Does the Gamma Knife dose rate affect outcomes in radiosurgery for trigeminal neuralgia?

Object The object of this study was to determine whether the radiation dose rate affects clinical outcomes in patients who undergo stereotactic Gamma Knife surgery (GKS) to manage typical trigeminal neuralgia (TN). Methods The authors retrospectively studied pain relief in 165 patients with medically intractable TN, who underwent 80-Gy GKS using a single 4-mm collimator between 1994 and 2005. No patient had received prior radiation treatment. The measured relative helmet output factor of the Gamma Knife was 0.8 throughout this interval, and the dose rate varied from 1.21 Gy/minute to 3.74 Gy/minute (median 2.06 Gy/minute). Irradiation time varied from 26.73 to 95.11 minutes. The authors divided patients into a low-dose-rate (LDR) group, in which the dose rate varied from 1.21 to 2.05 Gy/minute, and a high-dose-rate (HDR) group, in which the dose rate varied from 2.06 to 3.74 Gy/minute. Post-GKS, the patients' pain control was determined using the Barrow Neurological Institute (BNI) pain scale. There was no statistically significant difference between groups with respect to history of prior microvascular decompression (p = 0.410) or peripheral neuroablative procedures (p = 0.583). The length of symptoms in patients varied from 3 to 414 months with a median of 84 months (p = 0.698). Median follow-up was 26 months with a maximum of 139 months. Results Initial pain relief was obtained in 71% of patients in the LDR group and 78% in the HDR group (p = 0.547). Patients who initially obtained improved pain relief (BNI Scores I–IIIa) after GKS maintained pain control for median durations of 52 months (LDR group) and 54 months (HDR group) (p = 0.403). New or increased facial sensory dysfunction was found in 14.5% of patients in the LDR group and in 19.3% of patients in the HDR group (p = 0.479). Conclusions The authors found that the GKS dose rate did not affect pain control or morbidity within the range of 1.21–3.74 Gy/minute. Cobalt 60 source decay did not affect outcomes of GKS for TN pain management, even for dose rates approximating a 2-half-life decay of the isotope.

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Gamma knife surgery for idiopathic trigeminal neuralgia performed using a far-anterior cisternal target and a high dose of radiation

Journal of Neurosurgery ◽

10.3171/jns.2004.100.4.0597 ◽

2004 ◽

Vol 100 (4) ◽

pp. 597-605 ◽

Cited By ~ 88

Author(s):

Nicolas Massager ◽

José Lorenzoni ◽

Daniel Devriendt ◽

Françoise Desmedt ◽

Jacques Brotchi ◽

...

Keyword(s):

Prognostic Factors ◽

Pain Relief ◽

Radiation Dose ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Pain Control ◽

High Dose ◽

Content Type ◽

Idiopathic Trigeminal Neuralgia ◽

Fine Print

Object. Gamma knife surgery (GKS) has emerged as a suitable treatment of pharmacologically resistant idiopathic trigeminal neuralgia. The optimal radiation dose and target for this therapy, however, remain to be defined. The authors analyzed the results of GKS in which a high dose of radiation and a distal target was used, to determine the best parameters for this treatment. Methods. The authors evaluated results in 47 patients who were treated with this approach. All patients underwent clinical and magnetic resonance imaging examinations at 6 weeks, 6 months, and 1 year post-GKS. Fifteen potential prognostic factors associated with favorable pain control were studied. The mean follow-up period was 16 months (range 6–42 months). The initial pain relief was excellent (100% pain control) in 32 patients, good (90–99% pain control) in seven patients, fair (50–89% pain control) in three patients, and poor (< 50% pain control) in five patients. The actuarial curve of pain relief displayed a 59% rate of excellent pain control and a 71% excellent or good pain control at 42 months after radiosurgery. Radiosurgery-induced facial numbness was bothersome for two patients and mild for 18 patients. Three prognostic factors were found to be statistically significant factors for successful pain relief: a shorter distance between the target and the brainstem, a higher radiation dose delivered to the brainstem, and the development of a facial sensory disturbance after radiosurgery. Conclusions. To optimize pain control and minimize complications of this therapy, we recommend that the nerve be targeted at a distance of 5 to 8 mm from the brainstem.

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Gamma Knife surgery for recurrent or residual trigeminal neuralgia after a failed initial procedure

Journal of Neurosurgery ◽

10.3171/2010.8.gks10915 ◽

2010 ◽

Vol 113 (Special_Supplement) ◽

pp. 172-177 ◽

Cited By ~ 21

Author(s):

Chuan-Fu Huang ◽

Shyh-Ying Chiou ◽

Ming-Fang Wu ◽

Hsien-Tang Tu ◽

Wen-Shan Liu

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Pain Control ◽

Initial Treatment ◽

Gamma Knife Surgery ◽

Significant Difference ◽

Facial Numbness ◽

Initial Procedure

Object The purpose of this study was to assess outcomes of Gamma Knife surgery (GKS) as a second treatment for recurrent or residual trigeminal neuralgia (TN) after failure of 3 initial procedures: microvascular decompression (MVD), GKS, and percutaneous radiofrequency rhizotomy (PRR). Methods Between 1999 and 2008, 65 patients (31 men [48%] and 34 women [52%]) with recurrent TN were treated with GKS. All 65 patients had undergone previous medical procedures that failed to achieve sufficient pain relief: 27 patients (42%) had undergone MVD, 8 (12%) had undergone PRR, and 30 (46%) had undergone GKS as the initial treatment. The entry zone of the trigeminal nerve was targeted using a 4-mm collimator and treated with 35–90 Gy. The isocenter was positioned so that the brainstem surface was usually irradiated at an isodose no greater than 20% (59 patients) to 30% (6 patients). The median duration of TN symptoms in these patients was 39 months (range 1–192 months). Results At the clinical evaluation, 42 patients (65%) with idiopathic TN reported successful pain control at a median follow-up point of 64 months (range 18–132 months). Of these patients, 33 (51%) were no longer using medication. At the 1-, 2-, and 3-year follow-up examinations, 74%, 71%, and 66% of patients experienced successful pain control, respectively. There was no significant difference in pain relief in the initial MVD group compared with the initial GKS and initial PRR groups (74% vs 59% and 50%, respectively; p = 0.342). Recurrence of pain was noted in 23 patients. Twelve of these 23 patients underwent another GKS, resulting in pain control in 8 patients (67%); 8 other patients underwent MVD, resulting in pain relief in 7 patients (87.5%). The median time from GKS to pain recurrence was 7 months (range 3–48 months). There was no significant difference in new facial numbness among the 3 groups (p = 0.24); however, in the initial GKS group, facial numbness was significantly associated with freedom from pain (p = 0.0012). There was a significant correlation between the total radiation dose and facial numbness. The cutoff value for facial numbness ranged from 115 to 120 Gy (p = 0.037). Conclusions Gamma Knife surgery as a second treatment achieved acceptable levels of pain control in 65% of patients with residual or recurrent TN after long-term follow-up. Initial treatment was not a factor that affected pain control, but salvage surgery may be considered separately for each group.

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Does dose rate affect efficacy? The outcomes of 256 Gamma Knife surgery procedures for trigeminal neuralgia and other types of facial pain as they relate to the half-life of cobalt

Journal of Neurosurgery ◽

10.3171/jns.2006.105.5.730 ◽

2006 ◽

Vol 105 (5) ◽

pp. 730-735 ◽

Cited By ~ 24

Author(s):

Christopher J. Balamucki ◽

Volker W. Stieber ◽

Thomas L. Ellis ◽

Stephen B. Tatter ◽

Allan F. DeGuzman ◽

...

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Dose Rate ◽

Gamma Knife ◽

Half Life ◽

Pain Control ◽

Facial Pain ◽

Treatment Time ◽

Gamma Knife Surgery ◽

Chi Square

Object Gamma Knife surgery (GKS) is a treatment option for patients with refractory typical trigeminal neuralgia (TN), TN with atypical features, and atypical types of facial pain. The Gamma Knife’s 201 60Co sources decay with a half-life of 5.26 years. The authors examined whether the decrease in dose rate over 4.6 years between Co source replacements affected the control rates of facial pain in patients undergoing GKS. Methods The authors collected complete follow-up data on 239 of 326 GKS procedures performed in patients with facial pain. Patients were classified by their type of pain. The isocenter of a 4-mm collimator helmet was targeted at the proximal trigeminal nerve root, and the dose (80–90 Gy) was prescribed at the 100% isodose line. Patients reported the amount of pain control following radiosurgery by answering a standardized questionnaire. Eighty percent of patients experienced greater than 50% pain relief, and 56% of patients experienced complete pain relief after GKS. Neither dose rate nor treatment time was significantly associated with either the control rate or degree of pain relief. A significant association between the type of facial pain and the pain control rate after GKS was observed (p < 0.001; Pearson chi-square test). In their statistical analysis, the authors accounted for changes in prescription dose over time to prevent the dose rate from being a confounding variable. There was no observable effect of the dose rate or of the treatment duration within the typical period to source replacement. Conclusions Patients with facial pain appear to receive consistent treatment with GKS at any time during the first half-life of the Co sources.

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Outcome Predictors After Gamma Knife Radiosurgery for Recurrent Trigeminal Neuralgia

Neurosurgery ◽

10.1227/neu.0b013e3181fa098a ◽

2010 ◽

Vol 67 (6) ◽

pp. 1637-1645 ◽

Cited By ~ 33

Author(s):

Hideyuki Kano ◽

Douglas Kondziolka ◽

Huai-Che Yang ◽

Oscar Zorro ◽

Javier Lobato-Polo ◽

...

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Pain Control ◽

Surgical Procedure ◽

Gamma Knife Radiosurgery ◽

Sensory Loss ◽

Failed Surgery ◽

Gamma Knife Stereotactic Radiosurgery

Abstract BACKGROUND: Trigeminal neuralgia (TN) that recurs after surgery can be difficult to manage. OBJECTIVE: To define management outcomes in patients who underwent gamma knife stereotactic radiosurgery (GKSR) after failing 1 or more previous surgical procedures. METHODS: We retrospectively reviewed outcomes after GKSR in 193 patients with TN after failed surgery. The median patient age was 70 years (range, 26-93 years). Seventy-five patients had a single operation (microvascular decompression, n = 40; glycerol rhizotomy, n = 24; radiofrequency rhizotomy, n = 11). One hundred eighteen patients underwent multiple operations before GKSR. Patients were evaluated up to 14 years after GKSR. RESULTS: After GKSR, 85% of patients achieved pain relief or improvement (Barrow Neurological Institute grade I-IIIb). Pain recurrence was observed in 73 of 168 patients 6 to 144 months after GKSR (median, 6 years). Factors associated with better long-term pain relief included no relief from the surgical procedure preceding GKSR, pain in a single branch, typical TN, and a single previous failed surgical procedure. Eighteen patients (9.3%) developed new or increased trigeminal sensory dysfunction, and 1 developed deafferentation pain. Patients who developed sensory loss after GKSR had better long-term pain control (Barrow Neurological Institute grade I-IIIb: 86% at 5 years). CONCLUSION: GKSR proved to be safe and moderately effective in the management of TN that recurs after surgery. Development of sensory loss may predict better long-term pain control. The best candidates for GKSR were patients with recurrence after a single failed previous operation and those with typical TN in a single trigeminal nerve distribution.

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Assessment of pain control, quality of life, and predictors of success after gamma knife surgery for the treatment of trigeminal neuralgia

Neurosurgical FOCUS ◽

10.3171/foc.2005.18.5.9 ◽

2005 ◽

Vol 18 (5) ◽

pp. 1-7 ◽

Cited By ~ 29

Author(s):

Ajay Jawahar ◽

Rishi Wadhwa ◽

Caglar Berk ◽

Gloria Caldito ◽

Allyson Delaune ◽

...

Keyword(s):

Quality Of Life ◽

Patient Satisfaction ◽

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Pain Control ◽

Gamma Knife Surgery ◽

Patient Satisfaction Score

Object There are various surgical treatment alternatives for trigeminal neuralgia (TN), but there is no single scale that can be used uniformly to assess and compare one type of intervention with the others. In this study the objectives were to determine factors associated with pain control, pain-free survival, residual pain, and recurrence after gamma knife surgery (GKS) treatment for TN, and to correlate the patients' self-reported quality of life (QOL) and satisfaction with the aforementioned factors. Methods Between the years 2000 and 2004, the authors treated 81 patients with medically refractory TN by using GKS. Fifty-two patients responded to a questionnaire regarding pain control, activities of daily living, QOL, and patient satisfaction. The median follow-up duration was 16.5 months. Twenty-two patients (42.3%) had complete pain relief, 14 (26.9%) had partial but satisfactory pain relief, and in 16 patients (30.8%) the treatment failed. Seven patients (13.5%) reported a recurrence during the follow-up period, and 25 (48.1%) reported a significant (> 50%) decrease in their pain within the 1st month posttreatment. The mean decrease in the total dose of pain medication was 75%. Patients' self-reported QOL scores improved 90% and the overall patient satisfaction score was 80%. Conclusions The authors found that GKS is a minimally invasive and effective procedure that yields a favorable outcome for patients with recurrent or refractory TN. It may also be offered as a first-line surgical modality for any patients with TN who are unsuited or unwilling to undergo microvascular decompression.

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Outcomes of Gamma Knife surgery for trigeminal neuralgia secondary to vertebrobasilar ectasia

Journal of Neurosurgery ◽

10.3171/2011.8.jns11920 ◽

2012 ◽

Vol 116 (1) ◽

pp. 73-81 ◽

Cited By ~ 13

Author(s):

Kyung-Jae Park ◽

Douglas Kondziolka ◽

Hideyuki Kano ◽

Oren Berkowitz ◽

Safee Faraz Ahmed ◽

...

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Trigeminal Nerve ◽

Pain Control ◽

Invasive Procedure ◽

Gamma Knife Surgery ◽

Vascular Compression ◽

Recurrent Pain

Object Vertebrobasilar ectasia (VBE) is an unusual cause of trigeminal neuralgia (TN). The surgical options for patients with medically refractory pain include percutaneous or microsurgical rhizotomy and microvascular decompression (MVD). All such procedures can be technically challenging. This report evaluates the response to a minimally invasive procedure, Gamma Knife surgery (GKS), in patients with TN associated with severe vascular compression caused by VBE. Methods Twenty patients underwent GKS for medically refractory TN associated with VBE. The median patient age was 74 years (range 48–95 years). Prior surgical procedures had failed in 11 patients (55%). In 9 patients (45%), GKS was the first procedure they had undergone. The median target dose for GKS was 80 Gy (range 75–85 Gy). The median follow-up was 29 months (range 8–123 months) after GKS. The treatment outcomes were compared with 80 case-matched controls who underwent GKS for TN not associated with VBE. Results Intraoperative MR imaging or CT scanning revealed VBE that deformed the brainstem in 50% of patients. The trigeminal nerve was displaced in cephalad or lateral planes in 60%. In 4 patients (20%), the authors could identify only the distal cisternal component of the trigeminal nerve as it entered into the Meckel cave. After GKS, 15 patients (75%) achieved initial pain relief that was adequate or better, with or without medication (Barrow Neurological Institute [BNI] pain scale, Grades I–IIIb). The median time until pain relief was 5 weeks (range 1 day–6 months). Twelve patients (60%) with initial pain relief reported recurrent pain between 3 and 43 months after GKS (median 12 months). Pain relief was maintained in 53% at 1 year, 38% at 2 years, and 10% at 5 years. Some degree of facial sensory dysfunction occurred in 10% of patients. Eventually, 14 (70%) of the 20 patients underwent an additional surgical procedure including repeat GKS, percutaneous procedure, or MVD at a median of 14 months (range 5–50 months) after the initial GKS. At the last follow-up, 15 patients (75%) had satisfactory pain control (BNI Grades I–IIIb), but 5 patients (25%) continued to have unsatisfactory pain control (BNI Grade IV or V). Compared with patients without VBE, patients with VBE were much less likely to have initial (p = 0.025) or lasting (p = 0.006) pain relief. Conclusions Pain control rates of GKS in patients with TN associated with VBE were inferior to those of patients without VBE. Multimodality surgical or medical management strategies were required in most patients with VBE.

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Comparative study of Gamma Knife surgery and percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia in patients with multiple sclerosis

Journal of Neurosurgery ◽

10.3171/2012.6.gks12987 ◽

2012 ◽

Vol 117 (Special_Suppl) ◽

pp. 175-180 ◽

Cited By ~ 18

Author(s):

David Mathieu ◽

Khaled Effendi ◽

Jocelyn Blanchard ◽

Mario Séguin

Keyword(s):

Multiple Sclerosis ◽

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Pain Control ◽

Pain Scale ◽

Gamma Knife Surgery ◽

Sensory Loss ◽

Morbidity Rate

Object Among patients with multiple sclerosis (MS) there is a high incidence of trigeminal neuralgia (TN), and outcomes after treatment seem inferior to those in patients suffering from idiopathic TN. The goal of this study was to evaluate clinical outcomes in patients with MS-related TN after Gamma Knife surgery (GKS) and compare them with those obtained using percutaneous retrogasserian glycerol rhizotomy (PRGR). Methods The authors retrospectively reviewed the charts of 45 patients with MS-related TN. The first procedure undertaken was GKS in 27 patients and PRGR in 18 patients. Pain had been present for a median of 60 months (range 12–276 months) in patients who underwent GKS and 48 months (range 12–240 months) in patients who underwent PRGR. The following outcome measures were assessed in both groups of patients: pain relief (using the Barrow Neurological Institute [BNI] Pain Scale), procedure-related morbidity, time to pain relief and recurrence, and subsequent procedures that were performed. Results The median duration of follow-up was 39 months (range 13–69 months) in the GKS group and 38 months (range 2–75 months) in the PRGR group. Reasonable pain control (BNI Pain Scale Scores I–IIIb) was noted in 22 patients (81.5%) who underwent GKS and in 18 patients (100%) who underwent PRGR. For patients who underwent GKS, the median time to pain relief was 6 months; for those who underwent PRGR, pain relief was immediate. In the GKS group12 patients required subsequent procedures (3 patients for absence of response and 9 patients for pain recurrence), whereas in the PRGR group 6 patients required subsequent procedures (all for pain recurrence). As of the last follow-up, complete or reasonable pain control was finally achieved in 23 patients (85.2%) in the GKS group and in 16 patients (88.9%) in the PRGR group. The morbidity rate was 22.2% in the GKS group (all due to sensory loss and paresthesia) and 66.7% in the PRGR group (mostly hypalgesia, with 2 patients having corneal reflex loss and 1 patient suffering from meningitis). Conclusions Both GKS and PRGR are satisfactory strategies for treating MS-related TN. Gamma Knife surgery has a lower rate of sensory and overall morbidity than PRGR, but requires a delay before pain relief occurs. The authors propose that patients with extreme pain in need of fast relief should undergo PRGR. For other patients, both management strategies can lead to satisfactory pain relief, and the choice should be made based on patient preference and expectations.

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Clinical Outcomes of Gamma Knife Radiosurgery in the Treatment of Patients with Trigeminal Neuralgia

International Journal of Otolaryngology ◽

10.1155/2012/919186 ◽

2012 ◽

Vol 2012 ◽

pp. 1-13 ◽

Cited By ~ 8

Author(s):

Ameer L. Elaimy ◽

Peter W. Hanson ◽

Wayne T. Lamoreaux ◽

Alexander R. Mackay ◽

John J. Demakas ◽

...

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Pain Control ◽

Facial Pain ◽

Gamma Knife Radiosurgery ◽

Management Approach ◽

Review Of The Literature ◽

Facial Numbness ◽

Sensory Changes

Since its introduction by Leksell, Gamma Knife radiosurgery (GKRS) has become increasingly popular as a management approach for patients diagnosed with trigeminal neuralgia (TN). For this reason, we performed a modern review of the literature analyzing the efficacy of GKRS in the treatment of patients who suffer from TN. For patients with medically refractory forms of the condition, GKRS has proven to be an effective initial and repeat treatment option. Cumulative research suggests that patients treated a single time with GKRS exhibit similar levels of facial pain control when compared to patients treated multiple times with GKRS. However, patients treated on multiple occasions with GKRS are more likely to experience facial numbness and other facial sensory changes when compared to patients treated once with GKRS. Although numerous articles have reported MVD to be superior to GKRS in achieving facial pain relief, the findings of these comparison studies are weakened by the vast differences in patient age and comorbidities between the two studied groups and cannot be considered conclusive. Questions remain regarding optimal GKRS dosing and targeting strategies, which warrants further investigation into this controversial matter.

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Gamma Knife radiosurgery for bilateral trigeminal neuralgia

Journal of Neurosurgery ◽

10.3171/2018.6.jns172646 ◽

2019 ◽

Vol 131 (5) ◽

pp. 1591-1598

Author(s):

Corbin A. Helis ◽

Emory McTyre ◽

Michael T. Munley ◽

J. Daniel Bourland ◽

John T. Lucas ◽

...

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Treatment Outcomes ◽

Gamma Knife ◽

Median Duration ◽

Gamma Knife Radiosurgery ◽

Persistent Symptoms ◽

Significant Difference ◽

Facial Numbness

OBJECTIVEA small subset of patients with trigeminal neuralgia (TN) will experience bilateral symptoms. Treatment in these patients is controversial because the population is heterogeneous and patients may have nonvascular etiologies of their pain. This study reports treatment outcomes in the largest cohort of patients with bilateral TN who have undergone Gamma Knife radiosurgery (GKRS) to date.METHODSA retrospective chart review identified 51 individual nerves in 34 patients with bilateral TN who were treated with GKRS at the authors’ institution between 2001 and 2015, with 12 nerves in 11 patients undergoing repeat GKRS for recurrent or persistent symptoms. Long-term follow-up was obtained by telephone interview. Pain outcomes were measured using the Barrow Neurological Institute (BNI) pain scale, with BNI IIIb or better considered a successful treatment.RESULTSThere was sufficient follow-up to determine treatment outcomes for 48 individual nerves in 33 patients. Of these nerves, 42 (88%) achieved at least BNI IIIb pain relief. The median duration of pain relief was 1.9 years, and 1-, 3-, and 5-year pain relief rates were 64%, 44%, and 44%, respectively. No patients experienced bothersome facial numbness, and 1 case of anesthesia dolorosa and 2 cases of corneal dryness were reported. Patients with a history of definite or possible multiple sclerosis were significantly more likely to experience BNI IV–V relapse. There was no statistically significant difference in treatment outcomes between patients in this series versus a large cohort of patients with unilateral TN treated at the authors’ institution. There was sufficient follow-up to determine treatment outcomes for 11 individual nerves in 10 patients treated with repeat GKRS. Ten nerves (91%) improved to at least BNI IIIb after treatment. The median duration of pain relief was 2.8 years, with 1-, 3-, and 5-year rates of pain relief of 79%, 53%, and 53%, respectively. There was no statistically significant difference in outcomes between initial and repeat GKRS. One case of bothersome facial numbness and 1 case of corneal dryness were reported, with no patients developing anesthesia dolorosa with retreatment.CONCLUSIONSGKRS is a safe, well-tolerated treatment for patients with medically refractory bilateral TN. Efficacy of treatment appears similar to that in patients with unilateral TN. GKRS can be safely repeated in this population if necessary.

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Feasibility of Multiple Repeat Gamma Knife Radiosurgeries for Trigeminal Neuralgia: A Case Report and Review of the Literature

Case Reports in Medicine ◽

10.1155/2011/258910 ◽

2011 ◽

Vol 2011 ◽

pp. 1-4 ◽

Cited By ~ 3

Author(s):

Guy C. Jones ◽

Ameer L. Elaimy ◽

John J. Demakas ◽

Hansi Jiang ◽

Wayne T. Lamoreaux ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Gamma Knife ◽

Pain Control ◽

Radiation Treatment ◽

Treatment Options ◽

Gamma Knife Radiosurgery ◽

Treatment Modalities ◽

Small Subset ◽

The Individual ◽

Surgical Treatments

Treatment options for trigeminal neuralgia (TN) must be customized for the individual patient, and physicians must be aware of the medical, surgical, and radiation treatment modalities to prescribe optimal treatment courses for specific patients. The following case illustrates the potential for gamma knife radiosurgery (GKRS) to be repeated multiple times for the purpose of achieving facial pain control in cases of TN that have been refractory to other medical and surgical options, as well as prior GKRS. The patient described failed to achieve pain control with initial GKRS, as well as medical and surgical treatments, but experienced significant pain relief for a period of time with a second GKRS procedure and later underwent a third procedure. Only a small subset of patients have reportedly undergone more than two GKRS for TN; thus, further research and long-term clinical followup will be valuable in determining its usefulness in specific clinical situations.

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