Treatment Option For Trigeminal Neuralgia Research Articles

Repeat Gamma Knife radiosurgery for recurrent trigeminal neuralgia in patients with multiple sclerosis: a single-center retrospective study.

Gamma Knife radiosurgery (GKRS) has emerged as an effective treatment option for trigeminal neuralgia (TN) in patients with multiple sclerosis (MS). To date, the outcomes of repeat GKRS for patients with TN and MS with recurrent pain have been investigated in a few patients. This study aims to report the outcomes and predictive factors of pain reduction for MS patients undergoing repeat GKRS for recurrent TN. Eighteen patients with MS underwent repeat GKRS for recurrent TN. A retrospective chart review and telephone interviews were conducted to determine background medical history, dosimetric data, and outcomes of the procedure. Facial pain and sensory function were evaluated using the Barrow Neurological Institute (BNI) scales. Fifteen patients achieved a BNI pain score of IIIa or better, indicating pain reduction, within a median period of 21 days after repeat GKRS. The maximum dose for repeat GKRS ranged from 70 to 85 Gy. Pain recurred in 5 patients after a median period of 12 months after GKRS. Percentages of patients with pain reduction at 1, 2, 3, 5, and 7 years were 60%, 60%, 50%, 50%, and 50%, respectively. Older age at repeat GKRS predicted sustained pain reduction (P = 0.01). Seven patients developed facial sensory disturbances, which were bothersome in two patients. Repeat GKRS may be used as an effective treatment modality for prolonging the duration of pain reduction time in patients with MS and TN. After repeat GKRS, facial sensory disturbances are common; however, they are often not bothersome.

Pharmacological Treatment of Trigeminal Neuralgia

Although carbamazepine is the first-line treatment option for trigeminal neuralgia, it may not be sustained long-term. The benefits of carbamazepine are offset by adverse effects that lead to its withdrawal. The alternatives to carbamazepine include gabapentin, pregabalin, and microgabalin. Although used off-label in Japan, baclofen, lamotrigine, intravenous lidocaine, and botulinum toxin type A are also effective. Clinical experience has shown that alternative treatments are less effective than carbamazepine. Therefore, they can be used instead of or in addition to carbamazepine. The adverse effects of drugs include drowsiness, dizziness, rash, bone marrow suppression, and liver dysfunction. Carbamazepine and lamotrigine are particularly likely to cause severe drug eruptions such as Stevens-Johnson syndrome and toxic epidermal necrolysis. Low-dose titration is important to avoid the development of rashes and adverse effects.

Safety and efficacy of carbamazepine in the treatment of trigeminal neuralgia: A metanalysis in biomedicine.

Trigeminal neuralgia is a debilitating condition characterized by severe facial pain. Carbamazepine has been widely used as a first-line treatment option for trigeminal neuralgia, but there is a need to evaluate its safety and efficacy based on existing evidence. This meta-analysis aims to systematically assess the available literature and provide a comprehensive evaluation of the safety and efficacy of carbamazepine in the treatment of trigeminal neuralgia. A thorough search of electronic databases yielded a total of 15 relevant studies that met the inclusion criteria. The pooled analysis of these studies revealed that carbamazepine demonstrated significant efficacy in reducing pain intensity and frequency in patients with trigeminal neuralgia. Moreover, the drug was generally well-tolerated, with the most common adverse events being mild and transient. Subgroup analyses based on different dosages and treatment durations further supported the overall findings. However, caution should be exercised in patients with certain comorbidities or specific populations, as some rare but severe adverse events were reported. In conclusion, this meta-analysis provides strong evidence supporting the safety and efficacy of carbamazepine as a valuable therapeutic option for the management of trigeminal neuralgia. These results can guide clinicians in making informed decisions regarding the use of carbamazepine and contribute to optimizing treatment strategies for patients with trigeminal neuralgia. Further research is warranted to explore long-term safety and efficacy outcomes, as well as to compare carbamazepine with alternative treatment modalities.

Slow-Chronic Progressive Hydrocephalus as Complication of Microvascular Decompression for Trigeminal Neuralgia: A Case Report

Microvascular decompression (MVD) is one of the well-established treatment options for trigeminal neuralgia that may include posterior fossa surgery. However, Several complications were noted as being part of posterior fossa surgery and hydrocephalus is very rare to occur, especially the slow-chronic onset type. The pathophysiology is still unclear, but surgeons and patients must be warned about this possible surgical adverse event. Here we report a case of slow-chronic hydrocephalus in a 66-years old male who has a history of MVD procedure due to left trigeminal neuralgia. A shunt procedure was performed, in which after the surgery the patient’s complaints were resolved, and discharged without any morbidity.

Safety and Efficacy of Radiofrequency Ablation of Gasserian Ganglion in Trigeminal Neuralgia

Background: Trigeminal neuralgia (TN) is characterized by intractable pain in one or more division of trigeminal nerve. Pharmacologic management is first line treatment for TN, when it fails interventional treatment options are considered like percutaneous procedures or micro vascular decompression. Radio frequency thermoscoagulation is an effective option for medically refractory cases to control pain.Objective: To evaluate the safety and efficacy of Radiofrequency thermocoagulation of the gasserian ganglion for the treatment of trigeminal neuralgia.Methods: Total 44 patients were included in this prospective obsarvational study who were already diagnosed with trigeminal neuralgia and refractory to medical management. All patients were treated by radiofrequency thermocoagulation after confirming the position of needle tip by sensory and motor stimuli. Three lesions were created at 60-70oC for 90 second each. Patients were assessed for pain relief, corneal reflex, numbness and masticatory muscle weakness at immediate post procedural stage, 1 week, 1 month and at 6 months.Results: Twenty eight patients had pain over both mandibular (V3) and maxillary (V2) division, 12 patients had mandibular (V3) and 4 patients had only maxillary (V2) division involvement. Excellent pain relief was archived in 38 (86.36%) patients, 4 patients (9.09%) have good pain control and 2 (4.54%) patient developed poor pain control with development of Anesthesia dolorosa in 1 patient. None of them develop complete facial numbness, 41 patients developed tolerable numbness and 2 patients develop somewhat bothersome, Facial numbness. Three patients developed unilateral masseter muscle weakness however no patients developed corneal ulcers, blindness or other complications.Conclusion: Temperature controlled thermocoagulation is a safe and effective treatment options for trigeminal neuralgia.

A case of severe trigeminal neuralgia: recovery by means of stellate ganglion block with procaine. Discussion of possible mechanisms of action.

Drug and invasive treatment options for trigeminal neuralgia (TN) are often fraught with problems. Knowledge of the involvement of the autonomic nervous system, especially the sympathetic portion, in the pain process has grown rapidly in recent years. Both nociceptive and neuropathic pain can be maintained by the sympathetic nervous system, known as 'sympathetically maintained pain' (SMP). This current case report describes a patient with refractory TN that was treated with a stellate ganglion block (SGB). After the first SGB, the patient experienced significant pain relief that became long-lasting after repeated application of the SGB. These findings suggest that this patient had a high level of SMP. In patients with a low percentage of SMP, SGB may be less or not successful. A literature search did not find any case reports or studies about patients with refractory idiopathic TN treated with sympathetic blocks using local anaesthetics. From our point of view, it might be useful to test by means of SGB the extent to which an individual has SMP present, and, if that is the case, to perform a short series of SGB, as done in this current patient. Studies are needed to provide further insights.

Multivariate models to predict pain recurrence and sensitive complications after percutaneous balloon compression in trigeminal neuralgia.

Percutaneous balloon compression (PBC) is a popular treatment option for trigeminal neuralgia. However, the efficacy of PBC is widely considered to be associated with the occurrence of sensitive complications, although neither this correlation nor the underlying mechanisms have been established. The objectives of the present study were to identify factors predicting time to pain recurrence after PBC and identify factors predicting a severe sensitive complication. The authors conducted a retrospective study on patients who underwent PBC for the first time between 1985 and 2019 in two French hospitals. Data were retrieved from patients' medical records. Potential clinical and radiological predictors for time to pain recurrence and severe sensitive complication were evaluated using a Cox model and a logistic regression, respectively. A total of 131 patients were included in the study, with a median follow-up of 3.0 years. Pain recurrence occurred in 77 patients, and the median time to pain recurrence was 2.0 years. In the multivariate analysis, six independent factors predicting pain recurrence were identified: 1) longer duration of presurgical symptoms; 2) localization of the pain along the mandibular branch of the trigeminal nerve (V3); 3) atypical pain; 4) diagnosis of multiple sclerosis; 5) use of a medical device not specifically adapted for trigeminal neuralgia surgery; and 6) duration of balloon compression > 60 seconds. Regarding the secondary objective, 26 patients presented a severe sensitive complication after PBC, which the authors defined as the development of a new sensitivity disorder of the cornea, deafferentation pain known as anesthesia dolorosa, and/or long-lasting hypoesthesia augmentation characterized by the new appearance or increase in size or intensity of an area of hypoesthesia in the face for at least 3 months. The only predictor associated with a severe sensitive complication in the multivariate analysis was compression duration > 60 seconds. These results show that the risk of postoperative complications can be assessed at the patient level, the most important modifiable parameter being the time of compression by the balloon. Although this study shows the relevance of a personalized medicine approach, its clinical application remains to be validated.

Dosimetric Comparison between a Frameless Robotic Radiosurgery System and HyperArc Treatment Plans for Trigeminal Neuralgia: Cone-Based Robotic System vs. High-Definition MLC Based Linac System

<h3>Purpose/Objective(s)</h3> SRS is an effective and safe treatment option for trigeminal neuralgia (TN). Good dosimetric distribution has made HyperArc (HA) an attractive SRS/FRST technique for treating benign brain lesions. This study aims to evaluate the feasibility of HA for TN by comparing it with the dose distribution of frameless robotic radiosurgery systems. <h3>Materials/Methods</h3> Twenty patients with TN treated by cone-based CK were enrolled. The treatment location was targeted on the whole trigeminal nerve root entry zone (REZ) segment, leaving a 2-mm sparing from the brainstem. The prescription dose was 65 Gy in a single fraction, prescribing to the 80% isodose line with the highest dose of 81.25 Gy in the REZ. The segment of the trigeminal nerve encompassed by the 80% isodose line averaged 7.2 mm in length. Dose to brainstem surface was constrained with a maximum dose of 40 Gy. The corresponding HA plans were generated for the 20 patients to meet the same CK treatment plan criteria, using the high-definition MLC (2.5mm at the center) and SRS NTO optimization algorithm. The CK and HA treatment plans were compared with target coverage, sparing of organs at risk (OARs), and dose distribution metrics. <h3>Results</h3> All the OAR constraints were met in the HA treatment plans. The HA plans exhibited higher coverage of the PTVs than the CK plans, with statistically significant differences (HA vs. CK, 97.2% vs. 92.2%, P = 0.008). The HA plans consistently demonstrate better sparing of the OARs than the CK plans. The mean brain doses were 0.83 Gy and 1.15 Gy for HA and CK (P < 0.001), respectively. The brain V12 was significantly smaller with HA plans than with CK plans (5.9 c.c. in HA vs. 6.9 c.c. in CK, P = 0.019). Significant differences in the maximal and mean doses of the ipsilateral/contralateral CN VII/VIII were observed between the HA and CK plans. The HA plans exhibited a significantly greater conformity index than the CK plans (HA vs. CK, 1.59 vs. 1.71, P = 0.001). The dose gradient radius was similar in the CK and HA plans (HA, 0.28 vs. CK, 0.29). <h3>Conclusion</h3> Excellent sparing of OARs and good dosimetric distribution demonstrated HA is a feasible SRS technique for the treatment of TN. Further clinical studies using HA for TN would be necessary to confirm the therapeutic benefits and toxicity profiles.

The Focus and New Progress of Percutaneous Balloon Compression for the Treatment of Trigeminal Neuralgia.

Trigeminal neuralgia is a condition confined to the trigeminal nerve, causing one or more branches of facial nerve pain. Surgical treatment options for trigeminal neuralgia include microvascular decompression(MVD), percutaneous balloon compression (PBC), radiofrequency thermocoagulation(RF), percutaneous retrogasserian glycerol rhizotomy(PRGR), gamma knife, etc. Of these treatments, PBC is increasingly being used by clinicians for trigeminal neuralgia. PBC is a simple surgical operation performed to treat trigeminal neuralgia. Owing to its advantages, PBC is favored by many clinicians. In this study, we aimed to emphasize the need to analyze the shape of the balloon, position, compression time, and pressure, as these factors can affect the efficacy of PBC. The relief of pain by balloon compression is related to the shape of the balloon on X-ray, which is the key to the operation. Owing to continued progress and advances in current imaging technologies, clinicians revealed that the precise positioning of the foramen ovale is no longer an intraoperative problem. Instead, the anatomy of Meckel’s cave and the shape of the balloon must be the focus to achieve the best treatment effect. For clinicians, PBC is simple and is associated with a short operation time. PBC also has other advantages, such as low cost and immediate postoperative pain relief. The recurrence rate of pain post-PBC is low, despite the occurrence of facial numbness post-op. However, this side effect is reversible and does not affect daily life of the patient. In fact, the patient can be discharged 1–2 days after surgery. Overall, PBC can be considered as one of the preferred surgical methods for the treatment of primary trigeminal neuralgia. In this paper, we explain the main points of PBC operation in detail in terms of Meckel’s cave, surgical procedure, complications, discussion of the focus and new progress, etc.

Diffusivity Metrics Three Months After Upfront Gamma Knife Radiosurgery for Trigeminal Neuralgia May Be Correlated with Pain Relief

Gamma Knife radiosurgery (GKRS) is a safe and effective treatment option for trigeminal neuralgia (TN). However, there is no objective, noninvasive tool to identify nonresponders or late responders to GKRS and to facilitate longitudinal patient management. We hypothesized that diffusivity metrics obtained 3 months after GKRS may correlate with response to treatment. Sixteen patients with TN treated with GKRS underwent preprocedural and 3-month postprocedural 3-T magnetic resonance imaging of the brain. Diffusion tensor metrics of axial diffusivity, radial diffusivity, and fractional anisotropy were extracted from the pontine segments, the root entry zones, and the distal cisternal segments of both trigeminal nerves. Diffusivity metrics at the 3-month post-GKRS time point were compared with pain relief at last follow-up. Favorable response to GKRS was defined as pain intensity of I-III on the Barrow Neurological Institute scale. The median clinical follow-up was 11 months (range 3-18 months). Patients with favorable response to GKRS at last follow-up had lower mean fractional anisotropy values at the pontine segment (P= 0.04) and increased mean radial diffusivity values at the root entry zones (P= 0.032) of the treated trigeminal nerve on the 3-month diffusion tensor imaging sequences as compared with the nonresponders. Diffusivity metrics changes on the treated trigeminal nerve at the 3-month time point after GKRS for TN correlated with pain relief at last follow-up. Further, well-designed studies are warranted to establish the clinical application of diffusion tensor imaging as a noninvasive, prognostic tool in patients with TN managed with GKRS.

Treatment Planning Factors Associated with Long-Term Outcomes of Gamma Knife Surgery in Patients with Trigeminal Neuralgia

Gamma Knife surgery (GKS) is an established treatment option for trigeminal neuralgia (TN). However, the long-term efficacy of GKS for patients with TN has not been well studied. The aim of the study is to evaluate the sequential course of pain control after GKS and analyze the factors associated with the long-term analgesic effect, focusing on radiation dosimetry and neurovascular conflict (NVC) factors. We analyzed 83 patients undergoing GKS for TN in our institution between 2005 and 2013 with a follow-up duration >7 years. Tolerable pain with increased medication, persistent-intractable pain, and recurrence were classified as poor outcomes, and any other outcome was classified as a favorable outcome. The dosimetry factors and locational relationship between NVC and the target were analyzed in terms of their correlation with a favorable outcome. Adequate pain relief was achieved in 93% of patients a month and a half after GKS, but the pain recurred in 41.5% of patients on average 36 months after treatment. A larger V40Gy (P= 0.002) and higher homogeneity index (P= 0.027) were significantly associated with the long-term favorable outcomes. About 40% of patients had multiple NVC sites, and insufficient inclusion of the NVC in the target was significantly correlated with long-term poor outcomes (P= 0.002). Targeting the center of the trigeminal nerve in the area of NVC with GKS is associated with favorable long-term pain control.

Internal Neurolysis (Nerve Combing) for Trigeminal Neuralgia without Neurovascular Compression

AbstractObjective The aim of the present study was to describe and evaluate the initial and the long-term clinical outcome of internal neurolysis (IN) for trigeminal neuralgia (TN) without neurovascular compression (NVC).Methods A total of 170 patients diagnosed with TN were treated by posterior fossa exploration, during the period between April 2012 and October 2019. The patients were divided into two groups: Group A (50 patients) was treated by IN and Group B (120 patients) received microvascular decompression (MVD). Surgical outcomes and postoperative complications were compared between the two groups. Pain intensity was assessed by the Barrow Neurological Institute (BNI) pain intensity score and BNI facial numbness score. Pain recurrence was statistically evaluated with Kaplan-Meier analysis.Results Pain was completely relieved in 44 patients (88%) who underwent IN (group A); 3 (6%) experienced occasional pain but did not require medication (BNI 2). In group B, 113 (94%) experienced immediate pain relief after MVD. The median duration of follow-ups was 4 years (6 months to 7.5 years). In Group A, there was a meantime recurrence of 27 months in 3 patients (6%). The recurrence in Group B was of 5.8% during the follow-up period. There were no statistically significant differences in the surgical outcomes between the two groups. All patients with IN experienced some degree of numbness, 88% of the cases resolved in 6 months, on average.Conclusion Internal neurolysis is an effective, safe and durable treatment option for trigeminal neuralgia when NVC is absent.

Biplane Fluoroscopic-Guided Balloon Rhizotomy for Trigeminal Neuralgia: A Technical Note.

The classic percutaneous technique used to cannulate the foramen ovale for the treatment of trigeminal neuralgia can place important anatomic structures, such as the distal cervical internal carotid artery, at risk. To use fixed anatomic landmarks to safely and reliably locate the foramen ovale on anteroposterior (AP) fluoroscopy. Locating the foramen ovale was initially tested using AP fluoroscopy on cadaveric skulls in the neurosurgical simulation lab. Fluoroscopic landmarks were identified and utilized to assist in successfully locating the foramen ovale during percutaneous balloon rhizotomy procedures in patients with trigeminal neuralgia. This technique has been successfully used in multiple patients. In this report, we describe our technique in detail. The AP fluoroscopy is directed laterally in the coronal plane until a line drawn inferiorly from the lateral orbital rim bisects the inner concavity of the mandibular angle. Fluoroscopy is then directed inferiorly until the top of the petrous ridge bisects the mandibular ramus. The foramen ovale will come into view within the window between the mandibular ramus and hard palate. Two case illustrations are provided. Balloon rhizotomy is a commonly used treatment option for trigeminal neuralgia. Direct visualization of the foramen ovale can reliably be achieved on AP fluoroscopy using specific anatomic landmarks. This technique can be utilized to increase the accuracy and safety of the procedure.

Efficacy of coblation versus radiofrequency thermocoagulation for the clinical treatment of trigeminal neuralgia.

IntroductionPostoperative facial numbness is the main complication of radiofrequency thermocoagulation in treating trigeminal neuralgia, which could seriously affect the surgical efficacy. This problem is expected to be resolved by coblation technique.AimTo compare the long-term efficacy and safety of coblation and percutaneous trigeminal radiofrequency thermocoagulation (PT-RFT) under fluoroscopic guidance in the treatment of trigeminal neuralgia (TN).Material and methodsA case-control prospective study was carried out. Patients with TN were randomly scheduled to receive coblation or PT-RFT. Both surgical procedures were performed under fluoroscopic guidance. The data, including the degree of pain, pain relief and complications, were recorded during follow-up evaluation, which was performed on the first day and at the end of the first month, third month, sixth month and first year after surgery.ResultsA total of 50 patients were enrolled in this study, with 25 patients in each group. The visual analog scale (VAS) scores in both groups at each time point after surgery were significantly lower compared with before surgery (p < 0.05). There were no significant differences in VAS scores or pain relief between the two groups at any time point after surgery (p > 0.05). However, patients in the PT-RFT group exhibited greater facial numbness after surgery (p < 0.05). For other complications, there were no significant differences between the two groups (p > 0.05).ConclusionsCoblation and PT-RFT showed similar effectiveness in reducing pain; however, coblation was associated with a lower rate of postoperative facial numbness. Therefore, coblation may be a better treatment option for TN.

Cyberknife Radiosurgery for Trigeminal Neuralgia.

IntroductionImage-guided robotic radiosurgery is an emerging minimally-invasive treatment option for trigeminal neuralgia (TN). Our group has treated 560 cases up to date, and report here the clinical outcomes of 387 treatments with three years follow-up. This study represents the largest single-center experience on CyberKnife radiosurgery for the treatment of TN so far reported.MethodsCyberKnife radiosurgery treatment was offered to patients with drug-resistant TN, after the failure of other treatments or refusal of invasive procedures. A second treatment was offered to patients with a poor response after the first treatment or with recurrent pain. Treatment protocol required the non-isocentric delivery of 60 Gy prescribed to the 80% isodose to a 6 mm retrogasserian segment of the affected trigeminal nerve. Retreatments typically received 45 Gy, again prescribed to the 80% isodose. The final plan was developed accordingly to individual anatomy and dose distribution over the trigeminal nerve, gasserian ganglion, and brainstem. Clinical outcomes such as pain control and hypoesthesia/numbness have been evaluated after 6, 12, 24, and 36 months. ResultsOur group has treated 527 patients with Cyberknife radiosurgery at Centro Diagnostico Italiano (CDI), Milan, Italy, during the last decade. A minimum follow-up of six months was available on 496 patients. These patients received 560 treatments: 435 patients (87.7%) had a single treatment, 60 patients (12.1%) had two treatments, and one patient (0.2%) had five treatments (two on the right side, three on the left side). Twenty four patients had multiple sclerosis (4.8%). Four hundred and forty-three patients (84%) received the treatment without previous procedures, while 84 patients (16%) underwent radiosurgery after the failure of other treatments. A neurovascular conflict was identified in 59% of the patients. Three hundred and forty-three patients (receiving a total of 387 treatments) had a minimum of 36 months follow up. Pain relief rate at 6, 12, 18, 24, 30 and 36 months was respectively 92, 87, 87, 82, 78 and 76%. Forty-four patients out of 343 (12.8%) required a second treatment during the observed period. At 36 months post-treatment, 21 patients (6,1%) reported the presence of bothering facial hypoesthesia. Eighteen patients out of 21 (85.7%) developed this complication after a repeated treatment. ConclusionsFrameless image-guided robotic radiosurgery in experienced hands is a safe and effective procedure for the treatment of TN, providing excellent pain control rates in the absence of major neurological complications. Repeated treatments due to recurrent pain are associated with restored pain control but at the price of a higher rate of sensory complications.

Bi-Plane Fluoroscopic-Guided Balloon Rhizotomy for Trigeminal Neuralgia: A Technical Note

Abstract INTRODUCTION The classic partially blinded percutaneous technique using external landmarks to cannulate the foramen ovale for the treatment of trigeminal neuralgia can place important anatomical structures, such as the distal cervical internal carotid artery, at risk. We have developed a new technique in which we use anteroposterior fluoroscopy to reliably locate the foramen ovale and thus make it safer and easier to cannulate. METHODS Locating foramen ovale was initially tested using anteroposterior fluoroscopy on cadaveric skulls in the neurosurgical simulation lab. Fluoroscopic landmarks were identified and utilized to assist in successfully locating the foramen ovale during percutaneous balloon rhizotomy procedures performed in multiple patients with trigeminal neuralgia. This technique was successfully used in multiple patients at our institution without any immediate complications except for one cheek hematoma. In this report, we describe our technique in detail. RESULTS The AP fluoroscopy is directed laterally in the coronal plane until a line drawn inferiorly from the lateral orbital rim bisects the inner concavity of the mandibular angle. Fluoroscopy is then directed inferiorly until the top of the petrous ridge bisects the mandibular ramus. The foramen ovale will come into view within the window between the mandibular ramus and hard palate. Two case illustrations are provided CONCLUSION Balloon rhizotomy is a commonly used treatment option for trigeminal neuralgia. Direct visualization of the foramen ovale can reliably be achieved on AP fluoroscopy using specific anatomic landmarks. This technique can be utilized to increase the accuracy and safety of the procedure.

Re-Irradiation of Trigeminal Neuralgia with LINAC-Based Stereotactic Radiosurgery

Stereotactic radiosurgery (SRS) is an effective non-invasive treatment option for trigeminal neuralgia (TGN). If TGN pain recurs after SRS, re-irradiation with SRS can be considered. While there is published data regarding re-treatment with gamma-knife radiosurgery, little has been published regarding the safety and efficacy of retreatment with LINAC-based SRS. Between July 2007 and July 2017, there were 22 cases of repeat SRS for recurrent TGN to 21 patients (one patient had bilateral re-irradiation) available for analysis. Initial treatment consisted of 90 Gy to the isocenter using frameless LINAC SRS equipped with a 6D robotic table and for re-treatment 60 Gy was used to the root entry zone of CN V. Outcomes were categorized as excellent (minimal to no pain while still taking smaller amounts or fewer medications), good (pain controlled with medical management), and refractory (uncontrolled pain). Toxicity data was also collected and scored using CTCAE v4.0. The median follow up after re-irradiation was 7.5 months with a range of 1-72 months. The median time between SRS sessions was 16 months with a range of 5 to 76 months. Nine out of the twenty-two cases (40.9%) experienced an excellent outcome, six out of the twenty-two (27.3%) cases experienced a good outcome, and seven out twenty-two cases (31.8%) had a refractory outcome. Regarding toxicity from re-irradiation, there was only one episode of mild and non-bothersome unilateral facial numbness. For those 15 cases who had an excellent/good response to SRS, three (20%) had further recurrence of the TGN pain at a median interval of sixteen months from the second SRS (8-18 months). Re-irradiation of TGN with frameless LINAC based SRS appears to be both safe and effective with 68% of cases in this series responding to re-treatment along with minimal toxicity.

Trigeminal Neuralgia, Glossopharyngeal Neuralgia, and Myofascial Pain Dysfunction Syndrome: An Update.

Neuropathic pain is a common phenomenon that affects millions of people worldwide. Maxillofacial structures consist of various tissues that receive frequent stimulation during food digestion. The unique functions (masticatory process and facial expression) of the maxillofacial structure require the exquisite organization of both the peripheral and central nervous systems. Neuralgia is painful paroxysmal disorder of the head-neck region characterized by some commonly shared features such as the unilateral pain, transience and recurrence of attacks, and superficial and shock-like pain at a trigger point. These types of pain can be experienced after nerve injury or as a part of diseases that affect peripheral and central nerve function, or they can be psychological. Since the trigeminal and glossopharyngeal nerves innervate the oral structure, trigeminal and glossopharyngeal neuralgia are the most common syndromes following myofascial pain dysfunction syndrome. Nevertheless, misdiagnoses are common. The aim of this review is to discuss the currently available diagnostic procedures and treatment options for trigeminal neuralgia, glossopharyngeal neuralgia, and myofascial pain dysfunction syndrome.

Ophthalmic branch radiofrequency thermocoagulation for atypical trigeminal neuralgia:a case report.

BackgroundTrigeminal neuralgia is an intense neuralgia involving facial areas supplied by trigeminal nerve. The pain is characterized by sudden onset, short persistence, sharp or lancinating. Trigeminal neuralgia commonly affects frontal areas, infraorbital or paranasal areas, mandibular areas and teeth. While Trigeminal neuralgia affecting merely the upper eyelid is rare. Here we report a case of atypical Trigeminal neuralgia confined to the upper eyelid. The patient was pain free during the follow-up period of 6 months after unusual ophthalmic branch radiofrequency thermocoagulation.Case presentationA 55-year-old female patient was diagnosed as primary trigeminal neuralgia involving the right upper eyelid. As the pain could not be controlled by drug therapy, peripheral nerve branch radiofrequency thermocoagulation was recommended. A combination of infratrochlear, supratrochlear and lacrimal radiofrequency thermocoagulation was implemented in this case. The point where the bridge of the nose abuts the supraorbital ridge and the point slightly above the lateral canthus along outer border of the orbit were selected respectively as the puncture sites. After positive diagnostic test, radiofrequency thermocoagulation of the above-mentioned nerve branches was performed respectively. The patient was pain free immediately after the treatment and during the follow-up period of 6 months.DiscussionTrigeminal neuralgia is a common severe and chronic facial neuralgia which requires accurate diagnosis and effective therapy. With typical clinical symptoms, normal neurological signs, normal CT and MRI findings, the patient was diagnosed as classic trigeminal neuralgia. As the patient was drug resistant, some invasive treatments were considered. Peripheral branch neurolysis was chosen for its minimal invasiveness, convenience, low risk and not affecting further invasive treatments. According to the anatomic data and the diagnostic test results, infratrochlear, supratrochlear and lacrimal nerve were responsible, therefore, an unusual combination of infratrochlear, supratrochlear, and lacrimal radiofrequency thermocoagulation was implemented for this patient.ConclusionsRadiofrequency thermocoagulation is an effective treatment option for trigeminal neuralgia. Peripheral branch radiofrequency thermocoagulation for trigeminal neuralgia should be considered preferentially due to its minimal invasiveness and convenience. Furthermore, as the sensory innervation of the upper eyelid is complex, the knowledge of peripheral distribution of trigeminal nerve is essential.

Radiosurgery in trigeminal neuralgia

Trigeminal neuralgia is a rare but debilitating pain syndrome with a distinct clinical presentation mainly affecting people advancing in years. Compression of the trigeminal nerve by an aberrant vascular loop has been proposed as the causative factor in the majority of cases leading to the development of a highly effective surgical treatment approach termed “microvascular decompression”. Nevertheless the mainstay of treatment remains medical. This article gives a brief overview of current treatment options for trigeminal neuralgia with special emphasis on radiosurgery. Possible mechanisms underlying the therapeutic effect of radiosurgery are discussed with some consideration of implications for optimizing prescription dose and target definition.