Gamma knife surgery for trigeminal neuralgia: outcomes and prognostic factors
Gamma knife surgery for trigeminal neuralgia: outcomes and prognostic factors
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DOI：
10.3171/jns.2005.102.3.0434
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发表时间：
2005-03-01
影响因子：
4.1
通讯作者：
Steiner, L
中科院分区：
文献类型：
--
作者：
Sheehan, J;Pan, HC;Steiner, L
目的。微血管减压（MVD）和经皮消融手术历来是治疗难治性三叉神经痛（TN）的首选治疗方法。伽玛刀手术 (GKS) 已被用作 TN 的替代微创治疗方法。在本研究中，作者评估了 GKS 治疗 TN 的长期结果。方法。 1996年至2003年，GKS治疗了151例TN。本组中，136 名患者接受了一次放射外科治疗，14 名患者接受了两次放射外科治疗，1 名患者接受了 3 次放射外科治疗。 TN 类型如下：122 例典型 TN 患者，3 例非典型 TN，4 例多发性硬化相关 TN，7 例 TN 且有海绵窦肿瘤病史。在每种情况下，所选的放射外科目标位于三叉神经进入脑桥的入口前方 2 至 4 毫米。最大辐射剂量范围为 50 至 90 Gy。患者的中位年龄为68岁（范围22-90岁），从诊断到GKS的中位时间为72个月（范围1-276个月）。中位随访时间为 19 个月（范围 2-96 个月）。分析了临床结果和放射外科后磁共振 (MR) 成像研究。进行单变量和多变量分析以评估与有利的无痛结果相关的因素。疼痛缓解的平均时间为 24 天（范围 1-180 天）。在 1 年、2 年和 3 年的随访中，分别有 47%、45% 和 34% 的患者无需药物即可缓解疼痛。在 1 年、2 年和 3 年随访中，分别有 90%、77% 和 70% 的患者疼痛有所改善。 122 名初步改善的患者中，有 33 名 (27%) 在 GKS 治疗后中位 12 个月（范围 2-34 个月）内出现疼痛复发。在症状复发的患者中，14 名患者接受了额外的 GKS，6 名患者接受了 MVD，4 名患者接受了甘油注射，1 名患者接受了经皮射频根切断术。 12 名患者 (9%) 在 GKS 后出现新的面部麻木症状。变化。在 9 名患者 (7%) 中发现了 GKS 后 MR 图像的变化。在单变量分析中，右侧神经痛 (p = 0.0002) 和既往神经切除术 (p = 0.04) 与无痛结果相关；多变量分析显示，右侧神经痛 (p = 0.032) 和患者年龄 (p = 0.05) 均具有统计学意义。 GKS 后新发的面部麻木与接受不止一次 GKS 相关 (p = 0.002)。结论。在最后一次随访中，GKS 缓解了 44% 的患者疼痛。 GKS 治疗后 3 年，70% 的 TN 患者的疼痛有所改善。尽管效果不如 MVD，但对于那些不愿意或无法接受更具侵入性的手术方法的患者来说，GKS 仍然是一种合理的治疗选择，并且副作用风险较低。
Object. Microvascular decompression (MVD) and percutaneous ablation surgery have historically been the treatments of choice for medically refractory trigeminal neuralgia (TN). Gamma knife surgery (GKS) has been used as an alternative, minimally invasive treatment in TN. In the present study, the authors evaluated the long-term results of GKS in the treatment of TN.Methods. From 1996 to 2003, 151 cases of TN were treated with GKS. In this group, radiosurgery was performed once in 136 patients, twice in 14 patients, and three times in one patient. The types of TN were as follows: 122 patients with typical TN, three with atypical TN, four with multiple sclerosis-associated TN, and seven with TN and a history of a cavernous sinus tumor. In each case, the chosen radiosurgical target was located 2 to 4 mm anterior to the entry of the trigeminal nerve into the pons. The maximal radiation doses ranged from 50 to 90 Gy. The median age of the patients was 68 years (range 22-90 years), and the median time from diagnosis to GKS was 72 months (range 1-276 months). The median follow up was 19 months (range 2-96 months). Clinical outcomes and postradiosurgical magnetic resonance (MR) imaging studies were analyzed. Univariate and multivariate analyses were performed to evaluate factors that correlated with a favorable, pain-free outcome.The mean time to relief of pain was 24 days (range 1-180 days). Forty-seven, 45, and 34% of patients were pain free without medication at the 1-, 2-, and 3-year follow ups, respectively. Ninety, 77, and 70% of patients experienced some improvement in pain at the 1-, 2-, and 3-year follow ups, respectively. Thirty-three (27%) of 122 patients with initial improvement subsequently experienced pain recurrence a median of 12 months (range 2-34 months) post-GKS. Among those whose symptoms recurred, 14 patients underwent additional GKS, six MVD, four glycerol injection, and one patient a percutaneous radiofrequency rhizotomy. Twelve patients (9%) suffered the onset of new facial numbness post-GKS. Changes. on MR images post-GKS were noted in nine patients (7%). On univariate analysis, right-sided neuralgia (p = 0.0002) and a previous neurectomy (p = 0.04) correlated with a pain-free outcome; on multivariate analysis, both right-sided neuralgia (p = 0.032) and patient age (p = 0.05) were statistically significant. New onset of facial numbness following GKS correlated with undergoing more than one GKS (p = 0.002).Conclusions. At the last follow up, GKS effected pain relief in 44% of patients. Some degree of pain improvement at 3 years post-GKS was noted in 70% of patients with TN. Although less effective than MVD, GKS remains a reasonable treatment option for those unwilling or unable to undergo more invasive surgical approaches and offers a low risk of side effects.