Earlier radiosurgery leads to better pain relief and less medication usage for trigeminal neuralgia patients: an international multicenter study

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  • 1 Department of Neurosurgery, New York University Langone Medical Center, New York, New York;
  • 2 Departments of Neurosurgery and
  • 3 Radiation Oncology, University of Southern California, Los Angeles, California;
  • 4 Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic;
  • 5 Gamma Knife Center, Jewish Hospital, Mayfield Clinic, Cincinnati, Ohio;
  • 6 Centro Gamma Knife Dominicano, CEDIMAT, Santo Domingo, Dominican Republic;
  • 7 Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada;
  • 8 Department of Oncology, Division of Radiation Oncology, University of Alberta, Edmonton, Alberta, Canada;
  • 9 Department of Neurosurgery, University of Puerto Rico, School of Medicine, San Juan, Puerto Rico;
  • 10 Administración de Servicios Médicos de Puerto Rico, Centro Gamma Knife de Puerto Rico y El Caribe, San Juan, Puerto Rico;
  • 11 Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Québec, Canada;
  • 12 Center for Neuro-Restoration, Cleveland Clinic, Cleveland, Ohio;
  • 13 Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
  • 14 Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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OBJECTIVE

Trigeminal neuralgia (TN) is a chronic pain condition that is difficult to control with conservative management. Furthermore, disabling medication-related side effects are common. This study examined how stereotactic radiosurgery (SRS) affects pain outcomes and medication dependence based on the latency period between diagnosis and radiosurgery.

METHODS

The authors conducted a retrospective analysis of patients with type I TN at 12 Gamma Knife treatment centers. SRS was the primary surgical intervention in all patients. Patient demographics, disease characteristics, treatment plans, medication histories, and outcomes were reviewed.

RESULTS

Overall, 404 patients were included. The mean patient age at SRS was 70 years, and 60% of the population was female. The most common indication for SRS was pain refractory to medications (81%). The median maximum radiation dose was 80 Gy (range 50–95 Gy), and the mean follow-up duration was 32 months. The mean number of medications between baseline (pre-SRS) and the last follow-up decreased from 1.98 to 0.90 (p < 0.0001), respectively, and this significant reduction was observed across all medication categories. Patients who received SRS within 4 years of their initial diagnosis achieved significantly faster pain relief than those who underwent treatment after 4 years (median 21 vs 30 days, p = 0.041). The 90-day pain relief rate for those who received SRS ≤ 4 years after their diagnosis was 83.8% compared with 73.7% in patients who received SRS > 4 years after their diagnosis. The maximum radiation dose was the strongest predictor of a durable pain response (OR 1.091, p = 0.003). Early intervention (OR 1.785, p = 0.007) and higher maximum radiation dose (OR 1.150, p < 0.0001) were also significant predictors of being pain free (a Barrow Neurological Institute pain intensity score of I–IIIA) at the last follow-up visit. New sensory symptoms of any kind were seen in 98 patients (24.3%) after SRS. Higher maximum radiation dose trended toward predicting new sensory deficits but was nonsignificant (p = 0.075).

CONCLUSIONS

TN patients managed with SRS within 4 years of diagnosis experienced a shorter interval to pain relief with low risk. SRS also yielded significant decreases in adjunct medication utilization. Radiosurgery should be considered earlier in the course of treatment for TN.

ABBREVIATIONS BNI = Barrow Neurological Institute; MVD = microvascular decompression; SRS = stereotactic radiosurgery; TN = trigeminal neuralgia.

Supplementary Materials

    • Supplemental Tables A–C (PDF 406 KB)

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Contributor Notes

Correspondence Douglas Kondziolka: NYU Langone Medical Center, New York, NY. douglas.kondziolka@nyulangone.org.

INCLUDE WHEN CITING Published online July 3, 2020; DOI: 10.3171/2020.4.JNS192780.

Disclosures Dr. Lunsford reports being a consultant for Insightec (DSMB); he owns stock in Elekta AB. Dr. Kondziolka reports receiving support for non–study-related research or clinical efforts that he oversees from Brainlab.

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