Trigeminal root massage in microsurgical treatment of trigeminal neuralgia patients without arterial compression: When, how and why

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array:2 [ "nombre" => "Ana Isabel" "apellidos" => "Herrero-Gutiérrez" ] 7 => array:2 [ "nombre" => "Antonio" "apellidos" => "Rodríguez-Salazar" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147319300946?idApp=UINPBA00004B" "url" => "/11301473/0000003100000002/v1_202003040704/S1130147319300946/v1_202003040704/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Clinical Research" "titulo" => "Trigeminal root massage in microsurgical treatment of trigeminal neuralgia patients without arterial compression: When, how and why" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "53" "paginaFinal" => "63" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Enrique Urculo, Alejandro Elua, Mariano Arrazola, Patricia Torres, Sergio Torres, Jose Undabeitia" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Enrique" "apellidos" => "Urculo" "email" => array:1 [ 0 => "ENRIQUE.URCULOBARENO@osakidetza.eus" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Alejandro" "apellidos" => "Elua" ] 2 => array:2 [ "nombre" => "Mariano" "apellidos" => "Arrazola" ] 3 => array:2 [ "nombre" => "Patricia" "apellidos" => "Torres" ] 4 => array:2 [ "nombre" => "Sergio" "apellidos" => "Torres" ] 5 => array:2 [ "nombre" => "Jose" "apellidos" => "Undabeitia" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Masaje de la raíz trigeminal en el tratamiento quirúrgico de la neuralgia de trigémino sin contacto neurovascular arterial: cuándo, cómo y porqué" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1838 "Ancho" => 2500 "Tamanyo" => 246638 ] ] "descripcion" => array:1 [ "en" => "Case 2. Operative photos (from videoclip). After arachnoidal dissection a sSPVS grade I interposing the direct vision of V nerve. (B) Vein coagulation and dividing. (C) TRM maneuver. (D) Final vision of the field." ] ] ] "textoCompleto" => "Introductionwith classical trigeminal neuralgia, the microvascular decompression (MVD) of the trigeminal nerve by suboccipital route (colloquially known as Jannetta's technique), is actually the best surgical alternative after the failure of conservative treatment or other percutaneous and radiosurgical procedures. MVD surgery has become accepted as potencially curative for trigeminal neuralgia (TN) and might be considered as the first treatment choice in which is compared to the rest of surgical options. This is one of the most attractive surgical techniques for neurosurgeons and patients for many different reasons: for the neurosurgeon because it is an elegant anatomical form of microsurgery, where we have learned the arachnoid and vascular microdissection of the cerebellopontine angle in normal anatomical situation, and it is the only nondestructive procedure in trigeminal neuralgia surgery, and for the patients because they have good results and little recurrence of pain; which results in patient satisfaction after MVD.<a class="elsevierStyleCrossRefs" href="#bib0215">1–3</a>There are different degrees of severity compression and many possibilities of neurovascular conflict affecting the trigeminal root: one or more arteries alone or in combination with a vein or veins has been reported to be the main cause in most cases of trigeminal neuralgia, in which the existence of a marked cross-compression on the root correlates with a high percentage of cure and better outcome after microvascular decompression.<a class="elsevierStyleCrossRef" href="#bib0230">4</a> The vessel most commonly responsible for nerve compression is an arterial loop of the superior cerebellar artery and anterior–inferior cerebellar artery on its own or in combination with vein(s) affluent to the superior petrosal venous system (SPVS). However, the categorization of the patients without unequivocal arterial contact is somewhat problematic, an exclusively venous compression by one or more veins has been demonstrated to be responsible in up to 15% of TN, but the intraoperative management options in cases without trigeminal arterial compression has not been established and remains a matter of debate.<a class="elsevierStyleCrossRefs" href="#bib0235">5–8</a>During the microsurgical exploration of the trigeminal root in the superior cerebellar-pontine cistern, our job is to find any cause of trigeminal root compression, especially to find the artery or arteries compressing the trigeminal nerve in its cisternal trajectory and separate the offending vessel from the trigeminal root in order to relieve pulsatile vascular transmission on the nerve to assure true trigeminal microvascular decompression. But if after a meticulous microscopically dissection from the root entry zone at the pons to the porus trigemini, any arterial compression to the trigeminal root is found, except some vein or non venous contact, the surgeon is in an engaged situation, with the decision to continue the procedure or not. In absence of evident arterial conflict, there are some options in these cases: the most frequent used is the partial sensory rhizotomy,<a class="elsevierStyleCrossRef" href="#bib0255">9</a> and other accepted possibilities have been described such as internal neurolysis.<a class="elsevierStyleCrossRef" href="#bib0260">10</a>So, in such special cases without any vascular contact or with only venous contact (3.8% and 15.38% respectively of our total MVD cases), after arachnoid trigeminal liberation and compressive vein coagulation and section, we apply a slight gentle intermittent compressive massage along the length of the trigeminal root with the microforceps or the microdissector, which we call trigeminal root massage (TRM). The main objective of this article is to describe the TRM technique and its results during the microsurgical exploration of the trigeminal root, in patients with primary trigeminal neuralgia without an evident arterial compression. Furthermore, we also reviewed the literature and discussed the possible mechanisms and surgical strategies for those patients.Patients and methodsPatient characteristicsThe diagnosis of classical TN was made through patients records according to the International Headache Society, whether the neuralgia was purely paroxysmal (typical TN) or with concomitant continuous pain (atypical TN). All patients who underwent posterior fossa exploration have at least 2 years of proved refractory to or intolerance to of the usual medical therapies for TN such as carbamazepine, phenytoin, baclofen, gabapentin or other drugs used either alone or in various combinations and sent to us for the neurologist after failed medical treatment. We prefer to operate the patients in phase of trigeminal pain attacks, avoiding surgery in periods of remission. The senior author (EU) has operated at the Donostia University Hospital and Policlinica Gipuzkoa on 52 patients for primary trigeminal neuralgia by microsurgical suboccipital exploration as described by Jannetta<a class="elsevierStyleCrossRef" href="#bib0265">11</a> and Sindou.<a class="elsevierStyleCrossRef" href="#bib0270">12</a> All patients underwent preoperative CT Scan and magnetic resonance imaging (MRI). In 42 patients we found an artery as the major offending vessel, specially the superior cerebellar artery. During the surgical exploration, venous contact without arterial compression was noted in 8 (15.38%) cases and no offending vessel in 2, all of them were included in this study.This is a retrospective analysis of the 10 consecutive patients without a visible microsurgical trigeminal arterial contact in which we applied the technique of trigeminal root arachnoidal liberation, venous cut and divided if needed, and massage without interposition of any implant material.The clinical characteristics of the patients are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. No patient had multiple sclerosis.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Surgical techniqueBasically we performed microsurgical exploration of the trigeminal root in two different positions: semisitting and supine with the affected side up, shoulder elevation, head rotation to the opposite side and chin flexed. Sometimes we used intraoperative neuromonitoring: facial nerve electromyography and brainstem auditory evoked potentials (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). We utilize the conventional retrosigmoid approach described by Jannetta<a class="elsevierStyleCrossRef" href="#bib0275">13</a> and Samii, with some personal modifications. A linear or slightly curved skin incision extending superiorly 2cm behind the pinna, passing through the asterion and terminating 2cm medial to the mastoid tip. Mannitol is administered intravenously at the time of the skin incision. The burr hole is made in the asterion, and then a 2–3-cm retromastoid craniectomy or sometimes craniotomy toward the transvers and sigmoid sinus and the squamous part of the occipital bone. A high-speed diamond drill is used to expose the borders of the transvers sinus, the superolateral corner of the transverse-sigmoid sinuses, and the sigmoid sinus. Bone wax is used to pack the mastoid air cells and the emissary vein. The dura is opened under magnification using an operating microscope in a C-shape, some millimeters medially along the transverse and sigmoid sinus, followed by opening the cerebellomedulary cistern; CSF is withdrawn until cerebellar relaxation is achieved. Through the supracerebellar-infratentorial route we reach the petrotentorial corner to gain access to the trigeminal root entry zone (TREZ). During the approach we try to preserve the superficial petrosal vein, but it was coagulated and divided when it clearly participates in compressive neurocontact or when it riskily obstructs the lane to widen exposure to the trigeminal root. The arachnoid overlying the superior pontocerebellar cistern was fully opened, the fifth nerve was exposed, the vein was coagulated and divided; finishing the operation applying a slight gentle intermittent compressive massage along the length of the trigeminal root with the microforceps or the microdissector, which we call trigeminal root massage (TRM), without interposing any material (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). As important as the surgical opening and microsurgical procedure, an exquisite closure technique to avoid postoperative complications is mandatory. Hemostasis is achieved with the utmost care. At the end of the procedure, jugular vein compression is performed by the anesthesiologist to search for possible venous bleeding and to confirm a clean surgical field. The dura is closed in a watertight fashion with sutures and epidural sealant. The mastoid cells are covered with muscle and fibrin glue. Cranioplasty is performed with the bone chips taken from the craniectomy and mixed with fibrin glue molding it to the cranial contour. The neck muscles are sutured back, respecting the anatomical layers. No drains are used. A compressive bandage is used after the skin closure. We routinely perform a postoperative CT scan during the day after surgery on all patients operated on cerebellopontine angle, independently of its type, and emergently when recovery from anesthesia was delayed or when the patient's condition deteriorated.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Anatomical observations and surgical findingsThe two principal intraoperative findings in this series of ten patients without arterial contact were venous or/and thick arachnoid adhesions involved in root compression. We have adopted the Sindou classifications for both the petrosal venous systems and the degrees of compression to the trigeminal root: grade I is a simple but clear contact, grade II for displacement or distorsion, and grade III in cases of marked grooving in the root with a more or less focal demyelination under the form of a grayish aspect.<a class="elsevierStyleCrossRef" href="#bib0280">14</a>8 of our cases had a pure venous conflict, one of grade III, 3 grade II and 4 grade I. We found conflicting veins either of the superficial superior petrosal vein system (sSPVS) in 7 cases and/or of the deep superior petrosal vein system (dSPVS) in three cases. Only in 2 patients we found no clear vascular contact and, after arachnoid decompression, we finished surgery with TRM in both cases (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>5 cases presented with thick arachnoidal membrane, more or less adherent to the V nerve, 4 cases with some compressive veins that we coagulated and then cut. As in our case 1: After thick arachnoidal section we expose a venous grade III TR compression, which was coagulated and divided, observing finally the trigeminal indentation as a collar around the TR and its grayish color (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Sometimes we can find a prominent suprameatal petrous bone obscuring the vision of the porus trigemini. This part of the petrous bone was called suprameatal tubercle by Rhoton,<a class="elsevierStyleCrossRef" href="#bib0285">15</a> which blocks the view of the Meckel's segment of the trigeminal root, and can be drilled away if needed to enlarge access to this part of the nerve, which increases the surgeon's work space.<a class="elsevierStyleCrossRef" href="#bib0290">16</a> As in our case 10, in which during the exploration of the TR, a big prominence of the suprameatal tubercle obscure the direct vision of the distal portion of the TR, deciding to drill away to see the root entrance in Meckel cave and entirely expose the TR, a dSPVS grade II compressing the nerve was observed, and finally coagulated and divided to free the root, finishing with TRM without interposition of any material (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>ResultsThe operative findings, follow-up and final results are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. The operative time was between two and three hours. There was no mortality. There were 5 females and 5 males, and the age at the operation ranged for 44–74 years (mean 58 years). All patients had medically intractable TN at least for 2 years. The left side was affected in 7 (70%) patients, and the most affected area was V2 division of the TN, which was implicated in all cases, on its own or in combination. No patients suffered exclusively in the V1 or V3 trigeminal division.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>There are some scales for evaluating the results of various procedures in the treatment of TN as the well known visual analog scale and the Barrow Neurological Institute pain intensity score,<a class="elsevierStyleCrossRef" href="#bib0295">17</a> but we prefer the scale proposed by Kondo et al.,<a class="elsevierStyleCrossRef" href="#bib0300">18</a> because it is both simple and objective, combining the cure rate of symptoms with the complication rate.In an average follow-up of 5 years, the total evaluation grade of our results according to the classification by Kondo et al.,<a class="elsevierStyleCrossRef" href="#bib0220">2</a> was: excellent results (T-0) were achieved in 6 patients (60%), good in one (T-1), fair in 1 (T-2), and poor in 2 patients (T-3).Except in one case there have not been postoperative major complications. One patient operated in decubitus (case 3), developed arterial hypertension during the operation, and diffuse subdural bleeding and cerebellar edema was found during opening of the duramater and basal cistern drainage of a clear abundant CSF. Hemostasis finally was resolved with surgicel and fibrin glue after changing the position of the head. During MVD a superior petrosal vein was coagulated and divided to obtain a satisfactory view of the entire free trigeminal root, and finally we proceeded with TRM. The patient awoke from anesthesia without problems, neurologically intact and with completely free of pain, but over a few hours later she developed a headache, vomiting, and progressive deterioration of consciousness was constated, and a computed tomographic scan demonstrated ipsilateral hemispheric cerebellar hypodensity compatible with cerebellar swelling and acute hydrocephalus. External ventricular drainage was used and then replaced three times for 15 days until the meningitis and hydrocephalus resolved without needing a ventriculoperitoneal shunt. This patient in particular, gradually improved until being discharged 2 months later with left hypoacusia and slight cerebellar ataxia, without any further symptoms and neuralgia resolved. 8 years after the operation the patient is free of symptoms and no need for any medication.The average follow-up period was 5 years, with a range from 1 year to 10 years. At the last follow-up, excellent outcome was obtained in 6 patients (60%), while good and fair outcome was achieved in 2 patients and poor results in 2. The pain recurrence rate was in two patients (20%), and in all of them the time of apparition was during the first postoperative year: 3 and 4 months. It is important to recognize that both patients with recurrences had only TR arachnoid adhesions without associated compressive vein, or a simple grade I contact vein of Sindou classification.Some degrees of transitory facial hypoesthesia and numbness in V2–V3 territory is concurrent with the technique but in all cases have been well tolerated because the patient is pain free and the hypoesthesia progressively disappear. No patient has suffered corneal hypoesthesia or any painful postoperative anesthesia.A summarized description of the operative findings in some others representative cases are given (<a class="elsevierStyleCrossRefs" href="#fig0025">Figs. 5 and 6</a>).<elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia>DiscussionTreating trigeminal neuralgia we performed both MVD and percutaneous procedures (balloon microcompression and radiofrequency thermocoagulation) depending on the patient's record, preferences, and since the 90s preoperative MRI findings. During the 80s and 90s we have used percutaneous techniques in the majority of our cases, principally radiofrequency thermocoagulation. After 1992 we introduced in clinical practice the percutaneous balloon microcompression, and we have continued with the procedure since then in some selected cases.<a class="elsevierStyleCrossRefs" href="#bib0305">19,20</a> Currently we suggest as a first alternative an open surgical technique and exploration of the trigeminal nerve by suboccipital retrosigmoid approach based on patient records if the patient has no contraindications. The present study examined the safety and effectiveness of using finally a simple surgical maneuver such as trigeminal root massage, after wide cisternal arachnoidal dissection and vein coagulation and cut if they produce true root compression, without interposition of any material implant.Excellent anatomical studies have been published about infratentorial veins, in particular to the superior petrosal venous system and the risks for its sacrifice during the approach to the cerebellopontine angle to avoid complications.<a class="elsevierStyleCrossRefs" href="#bib0285">15,21–26</a> Every neurosurgeon knows the importance to respect as much as possible the venous drainage system, in particular during the approach to the cerebellopontine angle to avoid complications such as swelling and venous infarction: thus, that is why we always try to preserve the superficial petrosal vein complex. But, unfortunately, the superior venous system is a risky obstacle to reach the trigeminal root in the microvascular decompression and In 8 of our 10 cases we had to sacrifice this venous system for two principal reasons: because they obstruct the lane to widen exposure to the trigeminal root without inadvertent damage and risks of profuse bleeding, and because some of them played a role in the neurovascular conflict. Venous sacrifice in the cerebellopontine angle is a contentious issue, with unpredictable consequences. In our experience, except one case in this study, these venous sacrifices did not entail any clinical relevance. The temporary occlusion test described by Zhong et al. was negative in 91.4% of their cases, cutting the vein in these test-negative patients made the operation easy and offered a satisfactory decompression. According to McLaughlin et al.,<a class="elsevierStyleCrossRef" href="#bib0265">11</a> the petrosal complex anatomy can be quite variable and these veins are not always divided, but can be sectioned with impunity without venous complications. Despite this, several complications have been described related to venous coagulation and cutting of the superior petrosal venous system as peduncular hallucinosis,<a class="elsevierStyleCrossRef" href="#bib0345">27</a> cerebellar swelling<a class="elsevierStyleCrossRef" href="#bib0350">28</a> and cerebellar, brainstem and brain infarction. Nevertheless, cerebellar venous infarction after sacrifice of the superior petrosal vein (SPV) appears to be very rare. In the series of Pathmanaban et al. in which 184 patients had SPV sacrifice, did not identify any case, and the risk is likely to be less than 0.5%. In our complicated case 3 we attribute the mechanism responsible for cerebellar edema to the incorrect head positioning, long operative time with cerebellar retractor spatula looking for the bleeding point and final hemostasis, and for the sacrifice of the superior petrosal vein.The implications of veins at the source of classical TN have not been universally accepted, probably due to its high variability and because sometimes are difficult to demonstrate its implications in neurovascular conflict, speculating for different mechanisms in the pathogenesis of the neuralgia other than neurovascular conflict.<a class="elsevierStyleCrossRef" href="#bib0355">29</a> Nevertheless, some expert authors recently gave importance to the veins as cause TN and the outcome after their microvascular decompression.<a class="elsevierStyleCrossRefs" href="#bib0245">7,30–32</a> There is a great variability in the frequency on finding a vein an isolated cause of TR compression. In the bigger series, the rate of only venous conflicting vessel ranged from 8.9% to 23.6%.<a class="elsevierStyleCrossRef" href="#bib0375">33</a> 8 of our 52 MVD cases had exclusively a venous contact with TR, which means a 15.38%, but in two of our cases we could not find any vascular contact (3.8%). Compressing veins are located in a wider area than arteries, and the most common contact are in the distal portion of TR, predominantly around the porus trigemini. Inoue et al.,<a class="elsevierStyleCrossRef" href="#bib0370">32</a> proposed an anatomical and practical classification in four types of the veins possibilities location in relation with TR contact.A prominent suprameatal petrous bone can obscure the vision of the porus trigemini and blocks the view of the Meckel's segment of the trigeminal root, as in our case 10 (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Named by Rhoton suprameatal tubercle, this can be drilled away if wider access is needed to increase surgical work space.<a class="elsevierStyleCrossRef" href="#bib0285">15</a> Anatomically, an increase exposure of the TR has been reported in more than 10mm after drilling the suprameatal tubercle. This technique, first described and called by Samii et al.,<a class="elsevierStyleCrossRef" href="#bib0290">16</a> “retrosigmoid intradural suprameatal approach” (RISA), was in our case very useful to increase the space in this narrow area to expose a venous grade II TR compression, and decompress the root after coagulating and sectioning the vein (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).WhenTrigeminal root massage is not an alternative to microvascular decompression, it is just a complementary and simple maneuver during microsurgical exploration of the trigeminal root without a clear neurovascular compromise, avoiding other options such as partial sensory rhizotomy or more complicated and time consuming like nerve combing. When arterial compression is not evident during microsurgical exploration of the trigeminal root in the superior cerebellar-pontine cistern, the neurosurgeon is in an engaged situation, because there are not well-established surgical strategies. To improve the operative outcomes in these cases, some authors have tried to refine the operative techniques and paid great attention to patient selection for MVD.<a class="elsevierStyleCrossRefs" href="#bib0370">32,34</a> We use trigeminal root massage as the final step of the decompressive exploration of the TR only in cases without arterial contact and after trigeminal root liberation from the adhesive arachnoidal and/or venous compression.MR imaging is useful in evaluating neurovascular conflict of the trigeminal nerve at the REZ and helpful as a preoperative tool when trigeminal neuralgia is diagnosed by patients’ records. During the last years, high-resolution MRI techniques and different sequences as 3D-T2, 3D-TOF and 3D-T1 with gadolinium, have been developed to detect the offending vessel(s) in patients with neurovascular compression and trigeminal neuralgia.<a class="elsevierStyleCrossRef" href="#bib0385">35</a> This is important preoperative information for better selection of patients for arterial MVD, but not in most cases of venous contact or with simple arachnoid adhesions in which the MRI cannot detect a clear neurovascular contact, these symptomatic patients can also benefit from trigeminal nerve microsurgical exploration. Even more, the absence of vascular compression in patients with trigeminal neuralgia has been described in the literature and the existence of cases without vascular conflict, which were cured after MVD complicated the dilemma. On the other hand, vascular compression of the trigeminal nerve is a frequent anatomical variant and MRI finding in people with no symptoms of trigeminal neuralgia.<a class="elsevierStyleCrossRefs" href="#bib0390">36–38</a> That is why we think that based only on MRI images, this is not enough to decide surgical indication for MVD, because trigeminal neuralgia is a clinical diagnosis that does not depend exclusively on the presence of imaging of neurovascular conflict. According to Rasche et al.,<a class="elsevierStyleCrossRef" href="#bib0355">29</a> the decision for microvascular decompression operation is still based on clinical findings and not on neuroradiological findings.HowHow to deal with the TN patients without trigeminal root arterial compression or with venous neurovascular conflict is a challenge for all neurosurgeons. There are some surgical options depending on the operative findings. The most simple is a wide opening of the arachnoid adhesions to free the root, in some cases very adherent to the TR. But if a trigeminal root venous compression exists, the indication and management for these veins is still controversial. The decision to coagulate and cut the vein/s is risky; nevertheless it is an alternative choice for venous cases.<a class="elsevierStyleCrossRef" href="#bib0370">32</a>Rogelio Revuelta et al.,<a class="elsevierStyleCrossRef" href="#bib0245">7</a> described his technique in 3 steps: first, a meticulous dissection of the arachnoid to expose the entire trigeminal root, followed by slight compression (neuroapraxia) with bipolar tips on the trigeminal REZ (second step), and finally, the third step was the isolation of the TR with fragments of Teflon. Such a technique has been used by other authors.<a class="elsevierStyleCrossRef" href="#bib0380">34</a> Our TRM procedure is similar: after arachnoid trigeminal liberation and compressive vein coagulation and section, we apply a slight gentle intermittent compressive massage along the length of the trigeminal root three or four times with the microforceps or the microdissector, but we ended up with the second step, after the final root massage, without interposing any material implant.Partial sensory rhizotomy (PSR) is a classical alternative technique used in absence of arterial contact.<a class="elsevierStyleCrossRefs" href="#bib0255">9,39</a> The outcome of PSR reported by Young and Wilkins was excellent in 48% of patients, good in 22% and poor in 30%, and the failure rate was 17% for the 1st year.<a class="elsevierStyleCrossRef" href="#bib0405">39</a> Sensory loss is an inevitable and irreversible side effect after PSR and it has been reported to a lesser degree of patient satisfaction.<a class="elsevierStyleCrossRef" href="#bib0215">1</a>Another option is nerve combing, also called internal neurolysis, is a procedure in which all or portions of the trigeminal nerve are divided longitudinally by microneedle along its fibers into several fascicles between the pons and the porus trigemini.<a class="elsevierStyleCrossRefs" href="#bib0260">10,40</a> Postoperative numbness and facial hypoesthesia is consubstantial with the combing technique, carries the risk of anesthesia dolorosa and the rate of dysesthesias or deafferentation pain is 16%.<a class="elsevierStyleCrossRefs" href="#bib0260">10,40</a> Comparing to these techniques, we have no case of postoperative anesthesia dolorosa whatsoever.WhyBased on the proposed mechanisms of production of trigeminal neuralgia related to the compression of the sensitive trigeminal root of the 5th nerve in its intracranial route, non-destructive open surgical techniques have historically been directed toward a decompression of the trigeminal nerve at some point in its intracranial trajectory. In 1955, Shelden et al.,<a class="elsevierStyleCrossRef" href="#bib0415">41</a> advised that the common denominator to all procedures is operative trauma, introducing a new technique such as pressing with a blunt dissector the portio major nerve fibers of the trigeminal nerve surgically exposed through a middle cranial fossa approach, suggesting that the compression of the trigeminal fibers during the operation is the factor that relieves the pain. Jannetta using microneurosurgical techniques, considers that vascular compression of the trigeminal root is the principle cause of TN, expanded the concept of this neurovascular compression theory, popularizing the MVD operation procedure.<a class="elsevierStyleCrossRef" href="#bib0265">11</a> Since then, some authors, skeptical and critical of the microvascular decompression procedure, started a controversial discussion and hypothesis about the mechanisms of trigeminal pain disappearance after the MVD operation and suggests an alternative view as surgical trauma.<a class="elsevierStyleCrossRefs" href="#bib0250">8,42</a>Without getting into sterile controversies and in these cases without a clear arterial TR compression, and always after a careful trigeminal root liberation from the adhesive arachnoidal and/or venous compromise, we used the final maneuver of gentle TR intermittent compression called massage for some reasons. Mainly because after surgery the trigeminal pain immediately disappears and we considered that a little microsurgical manipulation of the TR can have an effect for initial pain disappearance, while the TR arachnoidal and venous decompression can influence in maintaining long term pain relief. TRM avoids the definitive and irreversible trigeminal nerve side effects such as facial sensory loss produced by other techniques such as rhizotomy. And finally, because it allows other types of surgery if there is pain recurrence.In summary, whatever mechanism makes the trigeminal neuralgia disappear, one of the best moments for the patient and for the neurosurgeon is when the patient awakes from the anesthesia without trigeminal pain and free of symptoms: that is the most satisfactory moment after MVD and TRM, which we always try to achieve in cases without TR arterial compression. But also we always take into consideration in the patient's satisfaction and the final results throughout the next few years, because we know that only 60% of our cases have excellent results after a average follow-up of 5 years: which means that there are no perfect surgical techniques at the moment for permanent cure of trigeminal neuralgia without arterial compression.ConclusionThe Trigeminal Root Massage (TRM) is a useful and simple alternative in cases of MVD without a clear arterial compression of the trigeminal root, with similar results in the short and long terms than other possibilities such as partial sensory rhizotomy or more complicated and time consuming surgery such as nerve combing. Only a 60% of excellent results after 5 years mean that is a good alternative, but not a definitive technique at the moment for permanent cure of trigeminal neuralgia without arterial compression.FundingNone declared.DisclosuresNone declared.Conflict of interestNone." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1314583" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1213219" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1213221" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres1314582" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1213220" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patient characteristics" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Surgical technique" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Anatomical observations and surgical findings" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 8 => array:3 [ "identificador" => "sec0035" "titulo" => "Discussion" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "When" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "How" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Why" ] ] ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0065" "titulo" => "Disclosures" ] 12 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflict of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-06-04" "fechaAceptado" => "2019-07-31" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1213219" "palabras" => array:6 [ 0 => "Trigeminal neuralgia" 1 => "Microvascular decompression" 2 => "Trigeminal root.massage" 3 => "Venous compression" 4 => "Petrosal venous system" 5 => "Pain" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1213221" "palabras" => array:5 [ 0 => "MVD" 1 => "TN" 2 => "TR" 3 => "TRM" 4 => "REZ" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1213220" "palabras" => array:6 [ 0 => "Neuralgia del trigémino" 1 => "Descompresión microvascular" 2 => "Masaje de la raíz trigeminal" 3 => "Compresión venosa" 4 => "Sistema venoso petroso" 5 => "Dolor" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundDuring the microsurgical exploration of trigeminal root in the pontocerebellar angle in patients with primary trigeminal neuralgia (TN) without an evident arterial compression, the surgeon is in an engaged situation because there are not well-established surgical strategies. The aim of this study is to describe in these cases the surgical maneuver we call “trigeminal root massage” (TRM). Methods52 consecutive patients with primary trigeminal neuralgia who had undergone a microsurgical suboccipital retrosigmoid exploration of trigeminal root were reviewed. Among them we found 10 patients without an evident arterial compression after a thorough microsurgical exploration. In the great majority of these 10 cases, we noticed a venous contact to the trigeminal root along this cisternal trajectory, in most cases we have had to coagulate the compressive vein/s and then cut. All underwent a simple trigeminal root massage, without interposition of any material implant. ResultsAll 10 patients experienced immediate pain disappearance and the postoperative course was uneventful except one case with a severe complication: cerebellar swelling, meningitis and hydrocephaly. The recurrence rate was 40%. Six patients achieved pain relief without specific medication with an average follow-up period of 5 years. There have been no mortalities nor any postoperative anesthesia dolorosa. ConclusionsThe described maneuver provides an easy and simple alternative way in cases where during a microsurgical exploration of trigeminal root, where we don’t find a clear arterial compression, with similar results than other possibilities such as partial sensory rhizotomy or more complicated and time consuming surgery as “nerve combing”. Nevertheless, a 40% of pain recurrence after an average follow-up of 5 years means that is a good alternative, but not a definitive technique at the moment for permanent cure of trigeminal neuralgia without arterial compression." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Introducción y objetivosDurante la exploración microquirúrgica de la raíz trigeminal en el ángulo pontocerebeloso en pacientes con neuralgia del trigémino (NT) primaria sin una evidente compresión arterial, el cirujano se encuentra en una situación comprometida, ya que no existe una estrategia quirúrgica establecida. El objetivo de este estudio es la de describir en esos casos una maniobra quirúrgica que llamamos «masaje de la raíz trigeminal» (MRT). MétodosSe revisan un total de 52 pacientes consecutivos con NT primaria a quienes se ha realizado una exploración de la raíz trigeminal por vía suboccipital retrosigmoidea. Entre ellos hemos encontrado 10 pacientes sin una evidente compresión arterial durante la exploración microquirúrgica. En 8 de los 10 casos ha existido un contacto venoso de la raíz trigeminal a lo largo de su trayectoria cisternal, procediendo a la coagulación y sección de la/s vena/s. En los 10 casos se ha procedido, finalmente, a un suave masaje de la raíz trigeminal sin interposición de ningún material. ResultadosLos 10 pacientes experimentaron una inmediata desaparición de la neuralgia y el curso postoperatorio fue favorable excepto por un caso de complicación severa con edema cerebeloso, meningitis e hidrocefalia. La recidiva fue del 40%. Seis pacientes obtuvieron una desaparición completa de la neuralgia, sin medicación específica, en un seguimiento medio de 5 años. No ha habido mortalidad ni anestesia dolorosa postoperatoria. ConclusionesLa maniobra quirúrgica descrita es una alternativa útil y sencilla en casos donde, durante la exploración microquirúrgica de la raíz trigeminal, no encontramos una clara compresión arterial, con resultados similares a otras posibilidades como la rizotomía parcial o más laboriosas como la llamada nerve combing. En cualquier caso, un 40% de recidiva dolorosa a los 5 años significa que, aunque es una buena alternativa, no es una técnica definitiva en la curación de todos los enfermos con NT sin conflicto arterial." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1386 "Ancho" => 2500 "Tamanyo" => 248668 ] ] "descripcion" => array:1 [ "en" => "Case 6. Patient position and intraoperative neuromonitoring. Different steps microsurgery technique. Leyends (more description) in the text." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1057 "Ancho" => 2500 "Tamanyo" => 151661 ] ] "descripcion" => array:1 [ "en" => "Case 7. Intraoperative photographs in a patient without any vascular contact. (A) The entire course of the cisternal TR is exposed after arachnoidal resection. (B) Final trigeminal root massage was used with microdissector." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1854 "Ancho" => 2500 "Tamanyo" => 292254 ] ] "descripcion" => array:1 [ "en" => "Case 1. Patient in semisitting position. (A) Photograph showing a thick arachnoidal adhesions (Arach. Adh.) covering the V nerve and compressive grade III deep superior petrosal venous system (dSPVS). r: retractor. (B and C) dSPVS veins coagulation. (D) Indentation of the V nerve with grayish color. E and F: final trigeminal root massage with microdissector." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1400 "Ancho" => 2500 "Tamanyo" => 241645 ] ] "descripcion" => array:1 [ "en" => "Case 10. A big tubercle prominence was found (arrow) and drilled away (B and C) to expose a dPVS compressing the V nerve. (E) Coagulation and cutting the vein. (F) Gentle intermittent trigeminal root massage with the microforceps." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1838 "Ancho" => 2500 "Tamanyo" => 246638 ] ] "descripcion" => array:1 [ "en" => "Case 2. Operative photos (from videoclip). After arachnoidal dissection a sSPVS grade I interposing the direct vision of V nerve. (B) Vein coagulation and dividing. (C) TRM maneuver. (D) Final vision of the field." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1539 "Ancho" => 2500 "Tamanyo" => 293235 ] ] "descripcion" => array:1 [ "en" => "Case 4. (A) Preoperative MRI image without evidence of vascular contact. (B) sSPVS compressive grade II. (C and D) Vein coagulation and section. (E and F) Final trigeminal root massage (arrows) with microdissector." ] ] 6 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case No. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age and sex \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">TN duration (years) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Side & location \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Previous operation No. & type \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical presentation \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R. V2–V3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 RT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Typical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">L. V2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atypical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">L. V2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Typical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R. V2–V3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Typical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R. V2–V3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Typical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">L. V2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Typical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">L. V2–V3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atypical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">L. V1–V2–V3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 RT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Typical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">L. V2–V3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Typical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">L. V1–V2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Per. Bot. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Typical \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2253392.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical characteristics of 10 patients who underwent trigeminal root massage." ] ] 7 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "sSPVS: superficial superior petrosal vein. dSPVS: deep superior petrosal vein system. Arach. Adh.: Arachnoid adhesions, VCC: vein coagulation and cutting. TRM: trigeminal root massage. Cer. Swelling: cerebellar swelling." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case No. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intraop. features (Sindou clas.) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Treatment modality \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Immediate postop. pain relief \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complic. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Length of stay (days) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recurrence (months) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Outcome (Kondo classif.) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Follow-up duration (years) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">sSPVS IIIdSPVS III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VCC+TRM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Excellent T-0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">sSPVS I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VCC+TRM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fair T-2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">sSPVS IIArach. Adh. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VCC+TRM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes Cer.Swelling \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Good T-1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">sSPVS IIArach. Adh. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VCC+TRM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Excellent T-0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">sSPVS I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VCC+TRM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Excellent T-0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">sSPVS IdSPVS IArach. Adh. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VCC+TRM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Excellent T-0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Arach. Adh. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TRM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes 4 m. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Poor T-3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Arach. Adh. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TRM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Excellent T-0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">sSPVS I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VCC+TRM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes 3m. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Poor T-3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">dSPVS II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VCC+TRM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Excellent T-0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2253391.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Operative findings, results and follow-up." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:42 [ 0 => array:3 [ "identificador" => "bib0215" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patient reports of satisfaction after microvascular decompression and partial sensory rhizotomy for trigeminal neuralgia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.M. Zakrzewska" 1 => "B.C. Lopez" 2 => "S.E. Kim" 3 => "H.B. Coakham" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1227/01.neu.0000159883.35957.e0" "Revista" => array:6 [ "tituloSerie" => "Neurosurgery" "fecha" => "2005" "volumen" => "56" "paginaInicial" => "1304" "paginaFinal" => "1311" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15918947" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0220" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A proposal for standardized analysis of the results of microvascular decompression for trigeminal neuralgia and hemifacial spasm" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Kondo" 1 => "I. Date" 2 => "S. Endo" 3 => "K. Fujii" 4 => "Y. Fujii" 5 => "T. 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Clinical Research

Trigeminal root massage in microsurgical treatment of trigeminal neuralgia patients without arterial compression: When, how and why

Masaje de la raíz trigeminal en el tratamiento quirúrgico de la neuralgia de trigémino sin contacto neurovascular arterial: cuándo, cómo y porqué

Enrique Urculo

Autor para correspondencia

ENRIQUE.URCULOBARENO@osakidetza.eus

Corresponding author.

, Alejandro Elua, Mariano Arrazola, Patricia Torres, Sergio Torres, Jose Undabeitia

Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">with classical trigeminal neuralgia&#44; the microvascular decompression &#40;MVD&#41; of the trigeminal nerve by suboccipital route &#40;colloquially known as Jannetta&#39;s technique&#41;&#44; is actually the best surgical alternative after the failure of conservative treatment or other percutaneous and radiosurgical procedures&#46; MVD surgery has become accepted as potencially curative for trigeminal neuralgia &#40;TN&#41; and might be considered as the first treatment choice in which is compared to the rest of surgical options&#46; This is one of the most attractive surgical techniques for neurosurgeons and patients for many different reasons&#58; for the neurosurgeon because it is an elegant anatomical form of microsurgery&#44; where we have learned the arachnoid and vascular microdissection of the cerebellopontine angle in normal anatomical situation&#44; and it is the only nondestructive procedure in trigeminal neuralgia surgery&#44; and for the patients because they have good results and little recurrence of pain&#59; which results in patient satisfaction after MVD&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There are different degrees of severity compression and many possibilities of neurovascular conflict affecting the trigeminal root&#58; one or more arteries alone or in combination with a vein or veins has been reported to be the main cause in most cases of trigeminal neuralgia&#44; in which the existence of a marked cross-compression on the root correlates with a high percentage of cure and better outcome after microvascular decompression&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">4</span></a> The vessel most commonly responsible for nerve compression is an arterial loop of the superior cerebellar artery and anterior&#8211;inferior cerebellar artery on its own or in combination with vein&#40;s&#41; affluent to the superior petrosal venous system &#40;SPVS&#41;&#46; However&#44; the categorization of the patients without unequivocal arterial contact is somewhat problematic&#44; an exclusively venous compression by one or more veins has been demonstrated to be responsible in up to 15&#37; of TN&#44; but the intraoperative management options in cases without trigeminal arterial compression has not been established and remains a matter of debate&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">5&#8211;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">During the microsurgical exploration of the trigeminal root in the superior cerebellar-pontine cistern&#44; our job is to find any cause of trigeminal root compression&#44; especially to find the artery or arteries compressing the trigeminal nerve in its cisternal trajectory and separate the offending vessel from the trigeminal root in order to relieve pulsatile vascular transmission on the nerve to assure true trigeminal microvascular decompression&#46; But if after a meticulous microscopically dissection from the root entry zone at the pons to the porus trigemini&#44; any arterial compression to the trigeminal root is found&#44; except some vein or non venous contact&#44; the surgeon is in an engaged situation&#44; with the decision to continue the procedure or not&#46; In absence of evident arterial conflict&#44; there are some options in these cases&#58; the most frequent used is the partial sensory rhizotomy&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">9</span></a> and other accepted possibilities have been described such as internal neurolysis&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">So&#44; in such special cases without any vascular contact or with only venous contact &#40;3&#46;8&#37; and 15&#46;38&#37; respectively of our total MVD cases&#41;&#44; after arachnoid trigeminal liberation and compressive vein coagulation and section&#44; we apply a slight gentle intermittent compressive massage along the length of the trigeminal root with the microforceps or the microdissector&#44; which we call trigeminal root massage &#40;TRM&#41;&#46; The main objective of this article is to describe the TRM technique and its results during the microsurgical exploration of the trigeminal root&#44; in patients with primary trigeminal neuralgia without an evident arterial compression&#46; Furthermore&#44; we also reviewed the literature and discussed the possible mechanisms and surgical strategies for those patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patient characteristics</span><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis of classical TN was made through patients records according to the International Headache Society&#44; whether the neuralgia was purely paroxysmal &#40;typical TN&#41; or with concomitant continuous pain &#40;atypical TN&#41;&#46; All patients who underwent posterior fossa exploration have at least 2 years of proved refractory to or intolerance to of the usual medical therapies for TN such as carbamazepine&#44; phenytoin&#44; baclofen&#44; gabapentin or other drugs used either alone or in various combinations and sent to us for the neurologist after failed medical treatment&#46; We prefer to operate the patients in phase of trigeminal pain attacks&#44; avoiding surgery in periods of remission&#46; The senior author &#40;EU&#41; has operated at the Donostia University Hospital and Policlinica Gipuzkoa on 52 patients for primary trigeminal neuralgia by microsurgical suboccipital exploration as described by Jannetta<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">11</span></a> and Sindou&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">12</span></a> All patients underwent preoperative CT Scan and magnetic resonance imaging &#40;MRI&#41;&#46; In 42 patients we found an artery as the major offending vessel&#44; specially the superior cerebellar artery&#46; During the surgical exploration&#44; venous contact without arterial compression was noted in 8 &#40;15&#46;38&#37;&#41; cases and no offending vessel in 2&#44; all of them were included in this study&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This is a retrospective analysis of the 10 consecutive patients without a visible microsurgical trigeminal arterial contact in which we applied the technique of trigeminal root arachnoidal liberation&#44; venous cut and divided if needed&#44; and massage without interposition of any implant material&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The clinical characteristics of the patients are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; No patient had multiple sclerosis&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical technique</span><p id="par0040" class="elsevierStylePara elsevierViewall">Basically we performed microsurgical exploration of the trigeminal root in two different positions&#58; semisitting and supine with the affected side up&#44; shoulder elevation&#44; head rotation to the opposite side and chin flexed&#46; Sometimes we used intraoperative neuromonitoring&#58; facial nerve electromyography and brainstem auditory evoked potentials &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; We utilize the conventional retrosigmoid approach described by Jannetta<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">13</span></a> and Samii&#44; with some personal modifications&#46; A linear or slightly curved skin incision extending superiorly 2<span class="elsevierStyleHsp" style=""></span>cm behind the pinna&#44; passing through the asterion and terminating 2<span class="elsevierStyleHsp" style=""></span>cm medial to the mastoid tip&#46; Mannitol is administered intravenously at the time of the skin incision&#46; The burr hole is made in the asterion&#44; and then a 2&#8211;3-cm retromastoid craniectomy or sometimes craniotomy toward the transvers and sigmoid sinus and the squamous part of the occipital bone&#46; A high-speed diamond drill is used to expose the borders of the transvers sinus&#44; the superolateral corner of the transverse-sigmoid sinuses&#44; and the sigmoid sinus&#46; Bone wax is used to pack the mastoid air cells and the emissary vein&#46; The dura is opened under magnification using an operating microscope in a C-shape&#44; some millimeters medially along the transverse and sigmoid sinus&#44; followed by opening the cerebellomedulary cistern&#59; CSF is withdrawn until cerebellar relaxation is achieved&#46; Through the supracerebellar-infratentorial route we reach the petrotentorial corner to gain access to the trigeminal root entry zone &#40;TREZ&#41;&#46; During the approach we try to preserve the superficial petrosal vein&#44; but it was coagulated and divided when it clearly participates in compressive neurocontact or when it riskily obstructs the lane to widen exposure to the trigeminal root&#46; The arachnoid overlying the superior pontocerebellar cistern was fully opened&#44; the fifth nerve was exposed&#44; the vein was coagulated and divided&#59; finishing the operation applying a slight gentle intermittent compressive massage along the length of the trigeminal root with the microforceps or the microdissector&#44; which we call trigeminal root massage &#40;TRM&#41;&#44; without interposing any material &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; As important as the surgical opening and microsurgical procedure&#44; an exquisite closure technique to avoid postoperative complications is mandatory&#46; Hemostasis is achieved with the utmost care&#46; At the end of the procedure&#44; jugular vein compression is performed by the anesthesiologist to search for possible venous bleeding and to confirm a clean surgical field&#46; The dura is closed in a watertight fashion with sutures and epidural sealant&#46; The mastoid cells are covered with muscle and fibrin glue&#46; Cranioplasty is performed with the bone chips taken from the craniectomy and mixed with fibrin glue molding it to the cranial contour&#46; The neck muscles are sutured back&#44; respecting the anatomical layers&#46; No drains are used&#46; A compressive bandage is used after the skin closure&#46; We routinely perform a postoperative CT scan during the day after surgery on all patients operated on cerebellopontine angle&#44; independently of its type&#44; and emergently when recovery from anesthesia was delayed or when the patient&#39;s condition deteriorated&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Anatomical observations and surgical findings</span><p id="par0045" class="elsevierStylePara elsevierViewall">The two principal intraoperative findings in this series of ten patients without arterial contact were venous or&#47;and thick arachnoid adhesions involved in root compression&#46; We have adopted the Sindou classifications for both the petrosal venous systems and the degrees of compression to the trigeminal root&#58; grade I is a simple but clear contact&#44; grade II for displacement or distorsion&#44; and grade III in cases of marked grooving in the root with a more or less focal demyelination under the form of a grayish aspect&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">14</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">8 of our cases had a pure venous conflict&#44; one of grade III&#44; 3 grade II and 4 grade I&#46; We found conflicting veins either of the superficial superior petrosal vein system &#40;sSPVS&#41; in 7 cases and&#47;or of the deep superior petrosal vein system &#40;dSPVS&#41; in three cases&#46; Only in 2 patients we found no clear vascular contact and&#44; after arachnoid decompression&#44; we finished surgery with TRM in both cases &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">5 cases presented with thick arachnoidal membrane&#44; more or less adherent to the V nerve&#44; 4 cases with some compressive veins that we coagulated and then cut&#46; As in our case 1&#58; After thick arachnoidal section we expose a venous grade III TR compression&#44; which was coagulated and divided&#44; observing finally the trigeminal indentation as a collar around the TR and its grayish color &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Sometimes we can find a prominent suprameatal petrous bone obscuring the vision of the porus trigemini&#46; This part of the petrous bone was called suprameatal tubercle by Rhoton&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">15</span></a> which blocks the view of the Meckel&#39;s segment of the trigeminal root&#44; and can be drilled away if needed to enlarge access to this part of the nerve&#44; which increases the surgeon&#39;s work space&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">16</span></a> As in our case 10&#44; in which during the exploration of the TR&#44; a big prominence of the suprameatal tubercle obscure the direct vision of the distal portion of the TR&#44; deciding to drill away to see the root entrance in Meckel cave and entirely expose the TR&#44; a dSPVS grade II compressing the nerve was observed&#44; and finally coagulated and divided to free the root&#44; finishing with TRM without interposition of any material &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">The operative findings&#44; follow-up and final results are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; The operative time was between two and three hours&#46; There was no mortality&#46; There were 5 females and 5 males&#44; and the age at the operation ranged for 44&#8211;74 years &#40;mean 58 years&#41;&#46; All patients had medically intractable TN at least for 2 years&#46; The left side was affected in 7 &#40;70&#37;&#41; patients&#44; and the most affected area was V2 division of the TN&#44; which was implicated in all cases&#44; on its own or in combination&#46; No patients suffered exclusively in the V1 or V3 trigeminal division&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">There are some scales for evaluating the results of various procedures in the treatment of TN as the well known visual analog scale and the Barrow Neurological Institute pain intensity score&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">17</span></a> but we prefer the scale proposed by Kondo et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">18</span></a> because it is both simple and objective&#44; combining the cure rate of symptoms with the complication rate&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In an average follow-up of 5 years&#44; the total evaluation grade of our results according to the classification by Kondo et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">2</span></a> was&#58; excellent results &#40;T-0&#41; were achieved in 6 patients &#40;60&#37;&#41;&#44; good in one &#40;T-1&#41;&#44; fair in 1 &#40;T-2&#41;&#44; and poor in 2 patients &#40;T-3&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Except in one case there have not been postoperative major complications&#46; One patient operated in decubitus &#40;case 3&#41;&#44; developed arterial hypertension during the operation&#44; and diffuse subdural bleeding and cerebellar edema was found during opening of the duramater and basal cistern drainage of a clear abundant CSF&#46; Hemostasis finally was resolved with surgicel and fibrin glue after changing the position of the head&#46; During MVD a superior petrosal vein was coagulated and divided to obtain a satisfactory view of the entire free trigeminal root&#44; and finally we proceeded with TRM&#46; The patient awoke from anesthesia without problems&#44; neurologically intact and with completely free of pain&#44; but over a few hours later she developed a headache&#44; vomiting&#44; and progressive deterioration of consciousness was constated&#44; and a computed tomographic scan demonstrated ipsilateral hemispheric cerebellar hypodensity compatible with cerebellar swelling and acute hydrocephalus&#46; External ventricular drainage was used and then replaced three times for 15 days until the meningitis and hydrocephalus resolved without needing a ventriculoperitoneal shunt&#46; This patient in particular&#44; gradually improved until being discharged 2 months later with left hypoacusia and slight cerebellar ataxia&#44; without any further symptoms and neuralgia resolved&#46; 8 years after the operation the patient is free of symptoms and no need for any medication&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The average follow-up period was 5 years&#44; with a range from 1 year to 10 years&#46; At the last follow-up&#44; excellent outcome was obtained in 6 patients &#40;60&#37;&#41;&#44; while good and fair outcome was achieved in 2 patients and poor results in 2&#46; The pain recurrence rate was in two patients &#40;20&#37;&#41;&#44; and in all of them the time of apparition was during the first postoperative year&#58; 3 and 4 months&#46; It is important to recognize that both patients with recurrences had only TR arachnoid adhesions without associated compressive vein&#44; or a simple grade I contact vein of Sindou classification&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Some degrees of transitory facial hypoesthesia and numbness in V2&#8211;V3 territory is concurrent with the technique but in all cases have been well tolerated because the patient is pain free and the hypoesthesia progressively disappear&#46; No patient has suffered corneal hypoesthesia or any painful postoperative anesthesia&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">A summarized description of the operative findings in some others representative cases are given &#40;<a class="elsevierStyleCrossRefs" href="#fig0025">Figs&#46; 5 and 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Treating trigeminal neuralgia we performed both MVD and percutaneous procedures &#40;balloon microcompression and radiofrequency thermocoagulation&#41; depending on the patient&#39;s record&#44; preferences&#44; and since the 90s preoperative MRI findings&#46; During the 80s and 90s we have used percutaneous techniques in the majority of our cases&#44; principally radiofrequency thermocoagulation&#46; After 1992 we introduced in clinical practice the percutaneous balloon microcompression&#44; and we have continued with the procedure since then in some selected cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">19&#44;20</span></a> Currently we suggest as a first alternative an open surgical technique and exploration of the trigeminal nerve by suboccipital retrosigmoid approach based on patient records if the patient has no contraindications&#46; The present study examined the safety and effectiveness of using finally a simple surgical maneuver such as trigeminal root massage&#44; after wide cisternal arachnoidal dissection and vein coagulation and cut if they produce true root compression&#44; without interposition of any material implant&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Excellent anatomical studies have been published about infratentorial veins&#44; in particular to the superior petrosal venous system and the risks for its sacrifice during the approach to the cerebellopontine angle to avoid complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">15&#44;21&#8211;26</span></a> Every neurosurgeon knows the importance to respect as much as possible the venous drainage system&#44; in particular during the approach to the cerebellopontine angle to avoid complications such as swelling and venous infarction&#58; thus&#44; that is why we always try to preserve the superficial petrosal vein complex&#46; But&#44; unfortunately&#44; the superior venous system is a risky obstacle to reach the trigeminal root in the microvascular decompression and In 8 of our 10 cases we had to sacrifice this venous system for two principal reasons&#58; because they obstruct the lane to widen exposure to the trigeminal root without inadvertent damage and risks of profuse bleeding&#44; and because some of them played a role in the neurovascular conflict&#46; Venous sacrifice in the cerebellopontine angle is a contentious issue&#44; with unpredictable consequences&#46; In our experience&#44; except one case in this study&#44; these venous sacrifices did not entail any clinical relevance&#46; The temporary occlusion test described by Zhong et al&#46; was negative in 91&#46;4&#37; of their cases&#44; cutting the vein in these test-negative patients made the operation easy and offered a satisfactory decompression&#46; According to McLaughlin et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">11</span></a> the petrosal complex anatomy can be quite variable and these veins are not always divided&#44; but can be sectioned with impunity without venous complications&#46; Despite this&#44; several complications have been described related to venous coagulation and cutting of the superior petrosal venous system as peduncular hallucinosis&#44;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">27</span></a> cerebellar swelling<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">28</span></a> and cerebellar&#44; brainstem and brain infarction&#46; Nevertheless&#44; cerebellar venous infarction after sacrifice of the superior petrosal vein &#40;SPV&#41; appears to be very rare&#46; In the series of Pathmanaban et al&#46; in which 184 patients had SPV sacrifice&#44; did not identify any case&#44; and the risk is likely to be less than 0&#46;5&#37;&#46; In our complicated case 3 we attribute the mechanism responsible for cerebellar edema to the incorrect head positioning&#44; long operative time with cerebellar retractor spatula looking for the bleeding point and final hemostasis&#44; and for the sacrifice of the superior petrosal vein&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The implications of veins at the source of classical TN have not been universally accepted&#44; probably due to its high variability and because sometimes are difficult to demonstrate its implications in neurovascular conflict&#44; speculating for different mechanisms in the pathogenesis of the neuralgia other than neurovascular conflict&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">29</span></a> Nevertheless&#44; some expert authors recently gave importance to the veins as cause TN and the outcome after their microvascular decompression&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">7&#44;30&#8211;32</span></a> There is a great variability in the frequency on finding a vein an isolated cause of TR compression&#46; In the bigger series&#44; the rate of only venous conflicting vessel ranged from 8&#46;9&#37; to 23&#46;6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">33</span></a> 8 of our 52 MVD cases had exclusively a venous contact with TR&#44; which means a 15&#46;38&#37;&#44; but in two of our cases we could not find any vascular contact &#40;3&#46;8&#37;&#41;&#46; Compressing veins are located in a wider area than arteries&#44; and the most common contact are in the distal portion of TR&#44; predominantly around the porus trigemini&#46; Inoue et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">32</span></a> proposed an anatomical and practical classification in four types of the veins possibilities location in relation with TR contact&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A prominent suprameatal petrous bone can obscure the vision of the porus trigemini and blocks the view of the Meckel&#39;s segment of the trigeminal root&#44; as in our case 10 &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Named by Rhoton suprameatal tubercle&#44; this can be drilled away if wider access is needed to increase surgical work space&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">15</span></a> Anatomically&#44; an increase exposure of the TR has been reported in more than 10<span class="elsevierStyleHsp" style=""></span>mm after drilling the suprameatal tubercle&#46; This technique&#44; first described and called by Samii et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">16</span></a> &#8220;retrosigmoid intradural suprameatal approach&#8221; &#40;RISA&#41;&#44; was in our case very useful to increase the space in this narrow area to expose a venous grade II TR compression&#44; and decompress the root after coagulating and sectioning the vein &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">When</span><p id="par0120" class="elsevierStylePara elsevierViewall">Trigeminal root massage is not an alternative to microvascular decompression&#44; it is just a complementary and simple maneuver during microsurgical exploration of the trigeminal root without a clear neurovascular compromise&#44; avoiding other options such as partial sensory rhizotomy or more complicated and time consuming like nerve combing&#46; When arterial compression is not evident during microsurgical exploration of the trigeminal root in the superior cerebellar-pontine cistern&#44; the neurosurgeon is in an engaged situation&#44; because there are not well-established surgical strategies&#46; To improve the operative outcomes in these cases&#44; some authors have tried to refine the operative techniques and paid great attention to patient selection for MVD&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">32&#44;34</span></a> We use trigeminal root massage as the final step of the decompressive exploration of the TR only in cases without arterial contact and after trigeminal root liberation from the adhesive arachnoidal and&#47;or venous compression&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">MR imaging is useful in evaluating neurovascular conflict of the trigeminal nerve at the REZ and helpful as a preoperative tool when trigeminal neuralgia is diagnosed by patients&#8217; records&#46; During the last years&#44; high-resolution MRI techniques and different sequences as 3D-T2&#44; 3D-TOF and 3D-T1 with gadolinium&#44; have been developed to detect the offending vessel&#40;s&#41; in patients with neurovascular compression and trigeminal neuralgia&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">35</span></a> This is important preoperative information for better selection of patients for arterial MVD&#44; but not in most cases of venous contact or with simple arachnoid adhesions in which the MRI cannot detect a clear neurovascular contact&#44; these symptomatic patients can also benefit from trigeminal nerve microsurgical exploration&#46; Even more&#44; the absence of vascular compression in patients with trigeminal neuralgia has been described in the literature and the existence of cases without vascular conflict&#44; which were cured after MVD complicated the dilemma&#46; On the other hand&#44; vascular compression of the trigeminal nerve is a frequent anatomical variant and MRI finding in people with no symptoms of trigeminal neuralgia&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">36&#8211;38</span></a> That is why we think that based only on MRI images&#44; this is not enough to decide surgical indication for MVD&#44; because trigeminal neuralgia is a clinical diagnosis that does not depend exclusively on the presence of imaging of neurovascular conflict&#46; According to Rasche et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">29</span></a> the decision for microvascular decompression operation is still based on clinical findings and not on neuroradiological findings&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">How</span><p id="par0130" class="elsevierStylePara elsevierViewall">How to deal with the TN patients without trigeminal root arterial compression or with venous neurovascular conflict is a challenge for all neurosurgeons&#46; There are some surgical options depending on the operative findings&#46; The most simple is a wide opening of the arachnoid adhesions to free the root&#44; in some cases very adherent to the TR&#46; But if a trigeminal root venous compression exists&#44; the indication and management for these veins is still controversial&#46; The decision to coagulate and cut the vein&#47;s is risky&#59; nevertheless it is an alternative choice for venous cases&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">32</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Rogelio Revuelta et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">7</span></a> described his technique in 3 steps&#58; first&#44; a meticulous dissection of the arachnoid to expose the entire trigeminal root&#44; followed by slight compression &#40;neuroapraxia&#41; with bipolar tips on the trigeminal REZ &#40;second step&#41;&#44; and finally&#44; the third step was the isolation of the TR with fragments of Teflon&#46; Such a technique has been used by other authors&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">34</span></a> Our TRM procedure is similar&#58; after arachnoid trigeminal liberation and compressive vein coagulation and section&#44; we apply a slight gentle intermittent compressive massage along the length of the trigeminal root three or four times with the microforceps or the microdissector&#44; but we ended up with the second step&#44; after the final root massage&#44; without interposing any material implant&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Partial sensory rhizotomy &#40;PSR&#41; is a classical alternative technique used in absence of arterial contact&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">9&#44;39</span></a> The outcome of PSR reported by Young and Wilkins was excellent in 48&#37; of patients&#44; good in 22&#37; and poor in 30&#37;&#44; and the failure rate was 17&#37; for the 1<span class="elsevierStyleSup">st</span> year&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">39</span></a> Sensory loss is an inevitable and irreversible side effect after PSR and it has been reported to a lesser degree of patient satisfaction&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">1</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Another option is nerve combing&#44; also called internal neurolysis&#44; is a procedure in which all or portions of the trigeminal nerve are divided longitudinally by microneedle along its fibers into several fascicles between the pons and the porus trigemini&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">10&#44;40</span></a> Postoperative numbness and facial hypoesthesia is consubstantial with the combing technique&#44; carries the risk of anesthesia dolorosa and the rate of dysesthesias or deafferentation pain is 16&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">10&#44;40</span></a> Comparing to these techniques&#44; we have no case of postoperative anesthesia dolorosa whatsoever&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Why</span><p id="par0150" class="elsevierStylePara elsevierViewall">Based on the proposed mechanisms of production of trigeminal neuralgia related to the compression of the sensitive trigeminal root of the 5<span class="elsevierStyleSup">th</span> nerve in its intracranial route&#44; non-destructive open surgical techniques have historically been directed toward a decompression of the trigeminal nerve at some point in its intracranial trajectory&#46; In 1955&#44; Shelden et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">41</span></a> advised that the common denominator to all procedures is operative trauma&#44; introducing a new technique such as pressing with a blunt dissector the portio major nerve fibers of the trigeminal nerve surgically exposed through a middle cranial fossa approach&#44; suggesting that the compression of the trigeminal fibers during the operation is the factor that relieves the pain&#46; Jannetta using microneurosurgical techniques&#44; considers that vascular compression of the trigeminal root is the principle cause of TN&#44; expanded the concept of this neurovascular compression theory&#44; popularizing the MVD operation procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">11</span></a> Since then&#44; some authors&#44; skeptical and critical of the microvascular decompression procedure&#44; started a controversial discussion and hypothesis about the mechanisms of trigeminal pain disappearance after the MVD operation and suggests an alternative view as surgical trauma&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">8&#44;42</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Without getting into sterile controversies and in these cases without a clear arterial TR compression&#44; and always after a careful trigeminal root liberation from the adhesive arachnoidal and&#47;or venous compromise&#44; we used the final maneuver of gentle TR intermittent compression called massage for some reasons&#46; Mainly because after surgery the trigeminal pain immediately disappears and we considered that a little microsurgical manipulation of the TR can have an effect for initial pain disappearance&#44; while the TR arachnoidal and venous decompression can influence in maintaining long term pain relief&#46; TRM avoids the definitive and irreversible trigeminal nerve side effects such as facial sensory loss produced by other techniques such as rhizotomy&#46; And finally&#44; because it allows other types of surgery if there is pain recurrence&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In summary&#44; whatever mechanism makes the trigeminal neuralgia disappear&#44; one of the best moments for the patient and for the neurosurgeon is when the patient awakes from the anesthesia without trigeminal pain and free of symptoms&#58; that is the most satisfactory moment after MVD and TRM&#44; which we always try to achieve in cases without TR arterial compression&#46; But also we always take into consideration in the patient&#39;s satisfaction and the final results throughout the next few years&#44; because we know that only 60&#37; of our cases have excellent results after a average follow-up of 5 years&#58; which means that there are no perfect surgical techniques at the moment for permanent cure of trigeminal neuralgia without arterial compression&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusion</span><p id="par0165" class="elsevierStylePara elsevierViewall">The Trigeminal Root Massage &#40;TRM&#41; is a useful and simple alternative in cases of MVD without a clear arterial compression of the trigeminal root&#44; with similar results in the short and long terms than other possibilities such as partial sensory rhizotomy or more complicated and time consuming surgery such as nerve combing&#46; Only a 60&#37; of excellent results after 5 years mean that is a good alternative&#44; but not a definitive technique at the moment for permanent cure of trigeminal neuralgia without arterial compression&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Funding</span><p id="par0170" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Disclosures</span><p id="par0175" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflict of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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    "fechaRecibido" => "2019-06-04"
    "fechaAceptado" => "2019-07-31"
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            0 => "Trigeminal neuralgia"
            1 => "Microvascular decompression"
            2 => "Trigeminal root&#46;massage"
            3 => "Venous compression"
            4 => "Petrosal venous system"
            5 => "Pain"
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          "clase" => "abr"
          "titulo" => "Abbreviations"
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            0 => "MVD"
            1 => "TN"
            2 => "TR"
            3 => "TRM"
            4 => "REZ"
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            0 => "Neuralgia del trig&#233;mino"
            1 => "Descompresi&#243;n microvascular"
            2 => "Masaje de la ra&#237;z trigeminal"
            3 => "Compresi&#243;n venosa"
            4 => "Sistema venoso petroso"
            5 => "Dolor"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">During the microsurgical exploration of trigeminal root in the pontocerebellar angle in patients with primary trigeminal neuralgia &#40;TN&#41; without an evident arterial compression&#44; the surgeon is in an engaged situation because there are not well-established surgical strategies&#46; The aim of this study is to describe in these cases the surgical maneuver we call &#8220;trigeminal root massage&#8221; &#40;TRM&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">52 consecutive patients with primary trigeminal neuralgia who had undergone a microsurgical suboccipital retrosigmoid exploration of trigeminal root were reviewed&#46; Among them we found 10 patients without an evident arterial compression after a thorough microsurgical exploration&#46; In the great majority of these 10 cases&#44; we noticed a venous contact to the trigeminal root along this cisternal trajectory&#44; in most cases we have had to coagulate the compressive vein&#47;s and then cut&#46; All underwent a simple trigeminal root massage&#44; without interposition of any material implant&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All 10 patients experienced immediate pain disappearance and the postoperative course was uneventful except one case with a severe complication&#58; cerebellar swelling&#44; meningitis and hydrocephaly&#46; The recurrence rate was 40&#37;&#46; Six patients achieved pain relief without specific medication with an average follow-up period of 5 years&#46; There have been no mortalities nor any postoperative anesthesia dolorosa&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The described maneuver provides an easy and simple alternative way in cases where during a microsurgical exploration of trigeminal root&#44; where we don&#8217;t find a clear arterial compression&#44; with similar results than other possibilities such as partial sensory rhizotomy or more complicated and time consuming surgery as &#8220;nerve combing&#8221;&#46; Nevertheless&#44; a 40&#37; of pain recurrence after an average follow-up of 5 years means that is a good alternative&#44; but not a definitive technique at the moment for permanent cure of trigeminal neuralgia without arterial compression&#46;</p></span>"
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          0 => array:2 [
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            "titulo" => "Background"
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          1 => array:2 [
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            "titulo" => "Methods"
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          2 => array:2 [
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Durante la exploraci&#243;n microquir&#250;rgica de la ra&#237;z trigeminal en el &#225;ngulo pontocerebeloso en pacientes con neuralgia del trig&#233;mino &#40;NT&#41; primaria sin una evidente compresi&#243;n arterial&#44; el cirujano se encuentra en una situaci&#243;n comprometida&#44; ya que no existe una estrategia quir&#250;rgica establecida&#46; El objetivo de este estudio es la de describir en esos casos una maniobra quir&#250;rgica que llamamos &#171;masaje de la ra&#237;z trigeminal&#187; &#40;MRT&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se revisan un total de 52 pacientes consecutivos con NT primaria a quienes se ha realizado una exploraci&#243;n de la ra&#237;z trigeminal por v&#237;a suboccipital retrosigmoidea&#46; Entre ellos hemos encontrado 10 pacientes sin una evidente compresi&#243;n arterial durante la exploraci&#243;n microquir&#250;rgica&#46; En 8 de los 10 casos ha existido un contacto venoso de la ra&#237;z trigeminal a lo largo de su trayectoria cisternal&#44; procediendo a la coagulaci&#243;n y secci&#243;n de la&#47;s vena&#47;s&#46; En los 10 casos se ha procedido&#44; finalmente&#44; a un suave masaje de la ra&#237;z trigeminal sin interposici&#243;n de ning&#250;n material&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los 10 pacientes experimentaron una inmediata desaparici&#243;n de la neuralgia y el curso postoperatorio fue favorable excepto por un caso de complicaci&#243;n severa con edema cerebeloso&#44; meningitis e hidrocefalia&#46; La recidiva fue del 40&#37;&#46; Seis pacientes obtuvieron una desaparici&#243;n completa de la neuralgia&#44; sin medicaci&#243;n espec&#237;fica&#44; en un seguimiento medio de 5 a&#241;os&#46; No ha habido mortalidad ni anestesia dolorosa postoperatoria&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La maniobra quir&#250;rgica descrita es una alternativa &#250;til y sencilla en casos donde&#44; durante la exploraci&#243;n microquir&#250;rgica de la ra&#237;z trigeminal&#44; no encontramos una clara compresi&#243;n arterial&#44; con resultados similares a otras posibilidades como la rizotom&#237;a parcial o m&#225;s laboriosas como la llamada <span class="elsevierStyleItalic">nerve combing&#46;</span> En cualquier caso&#44; un 40&#37; de recidiva dolorosa a los 5 a&#241;os significa que&#44; aunque es una buena alternativa&#44; no es una t&#233;cnica definitiva en la curaci&#243;n de todos los enfermos con NT sin conflicto arterial&#46;</p></span>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Case 6&#46; Patient position and intraoperative neuromonitoring&#46; Different steps microsurgery technique&#46; Leyends &#40;more description&#41; in the text&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Case 7&#46; Intraoperative photographs in a patient without any vascular contact&#46; &#40;A&#41; The entire course of the cisternal TR is exposed after arachnoidal resection&#46; &#40;B&#41; Final trigeminal root massage was used with microdissector&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Case 1&#46; Patient in semisitting position&#46; &#40;A&#41; Photograph showing a thick arachnoidal adhesions &#40;Arach&#46; Adh&#46;&#41; covering the V nerve and compressive grade III deep superior petrosal venous system &#40;dSPVS&#41;&#46; r&#58; retractor&#46; &#40;B and C&#41; dSPVS veins coagulation&#46; &#40;D&#41; Indentation of the V nerve with grayish color&#46; E and F&#58; final trigeminal root massage with microdissector&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Case 10&#46; A big tubercle prominence was found &#40;arrow&#41; and drilled away &#40;B and C&#41; to expose a dPVS compressing the V nerve&#46; &#40;E&#41; Coagulation and cutting the vein&#46; &#40;F&#41; Gentle intermittent trigeminal root massage with the microforceps&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Case 2&#46; Operative photos &#40;from videoclip&#41;&#46; After arachnoidal dissection a sSPVS grade I interposing the direct vision of V nerve&#46; &#40;B&#41; Vein coagulation and dividing&#46; &#40;C&#41; TRM maneuver&#46; &#40;D&#41; Final vision of the field&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Case 4&#46; &#40;A&#41; Preoperative MRI image without evidence of vascular contact&#46; &#40;B&#41; sSPVS compressive grade II&#46; &#40;C and D&#41; Vein coagulation and section&#46; &#40;E and F&#41; Final trigeminal root massage &#40;arrows&#41; with microdissector&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age and sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">TN duration &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Side &#38; location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Previous operation No&#46; &#38; type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#46; V2&#8211;V3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 RT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Typical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">L&#46; V2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Atypical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">L&#46; V2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Typical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#46; V2&#8211;V3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Typical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#46; V2&#8211;V3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Typical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">L&#46; V2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Typical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">L&#46; V2&#8211;V3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Atypical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">L&#46; V1&#8211;V2&#8211;V3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 RT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Typical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">L&#46; V2&#8211;V3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Typical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">L&#46; V1&#8211;V2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Per&#46; Bot&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Typical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2253392.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics of 10 patients who underwent trigeminal root massage&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">sSPVS&#58; superficial superior petrosal vein&#46; dSPVS&#58; deep superior petrosal vein system&#46; Arach&#46; Adh&#46;&#58; Arachnoid adhesions&#44; VCC&#58; vein coagulation and cutting&#46; TRM&#58; trigeminal root massage&#46; Cer&#46; Swelling&#58; cerebellar swelling&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intraop&#46; features &#40;Sindou clas&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Treatment modality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Immediate postop&#46; pain relief&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complic&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Length of stay &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recurrence &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Outcome &#40;Kondo classif&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Follow-up duration &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">sSPVS IIIdSPVS III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VCC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TRM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excellent T-0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">sSPVS I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VCC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TRM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fair T-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">sSPVS IIArach&#46; Adh&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VCC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TRM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes Cer&#46;Swelling&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Good T-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">sSPVS IIArach&#46; Adh&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VCC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TRM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excellent T-0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">sSPVS I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VCC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TRM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excellent T-0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">sSPVS IdSPVS IArach&#46; Adh&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VCC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TRM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excellent T-0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Arach&#46; Adh&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TRM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes 4 m&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Poor T-3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Arach&#46; Adh&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TRM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excellent T-0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">sSPVS I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">VCC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TRM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes 3<span class="elsevierStyleHsp" style=""></span>m&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Absence of neurovascular conflict during microvascular decompression while treating essential trigeminal neuralgia How to proceed&#63;&#46; Systematic review of literature"
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                        0 => array:2 [
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                    0 => array:2 [
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                      "autores" => array:1 [
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                          "etal" => false
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Información del artículo

ISSN: 11301473
Idioma original: Inglés

DOI:10.1016/j.neucir.2019.07.003

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