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.

  • View in gallery

    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.

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