251
|
Yao P, Hong T, Zhu YQ, Li HX, Wang ZB, Ding YY, Ma JM, Pan SN. Efficacy and safety of continuous radiofrequency thermocoagulation plus pulsed radiofrequency for treatment of V1 trigeminal neuralgia: A prospective cohort study. Medicine (Baltimore) 2016; 95:e5247. [PMID: 27858881 PMCID: PMC5591129 DOI: 10.1097/md.0000000000005247] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Patients may develop serious eye complications after continuous radiofrequency thermocoagulation (CRF) for V1 (ophthalmic division) trigeminal neuralgia (TN) at a higher temperature. Therefore, the temperature of clinical CRF for V1 TN has long been disputed, but there have few reports been found about how to achieve satisfactory pain relief, reduce the incidence rates of complications, and shorten the recovery time after CRF for V1 TN.To observe whether pulsed radiofrequency (PRF) can lead to increased rate in pain relief, reduced rate of complications, or shortened recovery time after CRF is used to treat V1 idiopathic trigeminal neuralgia (ITN).The prospective cohort study enrolled 56 patients with V1 ITN from May 2012 to April 2015. The patients were randomized into 2 treatment groups as follows: CRF only (group A, n = 28) and CRF plus PRF (group B, n = 28). The patients were followed 3 years up for pain relief, complications, and health-related quality of life (HRQoL).All the patients in either group achieved satisfactory pain relief at discharge. After treatment, patients completely pain free in group A and group B accounted for 81.6%, 92.0% at 1 year, 68.4%, 92.0% at 2 years, and 68.4%, 83.6% at 3 years, respectively. The pain relief rate was higher in group B patients than in group A, but the difference was not statistically significant. During the follow-up period, 9 (32.1%) patients in group A and 2 (7.1%) patients in group B developed recurrence (P < 0.05). Eleven patients in group A occurred corneal hypoesthesia and with recovery time was 11.9 ± 7.5 (4-18) months versus 3 patients in group B with recovery time was 3.4 ± 2.5 (2-6) months, the differences of incidence rate and recovery times were all significant (P < 0.05) between groups A and B. The mean scores of HRQoL in group B patients were higher than that in group A patients (P < 0.05).PRF after CRF results in decreased recurrence of V1 TN, reduced numbers of corneal hypoesthesia, shortened recovery time, and increased HRQoL scores. Its clinical use is recommended.
Collapse
Affiliation(s)
- Peng Yao
- Department of Pain Management Department of Radiology, Shenjing Hospital of China Medical University, Shenyang, China
| | | | | | | | | | | | | | | |
Collapse
|
252
|
Chivukula S, Kim W, Zhuo X, Tenn S, Kaprealian T, DeSalles A, Pouratian N. Radiosurgery for Secondary Trigeminal Neuralgia: Revisiting the Treatment Paradigm. World Neurosurg 2016; 99:288-294. [PMID: 27702706 DOI: 10.1016/j.wneu.2016.09.087] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The mechanisms by which surgery and radiation elicit pain relief in trigeminal neuralgia (TN) secondary to mass lesions vary widely. We aimed to evaluate the outcomes of radiation to the nerve rather than to the lesion in the treatment of secondary TN. METHODS We retrospectively reviewed all patients who underwent radiation at the University of California, Los Angeles for TN secondary to tumors. The Barrow Neurological Institute (BNI) pain score was used to evaluate pain outcomes. RESULTS Twelve patients were identified; 4 were male and 8 were female. Their mean age at treatment was 59.8 years (range, 47.7-84.7 years). Tumor pathologies included meningioma (n = 8), squamous cell carcinoma (n = 2), vestibular schwannoma (n = 1), and hemangiopericytoma (n = 1). No patient suffered from multiple sclerosis. Ten patients underwent initial radiation targeting their tumors-radiosurgery in 3 and fractionated radiation therapy in 7 others. Only 6 among these 10 experienced at least partial relief, which lasted a mean 6 months. Radiosurgery targeting the trigeminal nerve was eventually performed. Overall, 10 of 12 (83.3%) patients experienced good initial pain relief, complete in 6 (50%) patients. Pain recurred in 6 (60%) patients, at a mean 41 months after radiosurgery to the trigeminal nerve. Three patients experienced facial sensory dysfunction postprocedurally at a mean follow-up duration of 57 months. CONCLUSION In contrast to tumor radiation, radiosurgery to the trigeminal nerve root resulted in reasonable and longer pain reduction, on par with the literature regarding surgical resection, with low risk of additional complications.
Collapse
Affiliation(s)
- Srinivas Chivukula
- Department of Neurological Surgery, University of California, Los Angeles, Los Angeles, California, USA.
| | - Won Kim
- Department of Neurological Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Xiaoyi Zhuo
- Department of Neurological Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Stephen Tenn
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California, USA
| | - Tania Kaprealian
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California, USA
| | - Antonio DeSalles
- Department of Neurological Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Nader Pouratian
- Department of Neurological Surgery, University of California, Los Angeles, Los Angeles, California, USA; Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California, USA; Interdepartmental Program in Neuroscience, University of California, Los Angeles, Los Angeles, California, USA; Department of Bioengineering, University of California, Los Angeles, Los Angeles, California, USA; Brain Research Institute, University of California, Los Angeles, Los Angeles, California, USA
| |
Collapse
|
253
|
Kim SK, Kim DG, Se YB, Kim JW, Kim YH, Chung HT, Paek SH. Gamma Knife surgery for tumor-related trigeminal neuralgia: targeting both the tumor and the trigeminal root exit zone in a single session. J Neurosurg 2016; 125:838-844. [PMID: 26799302 DOI: 10.3171/2015.7.jns15451] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Gamma Knife surgery (GKS) represents an alternative treatment for patients with tumor-related trigeminal neuralgia (TRTN). However, in previous studies, the primary GKS target was limited to mass lesions. The authors evaluated whether GKS could target both the tumor and the trigeminal root exit zone (REZ) in a single session while providing durable pain relief and minimizing radiation dose–related complications for TRTN patients.
METHODS
The authors' institutional review board approved the retrospective analysis of data from 15 consecutive patients (6 men and 9 women, median age 67 years, range 45–79 years) with TRTN who had undergone GKS. In all cases, the radiation was delivered in a single session targeting both the tumor and trigeminal REZ. The authors assessed the clinical outcomes, including the extent of pain relief, durability of the treatment response, and complications. Radiation doses to organs at risk (OARs), including the brainstem and the cranial nerve VII–VIII complex, were analyzed as doses received by 2% or 50% of the tissue volume and the tissue volume covered by a dose of 12 Gy (V12Gy).
RESULTS
The median length of clinical follow-up was 38 months (range 12–78 months). Pain relief with GKS was initially achieved in 14 patients (93.3%) and at the last follow-up in 13 patients (86.7%). The actuarial recurrence-free survival rates were 93%, 83%, and 69% at 1, 3, and 5 years after GKS, respectively. Persistent facial numbness was observed in 3 patients (20.0%). There were no complications such as facial weakness, altered taste function, hearing impairment, and balance difficulties indicating impaired function of the cranial nerve VII–VIII complex. The V12Gy in the brainstem was less than or equal to 0.24 cm3 in all patients. There were no significant differences in any OAR values in the brainstem between patients with and without facial numbness after GKS.
CONCLUSIONS
The strategy of performing GKS for both tumor and trigeminal REZ in a single session is a safe and effective radiosurgical approach that achieves durable pain control for TRTN patients.
Collapse
|
254
|
Ding W, Chen S, Wang R, Cai J, Cheng Y, Yu L, Li Q, Deng F, Zhu S, Yu W. Percutaneous radiofrequency thermocoagulation for trigeminal neuralgia using neuronavigation-guided puncture from a mandibular angle. Medicine (Baltimore) 2016; 95:e4940. [PMID: 27749549 PMCID: PMC5059051 DOI: 10.1097/md.0000000000004940] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 12/04/2022] Open
Abstract
Percutaneous radiofrequency thermocoagulation (RFT) of the Gasserian ganglion is an effective treatment for primary trigeminal neuralgia (pTN). Currently Hartel anterior approach is the most commonly used method to access the Gasserian ganglion. However, this approach is associated with high recurrence rate and technical difficulties in certain patients with foramen ovale (FO) anatomical variations. In the present study, we assessed the feasibility of accessing the Gasserian ganglion through the FO from a mandibular angle under computed tomography (CT) and neuronavigation guidance.A total of 108 patients with TN were randomly divided into 2 groups (Group G and Group H) using a random number table. In Group H, Hartel anterior approach was used to puncture the FO; whereas in Group G, a percutaneous puncture through a mandibular angle was used to reach the FO. In both groups, procedures were guided by CT imaging and neuronavigation. The success rates, therapeutic effects, complications, and recurrence rates of the 2 groups were compared.The puncture success rates in Group H and Group G were 52/54 (96.30%) and 49/54 (90.74%), respectively (P = 0.24). The 2 procedural failures in Group H were rescued by using submandibular trajectory, and the 5 failures in Group G were successfully reapproached by Hartel method. Therapeutic effects as measured by Barrow Neurological Institute (BNI) pain scale (P = 0.03) and quality of life (QOL) scores (P = 0.04) were significantly better in Group G than those in Group H at 36 months posttreatment. Hematoma developed in 1/54 (1.85%) cases in Group H, and no cases of hematoma were observed in Group G (P = 0.33). In Group H, RFT resulted in injury to the unintended trigeminal nerve branches and motor fibers in 27/52 (51.92%) cases; in Group G, it resulted in the same type of injury in 7/49 cases (14.29%) (P < 0.01). In Group H, the 24- and 36-month recurrence rates were 12/51 (23.53%) and 20/51 (39.22%), respectively; in Group G, these recurrence rates were 7/49 (12.24%) and 9/49 (16.33%, P = 0.03), respectively.CT- and neuronavigation-guided puncture from a mandibular angle through the FO into the Gasserian ganglion can be safely and effectively used to deliver RFT for the treatment of pTN. This method may represent a viable option to treat TN in addition to Hartel approach.
Collapse
Affiliation(s)
- Weihua Ding
- Department of Anesthesia & Pain Medicine, The First Affiliated Hospital of Medical School of Zhejiang University
- Pain Clinic, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang, P.R. China
- Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Shuping Chen
- Pain Clinic, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang, P.R. China
| | | | - Jun Cai
- Pain Clinic, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang, P.R. China
| | - Yuan Cheng
- Pain Clinic, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang, P.R. China
| | - Liang Yu
- Pain Clinic, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang, P.R. China
| | - Qinghua Li
- Pain Clinic, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang, P.R. China
| | - Fang Deng
- Pain Clinic, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang, P.R. China
| | - Shengmei Zhu
- Department of Anesthesia & Pain Medicine, The First Affiliated Hospital of Medical School of Zhejiang University
| | - Wenhua Yu
- Department of Neurosurgery, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang, P.R. China
| |
Collapse
|
255
|
Weigel R, Polemikos M, Uksul N, Krauss JK. Tarlov cysts: long-term follow-up after microsurgical inverted plication and sacroplasty. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3403-3410. [DOI: 10.1007/s00586-016-4744-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/24/2016] [Accepted: 08/08/2016] [Indexed: 11/27/2022]
|
256
|
Dai ZF, Huang QL, Liu HP, Zhang W. Efficacy of stereotactic gamma knife surgery and microvascular decompression in the treatment of primary trigeminal neuralgia: a retrospective study of 220 cases from a single center. J Pain Res 2016; 9:535-42. [PMID: 27555796 PMCID: PMC4968995 DOI: 10.2147/jpr.s110161] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES A retrospective study was undertaken to compare the efficacy of stereotactic gamma knife surgery (GKS) and microvascular decompression (MVD) in the treatment of primary trigeminal neuralgia (TN) at a single center. The study included the evaluation of clinical outcomes of pain relief and pain recurrence and complications associated with GKS and MVD. METHODS The study included 202 patients with primary TN and was conducted between January 2013 and December 2014; about 115 patients were treated with GKS and 87 patients were treated with MVD. TN pain was evaluated using the Barrow Neurological Institute and the visual analog scale scoring systems. Preoperative magnetic resonance tomographic angiography was performed for all patients. Microscope-assisted MVD used the suboccipital retrosigmoid sinus approach. GKS targeted the trigeminal nerve root entry zone with a margin radiation dose of 59.5 Gy, and brainstem dose <12 Gy. Posttreatment follow-up was for 2 years. RESULTS Postoperative Barrow Neurological Institute scores for patients treated with GKS and MVD were significantly improved compared with preoperative scores (P<0.01). Reduction in postoperative pain following MVD (95.4% patients) was significantly greater than that following GKS (88.7% patients) (P<0.01). Postoperative visual analog scale scores of the MVD group were significantly reduced compared with those of patients treated with GKS at the same postoperative time points (P<0.01). Patients treated with GKS had a significantly increased rate of loss of corneal reflex compared with patients treated with MVD (P=0.002). CONCLUSION Both GKS and MVD are safe and effective first-line and adjunctive treatment options for patients with TN. The clinical outcomes of pain relief and reduction of pain recurrence were better with MVD. For GKS, this study showed that the optimal radiation therapeutic dose range was 70-90 Gy, but brainstem radiation protection is recommended.
Collapse
Affiliation(s)
- Zi-Feng Dai
- Department of Neurosurgery, Xinqiao Hospital, The Third Military Medical University, Chongqing, People's Republic of China
| | - Qi-Lin Huang
- Department of Neurosurgery, Xinqiao Hospital, The Third Military Medical University, Chongqing, People's Republic of China
| | - Hai-Peng Liu
- Department of Neurosurgery, Xinqiao Hospital, The Third Military Medical University, Chongqing, People's Republic of China
| | - Wei Zhang
- Department of Neurosurgery, Xinqiao Hospital, The Third Military Medical University, Chongqing, People's Republic of China
| |
Collapse
|
257
|
Yao P, Hong T, Wang ZB, Ma JM, Zhu YQ, Li HX, Ding YY, Jiang CL, Pan SN. Treatment of bilateral idiopathic trigeminal neuralgia by radiofrequency thermocoagulation at different temperatures. Medicine (Baltimore) 2016; 95:e4274. [PMID: 27442662 PMCID: PMC5265779 DOI: 10.1097/md.0000000000004274] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Radiofrequency thermocoagulation (RFT) is an effective treatment for trigeminal neuralgia, but consensus regarding an optimal treatment temperature is lacking. While treatment temperatures ranging from 60°C to 95°C have been reported, RFT at too high a temperature is often followed by serious complications, and comparative evaluations of RFT at different temperatures in a single study are rare.This current prospective cohort study was to compare immediate and long-term outcomes of RFT at varying temperatures in patients with bilateral idiopathic trigeminal neuralgia (ITN) of maxillary division of trigeminal nerve (V2), mandibular division of trigeminal nerve (V3), and V2+V3, including pain relief, complications, recurrence rate, and patient satisfaction. From May 2011 to April 2016, 62 consecutive patients with bilateral ITN of V2, V3, and V2+V3 were enrolled in the study. These patients underwent bilateral RFT at 68°C and 75°C, respectively, using the same RF parameters. Side-to-side results, including pain relief, complications, and patient satisfaction, were compared during a 5-year follow-up period.Overall pain relief was satisfactory after RFT. The rate of pain relief after treatment at 75°C was slightly higher than at 68°C (P > 0.05). The pain-free rate was 95.1% at 75°C and 93.5% at 68°C at 1 year, 84.3% and 78.1% at 3 years, and 80.7% and 74.4% at 5 years. There were 10 and 13 cases of recurrence, respectively, and 6 cases of bilateral recurrence. The incidence and severity of complications were greater at 75°C (P < 0.05) than at 68°C, and therefore the patient satisfaction at the higher temperature was lower (P < 0.05).Patients with bilateral ITN who underwent RFT at different temperatures had consistent pain relief after RFT at both 75°C and 68°C, but there were fewer and less severe complications at 68°C, which was accompanied by greater patient satisfaction. This suggests that RFT at lower temperatures may be preferable, and that a temperature of 68°C can be recommended.
Collapse
Affiliation(s)
- Peng Yao
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang
- Correspondence: Peng Yao, Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang 110004, China (e-mail: )
| | - Tao Hong
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang
| | - Zhi-bin Wang
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang
| | - Jia-ming Ma
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang
| | - Yong-qiang Zhu
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang
| | - Hong-xi Li
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang
| | - Yuan-yuan Ding
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang
| | - Chang-lin Jiang
- Department of Pain Management, Daqing Oilfield General Hospital, Daqing
| | - Shi-nong Pan
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, China
| |
Collapse
|
258
|
|
259
|
Wang JY, Bender MT, Bettegowda C. Percutaneous Procedures for the Treatment of Trigeminal Neuralgia. Neurosurg Clin N Am 2016; 27:277-95. [DOI: 10.1016/j.nec.2016.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
260
|
|
261
|
Taich ZJ, Goetsch SJ, Monaco E, Carter BS, Ott K, Alksne JF, Chen CC. Stereotactic Radiosurgery Treatment of Trigeminal Neuralgia: Clinical Outcomes and Prognostic Factors. World Neurosurg 2016; 90:604-612.e11. [DOI: 10.1016/j.wneu.2016.02.067] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 02/10/2016] [Accepted: 02/12/2016] [Indexed: 10/22/2022]
|
262
|
Yao P, Deng YY, Hong T, Wang ZB, Ma JM, Zhu YQ, Li HX, Ding YY, Pan SN. Radiofrequency thermocoagulation for V2/V3 idiopathic trigeminal neuralgia: effect of treatment temperatures on long-term clinical outcomes: A Cohort Study. Medicine (Baltimore) 2016; 95:e4019. [PMID: 27368021 PMCID: PMC4937935 DOI: 10.1097/md.0000000000004019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Radiofrequency thermocoagulation (RFT) is widely used to treat trigeminal neuralgia (TN); however, the optimal temperature at which RFT is most efficacious remains under much debate. Thus, the aim of the present study was to determine the lowest temperature at which morbidity could be minimized and patient outcomes maximized.A multivariate analysis was used to study 1354 patients who underwent computed tomography (CT)-guided RFT for V2/V3 idiopathic trigeminal neuralgia (ITN) during from June 2006 to May 2015. RFT was carried out at 62, 65, and 68°C, while keeping all other RF parameters the same. This was a prospective cohort study, in which we assessed intra- and postoperative complications, pain relief, and long-term health-related quality of life (HRQoL).The intraoperative and in-hospital complications of patients were mainly facial hematoma, mouth and external auditory meatus penetration, nausea, vomiting, dizziness, and headache, which were all treated symptomatically. In long-term follow-up, patients with pain relief (defined as no pain and no required drug intervention) at 62, 65, and 68°C accounted for 94.2%, 98.3%, and 98.8% (at discharge); 83.8%, 90.1%, and 91.4% (at 1 year); 66.7%, 80.5%, and 88.2% (at 3 years); 59.0%, 64.3%, and 77.2% (at 5 years); 48.7%, 57.8%, and 72.3% (at 7 years); 40.6%, 53.7%, and 60.3% (at 9 years), respectively. The number of patients with facial numbness, masticatory atonia, or corneal hypoesthesia was increased with the elevation of temperature, but these complications were all mild. No blindness, deafness, intracranial hemorrhage, or death as a result of the surgical intervention occurred in any patients. SF-36 scores showed highest HRQoL in the group treated at 68°C, followed by the 65 and 62°C groups, respectively.Our results demonstrate that 68°C is a good choice for RFT of V2/V3 ITN. The alternative option is 65 or 62°C for RFT to minimize the occurrence of complications including facial numbness, yet which often yields a higher recurrence rate.
Collapse
Affiliation(s)
- Peng Yao
- Department of Pain Management, Shenjing Hospital of China Medical University, Shenyang
- Correspondence: Peng Yao, Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang 110004, China (e-mail: )
| | - Yi-yong Deng
- Department of Pain Management, Siping Hospital of China Medical University (Siping Central Hospital of Jilin Province), Siping
| | - Tao Hong
- Department of Pain Management, Shenjing Hospital of China Medical University, Shenyang
| | - Zhi-bin Wang
- Department of Pain Management, Shenjing Hospital of China Medical University, Shenyang
| | - Jia-ming Ma
- Department of Pain Management, Shenjing Hospital of China Medical University, Shenyang
| | - Yong-qiang Zhu
- Department of Pain Management, Shenjing Hospital of China Medical University, Shenyang
| | - Hong-xi Li
- Department of Pain Management, Shenjing Hospital of China Medical University, Shenyang
| | - Yuan-yuan Ding
- Department of Pain Management, Shenjing Hospital of China Medical University, Shenyang
| | - Shi-nong Pan
- Department of Radiology, Shenjing Hospital of China Medical University, Shenyang, China
| |
Collapse
|
263
|
Kotecha R, Kotecha R, Modugula S, Murphy ES, Jones M, Kotecha R, Reddy CA, Suh JH, Barnett GH, Neyman G, Machado A, Nagel S, Chao ST. Trigeminal Neuralgia Treated With Stereotactic Radiosurgery: The Effect of Dose Escalation on Pain Control and Treatment Outcomes. Int J Radiat Oncol Biol Phys 2016; 96:142-8. [PMID: 27325473 DOI: 10.1016/j.ijrobp.2016.04.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 03/25/2016] [Accepted: 04/11/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To analyze the effect of dose escalation on treatment outcome in patients undergoing stereotactic radiosurgery (SRS) for trigeminal neuralgia (TN). METHODS AND MATERIALS A retrospective review was performed of 870 patients who underwent SRS for a diagnosis of TN from 2 institutions. Patients were typically treated using a single 4-mm isocenter placed at the trigeminal nerve dorsal root entry zone. Patients were divided into groups based on treatment doses: ≤82 Gy (352 patients), 83 to 86 Gy (85 patients), and ≥90 Gy (433 patients). Pain response was classified using a categorical scoring system, with fair or poor pain control representing treatment failure. Treatment-related facial numbness was classified using the Barrow Neurological Institute scale. Log-rank tests were performed to test differences in time to pain failure or development of facial numbness for patients treated with different doses. RESULTS Median age at first pain onset was 63 years, median age at time of SRS was 71 years, and median follow-up was 36.5 months from the time of SRS. A majority of patients (827, 95%) were clinically diagnosed with typical TN. The 4-year rate of excellent to good pain relief was 87% (95% confidence interval 84%-90%). The 4-year rate of pain response was 79%, 82%, and 92% in patients treated to ≤82 Gy, 83 to 86 Gy, and ≥90 Gy, respectively. Patients treated to doses ≤82 Gy had an increased risk of pain failure after SRS, compared with patients treated to ≥90 Gy (hazard ratio 2.0, P=.0007). Rates of treatment-related facial numbness were similar among patients treated to doses ≥83 Gy. Nine patients (1%) were diagnosed with anesthesia dolorosa. CONCLUSIONS Dose escalation for TN to doses >82 Gy is associated with an improvement in response to treatment and duration of pain relief. Patients treated at these doses, however, should be counseled about the increased risk of treatment-related facial numbness.
Collapse
Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Sujith Modugula
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Mark Jones
- MidMichigan Medical Center, Midland, Michigan
| | | | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gennady Neyman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Andre Machado
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sean Nagel
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.
| |
Collapse
|
264
|
Singh R, Davis J, Sharma S. Stereotactic Radiosurgery for Trigeminal Neuralgia: A Retrospective Multi-Institutional Examination of Treatment Outcomes. Cureus 2016; 8:e554. [PMID: 27182468 PMCID: PMC4858443 DOI: 10.7759/cureus.554] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives The purposes of this study are to assess the effectiveness of CyberKnife® stereotactic radiosurgery (SRS) in providing both initial and sustained pain relief for patients with both forms of trigeminal neuralgia (TN), assess potential prognostic factors, and examine treatment-related toxicities. Methods The RSSearch® Patient Registry was screened for TN cases from July 2007 to June 2015. We evaluated initial pain relief achieved by examining changes in the Visual Analog Scale (VAS) scores following SRS. Prognostic factors relating to initial pain relief and the relationship between maximum dose (Dmax) and toxicity incidence were analyzed via univariate logistic regressions. We evaluated prognostic factors relating to sustained pain relief using the Kaplan-Meier method and log-rank analysis. Results Our analysis included 125 TN1 patients and 38 TN2 patients with initial VAS scores ≥ 3 treated at 16 community radiotherapy centers. Median Dmax for both cohorts was 75 Gy with a larger range for TN1 cases (67.42 Gy - 110.29 Gy) as compared to TN2 cases (70.00 Gy - 78.48 Gy). At initial follow-up, mean VAS scores after SRS were significantly lower for TN1 and TN2 patients (p < 0.0001). The vast majority of TN1 (87.2%) and TN2 (86.8%) patients experienced initial pain relief. Higher initial VAS scores (p = 0.015) were correlated with a greater likelihood of initial treatment success for TN1 patients. We did not identify any treatment or patient characteristics that had significant effects on initial pain relief for TN2 patients. Of the TN1 cohort, 28 of 125 patients reported follow-ups one year or greater after SRS. Twenty-three of 28 TN1 patients (82%) reported VAS scores of 1 or less at one-year follow-up, and eight of 11 patients (72%) had VAS scores of 1 or less at the two-year follow-up. No potential prognostic factors for long-term pain relief were significant. Roughly 18% and 11% of TN1 and TN2 patients, respectively, experienced acute toxicities (all RTOG Grade 1 or 2), with the most common being sensory neuropathy, generalized pain, and nausea. Dmax > 75 Gy was not a predictor of toxicity incidence in TN1 cases (p = 0.597) but was significant for TN2 patients (p = 0.0009 following Fisher's exact test). Conclusions SRS is an effective treatment option for TN patients in community settings. Initial pain relief following SRS was achieved in a vast majority of TN patients with associated minor toxicities observed in less than 20% of all patients.
Collapse
Affiliation(s)
- Raj Singh
- Department of Radiation Oncology, Joan C. Edwards School of Medicine, Marshall University
| | | | - Sanjeev Sharma
- Department of Radiation Oncology, St. Mary's Medical Center
| |
Collapse
|
265
|
Ruiz-Juretschke F, Vargas AJ, Gonzalez-Quarante LH, Gil de Sagredo OL, Montalvo A, Fernandez-Carballal C. Microsurgical treatment of trigeminal neuralgia in patients older than 70 years: An efficacy and safety study. Neurologia 2016; 32:424-430. [PMID: 26968821 DOI: 10.1016/j.nrl.2016.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 01/25/2016] [Accepted: 01/26/2016] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION The increasing incidence of trigeminal neuralgia (TN) with age together with population ageing call for reexamination of surgical treatment options for refractory TN in elderly patients. METHODS Retrospective review of a consecutive series of patients older than 70 who underwent microvascular decompression (MVD) for refractory TN between 1997 and 2015. Outcomes based on the Barrow Neurological Institute pain intensity score (BNI score) and surgical complications were compared to those of patients younger than 70 undergoing MVD in the same period. RESULTS Forty patients older than 70 (mean = 74.8 years) underwent interventions. At a mean follow-up time of 34 months, 73% of the patients presented complete absence of pain without medication (BNI I) and 85% had good pain control with or without medication (BNI I-III). A comparison of these patients with the 85 patients younger than 70 treated surgically during the same period did not find a significant association between age and achievement of pain control (BNI I-II). However, there was a significant association between age older than 70 and complete pain relief (BNI I; P=.03). The mean hospital stay in patients over 70 was also significantly longer (P=.04), although the postsurgical complication rate was similar to that in younger patients. CONCLUSIONS Elderly patients with refractory TN may benefit from treatment with MVD and the probability of success and surgical risk are comparable to those in younger patients.
Collapse
Affiliation(s)
- F Ruiz-Juretschke
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - A J Vargas
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - L H Gonzalez-Quarante
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - O L Gil de Sagredo
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - A Montalvo
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - C Fernandez-Carballal
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España
| |
Collapse
|
266
|
Régis J, Tuleasca C, Resseguier N, Carron R, Donnet A, Yomo S, Gaudart J, Levivier M. The Very Long-Term Outcome of Radiosurgery for Classical Trigeminal Neuralgia. Stereotact Funct Neurosurg 2016; 94:24-32. [DOI: 10.1159/000443529] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 12/21/2015] [Indexed: 11/19/2022]
|
267
|
Park SC, Kwon DH, Lee DH, Lee JK. Repeat Gamma-Knife Radiosurgery for Refractory or Recurrent Trigeminal Neuralgia with Consideration About the Optimal Second Dose. World Neurosurg 2016; 86:371-83. [DOI: 10.1016/j.wneu.2015.08.056] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 08/15/2015] [Accepted: 08/18/2015] [Indexed: 11/17/2022]
|
268
|
Cordero Tous N, Cruz Sabido JDL, Román Cutillas AM, Saura Rojas EJ, Jorques Infante AM, Olivares Granados G. Outcome of radiosurgery treatment with a linear accelerator in patients with trigeminal neuralgia. Neurologia 2015; 32:166-174. [PMID: 26699209 DOI: 10.1016/j.nrl.2015.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 09/29/2015] [Accepted: 10/09/2015] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION An overview of the effectiveness of radiosurgery in patients diagnosed with trigeminal neuralgia with an analysis of potential predictors of good outcome. METHODS All patients treated with linear accelerator radiosurgery between 2004 and 2011 were analysed. A dose of 60Gy dose was administered 1 to 2mm from the root entry zone with a maximum isodose of 20% delivered to the brainstem. Clinical results for pain control and any side effects were analysed at 12 and 36 months (BNI score). RESULTS The study included 71 patients (mean follow-up 50.5 months). Pain improvement at 12 months was observed in 68.11% of the total (28.98% with BNI score i-ii; 39.12% with BNI score iii) and at 36 months in 58.21% (23.88% BNI score i-ii; 34.32% BNI score iii). Average recovery time was 3.69 months and the relapse rate was 44.68%. Patients with typical pain displayed statistically significant differences in improvement rates at 12 and at 36 months (P<047 and P<.002). Onset of improvement was analysed using Kaplan-Meyer plots. Statistically significant differences were observed between patients with typical and atypical pain at 36 months (P<.012) in Kaplan-Meyer plots. Side effects were recorded in 15 patients (20.89%), including 9 cases of facial numbness (13.43%); only 2 cases were clinically relevant (2.98%). CONCLUSION According to our results, radiosurgery is an effective treatment for trigeminal neuralgia, with few side effects. Typical pain seems to be a good predictor of pain relief.
Collapse
Affiliation(s)
- N Cordero Tous
- Servicio de Neurocirugía, Complejo Hospitalario de Jaén, Hospital Neurotraumatológico, Jaén, España.
| | - J de la Cruz Sabido
- Servicio de Neurocirugía, Hospital Universitario Virgen de las Nieves, Hospital de Rehabilitación y Traumatología, Granada, España
| | - A M Román Cutillas
- Servicio de Neurocirugía, Hospital Universitario Virgen de las Nieves, Hospital de Rehabilitación y Traumatología, Granada, España
| | - E J Saura Rojas
- Servicio de Neurocirugía, Hospital Universitario Virgen de las Nieves, Hospital de Rehabilitación y Traumatología, Granada, España
| | - A M Jorques Infante
- Servicio de Neurocirugía, Hospital Universitario Virgen de las Nieves, Hospital de Rehabilitación y Traumatología, Granada, España
| | - G Olivares Granados
- Servicio de Neurocirugía, Hospital Universitario Virgen de las Nieves, Hospital de Rehabilitación y Traumatología, Granada, España
| |
Collapse
|
269
|
Helis CA, Lucas JT, Bourland JD, Chan MD, Tatter SB, Laxton AW. Repeat Radiosurgery for Trigeminal Neuralgia. Neurosurgery 2015; 77:755-61; discussion 761. [PMID: 26214319 PMCID: PMC11177231 DOI: 10.1227/neu.0000000000000915] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND Repeat Gamma Knife radiosurgery (GKRS) is an established option for patients whose pain has recurred after the initial procedure, with reported success rates varying from 68% to 95%. Predictive factors for response to the repeat GKRS are ill-defined. OBJECTIVE This cohort study aimed to report the outcomes and factors predictive of success for patients who have undergone repeated GKRS for trigeminal neuralgia at Wake Forest University Baptist Medical Center. METHODS Between 1999 and 2013, 152 patients underwent repeat GKRS at Wake Forest, 125 of whom were available for long-term follow-up. A retrospective chart review and telephone interviews were conducted to determine background medical history, dosimetric data, outcomes, and adverse effects of the procedure. RESULTS Eighty-four percent of patients achieved at least Barrow Neurological Institute (BNI) IIIb pain relief, with 46% achieving BNI I. The 1-, 3-, and 5-year rates of BNI I pain relief were 63%, 50%, and 37%, respectively. The 1-, 3-, and 5-year rates of BNI IIIb or better pain relief were 74%, 59%, and 46%, respectively. One patient experienced bothersome numbness and 2 patients developed anesthesia dolorosa. The dominant predictive factors for pain relief were facial numbness after the first GKRS and a positive pain response to the first GKRS. CONCLUSION Repeat GKRS is an effective method of treating recurrent trigeminal neuralgia. Patients who have facial numbness after the first treatment and a positive pain response to the first GKRS are significantly more likely to respond well to the second treatment.
Collapse
Affiliation(s)
- Corbin A. Helis
- Departments of Neurosurgery, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - John T. Lucas
- Departments of Radiation Oncology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - J. Daniel Bourland
- Departments of Radiation Oncology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Michael D. Chan
- Departments of Radiation Oncology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Stephen B. Tatter
- Departments of Neurosurgery, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Adrian W. Laxton
- Departments of Neurosurgery, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
270
|
Régis J, Tuleasca C, Resseguier N, Carron R, Donnet A, Gaudart J, Levivier M. Long-term safety and efficacy of Gamma Knife surgery in classical trigeminal neuralgia: a 497-patient historical cohort study. J Neurosurg 2015; 124:1079-87. [PMID: 26339857 DOI: 10.3171/2015.2.jns142144] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife surgery (GKS) is one of the surgical alternatives for the treatment of drug-resistant trigeminal neuralgia (TN). This study aims to evaluate the safety and efficacy of GKS in a large population of patients with TN with very long-term clinical follow-up. METHODS Between July 1992 and November 2010, 737 patients presenting with TN were treated using GKS. Data were collected prospectively and were further retrospectively evaluated at Timone University Hospital. The frequency and severity of pain, as well as trigeminal nerve function, were evaluated before GKS and regularly thereafter. Radiosurgery using the Gamma Knife (model B, C, 4C, or Perfexion) was performed with the help of both MR and CT targeting. A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range 4-14 mm) anterior to the emergence of the nerve (retrogasserian target). A median maximum dose of 85 Gy (range 70-90 Gy) was prescribed. RESULTS The safety and efficacy are reported for 497 patients with medically refractory classical TN who were never previously treated by GKS and had a follow-up of at least 1 year. The median age in this series was 68.3 years (range 28.1-93.2 years). The median follow-up period was 43.8 months (range 12-174.4 months). Overall, 456 patients (91.75%) were initially pain free in a median time of 10 days (range 1-180 days). Their actuarial probabilities of remaining pain free without medication at 3, 5, 7, and 10 years were 71.8%, 64.9%, 59.7%, and 45.3%, respectively. One hundred fifty-seven patients (34.4%) who were initially pain free experienced at least 1 recurrence, with a median delay of onset of 24 months (range 0.6-150.1 months). However, the actuarial rate of maintaining pain relief without further surgery was 67.8% at 10 years. The hypesthesia actuarial rate at 5 years was 20.4% and at 7 years reached 21.1%, but remained stable until 14 years with a median delay of onset of 12 months (range 1-65 months). Very bothersome facial hypesthesia was reported in only 3 patients (0.6%). CONCLUSIONS Retrogasserian GKS proved to be safe and effective in the long term and in a very large number of patients. Even if the probability of long-lasting effects may be modest compared with microvascular decompression, the rarity of complications prompts discussion of using GKS as the pragmatic surgical first- or second-intention alternative for classical TN. However, a randomized trial, or at least a case-matched control study, would be required to compare with microvascular decompression.
Collapse
Affiliation(s)
- Jean Régis
- Functional and Stereotactic Neurosurgery Service and Gamma Knife Unit, Centre Hospitalier Universitaire La Timone Assistance Publique-Hopitaux de Marseille, Université de la Méditerranée, Marseille, France
| | - Constantin Tuleasca
- Functional and Stereotactic Neurosurgery Service and Gamma Knife Unit, Centre Hospitalier Universitaire La Timone Assistance Publique-Hopitaux de Marseille, Université de la Méditerranée, Marseille, France;,Signal Processing Laboratory (LTS-5), Swiss Federal Institute of Technology, Lausanne, Switzerland;,Medical Image Analysis Laboratory, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland;,Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; and.,Faculty of Biology and Medicine, University of Lausanne, Switzerland
| | - Noémie Resseguier
- Department of Public Health and Medical Information, Centre Hospitalier Universitaire La Timone, Assistance Publique-Hopitaux de Marseille, France
| | - Romain Carron
- Functional and Stereotactic Neurosurgery Service and Gamma Knife Unit, Centre Hospitalier Universitaire La Timone Assistance Publique-Hopitaux de Marseille, Université de la Méditerranée, Marseille, France
| | - Anne Donnet
- Department of Neurology, Clinical Neuroscience Federation, Centre Hospitalier Universitaire La Timone Assistance Publique-Hopitaux de Marseille, France
| | - Jean Gaudart
- Department of Public Health and Medical Information, Centre Hospitalier Universitaire La Timone, Assistance Publique-Hopitaux de Marseille, France
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; and.,Faculty of Biology and Medicine, University of Lausanne, Switzerland
| |
Collapse
|
271
|
Lai GH, Tang YZ, Wang XP, Qin HJ, Ni JX. CT-Guided Percutaneous Radiofrequency Thermocoagulation for Recurrent Trigeminal Neuralgia After Microvascular Decompression: A Cohort Study. Medicine (Baltimore) 2015; 94:e1176. [PMID: 26266350 PMCID: PMC4616680 DOI: 10.1097/md.0000000000001176] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This article evaluates the long-term outcomes of computed tomography (CT)-guided percutaneous radiofrequency thermocoagulation (PRT) for patients with recurrent trigeminal neuralgia (TN) after microvascular decompression (MVD).This is a retrospective study of 41 patients with intractable TN who after MVD underwent CT-guided PRT procedures between 2002 and 2012.The mean length of follow-up after PRT was 44.4 months. Immediate pain relief was in 37 patients (90.2%); the percentage of patients who remained in "excellent" or "good" pain relief condition after CT-guided PRT procedure was 85% at 1 year, 80% at 2 years, 51% at 5 years, and 41% at 10 years. Six patients received the second PRT and all achieved "excellent" or "good" pain relief. In total, 34 of these patients (82.9%) received multi-PRT procedure and remained satisfied with their pain relief during the follow-up period. Postoperative complications included facial numbness in 36 patients, limited eyes opening in 1 patient, ear paresthesia in 1 patient, no tears in 1 patient, and taste hypesthesia in 1 patient; these symptoms were all improved in the process of follow-up and their life had not severely affected. No mortality was observed during and after CT-guided PRT procedures.CT-guided PRT should be considered as an alternative treatment for patients with recurrent TN after MVD.
Collapse
Affiliation(s)
- Guang-Hui Lai
- From the Department of Pain Management (G-HL, Y-ZT, X-PW, J-XN), Xuanwu Hospital, Capital Medical University; and Department of Radiology (H-JQ), Beijing Electric Power Hospital, Beijing, China
| | | | | | | | | |
Collapse
|
272
|
Ibrahim TF, Garst JR, Burkett DJ, Toia GV, Braca JA, Hill JP, Anderson DE. Microsurgical Pontine Descending Tractotomy in Cases of Intractable Trigeminal Neuralgia. Oper Neurosurg (Hagerstown) 2015; 11:518-529. [DOI: 10.1227/neu.0000000000000926] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 06/22/2015] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Current treatment strategies in patients with trigeminal neuralgia (TN) include trials of medical therapy and surgical intervention, when necessary. In some patients, pain is not adequately managed with these existing strategies.
OBJECTIVE
To present a novel technique, ventral pontine trigeminal tractotomy via retrosigmoid craniectomy, as an adjunct treatment in TN when there is no significant neurovascular compression.
METHODS
We present a nonrandomized retrospective comparison between 50 patients who lacked clear or impressive arterial neurovascular compression of the trigeminal nerve as judged by preoperative magnetic resonance imaging and intraoperative observations. These patients had intractable TN unresponsive to previous treatment. Trigeminal tractotomy was performed either alone or in conjunction with microvascular decompression. Stereotactic neuronavigation was used during surgery to localize the descending tract via a ventral pontine approach for descending tractotomy.
RESULTS
Follow-up was a mean of 44 months. At first follow-up, 80% of patients experienced complete relief of their pain, and 18% had partial relief. At the most recent follow-up, 74% of patients were considered a successful outcome. Only 1 (2%) patient had no relief after trigeminal tractotomy. Of those with multiple sclerosis-related TN, 87.5% experienced successful relief of pain at their latest follow-up.
CONCLUSION
While patient selection is a significant challenge, this procedure represents an option for patients with TN who have absent or equivocal neurovascular compression, multiple sclerosis-related TN, or recurrent TN.
Collapse
Affiliation(s)
- Tarik F Ibrahim
- Department of Neurological Surgery at Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois
| | - Jonathan R Garst
- Department of Neurological Surgery at Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois
| | - Daniel J Burkett
- Department of Neurological Surgery at Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois
| | - Giuseppe V Toia
- Department of Neurological Surgery at Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois
| | - John A Braca
- Department of Neurological Surgery at Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois
| | - Jacquelyn P Hill
- Department of Neurological Surgery at Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois
| | - Douglas E Anderson
- Department of Neurological Surgery at Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois
| |
Collapse
|
273
|
Duan Y, Sweet J, Munyon C, Miller J. Degree of distal trigeminal nerve atrophy predicts outcome after microvascular decompression for Type 1a trigeminal neuralgia. J Neurosurg 2015; 123:1512-8. [PMID: 26186027 DOI: 10.3171/2014.12.jns142086] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECT Trigeminal neuralgia is often associated with nerve atrophy, in addition to vascular compression. The authors evaluated whether cross-sectional areas of different portions of the trigeminal nerve on preoperative imaging could be used to predict outcome after microvascular decompression (MVD). METHODS A total of 26 consecutive patients with unilateral Type 1a trigeminal neuralgia underwent high-resolution fast-field echo MRI of the cerebellopontine angle followed by MVD. Preoperative images were reconstructed and reviewed by 2 examiners blinded to the side of symptoms and clinical outcome. For each nerve, a computerized automatic segmentation algorithm was used to calculate the coronal cross-sectional area at the proximal nerve near the root entry zone and the distal nerve at the exit from the porus trigeminus. Findings were correlated with outcome at 12 months. RESULTS After MVD, 17 patients were pain free and not taking medications compared with 9 with residual pain. Across all cases, the coronal cross-sectional area of the symptomatic trigeminal nerve was significantly smaller than the asymptomatic side in the proximal part of the nerve, which was correlated with degree of compression at surgery. Atrophy of the distal trigeminal nerve was more pronounced in patients who had residual pain than in those with excellent outcome. Among the 7 patients who had greater than 20% loss of nerve volume in the distal nerve, only 2 were pain free and not taking medications at long-term follow-up. CONCLUSIONS Trigeminal neuralgia is associated with atrophy of the root entry zone of the affected nerve compared with the asymptomatic side, but volume loss in different segments of the nerve has very different prognostic implications. Proximal atrophy is associated with vascular compression and correlates with improved outcome following MVD. However, distal atrophy is associated with a significantly worse outcome after MVD.
Collapse
Affiliation(s)
- Yifei Duan
- Case Western Reserve University School of Medicine; and
| | - Jennifer Sweet
- Department of Neurological Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Charles Munyon
- Department of Neurological Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Jonathan Miller
- Department of Neurological Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| |
Collapse
|
274
|
Daugherty E, Bhavsar S, Hahn SS, Bassano D, Hall W. A successful case of multiple stereotactic radiosurgeries for ipsilateral recurrent trigeminal neuralgia. J Neurosurg 2015; 122:1324-9. [PMID: 25816083 DOI: 10.3171/2014.9.jns13959] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Trigeminal neuralgia is a common pain syndrome primarily managed medically, although many patients require surgical or radiotherapeutic intervention. Stereotactic radiosurgery has become a preferred method of treatment given its high efficacy rates and relatively favorable toxicity profile. However, many patients have refractory pain even after repeat courses of stereotactic radiosurgery. Historically, 2 courses have been the limit in such patients. The authors present a case of multiply recurrent trigeminal neuralgia treated with a third course of radiosurgery in which the patient had successful pain control and no additional toxicity. Meticulous attention to the therapeutic technique allows the continued application of stereotactic radiosurgery in patients.
Collapse
Affiliation(s)
| | - Shripal Bhavsar
- 2Department of Radiation Oncology, Integris Cancer Institute, Oklahoma City, Oklahoma
| | | | | | - Walter Hall
- 3Neurosurgery, SUNY Upstate Medical University, Syracuse, New York; and
| |
Collapse
|
275
|
Tuleasca C, Carron R, Resseguier N, Donnet A, Roussel P, Gaudart J, Levivier M, Régis J. Decreased Probability of Initial Pain Cessation in Classic Trigeminal Neuralgia Treated With Gamma Knife Surgery in Case of Previous Microvascular Decompression. Neurosurgery 2015; 77:87-94; discussion 94-5. [DOI: 10.1227/neu.0000000000000739] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Microvascular decompression (MVD) is the reference technique for pharmacoresistant trigeminal neuralgia (TN).
OBJECTIVE:
To establish whether the safety and efficacy of Gamma Knife surgery for recurrent TN are influenced by prior MVD.
METHODS:
Between July 1992 and November 2010, 54 of 737 patients (45 of 497 with >1 year of follow-up) had a history of MVD (approximately half also with previous ablative procedure) and were operated on with Gamma Knife surgery for TN in the Timone University Hospital. A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range, 3.9–11.9 mm) anterior to the emergence of the nerve. A median maximum dose of 85 Gy (range, 70–90 Gy) was delivered.
RESULTS:
The median follow-up time was 39.5 months (range, 14.1–144.6 months). Thirty-five patients (77.8%) were initially pain free in a median time of 14 days (range, 0–180 days), much lower compared with our global population of classic TN (P = .01). Their actuarial probabilities of remaining pain-free without medication at 3, 5, 7, and 10 years were 66.5%, 59.1%, 59.1%, and 44.3%. The hypoesthesia actuarial rate at 1 year was 9.1% and remained stable until 12 years (median, 8 months).
CONCLUSION:
Patients with previous MVD showed a significantly lower probability of initial pain cessation compared with our global population with classic TN (P = .01). The toxicity was low (only 9.1% hypoesthesia); furthermore, no patient reported bothersome hypoesthesia. However, the probability of maintaining pain relief without medication was 44.3% at 10 years, similar to our global series of classic TN (P = .85).
Collapse
Affiliation(s)
- Constantin Tuleasca
- Functional and Stereotactic Neurosurgery Unit, Centre Hospitalier Universitaire La Timone, Assistance Publique-Hopitaux de Marseille, Université de la Méditerranée, INSERM U 751, Marseille, France
- Signal Processing Laboratory (LTS 5), Swiss Federal Institute of Technology, Lausanne, Switzerland
- Medical Image Analysis Laboratory, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- Centre Hospitalier Universitaire Vaudois, Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne, Switzerland
- University of Lausanne, Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Romain Carron
- Functional and Stereotactic Neurosurgery Unit, Centre Hospitalier Universitaire La Timone, Assistance Publique-Hopitaux de Marseille, Université de la Méditerranée, INSERM U 751, Marseille, France
| | - Noémie Resseguier
- University of Lausanne, Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Anne Donnet
- Department of Neurology, Clinical Neuroscience Federation, Centre Hospitalier Universitaire La Timone Assistance Publique-Hopitaux de Marseille, Marseille, France
| | - Philippe Roussel
- Department of Neurology, Clinical Neuroscience Federation, Centre Hospitalier Universitaire La Timone Assistance Publique-Hopitaux de Marseille, Marseille, France
| | - Jean Gaudart
- Department of Public Health and Medical Information, Centre Hospitalier Universitaire La Timone Assistance Publique-Hopitaux de Marseille, UMR 912 (INSERM-IRD-Université de la Méditerranée), Marseille, France
| | - Marc Levivier
- Centre Hospitalier Universitaire Vaudois, Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne, Switzerland
- University of Lausanne, Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Jean Régis
- Functional and Stereotactic Neurosurgery Unit, Centre Hospitalier Universitaire La Timone, Assistance Publique-Hopitaux de Marseille, Université de la Méditerranée, INSERM U 751, Marseille, France
| |
Collapse
|
276
|
Ko AL, Ozpinar A, Lee A, Raslan AM, McCartney S, Burchiel KJ. Long-term efficacy and safety of internal neurolysis for trigeminal neuralgia without neurovascular compression. J Neurosurg 2015; 122:1048-57. [PMID: 25679283 DOI: 10.3171/2014.12.jns14469] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECT Trigeminal neuralgia (TN) occurs and recurs in the absence of neurovascular compression (NVC). While microvascular decompression (MVD) is the most effective treatment for TN, it is not possible when NVC is not present. Therefore, the authors sought to evaluate the safety, efficacy, and durability of internal neurolysis (IN), or "nerve combing," as a treatment for TN without NVC. METHODS This was a retrospective review of all cases of Type 1 TN involving all patients 18 years of age or older who underwent evaluation (and surgery when appropriate) at Oregon Health & Science University between July 2006 and February 2013. Chart reviews and telephone interviews were conducted to assess patient outcomes. Pain intensity was evaluated with the Barrow Neurological Institute (BNI) Pain Intensity scale, and the Brief Pain Inventory-Facial (BPI-Facial) was used to assess general and face-specific activity. Pain-free survival and durability of successful pain relief (BNI pain scores of 1 or 2) were statistically evaluated with Kaplan-Meier analysis. Prognostic factors were identified and analyzed using Cox proportional hazards regression. RESULTS A total of 177 patients with Type 1 TN were identified. A subgroup of 27 was found to have no NVC on high-resolution MRI/MR angiography or at surgery. These patients were significantly younger than patients with classic Type 1 TN. Long-term follow-up was available for 26 of 27 patients, and 23 responded to the telephone survey. The median follow-up duration was 43.4 months. Immediate postoperative results were comparable to MVD, with 85% of patients pain free and 96% of patients with successful pain relief. At 1 year and 5 years, the rate of pain-free survival was 58% and 47%, respectively. Successful pain relief at those intervals was maintained in 77% and 72% of patients. Almost all patients experienced some degree of numbness or hypesthesia (96%), but in patients with successful pain relief, this numbness did not significantly impact their quality of life. There was 1 patient with a CSF leak and 1 patient with anesthesia dolorosa. Previous treatment for TN was identified as a poor prognostic factor for successful outcome. CONCLUSIONS This is the first report of IN with meaningful outcomes data. This study demonstrated that IN is a safe, effective, and durable treatment for TN in the absence of NVC. Pain-free outcomes with IN appeared to be more durable than radiofrequency gangliolysis, and IN appears to be more effective than stereotactic radiosurgery, 2 alternatives to posterior fossa exploration in cases of TN without NVC. Given the younger age distribution of patients in this group, consideration should be given to performing IN as an initial treatment. Accrual of further outcomes data is warranted.
Collapse
Affiliation(s)
- Andrew L Ko
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | | | | | | | | | | |
Collapse
|
277
|
Masuoka J, Matsushima T, Inoue K, Nakahara Y, Takase Y, Kawashima M. Outcome of microvascular decompression for trigeminal neuralgia treated with the stitched sling retraction technique. Neurosurg Rev 2015; 38:361-5; discussion 365. [DOI: 10.1007/s10143-015-0607-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/23/2014] [Accepted: 11/16/2014] [Indexed: 12/01/2022]
|
278
|
Hung YC, Lee CC, Liu KD, Chung WY, Pan DHC, Yang HC. Radiosurgery target location and individual anatomical variation in trigeminal nerves. J Neurosurg 2015; 121 Suppl:203-9. [PMID: 25434954 DOI: 10.3171/2014.7.gks141432] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors evaluated individual anatomical variations in the trigeminal nerves of patients with medically intractable trigeminal neuralgia and clarified the relationships among the variations, radiosurgical target locations, and the clinical outcomes after high-dose Gamma Knife surgery (GKS). METHODS From 2006 through 2011, the authors conducted a retrospective review of 106 cases of primary or secondary trigeminal neuralgia consecutively treated with GKS targeting the dorsal root entry zone (DREZ) for which a maximal dose of 90 Gy and a 20% isodose line to the brainstem were used. A questionnaire was used to evaluate patients' pre- and post-GKS clinical conditions. To evaluate individual anatomical variations among trigeminal nerves, the authors used 3 parameters: the length of the trigeminal nerve in the cistern (nerve length), the length of the target between the radiation shot and the brainstem (targeting length), and the ratio between nerve length and targeting length (targeting ratio). RESULTS The median length of the trigeminal nerves in the 106 patients was 9.6 mm (range 6.04-20.74 mm), the median targeting length was 3.8 mm (range 1.81-10.84 mm), and the median targeting ratio was 38% (range 13%- 80%). No statistically significant differences in pain relief and pain recurrence were detected among patients with these various nerve characteristics. However, radiation-induced facial hypesthesia correlated with nerve length and targeting ratio (p < 0.05) but not with absolute distance from the brainstem (targeting length). CONCLUSIONS In trigeminal neuralgia patients who received DREZ-targeted GKS, the rate of pain relief did not differ according to anatomical nerve variations. However, the frequency of facial hypesthesia was higher among patients in whom the nerve was longer (> 11 mm) or the targeting ratio was lower (< 36%). Adjusting the target according to the targeting ratio, especially for patients with longer nerves, can reduce facial hypesthesia and enable maintenance of effective pain control.
Collapse
Affiliation(s)
- Yi-Chieh Hung
- Division of Neurosurgery, Department of Surgery, Chi-Mei Foundation Hospital, Tainan
| | | | | | | | | | | |
Collapse
|
279
|
Somaza S, Hurtado W, Montilla E, Ghaleb J. Gamma knife radiosurgery to the trigeminal ganglion for treatment of trigeminal neuralgia secondary to vertebrobasilar ectasia. Surg Neurol Int 2015; 5:S580-5. [PMID: 25593782 PMCID: PMC4287894 DOI: 10.4103/2152-7806.148056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 09/09/2014] [Indexed: 11/17/2022] Open
Abstract
Background: We report the result obtained using Gamma knife stereotactic radiosurgery on the trigeminal ganglion (TG) in a patient with trigeminal neuralgia (TN) secondary to vertebrobasilar ectasia (VBE). Case Description: Retrospective review of medical records corresponding to one patient with VBE-related trigeminal pain treated with radiosurgery. Because of the impossibility of visualization of the entry zone or the path of trigeminal nerve through the pontine cistern, we proceeded with stereotactic radiosurgery directed to the TG. The maximum radiation dose was 86 Gy with a 8-mm and a 4-mm collimator. The follow-up period was 24 months. The pain disappeared in 15 days, passing from Barrow Neurological Institute (BNI) grade V to BNI grade IIIa in 4 months and then to grade I. The patient did not experience noticeable subjective facial numbness. Conclusions: This experience showed that Gamma knife radiosurgery was effective in the management of VBE-related trigeminal pain, using the TG as radiosurgical target.
Collapse
Affiliation(s)
- Salvador Somaza
- Unit of Gamma Knife Radiosurgery, CDD Las Mercedes, Hospital de Clinicas Caracas, Caracas, Venezuela
| | - Wendy Hurtado
- Unit of Gamma Knife Radiosurgery, CDD Las Mercedes, Hospital de Clinicas Caracas, Caracas, Venezuela
| | - Eglee Montilla
- Unit of Gamma Knife Radiosurgery, CDD Las Mercedes, Hospital de Clinicas Caracas, Caracas, Venezuela
| | - Jose Ghaleb
- Unit of Gamma Knife Radiosurgery, CDD Las Mercedes, Hospital de Clinicas Caracas, Caracas, Venezuela
| |
Collapse
|
280
|
Tempel ZJ, Chivukula S, Monaco EA, Bowden G, Kano H, Niranjan A, Chang EF, Sneed PK, Kaufmann AM, Sheehan J, Mathieu D, Lunsford LD. The results of a third Gamma Knife procedure for recurrent trigeminal neuralgia. J Neurosurg 2015; 122:169-79. [DOI: 10.3171/2014.9.jns132779] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Gamma Knife radiosurgery (GKRS) is the least invasive treatment option for medically refractory, intractable trigeminal neuralgia (TN) and is especially valuable for treating elderly, infirm patients or those on anticoagulation therapy. The authors reviewed pain outcomes and complications in TN patients who required 3 radiosurgical procedures for recurrent or persistent pain.
METHODS
A retrospective review of all patients who underwent 3 GKRS procedures for TN at 4 participating centers of the North American Gamma Knife Consortium from 1995 to 2012 was performed. The Barrow Neurological Institute (BNI) pain score was used to evaluate pain outcomes.
RESULTS
Seventeen patients were identified; 7 were male and 10 were female. The mean age at the time of last GKRS was 79.6 years (range 51.2–95.6 years). The TN was Type I in 16 patients and Type II in 1 patient. No patient suffered from multiple sclerosis. Eight patients (47.1%) reported initial complete pain relief (BNI Score I) following their third GKRS and 8 others (47.1%) experienced at least partial relief (BNI Scores II–IIIb). The average time to initial response was 2.9 months following the third GKRS. Although 3 patients (17.6%) developed new facial sensory dysfunction following primary GKRS and 2 patients (11.8%) experienced new or worsening sensory disturbance following the second GKRS, no patient sustained additional sensory disturbances after the third procedure. At a mean follow-up of 22.9 months following the third GKRS, 6 patients (35.3%) reported continued Score I complete pain relief, while 7 others (41.2%) reported pain improvement (BNI Scores II–IIIb). Four patients (23.5%) suffered recurrent TN following the third procedure at a mean interval of 19.1 months.
CONCLUSIONS
A third GKRS resulted in pain reduction with a low risk of additional complications in most patients with medically refractory and recurrent, intractable TN. In patients unsuitable for other microsurgical or percutaneous strategies, especially those receiving long-term oral anticoagulation or antiplatelet agents, GKRS repeated for a third time was a satisfactory, low risk option.
Collapse
Affiliation(s)
- Zachary J. Tempel
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | | | - Edward A. Monaco
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | - Greg Bowden
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | - Hideyuki Kano
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | - Ajay Niranjan
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | | | - Penny K. Sneed
- 4Radiation Oncology, University of California, San Francisco, California
| | - Anthony M. Kaufmann
- 5Department of Neurological Surgery, University of Manitoba Health Sciences Centre, Winnipeg, Manitoba; and
| | - Jason Sheehan
- 6Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - David Mathieu
- 7Department of Neurological Surgery, Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada
| | - L. Dade Lunsford
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| |
Collapse
|
281
|
Sandhu SK, Halpern CH, Vakhshori V, Mirsaeedi-Farahani K, Farrar JT, Lee JYK. Brief Pain Inventory–Facial minimum clinically important difference. J Neurosurg 2015; 122:180-90. [DOI: 10.3171/2014.8.jns132547] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Neurosurgeons are frequently the primary physicians measuring pain relief in patients with trigeminal neuralgia (TN). Unfortunately, the measurement of pain can be complex. The Brief Pain Inventory–Facial (BPI-Facial) is a reliable and validated multidimensional tool that consists of 18 questions. It measures 3 domains of pain: 1) pain intensity (worst and average pain intensity), 2) interference with general activities of daily living (ADL), and 3) face-specific pain interference. The objective of this paper is to determine the patient-reported minimum clinically important difference (MCID) using the BPI-Facial.
METHODS
The authors conducted a retrospective study of 234 patients with TN seen in a single neurosurgeon's office. Patients completed baseline and 1-month follow-up BPI-Facial questionnaires. The MCID was calculated using an anchor-based approach in which the defined anchor was the 7-point patient global impression of change (PGIC). Two statistical methods were employed: mean change score and optimal cutoff point.
RESULTS
Using the mean change score method, the investigators calculated the MCID for the 3 domains of the BPIFacial: 44% and 30% improvement in pain intensity at its worst and average, respectively, 54% improvement in interference with general ADL, and 63% improvement in interference with facial ADL. Using the optimal cutoff point method, they also calculated the MCID for the 3 domains of the BPI-Facial: 57% and 28% improvement in pain intensity at its worst and average, respectively, 75% improvement in interference with general ADL, and 62% improvement in interference with facial ADL.
CONCLUSIONS
The BPI-Facial is a multidimensional pain scale that measures 3 domains of pain. Although 2 statistical methods were used to calculate the MCID, the optimal cutoff point method was the superior one because it used data from the majority of subjects included in this study. A 57% improvement in pain intensity at its worst and a 28% improvement in pain intensity at its average were the MCIDs for patients with facial pain. A greater improvement was needed to achieve the MCID for interference with general and facial ADL. A 75% improvement in interference with general ADL and a 62% improvement in interference with facial ADL were needed to achieve an MCID. While pain intensity is easier to measure, pain's interference with ADL may be more important for patient outcomes when designing or evaluating interventions in the field of TN. The BPI-Facial is a useful instrument to measure changes in multidimensional aspects of pain in patients with TN.
Collapse
Affiliation(s)
| | | | | | | | - John T. Farrar
- 2Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | |
Collapse
|
282
|
Tuleasca C, Carron R, Resseguier N, Donnet A, Roussel P, Gaudart J, Levivier M, Régis J. Repeat Gamma Knife surgery for recurrent trigeminal neuralgia: long-term outcomes and systematic review. J Neurosurg 2014; 121 Suppl:210-21. [DOI: 10.3171/2014.8.gks141487] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectThe purpose of this study was to establish the safety and efficacy of repeat Gamma Knife surgery (GKS) for recurrent trigeminal neuralgia (TN).MethodsUsing the prospective database of TN patients treated with GKS in Timone University Hospital (Marseille, France), data were analyzed for 737 patients undergoing GKS for TN Type 1 from July 1992 to November 2010. Among the 497 patients with initial pain cessation, 34.4% (157/456 with ≥ 1-year follow-up) experienced at least 1 recurrence. Thirteen patients (1.8%) were considered for a second GKS, proposed only if the patients had good and prolonged initial pain cessation after the first GKS, with no other treatment alternative at the moment of recurrence. As for the first GKS, a single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range 4–14 mm) anterior to the emergence of the nerve (retrogasserian target). A median maximum dose of 90 Gy (range 70–90 Gy) was delivered. Data for 9 patients with at least 1-year followup were analyzed. A systematic review of literature was also performed, and results are compared with those of the Marseille study.ResultsThe median time to retreatment in the Marseille study was 72 months (range 12–125 months) and in the literature it was 17 months (range 3–146 months). In the Marseille study, the median follow-up period was 33.9 months (range 12–96 months), and 8 of 9 patients (88.9%) had initial pain cessation with a median of 6.5 days (range 1–180 days). The actuarial rate for new hypesthesia was 33.3% at 6 months and 50% at 1 year, which remained stable for 7 years. The actuarial probabilities of maintaining pain relief without medication at 6 months and 1 year were 100% and 75%, respectively, and remained stable for 7 years. The systematic review analyzed 20 peer-reviewed studies reporting outcomes for repeat GKS for recurrent TN, with a total of 626 patients. Both the selection of the cases for retreatment and the way of reporting outcomes vary widely among studies, with a median rate for initial pain cessation of 88% (range 60%–100%) and for new hypesthesia of 33% (range 11%–80%).ConclusionsResults from the Marseille study raise the question of surgical alternatives after failed GKS for TN. The rates of initial pain cessation and recurrence seem comparable to, or even better than, those of the first GKS, according to different studies, but toxicity is much higher, both in the Marseille study and in the published data. Neither the Marseille study data nor literature data answer the 3 cardinal questions regarding repeat radiosurgery in recurrent TN: which patients to retreat, which target is optimal, and which dose to use.
Collapse
Affiliation(s)
- Constantin Tuleasca
- 1INSERM U 751 (Université de la Méditerranée), Functional and Stereotactic Neurosurgery Unit
- 4Signal Processing Laboratory (LTS 5), École polytechnique fédérale de Lausanne
- 5Medical Image Analysis Laboratory
- 6Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois; and
- 7Faculty of Biology and Medicine, University of Lausanne, Switzerland
| | - Romain Carron
- 1INSERM U 751 (Université de la Méditerranée), Functional and Stereotactic Neurosurgery Unit
| | - Noémie Resseguier
- 2Department of Public Health and Medical Information and UMR 912 (INSERM-IRD–Université de laMéditerranée); and
| | - Anne Donnet
- 3Department of Neurology, Clinical Neuroscience Federation, Centre Hospitalier Universitaire La Timone Assistance Publique–Hôpitaux de Marseille, France
| | - Philippe Roussel
- 1INSERM U 751 (Université de la Méditerranée), Functional and Stereotactic Neurosurgery Unit
| | - Jean Gaudart
- 2Department of Public Health and Medical Information and UMR 912 (INSERM-IRD–Université de laMéditerranée); and
| | - Marc Levivier
- 6Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois; and
- 7Faculty of Biology and Medicine, University of Lausanne, Switzerland
| | - Jean Régis
- 1INSERM U 751 (Université de la Méditerranée), Functional and Stereotactic Neurosurgery Unit
| |
Collapse
|
283
|
Cheng JS, Lim DA, Chang EF, Barbaro NM. A review of percutaneous treatments for trigeminal neuralgia. Neurosurgery 2014; 10 Suppl 1:25-33; discussion 33. [PMID: 24509496 DOI: 10.1227/neu.00000000000001687] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Common treatments for trigeminal neuralgia include percutaneous techniques, microvascular decompression, and Gamma Knife radiosurgery. Although microvascular decompression is considered the gold standard for treatment, percutaneous techniques remain an effective option for select patients. OBJECTIVE To review the historical development, advantages, and limitations of the most common percutaneous procedures for trigeminal neuralgia: balloon compression (BC), glycerol rhizotomy (GR), and radiofrequency thermocoagulation (RF). METHODS Publications reporting clinical outcomes after BC, GR, and RF were reviewed and included. Operative technique was based on the experience of the primary surgeon and senior author. RESULTS All 3 percutaneous techniques (BC, GR, and RF) provide effective pain relief but differ in method and specificity of nerve injury. BC selectively injures larger pain fibers while sparing small fibers and does not require an awake, cooperative patient. Pain control rates up to 91% at 6 months and 66% at 3 years have been reported. RF allows somatotopic nerve mapping and selective division lesioning and provides pain relief in up to 97% of patients initially and 58% at 5 years. Multiple treatments improve outcomes but carry significant morbidity risk. GR offers similar pain-free outcomes of 90% at 6 months and 54% at 3 years but with higher complication rates (25% vs. 16%) compared with BC. Advantages of percutaneous techniques include shorter procedure duration, minimal anesthesia risk, and in the case of GR and RF, immediate patient feedback. CONCLUSION Percutaneous treatments for trigeminal neuralgia remain safe, simple, and effective for achieving good pain control while minimizing procedural risk.
Collapse
Affiliation(s)
- Jason S Cheng
- *Department of Neurological Surgery, ‡Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, and §Veterans Affairs Medical Center, University of California, San Francisco, San Francisco, California; ¶Department of Neurological Surgery, Indiana University School of Medicine, and Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | | | | | | |
Collapse
|
284
|
McLaughlin N, Upadhyaya P, Buxey F, Martin NA. Value-based neurosurgery: measuring and reducing the cost of microvascular decompression surgery. J Neurosurg 2014; 121:700-8. [DOI: 10.3171/2014.5.jns131996] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Object
Care providers have put significant effort into optimizing patient safety and quality of care. Value, defined as meaningful outcomes achieved per dollar spent, is emerging as a promising framework to redesign health care. Scarce data exist regarding cost measurement and containment for episodes of neurosurgical care. The authors assessed how cost measurement and strategic containment could be used to optimize the value of delivered care after the implementation and maturation of quality improvement initiatives.
Methods
A retrospective study of consecutive patients undergoing microvascular decompression was performed. Group 1 comprised patients treated prior to the implementation of quality improvement interventions, and Group 2 consisted of those treated after the implementation and maturation of quality improvement processes. A third group, Group 3, represented a contemporary group studied after the implementation of cost containment interventions targeting the three most expensive activities: pre-incision time in the operating room (OR) and total OR time, intraoperative neuromonitoring (IOM), and bed assignment (and overall length of stay [LOS]). The value of care was assessed for all three groups.
Results
Forty-four patients were included in the study. Average preparation time pre-incision decreased from 73 to 65 to 45 minutes in Groups 1, 2, and 3, respectively. The average total OR time and OR cost were 434 minutes and $8513 in Group 1; 348 minutes and $7592 in Group 2; and 407 minutes and $8333 in Group 3. The average cost for IOM, excluding electrode needles, was $1557, $1585, and $1263, respectively, in Groups 1, 2, and 3. Average total cost for bed assignment was $5747, $5198, and $4535, respectively, in Groups 1, 2, and 3. The average total LOS decreased from 3.16 days in Group 1 to 2.14 days in Group 3. Complete relief of or a significant decrease in preoperative symptomatology was achieved in 42 of the 44 patients, respectively. Overall, the average cost of a surgical care episode (index hospitalization + readmission/reoperation) decreased 25% from Group 1 to 3.
Conclusions
Linking cost-containment and cost-reduction strategies to ongoing outcome improvement measures is an important step toward the optimization of value-based delivery of care.
Collapse
|
285
|
Squintani G, Turri M, Donato F, Tinazzi M, Masotto B, Tramontano V, Talacchi A, Sala F, Moretto G, Valeriani M. Trigeminal laser-evoked potentials: A neurophysiological tool to detect post-surgical outcome in trigeminovascular contact neuralgia. Eur J Pain 2014; 19:253-9. [DOI: 10.1002/ejp.543] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2014] [Indexed: 11/11/2022]
Affiliation(s)
- G. Squintani
- Neurology Unit; Department of Neurocience; Azienda Ospedaliera Universitaria Integrata; Verona Italy
| | - M. Turri
- Department of Neurological, Neuropsychological, Morphological and Movement Sciences; Section of Clinical Neurology; University of Verona; Italy
| | - F. Donato
- Neurology Unit; Department of Neurocience; Azienda Ospedaliera Universitaria Integrata; Verona Italy
- Department of Pharmacology; University of Messina; Italy
| | - M. Tinazzi
- Department of Neurological, Neuropsychological, Morphological and Movement Sciences; Section of Clinical Neurology; University of Verona; Italy
| | - B. Masotto
- Neurosurgery Unit; Azienda Ospedaliera Universitaria Integrata; Verona Italy
| | - V. Tramontano
- Neurosurgery Unit; Azienda Ospedaliera Universitaria Integrata; Verona Italy
| | - A. Talacchi
- Neurosurgery Unit; Azienda Ospedaliera Universitaria Integrata; Verona Italy
| | - F. Sala
- Neurosurgery Unit; Azienda Ospedaliera Universitaria Integrata; Verona Italy
| | - G. Moretto
- Neurology Unit; Department of Neurocience; Azienda Ospedaliera Universitaria Integrata; Verona Italy
| | - M. Valeriani
- Department of Neuroscience; Bambino Gesù Children's Hospital; IRCCS; Rome Italy
- Center for Sensory-Motor Interaction; Aalborg University; Denmark
| |
Collapse
|
286
|
Gerganov VM, Giordano M, Elolf E, Osamah A, Amir S, Madjid S. Operative management of patients with radiosurgery-related trigeminal neuralgia: Analysis of the surgical morbidity and pain outcome. Clin Neurol Neurosurg 2014; 122:23-8. [DOI: 10.1016/j.clineuro.2014.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 03/02/2014] [Accepted: 04/13/2014] [Indexed: 11/25/2022]
|
287
|
Tuleasca C, Carron R, Resseguier N, Donnet A, Roussel P, Gaudart J, Levivier M, Régis J. Trigeminal neuralgia related to megadolichobasilar artery compression: a prospective series of twenty-nine patients treated with gamma knife surgery, with more than one year of follow-up. Stereotact Funct Neurosurg 2014; 92:170-7. [PMID: 24943284 DOI: 10.1159/000362172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 03/11/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Trigeminal neuralgia (TN) secondary to megadolichobasilar artery (MBA) compression is considerably difficult to manage surgically. OBJECTIVE This study aims to evaluate the safety/efficacy of Gamma Knife surgery (GKS) in this special group of patients. METHODS Between July 1992 and November 2010, 29 patients with >1 year of follow-up presenting with MBA compression were treated with GKS at Timone University Hospital. Radiosurgery was performed using a Gamma Knife (model B, C or Perfexion). A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 9.1 mm (range: 6-18.2 mm) from the emergence. RESULTS The median follow-up period was 46.1 months (range: 12.9-157.9 months). Initially, all patients (100%) were pain free; the average time to complete pain relief was 13.5 days (range: 0-240 days). Their actuarial probability of remaining pain free without medication at 0.5, 1 and 2 years was 93.1, 79.3 and 75.7%, respectively, and remained stable until 13 years after treatment. The actuarial probability of hypoesthesia onset at 6 months was 4.3%; at 1 year it reached 13% and remained stable until 13 years after treatment. CONCLUSIONS GKS proved to be reasonably safe and effective on a long-term basis as a first- and/or second-line surgical treatment for TN due to MBA compression.
Collapse
Affiliation(s)
- Constantin Tuleasca
- Functional and Stereotactic Neurosurgery Unit, INSERM U751, Centre Hospitalier Universitaire La Timone Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | | | | | | | | | | | | | | |
Collapse
|
288
|
Sivakanthan S, Van Gompel JJ, Alikhani P, van Loveren H, Chen R, Agazzi S. Surgical Management of Trigeminal Neuralgia. Neurosurgery 2014; 75:220-6; discussion 225-6. [DOI: 10.1227/neu.0000000000000430] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Trigeminal neuralgia is a relatively common neurosurgical pathology with multiple management options. Microvascular decompression (MVD) is nonablative and is considered the gold standard. However, stereotaxic radiosurgery (SRS) and percutaneous stereotaxic rhizotomy (PSR) are 2 noninvasive but ablative options that have rapidly gained support.
OBJECTIVE:
To use Medicare claims data in conjunction with a literature review to assess the usage, effectiveness, and cost-effectiveness of the 3 different invasive treatments for trigeminal neuralgia.
METHODS:
All of the claims of trigeminal neuralgia treatment were extracted from the 2011 5% Inpatient and Outpatient Limited Data Set. Current Procedural Terminology, 4th Edition/International Classification of Diseases, Ninth Revision codes for the 3 different surgical treatment modalities were used to further classify these claims. Kaplan-Meier survival curves in key articles were used to calculate quality-adjusted life years and cost-effectiveness for each procedure.
RESULTS:
A total of 1582 claims of trigeminal neuralgia were collected. Ninety-four (6%) patients underwent surgical intervention. Forty-eight (51.1%) surgical patients underwent MVD, 39 (41.5%) underwent SRS, and 7 (7.4%) underwent PSR. The average weighted costs for MVD, SRS, and PSR were $;40 434.95, $;38 062.27, and $;3910.64, respectively. The quality-adjusted life years were 8.2 for MVD, 4.9 for SRS, and 6.5 for PSR. The cost per quality-adjusted life year was calculated as $;4931.1, $;7767.8, and $;601.64 for MVD, SRS, and PSR, respectively.
CONCLUSION:
This study shows that the most frequently used surgical management of trigeminal neuralgia is MVD, followed closely by SRS. PSR, despite being the most cost-effective, is by far the least utilized treatment modality.
Collapse
Affiliation(s)
- Sananthan Sivakanthan
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | | | - Puya Alikhani
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Harry van Loveren
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Ren Chen
- Department of Epidemiology and Biostatistics, University of South Florida, Tampa, Florida
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida
| |
Collapse
|
289
|
Tang YZ, Jin D, Li XY, Lai GH, Li N, Ni JX. Repeated CT-guided percutaneous radiofrequency thermocoagulation for recurrent trigeminal neuralgia. Eur Neurol 2014; 72:54-9. [PMID: 24853911 DOI: 10.1159/000357868] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 12/09/2013] [Indexed: 11/19/2022]
Abstract
AIMS To investigate the long-term outcomes of repeated percutaneous radiofrequency thermocoagulation (PRT) for recurrent trigeminal neuralgia (TN) patients. METHODS Between 2002 and 2012, 33 patients with recurrent TN following an initial PRT procedure were retrospectively studied and underwent 43 repeated PRT procedures. RESULTS The mean length of follow-up after repeated PRT was 34 months. Pain relief was immediate in 30 patients (90.9%), and no pain relief occurred in 3 patients (9.1%) following a second PRT procedure. The percentage of patients who remained in an 'excellent' and 'good' pain relief condition (pain intensity ≤BIN grade III) after the second PRT procedure was 75% at 1 year, 68% at 2 years and 68% at 5 years, and 22 of these patients (54.5%) remained satisfied with their pain relief during the follow-up period. Nine patients underwent PRT three times and 1 patient four times. The total number of patients who benefited from repeated PRT was 28 (84.8%). Postprocedure complications including masseter weakness were present in 3 patients and limited mouth opening affected 1 patient. No mortalities were observed during or after repeated PRT procedures. CONCLUSION Repeated PRT provides long-term pain relief benefits to patients with recurrent TN and should be considered as an alternative treatment for recurrent TN.
Collapse
Affiliation(s)
- Yuan-Zhang Tang
- Pain Management, Xuanwu Hospital of Capital Medical University, Beijing, PR China
| | | | | | | | | | | |
Collapse
|
290
|
Akram H, Mirza B, Kitchen N, Zakrzewska JM. Proposal for evaluating the quality of reports of surgical interventions in the treatment of trigeminal neuralgia: the Surgical Trigeminal Neuralgia Score. Neurosurg Focus 2014; 35:E3. [PMID: 23991816 DOI: 10.3171/2013.6.focus13213] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to design a checklist with a scoring system for reporting on studies of surgical interventions for trigeminal neuralgia (TN) and to validate it by a review of the recent literature. METHODS A checklist with a scoring system, the Surgical Trigeminal Neuralgia Score (STNS), was devised partially based on the validated STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) criteria and customized for TN after a literature review and then applied to a series of articles. These articles were identified using a prespecified MEDLINE and Embase search covering the period from 2008 to 2010. Of the 584 articles found, 59 were studies of interventional procedures for TN that fulfilled the inclusion criteria and 56 could be obtained in full. The STNS was then applied independently by 3 of the authors. RESULTS The maximum STNS came to 30, and was reliable and reproducible when used by the 3 authors who performed the scoring. The range of scores was 6-23.5, with a mean of 14 for all the journals. The impact factor scores of the journals in which the papers were published ranged from 0 to 4.8. Twenty-four of the studies were published in the Journal of Neurosurgery or in Neurosurgery. Studies published in neurosurgical journals ranked higher on the STNS scale than those published in nonneurosurgical journals. There was no statistically significant correlation between STNS and impact factors. Stereotactic radiosurgery (n = 25) and microvascular decompression (n = 15) were the most commonly reported procedures. The diagnostic criteria were stated in 35% of the studies, and 4 studies reported subtypes of TN. An increasing number of studies (46%) used the recommended Kaplan-Meier methodology for pain survival outcomes. The follow-up period was unclear in 8 studies, and 26 reported follow-ups of more than 5 years. Complications were reported fairly consistently but the temporal course was not always indicated. Direct interview, telephone conversation, and questionnaires were used to measure outcomes. Independent assessment of outcome was only clearly stated in 7 studies. Only 2 studies used the 36-Item Short Form Health Survey to measure quality of life and 4 studies reported on the severity of preoperative pain. The Barrow Neurological Institute pain questionnaire was the most commonly used outcome measure (n = 13), followed by the visual analog scale. CONCLUSIONS Similar to the STROBE criteria that provide a checklist of items that should be included in reports of observational studies in general, the authors' suggested checklist for the STNS could help editors and reviewers ensure that quality reports are published, and could prove useful for colleagues when reporting their results specifically on the surgical management of TN. It would help the patient and clinicians make a decision about selecting the appropriate neurosurgical procedure.
Collapse
Affiliation(s)
- Harith Akram
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, United Kingdom.
| | | | | | | |
Collapse
|
291
|
Lucas JT, Nida AM, Isom S, Marshall K, Bourland JD, Laxton AW, Tatter SB, Chan MD. Predictive nomogram for the durability of pain relief from gamma knife radiation surgery in the treatment of trigeminal neuralgia. Int J Radiat Oncol Biol Phys 2014; 89:120-6. [PMID: 24613811 DOI: 10.1016/j.ijrobp.2014.01.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 01/14/2014] [Accepted: 01/17/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine factors associated with the durability of stereotactic radiation surgery (SRS) for treatment of trigeminal neuralgia (TN). METHODS AND MATERIALS Between 1999 and 2008, 446 of 777 patients with TN underwent SRS and had evaluable follow-up in our electronic medical records and phone interview records. The median follow-up was 21.2 months. The Barrow Neurologic Institute (BNI) pain scale was used to determine pre- and post-SRS pain. Dose-volume anatomical measurements, Burchiel pain subtype, pain quality, prior procedures, and medication usage were included in this retrospective cohort to identify factors impacting the time to BNI 4-5 pain relapse by using Cox proportional hazard regression. An internet-based nomogram was constructed based on predictive factors of durable relief pre- and posttreatment at 6-month intervals. RESULTS Rates of freedom from BNI 4-5 failure at 1, 3, and 5 years were 84.5%, 70.4%, and 46.9%, respectively. Pain relief was BNI 1-3 at 1, 3, and 5 years in 86.1%, 74.3%, and 51.3% of type 1 patients; 79.3%, 46.2%, and 29.3% of type 2 patients; and 62.7%, 50.2%, and 25% of atypical facial pain patients. BNI type 1 pain score was achieved at 1, 3, and 5 years in 62.9%, 43.5%, and 22.0% of patients with type 1 pain and in 47.5%, 25.2%, and 9.2% of type 2 patients, respectively. Only 13% of patients with atypical facial pain achieved BNI 1 response; 42% of patients developed post-Gamma Knife radiation surgery (GKRS) trigeminal dysfunction. Multivariate analysis revealed that post-SRS numbness (hazard ratio [HR], 0.47; P<.0001), type 1 (vs type 2) TN (HR, 0.6; P=.02), and improved post-SRS BNI score at 6 months (HR, 0.009; P<.0001) were predictive of a durable pain response. CONCLUSIONS The durability of SRS for TN depends on the presenting Burchiel pain type, the post-SRS BNI score, and the presence of post-SRS facial numbness. The durability of pain relief can be estimated pre- and posttreatment by using our nomogram for situations when the potential of relapse may guide the decision for initial intervention.
Collapse
Affiliation(s)
- John T Lucas
- Department of Radiation Oncology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.
| | - Adrian M Nida
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, South Carolina
| | - Scott Isom
- Department of Biostatistical Sciences, Section of Biostatistics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - John D Bourland
- Department of Radiation Oncology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| |
Collapse
|
292
|
Park SH, Kano H, Niranjan A, Flickinger JC, Lunsford LD. Stereotactic radiosurgery for cerebellopontine angle meningiomas. J Neurosurg 2014; 120:708-15. [DOI: 10.3171/2013.11.jns131607] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
To assess the long-term outcomes of stereotactic radiosurgery (SRS) for cerebellopontine angle (CPA) meningiomas, the authors retrospectively reviewed data from a 20-year experience. They evaluated progression-free survival as well as improvement, stabilization, or deterioration in clinical symptoms.
Methods
Seventy-four patients with CPA meningiomas underwent SRS involving various Gamma Knife technologies between 1990 and 2010. The most common presenting symptoms were dizziness or disequilibrium, hearing loss, facial sensory dysfunction, and headache. The median tumor volume was 3.0 cm3 (range 0.3–17.1 cm3), and the median radiation dose to the tumor margin was 13 Gy (range 11–16 Gy). The median follow-up period was 40 months (range 4–147 months).
Results
At last imaging follow-up, the tumor volume had decreased in 46 patients (62%), remained stable in 26 patients (35%), and increased in 2 patients (3%). The progression-free survival after SRS was 98% at 1 year, 98% at 3 years, and 95% at 5 years. At the last clinical follow-up, 23 patients (31%) showed neurological improvement, 43 patients (58%) showed no change in symptoms or signs, and 8 patients (11%) had worsening symptoms or signs. The neurological improvement rate after SRS was 16% at 1 year, 31% at 3 years, and 40% at 5 years. The post-SRS deterioration rate was 5% at 1 year, 10% at 3 years, and 16% at 5 years. A multivariate analysis demonstrated that trigeminal neuralgia was the symptom most likely to worsen after SRS (HR 0.08, 95% CI 0.02–0.31; p = 0.001). Asymptomatic peritumoral edema occurred in 4 patients (5%) after SRS, and symptomatic adverse radiation effects developed in 7 patients (9%).
Conclusions
Stereotactic radiosurgery for CPA meningiomas provided a high tumor control rate and relatively low risk of ARE. Tumor compression of the trigeminal nerve by a CPA meningioma resulted in an increased rate of facial pain worsening in this patient experience.
Collapse
Affiliation(s)
- Seong-Hyun Park
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania; and
- 4Department of Neurosurgery, Kyungpook National University Hospital, Daegu, South Korea
| | - Hideyuki Kano
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania; and
| | - Ajay Niranjan
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania; and
| | - John C. Flickinger
- 2Radiation Oncology, and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania; and
| | - L. Dade Lunsford
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania; and
| |
Collapse
|
293
|
Xu Z, Schlesinger D, Moldovan K, Przybylowski C, Sun X, Lee CC, Yen CP, Sheehan J. Impact of target location on the response of trigeminal neuralgia to stereotactic radiosurgery. J Neurosurg 2014; 120:716-24. [DOI: 10.3171/2013.10.jns131596] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors evaluate the impact of target location on the rate of pain relief (PR) in patients with intractable trigeminal neuralgia (TN) undergoing stereotactic radiosurgery (SRS).
Methods
The authors conducted a retrospective review of 99 patients with idiopathic TN who were identified from a prospectively maintained database and were treated with SRS targeting the dorsal root entry zone with a maximum dose of 80 Gy. Targeting of the more proximal portion of a trigeminal nerve with the 50% isodose line overlapping the brainstem was performed in 36 patients (proximal group). In a matched group, 63 patients received SRS targeting the 20% isodose line tangential to the emergence of the brainstem (distal group). The median follow-up time was 33 months (range 6–124 months).
Results
The actuarial rate of maintenance of Barrow Neurological Institute (BNI) Pain Score I–IIIa was attained in 89% of patients at 1 year, 81% at 2 years, and 69% at 4 years, respectively, after SRS. Kaplan-Meier analysis revealed that durability of PR was only associated with the proximal location of the radiosurgical target (log-rank test, p = 0.018). Radiosurgery-induced facial numbness (BNI Score II or III) developed in 35 patients, which was significantly more frequent in the proximal group (19 patients [53%] compared with 16 [25%] in the distal group [p = 0.015]).
Conclusions
The radiosurgical target appears to affect the duration of pain relief in patients with idiopathic trigeminal neuralgia with the target closer to the brainstem affording extended pain relief. However, the proximal SRS target was also associated with an increased risk of mild to moderate facial numbness.
Collapse
Affiliation(s)
| | - David Schlesinger
- 1Departments of Neurosurgery and
- 2Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
| | | | | | | | | | | | - Jason Sheehan
- 1Departments of Neurosurgery and
- 2Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|
294
|
McLaughlin N, Buxey F, Chaw K, Martin NA. Value-based neurosurgery: the example of microvascular decompression surgery. J Neurosurg 2014; 120:462-72. [DOI: 10.3171/2013.9.jns13663] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Object
Value of care is emerging as a promising framework to restructure health care, emphasizing the importance of reporting multiple outcomes that encompass the entire care episode instead of isolated outcomes specific to care points during a patient's care. The authors assessed the impact of coordinated implementation of processes across the episode of surgical care on value of neurosurgical care, using microvascular decompression (MVD) as an example.
Methods
This study is a retrospective review of consecutive cases involving patients with either trigeminal neuralgia or hemifacial spasm undergoing first-time MVD. Patients were divided into 2 groups: Group 1 included patients who underwent surgery between February 2008 and November 2009 and Group 2 included those who underwent surgery between January 2011 and October 2012. The authors collected data on outcome measures spanning the entire surgical episode of care according to the Outcome Measures Hierarchy.
Results
Forty-nine patients were included: 20 patients in Group 1 and 29 patients in Group 2. Thirty-one patients underwent MVD for trigeminal neuralgia and 18 for hemifacial spasm. A zero mortality rate and high degree of symptom resolution were achieved in both groups. Group 2 benefited from a reduction in the average total operating room time, a decrease in the mean and median postoperative length of hospital stay, a decrease in the mean length of stay on the floor, and a reduction in the rates of complications and readmissions.
Conclusions
Comprehensive implementation of improvement processes throughout the continuum of care resulted in improved global outcome and greater value of delivered care. Enhanced-recovery perioperative protocols and diagnosis-specific clinical pathways are two avenues built around global care delivery that can help achieve an “optimal episode of surgical care” in every case.
Collapse
|
295
|
Baschnagel AM, Cartier JL, Dreyer J, Chen PY, Pieper DR, Olson RE, Krauss DJ, Maitz AH, Grills IS. Trigeminal neuralgia pain relief after gamma knife stereotactic radiosurgery. Clin Neurol Neurosurg 2014; 117:107-111. [DOI: 10.1016/j.clineuro.2013.12.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 12/05/2013] [Accepted: 12/08/2013] [Indexed: 10/25/2022]
|
296
|
Al-Otaibi F, Alhindi H, Alhebshi A, Albloushi M, Baeesa S, Hodaie M. Histopathological effects of radiosurgery on a human trigeminal nerve. Surg Neurol Int 2014; 4:S462-7. [PMID: 24605252 PMCID: PMC3935219 DOI: 10.4103/2152-7806.125463] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 11/19/2013] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Radiosurgery is a well-established treatment modality for medically refractory trigeminal neuralgia. The exact mechanism of pain relief after radiosurgery is not clearly understood. Histopathology examination of the trigeminal nerve in humans after radiosurgery is rarely performed and has produced controversial results. CASE DESCRIPTION We report on a 45-year-old female who received radiosurgery treatment for trigeminal neuralgia by Cyberknife. A 6-mm portion of the cisternal segment of trigeminal nerve received a dose of 60 Gy. The clinical benefit started 10 days after therapy and continued for 8 months prior to a recurrence of her previous symptoms associated with mild background pain. She underwent microvascular decompression and partial sensory root sectioning. Atrophied trigeminal nerve rootlets were grossly noted intraoperatively under surgical microscope associated with changes in trigeminal nerve color to gray. A biopsy from the inferolateral surface of the nerve proximal to the midcisternal segment showed histological changes in the form of fibrosis and axonal degeneration. CONCLUSION This case study supports the evidence of histological damage of the trigeminal nerve fibers after radiosurgery therapy. Whether or not the presence and degree of nerve damage correlate with the degree of clinical benefit and side effects are not revealed by this study and need to be explored in future studies.
Collapse
Affiliation(s)
- Faisal Al-Otaibi
- Division of Neurological Surgery, Neurosciences Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hindi Alhindi
- Division of Radiation Oncology, Oncology Center, Riyadh, Saudi Arabia
| | - Adnan Alhebshi
- Department of pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Saleh Baeesa
- Division of Neurological Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mojgan Hodaie
- Division of Neurosurgery, Toronto Western Hospital, Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, Canada
| |
Collapse
|
297
|
Tuleasca C, Carron R, Resseguier N, Donnet A, Roussel P, Gaudart J, Levivier M, Régis J. Multiple Sclerosis-Related Trigeminal Neuralgia: A Prospective Series of 43 Patients Treated with Gamma Knife Surgery with More than One Year of Follow-Up. Stereotact Funct Neurosurg 2014; 92:203-10. [DOI: 10.1159/000362173] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 03/11/2014] [Indexed: 11/19/2022]
|
298
|
Reddy VK, Parker SL, Lockney DT, Patrawala SA, Su PF, Mericle RA. Percutaneous Stereotactic Radiofrequency Lesioning for Trigeminal Neuralgia. Neurosurgery 2013; 74:262-6; discussion 266. [DOI: 10.1227/neu.0000000000000262] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
The Visual Analog Scale (VAS) and the Barrow Neurological Institute Pain Scale (BNI-PS) are 2 patient-reported outcome (PRO) tools frequently used to rate pain from trigeminal neuralgia (TN). Outcomes studies often use these patient-reported outcomes to assess treatment effectiveness, but it is unknown exactly what degree of change in the numerical scores constitutes the minimum clinically important difference (MCID). MCID remains uninvestigated for percutaneous stereotactic radiofrequency lesioning (RFL), a common surgical procedure for TN.
OBJECTIVE:
To determine MCID values for the VAS and BNI-PS in patients undergoing RFL.
METHODS:
Forty-three consecutive patients with TN who underwent RFL by a single surgeon were prospectively assessed with the VAS and BNI-PS preoperatively and 3 years postoperatively. Three anchors were used to assign each patient's outcome: satisfaction, willingness to have the surgery again, and Health Transition Index. We then used 3 well-established, anchor-based methods to calculate MCID: average change, minimum detectable change, and change difference.
RESULTS:
Patients experienced substantial improvement in both VAS (9.81 vs 3.35; P < .001) and BNI-PS (4.95 vs 2.44; P < .001) after RFL. The 3 MCID calculation methods generated a range of MCID values for each of the PROs (VAS, 4.13-8.20; BNI-PS, 1.03-3.30). The area under the receiver-operating characteristic curve was greater for BNI-PS compared with VAS for all 3 anchors, indicating that BNI-PS is probably better suited for calculating MCID.
CONCLUSION:
RFL-specific MCID is variable on the basis of the calculation technique. With the use of the minimum detectable change calculation method with the Health Transition Index anchor, the minimum clinically important difference is 4.49 for VAS and 1.16 for BNI-PS after RFL for TN.
Collapse
Affiliation(s)
| | | | | | | | - Pei-Fang Su
- Vanderbilt University Center for Quantitative Sciences, Nashville, Tennessee
- Department of Statistics, National Cheng Kung University, Tainan, Taiwan
| | | |
Collapse
|
299
|
Reddy VK, Parker SL, Patrawala SA, Lockney DT, Su PF, Mericle RA. Microvascular decompression for classic trigeminal neuralgia: determination of minimum clinically important difference in pain improvement for patient reported outcomes. Neurosurgery 2013; 72:749-54; discussion 754. [PMID: 23328688 DOI: 10.1227/neu.0b013e318286fad2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Outcomes studies use patient-reported outcome (PRO) measurements to assess treatment effectiveness, but can lack direct clinical meaning. Minimum clinically important difference (MCID) calculation provides a point estimate of the critical threshold needed to achieve clinically relevant treatment effectiveness. MCID remains uninvestigated for microvascular decompression (MVD), a common surgical procedure for trigeminal neuralgia. OBJECTIVE We aimed to determine MCID for the most commonly used PRO measures of pain after MVD: Visual Analog Scale (VAS) and Barrow Neurological Institute Pain Scale (BNI-PS). METHODS Sixty consecutive patients with classic trigeminal neuralgia who decided to undergo MVD by a single surgeon were prospectively assessed with VAS and BNI-PS preoperatively and 2 years postoperatively. Three anchors were used to assign each patient's outcome. We then used 3 well-established, anchor-based methods to calculate MCID. RESULTS Patients experienced significant improvement in both VAS (9.9 vs. 2.0, P < .001) and BNI-PS (5.0 vs. 1.9, P < .001) after MVD. The area under the receiver-operating characteristic curve was greater for BNI-PS than for VAS for all 3 anchors, indicating that BNI-PS is probably better suited for calculating MCID. The 3 MCID calculation methods generated a range of MCID values for each of the PROs (VAS: 1.40-8.87, BNI-PS: 0.95-3.26). CONCLUSION MVD-specific MCID is highly variable based on calculation technique. Some of these calculations appear to either overestimate or underestimate the patients' preoperative expectations. When the different MCID methods are averaged, the results are clinically appropriate and consistent with preoperative expectations. The average MCID for VAS is 6.25 and for BNI-PS is 2.44.
Collapse
|
300
|
Esparza-Moreno KP, García-Garduño OA, Ballesteros-Zebadúa P, Lárraga-Gutiérrez JM, Moreno-Jiménez S, Celis-Lopez MA. Comparison of trigeminal neuralgia radiosurgery plans using two film detectors for the commissioning of small photon beams. J Appl Clin Med Phys 2013; 14:3824. [PMID: 24257267 PMCID: PMC5714638 DOI: 10.1120/jacmp.v14i6.3824] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 07/01/2013] [Accepted: 06/18/2013] [Indexed: 11/23/2022] Open
Abstract
Trigeminal neuralgia (TN) is a chronic, episodic facial pain syndrome that can be extremely intense, and it occurs within the regions of the face that are innervated by the three branches of the trigeminal nerve. Stereotactic radiosurgery (SRS) is the least invasive procedure to treat TN. SRS uses narrow photon beams that require high spatial resolution techniques for their measurement. The use of radiographic or radiochromic films for small‐field dosimetry is advantageous because high spatial resolution and two‐dimensional dose measurements can be performed. Because these films have different properties, it is expected that the calculated dose distributions for TN patients will behave differently, depending on the detector used for the commissioning of the small photon beams. This work is based on two sets of commissioned data: one commissioned with X‐OMAT V2 film and one commissioned with EBT2 film. The calculated dose distributions for 23 TN patients were compared between the commissioning datasets. The variables observed were the differences in the half widths of the 35 and 40 Gy isodose lines (related to the entrance distance to the brainstem) and the volume of the brainstem that received a dose of 12 Gy or more (V12). The results of this comparison showed that there were statistically significant differences between the two calculated dose distributions. The magnitudes of these differences were up to 0.33 mm and 0.38 mm for the 35 and 40 Gy isodose lines. The corresponding difference for the V12 was up to 2.1 cc. It is clear that these differences may impact the treatment of TN patients, and then it must be important to perform this type of analysis when observing complication rates. Clinical reports on irradiation techniques for trigeminal neuralgia should consider that different detectors used for commissioning treatment planning systems might result in small but significant differences in dose distributions. PACS number: 87.55.km
Collapse
|