- Department of Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
- Department of Neuroradiology, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
Andres Humberto Morales-Martínez
Department of Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
DOI:10.4103/2152-7806.181824Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Rogelio Revuelta-Gutiérrez, Andres Humberto Morales-Martínez, Carolina Mejías-Soto, Jaime Jesús Martínez-Anda, Ortega-Porcayo LA. Microvascular decompression for glossopharyngeal neuralgia through a microasterional approach: A case series. Surg Neurol Int 05-May-2016;7:51
How to cite this URL: Rogelio Revuelta-Gutiérrez, Andres Humberto Morales-Martínez, Carolina Mejías-Soto, Jaime Jesús Martínez-Anda, Ortega-Porcayo LA. Microvascular decompression for glossopharyngeal neuralgia through a microasterional approach: A case series. Surg Neurol Int 05-May-2016;7:51. Available from: http://surgicalneurologyint.com/surgicalint_articles/microvascular-decompression-for-glossopharyngeal-neuralgia-through-a-microasterional-approach-a-case-series/
Background:Glossopharyngeal neuralgia (GPN) is an uncommon craniofacial pain syndrome. It is characterized by a sudden onset lancinating pain usually localized in the sensory distribution of the IX cranial nerve associated with excessive vagal outflow, which leads to bradycardia, hypotension, syncope, or cardiac arrest. This study aims to review our surgical experience performing microvascular decompression (MVD) in patients with GPN.
Methods:Over the last 20 years, 14 consecutive cases were diagnosed with GPN. MVD using a microasterional approach was performed in all patients. Demographic data, clinical presentation, surgical findings, clinical outcome, complications, and long-term follow-up were reviewed.
Results:The median age of onset was 58.7 years. The mean time from onset of symptoms to treatment was 8.8 years. Glossopharyngeal and vagus nerve compression was from the posterior inferior cerebellar artery in eleven cases (78.5%), vertebral artery in two cases (14.2%), and choroid plexus in one case (7.1%). Postoperative mean follow-up was 26 months (3–180 months). Pain analysis demonstrated long-term pain improvement of 114 ± 27.1 months and pain remission in 13 patients (92.9%) (P = 0.0001) two complications were documented, one patient had a cerebrospinal fluid leak, and another had bacterial meningitis. There was no surgical mortality.
Conclusions:GPN is a rare entity, and secondary causes should be discarded. MVD through a retractorless microasterional approach is a safe and effective technique. Our series demonstrated an excellent clinical outcome with pain remission in 92.9%.
Keywords: Glossopharyngeal nerve, microvascular decompression, neuralgia, neurovascular compression, vagus nerve
Glossopharyngeal neuralgia (GPN) is an uncommon craniofacial pain syndrome, representing 0.2–1.3%[
The first GPN description is attributed to Theodore H. Weisenburg in 1910.[
This study aims to review our surgical experience performing MVD using a microasterional approach in patients with GPN.
This study is a consecutive case series of 14 patients, who underwent MVD for the treatment of idiopathic GPN at the National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, in Mexico City, between 1994 and 2014. The senior author (Rogelio Revuelta-Gutiérrez) performed all the surgeries. A retrospective analysis of the clinical charts was performed. Patient data including gender, the age of onset, symptoms, previous medical management, operative findings, complications, and clinical outcome were collected. Pain intensity was graded according a three-grade scale: (1) No pain, no need for medication; (2) pain controlled with medical management; (3) pain not controlled with medication. All patients were previously managed with conservative treatment including carbamazepine, gabapentin, and pregabalin. No pain improvement for at least 6 months before surgical procedure was documented. Diagnosis work-up included a 3T magnetic resonance imaging (MRI). T1, T2, gadolinium-enhanced and FIESTA sequences were assessed to discard a secondary cause of the symptoms and identify vascular compression.
A statistical analysis was performed using SPSS Version 20 (IBM SPSS Statistics, New York, USA). Categorical variables were expressed as proportions and continuous variables were expressed using means and standard deviations. Clinical outcome was evaluated according to the surgical management, use of medications, pain recurrence, and postoperative complications. Descriptive statistics was performed for the patient data and the grade of pain preoperatively and postoperatively was analyzed using Wilcoxon signed-rank test. P < 0.05 was considered statistically significant.
Under general anesthesia patients were placed in park bench position with the head fixed in a Mayfield skull clamp. The upper shoulder was retracted, and the head was rotated 60° to the opposite side of the exposure with slight cervical lateral tilting (10°) toward the floor. A 5 cm retrosigmoid incision centered over the asterion was performed and a keyhole (2.5–3 cm) asterional craniectomy exposed the angle of the transverse and sigmoid sinuses [Figures
Glossopharyngeal microvascular decompression through a minimal invasive asterional approach. (a) Right microasterional approach (2.5–3 cm). (b) Durotomy exposing right cerebellar hemisphere, the base of the dural opening is reflected at the junction of the sigmoid and transverse sinus. (c) Cerebrospinal fluid drainage after arachnoid dissection allows proper visualization of the vertebral artery compressing the glossopharyngeal nerve. (d) A piece of Teflon is interposed between the affected nerve and the offending vessel
A total of 14 patients were diagnosed with GPN and were surgically treated [
The pain was more common on the left side (78.6%) compared to the right (21.4%). The primary location of the pain was pharyngeal in 13 cases (92.9%) and preauricular in one case (7.1%). Pain irradiation was referred in 6 cases (42.9%), 5 of them to the preauricular area and one to the pharynx. One patient (7.1%) presented with syncope and another one had an intraoperative vasovagal reflex during decompression.
Neuroradiological and operative findings
MRI showed vascular compression from the posterior inferior cerebellar artery (PICA) [
All 14 patients were contacted for long-term follow-up. Postoperative mean follow-up of was 26 months (3–180 months). All patients referred initial pain relief, and 13 were pain-free with no need of medication in the long-term follow-up. Only one patient referred pain 1 month after surgery and was treated with carbamazepine with complete relief of the pain and no further surgery was required. Pain analysis demonstrated long-term pain improvement of 114 ± 27.1 months and pain remission in 13 patients (92.9%) (P = 0.0001) [
Two patients presented complications related to surgical treatment. One patient presented with CSF leak, which resolved with lumbar drainage and acetazolamide 500 mg TID for 5 days without any complications. The second patient presented with meningitis and was treated with intravenous vancomycin 1 g. BID for 5 days recovering completely without clinical sequelae [
Wilfred Harris applied the term GPN when he described an entity similar to trigeminal neuralgia. At his initial report in 1937, Harris described two types of pathologies: Primary or idiopathic and secondary to carcinoma. Idiopathic GPN is explained due to nerve compression by a vessel, as it exits the medulla oblongata.[
Traditionally, a lateral suboccipital approach provides adequate exposure to the trigeminal, facial, and lower cranial nerves. Kawashima et al.[
In the MVD series, the overall surgical mortality is 1.1%. The rate of long-term pain remission is 84.7% with recurrence in 7%. Transient X cranial nerve dysfunction occurred in 13.2% and permanent deficits in 5.5%.[
Rey-Dios and Cohen-Gadol demonstrated in his analyses that the most effective surgical procedure to treat GPN is the MVD.[
It is important to rule out secondary causes such as neoplasm,[
As Lister et al.[
In refractory cases to MVD, we believe that sectioning the glossopharyngeal nerve and the upper roots of vagus nerve involved an unaccepted high morbidity. We advocate for compression of the glossopharyngeal and upper roots of the vagus nerve as a last option for pain recurrence as previously demonstrated for trigeminal neuralgia.[
Glossopharyngeal MVD through a retractorless microasterional approach is a safe technique in which surgical anatomical knowledge is essential to obtain good results with minimal morbidity. Our series demonstrate an excellent clinical outcome (pain remission - 92.9%) following MVD for GPN.
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Conflicts of interest
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