Conti Alfredo, Pontoriero Antonio, Iatì Giuseppe, Esposito Felice, Siniscalchi Enrico Nastro, Crimi Salvatore, Vinci Sergio, Brogna Anna, De Ponte Francesco, Germanò Antonino, Pergolizzi Stefano, Tomasello Francesco
Unit of Neurosurgery, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy.
Unit of Radiation Oncology, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy.
World Neurosurg. 2017 Jul;103:702-712. doi: 10.1016/j.wneu.2017.04.102. Epub 2017 Apr 26.
Trigeminal neuralgia (TN) affects 7% of patients with multiple sclerosis (MS). In such patients, TN is difficult to manage either pharmacologically and surgically. Radiosurgical rhizotomy is an effective treatment option. The nonisocentric geometry of radiation beams of CyberKnife introduces new concepts in the treatment of TN. Its efficacy for MS-related TN has not yet been demonstrated.
Twenty-seven patients with refractory TN and MS were treated. A nonisocentric beams distribution was chosen; the maximal target dose was 72.5 Gy. The maximal dose to the brainstem was <12 Gy. Effects on pain, medications, sensory disturbance, rate, and time of pain recurrence were analyzed.
Median follow-up was 37 (18-72) months. Barrow Neurological Institute pain scale score I-III was achieved in 23/27 patients (85%) within 45 days. Prescription isodose line (80%) accounting for a dose of 58 Gy incorporated an average of 4.85 mm (4-6 mm) of the nerve and mean nerve volume of 26.4 mm (range 20-38 mm). Seven out of 27 patients (26%) had mild, not bothersome, facial numbness (Barrow Neurological Institute numbness score II). The rate of pain control decreased progressively after the first year, and only 44% of patients retained pain control 4 years later.
Frameless radiosurgery can be effectively used to perform retrogasserian rhizotomy. Pain relief was satisfactory and, with our dose/volume constraints, no sensory complications were recorded. Nonetheless, long-term pain control was possible in less than half of the patients. This is a limitation that CyberKnife radiosurgery shares with other techniques in MS patients.
三叉神经痛（TN）影响7%的多发性硬化症（MS）患者。对于这类患者，TN无论是药物治疗还是手术治疗都很困难。放射外科神经根切断术是一种有效的治疗选择。射波刀辐射束的非等中心几何形状为TN的治疗引入了新的概念。其对MS相关性TN的疗效尚未得到证实。
对27例难治性TN和MS患者进行了治疗。选择非等中心束分布；最大靶剂量为72.5 Gy。脑干的最大剂量<12 Gy。分析了对疼痛、药物、感觉障碍、疼痛复发率和时间的影响。
中位随访时间为37（18 - 72）个月。23/27例患者（85%）在45天内达到巴罗神经学研究所疼痛量表I - III级。处方等剂量线（80%）剂量为58 Gy，平均包含4.85 mm（4 - 6 mm）的神经，神经平均体积为26.4 mm（范围20 - 38 mm）。27例患者中有7例（26%）有轻度、不困扰的面部麻木（巴罗神经学研究所麻木量表II级）。疼痛控制率在第一年之后逐渐下降，4年后只有44%的患者仍保持疼痛控制。
无框架放射外科可有效用于进行半月神经节后根切断术。疼痛缓解令人满意，并且在我们的剂量/体积限制下，未记录到感觉并发症。尽管如此，不到一半的患者能够实现长期疼痛控制。这是射波刀放射外科与MS患者其他技术共有的一个局限性。
