Stereotactic gamma knife surgery for trigeminal neuralgia: detailed analysis of treatment response

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Object. The purpose of this study was to assess the durability and completeness of pain relief in patients treated using stereotactic gamma knife surgery (GKS) for trigeminal neuralgia (TN).

Methods. Thirty-eight patients with refractory TN were treated with stereotactic GKS. All patients received a prescription radiation dose of 35, 40, or 45 Gy to the 50% isodose surface through a 4-mm collimator helmet. The group was assessed regularly based on physician-directed interviews for a median follow up of 24 months (range 6–27 months). Pain relief was classified as excellent (no pain without medication), good (well-controlled pain with continued medication), fair (decreased but residual pain with continued medication), or poor (unimproved or increased pain with the same or increased medication).

Three months after treatment, pain relief was good or excellent in 71% of patients. By 24 months post-GKS, 50% of the original cohort had poor pain relief, 21% continued to have either excellent or good relief, 3% had fair relief, and 26% had not reached the 24-month follow up. Based on their status at the last follow up, 29% of patients had excellent and 16% had good pain relief. Thirty-seven percent experienced facial numbness, which was dose related. In addition, there was a significantly higher rate of complete pain relief in patients who had facial numbness following treatment (p = 0.003).

Conclusions. Stereotactic GKS is an effective treatment in patients with TN; however, the durability of pain relief and the time to treatment response are limiting factors. As with other types of ablative treatment, facial numbness is strongly associated with better treatment response.

Article Information

Address reprint requests to: Robert A. Fenstermaker, M.D., Department of Neurosurgery, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, New York 14263. email: Robert.Fenstermaker@RoswellPark.org.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Graph of follow-up assessments of pain relief at 3-month intervals following stereotactic GKS for TN.

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    Graph depicting the percentage of patients with complete pain relief (without medication). Patients with new facial numbness have a significantly higher rate of pain relief.

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    Graph demonstrating results of a Kaplan—Meier analysis of the relationship between pain relief and the development of new trigeminal nerve dysfunction following stereotactic GKS. Pain relief is strongly associated with the development of postradiosurgical numbness (p = 0.003). GKSR = stereotactic GKS.

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    Graph depicting results of an actuarial analysis of pain relief durability by initial degree of pain relief.

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    Graph displaying results of a multistudy comparison between radiosurgical dose and the incidence of trigeminal nerve dysfunction (p = 0.02). This comparison shows a statistically significant linear correlation between radiation dose and complication rates. The patients in our study who received a radiation dose of 40 Gy were not included in this analysis given that the complication rate in this subgroup could not be assessed with certainty. Patients who received 40 Gy were treated later in the series and had a median follow up of only 6 months. Consequently, they had not reached the median time point for the development of complications (that is, 8 months).

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