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Trigeminal Neuralgia (TN) is a debilitating condition characterized by agonizing, paroxysmal, and lancinating pain. TN is also called “suicide disease”, terminology denoting the pain extent of these patients. Cyberknife® radiosurgery (CKRS) consists of a radiotherapy non-invasive image-guided procedure. Our propose is to evaluate the effectiveness and safety of CKRS for medically and surgically intractable TN.

We retrospectively evaluated 15 patients (3 male and 12 female) with recurrent TN submitted to CKRS between March 2016 and June 2021, at our institution (9 with left, 5 with right and 1 with bilateral TN). Patients received CKRS with a mean dose of 70 Gy applied to an average 77% isodose line on the affected trigeminal nerve. The final plan was developed according to the individual anatomy and dose distribution over the trigeminal nerve and maximum dose on the brainstem. Trigeminal pain and hypoesthesia were classified according to the Barrow Neurological Institute (BNI). 

Median age was 68 (44-81) years old. Before radiosurgery, all patients reported uncontrolled/recurrent pain with medication, being carbamazepine and pregabalin the most common drugs used. The median follow-up was 36,5 months (4-67). Median target volume was 0,08 cm³ (0,05-0,21) and median normalized conformity index was 1,83 (1,34-2,71). One patient had TN secondary to multiple sclerosis. One patient had been previously submitted to surgery and one had undergone CKRS one year before. All the patients reported pain relief within the first 3 months after CKRS treatment. The majority (62%) were free of antalgic medication (BNI I/II) for a median period of 34 months (1-64 months). In the last follow-up, 38% of the patients reported controlled pain with medication (BNI III) and we haven’t observed cases of inadequately controlled or severe pain (BNI IV-V). Most of the patients (72%) didn’t report facial numbness after CKRS. We observed facial hypoesthesia in 28% of the patients, half of them presented with bothersome facial numbness (BNI IV).

Frameless image-guided robotic radiosurgery in experienced hands is a safe and effective procedure for the treatment of TN, providing excellent pain control rates in absence of major neurological complications. Even patients with severely debilitating symptoms may experience significant and sustained pain relief after CKRS. Thus, it should be considered as a viable alternative to more invasive treatments for this painful condition, with a real impact on the quality of life of these patients.