Endoscopic versus microscopic microvascular decompression for trigeminal neuralgia: a systematic review and meta-analysis

Abstract Background Trigeminal neuralgia (TN) is a debilitating craniofacial pain disorder commonly caused by neurovascular compression (NVC). Microscopic microvascular decompression (MI-MVD) remains the gold-standard surgical treatment; however, its linear field of view may limit visualization of offending vessels. Endoscopic microvascular decompression (EN-MVD) offers enhanced illumination and panoramic visualization, potentially improving decompression completeness and reducing complications. However, comparative data remains inconsistent. This study compares the efficacy and safety of EN-MVD versus MI-MVD through a systematic review and meta-analysis. Methods Following PRISMA guidelines, PubMed, Embase, and Web of Science were searched for comparative studies. Outcomes included pain relief, recurrence, complications, operative time, and length of hospital stay. Pooled estimates were calculated using a random-effects model, with heterogeneity assessed using I 2 -statistic. Results Ten studies encompassing 1,051 patients (465 EN-MVD, 586 MI-MVD) were included. Adequate pain relief was comparable between approaches at all time points. However, complete long-term pain freedom favored EN-MVD (OR 2.72, p < 0.01). Recurrence was significantly lower with EN-MVD (OR 0.51, p = 0.02). Overall complications were reduced (OR 0.48, p < 0.001), particularly postoperative headache (OR 0.28, p < 0.001), whereas other complications were comparable. EN-MVD more frequently detected multiple offending vessels (OR 1.99, p = 0.035), with marginal differences in operative time (+ 6.4 min, p < 0.05) and decompression time (-2.8 min, p < 0.05). Conclusion EN-MVD appears to provide pain relief comparable to that of MI-MVD, with studies suggesting possible advantages at long-term complete pain relief, recurrence, and postoperative headache. Studies being non-randomized, and with low certainty, these associations cannot establish superiority or a causal effect of the endoscopic approach. Therefore, these findings should be hypothesis-generating and require confirmation in prospective, standardized ideally randomized or well-adjusted multicenter studies with long-term follow up.