Microvascular Decompression (MVD)

MVD is the only surgical procedure that addresses the purported cause of most trigeminal neuralgia (TN). It is the most invasive of all surgical options to treat TN, but it also offers the lowest probability that the pain will return. The MVD procedure has become widely accepted and many surgeons consider it the patient’s best chance at long-term pain relief without numbness. The MVD surgical treatment was designed to cause no additional nerve damage. 

What happens during MVD surgery?

The procedure requires a small opening to be made behind the ear. While viewing the trigeminal nerve through a microscope, the surgeon places a soft cushion between the nerve and the offending blood vessels. The aim of MVD is to hunt down one or more blood vessels compressing the trigeminal nerve and to move the two apart by inserting a small pad between them. This takes the offending mechanical force – a pulsating blood vessel – out of play. Technically, this is cranial surgery, not brain surgery, since nothing is being done to the brain itself. 

MVD may result in complete pain relief either immediately or gradually over days or weeks. The longer a person has had TN pain before having an MVD, the less likely it is that pain relief will be immediate.  

Before surgery, patients are screened to make sure their overall health is good enough to tolerate the stress of major surgery and anesthesia. Once the patient is asleep, a one-inch by three-inch area of hair is shaved, behind the ear on the side with the pain. The head is secured in a surgical clamping device to prevent any movement during the procedure.  

With the head in place, the surgeon cuts a half-dollar size or smaller hole in the skull just behind the ear. The dura (covering of the brain) is then opened. Using an operating microscope, the surgeon works next to the brain to locate the cranial nerves, looking for the root zone of the trigeminal nerve, the point where it connects to the pons or brainstem. This is where arteries and veins are most often found to be compressing the nerve. Another doctor, a neurologist or neurophysiologist, monitors a device that continually tests the nearby auditory nerve, which lies in the path between the skull opening and the trigeminal nerve.

While exploring the trigeminal nerve root through the operating microscope, the surgeon hopes to find one or more offending blood vessels. A pre-surgery MRI gives surgeons an idea ahead of time where they are likely to find compressing vessels, but not always. In most cases, the compressing vessel is obvious to the surgeon’s eye, but occasionally it is well hidden. In more than half of MVD surgeries, more than one vessel is compressing the nerve. In 10 to 15 percent of MVD surgeries, surgeons fail to find or recognize any compressing vessels. When that occurs, many surgeons cut some of the sensory nerve fibers to bring relief without troubling numbness.

In two-thirds to three-quarters of the cases, when a blood vessel is found to be compressing the nerve, that vessel is an artery. It is important to make this distinction because arteries cannot be cut or removed but must be padded off the nerve. Veins, however, can be divided by sealing them off and cutting them out rather than padding them. Once the padding is in place or the vein has been eliminated, the surgeon sutures together the dura and covers the skull opening with a variety of techniques. The entire MVD procedure typically takes two to four hours, although the actual repair takes more like 90 minutes.

MVD recovery- what to expect

It is important that you have patience during your recovery from MVD surgery, and accept that you will have some pain and discomfort.  Individual surgical cases can vary, depending on the nerve-vessel anatomy, and your recovery experience will be different from others.

After surgery, you can expect to stay in the hospital one to three days recovering while your doctor monitors you and manages any pain, dizziness, or other symptoms you may be experiencing. You will be taken to the recovery room where vital signs are monitored as you awake from anesthesia.  Next, you will be transferred to the intensive care unit (ICU) for close observation overnight.

You may experience some nausea and headache after surgery; medication can control these symptoms. As MVD is a major surgery, you can expect to have some pain at the incision site and headache postoperatively. Let your nurse know if you are uncomfortable, have a severe headache that is not relieved by medication, facial weakness, hearing loss or excessive drainage and pain at the incision site.

Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation. When your condition stabilizes, you will be transferred to a regular room where you will increase your activity level (sitting in a chair, walking).

Pain medicines are used for the first several days, and your doctor may advise that you continue your pre-operative medical regimen for the nerve pain. In the case of the anti-epileptic drugs (Carbamazepine, Dilantin, Neurontin, etc.) a bit of a taper for each drug is normally done after discharge. Coordination and other neurological tests are done at regular intervals for the first 24 hours.

Recovering back at home

                                                                                                              Your doctor’s orders may vary, but typically:

  • You will likely be able to resume your normal diet, medications, and activities, unless your physician instructs you differently.
  • Balance issues can be expected for several days, up to a week.
  • You will need to continue all preoperative medication for trigeminal neuralgia. You will be instructed how and when to slowly decrease your medication.
  • Staples/sutures are removed seven to 14 days after surgery.
  • Pain and stiffness from the operation usually subside within a week, and you can begin to resume normal activities at your own pace.
  • Do not drive after surgery until discussed with your surgeon and avoid sitting for long periods of time.
  • Do not lift anything heavier than five pounds.
  • Housework and yard-work are not  typically not permitted until the first follow-up office visit. This includes gardening, mowing, vacuuming, ironing, and loading/unloading the dishwasher, washer, or dryer.
  • Do not drink alcoholic beverages.
  • Gradually return to your normal activities. Fatigue is common.
  • An early exercise program to gently stretch the neck and back may be advised.
  • Walking is encouraged; start with short walks and gradually increase the distance. Wait to participate in other forms of exercise until discussed with your surgeon.
  • You may shower and shampoo three or four days after surgery unless otherwise directed by your surgeon.

Call your physician to report any of the following:

  • Severe headache that is not relieved by medication
  • Facial weakness
  • Hearing loss
  • A temperature that exceeds 101º F
  • An incision that shows signs of infection, such as redness, swelling, pain, or drainage.
  • If you are taking an anticonvulsant, and notice drowsiness, balance problems, or rashes.
  • Decreased alertness, increased drowsiness, weakness of arms or legs, increased headaches, vomiting, or severe neck pain that prevents lowering your chin toward the chest.

Getting back to normal after MVD

Setting reasonable expectations for returning to work, housework, exercise, and other activities will help you cope with your recovery. If it takes longer than you expect, you may be discouraged, frustrated, and wondering, “What is wrong with me?” In reality, every person is different and recovery from fatigue and your ability to resume some activities might take longer than other people- but that does not necessarily mean something is wrong- or that you will never recover.

Many patients can return to work within two weeks (longer if they have physically demanding jobs) and most say they are completely recovered in about two months. For some people, it takes longer – many people report feeling fatigued for longer than they expected. Put together a plan for your recovery time, so that you will have ample time to rest, have help with household chores, childcare, and time away from work. 

MVD outcomes

Microvascular decompression achieves the most sustained pain relief, with 90 percent of patients reporting initial pain relief and over 80 percent still pain free after one year, 75 percent after three years, and 73 percent after five years remaining pain-free.

In most cases, pain relief is immediate. Once the pressure of the blood vessel is removed, the nerve’s fibers are no longer pressed together and signals from the light-touch fibers stop jumping onto the pain-signaling fibers. However, in some cases – especially in those who have had pain for a long time – the pain may take a few days or even weeks to resolve. What isn’t always spelled out in the studies is whether success means no pain or whether it also includes people who are significantly improved but still in some pain.

A prospective, long-term study from 1996 of 1,185 patients who underwent MVD surgery at the University of Pittsburgh found that 82 percent of patients had no pain and 16 percent had at least a 75 percent reduction of pain post- MVD. The remaining two percent either had no relief or only minor improvement.

Dr. Raymond Sekula and colleagues (2020) developed a grading system to aid patients and referring clinicians in understanding if MVD is the optimal choice. A score is derived from adding points from the following three characteristic categories:

  • Type of TN: 0 for non-classical, 1 for classical
  • Response to carbamazepine/oxcarbazepine: 0 for no, 1 for yes
  • Neurovascular contact: 3 for arterial deformation, 2 for arterial contact, 1 for absent or venous contact

TN grading system score and estimated probability of long-term pain-free status (95%CI):

5 — 93% (0.92 – 0.93)

4 — 76% (0.74 – 0.78)

3 — 44% (0.40 – 0.47)

2 — 16% (0.12 – 0.21)

1 — 4% (0.03 – 0.06)

Panczykowski, David M., Ronak H. Jani, Marion A. Hughes, and Raymond F. Sekula Jr. “Development and evaluation of a preoperative trigeminal neuralgia scoring system to predict long-term outcome following microvascular decompression.” Neurosurgery 87, no. 1 (2020): 71-79. https://doi.org/10.1093/neuros/nyz376

This classification scheme suggests that the likelihood that you will have long-term painlessness can vary widely based on several factors.

MVD complications

MVD patients can expect to be stiff, have a headache, and have some pain around the incision for the first couple of weeks postoperatively. Occasionally, patients experience one or more of the following: blurred or double vision, muffled hearing, an outbreak of cold sores, nausea, dizziness, lack of coordination, fluid in the middle ear, or ringing in the ears. These typically resolve in a matter of days or weeks.

Other possible complications may require medical treatment. These may include meningitis (an infection of the membranes covering the brain), cerebrospinal fluid leaks, lung difficulties, and wound infections.

Complication rates

  • Infection 1%
  • Fluid leaks 2%
  • Non-bacterial meningitis 8%

These also are almost always short-term problems. Among the more serious risks are:

  • Hearing loss on the surgery side 1% or less
  • Nonfatal stroke or cranial bleed 1%
  • Facial paralysis/numbness 0.15%
  • Death 0.2%

Deaths have occurred due to brain seizures, cranial bleeding, heart attack, stroke, and pulmonary embolism. Facial numbness is almost always mild and almost always greatly improves or is gone within a few weeks. Permanent facial numbness in any part of the face occurs but is quite rare.

About five percent of MVD patients report sensations of tingling or crawling in the face, in the first few weeks.

Success rates

MVD surgery offers a high probability of complete pain relief (sometimes as much as 98 percent) with the best chance of any treatment that the pain won’t come back. It is important for patients, along with their doctors, to weight the potential risks vs. the potential benefits. MVD works best in classic TN1 and many TN2 cases; it is especially good to relieve those patients who have sharp, stabbing pain and definite trigger zones. The more the pain gravitates away from that, the lower the success rate.

Atypical or mixed cases are often helped, but the success rates are lower, 50 to 65 percent. What often happens is that the MVD helps the sharp, stabbing component of a person’s pain but not the more constant, burning, underlying pain. MVD is generally not recommended for neuropathic and deafferentation pains (these are caused by injured or disabled nerves, not blood-vessel compressions) and usually not helpful for facial pain related to multiple sclerosis. The exception is if a person with MS-related pain also happens to have a blood vessel compressing their trigeminal nerve. This sometimes can be seen up on an MRI.

As with the other procedures, pain can return after an MVD. When the pain does come back, it tends to come back soon after surgery. Learn more about pain recurrence after MVD.

Improvements in technique, anesthesia, and technology over the past 50 years have greatly-reduced serious risks. General health is now considered more important than chronological age. A healthy 70-year-old is probably a better MVD candidate than a 60-year-old with heart problems, for example. Besides those with heart problems, people who have breathing or lung problems and those with bleeding disorders are poorer risks.

Since the whole idea of an MVD is to find and correct a compressing blood vessel, it is important to have an accurate diagnosis before undergoing an MVD. Facial pains that are not TN and therefore are not being caused by a compressing blood vessel are not going to be helped by MVD. 


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