1 Q. Why is it recommended to wait approximately ten (10) months from the date of the last Botox injection before having MVD surgery?

A. We like to wait at least nine (9) months after botulinum toxin poisons the motor end plate, and new motor end plate connections have to grow. Every time botulinum toxin is given, this is harder for the body to do. We found out that we cannot monitor the completeness of microvascular decompression if we operate too soon after the prior injections.

(Source: Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

2 Q. Are people who took Botox injections more likely to have Bell's Palsy following MVD?

A. No, not in our experience.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

3 Q. Are former Botox patients more likely to have recurrence of HFS, and if so, why?

A. On the basis of my knowledge, I cannot say that patients who had botulinum toxin are more likely to have a recurrence of Hemifacial Spasm. I have not seen the preliminary data. There was a group who had early operations following the last botulinum toxin injections before we knew about the monitoring problems, and these are probably the patients in question.

(Source: Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

4 Q. Why is it essential that the hearing nerve be monitored via intraoperative monitoring (IOM) during MVD surgery?

A. I feel it is essential to have brainstem auditory evoked potentials monitored intraoperatively during microvascular decompression surgery for two reasons. First, it enables the surgeon to know what maneuvers are causing problems with the brainstem auditory evoked potentials. Secondly, it is a great training tool so that the surgeon can learn how to expose the facial nerve without causing any stress on the auditory nerve. The brainstem auditory evoked potentials do not monitor hearing directly, unfortunately, but the correlation is excellent.

(Source Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

5 Q. Why do some patients have a metallic taste post op?

A. I have never been able to explain the metallic taste that some patients get post operatively. It seems to be self-limited. We have not followed people to see how long it persists. This probably has something to do with nervus intermedius function. This is one of the nerves that has to do with taste and is located around the 7th and 8th nerves.

(Source Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

6 Q. What is Atypical HFS?

A. Atypical Hemifacial Spasm is Hemifacial Spasm that starts in the muscles of the cheek (the buccal muscles) and progresses, over time, up the face rather than starting in the eye muscles (orbicularis oculi) and progressing, over time, caudally down the face. About eight percent of patients have atypicalspasm. The location of the causative blood vessel in typical spasm is on the caudal side of the nerve, often over part of the nerve before it comes up into the cerebella pontine angle out of the brain. The atypical spasm patients have a blood vessel between the 7th and 8th nerves (that is behind the 7th nerve) or above the 7th nerve. If this is an artery, it can have a perforator to the brainstem, which is probably important, and it is difficult to treat. The exposure is a bit different, and the risk of hearing loss is slightly higher with Atypical Hemifacial spasm.

(Source: Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

7 Q. How often do you see patients with HFS on both sides, and does it require two separate surgeries?

A. We see bilateral sequential hemifacial spasm infrequently. I think we have seen six patients over the years. It requires two separate operations.

(Source: Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

8 Q. Why are second MVD's more difficult and less successful than the first MVD?

A. Second microvascular decompressions are more difficult and less successful than the first microvascular decompression because the implant that has been put into place may be in the way and because there is an opportunity for some, at least, mild injury to the facial nerve in dissecting it from the nerve. Frequently we find that the prior operation was not in the area where spasm is being caused by a blood vessel, and this makes it easier. We are doing better with repeat operations than we did in the past.

(Source: Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

9 Q. In your opinion, what is the reason for second MVD's?

A. Second microvascular decompressions are performed for intractable hemifacial spasm, which usually implies that there has been no adequate decompression of the nerve from the blood vessel the first time. Often, there is a second subtle blood vessel. We often see, unhappily, that a vessel not causing hemifacial spasm, such as a peripheral artery running around and through the nerves distal to the brainstem has been treated. These patients are easy to treat because no surgeon has been at the area where the blood vessel is causing the spasm the first time.

(Source: Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

10 Q. What is a CSF leak, how is it caused, and how is it repaired?

A. A cerebella spinal fluid (CSF) leak comes from a small opening, usually a pin hole, in the suture line of the dura mater in combination with a small opening in the bone so that spinal fluid can leak out from around the brain into the bone and out into the eustastian tube then into the nose and sinus regions. A second kind just comes out through the tissues into the incision. The second kind is easy to treat with a couple of stitches. Both may require a close-system drainage. This usually works and necessitates a catheter be placed in the spinal canal. It is inconvenient because the patient must stay in bed for two (2) or three (3) days.

(Source: Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

11 Q. What material is being used now to close the point of entry into the brain following MVD surgery?

A. There is no point of entry into the brain. We do close the dura mater usually with nylon suture, and sometimes, we have to sew a patch of material into this region (a dural graft).

(Source Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

12 Q. During MVD, how large is the opening, where is it physically located and how much hair is shaved before surgery?

A. The opening made into the bone is behind the ear and behind the mastoid eminence. The incision is placed one finger-breadth behind the hairline behind the ear. It is no longer than the length of the ear. We make the incision more posterior in larger people with thick skulls and heavy tissues and can make it closer to the ear in smaller people. A strip of hair about an inch wide is shaved in this area

(Source: Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

13 Q. How long following MVD must a patient wait before coloring their hair?

A. A patient should wait three (3) weeks after the operation before having hair colored.

(Source: Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

14 Q. What material is used to make the decompression between the nerve and the artery/vein, and what holds that material in place?

A. The material we have found to be most suitable because it is soft, easy to use and has very little, if any, reaction is shredded Teflon felt. It is sort of sticky just like absorbent cotton and stays in place very nicely. The vessel will help hold it in place also.

(Source: Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

15 Q. In your opinion, how many MVD's per week/month/year does a neurosurgeon have to perform to be considered experienced?

A. Neurosurgeons vary in their experience and their ability to feel comfortable with an operation. I would think someone should do more than one per month to stay comfortable with this operation.

(Source: Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (05/17/01)

16 Q. Is MVD the only cure for HFS?

A. It was a unanimous opinion of the HFSA Medical Advisory Board that microvascular decompression is the only cure for Hemifacial Spasm (HFS).

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

17 Q. Are there current published statistics on how MVD success rates compare to the rates of failure and/or post-op complications? If so, what are they?

A. There is extensive literature on the success rates which is available on the Internet, but basically the success rate ranges from 81-92 percent and as much as 95 per cent in a separate series with complication rates of 0.1 to 3 percent on average. One or two older papers reflect the complication rate of 9 percent before current monitoring.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

18 Q. Following MVD does the affected nerve regenerate?

A. The consensus statement would reflect, that since the relief following microvascular decompression is often times immediate in terms of the spasm, that the affected nerve has not, of course, had time to regenerate. Some patients, however, can take up to 4 months to improve, and this probably reflects in a sub group of patients, changes with the nerve. Over time on an average, 60-65 percent of the patients are spasm free at 5 days from surgery. At 6 months, 92 percent are spasm free, and 7 percent have some limited remaining spasm. At 10 years, those results improve a bit to 95 percent with most of the patients remaining free of spasm at 10.4 years if they are free of spasm at 6 months.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

19 Q. Is a virus ever the cause of HFS and nerve compression?

A. The uniform opinion is that no virus is known to be related.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

20 Q. If you have spasms on both sides of your face, is it called Meige Syndrome? If not, what is Meige Syndrome?

A. Meige syndrome is a situation of bilateral blepharospasm and oromandibular movements, which are dysrhythmic rather than undulating. It involves the neck muscles in the front half only of the throat area.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

21 Q. What drugs are frequently used to control spasms, what are the dosages, which of these drugs have serious side effects and why?

A. The consensus opinion is that no drugs taken orally control the spasms with any reasonable effectiveness. Botox (botulinum toxin A) and perhaps some of the soon-to-be-released additional types of Botox, control the spasms with the side effects of the possibility of having an immune reaction, the possibility of incomplete relief, and the possibility of some weakness in the face and throat.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

22 Q. Following MVD, what causes the clogged ear or feeling of ear fullness patients sometimes experience?

A. The consensus opinion was that local inflammation, rather than infection, produces a feeling of earfullness and that these can occur either on the surgical side more commonly and on the contralateral side due to localized pressure and fluid changes.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

23 Q. Why is the feeling of "ear fullness" following HFS sometimes on the non-MVD side? And, if decongestants and the passing of time do not relieve the "ear fullness or clogged-ear condition" following MVD, what else can be done?

A. The fullness on the contralateral side has the same causation as the operative side after MVD, namely inflammation and fluid congestion as a reaction to surgery. (Occurs after many MVD operations for face pain, throat pain, tinnutis etc.) Decongestants do not, in fact, help a great deal, but if there is an issue after 4-6 weeks, certainly an ENT (Ear, Nose & Throat) professional should have an opportunity to look at the patient.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

24 Q. Is the surgery less successful the longer you wait to have the MVD?

A. The doctors on our MAB are evenly split whether waiting makes the surgery less successful. There does not appear to be any literature, currently published, that conclusively supports either position.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

25 Q. What types of alternative treatments, i.e., acupuncture, diet, herbal medicines, holistic, mind-body connection, etc., have had documented success in controlling and/or reducing spasms, if any?

A. No member of the MAB was aware of any specific current treatments including acupuncture and the like that were helpful unless those helped reduce stress, and the stress reduced some of the irritability in the nerve.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

26 Q. Has there every been a connection between major dental work and the onset of HFS?

A. There was uniform consensus that there is no known connection between dental work and HFS.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

27 Q. My neurosurgeon did a spinal tap during the surgery in order to prevent the headaches from spinal fluid leak. I, therefore, did not have any after-surgery headaches at all. Is this becoming standard procedure for this type of surgery?

A. There was uniform consensus that the spinal tap following surgery, which can occur in as many as 8 percent of the patients, is not the standard nor is a lumbar drain.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

28 Q. If Bell's Palsy appears post-op, is there any known treatment for it?

A. Bell's Palsy or flatness of the nerve, more correctly called, can appear post op from the nerve that has had prolonged hyperactivity pre op. As the nerve heals over time, this typically improves. Local muscle treatments can help maintain muscle tone until the time of improvement, but no medications can speed the nerve changes required. Bell's Palsy is more classically a true viral illness and is probably not what patients are seeing post op unless there is an eruption of small vesicles on the face, and this would more likely represent Herpes Zoster.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

29 Q. Do people with HFS also experience dystonia in other parts of their bodies and why? Is it a serious condition?

A. There was unanimity among the doctors that dystonia is usually not part of the hemifacial spasm syndrome.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

30 Q. Do you believe that exercises, such as the example listed below, help to relieve HFS symptoms or is this a mind-over-matter myth?

Example: Keeping the body straight ahead and neck straight up, look as far over the right shoulder as possible for about 5 seconds. Then over the left shoulder. Repeat this 2 or 3 times. Force the chin down into the chest for 5 seconds. Repeat 2 or 3 times, etc.

A. The exercises such as the one described above, do not specifically help the HFS symptoms except where there is a reduction of stress, and this, in turn, leads to a reduction in the nerve irritability.

(Source: Hemifacial Spasm Association, Medical Advisory Board 10/08/01)

31 Q. Can hemifacial spasm be caused by multiple sclerosis? If so, in relapsing remitting MS, can it be expected to remit?

A. For some reason, MS causes facial myokymia rather than hemifacial spasm. These must be differentiated. It is a movement disorder wherein the facial muscles move "like a can of worms." EMG will differentiate the two problems. Some improve. I know of no valid statistics regarding the course.

(Source: Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (01/06/02)

32 Q. Can over-exertion (physical exercise) make hemifacial spasm worse?

A. I have seen people who say they are better, others who say they are worse, but most say that exercise has no effect. Same is true of tic.

(Source: Peter J. Jannetta, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (01/06/02)

33 Q. Is facial weakness a common side effect of MVD; can it be considered temporary; and, is there anything that can be done to alleviate it?

A. Facial weakness can occur after MVD, especially related to the degree of spasm present pre-op. The degree of weakness has been correlated to the preoperative use/timing of Botox-A. Within 9 months, it would appear the weakness is a bit more profound. Neither affects the rate of permanent change in nerve function 1 - 5.8%. Nothing specific can affect this.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (03/31/02)

34 Q. Is there a correlation between high blood pressure and hemifacial spasm?

A. Hypertension can co-exist in the setting of HFS, from compression of the brainstem. It is not a cause for Hemifacial Spasm (HFS).

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (03/31/02)

35 Q. Is a neurosurgeon who has performed 100 MVD’s for TN but only one for HFS a good choice to perform a MVD for HFS?

A. The sheer number of cases done for any surgeon is a poor measure of skill. There is the need to look at successes, complications as a percentage of the cases, and familiarity with the pathophysiology of the nerve problem to aid in the decision regarding surgery.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (03/31/02)

36 Q. What happens eventually if a person does not treat hemifacial spasm? Does HFS always gradually worsen, or does the condition sometimes reach a plateau?

A. The condition has a minimal rate of spontaneous recovery. The usual course is progressive, with more area of facial nerve involvement more of the time.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (03/31/02)

37 Q. At what point is it appropriate to seek a diagnosis for HFS? Many people experience "eye twitches" and the like, which are apparently caused by stress. When should one suspect HFS as opposed to stress?

A. Blepharospasm, Meige's syndrome (bilateral blepharospasm and orofacial dystonia) myokimia, tardive dyskinesia (orofacial tics usually with drug use) are all in the differential of a person with regular recurrent eyelid twitch. Recurrence, or spread from the inferior eye area to the upper eye muscle is a point in favor for evaluation.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (03/31/02)

38 Q. What is the percentage of people who suffer some form of hearing loss following MVD? What percentage have no hearing loss, percentage that have some, percentage that have total hearing loss on the HFS side? How much is permanent vs. temporary?

A. Hearing loss can be partial (30 dB or less) and is seen in 14-20% of patients in the first few weeks. Permanent loss of any or all hearing on the same side is reported from 1-6%.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, 03/31/02)

39 Q. I notice a worsening of my spasms when I am under stress. Please explain the physiological reason that stress makes the spasms more frequent and severe?

A. The theory of vascular cross compression of the nerve includes a susceptible nerve for either genetic or previous historical reasons. If the facial nerve nucleus is affected either primarily or after some injury, nerve dysfunction can result. The state of increased hormones (stress, activity, and fever) can result in more activity in the injured/irritated tissue.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (03/31/02)

40 Q. What are lateral spreads, and how is this tested?

A. Injury/irritation to the facial nerve results in reorganization of the neural connections in the brainstem around and in the nucleus for the facial nerve. During firing, synkinesis (over activity) can be seen in the muscle stimulated as well as other muscles in the face. We can see it clinically and document it with muscle recordings (EMG/NCV).

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (03/31/02)

41 Q. Why do some people experience loud noises (rushing water and metal-on-metal sounds) in their deaf ear following MVD? Vertigo?

A. Persistent low level function in a nerve with decreased/lost voice discrimination is typical for all forms of hearing loss. The slowly degenerating ear, like with loss from the work place, is a common example. Dysfunction or injury can affect the balance portion of the nerve or the balance organs in the ear, which also have a degenerative cycle.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (03/31/02)

42 Q. Is there any effective treatment for Bell's Palsy?

A. Bell's Palsy is a viral or trauma induced injury to the nerve. 5.7% of these patients will develop HFS after recovery, but all are not necessarily operative candidates and need to be evaluated one by one. Steroids sometimes help Bell's Palsy, but no study has proven this to be the first treatment.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

43 Q. Do most patients with HFS have extreme light sensitivity? Ex. Can bright lights or sunlight trigger HFS?

A. The impact of light sensitivity creating aggravation of hemifacial spasm is something that we have seen often. Light that can reflect onto the cornea (the white part of the eye) can be a tremendous stimulant. The eye is innervated by the 5th nerve (the trigeminal nerve), which has a direct reflex with the 7th nerve. It is our belief that stimulation of the eye and cornea is perceived as an irritant stimulant. In a patient with hemifacial spasm that has an abnormal response to normal stimuli, such as light, this response can be quite exaggerated. In so doing, certainly light can create a series of twitches resulting in a hemifacial spasm. This is no different than in some patient’s wind or other forms of stimulation, even movement, can create the same. This does not speak at all to the severity of the hemifacial spasm nor to the prognosis or long-term outcome.

(Source: Amin B. Kassam, M.D., FRCS, Department of Neurosurgery, UPMC Presbyterian Hospital, Pittsburgh, PA (USA) (11/24/07)

44 Q. Are there any long-term, post-op activity restrictions, i.e., no roller coaster riding, bungie jumping, sky diving, etc.?

A. No activity restrictions after post op phase.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

45 Q. Can Botox injections cause atrophy of facial muscles?

A. Yes.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

46 Q. Is there any history of an MVD having to be redone after 8-10 plus years?

A. Yes, due to recurrence of compression. Veins can grow over time to do this, as well as an artery can work its way under the Teflon felt. Both unusual.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

47 Q. Is there any benefit derived by a HFS patient by decreasing/eliminating facial spasms if there is a mind-body connection employed?

A. There have been some reports, but no organized study of this.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

48 Q. Do lungs deflate during/after MVD surgery as a result of general anesthesia being administered?

A. No.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

49 Q. In the medical community, is there a universally recognized definition for a successful MVD?

A. No, except we all want the patient to feel that their problem is better, or resolved.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

50 Q. Why are some patients spasm free immediately after MVD surgery and others are not until months later?

A. See the journal NEUROSURGERY April, 2002, pages 712-719. Detailing 143 patients. A link to the Journal abstract on Neurosurgery Online is as follows: Neurosurgery Online - Clinical Studies - Microvascular Decompression to Treat Hemifacial Spasm: Long-term Results for a Consecutive Series of 143 Patients.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

51 Q. Can seizures be associated with facial problems?

A. Rarely, a tumor in the cerebellum will present with facial seizures, but usually this is in children and there are other findings on exam.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

52 Q. What is tonus, and why does it occur?

A. Tonus is the sustained contraction of a muscle. In this setting it represents the degree of irritability in the nerve/muscle.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

53 Q. When tonus occurs does it indicate that serious injury has occurred to the VIII nerve by the compressions?

A. Tonus is from the seventh nerve. It indicates only the degree of irritability and expected muscle fatigue after surgery, not nerve injury.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

54 Q. Do exercises of the head/neck tend to help/aggravate HFS?

A. Neither.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

55 Q. If one experiences hemifacial spasms and facial pain is this an indication that the fifth nerve may also be compressed?

A. "Tic Convulsif" is the name for this problem which while rare does occur.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

56 Q. If HFS is caused by a blood vessel/artery pushing on the VII cranial nerve, why do the spasms not happen "in time" with the heartbeat?

A. The nerve muscle activity is related to changes in the nerve insulation, this affects the tone of the muscles, leading to the irritability.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

57 Q. Does tinnitus disappear after MVD?

A. Tinnitus is from eighth nerve irritation. If, while working on the seventh nerve, one moves the vessel offending the eighth nerve, some resolution might be expected. A serendipitous result.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

58 Q. Does the Teflon pad used in MVD eventually deteriorate or move?

A. No.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

59 Q. What keeps the Teflon pad used in MVD in place, and how great a trauma such as an accident, fall, hitting head, etc., will cause the pad to move?

A. The Teflon felt is not a single pad nor just sitting between the nerve and vessel, so the placement by the surgeon helps maintain the position and movement from trauma or other causes is rare.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

60 Q. Is there any criteria that makes one patient a better candidate for a successful MVD than another, i.e., degree of HFS, duration, size of the person (or their head or neck - thick-necked people's incisions are somewhat different than thin-necked people)? Does this make a difference in the chances for a successful outcome?

A. Surgical success is not related to patient size or such, or to muscles involved. History is important. Classic onset involves eye, then cheek, then neck. Less classic presentations give less good results, partial but not great.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

61 Q. Are there published statistics on the success/failure of MVD?

A. The best article is in the journal NEUROSURGERY April, 2002, pages 712-719, detailing 143 patients. We have roughly similar numbers for our patients, numbering some 200-230. A link to the Journal abstract on Neurosurgery Online is as follows: Neurosurgery Online - Clinical Studies - Microvascular Decompression to Treat Hemifacial Spasm: Long-term Results for a Consecutive Series of 143 Patients.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

62 Q. How prevalent is depression following MVD surgery?

A. No direct relationship is known.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (08/13/02)

63 Q. Will a EMG test determine what is compressing the facial nerve and will it give a positive HFS diagnosis?

A. The EMG is a tool to look at the function of the nerve. When the nerve is irritated, by whatever means, it can lose some aspect of its function. In the case of HFS, we see a phenomena described as "lateral spread". This means when the branch of the nerve going to the eye blink muscles is stimulated, there will be a twitch in the cheek or jaw muscles.This is common in HFS, but less so in other causes of facial nerve irritation.The EMG cannot reliably distinguish what is compressing the nerve.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA (USA) - (12/31/02)

64 Q. If lateral spread doesn't stop during monitoring and completion of surgery, will spasms eventually decrease or cease?

A. If lateral spread does not stop at the completion of surgery there remains the possibility that spasms will resolve post-operatively. There can be several explanations for persistence of lateral spreads after decompression. These include: inadequate decompression of the offending vessel(s) from the nerve at the brainstem and decompression of the nerve only distal to its exit from the brainstem, which is generally a location that does not cause HFS. At times, when the nerve is found to be compressed by veins, the loss of lateral spread can be gradual or delayed compared to when the nerve is compressed by arteries. An explanation for this finding eludes us. If lateral spread does not resolve by the end of surgery there is a significant chance that the HFS will not resolve as well. Some patients, however, who awaken with HFS after surgery, have a change in the severity. These patients may go on to resolution of HFS over the next 6 months. If a patient does awaken with HFS we usually wait 3-4 days to see if a decline in severity occurs. If they continue to have HFS we repeat the EMG. If the appearance of the post-operative lateral spread is identical to the pre-operative lateral spread we usually offer to re-explore the patient during the same hospital stay to look for another offending vessel. If the appearance of the lateral spread after surgery is significantly different from the pre-operative spread we usually recommend that the patient wait 6 months to see if the HFS will resolve on its own.

(Source: Amin Kassam, MD and Michael Horowitz, MD, Department of Neurosurgery, UPMC Presbyterian Hospital, Pittsburgh, PA (USA) - (09/01/07)

65 Q. What causes the level of spasm activity to increase following a MVD that supposedly found all compressions, if the increase was apparent immediately following the surgery and has continued?

A. It is difficult to determine what would cause spasms to worsen after surgery. While a hypothetical possibility could include a decompression that actually ended up compressing the nerve more by some repositioning of the offending vessel there is no way to provide a clear cut answer. We believe, however, that if spasms worsened and post-operative lateral spreads remained it would be reasonable to re-explore the patient.

(Source: Amin Kassam, MD and Michael Horowitz, MD, Department of Neurosurgery, UPMC Presbyterian Hospital, Pittsburgh, PA (USA) - (09/01/07)

66 Q. Is there a typical timeline of progression with HFS from the initial frequent eyelid twitches to the lower musculature?

A. Not really.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Detroit Receiving Hospital, Wayne State University, Detroit, MI (USA) - (09/02/07)

67 Q. Is it common for spasms to feel stronger than the facial movement appears in the mirror, or to friends?

A. Generally yes. This is best seen postoperatively, when many patients will report they feel the spasm is there, but they and the family agree none is seen. Or, how often have you heard a patient remark, "I knew the spasm was coming even before I felt it"? This is thought to be related to the conscious perception of the nuclear hyperactivity in the brain stem, but aside from a few human recordings under anesthesia, correlated with loss of lateral spread during decompression, this is conjecture. This is seen in other spasm situations as well.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Detroit Receiving Hospital, Wayne State University, Detroit, MI (USA) - (09/02/07)

68 Q. What are the latest results relative to the endoscopic vs. use of the operating microscope for MVD? Also, does the West Penn/Allegheny General group perform both approaches?

A. The endoscopic approach uses the same size opening as the microscopic, and the endoscope is an adjunct to the usual procedure. The endoscope is used in the Detroit portion of Jannetta clinics when warranted, as well as in Pittsburgh for Chiari procedures, when needed. The most useful test is the lateral spread EMG which helps both with firm diagnosis, and intraoperative decision making. This test aids in the decision whether to use the endoscope to effect the maximum results.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Detroit Receiving Hospital, Wayne State University, Detroit, MI (USA) - (10/01/07)

69 Q. Some people with HFS experience twitches and/or spasms on their unaffected side. Other than Bilateral Hemifacial Spasm, what causes this?

A. There is no reported data from human subjects, of bilateral recordings of the seventh nerve nucleus. Hemifacial spasm is when brain stem plus cranial nerve are affected and the nucleus is hyperactive. This means, within the brainstem, there are groups of cells firing off in a prolonged fashion. This we have seen in humans, on the same side as their spasms. Each of the seventh nerve nuclei are interconnected, so it is not unexpected that over activity in one nucleus might evoke some spontaneous activity in the opposite side, especially over time. The upper portions of the face have bilateral supranuclea (above the level of this cell firing group) innervation as well.

(Source: Kenneth F. Casey, MD, Department of Neurosurgery, Detroit Receiving Hospital, Wayne State University, Detroit, MI (USA) - (10/20/07)

70 Q. Why isn't acupuncture suggested to HFS sufferers, if done by neurologist, as my spasms have been significantly reduced with acupuncture?

A. I'm not personally aware of any patients whose HFS has been helped by it, nor any studies showing this to be an effective treatment for HFS. A medline search of "hemifacial spasm & acupuncture" comes up with no references. It would be interesting to hear from the HFSA membership if any others have had exepreinces with acupuncture.

(Source: Anthony M. Kaufmann, M.D. Health Sciences Centre Hospital, Winnipeg, Manitoba (Canada) - (10/24/07)

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