Microvascular Decompression with Selective Use of MVD-Plus for Classical Trigeminal Neuralgia: Outcomes, Predictors, and Role in Redo Surgery

Abstract: Background: Classical trigeminal neuralgia (TN) is a severe facial pain disorder most commonly caused by neurovascular conflict (NVC) at the trigeminal root entry zone. Microvascular decompression (MVD) provides durable pain relief by addressing the underlying vascular compression. However, Indian data evaluating predictors of failure, early relapse, redo surgery, and the role of adjunct nerve combing (MVD-plus) remain limited. Objective: To evaluate functional outcomes after MVD for classical TN and identify predictors of early failure, pain relapse, redo surgery, and the role of MVD-plus. Methods: A retrospective analysis was performed on 108 consecutive patients who underwent MVD for classical TN at a tertiary neurosurgical center in India between August 2018 and July 2025. Demographic characteristics; trigeminal division involvement; laterality; NVC grade; offending vessel; operative technique (Teflon alone vs. Teflon with adjunct nerve combing); complications (Ibañez classification); preoperative, immediate postoperative, and long-term Barrow Neurological Institute (BNI) pain scores; pain relapse; redo MVD; and history of dental or tooth extraction were analyzed. Kaplan–Meier survival analysis was used to assess pain-free survival. Results: The mean age at surgery was 51.39 years, with right-sided involvement in 62% of patients. V2–V3 involvement was the most frequent trigeminal division pattern (22.1%). Severe preoperative pain was universal (BNI IV–V). Ten patients (9.3%) underwent MVD-plus (Teflon with adjunct nerve combing), including six patients (5.6%) undergoing redo MVD for early failure or relapse. At a mean follow-up of 22.7 months, outcomes were BNI I in 41 patients (37.9%), BNI II in 57 (52.8%), and BNI III in 10 (9.3%), yielding a 90.7% pain-free rate (BNI I–II). Severe NVC (Grades 2–3) and arterial compression correlated with superior outcomes, while venous compression and early postoperative residual pain predicted relapse ( P < 0.05). The overall complication rate was 18.5%, predominantly minor, with no mortality. Conclusion: MVD is a safe and highly effective treatment for classical TN. NVC severity, offending vessel type, and early postoperative pain relief significantly influence outcomes. MVD-plus is valuable in cases where unfavorable anatomy does not allow adequate vascular decompression, redo surgery, and early failure.