Long-term pain outcomes for recurrent idiopathic trigeminal neuralgia after stereotactic radiosurgery: a prospective comparison of first-time microvascular decompression and repeat stereotactic radiosurgery

Restricted access

OBJECTIVE

Microvascular decompression (MVD) and stereotactic radiosurgery (SRS) are common surgical treatments for trigeminal neuralgia (TN). Many patients who receive SRS have pain recurrence; the ideal second intervention is unknown. The authors directly compared pain outcomes after MVD and repeat SRS in a population of patients in whom SRS failed as their first-line procedure for TN, and they identified predictors of pain control.

METHODS

The authors reviewed a prospectively collected database of patients undergoing surgery for TN between 1997 and 2014 at the University of California, San Francisco (UCSF). Standardized data collection focused on preoperative clinical characteristics, surgical characteristics, and postoperative outcomes. Patients with typical type 1, idiopathic TN with ≥ 1 year of follow-up were included.

RESULTS

In total, 168 patients underwent SRS as their first procedure. Of these patients, 90 had residual or recurrent pain. Thirty of these patients underwent a second procedure at UCSF and had ≥ 1 year of follow-up; 15 underwent first-time MVD and 15 underwent repeat SRS. Patients undergoing MVD were younger than those receiving repeat SRS and were more likely to receive ≥ 80 Gy during the initial SRS. The average follow-up was 44.9 ± 33.6 months for MVD and 48.3 ± 45.3 months for SRS. All patients achieved complete pain freedom without medication at some point during their follow-up. At last follow-up, 80% of MVD-treated patients and 33.3% of SRS-treated patients had a favorable outcome, defined as Barrow Neurological Institute Pain Intensity scores of I–IIIa (p < 0.05). Percentages of patients with favorable outcome at 1 and 5 years were 86% and 75% for the MVD cohort and 73% and 27% for the SRS cohort, respectively (p < 0.05). Multivariate Cox proportional hazards analysis demonstrated that performing MVD was statistically significantly associated with favorable outcome (HR 0.12, 95% CI 0.02–0.60, p < 0.01). There were no statistically significant predictors of favorable outcome in the MVD cohort; however, the presence of sensory changes after repeat SRS was associated with pain relief (p < 0.01).

CONCLUSIONS

Patients who received MVD after failed SRS had a longer duration of favorable outcome compared to those who received repeat SRS; however, both modalities are safe and effective. The presence of post-SRS sensory changes was predictive of a favorable pain outcome in the SRS cohort.

ABBREVIATIONS BNI = Barrow Neurological Institute; FIESTA = fast imaging employing steady-state acquisition; MVD = microvascular decompression; SRS = stereotactic radiosurgery; TN = trigeminal neuralgia; UCSF = University of California, San Francisco.
Article Information

Contributor Notes

Correspondence Edward F. Chang: University of California, San Francisco, CA. edward.chang@ucsf.edu.INCLUDE WHEN CITING Published online October 26, 2018; DOI: 10.3171/2018.5.JNS172243.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Headings
References
  • 1

    Al-Otaibi FAlhindi HAlhebshi AAlbloushi MBaeesa SHodaie M: Histopathological effects of radiosurgery on a human trigeminal nerve. Surg Neurol Int 4 (Suppl 6):S462S4672014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Aubuchon ACChan MDLovato JFBalamucki CJEllis TLTatter SB: Repeat gamma knife radiosurgery for trigeminal neuralgia. Int J Radiat Oncol Biol Phys 81:105910652011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Barker FG IIJannetta PJBissonette DJJho HD: Trigeminal numbness and tic relief after microvascular decompression for typical trigeminal neuralgia. Neurosurgery 40:39451997

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Barker FG IIJannetta PJBissonette DJLarkins MVJho HD: The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med 334:107710831996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Bederson JBWilson CB: Evaluation of microvascular decompression and partial sensory rhizotomy in 252 cases of trigeminal neuralgia. J Neurosurg 71:3593671989

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Burchiel KJ: A new classification for facial pain. Neurosurgery 53:116411672003

  • 7

    Burchiel KJClarke HHaglund MLoeser JD: Long-term efficacy of microvascular decompression in trigeminal neuralgia. J Neurosurg 69:35381988

  • 8

    Chun-Cheng QQing-Shi ZJi-Qing ZZhi-Gang W: A single-blinded pilot study assessing neurovascular contact by using high-resolution MR imaging in patients with trigeminal neuralgia. Eur J Radiol 69:4594632009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Cohen JMousavi SHFaraji AHAkpinar BMonaco EAFlickinger JC: Stereotactic radiosurgery as initial surgical management for elderly patients with trigeminal neuralgia. Stereotact Funct Neurosurg 95:1581652017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Dvorak TFinn APrice LLMignano JEFitzek MMWu JK: Retreatment of trigeminal neuralgia with Gamma Knife radiosurgery: is there an appropriate cumulative dose? Clinical article. J Neurosurg 111:3593642009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Foy ABParisi JEPollock BE: Histologic analysis of a human trigeminal nerve after failed stereotactic radiosurgery: case report. Surg Neurol 68:6556592007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Gorgulho ADe Salles AAMcArthur DAgazaryan NMedin PSolberg T: Brainstem and trigeminal nerve changes after radiosurgery for trigeminal pain. Surg Neurol 66:1271352006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Helis CALucas JT JrBourland JDChan MDTatter SBLaxton AW: Repeat radiosurgery for trigeminal neuralgia. Neurosurgery 77:7557612015

  • 14

    Hodaie MChen DQQuan JLaperriere N: Tractography delineates microstructural changes in the trigeminal nerve after focal radiosurgery for trigeminal neuralgia. PLoS One 7:e327452012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Huang CFChiou SYWu MFTu HTLiu WS: Gamma Knife surgery for recurrent or residual trigeminal neuralgia after a failed initial procedure. J Neurosurg 113 (Suppl):1721772010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Jannetta PJMcLaughlin MRCasey KF: Technique of microvascular decompression. Technical note. Neurosurg Focus 18(5):E52005

  • 17

    Kondziolka DLacomis DNiranjan AMori YMaesawa SFellows W: Histological effects of trigeminal nerve radiosurgery in a primate model: implications for trigeminal neuralgia radiosurgery. Neurosurgery 46:9719772000

    • Search Google Scholar
    • Export Citation
  • 18

    Kondziolka DZorro OLobato-Polo JKano HFlannery TJFlickinger JC: Gamma Knife stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg 112:7587652010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Leal PRHermier MFroment JCSouza MACristino-Filho GSindou M: Preoperative demonstration of the neurovascular compression characteristics with special emphasis on the degree of compression, using high-resolution magnetic resonance imaging: a prospective study, with comparison to surgical findings, in 100 consecutive patients who underwent microvascular decompression for trigeminal neuralgia. Acta Neurochir (Wien) 152:8178252010

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Leal PRHermier MSouza MACristino-Filho GFroment JCSindou M: Visualization of vascular compression of the trigeminal nerve with high-resolution 3T MRI: a prospective study comparing preoperative imaging analysis to surgical findings in 40 consecutive patients who underwent microvascular decompression for trigeminal neuralgia. Neurosurgery 69:15262011

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Linskey MERatanatharathorn VPeñagaricano J: A prospective cohort study of microvascular decompression and Gamma Knife surgery in patients with trigeminal neuralgia. J Neurosurg 109 (Suppl):1601722008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Marshall KChan MDMcCoy TPAubuchon ACBourland JDMcMullen KP: Predictive variables for the successful treatment of trigeminal neuralgia with gamma knife radiosurgery. Neurosurgery 70:5665732012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    McLaughlin MRJannetta PJClyde BLSubach BRComey CHResnick DK: Microvascular decompression of cranial nerves: lessons learned after 4400 operations. J Neurosurg 90:181999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Miller JPAcar FBurchiel KJ: Classification of trigeminal neuralgia: clinical, therapeutic, and prognostic implications in a series of 144 patients undergoing microvascular decompression. J Neurosurg 111:123112342009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25

    Miller JPMagill STAcar FBurchiel KJ: Predictors of long-term success after microvascular decompression for trigeminal neuralgia. J Neurosurg 110:6206262009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Park KJKondziolka DBerkowitz OKano HNovotny J JrNiranjan A: Repeat gamma knife radiosurgery for trigeminal neuralgia. Neurosurgery 70:2953052012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Pollock BE: Comparison of posterior fossa exploration and stereotactic radiosurgery in patients with previously nonsurgically treated idiopathic trigeminal neuralgia. Neurosurg Focus 18(5):E62005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Pollock BEFoote RLStafford SLLink MJGorman DASchomberg PJ: Results of repeated gamma knife radiosurgery for medically unresponsive trigeminal neuralgia. J Neurosurg 93 (Suppl 3):1621642000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Régis JTuleasca CResseguier NCarron RDonnet AGaudart J: Long-term safety and efficacy of Gamma Knife surgery in classical trigeminal neuralgia: a 497-patient historical cohort study. J Neurosurg 124:107910872016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Riesenburger RIHwang SWSchirmer CMZerris VWu JKMahn K: Outcomes following single-treatment Gamma Knife surgery for trigeminal neuralgia with a minimum 3-year follow-up. J Neurosurg 112:7667712010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Rogers CLShetter AGFiedler JASmith KAHan PPSpeiser BL: Gamma knife radiosurgery for trigeminal neuralgia: the initial experience of The Barrow Neurological Institute. Int J Radiat Oncol Biol Phys 47:101310192000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Sarsam ZGarcia-Fiñana MNurmikko TJVarma TREldridge P: The long-term outcome of microvascular decompression for trigeminal neuralgia. Br J Neurosurg 24:18252010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Sekula RF JrFrederickson AMJannetta PJQuigley MRAziz KMArnone GD: Microvascular decompression for elderly patients with trigeminal neuralgia: a prospective study and systematic review with meta-analysis. J Neurosurg 114:1721792011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Tatli MSatici OKanpolat YSindou M: Various surgical modalities for trigeminal neuralgia: literature study of respective long-term outcomes. Acta Neurochir (Wien) 150:2432552008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Tuleasca CCarron RResseguier NDonnet ARoussel PGaudart J: Repeat Gamma Knife surgery for recurrent trigeminal neuralgia: long-term outcomes and systematic review. J Neurosurg 121 (Suppl):2102212014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Tyler-Kabara ECKassam ABHorowitz MHUrgo LHadjipanayis CLevy EI: Predictors of outcome in surgically managed patients with typical and atypical trigeminal neuralgia: comparison of results following microvascular decompression. J Neurosurg 96:5275312002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Wang DDRaygor KPCage TAWard MMWestcott SBarbaro NM: Prospective comparison of long-term pain relief rates after first-time microvascular decompression and stereotactic radiosurgery for trigeminal neuralgia. J Neurosurg 128:68772018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Wolf ATyburczy AYe JCFatterpekar GSilverman JSKondziolka D: The relationship of dose to nerve volume in predicting pain recurrence after stereotactic radiosurgery in trigeminal neuralgia. J Neurosurg 128:8918962018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Zeng QZhou QLiu ZLi CNi SXue F: Preoperative detection of the neurovascular relationship in trigeminal neuralgia using three-dimensional fast imaging employing steady-state acquisition (FIESTA) and magnetic resonance angiography (MRA). J Clin Neurosci 20:1071112013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 290 290 30
Full Text Views 66 66 15
PDF Downloads 90 90 16
EPUB Downloads 0 0 0
PubMed
Google Scholar