Pivotal Factors for Minimizing the Risks of Therapeutic Failure in Trigeminal Neuralgia and Hemifacial Spasm

Despite the scarce literature regarding the matter, this current article identifies the most important factors that lead to the best outcomes in the therapeutic approach of trigeminal neuralgia and hemifacial spasm. However, notwithstanding the central focus lies on the neurosurgical perspective, the authors also integrate insights from adjacent medical specialties. Thus, the main objective of this comprehensive narrative review is to enhance understanding of the factors that can dramatically influence the course of these conditions.

This article provides a state-of-the-art perspective regarding the therapeutic management of trigeminal neuralgia and hemifacial spasm. Preoperative diagnosis has the first pivotal role in managing this condition, and 3D multimodal image fusion based on Time-Of-Flight Magnetic Resonance Angiography (TOF MRA) with high-resolution T2-weighted imaging has been proven to be the most effective and accurate method. Focusing on the correct therapeutic approach is the second pivotal factor, given that the therapeutic options comprise various approaches ranging from oral medication to neurosurgical microvascular decompression. It has been concluded that microvascular decompression remains the most effective treatment for drug-resistant trigeminal neuralgia and hemifacial spasm. Pain freedom is achieved in around 76-84% of patients, and long-term durability remains substantial, with 64-73% still pain-free at ten years, particularly when the compression is arterial rather than venous. The endoscopic approaches demonstrated efficacy in selected cases, while combined procedures such as MVD with partial sensory rhizotomy may increase numbness without improving long-term results. Systematic reviews concluded that radiosurgery and percutaneous procedures can provide pain relief in many patients, but with less durable outcomes. Altogether, these findings support MVD as the cornerstone surgical therapy while underlining the importance of careful patient selection and modern adjuncts to maximize success. When the neurosurgical intervention represents the treatment option for trigeminal neuralgia or hemifacial spasm, several pivotal factors must be taken into account in order to provide the best clinical results with minimal to no complications.