Craniotomy for decompression of cranial nerves

Craniotomy for decompression of cranial nerves

Anesthesia type	General
Airway	ETT
Lines and access	PIV ± Arterial line
Monitors	Standard 5-lead ECG Temperature ± ABP
Primary anesthetic considerations
Preoperative	Cranial nerve exam Oxygen mask may exacerbate symptoms
Intraoperative
Postoperative
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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.

Overview

Indications

• 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
• 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

Positioning

• Pinned frame

Maintenance and surgical considerations

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

Postoperative management

Disposition

• Typically PACU

Pain management

• Resume home regimen of neuropathic agents

Potential complications

• Nerve injury
• Vascular injury/hemorrhage