Navigating the learning curve of 3D-4K exoscopic microvascular decompression: technical nuances and clinical outcomes in a 37-patient cohort

Background The 3D-4K exoscope is an emerging digital technology in microneurosurgery. While feasible, its specific impact on surgical efficiency and diagnostic precision during microvascular decompression (MVD) remains under-researched. This study evaluates clinical outcomes, technical nuances, and the technical learning curve of 3D-4K exoscopic MVD for classic trigeminal neuralgia (TN1).Methods A retrospective, longitudinal, single-center study of 37 consecutive patients with refractory TN1 was conducted in 2024. Procedures used a retrosigmoid infra-asterional approach with a robotic 3D-4K exoscope. Outcomes included pain relief, via Visual Analog Scale and Barrow Neurological Institute (BNI) Pain Scale, and surgical efficiency (total operative time). Chronological tertile analysis modeled the learning curve.Results Mean operative time was 48 ± 13 minutes, a ~ 50% reduction compared to international benchmarks. Chronological analysis showed a significant reduction in operative duration from the early (53.2 min) to the late tertile (40.5 min) (p = 0.017) without added complications. Intraoperative 4K visualization identified additional venous conflicts in 16.2% of cases that were occult on preoperative 3T-MRI. At 6-month follow-up, successful pain relief (BNI I-II) reached 89.2%, with a significant median BNI score improvement from 4 (IQR 4–4) to 2 (IQR 1–4) (p < 0.001). The complication rate was 2.7%, consisting of a single incidental transverse sinus injury successfully managed.Conclusion 3D-4K exoscopic MVD is safe, and effective. By providing depth perception and a shared real-time visual axis, it enhances diagnostic accuracy for hidden venous conflicts, allowing a rapid technical transition without compromising traditional microscopic standards.