Endoscopic Microvascular Decompression for Primary Trigeminal Neuralgia: Surgical Experience and Early Outcomes

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Methods Clinical data of 63 patients who underwent endoscopic MVD surgery at our institution between January 2020 and January 2023 were collected. The study analyzed the severity of facial pain using the Barrow Neurological Institute (BNI) Pain Intensity Score and evaluated the clinical outcomes and application of endoscopic MVD. Results Postoperatively, 59 patients (93.7%) achieved complete pain relief with a BNI score of I. Four patients (6.3%) had residual pain, managed effectively with medication (BNI score III). Recurrence was observed in 3 patients (4.8%) during the 12–36 months follow-up, with 2 patients (3.2%) scoring II and 1 patient (1.2%) scoring III on the BNI scale. Postoperative complications occurred in 6 patients (9.5%), including 3 cases of aseptic meningitis (4.8%), 2 cases of low-pressure syndrome (3.2%), and 1 case of hearing loss (1.6%). There were no fatalities, strokes, hearing impairments, facial paralysis, or other complications. Conclusion Endoscopic microvascular decompression for primary trigeminal neuralgia is safe and feasible. The wide-angle and multi-angle views and close observation are technical features and advantages of endoscopic surgery. The identification and confirmation of neurovascular compression are key to surgical success, but the lack of stereopsis and blind spots behind the scope need to be addressed and overcome. endoscopic neurosurgery microvascular decompression primary trigeminal neuralgia outcome surgical experience Figures Figure 1 Figure 2 1. Introduction Primary Trigeminal Neuralgia (PTN), also known as idiopathic trigeminal neuralgia, has unclear etiology and pathogenesis. Most scholars believe that the lesion occurs within the trigeminal ganglion and its sensory nerve root, possibly due to vascular compression, bony deformities in the petrous bone, and other factors leading to mechanical compression, traction, and metabolic disturbances of the nerve. 1 , 2 It can cause severe, debilitating facial pain, significantly affecting quality of life. Typically, it presents as "recurrent unilateral paroxysmal stabbing pain, with sudden onset and termination, along the distribution of the trigeminal nerve, usually lasting from a few seconds to two minutes, often occurring in the facial area supplied by the maxillary or mandibular branches." Pain is often triggered by touching a specific sensitive area of the face, known as "trigger points." 3 Treatment methods mainly include drug therapy, radiofrequency thermocoagulation, balloon compression of the trigeminal ganglion, glycerol injection, trigeminal nerve rhizotomy, stereotactic radiosurgery, and microvascular decompression (MVD). 4 – 6 MVD has shown better efficacy compared to other treatment methods, providing longer pain relief duration, lower recurrence rates postoperatively, and preservation of nerve function, thus improving long-term quality of life for patients. 7 , 8 In recent years, the application value of endoscopy in cranial surgery has been demonstrated, such as in the treatment of lesions in the anterior skull base, saddle area, and slope. 9 Recently, endoscopy has been applied in lateral skull base surgery, especially in the surgical treatment of primary trigeminal neuralgia. 10 However, there are still few reports on the full endoscopic MVD for PTN. 11 This study aims to evaluate the clinical efficacy of full endoscopic MVD for PTN and share clinical experience. 2. Materials and Methods 2.1 General Information This study retrospectively analyzed the clinical data of 63 patients who underwent full endoscopic microvascular decompression (MVD) for PTN at the Affiliated Hospital of Xuzhou Medical University from January 2020 to January 2023. The data collected included: gender, age, duration of follow-up, length of postoperative hospital stay, side of pain, distribution range of pain, duration of illness, degree of postoperative pain relief, recurrence, occurrence of complications, duration of surgery, identification of responsible vessels, and types of responsible vessels (Table 1 ). Preoperative imaging systems were used to assess the relationship between the affected side of the trigeminal nerve and adjacent blood vessels. This study was in accordance with the provisions of the Medical Ethics Committee of the Affiliated Hospital of Xuzhou Medical University. It has been reviewed by the Ethics Committee and exempted from the informed consent requirement, Ethics No. ( XYFY2023-KL441-01 ). Table 1. Baseline Clinical Characteristics of 63 Patients Characteristics （ n=63 ） value (%) Gender Male Female Age (years) Pain side Left Right Course of disease (years) Distribution of pain V1 V2 V3 V1 + V2 V2 + V3 V1 + V2 + V3 Follow-up time (months) 24（38.1） 39（61.9） 60.29±9.81 27（42.9） 36（57.1） 3.5（1.0，7.0） 2（3.2） 8（12.7） 12（19.0） 4（6.3） 35（55.6） 2（3.2） 24.17±10.37 V1: Ophthalmic nerve; V2: Maxillary nerve; V3: Mandibular nerve 2.2 Inclusion and Exclusion Criteria: Inclusion criteria: Patients were included if they met the following criteria: (1) Diagnosis of PTN according to the 3rd edition of the International Classification of Headache Disorders; (2) Patients who experienced reduced efficacy or intolerance to standardized drug therapy; (3) Preoperative confirmation of the close relationship between the affected side of the trigeminal nerve and adjacent blood vessels through 3D FIESTA combined with 3D TOF sequence magnetic resonance imaging (Fig. 1 ); (4) Patients undergoing full endoscopic microvascular decompression for primary trigeminal neuralgia. Exclusion criteria: Patients were excluded if they met any of the following criteria: (1) Secondary trigeminal neuralgia; (2) Patients with recurrent PTN after MVD treatment; (3) Patients undergoing endoscopy-assisted/microvascular decompression under microscope or other treatments (such as radiofrequency ablation, balloon compression, gamma knife radiosurgery, or sensory root section) for PTN; (4) Patients who were unable to tolerate anesthesia and surgery or refused MVD treatment; (5) Patients with bilateral trigeminal neuralgia; (6) Patients lost to follow-up for various reasons during the follow-up period. 2.3 Surgical Procedure: The full endoscopic transverse sinus posterior approach was employed. A 0° and 30° endoscope with corresponding surgical instruments were used. Patients were placed in a lateral decubitus position with the back as close as possible to the edge of the operating table, and the head frame was secured to slightly tilt the head towards the incision side. A straight incision parallel and close to the midline was made, measuring 6–7 cm in length, and the skin, muscles, and periosteum were sequentially dissected. A bone window of approximately 2.5 cm × 2.5 cm was created using a bone drill, with the window positioned as close as possible to the transverse sinus and extending upward towards the lower edge of the transverse sinus. The dura mater was suspended along the periphery, and a "U" shaped incision was made in the dura mater, exposing the angle between the transverse and sigmoid sinuses. Under endoscopic guidance, the trigeminal nerve was dissected from the outer side to the inner side of the cerebellum, cerebrospinal fluid was slowly released, and the arachnoid membrane was thoroughly dissected to expose the trigeminal nerve. The 0° and 30° endoscopes were used to explore the entire length of the trigeminal nerve cisternal segment, identify the responsible vessels, and place Teflon pads for adequate decompression (Fig. 2 ). Before closing the skull, it was ensured that there was no active bleeding in the surgical field. Warm saline was gently injected under endoscopic observation to replace bloody cerebrospinal fluid and gas, while ensuring that the pads remained in place. The dura mater was meticulously sutured, the bone flap was replaced, and the skull was closed layer by layer. 2.4 Outcome Measures: Follow-up of all enrolled patients was completed as of March 31, 2024. The follow-up period for patients postoperatively exceeded 12 months, with the longest follow-up time being 36 months. The postoperative efficacy, surgical duration, hospitalization time, rate of responsible vessel identification, recurrence rates, and occurrence of postoperative complications were statistically analyzed. Patients did not use analgesic or antiepileptic drugs (such as carbamazepine) postoperatively to observe and assess the efficacy, and pain relief was monitored through telephone and outpatient follow-ups. 3. Results Postoperative efficacy was assessed using the Barrow Neurological Institute (BNI) pain intensity rating scale. Grade I: No pain; Grade II: Occasional pain, not requiring medication; Grade III: Intermittent pain, controlled with medication; Grade IV: Intermittent pain, not controlled with medication; Grade V: Severe pain/unrelieved pain. Grades I to III were defined as effective, with Grade I defined as complete cure and Grades II to III defined as partial relief. From January 2020 to January 2023, a total of 63 PTN patients underwent full endoscopic MVD treatment, with an average surgical duration of 186.61 ± 69.10 minutes. Among them, 59 (93.7%) patients achieved complete cure, 4 (6.3%) patients achieved partial relief. During the 12–36 months follow-up period, 3 (4.8%) patients experienced PTN recurrence, with 2 (3.2%) patients having a BNI score of II and 1 (1.6%) patient having a BNI score of III. Postoperatively, there were 3 cases (4.8%) of aseptic meningitis, 2 cases (3.2%) of hypotensive syndrome, and 1 case (1.6%) of hearing loss (Table 2 ). Table 2. Perioperative patients information Characteristics （ n=63 ） value (%) Efficacy Effective Healed Mitigation Invalid Recurrence Operative time (mins) Hospitalization time (days) Responsible vessels SCA AICA PICA VA BA PV SCA + AICA SCA + PICA SCA + PV SCA + BA Postoperative complications Aseptic meningitis Facial paralysis Intracranial infection Low intracranial pressure syndrome Postoperative intracranial hemorrhage cerebrospinal fluid leakage Hydrocephalus Hearing loss Transient diplopia Cerebellar infarction Death 59（93.7） 4（6.3） 0（0） 3（4.8） 186.61±69.10 7.28±2.73 46（73.1） 7（11.1） 1（1.6） 4（6.3） 1（1.6） 1（1.6） 2（3.2） 1（1.6） 0（0） 0（0） 3（4.8） 0（0） 0（0） 2（3.2） 0（0） 0（0） 0（0） 1（1.6） 0（0） 0（0） 0（0） SCA: Superior cerebellar artery; AICA: Anterior inferior cerebellar artery; PICA: Posterior inferior cerebellar artery; VA: Vertebral artery; BA: Basilar artery; PV: Petrosal vein 4. Discussion Long-standing clinical practices in neurosurgery have demonstrated that nearly all typical cases of trigeminal neuralgia (PTN) originate from the compression of the trigeminal nerve root by responsible vessels in the cerebellopontine angle (CPA) zone. 12 Therefore, achieving a 100% cure rate has always been the eternal pursuit for neurosurgeons performing MVD surgery for PTN. As a highly refined form of minimally invasive neurosurgery, MVD surgery requires further dissemination of its operative techniques to minimize the occurrence of unacceptable severe complications in patients. Full endoscopic MVD treatment for PTN serves as a beneficial supplement and improvement to traditional microscopic MVD, 13 presenting an effective therapeutic approach. The application of endoscopy in neurosurgery dates back to the 1960s, and its scope has rapidly expanded to include lesions in the anterior skull base, saddle area, and slope. 14 , 15 Recently, endoscopy has been widely utilized in lateral skull base surgeries, particularly in the surgical treatment of trigeminal neuralgia. 16 4.1 Surgical Experience of Full Endoscopic MVD Treatment for PTN In trigeminal neuralgia surgery, the most common responsible vessel is the superior cerebellar artery. 17 , 18 However, the compression situation of vessels during surgery may differ from preoperative expectations. Therefore, we recommend comprehensive preoperative 3DFIESTA and 3DTOF examinations to improve the accuracy of responsible vessel identification. 19 Regarding patient positioning requirements, the use of the full endoscopic microvascular decompression (MVD) position does not require excessive forward tilting compared to traditional microscopic MVD. We adopt a complete lateral position to allow gravity-induced sagging of the cerebellum posteriorly. The surgical approach typically involves a retrosigmoid approach, operating below the surface or lateral aspect of the cerebellum to enter the subarachnoid space and release cerebrospinal fluid. During the cerebrospinal fluid release process, we recommend appropriately preserving the arachnoid membrane, as it can serve to protect the transverse sinus. Excessive dissection of the arachnoid membrane may lead to decreased protection of the transverse sinus during surgery, potentially resulting in serious consequences such as tearing of the transverse sinus or cerebellar injury. 13 , 20 Once the cerebellum has sufficiently collapsed and an adequate operating space is obtained, the endoscope and related instruments are introduced, with the instruments kept at the forefront of the endoscope to enable the endoscope to follow the instruments into the surgical area. The endoscope is a telescopic instrument rather than a swinging instrument from side to side. Since the lateral side of the endoscope is out of view, changing the angle of view cannot rely solely on swinging the endoscope head. When it is necessary to change the endoscope angle, the endoscope should be removed first and then reinserted at the new angle. Any structure (such as the transverse sinus, perforating vessels, or nerves) between the two axes of rotation carries the risk of damage from the endoscope rod. 21 Therefore, regardless of how safe and broad the surgical field being operated on appears, it is essential to cultivate good habits to avoid injuring surrounding structures. The key to the success of microvascular decompression surgery lies in the clear identification of vascular compression during surgery. 22 , 23 The majority of responsible vessels are located in the brainstem segment of the nerve, requiring limited and effective dissection of the nerve at its exit from the brainstem. When necessary, cerebellar-related vessels can be sacrificed, while vessels (veins or arteries) originating from the brainstem should be preserved as much as possible. After confirming the responsible vessel, a pad should be placed between the brainstem and the vessel to elevate the vessel, while simultaneously providing loose Teflon isolation between the vessel and the nerve for better outcomes. 4.2 Feasibility and Safety of Full Endoscopic MVD Treatment for PTN In the study by Kabil et al., 24 microvascular decompression surgery for trigeminal neuralgia was performed endoscopically in 255 patients. The results showed a discovery rate of responsible vessels reaching 100%, with a postoperative pain relief rate as high as 95%. Furthermore, at the 3-year follow-up, the pain relief rate remained as high as 93%. In contrast, past literature reports have shown that the mortality rate of microscopic MVD surgery is less than 1%, while the incidence of postoperative complications ranges between 11% and 35%. 25,26 This study included 63 patients with trigeminal neuralgia who underwent full endoscopic microvascular decompression surgery. The intraoperative discovery rate of responsible vessels reached 100%, with a complete pain relief rate of 93.7% and a postoperative complication rate of 9.5%. These results suggest that compared to microscopic MVD surgery, full endoscopic microvascular decompression surgery can reduce the incidence of postoperative complications. The reasons for this result are as follows: (1) Endoscopy allows for close and multi-angle observation in the cerebellopontine angle (CPA) region without the need for bone grinding or excessive traction on surrounding brain tissue to obtain a surgical field of view, thereby avoiding damage to local nerves, vessels, and brain tissue. (2) Under the endoscope, abnormalities such as angulation, twisting, or deformation of the padded vessels can be examined, preventing ischemic complications of the cerebellum and brainstem, thereby reducing the incidence of postoperative complications. (3) A microscope projects a tubular parallel beam of light into the surgical field to magnify local anatomical structures. To provide a straight pathway for the microscope's light to irradiate the surgical target area, the cerebellum must be pulled excessively, increasing the risk of postoperative complications. 25 However, endoscopy can directly enter the CPA region through a narrow space without excessive traction on the cerebellum, and angled instruments can expand the operating range, correspondingly reducing the likelihood of brain tissue injury. 4.3 Clinical Significance of Full Endoscopic MVD Treatment for PTN Wide-angle view: Although surgical microscopes can magnify local anatomical structures through narrow channels, endoscopes themselves can enter the CPA region, providing a radial, smaller-caliber but wider field of view, similar to a flask shape. When observing deep intracranial lesions, endoscopy has an unparalleled advantage in field of view compared to microscopes. Under the endoscope, the condition of the trigeminal nerve from the Meckel's cave to the REZ area can be observed throughout the procedure. 27 This panoramic view is particularly beneficial during MVD surgery in the CPA region. Multi-angle view: Endoscopes' multi-angle views have the capability to overcome obstruction and occlusion. In some cases, microscopes cannot provide the required field of view, or larger craniotomies and higher complication rates are needed to operate. Angled endoscopes can directly observe anatomical blind spots that microscopes cannot see, such as the Meckel's cave, 28 the medial side of the trigeminal nerve, or the intracanalicular structures of the internal auditory canal. Typically, after inserting a 30° or 45° endoscope into the CPA region, the entire structure around the cistern can be observed by rotating the endoscope. Portions that are obscured by the petrous bone or veins under the microscope can also be easily observed under the endoscope. 29 Close-up observation: Endoscopy allows for further magnification of anatomical structures in the surgical area through close-up observation. When observing at close range, adjusting the focal length of the endoscope's camera can further magnify the structures in the surgical area. This magnified image combines optical and digital magnification effects. 30 Close-up observation can reveal minute details of vascular compression in the REZ area of the trigeminal nerve, especially aiding in distinguishing compression from small arteries and veins, and assisting in confirming nerve compression. 4.4 Limitations and Future Prospects of Full Endoscopic MVD Treatment for PTN One major limitation of endoscopic surgery compared to microscopic surgery is that the close-up observation provided by the endoscope is limited to local areas, while other extensive surgical channels are in blind spots, 31 including behind the mirror and outside the mirror. 32 Additionally, the endoscope displays a two-dimensional image with a fish-eye effect, where the center of the field of view is magnified the most while the peripheral vision is compressed, and the image lacks depth perception. Although it can clearly display tissue structures, the difficulty of intraoperative manipulation is greater, as one must overcome the inherent visual distortions of the endoscope to identify the true anatomical structures of the surgical area. Especially for beginners, there is a risk of injuring surrounding nerves and blood vessels. 33 Furthermore, if cerebrospinal fluid is slightly bloodstained during surgery, it significantly reduces the quality of the endoscopic image or even renders it unobservable. In the future, this issue may be addressed through methods such as automatic defogging, soaking in warm saline, and flushing. Conclusion Full endoscopic microvascular decompression for primary trigeminal neuralgia is a safe and feasible method. The key to successful surgery lies in the intraoperative identification and confirmation of responsible vessels. Endoscopy has the technical characteristics and advantages of wide-angle and multi-angle vision as well as close-up observation, which are of great clinical significance for microvascular decompression in the treatment of primary trigeminal neuralgia. However, it is important to acknowledge and address the limitations of endoscopic surgery, including the lack of depth perception and issues with blind spots behind the mirror. Declarations Data Availability All data generated or analyzed during this study are included in this published article and its supplementary information file. Funding This study is supported by the China Jiangsu High-level hospital construction project, GSPJS202407. References Bendtsen L, Zakrzewska JM, Heinskou TB, Hodaie M, Leal PRL, Nurmikko T, et al. Advances in diagnosis, classification, pathophysiology, and management of trigeminal neuralgia. Lancet Neurol : 2020;19:784–796. https://doi.org/10.1016/S1474-4422(20)30233-7. Bennetto L, Patel NK, Fuller G. 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Supplementary Files Data.xlsx Cite Share Download PDF Status: Published Journal Publication published 25 Mar, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 16 Jan, 2025 Reviews received at journal 09 Jan, 2025 Reviewers agreed at journal 07 Jan, 2025 Reviews received at journal 05 Jan, 2025 Reviewers agreed at journal 05 Jan, 2025 Reviewers agreed at journal 05 Jan, 2025 Reviewers invited by journal 24 Nov, 2024 Editor assigned by journal 24 Nov, 2024 Editor invited by journal 07 Nov, 2024 Submission checks completed at journal 04 Nov, 2024 First submitted to journal 16 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5273414","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":377272306,"identity":"d00219f0-2fd7-4e03-a599-5497bd769b35","order_by":0,"name":"Feng Bao","email":"","orcid":"","institution":"Graduate School of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Feng","middleName":"","lastName":"Bao","suffix":""},{"id":377272307,"identity":"bc26ca6b-f645-4c2f-b09f-93d1a93d2bef","order_by":1,"name":"Chai Xin","email":"","orcid":"","institution":"Shanting District People 's Hospital of Zaozhuang City","correspondingAuthor":false,"prefix":"","firstName":"Chai","middleName":"","lastName":"Xin","suffix":""},{"id":377272308,"identity":"6ed599ab-0fc8-4d69-8831-feeb0e95539b","order_by":2,"name":"Yu Yi","email":"","orcid":"","institution":"Graduate School of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Yi","suffix":""},{"id":377272309,"identity":"68ffd2c9-2362-4540-add6-e103b61402fd","order_by":3,"name":"Xia Hao","email":"","orcid":"","institution":"Graduate School of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xia","middleName":"","lastName":"Hao","suffix":""},{"id":377272310,"identity":"265692c5-62e4-4d2f-bbe0-350c27618283","order_by":4,"name":"Junyi Wu","email":"","orcid":"","institution":"Graduate School of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Junyi","middleName":"","lastName":"Wu","suffix":""},{"id":377272311,"identity":"bfcc93a3-4402-45f3-80e5-bf4d15e24c55","order_by":5,"name":"Ren Yin","email":"","orcid":"","institution":"Graduate School of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ren","middleName":"","lastName":"Yin","suffix":""},{"id":377272312,"identity":"4c4a5e24-d3ee-4129-80ba-26387500561f","order_by":6,"name":"PeiMin Yu","email":"","orcid":"","institution":"Graduate School of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"PeiMin","middleName":"","lastName":"Yu","suffix":""},{"id":377272313,"identity":"61b368d7-da18-44d6-a708-02b2fbfc2997","order_by":7,"name":"Yufu Zhu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwklEQVRIiWNgGAWjYBAC9gYGxgMMFTZybOzNB4jTwgNUd4DhTJoxH8+xBBK0MLYdTpwnkaNApBaJ9AsHPrYdTm9jyGFg+FGxjRgtOQUHZ5xLz21jOHuAsefMbcJa7CVyEg7zlFnntjH2JTAzthGhhQek5Q8bczobM48BsVrSDxxmaHNOYGMjWgvPG4aDPWfSDNt42BIOEuUXHvb0hw9+VNjIy89/fBDIIEILUJMBnHmAGPVAwP6ASIWjYBSMglEwYgEAQE0+2N+o78IAAAAASUVORK5CYII=","orcid":"","institution":"Affiliated Hospital of Xuzhou Medical University","correspondingAuthor":true,"prefix":"","firstName":"Yufu","middleName":"","lastName":"Zhu","suffix":""}],"badges":[],"createdAt":"2024-10-16 07:08:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5273414/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5273414/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-94797-2","type":"published","date":"2025-03-25T15:56:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70507960,"identity":"d91f3e2b-b721-4f47-a440-6bb0dd5b4d72","added_by":"auto","created_at":"2024-12-04 00:00:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":290938,"visible":true,"origin":"","legend":"\u003cp\u003eA: Magnetic resonance 3D TOF sequence scanning result; \u0026nbsp;B: Magnetic resonance 3D FIESTA sequence scanning result; Preoperative magnetic resonance scan confirmed that there were anterior and posterior vessels in the upper part of the right trigeminal nerve, and it was in close contact with the right trigeminal nerve.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5273414/v1/88caf22c3dad30b67222c9ff.png"},{"id":70507961,"identity":"41847214-efd1-4633-8d0d-62ee279ec87d","added_by":"auto","created_at":"2024-12-04 00:00:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":178847,"visible":true,"origin":"","legend":"\u003cp\u003eA: Microvascular decompression field under microscope; B: Microvascular decompression field under endoscope 0 ° mirror, C: Microvascular decompression field under endoscope 30 ° mirror.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5273414/v1/649da5bab86443a0c1db006b.png"},{"id":79604708,"identity":"75bd43c4-7e35-4256-8add-dedfbf9914a5","added_by":"auto","created_at":"2025-03-31 15:59:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1117940,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5273414/v1/545bc3e8-2348-4158-a5a6-43d591dcd106.pdf"},{"id":70507959,"identity":"0d40605c-8816-4d23-88b2-5c0bac7c3941","added_by":"auto","created_at":"2024-12-04 00:00:18","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20734,"visible":true,"origin":"","legend":"","description":"","filename":"Data.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-5273414/v1/b4ea7074565816ea92ba18c3.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Endoscopic Microvascular Decompression for Primary Trigeminal Neuralgia: Surgical Experience and Early Outcomes","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePrimary Trigeminal Neuralgia (PTN), also known as idiopathic trigeminal neuralgia, has unclear etiology and pathogenesis. Most scholars believe that the lesion occurs within the trigeminal ganglion and its sensory nerve root, possibly due to vascular compression, bony deformities in the petrous bone, and other factors leading to mechanical compression, traction, and metabolic disturbances of the nerve.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e It can cause severe, debilitating facial pain, significantly affecting quality of life. Typically, it presents as \"recurrent unilateral paroxysmal stabbing pain, with sudden onset and termination, along the distribution of the trigeminal nerve, usually lasting from a few seconds to two minutes, often occurring in the facial area supplied by the maxillary or mandibular branches.\" Pain is often triggered by touching a specific sensitive area of the face, known as \"trigger points.\"\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTreatment methods mainly include drug therapy, radiofrequency thermocoagulation, balloon compression of the trigeminal ganglion, glycerol injection, trigeminal nerve rhizotomy, stereotactic radiosurgery, and microvascular decompression (MVD).\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e MVD has shown better efficacy compared to other treatment methods, providing longer pain relief duration, lower recurrence rates postoperatively, and preservation of nerve function, thus improving long-term quality of life for patients.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e In recent years, the application value of endoscopy in cranial surgery has been demonstrated, such as in the treatment of lesions in the anterior skull base, saddle area, and slope. \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003eRecently, endoscopy has been applied in lateral skull base surgery, especially in the surgical treatment of primary trigeminal neuralgia. \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003eHowever, there are still few reports on the full endoscopic MVD for PTN. \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003eThis study aims to evaluate the clinical efficacy of full endoscopic MVD for PTN and share clinical experience.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003e2.1 General Information\u003c/h2\u003e\n \u003cp\u003eThis study retrospectively analyzed the clinical data of 63 patients who underwent full endoscopic microvascular decompression (MVD) for PTN at the Affiliated Hospital of Xuzhou Medical University from January 2020 to January 2023. The data collected included: gender, age, duration of follow-up, length of postoperative hospital stay, side of pain, distribution range of pain, duration of illness, degree of postoperative pain relief, recurrence, occurrence of complications, duration of surgery, identification of responsible vessels, and types of responsible vessels (Table \u003cspan\u003e1\u003c/span\u003e). Preoperative imaging systems were used to assess the relationship between the affected side of the trigeminal nerve and adjacent blood vessels. This study was in accordance with the provisions of the Medical Ethics Committee of the Affiliated Hospital of Xuzhou Medical University. It has been reviewed by the Ethics Committee and exempted from the informed consent requirement, Ethics No. ( XYFY2023-KL441-01 ).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Baseline Clinical Characteristics of 63 Patients\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003en=63\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003evalue (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eGender\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAge (years)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePain side\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLeft\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRight\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCourse of disease (years)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDistribution of pain\u003c/p\u003e\n \u003cp\u003eV1\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eV2\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eV3\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eV1 + V2\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eV2 + V3\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eV1 + V2 + V3\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFollow-up time (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24（38.1）\u003c/p\u003e\n \u003cp\u003e39（61.9）\u003c/p\u003e\n \u003cp\u003e60.29\u0026plusmn;9.81\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27（42.9）\u003c/p\u003e\n \u003cp\u003e36（57.1）\u003c/p\u003e\n \u003cp\u003e3.5（1.0，7.0）\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2（3.2）\u003c/p\u003e\n \u003cp\u003e8（12.7）\u003c/p\u003e\n \u003cp\u003e12（19.0）\u003c/p\u003e\n \u003cp\u003e4（6.3）\u003c/p\u003e\n \u003cp\u003e35（55.6）\u003c/p\u003e\n \u003cp\u003e2（3.2）\u003c/p\u003e\n \u003cp\u003e24.17\u0026plusmn;10.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eV1: Ophthalmic nerve; V2: Maxillary nerve; V3: Mandibular nerve\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\"\u003e\n \u003ch2\u003e2.2 Inclusion and Exclusion Criteria:\u003c/h2\u003e\n \u003cp\u003eInclusion criteria: Patients were included if they met the following criteria: (1) Diagnosis of PTN according to the 3rd edition of the International Classification of Headache Disorders; (2) Patients who experienced reduced efficacy or intolerance to standardized drug therapy; (3) Preoperative confirmation of the close relationship between the affected side of the trigeminal nerve and adjacent blood vessels through 3D FIESTA combined with 3D TOF sequence magnetic resonance imaging (Fig. \u003cspan\u003e1\u003c/span\u003e); (4) Patients undergoing full endoscopic microvascular decompression for primary trigeminal neuralgia.\u003c/p\u003e\n \u003cp\u003eExclusion criteria: Patients were excluded if they met any of the following criteria: (1) Secondary trigeminal neuralgia; (2) Patients with recurrent PTN after MVD treatment; (3) Patients undergoing endoscopy-assisted/microvascular decompression under microscope or other treatments (such as radiofrequency ablation, balloon compression, gamma knife radiosurgery, or sensory root section) for PTN; (4) Patients who were unable to tolerate anesthesia and surgery or refused MVD treatment; (5) Patients with bilateral trigeminal neuralgia; (6) Patients lost to follow-up for various reasons during the follow-up period.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003e2.3 Surgical Procedure:\u003c/h2\u003e\n \u003cp\u003eThe full endoscopic transverse sinus posterior approach was employed. A 0\u0026deg; and 30\u0026deg; endoscope with corresponding surgical instruments were used. Patients were placed in a lateral decubitus position with the back as close as possible to the edge of the operating table, and the head frame was secured to slightly tilt the head towards the incision side. A straight incision parallel and close to the midline was made, measuring 6\u0026ndash;7 cm in length, and the skin, muscles, and periosteum were sequentially dissected. A bone window of approximately 2.5 cm \u0026times; 2.5 cm was created using a bone drill, with the window positioned as close as possible to the transverse sinus and extending upward towards the lower edge of the transverse sinus. The dura mater was suspended along the periphery, and a \u0026quot;U\u0026quot; shaped incision was made in the dura mater, exposing the angle between the transverse and sigmoid sinuses. Under endoscopic guidance, the trigeminal nerve was dissected from the outer side to the inner side of the cerebellum, cerebrospinal fluid was slowly released, and the arachnoid membrane was thoroughly dissected to expose the trigeminal nerve. The 0\u0026deg; and 30\u0026deg; endoscopes were used to explore the entire length of the trigeminal nerve cisternal segment, identify the responsible vessels, and place Teflon pads for adequate decompression (Fig. \u003cspan\u003e2\u003c/span\u003e). Before closing the skull, it was ensured that there was no active bleeding in the surgical field. Warm saline was gently injected under endoscopic observation to replace bloody cerebrospinal fluid and gas, while ensuring that the pads remained in place. The dura mater was meticulously sutured, the bone flap was replaced, and the skull was closed layer by layer.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\"\u003e\n \u003ch2\u003e2.4 Outcome Measures:\u003c/h2\u003e\n \u003cp\u003eFollow-up of all enrolled patients was completed as of March 31, 2024. The follow-up period for patients postoperatively exceeded 12 months, with the longest follow-up time being 36 months. The postoperative efficacy, surgical duration, hospitalization time, rate of responsible vessel identification, recurrence rates, and occurrence of postoperative complications were statistically analyzed. Patients did not use analgesic or antiepileptic drugs (such as carbamazepine) postoperatively to observe and assess the efficacy, and pain relief was monitored through telephone and outpatient follow-ups.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003ePostoperative efficacy was assessed using the Barrow Neurological Institute (BNI) pain intensity rating scale. Grade I: No pain; Grade II: Occasional pain, not requiring medication; Grade III: Intermittent pain, controlled with medication; Grade IV: Intermittent pain, not controlled with medication; Grade V: Severe pain/unrelieved pain. Grades I to III were defined as effective, with Grade I defined as complete cure and Grades II to III defined as partial relief. From January 2020 to January 2023, a total of 63 PTN patients underwent full endoscopic MVD treatment, with an average surgical duration of 186.61\u0026thinsp;\u0026plusmn;\u0026thinsp;69.10 minutes. Among them, 59 (93.7%) patients achieved complete cure, 4 (6.3%) patients achieved partial relief. During the 12\u0026ndash;36 months follow-up period, 3 (4.8%) patients experienced PTN recurrence, with 2 (3.2%) patients having a BNI score of II and 1 (1.6%) patient having a BNI score of III. Postoperatively, there were 3 cases (4.8%) of aseptic meningitis, 2 cases (3.2%) of hypotensive syndrome, and 1 case (1.6%) of hearing loss (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Perioperative patients information\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003en=63\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003evalue (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eEfficacy\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEffective\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHealed\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMitigation\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInvalid\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRecurrence\u003c/p\u003e\n \u003cp\u003eOperative time (mins)\u003c/p\u003e\n \u003cp\u003eHospitalization time (days)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eResponsible vessels\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSCA\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAICA\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePICA\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVA\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBA\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePV\u003c/p\u003e\n \u003cp\u003eSCA + AICA\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSCA + PICA\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSCA + PV\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSCA + BA\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePostoperative complications\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAseptic meningitis\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFacial paralysis\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIntracranial infection\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLow intracranial pressure syndrome\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePostoperative intracranial hemorrhage\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ecerebrospinal fluid leakage\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHydrocephalus\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHearing loss\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTransient diplopia\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCerebellar infarction\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDeath\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e59（93.7）\u003c/p\u003e\n \u003cp\u003e4（6.3）\u003c/p\u003e\n \u003cp\u003e0（0）\u003c/p\u003e\n \u003cp\u003e3（4.8）\u003c/p\u003e\n \u003cp\u003e186.61\u0026plusmn;69.10\u003c/p\u003e\n \u003cp\u003e7.28\u0026plusmn;2.73\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e46（73.1）\u003c/p\u003e\n \u003cp\u003e7（11.1）\u003c/p\u003e\n \u003cp\u003e1（1.6）\u003c/p\u003e\n \u003cp\u003e4（6.3）\u003c/p\u003e\n \u003cp\u003e1（1.6）\u003c/p\u003e\n \u003cp\u003e1（1.6）\u003c/p\u003e\n \u003cp\u003e2（3.2）\u003c/p\u003e\n \u003cp\u003e1（1.6）\u003c/p\u003e\n \u003cp\u003e0（0）\u003c/p\u003e\n \u003cp\u003e0（0）\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3（4.8）\u003c/p\u003e\n \u003cp\u003e0（0）\u003c/p\u003e\n \u003cp\u003e0（0）\u003c/p\u003e\n \u003cp\u003e2（3.2）\u003c/p\u003e\n \u003cp\u003e0（0）\u003c/p\u003e\n \u003cp\u003e0（0）\u003c/p\u003e\n \u003cp\u003e0（0）\u003c/p\u003e\n \u003cp\u003e1（1.6）\u003c/p\u003e\n \u003cp\u003e0（0）\u003c/p\u003e\n \u003cp\u003e0（0）\u003c/p\u003e\n \u003cp\u003e0（0）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSCA: Superior cerebellar artery; AICA: Anterior inferior cerebellar artery; PICA: Posterior inferior cerebellar artery; VA: Vertebral artery; BA: Basilar artery; PV: Petrosal vein\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eLong-standing clinical practices in neurosurgery have demonstrated that nearly all typical cases of trigeminal neuralgia (PTN) originate from the compression of the trigeminal nerve root by responsible vessels in the cerebellopontine angle (CPA) zone. \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003eTherefore, achieving a 100% cure rate has always been the eternal pursuit for neurosurgeons performing MVD surgery for PTN. As a highly refined form of minimally invasive neurosurgery, MVD surgery requires further dissemination of its operative techniques to minimize the occurrence of unacceptable severe complications in patients. Full endoscopic MVD treatment for PTN serves as a beneficial supplement and improvement to traditional microscopic MVD,\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e presenting an effective therapeutic approach. The application of endoscopy in neurosurgery dates back to the 1960s, and its scope has rapidly expanded to include lesions in the anterior skull base, saddle area, and slope. \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003eRecently, endoscopy has been widely utilized in lateral skull base surgeries, particularly in the surgical treatment of trigeminal neuralgia.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Surgical Experience of Full Endoscopic MVD Treatment for PTN\u003c/h2\u003e \u003cp\u003eIn trigeminal neuralgia surgery, the most common responsible vessel is the superior cerebellar artery.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e However, the compression situation of vessels during surgery may differ from preoperative expectations. Therefore, we recommend comprehensive preoperative 3DFIESTA and 3DTOF examinations to improve the accuracy of responsible vessel identification. \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003eRegarding patient positioning requirements, the use of the full endoscopic microvascular decompression (MVD) position does not require excessive forward tilting compared to traditional microscopic MVD. We adopt a complete lateral position to allow gravity-induced sagging of the cerebellum posteriorly. The surgical approach typically involves a retrosigmoid approach, operating below the surface or lateral aspect of the cerebellum to enter the subarachnoid space and release cerebrospinal fluid. During the cerebrospinal fluid release process, we recommend appropriately preserving the arachnoid membrane, as it can serve to protect the transverse sinus. Excessive dissection of the arachnoid membrane may lead to decreased protection of the transverse sinus during surgery, potentially resulting in serious consequences such as tearing of the transverse sinus or cerebellar injury.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOnce the cerebellum has sufficiently collapsed and an adequate operating space is obtained, the endoscope and related instruments are introduced, with the instruments kept at the forefront of the endoscope to enable the endoscope to follow the instruments into the surgical area. The endoscope is a telescopic instrument rather than a swinging instrument from side to side. Since the lateral side of the endoscope is out of view, changing the angle of view cannot rely solely on swinging the endoscope head. When it is necessary to change the endoscope angle, the endoscope should be removed first and then reinserted at the new angle. Any structure (such as the transverse sinus, perforating vessels, or nerves) between the two axes of rotation carries the risk of damage from the endoscope rod.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Therefore, regardless of how safe and broad the surgical field being operated on appears, it is essential to cultivate good habits to avoid injuring surrounding structures.\u003c/p\u003e \u003cp\u003eThe key to the success of microvascular decompression surgery lies in the clear identification of vascular compression during surgery. \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003eThe majority of responsible vessels are located in the brainstem segment of the nerve, requiring limited and effective dissection of the nerve at its exit from the brainstem. When necessary, cerebellar-related vessels can be sacrificed, while vessels (veins or arteries) originating from the brainstem should be preserved as much as possible. After confirming the responsible vessel, a pad should be placed between the brainstem and the vessel to elevate the vessel, while simultaneously providing loose Teflon isolation between the vessel and the nerve for better outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Feasibility and Safety of Full Endoscopic MVD Treatment for PTN\u003c/h2\u003e \u003cp\u003eIn the study by Kabil et al., \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003emicrovascular decompression surgery for trigeminal neuralgia was performed endoscopically in 255 patients. The results showed a discovery rate of responsible vessels reaching 100%, with a postoperative pain relief rate as high as 95%. Furthermore, at the 3-year follow-up, the pain relief rate remained as high as 93%. In contrast, past literature reports have shown that the mortality rate of microscopic MVD surgery is less than 1%, while the incidence of postoperative complications ranges between 11% and 35%.\u003csup\u003e25,26\u003c/sup\u003e This study included 63 patients with trigeminal neuralgia who underwent full endoscopic microvascular decompression surgery. The intraoperative discovery rate of responsible vessels reached 100%, with a complete pain relief rate of 93.7% and a postoperative complication rate of 9.5%. These results suggest that compared to microscopic MVD surgery, full endoscopic microvascular decompression surgery can reduce the incidence of postoperative complications. The reasons for this result are as follows:\u003c/p\u003e \u003cp\u003e(1) Endoscopy allows for close and multi-angle observation in the cerebellopontine angle (CPA) region without the need for bone grinding or excessive traction on surrounding brain tissue to obtain a surgical field of view, thereby avoiding damage to local nerves, vessels, and brain tissue.\u003c/p\u003e \u003cp\u003e(2) Under the endoscope, abnormalities such as angulation, twisting, or deformation of the padded vessels can be examined, preventing ischemic complications of the cerebellum and brainstem, thereby reducing the incidence of postoperative complications.\u003c/p\u003e \u003cp\u003e(3) A microscope projects a tubular parallel beam of light into the surgical field to magnify local anatomical structures. To provide a straight pathway for the microscope's light to irradiate the surgical target area, the cerebellum must be pulled excessively, increasing the risk of postoperative complications.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e However, endoscopy can directly enter the CPA region through a narrow space without excessive traction on the cerebellum, and angled instruments can expand the operating range, correspondingly reducing the likelihood of brain tissue injury.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Clinical Significance of Full Endoscopic MVD Treatment for PTN\u003c/h2\u003e \u003cp\u003eWide-angle view: Although surgical microscopes can magnify local anatomical structures through narrow channels, endoscopes themselves can enter the CPA region, providing a radial, smaller-caliber but wider field of view, similar to a flask shape. When observing deep intracranial lesions, endoscopy has an unparalleled advantage in field of view compared to microscopes. Under the endoscope, the condition of the trigeminal nerve from the Meckel's cave to the REZ area can be observed throughout the procedure. \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003eThis panoramic view is particularly beneficial during MVD surgery in the CPA region.\u003c/p\u003e \u003cp\u003eMulti-angle view: Endoscopes' multi-angle views have the capability to overcome obstruction and occlusion. In some cases, microscopes cannot provide the required field of view, or larger craniotomies and higher complication rates are needed to operate. Angled endoscopes can directly observe anatomical blind spots that microscopes cannot see, such as the Meckel's cave, \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003ethe medial side of the trigeminal nerve, or the intracanalicular structures of the internal auditory canal. Typically, after inserting a 30° or 45° endoscope into the CPA region, the entire structure around the cistern can be observed by rotating the endoscope. Portions that are obscured by the petrous bone or veins under the microscope can also be easily observed under the endoscope.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eClose-up observation: Endoscopy allows for further magnification of anatomical structures in the surgical area through close-up observation. When observing at close range, adjusting the focal length of the endoscope's camera can further magnify the structures in the surgical area. This magnified image combines optical and digital magnification effects. \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003eClose-up observation can reveal minute details of vascular compression in the REZ area of the trigeminal nerve, especially aiding in distinguishing compression from small arteries and veins, and assisting in confirming nerve compression.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Limitations and Future Prospects of Full Endoscopic MVD Treatment for PTN\u003c/h2\u003e \u003cp\u003eOne major limitation of endoscopic surgery compared to microscopic surgery is that the close-up observation provided by the endoscope is limited to local areas, while other extensive surgical channels are in blind spots, \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003eincluding behind the mirror and outside the mirror. \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003eAdditionally, the endoscope displays a two-dimensional image with a fish-eye effect, where the center of the field of view is magnified the most while the peripheral vision is compressed, and the image lacks depth perception. Although it can clearly display tissue structures, the difficulty of intraoperative manipulation is greater, as one must overcome the inherent visual distortions of the endoscope to identify the true anatomical structures of the surgical area. Especially for beginners, there is a risk of injuring surrounding nerves and blood vessels. \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003eFurthermore, if cerebrospinal fluid is slightly bloodstained during surgery, it significantly reduces the quality of the endoscopic image or even renders it unobservable. In the future, this issue may be addressed through methods such as automatic defogging, soaking in warm saline, and flushing.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFull endoscopic microvascular decompression for primary trigeminal neuralgia is a safe and feasible method. The key to successful surgery lies in the intraoperative identification and confirmation of responsible vessels. Endoscopy has the technical characteristics and advantages of wide-angle and multi-angle vision as well as close-up observation, which are of great clinical significance for microvascular decompression in the treatment of primary trigeminal neuralgia. However, it is important to acknowledge and address the limitations of endoscopic surgery, including the lack of depth perception and issues with blind spots behind the mirror.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article and its supplementary information file.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is supported by the China Jiangsu High-level hospital construction project, GSPJS202407.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBendtsen L, Zakrzewska JM, Heinskou TB, Hodaie M, Leal PRL, Nurmikko T, \u003cem\u003eet al.\u003c/em\u003e Advances in diagnosis, classification, pathophysiology, and management of trigeminal neuralgia. \u003cem\u003eLancet Neurol\u003c/em\u003e: 2020;19:784\u0026ndash;796. https://doi.org/10.1016/S1474-4422(20)30233-7.\u003c/li\u003e\n\u003cli\u003eBennetto L, Patel NK, Fuller G. 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[Endoscopic assistance in microvascular decompression of cranial nerves]. \u003cem\u003eZh Vopr Neirokhir Im N N Burdenko\u003c/em\u003e: 2012;76:3\u0026ndash;10; discussion 10.\u003c/li\u003e\n\u003cli\u003eYang L, Cheng H. Surgical technique management of microvascular decompression for trigeminal neuralgia. \u003cem\u003eIdeggyogy Sz\u003c/em\u003e: 2022;75:369\u0026ndash;375. https://doi.org/10.18071/isz.75.0369.\u003c/li\u003e\n\u003cli\u003eSo RJ, Kalluri AL, Storm K, Nair SK, Budihal BR, Huang J, \u003cem\u003eet al.\u003c/em\u003e A racial analysis of pain outcomes following microvascular decompression for trigeminal neuralgia. \u003cem\u003eJ Neurosurg\u003c/em\u003e: 2023;139:633\u0026ndash;639. https://doi.org/10.3171/2022.12.JNS221884.\u003c/li\u003e\n\u003cli\u003eWang L, Zhang X, Zhao M, Wang Q. 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Complete neuroendoscopic versus microscopical trigeminal neuralgia microvascular decompression (MVD) in primary trigeminal neuralgia (PTN). \u003cem\u003eAm J Transl Res\u003c/em\u003e: 2021;13:12905\u0026ndash;12912.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"endoscopic neurosurgery, microvascular decompression, primary trigeminal neuralgia, outcome, surgical experience","lastPublishedDoi":"10.21203/rs.3.rs-5273414/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5273414/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aimed to investigate the clinical efficacy and early outcomes of endoscopic microvascular decompression (MVD) for primary trigeminal neuralgia (TN) and provide clinical experience for the application of full endoscopic techniques in MVD surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eClinical data of 63 patients who underwent endoscopic MVD surgery at our institution between January 2020 and January 2023 were collected. The study analyzed the severity of facial pain using the Barrow Neurological Institute (BNI) Pain Intensity Score and evaluated the clinical outcomes and application of endoscopic MVD.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePostoperatively, 59 patients (93.7%) achieved complete pain relief with a BNI score of I. Four patients (6.3%) had residual pain, managed effectively with medication (BNI score III). Recurrence was observed in 3 patients (4.8%) during the 12\u0026ndash;36 months follow-up, with 2 patients (3.2%) scoring II and 1 patient (1.2%) scoring III on the BNI scale. Postoperative complications occurred in 6 patients (9.5%), including 3 cases of aseptic meningitis (4.8%), 2 cases of low-pressure syndrome (3.2%), and 1 case of hearing loss (1.6%). There were no fatalities, strokes, hearing impairments, facial paralysis, or other complications.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eEndoscopic microvascular decompression for primary trigeminal neuralgia is safe and feasible. The wide-angle and multi-angle views and close observation are technical features and advantages of endoscopic surgery. The identification and confirmation of neurovascular compression are key to surgical success, but the lack of stereopsis and blind spots behind the scope need to be addressed and overcome.\u003c/p\u003e","manuscriptTitle":"Endoscopic Microvascular Decompression for Primary Trigeminal Neuralgia: Surgical Experience and Early Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-04 00:00:13","doi":"10.21203/rs.3.rs-5273414/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-16T05:50:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-09T09:44:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140737705998964006565590218700474972432","date":"2025-01-07T15:20:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-05T14:05:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53202600689176165505854795219127301233","date":"2025-01-05T13:58:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"299452484698704267482122168154934632952","date":"2025-01-05T09:24:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-25T03:02:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-25T02:59:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-11-07T07:04:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-04T08:46:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-10-16T06:59:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0f1dd6da-ac73-44b3-9a6f-30b4654d2c15","owner":[],"postedDate":"December 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T15:58:10+00:00","versionOfRecord":{"articleIdentity":"rs-5273414","link":"https://doi.org/10.1038/s41598-025-94797-2","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-03-25 15:56:51","publishedOnDateReadable":"March 25th, 2025"},"versionCreatedAt":"2024-12-04 00:00:13","video":"","vorDoi":"10.1038/s41598-025-94797-2","vorDoiUrl":"https://doi.org/10.1038/s41598-025-94797-2","workflowStages":[]},"version":"v1","identity":"rs-5273414","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5273414","identity":"rs-5273414","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}