Microvascular Decompression for Vertebrobasilar Dolichoectasia-Related Primary Trigeminal Neuralgia: Surgical Strategies, Technical Nuances, and Clinical Outcomes

Objectives: To investigate the surgical strategies, technical key points, and clinical efficacy of microvascular decompression (MVD) in treating primary trigeminal neuralgia (PTN) associated with vertebrobasilar dolichoectasia (VBD). Methods: A retrospective analysis was conducted on 34 consecutive VBD-related PTN patients treated by a single neurosurgeon at the China-Japan Friendship Hospital between January 2020 and April 2025. VBD compression patterns were classified into two types: ​Type I: Imaging showing significant brainstem deformation and obliterated arachnoid space by VBD (n=16, 47.1%). ​Type II: Imaging confirming VBD presence without or with minimal brainstem deformation and preserved arachnoid space (n=18, 52.9%). Type-specific MVD techniques were applied: a four-step approach for Type I and a three-step approach for Type II. Outcomes were evaluated using the Barrow Neurological Institute Pain Intensity Scale (BNI) during follow-up (range: 2–64 months). Results: Among 1,214 PTN patients treated during the study period, 34 (2.8%) had VBD-related PTN. ​Preoperative BNI grades: Grade V in 8 patients (23.5%); Grade IV in 26 patients (76.5%). 17.6% (6/34) had comorbid cranial neuropathies. ​Postoperative outcomes: BNI Grade I: 91.2% (31/34)，BNI Grade II: 8.9% (3/34)，Overall success rate (BNI ≤ II): 100%. Conclusion: VBD-related PTN is a rare clinical entity characterized by severe refractory pain. Based on VBD compression morphology (Type I vs. Type II), tailored MVD strategies provide a safe and effective surgical approach, achieving excellent pain relief.