Neurosurgery. 2026;99(4):920–927
An eightieth birthday should not automatically exclude microvascular decompression for classical trigeminal neuralgia. Sabahi and colleagues report encouraging early outcomes in carefully selected octogenarians, although their findings do not establish equivalent safety or long-term durability. The practical message is to assess surgical fitness and the pain phenotype rather than use chronological age as the sole deciding factor.
Study and key findings
This retrospective Cleveland Clinic study examined operations performed between 2018 and 2024. From 280 patients, propensity matching followed by exclusion of previous decompression procedures produced a final cohort of 33 octogenarians and 119 younger controls.
Octogenarians were selected for medication-refractory classical neuralgia, a purely paroxysmal phenotype, MRI-confirmed neurovascular conflict and acceptable anesthetic risk after multidisciplinary assessment.
Median hospital stay was two days in both groups. Thirty-day readmission occurred in 6.1% of octogenarians and 5.9% of controls. New or worsened arrhythmia occurred in two octogenarians (6.1%) and no controls; pre-existing arrhythmia was also more common in the older group.
At the last assessment, BNI grade I pain status was recorded in 54.6% of octogenarians and 59.7% of younger patients. However, median follow-up was only two months in octogenarians versus five months in controls, substantially limiting conclusions about sustained relief.
Interpretation and limitations
These results support discussing decompression with fit older patients rather than automatically directing them toward an ablative procedure. They do not compare decompression against rhizotomy or radiosurgery, nor identify a superior operative technique.
Selection bias is central: only patients actually offered and undergoing surgery were analyzed. Frailty, cognition and social support were not fully captured by matching. The small octogenarian sample and short, unequal follow-up reduce confidence about uncommon complications and recurrence. Absence of a statistically significant difference is not proof of equivalence.
Clinical takeaway
For an appropriately selected octogenarian with classical neuralgia and neurovascular conflict, decompression remains a reasonable option to discuss. Individual anesthetic assessment, attention to cardiac rhythm and realistic counseling about the limited long-term evidence are more informative than age alone.