• IRSA. Stereotactic radiosurgery for patients with intractable typical trigeminal neuralgia who have failed medical management. Harrisburg (PA): IRSA; 2009 Jan. 11 p. (Radiosurgery practice guideline report; no. 1-03). [68 references]

This is the current release of the guideline.

This guideline updates a previous version: IRSA. Stereotactic radiosurgery for patients with intractable typical trigeminal neuralgia who have failed medical management. Harrisburg (PA): IRSA; 2003 Sep. 10 p. (Radiosurgery practice guideline report; no. 1-03). [43 references]

• Brain Stereotactic Radiosurgery (SRS) involves the use of precisely directed, closed skull, single fraction (one session) of radiation to create a desired radiobiologic response within the brain with minimal effects to surrounding structures or tissues. In the case of trigeminal neuralgia a relatively high dose of focused radiation is delivered precisely to the trigeminal nerve under the direct supervision of a radiosurgery team. In Centers of Excellence, the radiosurgery team is composed of a neurosurgeon, radiation oncologist, physicist and registered nurse.
• Patients with typical trigeminal neuralgia who have had an adequate trial of medications can be offered stereotactic radiosurgery. Radiosurgery is typically used in patients with medical co-morbidities or pain refractory to prior surgical procedures, patients at risk for side effects from percutaneous ablative procedures, and those in more advanced age groups.
• The optimal dose range for trigeminal neuralgia has been established. A commonly used dose range of 75 to 90 Gy in a single fraction to the trigeminal nerve is suggested, using a 4-mm collimator radiation field. Most centers prefer 80 Gy as a central dose targeted to the trigeminal nerve a few millimeters proximal to its entry into the brain stem; however, 90 Gy as a central dose to the trigeminal nerve near the trigeminal ganglion has also been used routinely in some centers.
• Patients who have failed other surgical procedures for trigeminal neuralgia should also receive 75 to 90 Gy to the trigeminal nerve. A safe interval between the initial surgery and stereotactic radiosurgery is unknown, but it is reasonable to perform radiosurgery if there is no improvement or pain recurs following the initial surgical procedures.
• After radiosurgery, patients are followed to assess pain relief at three months and six months, then at yearly intervals. Their pre-radiosurgery pain medications are continued at the same doses until pain relief is obtained. Medications can be gradually tapered off if the patient remains pain free.
• Patients who have recurrence of pain following trigeminal neuralgia radiosurgery or who had a partial initial response can undergo a second stereotactic radiosurgery using 50 to 70 Gy to the trigeminal nerve (depending on the elapsed time between treatments). A generally safe interval between first and second radiosurgeries is six months.
• At present, technology to deliver focal small-volume fields is limited to Gamma Knife^® by the strength of published data. Current data suggest that CyberKnife^® stereotactic radiosurgery for trigeminal neuralgia has an increased risk of sensory dysfunction and other neurological complications (see Table 1 in the original guideline document).

The original guideline contains a clinical algorithm for "Trigeminal Neuralgia Management."

Type II and III evidence exists in support of stereotactic radiosurgery for intractable trigeminal neuralgia. Refer to the "Rating Scheme for the Strength of the Evidence" field.

• IRSA. Stereotactic radiosurgery for patients with intractable typical trigeminal neuralgia who have failed medical management. Harrisburg (PA): IRSA; 2009 Jan. 11 p. (Radiosurgery practice guideline report; no. 1-03). [68 references]

Not applicable: The guideline was not adapted from another source.

2003 Sep (revised 2009 Jan)

IRSA - Professional Association

IRSA (International RadioSurgery Association)

The IRSA Medical Advisory Board Guidelines Committee and representatives in the industry.

The radiosurgery guidelines group is comprised of neurosurgeons and radiation oncologists. Community representatives did not participate in the development of this guideline.

Committee members: L. Dade Lunsford, M.D., Neurosurgeon, Chair; Ajay Niranjan, M.B.B.S., M.Ch., Neurosurgeon; Ron Young, M.D., Neurosurgeon; Ronald Brisman, M.D., Neurosurgeon; David Cunningham, M.D., Neurosurgeon; Christer Lindquist, M.D., Neurosurgeon; David Newell, M.D., Neurosurgeon; John C. Flickinger, M.D., Radiation Oncologist; Tonya K. Ledbetter, M.S., M.F.S, Editor; Rebecca L. Emerick, M.S., M.B.A., C.P.A., ex officio

The International RadioSurgery Association (IRSA) makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of a personal, professional, or business interest of a member of the radiosurgery guidelines group.

This is the current release of the guideline.

This guideline updates a previous version: IRSA. Stereotactic radiosurgery for patients with intractable typical trigeminal neuralgia who have failed medical management. Harrisburg (PA): IRSA; 2003 Sep. 10 p. (Radiosurgery practice guideline report; no. 1-03). [43 references]

None available

This NGC summary was completed by ECRI on March 8, 2004. The information was verified by the guideline developer on April 7, 2004. This NGC summary was updated by ECRI Institute on August 11, 2009. The updated information was verified by the guideline developer on August 31, 2009.

This guideline is copyrighted by IRSA and may not be reproduced without the written permission of IRSA. IRSA reserves the right to revoke copyright authorization at any time without reason.