Surgical Decision-Making in Trigeminal Neuralgia: A Focused Evidence Synthesis and Proposed Clinical Algorithm

Background: Trigeminal neuralgia (TN) is a severe neuropathic pain disorder for which a significant proportion of patients require surgical intervention following failure of pharmacological therapy. Despite the availability of multiple surgical and neuromodulatory options, there is no unified, evidence-informed framework to guide procedure selection across different clinical scenarios. Objective: To synthesize contemporary evidence on surgical and neuromodulatory interventions for TN and to develop a structured clinical decision algorithm to support patient-specific management. Methods: A focused evidence synthesis was conducted using PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases for studies published between January 2016 and January 2026. Eligibility was restricted to high-level evidence, including systematic reviews, meta-analyses, large clinical series, and consensus guidelines. Data on study design, patient population, intervention type, outcomes, and complications were extracted and synthesized narratively. Based on the synthesized evidence, a stepwise clinical decision algorithm was developed. Results: Six high-quality sources met the inclusion criteria. Microvascular decompression (MVD) demonstrated the highest rates of initial pain freedom (85–96%) and the lowest long-term recurrence, particularly in patients with MRI-confirmed arterial neurovascular conflict. Stereotactic radiosurgery (SRS) offered a favorable safety profile with moderate durability but higher recurrence rates. Percutaneous procedures provided effective minimally invasive alternatives, with selection guided by patient-specific factors. Peripheral nerve stimulation was identified as a viable option in refractory cases. Key limitations in the evidence base include the absence of randomized comparative trials and heterogeneity in outcome reporting. Conclusions: Current evidence supports a stratified, patient-centered approach to the surgical management of TN. The proposed clinical algorithm integrates available data into a structured framework to support decision-making in clinical practice. Further prospective validation and standardized outcome reporting are required to strengthen the evidence base.