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S005: ADOPTING KEYHOLE STRATEGIES IN MICROVASCULAR DECOMPRESSION SURGERY FOR VASCULAR COMPRESSION SYNDROMES IN EARLY CAREER ACADEMIC PRACTICE: OUTCOMES, TECHNICAL NUANCES AND COMPLICATION AVOIDANCE
Mehdi Khaleghi, MD; Adnan Shahid; Asa Barnett; Garrett Dyess; Brandon Kaye; Ursula Hummel; Jai Thakur; University of South Alabama

Introduction: Failure and complications in microvascular decompression are directly related to suboptimal visualization and neurovascular retraction.

Objective: To present the outcome of keyhole microvascular decompression (KMVD) for various vascular compression syndromes in early academic practice.

Methods: The surgical outcome was assessed, considering the modified BNI pain scores I-II in trigeminal neuralgia (TN) and Sekula grades I-II in hemifacial spasm (HS) as favorable outcomes. The impact of suprameatal drilling (SMD) and the learning curve stage on TN outcomes was investigated. Log-ranked Kaplan-Meier survival curves were used to compare long-term medication-free TN outcomes.

Results: Over 53 months, 36 KMVDs were performed on 29 TN, 6 HS, and one glossopharyngeal neuralgia (GN) patient. Median age was 58 years. 73.1% of TN cases had Burchiel type I pain. A failed SRS was noted in 24.1% of TN cases, of whom one had two prior MVDs. Mean craniectomy size was 2.03±0.31cm. Common offenders were the superior cerebellar artery (SCA, 34.5%) and SCA-SPV (24.1%) in TN and the anterior inferior cerebellar artery (AICA, 50%) in HS. Trigeminal nerve deformity was noted in 27.6% of TN cases intraoperatively. Vessel handling in TN included interposition (55.2%), transposition (31%), or both (13.8%), while an interposition was used for 50% of HS and the only GN patient. Partial neurolysis was performed in 34.5% of TN cases and aggressive interfascicular neurolysis in 17.2%. In HS, four patients showed complete lateral spread disappearance. Median hospital stay was 3 days, and no complications occurred except hearing loss in the GN patient. At 2 weeks post-surgery, BNI pain scores were I in 34.4% and II in 6.9%, improving to 48.1% and 7.4% at the last follow-up. During a median follow-up of 21 months, KMVD failed in 6.9% of TN cases. Favorable HS outcomes were achieved in 83.3% at a 2-week and 100% in the long-term. Superior petrosal vein (SPV) was preserved in all TN cases, with 17.2% requiring SMD. A need for SMD was significantly associated with worse short-term outcomes (odds:2,CI 1.34-2.98,p=0.039). Kaplan-Meier analysis showed significantly lower long-term medication-free outcomes in cases requiring SMD (p<0.001) and the second half of the learning curve (p<0.001). The only significant difference was lower Burchiel type I TN in the second half (44.4% vs. 100%,p=0.004).

Conclusions: No neuronavigation needed, shorter stays, and avoiding readmissions reduced costs and improved quality of life in early-year practice of endoscopic-assisted KMVD, with acceptable symptom-free outcomes achieved. SPV preservation and selective SMD addressed complex NVCs, although optimal medication-free outcomes warrant considering the pain type and petrous bone topography.

 

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