Predictive nomogram for the durability of pain relief from gamma knife radiation surgery in the treatment of trigeminal neuralgia

Purpose: To determine factors associated with the durability of stereotactic radiation surgery (SRS) for treatment of trigeminal neuralgia (TN).

Methods and materials: Between 1999 and 2008, 446 of 777 patients with TN underwent SRS and had evaluable follow-up in our electronic medical records and phone interview records. The median follow-up was 21.2 months. The Barrow Neurologic Institute (BNI) pain scale was used to determine pre- and post-SRS pain. Dose-volume anatomical measurements, Burchiel pain subtype, pain quality, prior procedures, and medication usage were included in this retrospective cohort to identify factors impacting the time to BNI 4-5 pain relapse by using Cox proportional hazard regression. An internet-based nomogram was constructed based on predictive factors of durable relief pre- and posttreatment at 6-month intervals.

Results: Rates of freedom from BNI 4-5 failure at 1, 3, and 5 years were 84.5%, 70.4%, and 46.9%, respectively. Pain relief was BNI 1-3 at 1, 3, and 5 years in 86.1%, 74.3%, and 51.3% of type 1 patients; 79.3%, 46.2%, and 29.3% of type 2 patients; and 62.7%, 50.2%, and 25% of atypical facial pain patients. BNI type 1 pain score was achieved at 1, 3, and 5 years in 62.9%, 43.5%, and 22.0% of patients with type 1 pain and in 47.5%, 25.2%, and 9.2% of type 2 patients, respectively. Only 13% of patients with atypical facial pain achieved BNI 1 response; 42% of patients developed post-Gamma Knife radiation surgery (GKRS) trigeminal dysfunction. Multivariate analysis revealed that post-SRS numbness (hazard ratio [HR], 0.47; P<.0001), type 1 (vs type 2) TN (HR, 0.6; P=.02), and improved post-SRS BNI score at 6 months (HR, 0.009; P<.0001) were predictive of a durable pain response.

Conclusions: The durability of SRS for TN depends on the presenting Burchiel pain type, the post-SRS BNI score, and the presence of post-SRS facial numbness. The durability of pain relief can be estimated pre- and posttreatment by using our nomogram for situations when the potential of relapse may guide the decision for initial intervention.