Neurosurgical Management of Refractory Trigeminal Neuralgia in Older Adults: A Structured Narrative Review

Trigeminal neuralgia (TN) disproportionately affects older adults, in whom medication intolerance, drug interactions, comorbidities, and limited physiological reserve may complicate management. This structured narrative review examines the evidence concerning the selection, effectiveness, durability, and complications of neurosurgical treatments for medication-refractory TN in older adults.

PubMed was searched from database inception through 1 July 2026 using terms related to TN, older age, and neurosurgical treatment. Eligible publications evaluated microvascular decompression (MVD), radiofrequency lesioning, percutaneous balloon compression (PBC), glycerol rhizotomy, or stereotactic radiosurgery (SRS). Titles and abstracts were screened using predefined eligibility criteria, followed by further assessment of potentially eligible publications and standardized data extraction. Studies reporting separately extractable outcomes for defined older populations were classified as direct evidence; mixed-age studies without age-stratified outcomes were treated as indirect evidence and used primarily for procedural and comparative context.

The principal search identified 1324 unique records, and 22 publications were included: six provided direct older-adult evidence and 16 provided indirect contextual evidence. Direct evidence was largely limited to MVD and PBC. In selected older adults, MVD was associated with favorable and potentially durable pain outcomes, whereas PBC generally provided rapid initial pain relief. However, differences in outcome definitions, assessment times, follow-up, and patient selection precluded direct comparison. No included study provided separately extractable outcomes for adults aged ≥65 years undergoing radiofrequency lesioning, glycerol rhizotomy, or SRS. GRADE certainty was low or very low for most procedure-specific and comparative conclusions.

Favorable observational outcomes in selected older patients suggest that chronological age alone should not automatically exclude an otherwise appropriate patient from consideration for MVD. Treatment should be individualized according to TN subtype, physiological reserve, comorbidity and anesthetic risk, imaging findings, pain urgency, previous interventions, baseline facial sensation, and patient preferences.