Preoperative Decision-Making in Microvascular Decompression for Trigeminal Neuralgia: A Survey of Practicing Neurosurgeons

OBJECTIVE: Microvascular decompression (MVD) for trigeminal neuralgia (TN) results in durable pain freedom in a large percentage of appropriately selected patients. The decision to perform MVD is based on a combination of clinical symptomatic presentation and imaging findings demonstrating neurovascular compression (NVC) with surgeons weighting these variables differently. This study sought to determine the relative importance of clinical symptomatic presentation and imaging findings of NVC in decision-making to pursue MVD for TN among North American board-certified neurosurgeons. METHODS: An online survey detailing the decisionmaking process involved in the workup and treatment of TN with MVD was distributed to all American Association of Neurological Surgeons registered board-certified neurosurgeons in North America. RESULTS: From 3010 functional email addresses, there were 309 responses to the survey (10% response rate). The majority of respondents (76%) reported only operating on patients with classic type 1 TN (T1TN) while only 32% chose to operate on patients with imaging findings of vascular compression in the absence of T1TN symptoms. In contrast to low-volume surgeons, high-volume surgeons weighed imaging evidence of vascular compression more heavily into the decision-making process to operate. CONCLUSIONS: The majority of responding neurosurgeons weigh symptomatic presentation more heavily than imaging evidence of NVC when deciding on whom to perform MVD. High-volume surgeons tend to be more attentive to NVC in their decision-making to perform MVD when compared with low-volume surgeons.