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Outcomes After Standardized Burr-Hole Surgery for Chronic Subdural Hematomas: A Population-Based Consecutive Cohort Study of 2655 Patients

Neurosurgery 97:298–309, 2025

This large population-based study of 2655 chronic subdural hematoma patients treated with mostly single burr-hole craniotomy found an 11% recurrence and complication rate, 12% 1-year mortality, and identified male sex, diabetes, antithrombotic use, midline shift, and bilateral surgery as independent recurrence predictors.

• Large cohort study (n=2655) analyzed outcomes after standardized burr-hole craniotomy (BHC) for chronic subdural hematoma (CSDH) at a single center (2006–2022).

• Reoperation for hematoma recurrence occurred in 11% of patients, with most recurrences happening within 23 days.

• Independent predictors of recurrence included male sex, diabetes, preoperative antithrombotic therapy, midline shift, and bilateral hematomas.

• Postoperative complications occurred in 11% (3.9% moderate-to-severe); urinary tract infections, subdural empyema, and seizures were most common.

• 1-year postoperative mortality was 12%.

• Higher Charlson Comorbidity Index and lower Glasgow Coma Scale score were independent predictors of moderate-to-severe complications.

• Minicraniotomy was used in 9.3% of cases, with similar recurrence but slightly higher complication rates compared to BHC.

• Predictive models for recurrence and complications had low performance, suggesting other unmeasured factors are important.

 

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Predicting the natural history of unruptured brain arteriovenous malformations: external validation of rupture risk scores

J Neurosurg 143:490–498, 2025

This retrospective study externally validated four rupture risk scoring systems for unruptured brain arteriovenous malformations (bAVMs) and found their predictive performance ranged from nondiscriminatory to poor. The R2eD AVM scale performed best but still showed limited accuracy, highlighting the need for improved predictive models.

• The study externally validated four rupture risk scoring systems for unruptured brain arteriovenous malformations (bAVMs): Nataf, R2eD AVM, ARI, and VALE.

• Current rupture risk scores showed nondiscriminatory to poor performance in predicting ruptured presentation in a Peruvian single-center population.

• The R2eD AVM scale had the best performance among evaluated scores, but its discrimination was still poor (AUROC 0.664).

• A logistic regression model using size, location, venous tortuosity, and ventricular involvement showed only fair discrimination (AUROC 0.709).

• Key risk factors for rupture included smaller size, periventricular/infratentorial location, absence of venous tortuosity, and ventricular involvement.

• Some variables in published scores, such as venous tortuosity and venous drainage features, were not predictive in this cohort.

• Further research and better predictive factors are needed to improve rupture risk assessment in bAVMs.

• The R2eD AVM score can be used preferentially in clinical practice, but with caution due to its limited performance.

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Comparison of suboccipital craniectomy versus suboccipital cranioplasty in foramen magnum decompression for adult Chiari malformation

J Neurosurg Spine 43:237–245, 2025

This retrospective study compared suboccipital craniectomy and cranioplasty for foramen magnum decompression in adult Chiari malformation. Both techniques improved symptoms and syrinx size, but cranioplasty incurred higher costs without significant clinical or radiological advantages. Cost considerations should be discussed during shared decision-making.

• Suboccipital craniectomy and suboccipital cranioplasty are two surgical techniques for foramen magnum decompression (FMD) in adult Chiari malformation.

• Both procedures significantly improve preoperative symptoms and reduce syrinx size, with no significant difference in clinical outcomes.

• Suboccipital craniectomy results in a greater increase in subarachnoid space compared to cranioplasty.

• No significant differences were found in surgical time, estimated blood loss, or cervical alignment between the two groups.

• Suboccipital cranioplasty incurs higher daily medical costs due to the use of plates and screws for bony reconstruction.

• Both techniques have similar rates of complications and secondary surgeries.

• The additional costs of cranioplasty should be discussed with patients during shared decision-making.

• Study limitations include retrospective design, small sample size, surgeon preference, and shorter follow-up for cranioplasty.

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High-grade glioma: combined use of 5-aminolevulinic acid and intraoperative ultrasound for resection and a predictor algorithm for detection

J Neurosurg 143:323–331, 2025

Combining 5-aminolevulinic acid (5-ALA) fluorescence and intraoperative ultrasound (ioUS) significantly improved the sensitivity and specificity for detecting high-grade glioma during surgery, compared to either technique alone. A machine learning algorithm (HGGPredictor) further enhanced intraoperative tumor margin prediction, suggesting a new standard for safer, more effective resections.

• Combining 5-ALA fluorescence and intraoperative ultrasound (ioUS) improves the accuracy of high-grade glioma (HGG) resection compared to using either method alone.

• 5-ALA shows higher sensitivity (84.9%), while ioUS provides higher specificity (84.5%); combined, they reach sensitivity of 91% and specificity of 86%.

• The combined approach is especially valuable for maximizing tumor removal while minimizing neurological damage, particularly near eloquent brain regions.

• A machine learning algorithm (HGGPredictor) was developed to predict tumor presence during surgery based on 5-ALA and ioUS results.

• The study included 72 patients and 301 biopsies, with histological analysis as the reference standard.

• The benefit of combination is greatest for strong fluorescence or hyperechogenicity; ioUS is particularly helpful when 5-ALA fluorescence is weak.

• The combined method is accessible and can be integrated into existing surgical protocols without major additional costs.

• Limitations include single-center design and lack of a control group, but results suggest a new standard for HGG resection.

 

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Intraoperative brain tumor classification via laser-induced fluorescence spectroscopy and machine learning

J Neurosurg 143:313–322, 2025

A laser-based device, TumorID, combined with machine learning, rapidly and nondestructively classifies brain tumor tissue intraoperatively. Tested on 46 patients, it distinguished glioma, meningioma, pituitary adenoma, and normal tissue with high accuracy, offering potential to improve neurosurgical decision-making and outcomes

• TumorID is a laser-induced endogenous fluorescence spectroscopy device paired with machine learning for rapid intraoperative brain tumor classification.

• It distinguishes glioma, meningioma, pituitary adenoma, and nonneoplastic tissue in near real time using a 405-nm laser and support vector machine (SVM) algorithm.

• The device requires only 0.5 seconds per scan and does not damage tissue.

• In a study of 46 patients and 761 scans, TumorID achieved a multiclass AUROC of 0.809, demonstrating high classification accuracy.

• Neutral porphyrin emission regions were most significant for tissue differentiation.

• TumorID offers objective, fast, and nondestructive tissue diagnostics, potentially improving surgical decision-making and resection outcomes.

• Future directions include in vivo use, prediction of tumor subtypes and genetics, and integration with other data sources for improved accuracy.

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Is FLAIRectomy Directly Correlated with Prolonged Survival in Glioblastoma? A Prospective National Multicenter Study on Correlation Between Extent of Tumor Resection and Clinical Outcome

Neurosurgery 97:489–500, 2025

This multicenter prospective study shows that the extent of FLAIRectomy (resection of FLAIR-positive areas) in glioblastoma is a stronger predictor of survival than traditional resection, with higher EOFR significantly improving progression-free and overall survival, especially in IDH-mutant tumors, without increasing neurological complications.

• FLAIRectomy, or resection of FLAIR-MRI hyperintense regions beyond the contrast-enhancing tumor, was studied in a prospective multicenter cohort of 150 glioblastoma patients.

• A higher extent of FLAIR resection (EOFR) was associated with significantly improved overall survival (OS) and progression-free survival (PFS), more so than resection of contrast-enhancing tumor alone.

• Each 1% increase in EOFR correlated with a 6.8% reduction in mortality risk for IDH-wildtype and 12.1% for IDH-mutant tumors.

• Mean OS was 28.4 months and mean PFS was 16.3 months in the study cohort.

• IDH1 mutation status was also associated with longer survival, but EOFR remained an independent predictor after adjustment.

• AI analysis confirmed that patients with higher EOFR clustered with longer survival.

• Neurological safety was addressed with intraoperative neuromonitoring and careful planning; permanent deficits occurred in 9/150 patients.

• The study concludes that FLAIR-based supramarginal resection may be a more reliable predictor of survival in glioblastoma than conventional imaging-guided resection.

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Quantitative Volumetric Computed Tomography Density Predicts Basal Ganglia Hemorrhage Expansion and Enhances Spot Sign Diagnostic Accuracy

Neurosurgery 97:481–488, 2025

Automated quantitative CT analysis using normalized volumetric CT density (nv-CTD) enhances prediction of basal ganglia hematoma expansion, especially when combined with the spot sign. nv-CTD offers high sensitivity for ruling out expansion and enables improved risk stratification for early intervention in intracerebral hemorrhage.

• Automated quantitative CT analysis (nv-CTD) predicts hematoma expansion (HE) in basal ganglia intracerebral hemorrhage (ICH), improving risk stratification for early surgical intervention.

• nv-CTD is calculated as mean ICH CT density divided by surrounding parenchyma density, providing a normalized measure of hemorrhage acuity.

• Lower nv-CTD (<2.3) is highly sensitive (96%) for predicting HE, while the spot sign is highly specific (95%); using both improves diagnostic accuracy (AUC 0.80 vs 0.68 for spot sign alone).

• nv-CTD alone performs similarly to the spot sign for HE prediction and can be used when CTA is unavailable, especially to rule out HE.

• Automated computer vision segmentation enables consistent, rapid, and reproducible feature extraction, overcoming limitations of manual CT interpretation.

• The study included 108 patients and used a custom-trained neural network for image analysis, excluding those with thalamic ICH, high IVH burden, or small hemorrhages.

• Limitations include retrospective design, modest sample size, and narrow inclusion criteria, which may limit generalizability.

• Volumetric and quantitative imaging analysis can augment clinical decision-making for basal ganglia ICH management.

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Feasibility, Safety, and Impact of Awake Resection for Recurrent Insular Diffuse Gliomas in Adults

Neurosurgery 97:399–409, 2025

Function-based transopercular awake resection for recurrent insular diffuse gliomas in adults is feasible and safe, with similar resection rates, complications, and outcomes as first-time surgery, though prior combined treatments may increase intraoperative cooperation difficulties and sick leave, especially in high-grade gliomas.

• Transopercular awake resection for recurrent insular diffuse gliomas is feasible and safe, showing similar resection rates and outcomes to first-time surgery.

• No significant increase in intraoperative adverse events or surgery-related complications was observed for recurrent cases compared to first-line surgeries.

• Patients with previous combined oncological treatments had a higher risk of insufficient intraoperative cooperation, but this did not lead to mapping failure.

• Extent of resection and 6-month postoperative outcomes (Karnofsky Performance Status, seizure control, sick leave) were similar between recurrent and first-line groups.

• Longer sick leave was associated with high-grade gliomas and adjuvant treatments, not with surgery type.

• Shorter awake phase duration was observed in recurrent cases, likely due to easier access from prior surgeries and smaller tumor volumes.

• Study supports careful preoperative counseling and patient selection, especially for those with previous combined treatments.

• Results are specific to adult insular glioma patients treated with transopercular awake surgery and may not generalize to other populations or techniques.

 

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Microsurgical pineal cyst fenestration: A safe and effective treatment strategy in patients with symptomatic pineal cyst syndrome

Acta Neurochirurgica (2025) 167:179

Microsurgical fenestration of pineal cysts significantly improved symptoms in 94% of non-hydrocephalic patients with nonspecific symptoms, with no mortality or severe adverse events. Cyst size and radiological features did not predict outcomes. The study supports fenestration as a safe, effective treatment, but optimal indications remain unclear.

• Microsurgical fenestration of pineal cysts (PC) was studied as a treatment for symptomatic patients without hydrocephalus.

• Most patients had nonspecific symptoms like headache, dizziness, and sleep disturbances; nearly all saw surgery as a last resort.

• 47 patients were analyzed, with an average follow-up of about 7 years post-surgery.

• Significant symptom improvement was observed: mean pain score (VAS) dropped from 7 to 1, with 96% reporting relief.

• No mortality or severe complications occurred; minor complications included CSF leaks (10%) and one surgical site infection.

• No clinical or radiological factors predicted better outcomes; even small cysts could benefit from surgery.

• Fenestration of both anterior and posterior cyst walls was seen as key to success, potentially safer than full resection.

• Further research is needed to define indications, optimal technique, and pathophysiology of symptomatic pineal cysts.

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Anatomy of the superior hypogastric plexus and its relevance to anterior lumbar interbody fusion

J Neurosurg Spine 43:19–25, 2025

This cadaveric study details the anatomy of the superior hypogastric plexus (SHP) at L5–S1, its variations, and implications for anterior lumbar interbody fusion (ALIF). The authors recommend left-sided SHP retraction to minimize nerve injury and retrograde ejaculation; if unfeasible, midline splitting and lateral mobilization are advised.

• The study examined the anatomy of the superior hypogastric plexus (SHP) at the L5–S1 level and its relevance to anterior lumbar interbody fusion (ALIF) surgery.

• Injury to the SHP during ALIF can cause retrograde ejaculation (RE) in males and sexual dysfunction in females.

• The SHP typically overlays the midline at L5–S1 with a slight leftward shift and is covered by connective tissue beneath the peritoneum.

• Three morphological types of SHP were found: single cord, plexiform, and fiber; the plexus divides into hypogastric nerves below the aortic bifurcation.

• Retraction of the SHP to the left side is generally more feasible (up to 15.3 mm) than to the right (up to 5.3 mm); left-sided retraction is recommended.

• If left retraction is not possible, splitting the SHP at the midline and retracting both components laterally is advised.

• Careful SHP mobilization and avoidance of electrocautery are crucial to reduce risk of RE and sexual dysfunction in ALIF patients.

• The findings highlight the importance of detailed SHP anatomy knowledge for safer ALIF, especially with minimally invasive approaches.

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A survival analysis for predictors of implant subsidence following 1- or 2-level transforaminal lumbar interbody fusion

J Neurosurg Spine 43:42–51, 2025

This study found that after 1- or 2-level TLIF, aggressive disc height restoration and taller interbody implants significantly increase the risk of implant subsidence, especially in patients with poor bone quality. Surgeons should balance correction goals with subsidence risk, particularly in those with low Hounsfield unit measurements.

• This study analyzed predictors of interbody implant subsidence after 1- or 2-level transforaminal lumbar interbody fusion (TLIF) using a time-to-event (survival) analysis.

• Aggressive disc height restoration and use of taller interbody implants significantly increased the risk of subsidence.

• Poor baseline bone quality, measured by lower Hounsfield units (HU) on CT, was a strong independent predictor for significant (≥4 mm) subsidence.

• Longer fusion constructs (more instrumented levels) also increased the risk of significant subsidence.

• No significant association was found between cage material (titanium vs PEEK), device geometry, or lumbopelvic parameters and subsidence risk.

• Subsidence occurred in 38.2% of levels (≥2 mm) and significant subsidence in 10.4% (≥4 mm) by last follow-up.

• Clinical implications suggest balancing correction goals with subsidence risk, especially in patients with poor bone quality.

• Further multicenter and prospective studies are recommended to validate these findings.

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Segmental and overall lumbar lordosis after single-level minimally invasive transforaminal lumbar interbody fusion: a systematic review and meta-analysis

J Neurosurg Spine 43:70–82, 2025

This systematic review and meta-analysis found that single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) generally preserves segmental and overall lumbar lordosis, with preoperative alignment and use of expandable cages predicting postoperative lordosis. Greater segmental lordosis improvement was associated with reduced leg pain, but clinical outcome correlations were otherwise limited.

• Single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) generally preserves or slightly increases segmental and overall lumbar lordosis.

• Meta-analysis of 35 studies (1935 patients) showed significant but modest increases in segmental lordosis (mean +2.2°) and lumbar lordosis (mean +2.8°) postoperatively.

• Preoperative alignment and use of expandable cages are significant predictors of postoperative lordosis change.

• Greater improvement in segmental lordosis was associated with larger reductions in postoperative leg pain, but no strong correlation with other clinical outcomes was found.

• Most included studies were retrospective case series, with high heterogeneity in surgical technique and reporting.

• No significant association was found between facetectomy type, operative bed, or fixation technique and changes in lordosis.

• The main goal of MI-TLIF is neural decompression and fusion, not alignment correction; alternative approaches may be needed for major lordosis restoration.

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Imaging efficacy and safety of low dose intraventricular tissue plasminogen activator in aneurysmal subarachnoid hemorrhage

Acta Neurochirurgica (2025) 167:202

Low-dose intraventricular tPA (1 mg every 8 hours for up to 3 doses) via EVD after aneurysmal subarachnoid hemorrhage significantly accelerated subarachnoid blood clearance without hemorrhagic or infectious complications, but did not reduce shunt dependency. Larger studies are needed to assess effects on delayed cerebral ischemia.

• Low-dose intrathecal tPA (1 mg every 8 hours for up to 3 doses via EVD) was administered to 8 aSAH patients after aneurysm coiling to enhance subarachnoid blood clearance.

• Significant blood clearance was achieved: mean Hijdra Sum Score (HSS) reduction was 81.1% within 3 days, compared to 41.3% in a prior natural history cohort (p = 0.001).

• No patients experienced hemorrhagic complications or ventriculitis following IT-tPA treatment.

• Two patients (25%) developed delayed cerebral ischemia (DCI) and radiographic vasospasm, which is lower than historical rates (47.9%).

• Most patients (75%) required ventriculoperitoneal shunt placement, a higher rate than institutional averages.

• IT-tPA was well tolerated and effective for rapid clot clearance, but the impact on clinical outcomes like DCI prevention and shunt dependency remains unclear due to small sample size.

• Further randomized controlled trials are needed to determine optimal dosing, timing, and clinical benefits of IT-tPA for aSAH patients.

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Development and internal validation of a risk score for subsidence of expandable spacers in transforaminal lumbar interbody fusion (TLIF) surgery

Brain and Spine 5 (2025) 104322

This study developed and validated the Expandable TLIF Subsidence Index (ETSI) to predict risk of cage subsidence after TLIF surgery with expandable spacers. Key risk factors include high ASA score, non-degenerative indications, lower lumbar level, small cage size, and posterior cage position. Some risk factors are modifiable.

• A risk score (ETSI) was developed to predict cage subsidence (CS) after TLIF surgery using expandable spacers.

• Independent risk factors for CS include high ASA score, non-degenerative surgical indication, lower lumbar level, small cage size, and posterior cage position.

• ETSI ranges from -2 to 6 points and shows a moderate ability to classify CS risk (AUROC ≈ 0.68).

• Modifiable risk factors (cage size and position) can reduce CS risk if optimized by the surgeon.

• Higher ETSI scores are associated with increased risk of non-union/pseudarthrosis at 3 and 12 months.

• Anterior placement of the cage lowers subsidence risk, while posterior placement increases it.

• The study included 388 patients with a 3-month CS rate of 31.7%.

• The ETSI is the first comprehensive scoring system for CS risk with expandable TLIF cages.

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Multicentre study of the role of lumbar puncture in the diagnosis of spontaneous subarachnoid haemorrhage

Acta Neurochirurgica (2025) 167:193

A multicentre UK and Ireland study found that 1% of aneurysmal subarachnoid haemorrhage (SAH) cases were diagnosed by lumbar puncture (LP) after a negative CT within 6 hours. LP remains crucial in diagnosing SAH missed by early CT, suggesting NICE guidelines may need reconsideration.

• A multicentre UK and Ireland study assessed the role of lumbar puncture (LP) in diagnosing spontaneous subarachnoid haemorrhage (SAH), especially after negative CT scans.

• Out of 10,187 spontaneous SAH cases, 7% were diagnosed by LP, with 3% of aneurysmal SAH confirmed by LP after a non-diagnostic CT.

• 1% of aneurysmal SAH cases were detected by LP following a negative CT scan performed within 6 hours of symptom onset.

• There was no significant change in diagnostic practice following the introduction of the 2022 NICE guidelines, which recommend not routinely offering LP after a negative CT within 6 hours.

• Concerns remain that relying solely on CT, especially when reported by non-expert radiologists, risks missing SAH cases.

• LP remains important for diagnosing SAH in patients with strong clinical suspicion and negative early CT, potentially impacting future NICE guidance.

• Study limitations include retrospective design, possible under-reporting, and focus on neurosurgical referrals only.

• The findings support continued use of LP in select patients despite new guidelines.

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Measurement of CSF flow and brain motion in Chiari malformation type I subjects undergoing posterior fossa decompression surgery

J Neurosurg 143:13–23, 2025

Advanced MRI techniques show that in Chiari malformation type I, presurgical CSF flow and brain motion measurements better predict improvements after posterior fossa decompression surgery than traditional tonsillar descent metrics, potentially enabling more accurate identification of patients likely to benefit from surgery.

• Chiari malformation type I (CM-I) is defined by ≥5 mm cerebellar tonsil herniation through the foramen magnum, but tonsillar descent does not correlate well with symptom severity or surgical outcome.

• Posterior fossa decompression (PFD) surgery improves symptoms in ~75% of symptomatic CM-I patients, but carries risks, making optimal patient selection important.

• This study used advanced MRI (phase-contrast for CSF flow and DENSE for brain motion) to evaluate 108 CM-I patients, 61 of whom had PFD surgery.

• After PFD, CSF stroke volume increased by 28.9%, brainstem motion decreased by 17.3%, and cerebellar motion decreased by 45.2%.

• Improvements in CSF flow and brain motion after surgery were better predicted by presurgical CSF flow and brain motion, not by the amount of tonsillar descent.

• Presurgical dynamic measures (CSF flow, brain motion) are more informative for predicting surgical benefit than conventional anatomical metrics.

• These quantitative imaging assessments may help identify which patients will benefit most from surgery, improving patient care.

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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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