Horn Alexander C, Kolahi Sohrabi Arian, Chan Michael D, Kittel Carol, Helis Corbin A, Bourland Daniel, Ververs James D, Cramer Christina K, White Jaclyn J, Tatter Stephen B, Laxton Adrian W
Departments of1Neurosurgery and.
2Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina; and.
J Neurosurg. 2024 Nov 29;142(5):1247-1255. doi: 10.3171/2024.7.JNS232274. Print 2025 May 1.
Gamma Knife radiosurgery (GKRS) is a treatment option for refractory trigeminal neuralgia (TN). However, there is a paucity of data regarding the effectiveness of GKRS for relapsing TN following microvascular decompression (MVD). The aim of this study was to characterize the response rate, complications, pain relief durability, and predictors of pain relapse for salvage GKRS following MVD for TN.
A retrospective study of all patients who received GKRS for Burchiel type 1 TN (TN1) or type 2 TN (TN2) pain at Wake Forest University School of Medicine was conducted. Pain was measured using the Barrow Neurological Institute (BNI) pain intensity score. After an initial pain response of BNI scores I-III, a BNI score of IV or V constituted relapse. Durability of pain relief was characterized using the Kaplan-Meier estimator. Predictors of relapse were investigated using Cox regression models. Statistical significance was set at p < 0.05.
Of 2065 patients with TN1 or TN2, 59 had GKRS post-MVD. Forty-nine (83.1%) of these patients experienced a BNI pain score of I-III at the first follow-up post-GKRS. The median time to relapse was 1.75 years; freedom rates from relapse were 77%, 45.9%, and 30.7% at 1, 2, and 5 years, respectively. Radiofrequency ablation prior to MVD significantly decreased the likelihood of an initial response to salvage GKRS (Fisher's exact test, p = 0.02). After controlling for baseline and clinical characteristics, facial numbness significantly decreased the likelihood of pain relapse (Cox regression, HR 0.15, 95% CI 0.03-0.73; p = 0.01). Conversely, a worse initial pain response significantly increased the likelihood of pain relapse (Cox regression, HR 3.64, 95% CI 1.02-12.95; p = 0.04). Pain relapse within 24 months of the original MVD did not predict durability of pain relief following salvage GKRS (Cox regression, HR 0.94, 95% CI 0.40-2.22; p = 0.89). The overall toxicity rate of salvage GKRS was 35.6%.
Salvage GKRS presents an effective, noninvasive option for recurring TN after MVD, with a comparable response rate to primary GKRS or MVD, and a favorable complications profile relative to salvage MVD. Patients with postoperative facial numbness and a better initial pain response may experience more durable pain relief following salvage GKRS.
伽玛刀放射外科治疗（GKRS）是难治性三叉神经痛（TN）的一种治疗选择。然而，关于GKRS治疗微血管减压术（MVD）后复发的TN的有效性的数据较少。本研究的目的是描述TN患者MVD术后挽救性GKRS的缓解率、并发症、疼痛缓解的持久性以及疼痛复发的预测因素。
对在维克森林大学医学院接受GKRS治疗Burchiel 1型TN（TN1）或2型TN（TN2）疼痛的所有患者进行回顾性研究。使用巴罗神经学研究所（BNI）疼痛强度评分来测量疼痛。在BNI评分为I - III的初始疼痛缓解后，BNI评分为IV或V则构成复发。使用Kaplan - Meier估计器来描述疼痛缓解的持久性。使用Cox回归模型研究复发的预测因素。设定统计学显著性为p < 0.05。
在2065例TN1或TN2患者中，59例在MVD后接受了GKRS。其中49例（83.1%）患者在GKRS后的首次随访时BNI疼痛评分为I - III。复发的中位时间为1.75年；1年、2年和5年的无复发率分别为77%、45.9%和30.7%。MVD前进行的射频消融显著降低了挽救性GKRS初始缓解的可能性（Fisher精确检验，p = 0.02）。在控制基线和临床特征后，面部麻木显著降低了疼痛复发的可能性（Cox回归，风险比0.15，95%置信区间0.03 - （此处原文有误，应为0.73）；p = 0.01）。相反，初始疼痛缓解较差显著增加了疼痛复发的可能性（Cox回归，风险比3.64，95%置信区间1.02 - 12.95；p = 0.04）。原始MVD后24个月内的疼痛复发并不能预测挽救性GKRS后疼痛缓解的持久性（Cox回归，风险比0.94，95%置信区间0.40 - 2.22；p = 0.89）。挽救性GKRS的总体毒性率为35.6%。
挽救性GKRS为MVD后复发的TN提供了一种有效、无创的选择，其缓解率与原发性GKRS或MVD相当，且相对于挽救性MVD并发症情况较好。术后面部麻木且初始疼痛缓解较好的患者在挽救性GKRS后可能会有更持久的疼痛缓解。
