Cyberknife stereotactic radiosurgical rhizotomy for

trigeminal neuralgia: anatomic and morphological

considerations.
Author: Borchers JD 3rd, Yang HJ, Sakamoto GT, Howes GA, Gupta G, Chang SD, Adler JR Jr.

Key words: The CyberKnife Robotic Radiosurgery System is a non-invasive alternative to

surgery for the treatment of both cancerous and non-cancerous tumors anywhere in the body,
including the prostate, lung, brain, spine, liver, pancreas and kidney. The treatment – which
delivers beams of high dose radiation to tumors with extreme accuracy

OBJECTIVE: To search for correlations between specific anatomic, geometric, and

morphological properties of the trigeminal nerve and the success of radiosurgical treatment and
elimination of facial hypesthesia as a complication.

METHODS: Forty-six patients with at least 6 months of follow-up after CyberKnife (Accuray,
Inc., Sunnyvale, CA) rhizotomy were retrospectively reviewed. Patients treated after 2004 were
entered into the study after congruity in treatment parameters was established. Anatomic
variations regarding the length of each nerve segment and angle of trigeminal nerve takeoff from
brainstem to Meckel's cave in the axial and sagittal planes were studied. Dose distribution to
surrounding critical structures (brainstem and trigeminal ganglion) was measured. After spatial
relationships of involved structures and dose distributions were recorded, their relationship to
treatment success, failure, or complication (primarily facial numbness) was tabulated.

RESULTS: Forty-five patients (97.2%) experienced pain relief immediately or within weeks.
Thirty-four patients maintained excellent outcome. Some degree of facial numbness developed in
18 patients (39.1%) and was mild in 11 of them (Grade II on the Barrow Neurological Institute
scale). Patients with a sagittal-angle trigeminal nerve takeoff from the brainstem in the range of
150 to 170 degrees measured from the horizontal plane had a more favorable outcome (P = 0.03)
than patients with less obtuse relationships to the proximal nerve origin. Patients who received
higher doses of radiation to the brainstem/dorsal root entry zone of the trigeminal nerve
experienced a higher rate of posttreatment facial anesthesia.

CONCLUSION: There may be important anatomic and geometric relationships between the
treated trigeminal nerve and surrounding critical structures that warrant pretreatment target
volume placement and dose distribution considerations.
The CyberKnife Robotic Radiosurgery System is
a non-invasive alternative to surgery for the
treatment of both cancerous and non-cancerous
tumors anywhere in the body, including the
prostate, lung, brain, spine, liver, pancreas and
kidney. The treatment – which delivers beams of
high dose radiation to tumors with extreme
accuracy – offers new hope to patients
worldwide.

Though its name may conjure images of scalpels

and surgery, the CyberKnife treatment involves no cutting. In fact, the CyberKnife System is the
world’s first and only robotic radiosurgery system designed to treat tumors throughout the body
non-invasively. It provides a pain-free, non-surgical option for patients who have inoperable or
surgically complex tumors, or who may be looking for an alternative to surgery.

How is CyberKnife unique

The CyberKnife System is a one-of-a-kind device for several reasons.

First, the CyberKnife System uses image guidance software to track and continually adjust
treatment for any patient or tumor movement. This sets it far ahead of other similar treatments. It
allows patients to breathe normally and relax comfortably during treatment.

Second, some forms of radiosurgery require rigid head-frames that are screwed into the patient’s
skull to minimize any movement. The CyberKnife System does not require such extreme
procedures to keep patients in place, and instead relies on sophisticated tracking software,
allowing for a much more comfortable and non-invasive treatment.

Third, unlike some radiosurgery systems, which can only treat tumors in the head, the
CyberKnife System has unlimited reach to treat a broad range of tumors throughout the body,
including the prostate, lung, brain, spine, liver, pancreas, and kidney.

And finally, the CyberKnife System’s treatment accuracy is unrivaled. Its ability to treat tumors
with pin-point accuracy is unmatched by other radiation therapy and radiosurgery systems. The
CyberKnife System can essentially “paint” the tumor with radiation allowing it to precisely
deliver treatment to the tumor alone, sparing surrounding healthy tissue.

What is the treatment process

CyberKnife treatments involve a team approach in which several specialists participate.

Prior to the procedure, the patient is imaged using a high-resolution CT scan, to determine the
size, shape and location of the tumor.
Following scanning, the image data is digitally transferred to the CyberKnife System’s
workstation, where the treatment planning begins.

A qualified clinician then uses the CyberKnife software to generate a treatment plan. The plan is
used to match the desired radiation dose to the identified tumor location while limiting radiation
exposure to the surrounding healthy tissue.

Once the treatment plan has been developed, the patient is ready to undergo the CyberKnife
procedure. After arriving at the CyberKnife Center, patients are comfortably positioned on the
treatment table. Then the CyberKnife System’s computer-controlled robot will slowly move
around the patient to the various locations from which it will deliver radiation to the tumor.

Each treatment session will last between 30 and 90 minutes, depending on the type of tumor
being treated. If treatment is being delivered in stages, patients will need to return for additional
treatments over several days (typically no more than five), as determined by the patients doctor.
Patients may experience some minimal side effects, but those often go away within the first week
or two after treatment.

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