Original ArticleStereotactic Radiosurgery Treatment of Trigeminal Neuralgia: Clinical Outcomes and Prognostic Factors
Introduction
Trigeminal neuralgia (TN) is characterized by paroxysmal lancinating pain that is confined to the territories of trigeminal innervation and magnified by cutaneous perturbations.1 Patients with this prototypical presentation carry the diagnosis of classical TN. The term atypical TN has been used to describe facial pain presentation which does not fit this clinical pattern, such as burning pain or pain in a nonanatomic distribution.2 Medical therapy is the first line of treatment for both classical and atypical TN. However, many patients develop resistance to therapy or cannot tolerate the side effects of treatment. For these patients, surgical interventions are frequently performed, including microvascular decompression (MVD), percutaneous procedures, such as glycerol rhizotomy, radiofrequency rhizotomy, or balloon microcompression, and stereotactic radiosurgery (SRS).3 Of these procedures, SRS remains the least invasive procedure and achieves excellent pain relief in selected patients.4 As such, there has been a notable increase in SRS as a treatment for TN over the last 2 decades.5
There is variability in the clinical practice and selection of patients pertaining to SRS as treatment for TN. For instance, the efficacy of SRS in TN patients with multiple sclerosis (MS)6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 or in patients who underwent prior SRS treatment12, 14, 19, 20, 23, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51 remains controversial. Here, we reviewed our 10 years of institutional experience with patients treated at the University of California, San Diego/San Diego Gamma Knife Center. Our results suggest that SRS is efficacious in patients afflicted with classical TN despite concurrent diagnosis of MS or history of prior SRS.
Section snippets
Patient Population and Follow-Up
We performed an institutional board review–approved review of consecutive patients undergoing Gamma Knife for TN at the center who were 1) treated with Gamma Knife SRS at the University of California, San Diego/San Diego Gamma Knife Center between 2001 and 2013 (IRB121691X) and 2) followed for more than 6 months through questionnaire surveys. Patients with a diagnosis of atypical TN and MS or who underwent previous procedures/SRS were included in this series. The demographic of the patient
Patient Population, Follow-Up, and SRS Dosimetry
Patient demographics and presentation are shown in Table 1. The median age of the cohort was 69 years (range, 27–91 years). There were 83 men and 180 women. There was no predominance of right- or left-sided TN. The pattern of pain distribution (V1, V2, or V3) was consistent with the published literature.52 Most patients (n = 229) presented with classical TN; however, 31 (12%) patients presented with atypical TN. All except for 18 patients presented with idiopathic TN. Four of these patients
Discussion
Our clinical experience over the last decade supports SRS as a minimally invasive and efficacious treatment option for patients suffering from TN. Our results are largely comparable with other series that examined the efficacy of SRS as treatment for TN.4, 42, 53, 54, 55 Of the patients with more than 6-month follow-up, 79% of the patients experienced favorable response (BNI score < 3 pain relief). The median time to pain relief was approximately 2.5 months. The relief was durable for more than
Conclusions
Patients with the diagnosis of classical TN, with age older than 70 years, or who underwent previous percutaneously procedures are more likely to derive therapeutic benefit from SRS. For patients who presented with classical TN, concurrent diagnosis of MS did not decrease the likelihood of pain relief after SRS.
References (101)
- et al.
Trigeminal neuralgia pain relief after gamma knife stereotactic radiosurgery
Clin Neurol Neurosurg
(2014) - et al.
Repeat gamma knife radiosurgery for refractory or recurrent trigeminal neuralgia: treatment outcomes and quality-of-life assessment
Int J Radiat Oncol Biol Phys
(2004) - et al.
Repeat radiosurgery for idiopathic trigeminal neuralgia
Int J Radiat Oncol Biol Phys
(2005) - et al.
Where to locate the isocenter? The treatment strategy for repeat trigeminal neuralgia radiosurgery
Int J Radiat Oncol Biol Phys
(2005) - et al.
Salvage gamma knife stereotactic radiosurgery for surgically refractory trigeminal neuralgia
Int J Radiat Oncol Biol Phys
(2009) - et al.
Repeat gamma knife radiosurgery for trigeminal neuralgia
Int J Radiat Oncol Biol Phys
(2011) - et al.
Repeat Gamma-Knife radiosurgery for refractory or recurrent trigeminal neuralgia with consideration about the optimal second dose
World Neurosurg
(2016) - et al.
Trigeminal neuralgia: what are the important factors for good operative outcomes with microvascular decompression
Surg Neurol
(2004) - et al.
Surgical risk factors, morbidity, and mortality in elderly patients
J Am Coll Surg
(2006) - et al.
Does increased nerve length within the treatment volume improve trigeminal neuralgia radiosurgery? A prospective double-blind, randomized study
Int J Radiat Oncol Biol Phys
(2001)
Multimodality treatment of trigeminal neuralgia: impact of radiosurgery and high resolution magnetic resonance imaging
J Clin Neurosci
Linear accelerator-based flattening-filter-free stereotactic radiosurgery for trigeminal neuralgia: feasibility and patient-reported outcomes
Pract Radiat Oncol
Dedicated linear accelerator radiosurgery for trigeminal neuralgia: a single-Center experience in 179 patients with varied dose prescriptions and treatment plans
Int J Radiat Oncol Biol Phys
Gamma knife radiosurgery for idiopathic trigeminal neuralgia as primary vs. secondary treatment option
Clin Neurol Neurosurg
Outcomes after microvascular decompression for patients with trigeminal neuralgia and suspected multiple sclerosis
World Neurosurg
Gamma knife radiosurgery for trigeminal neuralgia: the initial experience of the Barrow Neurological Institute
Int J Radiat Oncol Biol Phys
Predictive nomogram for the durability of pain relief from gamma knife radiation surgery in the treatment of trigeminal neuralgia
Int J Radiat Oncol Biol Phys
Trigeminal neuralgia: an anatomically oriented review
Clin Anat
Atypical trigeminal neuralgia
JAMA
Treatment options in trigeminal neuralgia
Ther Adv Neurol Disord
Predictive variables for the successful treatment of trigeminal neuralgia with gamma knife radiosurgery
Neurosurgery
Editorial: Fifteen years of Gamma Knife surgery for trigeminal neuralgia in the Journal of Neurosurgery: history of a revolution in functional neurosurgery
J Neurosurg
Gamma knife radiosurgery for trigeminal neuralgia: results and expectations
Arch Neurol
Gamma knife radiosurgery for primary management for trigeminal neuralgia
J Neurosurg
Gamma knife radiosurgery for trigeminal neuralgia: dose-volume histograms of the brainstem and trigeminal nerve
J Neurosurg
Role of enhanced MRI in the follow-up of patients with medically refractory trigeminal neuralgia undergoing stereotactic radiosurgery using the gamma knife: initial experience
J Comput Assist Tomogr
Gamma knife radiosurgery for recurrent trigeminal neuralgia
J Neurosurg
Gamma knife radiosurgery for treatment of trigeminal neuralgia in multiple sclerosis patients
Stereotact Funct Neurosurg
Treatment of trigeminal neuralgia with linear accelerator radiosurgery: initial results
J Neurosurg
Gamma knife surgery for trigeminal neuralgia: improved initial response with two isocenters and increasing dose
J Neurosurg
Gamma knife surgery for trigeminal neuralgia: outcomes and prognostic factors
J Neurosurg
Gamma knife radiosurgery for trigeminal neuralgia
Neurosurgery
Prospective controlled trial of gamma knife surgery for essential trigeminal neuralgia
J Neurosurg
Doses greater than 85 Gy and two isocenters in Gamma Knife surgery for trigeminal neuralgia: updated results
J Neurosurg
Gamma knife radiosurgery for multiple sclerosis–related trigeminal neuralgia
Neurology
Gamma Knife surgery for trigeminal neuralgia: a review of 450 consecutive cases
J Neurosurg
Stereotactic radiosurgery for trigeminal neuralgia: outcomes and complications
Br J Neurosurg
Comparative study of Gamma Knife surgery and percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia in patients with multiple sclerosis
J Neurosurg
Surgical outcomes of trigeminal neuralgia in patients with multiple sclerosis
Neurosurgery
Multiple sclerosis-related trigeminal neuralgia: a prospective series of 43 patients treated with gamma knife surgery with more than one year of follow-up
Stereotact Funct Neurosurg
Gamma Knife rhizotomy-induced histopathology in multiple sclerosis-related trigeminal neuralgia
J Neurosurg
Results of repeated gamma knife radiosurgery for medically unresponsive trigeminal neuralgia
J Neurosurg
Repeat radiosurgery for refractory trigeminal neuralgia
Neurosurgery
Stereotactic radiosurgery for primary trigeminal neuralgia using the Leksell Gamma unit
Stereotact Funct Neurosurg
Gamma knife radiosurgery for recurrent trigeminal neuralgia
J Neurosurg
Repeat gamma knife radiosurgery for trigeminal neuralgia
Stereotact Funct Neurosurg
Treatment of essential trigeminal neuralgia with gamma knife surgery
J Neurosurg
Repeat gamma knife radiosurgery for recurrent or refractory trigeminal neuralgia
Neurol India
Recurrent trigeminal neuralgia: long term outcome of repeat gamma knife radiosurgery
J Neurol Neurosurg Psychiatry
Long-term pain response and quality of life in patients with typical trigeminal neuralgia treated with gamma knife stereotactic radiosurgery
Neurosurgery
Cited by (0)
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
John Alksne and Clark C. Chen contributed equally as senior author.
Supplementary digital content available online.