Trigeminal Neuralgia: A Minimally Invasive, Endoscopic "Keyhole Approach" for Neurovascular Compression Syndromes

The endoscopic approach is being performed at the Skull Base Institute to surgically treat trigeminal neuralgia, utilizing the most highly advanced and minimally invasive techniques available. Trigeminal Neuralgia is universally acknowledged as the most painful affliction known to adult men and women and affects thousands of Americans each year. The episodes of intense, stabbing, electric shock-like facial pain are caused when a blood vessel comes in contact with the fifth cranial (trigeminal) nerve, applying pressure to the nerve. Patients with neurovascular problems such as trigeminal neuralgia, hemifacial spasm, intractable vertigo and spasmodic torticollis benefit tremendously from the Skull Base Institute's innovative endoscopic "keyhole" approach to these disorders and spend less down time, with fewer complications.

At the Skull Base Institute, Hrayr Shahinian, M.D., performs this delicate microvascular decompression procedure through a dime-size keyhole opening behind the ear. Through this opening, he inserts a 2.7 mm endoscope. Dr. Hrayr K. Shahinian can then identify the problem and perform the surgery - meticulously separating the nerve and blood vessel, and inserting a Teflon disk between them. Once the pressure has been relieved, patients usually report immediate and complete relief from the pain. In many cases, the endoscopic "keyhole" surgery for trigeminal neuralgia is the preferred approach over traditional methods, in which metal retractors and instruments are inserted through a much larger opening behind the ear, and the brain is pushed aside to reach the nerve compression area.

Since the introduction of the minimally invasive, endoscopic “keyhole” approach, numerous presentations have been made nationally and internationally to both colleagues in the field and patients suffering from neurovascular compression syndromes, such as Trigeminal Neuralgia. Video tapes of the procedure have been requested by both the National Trigeminal Neuralgia Association and several of their regional support groups. These videos can also be viewed on the Skull Base Institute website in the dedicated Trigeminal Neuralgia treatment section.

Pituitary Tumor: Endoscopic Procedure Revolutionizes Pituitary Surgery at the Skull Base Institute

One of the most extraordinary advances pioneered at the Skull Base Institute is the minimally invasive, fully endoscopic approach to treating pituitary tumors and other skull base disorders. This innovative procedure utilizes a tiny endoscope - 2.7 mm wide and 20 cm long - with an angled tip that is inserted through the nostril and into the skull base. This next-generation surgical approach to treating pituitary tumors offers numerous advantages in terms of decreased complications and recovery period.

First, because the camera is positioned at the tip of the endoscope, Dr. Shahinian has a vivid panoramic view of the brain. He can look around corners and make a full visual assessment. This panoramic view also provides Dr. Hrayr Shahinian with the ability to remove the entire pituitary tumor, in most cases. The process is in sharp contrast to the traditional approach that requires viewing the tumor site through a microscope outside of the skull, which extensively limits visibility.

The point of entry for the Skull Base Institute’s minimally invasive, fully endoscopic pituitary surgery is through a nostril, so no incision is required. Consequently, there is no scarring, no nasal packing, and the brain is undisturbed. The time required for the actual surgical procedure, the length of hospital stay and overall recovery time are dramatically reduced. Patients return home within 24 hours of surgery, and return to work and normal activities within a week. Since the minimally invasive, endoscopic approach to pituitary tumors started at the Skull Base Institute in 1994, numerous presentations have been made nationally and internationally to both colleagues and patients suffering from pituitary tumors. Articles, videos and 3-D animations of the procedure have been requested by the world-renowned Pituitary Network Association, several of their regional support groups and major media outlets such as CNN and the Ellen DeGeneres Show. This information can also be viewed on the Skull Base Institute website in the dedicated Pituitary Tumor treatment section.

BOOK CHAPTERS excerpt (click to category)

Pituitary Surgery: The Evolution from Open Transcranial to Fully Endoscopic Transnasal Surgery, and Beyond
By Mohamed S. Kabil, M.D. and Hrayr K. Shahinian, M.D.

Fully Endoscopic Pituitary Surgery

With the advent of modern endoscopic equipment, momentum in the field of endoscopic pituitary surgery has stemmed from studies, which show endoscopes provide more comprehensive images of the pituitary gland and its surrounding structures than does the operating microscope.^38,52 This in turn should allow for a more thorough tumor resection and fewer associated surgical complications.

The clinical implications of these findings have been reflected in two separate studies of patients who underwent endoscope-assisted microscopic resections of pituitary tumors.^15,47,52,53 These patients underwent a traditional microscopic transseptal-transsphenoidal approach to their pituitary gland tumor. Then, following what the surgeon believed to be complete tumor resection using the microscope, endoscopes were introduced into the pituitary region looking for residual tumor. In both series, an average of 40% of patients were found to have tumor left behind that was only discovered and resected during the endoscopic surveys. In other words, the microscope alone allowed for complete tumor removal in only 60% of patients.

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CLINICAL STUDIES excerpt (click to category)

The Changing Face of Cushing's Syndrome: Mild and Periodic Cases Makes the Diagnosis More Difficult
By Theodore C. Friedman, M.D., PhD, Erik Zuckerbraun M.D., Kimberly Daigle, Hrayr Shahinian, M.D., FACS

Additional Challenges of Cushing’s Syndrome

Many of the articles on Cushing's syndrome have examined patients with sustained and severe hypercortisolemia. Because CBG limits the amount of free cortisol (F) in circulation as F production increases, many of the tests used to diagnose Cushing's syndrome, such as UFC or night-time salivary cortisol may not detect a mild increase in F production. Furthermore, the periodic nature of Cushing's syndrome may lead to a normal measurement of F status when a patient is tested during a quiescent phase. Therefore, we determined the usefulness of several tests when performed on multiple occasions in consecutive patients with mild and/or periodic Cushing's syndrome.

Conclusion
We conclude that the great majority of patients presenting to this tertiary Endocrinology clinic had periodic Cushing's syndrome as evident by normal testing on 1 or more occasions. Urinary 17-OHS was at least as sensitive as the more widely used test, UFC. We conclude that there is no single test that can always diagnose Cushing's syndrome and that the diagnosis needs to be made by a careful history and physical coupled with multiple tests assessing hypercortisolism.

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REVIEW ARTICLES excerpt (click to category)

527 Fully Endoscopic Resections of Vestibular Schwannomas
By H. K. Shahinian , Y. Ra

Fully Endoscopic Acoustic Neuroma Surgery

Abstract: Background
We report a series of 527 patients with unilateral vestibular schwannomas (VS) who underwent fully endoscopic resection of their tumors during the period of October, 2001 to July, 2010. Patients ’ outcomes were evaluated, with specific regard to hearing preservation, facial nerve function, postoperative complications and completeness of the resection.

Results
Utilizing the fully endoscopic technique, 94% of tumors were completely removed; subtotal removal was performed in 6% of patients in an attempt to preserve their hearing. Anatomic preservation of the facial nerve was achieved in all of the patients. Functionally, measurable hearing (serviceable / some) was preserved in 57% of cases that had either "serviceable" or "some" hearing pre-operatively. There were no major neurological complications such as quadriparesis, hemiparesis, bacterial or aseptic meningitis, permanent lower cranial nerve deficits, or deaths.

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REVIEW ARTICLES excerpt (click to category)

Endoscopic Vascular Decompression vs. Microvascular Decompression of The Trigeminal Nerve
By Kabil M, Eby J, Shahinian HK

Fully Endoscopic Surgery for Trigeminal Neuralgia

From September 1999 till October 2004, 255 patients underwent endoscopic vascular decompression of the trigeminal nerve. These patients' records were retrospectively reviewed, and additional data from follow-up visits was collected and analyzed to ascertain success rates and review the incidence of complications.

From a total of 255 patients who underwent Endoscopic Vascular Decompression (EVD) of the trigeminal nerve we noted an initial, complete, postoperative success rate in 95% of patients. Initial, being defined as within the first 3 months postoperative, and "complete" being judged if the patient reported 98% relief of pain postoperatively without the need for medication (Barker's classification). Additionally, we documented a 93% complete success rate for 118 patients who completed at least a three-year follow-up period. Complication rates were compared to those reported for MVD. There were no serious complications or mortality in this series.

We conclude that EVD is a safe and effective method to remove neuro-vascular conflicts related to the trigeminal nerve. The results of this series demonstrate an improved rate of trigeminal neuralgia relief with EVD when compared to MVD, a lower incidence of complications and a better outcome.

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