Current practice patterns in microvascular decompression for trigeminal neuralgia: results from an international survey

Current practice patterns in microvascular decompression for trigeminal neuralgia: results from an international survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Current practice patterns in microvascular decompression for trigeminal neuralgia: results from an international survey Johann Klein This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7446556/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Trigeminal neuralgia is a facial pain disorder, most often caused by neurovascular contact at the trigeminal root. In cases refractory to pharmacotherapy, microvascular decompression (MVD) is an established treatment. Since its description, various modifications have been introduced. The extent to which current practice deviates from the original approach remains unclear. This study aimed to assess current strategies in MVD for trigeminal neuralgia. Methods A web-based 14-item questionnaire was distributed to neurosurgeons with expertise in MVD from Germany, Austria, Switzerland, Italy, and Luxembourg. The link to the survey was shared between May and August 2025 and was not made public. To avoid institutional clustering, only one practitioner per institution was invited to participate anonymously. Results Of 123 neurosurgeons invited, 63 completed the questionnaire (response rate 51.2%). 93.7% of respondents do not consider an age limit for MVD. Surgery is most commonly performed in the supine (46.0%) or lateral (39.7%) position, either purely microscopically (65.1%) or with endoscopic assistance (30.2%). 71.4% of practitioners regularly use neuromonitoring. Trepanation is usually performed either osteoplastically or osteoclastically with Palacos cranioplasty (36.5% each). Teflon is the most frequently used interposition material (74.6%). 65.1% never sacrifice the superior petrosal vein. Only 7.9% would generally refrain from MVD if no neurovascular contact is evident on radiological examination. Conclusion This survey demonstrates current practice patterns in MVD for trigeminal neuralgia in central Europe. While some principles of the original technique remain widely adopted, notable changes in operative strategy are apparent, highlighting areas for future consensus-building and research, and informing operative decision-making. trigeminal neuralgia microvascular decompression Jannetta procedure survey Introduction Trigeminal neuralgia is a painful disorder characterized by brief paroxysms in the distribution area of one or several branches of the trigeminal nerve [ 9 ]. The pain attacks are most often described as electric shock-like [ 21 ], and are typically triggered by innocuous stimuli such as chewing, touch, brushing teeth, eating, talking, and cold wind [ 27 ]. Depending on the etiology, trigeminal neuralgia is classified as classical if caused by vascular compression of the trigeminal root, secondary if attributed to multiple sclerosis, tumor, or other cause, or idiopathic if no abnormalities are detected upon radiological and electrophysiological examination [ 51 ]. Pharmacotherapy is the initial treatment, with carbamazepine and oxcarbazepine being the most effective drugs [ 28 ]. While the initial response rates are 98% and 94%, respectively, adverse events are frequent, causing 27% (carbamazepine) and 18% (oxcarbazepine) of patients to withdraw from the treatment [ 43 ]. In patients with classical trigeminal neuralgia who cannot be satisfactorily managed with pharmacotherapy, microvascular decompression (MVD), initially described by Peter Jannetta, is the surgical treatment of choice [ 14 , 15 ]. The operation includes a retrosigmoid trepanation and dissection of the trigeminal nerve in the cerebellopontine angle to separate the offending vessel from the nerve [ 37 ]. A prospective study with independent pre- and postoperative evaluation revealed a success rate of 86% [ 2 ]. Retrospective analyses consistently show a high proportion of favorable outcomes in the long term [ 3 , 6 , 40 ]. After decades of experience, the Jannetta group published their surgical method, which defined, among other steps, the placement of the patient in the lateral position, retrosigmoid craniectomy, insertion of a retractor, coagulation and division of the petrosal veins, mobilization of the offending vessel, interposition with a Teflon felt, watertight dural closure, and cranioplasty with methylmethacrylate or wire mesh as crucial elements of the technique [ 30 ]. Since then, significant technological advances have shaped the field of neurosurgery, including improvements in operating microscopes, neuroendoscopy, neuronavigation, and operating techniques such as sling retraction or the use of alternative interposition materials. An increasing number of elderly patients, as well as progress in anesthesiology and peri-procedural care, raises the question of performing surgery in patients once deemed too old. While a multitude of variations to the Jannetta procedure grounded in these developments were reported, comparative studies are scarce and often not feasible. Furthermore, it is unknown how many of these variations are adopted by the neurosurgical community and how far MVD, as it is performed today, departs from the principles defined by Peter Jannetta. This study aimed to determine current practice patterns and operative standards in MVD for trigeminal neuralgia among German-speaking neurosurgeons and discuss them in the context of the available literature. Materials and methods A web-based questionnaire was developed using an online platform ( www.survio.com ). It consisted of 14 questions with one item per page and was written in German. No questions on personal data (such as age, sex, location, duration of occupation, or number of surgeries performed) were included to protect anonymity in a relatively small specialist cohort. The survey was distributed among neurosurgeons in Germany, Austria, Luxembourg, and the German-speaking parts of Switzerland and Italy (South Tyrol), who have expertise in MVD. To determine appropriate institutions and practitioners, a list containing all neurosurgical departments in the relevant areas was created using information from the respective neurosurgical societies. Departments with a focus on spine surgery were excluded, as were those for which no sufficient expertise in MVD could be assumed. Appropriate addressees within the departments were determined by research (including information on the practitioners’ or their employers’ websites and publications), acquaintance, or inquiry. If no practitioner involved in the management of trigeminal neuralgia and MVD could be determined, the head of the department was addressed. Only one neurosurgeon per institution was invited to participate. A link to the survey was distributed either in person at neurosurgical events or via email between May 27 and August 11, 2025. Each invitee was addressed individually. No mass emails were sent, and the link to the survey was not made public. No incentive, financial or otherwise, was offered for participation. Descriptive statistics are presented as percentages and absolute numbers, as appropriate. Sums exceeding 100% are due to rounding. No inferential statistics were employed. The ethics committee of the Medical Association of Hesse waived the need for informed consent or a formal assessment. The reporting of this study follows the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). Results Six neurosurgeons were invited to participate in person, and 117 via email. Of 123 neurosurgeons invited, 63 completed the survey (response rate 51.2%). The majority of respondents (93.7%) do not see an age limit for MVD indication. A microsurgical approach is most frequently employed (65.1%), followed by microsurgery with endoscopic assistance (30.2%), whereas fully endoscopic or exoscopic approaches are rarely used. 46.0% reported preferring a supine and 39.7% a lateral/park-bench position. Neuronavigation is never or rarely used by 63.5% of participants, while 25.4% reported regular use. Neuromonitoring is routinely applied by 71.4% of respondents. Most respondents perform either craniotomy or craniectomy with cranioplasty using Palacos, bone cement, etc. Fixed retraction is generally or often applied by 52.4%, whereas 39.7% avoid or limit its use. The superior petrosal vein is preserved by most (65.1%), but 28.6% sacrifice it when necessary. Teflon is the most common interposition material (74.6%), while muscle, other materials, and transposition without interposition were less frequently reported. Most respondents regularly secure the graft with fibrin glue (63.5%). Of note, all six neurosurgeons who indicated using muscle as interposition material reported applying fibrin glue. Watertight dural closure is pursued by the majority. Lumbar drains are rarely used. When asked about MVD in trigeminal neuralgia secondary to multiple sclerosis, 55.6% consider surgery if MRI showed neurovascular contact, 14.3% would generally perform MVD, while 30.2% would not. In idiopathic trigeminal neuralgia with the absence of neurovascular contact on imaging, 66.7% sometimes offer MVD after shared decision-making, 25.4% generally do, and 7.9% do not. Table 1 provides a detailed account of questions and responses. Table 1 Survey items and distribution of responses (n = 63) Item Question Response Options n (%) 1 Age limit for MVD indication None 59 (93.7) Yes ≥ 80 years 4 (6.4) Yes, 75–79 years 0 (0.0) Yes, 70–74 years 0 (0.0) 2 Approach Microsurgical 39 (65.1) Microsurgical + endoscopic 19 (30.2) Fully endoscopic 1 (1.6) Exoscopic 1 (1.6) Varies 1 (1.6) 3 Positioning Supine 29 (46.0) Lateral/park bench 25 (39.7) Prone 4 (6.4) Sitting/half-sitting 1 (1.6) Varies 4 (6.4) 4 Use of neuronavigation No/rarely 40 (63.5) Yes, always/often 16 (25.4) Sometimes 7 (11.1) 5 Use of neuromonitoring Yes 45 (71.4) No 13 (20.6) Sometimes 5 (7.9) 6 Type of trepanation Osteoplastic 23 (36.5) Osteoclastic + Palacos, bone cement, etc. 23 (36.5) Osteoclastic, no cranioplasty 1 (1.6) Osteoclastic + allogenic material (mesh, etc.) 2 (3.2) Osteoclastic + bone dust 7 (11.1) Varies 7 (11.1) 7 Fixed retraction Yes, always/often 33 (52.4) No/only during approach 25 (39.7) Varies 7 (11.1) 8 Sacrifice of superior petrosal vein No, never or only upon hemorrhage 41 (65.1) Yes, if necessary 18 (28.6) Yes, generally/often 4 (6.4) 9 Interposition material Teflon 47 (74.6) Muscle 6 (9.5) Other 4 (6.4) Transposition/sling retraction without interposition 6 (9.5) 10 Fixation with fibrin glue Yes, always/usually 40 (63.5) No/rarely 16 (25.4) Sometimes 7 (11.1) 11 Watertight dural closure Yes, absolutely 53 (84.1) No, not imperatively 10 (15.9) 12 Routine lumbar drain placement No 60 (95.2) Yes, before surgery 3 (4.8) Yes, after surgery 0 (0.0) 13 MVD in TN with MS Yes, if NVC on MRI 35 (55.6) Yes 9 (14.3) No 19 (30.2) 14 MVD in TN without NVC on MRI Sometimes (shared decision) 42 (66.7) Yes 16 (25.4) No 5 (7.9) MRI = magnetic resonance imaging, MS = multiple sclerosis, MVD = microvascular decompression, NVC = neurovascular contact, TN = trigeminal neuralgia Several respondents provided additional comments via email after completing the survey, thereby identifying themselves. While these comments were generally not linked to survey responses, one clarification led to the reclassification of a response in item 9, where an answer originally marked “Teflon” was reassigned to “Transposition without interposition material” based on the participant’s detailed explanation. Discussion This study provides an overview of current views on both indications for MVD and operative techniques among a selected group of neurosurgeons in central Europe. It is, to the author’s knowledge, the first to systematically examine intraoperative strategies and technical details in MVD for trigeminal neuralgia. A prior survey from the United States was distributed to all members of the American Association of Neurological Surgeons and exclusively addressed preoperative decision making, without exploring operative conduct [ 32 ]. By focusing on operative nuances, the present study provides novel insight into how the procedure has evolved. Patient selection While the incidence of trigeminal neuralgia increases with age, so does the fear of surgical complications. Therefore, the finding that the vast majority of the respondents see no age limit for the indication for MVD is particularly noteworthy. Concerning elderly patients in reduced general condition, it should be pointed out that percutaneous rhizotomies may present a reasonable alternative to MVD [ 34 , 42 ]. The same applies to trigeminal neuralgia secondary to multiple sclerosis and idiopathic trigeminal neuralgia [ 4 , 33 , 35 ]. The use of MVD in treating these conditions is unclear. A seminal study by Truini et al. suggested a double-crush mechanism in trigeminal neuralgia secondary to multiple sclerosis, with both inflammatory demyelination and neurovascular compression contributing to the manifestation of the disorder concurrently, implying a role for MVD in its treatment [ 44 ]. Others, however, have challenged this observation [ 36 ], but still recognized that MVD should be considered in this patient population if neurovascular contact with morphological changes is established [ 47 ]. Overall, MVD may be appropriate in trigeminal neuralgia secondary to multiple sclerosis, although the success rates appear to be lower compared to classical trigeminal neuralgia [ 12 , 39 ]. In this survey, 14.3% of participants stated they generally consider MVD in patients with multiple sclerosis, while 55.6% do so if neurovascular contact is demonstrated. Only 7.9% of respondents indicated that they don’t consider MVD if no neurovascular contact is shown on magnetic resonance imaging (MRI). This finding likely reflects the observation that despite advances in modern radiological examinations, false-negative results are possible. In one study, 14 out of 17 patients with trigeminal neuralgia, in whom the preoperative MRI was negative for neurovascular relationship, were found to have a vascular contact to the trigeminal nerve during surgery [ 46 ]. Operative technique While some operative details have largely been maintained since Jannetta’s description, other aspects show greater variation, for example, positioning or trepanation. In some regards, notably the handling of the superior petrosal vein, Jannetta’s approach has largely been abandoned, as only 6.4% of practitioners routinely sacrifice it, and 65.1% will never do so unless hemorrhage forces them to. In the past, some authors argued that obliteration of veins in the cerebellopontine angle is safe. In a recent review, however, Joswig et al. undertook a thorough appraisal of reports on superior petrosal vein sacrifice and its ensuing complications and concluded that the maneuver poses too significant a risk and should be considered obsolete [ 18 ]. Nearly one-third of participants use neuroendoscopy, albeit only one practitioner (1.6%) indicated performing fully endoscopic MVD. Proponents of endoscopy cite improved visualization of anatomic structures and, in the case of fully endoscopic approaches, less need for tissue dissection compared with purely microsurgical approaches [ 16 , 17 ]. However, comparative studies failed to detect differences in clinical outcomes [ 24 , 48 ]. Neuronavigation is regularly used in MVD by one in four respondents. Purported advantages include reduced craniotomy size, avoidance of unnecessary opening of mastoid air cells, and reduced incidence of CSF leaks [ 23 , 26 ]. To avoid complications such as postoperative hearing loss and facial palsy, the majority of neurosurgeons in this survey indicated regularly using neuromonitoring, which is an established method to improve outcomes in MVD [ 29 ]. Damage to the VII and VIII cranial nerves during MVD may result from direct manipulation, vasospasm, forceful irrigation, CSF egress, acoustic trauma from drilling, or tension injury through retraction of the cerebellum [ 22 , 31 , 50 ]. Although described in MVD for hemifacial spasm rather than trigeminal neuralgia, greater cerebellar retraction depth has been identified as significantly associated with postoperative hearing loss [ 25 ]. To avoid this complication, 39.7% of neurosurgeons in this survey don’t use fixed cerebellar retraction during MVD or do so only during the approach to the cerebellopontine angle. A minority places a lumbar drain before the surgery to drain CSF and relax the cerebellum. A lumbar drain, if kept in place for a few days postoperatively, may also aid in preventing CSF leak [ 8 ]. A large MVD series identified the lack of primary dural closure as a significant risk factor for postoperative CSF leak [ 49 ]. Accordingly, 84.1% of respondents in this survey pursue watertight dural closure, independently of the use of dural sealants or augmentation. Interposition and transposition The majority of the participants separate the offending vessel from the nerve using Teflon as interposition material. Despite high success rates using this technique, Teflon granulomas or adhesions may lead to pain recurrence [ 5 ]. To avoid these occurrences, some authors favor transposition of the offending artery without interposition material [ 11 , 41 ]. In this survey, 9.5% indicated attempting transposition over interposition, if feasible. However, comparative studies show no significant differences in outcomes between the two techniques [ 20 , 45 ]. An additional 9.5% of respondents use autologous muscle as interposition material. Numerous reports indicate excellent results with muscle grafting [ 1 , 3 , 7 , 13 , 19 , 38 ], while there is no conclusive evidence to favor one interposition material over the other. Noteworthy, all participants using muscle in this study apply fibrin glue to secure the graft, while, overall, 25.4% never do so in MVD. This can be interpreted as confirming the observation that Teflon has a higher tendency to adhere to the surrounding tissues than does muscle. Strengths and limitations Strengths of the present study include its strict methodology, inviting only one practitioner per institution, and an attempt to make the survey accessible only to neurosurgeons with experience in MVD. The high response rate of more than 50% indicates the relevance and importance of the questions raised. Still, there are limitations. Despite efforts to identify appropriate addressees, there can be no certainty that the respondents are representative of all MVD practitioners. This is especially true for neurosurgeons outside of the geographic region included in this survey, which was limited to German-speaking central Europe. A self-selection bias is inherently possible in surveys, as those more interested in the subject of the questionnaire may have been more likely to respond. The results do not allow for allocation of the responses to individual levels of experience or treatment outcomes. However, questions about personal qualifications, such as the number of MVD procedures performed, were deliberately omitted to ensure anonymity in a comparatively small neurosurgical cohort and to avoid bias, as the self-assessment of physicians is demonstrably of limited accuracy [ 10 ]. Conclusion This study shows that the surgical techniques in MVD have evolved since the procedure was developed by Peter Jannetta. While key principles remain widely adopted, significant changes in intraoperative strategy are evident. These findings may help inform consensus-building and identify areas for further research, including the development of a registry for MVD. Furthermore, for operative steps that lack evidence-based consensus, it can be valuable for practitioners to consider the approach of others, as presented in this article, for their own decision-making. Finally, the author would like to encourage neurosurgeons from other parts of the world to research practice patterns in MVD in their respective regions. Declarations Conflict of Interest: The author declares no conflict of interest. Declarations Funding: The author declares that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests: The author has no relevant financial or non-financial interests to disclose. Author Contribution J.K. is the sole author and was responsible for the study design, data acquisition, analysis, and writing of the manuscript Acknowledgement The author wishes to thank all colleagues who participated in the survey, especially those who provided additional feedback and comments. Their insights were valuable and greatly contributed to this project. References Alasta A, Al_Naggar AM, AL-saidy A, Al Wesabi F (2025) Microvascular Decompression for Trigeminal Neuralgia Using Autologous Muscle Grafting: A Retrospective Analysis in a Resource-Limited Setting. Cureus 17. 10.7759/CUREUS.81362 Andersen ASS, Heinskou TB, Rochat P, Springborg JB, Noory N, Smilkov EA, Bendtsen L, Maarbjerg S (2022) Microvascular decompression in trigeminal neuralgia - a prospective study of 115 patients. 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Br J Neurosurg 14:132–134. 10.1080/02688690050004561 Shi Y, Liu W, Peng S, Liu J (2024) Percutaneous ballon compression, a better choice for primary trigeminal neuralgia compared to microvascular decompression? Front Surg 11:1517064. 10.3389/fsurg.2024.1517064 Di Stefano G, La Cesa S, Truini A, Cruccu G (2014) Natural history and outcome of 200 outpatients with classical trigeminal neuralgia treated with carbamazepine or oxcarbazepine in a tertiary centre for neuropathic pain. J Headache Pain 15:1–5. 10.1186/1129-2377-15-34/FIGURES/1 Truini A, Prosperini L, Calistri V, Fiorelli M, Pozzilli C, Millefiorini E, Frontoni M, Cortese A, Caramia F, Cruccu G (2016) A dual concurrent mechanism explains trigeminal neuralgia in patients with multiple sclerosis. Neurology 86:2094–2099. 10.1212/WNL.0000000000002720 UHL C, VAJKOCZY P (2023) Contact-free transposition and interposition techniques for trigeminal neuralgia: a systematic review. J Neurosurg Sci 67. 10.23736/S0390-5616.22.05514-X Wei SC, Yu R, Meng Q, Qu C (2020) Efficacy of microvascular decompression in patients with trigeminal neuralgia with negative neurovascular relationship shown by magnetic resonance tomography. Clin Neurol Neurosurg 197. 10.1016/j.clineuro.2020.106063 Worm J, Noory N, Smilkov EA, Heinskou TB, Andersen ASS, Springborg JB, Rochat P, Frederiksen JL, Bendtsen L, Maarbjerg S (2023) Efficacy of surgical treatment in patients with trigeminal neuralgia secondary to multiple sclerosis: A prospective study of 18 cases with evaluation of outcome and complications by independent evaluators. Cephalalgia 43. 10.1177/03331024231167130 Xiang H, Wu G, Ouyang J, Liu R (2018) Prospective Study of Neuroendoscopy versus Microscopy: 213 Cases of Microvascular Decompression for Trigeminal Neuralgia Performed by One Neurosurgeon. World Neurosurg 111:e335–e339. 10.1016/j.wneu.2017.12.051 Xu R, So RJ, Materi J, Nair SK, Alomari SO, Huang J, Lim M, Bettegowda C (2023) Factors Predicting Cerebrospinal Fluid Leaks in Microvascular Decompressions: A Case Series of 1011 Patients. Oper Neurosurg 24:262–267. 10.1227/ONS.0000000000000503 Ying T, Thirumala P, Shah A, Nikonow T, Wichman K, Holmes M, Hirsch B, Chang Y, Gardner P, Habeych M, Crammond DJ, Burkhart L, Horowitz M, Balzer J (2013) Incidence of high-frequency hearing loss after microvascular decompression for hemifacial spasm: Clinical article. J Neurosurg 118:719–724. 10.3171/2013.1.JNS121153 (2018) Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia 38:1–211. 10.1177/0333102417738202 Additional Declarations No competing interests reported. Supplementary Files Supplementarytable1.docx Supplementarytable2.docx CHERRIESsupplement.docx Cite Share Download PDF Status: Posted Version 1 posted 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-7446556","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":506636109,"identity":"00d38bb3-4c51-4837-9090-d2450d06a8dc","order_by":0,"name":"Johann Klein","email":"data:image/png;base64,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","orcid":"","institution":"Helios Dr. Horst Schmidt Kliniken Wiesbaden","correspondingAuthor":true,"prefix":"","firstName":"Johann","middleName":"","lastName":"Klein","suffix":""}],"badges":[],"createdAt":"2025-08-24 13:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7446556/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7446556/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95527861,"identity":"27d775a5-99ae-468b-a7c1-457b374057f2","added_by":"auto","created_at":"2025-11-10 10:15:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":592171,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7446556/v1/07abb4d5-39f1-4731-a3b2-918893818b4c.pdf"},{"id":90578360,"identity":"a94d2e79-36a6-40de-bb0a-6725e7663d9a","added_by":"auto","created_at":"2025-09-04 09:41:25","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":20519,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarytable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7446556/v1/2baf14065a73dbac19bbcf39.docx"},{"id":90575832,"identity":"bef6e891-035e-4a47-80eb-548d875f143c","added_by":"auto","created_at":"2025-09-04 09:17:25","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20716,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarytable2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7446556/v1/4f7f17bd9a077898be573054.docx"},{"id":90577025,"identity":"30f5ac48-2161-4e0b-90d2-ff625849b047","added_by":"auto","created_at":"2025-09-04 09:25:25","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":16655,"visible":true,"origin":"","legend":"","description":"","filename":"CHERRIESsupplement.docx","url":"https://assets-eu.researchsquare.com/files/rs-7446556/v1/86ddb0d6c72ac9cf9b8a114d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Current practice patterns in microvascular decompression for trigeminal neuralgia: results from an international survey","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTrigeminal neuralgia is a painful disorder characterized by brief paroxysms in the distribution area of one or several branches of the trigeminal nerve [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The pain attacks are most often described as electric shock-like [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and are typically triggered by innocuous stimuli such as chewing, touch, brushing teeth, eating, talking, and cold wind [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Depending on the etiology, trigeminal neuralgia is classified as classical if caused by vascular compression of the trigeminal root, secondary if attributed to multiple sclerosis, tumor, or other cause, or idiopathic if no abnormalities are detected upon radiological and electrophysiological examination [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Pharmacotherapy is the initial treatment, with carbamazepine and oxcarbazepine being the most effective drugs [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. While the initial response rates are 98% and 94%, respectively, adverse events are frequent, causing 27% (carbamazepine) and 18% (oxcarbazepine) of patients to withdraw from the treatment [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn patients with classical trigeminal neuralgia who cannot be satisfactorily managed with pharmacotherapy, microvascular decompression (MVD), initially described by Peter Jannetta, is the surgical treatment of choice [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The operation includes a retrosigmoid trepanation and dissection of the trigeminal nerve in the cerebellopontine angle to separate the offending vessel from the nerve [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. A prospective study with independent pre- and postoperative evaluation revealed a success rate of 86% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Retrospective analyses consistently show a high proportion of favorable outcomes in the long term [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. After decades of experience, the Jannetta group published their surgical method, which defined, among other steps, the placement of the patient in the lateral position, retrosigmoid craniectomy, insertion of a retractor, coagulation and division of the petrosal veins, mobilization of the offending vessel, interposition with a Teflon felt, watertight dural closure, and cranioplasty with methylmethacrylate or wire mesh as crucial elements of the technique [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSince then, significant technological advances have shaped the field of neurosurgery, including improvements in operating microscopes, neuroendoscopy, neuronavigation, and operating techniques such as sling retraction or the use of alternative interposition materials. An increasing number of elderly patients, as well as progress in anesthesiology and peri-procedural care, raises the question of performing surgery in patients once deemed too old. While a multitude of variations to the Jannetta procedure grounded in these developments were reported, comparative studies are scarce and often not feasible. Furthermore, it is unknown how many of these variations are adopted by the neurosurgical community and how far MVD, as it is performed today, departs from the principles defined by Peter Jannetta.\u003c/p\u003e\u003cp\u003eThis study aimed to determine current practice patterns and operative standards in MVD for trigeminal neuralgia among German-speaking neurosurgeons and discuss them in the context of the available literature.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eA web-based questionnaire was developed using an online platform (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.survio.com\" target=\"_blank\"\u003ewww.survio.com\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.survio.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). It consisted of 14 questions with one item per page and was written in German. No questions on personal data (such as age, sex, location, duration of occupation, or number of surgeries performed) were included to protect anonymity in a relatively small specialist cohort.\u003c/p\u003e\u003cp\u003eThe survey was distributed among neurosurgeons in Germany, Austria, Luxembourg, and the German-speaking parts of Switzerland and Italy (South Tyrol), who have expertise in MVD. To determine appropriate institutions and practitioners, a list containing all neurosurgical departments in the relevant areas was created using information from the respective neurosurgical societies. Departments with a focus on spine surgery were excluded, as were those for which no sufficient expertise in MVD could be assumed. Appropriate addressees within the departments were determined by research (including information on the practitioners\u0026rsquo; or their employers\u0026rsquo; websites and publications), acquaintance, or inquiry. If no practitioner involved in the management of trigeminal neuralgia and MVD could be determined, the head of the department was addressed. Only one neurosurgeon per institution was invited to participate. A link to the survey was distributed either in person at neurosurgical events or via email between May 27 and August 11, 2025. Each invitee was addressed individually. No mass emails were sent, and the link to the survey was not made public. No incentive, financial or otherwise, was offered for participation.\u003c/p\u003e\u003cp\u003eDescriptive statistics are presented as percentages and absolute numbers, as appropriate. Sums exceeding 100% are due to rounding. No inferential statistics were employed. The ethics committee of the Medical Association of Hesse waived the need for informed consent or a formal assessment. The reporting of this study follows the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSix neurosurgeons were invited to participate in person, and 117 via email. Of 123 neurosurgeons invited, 63 completed the survey (response rate 51.2%).\u003c/p\u003e\u003cp\u003eThe majority of respondents (93.7%) do not see an age limit for MVD indication. A microsurgical approach is most frequently employed (65.1%), followed by microsurgery with endoscopic assistance (30.2%), whereas fully endoscopic or exoscopic approaches are rarely used. 46.0% reported preferring a supine and 39.7% a lateral/park-bench position.\u003c/p\u003e\u003cp\u003eNeuronavigation is never or rarely used by 63.5% of participants, while 25.4% reported regular use. Neuromonitoring is routinely applied by 71.4% of respondents. Most respondents perform either craniotomy or craniectomy with cranioplasty using Palacos, bone cement, etc.\u003c/p\u003e\u003cp\u003eFixed retraction is generally or often applied by 52.4%, whereas 39.7% avoid or limit its use. The superior petrosal vein is preserved by most (65.1%), but 28.6% sacrifice it when necessary. Teflon is the most common interposition material (74.6%), while muscle, other materials, and transposition without interposition were less frequently reported.\u003c/p\u003e\u003cp\u003eMost respondents regularly secure the graft with fibrin glue (63.5%). Of note, all six neurosurgeons who indicated using muscle as interposition material reported applying fibrin glue. Watertight dural closure is pursued by the majority. Lumbar drains are rarely used.\u003c/p\u003e\u003cp\u003eWhen asked about MVD in trigeminal neuralgia secondary to multiple sclerosis, 55.6% consider surgery if MRI showed neurovascular contact, 14.3% would generally perform MVD, while 30.2% would not. In idiopathic trigeminal neuralgia with the absence of neurovascular contact on imaging, 66.7% sometimes offer MVD after shared decision-making, 25.4% generally do, and 7.9% do not. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides a detailed account of questions and responses.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSurvey items and distribution of responses (n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQuestion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eResponse Options\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge limit for MVD indication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e59 (93.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u0026thinsp;\u0026ge;\u0026thinsp;80 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4 (6.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes, 75\u0026ndash;79 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes, 70\u0026ndash;74 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eApproach\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMicrosurgical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e39 (65.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMicrosurgical\u0026thinsp;+\u0026thinsp;endoscopic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19 (30.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFully endoscopic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1 (1.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExoscopic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1 (1.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVaries\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1 (1.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositioning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSupine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e29 (46.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLateral/park bench\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25 (39.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProne\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4 (6.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSitting/half-sitting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1 (1.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVaries\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4 (6.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUse of neuronavigation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo/rarely\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40 (63.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes, always/often\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16 (25.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSometimes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7 (11.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUse of neuromonitoring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e45 (71.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13 (20.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSometimes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5 (7.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eType of trepanation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOsteoplastic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23 (36.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOsteoclastic\u0026thinsp;+\u0026thinsp;Palacos, bone cement, etc.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23 (36.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOsteoclastic, no cranioplasty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1 (1.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOsteoclastic\u0026thinsp;+\u0026thinsp;allogenic material (mesh, etc.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2 (3.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOsteoclastic\u0026thinsp;+\u0026thinsp;bone dust\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7 (11.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVaries\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7 (11.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFixed retraction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes, always/often\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33 (52.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo/only during approach\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25 (39.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVaries\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7 (11.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSacrifice of superior petrosal vein\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo, never or only upon hemorrhage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e41 (65.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes, if necessary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18 (28.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes, generally/often\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4 (6.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInterposition material\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTeflon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e47 (74.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMuscle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6 (9.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4 (6.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTransposition/sling retraction without interposition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6 (9.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFixation with fibrin glue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes, always/usually\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40 (63.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo/rarely\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16 (25.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSometimes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7 (11.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWatertight dural closure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes, absolutely\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53 (84.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo, not imperatively\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10 (15.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRoutine lumbar drain placement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e60 (95.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes, before surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3 (4.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes, after surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMVD in TN with MS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes, if NVC on MRI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35 (55.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9 (14.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19 (30.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMVD in TN without NVC on MRI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSometimes (shared decision)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e42 (66.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16 (25.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5 (7.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eMRI\u0026thinsp;=\u0026thinsp;magnetic resonance imaging, MS\u0026thinsp;=\u0026thinsp;multiple sclerosis, MVD\u0026thinsp;=\u0026thinsp;microvascular decompression, NVC\u0026thinsp;=\u0026thinsp;neurovascular contact, TN\u0026thinsp;=\u0026thinsp;trigeminal neuralgia\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSeveral respondents provided additional comments via email after completing the survey, thereby identifying themselves. While these comments were generally not linked to survey responses, one clarification led to the reclassification of a response in item 9, where an answer originally marked \u0026ldquo;Teflon\u0026rdquo; was reassigned to \u0026ldquo;Transposition without interposition material\u0026rdquo; based on the participant\u0026rsquo;s detailed explanation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides an overview of current views on both indications for MVD and operative techniques among a selected group of neurosurgeons in central Europe. It is, to the author\u0026rsquo;s knowledge, the first to systematically examine intraoperative strategies and technical details in MVD for trigeminal neuralgia. A prior survey from the United States was distributed to all members of the American Association of Neurological Surgeons and exclusively addressed preoperative decision making, without exploring operative conduct [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. By focusing on operative nuances, the present study provides novel insight into how the procedure has evolved.\u003c/p\u003e\n\u003ch3\u003ePatient selection\u003c/h3\u003e\n\u003cp\u003eWhile the incidence of trigeminal neuralgia increases with age, so does the fear of surgical complications. Therefore, the finding that the vast majority of the respondents see no age limit for the indication for MVD is particularly noteworthy. Concerning elderly patients in reduced general condition, it should be pointed out that percutaneous rhizotomies may present a reasonable alternative to MVD [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The same applies to trigeminal neuralgia secondary to multiple sclerosis and idiopathic trigeminal neuralgia [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The use of MVD in treating these conditions is unclear. A seminal study by Truini et al. suggested a double-crush mechanism in trigeminal neuralgia secondary to multiple sclerosis, with both inflammatory demyelination and neurovascular compression contributing to the manifestation of the disorder concurrently, implying a role for MVD in its treatment [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Others, however, have challenged this observation [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], but still recognized that MVD should be considered in this patient population if neurovascular contact with morphological changes is established [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Overall, MVD may be appropriate in trigeminal neuralgia secondary to multiple sclerosis, although the success rates appear to be lower compared to classical trigeminal neuralgia [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In this survey, 14.3% of participants stated they generally consider MVD in patients with multiple sclerosis, while 55.6% do so if neurovascular contact is demonstrated.\u003c/p\u003e\u003cp\u003eOnly 7.9% of respondents indicated that they don\u0026rsquo;t consider MVD if no neurovascular contact is shown on magnetic resonance imaging (MRI). This finding likely reflects the observation that despite advances in modern radiological examinations, false-negative results are possible. In one study, 14 out of 17 patients with trigeminal neuralgia, in whom the preoperative MRI was negative for neurovascular relationship, were found to have a vascular contact to the trigeminal nerve during surgery [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eOperative technique\u003c/h3\u003e\n\u003cp\u003eWhile some operative details have largely been maintained since Jannetta\u0026rsquo;s description, other aspects show greater variation, for example, positioning or trepanation. In some regards, notably the handling of the superior petrosal vein, Jannetta\u0026rsquo;s approach has largely been abandoned, as only 6.4% of practitioners routinely sacrifice it, and 65.1% will never do so unless hemorrhage forces them to. In the past, some authors argued that obliteration of veins in the cerebellopontine angle is safe. In a recent review, however, Joswig et al. undertook a thorough appraisal of reports on superior petrosal vein sacrifice and its ensuing complications and concluded that the maneuver poses too significant a risk and should be considered obsolete [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNearly one-third of participants use neuroendoscopy, albeit only one practitioner (1.6%) indicated performing fully endoscopic MVD. Proponents of endoscopy cite improved visualization of anatomic structures and, in the case of fully endoscopic approaches, less need for tissue dissection compared with purely microsurgical approaches [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, comparative studies failed to detect differences in clinical outcomes [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Neuronavigation is regularly used in MVD by one in four respondents. Purported advantages include reduced craniotomy size, avoidance of unnecessary opening of mastoid air cells, and reduced incidence of CSF leaks [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. To avoid complications such as postoperative hearing loss and facial palsy, the majority of neurosurgeons in this survey indicated regularly using neuromonitoring, which is an established method to improve outcomes in MVD [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Damage to the VII and VIII cranial nerves during MVD may result from direct manipulation, vasospasm, forceful irrigation, CSF egress, acoustic trauma from drilling, or tension injury through retraction of the cerebellum [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Although described in MVD for hemifacial spasm rather than trigeminal neuralgia, greater cerebellar retraction depth has been identified as significantly associated with postoperative hearing loss [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. To avoid this complication, 39.7% of neurosurgeons in this survey don\u0026rsquo;t use fixed cerebellar retraction during MVD or do so only during the approach to the cerebellopontine angle. A minority places a lumbar drain before the surgery to drain CSF and relax the cerebellum. A lumbar drain, if kept in place for a few days postoperatively, may also aid in preventing CSF leak [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A large MVD series identified the lack of primary dural closure as a significant risk factor for postoperative CSF leak [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Accordingly, 84.1% of respondents in this survey pursue watertight dural closure, independently of the use of dural sealants or augmentation.\u003c/p\u003e\n\u003ch3\u003eInterposition and transposition\u003c/h3\u003e\n\u003cp\u003eThe majority of the participants separate the offending vessel from the nerve using Teflon as interposition material. Despite high success rates using this technique, Teflon granulomas or adhesions may lead to pain recurrence [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. To avoid these occurrences, some authors favor transposition of the offending artery without interposition material [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In this survey, 9.5% indicated attempting transposition over interposition, if feasible. However, comparative studies show no significant differences in outcomes between the two techniques [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. An additional 9.5% of respondents use autologous muscle as interposition material. Numerous reports indicate excellent results with muscle grafting [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], while there is no conclusive evidence to favor one interposition material over the other. Noteworthy, all participants using muscle in this study apply fibrin glue to secure the graft, while, overall, 25.4% never do so in MVD. This can be interpreted as confirming the observation that Teflon has a higher tendency to adhere to the surrounding tissues than does muscle.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eStrengths of the present study include its strict methodology, inviting only one practitioner per institution, and an attempt to make the survey accessible only to neurosurgeons with experience in MVD. The high response rate of more than 50% indicates the relevance and importance of the questions raised. Still, there are limitations. Despite efforts to identify appropriate addressees, there can be no certainty that the respondents are representative of all MVD practitioners. This is especially true for neurosurgeons outside of the geographic region included in this survey, which was limited to German-speaking central Europe. A self-selection bias is inherently possible in surveys, as those more interested in the subject of the questionnaire may have been more likely to respond. The results do not allow for allocation of the responses to individual levels of experience or treatment outcomes. However, questions about personal qualifications, such as the number of MVD procedures performed, were deliberately omitted to ensure anonymity in a comparatively small neurosurgical cohort and to avoid bias, as the self-assessment of physicians is demonstrably of limited accuracy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study shows that the surgical techniques in MVD have evolved since the procedure was developed by Peter Jannetta. While key principles remain widely adopted, significant changes in intraoperative strategy are evident. These findings may help inform consensus-building and identify areas for further research, including the development of a registry for MVD. Furthermore, for operative steps that lack evidence-based consensus, it can be valuable for practitioners to consider the approach of others, as presented in this article, for their own decision-making. Finally, the author would like to encourage neurosurgeons from other parts of the world to research practice patterns in MVD in their respective regions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflict of Interest:\u003c/h2\u003e\u003cp\u003eThe author declares no conflict of interest.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eDeclarations Funding:\u003c/h2\u003e\u003cp\u003eThe author declares that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\u003cp\u003eCompeting Interests: The author has no relevant financial or non-financial interests to disclose.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJ.K. is the sole author and was responsible for the study design, data acquisition, analysis, and writing of the manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe author wishes to thank all colleagues who participated in the survey, especially those who provided additional feedback and comments. Their insights were valuable and greatly contributed to this project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlasta A, Al_Naggar AM, AL-saidy A, Al Wesabi F (2025) Microvascular Decompression for Trigeminal Neuralgia Using Autologous Muscle Grafting: A Retrospective Analysis in a Resource-Limited Setting. Cureus 17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/CUREUS.81362\u003c/span\u003e\u003cspan address=\"10.7759/CUREUS.81362\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAndersen ASS, Heinskou TB, Rochat P, Springborg JB, Noory N, Smilkov EA, Bendtsen L, Maarbjerg S (2022) Microvascular decompression in trigeminal neuralgia - a prospective study of 115 patients. 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Cephalalgia 38:1\u0026ndash;211. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0333102417738202\u003c/span\u003e\u003cspan address=\"10.1177/0333102417738202\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"trigeminal neuralgia, microvascular decompression, Jannetta procedure, survey","lastPublishedDoi":"10.21203/rs.3.rs-7446556/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7446556/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eTrigeminal neuralgia is a facial pain disorder, most often caused by neurovascular contact at the trigeminal root. In cases refractory to pharmacotherapy, microvascular decompression (MVD) is an established treatment. Since its description, various modifications have been introduced. The extent to which current practice deviates from the original approach remains unclear. This study aimed to assess current strategies in MVD for trigeminal neuralgia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA web-based 14-item questionnaire was distributed to neurosurgeons with expertise in MVD from Germany, Austria, Switzerland, Italy, and Luxembourg. The link to the survey was shared between May and August 2025 and was not made public. To avoid institutional clustering, only one practitioner per institution was invited to participate anonymously.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf 123 neurosurgeons invited, 63 completed the questionnaire (response rate 51.2%). 93.7% of respondents do not consider an age limit for MVD. Surgery is most commonly performed in the supine (46.0%) or lateral (39.7%) position, either purely microscopically (65.1%) or with endoscopic assistance (30.2%). 71.4% of practitioners regularly use neuromonitoring. Trepanation is usually performed either osteoplastically or osteoclastically with Palacos cranioplasty (36.5% each). Teflon is the most frequently used interposition material (74.6%). 65.1% never sacrifice the superior petrosal vein. Only 7.9% would generally refrain from MVD if no neurovascular contact is evident on radiological examination.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis survey demonstrates current practice patterns in MVD for trigeminal neuralgia in central Europe. While some principles of the original technique remain widely adopted, notable changes in operative strategy are apparent, highlighting areas for future consensus-building and research, and informing operative decision-making.\u003c/p\u003e","manuscriptTitle":"Current practice patterns in microvascular decompression for trigeminal neuralgia: results from an international survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-04 09:17:20","doi":"10.21203/rs.3.rs-7446556/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"48f6cd45-8229-4f9b-8345-56655b9d40e4","owner":[],"postedDate":"September 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-09T02:23:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-04 09:17:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7446556","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7446556","identity":"rs-7446556","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}