What is the role of MVD in the treatment of trigeminal neuralgia (TN)?

Updated: Sep 30, 2019
  • Author: Kim J Burchiel, MD, FACS; Chief Editor: Brian H Kopell, MD  more...
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Answer

Answer

MVD is the classic surgical procedure for TN, and the most effective one. Its rationale is based on the hypothesis that compression from vessels in the vicinity of the trigeminal nerve leads to abnormal nerve activity. Usually, it requires the demonstration of true contact and compression by the artery on the nerve (neurovascular compression [NVC]) , but some series report almost equally good results without any demonstrated abnormality on imaging or even frank compression shown preoperatively.

NVC can now be imaged preoperatively using MRI and MRA scans, fused into one 3-dimensional image volume (see video below). The fidelity of this type of imaging and intraoperative findings of NVC is high (96% sensitive). [19]

Preoperative 3-dimensional MRA/MRI on a trigeminal neuralgia showing neurovascular compression.

This video shows the 3-dimensional MRA/MRI on a TN patient whose intraoperative video shows identical NVC to that predicted by the preoperative imaging. This video also shows the microvascular decompression of the nerve and placement of Teflon "cotton" between the nerve and artery.

Intraoperative video of the patient whose MRA/MRI is shown above documenting neurovascular compression of the trigeminal nerve and microvascular decompression using Teflon felt interposed between the nerve and vessel.

MVD is commonly performed in younger, healthier patients, especially those with pain isolated to the ophthalmic division or in all 3 divisions of the trigeminal nerve and in those with secondary TN. It is now the most common surgical procedure performed for TN.

In MVD, the skin is incised behind the ear and a 3-cm craniotomy performed. The dura is retracted to expose the trigeminal nerve, and the vascular elements compressing the nerve as it enters the pons are identified. Teflon felt is then used to pad the nerve away from the offending artery or vein. Patients spend 3–4 days in the hospital and another week convalescing at home. Thus, recovery is more prolonged than with percutaneous procedures.

Large series have been published, and the initial efficacy is greater than 80%. The recurrence rates after MVD, compared with those after other invasive treatments, are among the lowest (20% at 1 y, 25% at 5 y). [20, 6]

Complications include chemical meningitis, ipsilateral hearing loss, and facial sensory loss or palsy. Mortality rates in experienced centers are less than 0.5%. Mortality for MVD approaches 0.5%. Serious morbidity includes dizziness, temporary facial palsy, cerebrospinal fluid leaks, meningitis, cerebellar stroke, and hearing loss, which may occur in 1-5% of cases.


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