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Akcakaya MO, Mirkhasilova M, Ozturk O, Ugurlar D, Tonge M, Alco G, Ercan T, Igdem S, Karadereler S. Gamma Knife radiosurgery for the treatment of trigeminal neuralgia: A single center-experience. NEUROCIRUGIA (ENGLISH EDITION) 2024:S2529-8496(24)00020-0. [PMID: 38642616 DOI: 10.1016/j.neucie.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/20/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION AND OBJECTIVES We aimed to assess the outcomes of patients with trigeminal neuralgia (TGN) who underwent Gamma Knife radiosurgery (GKRS). MATERIALS AND METHODS Fifty-three patients with typical TGN underwent GKRS from May 2012 until December 2022. Among these patients, 45 patients who were follow-up for at least 12 months were included in the study. A mean dose of 87.5 Gy (range, 80-90) was administered to the trigeminal nerve. Postoperatively, outcome was considered excellent if the patient was pain- and medication-free. RESULTS The mean symtpom duration was 9.53 years, and the mean patient age was 59.8 years (range, 34-85). The mean follow-up period was 46.8 months (range, 12-127 months). 46.7% of patients had a history of previous surgical interventions. A single nerve division was affected in 14 patients (31.1%), and multiple divisions were affected in 31 patients (68.9%). The rate of initial pain relief was 80%. Hypoesthesia in the area of trigeminal nerve developed in 30 (66.7%). Twenty patients (44.4%) exhibited excellent results within 72.4 months. Recurrence occurred in 11 patients (24.4%) with 27.6 months. CONCLUSIONS Our results suggest that GKRS is a safe and effective procedure. Thus, it is an attractive first- and second-line treatment choice for TGN.
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Affiliation(s)
- Mehmet Osman Akcakaya
- Department of Neurosurgery, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey
| | | | - Onur Ozturk
- Department of Neurosurgery, Acibadem Taksim Hospital, Istanbul, Turkey.
| | - Doga Ugurlar
- Department of Neurosurgery, Samatya Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Tonge
- Department of Neurosurgery, Medipol Mega Hospital, Istanbul, Turkey
| | - Gul Alco
- Department of Radiation Oncology, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey
| | - Tulay Ercan
- Department of Radiation Oncology, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey
| | - Sefik Igdem
- Department of Radiation Oncology, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey
| | - Selhan Karadereler
- Department of Neurosurgery, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey
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Moreira A, Santos Hernández DA, Caceros V, Barahona KC, Campos F, Reyes WA, Blanco A, Soto T, Ramirez J, Mejias R, Cruz C, Lovo EE. Dual-Target Radiosurgery for Concomitant Continuous Pain Presentation of Trigeminal Neuralgia: Radiomodulation Effect and Dose. Cureus 2024; 16:e51602. [PMID: 38313895 PMCID: PMC10836852 DOI: 10.7759/cureus.51602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 02/06/2024] Open
Abstract
OBJECTIVES Patients with trigeminal neuralgia (TN) experience concomitant continuous pain (CCP) that can be difficult to treat. A dual-target approach delivering a high dose of radiation to the nerve and the contralateral thalamus can develop a fast radiomodulation effect on lowering pain. We sought to determine if this effect was dose dependent. METHODS We retrospectively reviewed 21 patients treated with radiosurgery in CCP and severe TN pain, with a visual analog scale (VAS) score of nine out of 10 at the time of treatment. Ten patients were treated with a high dose (>120 Gy) in the thalamus 90 Gy to the nerve, and the rest with a low dose (<120 Gy) to the thalamus and >90 Gy to the nerve. RESULTS Of those who received the high dose to the thalamus, six patients (60%) received 140 Gy, and four (40%) received 120 Gy, with a median dose to the trigeminal nerve of 90 and 85 Gy, respectively. The high thalamus dose showed a radiomodulation effect from day 1. The low thalamus dose did not produce radiomodulation on any of the first four days. The percentage of VAS score reduction one month after treatment was higher in the high-thalamus dose group than in the low-thalamus dose group. At three months, VAS score was 2 in the high-dose group and 4 in the low-dose group. CONCLUSIONS The radiomodulation effect in pain and dual-target radiosurgery is dose dependent in CCP in TN; a high dose can provide a more consistent clinical result than a lower dose.
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Affiliation(s)
| | | | - Victor Caceros
- Radiation Oncology, International Cancer Center, San Salvador, SLV
| | - Kaory C Barahona
- Radiation Oncology, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Fidel Campos
- Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - William A Reyes
- Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | | | - Tatiana Soto
- Radiation, Robotic Radiosurgery Center, San Jose, CRI
| | - Juliana Ramirez
- Radiosurgery, Centro de Radiocirugia Robotica, San Jose, CRI
| | - Ricardo Mejias
- Medical Physics, Robotic Radiosurgery Center, San Jose, CRI
| | - Claudia Cruz
- Anesthesia and Pain Management, Hospital De Diagnóstico, San Salvador, SLV
| | - Eduardo E Lovo
- Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
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Orlev A, Feghali J, Kimchi G, Sun L, Pierre C, Gragnaniello C, Cotrutz C, Loiselle C, Vermeulen S, Litvack Z. TN-RS: a novel scoring system predicts Gamma Knife Radiosurgery outcome for trigeminal neuralgia patients. Acta Neurochir (Wien) 2023; 165:3895-3903. [PMID: 37922000 DOI: 10.1007/s00701-023-05835-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/03/2023] [Indexed: 11/05/2023]
Abstract
BACKGROUND Gamma Knife Radiosurgery (GKRS) is an effective treatment option for medically refractory trigeminal neuralgia (TN). This study examines GKRS outcome in a large cohort of TN patients and highlights pretreatment factors associated with pain relief. METHODS This is a single-center retrospective analysis of patients treated with GKRS for TN between 2011 and 2019. Pain relief was assessed at 1 year, and 2-3 years following GKRS. Multivariable analysis identified several factors that predicted pain relief. These predicting factors were applied to establish a pain relief scoring system. RESULTS A total of 162 patients met inclusion criteria. At 1 year post-GKRS, the breakdown of Barrow Neurological Institute (BNI) score for pain relief was as follows: 77 (48%) score of I, 13 (8%) score of II, 37 (23%) score of III, 22 (14%) score of IV, and 13 (8%) score of V. Factors that were significantly associated with pain-free outcome at 1 year were: Typical form of TN (OR = 2.2 [1.1, 4.9], p = 0.049), No previous microvascular decompression (OR = 4.4 [1.6, 12.5], p = 0.005), Response to medical therapy (OR = 2.7 [1.1, 6.1], p = 0.018), and Seniority > 60 years (OR = 2.8 [1.4, 5.5], p = 0.003). The term "Trigeminal Neuralgia-RadioSurgery" was used to create the TN-RS acronym representing the significant factors. A stepwise increase in the median predicted probability of pain-free outcome at 1 year from 3% for patients with a score of 0 to 69% for patients with a maximum score of 4. CONCLUSION The TN-RS scoring system can assist clinicians in identifying patients that may benefit from GNRS for TN by predicting 1-year pain-free outcomes.
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Affiliation(s)
- Alon Orlev
- Swedish Neuroscience Institute, Seattle, WA, USA.
- Department of Neurosurgery, Rabin Medical Center, Affiliated to Sackler Medical School, 39 Jabotynski St., 49414, Petach Tikva, Israel.
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gil Kimchi
- Department of Neurosurgery, Sheba Medical Center, Ramat-Gan, Affiliated to Sackler Medical School, Tel-Aviv University, Tel-Aviv, Israel
| | - Lian Sun
- Department of Biology, University of Washington, Bothell, WA, USA
| | | | - Cristian Gragnaniello
- Swedish Neuroscience Institute, Seattle, WA, USA
- Department of Neurosurgery, Long School of Medicine, University of Texas, San Antonio, TX, USA
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Guillemette A, Heymann S, Roberge D, Ménard C, Fournier-Gosselin MP. CyberKnife radiosurgery for trigeminal neuralgia: a retrospective review of 168 cases. Neurosurg Focus 2022; 53:E4. [DOI: 10.3171/2022.8.focus22370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE
Gamma Knife radiosurgery is recognized as an efficient intervention for the treatment of refractory trigeminal neuralgia (TN). The CyberKnife, a more recent frameless and nonisocentric radiosurgery alternative, has not been studied as extensively for this condition. This study aims to evaluate the clinical outcomes of a first CyberKnife radiosurgery (CKRS) treatment in patients with medically refractory TN.
METHODS
A retrospective cohort study of 166 patients (168 procedures) with refractory TN treated from 2009 to 2021 at the Centre Hospitalier de l’Université de Montréal was conducted. The treatment was performed using a CyberKnife (model G4, VSI, or M6). The treatment median maximum dose was 80 (range 70.0–88.9) Gy.
RESULTS
Adequate pain relief, evaluated using Barrow Neurological Institute pain scale scores (I–IIIb), was achieved in 146 cases (86.9%). The median latency period before adequate pain relief was 35 (range 0–202) days. The median duration of pain relief for cases with a recurrence of pain was 8.3 (range 0.6–85.0) months. The actuarial rates of maintaining adequate pain relief at 12, 36, and 60 months from the treatment date were 77.0%, 62.5%, and 50.2%, respectively. There was new onset or aggravation of facial numbness in 44 cases (26.2%). This facial numbness was predictive of better maintenance of pain relief (p < 0.001). The maintenance of adequate pain relief was sustained longer in idiopathic cases compared with cases associated with multiple sclerosis (MS; p < 0.001).
CONCLUSIONS
In the authors’ experience, CKRS for refractory TN is efficient and safe. The onset or aggravation of facial hypoesthesia after treatment was predictive of a more sustained pain relief, and idiopathic cases had more sustained pain relief in comparison with MS-related cases.
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Affiliation(s)
- Albert Guillemette
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CR-CHUM)
| | - Sami Heymann
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CR-CHUM)
- Service of Neurosurgery, Centre Hospitalier de l’Université de Montréal (CHUM); and
| | - David Roberge
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CR-CHUM)
- Department of Radiation Oncology, Centre Hospitalier de l’Université de Montréal (CHUM)
| | - Cynthia Ménard
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CR-CHUM)
- Department of Radiation Oncology, Centre Hospitalier de l’Université de Montréal (CHUM)
| | - Marie-Pierre Fournier-Gosselin
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CR-CHUM)
- Service of Neurosurgery, Centre Hospitalier de l’Université de Montréal (CHUM); and
- Department of Surgery, Université de Montréal (UdeM), Montréal, Québec, Canada
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Chen Q, Yi DI, Perez JNJ, Liu M, Chang SD, Barad MJ, Lim M, Qian X. The Molecular Basis and Pathophysiology of Trigeminal Neuralgia. Int J Mol Sci 2022; 23:ijms23073604. [PMID: 35408959 PMCID: PMC8998776 DOI: 10.3390/ijms23073604] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/19/2022] [Accepted: 03/21/2022] [Indexed: 02/04/2023] Open
Abstract
Trigeminal neuralgia (TN) is a complex orofacial pain syndrome characterized by the paroxysmal onset of pain attacks in the trigeminal distribution. The underlying mechanism for this debilitating condition is still not clearly understood. Decades of basic and clinical evidence support the demyelination hypothesis, where demyelination along the trigeminal afferent pathway is a major driver for TN pathogenesis and pathophysiology. Such pathological demyelination can be triggered by physical compression of the trigeminal ganglion or another primary demyelinating disease, such as multiple sclerosis. Further examination of TN patients and animal models has revealed significant molecular changes, channelopathies, and electrophysiological abnormalities in the affected trigeminal nerve. Interestingly, recent electrophysiological recordings and advanced functional neuroimaging data have shed new light on the global structural changes and the altered connectivity in the central pain-related circuits in TN patients. The current article aims to review the latest findings on the pathophysiology of TN and cross-examining them with the current surgical and pharmacologic management for TN patients. Understanding the underlying biology of TN could help scientists and clinicians to identify novel targets and improve treatments for this complex, debilitating disease.
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Affiliation(s)
- QiLiang Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; (Q.C.); (D.I.Y.); (J.N.J.P.); (M.L.); (M.J.B.)
| | - Dae Ik Yi
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; (Q.C.); (D.I.Y.); (J.N.J.P.); (M.L.); (M.J.B.)
| | - Josiah Nathan Joco Perez
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; (Q.C.); (D.I.Y.); (J.N.J.P.); (M.L.); (M.J.B.)
| | - Monica Liu
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; (Q.C.); (D.I.Y.); (J.N.J.P.); (M.L.); (M.J.B.)
| | - Steven D. Chang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.D.C.); (M.L.)
| | - Meredith J. Barad
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; (Q.C.); (D.I.Y.); (J.N.J.P.); (M.L.); (M.J.B.)
| | - Michael Lim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.D.C.); (M.L.)
| | - Xiang Qian
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; (Q.C.); (D.I.Y.); (J.N.J.P.); (M.L.); (M.J.B.)
- Correspondence:
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Lovo EE, Moreira A, Barahona KC, Torres B, Blanco A, Caceros V, Campos F, Gorgulho A. Gamma Ray Radiosurgery for Trigeminal Neuralgia: Targeting Proximal or Distal to the Dorsal Root Entry Zone. Cureus 2021; 13:e15194. [PMID: 34178514 PMCID: PMC8218962 DOI: 10.7759/cureus.15194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Stereotactic radiosurgery for trigeminal neuralgia (TN) has gained interest among patients who are not suitable for surgical procedures. Although two target zones are more recognized - dorsal root entry zone (DREZ) and retrogasserian zone (RGZ) - the optimal targeting technique remains controversial in terms of clinical outcomes and rates of complications. Therefore, various modifications to the radiosurgical technique for TN have been made. Objective This study aimed to determine the differences in shoot location (i.e., RGZ vs. DREZ) regarding effectiveness and adverse effects in patients with medically refractory TN. Additionally, we evaluated the effect of the integral dose (ID) on treatment outcomes and complications. Methods We present a retrospective cohort study of 49 patients with primary, drug-resistant TN treated with gamma knife radiosurgery targeting the distal and proximal parts of the nerve regarding the DREZ with a prescription dose of 90 Gy (80 to 96 Gy). A subset of these patients (n=38) where the ID could be measured to the nerve was correlated to treatment outcomes and complications. Results The median follow-up time was 36 months for RGZ and 51 months for DREZ targets. Neurovascular conflict was identified in 87.5% of the RGZ group and 88.2% of the DREZ group. Using the Barrow Neurological Institute (BNI) pain score, 26 (81.3%) RGZ and 12 (70.6%) DREZ patients were successfully treated (BNI I-IIIb; p=0.02). Seven (21.9%) RGZ and eight (47.1%) DREZ patients reported complete pain relief without medication (BNI I). Time response was 22.3 days for RGZ and 34.1 days for DREZ (p=0.277). There were 10 (31.3%) patients in the RGZ group with associated complications versus six (35.3%) patients in the DREZ group (χ2=0.0826, degree of freedom=1, p=0.773). Treatment outcomes using higher ID were better in the RGZ than DREZ (81.8% vs. 57.1, respectively), and a significant association was found between a higher ID delivered to the nerve and the development of complications (p=0.02). Conclusion Based on the obtained results, the RGZ was a more effective targeting area with better treatment outcomes without significant differences in complication rates than DREZ. A higher ID at the RGZ than DREZ had a greater therapeutical effect. Further investigation regarding the optimal target area along the ID delivered and clinical outcomes are required.
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Affiliation(s)
- Eduardo E Lovo
- Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Alejandra Moreira
- Neurosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Kaory C Barahona
- Radiation Oncology, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Boheris Torres
- Neurosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | | | - Victor Caceros
- Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Fidel Campos
- Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
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Park H, Jeong SS, Chung HT, Lee EJ. Treatment Planning Factors Associated with Long-Term Outcomes of Gamma Knife Surgery in Patients with Trigeminal Neuralgia. World Neurosurg 2021; 151:e899-e910. [PMID: 33989823 DOI: 10.1016/j.wneu.2021.05.008] [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: 03/17/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Gamma Knife surgery (GKS) is an established treatment option for trigeminal neuralgia (TN). However, the long-term efficacy of GKS for patients with TN has not been well studied. The aim of the study is to evaluate the sequential course of pain control after GKS and analyze the factors associated with the long-term analgesic effect, focusing on radiation dosimetry and neurovascular conflict (NVC) factors. METHODS We analyzed 83 patients undergoing GKS for TN in our institution between 2005 and 2013 with a follow-up duration >7 years. Tolerable pain with increased medication, persistent-intractable pain, and recurrence were classified as poor outcomes, and any other outcome was classified as a favorable outcome. The dosimetry factors and locational relationship between NVC and the target were analyzed in terms of their correlation with a favorable outcome. RESULTS Adequate pain relief was achieved in 93% of patients a month and a half after GKS, but the pain recurred in 41.5% of patients on average 36 months after treatment. A larger V40Gy (P = 0.002) and higher homogeneity index (P = 0.027) were significantly associated with the long-term favorable outcomes. About 40% of patients had multiple NVC sites, and insufficient inclusion of the NVC in the target was significantly correlated with long-term poor outcomes (P = 0.002). CONCLUSIONS Targeting the center of the trigeminal nerve in the area of NVC with GKS is associated with favorable long-term pain control.
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Affiliation(s)
- Hangeul Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang Soon Jeong
- GammaKnife Radiosurgery Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun-Tai Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea; GammaKnife Radiosurgery Center, Seoul National University Hospital, Seoul, Republic of Korea; Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun Jung Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea; GammaKnife Radiosurgery Center, Seoul National University Hospital, Seoul, Republic of Korea; Seoul National University College of Medicine, Seoul, Republic of Korea.
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Quinzi V, Paskay LC, Manenti RJ, Giancaspro S, Marzo G, Saccomanno S. Telemedicine for a Multidisciplinary Assessment of Orofacial Pain in a Patient Affected by Eagle’s Syndrome: A Clinical Case Report. Open Dent J 2021. [DOI: 10.2174/1874210602115010102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background:
Orofacial pain has a broad range of origins and a multidisciplinary approach occupies a relevant role.
Objective:
The aim of this study was to review the literature regarding the evolution of telemedicine and orofacial pain related to a case report of a patient affected by Eagle's syndrome.
Materials and Methods:
Two authors (RJM and SG) independently reviewed the literature up to March 2020. A case report was developed by including the interdisciplinary assessment and initial treatment of orofacial pain in a 38-year-old female patient affected by Eagle’s syndrome. The patient was interviewed by two different specialists (from Rome, Italy and Los Angeles, California) through an online meeting platform in order to evaluate her complex situation, demonstrating the possibilities that telemedicine offered during the COVID-19 pandemic.
Conclusion:
An interdisciplinary approach can be performed for future follow ups on patients as various advantages were found by the patient and by the clinicians themselves.
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Barzaghi LR, Albano L, Scudieri C, Gigliotti CR, Del Vecchio A, Mortini P. Factors affecting long-lasting pain relief after Gamma Knife radiosurgery for trigeminal neuralgia: a single institutional analysis and literature review. Neurosurg Rev 2021; 44:2797-2808. [PMID: 33432463 DOI: 10.1007/s10143-021-01474-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 12/16/2020] [Accepted: 01/05/2021] [Indexed: 12/29/2022]
Abstract
Gamma Knife radiosurgery (GKRS) is a well-established safe and effective treatment for trigeminal neuralgia (TN) with high initial success rate (80-90%). Why the pain relief is progressively decreased with time is a matter of considerable debate. To investigate factors related to long-lasting pain relief, the authors conducted a retrospective analysis focusing on anatomical and radiosurgical related parameters, chosen according to literature review. One hundred and twelve patients with classical trigeminal neuralgia and follow-up longer than 12 months were selected from our institutional consecutive series of patients treated by GKRS. Patients were followed for a mean period of 61.5 ± 3.5 months (range, 12-126 months) to evaluate, as endpoints, long-term pain relief and hypoesthesia onset. The median maximum radiation dose was 80 Gy (range 70-90 Gy). Factors related to poor long-term pain relief were prescription dose < 80 Gy (p = 0.038), calibration dose rate < 2.5 Gy/min (p = 0.018), and distance between isocenter and trigeminal nerve emergence > 8 mm (p < 0.001). When analyzing patients who received 80 Gy as maximum dose without any sector blocking, we notice that ID50 < 2.7 mJ was predictive for longer period of pain control (p = 0.043). It was experienced also among patients in which a small volume of the nerve (< 35%) received more than 80% of the maximal dose, compared to those in which a larger volume of the nerve was irradiated with maximal dose (p 0.034). This last result was significant if the shot was 8 mm or less from the pons. Several single-patient anatomical and radiosurgical parameters should be considered to improve GKRS effectiveness.
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Affiliation(s)
- Lina R Barzaghi
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy.
| | - Luigi Albano
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy.,Neuroimaging Research Unit, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy
| | - Claudia Scudieri
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
| | - Carmen R Gigliotti
- Department of Medical Physics, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy
| | - Antonella Del Vecchio
- Department of Medical Physics, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
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10
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Somaza S, Montilla EM. Novel theory about radiosurgery's action mechanisms on trigeminal ganglion for idiopathic trigeminal neuralgia: Role of the satellite glial cells. Surg Neurol Int 2020; 11:412. [PMID: 33365175 PMCID: PMC7749945 DOI: 10.25259/sni_484_2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 06/15/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There are many theories about the cause of trigeminal neuralgia (TN). None of them satisfactorily explains how demyelination alone through the ephaptic mechanism can contribute to the development of the TN crisis. The main characteristic of TN pain is its dynamic nature, which is difficult to explain based only on anatomical findings. With these antecedents, the exact mechanism by which radiosurgery produces pain relief in TN is unknown. METHODS It is based on the trigeminal ganglion (TG) cytoarchitecture and the pathophysiological findings observed after an injury to a trigeminal branch. TG seems to have a predominant role given its cellular structure. The neuronal component in sensory ganglia is generally surrounded by a single layer of satellite glial cells (SGC), which forms a sheath around each body cell. There is increasing evidence that SGCs play a key role in nociception. This depends on their ability to influence the neuronal excitability that occurs in conditions of neuropathic and inflammatory pain; contributing to both the generation and maintenance of pain. RESULTS We have already published the beneficial effects of radiosurgery on the TG for the treatment of idiopathic TN and secondary to vertebrobasilar ectasia. Now, we are investigating the functioning of the TG and how radiosurgery could act on the SGC, deactivating them, and contributing to the decrease or disappearance of the painful condition. CONCLUSION We are postulating a theory on how radiosurgery in TG produces changes in the SGC, with implications in the pathological mechanisms initiated by the alteration caused in the neuron after a nerve injury.
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Affiliation(s)
- Salvador Somaza
- Department of Neurosurgery, Centro Diagnostico Docente Las Mercedes, Hospital de Clinicas Caracas
| | - Eglee M. Montilla
- Department of Radiation Oncologist Radiation Oncology, Centro Diagnostico Docente Las Mercedes, Caracas, Miranda, Venezuela
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11
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Constanzo F, Silva RSD, de Almeida DB, Ferragut MA, Coelho Neto M, Toledo HV, Ramina R. Gamma knife radiosurgery for trigeminal neuralgia: first case series from Latin America. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 77:232-238. [PMID: 31090803 DOI: 10.1590/0004-282x20190027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 12/21/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Gamma Knife® radiosurgery (GKRS) for trigeminal neuralgia is an effective treatment with at least a 50% reduction of pain in 75-95% of patients. OBJECTIVE To present the first series of patients treated for trigeminal neuralgia using GKRS in Latin America. METHODS Retrospective analysis. Analysis consisted of time to improvement of symptoms, best Barrow Neurological Institute scale (BNI) score after procedure, time without pain, time to recurrence and post-procedural hypoesthesia. RESULTS Nineteen cases of classical trigeminal neuralgia were analyzed and three cases of symptomatic trigeminal neuralgia were described. Mean time from symptom onset to radiosurgery was 99.6 months, and 78.9% of patients had undergone invasive procedures before treatment. Patients were followed for a mean of 21.7 months. BNI I was achieved in 36.8%, IIIa in 21.1%, IIIb in 21.1%, IV in 5.3% and V in 15.7%. New hypoesthesia developed in 12.1% patients, which was associated with achieving BNI I after the procedure (p < 0.05). Time from diagnosis to GKRS was higher in patients who failed to achieve BNI I (143 vs. 76 months). The distance from the root entry zone in patients who achieved BNI I was greater than patients who did not (1.94 vs. 1.14 mm). Mean distance from the root entry zone in patients with new hypoesthesia was 2.85 mm vs. 1.06 mm (p = 0.06). CONCLUSION Clinical response to GKRS is related to the time between diagnosis and procedure, thus its indication should be considered early in the management of these patients.
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Affiliation(s)
- Felipe Constanzo
- Instituto de Neurologia de Curitiba, Departamento de Neurocirurgia, Curitiba PR, Brasil
| | - Rodrigo Souza da Silva
- Instituto de Neurologia de Curitiba, Departamento de Anestesiologia, Curitiba PR, Brasil
| | - Daniel Benzecry de Almeida
- Instituto de Neurologia de Curitiba, Departamento de Neurocirurgia, Curitiba PR, Brasil.,Instituto de Neurologia de Curitiba, Departamento de Gamma Knife, Curitiba PR, Brasil
| | - Maria Alice Ferragut
- Instituto de Neurologia de Curitiba, Departamento de Gamma Knife, Curitiba PR, Brasil
| | - Mauricio Coelho Neto
- Instituto de Neurologia de Curitiba, Departamento de Neurocirurgia, Curitiba PR, Brasil.,Instituto de Neurologia de Curitiba, Departamento de Gamma Knife, Curitiba PR, Brasil
| | - Hugo Veroneze Toledo
- Instituto de Neurologia de Curitiba, Departamento de Gamma Knife, Curitiba PR, Brasil.,Clínica Paranaense de Tumores, Curitiba PR, Brasil
| | - Ricardo Ramina
- Instituto de Neurologia de Curitiba, Departamento de Neurocirurgia, Curitiba PR, Brasil
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Tajali Y, Ward M, Abraham M, Hillen M, Mahmoud O, Herschman Y, Mammis A, Paskhover B. Minimally invasive trigeminal ablation in patients with refractory trigeminal neuralgia who are ineligible for intracranial intervention. J Clin Neurosci 2019; 70:42-46. [PMID: 31537461 DOI: 10.1016/j.jocn.2019.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 07/30/2019] [Accepted: 09/04/2019] [Indexed: 11/18/2022]
Abstract
We describe the use of minimally invasive trigeminal ablation, an endoscopic ablative technique to treat trigeminal neuralgia in patients who are traditionally poor surgical candidates. We present 4 patients who presented with refractory unilateral trigeminal neuralgia. Three of the patients had previously failed stereotactic radiosurgery and three of them have multiple sclerosis. Due either to lack of neurovascular compression, minimally invasive trigeminal ablation was offered. Intraoperatively, an incision is made along the buccal mucosa or mid-brow and the tissue is endoscopically dissected in a plane towards the symptomatic nerve. Once isolated, the epineurium is partially ablated with thermocautery and the tissue surrounding the nerve is decompressed. All patients reported resolution of their pain post-operatively and were pain free at last follow up. Two patients had mild hypesthesia over the ablated nerve territory. Minimally invasive trigeminal ablation is a safe and effective technique for symptomatic control of trigeminal neuralgia. The efficacy, low risk, and relative ease of the procedure makes it ideal for use in patients who are refractory to medical management and have no neurovascular compression, are unable to tolerate traditional surgery or have failed other therapies.
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Affiliation(s)
- Yasser Tajali
- Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Max Ward
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Mickey Abraham
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Machteld Hillen
- Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ, United States.
| | - Omar Mahmoud
- Department of Radiation Oncology, Cancer Institute of New Jersey, Newark, NJ, United States
| | - Yehuda Herschman
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Antonios Mammis
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Boris Paskhover
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, United States; Department of Facial Plastic Surgery, Rutgers New Jersey Medical School, Newark, NJ, United States
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Bervitskiy AV, Moysak GI, Zubatkina IS, Ivanov PI, Rzaev DA, Amelina EV. [Stereotactic radiosurgery in treatment of trigeminal neuralgia]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 83:37-48. [PMID: 31166316 DOI: 10.17116/neiro20198302137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It was not until relatively recently that the method of stereotactic radiosurgery has started to be used for treating trigeminal neuralgia. Being minimally invasive, this method can be considered an attractive alternative to invasive surgical methods. OBJECTIVE The objective of this study was to analyze the results of treatment in patients with trigeminal neuralgia using the Leksell Gamma Knife system. MATERIAL AND METHODS The results of stereotactic radiosurgery were analyzed in 52 patients (31 females and 21 males aged 31 to 79 years) who had undergone treatment at the Radiosurgical Center of MIBS (St. Petersburg) in 2009-2016. Forty-four patients were diagnosed with typical trigeminal neuralgia; four patients, with atypical neuralgia; and four patients, with symptomatic neuralgia (accompanying multiple sclerosis). Pain severity was assessed using the Visual Analogue Scale (VAS) and the Barrow Neurological Institute Scale (BNIPS) before and after the surgery, as well as during the follow-up period (mean duration, 3 years). RESULTS Pain was reduced in 38 (86.4%) patients with type 1 neuralgia. The effect usually was not observed immediately after the surgery but was delayed from several weeks to 12 months (median, 2 months; interquartile range) [1, 4]. The surgery was ineffective in 6 (14%) patients. Eight (18%) patients had a relapse on average after 2 years and 5 months. By the end of the follow-up period, score I according to the BNIPS was achieved in 22 (50%) patients; score II or III was achieved in 7 (16%) patients. Primary reduction of pain was achieved in two patients with type 2 neuralgia; one of them had a relapse after 19 months. Among patients with symptomatic neuralgia, the primary effect was achieved in three patients, but two of them later had a relapse. CONCLUSION Stereotactic radiosurgery can be used to alleviate pain in most patients with type 1 trigeminal neuralgia, but its results are inferior to those of invasive interventions. According to our findings, 18% of patients had a relapse. For patients with multiple sclerosis accompanied by type 2 and symptomatic trigeminal neuralgia, this method is not sufficiently effective. When both microvascular decompression and stereotactic radiosurgery can be used to treat for type 1 and 2 trigeminal neuralgia, patient's choice is crucial. It is important to inform the patient both about the potential complications of the interventions and about the delayed effect of the surgery and relapse frequency.
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Affiliation(s)
| | - G I Moysak
- Federal Center of Neurosurgery, Novosibirsk, Russia; Novosibirsk State University, Novosibirsk, Russia
| | - I S Zubatkina
- Radiosurgery, Stereotactic Radiotherapy and General Oncology Clinic MIBS, St. Petersburg, Russia
| | - P I Ivanov
- Radiosurgery, Stereotactic Radiotherapy and General Oncology Clinic MIBS, St. Petersburg, Russia; Polenov Russian Research Institute of Neurosurgery, Division of the V.A. Almazov Northwest Federal Medical Research Center, Ministry of Health of the Russian Federation, St. Petersburg, Russia; Division of Neurosurgery, S.M. Kirov Military Medical Academy, St. Petersburg, Russia
| | - D A Rzaev
- Federal Center of Neurosurgery, Novosibirsk, Russia; Novosibirsk State University, Novosibirsk, Russia
| | - E V Amelina
- Novosibirsk State University, Novosibirsk, Russia
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Diffusion tensor imaging abnormalities of the trigeminal nerve root in patients with classical trigeminal neuralgia: a pre- and postoperative comparative study 4 years after microvascular decompression. Acta Neurochir (Wien) 2019; 161:1415-1425. [PMID: 31049710 DOI: 10.1007/s00701-019-03913-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/13/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND As diffusion tensor imaging (DTI) is able to assess tissue integrity, authors used diffusion to detect abnormalities in trigeminal nerves (TGN) in patients with trigeminal neuralgia (TN) caused by neurovascular compression (NVC) who had undergone microvascular decompression (MVD). The authors also studied anatomical TGN parameters (cross-sectional area [CSA] and volume [V]). The study compared pre- and postoperative findings. METHODS Using DTI sequencing on a 3-T MRI scanner, we measured the fraction of anisotropy (FA) and apparent diffusion coefficient (ADC) of the TGN in 10 patients who had undergone MVD for TN and in 6 normal subjects. We compared data between affected and unaffected nerves in patients and both nerves in normal subjects (controls). We then correlated these data with CSA and V. Data from the affected side and the unaffected side before and 4 years after MVD were compared. RESULTS Before MVD, the FA of the affected side (0.37 ± 0.03) was significantly lower (p < 0.05) compared to the unaffected side in patients (0.48 ± 0.03) and controls (0.52 ± 0.02), and the ADC in the affected side (5.6 ± 0.34 mm2/s) was significantly higher (p < 0.05) compared to the unaffected side in patients (4.26 ± 0.25 mm2/s) and controls (3.84 ± 0.18 mm2/s). Affected nerves had smaller V and CSA compared to unaffected nerves and controls (p < 0.05). After MVD, the FA in the affected side (0.41 ± 0.02) remained significantly lower (p < 0.05) compared to the unaffected side (0.51 ± 0.02), but the ADC in the affected side (4.24 ± 0.34 mm2/s) had become similar (p > 0.05) to the unaffected side (4.01 ± 0.33 mm2/s). CONCLUSIONS DTI revealed a loss of anisotropy and an increase in diffusivity in affected nerves before surgery. Diffusion alterations correlated with atrophic changes in patients with TN caused by NVC. After removal of the compression, the loss of FA remained, but ADC normalized in the affected nerves, suggesting improvement in the diffusion of the trigeminal root.
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Somaza S, Montilla EM, Mora MC. Gamma knife radiosurgery on the trigeminal ganglion for idiopathic trigeminal neuralgia: Results and review of the literature. Surg Neurol Int 2019; 10:89. [PMID: 31528427 PMCID: PMC6744789 DOI: 10.25259/sni-134-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 02/21/2019] [Indexed: 11/04/2022] Open
Abstract
Background In the present study, we evaluate the results of gamma knife surgery (GKS) for the treatment of trigeminal neuralgia (TN) using the trigeminal ganglion (TG') and the adjacent fibers of trigeminal nerve as a target. Methods From February 2013 to July 2017, we treated 30 cases of TN with GKS. In this group, all patients had an idiopathic typical TN. The radiosurgical target was conformed through two isocenters, 8 and 4 mm at the cavum de Meckel. The maximum dose was 86 Gy using the isodose line of 50%. The median age of the patients was 58.5 (range 28-94) years old, and the median time from diagnosis to GKS was 94 months (range 13-480 months). The median follow-up was 28.5 (range 12-49) months. Clinical outcomes were analyzed. Univariate and multivariate analyses were performed to evaluate factors that correlated with a favorable, pain-free outcome. Results The mean time to relief of pain was 7 (range 1-40) days. The percentage of patients with significant pain relief was 93.3%. Relapse in pain was noted in four patients at 3, 16, 19, and 36 months. Nine patients were treated in acute status. Fourteen patients had intense pain between 1 and 7 days before the procedure. Among those with the recurrence of their symptoms, one patient had a microvascular decompression. Multivariate regression adjusted for age and sex suggests that, by 40 months, 70% of the patients treated with radiosurgery will remain pain free. At the last follow-up, GKS resulted in pain relief in 86.6% of patients. Our analysis suggests that, using this technique, we can expect that approximately 70% of patients with TN will have some degree of pain improvement at 3 years' post radiosurgery. Conclusions GKS on TG appears to be a reasonable treatment option with short latency period, minor collateral effects, and high percentage of pain control. The mechanism of action of radiosurgery could be related to the inactivation of the satellite glial cells in the TG.
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Affiliation(s)
- Salvador Somaza
- Departments of Neurosurgery, Centro Diagnostico Docente Las Mercedes, Hospital de Clinicas Caracas, Caracas, Venezuela
| | - Eglee M Montilla
- Departments of Radiation Oncology, Centro Diagnostico Docente Las Mercedes, Hospital de Clinicas Caracas, Caracas, Venezuela
| | - Maria C Mora
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, United States
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Koca S, Distel L, Lubgan D, Weissmann T, Lambrecht U, Lang-Welzenbach M, Eyüpoglu I, Bischoff B, Buchfelder M, Semrau S, Fietkau R, Lettmaier S, Putz F. Time course of pain response and toxicity after whole-nerve-encompassing LINAC-based stereotactic radiosurgery for trigeminal neuralgia-a prospective observational study. Strahlenther Onkol 2019; 195:745-755. [PMID: 30877350 DOI: 10.1007/s00066-019-01450-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/26/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE To prospectively evaluate the time course of pain response and toxicity after linear accelerator-based whole-nerve-encompassing radiosurgery (LINAC-SRS) using a uniform treatment schedule for dosing and target volume definition in patients with refractory trigeminal neuralgia. METHODS From December 2012 to December 2016, 21 patients were treated using a standardized protocol. Patients received LINAC-SRS with 70 Gy to the cisternal portion while aiming for the 90% isodose to fully envelope the nerve in one cross-sectional plane. Data on pain, analgesics, and toxicity were gathered prospectively. Four time intervals (1-6, 6-12, 12-18, and 18-24 months) were defined and compared to baseline and each other. RESULTS The median follow-up from radiotherapy was 16 months. Freedom from pain was achieved at least once in 90.5, 81.0, and 85.7% of patients for everyday pain, rest pain, and pain peaks, respectively. At 1-6 months, pain was significantly reduced in everyday routine (mean VAS, 2.0/10 vs. 5.8/10; P = 0.004), at rest (1.5/10 vs. 4.0/10; P = 0.002), and for pain peaks (2.9/10 vs. 10/10; P < 0.001), as was the number of analgesics (mean 1.5 vs. 2.9; P < 0.001). No significant increase in pain or analgesics was observed for subsequent time intervals. At last follow-up, reduction in pain compared to baseline for everyday routine (2.1/10 vs. 5.8/10; P = 0.010) and for pain peaks (3.3/10 vs. 10/10; P < 0.001) was significant, whereas it was not for rest pain (1.8/10 vs. 3.9/10; P = 0.073). Most toxicities were related to trigeminal nerve impairment, with 42.9% reporting new-onset hypoesthesia at last follow-up. CONCLUSION This study provides prospective data after whole nerve encompassing LINAC-SRS for trigeminal neuralgia. No significant pain relapse was observed.
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Affiliation(s)
- Selim Koca
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Luitpold Distel
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Dorota Lubgan
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Thomas Weissmann
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Ulrike Lambrecht
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Marga Lang-Welzenbach
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Ilker Eyüpoglu
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Barbara Bischoff
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Florian Putz
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany.
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The efficiency of the prescribed dose of the gamma knife for the treatment of trigeminal neuralgia. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.05.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Gündüz A, Uygunoğlu U, Uluduz D, Saip S, Siva A, Göksan B, Kızıltan ME. Reduced inhibition in brainstem circuits in classical trigeminal neuralgia. Eur J Pain 2018; 23:142-149. [PMID: 30055103 DOI: 10.1002/ejp.1293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE We hypothesized that prepulse modulation (PPM) would be altered in trigeminal neuralgia (TN) if suprasegmental inhibitory network involvement was present and tested our hypothesis in a group of patients with classical TN. METHODS The study enrolled nine consecutive patients with classical TN and 14 healthy subjects. Diagnosis and classification followed the International Classification of Headache Disorders-third edition (beta version). The blink reflex (BR) and BR-PPM were recorded. Ipsilateral recordings were made after stimulating each trigeminal nerve in the patient group whereas right-sided recordings were performed after stimulating the right trigeminal nerve in the healthy subjects. A conditioning electrical stimulus was applied to the ipsilateral median nerve at interstimulus intervals (ISIs) of 50 and 100 ms before the test stimulus to the supraorbital nerve. RESULTS The unconditioned BR recordings were similar in all groups. In the healthy subjects, the prepulse stimulus resulted in a reduced R2 magnitude (p = 0.000, Friedman's test) and longer R2 latency (p = 0.008, Friedman's test) at ISIs of 50 and 100 ms in comparison with unconditioned recordings. The R2 latency differed significantly between the unconditioned recordings and the ISI of 100 ms. In the patients with TN, no significant change was observed on either the symptomatic or asymptomatic sides. CONCLUSIONS There is a bilateral prepulse inhibition deficit in TN, even on the asymptomatic side. Our findings provide electrophysiological evidence for suprasegmental changes and loss of filtering activity at the brainstem in level TN.
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Affiliation(s)
- A Gündüz
- Department of Neurology, Cerrahpasa Medical School, Istanbul University, Turkey
| | - U Uygunoğlu
- Department of Neurology, Cerrahpasa Medical School, Istanbul University, Turkey
| | - D Uluduz
- Department of Neurology, Cerrahpasa Medical School, Istanbul University, Turkey
| | - S Saip
- Department of Neurology, Cerrahpasa Medical School, Istanbul University, Turkey
| | - A Siva
- Department of Neurology, Cerrahpasa Medical School, Istanbul University, Turkey
| | - B Göksan
- Department of Neurology, Cerrahpasa Medical School, Istanbul University, Turkey
| | - M E Kızıltan
- Department of Neurology, Cerrahpasa Medical School, Istanbul University, Turkey
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Abstract
A short review of clinical use of radiosurgery in trigeminal neuralgia is offered.
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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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Abstract
Trigeminal neuralgia (TN) is a sudden, severe, brief, stabbing, and recurrent pain within one or more branches of the trigeminal nerve. Type 1 as intermittent and Type 2 as constant pain represent distinct clinical, pathological, and prognostic entities. Although multiple mechanism involving peripheral pathologies at root (compression or traction), and dysfunctions of brain stem, basal ganglion, and cortical pain modulatory mechanisms could have role, neurovascular conflict is the most accepted theory. Diagnosis is essentially clinically; magnetic resonance imaging is useful to rule out secondary causes, detect pathological changes in affected root and neurovascular compression (NVC). Carbamazepine is the drug of choice; oxcarbazepine, baclofen, lamotrigine, phenytoin, and topiramate are also useful. Multidrug regimens and multidisciplinary approaches are useful in selected patients. Microvascular decompression is surgical treatment of choice in TN resistant to medical management. Patients with significant medical comorbidities, without NVC and multiple sclerosis are generally recommended to undergo gamma knife radiosurgery, percutaneous balloon compression, glycerol rhizotomy, and radiofrequency thermocoagulation procedures. Partial sensory root sectioning is indicated in negative vessel explorations during surgery and large intraneural vein. Endoscopic technique can be used alone for vascular decompression or as an adjuvant to microscope. It allows better visualization of vascular conflict and entire root from pons to ganglion including ventral aspect. The effectiveness and completeness of decompression can be assessed and new vascular conflicts that may be missed by microscope can be identified. It requires less brain retraction.
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Affiliation(s)
- Yad Ram Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Yadav Nishtha
- Department of Radio Diagnosis and Imaging, All India Institute of Medical Science, New Delhi, India
| | - Pande Sonjjay
- Department of Radio Diagnosis and Imaging, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Parihar Vijay
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Ratre Shailendra
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Khare Yatin
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
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Park SC, Lee DH, Lee JK. Two-Session Tumor and Retrogasserian Trigeminal Nerve-Targeted Gamma Knife Radiosurgery for Secondary Trigeminal Neuralgia Associated with Benign Tumors. World Neurosurg 2016; 96:136-147. [DOI: 10.1016/j.wneu.2016.08.082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 11/16/2022]
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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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Radiosurgery in trigeminal neuralgia. Phys Med 2014; 30:592-5. [DOI: 10.1016/j.ejmp.2014.05.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 05/13/2014] [Accepted: 05/14/2014] [Indexed: 11/23/2022] Open
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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.
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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
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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.
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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
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Sudahar H, Kurup PGG, Murali V, Velmurugan J. Comparative analysis between 5 mm and 7.5 mm collimators in CyberKnife radiosurgery for trigeminal neuralgia. J Med Phys 2013; 38:120-4. [PMID: 24049318 PMCID: PMC3775035 DOI: 10.4103/0971-6203.116364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 04/02/2013] [Accepted: 04/18/2013] [Indexed: 11/06/2022] Open
Abstract
Trigeminal neuralgia (TN) is treated in CyberKnife (Accuray Inc, Sunnyvale, USA) with the 5 mm collimator whose dosimetric inaccuracy is higher than the other available collimators. The 7.5 mm collimator which is having less dosimetric uncertainty can be an alternative for 5 mm collimator provided the dose distribution with 7.5 mm collimator is acceptable. Aim of this study is to analyze the role of 7.5 mm collimator in CyberKnife treatment plans of TN. The treatment plans with 5 mm collimators were re-optimized with 7.5 mm collimator and a bi-collimator system (5 mm and 7.5 mm). The treatment plans were compared for target coverage, brainstem doses, and the dose to normal tissues. The target and brainstem doses were comparable. However, the conformity indices were 2.31 ± 0.52, 2.40 ± 0.87 and 2.82 ± 0.51 for 5 mm, bi-collimator (5mm and 7.5 mm), 7.5 mm collimator plans respectively. This shows the level of dose spillage in 7.5 mm collimator plans. The 6 Gy dose volumes in 7.5 mm plans were 1.53 and 1.34 times higher than the 5 mm plan and the bi-collimator plans respectively. The treatment time parameters were lesser for 7.5 mm collimators. Since, the normal tissue dose is pretty high in 7.5 mm collimator plans, the use of it in TN plans can be ruled out though the treatment time is lesser for these 7.5 mm collimator plans.
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Affiliation(s)
- H Sudahar
- Department of Radiotherapy, Apollo Speciality Hospital, Chennai, Tamil Nadu, India
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