Gamma Knife Radiosurgery for Trigeminal Neuralgia—A Review observed (11 % rate of new permanent neurological deficits).43 Park et al.
explored the role of GKRS as a minimally invasive alternative in TN caused by VBE.2
In this study of 20 patients, only 30 % achieved BNI
score I pain control, while 75 % achieved BNI scores I–IIIb pain control. Sixty per cent had pain recurrence, while 10 % developed facial sensory dysfunction. Long-term pain control (BNI scores I–IIIb) rates were 53, 20, and 10 % at one, three, and five years, respectively. These results are not as good as those for patients without VBE but, due to the minimal rate of complications, GKRS should be considered as a reasonable option for these patients.
TN often recurs regardless of treatment approach. At least one-quarter of patients have pain recurrence after an initial MVD.4
We have observed
Thus, patients often require multimodality therapy and repeat procedures, even repeat GKRS. Park et al. evaluated the validity of a repeat GKRS strategy after previous failed GKRS treatment for TN in 119 patients.2
a recurrence rate of one-quarter to one-third in patients treated by glycerol rhizotomy44 by GKRS.21
and approximately 40 % in patients treated In this cohort, 54 % of patients had undergone previous surgical
procedures in addition to their first GKRS procedure. Following repeat GKRS, 32 % achieved complete pain relief (BNI score I) and 87 % achieved BNI scores I–IIIb pain control after a median latency of 1.5 months. Although 34 % of patients had pain recurrence, long-term pain control (BNI scores I–IIIb) was achieved in 88, 70, and 44 % of patients after one, three, and five years, respectively. Twenty-one per cent of patients developed new or worsened facial sensory dysfunction, a rate twice the
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4. Barker FG II, Jannetta PJ, Bissonette DJ, et al., The long-term outcome of microvascular decompression for trigeminal neuralgia, N Engl J Med, 1996;334:1077–83.
5. Hilton DA, Love S, Gradidge T, Coakham HB, Pathological findings associated with trigeminal neuralgia caused by vascular compression, Neurosurgery, 1994;35:299–303.
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12. Oh IH, Choi SK, Park BJ, et al., The treatment outcome of elderly patients with idiopathic trigeminal neuralgia: micro-vascular decompression versus gamma knife radiosurgery, J Korean Neurosurg Soc, 2008;44:199–204.
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original procedure. Patients who had good relief from the initial GKRS procedure and those with some degree of facial sensory dysfunction had improved outcomes after repeat GKRS. These results suggest that repeat GKRS is a useful treatment modality, but is associated with an increased risk of facial sensory dysfunction.
TN is a debilitating condition for its sufferers and its management is, at times, not straightforward. Many patients will fail medical management and request some sort of surgical intervention. The vascular compression theory is well accepted and MVD has proven the most efficacious and longest lasting of the surgical options, but it is the most invasive and involves the greatest intrinsic risks. When patients are willing to accept these risks and can tolerate surgery, we recommend MVD. Percutaneous procedures involve less risk than open posterior fossa surgery and they offer relief in a similar immediate fashion, but are less efficacious and can result in a meaningful degree of facial sensory dysfunction. We offer percutaneous glycerol rhizotomy to patients with severe pain, where the latency of GKRS is unacceptable. GKRS is a first-line treatment for TN in patients unwilling or unable to tolerate open procedures or when open procedures have no role (i.e. MVD for MS-related TN). It offers patients an opportunity for meaningful long-lasting pain relief with virtually none of the risks of open surgery and it can be repeated with similar effectiveness. Figure 2 depicts our typical treatment algorithm for TN. Low-risk pain relief and preservation of trigeminal sensation are both appropriate goals for the management of TN. n
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20. Kondziolka D, Lacomis D, Niranjan A, et al., Histological effects of trigeminal nerve radiosurgery in a primate model: implications for trigeminal neuralgia recovery, Neurosurgery, 2000;46:971–7.
21. Kondziolka D, Zorro O, Lobato-Polo J, et al., Gamma knife stereotactic radiosurgery for idiopathic trigeminal neuralgia, J Neurosurg, 2010;112:758–65.
22. Rogers CL, Shetter AG, Fiedler JA, et al., Gamma Knife radiosurgery for trigeminal neuralgia: the initial experience of the Barrow Neurological Institute, Int J Radiat Oncol Biol Phys, 2000;47:1013–9.
23. Pollock BE, Phuong LK, Gorman DA, et al., Stereotactic radiosurgery for idiopathic trigeminal neuralgia, J Neurosurg, 2002;97:347–53.
24. Sheehan J, Pan H, Stroila M, Steiner L, Gamma knife surgery for trigeminal neuralgia: outcomes and prognostic factors, J Neurosurg, 2005;102;434–41.
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27. Flickinger JC, Pollock BE, Kondziolka D, 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;51:449–54.
28. Massager N, Lorenzoni J, Devriendt D, et al., Gamma Knife surgery for idiopathic trigeminal neuralgia using a far-anterior cisternal target and a high dose of radiation, J Neurosurg, 2004;100:597–605.
29. Régis J, Metellus P, Hayashi M, et al., Prospective controlled trial of Gamma Knife surgery for essential trigeminal neuralgia, J Neurosurg, 2006;104:913–24.
30. Matsuda S, Serizawa T, Nagano O, Ono J, Comparison of the results of 2 targeting methods in Gamma Knife surgery for trigeminal neuralgia, J Neurosurg, 2008;109(Suppl.):185–9.
31. Brisman R, Microvascular decompression vs. Gamma Knife for typical trigeminal neuralgia: preliminary findings, Stereotact Funct Neurosurg, 2007;85:94–8.
32. Linskey ME, Ratanatharathorn V, Penagarciano J, A prospective cohort study of microvascular decompression and Gamma Knife surgery in patients with trigeminal neuralgia, J Neurosurg, 2008;109(Suppl.):160–72.
33. Pollock BE, Schoeberl KA, Prospective comparison of posterior fossa exploration and stereotactic radiosurgery dorsal root entry zone target as a primary surgery for patients with idiopathic trigeminal neuralgia, Neurosurgery, 2010;67:633–9.
34. Tronnier VM, Rasche D, Hamer J, et al., Treatment of idiopathic trigeminal neuralgia: comparison of long-term outcomes after radiofrequency rhizotomy and microvascular decompression, Neurosurgery, 2001;48:1261–7; discussion 1267–8.
35. Tatli M, Satici O, Kanpolat Y, Sindou M, Various surgical modalities for trigeminal neuralgia: literature study of respective long-term outcomes, Acta Neurochir (Wien), 2008;150:243–55.
36. Henson CF, Goldman HW, Rosenwasser RH, et al., Glycerol rhizotomy versus gamma knife radiosurgery for the treatment of trigeminal neuralgia: an analysis of patients treated at one institution, Int J Radiat Oncol Biol Phys, 2005;63:82–90.
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