Surgical treatment of trigeminal neuralgia - Home Study Program

AORN Journal,  Nov, 2003  by Cassi Brown

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The surgeon uses the microscope to open the dura, after which he or she drains the lateral cerebellomedullary cistern and gently places a retractor lateral to the eighth cranial nerve. The surgeon inspects the petrosal venous complex. If the veins are prominent, they must be cauterized and occluded. The surgeon opens the arachnoid membrane dorsal to the seventh and eighth nerves and continues the opening upward to the fourth nerve.

A retractor is placed just posterior to the root entry zone of the trigeminal nerve, dissecting the cerebellum away from the area. Compression of the nerve usually is caused by the superior cerebellar artery; however, other large arteries or small arterioles or veins that drain into the superior petrosal sinus near Meckel's cave also may cause compression. The surgeon mobilizes the entire compressive artery (Figure 3) and then places shredded pieces of polytetrafluorethylene felt between the artery and the nerve. Some surgeons, however, believe that placing felt may cause scarring, which could result in recurrence. Sometimes a 7-0 polypropylene suture is used to hang or sling the decompressed artery from the tentorium (Figure 4). If veins are causing compression, they are cauterized and divided. The trigeminal nerve must be thoroughly explored from Meckel's cave all the way to the root entry zone at the pons.

[FIGURES 3-4 OMITTED]

When decompression is believed to be complete, the circulating nurse attaches the light source and camera to the endoscope and defogs and white balances it. The surgeon uses 0[degrees] and 30[degrees], 2-mm endoscopes and can press a button on the hand control of the microscope to see the endoscopic view. The surgeon inspects the nerve on all sides, looking for other veins or arteries that might cause a problem.

The surgeon closes the dura, frequently with fibrin glue, to help prevent CSF leaks. The surgeon replaces the bone flap using screws and plates and a bone substitute, such as hydroxyapatite cement, to fill in defects. He or she closes the scalp, after which, the surgical team removes the patient from the neurosurgical stabilizing headrest and wraps the patient's head with antibiotic ointment, dressing sponges, and two to four woven cotton roll bandages in a standard head dressing.

POSTOPERATIVE CARE

The anesthesia care provider awakens and extubates the patient and removes the oral gastric tube. Surgical team members move the patient to a postoperative bed, with the head of the bed elevated 30[degrees] to 45[degrees]. The anesthesia care provider, circulating nurse, and surgeon transport the patient to the postanesthesia care unit (PACU). Patients who have undergone a MVD procedure generally remain in the PACU for several hours. Most patients awaken from anesthesia with their neuralgia gone. Nursing care of these patients is similar to that for any patient recovering from craniotomy and general anesthesia. The PACU nurse measures vital signs and performs neurological checks every 15 minutes times four and then 30 minutes times two. Neurological checks include