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      Microvascular Decompression Versus Stereotactic Radiosurgery for Trigeminal Neuralgia: A Decision Analysis

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          Abstract

          Introduction: Both microvascular decompression (MVD) and stereotactic radiosurgery (SRS) have been demonstrated to be effective in treating medically refractory trigeminal neuralgia. However, there is controversy over which one offers more durable pain relief and the patient selection for each treatment. We used a decision analysis model to calculate the health-related quality of life (QOL) for each treatment.

          Methods: We searched PubMed and the Cochrane Database of Systematic Reviews for relevant articles on MVD or SRS for trigeminal neuralgia published between 2000 and 2015. Using data from these studies, we modeled pain relief and complication outcomes and assigned QOL values. A sensitivity analysis using a Monte Carlo simulation determined which procedure led to the greatest QOL.

          Results: MVD produced a significantly higher QOL than SRS at a seven-year follow-up. Additionally, MVD patients had a significantly higher rate of complete pain relief and a significantly lower rate of complications and recurrence.

          Conclusions: With a decision-analytic model, we calculated that MVD provides more favorable outcomes than SRS for the treatment of trigeminal neuralgia.

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          AAN-EFNS guidelines on trigeminal neuralgia management.

          G Cruccu, G. Gronseth, J Alksne … (2008)
          Several issues regarding diagnosis, pharmacological treatment, and surgical treatment of trigeminal neuralgia (TN) are still unsettled. The American Academy of Neurology and the European Federation of Neurological Societies launched a joint Task Force to prepare general guidelines for the management of this condition. After systematic review of the literature the Task Force came to a series of evidence-based recommendations. In patients with TN MRI may be considered to identify patients with structural causes. The presence of trigeminal sensory deficits, bilateral involvement, and abnormal trigeminal reflexes should be considered useful to disclose symptomatic TN, whereas younger age of onset, involvement of the first division, unresponsiveness to treatment and abnormal trigeminal evoked potentials are not useful in distinguishing symptomatic from classic TN. Carbamazepine (stronger evidence) or oxcarbazepine (better tolerability) should be offered as first-line treatment for pain control. For patients with TN refractory to medical therapy early surgical therapy may be considered. Gasserian ganglion percutaneous techniques, gamma knife and microvascular decompression may be considered. Microvascular decompression may be considered over other surgical techniques to provide the longest duration of pain freedom. The role of surgery versus pharmacotherapy in the management of TN in patients with multiple sclerosis remains uncertain.
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            Utility Functions for Life Years and Health Status

            Joseph S Pliskin, Donald S. Shepard, Milton C. Weinstein (1980)
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              Gamma knife radiosurgery for trigeminal neuralgia: the initial experience of The Barrow Neurological Institute.

              A G Shetter, Michael Fiedler, Lorraine P. Smith … (2000)
              To assess the efficacy and complications of Gamma Knife radiosurgery for trigeminal neuralgia. The Barrow Neurological Institute (BNI) Gamma Knife facility has been operational since March 17, 1997. A total of 557 patients have been treated, 89 for trigeminal neuralgia (TN). This report includes the first 54 TN patients with follow-up exceeding 3 months. Patients were treated with Gamma Knife stereotactic radiosurgery (RS) in uniform fashion according to two sequential protocols. The first 41 patients received 35 Gy prescribed to the 50% isodose via a single 4-mm isocenter targeting the ipsilateral trigeminal nerve adjacent to the pons. The dose was increased to 40 Gy for the remaining 13 patients; however, the other parameters were unvaried. Outcome was evaluated by each patient using a standardized questionnaire. Pain before and after RS was scored as level I-IV per our newly-developed BNI pain intensity scoring criteria (I: no pain; II: occasional pain, not requiring medication; III: some pain, controlled with medication; IV: some pain, not controlled with medication; V: severe pain/no pain relief). Complications, limited to mild facial numbness, were similarly graded by a BNI scoring system. Among our 54 TN patients, 52 experienced pain relief, BNI score I in 19 (35%), II in 3 (6%), III in 26 (48%), and IV in 4 (7%). Two patients (4%) reported no relief (BNI score V). Median follow-up was 12 months (range 3-28). Median time to onset of pain relief was 15 days (range 0-192), and to maximal relief 63 days (range 0-253). Seventeen (31%) noted immediate improvement (
              Article 0 comments Cited 64 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cureus
                Journal ID (iso-abbrev): Cureus
                Journal ID (issn): 2168-8184
                Title: Cureus
                Publisher: Cureus (Palo Alto (CA) )
                ISSN (Electronic): 2168-8184
                Publication date (Electronic, pub): 26 January 2017
                Publication date (Electronic, collection): January 2017
                Volume: 9
                Issue: 1
                Electronic Location Identifier: e1000
                Affiliations
                [1 ] School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
                [2 ] Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
                Author notes
                Article
                DOI: 10.7759/cureus.1000
                PMC ID: 5325747
                SO-VID: e74e4442-7397-42c0-a9c5-b4f7a96d5ebe
                Copyright © Copyright © 2017, Berger et al.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 27 October 2016
                Date accepted : 26 January 2017
                Categories
                Subject: Neurosurgery
                Subject: Neurology

                Keywords: trigeminal neuralgia,microvascular decompression,radiosurgery,gamma knife,cyberknife,decision analysis
                Data availability:
                Keywords: trigeminal neuralgia, microvascular decompression, radiosurgery, gamma knife, cyberknife, decision analysis

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