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Recently, neurosurgeons have increasingly adopted smaller approaches; however, the available evidence has not yet been systematically compiled. This is the first systematic review and meta-analysis on the efficacy and safety of \u2264\u20092-cm-keyhole retrosigmoid MVD. PubMed and Embase databases were searched for studies involving adults with trigeminal neuralgia (TN), hemifacial spasm (HFS), or glossopharyngeal neuralgia (GPN), who underwent first-time retrosigmoid keyhole MVD (diameter\u2009\u2264\u20092\u00a0cm). Primary outcomes were symptom relief and complications. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS). Pooled estimates were calculated using a random-effects single-arm meta-analysis. 32 publications met the inclusion criteria. 93.7% had a retrospective design. The mean MINORS score was 9.9\u2009\u00b1\u20091.4 out of 16. Among 5,883 patients, 37.7% had TN, 61.6% HFS, and 0.7% GPN. The complete symptom resolution rate was 89.8% (95% CI [0.855\u20130.930]) for TN, 91.1% (95% CI [0.871\u20130.940]) for HFS and 88.7% (95% CI [0.746\u20130.954]) for GPN. The overall complication rate was 13.9% (95% CI, 0.107\u20130.180), with a permanent neurological deficit rate of 4.7% (95% CI, 0.030\u20130.074), all involving cranial nerves (CN). In patients with TN, the most frequent permanent neurological deficit was a sensory CN V deficit, occurring in 2.6% (95% CI, 0.013\u20130.050), followed by a CN VIII deficit in 1.9% (95% CI, 0.011\u20130.035). Among HFS patients, the most frequent permanent deficits were CN VIII in 5.0% (95% CI, 0.026\u20130.094) and CN VII in 2.1% (95% CI, 0.008\u20130.050). None of the studies described cases requiring conversion from a keyhole approach to a standard craniotomy. The keyhole retrosigmoid approach for MVD appears to be safe and effective. Comparative studies are needed to evaluate potential advantages of a keyhole approach over a standard craniotomy.<\/jats:p>","DOI":"10.1007\/s10143-026-04178-0","type":"journal-article","created":{"date-parts":[[2026,2,17]],"date-time":"2026-02-17T00:50:20Z","timestamp":1771289420000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Keyhole retrosigmoid approach for microvascular decompression surgery: Systematic review and single-arm meta-analysis"],"prefix":"10.1007","volume":"49","author":[{"ORCID":"https:\/\/orcid.org\/0009-0002-2799-6875","authenticated-orcid":false,"given":"Valentin F.","family":"Weiger","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2755-9501","authenticated-orcid":false,"given":"Florian S.","family":"Halbeisen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6736-7195","authenticated-orcid":false,"given":"Felipe","family":"Constanzo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0932-0193","authenticated-orcid":false,"given":"Michel","family":"Roethlisberger","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1900-9286","authenticated-orcid":false,"given":"Jehuda","family":"Soleman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1971-5095","authenticated-orcid":false,"given":"Luigi","family":"Mariani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9620-0581","authenticated-orcid":false,"given":"Raphael","family":"Guzman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1121-6996","authenticated-orcid":false,"given":"Jonathan","family":"Rychen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,2,17]]},"reference":[{"key":"4178_CR1","doi-asserted-by":"publisher","first-page":"995","DOI":"10.1097\/MAO.0b013e318184601a","volume":"29","author":"GJ Artz","year":"2008","unstructured":"Artz GJ, Hux FJ, Larouere MJ, Bojrab DI, Babu S, Pieper DR (2008) Endoscopic vascular decompression. 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