Clinical, Intraoperative, and Radiological Predictors and Prognostic Scoring Model of Long-Term Outcomes Following Microvascular Decompression for Trigeminal Neuralgia

Abstract Microvascular decompression (MVD) is the most effective surgical treatment for classical trigeminal neuralgia (TN), providing durable pain relief by addressing neurovascular compression at the trigeminal root entry zone. However, a subset of patients experience persistent pain or recurrence. To evaluate the influence of clinical, radiological, and intraoperative factors on long-term outcomes following MVD for classical TN and to develop a prognostic scoring model. This retrospective cohort study included 98 patients who underwent MVD for classical TN between 2017 and 2023 with a minimum follow-up of 24 months. Clinical variables, magnetic resonance imaging (MRI) characteristics, and intraoperative findings were analyzed. Long-term outcome was assessed using the Barrow Neurological Institute (BNI) pain score. Favorable outcome was defined as BNI I to II without need for reintervention. Univariate and multivariate logistic regression analyses were performed. A weighted prognostic score was derived and evaluated using receiver operating characteristic analysis. Favorable outcomes were achieved in 80 patients (81.6%), while 18 (18.4%) had unfavorable outcomes. Independent predictors of unfavorable outcome included incomplete decompression, venous compression, symptom duration > 60 months, trigeminal nerve atrophy on MRI, poor carbamazepine response, and continuous background pain. These variables were incorporated into the MVD–TN Prognostic Score (0–8 points). The model demonstrated good predictive performance with an area under the curve of 0.85 (95% confidence interval: 0.76–0.94). An optimal cutoff score of ≥ 4 predicted unfavorable outcome with a sensitivity of 83.3% and specificity of 80.0%. Higher scores were associated with a significantly increased risk of recurrence. Surgical adequacy, vascular conflict type, chronicity of symptoms, imaging evidence of nerve injury, and clinical pain phenotype significantly influence outcomes after MVD for TN.