Long-term outcome of high-dose Gamma Knife surgery in treatment of trigeminal neuralgia

Clinical article

Byron Young M.D.1, Armin Shivazad B.S.2, Richard J. Kryscio Ph.D.4,5, William St. Clair M.D., Ph.D.3, and Heather M. Bush Ph.D.4
View More View Less
  • 1 Departments of Neurosurgery,
  • | 3 Radiation Medicine,
  • | 4 Biostatistics, and
  • | 5 Statistics, and
  • | 2 College of Medicine, University of Kentucky, Lexington, Kentucky
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

Object

Despite the widespread use of Gamma Knife surgery (GKS) for trigeminal neuralgia (TN), controversy remains regarding the optimal treatment dose and target site. Among the published studies, only a few have focused on long-term outcomes (beyond 2 years) using 90 Gy, which is in the higher range of treatment doses used (70–90 Gy).

Methods

The authors followed up on 315 consecutive patients treated with the Leksell Gamma Knife unit using a 4-mm isocenter without blocks. The isocenter was placed on the trigeminal nerve with the 20% isodose line tangential to the pontine surface (18 Gy). At follow-up, 33 patients were deceased; 282 were mailed an extensive questionnaire regarding their outcomes, but 32 could not be reached. The authors report their analysis of the remaining 250 cases. The patients' mean age at the time of survey response and the mean duration of follow-up were 70.8 ± 13.1 years and 68.9 ± 41.8 months, respectively.

Results

One hundred eighty-five patients (85.6%) had decreased pain intensity after GKS. Modified Marseille Scale (MMS) pain classifications after GKS at follow-up were: Class I (pain free without medication[s]) in 104 (43.7%), Class II (pain free with medication[s]) in 66 (27.7%), Class III (> 90% decrease in pain intensity) in 23 (9.7%), Class IV (50%–90% decrease in pain intensity) in 20 (8.4%), Class V (< 50% decrease in pain intensity) in 11 (4.6%), and Class VI (pain becoming worse) in 14 (5.9%). Therefore, 170 patients (71.4%) were pain free (Classes I and II) and 213 (89.5%) had at least 50% pain relief. All patients had pain that was refractory to medical management prior to GKS, but only 111 (44.4%) were being treated with medication at follow-up (p < 0.0001). Eighty patients (32.9%) developed numbness after GKS, and 74.5% of patients with numbness had complete pain relief. Quality of life and patient satisfaction on a 10-point scale were reported at mean values (± SD) of 7.8 ± 3.1 and 7.7 ± 3.4, respectively. Most of the patients (87.7%) would recommend GKS to another patient. Patients with prior surgical treatments had increased latency to pain relief and were more likely to continue medicines (p < 0.05). Moreover, presence of altered facial sensations prior to radiosurgery was associated with higher pain intensity, longer pain episodes, more frequent pain attacks, worse MMS pain classification, and more medication use after GKS (p < 0.05). Conversely, increase in numbness intensity after GKS was associated with a decrease in pain intensity and pain length (p < 0.05).

Conclusions

Gamma Knife surgery using a maximum dose of 90 Gy to the trigeminal nerve provides satisfactory long-term pain control, reduces the use of medication, and improves quality of life. Physicians must be aware that higher doses may be associated with an increase in bothersome sensory complications. The benefits and risks of higher dose selection must be carefully discussed with patients, since facial numbness, even if bothersome, may be an acceptable trade-off for patients with severe pain.

Abbreviations used in this paper:

BNI = Barrow Neurological Institute; GKS = Gamma Knife surgery; MMS = Modified Marseille Scale; TN = trigeminal neuralgia; WBFS = Wong-Baker FACES Scale.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Dhople AA, , Adams JR, , Maggio WW, , Naqvi SA, , Regine WF, & Kwok Y: Long-term outcomes of Gamma Knife radiosurgery for classical neuralgia: implications of treatment and critical review of the literature. Clinical article. J Neurosurg 111:351358, 2009

    • Search Google Scholar
    • Export Citation
  • 2

    Kano H, , Kondziolka D, , Yang HC, , Zorro O, , Lobato-Polo J, & Flannery TJ, et al.: Outcome predictors after gamma knife radiosurgery for recurrent trigeminal neuralgia. Neurosurgery 67:16371645, 2010

    • Search Google Scholar
    • Export Citation
  • 3

    Kondziolka D, , Zorro O, , Lobato-Polo J, , Kano H, , Flannery TJ, & Flickinger JC, et al.: Gamma Knife stereotactic radiosurgery for idiopathic trigeminal neuralgia. Clinical article. J Neurosurg 112:758765, 2010

    • Search Google Scholar
    • Export Citation
  • 4

    Little AS, , Shetter AG, , Shetter ME, , Bay C, & Rogers CL: Long-term pain response and quality of life in patients with typical trigeminal neuralgia treated with gamma knife stereotactic radiosurgery. Neurosurgery 63:915924, 2008

    • Search Google Scholar
    • Export Citation
  • 5

    Massager N, , Lorenzoni J, , Devriendt D, , Desmedt F, , Brotchi J, & Levivier M: Gamma knife surgery for idiopathic trigeminal neuralgia performed using a far-anterior cisternal target and a high dose of radiation. J Neurosurg 100:597605, 2004

    • Search Google Scholar
    • Export Citation
  • 6

    Massager N, , Murata N, , Tamura M, , Devriendt D, , Levivier M, & Régis J: Influence of nerve radiation dose in the incidence of trigeminal dysfunction after trigeminal neuralgia radiosurgery. Neurosurgery 60:681688, 2007

    • Search Google Scholar
    • Export Citation
  • 7

    Massager N, , Nissim O, , Murata N, , Devriendt D, , Desmedt F, & Vanderlinden B, et al.: Effect of beam channel plugging on the outcome of gamma knife radiosurgery for trigeminal neuralgia. Int J Radiat Oncol Biol Phys 65:12001205, 2006

    • Search Google Scholar
    • Export Citation
  • 8

    Matsuda S, , Nagano O, , Serizawa T, , Higuchi Y, & Ono J: Trigeminal nerve dysfunction after Gamma Knife Surgery for trigeminal neuralgia: a detailed analysis. Clinical article. J Neurosurg 113:Suppl 184190, 2010

    • Search Google Scholar
    • Export Citation
  • 9

    Morbidini-Gaffney S, , Chung CT, , Alpert TE, , Newman N, , Hahn SS, & Shah H, et al.: Doses greater than 85 Gy and two isocenters in Gamma Knife surgery for trigeminal neuralgia: updated results. J Neurosurg 105:Suppl 107111, 2006

    • Search Google Scholar
    • Export Citation
  • 10

    Nicol B, , Regine WF, , Courtney C, , Meigooni A, , Sanders M, & Young B: Gamma knife radiosurgery using 90 Gy for trigeminal neuralgia. J Neurosurg 93:Suppl 3 152154, 2000

    • Search Google Scholar
    • Export Citation
  • 11

    Pan HC, , Sheehan J, , Huang CF, , Sheu ML, , Yang DY, & Chiu WT: Quality-of-life outcomes after Gamma Knife surgery for trigeminal neuralgia. Clinical article. J Neurosurg 113:Suppl 191198, 2010

    • Search Google Scholar
    • Export Citation
  • 12

    Pollock BE: Radiosurgery for trigeminal neuralgia: is sensory disturbance required for pain relief?. J Neurosurg 105:Suppl 103106, 2006

    • Search Google Scholar
    • Export Citation
  • 13

    Pollock BE, , Phuong LK, , Foote RL, , Stafford SL, & Gorman DA: High-dose trigeminal neuralgia radiosurgery associated with increased risk of trigeminal nerve dysfunction. Neurosurgery 49:5864, 2001

    • Search Google Scholar
    • Export Citation
  • 14

    Régis J, , Metellus P, , Hayashi M, , Roussel P, , Donnet A, & Bille-Turc F: Prospective controlled trial of gamma knife surgery for essential trigeminal neuralgia. J Neurosurg 104:913924, 2006

    • Search Google Scholar
    • Export Citation
  • 15

    Riesenburger RI, , Hwang SW, , Schirmer CM, , Zerris V, , Wu JK, & Mahn K, et al.: Outcomes following single-treatment Gamma Knife surgery for trigeminal neuralgia with minimum 3-year follow-up. Clinical article. J Neurosurg 112:766771, 2010

    • Search Google Scholar
    • Export Citation
  • 16

    Rogers CL, , Shetter AG, , Fiedler JA, , Smith KA, , Han PP, & Speiser BL: Gamma knife radiosurgery for trigeminal neuralgia: the initial experience of The Barrow Neurological Institute. Int J Radiat Oncol Biol Phys 47:10131019, 2000

    • Search Google Scholar
    • Export Citation
  • 17

    Sheehan J, , Pan HC, , Stroila M, & Steiner L: Gamma knife surgery for trigeminal neuralgia: outcomes and prognostic factors. J Neurosurg 102:434441, 2005

    • Search Google Scholar
    • Export Citation
  • 18

    Tawk RG, , Duffy-Fronckowiak M, , Scott BE, , Alberico RA, , Diaz AZ, & Podgorsak MB, et al.: Stereotactic gamma knife surgery for trigeminal neuralgia: detailed analysis of treatment response. J Neurosurg 102:442449, 2005

    • Search Google Scholar
    • Export Citation
  • 19

    Verheul JB, , Hanssens PEJ, , Lie ST, , Leenstra S, , Piersma H, & Beute GN: Gamma Knife surgery for trigeminal neuralgia: a review of 450 consecutive cases. J Neurosurg 113:Suppl 160167, 2010

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1705 655 48
Full Text Views 261 27 4
PDF Downloads 305 32 4
EPUB Downloads 0 0 0