Historical evolution of microvascular decompression after Jannetta's establishment: Anatomical maps and physiological compasses-a narrative review.

PURPOSE: Building on the pioneering observations of Dandy and Gardner and on Jannetta's establishment of microvascular decompression (MVD) through microsurgical demonstration of vascular compression, MVD has continuously evolved into a safe and durable treatment for neurovascular compression syndromes. Despite advances in radiosurgery and pharmacotherapy, MVD remains widely used as a first-line surgical option for appropriately selected patients with trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia.

METHODS: This selective narrative historical review traces MVD's modern evolution after its establishment by Jannetta, organized into four pillars: surgical anatomy, optimization of approaches, decompression strategies, and operative support.

RESULTS: Detailed microsurgical anatomy, including the "Rule of Three" framework for the cerebellopontine angle, has helped guide tailored, minimally invasive approaches (e.g., the lateral supracerebellar-infratentorial route for trigeminal neuralgia and infrafloccular exposure for hemifacial spasm). Decompression strategies have extended from prosthetic interposition toward noncompressive transposition and biologically harmonious fixation. Advances in visualization (endoscopic and exoscopic systems), simulation, and neuronavigation have extended the original visualization ethos and enhanced surgical education. Intraoperative monitoring, including brainstem auditory evoked potentials and lateral spread responses, has improved both complication avoidance and intraoperative confidence.

CONCLUSION: Together, these anatomical "maps" and physiological "compasses" help define contemporary MVD practice aimed at safe and durable outcomes across diverse patient anatomies.