Outcomes of Microvascular Decompression Versus Stereotactic Radiosurgery in the Treatment of Trigeminal Neuralgia: A Decades-Long, Single-Center Retrospective Cohort Analysis

BACKGROUND AND OBJECTIVES: Trigeminal neuralgia (TN) can be a severe, debilitating facial pain disorder often resistant to medical therapy. Microvascular decompression (MVD) and stereotactic radiosurgery (SRS) are widely used interventions, but the long-term comparative outcomes when each treatment is used as an index procedure remain unclear. We evaluated their efficacy and safety in a single-center cohort tracked over 2 decades. METHODS: We retrospectively reviewed 290 patients with type 1 TN who underwent MVD or SRS between September 2001 and May 2025. Data included demographics, imaging, procedural details, medication use, and long-term outcomes. Statistical significance was set at P < .05. RESULTS: Patients with MVD were significantly younger than SRS patients (median 60 vs 74 years, P < .001). When controlling for age and sex, MVD was superior in initial postprocedural pain relief (Barrow Neurological Institute: 1.74 vs 1.96, P = .007, adjusted β -0.427 [95% CI, -0.738 to -0.117]) and recurrence rate (7.9% vs 22.6%, P < .001, adjusted odds ratio 0.26 [95% CI, 0.12-0.56]). Postprocedural numbness was more frequent with SRS (34.5% vs 8.6%, P < .001, adjusted odds ratio 0.18 [95% CI, 0.08-0.37]). MVD achieved greater percent medication reduction (-53.3% vs -17.5%, P < .001). No complications occurred with SRS, whereas MVD had a 13.7% complication rate, mostly minor and managed conservatively. Recurrence after MVD was lower in patients with vascular conflict on preoperative MRI (7.9% vs 22.5%, P < .001). Patients without vascular conflict intraoperatively who underwent neurolysis had greater medication reduction than SRS (53.3% vs 17.5%, P = .007) but similar pain scores and numbness rates. CONCLUSION: Both MVD and SRS were effective in treating TN-associated pain, but MVD offers superior durability and medication reduction at the cost of higher complication rates but still an acceptable risk profile. MVD may be preferred for low surgical-risk patients, while SRS remains a valuable noninvasive option. MRI reliably predicts neurovascular conflict, and neurolysis may be considered when no vascular conflict is present.