Radiosurgical management of trigeminal neuralgia; Differences in outcomes between proximal and distal targeting:...

Trigeminal neuralgia (TN) is a chronic pain disorder characterized by recurrent pain. The most common stereotactic radiosurgery (SRS) targets for treatment are proximal and distal; however, there are important discrepancies among authors in the appraisal of the different targets used. A meta-analysis is warranted to evaluate the comparative effectiveness between these targets. Databases were searched until March 6, 2024, to identify studies that compared outcomes for patients with TN treated with SRS between proximal and distal targets. The outcomes included pain relief (PR), pain freedom (PF), facial numbness (FN) and medication de-escalation. Of the 539 screened articles, 6 retrospective cohorts met our inclusion criteria, considering 1055 patients for analysis. Pain relief at 30 days was significantly higher in patients who underwent distal compared to proximal SRS (RR = 1.37, 95%CI: 1.14-1.65; P = 0.001). In pain relief at 90 days, there was no significant difference between targets (RR = 1.11, 95%CI: 0.92-1.34, P = 0.30), nor the rate of PF at last follow-up (RR = 1.24, 95%CI: 0.70-2.20; P = 0.46). The rate of facial numbness did not differ between targets (RR = 1.10, 95%CI: 0.63-1.92, P = 0.75) in both targets. Medication de-escalation rates were not statistically different between targets (RR = 1.29, 95% CI: 0.86-1.94). Our analysis demonstrated significantly greater pain relief at 30 days when distal targeting was used. Given its improved early pain control and comparable safety profile, distal targeting may be preferred when rapid pain relief is a primary treatment objective. However, both targets demonstrated similar efficacy at 90 days and comparable long-term safety outcomes.