Repeat radiosurgery for refractory trigeminal neuralgia.

Abstract

Stereotactic radiosurgery has become an important and minimally invasive alternative for patients with refractory trigeminal neuralgia. When a second procedure is necessary, the outcomes are unknown. The degree of pain relief and morbidity after repeat radiosurgery were studied. Thirty-one patients underwent a second gamma knife radiosurgery procedure because of unsatisfactory or unsustained relief of pain after the first procedure. Twenty-seven patients were assessable at median follow-up periods of 42.7 and 20.4 months after the first and second procedures, respectively. Most patients had undergone multiple previous operations of other types (microvascular decompression, radiofrequency rhizotomy, glycerol rhizotomy, balloon compression). The median target doses of the first and second radiosurgeries were 75 and 64 Gy, respectively. All patients were evaluated by a physician who did not participate in patient treatment. After the first radiosurgical procedure, 13 patients had an excellent response initially (complete relief without any medication), 3 had a good response (complete relief with some medication), 7 had a fair response (>50% relief), and 4 had a poor response (<50% pain relief or treatment failure). Repeat radiosurgery was performed in patients with recurrent or residual pain. After the second radiosurgical procedure, 5 patients had an excellent response, 8 had a good response, 10 had a fair response, and 4 had a poor response. Thirteen patients (48%) achieved complete pain relief (with or without medication). Two patients (7.4%) experienced new sensory symptoms after the first radiosurgical procedure, and three (12.7%, actuarial) experienced new sensory symptoms after the second procedure. Repeat radiosurgery provided a similar rate of pain relief as the first procedure, despite a modest dose reduction. The risk of new sensory symptoms was increased, but no other morbidity was identified. For patients who experience recurrent pain and choose to undergo a second procedure, our current procedure is to deliver a maximum dose of 50 to 60 Gy to a trigeminal target anterior to the root entry zone near the entrance of the nerve beneath the petrous dura.