Microvascular Decompression Techniques for Trigeminal Neuralgia: A Comparative Review of Outcomes and Complications

Introduction: Trigeminal neuralgia (TN) is a disabling syndrome characterized by severe, shock-like paroxysms of facial pain caused by neurovascular compression. For classical TN patients failing pharmacotherapy, microvascular decompression (MVD) is surgical treatment-of-choice. Interposition is the most common MVD technique, which involves placing a Teflon pad between the nerve and offending vessel; however, numerous modifications have been reported, including endoscope-assisted interposition, transposition (e.g., slinging), and autologous muscle graft (AMG). We sought to comparatively assess contemporary outcomes and complication rates across MVD techniques for TN.

Methods: Systematic literature review from 2013-present using MEDLINE and Embase with search terms “trigeminal neuralgia” OR “facial pain” AND “microvascular decompression surgery” OR “surgical decompression” AND “treatment outcome.” Two independent reviewers screened all candidate citations against study criteria. Original studies of surgical outcomes after MVD for TN were included; revision operations, atypical facial pain, or multiple reported techniques without discretely parsed data were excluded.

Results: 49 studies representing 4191 patients were included. Four MVD techniques were represented: interposition (n=3529), endoscope-assisted interposition (n=307), transposition (n=625), AMG (n=130). Endoscope-assisted interposition demonstrated the lowest recurrence rate at 7%; traditional interposition, transposition, and AMG recurred at 14%, 12%, and 15%, respectively. Transposition had the highest complication rate at 13%, followed by interposition at 12%, endoscopic-assisted interposition at 4%, and AMG at 2%.

Conclusion : Contemporary outcomes across all MVD techniques are reassuring, with consistently low recurrence and complication rates reported by all included studies. Endoscope-assisted techniques appeared to have a small potential advantage on both outcomes; however, given the limitations of study heterogeneity, comparative analysis was not possible, and the small sample size for this technique may mask a spurious result. Further study in a larger, prospective, ideally randomized format is recommended.