Radiosurgical Methods

The authors deserve thanks for their interesting and excellent overview (1). I wish to add to the section on trigeminal neuralgia and its treatment after medication failure. Because of the inevitably necessary brevity to the article format, the not entirely correct impression created here was that the so called neuroablative methods are always the second choice in the treatment sequence after microvascular decompression (as proposed by Jannetta)—quasi second-rate therapeutic options. This is not the case. The neuroablative methods have their place and can in some cases be used as near-equivalents to open surgery or in escalating form from non-invasive to minimally invasive to invasive (2). Because of space constraints this paragraph does not clarify that the Jannetta operation is a moderately major surgical intervention under full anesthesia and has a side effect profile that merits attention. For this reason, this approach is certainly not always the method of choice, especially in older and sicker patients (3). For older patients with typical trigeminal neuralgia, radiosurgery, for example, as a non-invasive method without anesthesia is an approach with a good ratio of risk to benefit. However, this method is slower to have an effect. If more rapid therapeutic success is desired, other minimally invasive methods—such as thermo-ablation—may be selected. Radiosurgery in not as widespread in Germany as it is in anglophone and francophone countries, where, for example, gamma knife therapy is also more common. In some radiosurgery centers in Germany, however, this therapeutic option is available (4).

The International RadioSurgery Association (IRSA) proposed a treatment algorithm that takes into account the risks and benefits of each method.