Stereotactic radiosurgery for trigeminal neuralgia: Current therapeutic applications, comparative efficacy, and future directions

Abstract

Trigeminal neuralgia (TN) significantly impairs quality of life. While first-line medications (e.g., carbamazepine) and surgical interventions like microvascular decompression (MVD) are standard, their limitations—namely side effects, invasiveness, and recurrence—drive demand for alternatives. Stereotactic radiosurgery (SRS) has emerged as a non-invasive option, yet its comprehensive evaluation remains critical. This review examines the efficacy, safety, mechanisms, and evolving role of SRS in TN management, particularly for medication-refractory or surgically high-risk patients. The aim of this review is to critically examine the fundamentals of SRS, establish its trajectory in neurology, and identify challenges while proposing practical and workable solutions for clinical practice. We also attempt to summarize outcome determinants and provide guidance on selecting single vs. multi-fraction strategies. We analyzed original studies, meta-analyses, systematic reviews, and retrospective cohorts evaluating SRS outcomes, complications, and comparative effectiveness against pharmacotherapy, MVD, and percutaneous procedures. SRS delivers targeted radiation (70–90 Gy) to the trigeminal nerve root entry zone, achieving initial pain relief in 70–85% of patients, with 50–70% sustaining relief for ≥5 years. While slower-acting than MVD, SRS offers comparable long-term efficacy with fewer risks (e.g., stroke, infection). Facial numbness (10–30%) is the most common side effect; severe complications (e.g., radiation necrosis) are rare. SRS is particularly advantageous for TN secondary to multiple sclerosis or vascular compression, and for elderly/comorbid patients. Challenges include precision, recurrence and accessibility barriers. Future advancements may enhance precision and reduce sensory complications. Prioritizing cost-effectiveness studies and global access will solidify SRS’s role in multidisciplinary TN care.