BACKGROUND: The cranial nerve (CN) V and adjacent neurovascular structures are crucial landmarks in microvascular decompression (MVD). MVD of CN V is the most effective treatment for patients with drug-resistant trigeminal neuralgia (TN) diagnosis. The endoscope-assisted retrosigmoid approach (RSA) provides better exposure and less cerebellar retraction in the corridor towards the cerebellopontine angle (CPA). METHODS: Five adult cadaver heads (10 sides) underwent dissection of the MVD in park bench position. MVD was simulated using microsurgical RSA, and the anatomical landmarks were defined. Microsurgical dissections were additionally performed along the endoscopic surgical path. Additionally, we present an illustrative case with TN caused by anterior inferior cerebellar artery (AICA) compression. The CN V and its close relationships were demonstrated. Endoscopic and microscopic three-dimensional pictures were obtained. RESULTS: This study increases the anatomical and surgical orientation for CN V and surrounding structures. The CN V arises from the lateral part of the pons and runs obliquely upward toward the petrous apex. It has motor roots that leave from pons antero-supero-medial direction to the sensory root. The endoscopic instruments provide perfect visualization with minimal cerebellar retraction during MVD. CONCLUSION: MVD surgically targets the offending vessel(s) leading to TN and aims to create a disconnected area. The combination of preoperative radiographic assessment with and anatomical correlation provides safe and effective application while facilitating selection of the most appropriate approach. The RSA allows satisfactory visualization for CN V. Endoscope-assisted microsurgery through the CPA is a challenge, it should be performed with advanced anatomical knowledge.

Antalya Ataturk State Hospital Department of Neurosurgery Antalya Turkey

Cleveland Clinic Abu Dhabi Neurological Institute Department of Neurosurgery Abu Dhabi UAE

Eberhard Karls University of Tübingen Department of Neurosurgery Tubingen Germany

Elbistan State Hospital Department of Neurosurgery Kahramanmaras Turkey

Izmir City Hospital Department of Neurosurgery Izmir Turkey

University Hospital San Juan de Dios Department of Neurosurgery Armenia Quindio Colombia

University of Health Sciences Izmir Faculty of Medicine Department of Neurosurgery Izmir Turkey

University of Minnesota Department of Neurosurgery Neuroanatomy Laboratory Minnesota USA

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