Original ArticleOutcomes of Two-Isocenter Gamma Knife Radiosurgery for Patients with Typical Trigeminal Neuralgia: Pain Response and Quality of Life
Introduction
Trigeminal neuralgia (TN) is a syndrome characterized by severe, sharp pain attacks occurring in the distribution of the trigeminal nerve. Patients with TN have a variety of available treatment options, including medication, percutaneous rhizotomies, microvascular decompression (MVD), and Gamma Knife surgery (GKS) (Elekta, Stockholm, Sweden). Medications such as carbamazepine and oxcarbazepine are usually chosen by physicians as the first-line option to control TN, but their application is sometimes limited because of patients' intolerance of the side effects. Percutaneous rhizotomies are often criticized for their high rate of sensory disturbances and recurrence.1, 2 MVD is an invasive method and may not be suitable for every patient. Above all, GKS is usually considered as a safe, noninvasive, and highly effective method, which is increasingly accepted by most clinicians.3, 4 Single-target GKS for TN treatment was widely used by many researchers and its effectiveness and safety were already confirmed.5, 6 The classic target for GKS is usually selected in the root entry zone (REZ).7 Recently, we began to use a 2-isocenter technique for TN treatment and the initial effectiveness was satisfactory, although long-term data are limited.
In the present study, we reviewed patients with TN who underwent 2-isocenter GKS protocol in our center during the last 10 years. It was essential to evaluate the initial response rate of a treatment as well as the durability of response. We used the Barrow Neurological Institute (BNI) pain intensity scale to evaluate postoperative pain relief.8 Numerous retrospective reports have clearly documented the effectiveness of single-target GKS.9, 10 However, long-term follow-up data of patients undergoing 2-isocenter GKS is lacking. To our knowledge, our experience provides actuarial analysis of 2-isocenter GKS treatment with the longest reported median follow-up in a cohort of patients with TN.
Section snippets
Patient Population
Between January 2006 and December 2015, 247 patients underwent 2-isocenter GKS in our center (105 men and 142 women). The median age was 61 years (range, 27–87 years). A total of 199 patients had a long-term medication history with agents such as carbamazepine. Thirty-one patients underwent other surgical operations such as percutaneous rhizotomy before the GKS treatment. Treatments failed because of pain recurrence or intolerance to side effects. The median symptom duration was 5 years (range,
Results
The median follow-up time was 49.7 months (range, 1–122.8 months). The median age at GKS treatment was 61 years. The average pain duration after treatment was 5.0 months (range, 0.1–30.0 months). The branch of the trigeminal nerve most often affected was V3 (92 cases, 37.2%). Compared with single branch involvement, multibranch involvement was a significant favorable factor for initial pain relief (P < 0.05). Thirty-one cases underwent preoperative percutaneous interventions and 23 of them had
Discussion
Radiosurgical management of TN was pioneered by Lars Leksell in 1951.11 Since then, numerous groups have shown the role of GKS in the treatment of medically refractory TN.12, 13 In the present retrospective study, questions regarding treatment durability, long-term complications, and appropriate patient selection have challenged physicians to place GKS in the context of other treatment modalities for this disorder.14 This study attempted to address these questions by analyzing clinical outcomes
Conclusions
The present study evaluated the effectiveness of 2-isocenter GKS for TN. Patients who underwent 2-isocenter GKS obtained earlier initial pain relief. The median time of initial pain relief was 2.0 months. Thirty-seven patients gained pain relief within 1 week after GKS (15.0%) and 67 cases within 1 month (27.0%). Kaplan-Meier analysis showed that patients with a shorter history of TN and patients without preoperative surgery obtained earlier initial pain relief. The recurrence rate was
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Conflict of interest statement: This project was supported by the National Natural Science Foundation of China (number 81201026).
Co-first author are Hongyang Zhao and Yin Shen.