伽玛刀再治疗首次治疗无效或复发的药物难治性三叉神经痛疗效分析

Efficacy of a second gamma knife treatment for drug-refractory trigeminal neuralgia that has failed to respond to the initial treatment or relapsed

目的观察分析伽玛刀再次治疗首次治疗无效或复发的药物难治性三叉神经痛(TN)患者的有效性和安全性。方法2010年6月至2019年9月四川大学华西医院神经外科伽玛刀中心采用伽玛刀治疗823例原发性药物难治性TN患者,其中16例(1.9%)因治疗无效或复发再次行伽玛刀治疗,回顾性分析16例患者的临床资料。采用巴罗神经学研究所(BNI)疼痛评级标准评估疼痛缓解程度(Ⅰ~Ⅲb级为有效,Ⅳ~Ⅴ级为无效);随访与放射治疗相关的脑神经功能损伤情况,采用BNI面部麻木评分标准评估面部麻木程度。结果首次治疗后10例患者有效,6例无效;中位显效时间为30(1~180)d。首次治疗至复发的中位时间为28.4(6~60)个月。再次治疗后,13例有效,3例无效;中位显效时间为7(1~180)d。再次治疗后中位随访时间为30.5(16~92)个月,有效的13例患者中,2例在治疗后第35个月症状完全复发。末次随访治疗有效者11例(11/16),BNI疼痛缓解评级Ⅰ级者7例,Ⅱ级者2例,Ⅲa、Ⅲb级者各1例;5例无效或复发者,BNI评级均为Ⅴ级。首次治疗有效的10例患者中,再次治疗后9例有效;首次治疗无效的6例中,再次治疗后仅2例有效(P=0.035)。2次治疗共12例患者发生了放射相关损伤,其中同侧面部麻木11例,昧觉受损2例。治疗后至出现面部麻木的中位时间为2.5(1~18)个月,其中轻度7例,中度4例。再次治疗的中位中心剂量、边缘剂量分别为73.0 Gy、36.5 Gy,与首次治疗的85.0 Gy、42.5 Gy比较,差异均有统计学意义(均P<0.001)。结论采用伽玛刀治疗后复发或无效的TN患者,再次行伽玛刀治疗大部分患者仍然有效,并发症发生率相对较高,但均相对较轻;其中首次治疗有效者再治疗后疗效可能更好。

Objective To observe the effectiveness and safely of gamma knife for re-treatment of patients with drug-refractory trigeminal neuralgia(TN)who failed to respond to the first treatment or relapsed.Methods From June 2010 to September 2019,a total of 823 drug-refractory TN patients underwent gamma knife treatment at the Gamma Knife Center of Neurosurgery Department,West China Hospital,Sichuan University.Among them,16 patients(1.9%)received gamma knife treatment again due to initial treatment failure or recurrence,and their clinical data were retrospectively analyzed.The Barrow Neurological Institute pain scale(BNI)was used to assess the degree of pain relief(gradeⅠ-Ⅲb;effective,gradeⅣ-Ⅴ:failed).The cranial nerve damage related to radiation therapy was followed up.Barrow Neurological Institute facial numbness score was used to evaluate the degree of facial numbness.Results After the first treatment,10 patients were effective and 6 were ineffective;the median effective time was 30(1-180)days.The median time from first treatment to relapse was 28.4(6-60)months.After re-treatment,13 cases were effective and 3 cases were ineffective;the median effective time was 7(1-180)days.The median follow-up time after retreatment was 30.5(16-92)months,and 2 of the 13 effective cases had a complete recurrence of symptoms in the 3rd and 5th months after treatment.At the latest follow-up,11 cases(11/16)were effective,the BNI pain grade Ⅰ was reported in 7 cases,Ⅱ in 2 cases,Ⅲ a in 1 case and Ⅲ b in 1 case.The BNI scores of 5 patients who failed or relapsed were all Ⅴ.Among the 10 patients who were effective for the first treatment,9 cases were effective after the second treatment;of the 6 cases that failed the first treatment,only 2 cases were effective after the second treatment(P=0.035).A total of 12 patients suffered radiation-related injuries during the two treatments.Among them,11 cases had numbness on the same side and 2 cases had impaired taste.The median time from treatment to facial numbness was 2.5(1-18)months,of which 7 cases were mild and 4 cases were moderate.The median maximum dose and margin dose for the first treatment were 85.0 Gy and 42.5 Gy,respectively,compared with 73.0 Gy and 36.5 Gy for the second treatment,and the differences were statistically significant(both P<0.001).Conclusions Gamma-knife treatment for relapsed or ineffective TN patients is still effective after re-treatment with gamma-knife.The incidence of complications is relatively high,but they are relatively mild.Among them,those who are effective for the first time may have better results after a second treatment.