Traditional wisdom teaches that “good surgeons know how to operate, better ones when to operate, and the best when not to operate”.¹ When treating patients with chronic facial pain, prudent application of this aphorism draws not only from experience but also from rigorous scientific investigation. Lang et al (pages1506–9 of this issue) have strengthened the base of scientific evidence that informs the clinical decision not to recommend microvascular decompression for persistent idiopathic facial pain (PIFP).

Suboccipital microvascular decompression of the trigeminal nerve root is well established for the treatment of …