Feasibility of redo endoscopic microvascular decompression for recurrent trigeminal neuralgia: An illustrative case

Trigeminal neuralgia (TN) is often treated with microvascular decompression (MVD), providing long-term pain relief for most patients. However, a subset experiences recurrence requiring reoperation. Endoscopic MVD techniques have gained traction due to enhanced visualization and potentially lower morbidity, yet their feasibility for redo procedures - particularly in complex cases with dense adhesions - remains uncertain.

We report the case of a 63-year-old male who initially presented with Barrow Neurological Institute (BNI) grade V TN in the V2-V3 distribution. After an endoscopic MVD, the patient achieved immediate pain relief (BNI I) but developed recurrent symptoms 10 months later (BNI III), controlled by carbamazepine. A subsequent escalation (BNI IV) prompted surgical re-exploration. Imaging revealed no residual or new neurovascular conflict. Instead, intraoperative findings demonstrated dense adhesions tethering the trigeminal nerve to the tentorium, causing nerve tension. Careful endoscopic dissection restored nerve mobility and resulted in complete symptom resolution.

This case highlights the feasibility and effectiveness of a fully endoscopic redo MVD in recurrent TN where dense adhesions, rather than persistent vascular compression, were the primary mechanism of recurrence. Further investigation is warranted to optimize endoscopic techniques, reduce adhesion formation, and improve long-term outcomes in redo MVD cases.