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Saturday, June 20, 2009

A Question about Cyberknife for Trigeminal Neuralgia

"I did not know where to put this. I had a question about Cyber Knife. Has it been used at West Jefferson/LSU to treat TN successfully?I'm post Gamma Knife and am considering Cyber Knife as my next move."

Great question. Radiosurgery in general has gotten quite a bit of attention over the past several years as a treatment for Trigeminal Neuralgia (TGN), a severe disorder of facial pain.

Unfortunately, the information isn't always unbiased, and the companies that make and buy the radiosurgery units have often done a really good sell job.

That's not to say that radiosurgery isn't an important option, just that many people have chosen it out of a fear of surgery, with an unrealistic expectation from the radiosurgery.

To make things more complicated, people aren't even really clear on the term "trigeminal neuralgia" and they aren't always talking about the same thing.

Traditionally, neurosurgeons have limited the term "trigeminal neuralgia" or "classical trigeminal neuralgia" to a very specific disorder in which the pain is "lancinating" or stabbing. In classical trigeminal neuralgia, the rest of the time everything is completely normal. There is no constant pain. There is no numbness. This kind of pain usually responds fairly well to medications, particularly a seizure medicine called Tegretol. Many people, however, have side effects on the doses that they need to stop the pain. In these people, we offer surgery. There are two main kinds of surgery -- usually the cause is a small artery bumping up against the nerve, so we tend to offer "Microvascular Decompression" (MVD) where we make a small hole in the back of the skull and put a tiny foam pad alongside the nerve to protect it. This cures better than 8 out of 10 people, tends to last pretty well, and rarely causes any numbness in the face. Most of us really find this to be the best option in young healthy people.

In those who are older or not healthy enough to undergo anesthesia, the other primary options are different ways of passing a needle into the nerve under xray guidance to burn it or crush it. This leaves the face somewhat numb, but stops the pain in the high ninety percents.

Radiosurgery is more like the latter. The disadvantage over the needle procedures is that it can take up to 6 months to take effect. Since the effect typically lasts for less than 2 years, the difference is substantial. It can leave the face numb, and can lead to a condition called "anesthesia dolorosa" in which the face is numb and in pain at the same time, which is extremely difficult to treat. The biggest problem we've seen is that people get radiosurgical treatment for face pain that does not meet the criteria for classic TGN, but is now being called TGN type II. Unfortunately, the success rates in type II are very poor, essentially no benefit by 2 years.

Cyberknife and Gamma Knife each have their strong adherants who think one is better than the other, but there's essentially no data to back that up. The Cyberknife provides a comfort advantage, as you don't have to have your head pinned in a frame for the procedure.

For the type II pain, the most successful procedure appears to be none of the above, but something called motor cortex stimulation.

All in all, the answer depends on the specifics of your case. Your best bet is to talk to an expert in all the treatments for TGN, both radiosurgical and otherwise. Because of our affiliation with WJMC and the Cyberknife unit, most LSU neurosurgeons see their patients now at the Cullicchia Clinic in Marrero. We'd be happy to make an appointment and talk about your options in detail.

1 comment:

  1. I have a question about Aneurysms. When you go in and do a neurosurgery after an aneurysm, and you clip the vessel, what is the most difficult part of the procedure? Also how do you know the clipping was successful and how sure are you? Thanks!