Trigeminal neuralgia SRS
Objective:
There is a wide selection of studies concerning this issue; I chose one meta-analysis,
one study presenting other publications and two sets of individual results,
showing only particular results to allow to compare them.
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Metaanalysis
- C. Tulesca et al. J Neurosurg. 2018
GammaKnife
based SRS (GK) – 5687 pts – 60-97 Gy,
freedom from pain (FFP) – med. 52%, hypoesthesia – med. 19%
Linear
accelerator based SRS (LINAC) – 511 pts – 50-90 Gy, FFP – med. 43%,
hypoesthesia – 29%
Cyber knife
based SRS (CK) – 263 pts – 66-90 Gy, FFP – med. 58%, hypoesthesia – 19%
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Comparison
to other publications - S.C. Park et al. Yonsei Med J. 2020
GK – 4279
pts (18 studies), % patients with pain relief – 70-96%, complications rate –
2.7-42%
GK (S.C.
Park – own results) – 235 pts – 60-90 Gy, % patients with pain relief – 93.7%,
complications rate - 17.6%, hypoesthesia – 13.4%
Individual
series
-
Peng
Li et al. J Clin Neurosci. 2012
GK – 129
pts, - 80-90 Gy, % patients with pain relief – 86%, complications rate – 39%
-
P.
Romanelli et al. Cureus 2019
CK – 387 pt.
– 60 Gy, % patients with pain relief – 92%, hypoesthesia – 6.1%
Our results
Material:
93 patients irradiated (61 F, 32 M). 48 previously treated with other
non-pharmacological methods. 48.8% used NSAIDs, 40% opioids, 15% steroids, 62%
antiepileptic and19% anti-depressive drugs. 60% suffered from acute
(classical), 29% from chronic and 11% from both types of trigeminalgia. V1 was
involved in 39%, V2 in 66% and V3 in 50% of cases. NRS before SRS varied from 5
to 10 (mean 9.6, median 10).
Method: All
patients irradiated with CyberKnife using 25-246 beams. In 83 cases single dose
of 60 Gy and in 1 – 50 Gy were delivered. In 7 cases 2x35 Gy and in 2 – 2x30 Gy
were given. 22 cases were irradiated second time after previous ineffective
linac-based SRS.
Results: In
37% complete, in 45% partial pain relief
was noted (82% of response). An improvement appeared in the period 1-12 months
(54% < 1, 38% 2-3, 7% 4-6 and 1 in 12th month). 18% of patient
failed. NRS after SRS varied from 0 to 10 (mean 3.2, median 2). 48% of patients
discontinued and 3% reduced drugs uptake. Adverse effects were reported in 11
cases (6 – paresthesia, 3 – hypoesthesia, 3 – pain increase).
Parkinson’s disease (PD) related tremor SRS
Objective: I
found only 1 case report considering CK based SRS of PD. I chose 3 studies to
present GK SRS results.
-
J.
R. Pérez-Sánchez et al. Neurologia 2020
GK – 13 pts
(6-PD, 4 ET [essential tremor], 3 PD+ET) – 130 Gy, Unified Parkinson's disease
rating scale (UDPRS) improvement after 1 year 71.3% and 60.3% at the end of FU
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S.S.
Raju et al. Stereotact Funct Neurosurg 2017
GK – 33 pts
(PD) – 130-150 Gy, 93.9% of improvement (70% complete or nearly complete
relief). In the last FU – 96.8% of responders. 6% of toxicity
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C.
Ohye et al. 2012
GK – 72 pts
(59 PD, 13 ET) – 130 Gy, in 2 years of FU (53 pts) – 81.1% of improvement
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A.
Franzini et al. Acta Neurochir 2011
CK – 2 pts
with unilateral DBS and contralateral SRS – both with tremor control
Our results
Material:
23 patients irradiated (3 F, 20 M). Duration of the disease before SRS - 60 to
192 months (med. 96). In 16 cases right and in 7 left side was dominant. 91%
used levodopa (300-1800 mg/24 h, med. 700), 83% benserazide and 39% carbidopa.
Beck’s Depression Inventory (BDI) before treatment varied from 3 to 39 points
(med. 16) and UDPRS from 1 to 4 (mean 2.5). FU was 3 – 72.2 months (med. 27.9).
Method:
Every three patients were irradiated using CK with increasing dose (step 5 Gy)
starting from 70 Gy to 105 Gy (only 2 pts were irradiated with 105 Gy – study was
interrupted because of severe adverse event of one patient). The maximal dose
for an internal capsule was 8-34 Gy (mean 23 Gy).
Results: In
the time of last control 73.3% of patients reported decrease, 13.3% stagnation
and 13.3% increase of tremor. In responders group relief varied from 10 to 100%
(med. 60). 35.7% reported subjective
improvement, 21.4% stagnation and 42.9% worsening. In group with good answer an
improvement was 10-60% (med. 30). In 39% of patients we noted new symptoms
which could be related to treatment toxicity. During the last control 87% used
levodopa, 47% benserazide and 47% carbidopa. BDI after 1 year ranged from 4 to 31
(med. 14.5) and UDPRS from 1to 3 (med. 2). There were no significant difference
between UDRS and BDI scores before SRS and one year later.
Conclusions:
Published and our own data permit us to conclude that SRS for trigeminal
neuralgia is safe and effective treatment modality.
Indirect
comparison of own result to published ones shows worse results after CK SRS of
PD, what could be influenced by suboptimal treatment modality (?), lower dose
or patients’ selection (mixed material in other publications and homogenous our
PD group (ET patients respond better for SRS).