Elsevier

World Neurosurgery

Volume 90, June 2016, Pages 604-612.e11
World Neurosurgery

Original Article
Stereotactic Radiosurgery Treatment of Trigeminal Neuralgia: Clinical Outcomes and Prognostic Factors

https://doi.org/10.1016/j.wneu.2016.02.067Get rights and content

Background

Stereotactic radiosurgery (SRS) is a minimally invasive surgical option for the treatment of trigeminal neuralgia (TN). Here we review our institutional experience to identify prognostic factors associated with pain relief after SRS.

Methods

263 patients with TN treated at the University of California, San Diego/San Diego Gamma Knife (2001–2013) were followed for more than 6 months. Univariate and multivariate Cox proportional hazard models analysis of factors associated with outcome was performed.

Results

Of the 263 patients, 229 (87%) presented with classical idiopathic TN, 31 (12%) presented with atypical TN, and 4 (1%) presented with secondary TN. 143 (54%) had undergone prior treatment. Most patients were treated with 85 (52%) or 90 Gy (42%). 79% of the SRS treated patients experienced a favorable response (defined as Barrow Neurological Institute Pain Scale <3 pain relief), with a median time to relief of 2.5 months. In a multivariate analysis, diagnosis of classical TN, previous percutaneous procedures, and age older than 70 years were associated with favorable responses; classical TN was associated with sustained pain relief. Dose prescription >85 Gy and prior SRS were associated with bothersome facial numbness posttreatment. For patients presenting with classical TN, diagnosis of multiple sclerosis (MS) did not decrease the likelihood of pain relief after SRS.

Conclusions

Excellent TN pain relief was achieved with the delivery of 85 Gy in a single-shot, 4-mm isocenter SRS targeting the dorsal root entry zone. Patients with classical TN, with age older than 70 years, or who underwent previous percutaneous procedures were more likely to benefit from SRS. SRS is efficacious in patients with classical TN despite concurrent diagnosis of MS.

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.

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    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.

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