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. 2022 Mar 25:13:864061.
doi: 10.3389/fneur.2022.864061. eCollection 2022.

Microvascular Decompression for Trigeminal Neuralgia Caused by Venous Offending on the Ventral Side of the Root Entrance/Exit Zone: Classification and Management Strategy

Wenhua Wang  1 , Feng Yu  2 , Sze Chai Kwok  3   4   5 , Yuhai Wang  6 , Jia Yin  1
Affiliations

Microvascular Decompression for Trigeminal Neuralgia Caused by Venous Offending on the Ventral Side of the Root Entrance/Exit Zone: Classification and Management Strategy

Wenhua Wang et al. Front Neurol. .

Abstract

Background: Trigeminal neuralgia (TGN) is typically caused by an offending artery (OA) but may also involve an offending vein. Venous offending on the ventral side of the root entrance/exit zone (VO-VREZ) is particularly challenging.

Objective: To analyze the rate and pattern of VO-VREZ and propose management strategy accordingly.

Methods: VO-VREZ was classified into 3 types based on its anatomical relationship with a nerve root (A, the vein was covered by the nerve root entirely; B, the vein was lateral to the nerve root; and C, the vein penetrated the nerve root) and 3 groups based on the absence/presence of offending artery (I, no OA; II, suspected OA; and III, definitive OA).

Results: The analysis included 143 cases with complete follow-up. Type A, B, and C accounted for 11.9, 31.5, and 56.6% of the cases, respectively. Group I, II, and III accounted for 24.5, 26.6, and 49.0%, respectively. Most group I VO-VREZ cases (26 out of 31) were managed with coagulation followed by division. Most group II VO-VREZ cases (31 out of 38) were decompressed with shredded Teflon interposition. Group III VO-VREZ was left in place in all 70 cases. Immediate pain relief was achieved in all cases. Temporary hemifacial hypesthesia occurred in 21 patients (14.7%), among which 14 were managed with Teflon decompression. Within the 4.5-year median follow-up, pain recurred in 11 patients (7.7%), but all with lesser intensity.

Conclusion: VO-VREZ is not uncommon in patients with TGN. Different management strategy should be chosen according to the anatomical feature and the absence/presence of arterial conflict.

Keywords: microvascular decompression; offending artery; offending vein; root entrance/exit zone; trigeminal neuralgia.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Three types of venous offending on the ventral side of the root entrance/exit zone (VO-VREZ) based on anatomical relationship of the vein and the trigeminal nerve root entrance/exit zone. (A) The full route of the vein was covered by the root entrance/exit zone; (B) The vein went out laterally from the root; (C) The VO-VREZ ran through the root. TN, trigeminal nerve; BS, brain stem; VO-V, venous offending on the ventral side of root entrance/exit zone.
Figure 2
Figure 2
A representative case of typical group I, type A VO-VREZ. (A) The full route of the vein was covered by the nerve root entrance/exit zone. (B) The VO-VREZ was electrocoagulated. (C) The trace of VO-VREZ after electrocoagulation and division. TN, trigeminal nerve; VO-V, venous offending on the ventral side of root entrance/exit zone.
Figure 3
Figure 3
A representative case of group I, type B VO-VREZ with relatively large diameter. (A) The VO-VREZ was lateral to the nerve root. (B) The VO-VREZ was dissected. (C) The nerve root was decompressed with shredded Teflon interposition. TN, trigeminal nerve; VO-V, venous offending on the ventral side of root entrance/exit zone; Teflon, shredded Teflon interposition.
Figure 4
Figure 4
A representative case of typical group II, type B VO-VREZ. (A) The VO-VREZ was lateral to the nerve root and a suspected offending artery was found. (B) Decompression of the offending artery with shredded Teflon interposition. (C) Dissection and decompression of VO-VREZ with shredded Teflon interposition.TN, trigeminal nerve; VO-V, venous offending on the ventral side of root entrance/exit zone; OA, offending artery.
Figure 5
Figure 5
A representative case of group II, type A VO-VREZ. (A) The whole length of the vein was covered by the nerve root. (B) There was a suspected offending artery behind the trigeminal nerve. (C) The suspected offending artery was decompressed by a shredded Teflon interposition. VO-VREZ was electrocoagulated and then divided. TN, trigeminal nerve; VO-V, venous offending on the ventral side of root entrance/exit zone; Teflon, the shredded Teflon interposition.
Figure 6
Figure 6
A representative case of group III, type C VO-VREZ. (A) A definitive offending artery was identified. The small VO-VREZ ran through the trigeminal nerve root. (B) The offending artery was dissected. (C) The nerve root was decompressed from the artery with shredded Teflon interposition. The VO-VREZ was left alone. TN, trigeminal nerve; OA, offending artery; VO-V, venous offending on the ventral side of root entrance/exit zone; Teflon, shredded Teflon interposition.
Figure 7
Figure 7
Kaplan–Meier survival analysis. Pain recurred in 11 patients.
See this image and copyright information in PMC

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