LINAC stereotactic radiosurgery for trigeminal neuralgia -retrospective two-institutional examination of treatment outcomes

Ali Rashid, Bogdan Pintea, Thomas M Kinfe, Gunnar Surber, Klaus Hamm, Jan P Boström, Ali Rashid, Bogdan Pintea, Thomas M Kinfe, Gunnar Surber, Klaus Hamm, Jan P Boström

Abstract

Background: In this pooled 2-center series LINAC radiosurgery (SRS) has been applied as a treatment option for a subset of refractory trigeminal neuralgia (TN) patients. This study approached to retrospectively assess the efficacy and safety of LINAC SRS and to provide a brief overview addressed to the technical development from frame-based towards frameless robotic SRS.

Methods: From 2001 to 2017 n = 55 patients (pts) were treated, n = 28 were female (51%), mean age: 66 years (range 36-93 years); TN etiology: 37 classic TN, 15 multiple sclerosis (MS)-related TN, 2 symptomatic TN, and 1 atypical TN. Previous treatment was present in n = 35 (63.6%) pts. (some multiple or combined) with n = 23 microsurgical vascular decompression and n = 17 percutaneous retrogasserian rhizotomy. A 6 MV LINAC (4-5 mm collimators) was applied in all pts. (n = 26 framebased - n = 29 frameless robotic). The dorsal root entry zone (DREZ) was targeted in n = 35 cases and the retrogasserian target in n = 20 pts. with a homogeneous dose for the entire study cohort (90 Gy). SRS outcome was measured using the Barrow Neurological Institute (BNI) score for pain and hypaesthesia and statistically evaluated by univariate and multivariate analyzes.

Results: Mean follow-up (FU) was 30 months (2 lost FU); the total rate of post SRS BNI pain I-IIIa (=painfree w or w/o medication) was 69% (88% for the classic TN pts), 29% (38.8% classic TN) were classified as BNI pain I-II (=painfree w/o medication). A BNI hypaesthesia II-III was present in 9.4% (n = 5) and BNI hypaesthesia IV in n = 2. Between groups analysis demonstrated no correlation of SRS responsiveness with age, gender, MS- or not MS-associated TN, previous surgery, framebased/frameless robotic SRS. DREZ targeting significantly better suppressed TN compared to RG targeting (p = 0.01). Additionally, a statistical trend for a better BNI pain outcome (p = 0.07) along with a significant increase in BNI hypaesthesia (p = 0.01) was found when using a larger partial trigeminal 70 Gy volume.

Conclusion: Our retrospective analysis support LINAC SRS as an effective and safe treatment option in TN. Frameless robotic SRS of TN is safe when using a dedicated LINAC system. A target definition closer to the brainstem and tendencially a larger target volume were associated with a better outcome for pain.

Keywords: Linear accelerator; Outcome; Radiosurgery; Trigeminal neuralgia.

Conflict of interest statement

Ethics approval and consent to participate

For all patients informed consent was obtained in accordance with the tenets of the Declaration of Helsinki. Because of the retrospective nature of the study no special approval by the local Ethics Committee was necessary. This manuscript does not report on or involve the use of any animal or human data or tissue.

Consent for publication

Not applicable, because this manuscript does not contain any individual persons data.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Dorsal root entry zone (DREZ) target. Typical plan with DREZ target (red circle), isodoses and dose-volume histograms (DVH) for trigeminal nerve (yellow line) and for different organs at risk (OAR) (blue line = brainstem)
Fig. 2
Fig. 2
a-c Retrogasserian (RG) target post Janetta decompression. Different situation pre (a) and post (b) Janetta decompression with narrowed space in the prepontine cistern (red arrow). Typical small dot-shaped contrast enhancement 2 months after radiosurgery (c)
Fig. 3
Fig. 3
BNI pain scores for different subgroups. Results of uni- and multivariate analyses. TN = trigeminal neuralgia, RS = radiosurgery, DREZ = dorsal root entry zone, RG = retrogasserian, μMLC = micro multi-leaf collimator
Fig. 4
Fig. 4
BNI hypaesthesia scores for different subgroups. Results of univariate analyses. TN = trigeminal neuralgia, RS = radiosurgery, DREZ = dorsal root entry zone, RG = retrogasserian, μMLC = micro multi-leaf collimator
Fig. 5
Fig. 5
Relation of BNI pain at 1. FU and partial trigeminal 70 Gy volume. BNI=Barrow Neurological Institute, FU = follow-up

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