Repeat Gamma Knife radiosurgery versus microvascular decompression following failure of GKRS in trigeminal neuralgia: a systematic review and meta-analysis

Abstract

OBJECTIVEGamma Knife radiosurgery (GKRS) has emerged as a promising treatment modality for patients with classical trigeminal neuralgia (TN); however, considering that almost half of the patients experience post-GKRS failure or lesion recurrence, a repeat treatment is typically necessary. The existing literature does not offer clear evidence to establish which treatment modality, repeat GKRS or microvascular decompression (MVD), is superior. The present study aimed to compare the overall outcome of patients who have undergone either repeat GKRS or MVD after failure of their primary GKRS; the authors do so by conducting a systematic review and meta-analysis of the literature and analysis of data from their own institution.METHODSThe authors conducted a systematic review and meta-analysis of the PubMed, Cochrane Library, Web of Science, and CINAHL databases to identify studies describing patients who underwent either repeat GKRS or MVD after initial failed GKRS for TN. The primary outcomes were complete pain relief (CPR) and adequate pain relief (APR) at 1 year. The secondary outcomes were rate of postoperative facial numbness and the retreatment rate. The pooled data were analyzed with R software. Bias and heterogeneity were assessed using funnel plots and I2 tests, respectively. A retrospective analysis of a series of patients treated by the authors who underwent repeat GKRS or MVD after post-GKRS failure or relapse is presented.RESULTSA total of 22 studies met the selection criteria and were included for final data retrieval and meta-analysis. The search did not identify any study that had directly compared outcomes between patients who had undergone repeat GKRS versus those who had undergone MVD. Therefore, the authors’ final analysis included two groups: studies describing outcome after repeat GKRS (n = 17) and studies describing outcome after MVD (n = 5). The authors’ institutional study was the only study with direct comparison of the two cohorts. The pooled estimates of primary outcomes were APR in 83% of patients who underwent repeat GKRS and 88% of those who underwent MVD (p = 0.49), and CPR in 46% of patients who underwent repeat GKRS and 72% of those who underwent MVD (p = 0.02). The pooled estimates of secondary outcomes were facial numbness in 32% of patients who underwent repeat GKRS and 22% of those who underwent MVD (p = 0.11); the retreatment rate was 19% in patients who underwent repeat GKRS and 13% in those who underwent MVD (p = 0.74). The authors’ institutional study included 42 patients (repeat GKRS in 15 and MVD in 27), and the outcomes 1 year after retreatment were APR in 80% of those who underwent repeat GKRS and 81% in those who underwent MVD (p = 1.0); CPR was achieved in 47% of those who underwent repeat GKRS and 44% in those who underwent MVD (p = 1.0). There was no difference in the rate of postoperative facial numbness or retreatment.CONCLUSIONSThe current meta-analysis failed to identify any superiority of one treatment over the other with comparable outcomes in terms of APR, postoperative facial numbness, and retreatment rates. However, MVD was shown to provide a better chance of CPR compared with repeat GKRS.

Chronic Facial Pain: Trigeminal Neuralgia, Persistent Idiopathic Facial Pain, and Myofascial Pain Syndrome—An Evidence-Based Narrative Review and Etiological Hypothesis

“…A number of systematic reviews and meta-analyses compared GKRS with microvascular de-compression (MVD), which will be discussed below in connection with MVD, the only treatment that directly corrects the cause of TN in at least 50% of cases [ 70 , 71 , 72 , 73 , 74 , 75 , 76 ].…”

“…As expected, retreatment rates are higher for GKRS than for MVD, 17% vs. 10.3%, though the difference is not statistically significant (OR, 1.76; 95% CI, 0.93–3.55; p = 0.08). However, a systematic review and meta-analysis found that once GKRS had failed, there was no difference in the outcome between repeat GKRS and MVD [ 72 ]. One possible factor contributing to this is that the initial choice in selecting GKRS could have been based on the lack of neurovascular compression.…”

Repeat Gamma Knife Radiosurgery for Recurrent Glossopharyngeal Neuralgia: A Systematic Review and Our Initial Experience

“…The literature overall suggests that outcomes for TN after repeat SRS are comparably good, or better, than after the initial SRS; however, the toxicity is higher [25-27]. A recent meta-analysis by Patra et al [28] found no difference between repeat SRS and MVD in producing adequate pain relief (BNI I–III) for recurrent TN at 1 year.…”

Craniofacial neuralgias

“…117 When GKRS fails, MVD may provide better likelihood of complete pain relief as opposed to repeat GKRS. 118 MVD may pose small risk (less than 3% each) of incisional infection, facial palsy, CSF leak and hearing deficits and risk of mortality was 0.1%. 119…”