Resection of the suprameatal tubercle in microvascular decompression for trigeminal neuralgia

Background The suprameatal tubercle (SMT) may obscure the neurovascular compression (NVC) in microvascular decompression (MVD) for trigeminal neuralgia (TGN). The aim of this study is to address the necessity of resecting SMT in MVD for TGN. Methods We retrospectively analyzed radiological findings of 461 MVDs in patients with TGN, focusing on the relation between SMT and the NVC site. Three-dimensional (3D) images were used for preoperative evaluation. The NVC sites were obscured by SMT in 48 patients (10.4%) via the retrosigmoid approach. This study was conducted to review the management of SMT among these patients. Resection of SMT was performed in 8 patients (resected group) for direct visualization of the NVC site. On the other hand, nerve decompression was achieved without resecting SMT for the rest of the 40 patients (non-resected group). Biographical data, radiological findings, intraoperative findings, and surgical outcomes were retrospectively evaluated. Results The mean height of SMT obscuring NVC was 5.0 mm (2.8-13.9 mm) above the petrous surface. The NVC was located at a mean of 1.9 mm (0-5.9 mm) from the porous trigeminus. The most common offending vessel was the superior cerebellar artery (SCA, 56.3%), followed by the transverse pontine vein (TPV, 29.2%). In the resected group, the transposing culprit vessels were feasibly performed after direct visualization of the NVC site, whereas in the non-resected group, the SCA was successfully transposed using curved instruments after thorough dissection around the nerve. TPV having contact with the nerve was coagulated and divided. Immediate pain relief was obtained in all patients except one who experienced delayed pain relief 1 month after surgery. Facial numbness at discharge was noted in 9 patients (18.8%); thereafter, numbness diminished over time. Numbness at the final visit was observed in 5 patients (10.4%) at mean of 49 months after MVD. Recurrent pain occurred in 4 patients (8.3%) in total. Statistical analysis showed no significant differences in surgical outcomes between both groups. Conclusions Direct visualization of the NVC site by resecting the SMT does not affect surgical outcomes in the immediate and long term. Resecting the SMT is not always necessary to accomplish nerve decompression in most cases by use of suitable instruments and techniques.