Nonisocentric radiosurgical rhizotomy for trigeminal neuralgia

John R. Adler, Regina Bower, Gaurav Gupta, Michael Lim, Allen Efron, Iris C. Gibbs, Steven D. Chang, Scott G. Soltys

Research output: Contribution to journalArticle

Abstract

OBJECTIVE: Although stereotactic radiosurgery is an established procedure for treat ing trigeminal neuralgia (TN), the likelihood of a prompt and durable complete responst is not assured. Moreover, the incidence of facial numbness remains a challenge. Tc address these limitations, a new, more anatomic radiosurgical procedure was developed that uses the CyberKnife (Accuray, Inc., Sunnyvale, CA) to lesion an elongatec segment of the retrogasseriancisternal portion of the trigeminal sensory root. Because the initial experience with this approach resulted in an unacceptably high Incidence ol 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 non-isocentric 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 firsfweek. 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 ipsi lateral facial numbness (Grade 111 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.

Original languageEnglish (US)
JournalNeurosurgery
Volume64
Issue number2 SUPPL.
DOIs
StatePublished - Feb 2009

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Rhizotomy
Trigeminal Neuralgia
Hypesthesia
Incidence
Microvascular Decompression Surgery
Pain
Radiosurgery
Telephone
Prescriptions

Keywords

  • Cyberknife
  • Nonisocentric
  • Radiosurgery
  • Rhizotomy
  • Trigeminal neuralgia

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

Cite this

Adler, J. R., Bower, R., Gupta, G., Lim, M., Efron, A., Gibbs, I. C., ... Soltys, S. G. (2009). Nonisocentric radiosurgical rhizotomy for trigeminal neuralgia. Neurosurgery, 64(2 SUPPL.). https://doi.org/10.1227/01.NEU.0000341631.49154.62

Nonisocentric radiosurgical rhizotomy for trigeminal neuralgia. / Adler, John R.; Bower, Regina; Gupta, Gaurav; Lim, Michael; Efron, Allen; Gibbs, Iris C.; Chang, Steven D.; Soltys, Scott G.

In: Neurosurgery, Vol. 64, No. 2 SUPPL., 02.2009.

Research output: Contribution to journalArticle

Adler, JR, Bower, R, Gupta, G, Lim, M, Efron, A, Gibbs, IC, Chang, SD & Soltys, SG 2009, 'Nonisocentric radiosurgical rhizotomy for trigeminal neuralgia', Neurosurgery, vol. 64, no. 2 SUPPL.. https://doi.org/10.1227/01.NEU.0000341631.49154.62
Adler, John R. ; Bower, Regina ; Gupta, Gaurav ; Lim, Michael ; Efron, Allen ; Gibbs, Iris C. ; Chang, Steven D. ; Soltys, Scott G. / Nonisocentric radiosurgical rhizotomy for trigeminal neuralgia. In: Neurosurgery. 2009 ; Vol. 64, No. 2 SUPPL.
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abstract = "OBJECTIVE: Although stereotactic radiosurgery is an established procedure for treat ing trigeminal neuralgia (TN), the likelihood of a prompt and durable complete responst is not assured. Moreover, the incidence of facial numbness remains a challenge. Tc address these limitations, a new, more anatomic radiosurgical procedure was developed that uses the CyberKnife (Accuray, Inc., Sunnyvale, CA) to lesion an elongatec segment of the retrogasseriancisternal portion of the trigeminal sensory root. Because the initial experience with this approach resulted in an unacceptably high Incidence ol 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 non-isocentric 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 firsfweek. 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 ipsi lateral facial numbness (Grade 111 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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AU - Bower, Regina

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AU - Chang, Steven D.

AU - Soltys, Scott G.

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N2 - OBJECTIVE: Although stereotactic radiosurgery is an established procedure for treat ing trigeminal neuralgia (TN), the likelihood of a prompt and durable complete responst is not assured. Moreover, the incidence of facial numbness remains a challenge. Tc address these limitations, a new, more anatomic radiosurgical procedure was developed that uses the CyberKnife (Accuray, Inc., Sunnyvale, CA) to lesion an elongatec segment of the retrogasseriancisternal portion of the trigeminal sensory root. Because the initial experience with this approach resulted in an unacceptably high Incidence ol 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 non-isocentric 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 firsfweek. 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 ipsi lateral facial numbness (Grade 111 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.

AB - OBJECTIVE: Although stereotactic radiosurgery is an established procedure for treat ing trigeminal neuralgia (TN), the likelihood of a prompt and durable complete responst is not assured. Moreover, the incidence of facial numbness remains a challenge. Tc address these limitations, a new, more anatomic radiosurgical procedure was developed that uses the CyberKnife (Accuray, Inc., Sunnyvale, CA) to lesion an elongatec segment of the retrogasseriancisternal portion of the trigeminal sensory root. Because the initial experience with this approach resulted in an unacceptably high Incidence ol 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 non-isocentric 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 firsfweek. 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 ipsi lateral facial numbness (Grade 111 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.

KW - Cyberknife

KW - Nonisocentric

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