Franklin Lima1,2,3,4, Norberto Andaluz5,6,7,8,9, Lee A Zimmer1,2,3,4. 1. Departments of Neurosurgery, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA. 2. Departments of Otolaryngology Head and Neck Surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA. 3. Brain Tumor Center at UC Gardner Neuroscience Institute, Cincinnati, OH, USA. 4. Mayfield Clinic, Cincinnati, OH, USA. 5. Departments of Neurosurgery, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA. norberto.andaluz@louisville.edu. 6. Departments of Otolaryngology Head and Neck Surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, OH, USA. norberto.andaluz@louisville.edu. 7. Brain Tumor Center at UC Gardner Neuroscience Institute, Cincinnati, OH, USA. norberto.andaluz@louisville.edu. 8. Mayfield Clinic, Cincinnati, OH, USA. norberto.andaluz@louisville.edu. 9. Neurological Surgery, University of Louisville School of Medicine, Louisville, KY, 40202, USA. norberto.andaluz@louisville.edu.
Abstract
BACKGROUND: Surgical access to the second (V2, maxillary) and third (V3, mandibular) branches of the trigeminal nerve (V) has been classically through a transoral approach. Increasing expertise with endoscopic anatomy has achieved less invasive, more efficient access to skull base structures. The authors present a surgical technique using an endoscopic endonasal approach for the treatment of painful V2 neuropathy. METHODS: Endoscopic endonasal dissections using a transmaxillary approach were performed in four formalin-fixed cadaver heads to expose the V2 branch of the trigeminal nerve. Relevant surgical anatomy was evaluated and anatomic parameters for neurectomy were identified. RESULTS: Endoscopic endonasal transmaxillary approaches completed bilaterally to the pterygopalatine and pterygomaxillary fossae exposed the V2 branch where it emerged from the foramen rotundum. The anatomy defined for the location of neurectomy was determined to be the point where V2 emerged from the foramen rotundum into the pterygopalatine fossa. The technique was then performed in 3 patients with intractable painful V2 neuropathy. CONCLUSIONS: In our cadaveric study and clinical cases, the endoscopic endonasal approach to the pterygopalatine fossa achieved effective exposure and treatment of isolated V2 painful neuropathy. Important surgical steps to visualize the maxillary nerve and its branches and key landmarks of the pterygopalatine fossa are discussed. This minimally invasive approach appears to be a valid alternative for select patients with painful V2 trigeminal neuropathy.
BACKGROUND: Surgical access to the second (V2, maxillary) and third (V3, mandibular) branches of the trigeminal nerve (V) has been classically through a transoral approach. Increasing expertise with endoscopic anatomy has achieved less invasive, more efficient access to skull base structures. The authors present a surgical technique using an endoscopic endonasal approach for the treatment of painful V2 neuropathy. METHODS: Endoscopic endonasal dissections using a transmaxillary approach were performed in four formalin-fixed cadaver heads to expose the V2 branch of the trigeminal nerve. Relevant surgical anatomy was evaluated and anatomic parameters for neurectomy were identified. RESULTS: Endoscopic endonasal transmaxillary approaches completed bilaterally to the pterygopalatine and pterygomaxillary fossae exposed the V2 branch where it emerged from the foramen rotundum. The anatomy defined for the location of neurectomy was determined to be the point where V2 emerged from the foramen rotundum into the pterygopalatine fossa. The technique was then performed in 3 patients with intractable painful V2 neuropathy. CONCLUSIONS: In our cadaveric study and clinical cases, the endoscopic endonasal approach to the pterygopalatine fossa achieved effective exposure and treatment of isolated V2 painful neuropathy. Important surgical steps to visualize the maxillary nerve and its branches and key landmarks of the pterygopalatine fossa are discussed. This minimally invasive approach appears to be a valid alternative for select patients with painful V2 trigeminal neuropathy.
Authors: Yuanzhi Xu; Maximiliano Alberto Nunez; Ahmed Mohyeldin; Juan C Fernandez-Miranda; Aaron A Cohen-Gadol Journal: J Neurol Surg B Skull Base Date: 2021-12-14