Preoperative MRI neurovascular compression as a key predictor of surgical success in trigeminal neuralgia: a retrospective cohort study

Background Trigeminal neuralgia is the most common cranial neuralgia, and microvascular decompression (MVD) is considered the most effective surgical treatment for medically refractory cases. Results A retrospective study including 110 patients who underwent MVD between 2013 and 2023 at two tertiary hospitals was performed. Demographic, clinical, radiological, intraoperative, and postoperative variables were analyzed. Pain outcomes were assessed using the Barrow Neurological Institute (BNI) facial pain scale. Univariate and multivariate statistical analyses were conducted. The mean duration of symptoms prior to surgery was 7.8 years, and 57.1% ( n = 63) of patients required three or more medications. Intraoperative vascular compression was identified in 82.9% ( n = 91), most commonly involving the superior cerebellar artery (48.6%). At one month, 94.3% ( n = 104) of patients achieved complete pain relief (BNI I), and at six months, 82.9% ( n = 91) remained pain-free without medication.Multivariate analysis identified radiological neurovascular compression as the only independent predictor of favorable outcome (OR 24.3; 95% CI 7.1–82.5; p < 0.001). These findings highlight the strong predictive value of preoperative MRI in identifying patients most likely to benefit from surgery. Conclusion Microvascular decompression provides excellent outcomes in patients with refractory trigeminal neuralgia. Preoperative MRI evidence of neurovascular compression is the strongest predictor of postoperative success and should play a central role in surgical decision-making and patient selection.