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Vestibular neurectomy can be an effective operation for the control of persistent dizziness refractory to medical treatment or even endolymphatic sac surgery. Past studies have reported favorable results, creating an almost deceptive impression of the proceduretextquoterights success rate. However, not all patients will respond favorably. Some will continue to have significant postoperative disequilibrium and, worse yet, persistent vertigo. To analyze the reasons for continued problems, 142 patients undergoing various surgical approaches employed to divide the vestibular nerve (retrolabyrinthine, middle fossa, retrosigmoid and translabyrinthine) were retrospectively, reviewed. Twenty-nine patients (20%) continued to have significant dizziness despite vestibular neurectomy. The reasons for failure were incomplete vestibular nerve section, poor central nervous system compensation, new vestibular disease in the opposite ear, obstructive anatomy, the presence of other central nervous system diseases, and unknown causes. This paper will detail the advantages and disadvantages of various vestibular neurectomy approaches and will present recommendations for further treatment of this difficult-to-manage group of patients.