Microvascular decompression versus percutaneous balloon compression for trigeminal neuralgia: a systematic review and meta-analysis of double-arm studies

Trigeminal neuralgia (TN) causes disabling facial pain often refractory to medication. Microvascular decompression (MVD) and percutaneous balloon compression (PBC) are established surgical options, yet their comparative efficacy and safety remain debated. Following PRISMA guidelines, a systematic review and meta-analysis of 19 double-arm studies (2,674 patients; 1486 MVD, 1188 PBC) was performed. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were computed. Evidence certainty was graded via GRADE. MVD and PBC achieved similar initial complete pain relief (RR = 1.01, 95% CI 0.98–1.05, <i>p</i> = 0.49) and adequate relief (RR = 1.00, 95% CI 0.97–1.02, <i>p</i> = 0.67). Long-term complete (RR = 1.11, 95% CI 0.97–1.27, <i>p</i> = 0.13) and adequate relief (RR = 1.06, 95% CI 0.97–1.15, <i>p</i> = 0.17) were likewise equivalent. Pain recurrence modestly favored MVD (RR = 0.72, 95% CI 0.51–1.00, <i>p</i> = 0.05), while permanent complications did not differ (RR = 1.09, 95% CI 0.43–2.75, <i>p</i> = 0.86). Leave-one-out analyses confirmed robustness, and Egger’s tests showed no publication bias. GRADE rated certainty high for initial relief, moderate for long-term outcomes and recurrence, and low for complications. MVD and PBC yield equivalent short-term and long-term pain relief, as well as similar safety, in TN. MVD may offer slightly lower recurrence, whereas PBC remains advantageous for elderly or medically fragile patients. These data support the use of tailored surgical selection guided by patient comorbidity and durability expectations.