Letter to the Editor. Radiosurgery is a valuable alternative to microvascular decompression for glossopharyngeal neuralgia

View More View Less
  • 1 CHU Lille, Roger Salengro Hospital, Lille, France
  • 2 Lille University, INSERM U1189, Lille, France
  • 3 Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
  • 4 University of Lausanne (Unil), Faculty of Biology and Medicine (FBM), Lausanne, Switzerland
  • 5 Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
Free access

If the inline PDF is not rendering correctly, you can download the PDF file here.

TO THE EDITOR: We read with great interest the article by Teton et al.1 on nerve sectioning with or without microvascular decompression (MVD) for drug-resistant glossopharyngeal neuralgia (GPN) (Teton ZE, Holste KG, Hardaway FA, et al. Pain-free survival after vagoglossopharyngeal complex sectioning with or without microvascular decompression in glossopharyngeal neuralgia. J Neurosurg. 2020;132[1]:232–238). The authors reported an 88% pain-free rate at the last follow-up in a small cohort of 18 patients. However, this rate should be balanced against a high rate of secondary side effects, including a 50% (n = 9) rate of persistent symptoms.

In our opinion, minimally invasive alternatives to MVD do exist in this rare pathology and deserve mention in such an important study. Regarding MVD, in 2002, Patel et al. reported a large cohort of 217 patients with a complete pain relief rate of 60% and 5.8% mortality in the initial part of their series, after MVD.2

As an alternative, Gamma Knife radiosurgery (GKRS) has proved to be safe and effective since the first case report published by Stieber et al. in 2005,3 followed by several other reports.4 The largest series published by Kano et al. showed a 73% initial good response.5 Data from a combined series in Marseille and Lausanne revealed 84% Barrow Neurological Institute (BNI) pain intensity scores I–IIIa at the last follow-up, with only one transient side effect (i.e., paresthesia of the edge of the tongue).6 These good results have been confirmed by a small series published by the Lille group, with a short time to clinical improvement after a mean period of 2 months.7 More recently, Balossier et al. reported the outcomes of second and third GKRS for recurrent GPN.8 These results were comparable to those after a first GKRS even in cases with a neurovascular conflict. In this small series, 1 patient experienced pharyngeal hypesthesia after a second GKRS.

In sum, we consider GKRS to be a valuable alternative to MVD in this rare condition because of its minimal invasiveness and extremely rare complications. Moreover, previous GKRS does not preclude further MVD, and vice versa. These techniques could be rather complementary in the frame of pain management in these patients.

We congratulate the authors for a very nice study with a long-term follow-up. We believe that tailored management for such a rare condition should take into account the patient’s medical condition, previous surgeries, etc., before deciding which therapy fits best for an individual need.

Acknowledgments

We acknowledge Lille University Hospital, Lausanne University Hospital.

Constantin Tuleasca gratefully acknowledges receipt of a Young Researcher in Clinical Research Grant (Jeune Chercheur en Recherche Clinique) from the University of Lausanne (UNIL), Faculty of Biology and Medicine (FBM), and Lausanne University Hospital (CHUV).

Disclosures

Dr. Tuleasca is a scientific advisor for Elekta Instruments, AB, Sweden.

References

  • 1

    Teton ZE, Holste KG, Hardaway FA, Pain-free survival after vagoglossopharyngeal complex sectioning with or without microvascular decompression in glossopharyngeal neuralgia. J Neurosurg. 2020;132(1):232238.

    • Search Google Scholar
    • Export Citation
  • 2

    Patel A, Kassam A, Horowitz M, Chang Y-F. Microvascular decompression in the management of glossopharyngeal neuralgia: analysis of 217 cases. Neurosurgery. 2002;50(4):705711.

    • Search Google Scholar
    • Export Citation
  • 3

    Stieber VW, Bourland JD, Ellis TL. Glossopharyngeal neuralgia treated with gamma knife surgery: treatment outcome and failure analysis. Case report. J Neurosurg. 2005;102(suppl):155157.

    • Search Google Scholar
    • Export Citation
  • 4

    Martinez-Alvarez R, Martinez-Moreno N, Kusak ME, Rey-Portoles G. Glossopharyngeal neuralgia and radiosurgery. J Neurosurg. 2014;121(suppl):222225.

    • Search Google Scholar
    • Export Citation
  • 5

    Kano H, Urgosik D, Liscak R, Stereotactic radiosurgery for idiopathic glossopharyngeal neuralgia: an international multicenter study. J Neurosurg. 2016;125(suppl 1):147153.

    • Search Google Scholar
    • Export Citation
  • 6

    Borius P-Y, Tuleasca C, Muraciole X, Gamma Knife radiosurgery for glossopharyngeal neuralgia: a study of 21 patients with long-term follow-up. Cephalalgia. 2018;38(3):543550.

    • Search Google Scholar
    • Export Citation
  • 7

    Pommier B, Touzet G, Lucas C, Glossopharyngeal neuralgia treated by Gamma Knife radiosurgery: safety and efficacy through long-term follow-up. J Neurosurg. 2018;128(5):13721379.

    • Search Google Scholar
    • Export Citation
  • 8

    Balossier A, Tuleasca C, Muracciole X, The outcomes of a second and third Gamma Knife radiosurgery for recurrent essential glossopharyngeal neuralgia. Acta Neurochir (Wien). 2020;162(2):271277.

    • Search Google Scholar
    • Export Citation
View More View Less
  • Oregon Health & Science University, Portland, OR

Response

We recognize the value of various treatment options in one’s armamentarium; however, the use of radiosurgery to treat GPN appears costly.

We noted that cranial nerve sectioning with or without MVD demonstrated 94% relief of symptoms, with just one episode of recurrence despite a follow-up ranging from 5 to 13 years (average > 9 years). It is important to note that the “persistent symptoms” for 50% of the patients noted by the authors was in reference to complications from the procedures, the majority of which were transient and/or deemed tolerable by patients at the longest follow-up. Despite this, of those patients contacted by telephone, all but one said that they would undergo the procedure again.

It should also be noted that while a mortality rate of 5.8% is high for an elective procedure such as this, all deaths noted in the referenced Patel study occurred shortly after the advent of the procedure, between the years of 1973 and 1987, with no deaths noted since.1

In a large study on stereotactic radiosurgery (SRS) for GPN, as noted by the authors, 50% of patients had initial complete pain relief (23% required pain medications to treat their symptoms) and “initial” only accounted for the first 3 months following their procedure.2 Less than half of these patients (22%) would maintain that pain freedom at 7 years, which stands in sharp contrast to the patients in our study, who experienced pain-free survival of 7.5 years, on average. Additionally, follow-up times in the Kano study were significantly limited—as little as 6 months for 1 patient and less than 4 years for the majority. This is especially concerning given that the average time to recurrence following SRS in this study was close to 2 years, suggesting that even more patients may eventually experience a recurrence given longer follow-up. In addition, half of the patients included in the study required another procedure to treat their pain and, nearly 40% of the time, it was an MVD and/or sectioning.

In the Borius study, there are two items of note.3 First, less than half of the study patients experienced initial pain relief without medication, while half of those with pain relief still required the use of medication to control their symptoms—a particularly important caveat in the age of the opioid crisis. Of note, these findings are similar to those of the Pommier study in which 44% of patients actually achieved pain freedom without medication,4 half of the total observed in our study. Second, nearly 60% of the patients in the Borius study who had experienced initial pain relief also had an eventual pain recurrence,3 which is 10 times the recurrence rate of the MVD with or without sectioning used in our study. Of those with recurrence, 40% required additional procedures, which notably come with additional risk.3

Finally, the Balossier study on repeat GKRS reports on 6 patients, with just 3 experiencing symptom freedom at the longest follow-up, even after 2 or 3 additional procedures.5 In addition, given the short follow-up times (median 12 months) and a treatment known to result in frequent recurrence, this percentage may be an overestimation of efficacy.

We acknowledge, as do the authors, the minimal adverse effects from radiosurgery for the treatment of GPN; however, one should consider the risk of additional procedures, the added cost, and the impact on long-term efficacy.

References

  • 1

    Patel A, Kassam A, Horowitz M, Chang Y-F. Microvascular decompression in the management of glossopharyngeal neuralgia: analysis of 217 cases. Neurosurgery. 2002;50(4):705711.

    • Search Google Scholar
    • Export Citation
  • 2

    Kano H, Urgosik D, Liscak R, Stereotactic radiosurgery for idiopathic glossopharyngeal neuralgia: an international multicenter study. J Neurosurg. 2016;125(suppl 1):147153.

    • Search Google Scholar
    • Export Citation
  • 3

    Borius P-Y, Tuleasca C, Muraciole X, Gamma Knife radiosurgery for glossopharyngeal neuralgia: a study of 21 patients with long-term follow-up. Cephalalgia. 2018;38(3):543550.

    • Search Google Scholar
    • Export Citation
  • 4

    Pommier B, Touzet G, Lucas C, Glossopharyngeal neuralgia treated by Gamma Knife radiosurgery: safety and efficacy through long-term follow-up. J Neurosurg. 2018;128(5):13721379.

    • Search Google Scholar
    • Export Citation
  • 5

    Balossier A, Tuleasca C, Muracciole X, The outcomes of a second and third Gamma Knife radiosurgery for recurrent essential glossopharyngeal neuralgia. Acta Neurochir (Wien). 2020;162(2):271277.

    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

Contributor Notes

Correspondence Iulia Peciu-Florianu: iuliapeciu_florianu@yahoo.com.

INCLUDE WHEN CITING Published online May 1, 2020; DOI: 10.3171/2020.2.JNS20277.

Disclosures Dr. Tuleasca is a scientific advisor for Elekta Instruments, AB, Sweden.

  • 1

    Teton ZE, Holste KG, Hardaway FA, Pain-free survival after vagoglossopharyngeal complex sectioning with or without microvascular decompression in glossopharyngeal neuralgia. J Neurosurg. 2020;132(1):232238.

    • Search Google Scholar
    • Export Citation
  • 2

    Patel A, Kassam A, Horowitz M, Chang Y-F. Microvascular decompression in the management of glossopharyngeal neuralgia: analysis of 217 cases. Neurosurgery. 2002;50(4):705711.

    • Search Google Scholar
    • Export Citation
  • 3

    Stieber VW, Bourland JD, Ellis TL. Glossopharyngeal neuralgia treated with gamma knife surgery: treatment outcome and failure analysis. Case report. J Neurosurg. 2005;102(suppl):155157.

    • Search Google Scholar
    • Export Citation
  • 4

    Martinez-Alvarez R, Martinez-Moreno N, Kusak ME, Rey-Portoles G. Glossopharyngeal neuralgia and radiosurgery. J Neurosurg. 2014;121(suppl):222225.

    • Search Google Scholar
    • Export Citation
  • 5

    Kano H, Urgosik D, Liscak R, Stereotactic radiosurgery for idiopathic glossopharyngeal neuralgia: an international multicenter study. J Neurosurg. 2016;125(suppl 1):147153.

    • Search Google Scholar
    • Export Citation
  • 6

    Borius P-Y, Tuleasca C, Muraciole X, Gamma Knife radiosurgery for glossopharyngeal neuralgia: a study of 21 patients with long-term follow-up. Cephalalgia. 2018;38(3):543550.

    • Search Google Scholar
    • Export Citation
  • 7

    Pommier B, Touzet G, Lucas C, Glossopharyngeal neuralgia treated by Gamma Knife radiosurgery: safety and efficacy through long-term follow-up. J Neurosurg. 2018;128(5):13721379.

    • Search Google Scholar
    • Export Citation
  • 8

    Balossier A, Tuleasca C, Muracciole X, The outcomes of a second and third Gamma Knife radiosurgery for recurrent essential glossopharyngeal neuralgia. Acta Neurochir (Wien). 2020;162(2):271277.

    • Search Google Scholar
    • Export Citation
  • 1

    Patel A, Kassam A, Horowitz M, Chang Y-F. Microvascular decompression in the management of glossopharyngeal neuralgia: analysis of 217 cases. Neurosurgery. 2002;50(4):705711.

    • Search Google Scholar
    • Export Citation
  • 2

    Kano H, Urgosik D, Liscak R, Stereotactic radiosurgery for idiopathic glossopharyngeal neuralgia: an international multicenter study. J Neurosurg. 2016;125(suppl 1):147153.

    • Search Google Scholar
    • Export Citation
  • 3

    Borius P-Y, Tuleasca C, Muraciole X, Gamma Knife radiosurgery for glossopharyngeal neuralgia: a study of 21 patients with long-term follow-up. Cephalalgia. 2018;38(3):543550.

    • Search Google Scholar
    • Export Citation
  • 4

    Pommier B, Touzet G, Lucas C, Glossopharyngeal neuralgia treated by Gamma Knife radiosurgery: safety and efficacy through long-term follow-up. J Neurosurg. 2018;128(5):13721379.

    • Search Google Scholar
    • Export Citation
  • 5

    Balossier A, Tuleasca C, Muracciole X, The outcomes of a second and third Gamma Knife radiosurgery for recurrent essential glossopharyngeal neuralgia. Acta Neurochir (Wien). 2020;162(2):271277.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 204 204 8
Full Text Views 33 33 1
PDF Downloads 34 34 2
EPUB Downloads 0 0 0