Prospective controlled trial of gamma knife surgery for essential trigeminal neuralgia

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Object

Stereotactic radiosurgery is an alternative to conventional surgery for the treatment of trigeminal neuralgia. The authors conducted a prospective evaluation of the safety and efficacy of this method in a large series of patients.

Methods

A total of 100 patients presenting with trigeminal neuralgia were treated and followed up for a minimum of 12 months. The mean age was 68.2 years; 54 patients were male, and 46 were female. Seven had a history of multiple sclerosis, and 42 had already received conventional surgical treatment for trigeminal neuralgia. The intervention consisted of gamma knife surgery to the retrogasserian cisternal portion of the fifth cranial nerve. The median dose used at the maximum was 85 Gy (range 70–90 Gy). The number and intensity of pain attacks were recorded by the patient from 3 months before radiosurgery to a minimum of 12 months after treatment. Before and a minimum of 12 months after treatment, the patient completed a quality-of-life questionnaire. Neurological examination and quantitative sensory testing to evaluate sensory perception were performed by an independent neurologist over this same time period.

At the last visit 83 of 100 patients were reported to be pain free. Fifty-eight of these 83 patients had stopped taking medication during the study. All quality-of-life parameters were improved (p < 0.001). Six patients reported facial paresthesia, and four patients reported hypesthesia. These symptoms were classified as mild. None of the complications reported for other techniques were observed.

Conclusions

Radiosurgery is a safe and effective alternative treatment for trigeminal neuralgia and is associated with a particularly low rate of hypesthesia.

Abbreviations used in this paper:CT = computerized tomography; GKS = gamma knife surgery; MR = magnetic resonance; MVD = microvascular decompression; VAS = visual analog scale.

Article Information

Address reprint requests to: Jean Régis, M.D., Service de Neuro-chirurgie Fonctionnelle et Stéréotaxique, 264 Blvd St Pierre, 13385 Marseille Cedex 05, France. email: jregis@ap-hm.fr.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Axial high-resolution stereotactic MR image (acquired on a 1.5-tesla MR imaging unit [Siemens Medical Solutions, Erlangen, Germany] by using a constructive interference in steady state sequence) fused with osseous window of a high-resolution CT scan showing the positioning of a single 4-mm isocenter on the anterior portion of the trigeminal nerve approximately 7.5 mm from the emergence at the brainstem. A very low dose was delivered to the part of the brainstem corresponding to the trigeminal pathway.

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    Graphs depicting cumulative proportions of patients with trigeminal neuralgia who were pain free in relation to days from GKS (upper) and months from pain cessation (lower). Censored values represent patients with pain cessation who are at increased risk of pain recurrence.

  • View in gallery

    Graphs depicting the mean number and mean intensity of pain attacks before GKS and at last follow up after GKS in patients with trigeminal neuralgia. V = visit.

  • View in gallery

    Graph depicting three quality-of-life composite scores for 65 patients with trigeminal neuralgia who completed the Epilepsy Surgery Inventory–55 before GKS and at follow up after GKS.

  • View in gallery

    Graphs depicting objective evaluation of sensory perception by quantitative sensory testing before GKS and at a minimum of 12 months after GKS. The thresholds for temperature warm, temperature cold, pain warm, and pain cold were evaluated in the territory of the pain (affected), the neighboring territory (neighbor), the contralateral territory symmetrical to the affected territory (mirror), and the contralateral territory(ies) neighboring the “mirror” territory (contralateral). Statistically significant differences are indicated with an asterisk.

References

  • 1

    Barker FG IIJannetta PJBabu RPPomonis SBissonette DJDong Jho H: Long-term outcome after operation for trigeminal neuralgia in patients with posterior fossa tumors. J Neurosurg 84:8188251996

  • 2

    Barker FG IIJannetta PJBissonette DJJho HD: Trigeminal numbness and tic relief after microvascular decompression for typical trigeminal neuralgia. Neurosurgery 40:39451997

  • 3

    Barker FG IIJannetta PJBissonette DJLarkins MVJho HD: The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med 334:107710831996

  • 4

    Brisman R: Gamma knife radiosurgery for primary management for trigeminal neuralgia. . J Neurosurg 93:(Suppl 3)1591612000

  • 5

    Brisman RKhandji AGMooij RB: Trigeminal nerve-blood vessel relationship as revealed by high-resolution magnetic resonance imaging and its effect on pain relief after gamma knife radio-surgery for trigeminal neuralgia. Neurosurgery 50:126112672002

  • 6

    Broggi GFerroli PFranzini AServello DDones I: Microvascular decompression for trigeminal neuralgia: comments on a series of 250 cases, including 10 patients with multiple sclerosis. J Neurol Neurosurg Psychiatry 68:59642000

  • 7

    Brown JAMcDaniel MDWeaver MT: Percutaneous trigeminal nerve compression for treatment of trigeminal neuralgia: results in 50 patients. Neurosurgery 32:5705731993

  • 8

    Chang JWChang JHPark YGChung SS: Gamma knife radio-surgery for idiopathic and secondary trigeminal neuralgia. J Neurosurg 93:Suppl 31471512000

  • 9

    De Ridder DMoller AVerlooy JCornelissen MDe Ridder L: Is the root entry/exit zone important in microvascular compression syndromes?. Neurosurgery 51:4274342002

  • 10

    Flickinger JCPollock BEKondziolka DPhuong LKFoote RLStafford SL: Does increased nerve length within the treatment volume improve trigeminal neuralgia radiosurgery? A prospective double-blind, randomized study. Int J Radiat Oncol Biol Phys 51:4494542001

  • 11

    Frighetto LDe Salles AASmith ZAGoss BSelch MSolberg T: Noninvasive linear accelerator radiosurgery as the primary treatment for trigeminal neuralgia. Neurology 62:6606622004

  • 12

    Goss BWFrighetto LDeSalles AASmith ZSolberg TSelch M: Linear accelerator radiosurgery using 90 gray for essential trigeminal neuralgia: results and dose volume histogram analysis. Neurosurgery 53:8238302003

  • 13

    Han PPShetter AGSmith KAFiedler JARogers CLSpeiser B: Gamma knife radiosurgery for trigeminal neuralgia: experience at the Barrow Neurological Institute. Stereotact Funct Neurosurg 73:1311331999

  • 14

    Headache Classification Subcommittee of the International Headache Society: The international classification and diagnostic criteria for headache disorders, cranial neuralgia and facial pain, ed 2. Cephalalgia 24:Suppl 191602004

  • 15

    Huang ETeh BSZeck OWoo SYLu HHChiu JK: Gamma knife radiosurgery for treatment of trigeminal neuralgia in multiple sclerosis patients. Stereotact Funct Neurosurg 79:44502002

  • 16

    Jawahar AKondziolka DKanal EBissonette DJLunsford LD: Imaging the trigeminal nerve and pons before and after surgical intervention for trigeminal neuralgia. Neurosurgery 48:1011072001

  • 17

    Kannan VDeopujari CEMisra BKShetty PGShroff MMPendse AM: Gamma-knife radiosurgery for trigeminal neuralgia. Australas Radiol 43:3393411999

  • 18

    Kanner AANeyman GSuh JHWeinhous MSLee SYBarnett GH: Gamma knife radiosurgery for trigeminal neuralgia: comparing the use of a 4-mm versus concentric 4– and 8-mm collimators. Stereotact Funct Neurosurg 82:49572004

  • 19

    Kanpolat YSavas ABekar ABerk C: Percutaneous controlled radiofrequency trigeminal rhizotomy for the treatment of idiopathic trigeminal neuralgia: 25-year experience with 1,600 patients. Neurosurgery 48:5245342001

  • 20

    Kondziolka DFlickinger JCLunsford LDHabeck M: Trigeminal neuralgia radiosurgery: the University of Pittsburgh experience. Stereotact Funct Neurosurg 66:Suppl 13433481996

  • 21

    Kondziolka DLunsford LDFlickinger JC: Gamma knife radio-surgery as the first surgery for trigeminal neuralgia. Stereotact Funct Neurosurg 70:Suppl 11871911998

  • 22

    Kondziolka DLunsford LDFlickinger JC: Stereotactic radio-surgery for the treatment of trigeminal neuralgia. Clin J Pain 18:42472002

  • 23

    Kondziolka DLunsford LDFlickinger JCYoung RFVermeulen SDuma CM: Stereotactic radiosurgery for trigeminal neuralgia: a multiinstitutional study using the gamma unit. J Neurosurg 84:9409451996

  • 24

    Kondziolka DLunsford LDHabeck MFlickinger JC: Gamma knife radiosurgery for trigeminal neuralgia. Neurosurg Clin N Am 8:79851997

  • 25

    Kondziolka DPerez BFlickinger JCHabeck MLunsford LD: Gamma knife radiosurgery for trigeminal neuralgia: results and expectations. Arch Neurol 55:152415291998

  • 26

    Kondziolka DPerez BFlickinger JCLunsford LDGamma knife radiosurgery for trigeminal neuralgia. Lunsford LDKondziolka DFlickinger JC: Progress in Neurological Surgery: Gamma Knife Brain Surgery BaselKarger14:2122211998

  • 27

    Latchaw JP JrHardy RW JrForsythe SBCook AF: Trigeminal neuralgia treated by radiofrequency coagulation. J Neurosurg 59:4794841983

  • 28

    Leksell L: Stereotaxic radiosurgery in trigeminal neuralgia. Acta Chir Scand 137:3113141971

  • 29

    Leksell L: Stereotaxis and radiosurgery. An Operative System Springfield, ILCharles C Thomas1971

  • 30

    Lindquist CKihlstrom LHellstrand E: Functional neurosurgery—a future for the gamma knife?. Stereotact Funct Neurosurg 57:72811991

  • 31

    Lopez BCHamlyn PJZakrzewska JM: Stereotactic radiosurgery for primary trigeminal neuralgia: state of the evidence and recommendations for future reports. J Neurol Neurosurg Psychiatry 75:101910242004

  • 32

    Lopez BCHamlyn PJZakrzewska JM: Systematic review of ablative neurosurgical techniques for the treatment of trigeminal neuralgia. Neurosurgery 54:9739832004

  • 33

    Love SCoakham HB: Trigeminal neuralgia: pathology and pathogenesis. Brain 124:234723602001

  • 34

    Lunsford LDYoung RF: Radiosurgery for trigeminal neuralgia. Surg Neurol 54:2852872000

  • 35

    Maesawa SSalame CFlickinger JCPirris SKondziolka DLunsford LD: Clinical outcomes after stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg 94:14202001

  • 36

    Maher COPollock BE: Radiation induced vascular injury after stereotactic radiosurgery for trigeminal neuralgia: case report. Surg Neurol 54:1891932000

  • 37

    Massager NLorenzoni JDevriendt DDesmedt FBrotchi JLevivier M: Gamma knife surgery for idiopathic trigeminal neuralgia performed using a far-anterior cisternal target and a high dose of radiation. J Neurosurg 100:5976052004

  • 38

    Matsuda SSerizawa TSato MOno J: Gamma knife radiosurgery for trigeminal neuralgia: the dry-eye complication. J Neurosurg 97:5 Suppl5255282002

  • 39

    McLaughlin MRJannetta PJClyde BLSubach BRComey CHResnick DK: Microvascular decompression of cranial nerves: lessons learned after 4400 operations. J Neurosurg 90:181999

  • 40

    Mehta VMeier RGilrein JVermeulen SYoung R: Gamma knife radiosurgery for treatment of trigeminal neuralgia. Int J Radiat Oncol Biol Phys 57:2 SupplS1362003

  • 41

    Merrison AFFuller G: Treatment options for trigeminal neuralgia. BMJ 327:136013612003

  • 42

    Nicol BRegine WFCourtney CMeigooni ASanders MYoung B: Gamma knife radiosurgery using 90 Gy for trigeminal neuralgia. J Neurosurg 93:(Suppl 3)1521542000

  • 43

    North RBKidd DHPiantadosi SCarson BS: Percutaneous ret-rogasserian glycerol rhizotomy. Predictors of success and failure in treatment of trigeminal neuralgia. J Neurosurg 72:8518561990

  • 44

    Nurmikko T: Clinical features and pathophysiologic mechanisms of postherpetic neuralgia. Neurology 45:12 Suppl 8S54S551995

  • 45

    Oturai ABJensen KEriksen JMadsen F: Neurosurgery for trigeminal neuralgia: comparison of alcohol block, neurectomy, and radiofrequency coagulation. Clin J Pain 12:3113151996

  • 46

    Petit JHHerman JMNagda SDiBiase SJChin LS: Radiosurgical treatment of trigeminal neuralgia: evaluating quality of life and treatment outcomes. Int J Radiat Oncol Biol Phys 56:114711532003

  • 47

    Pollock BEPhuong LKFoote RLStafford SLGorman DA: High-dose trigeminal neuralgia radiosurgery associated with increased risk of trigeminal nerve dysfunction. Neurosurgery 49:58642001

  • 48

    Pollock BEPhuong LKGorman DAFoote RLStafford SL: Stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg 97:3473532002

  • 49

    Rand RW: Leksell Gamma Knife treatment of tic douloureux. Neurosurg Clin N Am 8:75781997

  • 50

    Rand RWJacques DBMelbye RWCopcutt BGLevenick MNFisher MR: Leksell Gamma Knife treatment of tic douloureux. Stereotact Funct Neurosurg 61:Suppl 111881993

  • 51

    Régis JBartolomei FMetellus PRey MGenton PDravet C: Radiosurgery for trigeminal neuralgia and epilepsy. Neurosurg Clin N Am 10:3593771999

  • 52

    Régis JManera LDufour HPorcheron DSedan RPeragut JC: Effect of the Gamma Knife on trigeminal neuralgia. Stereotact Funct Neurosurg 64:Suppl 11821921995

  • 53

    Rogers CLShetter AGFiedler JASmith KAHan PPSpeiser BL: Gamma knife radiosurgery for trigeminal neuralgia: the initial experience of The Barrow Neurological Institute. Int J Radiat Oncol Biol Phys 47:101310192000

  • 54

    Rogers CLShetter AGPonce FAFiedler JASmith KASpeiser BL: Gamma knife radiosurgery for trigeminal neuralgia associated with multiple sclerosis. J Neurosurg 97:5 Suppl5295322002

  • 55

    Romanelli PHeit GChang SDMartin DPham CAdler J: Cyberknife radiosurgery for trigeminal neuralgia. Stereotact Funct Neurosurg 81:1051092003

  • 56

    Shetter AGRogers CLPonce FFiedler JASmith KSpeiser BL: Gamma knife radiosurgery for recurrent trigeminal neuralgia. J Neurosurg 97:5 Suppl5365382002

  • 57

    Siegfried J: 500 Percutaneous thermocoagulations of the Gasserian ganglion for trigeminal pain. Surg Neurol 8:1261311977

  • 58

    Sinay VJBonamico LHDubrovsky A: Subclinical sensory abnormalities in trigeminal neuralgia. Cephalalgia 23:5415442003

  • 59

    Sindou MKeravel YAbdennebi BSzapiro J: Traitement neuro-chirurgical de la névralgie trigéminale. Neurochirurgie 33:891111987

  • 60

    Slettebo HHirschberg HLindegaard KF: Long-term results after percutaneous retrogasserian glycerol rhizotomy in patients with trigeminal neuralgia. Acta Neurochir (Wien) 122:2312351993

  • 61

    Smith ZADe Salles AAFrighetto LGoss BLee SPSelch M: Dedicated linear accelerator radiosurgery for the treatment of trigeminal neuralgia. J Neurosurg 99:5115162003

  • 62

    Taarnhoj P: Decompression of the trigeminal root and the posterior part of the ganglion as treatment in trigeminal neuralgia; preliminary communication. J Neurosurg 9:2882901952

  • 63

    Urgosik DVymazal JVladyka VLiscak R: Gamma knife treatment of trigeminal neuralgia: clinical and electrophysiological study. Stereotact Funct Neurosurg 70:Suppl 12002091998

  • 64

    Verdugo ROchoa JL: Quantitative somatosensory thermotest. A key method for functional evaluation of small caliber afferent channels Brain 115:Pt 38939131992

  • 65

    Vickrey BGHays RDGraber JRausch REngel J JrBrook RH: A health-related quality of life instrument for patients evaluated for epilepsy surgery. Med Care 30:2993191992

  • 66

    Vickrey BGHays RDRausch REngel J JrVisscher BRAry CM: Outcome in 248 patients who had diagnostic evaluations for epilepsy surgery. Lancet 346:144514491995

  • 67

    Yarnitsky DKunin MBrik RSprecher E: Vibration reduces thermal pain in adjacent dermatomes. Pain 69:75771997

  • 68

    Young RF: Functional neurosurgery with the Leksell Gamma knife. Stereotact Funct Neurosurg 66:19231996

  • 69

    Young RFVermeulen SPosewitz A: Gamma knife radiosurgery for the treatment of trigeminal neuralgia. Stereotact Funct Neurosurg 70:Suppl 11921991998

  • 70

    Young RFVermeulen SSGrimm PBlasko JPosewitz A: Gamma Knife radiosurgery for treatment of trigeminal neuralgia: idiopathic and tumor related. Neurology 48:6086141997

  • 71

    Zakrzewska JMJassim SBulman JS: A prospective, longitudinal study on patients with trigeminal neuralgia who underwent radio-frequency thermocoagulation of the Gasserian ganglion. Pain 79:51581999

  • 72

    Zakrzewska JMLopez BC: Quality of reporting in evaluations of surgical treatment of trigeminal neuralgia: recommendations for future reports. Neurosurgery 53:1101222003

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