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

Trigeminal Neuralgia, characterised by paroxysmal facial pain, is often managed surgically via microvascular decompression (MVD). While microscopic MVD (M-MVD) is the traditional gold standard, it has many limitations, such as a restricted field of view. Endoscopic MVD (E-MVD) offers panoramic visualisation, potentially improving outcomes. This systematic review compares the safety and efficacy of E-MVD versus M-MVD.

A systematic review was conducted, adhering to PRISMA 2020 guidelines, searching PubMed, Embase, and Scopus. Nine studies involving 1,205 patients (556 E-MVD, 649 M-MVD) were included. Primary outcomes included pain relief and recurrence; secondary outcomes included operative time, hospitalisation time, and adverse effects. Risk of bias was assessed using the Newcastle-Ottawa Scale.

Pooled meta-analysis showed no significant difference in postoperative pain relief (OR: 1.16, 95% CI: 0.88-1.54). However, E-MVD demonstrated a significantly lower recurrence rate (OR: 0.58, 95% CI: 0.37-0.93) and reduced hospital stay (SMD: -0.45, 95% CI: (-0.70) - (-0.20)), despite longer operative times (SMD: 0.40, 95% CI: 0.20-0.60). E-MVD significantly reduced facial numbness (OR: 0.63) and total complications (OR: 0.67), with no difference in facial paralysis or hearing loss.

E-MVD offers comparable efficacy to M-MVD for initial pain relief but potentially offers superior long-term durability (lower recurrence) and a better safety profile. Further validation through randomised trials is necessary to determine if a shift in the surgical standard is warranted. Endoscope-assisted microscopic MVD may be a therapy that represents the best of both surgical techniques, especially in the intermediate term, where more literature is needed to establish the potential benefits of E-MVD and to determine the optimal technique.