Acta Neurochirurgica (2026) 168:62
This surgical how-to describes microvascular decompression (MVD) for vago‑glossopharyngeal neuralgia, detailing patient selection, imaging requirements, anesthesia, positioning, and a retrosigmoid infrafloccular approach to expose the IX–X root entry zones. It emphasizes preoperative high-resolution MRI identification of neurovascular conflict—most often PICA or vertebrobasilar compression—and perioperative neurophysiological monitoring.
The technique section outlines stepwise microsurgical maneuvers: arachnoid dissection, vessel mobilization or transposition, cautious Teflon interposition when needed, hemostasis, watertight closure, and targeted postoperative surveillance for dysphagia, hoarseness, CSF leak, and other complications. Practical tips for avoiding complications and key informed‑consent elements are provided.
Vago-Glossopharyngeal Neuralgia (VGN): Rare craniofacial pain syndrome (<1% of facial pain cases), often caused by neurovascular conflict involving the posterior inferior cerebellar artery (PICA) and sometimes the vertebrobasilar artery.
Clinical Features: Characterized by paroxysmal, lancinating pain in the oropharynx, tonsillar fossa, base of tongue, or deep ear canal, typically triggered by swallowing, talking, or coughing.
Diagnosis: High-resolution MRI (T2-weighted CISS/FIESTA/DRIVE, 3D TOF angiography) is mandatory to demonstrate neurovascular conflict and guide surgical planning.
First-line Surgical Treatment: Microvascular decompression (MVD) is the most effective and durable option for drug-refractory VGN, aiming to relieve neurovascular conflict without damaging nerve rootlets.
Surgical Approach: Keyhole retrosigmoid craniectomy with infrafloccular approach exposes the root entry zone of cranial nerves IX and X; careful arachnoid dissection and vessel mobilization or Teflon interposition are performed.
Intraoperative Considerations: Intraoperative neuromonitoring of lower cranial nerves is recommended to minimize risk of postoperative deficits such as dysphagia or hoarseness.
Complications: Main risks include transient dysphagia, hoarseness, or lower cranial nerve palsies, which are usually temporary and resolve within three months.
Outcomes: MVD offers superior and lasting pain relief with functional preservation compared to ablative procedures, making it the preferred surgical option.
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