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, et al. Pain-free survival after vagoglossopharyngeal complex sectioning with or without microvascular decompression in glossopharyngeal neuralgia. J Neurosurg. 2020;132(1):232–238.
- 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):705–711.
- 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):155–157.
- 4↑
Martinez-Alvarez R, Martinez-Moreno N, Kusak ME, Rey-Portoles G. Glossopharyngeal neuralgia and radiosurgery. J Neurosurg. 2014;121(suppl):222–225.
- 5↑
Kano H, Urgosik D, Liscak R, et al. Stereotactic radiosurgery for idiopathic glossopharyngeal neuralgia: an international multicenter study. J Neurosurg. 2016;125(suppl 1):147–153.
- 6↑
Borius P-Y, Tuleasca C, Muraciole X, et al. Gamma Knife radiosurgery for glossopharyngeal neuralgia: a study of 21 patients with long-term follow-up. Cephalalgia. 2018;38(3):543–550.
- 7↑
Pommier B, Touzet G, Lucas C, et al. Glossopharyngeal neuralgia treated by Gamma Knife radiosurgery: safety and efficacy through long-term follow-up. J Neurosurg. 2018;128(5):1372–1379.
- 8↑
Balossier A, Tuleasca C, Muracciole X, et al. The outcomes of a second and third Gamma Knife radiosurgery for recurrent essential glossopharyngeal neuralgia. Acta Neurochir (Wien). 2020;162(2):271–277.
