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Altamirano JM, Jimenez-Olvera M, Moreno-Jimenez S, Gutierrez-Aceves GA, Velasco-Campos F, Navarro-Olvera JL, Carrillo-Ruiz JD. Comparison of microvascular decompression, percutaneous radiofrequency rhizotomy, and stereotactic radiosurgery in the treatment of trigeminal neuralgia: A long term quasi-experimental study. Pain Pract 2024; 24:514-524. [PMID: 38071446 DOI: 10.1111/papr.13327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
BACKGROUND Microvascular decompression (MVD), radiofrequency rhizotomy (RFR), and stereotactic radiosurgery (SRS) are surgical techniques frequently used in the treatment of idiopathic trigeminal neuralgia (TN), although the results reported for each of these are diverse. OBJECTIVE This study aimed to compare long-term pain control obtained by MVD, SRS, and RFR in patients with idiopathic TN. METHODS To compare the results obtained by MVD, SRS, and RFR we chose a quasi-experimental, ambispective design with control groups but no pretest. A total of 52 participants (MVD n = 33, RFR n = 10, SRS n = 9) were included. Using standardized outcome measures, pain intensity, pain relief, quality of life, and satisfaction with treatment were assessed by an independent investigator. The TREND statement for reporting non-randomized evaluations was applied. Clinical outcomes were evaluated at the initial postoperative period and at 6 months, 1, 2, 3, 4, and 5 years postoperatively. RESULTS MVD has shown better results in pain scales compared to ablative procedures. Significant differences between groups were found regarding pain intensity and pain relief at the initial postoperative period (p < 0.001) and 6 months (p = 0.022), 1 year (p < 0.001), 2 years (p = 0.002), and 3 years (p = 0.004) after the intervention. Those differences exceeded the thresholds of the minimal clinically important difference. A higher percentage of patients free of pain was observed in the group of patients treated by MVD, with significant differences at the initial postoperative period (p < 0.001) and 6 months (p = 0.02), 1 year (p = 0.001), and 2 years (p = 0.04) after the procedure. Also, a higher risk of pain recurrence was observed in the RFR and SRS groups (HR 3.15, 95% CI 1.33-7.46; p = 0.009; and HR 4.26, 95% CI 1.77-10.2; p = 0.001, respectively) compared to the MVD group. No significant differences were found in terms of quality of life and satisfaction with treatment. A higher incidence of complications was observed in the MVD group. CONCLUSION Concerning pain control and risk of pain recurrence, MVD is superior to RFR and SRS, but not in terms of quality of life, satisfaction with treatment, and safety profile.
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Affiliation(s)
- Juan M Altamirano
- Research Direction, Mexico General Hospital "Dr. Eduardo Liceaga", Mexico City, Mexico
- Neurosurgery Department, Hospital Angeles Clínica Londres, Mexico City, Mexico
| | - Miguel Jimenez-Olvera
- Pain management Unit, Mexico General Hospital "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Sergio Moreno-Jimenez
- Radiosurgery Unit, Department of Neurosurgery, Neurological Center, National Institute of Neurology and Neurosurgery "Dr. Manuel Velasco Suarez", Mexico City, Mexico
| | - Guillermo A Gutierrez-Aceves
- Radiosurgery Unit, Department of Neurosurgery, Neurological Center, National Institute of Neurology and Neurosurgery "Dr. Manuel Velasco Suarez", Mexico City, Mexico
| | - Francisco Velasco-Campos
- Unit for Stereotactic and Functional Neurosurgery, Mexico General Hospital "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - José L Navarro-Olvera
- Unit for Stereotactic and Functional Neurosurgery, Mexico General Hospital "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - José D Carrillo-Ruiz
- Research Direction, Mexico General Hospital "Dr. Eduardo Liceaga", Mexico City, Mexico
- Unit for Stereotactic and Functional Neurosurgery, Mexico General Hospital "Dr. Eduardo Liceaga", Mexico City, Mexico
- Neuroscience Coordination, Psychology Faculty, Mexico Anahuac University, México City, Mexico
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Mulford KL, Moen SL, Grande AW, Nixdorf DR, Van de Moortele PF. Identifying symptomatic trigeminal nerves from MRI in a cohort of trigeminal neuralgia patients using radiomics. Neuroradiology 2022; 64:603-609. [PMID: 35043225 DOI: 10.1007/s00234-022-02900-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/09/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Trigeminal neuralgia (TN) is a devastating neuropathic condition. This work tests whether radiomics features derived from MRI of the trigeminal nerve can distinguish between TN-afflicted and pain-free nerves. METHODS 3D T1- and T2-weighted 1.5-Tesla MRI volumes were retrospectively acquired for patients undergoing stereotactic radiosurgery to treat TN. A convolutional U-net deep learning network was used to segment the trigeminal nerves from the pons to the ganglion. A total of 216 radiomics features consisting of image texture, shape, and intensity were extracted from each nerve. Within a cross-validation scheme, a random forest feature selection method was used, and a shallow neural network was trained using the selected variables to differentiate between TN-affected and non-affected nerves. Average performance over the validation sets was measured to estimate generalizability. RESULTS A total of 134 patients (i.e., 268 nerves) were included. The top 16 performing features extracted from the masks were selected for the predictive model. The average validation accuracy was 78%. The validation AUC of the model was 0.83, and sensitivity and specificity were 0.82 and 0.76, respectively. CONCLUSION Overall, this work suggests that radiomics features from MR imaging of the trigeminal nerves correlate with the presence of pain from TN.
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Affiliation(s)
- Kellen L Mulford
- Department of Radiology, University of Minnesota, Minneapolis, MN, USA.
| | - Sean L Moen
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Andrew W Grande
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Donald R Nixdorf
- Department of Diagnostic and Biological Science, University of Minnesota, Minneapolis, MN, USA
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Tuleasca C, Régis J, Sahgal A, De Salles A, Hayashi M, Ma L, Martínez-Álvarez R, Paddick I, Ryu S, Slotman BJ, Levivier M. Stereotactic radiosurgery for trigeminal neuralgia: a systematic review. J Neurosurg 2019; 130:733-757. [PMID: 29701555 DOI: 10.3171/2017.9.jns17545] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 09/11/2017] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The aims of this systematic review are to provide an objective summary of the published literature specific to the treatment of classical trigeminal neuralgia with stereotactic radiosurgery (RS) and to develop consensus guideline recommendations for the use of RS, as endorsed by the International Society of Stereotactic Radiosurgery (ISRS). METHODS The authors performed a systematic review of the English-language literature from 1951 up to December 2015 using the Embase, PubMed, and MEDLINE databases. The following MeSH terms were used in a title and abstract screening: "radiosurgery" AND "trigeminal." Of the 585 initial results obtained, the authors performed a full text screening of 185 studies and ultimately found 65 eligible studies. Guideline recommendations were based on level of evidence and level of consensus, the latter predefined as at least 85% agreement among the ISRS guideline committee members. RESULTS The results for 65 studies (6461 patients) are reported: 45 Gamma Knife RS (GKS) studies (5687 patients [88%]), 11 linear accelerator (LINAC) RS studies (511 patients [8%]), and 9 CyberKnife RS (CKR) studies (263 patients [4%]). With the exception of one prospective study, all studies were retrospective.The mean maximal doses were 71.1-90.1 Gy (prescribed at the 100% isodose line) for GKS, 83.3 Gy for LINAC, and 64.3-80.5 Gy for CKR (the latter two prescribed at the 80% or 90% isodose lines, respectively). The ranges of maximal doses were as follows: 60-97 Gy for GKS, 50-90 Gy for LINAC, and 66-90 Gy for CKR.Actuarial initial freedom from pain (FFP) without medication ranged from 28.6% to 100% (mean 53.1%, median 52.1%) for GKS, from 17.3% to 76% (mean 49.3%, median 43.2%) for LINAC, and from 40% to 72% (mean 56.3%, median 58%) for CKR. Specific to hypesthesia, the crude rates (all Barrow Neurological Institute Pain Intensity Scale scores included) ranged from 0% to 68.8% (mean 21.7%, median 19%) for GKS, from 11.4% to 49.7% (mean 27.6%, median 28.5%) for LINAC, and from 11.8% to 51.2% (mean 29.1%, median 18.7%) for CKR. Other complications included dysesthesias, paresthesias, dry eye, deafferentation pain, and keratitis. Hypesthesia and paresthesia occurred as complications only when the anterior retrogasserian portion of the trigeminal nerve was targeted, whereas the other listed complications occurred when the root entry zone was targeted. Recurrence rates ranged from 0% to 52.2% (mean 24.6%, median 23%) for GKS, from 19% to 63% (mean 32.2%, median 29%) for LINAC, and from 15.8% to 33% (mean 25.8%, median 27.2%) for CKR. Two GKS series reported 30% and 45.3% of patients who were pain free without medication at 10 years. CONCLUSIONS The literature is limited in its level of evidence, with only one comparative randomized trial (1 vs 2 isocenters) reported to date. At present, one can conclude that RS is a safe and effective therapy for drug-resistant trigeminal neuralgia. A number of consensus statements have been made and endorsed by the ISRS.
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Affiliation(s)
- Constantin Tuleasca
- 1Centre Hospitalier Universitaire Vaudois, Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center
- 4Signal Processing Laboratory (LTS 5), Ecole Politechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Jean Régis
- 11Department of Functional and Stereotactic Neurosurgery and Gamma Knife Unit, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Arjun Sahgal
- 5Department of Radiation Oncology, University of Toronto, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
| | - Antonio De Salles
- 6Department of Neurosurgery, University of California, Los Angeles, California
| | - Motohiro Hayashi
- 7Department of Neurosurgery, Tokyo Women's Medical University, Tokyo
| | - Lijun Ma
- 8Department of Radiation Oncology, Kyoto University, Kyoto, Japan
- 9Department of Radiation Oncology, University of California, San Francisco, California
| | | | - Ian Paddick
- 14Queen Square Radiosurgery Centre, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Samuel Ryu
- 12Department of Radiation Oncology, Stony Brook University, Stony Brook, New York
| | - Ben J Slotman
- 13Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands; and
| | - Marc Levivier
- 10Department of Neurosurgery, Ruber International Hospital, Madrid, Spain
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Tripathi M, Batish A. Letter to the Editor. Cafeteria approach to management of trigeminal neuralgia: stereotactic radiosurgery as a preferred option. J Neurosurg 2019; 130:1029. [PMID: 29957108 DOI: 10.3171/2018.5.jns181203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Mhatre VR, Chadha P, Kumar AP, Talapatra K. Dosimetric Comparison of 6 MV Flattening Filter Free and 6 MV Stereotactic Radiosurgery Beam Using 4 mm Conical Collimator for Trigeminal Neuralgia Radiosurgery. ACTA ACUST UNITED AC 2018. [DOI: 10.14407/jrpr.2018.43.3.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Gubian A, Rosahl SK. Meta-Analysis on Safety and Efficacy of Microsurgical and Radiosurgical Treatment of Trigeminal Neuralgia. World Neurosurg 2017; 103:757-767. [DOI: 10.1016/j.wneu.2017.04.085] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 11/30/2022]
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Reversal of insular and microstructural nerve abnormalities following effective surgical treatment for trigeminal neuralgia. Pain 2016; 156:1112-1123. [PMID: 25782366 DOI: 10.1097/j.pain.0000000000000156] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Classical trigeminal neuralgia (TN) is a severe neuropathic facial pain disorder commonly associated with neurovascular compression at the trigeminal nerve root entry zone (REZ). Neurosurgical interventions can relieve TN pain, but the mechanisms underlying these effects are unknown. We determined whether the abnormalities we previously reported at the REZ of TN patients using diffusion tensor imaging (DTI) and brain gray matter (GM) analyses resolve after effective neurosurgical treatment. Twenty-five patients who underwent either microvascular decompression surgery or Gamma Knife radiosurgery for right-sided TN had magnetic resonance imaging scans before and after treatment and were compared with age-matched controls. Cortical thickness and voxel-based morphometry examined specific brain GM we previously reported as abnormal in TN. White matter metrics of fractional anisotropy (FA), mean, radial, and axial diffusivities (MD, RD, and AD, respectively) were extracted bilaterally from each trigeminal REZ. Before treatment, patients had widespread GM abnormalities including thinner ventral anterior insula (vAI) cortex, and REZ microstructural abnormalities (lower FA, and higher MD, RD, and AD) compared with controls. We considered a 75% reduction in pain as effective treatment. The right vAI was the only GM region that normalized toward the level of healthy controls after effective treatment. At the REZ, effective treatment reversed FA, MD, RD, and AD abnormalities and was correlated with pain relief after treatment. These results demonstrate that treatment can effectively resolve pain by normalizing REZ abnormalities, which may influence vAI abnormalities. Future studies should consider DTI as an adjunct to assess the patient outcome and subtle microstructural changes after treatment.
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Zhou X, Liu Y, Yue Z, Luan D, Zhang H, Han J. Comparison of nerve combing and percutaneous radiofrequency thermocoagulation in the treatment for idiopathic trigeminal neuralgia. Braz J Otorhinolaryngol 2016; 82:574-9. [PMID: 26832635 PMCID: PMC9444671 DOI: 10.1016/j.bjorl.2015.11.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 10/07/2015] [Accepted: 11/02/2015] [Indexed: 11/30/2022] Open
Abstract
Introduction Idiopathic trigeminal neuralgia (ITN) is a common pain disease in elderly people. Many methods have been used to alleviate the pain of patients, but few studies in the literature have compared the effect of nerve combing and percutaneous radiofrequency thermocoagulation. Objective The purpose of this study was to describe and evaluate the clinical outcome of idiopathic trigeminal neuralgia after nerve combing (NC) and compare them with those obtained using percutaneous radiofrequency thermocoagulation (RF). Methods The study included 105 idiopathic trigeminal neuralgia patients with similar symptom, age and underlying disease, which were divided into two groups. One group was treated by nerve combing (50 patients), the other by RF (55 cases). All patients were considered medical failures prior to the surgeries. A questionnaire was used to assess the long-term outcomes: pain relief, recurrence, complication and need for additional treatment. Results The median duration of follow-up in both groups was 90 months. Satisfactory relief was noted in 41 patients (82%), 5 patients (10%) initially experienced pain relief, then recurred, and four patients (8%) were designated poor among the group NC. In the group RF, satisfactory relief was noted in 42 patients (76.4%). There were eight “pain free with recurrence patients (14.5%) and 5 poor cases (9.1%). No statistically significant differences existed in the outcomes between both groups (p > 0.05). Postoperative morbidity included dysesthesia, diplopia, partial facial nerve palsy, hearing loss, tinnitus, cerebrospinal fluid leak, meningitis and mortality. Conclusion Nerve combing and RF are both satisfactory treatment strategies for patients with ITN. Because of the higher risk of sensory morbidity and surgical risk as open surgery, RF is preferred as the recommended procedure for patients with ITN.
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Affiliation(s)
- Xuanchen Zhou
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Otorhinolaryngology Head and Neck Surgery, Jinan, China
| | - Yiqing Liu
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Otorhinolaryngology Head and Neck Surgery, Jinan, China
| | - Zhiyong Yue
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Otorhinolaryngology Head and Neck Surgery, Jinan, China
| | - Deheng Luan
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Otorhinolaryngology Head and Neck Surgery, Jinan, China
| | - Hong Zhang
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Care Gastroenterology, Jinan, China
| | - Jie Han
- Shandong Provincial Hospital Affiliated to Shandong University, Department of Otorhinolaryngology Head and Neck Surgery, Jinan, China.
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10
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Al-Quliti KW. Update on neuropathic pain treatment for trigeminal neuralgia. The pharmacological and surgical options. ACTA ACUST UNITED AC 2015; 20:107-14. [PMID: 25864062 PMCID: PMC4727618 DOI: 10.17712/nsj.2015.2.20140501] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Trigeminal neuralgia is a syndrome of unilateral, paroxysmal, stabbing facial pain, originating from the trigeminal nerve. Careful history of typical symptoms is crucial for diagnosis. Most cases are caused by vascular compression of the trigeminal root adjacent to the pons leading to focal demyelination and ephaptic axonal transmission. Brain imaging is required to exclude secondary causes. Many medical and surgical treatments are available. Most patients respond well to pharmacotherapy; carbamazepine and oxcarbazepine are first line therapy, while lamotrigine and baclofen are considered second line treatments. Other drugs such as topiramate, levetiracetam, gabapentin, pregabalin, and botulinum toxin-A are alternative treatments. Surgical options are available if medications are no longer effective or tolerated. Microvascular decompression, gamma knife radiosurgery, and percutaneous rhizotomies are most promising surgical alternatives. This paper reviews the medical and surgical therapeutic options for the treatment of trigeminal neuralgia, based on available evidence and guidelines.
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Affiliation(s)
- Khalid W Al-Quliti
- Department of Medicine, College of Medicine, Taibah University, Almadinah Almunawwarah, Kingdom of Saudi Arabia. E-mail:
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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.
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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
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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
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De Salles A, Gorgulho A. Influence of the brain function through the peripheral nerves. Surg Neurol Int 2012; 3:S245-6. [PMID: 23230528 PMCID: PMC3514918 DOI: 10.4103/2152-7806.103012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 09/18/2012] [Indexed: 11/04/2022] Open
Affiliation(s)
- Antonio De Salles
- Department of Neurosurgery and Radiation Oncology, David Geffen School of Medicine, University of California Los Angeles, USA
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Latorzeff I, Debono B, Sol JC, Ménégalli D, Mertens P, Redon A, Muracciole X. Traitement de la névralgie essentielle du trijumeau par radiochirurgie stéréotaxique. Cancer Radiother 2012; 16 Suppl:S57-69. [DOI: 10.1016/j.canrad.2012.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 01/23/2012] [Indexed: 10/28/2022]
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Soleymani T, Pieton D, Pezeshkian P, Miller P, Gorgulho AA, Pouratian N, De Salles AAF. Surgical approaches to tinnitus treatment: A review and novel approaches. Surg Neurol Int 2011; 2:154. [PMID: 22140639 PMCID: PMC3228384 DOI: 10.4103/2152-7806.86834] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 08/30/2011] [Indexed: 11/21/2022] Open
Abstract
Background: Tinnitus, a profoundly widespread auditory disorder, is characterized by the perception of sound in the absence of external stimulation. The aim of this work is to review the various surgical treatment options for tinnitus, targeting the various disruption sites along the auditory pathway, as well as to indicate novel neuromodulatory techniques as a mode of tinnitus control. Methods: A comprehensive analysis was conducted on published clinical and basic neuroscience research examining the pathophysiology and treatment options of tinnitus. Results: Stereotactic radiosurgery methods and microvascular decompressions are indicated for tinnitus caused by underlying pathologies such as vestibular schwannomas or neurovascular conflicts of the vestibulocochlear nerve at the level of the brainstem. However, subsequent hearing loss and secondary tinnitus may occur. In patients with subjective tinnitus and concomitant sensorineural hearing loss, cochlear implantation is indicated. Surgical ablation of the cochlea, vestibulocochlear nerve, or dorsal cochlear nucleus, though previously suggested in earlier literature as viable treatment options for tinnitus, has been shown to be ineffective and contraindicated. Recently, emerging research has shown the neuromodulatory capacity of the somatosensory system at the level of the trigeminal nerve on the auditory pathway through its inputs at various nuclei in the central auditory pathway. Conclusion: Tinnitus remains to be a difficult disorder to treat despite the many surgical interventions aimed at eliminating the aberrant neuronal activity in the auditory system. A promising novel neuromodulatory approach using the trigeminal system to control such a bothersome and difficult-to-treat disorder deserves further investigation and controlled clinical trials.
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Affiliation(s)
- Teo Soleymani
- School of Medicine, University of California at Irvine, Irvine, CA, USA
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Hayashi M, Chernov M, Tamura N, Taira T, Izawa M, Yomo S, Nagai M, Chang CS, Ivanov P, Tamura M, Muragaki Y, Okada Y, Iseki H, Takakura K. Stereotactic radiosurgery of essential trigeminal neuralgia using Leksell Gamma Knife model C with automatic positioning system. Neurosurg Rev 2011; 34:497-508. [DOI: 10.1007/s10143-011-0330-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 01/24/2011] [Accepted: 03/09/2011] [Indexed: 11/29/2022]
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Park YS, Kim JP, Chang WS, Kim HY, Park YG, Chang JW. Gamma knife radiosurgery for idiopathic trigeminal neuralgia as primary vs. secondary treatment option. Clin Neurol Neurosurg 2011; 113:447-52. [PMID: 21330049 DOI: 10.1016/j.clineuro.2011.01.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 10/24/2010] [Accepted: 01/19/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To enable physicians to remain informed of secondary GKR after multiple surgical choices. This study compares gamma knife radiosurgery (GKR) as a first and a second treatment for the management of medically refractory idiopathic trigeminal neuralgia (TN). METHODS Between May 1998 and May 2008, a total of 86 patients with idiopathic TN underwent GKR, with 62 patients receiving the treatment as a first therapy (primary GKR group) and 24 patients receiving the treatment as a second procedure (secondary GKR group). The median follow-up time was 76.4 months (range 12-161 months). The mean prescription marginal dose delivered to the involved trigeminal nerve root entry zone was 82.4±6.25Gy for the primary GKR group, and 81.0±4.89Gy for the secondary GKR group. In the secondary group, eleven patients underwent percutaneous radiofrequency rhizotomy (PRFR), seven underwent microvascular decompression (MVD), three underwent percutaneous glycerol rhizotomy and another three underwent GKR as their first treatment. We excluded a typical, multiple sclerosis or secondary trigeminal neuralgia. RESULTS No significant differences in radiation dose, time to initial response, recurrence or pain relief were observed between the use of GKR as a primary and a secondary procedure for idiopathic TN. The occurrence of new onset after GKR were the same for the two groups, but overall facial sensory changes was higher in the secondary GKR group. CONCLUSION For pain control, GKR can be offered both as a primary and as a secondary procedure, but shows higher overall facial sensory changes in secondary GKR group. The results of our study enable physicians to remain informed of secondary GKR after multiple surgical choices. GKR would be an alternative treatment modality after other surgical treatments including GKR, MVD, PRFR and Glycerol.
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Affiliation(s)
- Young Seok Park
- Department of Neurosurgery, Bundang CHA Hospital, CHA University School of Medicine, Seongnam, Korea
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Radiosurgery scope of practice in Canada: A report of the Canadian association of radiation oncology (CARO) radiosurgery advisory committee. Radiother Oncol 2010; 95:122-8. [DOI: 10.1016/j.radonc.2010.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 01/07/2010] [Indexed: 11/20/2022]
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Headache, facial pain, and disorders of facial sensation. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Regis J, Arkha Y, Yomo S, Murata N, Roussel P, Donnet A, Peragut JC. La radiochirurgie dans le traitement de la névralgie trigéminale : résultats à long terme et influence des nuances techniques. Neurochirurgie 2009; 55:213-22. [DOI: 10.1016/j.neuchi.2009.01.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Accepted: 01/27/2009] [Indexed: 11/29/2022]
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Borchers JD, Yang HJ, Sakamoto GT, Howes GA, Gupta G, Chang SD, Adler JR. Cyberknife stereotactic radiosurgical rhizotomy for trigeminal neuralgia: anatomic and morphological considerations. Neurosurgery 2009; 64:A91-5. [PMID: 19165080 DOI: 10.1227/01.neu.0000340795.87734.70] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To search for correlations between specific anatomic, geometric, and morphological properties of the trigeminal nerve and the success of radiosurgical treatment and elimination of facial hypesthesia as a complication. METHODS Forty-six patients with at least 6 months of follow-up after CyberKnife (Accuray, Inc., Sunnyvale, CA) rhizotomy were retrospectively reviewed. Patients treated after 2004 were entered into the study after congruity in treatment parameters was established. Anatomic variations regarding the length of each nerve segment and angle of trigeminal nerve takeoff from brainstem to Meckel's cave in the axial and sagittal planes were studied. Dose distribution to surrounding critical structures (brainstem and trigeminal ganglion) was measured. After spatial relationships of involved structures and dose distributions were recorded, their relationship to treatment success, failure, or complication (primarily facial numbness) was tabulated. RESULTS Forty-five patients (97.2%) experienced pain relief immediately or within weeks. Thirty-four patients maintained excellent outcome. Some degree of facial numbness developed in 18 patients (39.1%) and was mild in 11 of them (Grade II on the Barrow Neurological Institute scale). Patients with a sagittal-angle trigeminal nerve takeoff from the brainstem in the range of 150 to 170 degrees measured from the horizontal plane had a more favorable outcome (P = 0.03) than patients with less obtuse relationships to the proximal nerve origin. Patients who received higher doses of radiation to the brainstem/dorsal root entry zone of the trigeminal nerve experienced a higher rate of posttreatment facial anesthesia. CONCLUSION There may be important anatomic and geometric relationships between the treated trigeminal nerve and surrounding critical structures that warrant pretreatment target volume placement and dose distribution considerations.
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Affiliation(s)
- John D Borchers
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California 94305, USA
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Adler JR, Bower R, Gupta G, Lim M, Efron A, Gibbs IC, Chang SD, Soltys SG. Nonisocentric radiosurgical rhizotomy for trigeminal neuralgia. Neurosurgery 2009; 64:A84-90. [PMID: 19165079 DOI: 10.1227/01.neu.0000341631.49154.62] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Although stereotactic radiosurgery is an established procedure for treating trigeminal neuralgia (TN), the likelihood of a prompt and durable complete response is not assured. Moreover, the incidence of facial numbness remains a challenge. To address these limitations, a new, more anatomic radiosurgical procedure was developed that uses the CyberKnife (Accuray, Inc., Sunnyvale, CA) to lesion an elongated segment of the retrogasserian cisternal portion of the trigeminal sensory root. Because the initial experience with this approach resulted in an unacceptably high incidence of facial numbness, a gradual dose and volume de-escalation was performed over several years. In this single-institution prospective study, we evaluated clinical outcomes in a group of TN patients who underwent lesioning with seemingly optimized nonisocentric radiosurgical parameters. METHODS Forty-six patients with intractable idiopathic TN were treated between January 2005 and June 2007. Eligible patients were either poor surgical candidates or had failed previous microvascular decompression or destructive procedures. During a single radiosurgical session, a 6-mm segment of the affected nerve was treated with a mean marginal prescription dose of 58.3 Gy and a mean maximal dose of 73.5 Gy. Monthly neurosurgical follow-up was performed until the patient became pain-free. Longer-term follow-up was performed both in the clinic and over the telephone. Outcomes were graded as excellent (pain-free and off medication), good (>90% improvement while still on medication), fair (50-90% improvement), or poor (no change or worse). Facial numbness was assessed using the Barrow Neurological Institute Facial Numbness Scale score. RESULTS Symptoms disappeared completely in 39 patients (85%) after a mean latency of 5.2 weeks. In most of these patients, pain relief began within the first week. TN recurred in a single patient after a pain-free interval of 7 months; all symptoms abated after a second radiosurgical procedure. Four additional patients underwent a repeat rhizotomy after failing to respond adequately to the first operation. After a mean follow-up period of 14.7 months, patient-reported outcomes were excellent in 33 patients (72%), good in 11 patients (24%), and poor/no improvement in 2 patients (4%). Significant ipsilateral facial numbness (Grade III on the Barrow Neurological Institute Scale) was reported in 7 patients (15%). CONCLUSION Optimized nonisocentric CyberKnife parameters for TN treatment resulted in high rates of pain relief and a more acceptable incidence of facial numbness than reported previously. Longer follow-up periods will be required to establish whether or not the durability of symptom relief after lesioning an elongated segment of the trigeminal root is superior to isocentric radiosurgical rhizotomy.
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Affiliation(s)
- John R Adler
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California 94305, USA.
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Fariselli L, Marras C, De Santis M, Marchetti M, Milanesi I, Broggi G. CYBERKNIFE RADIOSURGERY AS A FIRST TREATMENT FOR IDIOPATHIC TRIGEMINAL NEURALGIA. Neurosurgery 2009; 64:A96-101. [DOI: 10.1227/01.neu.0000341714.55023.8f] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
OBJECTIVE
To report the level of effectiveness and safety, in our experience, of CyberKnife (Accuray, Inc., Sunnyvale, CA) robotic radiosurgery as a first-line treatment against pharmacologically refractory trigeminal neuralgia.
METHODS
We treated 33 patients with the frameless CyberKnife system as a monotherapy. The retrogasserian portion of the trigeminal nerve (a length of 4 mm, 2–3 mm anterior to the root entry zone) was targeted. Doses of 55 to 75 Gy were prescribed to the 100% isodose line, according to a dose escalation protocol. The patients were evaluated for the level of pain control, time to pain relief, hypesthesia, and time to pain recurrence.
RESULTS
The median age was 74 years. All but 2 patients (94%) achieved a successful treatment outcome. The follow-up period was 9 to 37 months (mean, 23 months). The Barrow Neurological Institute Pain Intensity Scale (BPS) score before radiosurgery was III in 2 patients (6%), IV in 8 patients (24%), and V in 23 patients (70%). The time to pain relief was 1 to 180 days (median, 30 days). No facial numbness was observed. Only 1 patient developed a transitory dysesthesia of the tongue. After treatment, the BPS score was I, II, or III in 31 patients (97%). Pain recurred in 33% (11 patients) at a mean of 9 months (range, 1–43 months). Three patients with recurrences had low pain control by medication (BPS score, IV), and 1 patient (BPS score, V) needed a radiofrequency lesioning (BPS score, I at 12 months).
CONCLUSION
CyberKnife radiosurgery for trigeminal neuralgia allows pain relief at safe doses and is suggested for pharmacologically refractory trigeminal neuralgia. Higher prescribed doses were not associated with improvement in pain relief or recurrence rate.
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Affiliation(s)
- Laura Fariselli
- Division of Radiotherapy, Fondazione Istituto Neurologico C. Besta, and Centro Diagnostico Italiano, Milan, Italy
| | - Carlo Marras
- Department of Neurosurgery, Fondazione Istituto Neurologico C. Besta, Milan, Italy
| | - Michela De Santis
- Division of Radiotherapy, Fondazione Istituto Neurologico C. Besta, Milan, Italy
| | - Marcello Marchetti
- Department of Neurosurgery and Division of Radiotherapy, Fondazione Istituto Neurologico C. Besta, Milan, Italy
| | - Ida Milanesi
- Division of Radiotherapy, Fondazione Istituto Neurologico C. Besta, Milan, Italy
| | - Giovanni Broggi
- Department of Neurosurgery, Fondazione Istituto Neurologico C. Besta, and Centro Diagnostico Italiano, Milan, Italy
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Nedzi LA. The implementation of ablative hypofractionated radiotherapy for stereotactic treatments in the brain and body: observations on efficacy and toxicity in clinical practice. Semin Radiat Oncol 2008; 18:265-72. [PMID: 18725114 DOI: 10.1016/j.semradonc.2008.04.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Radiosurgery has a long history dating back to the 1950s. Only in the last decade or so have advances in radiation delivery and visualization allowed export of this paradigm to extracranial sites. This review evaluates the efficacy and safety of such ablative radiation courses using dose per fraction schedules of 10 Gy or above. Retrospective published experience in functional and benign tumor radiosurgery is reviewed. Prospective controlled clinical trials in ablative cancer therapy of early-stage lung cancer and metastatic disease in the brain, liver, and spine are reviewed.
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Kang JH, Yoon YS, Kang DW, Chung SS, Chang JW. Gamma knife radiosurgery for medically refractory idiopathic trigeminal neuralgia. ACTA NEUROCHIRURGICA. SUPPLEMENT 2008; 101:35-8. [PMID: 18642631 DOI: 10.1007/978-3-211-78205-7_6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Gamma knife radiosurgery (GKS) has been generally considered as a viable therapeutic option for the management of medically refractory idiopathic trigeminal neuralgia (TN). We reviewed our experience with GKS in patients with TN. Between Feb 1996 and May 2006, 77 patients with medical refractory idiopathic TN were treated using GKS. Thirty-six patients who had undergone other previous procedures, previous GKS, or had brain stem lesion, atypical symptoms, were excluded from this study. Pain improvement was achieved in 38 of the patients with TN (pain response rate 92.7%). Twenty-three patients were pain free and 15 had reduced pain. There were no serious complications. We think that GKS is an effective treatment option for patients with medical refractory idiopathic TN.
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Affiliation(s)
- J H Kang
- Department of Neurosurgery, Brain Korea 21 Project for Medical Science & Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Abstract
Trigeminal neuralgia (TN) is reputed to be one of the most painful conditions in human experience. Thus, many treatments, both medical and surgical, have been developed for this relapsing and remitting, paroxysmal stabbing or electrical, facial pain syndrome. The likely etiology in many cases is vascular compression of the trigeminal nerve root entry zone, leading to focal demyelination and aberrant neural discharges. MRI may disclose neurovascular contact, although not with sufficient sensitivity or specificity to substitute for careful clinical diagnosis. In treating TN, antiepileptic drugs are superior to traditional analgesics. Carbamazepine is the first choice drug. Additional drugs for which there is evidence of efficacy include oxcarbazepine, baclofen, gabapentin, lamotrigine and phenytoin. Many patients eventually experience tachyphylaxis or may not tolerate effective doses. Surgical options include: microvascular decompression; balloon compression; radiofrequency thermocoagulation or glycerol rhizotomies; and subcutaneous alcohol branch blockade. Stereotactic gamma knife radiosurgery is a further option. Motor cortex stimulation and transcranial magnetic stimulation, although having shown initial promise for trigeminal neuropathic pain, seem to be ineffective for classical TN. The choice of drug, whether or when to operate, and which procedure to choose should be individualized to the particular needs and conditions of the patient.
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Affiliation(s)
- William P Cheshire
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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De Salles AAF, Gorgulho AA, Selch M, De Marco J, Agazaryan N. Radiosurgery from the brain to the spine: 20 years experience. RECONSTRUCTIVE NEUROSURGERY 2008; 101:163-8. [DOI: 10.1007/978-3-211-78205-7_28] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Yang SY, Kim DG, Chung HT. Radiosurgery for Intracranial Disorders. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2008. [DOI: 10.5124/jkma.2008.51.1.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Seung-Yeob Yang
- Department of Neurosurgery, Dongguk University International Hospital, Korea.
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Korea. ,
| | - Hyun-Tai Chung
- Department of Neurosurgery, Seoul National University College of Medicine, Korea. ,
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