Pain-Free Outcomes and Durability of Surgical Intervention for Trigeminal Neuralgia: A Comparison of Gamma Knife and Microvascular Decompression

Mendelson, Zachary S.; Velagala, Jayant; Kohli, Gurkirat; Heir, Gary M.; Mammis, Antonios; Liu, James K.

doi:10.1016/j.wneu.2018.01.141

Cited by 34 publications

(32 citation statements)

References 55 publications

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“…The average length of recurrence-free intervals was the same for the two procedures—30.40 months with MVD and 30.55 months with GKRS. A more recent systematic review confirmed the previous findings that MVD results in a higher percentage of favorable results with a lower incidence of complications [ 73 ]. Another meta-analysis published in 2018 showed an even greater initial success rate of 96% (95% CI 93.3–98.6%) for MVD compared to 71.8% for GKRS [ 75 ].…”

Section: Discussionsupporting

confidence: 75%

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

Gerwin

2020

IJERPH

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Trigeminal neuralgia (TN), the most common form of severe facial pain, may be confused with an ill-defined persistent idiopathic facial pain (PIFP). Facial pain is reviewed and a detailed discussion of TN and PIFP is presented. A possible cause for PIFP is proposed. (1) Methods: Databases were searched for articles related to facial pain, TN, and PIFP. Relevant articles were selected, and all systematic reviews and meta-analyses were included. (2) Discussion: The lifetime prevalence for TN is approximately 0.3% and for PIFP approximately 0.03%. TN is 15–20 times more common in persons with multiple sclerosis. Most cases of TN are caused by neurovascular compression, but a significant number are secondary to inflammation, tumor or trauma. The cause of PIFP remains unknown. Well-established TN treatment protocols include pharmacotherapy, neurotoxin denervation, peripheral nerve ablation, focused radiation, and microvascular decompression, with high rates of relief and varying degrees of adverse outcomes. No such protocols exist for PIFP. (3) Conclusion: PIFP may be confused with TN, but treatment possibilities differ greatly. Head and neck muscle myofascial pain syndrome is suggested as a possible cause of PIFP, a consideration that could open new approaches to treatment.

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Section: Discussionsupporting

confidence: 75%

“…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 ].…”

Section: Discussionmentioning

confidence: 99%

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

Gerwin

2020

IJERPH

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“…Two recently published meta-analyses have established the superiority of MVD as a primary treatment over GKRS due to higher initial pain-free rates and long-term pain-free rates. 9,17 However, the role of MVD after failure of other procedures has been less clearly established than its role as a primary procedure. The primary mechanism by which MVD produces pain relief in patients with vascular compression (reversal of physiological changes produced by demyelination) is altered with prior ablative procedures, including GKRS.…”

Section: Role Of Repeat Gkrs In Tnmentioning

confidence: 99%

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

Patra¹,

Savardekar²,

Dossani³

et al. 2019

Journal of Neurosurgery

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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.

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“…8,18,22 Although all neurosurgical procedures for TN have some variability in response rate, this is especially significant with GKRS, where long-term pain relief is less likely. 17,20,28 At present, there are no clinical imaging protocols that can determine how effective GKRS has been in the treatment of TN. Current protocols rely on the presence of posttreatment focal Gd enhancement on the trigeminal nerve in T1-weighted anatomical images to confirm the accuracy of radiation delivery.…”

mentioning

confidence: 99%

Early postsurgical diffusivity metrics for prognostication of long-term pain relief after Gamma Knife radiosurgery for trigeminal neuralgia

Tohyama

Hung

Zhong

et al. 2019

Journal of Neurosurgery

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OBJECTIVE Gamma Knife radiosurgery (GKRS) is an important treatment modality for trigeminal neuralgia (TN). Current longitudinal assessment after GKRS relies primarily on clinical diagnostic measures, which are highly limited in the prediction of long-term clinical benefit. An objective, noninvasive, predictive tool would be of great utility to advance the clinical management of patients. Using diffusion tensor imaging (DTI), the authors' aim was to determine whether early (6 months post-GKRS) target diffusivity metrics can be used to prognosticate long-term pain relief in patients with TN. METHODS Thirty-seven patients with TN treated with GKRS underwent 3T MRI scans at 6 months posttreatment. Diffusivity metrics of fractional anisotropy, axial diffusivity, radial diffusivity, and mean diffusivity were extracted bilaterally from the radiosurgical target of the affected trigeminal nerve and its contralateral, unaffected nerve. Early (6 months post-GKRS) diffusivity metrics were compared with long-term clinical outcome. Patients were identified as long-term responders if they achieved at least 75% reduction in preoperative pain for 12 months or longer following GKRS. RESULTS Trigeminal nerve diffusivity at 6 months post-GKRS was predictive of long-term clinical effectiveness, where long-term responders (n = 19) showed significantly lower fractional anisotropy at the radiosurgical target of their affected nerve compared to their contralateral, unaffected nerve and to nonresponders. Radial diffusivity and mean diffusivity, correlates of myelin alterations and inflammation, were also significantly higher in the affected nerve of long-term responders compared to their unaffected nerve. Nonresponders (n = 18) did not exhibit any characteristic diffusivity changes after GKRS. CONCLUSIONS The authors demonstrate that early postsurgical target diffusivity metrics have a translational, clinical value and permit prediction of long-term pain relief in patients with TN treated with GKRS. Importantly, an association was found between the footprint of radiation and clinical effectiveness, where a sufficient level of microstructural change at the radiosurgical target is necessary for long-lasting pain relief. DTI can provide prognostic information that supplements clinical measures, and thus may better guide the postoperative assessment and clinical decision-making for patients with TN.

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Pain-Free Outcomes and Durability of Surgical Intervention for Trigeminal Neuralgia: A Comparison of Gamma Knife and Microvascular Decompression

Cited by 34 publications

References 55 publications

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

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

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

Early postsurgical diffusivity metrics for prognostication of long-term pain relief after Gamma Knife radiosurgery for trigeminal neuralgia

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