A comparative study of gamma knife radiosurgery and percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia in multiple sclerosis patients.

Keywords: pain, gamma knife, trigeminal neuralgia, outcome, glycerol

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     Patients with multiple sclerosis (MS) present a high incidence of trigeminal neuralgia (TN), and the outcomes after treatment seem inferior than in patients suffering from idiopathic TN. 
     The goal of this study was to evaluate the clinical outcomes after gamma knife radiosurgery (GKRS) compared to percutaneous retrogasserian glycerol rhizotomy (PRGR).
     GKRS was the first procedure in 27 patients, and PRGR in 18. Pain had been present for a median of 60 months (12-276) and 48 (12- 240) for patients receiving both procedures, respectively.
     We retrospectively reviewed the charts of 45 patients with MS-related TN.  The following outcome measures were assessed: pain relief (using the BNI scale), procedural morbidity, time to pain relief and recurrence, and subsequent procedures performed.
     The median follow-up length was 39 months (13-69) in the GKRS group and 38 months (2-75) in the PRGR group. Reasonable pain control (BNI grades I to IIIb) was noted in 22 (81.4%) and 18 patients (100%) after GKRS and PRGR, respectively. The median time to pain relief was 204 days for GKRS, and immediate relief in all PRGR patients. In the GKRS group, 17 patients required subsequent procedures (3 for absence of response and 14 for pain recurrence) compared with 7 in the PRGR group (all for recurrence). At the last follow-up, complete or reasonable pain control was finally achieved in 23 (85.2%) patients in the GKRS group and 16 (88.9%) patients in the PRGR group. The morbidity rate was 22.2% in the GKRS group (all sensory loss and paresthesia) and 66.7% in the PRGR group (most being hypalgesia, with 2 patients having corneal reflex loss and one patient suffering from meningitis).
     This was a retrospective evaluation.
     GKRS and PRGR are both satisfactory strategy for multiple sclerosis related TN with similar long-term pain outcome. GKRS has lower sensory and overall morbidity than PRGR, but requires a delay before pain relief occurs. 
     We propose that patients with extreme pain who need fast relief undergo PRGR. For other patients, GKRS seems to be an appropriate first-line management modality.


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