Recurrent trigeminal neuralgia following MVD: a meta-analysis of second-line treatment strategies.

Objective: This study aimed to compare pain outcomes and complication rates between reexploration microvascular decompression (MVD), percutaneous rhizotomy (PR), and stereotactic radiosurgery (SRS) as second-line treatments for recurrent or persistent trigeminal neuralgia (TN) following an initial MVD.

Methods: A systematic review and meta-analysis was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and MOOSE (Meta-Analysis of Observational Studies in Epidemiology) guidelines. Studies were included if they reported outcomes of reexploration MVD, PR, or SRS in adult patients with classic or idiopathic TN after a failed initial MVD. Primary outcomes included early and long-term pain relief. Secondary outcomes included recurrence, facial numbness, and complications. Random-effects models were used for meta-analyses, and subgroup and sensitivity analyses were conducted.

Results: Twenty-seven studies including 886 patients were analyzed (MVD + MVD: 505; MVD + PR: 267; MVD + SRS: 114). Early pain relief rates were similar between the MVD + MVD (83%) and MVD + PR (88%) groups, but lower in the MVD + SRS (76%) group. Long-term pain relief was highest in the MVD + MVD (82%) group, followed by the MVD + PR (68%) and MVD + SRS (67%) groups. New facial numbness occurred most frequently in the MVD + PR (93%) group, compared with the MVD + MVD (29%) and MVD + SRS (12%) groups. Neurolysis during reexploration was associated with significantly improved pain outcomes (OR 4.0, p = 0.00017). No clinical variables significantly predicted early pain relief.

Conclusions: Reexploration MVD provides durable long-term pain relief but carries a risk of complications. PR offers comparable short-term efficacy with higher rates of sensory disturbance but lower surgical morbidity. The benefit of nerve manipulation even in the absence of neurovascular compression highlights the need to better understand the pathophysiology of recurrent TN and supports the necessity for randomized controlled trials to inform treatment algorithms.