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Stitched sling retraction technique for microvascular decompression: procedures and techniques based on an anatomical viewpoint

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Abstract

The success of microvascular decompression (MVD) depends on the permanent and complete transposition of the offending vessels. This paper describes the stitched sling retraction techniques for treating trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN), focusing on the stitching point for slinging the offending artery in the appropriate direction. Between January 2007 and March 2009, 28 patients with TN, 5 patients with HFS, and 3 patients with GPN underwent MVD with a sling retraction technique. In cases of TN, MVD was performed using the infratentorial lateral supracerebellar approach, and the offending superior cerebellar artery was superomedially transposed with a sling stitched to the tentorium cerebelli. In cases of HFS, MVD was performed using the lateral suboccipital infrafloccular approach, and the offending vertebral artery was superolaterally transposed with a sling stitched to the petrous dura. In cases of GPN, MVD was performed using the transcondylar fossa approach, in which the posterior inferior cerebellar artery was inferolaterally mobilized with a sling secured to the jugular tubercle. No patient suffered recurrence in the follow-up period. For the sling retraction technique to be performed successfully, it is important for a stitch to be placed at a suitable site to sling the offending vessel in the intended direction. An appropriate surgical approach must be used to obtain a sufficient operative field for performing the stitching procedures safely.

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Authors and Affiliations

  1. Department of Neurosurgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan

    Jun Masuoka, Toshio Matsushima, Masatou Kawashima, Yukiko Nakahara, Takeshi Funaki & Toshihiro Mineta

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  1. Jun Masuoka
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  2. Toshio Matsushima
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  3. Masatou Kawashima
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  4. Yukiko Nakahara
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  5. Takeshi Funaki
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  6. Toshihiro Mineta
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Correspondence to Jun Masuoka.

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Comments

Alessandro Ducati, Turin, Italy

In this useful paper about microvascular decompression, the authors describe in detail the technique to transpose the offending vessel by means of a sling retraction stitched to the dura. They put the attention both to the most effective direction to retract the vessel and to the safest location in the dura to place a stitch, avoiding venous lakes that may cause dangerous bleedings. The case presentation is very effective; the figures are clear and illustrative; the discussion of the literature is complete. I found this work useful for experienced surgeons, to reevaluate the technique of microvascular decompression, using the transposition of the vessel instead of the interposition of foreign material between the nerve and the vessel, and useful for beginners as well because the anatomical detail of this presentation is so accurate that “drive the hand” of surgeons step by step.

Ludwig Benes, Marburg, Germany

This is a well-presented paper on a transposition technique for microvascular decompression in patients suffering trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia by an experienced writing group.

Although a variety of sling retraction techniques for securing vascular transposition have been previously published, this paper is focusing on the anatomical details especially on the preferred stitching point for effective vessel transposition.

To achieve a sufficient vessel transposition, the operative field has to be prepared by a tailored approach to offer all possibilities to the surgeon performing this technique.

I share the author’s opinion that the transposition method is more suitable in comparison with interposition techniques, e.g., with “Teflon” as long as the perforators are long enough for an adequate vessel management.

Meticulous care should be taken to prevent vessel kicking when utilizing the described sling retraction technique.

Volker Tronnier, Lübeck, Germany

Trigeminal neuralgia and other neurovascular compression syndromes as hemifacial spasm, glossopharyngeal neuralgia, and others still are puzzling with regard to their pathophysiology. Although a neurovascular conflict is considered to be the cause for these attack-like syndromes, several aspects as the intermittent clinical course, the usually excellent relief by sodium channel blockers, the instantaneous relief after microvascular decompression as well as the relief by lesioning or irradiating the nerve are not well understood. Meanwhile, the question is solved that microvascular decompression does not produce pain relief purely by surgical trauma or manipulation of the nerve. Careful neurological examination with quantitative sensory testing has revealed that patients with hypoesthesia due to trauma do not benefit to a higher extent regarding pain-free intervals than patients without any postoperative sensory deficit. Not yet solved is the question whether pure removal of a vessel wall from the nerve will give some benefit due to removal of nerve cell membrane depolarizing or exciting mediators or whether a pure mechanical pressure plays the most important role. However, it is well-known in cases of recurrent pain that scar tissue or granulomas by the interposition material can also cause typical tic-like symptoms.

Several neurosurgeons were looking for alternatives to the technique of interpositioning some material between nerve and vessel as originally favored by Jannetta and were looking to separate the vessel from the nerve without causing any trauma and fixing the vessel to the dura [1–3]. This technique soon became popular by other neurosurgeons as well [4–6].

It is well-known to neurosurgeons that the so-called sling retraction technique can be challenging depending on the anatomical site, the size of the cistern and the vascular variability, and finally the characteristics of the involved vessel. Especially in cases with large vertebral or basilar, partially calcified, vessels, it can be even difficult to hold these vessels with a microdissector away, so everybody will be happy if some material could be placed between the offending vessel and the compromised neural structures. On the other hand, the actual paper by Masuoka et al. [7] gives invaluable surgical hints and details how to dislocate and stitch the vessels to the surrounding dura in “normal” anatomical cases. They nicely detail in a small series the stitching points in the tentorium for separating the SCA from the trigeminal nerve sparing the sinuses, separating the AICA in a caudolateral direction, when the compression of the trigeminal nerve comes from underneath and how to separate the AICA from the seventh nerve as well as the PICA from the glossopharyngeal nerve. Their technique is underlined by intraoperative photographs and anatomical sketches. One has, however, to keep in mind the enormous anatomical variability in these areas. Sometimes the AICA cannot be displaced without harming the labyrinthine artery or the PICA cannot be displaced because of kinking perforators. The use of stitches is preferable to glue which can cause compression or adhesion to adjacent structures and cause recurrent compression.

In summary, this paper is very instructive to think of theses neurovascular conflicts and their treatment in a systematic anatomical way which might be very helpful for surgeons not dealing regularly with these syndromes. The authors are to be congratulated for their highly didactic publication.

References

1. Fukushima T (1986) Surgery for hemifacial spasm (in Japanese). Clin Neurosci 4:584–585

2. Rawlinson JN, Coakham JB (1988) The treatment of hemifacial spasm by sling retraction. Br J Neurosurg 2:173–178

3. Sindou M, Amrani F, Mertens P (1990) Microsurgical vascular decompression in trigeminal neuralgia. Comparison of 2 technical modalities and physiopathologic deductions. A study of 120 cases (in French). Neurochirurgie 36:16–25

4. Melvill RL, Baxter BL (1996) A tentorial sling in microvascular decompression for trigeminal neuralgia. J Neurosurg 84:127–128

5. Suzuki S, Tsuchita T, Kurokawa Y et al (1990) New method of MVD using a vascular tape for neurovascular compression involving the vertebrobasilar artery. Neurol Med Chir 30:1020–1023

6. Matsushima T, Yamaguchi T, Inoue K et al (2000) Recurrent trigeminal neuralgia after microvascular decompression using an interposing technique. Teflon felt and the sling retraction technique. Acta Neurochir 142:557–561

7. Masuoka J, Matsushima T, Kawashima M (2011) Stitched sting retraction technique for microvascular decompression. Procedures and techniques based on an anatomical viewpoint. Neurosurg Rev doi:10.1007/s10143-011-0310-0

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Masuoka, J., Matsushima, T., Kawashima, M. et al. Stitched sling retraction technique for microvascular decompression: procedures and techniques based on an anatomical viewpoint. Neurosurg Rev 34, 373–380 (2011). https://doi.org/10.1007/s10143-011-0310-0

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