Procedure description

A craniotomy for microvascular decompression of the trigeminal nerve is done to treat trigeminal neuralgia.  Trigeminal neuralgia is characterized by severe spasmodic episodes of lancinating pain which travels to one side of the face.  Often it is related to an artery (the superior cerebellar artery) compressing the trigeminal nerve (5th cranial nerve which supplies sensation to the face) as it leaves the brainstem.  A vein may be responsible.  Surgery involves moving the artery off of the nerve, and placing a small ivalon sponge or a piece of teflon felt between the aftery and the nerve.  The surgeon will  close the dura, and may or may not elect to place a covering over the skull.  Possible options for skull replacement are the patient's own bone, surgical cement, methylmethacrylate ( a type of hardened plastic), or titanium mesh.   Next the scalp will be closed in layers.

Procedure Risks

Risks for craniotomy for microvascular decompression can be broken down into two categories, 1) those related to the operative site, and 2) those related to the risks of anesthesia. 

Risks related to the operative site: 

Surgical Exposure: The patient is placed in a position so as to allow the surgeon good access to back of the head, behind the ear. There is risk of non healing of the scalp  post operatively.  Although very uncommon, there can be injury to or tearing of the scalp from the pins on the Mayfield clamp. There is the potential for spinal fluid leak postoperatively, which may require additional surgery to repair.

Brain injury: The surgery involves opening the back of the skull behind the ear, and gently retracting the cerebellum ( back of the brain), to expose the fifth cranial nerve (trigeminal nerve) as it leaves the brainstem. There can be damage to the cerebellum, brainstem, and cranial nerves (nerves leaving the brainstem and providing functions such as hearing, facial movement, and facial sensation).  If there is any damage to the cranial nerves leaving the brainstem, there may be difficulty with facial sensation and movement, hearing, eye movement, swallowing, speech, and tongue movement.   If there is brain injury, this could result in weakness, seizures, stroke, paralysis, coma or death. There may be residual fluid or blood, requiring additional surgery in the future.  There is a possibility of facial pain recurring in the future.  Facial numbness may occur.  In addition, there could be a painful burning of the face which occurs in the future (this condition is known as anesthesia dolorosa). 

General Risks: These include  general difficulties, such as bleeding, infection, stroke, paralysis, coma and death. Incisions in the scalp generally heal well, but could become  tender, numb, or may heal in an unpleasant manner. The trigeminal neuralgia  may recur, requiring additional treatment in the future.  In addition, although every attempt is made to protect all areas of the body from pressure on nerves, skin and bones, injuries to these areas can occur, particularly with prolonged cases.

Risks of Anesthesia:
Blood clots in the legs, heart attacks, reaction to the anesthetic, reaction to blood transfusion, if given.

Post-operative care:

There is surprisingly relatively little pain associated with craniotomies.  Your surgeon will prescribe pain medications for any pain associated with the incision.

1. Immediately upon discharge, contact our office and set up an appointment for staple removal if one has not already been made.
   
2. Take it easy until seen by the physician.  This does not mean bed rest, but athletic activities during this period are definitely not recommended.  Please give your incision a chance to heal.  Avoid any type of activity which might risk a blow to the head.
   
3. You may resume activity as your body permits, but avoid extremes.  For example, walking is fine, but avoid any strenuous running.  USE GOOD JUDGMENT  AND COMMON SENSE.  If you have a question, ask your doctor.
   
4. No driving until cleared with your surgeon.  A driving test may be required, at the discretion of your surgeon.  Even though you may feel fine, your peripheral vision and reflexes may have been affected, and we want you to be safe on the road for yourself as well as for others.
   
5. You may shower after you go home unless otherwise instructed.  Cover the incision with plastic wrap before the shower and remove it afterward.  Change dressing immediately.    You may shower without covering the incision one week after the staples are out.  Follow instructions concerning care of tapestrips, stitches or staples.  Your surgeon or nurse clinician will explain the techniques used in the closure of your incision.
   
6. Sexual activities are permitted.
   
7. If you notice swelling, redness or opening of the incision, or if there is any clear fluid draining from it, please contact your surgeon immediately!  If you develop a fever, stiff neck or chills, contact the office immediately.  Take your temperature at 4:00 PM daily until the clips are removed.  Call if greater than 101 degrees Fahrenheit.
   
8. If you have a seizure, notify our office or come to the emergency room.
   
9. If you develop any new weakness, notify our office.
   
10. If you have any paralysis or weakness, post-operative care will need to be tailored to this.  If a brace for an arm of a leg has been prescribed, use it as recommended by your surgeon.
    
11. If you have any questions, call our office, and for after hours emergencies, call the medical society.
    
12. Take your medications prescribed on discharge, as directed.
    
13. Do not take any medications which will "thin the blood" such as coumadin or aspirin, or other non-steroidal antiinflammatory medications, unless otherwise advised by your physicians.
    
14. Make sure to follow up with any other physicians involved in your care.  These may include your family physician and  neurologist.