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Abstract BACKGROUND Microvascular decompression (MVD) is a potentially curative surgery for drug-resistant trigeminal neuralgia (TN). Predictors of pain freedom after MVD are not fully understood. OBJECTIVE To describe rates and predictors for pain freedom following MVD. METHODS Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, PubMed, Cochrane Library, and Scopus were queried for primary studies examining pain outcomes after MVD for TN published between 1988 and March 2018. Potential biases were assessed for included studies. Pain freedom (ie, Barrow Neurological Institute score of 1) at last follow-up was the primary outcome measure. Variables associated with pain freedom on preliminary analysis underwent formal meta-analysis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for possible predictors. RESULTS Outcome data were analyzed for 3897 patients from 46 studies (7 prospective, 39 retrospective). Overall, 76.0% of patients achieved pain freedom after MVD with a mean follow-up of 1.7 ± 1.3 (standard deviation) yr. Predictors of pain freedom on meta-analysis using random effects models included (1) disease duration ≤5 yr (OR = 2.06, 95% CI = 1.08-3.95); (2) arterial compression over venous or other (OR = 3.35, 95% CI = 1.91-5.88); (3) superior cerebellar artery involvement (OR = 2.02, 95% CI = 1.02-4.03), and (4) type 1 Burchiel classification (OR = 2.49, 95% CI = 1.32-4.67). CONCLUSION Approximately three-quarters of patients with drug-resistant TN achieve pain freedom after MVD. Shorter disease duration, arterial compression, and type 1 Burchiel classification may predict more favorable outcome. These results may improve patient selection and provider expectations. Graphical Abstract Graphical Abstract

Abstract BACKGROUND Microvascular decompression (MVD) can be an effective intervention for trigeminal neuralgia (TN); however, an optimal system for patient selection and surgical outcome prediction has not been defined. OBJECTIVE To develop and validate a preoperative TN grading system for the prediction of long-term pain relief after MVD. METHODS This retrospective cohort study included consecutive patients suffering unilateral TN who underwent MVD with >18-mo follow-up. A grading system was formulated using 3 previously validated preoperative characteristics. The primary end-point was long-term, pain-free status without use of medication. Ability to predict pain-free status was analyzed by multiple regression and assessed by area under the receiver operating characteristic curve (AUC). Clinical utility to predict MVD success and reduce unnecessary surgeries was assessed by decision-curve analysis. RESULTS Of 208 patients analyzed, 73% were pain-free without medication at >18-mo follow-up. Pain-free status was predicted by classical TN type, positive response to carbamazepine and/or oxcarbazepine, and presence and nature of neurovascular compression demonstrated on MRI (all P < .01). The TN grading system demonstrated good discriminatory ability for prediction of pain-free status (AUC 0.85, 95% CI 0.80-0.91). Decision-curve analysis demonstrated a net reduction of 20 cases likely to be unsuccessful per 100 patients evaluated with this grading system above a decision threshold of 80%. CONCLUSION This TN grading system reliably predicts long-term pain-free status without medications following MVD. The use of the TN grading system as part of a comprehensive work-up may reduce the number of unsuccessful operations.

BACKGROUND:In trigeminal neuralgia type 1 (TN1), neurovascular compression (NVC) is often assumed to be the pain initiating mechanism. NVC can be surgically addressed by microvascular decompression (MVD). However, some patients with TN1 present without NVC (WONVC). OBJECTIVE:To characterize and analyze the clinical spectrum of a TN1 patient population WONVC. METHODS:A retrospective chart review of patients presenting with TN1 between 2007 and 2017 was performed. Patients who were potential candidates for MVD surgery underwent high-resolution imaging with 3-dimensional (3D) reconstruction to address the presence, or absence, of NVC. Demographic data about the populations with NVC (WNVC) and WONVC were collected. RESULTS:Of 242 patients with TN1, 32% did not have NVC. Patients WONVC were on average 10.6 yr younger than those WNVC. TN1 onset in patients WONVC was more frequent below 48.7 yr, and the opposite was found in patients WNVC. Compared to patients WNVC, those WONVC were predominantly female (odds ratio 4.8), on average were 4 yr younger at symptom onset (34.7 yr) and 7.8 yr younger at first clinic visit, and had a 3.7 yr shorter symptom duration. CONCLUSION:Patients presenting with TN1 WONVC were predominantly females in their mid-30s with short symptom duration. In the absence of NVC, this subgroup of TN1 patients has limited surgical options, and potentially a longer condition duration that must be managed medically or surgically. This population WONVC might provide insights into the true pathophysiology of TN1.

Background Microvascular decompression (MVD) is the gold-standard surgical treatment for cranial nerve compression disorders, including trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN). This review synthesizes historical milestones, recent advances, and evolving techniques in MVD, with a primary focus on these conditions. Methods A comprehensive literature review was conducted using databases such as PubMed, SpringerLink, Google Scholar, BioMed Central, Scopus, and ScienceDirect. Studies published between 1970 and 2024 were analyzed, emphasizing surgical techniques, clinical outcomes, and technological innovations in MVD. Articles addressing TN, HFS, GPN, and other cranial nerve disorders treated with MVD were selected for detailed evaluation. Results MVD demonstrates high efficacy, with 80–90% of patients achieving immediate symptom relief. Nevertheless, 15–25% of patients experience symptom recurrence, though long-term outcomes remain favorable. Fully endoscopic MVD has shown potential for enhanced intraoperative visualization, particularly in complex anatomical regions; however, its impact on surgical precision and clinical outcomes is still under investigation. Moreover, innovations in visualization technologies, including three-dimensional exoscopic systems and artificial intelligence-assisted surgery, continue to improve procedural safety and outcomes. Despite these advancements, complications such as hearing loss (1–2%) and cerebrospinal fluid leakage (2–4%) persist, highlighting the need for continuous refinement of techniques. Conclusions MVD is evolving with the integration of cutting-edge technologies, resulting in improved clinical outcomes and reduced complication rates. Emerging innovations such as robotic-assisted MVD and gene therapies for cranial nerve disorders, including TN and GPN, promise even greater efficacy and precision. However, further research is necessary to standardize surgical protocols and address disparities in healthcare systems globally. Graphical Abstract

Depression is believed to be prevalent in patients with trigeminal neuralgia (TN); however, its effect on postoperative outcomes in patients undergoing microvascular decompression (MVD) is not well understood. This study aims to characterize the association between a history of diagnosed depression and postoperative outcomes in patients undergoing MVD for TN. The medical records for 1007 patients with TN who underwent MVD at our institution from 2007 to 2023 were reviewed. Demographic characteristics, comorbid conditions, clinical TN characteristics, pain recurrence, and pre-operative and post-operative Modified Barrow Neurological Institute (BNI) pain and numbness scores were compared between groups. Differences in pain outcomes were evaluated via multivariate ordinal regression, Kaplan-Meier analysis, and Cox proportional hazards analysis. 181 (18.0 %) of patients had diagnosed depression. Patients with depression were younger (p = 0.005), more often female (p < 0.001), and more likely to be White (p = 0.012). Type 2 TN was more common in those with depression (p < 0.001). Depression was independently associated with higher pain at last follow-up (p = 0.009), less time to recurrent pain on Kaplan-Meier analysis (p = 0.0063), and was predictive of recurrent pain on Cox proportional hazards regression (p = 0.048). A diagnosis of depression in patients undergoing MVD for TN is associated with greater postoperative pain and increased risk of pain recurrence, suggesting that depression is not only highly prevalent in patients with TN, but also may contribute to worse outcomes. These findings emphasize the need for adequate psychiatric screening before MVD and have implications for the preoperative counseling and management of this population. •Preoperative depression is prevalent in trigeminal neuralgia (TN).•Preoperative depression may be a predictor of increased post-MVD pain.•Preoperative depression may also predict earlier pain recurrence after MVD.•Preoperative psychiatric screening may inform TN management and operative planning.

The degree of disability due to glossopharyngeal neuralgia (GN) refractory to conservative treatments justifies surgical procedures as second-line treatments. Since the first description of this facial pain disorders, many surgical options have been described either via a percutaneous or an open surgical way. Actually, when a neurovascular conflict on root entry zone (REZ) or cisternal portion of the ninth and tenth cranial nerves is identified, microvascular decompression (MVD) is the first surgical option to consider. Many studies have demonstrated its efficacy and safety for the treatment of GN. Recently, stereotactic radiosurgery has gained space in the treatment of selected cases of GN. We provide an overview of the surgical procedures for the treatment of GN and of our own experience.

Abstract BACKGROUND Microvascular decompression (MVD) is the surgical treatment of choice for hemifacial spasm (HFS). During MVD, monitoring of the abnormal lateral spread response (LSR), an evoked response to facial nerve stimulation, has been traditionally used to monitor adequacy of cranial nerve (CN) VII decompression. OBJECTIVE To assess the utility of LSR monitoring in predicting spasm-free status after MVD postoperatively. METHODS We searched PubMed, Web of Science, and Embase for relevant publications. We included studies reporting on intraoperative LSR monitoring during MVD for HFS and spasm-free status following the procedure. Sensitivity of LSR, specificity, diagnostic odds ratio, and positive predictive value were calculated. RESULTS From 148 studies, 26 studies with 7479 patients were ultimately included in this meta-analysis. The final intraoperative LSR status predicted the clinical outcome of MVD with the following specificities and sensitivities: 89% (0.83- 0.93) and 40% (0.30- 0.51) at discharge, 90% (0.84-0.94) and 41% (0.29-0.53) at 3 mo, 89% (0.83-0.93) and 40% (0.30-0.51) at 1 yr. When LSR persisted after MVD, the probability (95% CI) for HFS persistence was 47.8% (0.33-0.63) at discharge, 40.8% (0.23-0.61) at 3 mo, and 24.4% (0.13-0.41) at 1 yr. However, when LSR resolved, the probability for HFS persistence was 7.3% at discharge, 4.2% at 3 mo, and 4.0% at 1 yr. CONCLUSION Intraoperative LSR monitoring has high specificity but modest sensitivity in predicting the spasm-free status following MVD. Persistence of LSR carries high risk for immediate and long-term facial spasm persistence. Therefore, adequacy of decompression should be thoroughly investigated before closing in cases where intraoperative LSR persists. Graphical Abstract Graphical Abstract

•Safety and efficacy of MVD for elderly patients with TN were analyzed.•Detailed data of 27 elderly patients were compared with that of 72 non-elderly patients.•There was no significant difference in efficacy of surgical outcome.•All the comorbidity and complication were successfully managed.•MVD for elderly patients with TN can be achieved safely. The present study compared the safety and efficacy of microvascular decompression (MVD) in groups of elderly patients and non-elderly patients with medically refractory trigeminal neuralgia (TN) and collected detailed perioperative data. Retrospective analysis of clinical data was performed in 99 patients who underwent MVD from May 2012 to June 2015. The outcome data from 27 MVD operations for 27 patients aged 70–80 years (mean 74.6 years) were compared with 72 MVD operations with 72 patients aged 25–69 years (mean 55.7 years). Preoperative comorbidities were recorded and postoperative worsening comorbidities and non-neurological complications were evaluated at discharge. Efficacy of the surgery and neurological complications were evaluated in July 2015. No decrease in activity of daily living was found in any patient. Complete pain relief without medication was achieved in 77.8% and partial pain relief in 14.8% in the elderly group, and 83.3% and 9.7%, respectively, in the non-elderly group (p=0.750). Permanent neurological complication was not observed in the elderly group, whereas Vth nerve and VIIIth nerve complications were observed in the non-elderly group. Rates of preoperative multiple comorbidities and of cardiovascular comorbidity were significantly higher in the elderly group (p<0.01). Worsening comorbidity and new pathology at discharge were mainly hypertension in both groups, but glaucoma attack and asthma attack were observed in the elderly group. All pathologies were successfully managed. MVD for elderly patients with TN can be achieved safely with careful perioperative management. Information of comorbidity should be shared with all staff involved in the treatment, who should work as a team to avoid worsening comorbidity. The possibility of unpredictable events in the elderly patients should always be considered.

Essential or unexplained hypertension exists in a significant segment of the US population. Among those with essential or unexplained hypertension is a subset of patients who are diagnosed with 'refractory hypertension' (RHTN) or uncontrolled hypertension despite sustained therapy with at least three antihypertensive agents. Neurogenic etiologies are prevalent among patients with RHTN, with a notable proportion requiring surgical intervention to normalize their blood pressure. Microvascular decompression (MVD) has emerged as a surgical intervention that may be efficacious for the treatment of RHTN. A review of studies reporting outcomes associated with MVD as a treatment approach for refractory hypertension of neurogenic causes (RHTN-N) suggests that blood pressure can be normalized after MVD in some patients with RHTN-N. Consequently, additional studies are needed to offer additional evidence to support MVD as an effective surgical intervention for difficult-to-treat patients with RHTN-N.