Optimizing microvascular decompression for venous compression in trigeminal neuralgia: clinical outcomes and technical considerations

Objectives Venous compression is an underrecognized cause of trigeminal neuralgia (TN) and remains controversial due to its subtle imaging manifestations, variable anatomy, and uncertain optimal surgical management. This study aimed to clarify the anatomical spectrum of venous offenders, evaluate surgical outcomes, and explore the role of adjunctive trigeminal nerve combing (NC) in selected cases.Methods We retrospectively analyzed 31 patients with primary TN who underwent microvascular decompression (MVD) between 2017 and 2023 and were confirmed intraoperatively to have pure venous compression (n = 11) or mixed arteriovenous compression (n = 20). Preoperative evaluation, operative videos, complications, and follow-up status were reviewed. Follow-up averaged 5 years.Results Pure venous compression was frequently associated with mild indentation-type conflict and markedly thickened arachnoid membranes, whereas mixed compression more commonly caused trigeminal root entry zone (REZ) distortion. The transverse pontine vein was the predominant offender. At discharge, pain-free status (BNI I) was achieved in 82% of pure venous and 95% of mixed cases. Long-term pain-free rates were 72% of pure venous and 80% of mixed patients. Recurrence occurred in 18% of pure venous and 10% of mixed cases (p > 0.05). Five patients with low-tension pure venous compression underwent adjunctive NC, achieving satisfactory long-term relief. Complications were mild and transient; no venous infarction occurred.Conclusion Venous compression constitutes a distinct and surgically manageable subtype of TN. When combined with full-length exposure from the REZ to Meckel’s cave, tailored approaches – including selective venous transposition or division and NC for low-tension adhesions – achieve durable pain control with minimal morbidity.