Hello, and welcome to a case report of disequilibrium secondary to retromastoid craniectomy and microvascular decompression for refractory trigeminal neuralgia. My name is George Schilling, and I'm a third-year PMNR resident at East Carolina University. Our patient presented with a 20-year history of progressively worsening pain from trigeminal neuralgia, which had thus far been refractory to all attempted pharmaceutical interventions and modalities, including carbamazepine, baclofen, amyotryptaline, pregabalin, phenytoin, and B12 injections. Brain stereotactic radiosurgery resulted in worsening of symptomatology. As a result, the patient underwent retromastoid craniectomy and microvascular decompression, MVD, of cranial nerve 5, with immediate resolution of his pain. Postoperatively, the patient experienced new-onset disequilibrium. He was admitted to inpatient rehab, where several of his chronic pain medications were tapered. The patient underwent therapies for disequilibrium in order to be discharged to a safe level of supervision at home. Postoperative MRI was significant for surgical material at the left cerebellar pontine angle, as well as expected postoperative subarachnoid and subdural gas. The patient had no exacerbation of pain upon palpation of the left cranial nerve 5 sensory distribution, whereas previously his pain was severe at rest. The top image shows the postoperative MRI, which was significant for the cotinoid rolls found at the left cerebellar pontine angle, adjacent to the cisternal segment of the left trigeminal nerve. Bottom images are provided by Mayfield Brain and Spine at Cincinnati, Ohio, and describe the procedure taking place. The craniectomy site is located posterior to the ear. The vascular compression in this image is the superior cerebellar artery, but in our patient it was the superior pterosal vein, which is often the culprit for cranial nerve 5 compression. The final image shows the placement of the surgical material to continue further vascular decompression. Disequilibrium is a rare prosurgical complication of MVD for tragendinal neuralgia. This can occur due to the close proximity of the cerebellar pontine angle. Patients are at a high risk for falls at home if discharged without treatment of their decreased balance. Inpatient rehabilitation is important for a safe transition home and community to prevent further complications. In this patient, MVD has shown to be an extremely effective treatment for tragendinal neuralgia as his chronic pain medications were tapered down during his inpatient rehabilitation course. Again, my name is George Schilling and thank you for joining us.

refractory trigeminal neuralgia

retromastoid craniectomy

microvascular decompression

disequilibrium

inpatient rehabilitation