Treatments

Non-percutaneous destructive neurosurgical techniques (stereotactic radiosurgery)

In this section:

Key points | Benefits and Harms | Comment

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Key points

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Benefits and harms

Non-percutaneous destructive neurosurgical techniques (stereotactic radiosurgery):

We found three systematic reviews (search dates 2003),[54][55][56] which identified no RCTs comparing stereotactic radiosurgery versus placebo/no treatment or other treatments covered in this review.

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Comment

As Clinical Evidence was unable to perform a second appraisal of results retrieved by the contributor's search, we may have missed studies that could affect our overall assessment of this intervention.

Clinical guide:

One of the systematic reviews[54] identified nine observational studies (mainly case series, 2077 people) comparing stereotactic radiosurgery versus percutaneous destructive neurosurgical techniques to the Gasserian ganglion and/or pre-ganglionic nerve route. It suggested that radiofrequency thermocoagulation may offer higher rates of complete pain relief than stereotactic radiosurgery and glycerol rhizolysis (a percutaneous destructive neurosurgical technique), but it is associated with the highest rate of complications. We found stronger RCT evidence for stereotactic radiosurgery than for other destructive neurosurgical techniques, but the RCT comparing different regimens does not allow conclusions to be drawn about the effects of stereotactic radiosurgery compared with no treatment. RCTs comparing the effects of stereotactic radiosurgery with no treatment have not been undertaken and are unlikely to be in future because of ethical considerations. We found two prospective comparative cohort studies comparing stereotactic radiosurgery versus microvascular decompression (see Comment section for Microvascular decompression).[48][49] The studies showed superiority of microvascular decompression over stereotactic radiosurgery for initial complete pain relief, durability of response (up to 5 years), and preservation of trigeminal sensation.

We also found one systematic review[57] that identified one RCT that compared stereotactic radiosurgery using either one or two isocentres, the latter regimen to treat a longer length of the trigeminal nerve.[58] The study found that stereotactic radiosurgery using one isocentre was as effective as stereotactic radiosurgery using two isocentres at relieving pain at 26 months (with or without additional pain-relieving drugs).

Stereotactic radiosurgery is performed using technologies such as the Gamma Knife®, CyberKnife®, and linear accelerators with multileaf collimator capabilities (LINAC-MLC). Unlike other surgical interventions for trigeminal neuralgia, stereotactic radiosurgery does not require general anaesthesia (or any form of sedation) to perform. However, the pain-relieving effects of this procedure are not immediate,[59] therefore, it is not considered an option for the emergency management of people with trigeminal neuralgia in acute extremis.

As with percutaneous destructive neurosurgical techniques, stereotactic radiosurgery can be used to treat people with multiple sclerosis-related trigeminal neuralgia, albeit with somewhat lower anticipated success rates.[60][61][62]

If stereotactic radiosurgery is repeated for pain recurrence, a significantly lower dose of radiation must be used, otherwise significantly higher rates of numbness will be encountered. De-afferentation pain, in addition to trigeminal neuralgia pain, could then become a problem.[63][64][65][66]