchuan Zhang
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  6. Xinyuan Li
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  7. Jin Zhu
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  8. Jun Zhong
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  9. Xuming Hua
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  10. Shunqing Xu
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  11. Liang Wan
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  12. Xuhui Wang
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  13. Min Yang
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  14. Yi Li
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  15. Xuesheng Zheng
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Corresponding author

Correspondence to Xuesheng Zheng.

Additional information

Comment

This paper, from a well-experienced team in the neurosurgical treatment of hemifacial spasm (HFS) with microvascular decompression (MVD), is interesting as it pushes to controversy. The authors plead for early re-operation in (immediate) failed cases, i.e., within the first week after surgery. Most neurosurgeons dealing with MVD for HFS know that in a significant percentage of so-called immediate failure, HFS spontaneously disappears after a certain delay, a few weeks to a few months and for some cases even 1 to 3 years. In our series, 13% was cured after HFS with a delay of several months to 1 year (1). This is physiologically understandable if it is considered that HFS is due to (central) hyperactivity at the facial nucleus and therefore needs a certain period of time to progressively vanish after removal of the causal vascular compressive factor.

When looking at Table 1 with perhaps the exception of case 1 in which AICA was found at re-exploration still offending the seventh nerve at its cisternal portion, we notice that a (if not the) major compressive vessel (an arterial loop of AICA and/or PICA and/or VA) had been properly treated. In all those patients, we strongly hypothesize that the spasm would have disappeared spontaneously with time. The immediate and then persistent relief after the second operation could well have been obtained by a—at least slight—traumatizing effect of the surgery, manipulation of the Teflon Felt, coagulation of the vein. In five of the 13 cases a, at least, transient facial weakness was observed.

Using intraoperative monitoring of abnormal muscles responses (AMR) to check the completeness and quality of the decompression, although a logical method from physiological aspect (2, 3, 4), we did not find it quite a reliable tool (5). Reliability is hampered by the fact that AMR are sensitive to manipulation of the facial nerve. In other words, disappearance of AMR might well be due to a block of conduction produced by surgery.

In a previous personal work, we showed that patients whose AMR disappeared during MVD still had muscle twitches postoperatively for a certain period of time. Conversely, patients whose AMR were still present at end of decompression had their HFS cure generally after a few weeks to a few months of delay (3). Further, we could notice that the more atraumatic was the surgery, the more frequent was a “delayed cure.”

Whatever it might be, before making a decision for re-operation in so-called immediate failure cases, we advise to wait in the order of 1 year after initial surgery, especially when a significant compressive artery has been found and likely properly treated at first surgery.

References

1) Sindou M (2005) Microvascular decompression for primary HFS. Importance of intraoperative neurophysiological monitoring. Acta Neurochir 147:1019–1025

2) Moller AR (1999) Vascular compression of cranial nerves II. Pathophysiology. Neurol Research 21:439–443

3) Moller AR, Jannetta, PJ (1987) Monitoring facial EMG responses during microvascular decompression operations for HFS. J Neurosurg 66: 681–685

4) Mooij JJ, Mustafa MR, Van Weerden TW (2001) Hemifacial spasm: intraoperative electromyographic monitoring as a guide for microvascular decompression. Neurosurgery 49:1365–1370

5) Hatem J, Sindou M, Vial C (2001) Intraoperative monitoring for HFS. Prognostic value for long-term outcome: a study in a 33-patient series. Br J Neurosurg 15: 496–499

Doctor Marc Sindou, M.D., D.Sc.

University of Lyon

Shiting Li, Wenyao Hong, Yinda Tang and Tingting Ying contributed equally to this study.

This is a retrospective clinical study.

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Li, S., Hong, W., Tang, Y. et al. Re-operation for persistent hemifacial spasm after microvascular decompression with the aid of intraoperative monitoring of abnormal muscle response. Acta Neurochir 152, 2113–2118 (2010). https://doi.org/10.1007/s00701-010-0837-9

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  • DOI: https://doi.org/10.1007/s00701-010-0837-9

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