Tag: Trigeminal neuralgia

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Hybrid fluoroscopy–neuronavigation technique for percutaneous balloon compression in trigeminal neuralgia

Acta Neurochirurgica (2026) 168:110

This article presents a hybrid fluoroscopy–electromagnetic neuronavigation technique for percutaneous balloon compression in trigeminal neuralgia, detailing preoperative CT trajectory planning, intraoperative dual guidance, and practical steps to optimize foramen ovale cannulation. Emphasis is placed on safety measures, anesthesia considerations, and procedural specifics such as entry point, stylet use, and balloon inflation parameters.

The manuscript discusses candidate selection, advantages for elderly or comorbid patients, limitations including equipment needs and limited evidence, and practical tips to minimize complications. Key points summarize indications, procedural timing, anatomical landmarks, and the hybrid approach’s potential to shorten the learning curve for junior surgeons.

Purpose: Hybrid fluoroscopy + electromagnetic neuronavigation improves accuracy and safety of foramen ovale cannulation for percutaneous balloon compression in trigeminal neuralgia, reducing multiple passes in anatomically variable cases

Planning: Preoperative thin-slice CT is used to design an individualized needle trajectory to the foramen ovale, sometimes modifying the classical Hartel entry point to avoid bony collision

Anesthesia: Performed under general anesthesia because trigeminal ganglion manipulation can trigger a vagal reflex causing severe bradycardia/asystole; atropine readiness is required

Setup & entry: Patient supine with slight head extension; entry point is typically ~2.5 cm lateral to the oral commissure, with neuronavigation confirming the skin site/trajectory and C-arm fluoroscopy providing real-time position checks

Needle guidance: Needle advanced under fluoroscopy toward the petrous ridge–clivus junction (lateral view alignment), then an electromagnetic sensor/stylet is inserted to confirm and fine-tune alignment with the preplanned path before FO passage

Balloon step: After cannulation, a 4F Fogarty balloon is inflated with ~0.75 ml iopamidol to achieve the characteristic pear-shaped configuration under fluoroscopy

Compression time: Balloon compression is maintained for ~1–3 minutes to balance pain relief with risks such as hypoesthesia and masticatory weakness; limit to a maximum of 3 minutes

Clinical role & limits: Useful for medication-refractory TN, especially elderly/comorbid patients or when MRI shows no neurovascular conflict; limitations include added cost/skill needs and low evidence base (lack of randomized trials)

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The utility of partial sensory rhizotomy and adjunct procedures in the surgical management of trigeminal neuralgia secondary to multiple sclerosis

J Neurosurg 144:1145–1153, 2026

This clinical study evaluates long-term outcomes of partial sensory rhizotomy (PSR) for trigeminal neuralgia (TN) secondary to multiple sclerosis (MS), comparing PSR alone, redo PSR, and PSR combined with microvascular decompression (MVD) or internal neurolysis (IN). Retrospective analysis of 37 procedures in 30 patients shows high immediate pain relief (89.2%), mean recurrence at 1.64 years, and variable durability across groups.

At final follow-up, combination therapy (PSR+MVD or PSR+IN) trended toward superior sustained pain freedom without increased complications, while first PSR commonly required additional interventions. The authors conclude PSR is an effective salvage option and suggest adjunctive MVD or IN may improve long-term outcomes, recommending prospective validation.

Objective Evaluate long-term outcomes of partial sensory rhizotomy (PSR) alone versus PSR combined with microvascular decompression (MVD) or internal neurolysis (IN) for trigeminal neuralgia secondary to multiple sclerosis.

Methods Retrospective review of PSR cases (2012–2023) grouped as first PSR, redo PSR, PSR+MVD, and PSR+IN; assessed pain outcomes, recurrence, and complications.

Cohort 30 patients underwent 37 procedures; 89.2% of procedures followed at least one prior ipsilateral TN procedure.

Immediate outcomes 89.2% achieved immediate postoperative pain relief (pain free with or without medication), with no significant differences between procedure groups.

Durability Pain recurred on average at 1.64 ± 1.71 years after the procedure, with no significant differences among groups.

Final follow-up pain freedom At mean 3.14 ± 2.58 years follow-up, 75% of PSR+MVD and 100% of PSR+IN cases were pain free; 52.3% of first PSR cases required additional procedures.

Complications Overall complication rate was 29.7% with no significant differences between groups; ipsilateral facial numbness was common (59.5%) and treated as an expected outcome rather than a complication.

Conclusion PSR functions effectively as a salvage option for MS-related TN, and adding MVD or IN may improve long-term pain relief without increasing complication rates.

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Long-term outcomes of microvascular decompression for trigeminal neuralgia in multiple sclerosis

J Neurosurg 144:1122–1133, 2026

This systematic review and meta-analysis evaluates microvascular decompression (MVD) outcomes for trigeminal neuralgia in patients with multiple sclerosis (TN-MS). The authors pooled 30 studies (265 unique TN-MS patients), finding neurovascular compression in 96.6% and a pooled long-term pain-free (BNI I) success rate of about 30%, with low heterogeneity and primarily transient sensory complications.

The report discusses limited, mostly retrospective evidence, methodological limitations, and potential dual mechanisms of TN in MS. Authors conclude MVD yields lower success than in classic TN but remains a reasonable option for selected TN-MS patients with demonstrable neurovascular compression; they call for prospective studies and refined patient selection.

Objective Evaluate long-term pain relief and complications of microvascular decompression (MVD) for trigeminal neuralgia in patients with multiple sclerosis (TN-MS), a group traditionally considered poor candidates for MVD.

Methods Systematic review/meta-analysis (PRISMA) of PubMed, Embase, Scopus, and Web of Science (search June 2024); primary endpoint was long-term pain-free status BNI I at final follow-up using random-effects meta-analysis of proportions.

Evidence base 30 studies were included, covering 429 TN-MS patients treated with MVD, representing 265 unique patients.

Neurovascular compression Compression was identified in 96.6% of reported TN-MS cases (via MRI and/or intraoperative findings).

Long-term efficacy Pooled long-term pain-free outcome (BNI I) after MVD was 30.2% (95% CI 24.2%–36.9%), with low heterogeneity across analyses.

Complications The most commonly reported complication after MVD was transient facial numbness (with other complications variably reported).

Interpretation MVD is less effective in TN-MS than in classic TN, but can still provide meaningful benefit, particularly when neurovascular compression is present.

Conclusion/implication MVD should not be categorically excluded for TN-MS; further prospective studies are needed to improve selection and outcomes.

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Partial sensory rhizotomy in therapy‑refractory and recurrent trigeminal neuralgia

Acta Neurochirurgica (2026) 168:42

This single-center retrospective analysis reports outcomes of partial sensory rhizotomy (PSR) for therapy-refractory or recurrent trigeminal neuralgia (TN) in 48 patients treated between 2004 and 2023. The study details patient selection, surgical technique, and perioperative findings, noting immediate pain relief in most patients, variable hypesthesia, and acceptable complication rates without permanent deficits.

Long-term follow-up (mean 38 months) found 65% pain-free without medication and 95% overall satisfaction (BNI 1–3), including a substantive subset with multiple sclerosis; recurrence occurred in 27% with some successfully re-operated. The authors conclude PSR is a viable option for selected refractory or recurrent TN patients, emphasizing informed consent about unpredictable sensory deficits

Partial Sensory Rhizotomy (PSR) Role: PSR is a surgical option for therapy-refractory or recurrent trigeminal neuralgia (TN), especially in patients without neurovascular conflict or those who failed previous microvascular decompression (MVD) or other interventions.

Efficacy: PSR provided immediate total pain relief in 87.5% (42/48) of patients; long-term, 72.1% (31/43) had complete or partial pain relief without medication, and 23.3% were satisfied with ongoing medication.

Indications: PSR is particularly relevant for patients with multiple sclerosis (MS)-related TN and those without a clear neurovascular conflict, as well as for those not responding to or preferring to avoid repeated percutaneous or radiosurgical procedures.

Complications: Postoperative hypesthesia is expected and occurred in 77.1% of patients, but was generally well tolerated; no cases of anesthesia dolorosa or corneal anesthesia were observed. Other complications (e.g., CSF fistula, transient hearing impairment) were rare and resolved with treatment.

Recurrence: The observed recurrence rate after PSR was 27.1%, consistent with previously reported rates (10–49% over five years), and repeat PSR was effective in patients with recurrent pain.

Comparison with Other Treatments: While MVD is preferred when neurovascular conflict is present, PSR offers comparable long-term pain relief in selected patients, but with a higher risk of sensory deficits. Combined MVD+PSR does not improve long-term outcomes if no vascular conflict exists.

Patient Satisfaction: Overall, 95% of patients reported meaningful improvement and satisfaction with PSR, despite sensory deficits, when adequately counseled preoperatively.

Recommendation: PSR should be considered and discussed as a viable surgical alternative for therapy-refractory or recurrent TN, particularly in MS patients and those not suitable for or preferring to avoid other invasive procedures.

 

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Microvascular Decompression for Patients With Type 1 Trigeminal Neuralgia Using Vein Sacrifice and a Teflon Transposition Technique: A 23-Year Cohort

Neurosurgery 98:588–596, 2026

This study reports outcomes from a 23-year, prospectively maintained cohort of 523 patients with unilateral Type 1 trigeminal neuralgia treated by microvascular decompression using vein sacrifice and a Teflon transposition technique. Primary outcome was long-term pain-free survival without medications, with median follow-up 8.2 years and 5-, 10-, 15-year pain-free rates of 77.6%, 72.5%, and 69.7%, respectively.

Operative details, complications, and reoperation rates are presented: arterial transposition was performed when possible, veins contacting the nerve were sacrificed, and Teflon pledgets used to maintain separation. Complications were uncommon and generally non-disabling (most frequent: facial numbness, diplopia); true Teflon granulomas were rare but noted in isolated reoperations.

Microvascular decompression (MVD) is the most effective surgical treatment for medically unresponsive Type 1 trigeminal neuralgia (TN), aiming to eliminate neurovascular contact with the trigeminal nerve using arterial transposition, vein sacrifice, and polytetrafluoroethylene (PTFE, “Teflon”) implantation when appropriate.

Study outcomes show that 92.7% of patients were initially pain-free without medications after MVD, with pain-free survival rates of 77.6% at 5 years, 72.5% at 10 years, and 69.7% at 15 years.

Operative technique selection depends on intraoperative findings: arteries are transposed and secured with PTFE whenever possible, veins in contact with the nerve are sacrificed, and partial sensory rhizotomy is reserved for cases without significant vascular compression.

Complication rates are low; the most common was new or worsened facial numbness (7.1%), with higher rates when veins were sacrificed (6.9%) versus arterial decompression alone (1.6%). Venous infarction occurred in 0.6% of patients, and Teflon granuloma in 0.4%.

Pain-free survival was lower in women (hazard ratio 1.48, P = .03), but not associated with pain duration, previous ablative surgery, or new facial numbness.

Vein sacrifice is generally safe and facilitates surgical exposure, though it carries a low but real risk of venous complications; evidence is mixed regarding whether preserving or sacrificing the superior petrosal vein impacts complication rates.

PTFE (“Teflon”) material is widely used for vessel transposition; however, true Teflon granulomas—characterized by mass effect, edema, and inflammatory response—are rare and should not be used to describe all cases of recurrent pain with adherent PTFE.

Terminology precision is important: “Teflon” is a trademark for Chemours’ PTFE products, and not all PTFE felt used in surgery is identical. Variability in material properties may affect surgical outcomes and study reproducibility.

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Electrophysiological monitoring of trigeminal nerve sensory root using sensory-masseter response for microvascular decompression in trigeminal neuralgia

Acta Neurochirurgica (2026) 168:13

This study presents a novel intraoperative electrophysiological technique—the sensory-masseter response (SMR)—for localizing neurovascular compression (NVC) during microvascular decompression (MVD) for trigeminal neuralgia. In 34 patients, SMR was recorded in 82.4% and showed strong spatial correlation with intraoperatively identified NVC, with significantly lower stimulation thresholds at compression sites (median 0.3 mA).

The authors describe methodology, threshold analyses, mechanistic hypotheses linking focal demyelination and sensory-motor anastomoses to SMR, illustrative cases, safety considerations, and limitations. They conclude SMR offers high spatial specificity as a potential real-time adjunct for MVD, but recommend larger studies to validate clinical utility.

Sensory-Masseter Response (SMR) Technique: SMR is a novel intraoperative electrophysiological monitoring method that applies microcurrent stimulation to the intracranial trigeminal sensory root and records compound muscle action potentials (CMAPs) from the masseter muscle to localize neurovascular compression (NVC) during microvascular decompression (MVD) for trigeminal neuralgia (TN).

High Spatial Specificity and Correlation with NVC: SMR was successfully recorded in 82.4% of cases (28/34), with a strong spatial correlation between SMR-positive sites and intraoperatively identified NVC (p < 0.001).

Lower Stimulation Threshold at NVC Sites: The stimulation threshold required to elicit SMR was significantly lower at NVC sites (median 0.3 mA, IQR 0.2–0.4 mA) compared to distal, central, or non-compressed segments, indicating localized neural hyperexcitability likely due to demyelination.

Mechanistic Basis—Sensory-Motor Root Anastomoses: SMR is likely mediated by abnormal anastomotic pathways between the trigeminal sensory and motor roots at the NVC site, enabling direct excitation of the masseter muscle and bypassing the central reflex arc.

Clinical Utility and Limitations: SMR provides real-time functional feedback for intraoperative localization of NVC, but its clinical value and influence on surgical outcomes require further validation in larger, controlled studies.

Potential Pathogenic Insight: The ability to elicit SMR at NVC sites supports the hypothesis that focal demyelination and abnormal sensory-motor conduction contribute to TN pathogenesis and characteristic symptoms like chewing-triggered pain.

Safety Considerations: SMR stimulation can cause transient blood pressure elevation due to sympathetic activation; precautions include deepening anesthesia and monitoring hemodynamics during stimulation.

Study Limitations: The main limitations include small sample size, absence of SMR testing in non-TN or healthy controls, possible technical constraints in nerve exposure, and restriction of recordings to the masseter muscle only.

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Factors Affecting Long-Term Pain Control After Gamma Knife Radiosurgery in Secondary Tumor-Related Trigeminal Neuralgia

Neurosurgery 97:1003–1011, 2025

This clinical study evaluates long-term pain outcomes after Gamma Knife radiosurgery (GKRS) for secondary tumor-related trigeminal neuralgia in 156 patients, reporting complete pain relief (BNI 1) in 38.8% and adequate relief (BNI 2–3) in 47.4% over a median 48.5-month follow-up. The cohort—predominantly schwannomas and meningiomas—received tumor-targeted single-session GKRS with a median dose of 12 Gy and facial hypesthesia noted in 8.3%.

Multivariable analysis identified age ≥50 years and decreased or stable tumor volume at follow-up as strong predictors of favorable pain outcomes, while tumor progression and younger age predicted failure. The authors conclude tumor control contributes to pain relief but is not the sole mechanism, and targeting tumor alone achieved similar BNI 1–3 rates as reports that also targeted the nerve.

• Gamma Knife Radiosurgery (GKRS) Efficacy: GKRS provides complete pain relief (BNI 1) in 38.8% and adequate pain relief (BNI 2-3) in 47.4% of patients with secondary tumor-related trigeminal neuralgia, with a median follow-up of about 48.5 months.

• Predictors of Pain Relief: Age ≥50 years (odds ratio: 6.95) and decreased or stable tumor volume at follow-up (odds ratio: 40.38) significantly predict successful pain relief (BNI 1-3) after GKRS.

• Tumor Control and Pain Relief Relationship: While tumor control (stable or reduced volume) strongly correlates with pain relief, pain relief can still occur without significant tumor shrinkage, indicating other contributing mechanisms.

• Most Common Tumor Types: Schwannomas (67.9%) and meningiomas (29.6%) are the most frequent causes of secondary tumor-related trigeminal neuralgia treated with GKRS.

• Complications: Facial hypesthesia is the most common complication post-GKRS, affecting 8.3% of patients; no cases of anesthesia dolorosa or worsening pain were reported.

• Tumor Volume Impact: Larger pre-treatment tumor volume is associated with higher rates of pain relief failure; patients with pain relief failure had a median tumor volume of 5.9 cc versus 3.1–4 cc in those with successful outcomes.

• Prior Procedures: Previous interventions (such as radiofrequency ablation, rhizotomy, or tumor resection) do not significantly affect pain relief outcomes after GKRS.

• Alternative Approaches: Targeting the tumor alone with GKRS is effective; nerve targeting may be reserved for cases where tumor-targeted GKRS fails.

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Outcomes After Repeat-Percutaneous Balloon Compression for Recurrent Trigeminal Facial Pain

Neurosurgery 97:1012–1020, 2025

This clinical case series evaluates the safety and efficacy of repeat percutaneous balloon compression (PBC) for recurrent trigeminal neuralgia in 36 patients treated from 2019–2023, reporting 55 procedures. Outcomes include pain-free duration, BNI pain scores, facial numbness, medication reduction, operative metrics, and complications, with midterm follow-up averaging 33 months.

Key findings indicate repeat PBC yields durable pain relief for most patients (72% sustained complete relief), enables medication reduction in 71%, and incurs low complication rates without observed deafferentation pain; multiple sclerosis patients required more repeats but benefited similarly. The study calls for larger comparative trials to confirm these single-center results.

• Repeat Percutaneous Balloon Compression (PBC) Efficacy: Repeat PBC procedures are effective in managing recurrent trigeminal neuralgia, with 72% of patients maintaining complete pain relief at midterm follow-up (mean: 33 months), and 71% able to permanently decrease or eliminate facial pain medications.

• Safety of Repeat PBC: Repeat PBCs do not increase the risk of complications, regardless of the number of procedures or balloon inflation time, and no patients experienced deafferentation pain in this cohort.

• Complication Profile: Minor transient complications occurred in 10.9% of procedures, with only one major complication (carotid artery puncture); most adverse effects were temporary and non-severe, such as transient numbness, chewing difficulties, or partial corneal anesthesia.

• Pain-Free Interval: The mean pain-free interval after the first PBC was 18 months, with longer intervals observed after subsequent procedures (second: 20 months, third: 41 months in one case), and a decreasing proportion of patients requiring further interventions with each repeat procedure.

• Patient Selection and Outcomes: PBC was performed in patients with predominantly neuralgic facial pain who were not candidates for microvascular decompression; patients with multiple sclerosis (MS) required more repeat procedures but still achieved high rates of pain relief.

• Comparison to Other Techniques: Compared to other percutaneous procedures like radiofrequency thermocoagulation (RFT) and glycerol rhizotomy, repeat PBC appears to have fewer severe complications such as deafferentation pain, dysesthesia, or persistent sensory deficits.

• Balloon Compression Time: Longer balloon inflation times (up to 10 minutes for repeat procedures) did not correlate with increased complications and may contribute to longer pain-free intervals, though no statistical significance was found in this study.

• Clinical Recommendation: Given the likelihood of recurrence after percutaneous procedures, PBC is a safe and effective option for recurrent trigeminal neuralgia, especially for patients unsuitable for more invasive surgery, but larger multi-institutional studies are needed for broader validation.

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An Artificial Intelligence Tool for the Diagnosis of Facial Pain

Neurosurgery 97:993–1002, 2025

This study presents development and validation of an AI-based diagnostic decision support tool that distinguishes temporomandibular disorders (TMDs) from trigeminal neuralgia (TN) using a standardized facial pain questionnaire and targeted orofacial examination. Supervised machine learning models (Random Forest, Logistic Regression, SVM) were trained on data from 101 patients, with the Random Forest achieving the best performance (≈90% accuracy; ROC-AUC ~0.95).

The analysis identifies clinically interpretable predictors—TMJ and masticatory muscle tenderness favor TMD, while brief electric-shock–like pain and prior response to trigeminal surgery favor TN—and evaluates class imbalance effects and limitations for clinical deployment. The work emphasizes the need for external validation, cautious integration into workflows, and balanced training to improve generalizability.

• Differentiation Challenge: Temporomandibular disorders (TMDs) and trigeminal neuralgia (TN) both cause orofacial pain but require very different treatments, making accurate diagnosis crucial; TMDs are far more common and often misdiagnosed as TN, leading to inappropriate management.

• AI Diagnostic Tool: A machine learning (ML) model using questionnaire data and physical examination can reliably distinguish TMD from TN with approximately 90% accuracy, with a Random Forest Classifier showing the best performance (F1 score up to 0.953).

• Key Predictive Features: The most important diagnostic indicators are TMJ tenderness and masticatory muscle tenderness (favoring TMD), and brief, unpredictable, electric shock–like pain episodes (favoring TN).

• Data Collection: Comprehensive data—including both patient-reported symptoms and structured physical examination—significantly improves diagnostic accuracy compared to using only a subset of features.

• Prevalence and Misdiagnosis: TMDs affect 5–12% of the population, while TN is much rarer (0.03–0.3%); the high prevalence of TMD means misdiagnosis as TN is a significant concern, with many patients meeting criteria for TN2 possibly having TMD instead.

• Model Robustness: Training ML models on balanced datasets (even when real-world prevalence is imbalanced) improves accuracy and reduces false positives for the minority class (TN).

• Clinical Utility: The AI tool provides transparent, interpretable results that align with clinical reasoning, supporting clinicians in differentiating between TMD and TN, but external validation in diverse populations is needed before routine clinical adoption.

• Limitations: Further research is required for external validation, integration into workflows, and to address potential algorithmic bias; overreliance on algorithmic output should be avoided in favor of combined clinical expertise.

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Long-term outcomes of peripheral nerve field stimulation in patients with refractory trigeminal neuralgia: a cohort study

J Neurosurg 143:982–986, 2025

Peripheral nerve field stimulation (PNFS) for refractory trigeminal neuralgia showed high long-term treatment failure, especially in females, with frequent complications and revisions. Only half of male patients reported lasting benefit. PNFS should be considered cautiously for this condition.

Peripheral nerve field stimulation (PNFS) was studied for refractory trigeminal neuralgia with a long-term follow-up.

Fifteen patients (6 male, 9 female; median age 70) were included, with a median follow-up of 93 months.

PNFS had a high rate of long-term treatment failure, especially in females.

The median time to treatment failure was 2 years (5.1 years in males, 1.5 years in females; p = 0.003).

Only 3 patients (all male) reported ongoing benefit.

Complications and revision surgeries were common (4 patients, 7 revisions).

No significant differences in outcomes were found between classic and secondary trigeminal neuralgia or by patient age.

PNFS should be considered cautiously due to limited long-term efficacy and frequent complications.

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Outcome comparison between interposition and “contactless” transposition microvascular decompression approaches for trigeminal neuralgia

J Neurosurg 143:970–981, 2025

This study compared interposition and “contactless” transposition (Teflon and pericranial sling) microvascular decompression techniques for trigeminal neuralgia. Both were effective, but sling transposition showed improved midterm pain control and fewer complications. The only significant predictor of pain freedom was MRI evidence of clear nerve compression.

• Microvascular decompression (MVD) is a main surgical treatment for trigeminal neuralgia (TN), traditionally using Teflon interposition between nerve and artery.

• Recurrence of TN pain after MVD is often due to Teflon complications, prompting the development of “contactless” transposition techniques such as Teflon and pericranial sling transpositions.

• This retrospective study compared outcomes of interposition, Teflon transposition, and pericranial sling transposition in 305 TN patients.

• Sling transposition was mainly used for severe compression by the superior cerebellar artery and involved securing the artery to the tentorium with a pericranial graft.

• All techniques had similar short-term pain relief and complication rates, but sling transposition showed significantly higher pain-free rates at 2 years compared to other methods.

• Clear vascular compression on MRI was the only significant predictor of pain freedom in multivariate analysis.

• Sling transposition uses autologous tissue, avoids foreign body reactions, and may provide more durable pain control, but is technically more complex.

• Further long-term studies are needed to confirm the durability of sling transposition for TN pain control.

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Enhanced Recovery After Surgery Protocol for Microvascular Decompression in Trigeminal Neuralgia: A Retrospective Matched Cohort Study

Neurosurgery 97:936–944, 2025

Implementation of an enhanced recovery after surgery (ERAS) protocol for microvascular decompression in trigeminal neuralgia significantly reduced hospital length of stay, improved postoperative pain scores, and decreased transient hearing alterations compared to conventional care, without increasing complications, according to a retrospective matched cohort study.

• Enhanced Recovery After Surgery (ERAS) protocol was implemented for microvascular decompression (MVD) in trigeminal neuralgia (TN) patients and compared to conventional care in a retrospective matched cohort study.

• ERAS protocol included preoperative counseling, scalp block, small incisions, minimal muscle dissection, total intravenous anesthesia without narcotics, early enteral feeding, and early mobilization.

• 130 patients (65 ERAS, 65 non-ERAS) were analyzed after propensity score matching for key demographics and comorbidities.

• ERAS group had significantly shorter hospital length of stay (1.46 vs 2.95 days, P < .001) and lower postoperative verbal pain scores (1.63 vs 2.48, P = .03) than controls.

• ERAS patients experienced fewer transient postoperative subjective hearing alterations (0 vs 6 cases, P = .03).

• No significant difference in postoperative Barrow Neurological Institute (BNI) pain scores or major complications between groups.

• Subgroup analysis showed ERAS patients discharged at 24 hours had even lower pain scores than controls.

• Study limitations include retrospective design, small sample size, and use of subjective pain scores; larger randomized trials are needed.

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How to deal with the superior petrosal vein in microvascular decompression for trigeminal neuralgia?

Neurosurg Focus 59(3):E12, 2025

Sectioning the superior petrosal vein at its main trunk while maintaining venous crossflow is a safe and effective strategy during microvascular decompression for trigeminal neuralgia, improving surgical access without significantly increasing venous-related complications, according to a large retrospective study.

• Management of the superior petrosal vein (SPV) during microvascular decompression (MVD) for trigeminal neuralgia (TN) is controversial, with concerns about operative field access and potential complications.

• A retrospective study evaluated a technique of SPV division at its main trunk near the superior petrosal sinus, maintaining venous crossflow through contributories, in 171 out of 217 patients (79%).

• No statistically significant increase in venous-related complications was observed in the SPV division group compared to the preservation group.

• Only 3 possibly venous-related complications occurred in the SPV division group, all of which were mild and transient.

• Anatomical variations of the SPV require careful intraoperative assessment and preservation of collateral venous drainage for safety.

• Preoperative imaging and intraoperative techniques (e.g., indocyanine green angiography) are recommended to assess collateral flow before SPV division.

• The study concludes that SPV division at the main trunk with preservation of crossflow is a safe strategy that improves surgical exposure during MVD for TN.

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Perioperative Evaluation and Monitoring of Percutaneous Balloon Compression in Treatment of Trigeminal Neuralgia

Operative Neurosurgery 29:263–270, 2025

This prospective study found that higher intraluminal balloon pressure during percutaneous balloon compression for trigeminal neuralgia reduces long-term pain recurrence without increasing persistent facial numbness. Preoperative MRI-based Meckel’s cave assessment and intraoperative pressure monitoring help optimize outcomes and balance pain relief with sensory side effects.

• Percutaneous balloon compression (PBC) is used to treat trigeminal neuralgia (TN), with outcomes influenced by intraluminal balloon pressure, balloon volume, and Meckel’s cave volume.

• Preoperative high-resolution MRI enables 3D reconstruction of Meckel’s cave, aiding in predicting intraoperative balloon volume.

• Intraoperative monitoring of balloon pressure and volume was performed in 37 patients; primary outcomes were facial numbness and pain recurrence up to 24 months.

• Facial numbness was common in the first month (38%), but typically resolved by 24 months; numbness was not linked to balloon pressure.

• TN recurrence rate was about 25% at 24 months and was significantly associated with lower intraluminal balloon pressure.

• No significant differences in Meckel’s cave or balloon volume were observed between subgroups, but Meckel’s cave volume correlated positively with balloon volume.

• Authors recommend maintaining intraluminal balloon pressure around 135.7 ± 27.1 kPa (with 120 seconds compression) to minimize recurrence without increasing sensory deficits.

• Perioperative assessment of balloon compression (including MRI and pressure monitoring) is feasible and may help balance TN recurrence risk and sensory complications.

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Neuroapraxia of Trigeminal Nerve Controlled by Neuromonitoring During Microvascular Decompression in Multiple Sclerosis Patients Affected by Drug-Resistant Trigeminal Neuralgia Recurrent After Previous Operations

Operative Neurosurgery 29:295–300, 2025

This case series reports the first use of intraoperative neuromonitoring-controlled neuroapraxia of the trigeminal nerve with a temporary aneurysm clip during microvascular decompression for drug-resistant, recurrent trigeminal neuralgia in multiple sclerosis patients, showing immediate pain relief and no complications at up to 10 months’ follow-up.

• Trigeminal neuralgia (TN) in multiple sclerosis (MS) patients is difficult to treat and often recurs after surgery.

• This report describes the first 3 cases of recurrent, drug-resistant MS-related TN treated with intraoperative neuromonitoring (IONM)-controlled neuroapraxia during microvascular decompression (MVD).

• Neuroapraxia was induced by applying a temporary titanium aneurysm clip to the trigeminal nerve for up to 30 seconds, with real-time IONM to avoid nerve damage.

• All patients achieved immediate pain relief and maintained Barrow Neurological Institute pain score I at 9–10 months follow-up, with no major complications.

• Compared to previous techniques, this approach minimized complications by reducing clip time and using neuromonitoring.

• This technique may offer a safe, promising option for MS patients with recurrent TN, but larger studies with longer follow-up are needed.

• The study’s main limitation is the small patient number and short follow-up period.

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The efficacy of combining pulsed radiofrequency with low-temperature continuous radiofrequency for the treatment of primary trigeminal neuralgia

J Neurosurg 143:100–110, 2025

High-voltage pulsed radiofrequency (PRF) combined with low-temperature continuous radiofrequency (CRF) significantly improved 12-month response rates and pain scores in primary trigeminal neuralgia compared to PRF alone, with minimal complications. This combined approach offers a promising alternative for patients unresponsive to medication.

High-voltage pulsed radiofrequency (PRF) combined with low-temperature (60°C) continuous radiofrequency (CRF) was compared to high-voltage PRF alone for treating primary trigeminal neuralgia (TN) in a randomized controlled trial.

• 146 patients were randomized to either PRF+CRF or PRF alone, with 12-month response rate as the primary outcome.

• The PRF+CRF group had a significantly higher response rate at 12 months (83.6% vs 67.1%, p = 0.021) and better pain relief at all measured time points.

• Patient satisfaction scores were higher in the PRF+CRF group at 1, 6, and 12 months.

• Facial numbness and masseter muscle weakness were more frequent in the PRF+CRF group but were mild and resolved within months; no serious complications occurred.

• Both treatments were safe, with no cases of anesthesia dolorosa, corneal anesthesia, or keratitis.

• The study was limited by single-center design, open-label nature, and a smaller than expected difference in primary outcome, suggesting the need for larger studies.

• Conclusion: High-voltage PRF combined with low-temperature CRF offers better pain control and satisfaction than PRF alone, with minimal side effects, for patients with refractory TN.

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Stratifying trigeminal neuralgia and characterizing an abnormal property of brain functional organization: a resting-state fMRI and machine learning study

J Neurosurg 143:74–82, 2025

Resting-state fMRI and machine learning revealed distinct brain connectivity and activity differences between classical and idiopathic trigeminal neuralgia (TN) and controls. These findings identify potential neuroimaging biomarkers for TN subtypes, aiding diagnosis and understanding of TN pathophysiology.

Primary trigeminal neuralgia (TN) includes classical (CTN) and idiopathic (ITN) types, sharing clinical features but differing in neurovascular compression (NVC) presence.

• Resting-state fMRI and machine learning were used to analyze brain functional connectivity and spontaneous activity in 50 TN patients (28 CTN, 22 ITN) and 43 controls.

• TN patients showed increased connectivity between the medial prefrontal cortex (mPFC) and left planum temporale, and decreased connectivity between mPFC and left superior frontal gyrus.

• CTN patients had further reduced connectivity between the left insula and left occipital pole, and decreased activity in the right temporal pole compared to ITN.

• TN patients exhibited heightened neural activity in frontal regions compared to controls.

• Machine learning (support vector machine) distinguished TN patients from controls with moderate accuracy (AUC 0.80).

• Findings suggest potential fMRI biomarkers for TN subtypes, aiding understanding of pathophysiology and improving diagnosis.

• Study limitations include small sample size and exclusion of bilateral/secondary TN, warranting further research.

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Effects of the length of preoperative conservative management on postoperative outcomes after primary microvascular decompression for trigeminal neuralgia

J Neurosurg 143:92–99, 2025

Prolonged preoperative conservative management with anticonvulsants in trigeminal neuralgia is associated with worse pain outcomes and higher pain recurrence after microvascular decompression. Early surgical intervention may improve postoperative results and reduce pain recurrence risk in these patients.

• Longer duration of preoperative conservative management (anticonvulsant use) before microvascular decompression (MVD) for trigeminal neuralgia (TN) is linked to worse postoperative pain outcomes and higher risk of pain recurrence.

• Median duration of conservative management before surgery was 1.74 years.

• Patients with longer conservative management had higher final BNI pain scores and greater rates of pain recurrence than those with shorter management.

• Longer conservative management predicted shorter pain-free survival after MVD.

• Younger age and longer conservative management duration were independent predictors of worse postoperative pain and recurrence.

• No significant difference in preoperative pain scores between groups; both had high pain levels pre-surgery.

• Findings suggest early surgical intervention may benefit TN patients who are candidates for MVD.

• Study was retrospective and single-institution, limiting generalizability; further research is needed.

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Deep learning–based segmentation of the trigeminal nerve and surrounding vasculature in trigeminal neuralgia

J Neurosurg 143:83–91, 2025

This study developed and validated deep learning U-Net models for automated 3D segmentation of the trigeminal nerve and surrounding vasculature in MRI of trigeminal neuralgia patients, enabling objective quantification of neurovascular conflict features and potentially improving preoperative evaluation and treatment planning.

• Deep learning (U-Net) models were used to segment the trigeminal nerve and surrounding vasculature in patients with trigeminal neuralgia using high-resolution CISS MRI.

• Six U-Net variants with different encoder backbones were tested; SE-ResNet50 performed best overall (Dice score = 0.775, IoU = 0.681).

• The models quantified anatomical features such as the surface area of neurovascular contact and distance to the contact point, showing no significant difference from manual segmentations.

• The best model achieved 100% sensitivity and specificity in detecting neurovascular conflict in the testing set.

• Automated 3D segmentation allows for objective, quantitative evaluation, improving on subjective and time-intensive manual methods.

• Limitations include inability to distinguish vessel type (artery vs. vein) and data from a single institution; future work should address these.

• The method may help standardize neurovascular conflict assessment and improve treatment selection for trigeminal neuralgia.

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Revisiting Härtel’s technique for percutaneous transoval glycerol injection

Acta Neurochirurgica (2025) 167:126

The study revisits Härtel’s technique for percutaneous transoval glycerol injection in treating trigeminal neuralgia. It identifies an optimal entry point in the cheek, 2 mm below the horizontal plane, to improve procedural success and reduce complications, emphasizing the importance of precise needle guidance.

• Purpose: The study revisits Härtel’s technique for percutaneous transoval glycerol injection (GI) to treat trigeminal neuralgia, aiming to identify optimal needle entry points and trajectories using imaging-based simulations.

• Methods: CT and MRI-based simulations were conducted on eleven patients to determine optimal entry points and trajectories through the foramen ovale (FO) to reach Meckel’s cave.

• Findings: The optimal entry point is 2 mm below the horizontal plane through the angle of the mouth, providing better access to Meckel’s cave in most cases.

• Conclusion: Technical results of GI can be improved by selecting the optimal entry point and guiding the needle through the medial part of FO under fluoroscopy.

• Historical Context: Härtel’s technique, developed in 1912, provided a systematic approach to reach the trigeminal ganglion through FO.

• Variability in Techniques: Different variations of GI techniques have led to variable outcomes, highlighting the importance of standardizing the procedure.

• Simulation Insights: 3D simulations help in identifying reliable entry points and can be useful in cases with anatomical variations.

• Clinical Implications: The study suggests that lowering the entry point in the cheek could improve the success rate of GI procedures.

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