Stereotactic radiosurgery for bilateral trigeminal neuralgia: A systematic review and proposed framework for staged treatment.

In 30 seconds

This systematic review assessed stereotactic radiosurgery (SRS) for medically refractory bilateral trigeminal neuralgia (BTN) in adults. Six reports met inclusion criteria; five described 88 patients, including 54 treated with SRS across four reports. Reported initial pain relief ranged from 71.4% to 100%, although outcome definitions and analytical units varied. Recurrence was frequent, and durability differed substantially across reports. Repeat SRS provided adequate relief in 10 of 11 retreated nerves (91%) in the largest cohort, with median durability of 2.8 years. The authors judged the evidence very low certainty and proposed individualized, staged treatment decisions.

Key findings

• Across heterogeneous reports, initial pain relief ranged from 71.4% to 100%.
• In the largest cohort, repeat SRS relieved pain adequately in 10 of 11 retreated nerves (91%); median durability was 2.8 years.
• Pain recurrence was frequent, with reported durability varying markedly, including 14 months to 1697 days in the sequential-onset series.
• Sensory disturbance was the most common adverse event; the incidence of anesthesia dolorosa remains uncertain.

Why it matters

BTN presents a difficult balance between pain control and sensory morbidity when treating both sides. This review suggests SRS can provide early relief for some medically refractory patients, but recurrence and uncertain bilateral toxicity limit confidence in its durability and safety. The findings highlight the importance of considering etiology, response to first-side treatment, and cumulative sensory effects when evaluating staged treatment.

What to keep in mind

Evidence came from only six reports, with small samples, heterogeneous outcome definitions, and incomplete reporting of treated nerves. Findings were synthesized narratively rather than by meta-analysis, and certainty was very low.