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Trigeminal Neuralgia

Why Gamma Knife treatment

The Gamma Knife produces over 200 precise beams of low-dose radiation that all focus and intersect directly on the tumor, killing the tumor, yet keeping normal healthy brain tissue safe.

The head is fixed in a frame that keeps the brain stable and secure, setting up a GPS-like coordinate system that allows the doctors to target the tumor with sub-millimeter precision. The surgeon numbs up the areas where the frame is placed (much like a dentist numbs the gums) so there is little discomfort. Other treatments that do not use a head frame simply are not as accurate, and therefore more normal brain tissue is at risk.

Also, unlike other forms of treatment, it will only take us one day to treat these tumors and get patients back to their medical oncologist.

For this reason, we recommend that lung cancer patients have an MRI of their brain immediately upon diagnosis, before beginning chemotherapy. It is possible to have metastatic brain tumors without having symptoms. Gamma Knife of Spokane can treat these brain tumors and systemic treatment of the lung cancer can start as soon as the next day. However, once chemotherapy has begun, Gamma Knife treatment must wait.

Why Gamma Knife of Spokane

You are in good hands at Gamma Knife of Spokane. As one of the top 10 Gamma Knife treatment centers in the country for the number of patients treated, no one in the region has more experience in treating brain tumors. No one. Over 60% of the patients we have treated at Gamma Knife of Spokane have come to us with brain metastases.

With Gamma Knife of Spokane, patients have access to a $5 million, 45,000 pound cancer-killing machine that can, in a few hours, deliver a dose of radiation that can stop the growth of most tumors or even eliminate tumors altogether.

In addition to our experience of over a decade treating patients, we have one of the most prolific clinical research departments in the country (7th of 130 centers). We are frequently asked to write book chapters for oncology textbooks. The national medical community considers us experts in the field of brain tumor research and treatment.

Clinical Outcomes of Gamma Knife Treatment

Trigeminal Neuralgia / Pain Management
If your pain is not under control with your current treatment for facial pain, Gamma Knife of Spokane may be able to help you. If your pain has been diagnosed as Trigeminal Neuralgia, contact our office and we'll set you up for evaluation by one of our neurosurgeons (refer a patient). If you suffer from pain associated with bone cancer, we may also be able to help you. Please contact our office and Jill, the nurse coordinator, will set you up for an evaluation.

Most of our trigeminal neuralgia patients have been on medication to control their facial pain, which feels like an electrical shock. The source of the pain is not in the face at all but frequently comes from an irritation to the fifth cranial nerve, which conducts facial sensation. While surgical intervention has been very effective for these patients, Gamma Knife offers an alternative that creates a lesion on the nerve itself that blocks the transmission of this pain.

Definition

Trigeminal neuralgia, also called tic douloureux, is a condition that affects the trigeminal nerve (the 5th cranial nerve), one of the largest nerves in the head. The trigeminal nerve is responsible for sending impulses of touch, pain, pressure, and temperature to the brain from the face, jaw, gums, forehead, and around the eyes. Trigeminal neuralgia is characterized by a sudden, severe, electric shock-like or stabbing pain typically felt on one side of the jaw or cheek. The disorder is more common in women than in men and rarely affects anyone younger than 50. The attacks of pain, which generally last several seconds and may be repeated one after the other, may be triggered by talking, brushing teeth, touching the face, chewing, or swallowing. The attacks may come and go throughout the day and last for days, weeks, or months at a time, and then disappear for months or years.

Treatment

This procedure requires no incision. Using highly focused beams of radiation, a lesion (an area of controlled damage) is created in the root of the trigeminal nerve. The nerve isn't burned as in a laser treatment, but the radiation causes the slow formation of a lesion in the nerve over period of time to interrupt the pain transmission.

All these procedures show varying degrees of immediate success and periods of long-term relief from pain. Generally, the average overall rate of success is 85% with about 25% of this group having some level of recurrence in 1-5 years. Many patients respond quite well when additional measures are pursued if the initial procedure is not successful or if the pain returns. There is no one procedure that is 100% effective in all cases.

CLINICAL RESEARCH

Gamma Knife Solution

Stereotactic radiosurgery for the treatment of trigeminal neuralgia.


Kondziolka D, Lunsford LD, Flickinger JC.


Clin J Pain 2002 Jan-Feb;18(1):42-7


Department of Neurological Surgery, University of Pittsburgh, and the Center for Image-Guided Neurosurgery, Pittsburgh, Pennsylvania, USA. kondziol@neuronet.pitt.edu


Stereotactic radiosurgery is an increasingly used and the least invasive surgical option for patients with medically refractory trigeminal neuralgia (TN). The authors began use of this technique at our center in 1992 and have evaluated outcomes serially. Independently acquired data from 220 patients with idiopathic TN that had Gamma Knife radiosurgery was reviewed. The median radiosurgery dose was 80 Gy with a range of 60 to 90 Gy. Most patients had features of typical TN, although 16 (7.3%) described additional atypical features. One hundred thirty-five patients (61.4%) had prior surgery.

Patients were followed to a maximum of 6.5 years (median, 2 years). Complete or partial pain relief was achieved in 85.6% of patients at 1 year.

Complete pain relief was achieved in 64.9 % of patients at 6 months, 70.3% at 1 year, and 75.4% patients at 33 months. Patients with an atypical pain component had a lower rate of achieving pain relief ( p = 0.025). Due to recurrences, 55.8% of patients had complete or partial pain relief at 5 years. The absence of preoperative sensory disturbance or prior surgery correlated with an increased proportion of patients in complete or partial pain relief over time. Ten percent of patients developed new or increased subjective facial paresthesia or facial numbness.

Radiosurgery for idiopathic TN was safe and effective, and provided benefit to a patient population with a high frequency of prior surgical intervention. It is an important addition to the surgical armamentarium for TN.

Gamma Knife radiosurgery for treatment of trigeminal neuralgia: idiopathic and tumor related.

Young RF, Vermeulen SS, Grimm P, Blasko J, Posewitz A.


Neurology 1997 Mar;48(3):608-14


Northwest Neurosciences Institute and Gamma Knife Center Northwest Hospital, Seattle, WA 98133, USA.


Sixty patients with trigeminal neuralgia who did not have a response to pharmacologic treatment (including 22 who had no response to conventional surgical treatment) underwent stereotactic radiosurgical treatment with the Leksell Gamma Knife.

METHOD: A radiosurgical maximum dose of 70 Gy was delivered to the trigeminal nerve root adjacent to the pons via a 4-mm collimator helmet in 51 patients who presented with trigeminal neuralgia unrelated to tumors. In these patients, the root was localized by stereotactic MRI. Follow-up assessment of pain relief was accomplished by a third party not involved in the patients' clinical care.

RESULTS: Within a latency period of 1 day to 4 months following the treatment, 38 of 51 patients (74.5%) were completely free of pain and eventually all medications were tapered off. An additional seven patients (13.7%) experienced reductions in pain from 50 to 90% and utilized little or no medications. Patients who had no prior surgical intervention fared much better than those who had previous surgery to relieve their facial pains. At last follow-up, a mean of 16.3 months (range 6-36 months) after treatment, 41 patients (80.4%) remained pain-free or had marked pain reduction. There were four patients with recurrent pain. All 26 patients with classical symptoms of trigeminal neuralgia with no atypical features who had no prior surgery, had complete or nearly complete pain relief, and none of these patients had recurrent pain. Nine patients with trigeminal neuralgia due to tumors received standard radiosurgical treatment directed at their tumors, and eight of nine (88.8%) had pain relief. Of the total of 60 patients treated for trigeminal neuralgia, 49 (81.7%) experienced complete or nearly complete relief of pain at last follow-up. Only one patient with pre-existing facial sensory loss due to a tumor had a mild increase in facial numbness. No other patient experienced either loss of facial sensation or any other complication.

CONCLUSION: Gamma Knife radiosurgery appears to be a minimally invasive, safe, and effective therapy of trigeminal neuralgia.

PMID: 9065534 [PubMed - indexed for MEDLINE]

Gamma knife radiosurgery for trigeminal neuralgia: the initial experience of The Barrow Neurological Institute.

Rogers CL, Shetter AG, Fiedler JA, Smith KA, Han PP, Speiser BL.


Int J Radiat Oncol Biol Phys 2000 Jul 1;47(4):1013-9 [Abstract]


St. Joseph's Hospital and Barrow Neurological Institute, Phoenix, AZ, USA. lelandroge@aol.com


PURPOSE: To assess the efficacy and complications of Gamma Knife radiosurgery for trigeminal neuralgia.

METHODS AND MATERIALS: 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.

RESULTS: 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 (</= 24 h). Prior to RS, all patients were on pharmacologic therapy felt to be optimal or maximal. Twenty-two (41%) were able to stop medications entirely (BNI score I or II). Another 16 (30%), with BNI Score III relief, decreased medication intake by at least 50%. Patients with classical TN pain symptoms were more likely to stop medications than those with atypical features, 49% (21 of 43) versus 9% (1 of 11). This difference was significant at p = 0.040. Statistically, the finding most predictive for pain relief was new facial numbness following RS. Each of the 5 patients with new numbness after RS developed BNI score I relief, contrasting with 35% for the 49 patients with no new numbness (p = 0.019). Complications have been limited to delayed, mild facial sensory loss. Before RS, 17 patients had numbness from prior invasive procedures, none of whom reported a worse numbness score after treatment. Thirty-seven patients had no facial numbness at the time of RS, of whom 5 developed facial hypesthesia. Each rated this as "mild, not bothersome." There have been no other sequellae.

CONCLUSION: RS is an effective treatment, and is the least invasive nonpharmacologic therapy for TN. It carries a small risk of mild facial hypesthesia, a side effect which, somewhat ironically, may be desirable, because it appears to correlate favorably with an excellent pain response. We currently include radiosurgery among the appropriate options for TN patients who have failed optimal medical management, with or without prior invasive neurosurgical procedures. We present here BNI scoring systems for pain intensity and facial numbness. These have proved simple and reliable, have facilitated data collection, rendered analysis more objective, and improved our ability to discuss results with patients and colleagues.

PMID: 10863073 [PubMed - indexed for MEDLINE]

Peer-reviewed Journals

Clinical outcomes of gamma knife radiosurgery in the treatment of patients with trigeminal neuralgia. Elaimy AL, Hanson PW, Lamoreaux WT, Mackay AR, Demakas JJ, Fairbanks RK, Cooke BS, Thumma SR, Lee CM. Int J Otolaryngol. 2012;2012:919186. doi: 10.1155/2012/919186. Epub 2011 Oct 25. View PDF
Feasibility of multiple repeat gamma knife radiosurgeries for trigeminal neuralgia: a case report and review of the literature. Jones GC, Elaimy AL, Demakas JJ, Jiang H, Lamoreaux WT, Fairbanks RK, Mackay AR, Cooke BS, Lee CM. Case Report Med. 2011;2011:258910. doi: 10.1155/2011/258910. Epub 2011 Sep 4. View PDF
Clinical outcomes of gamma knife radiosurgery in the treatment of patients with trigeminal neuralgia. Elaimy AL, Lamoreaux WT, Mackay AR, Demakas JJ, Fairbanks RK, Cooke BS, Thumma SR, Lee CM. Int J Otolaryngol. In press.
Feasibility of multiple repeat gamma knife radiosurgeries for trigeminal neuralgia: a case report and review of the literature. Jones GC, Elaimy AL, Demakas JJ, Jiang H, Lamoreaux WT, Fairbanks RK, Mackay AR, Cooke BS, Lee CM. Case Report Med. In press.
Atypical tongue pain from trigeminal neuralgia: gamma knife as a treatment strategy. Elaimy AL, Lamoreaux WT, Mackay AR, Fairbanks RK, Demakas JJ, Cooke BS, Hanson PW, Lee CM. Tongue: Anatomy, Kinematics and Diseases. Nova: New York. In press. More Information.

The content of this web site is for informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider. If you have a medical problem or a health-related question, consult your physician or call our center at 509.473.3800 for an appointment with one of our neurosurgeons.

Gamma Knife: The best solution

Caring with precision

Treating brain tumors and other conditions in the brain requires absolute precision, because every bit of healthy tissue helps make you who you are. And nothing provides more precision than Gamma Knife stereotactic radiosurgery, especially in the hands of a caring, superbly skilled and experienced team of neurosurgeons and radiation oncologists.

In fact, Gamma Knife of Spokane ranks in the top 10 Gamma Knife Centers in the U.S. for published clinical research and patient volumes.

It's YOUR brain. Call us at 1.800.927.5051 and we can help you determine whether Gamma Knife treatment is a helpful option for you.

Let us help you get on with living.

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