Craniotomy for decompression of cranial nerves
Anesthesia type




Lines and access

PIV ± Arterial line


Standard 5-lead ECG Temperature ± ABP

Primary anesthetic considerations

Cranial nerve exam Oxygen mask may exacerbate symptoms

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A craniotomy for decompression of cranial nerves is a surgical procedure used to relieve abnormal pressure on a cranial nerve from an artery or vein, which can alleviate symptoms of several cranial nerve disorders.



  • Trigeminal neuralgia
  • Hemifacial spasm
  • Geniculate neuralgia
  • Glossopharyngeal neuralgia

Surgical procedure

The procedure is performed through a small craniectomy behind the ear. Retractors are placed to expose the relevant nerves and vascular structures. Under microscopy, a small sponge is placed to separate the suspected blood vessel and nerve. In some circumstances, adherent veins may be cauterized or a rhizotomy may be performed. The dura is then closed and the craniectomy site is covered with a titanium plate.

Preoperative management

Patient evaluation

System Considerations
Airway Airway exam may be limited by neurologic symptoms
Neurologic Cranial nerve exam to identify symptoms and exacerbating factors

Labs and studies

  • BMP
  • CBC

Patient preparation and premedication

  • Consider preoperative multimodal analgesia
  • Continue home regimen of neuropathic agents

Intraoperative management

Monitoring and access

  • Noninvasive blood pressure monitoring is typically sufficient[1]
  • Intraoperative neuromonitoring may be used

Induction and airway management

  • Oxygen mask may exacerbate neuralgia symptoms
  • For glossopharyngeal neuralgia, if neuromonitoring, will require a neuromonitoring endotracheal tube
    • Consider video laryngoscopy to ensure correct electrode placement across vocal cords


  • Pinned frame

Maintenance and surgical considerations

  • Consider hyperventilation and/or mannitol to reduce intracranial volume to improve surgical conditions


Postoperative management


  • Typically PACU

Pain management

  • Resume home regimen of neuropathic agents

Potential complications

  • Nerve injury
  • Vascular injury/hemorrhage


  1. Xu, Risheng; Nair, Sumil K.; Materi, Josh; Raj, Divyaansh; Medikonda, Ravi; Shah, Pavan P.; Kannapadi, Nivedha V.; Wang, Andrew; Mintz, David; Gottschalk, Allan; Antonik, Laurie J. (2022-05-01). "Case Series in the Utility of Invasive Blood Pressure Monitoring in Microvascular Decompression". Operative Neurosurgery (Hagerstown, Md.). 22 (5): 262–268. doi:10.1227/ons.0000000000000130. ISSN 2332-4260. PMID 35315836 Check |pmid= value (help).