Chrono-anatomical precision in salvage therapy for recurrent trigeminal neuralgia: mechanistic insights and cost-utility analysis of percutaneous balloon compression

Objective To evaluate the efficacy, mechanisms, and cost-effectiveness of percutaneous balloon compression (PBC) for recurrent trigeminal neuralgia (TN) after failed microvascular decompression (MVD). Methods We retrospectively analyzed 56 patients with recurrent TN after MVD who underwent PBC between 2018 and 2023. Clinical outcomes (BNI pain scores, recurrence-free survival) were assessed using Kaplan–Meier analysis and Cox regression. Latent class analysis (LCA) identified patient subtypes based on clinical and biomarker data. A 10-year Markov model compared the cost-effectiveness of PBC versus Gamma Knife radiosurgery (GKRS). Results Immediate pain relief (BNI I–III) was achieved in 94.6%. Median pain-free survival was 3.21 years, with 1-, 2-, and 5-year recurrence-free survival rates of 82.1, 68.4, and 45.2%, respectively. Hypertension and V1 involvement predicted early recurrence. LCA revealed two subtypes: Cluster 1 (PBC-sensitive) showed better outcomes and was associated with normotension and V2/V3 involvement, while Cluster 2 (PBC-resistant) had higher IL-6 levels and fMRI abnormalities. PBC reduced lifetime costs by $18,450 and increased QALYs by 0.8, with an ICER of $12,300/QALY compared to GKRS. Conclusion PBC is a safe, effective, and cost-efficient salvage therapy for recurrent TN after MVD, with subtype-dependent neuromodulatory effects, supporting a precision-guided approach to treatment.