Retrosigmoid approach for vestibular neurectomy in Meniere’s disease

Acta Neurochirurgica (Impact Factor: 1.55). 03/2005; 147(4):401-404. DOI: 10.1007/s00701-004-0431-0

ABSTRACT Background. Vestibular nerve section is considered to be the most effective surgical procedure to control intractable symptoms secondary to Menires disease (MD). This study was developed to analyze the adequacy of retrosigmoid vestibular neurectomy in terms of vertigo control, hearing preservation and clinical complications of this procedure.Methods. A retrospective review was carried out on 14 patients affected by definite unilateral MD who underwent vestibular neurectomy via the retrosigmoid approach.Findings. One patient was lost from follow-up; another one had only a short postoperative observation. At follow-up performed on 12 cases, no patients reported any crisis of acute vertigo. Four patients were free from any vestibular symptoms, while 8 reported some slight gait disturbances. Hearing function was preserved in 10 patients and improved in 2. 1 year postoperative vestibular function was absent at the side operated on and unchanged on the other side in all the cases.Conclusions. Vestibular neurectomy via the retrosigmoid approach can be considered a safe and effective procedure in relieving medically refractory vertigo in Menires disease, while preserving hearing.

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    ABSTRACT: Vestibular nerve sectioning is an accepted surgical treatment option for patients with medically refractory Ménière disease. In this paper the authors introduce and evaluate a 2-handed endoscopic-directed technique for vestibular nerve section. Eleven patients underwent a retrosigmoid craniectomy for endoscopic-directed vestibular nerve sectioning as treatment for intractable vertigo associated with Ménière disease. In all patients, identification and dissection of the cranial nerve VII/VIII complex was performed entirely under endoscopic guidance. The authors used the specially designed Frazee II neuroendoscope, consisting of a traditional endoscope lens with a microsuction attachment. Vestibular nerve sectioning was completed in all 11 patients. Postoperative improvement in vertiginous episodes was achieved in 10 patients (91%). Auditory function was noted to be worse postoperatively in only 1 patient (9%). The same patient also developed a House-Brackmann Grade III facial nerve palsy, which improved gradually over time. There were no further complications, including no delayed CSF leaks. The endoscopic-directed approach represents a safe and effective method for performing vestibular nerve sectioning. Until now, the endoscope has been used primarily as an adjunct to the operating microscope in surgery at the cerebellopontine angle. In addition, previous endoscopic techniques typically require a third hand to manipulate the endoscope. With the 2-handed endoscopic-directed technique, however, the endoscope is used as the primary means of visualization, and the unique design of this endoscope allows for a bimanual procedure without the requirement of a cosurgeon. Advantages of using this technique compared with the microscope include superior brightness at close distances, greater depth of field, increased maneuverability within small regions, and an improved ability to visualize objects not in a direct line of sight. Among other things, this allows for minimally invasive openings, decreased cerebellar retraction, and better identification of nerve cleavage planes and vascular anatomy.
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    ABSTRACT: Vestibular neurectomy is considered the reference treatment of incapacitating vertigo accompanying Meniere disease, with an efficiency rate of 85-95% in most literature reports. The aim of this study is to evaluate if vestibular neurectomy can provide a complete vestibular deafferentation by investigating complete vestibular function after surgery. Prospective study. Twenty-four patients suffering from incapacitated Meniere vertigo crisis beneficiated from a vestibular neurectomy by retrosigmoid approach. The average time between surgery and vestibular evaluation was 1 year. We performed (i) kinetic test, (ii) caloric test and (iii) vibration-induced nystagmus (VIN) at 30, 60 and 100Hz under videonystagmography recording, (iv) vestibular evoked myogenic potentials (VEMP), (v) video head impulsed test (VHIT) for each semicircular canals and (vi) an evaluation of visual vertical and horizontal subjective (VVS and HVS). On clinical evaluation, all the patients except one had never experienced any recurrence of vertigo crisis after surgery. The 24 patients would definitely undergo the surgery again. On vestibular evaluation, on the operated side, all patients showed a total areflexia at caloric test; 23 patients had no VEMP response; 23 patients had abolished canals response to VHIT. All the patients had VVS and HVS deviated towards the operated side; 23 patients had a high velocity VIN from 30 to 60Hz. This study proves that vestibular neurectomy can provide a complete vestibular deafferentation. We discuss this vestibular evaluation protocol and the main difficulties encounter during surgery, which could lead to partial nerve section and partial relief, and explain residual vestibular function after vestibular neurectomy.
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    ABSTRACT: The aim of this study was to evaluate the frequency of surgical approach in a population of patients affected by definite Menière's disease (MD). In the majority of patients, relief from vertigo attacks can be achieved by means of medical therapy (MT). In cases in which MT fails surgery may offer relief to vertigo. The most applied surgical procedures are intratympanic gentamicin (ITG) and vestibular neurectomy (VN), based on vestibular deafferentation. Until now, the real incidence of the different therapeutic approaches for MD has not been evaluated. The study design was a retrospective study. The study was performed in 177 patients affected by definite MD. Subjects referred directly for surgery by other centers were excluded from the study. All the patients were medically treated with salt restriction and diuretics. In case of MT failure, surgical therapy, ITG or retrosigmoid VN were proposed. In the 75% of cases, the only therapeutic approach was MT, while in 20% of cases we carried out ITG and in 5% VN. In 33% of VN group, this operation was carried out after ITG failure and in 67% as the first surgical approach. The VN group was characterized by younger age and higher disability degree. The primary therapy in definite MD seems to be MT. Ablative therapy represents the second choice: ITG was carried out in 80% of cases, while VN was performed in 20%.
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May 29, 2014