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Introduction <p>Trigeminal neuralgia (TN) is a chronic, debilitating neuropathy characterized by sudden, severe facial pain. Given the variety of available procedural options, we performed a systematic review and network meta-analysis to compare the relative efficacy and safety of interventions for medication-refractory TN, primarily based on observational evidence.</p> Methods <p>We conducted a systematic review and network meta-analysis registered in PROSPERO (CRD420251163324). PubMed, Embase, and CENTRAL were searched from inception to July 2025. A frequentist random-effects network meta-analysis was performed, estimating risk ratios (RRs) with 95% confidence intervals (CIs) for binary outcomes.</p> Results <p>Eleven studies comprising 10,741 patients were included, evaluating microvascular decompression (MVD), percutaneous procedures (PP), Gamma Knife Surgery (GKS), and combined MVD + PP. Compared with MVD, GKS was associated with a lower risk of complications (RR 0.24; 95% CI 0.11–0.52), followed by PP (RR 0.34; 95% CI 0.12–0.93), whereas MVD + PP showed higher complication rates (RR 4.27; 95% CI 1.18–15.46). For complete pain relief (BNI I), combined MVD + PP showed a trend toward higher success (RR 1.18; 95% CI 0.72–1.93), while GKS was associated with lower rates (RR 0.52; 95% CI 0.39–0.70). For poor outcomes (BNI IV–V), estimates for MVD + PP were imprecise (RR 0.55; 95% CI 0.13–2.21), whereas higher risks were observed with GKS (RR 2.65; 95% CI 1.17–5.98) and PP (RR 3.73; 95% CI 0.68–20.64). Recurrence tended to be lower with MVD + PP (RR 0.66; 95% CI 0.21–2.12), while higher risks were observed with GKS (RR 3.14; 95% CI 1.43–6.85) and PP (RR 2.99; 95% CI 1.12–8.00). For facial numbness, stand-alone MVD showed the most favorable profile, whereas MVD + PP (RR 11.08; 95% CI 3.61–33.99) and PP (RR 3.69; 95% CI 1.92–7.09) were associated with higher risks.</p> Conclusions <p>Among patients with medication-refractory TN, different interventions exhibit distinct efficacy–safety trade-offs. While combined MVD + PP showed favorable pain-related trends, these findings are based on limited observational data and are accompanied by increased sensory morbidity. GKS demonstrated a favorable safety profile but with lower durability of pain control. Given the predominantly observational nature of the evidence and the low to very low certainty assessed by GRADE, these results should be interpreted cautiously and considered hypothesis-generating rather than practice-changing.</p>

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From microvascular decompression to radiosurgery: a network meta-analysis of interventions for medication-refractory trigeminal neuralgia

  • 期刊论文

  • 发表日期：

    2026年3月7日

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  • Pandora E. O. Fonseca,
  • Bárbara F. Bonatti,
  • Helen M. de Oliveira,
  • Wellgner Fernandes Oliveira Amador,
  • Renata T. Fernandes,
  • Afonso H. Dutra-Melo

摘要

Introduction

Trigeminal neuralgia (TN) is a chronic, debilitating neuropathy characterized by sudden, severe facial pain. Given the variety of available procedural options, we performed a systematic review and network meta-analysis to compare the relative efficacy and safety of interventions for medication-refractory TN, primarily based on observational evidence.

Methods

We conducted a systematic review and network meta-analysis registered in PROSPERO (CRD420251163324). PubMed, Embase, and CENTRAL were searched from inception to July 2025. A frequentist random-effects network meta-analysis was performed, estimating risk ratios (RRs) with 95% confidence intervals (CIs) for binary outcomes.

Results

Eleven studies comprising 10,741 patients were included, evaluating microvascular decompression (MVD), percutaneous procedures (PP), Gamma Knife Surgery (GKS), and combined MVD + PP. Compared with MVD, GKS was associated with a lower risk of complications (RR 0.24; 95% CI 0.11–0.52), followed by PP (RR 0.34; 95% CI 0.12–0.93), whereas MVD + PP showed higher complication rates (RR 4.27; 95% CI 1.18–15.46). For complete pain relief (BNI I), combined MVD + PP showed a trend toward higher success (RR 1.18; 95% CI 0.72–1.93), while GKS was associated with lower rates (RR 0.52; 95% CI 0.39–0.70). For poor outcomes (BNI IV–V), estimates for MVD + PP were imprecise (RR 0.55; 95% CI 0.13–2.21), whereas higher risks were observed with GKS (RR 2.65; 95% CI 1.17–5.98) and PP (RR 3.73; 95% CI 0.68–20.64). Recurrence tended to be lower with MVD + PP (RR 0.66; 95% CI 0.21–2.12), while higher risks were observed with GKS (RR 3.14; 95% CI 1.43–6.85) and PP (RR 2.99; 95% CI 1.12–8.00). For facial numbness, stand-alone MVD showed the most favorable profile, whereas MVD + PP (RR 11.08; 95% CI 3.61–33.99) and PP (RR 3.69; 95% CI 1.92–7.09) were associated with higher risks.

Conclusions

Among patients with medication-refractory TN, different interventions exhibit distinct efficacy–safety trade-offs. While combined MVD + PP showed favorable pain-related trends, these findings are based on limited observational data and are accompanied by increased sensory morbidity. GKS demonstrated a favorable safety profile but with lower durability of pain control. Given the predominantly observational nature of the evidence and the low to very low certainty assessed by GRADE, these results should be interpreted cautiously and considered hypothesis-generating rather than practice-changing.