The efficacy of temporary clamping of V3 with a suboccipital far-lateral approach in microvascular decompression for Hemifacial spasm associated with the vertebral artery

Hemifacial spasm (HFS) is often caused by compression of the vertebral artery (VA) directly or indirectly as a result of other intervening vessels, so VA-associated HFS is difficult to treat. Recently, we have achieved good surgical outcomes using a far lateral approach and temporary clamping of V3 for VA-associated HFS. Herein, we present our method with an accompanying surgical video. From April 2018 to March 2019, 5 patients with VA-associated HFS underwent surgery, and pre-and postoperative symptoms and postoperative complications were evaluated. In the procedure, the suboccipital muscles were dissected and reflected layer by layer, and the extracranial VA (V3) was secured within the suboccipital triangle. A lateral suboccipital craniotomy followed by far lateral drilling was made to widen the surgical field from the caudolateral side. After reducing the VA flow pressure by temporary clamping of V3, the VA was transposed using a Teflon sling via two triangular space above and below the lower cranial nerves (LCNs). Causative vessels included direct VA compression in two cases and intervening vessels in three cases. The symptoms disappeared in four cases and improved satisfactorily in one case. One patient had mild hearing loss (approximately 10 dB) and hoarseness, but both improved 9 months after surgery. There was no postoperative cerebrospinal fluid leakage in any cases. A wide surgical field via the far lateral approach and the temporary clamping of V3 contributed to thorough observation of the REZ and safe and complete VA transposition.