Gamma Knife radiosurgery for bilateral trigeminal neuralgia

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OBJECTIVE

A small subset of patients with trigeminal neuralgia (TN) will experience bilateral symptoms. Treatment in these patients is controversial because the population is heterogeneous and patients may have nonvascular etiologies of their pain. This study reports treatment outcomes in the largest cohort of patients with bilateral TN who have undergone Gamma Knife radiosurgery (GKRS) to date.

METHODS

A retrospective chart review identified 51 individual nerves in 34 patients with bilateral TN who were treated with GKRS at the authors’ institution between 2001 and 2015, with 12 nerves in 11 patients undergoing repeat GKRS for recurrent or persistent symptoms. Long-term follow-up was obtained by telephone interview. Pain outcomes were measured using the Barrow Neurological Institute (BNI) pain scale, with BNI IIIb or better considered a successful treatment.

RESULTS

There was sufficient follow-up to determine treatment outcomes for 48 individual nerves in 33 patients. Of these nerves, 42 (88%) achieved at least BNI IIIb pain relief. The median duration of pain relief was 1.9 years, and 1-, 3-, and 5-year pain relief rates were 64%, 44%, and 44%, respectively. No patients experienced bothersome facial numbness, and 1 case of anesthesia dolorosa and 2 cases of corneal dryness were reported. Patients with a history of definite or possible multiple sclerosis were significantly more likely to experience BNI IV–V relapse. There was no statistically significant difference in treatment outcomes between patients in this series versus a large cohort of patients with unilateral TN treated at the authors’ institution. There was sufficient follow-up to determine treatment outcomes for 11 individual nerves in 10 patients treated with repeat GKRS. Ten nerves (91%) improved to at least BNI IIIb after treatment. The median duration of pain relief was 2.8 years, with 1-, 3-, and 5-year rates of pain relief of 79%, 53%, and 53%, respectively. There was no statistically significant difference in outcomes between initial and repeat GKRS. One case of bothersome facial numbness and 1 case of corneal dryness were reported, with no patients developing anesthesia dolorosa with retreatment.

CONCLUSIONS

GKRS is a safe, well-tolerated treatment for patients with medically refractory bilateral TN. Efficacy of treatment appears similar to that in patients with unilateral TN. GKRS can be safely repeated in this population if necessary.

ABBREVIATIONS BNI = Barrow Neurological Institute; CMT = Charcot-Marie-Tooth; DM = diabetes mellitus; EMR = electronic medical records; GKRS = Gamma Knife radiosurgery; HR = hazard ratio; IQR = interquartile range; MS = multiple sclerosis; MVD = microvascular decompression; PN = peripheral neuropathy; PTR = percutaneous trigeminal rhizotomy; REZ = root entry zone; TN = trigeminal neuralgia.
Article Information

Contributor Notes

Correspondence Corbin A. Helis: Wake Forest Baptist Medical Center, Winston-Salem, NC. chelis@wakehealth.edu.INCLUDE WHEN CITING Published online November 30, 2018; DOI: 10.3171/2018.6.JNS172646.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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