Microvascular decompression in classical trigeminal neuralgia: analysis of long-term outcome, complications, and risk factors for treatment failure

Objective Trigeminal neuralgia (TN) is one of the most severe pain sensations and is often not sufficiently manageable with pharmacotherapy. Microvascular decompression (MVD) is considered the most effective long-term treatment for classical TN. This study evaluates surgical outcomes and complications following MVD. Methods We performed a retrospective chart review of all patients who underwent MVD for classical TN at our institution from January 2000 through December 2023. We reviewed clinical data, imaging results, surgical methods, treatment efficacy, complications, and follow-up data. Pain relief was assessed according to the Barrow Neurological Institute pain score (BNI). Results We identified 103 patients (50 female and 53 male) with a mean age of 60 years and a mean follow-up of 79.08 months. In 99% of patients, the pain distribution corresponded to the V2 and/or V3 branch. Preoperative MRI demonstrated neurovascular contact in 98% of patients. The superior cerebellar artery was the most common offending vessel (81.6%), while venous compression was identified in 13.6% of cases. The most frequent complications were hearing loss in 5.8% ( n = 6) of patients, wound infection in 2.9% ( n = 3), CSF leakage in 1.9% ( n = 2), facial palsy in 1%, and cerebellar hemorrhage in 1% ( n = 1, each). At the first follow-up visit, 87.3% of the patients had achieved significant relief of pain (BNI score 1 or 2), and 8.7% could reduce medication significantly. After five years, 67% ( n = 69) were still satisfied with no or occasional pain without medication. The recurrence rate was 24.3% ( n = 25). Interestingly, 43% of patients with a venous compression had an unfavorable outcome (BNI 4 or 5) at 6 months and 57% a recurrence within five years ( p = 0.0001 and p < 0.001, respectively). Conclusion Microvascular decompression is an effective and safe therapy in patients with classical TN. Venous compression is associated with a significantly worse outcome compared to arterial compression of the trigeminal nerve.