Early radiosurgery provides superior pain relief for trigeminal neuralgia patients

Mousavi, Seyed H.; Niranjan, Ajay; Huang, Marshall J.; Laghari, Fahad J.; Shin, Samuel S.; Mindlin, Josh L.; Flíckinger, John C.; Lunsford, L. Dade

doi:10.1212/wnl.0000000000002216

Cited by 49 publications

(28 citation statements)

References 33 publications

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“…[335] Patients with refractory TN undergo microvascular decompression (MVD) or ablative procedures. [319212227] Data regarding the role of surgical management in the younger TN patient population are limited. In prior studies reporting the outcomes of MVD in the younger versus older patient population, a lower efficacy for MVD in the younger population has been reported, suggesting that vascular compression is not the main etiology of pain in this group.…”

Section: Introductionmentioning

confidence: 99%

Concomitant depression and anxiety negatively affect pain outcomes in surgically managed young patients with trigeminal neuralgia: Long-term clinical outcome

et al. 2016

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Background:Onset of trigeminal neuralgia (TN) is uncommon in young adults with less favorable benefit from surgical interventions. The aim of this study was to evaluate the role of concomitant psychosomatic disorders in long-term surgical outcomes in this population.Methods:Twenty-one patients younger than 30 years of age were diagnosed initially as having medically refractory TN, and each patient underwent microvascular decompression (MVD) as initial surgical management. Correlation of clinical outcome and psychosomatic disorders (DSM-IV) was evaluated during a 15-year interval.Results:A total of 93 procedures were performed for the management of TN and subsequent iatrogenic craniofacial pain disorders. At a median of 81 months, 8 of 21 patients were free of facial pain. Fourteen patients with concomitant major depressive disorder (MDD) or other anxiety disorders underwent a higher median of procedures compared with 7 patients without known MDD or anxiety (4.5 versus 1 intervention, P = 0.038). Two of 14 patients who were diagnosed with MDD or other anxiety disorders were free of craniofacial pain, whereas 6 of 7 patients without mood or anxiety disorders were free of craniofacial pain (P = 0.0005). Thirteen patients developed treatment-related complications that required further surgical procedures. Presence of MDD or other anxiety disorders was associated with higher rate of complications (P = 0.026). One patient with past medical history of severe anxiety died of unknown causes.Conclusions:In young patients with TN, comorbid MDD or anxiety disorders was associated with seeking multiple invasive procedures in multiple academic centers with limited benefit and high rates of surgical induced complications.

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Section: Introductionmentioning

confidence: 99%

Concomitant depression and anxiety negatively affect pain outcomes in surgically managed young patients with trigeminal neuralgia: Long-term clinical outcome

et al. 2016

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“…2 SRS is a widely used method to precisely deliver focused radiation and has been applied to more than 100,000 TN patients worldwide. 11,13,17 Given its minimally invasive nature, it is now considered to be a primary option for management of TN in patients who are poor surgical candidates. 11 SRS exerts its radiobiological effect on the trigeminal nerve by axonal and myelin sheath damage and destruction of ionic channels, resulting in a blockade of electrical conduction.…”

Section: Discussionmentioning

confidence: 99%

“…11,13,17 Given its minimally invasive nature, it is now considered to be a primary option for management of TN in patients who are poor surgical candidates. 11 SRS exerts its radiobiological effect on the trigeminal nerve by axonal and myelin sheath damage and destruction of ionic channels, resulting in a blockade of electrical conduction. 6,14 The radiation dose that leads to sufficient pain control is considered to be the best therapeutic dose.…”

Section: Discussionmentioning

confidence: 99%

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A proposed plan for personalized radiosurgery in patients with trigeminal neuralgia

Mousavi¹,

Niranjan²,

Akpinar

et al. 2018

Journal of Neurosurgery

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OBJECTIVE During the last 25 years, more than 100,000 patients worldwide with trigeminal neuralgia (TN) have undergone stereotactic radiosurgery (SRS) with a standard dose of radiation. However, the radiobiological effect of radiation is determined by the amount of energy delivered to the tissue (integral dose [ID] = mean dose × target volume) and is directly associated with the nerve volume. Although the trigeminal nerve volume varies among patients with TN, the clinical impact of this variation in delivered energy is unknown. The objective of this study was to evaluate the effect of delivered ID on the outcome of TN radiosurgery. METHODS The authors evaluated 155 patients with unilateral TN who had undergone SRS as their initial surgical management over a 13-year period. The authors measured the postganglionic ID within the SRS target and retrospectively stratified patients into 3 groups: low (< 1.4 mJ), medium (1.4-2.7 mJ), and high (> 2.7 mJ) ID. Clinical outcomes, which included pain status (scored using the Barrow Neurological Institute Pain Scale) and sensory dysfunction (scored using the Barrow Neurological Institute Numbness Scale), were evaluated at a median follow-up of 71 months. RESULTS Patients who were treated with a medium ID had superior pain relief either with or without medications (p = 0.006). In the medium ID group, the rates of complete pain relief without medications at 1, 3, and 6 years after SRS were 67%, 54%, and 33%, respectively, while the rates in the rest of the cohort were 55%, 36%, and 19%, respectively. Patients given a high ID had a higher rate of post-SRS trigeminal sensory deterioration (p < 0.0001). At 1, 3, and 6 years after SRS, the high ID group had an estimated rate for developing sensory dysfunction of 35%, 45%, and 50%, respectively, while the rates in patients receiving low and medium IDs were 3%, 4%, and 9%, respectively. The optimal clinical outcome (maximum pain relief and minimal trigeminal sensory dysfunction) was obtained in patients who had received a medium ID. CONCLUSIONS With current dose selection methods, nerve volume affects long-term clinical outcomes in patients with TN who have undergone SRS. This study suggests that the prescribed SRS dose should be customized for each TN patient based on the nerve volume.

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“…Older patients may not tolerate high doses of neuroleptics as well as younger patients, so moving to radiosurgery relatively early in their management may be extremely helpful. In addition, there is evidence that early radiosurgery may lead to better long-term pain control [27]. …”

Section: Discussionmentioning

confidence: 99%

Stereotactic Radiosurgery as Initial Surgical Management for Elderly Patients with Trigeminal Neuralgia

Cohen

Mousavi

Faraji

et al. 2017

Stereotact Funct Neurosurg

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Background: Management of older patients with medically refractory trigeminal neuralgia (TN) is yet a matter of debate. Objective: We sought to determine the benefit of stereotactic radiosurgery (SRS) as the sole surgical management in older patients (≥70 years). Methods: One hundred and twenty-seven patients (≥70 years) with typical TN underwent SRS as initial surgical management. The median maximum dose for the first procedure was 80 Gy. Repeat SRS was performed in 46 patients who developed recurrent pain. Results: After the first SRS, the initial pain control was achieved in 91% of patients. Complete pain relief (Barrow Neurological Institute [BNI] score I) developed in 75 patients (59%) and was maintained in 59, 39, and 22% of patients at 1, 3, and 5 years. Following repeat SRS, the rate of complete pain relief was 79, 55, and 41% at 1, 3, and 5 years. The chance of BNI I preservation was greater after repeat SRS compared to initial SRS (hazards ratio: 2.02, p < 0.0001). The incidence of trigeminal sensory loss was 17% after initial SRS but increased to 39% after repeat SRS. Conclusions: SRS alone was used effectively in older TN patients to achieve pain control. Recurrent pain responded to retreatment but was associated with an increased risk of sensory dysfunction.

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Early radiosurgery provides superior pain relief for trigeminal neuralgia patients

Abstract: This study provides Class IV evidence that in patients with medically refractory trigeminal neuralgia, early stereotactic radiosurgery as the initial procedure provides faster, better, and longer pain relief.

Cited by 49 publications

References 33 publications

Concomitant depression and anxiety negatively affect pain outcomes in surgically managed young patients with trigeminal neuralgia: Long-term clinical outcome

Concomitant depression and anxiety negatively affect pain outcomes in surgically managed young patients with trigeminal neuralgia: Long-term clinical outcome

A proposed plan for personalized radiosurgery in patients with trigeminal neuralgia

Stereotactic Radiosurgery as Initial Surgical Management for Elderly Patients with Trigeminal Neuralgia

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