Elsevier

World Neurosurgery

Volume 109, January 2018, Pages e531-e538
World Neurosurgery

Original Article
Outcomes of Two-Isocenter Gamma Knife Radiosurgery for Patients with Typical Trigeminal Neuralgia: Pain Response and Quality of Life

https://doi.org/10.1016/j.wneu.2017.10.014Get rights and content

Objective

To evaluate the effectiveness and safety of 2-isocenter Gamma Knife surgery (GKS) by reviewing patients with trigeminal neuralgia (TN) from the last 10 years.

Methods

A total of 247 patients were followed up and the Barrow Neurological Institute scale was used to evaluate pain degree. Patients' age, gender, pain duration and location, preoperative/postoperative Barrow Neurological Institute scale score, time to initial pain relief, recurrence time, and complications were documented and analyzed.

Results

Patients who underwent a 2-isocenter GKS achieved earlier initial pain relief. The median time of initial pain relief was 2.0 months. Kaplan-Meier analysis showed that the patients with a shorter history of TN and the patients without preoperative surgery achieved earlier initial pain relief. During the 122.8 months of follow-up, the median time of recurrence-free pain relief was 49.7 months. Age was found to be a risk factor of recurrence. Patients who underwent 2-isocenter GKS had a higher rate of postoperative facial numbness, but only 9 cases reported bothersome facial numbness. Multibranch involvement was a risk factor for postoperative facial numbness.

Conclusions

Compared with other modalities, 2-isocenter GKS was a safe and highly effective option for patients with TN. However, more data need to be collected to verify its long-term effect.

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.

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