Early radiosurgery provides superior pain relief for trigeminal neuralgia patients

Objective: We evaluated factors associated with better outcomes after stereotactic radiosurgery (SRS) when it was performed as the first surgical procedure for medically refractory trigeminal neuralgia.

Methods: A total of 121 patients (median age 72 years) with medically refractory pain and no prior surgery underwent Gamma Knife SRS as their initial surgical procedure for trigeminal neuralgia. Using a single 4-mm isocenter, patients received an average maximum dose of 80 Gy, delivered to the trigeminal nerve target defined by intraoperative MRI. The median follow-up was 36 months.

Results: Pain relief (Barrow Neurological Institute [BNI] score I–IIIa) was achieved in 107 (88%) patients at a median time of 1 month. Patients who underwent earlier SRS (within 3 years of pain onset) had a shorter interval until pain relief (1 week, p < 0.001), had a longer interval of pain relief off medication (BNI-I, p < 0.001), and had a longer duration of adequate pain control (BNI-I–IIIa, p < 0.001). Median pain-free intervals for patients who underwent SRS at 1, 2, 3, and more than 3 years after trigeminal neuralgia diagnosis were 68, 37, 36, and 10 months, respectively. Patients who responded to SRS within the first 3 weeks after SRS had a longer duration of complete pain relief compared to those with longer response times (p = 0.001). Fifteen patients (12%) reported new sensory dysfunction after SRS.

Conclusion: Early SRS as the initial surgical procedure for management of refractory trigeminal neuralgia was associated with faster, better, and longer pain relief when compared to late SRS.

Classification of evidence: 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.