Turkish Neurosiirgery 6: 108 - 110, 1996

TECHNIQUE, INSTRUMENTATION, MATERIALS

Caiier: Gore- Tex ii! Neiirosiirgery

Use of Gore-Tex•in N eurosurgical Practice

Nörosirürjide Gore-Tex Kullanimi

HAKAN CANER, NUR AL TINÖRS, AHMET ALBA YRAK, TARKAN ÇALISANELLER

Baskent University Hospital, Department of Neurosurgery, Ankara, Turkey

Abstract: Five patients in whose surgical interventionsGore-Tex graft has been used for various reasons arepresented.Key Words:Gore-Tex surgical membrane, hemifacialspasm, magnetic resonance imaging, tethered spinal cord,trigeminal neuralgia

INTRODUCTION

Gare- Tex surgical membrane is apalytetrafluaroethylene which was develaped farcardiavascular surgery ta prevent tissue adhesians(5,10,11). Gare-Tex is alsa used as a vasculargraft.These nanabsarbable grafts have innerdiameters af 3-10 mm and are resistant ta the spreadaf infectian.

CASE REPORTS

Cas e 1: A 73 year ald male was haspitalizedfar severe left hemifacial spasm including the eye andmauth. His medical histary included twa aperatiansin anather center far hemifacial spasm. Hemifacialspasm, trigeminal neuralgia and trigeminal pain haddevelaped shartly after the secand aperatian in April1992.On examinatian, frequent hemifacial spasm (3­4/minute) was nated. Left facial paralysis was alsaevident. His gaze was full and the fifth nerve wasintad. Magnetic resanance angiagram revealed astenatic segment in the right distal vertebralarteryThe basilar and left vertebral arteries seemed

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Özet: Cerrahi tedavilerinde degisik amaçlarlaGore- Tex cerrahi membrani kullanilan bes hastabildirilmistir.Anahtar Sözcükler: Gergin omurilik, Gore-Tex cerrahimembran, hemifasiyal spazm, manyetik rezonansgörüntülerne, trigeminal nevralji

dilated and had clase relatianship with the seventhnerve in the cerebellapantine angle. The patient wasaperated an in January 16,1995.The facial nerve,surraunded by cerebellar gliatic tissue, was isalatedby micradissectianThe arterial laap campressing thenerve fram abave and belaw and anather fine arterial

branch lying campletely an the nerve weredecampressed by placement af three pieces af Gare­Tex vascular graft. Pastaperatively hemifacial spasmresolved campletely in twa weeks with imprayementaf fadal paralysis and relief af trigeminal pain.

Case 2: A 40 year ald male patient camplainedaf an electric shack-like sensatian aver the right sideaf his face which had be en refractary ta medicaltherapy. Cranial magnetic resanance imaging (MRI)and neuralagic examinatian were narrnaL. He wasaperated an in Octaber 31,1995. Through a rightretrosigmaid approach the cerebellapantine anglewas explaredThe arachnaid aver the fifth nerve wasmarkedly thickened and the nerve shawed adhesianta a vein crassing it.The adhesians were carefullydissected and the relatian between the trigeminalnerve and the ve in was terminated by placing a piece

Tiirkish Neiirosurgery 6: 108 - 110, 1996

of Gore-Tex in between. Postoperatively the patientwas completely free of his complaints.

Cas e 3: A 25 year old male had suffered agunshot wound in his left arm six months ago. Hehad received no treatment. He was admitted to our

hospital due to the atrophy of the left forearm. Onphysical examination the entran ce and exit woundsof the bullet were evident above the elbow. Pulse over

the axillary ar tery was normal, but was absent distalto the axillary artery. Motor and sensory findingswere consistent with median and ulnar nerve lesions

along with 3 cm atrophy of the left forearm.Angiography revealed normal subclavian andaxillary arteries. The left brachial artery wasinterrupted at about mid-humerus and wasreconstructed about 6 cm. proximal to the elbowjoint.The artery showed normal calibration at theelbow joint. The radiaI, ulnar and digital arteries wereall normaL. Electromyography (EMG) show edmarked partiallesions of the left median and ulnarnerves. Only the pronator teres muscle showedreinnervation.The patient was operated on in January25,1996 by the vascular and neurosurgical teams.Initially, an axillo-brachial by-pass was performedwith restoration of normal blood flow. Following thisprocedure, the median and the ulnar nerves wereexplored and identified. Both nerves wereanatomically intact but were swollen, morepronounced on the median nerve. Additionally, themedian nerve was encircled by dense granulationtissue. This tissue was dissected and removed under

the microscope. Neurolysis was performed for bothnerves and the median nerve was wrapped with asingle piece of Gore-Tex. The patient had markedmotor and sensory improvement at the postoperativesecond month.

Case 4: A 41 year old female had been operatedon for L4-5 disc herniation in the previous year. Shehad been suffering from severe causalgic pain andhyperesthesia in her left leg. Neurologicalexamination revealed a positive Lasegue test at 30degrees on the left and at 60 degrees on the rightside. Anterior tibial power was markedly diminishedon the left and hypoesthesia was observed over theleft L4, L5 and SI dermatomes. Lumbar motion waslimited and painful. Lumbar MRI revealedgranulation tissue surrounding the left L5 root.Thepatient was operated on in March 13, 1996. Thegranulation tissue was completely removed thusisolating the root selectively. The root was encircledby two semicylindrical pieces of Gore- Tex puttogether by stay sutures.

Caner: Gore- Tex in Neitrosiirgery

Case 5: A 65 year old woman had very irritating,nearly continuous left hemifacial spasm. She hadused carbamazepine with no practical benefiL Theneurological examination was normal except forhemifacial spasm. MR tomographic angiography(MRTA) and MR angiography both revealedcompression of the left facial nerve by left PICA atthe root entry zone. The patient was operated onthrough the retrosigmoid approach. The pulsatileeffect of PICA on the facial nerve was veryobvious. This relation was terminated by placinga small piece of Gore-Tex over the facial nerve.Hemifacial spasm resolved completely andimmediately after the operation and did not recur.

DISCUSSION

Neurovascular compression of the cranialnerves as a possible mechanism for clinicalsyndromes like hemifacial spasm and trigeminalneuralgia was first postulated by Gardner (4) andmicrovascular decompression (MVD) as treatmentwas initiated and popularized by Jannetta (8). MVDhas a success rate of about 75-90 % (3,6,14). In someinstances, no improvement at all or recurrence afteran initial phase of remission following MVD havebeen correlated with the type of prosthesis used.Muscle, surgicel,Teflon cotton and collagen spongeare some of the materials used for this purpose.Vascular compression resulting in hemifacial spasmand trigeminal neuralgia are well delineated bymagnetic resonance imaging and magnetic

.resonance tomographic angiography (1,2,9). Weused Gore- Tex in our cases I, 2 and 5 fordecompression of the offended nerves.There is onlyone similar experience in the literature related to theuse of Gore-Tex for MVD (12). These authors report10 patients with hemifacial spasm treated by MVDusing Gore-Tex. All of their patients have been curedand they have encountered onlyone case of transientdeafness.

In neurosurgical practice, Gore-Tex surgicalmembrane has been used in the treatment and

prevention of tethered and retethered spinal cord (7)and has also been used as an artificial dura

mater in preventing the adhesion of the braintissue to the repair site (13). We have noinformation In the literature about the use of

Gore- Tex to prevent granulation tissue adhesions tothe peripheral or spinal nerves as we have used inour cases 3 and 4.

Three main points which prompted us to report

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Tiirkis/i Neiirosiirgery 6: 108 - 110, 1996

this paper are to advocate the use of Gore-Tex inMVD procedures, to point out the possibility ofsuccess with MVD in multiple surgical interventionssince in most incidents of failure, reported in theliterature, patients have been reoperated on only once(14) (our case 1 showed excellent clinicalimprovement after the third surgery); and to initiatenew research activity to study the efficacy of Gore­Tex in preventing tissue adhesions.

Correspondence: Hakan Caner, MDBaskent University HospitalDepartment of NeurosurgeryBahçelievler, Ankara, TurkeyPhone: (312) 212 6868/ext. 1283 -1179Fax: (312) 223 7333

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