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There are substantive articles published within the last ten years describing the use of linear accelerator (Linac) based treatment of trigeminal neuralgia (TN). In this paper, we report a single case of a patient with classic TN successfully treated by radiosurgical rhizotomy using a modern image-guided linear accelerator with a high-definition multileaf collimator and an optically guided targeting system. The measurement of absolute dose prior to treatment greatly facilitated our confidence with radiosurgical lesioning. Materials and Methods: This 54-year-old patient had a six-year history of lancinating pain involving the lower third of the right face which dramatically intensified in December of 2012, shortly after beginning Vincristine. A treatment plan was generated using a nine-field dynamic arc technique. A target volume was placed at 2-3 mm from the root entry zone measuring 6 x 3 x 3 mm. The PTV dose was prescribed to 60 Gy to the 80% isodose line. Initial verification of absolute dose using Gafchromic film resulted in an increase of the planned MU's by 7.5%. Remeasurement improved the absolute dose to within ±2 % of the calculated dose. Results: The patient was evaluated two weeks and three months following treatment. Her trigeminal pain was 80% resolved after two weeks and 100% at the three-month evaluation. She required none of her chronic pre-treatment medications and demonstrated no clinically detected sensory deficits. Conclusions: Linear accelerator-based radiosurgery utilizing intrafraction motion management and image guidance offers an acceptable alternative for the radiation treatment of trigeminal neuralgia patients if absolute doses are measured prior to treatment.

Trigeminal Rhizotomy Performed with Modern Image-guided Linac: Case Report