British Journal of Neurosurgery

ISSN: 0268-8697 (Print) 1360-046X (Online) Journal homepage: http://www.tandfonline.com/loi/ibjn20

Long-term outcome of microvascular

decompression for hemifacial spasm

Ming-Yi Lv, Shu-Ling Deng, Xiao-Feng Long & Zeng-Liang Liu

To cite this article: Ming-Yi Lv, Shu-Ling Deng, Xiao-Feng Long & Zeng-Liang Liu (2017):
Long-term outcome of microvascular decompression for hemifacial spasm, British Journal of
Neurosurgery, DOI: 10.1080/02688697.2017.1297368

To link to this article: http://dx.doi.org/10.1080/02688697.2017.1297368

Published online: 13 Mar 2017.

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BRITISH JOURNAL OF NEUROSURGERY, 2017
http://dx.doi.org/10.1080/02688697.2017.1297368

ORIGINAL ARTICLE

Long-term outcome of microvascular decompression for hemifacial spasm

Ming-Yi Lva, Shu-Ling Denga, Xiao-Feng Longa and Zeng-Liang Liub
a
Department of Internal Medicine, ICU, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, P.R. China; bDepartment of
Neurosurgery, The Second Affiliated Hospital, Qiqihar Medical College, Qiqihar, P.R. China

ABSTRACT ARTICLE HISTORY

Aim: To investigate the long term outcomes of microvascular decompression (MVD) for hemifacial spasm Received 11 March 2016
(HFS) and to identify any prognostic factors. Revised 4 February 2017
Methods: A retrospective analysis of 189 consecutive patients with typical HFS who underwent MVD. Accepted 10 February 2017
Multiple logistic regression analysis of variables at various time points including at least immediate time
point and one at no less than six years was performed. KEYWORDS
Results: Short-term follow-up showed a cure rate of 91%, including 51 cases of delayed resolution (27%). Hemifacial spasm;
At two years or more information was available in 148 (out of 189) cases of patients. 101 cases (68% - of Microvascular decompres-
148 cases) had complete recovery, 28 cases (19%) achieved a partial though worthwhile recovery, so that sion; Follow-up;
the effective rate of symptoms relief at six years was 87%. Complications were found (66/189, 34.92%) and Intraoperative indentation
cured within the follow-up period (cure rate of 100%). In both the univariate and multivariate analyses, the of the root exit zone
postoperative findings of clinical outcomes showed that preoperative illness duration, compressive pattern,
the intraoperative indentation of the root exit zone (REZ) of the facial nerve and intraoperative AMR dis-
appearance were negative predictors and age considered to be positive, which significantly predicted the
clinical outcome of patients following MVD.
Conclusions: MVD may be a safe and effective strategy for HFS patients in view of relatively higher cure
rates and lower complication risks within follow-up. Besides, patients’ age, duration of disease, intraopera-
tive indentation of the REZ of the facial nerve, and disappearance of AMR were the major influential varia-
bles may be useful for the prediction of prognosis in the patients underwent MVD.

Introduction
Hemifacial spasm (HFS) is a form of segmental myoclonus asso-
ciated with pulsatile vascular compression upon the facial nerve
root exit zone.1,2 It is more common in middle aged and elderly
individuals, and has been observed to affect women chiefly, and
also more common in Asians.3,4 About 8 0
90% cases of HFS
are associated with arterial compression in the facial nerve at the
end of the brain stem.5 Meanwhile, secondary HFS is associated
with extrinsic factors such as tumors, demyelination, trauma, or
infection.6 The clinical manifestations comprise paroxysmal,
involuntary twitches of the unilateral facial muscles, and when
more serious causing severe muscle spasms. Emotional and men-
tal stress, anxiety and facial autonomic activities may aggravate
the condition.7 HFS is progressive, and gradually involves the
entire side of the face, and be complicated by facial pain, numb-
ness, decreased vision, hearing loss or even deafness, significantly
and seriously affecting normal life and work.8,9 At present, whilst
there is no definite theory about the pathogenesis and the exact
mechanism of HFS, vascular compression is widely accepted to
play a significant role.10–12
In the 1960s, Gardner first adopted vascular decompression
for treatment of HFS and proposed the etiology of vascular com-
pression.13 Afterwards, Jannetta pioneered the development of
microvascular decompression (MVD) in treating HFS,14 aims at
decompressing the offending vessels and also at freeing the entire
root to the root entry zone (REZ) of the facial nerve.15 Jannetta
also put forward a hypothesis that the central cause of HFS a vas-
cular compression of the facial nerve out of the brainstem at its
REZ, leading to cross transmission of impulses is across nerve
fibres.16 The procedure of MVD may contribute to the relief of
pressure on the facial nerve, reversing this pathology leading to
excellent to good long term results of MVD reported.12,17,18
However and importantly, although HFS is nonfatal, MVD is still
an invasive major procedure so there is risk to life or of stroke
albeit small; of failure or recurrence and of more common com-
plications including risks of facial palsy and to hearing.19,20
Therefore, this study was designed to evaluate the clinical thera-
peutic outcomes of MVD for HFS in a relatively long follow-up
period of six years and to identify potential influential factors, so
as to provide information for better pre-operative counseling of
patients.
Materials and methods
Ethical statement
The present study was approved by the ethics committee of
Affiliated Zhongshan Hospital of Dalian University and adhered
to the tenets of the Declaration of Helsinki. Additionally written
informed consent was obtained from all the eligible subjects prior
to the start of the experiment.

CONTACT Xiao-Feng Long longxiaofeng88@sina.cn Department of internal medicine, ICU, Affiliated Zhongshan Hospital of Dalian University, No 6 Jiefang
Street, Zhongshan District, Dalian, 116000, Liaoning Province, P.R. China
ß 2017 The Neurosurgical Foundation
2 M.-Y. LV ET AL.
Patients’ selection
From March 2008 to June 2010, a total of 189 consecutive
patients with typical HFS who underwent MVD were included in
the study, without the inclusion of HFS patients who did not
receive MVD (n ¼ 66). Before operation, all patients underwent
thin-slice MRI scanning to exclude the possibility of secondary
HFS or the risk of potential tumors. Inclusion criteria for patients
who can be treated by surgery: (1) patients who had a general
good condition; (2) patients who had a definite diagnosis of HFS;
(3) patients who were willing to receive operative treatment and
had surgical indications of MVD; (4) patients aged less than 75
years old; (5) patients without obvious surgical contraindications;
(6) patients with no positive signs of nervous system characteris-
tics except the facial spasm; (7) patients with complete clinical
information recording and who were willing to cooperate with
complete efficacy evaluation and the follow-up. Importantly, all
patients received MRI examination to verify the existence of
indentation of REZ (medullary root entry zone were oppressed
by ectopic blood vessels), and secondary HFS (cause of external
force such as cerebral vascular diseases and tumor occupying,
etc.) was also excluded from preoperative MRI examination.
Exclusion criteria were also preset as follows: (1) patients who
aged over 75 years old; (2) patients who had obvious craniotomy
contraindications such as decreased cardiac and pulmonary func-
tion and other important organ diseases; (3) patients with sec-
ondary HFS induced by malignant tumor attack and/or
administration of certain drugs, or patients with untypical clinical
symptoms of HFS that cannot be diagnosed; (4) patients who
have serious systemic diseases or secondary to tumors, and who
were unwilling to be treated with operation; (5) Patients who
underwent re-operation.; (6) patients who lost to followed up and
who were unwilling to be followed. The method for determining
the degree of HFS was according to the classification standard
mentioned by Shorr N et al.21 regarding spasticity severity.
Patients’ general information, chief complaint, present illness,
past history were registered preoperatively carefully.
Operative procedure
The REZ of the facial nerve was then exposed and target vessels
identified. Soft Teflon of the appropriate size was used to separate
blood vessels from the adjacent brain stem and to avoid contact
with the nerve. When there was no compression a direct sharp
separation of arachnoid membranes was performed to that a full
release of the facial nerve and surrounding adhesions was
achieved. Intraoperative monitoring of abnormal muscle response
(AMR) was undertaken using a Cadwell-based intraoperative
neurophysiology system (stimulus parameter: wave width of
0.1ms, frequency of 1 Hz, stimulus intensity of 5
30 mA, and
recorded filter range of 3
3000 Hz). The offending vessels could
be identified if the AMR disappeared.
Outcome evaluation
The follow-up was completed on June 2016 to ensure that all sur-
gical patients have at least two years of recovery period. The
long-term follow-up period was 2 to 6 years in 78.31% of the
patients (148/189), using the method of telephone interview, out-
patient clinic follow-up and dropping-in follow-up during this
period. Follow-up content included: (1) the recovery situation of
HFS in a short-term (postoperative 1 week, follow-up rate of
100%) and long-term follow-up period (available for 2 to 6 years).
Postoperative outcomes evaluation was performed by the special-
ized nurse practitioner who was blinded to the operative details,
and individual clinical information, though not the fact of MVD.
The postoperative result was judged based on to the classification
standard of the degree of spasticity by Shorr N et al.21 (A) com-
plete recovery, symptoms of HFS were completely disappeared
and without recurrence at the end of the follow-up; (B) partial
recovery, the frequency and amplitude of spasm significantly
decreased within half a year after surgery; (C) no relief, symp-
toms of HFS showed no improvement in one year after treat-
ment; (D) recurrence, the symptoms of the patients appeared
again after the disappearance of those symptoms postoperatively,
and indicated no improvement one year after operation. Total
effective rate ¼ complete recovery rate þ partial recovery rate. In
addition, a delayed resolution was predefined as the recurrence of
facial convulsions after the postoperative disappearance of the
symptom at the end of the follow-up period. (2) Postoperative
complications were recorded during and after the operation:
facial paralysis, hearing loss, epimorphosis, tinnitus, cerebrospinal
fluid leakage, posterior cranial nerve injury, intracranial hema-
toma and cerebral infarction. Facial paralysis and hearing loss
were assessed 24 hours after surgery, hearing loss was determined
based on audiologic questions and answers in the telephone fol-
low-up, and delayed hearing loss was confirmed not exceeded the
first month after operation.
Statistical analyses
SPSS software (version 17.0 SPSS Inc., Chicago, IL, USA) was
applied for data analysis in the whole study. Multiple logistic
regression analysis of variables assessed independent influential
factors in HFS patients received MVD treatment. P value of less
than .05 meant statistical difference, and P value of less than .001
referred to significant statistical difference.
Results
General data and clinical outcome of operation
In the study, a total of 189 cases of patients with HFS were
involved for the treatment of MVD. There were 88 cases of males
and 101 cases of females in a female/male ratio of 1.15:1 (mean
age of 46.02 ± 10.11 years old, ranging from 24 to 75 years old).
There were 120 cases of vascular compression based on the detec-
tion results of pre-operative 3D-TOF MRI scan in all patients, a
positive rate of 63%. There were 82 cases of patients with HFS in
the right side of the face, and 107 cases in the left side of the
face. Patients’ duration of disease ranged from 1 years to 22
years, with a mean duration time of 8.8 years. The pre-operative
grades of spasm were grade II of 30 cases, grade III of 49 cases,
and grade IV of 110 cases. At surgery 120 cases showed a positive
compressive pattern at surgery; of these 109 cases of patient
revealed intraoperative indentation. Of the MRI positive cases
(n ¼ 121), 91 cases were positive at surgery – of the MRI negative
cases (n ¼ 68), 18 cases were positive at surgery. The AMR
response was abolished during surgery in 144 cases. There were
51 out of the 189 cases (27%) showed delayed resolution at the
end of the follow-up. The short-term follow-up (postoperative 1
week) rate was complete, with 130 (69%) of patients achieved
complete symptoms recovery, and 42 (22%) patients achieved
partial symptoms recovery, with the total cure rate of 91% and a
failure rate of 9% (Table 1). Long-term follow-up information
revealed that the rate of follow-up was 74%, with 148 cases of
 BRITISH JOURNAL OF NEUROSURGERY 3

patients being followed up successfully, and 101/148 cases (68%) recovered within 1 to 6 months after operation; however 2 cases
achieved complete symptoms recovery, 28/148 cases (19%) were left with permanent facial paralysis. 26/189 cases of patients
achieved partial symptoms recovery, with the effective rate of showed hearing loss, and 19/189 cases showed tinnitus after the
symptoms relief of 87% excluding the cases lost to follow-up. surgery. In 18 cases of patients the hearing loss and in 12 cases
The short-term follow-up of 1 week after operation found that the tinnitus was permanent.
younger age, shorter preoperative illness duration, presence of
compressive pattern, the finding of intraoperative indentation of
Logistic analyses of prognostic factors in the follow-up
REZ and abolition at surgery of the intraoperative AMR pre-
period
dicted better early outcomes (all P < .05) (Table 1).
Using multiple logistic regression analysis on the basis of six
years of follow-up (Table 2), decreasing age, shorter disease dur-
Complications ation, presence of intraoperative indentation of the REZ of the
facial nerve and abolition of the AMR were independent prog-
There was no mortality. In the total number, a few complications
nostic predictors (all P < .05).
cropped up post-surgery in 66 patients (34.92%). To be specific,
cerebrospinal fluid leakage was detected in 5 cases, and were
cured by lumbar catheter drainage. There were no cases of pos- Discussion
terior cranial nerve injury other than to the facial acoustic com-
plex. Intracranial hematoma (n ¼ 2) and cerebral infarction HFS is a commonly seen functional neurological disorder, mainly
(n ¼ 0) occurred early postoperatively, patients recovered well fol- manifested as the paroxysmal involuntary fast twitch of facial
lowing surgical removal of hematoma. And 18 (10%) of cases of muscles of one side of the facial nerves, which is suggested to be
patients showed mild temporary facial weakness which gradually attributed to the compression of intracranial facial nerves at the
REZ of the facial nerve. Through the identification of offending
vessels (the responsible vessels for the compression), the offend-
ing vessels were pushed off during the operation of MVD, hence
Table 1. General information in hemifacial spasm patients underwent micro-
vascular decompression.
the therapeutic purpose can be achieved with the placement of
Teflon between the offending vessels and the REZ of the facial
Short-term efficacy of 1 week
after operation nerve. In the present study, the immediate “effective” cure rate of
MVD in the treatment of HFS was 95% falling to 87% (68%
N Recovery Remission Ineffective P completely symptom free) in the long-term follow-up periods,
Gender (M/F) respectively. However some caution is needed since the long term
M 88 59 19 10 .527
F 101 71 23 7
effective cure rate would fall to 69% if it is assumed that all of
Age (years old) those lost to follow-up relapsed. These results are broadly consist-
24
40 98 68 25 5 ent with previous reports in the same investigation field.22,23 As
41
60 72 56 12 4 <.001 with other studies a significant delayed resolution rate is
>60 19 6 5 8 found-51 cases of patients (26%); therefore any decision over
Affected side
Left 107 71 26 10 .440 re-exploration or other retreatment should not be earlier than 1
Right 82 59 16 7 year post-operatively.22,24
Preoperative illness duration (years) Although good to excellent therapeutic results have been
1
3 99 67 27 5 achieved in the treatment of HFS, underlying mechanisms related
4
10 73 59 10 4 <.001
>10 17 4 5 8 to the pathogenesis of HFS is still needed to be explored in the
Intraoperative degree of spasticity next phase of study. In the present study, based on the recording
Grade II 30 25 4 1 and identification of patients clinical pathological features that
Grade III 49 35 12 2 .079 were hypothesized to be associated with the pathogenesis and
Grade IV 110 70 26 14
Compressive pattern
prognostic outcomes of HFS, univariate and multivariate analyses
With contact 120 100 13 7 <.001 were then conducted based on the short-term and long-term fol-
Without contact 69 30 29 10 low-up period of six years, though the same caution regarding
Intraoperative Indentation of REZ this analysis must be applied with respect to the cases lost to fol-
With 109 98 9 2 <.001
low-up. Finally, our logistic analyses results supported that the
Without 80 32 33 15
Intraoperative AMR monitoring patients age, duration of disease, intraoperative indentation of
Disappearance 144 120 19 5 <.001 the REZ of the facial nerve, and disappearance of AMR were the
Appearance 45 10 23 12 major influential variables that have close association with the
M: male; F: female; AMR: abnormal muscle response; REZ: root entry zone. clinical outcome of HFS patients following MVD. There is no

Table 2. Multiple logistic regression analysis based on long-term follow-up period of six years results in hemifacial spasm patients underwent microvascular
decompression.
95%CI
Estimate Std. Error Wald P Lower Upper
Decreasing age 4.042 1.304 9.606 .002 6.598 1.486
Shorter disease duration 4.606 1.180 15.227 <.001 2.292 6.919
Resence of intraoperative indentation of the REZ of the facial nerve 18.292 2.928 39.041 <.001 24.030 12.554
Abolition of the AMR 1.374 0.671 4.194 .041 0.059 2.689
95%CI: 95% confidence interval; REZ: root entry zone; AMR: abnormal muscle response.
4 M.-Y. LV ET AL.
doubt that younger patients will have a relatively better operation
condition for craniotomy, and also indicate relatively rapid recov-
ery process than those of elderly patients. Meanwhile, with the
extension of the duration of the disease and with aging, the inci-
dence of microvascular complications may significantly increase
accordingly, and hence associated with a relatively poor prognos-
tic outcome. Such results were in line with previous studies,25,26
suggesting that an adoption of MVD treatment should be as early
as possible following a careful evaluation of patients’ condition
and operation condition. Furthermore, prognostic factors influ-
encing the prognostic outcomes of HFS patients managed with
MVD has not been definitely established. Research on the identi-
fication of prognostic factors in patients undergoing MVD will
therefore be critical for better management of the disease and
improve the cure effect. Patients with obvious intraoperative
indentation of the REZ of the facial nerve had relatively better
outcomes than those patients with no or mild indentation of the
REZ. REZ of the facial nerve is located in the front flocculus cer-
ebelli, which is closely related to the origin of the glossopharyn-
geal nerve, the vagus nerve and the accessory nerve.27
Compression or contact between the REZ and offending vessels
at this point is reported as the primary cause of HFS;28 mean-
while, REZ of the facial nerve was an area with complex vascular
structure, detailed understanding of the anatomical structure of
the region, and the development of a reasonable surgical proced-
ure is the key to the success of surgery according to the their
characteristics.29,30 Importantly, the value of the identification of
REZ indentation of the facial nerve induced by the intervention
of an offending vessel lies in the determination of the severity of
vascular compression,31 which indicated the significance of the
determination of optimal operating site for decompression in the
operating room. Possible reason for this is that during the oper-
ation, the presence of REZ indentation of the facial nerve gives
direct evidence that the facial nerve was compressed by the
offending vascular, which is therefore help to the direct identifi-
cation of the cause of compression and conducive to the decom-
pression.32 The finding was similar to this in a previous study
that found that possible prognostic factors included the indenta-
tion of the REZ after MVD in HFS patients, although the factors
associated with HFS were still controversial.32 Meanwhile, Lijima
K and his colleagues conducted a clinical investigation in patients
treated with MVD, their identification supported the idea that
the REZ of the facial nerve was the target in MVD for HFS.33 In
this series the abolition of the AMR was accompanied with a
relatively better cure effect in both short and long term, taking
into account that 25% of cases were lost to long term follow-up.
It appears therefore that assessment of the AMR can help identi-
fication of offending vessels,34–36 direct intraoperative decompres-
sion, and finally helpful to predict the prognosis of MVD in
particular the likelihood of delayed resolution of the HFS.
Meanwhile, even though there were previous evidence strength-
ened the value of monitoring compressive pattern in predicting
surgical outcomes,37,38 there was a relatively low rate of positivity
of cases showing vascular compression coming to surgery, indi-
cating that there are still worthy of consideration of the predictive
value of vascular compression in later work with the incorpor-
ation of more samples.
In conclusion, MVD may be a safe and effective strategy for
HFS patients in view of relatively higher cure rates and lower
complication risks within follow-up. Patients’ age, duration of
disease, intraoperative indentation of the REZ of the facial nerve,
and disappearance of AMR were the major influential variables
may be useful for the prediction of prognosis in the patients
underwent MVD.
Disclosure statement
The authors have declared that no competing interests exist.
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