Transposition vs Interposition in Microvascular Decompression for Trigeminal Neuralgia

As featured in the Facial Pain Association’s Spring Quarterly

Dr. Raymond Sekula, National Chairman for the Medical Advisory Board for the Facial Pain Association’s (FPA), has completed over 2,000 trigeminal neuralgia surgeries.  The FPA’s mission is to serve as the “largest patient organization supporting all people affected by neuropathic facial pain, leading the world in resources for information and healthcare guidance.”

In the FPA’s recent quarterly report, Dr. Sekula and his Research Fellow, Colby Joncas review some of the latest microvascular decompression (MVD) techniques to treat trigeminal neuralgia in the context of this large quantity of cases to determine what new learnings can be used to shape each patient’s approach to care and best practices to minimize recurrent pain.

Dr. Sekula explains, “In microvascular decompression (MVD) for trigeminal neuralgia, two primary surgical techniques are used: interposition, where a material—often polytetrafluoroethylene (PTFE)—is placed between the trigeminal nerve and the offending vessel, and transposition, where the vessel is relocated to relieve nerve contact. Currently, there is no definitive evidence favoring one technique over the other.”
He continues, “Some recent concerns have focused on PTFE granulomas contributing to trigeminal neuralgia recurrence following MVD. However, most MVD failures stem from suboptimal preoperative evaluation. MVD is most effective in patients presenting with brief, electric shock-like pain and MRI-confirmed neurovascular compression. In our practice, we reserve interpositional MVD for fewer than 10% of cases and typically perform transposition using resorbable glue instead of PTFE. This approach aims to minimize the risk of recurrent neurovascular compression, reduce scarring in the event of reoperation, and improve long-term outcomes.” 

Read more in the FPA’s Spring 2025 Quarterly Journal, where Dr. Sekula and Colby Joncas explore the pros and cons of transposition versus interposition in MVD for trigeminal neuralgia.

Key takeaways from this article:

• The concept that PTFE or Teflon^TM granulomas are the cause of recurrent trigeminal neuralgia in a large number of patients is untrue.
• There is no evidence that either transposition or interposition MVD is better than the other.
• Microvascular decompression is a surgery that should be tailored to the individual – every patient has unique anatomy – there is no one size fits all approach.