Stereotactic radiosurgery for trigeminal neuralgia

Evidence-based recommendations on stereotactic radiosurgery for trigeminal neuralgia in adults. This involves focusing radiation on the trigeminal nerve to damage it, thereby relieving pain.

# Recommendations
Evidence on the safety and efficacy of stereotactic radiosurgery for trigeminal neuralgia is adequate to support using this procedure provided that standard arrangements are in place for clinical governance, consent and audit. Find out what standard arrangements mean on the NICE interventional procedures guidance page.
For auditing the outcomes of this procedure, the main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Patient selection should be done by a multidisciplinary team experienced in managing trigeminal neuralgia.
The procedure should only be done in specialist centres.# The condition, current treatments and procedure

# The condition
Trigeminal neuralgia is a chronic pain condition that affects the trigeminal (fifth) cranial nerve, one of the most widely distributed nerves in the head. The pain occurs in areas supplied by the trigeminal nerve: the cheeks, jaw, teeth, gums, lips and around the eye or forehead. The typical form, type 1, causes sudden and severe facial pain, usually affecting 1 side of the face and lasting for a few seconds or minutes. It may be triggered by touch, talking, eating or brushing teeth. Atypical trigeminal neuralgia (type 2) is characterised by constant aching, burning, or stabbing pain of lower intensity than type 1. Some people have both types.
Trigeminal neuralgia can be idiopathic or may be caused by pressure on the trigeminal nerve from an artery or a vein (primary trigeminal neuralgia). It can also result from a medical condition such as a tumour, multiple sclerosis or injury (secondary trigeminal neuralgia).

# Current treatments
Medication is the first-line treatment for trigeminal neuralgia. Other treatment options are considered for people who experience severe pain despite medication, or who have side effects from medication.
Percutaneous treatments include glycerol injection, radiofrequency lesioning (applying short bursts of radiofrequency to the nerve through a needle), and balloon microcompression (inflating a balloon near the nerve). The aim is to damage the trigeminal nerve and stop the transmission of pain signals. Recurrence rates of trigeminal neuralgia after these procedures are typically high.
Microvascular decompression is a more invasive procedure involving opening the skull to relieve the pressure on the trigeminal nerve. This can provide longer lasting relief but carries a risk of potentially serious complications such as facial numbness, hearing loss, stroke and death.

# The procedure
Stereotactic radiosurgery for trigeminal neuralgia uses precisely focused multiple beams of ionising radiation aimed at the trigeminal nerve where it enters the brainstem, to deliver a high dose in a single treatment session. It does not require open surgery, needle insertion or general anaesthesia. The aim is to damage the trigeminal nerve and stop the transmission of pain signals as with other percutaneous techniques.
There are different systems available for stereotactic radiosurgery and details of the techniques vary. Imaging is used to accurately locate the target area for treatment. A variety of approaches such as an external frame or a thermoplastic mask can be used to hold the head in a fixed position while the treatment is delivered.
It can take a few weeks or months for the patient to notice any change after stereotactic radiosurgery.