Radiosurgery for Facial Pain: A Narrative Review

The surgical treatment of pain has been an integral part of neurosurgery since the early 20th century when Harvey Cushing pioneered ganglionectomy for trigeminal neuralgia. Over the ensuing years, as anatomic and physiologic knowledge of pain systems grew, new techniques aimed at new targets were developed for various pain conditions. Our objective was to provide an informative and up-to-date summary of radiosurgery for chronic facial pain, emphasizing trigeminal neuralgia and discussing the advantages and challenges of this modality. A PubMed search with keywords ("trigeminal neuralgia" or "cluster headache" or "glossopharyngeal neuralgia") and ("radiosurgery") and ("systematic review" or "review") was conducted. Relevant publications in English published from January 2000 to May 2022 were screened manually for their title, abstract, and even full text to determine their relevance. References from the searched articles were also searched as other supplementary articles. We excluded original articles and personal series from the analysis and only considered systematic reviews to maintain the transparency in the record. A total of 19 studies for trigeminal neuralgia (n > 100), 52 cases of cluster headache, and 42 cases of glossopharyngeal neuralgia were found. Radiosurgery remains the safest among various treatment options with equitable pain control with other percutaneous procedures. MVD remains the gold standard for long-term pain control. There is no difference in efficacy or tolerance between patients treated with gamma knife, linear accelerator, or CyberKnife. The minimum recommended prescription dose was 70 Gy (level of evidence II), and the maximum dose was 90 Gy (level of evidence III) in a single fraction. Radiosurgery provides 5-year pain control in 50% of patients without medication (85% of patients with/without medication) with an average latency period of 1-3 months. Approximately 8-15% of patients will experience a recurrence of pain after an average period of 1 year. Prospective pain relief will be about 60% at 3 years, 40% at 7 years, and 37% in 10 years. The main complication was facial hypoesthesia occurring in 25-50% of patients within 6 months-3 years and disabling in 10% of cases. Cluster headache and glossopharyngeal neuralgia are emerging conditions for treatment with GKRS, although long-term efficacy remains to be studied. Having searched PubMed and other databases and summarized the application of radiosurgery for facial pain, we concluded that radiosurgery is undoubtedly a promising tool for chronic facial pain, but further studies are needed to realize its long-term efficiency and advanced applications of the same.