What is the best treatment of drug-resistant trigeminal neuralgia in patients affected by multiple sclerosis? A literature analysis of surgical procedures

Partial sensory rhizotomy in recurrent trigeminal neuralgia. Our experience and literature review

BACKGROUND AND OBJECTIVE

Trigeminal Neuralgia (NT) is a common pathology in Neurosurgery. It can be classified as idiopathic or secondary to other pathologies, such as Multiple Sclerosis (MS). Several surgical treatments have been described, some of them being replaced by more modern techniques. Partial sensory rhizotomy (PSR), described by Dandy is a technique replaced by other techniques due to its permanent side effects. We present our experience with this technique in patients with recurrent NT.

METHODS AND MATERIALS

A retrospective review is carried out on five patients who underwent surgery at our center from 2018 to 2023 using the PSR technique.

RESULTS

All the patients intervened showed significant clinical improvement, except one patient who required reintervention due to uncontrolled pain. According to the Barrow Neurological Institute (BNI) scale, 80% (4/5) of patients showed improvement from grade V to grades I/II except for one of them. This patient suffered from MS. Additionally, one patient presented a corneal ulcer after surgery due to impairment of the corneal reflex.

CONCLUSION

In our experience, PSR is a valid treatment option in selected patients with recurrent TN. It has a low incidence of complications with an adequate surgical technique and anatomical knowledge of the region. To the best of our knowledge, we are one of the few centers in Spain to publish our results with PSR in the last ten years. We report good results in pain control withdrawing medication in 80% (4/5) of the operated patients.

Efficacy and Challenges: Minimally Invasive Procedures for Trigeminal Neuralgia Treatment in Multiple Sclerosis - A Systematic Review and Meta-Analysis

INTRODUCTION

Trigeminal neuralgia (TGN) poses a therapeutic challenge, particularly within the context of multiple sclerosis (MS). This study aimed to conduct a comprehensive meta-analysis and systematic review of four less-invasive treatment modalities for TGN in MS patients, namely, gamma knife radiosurgery (GKRS), glycerol rhizotomy (GR), balloon compression (BC), and radiofrequency ablation (RFA).

METHODS

Single-armed meta-analyses were employed to assess the overall efficacy of each treatment, while double-armed analyses compared the efficacy between different treatment options in double-armed studies. Outcome evaluations included acute pain relief (within 1 month post-procedure), recurrence rates throughout 18 months of follow-up, and reported complication rates.

RESULTS

The meta-analysis revealed diverse outcomes for each intervention. GKRS demonstrated favorable outcomes, achieving a 77% success rate in alleviating pain among a pooled cohort of 863 patients, reinforcing its status as a viable therapeutic option. Additionally, GR, BC, and RFA exhibited efficacy, with success rates of 77%, 71%, and 80%, respectively, based on outcomes observed in 611, 385, and 203 patients. Double-armed analyses highlighted distinctions between the treatments, providing nuanced insights for clinical decision-making.

CONCLUSION

This meta-analysis provides a comprehensive overview of less-invasive treatments for TGN in MS patients. GKRS emerges as a leading option with comparable efficacy and fewer complications. However, the study underscores the nuanced efficacy and considerations associated with GR, BC, and RFA. The findings offer valuable insights for clinicians navigating treatment choices in this challenging patient population, considering acute pain relief, recurrence rates, and complication profiles.

Impact of Multiple Sclerosis Subtypes on Pain Management in Patients With Trigeminal Neuralgia After Stereotactic Radiosurgery: An International Multicenter Analysis

BACKGROUND AND OBJECTIVES

Trigeminal neuralgia affects approximately 2% of patients with multiple sclerosis (MS) and often shows higher rates of pain recurrence after treatment. Previous studies on the effectiveness of stereotactic radiosurgery (SRS) for trigeminal neuralgia did not consider the different MS subtypes, including remitting relapsing (RRMS), primary progressive (PPMS), and secondary progressive (SPMS). Our objective was to investigate how MS subtypes are related to pain control (PC) rates after SRS.

METHODS

We conducted a retrospective multicenter analysis of prospectively collected databases. Pain status was assessed using the Barrow National Institute Pain Intensity Scales. Time to recurrence was estimated through the Kaplan-Meier method and compared groups using log-rank tests. Logistic regression was used to calculate the odds ratio (OR).

RESULTS

Two hundred and fifty-eight patients, 135 (52.4%) RRMS, 30 (11.6%) PPMS, and 93 (36%) SPMS, were included from 14 institutions. In total, 84.6% of patients achieved initial pain relief, with a median time of 1 month; 78.7% had some degree of pain recurrence with a median time of 10.2 months for RRMS, 8 months for PPMS, 8.1 months for SPMS ( P = .424). Achieving Barrow National Institute-I after SRS was a predictor for longer periods without recurrence ( P = .028). Analyzing PC at the last available follow-up and comparing with RRMS, PPMS was less likely to have PC (OR = 0.389; 95% CI 0.153-0.986; P = .047) and SPMS was more likely (OR = 2.0; 95% CI 0.967-4.136; P = .062). A subgroup of 149 patients did not have other procedures apart from SRS. The median times to recurrence in this group were 11.1, 9.8, and 19.6 months for RRMS, PPMS, and SPMS, respectively (log-rank, P = .045).

CONCLUSION

This study is the first to investigate the relationship between MS subtypes and PC after SRS, and our results provide preliminary evidence that subtypes may influence pain outcomes, with PPMS posing the greatest challenge to pain management.

Efficacy and safety of percutaneous balloon compression for bilateral trigeminal neuralgia: a retrospective study

BACKGROUND

Percutaneous balloon compression (PBC) of the Gasserian ganglion is steadily gaining traction within the trigeminal neuralgia (TN) community. Bilateral trigeminal neuralgia (BTN) is a rare condition, and its treatment remains challenging. As far as we know, there are currently no research reports on the treatment outcomes of PBC for BTN.The purpose of this study is to meticulously evaluate the efficacy and safety of PBC for BTN in our medical institution.

METHODS

In this retrospective study, we collected and analyzed the medical records of all patients with BTN who underwent the PBC procedure at the Department of Neurosurgery at Hebei General Hospital from July 2017 to July 2023. After undergoing PBC therapy, all patients were promptly assessed for treatment efficacy based on the modified Barrow Neurological Institute (BNI) pain intensity grading scale.

RESULTS

All 37 patients with BTN experienced significant pain relief (BNI I-IIIb) immediately following unilateral PBC treatment. Among these patients, 25 reported relief from pain on the non-operative side, which was effectively managed with medication. Out of the 12 patients who did not experience improvement in contralateral symptoms, 11 received contralateral PBC. Out of the 48 treated sides, 47 sides (97.9%) achieved excellent pain control following a single PBC procedure. The follow-up times ranged from 2 to 62 months. At the 1-year follow-up, 94.6% of the patients maintained excellent therapeutic outcomes.Three recurrent patients underwent repeated unilateral PBC, and all of them maintained excellent pain control postoperatively. At the last follow-up, satisfaction was at 91.7% (measured using the Likert scale), with no severe complications occurring.

CONCLUSIONS

The results indicate that PBC is an effective and relatively safe method for treating BTN, offering a valuable option for pain control in these rare cases of TN.

Repeat Gamma Knife radiosurgery for recurrent trigeminal neuralgia in patients with multiple sclerosis: a single-center retrospective study

PURPOSE

Gamma Knife radiosurgery (GKRS) has emerged as an effective treatment option for trigeminal neuralgia (TN) in patients with multiple sclerosis (MS). To date, the outcomes of repeat GKRS for patients with TN and MS with recurrent pain have been investigated in a few patients. This study aims to report the outcomes and predictive factors of pain reduction for MS patients undergoing repeat GKRS for recurrent TN.

METHODS

Eighteen patients with MS underwent repeat GKRS for recurrent TN. A retrospective chart review and telephone interviews were conducted to determine background medical history, dosimetric data, and outcomes of the procedure. Facial pain and sensory function were evaluated using the Barrow Neurological Institute (BNI) scales.

RESULTS

Fifteen patients achieved a BNI pain score of IIIa or better, indicating pain reduction, within a median period of 21 days after repeat GKRS. The maximum dose for repeat GKRS ranged from 70 to 85 Gy. Pain recurred in 5 patients after a median period of 12 months after GKRS. Percentages of patients with pain reduction at 1, 2, 3, 5, and 7 years were 60%, 60%, 50%, 50%, and 50%, respectively. Older age at repeat GKRS predicted sustained pain reduction (P = 0.01). Seven patients developed facial sensory disturbances, which were bothersome in two patients.

CONCLUSIONS

Repeat GKRS may be used as an effective treatment modality for prolonging the duration of pain reduction time in patients with MS and TN. After repeat GKRS, facial sensory disturbances are common; however, they are often not bothersome.

Effectiveness of gamma knife radiosurgery in the management of trigeminal neuralgia associated with multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

Trigeminal neuralgia (TN) is a chronic condition characterized by intense facial pain akin to electric shocks, often associated with the trigeminal nerve. It can be either idiopathic or secondary, with multiple sclerosis (Ms) being a significant contributing factor. Non-responsive patients may opt for minimally invasive procedures, such as gamma knife radiosurgery (GKRS), which offers precise, non-invasive treatment and is frequently chosen as a primary approach. This meta-analysis evaluates the long-term efficacy of GKRS in TN management in Ms patients.

METHODS

We conducted a focused search across various databases. Inclusion criteria encompassed studies with ≥ 30 patients using GKRS for TN in Ms, reporting pertinent clinical outcomes. Primary outcomes assessed GKRS efficacy through Barrow Neurological Institute Pain scores. Secondary outcomes encompassed bothersome numbness, facial numbness, and recurrence. Data analysis employed OpenMeta, random effect models, and odds ratios with 95% confidence intervals. Heterogeneity was assessed using I2 statistics.

RESULTS

Fourteen studies with 752 cases of GKRS for TN were included. Regarding the outcomes, 83% of patients experienced a positive initial pain response, while the overall treatment success rate was 51%. Additionally, 19.6% of patients reported facial numbness, 4.1% experienced bothersome numbness, and 40% faced recurrence. The odds ratio for positive initial pain response was 0.83 (95% CI, 0.76-0.89), while for treatment success, it was 0.51 (95% CI, 0.379-0.639). Facial numbness had an odds ratio of 0.196 (95% CI, 0.130-0.262), bothersome numbness had an odds ratio of 0.041 (95% CI, 0.013-0.069), and recurrence had an odds ratio of 0.403 (95% CI, 0.254-0.551).

CONCLUSIONS

In conclusion, treating trigeminal neuralgia in multiple sclerosis patients remains challenging. GKRS shows promise, but customized treatment approaches tailored to individual patient characteristics are urgently needed to address the unique challenges of this condition.

Pre-operative MRI measurement of the Meckel's cave volume in percutaneous balloon compression of the trigeminal nerve

OBJECTIVE

To explore the feasibility of measuring the volume of Meckel's cave by MRI before operation and its value in guiding percutaneous balloon compression (PBC) of trigeminal nerve (TN).

METHODS

The pre-operative MRI and operative data of 31 patients, who underwent PBC of TN, were analyzed retrospectively. Axial scanning was performed using T2 weighted three-dimensional high-resolution MRI, and then coronal and sagittal images were reconstructed. Volumes of Meckel's cave were measured by two radiologists, and their consistence was assessed using intraclass correlation coefficient. Pearson and Spearman analyses were used to assess the correlations of the volumes of Meckel's cave among coronal, sagittal, and axial MRI images, and between that measured by MRI and the filling volume of operative balloon, respectively. Bland-Altman plot was used to assess their agreements.

RESULTS

There was high consistency in volumes of Meckel's cave between the two radiologists with intraclass correlation coefficient from 0.921 to 0.962. High correlations and good agreements in volumes of Meckel's cave were obtained from the three orientations, with Pearson coefficients and differences of 0.96 and 0.01 ml (coronal vs sagittal), 0.95 and 0.01 ml (coronal vs axial), and 0.95 and 0.00 ml (sagittal vs axial), respectively. The moderate correlation and good agreements were also obtained between MRI and operative balloon volume (ρ = 0.448, p < 0.05; difference, 0.02 ml).

CONCLUSION

It is feasible to measure the volume of Meckel's cave by MRI before operation, and it is of guiding significance for the individual selection of balloon filling volume in PBC of TN.

ADVANCES IN KNOWLEDGE

This is the first study to investigate the relationships between the three-dimensional high resolution MRI images and the clinical volume of Meckel's cave. The high-resolution MRI method can help guide PBC of TN.

Effect of Non-Ablative Non-Thermal CO2 Laser on Drug-Resistant Trigeminal Neuralgia: A Pilot Study

Background: Trigeminal neuralgia is one of the most severe pain conditions that humans experience. Drug resistance is a challenging event during treatment that results in using higher doses of drugs or referring for neurosurgical treatment. Laser therapy is also an effective method for pain control. Objective: The aim of this study was to evaluate the effect of non-ablative non-thermal CO₂ laser (NANTCL) on reducing pain in patients with drug-resistant trigeminal neuralgia (DRTN) for the very first time. Materials and methods: Twenty-four patients with DRTN were randomly divided into laser and placebo groups. Patients in the laser group received NANTCL (10,600 nm, 1.1 W, 100 HZ, 20 sec) on trigger points that were covered with lubricant gel 3 days in a week for 2 weeks. The placebo group received sham laser. The patients were requested to grade their pain on a visual analog scale (VAS) immediately, 1 week, 1 month, and 3 months after treatment. Results: In the laser group, the results revealed a significant decrease between the initial pain and the pain in all follow-up sessions. Only in three patients, 3 months after completion of laser therapy, pain returned to the initial level. In the control group, a significant difference was seen only between the pain of baseline and final session of laser irradiation. In laser group, the mean of pain (VAS) was lower than the placebo group in all follow-up sessions; however, it was only significant for 1 week after laser therapy. Conclusions: This study revealed that short-period application of NANTCL is effective for pain relief in patients with DRTN, especially those with extraoral trigger points. Clinical trial registration number: IRCT2013052113406N1.

Is percutaneous balloon compression better than microvascular decompression to treat trigeminal neuralgia? A systematic review and meta-analysis

BACKGROUND

Trigeminal neuralgia (TN) is a neuropathic pain that affects one or more branches of the trigeminal nerve. Surgical options after pharmacological failure are Microvascular Decompression (MVD) or percutaneous procedures, which include Balloon Compression (PBC). This study aims to describe pain outcomes and complications after PBC and MVD procedures for patients with trigeminal neuralgia.

METHODS

We performed a systematic review and meta-analysis on PubMed, EMBASE, LILACS, and Web of Science databases up to April 2022, following PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and meta-Analysis). Articles that separately describe pain outcome for MVD and PBC were included. MINORS tool was used for bias assessment. Meta-analysis results are presented in forest plot and funnel plot.

RESULTS

853 studies were assessed for screening, and 11 studies met the inclusion criteria for this review. A total of 1046 patients underwent PBC and 1324 underwent MVD. The subgroup analysis for patients without multiple sclerosis shows that MVD was associated with lower number of patients with pain than PBC, with an OR value of 0.54 (95 % CI 0.34-0.84). All other analyses evidenced a tendency for better outcomes after the MVD procedure, but with no statistically significant difference.

CONCLUSION

Considering short and long pain relief, recurrence of pain and total complications for MVD and PBC, our study found that MVD is the best surgical option available for trigeminal neuralgia.

Metabolomics as a promising tool for improving understanding of Multiple Sclerosis: a review of recent advances

Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system that usually affects young adults. The development of MS is closely related to the changes in the metabolome. Metabolomics studies have been performed using biofluids or tissue samples from rodent models and human patients to reveal metabolic alterations associated with MS progression. This review aims to provide an overview of the applications of metabolomics that for the investigations of the perturbed metabolic pathways in MS and to reveal the potential of metabolomics in personalizing treatments. In conclusion, informative variations of metabolites can be potential biomarkers in advancing our understanding of MS pathogenesis for MS diagnosis, predicting the progression of the disease, and estimating drug effects. Metabolomics will be a promising technique for improving clinical care in MS.

[Neuropathic pain syndromes in patients with multiple sclerosis]

Among the numerous pain syndromes (PS) of various localizations and types, observed in patients with multiple sclerosis (MS), the greatest attention of researchers is attracted by neuropathic PS. Neuropathic PS are often present already in the early stage of MS, significantly reduce the quality of life, hinder the social adaptation of patients, poorly respond to therapy. Central neuropathic PS, which pathogenesis is closely related with plaques in the central nervous system, are most common in patients with MS. Diagnostics of neuropathic PS in MS is based mainly on typical clinical symptoms; MRI and neurophysiological methods data are of secondary importance. This review focuses on modern concepts of three main neuropathic PS in MS: ongoing extremity pain, trigeminal neuralgia and Lhermitte's sign. Clinical symptoms of neuropathic PS, current ideas about their pathogenetic mechanisms, MRI and neurophysiological techniques data and the existing approaches to conservative therapy and surgical treatment based on randomized trials data are presented.

Efficacy and safety of radiofrequency in the treatment of trigeminal neuralgia: a systematic review and meta-analysis

To assess the effectiveness of radiofrequency (RF) versus other percutaneous strategies (balloon compression, glycerol rhizotomy [GR], and microvascular decompression [MVD]) in patients with trigeminal neuralgia. We systematically searched the electronic databases of PubMed, Embase, and the Cochrane Library to identify eligible studies throughout October 2020. The odds ratio (OR) with 95% confidence interval (CI) was applied to assess effect estimates using the random-effects model. Eighteen retrospective cohort studies that enrolled 6391 patients with trigeminal neuralgia were included. We noted that RF was associated with an increased incidence of immediate pain relief compared with GR (OR 2.65; 95% CI 1.29-5.44; P = 0.008). Moreover, RF was associated with an increased risk of pain recurrence compared with MVD (OR 3.80; 95% CI 2.00-7.20; P < 0.001). Furthermore, RF was associated with an increased incidence of postoperative anesthesia compared with GR (OR 3.01; 95% CI 1.11-8.13; P = 0.030) or MVD (OR 4.62; 95% CI 2.15-9.93; P < 0.001). This study found that RF was superior to GR for the improvement in immediate pain relief; whereas, RF yielded an excess risk of pain recurrence compared with MVD. Moreover, the incidence of postoperative anesthesia in patients treated with RF significantly increased compared with the incidence after treatment with GR and MVD.

Gamma Knife Radiosurgery for the Treatment of Trigeminal Neuralgia in Patients with Multiple Sclerosis: A Single-Center Retrospective Study and Literature Review

OBJECTIVE

Trigeminal neuralgia (TN) in patients with multiple sclerosis (MS) is a challenging condition to manage that is treated with Gamma Knife radiosurgery (GKRS). The aim of this report is to assess the safety, efficacy, and durability of GKRS for the treatment of TN in patients with MS. Our findings are compared with those of the existing literature and discussed.

METHODS

We retrospectively reviewed all patients at our institution who underwent GKRS for the treatment of TN secondary to MS and had 1 or more years of follow-up. Preoperative and postoperative pain intensities and facial numbness were evaluated with the Barrow Neurological Institute scores. Durability of successful pain relief was statistically evaluated with Kaplan-Meier analysis. The prognostic role of perioperative factors was investigated and analyzed using Cox proportional hazards regression.

RESULTS

There were 29 patients with MS-TN who underwent GKRS at our institution. Two patients underwent bilateral treatment. Four patients underwent repeat GKRS for pain recurrence. The median period of follow-up assessment was 33 months. Rates of reasonable pain reduction at 1, 3, and 5 years were 70%, 57%, and 57% respectively. All patients who underwent repeat GKRS had durable pain reduction. No prognostic factor for successful pain reduction was found.

CONCLUSIONS

Our study shows that GKRS for the treatment of TN secondary to MS is a safe and effective procedure in controlling pain in the short term but often fails to provide long-term pain control. GKRS can be safely repeated to prolong the time of pain reduction.

Efficacy of Gamma Knife radiosurgery in the management of multiple sclerosis-related trigeminal neuralgia: a systematic review and meta-analysis

Trigeminal neuralgia (TN) is the most frequent craniofacial pain condition, which commonly affects patients suffering from multiple sclerosis (MS). Stereotactic radiosurgery, especially Gamma Knife radiosurgery (GKRS), represents a safe and effective treatment for TN, and it has been adopted also for MS-TN, with a lower success rate. Therefore, we aimed to analyze the outcome of GKRS for MS-TN. PubMed, Web of Science, and Google Scholar and the reference list of relevant articles were searched for GKRS in MS-TN. Two investigators independently identified the articles, assessed the study quality, and extracted the data. Endpoints of interest were initial pain responders, successful treatments at the end of follow-up, and factors influencing the outcome. Data analyses were performed using R software. Twelve articles involving 646 patients met our inclusion criteria. Pooled proportion of patients who experienced an initial response to GKRS treatment was 83% (CI 74-90%). The cumulative proportion of successful treatments at the end of follow-up was 47% (CI 33-60%). No variables were found to have a significant contribution to heterogeneity regarding the initial response outcome. The only variable significantly explaining the heterogeneity found in the proportion of successful treatments was the length of the follow-up, with a negative b coefficient (- 0.0051, p value = 0.0047). Regarding the efficacy of GKRS in MS-TN, the initial pain response rate was 83%, which dramatically decreases to 47% during follow-up. GKRS still represents a valuable option for MS-TN; however, its long-term efficacy should be always considered.

Operative findings and outcome of microvascular decompression/adhesiolysis for trigeminal neuralgia in multiple sclerosis without demyelinating brain stem lesions

OBJECTIVE

Trigeminal neuralgia (TN) in multiple sclerosis (MS) poses several challenges for treatment. Although these patients often have typical attacks, they may not be considered as candidates for microvascular decompression (MVD). Here we report on surgical findings and long term follow-up of MVD/ adhesiolysis in a series of patients with multiple sclerosis but without demyelinating brain stem lesions.

METHODS

Fifteen patients with MS-related TN underwent MVD/ adhesiolysis. Demyelinating brain stem lesions were excluded radiologically. Outcome of the intervention was assessed according to the Barrow Neurological Institute (BNI) pain intensity score at 3, 12, 24 months follow-up and at the last available follow-up (mean 88.2 months, range 38-146).

RESULTS

All 15 patients benefited from MVD/adhesiolysis and were pain free on the first day of surgery. Intraoperative findings included arterial contact in 7/15 (47 %) patients, venous contact in 9/15 (60 %), and prominent arachnoid thickening in 12/15 (80 %). The distribution of the BNI pain intensity scores showed marked improvement at all follow-up evaluations. Five patients underwent repeat MVD/adhesiolysis for pain recurrence at a mean of 43 months after the first surgery. Long term evaluation at the last available follow-up demonstrated favorable outcome in 13/15 patients (BNI I-IIIa) (87 %), while 2/15 patients had limited benefit (BNI IV).

CONCLUSIONS

MS-related TN in patients without demyelinating brain stem lesions may be related either to vascular conflicts or to focal arachnoiditis at the trigeminal nerve entry zone. MVD/ adhesiolysis may be considered as a useful treatment option in this subgroup of patients with regard to long term outcome.

Percutaneous Surgical Approaches in Multiple Sclerosis-Related Trigeminal Neuralgia: A Systematic Review and Meta-analysis

OBJECTIVE

The prevalence of trigeminal neuralgia (TN) in the setting of multiple sclerosis (MS) is reported to be 20-fold higher than in the general population. In these patients, TN can be medically refractory and often requires neurosurgical interventions. Ablative percutaneous approaches such as balloon compression (BC), glycerol rhizolysis (GR), and radiofrequency ablation (RF) can be used and often provide rapid pain relief. The aim of this meta-analysis was to compare the safety and efficacy profile of these approaches.

METHODS

This study was performed according to the PRISMA guidelines. A random effects model meta-analysis was conducted.

RESULTS

Five studies with 481 percutaneous approaches were included. No differences in terms of immediate pain relief were identified between BC and GR (odds ratio [OR]: 0.94; 95% confidence interval [CI]: 0.52-1.71). BC was associated with statistically significant higher odds of postoperative mastication weakness compared to GR (OR: 8.58; 95% CI: 1.52-48.43). The rates of pain recurrence (OR: 1.19; 95% CI: 0.04-40.12), hypoesthesia (OR: 0.98; 95% CI: 0.51-1.87), and reduced corneal reflex (OR: 1.07; 95% CI: 0.18-6.17) were similar between BC and GR. In addition, no differences in terms of immediate pain relief (OR: 2.01; 95% CI: 0.77-5.27), pain recurrence (OR: 5.37; 95% CI: 0.30-97.43), and hypoesthesia (OR: 0.63; 95% CI: 0.02-17.66) were identified between RF and GR. The comparison between BC versus RF showed similar rates of immediate pain relief (OR: 0.50; 95% CI: 0.10-2.44), pain recurrence (OR: 1.04; 95% CI: 0-325.96), and hypoesthesia (OR: 2.63; 95%CI: 0.01-735.71).

CONCLUSIONS

No significant differences in the immediate pain relief rates between BC, GR, and RF in MS patients were found. However, BC was associated with a higher risk of postoperative mastication weakness compared with GR.

Microvascular decompression in patients with trigeminal neuralgia and multiple sclerosis: results and analysis of possible prognostic factors

We evaluated the results of microvascular decompression (MVD) in patients with trigeminal neuralgia (TN) and multiple sclerosis (MS) and we studied the role of several clinical and surgical factors as possible prognosticators of good outcome. To do this we performed, to our knowledge, the first literature review with a pooled analysis of data. A PubMed search of literature was conducted using the following terms: "microvascular decompression", "trigeminal neuralgia" and "multiple sclerosis". We screened 64 articles. Of them, 7 studies were eligible for this review. As outcome indicators we used the acute pain relief (APR) and the recurrence of pain. An APR was obtained in 71.42% and a recurrence of pain was reported in 26.00% of cases, respectively. At univariate analysis, younger age at surgery (p = 0.0419) and performing MVD as the first treatment (p = 0.0384) were associated to a higher probability of APR. The evidence of an MRI brainstem lesion related to the TN (p = 0.0482) was associated to a lower probability to obtain an APR after MVD. None of the evaluated factors affect the probability of recurrence of pain. At multivariate analysis the evidence of a brainstem MRI lesion related to the TN emerged as a negative prognosticator of APR (p = 0.0169). Our literature pooled analysis showed that MVD is effective in treating patients with MS-related TN. The evidence on MRI of a demyelinating plaque related to the TN is associated with a worse response to MVD. These data could suggest that MVD would be indicated mainly in patients without brainstem MRI lesions.

Stereotactic Radiosurgery for Trigeminal Neuralgia in Patients With Multiple Sclerosis: A Multicenter Study

BACKGROUND

Facial pain response (PR) to various surgical interventions in patients with multiple sclerosis (MS)-related trigeminal neuralgia (TN) is much less optimal. No large patient series regarding stereotactic radiosurgery (SRS) has been published.

OBJECTIVE

To evaluate the clinical outcomes of MS-related TN treated with SRS.

METHODS

This is a retrospective cohort study. A total of 263 patients contributed by 9 member tertiary referral Gamma Knife centers (2 in Canada and 7 in USA) of the International Gamma Knife Research Consortium (IGKRF) constituted this study.

RESULTS

The median latency period of PR after SRS was 1 mo. Reasonable pain control (Barrow Neurological Institute [BNI] Pain Scores I-IIIb) was achieved in 232 patients (88.2%). The median maintenance period from SRS was 14.1 months (range, 10 days to 10 years). The actuarial reasonable pain control maintenance rates at 1 yr, 2 yr, and 4 yr were 54%, 35%, and 24%, respectively. There was a correlation between the status of achieving BNI-I and the maintenance of facial pain recurrence-free rate. The median recurrence-free rate was 36 mo and 12.2 mo in patients achieving BNI-I and BNI > I, respectively (P = .046). Among 210 patients with known status of post-SRS complications, the new-onset of facial numbness (BNI-I or II) after SRS occurred in 21 patients (10%).

CONCLUSION

In this largest series SRS offers a reasonable benefit to risk profile for patients who have exhausted medical management. More favorable initial response to SRS may predict a long-lasting pain control.

Characteristics and treatment of Multiple Sclerosis-related trigeminal neuralgia: An Italian multi-centre study

BACKGROUND

The prevalence of trigeminal neuralgia (TN) in Multiple Sclerosis (MS) patients is higher than in the general population and its management can be particularly challenging. Our aim is to describe the characteristics, treatment and prognostic factors of MS-related TN in a retrospective multicentre study.

METHODS

Neurologists members of the RIREMS group (Rising Researchers in MS) enrolled MS patients with a TN diagnosis and filled out a spreadsheet comprising their clinical data.

RESULTS

Population consisted of 298 patients. First-choice preventive treatments were carbamazepine and oxcarbazepine. A surgical procedure was performed in 81 (30%) patients, most commonly gamma knife stereotactic radiosurgery (37%), followed by microvascular decompression (22%) and radiofrequency thermocoagulation (21%); one third of patients underwent at least two procedures. Surgery was associated with higher disability, male sex and longer interval between MS and TN onset. Patients (77%) who stayed on at least one preventive medication at most recent follow-up, after a mean period of 8 years, had a higher disability compared to the untreated group. Furthermore, patients with higher disability at TN onset were less likely to discontinue their first preventive medication due to pain remission, had bilateral TN more frequently and underwent surgical interventions earlier.

CONCLUSION

MS patients with a higher disability at TN onset and with a longer interval between MS and TN onset had differing clinical features and outcomes: pain was more frequently bilateral, surgery was more frequent and anticipated, and preventive medication discontinuation due to pain remission was less common.

Association between time of hospitalization with acute myocardial infarction and in-hospital mortality

AIMS

To study the association between time of hospitalization and in-hospital mortality for acute myocardial infarction (AMI).

METHODS AND RESULTS

Patients admitted with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) across 243 hospitals in England and Wales between 1 January 2004 and 31 March 2013 were included. The outcome measure was in-hospital mortality. Adjusted odds ratios (ORs) for in-hospital mortality were estimated across six 4-hourly time periods over the 24-h clock using multilevel logistic regression, inverse-probability weighting propensity score, and instrumental variable analysis. Among 615 035 patients [median age 70.0 years, interquartile range 59.0-80.0 years; 406 519 (66.0%) men], there were 52 777 (8.8%) in-hospital deaths. At night, patients with NSTEMI were more frequently comorbid, and for STEMI had longer symptom-onset-to-reperfusion times. For STEMI, unadjusted in-hospital mortality was highest between 20:00 and 23:59 [4-h period range 8.4-9.9%; OR compared with 00:00-03:59 reference 1.13, 95% confidence interval (CI) 1.07-1.20], and for NSTEMI highest between 12:00 and 15:59 (8.0-8.8%; OR compared with 00:00-03:59 reference 1.07, 95% CI 1.03-1.12). However, these differences were only apparent in the earlier years of the study, and were attenuated by adjustment for demographics, comorbidities, and clinical presentation. Differences were not statistically significant after adjustment for acute clinical treatment provided.

CONCLUSION

There is little evidence to support an association between time of hospitalization and in-hospital mortality for AMI; variation in in-hospital mortality may be explained by case mix and the use of treatments.

Trigeminal neuralgia secondary to multiple sclerosis: from the clinical picture to the treatment options

BACKGROUND

Trigeminal neuralgia is one of the most characteristic and difficult to treat neuropathic pain conditions in patients with multiple sclerosis. The present narrative review addresses the current evidence on diagnostic tests and treatment of trigeminal neuralgia secondary to multiple sclerosis.

METHODS

We searched for relevant papers within PubMed, EMBASE and the Cochrane Database of Systematic Reviews, taking into account publications up to December 2018.

RESULTS

Trigeminal neuralgia secondary to multiple sclerosis manifests with facial paroxysmal pain triggered by typical manoeuvres; neurophysiological investigations and MRI support the diagnosis, providing the definite evidence of trigeminal pathway damage. A dedicated MRI is required to identify pontine demyelinating plaques. In many patients with multiple sclerosis, neuroimaging and surgical evidence suggests that neurovascular compression might act in concert with the pontine plaque through a double-crush mechanism. Although no placebo-controlled trials have been conducted in these patients, according to expert opinion the first-line therapy for trigeminal neuralgia secondary to multiple sclerosis relies on sodium-channel blockers, i.e. carbamazepine and oxcarbazepine. The sedative and motor side effects of these drugs frequently warrant an early consideration for neurosurgery. Surgical procedures include Gasserian ganglion percutaneous techniques, gamma knife radiosurgery and microvascular decompression in the posterior fossa.

CONCLUSIONS

The relatively poor tolerability of the centrally-acting drugs carbamazepine and oxcarbazepine highlights the need to develop new selective and better-tolerated sodium-channel blockers. Prospective studies based on more advanced neuroimaging techniques should focus on how trigeminal anatomical abnormalities may be able to predict the efficacy of microvascular decompression.

Efficacy and Safety of Repeated Percutaneous Radiofrequency Thermocoagulation for Recurrent Trigeminal Neuralgia

Background: Percutaneous radiofrequency thermocoagulation (PRT) is used to treat trigeminal neuralgia (TN) with a satisfactory pain relief but a high recurrence rate. Objective: To explore the efficacy and safety of repeated PRT for recurrent TN as compared to patients who received the first PRT. Methods: Between January 2013 to May 2013, 31 patients with recurrent TN who have been treated with PRT previously were recruited and underwent repeated PRT (group A), and compared with 41 TN patients received the first initial PRT (group B). Visual Analog Scale (VAS) score was assessed preoperatively and postoperatively after 2 years of follow-up, and compared in terms of initial pain relief, complications, and recurrence rate between the two groups. Results: In group A, 27 patients (87.0%) were pain free immediately, and 30 patients (96.8%) experienced pain relief at 48 h, whereas that was 37 patients (90.0%) and 40 patients (97.6%) in group B (p ≧ 0.05). Patients in group A who remained an "excellent" or "good" pain relief condition (VAS score ≦ 1) were 96.8% at 6 months, 83.9% at 1 year, 74.2% at 2 years, whereas the percentage in group B was 97.6, 85.4, and 73.2% (p ≧ 0.05). Conclusion: For patients with recurrent TN after PRT, repeated PRT might be considered as a useful treatment option when other treatments fail. In addition, the frequency and severity of adverse events for repeated PRT were similar as compared to initial PRT.

Laser Effects on the Prevention and Treatment of Dentinal Hypersensitivity: A Systematic Review

Introduction: Dentinal hypersensitivity (DH) is an acute intensive tooth pain which can lead to dental annoyances during eating and drinking. Stimulating exposed dentinal tubules by either kind of thermal, tactile, chemical and/or osmotic stimuli is believed to be the cause of this pain. It is hypothesized that dentinal tubules' orifice occlusion (DOO) can help relieve such dental irritations. Thus, this systematic review was conducted to evaluate the effectiveness of laser application as a prevention and treatment modality on DH reduction. Methods: Electronic databases (MEDLINE, SCOPUS) were searched among randomized clinical trials from January 2007 to December 2016. The extraction of data and quality assessments were carried out by different independent observers. Results: A total of 499 items were found of which3 9 relevant articles were extracted. The profound findings proved lasers' effectiveness as a treatment of DH. Although some of the researches reported no significant difference between laser and other desensitizing agents, most of the studies suggested that better results (both rapid and long-lasting) were obtained in combined modalities. Furthermore, the preventive role of this new technology has been emphasized as well. Nd-YAG (neodymium-doped yttrium aluminum garnet) and diode lasers reduce DH after bleaching. Lasers can also protect cervical restorations from DH due to tubular occlusion. Moreover, it is suggested to apply lasers in relief of DH following scaling and root planning. Nevertheless, a few researchers dispute its beneficence as a result of placebo effect. Conclusion: The results obtained from several studies in the present review revealed that the application of lasers is effective not only in terms of treatment of DH, but also in the prevention of this intensive tooth pain. Among various types of lasers, the application of Nd:YAG laser has shown the best results in DH treatment.

The role of radiosurgery in trigeminal neuralgia

A short review of clinical use of radiosurgery in trigeminal neuralgia is offered.

A Systematic Review of the Management of Trigeminal Neuralgia in Patients with Multiple Sclerosis

BACKGROUND AND OBJECTIVE

Patients with trigeminal neuralgia (TN) and multiple sclerosis (MS) are often treated with medications or a surgical procedure. However, there is little evidence that such treatments result in 50% pain reduction and improvement in quality of life. The aim of this systematic review is to evaluate the clinical effectiveness of treatments in patients with MS and trigeminal neuralgia.

METHODS

We searched Medline, EMBASE, and the Cochrane Collaboration database from inception until October 2016. Two authors independently selected studies for inclusions, data extraction, and bias assessment.

RESULTS

All studies were of low quality using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. For medical management, 10 studies were included, of which one was a randomized controlled trial. Two studies were on the use of misopropol, unique to patients with MS. For surgical therapy, 26 studies with at least 10 patients and a minimum of 2 years follow-up were included. All types of surgical procedures are reported and the results are poorer for TN with MS, with 50% having a recurrence by 2 years. The main complication was sensory loss. Many patients had to undergo further procedures to become pain free and there were no agreed prognostic factors.

CONCLUSIONS

There was insufficient evidence to support any 1 medical therapy and so earlier surgery may be preferable. A patient with TN and MS has therefore to make a decision based on low-level evidence, beginning with standard drug therapy and then choosing a surgical procedure.

Long-term outcome of percutaneous balloon compression for trigeminal neuralgia patients elder than 80 years: A STROBE-compliant article

This article evaluates the long-term outcome of percutaneous balloon compression (PBC) for trigeminal neuralgia (TN) patients elder than 80 years. A total of 138 elderly patients aged above 80 years with primary TN, who were admitted to Neurosurgery Department, Hangzhou First People's Hospital from January 2007 to December 2011 for PBC treatment, were retrospectively analyzed in this study. The postoperative cure rate of immediate pain was 98.6% (Barrow Neurological Institute [BNI] classes I, II); according to the follow-up, the pain cure rates at 1, 2, 3, 4, and 5 years after surgery were 93.5%, 90.4%, 84.7%, 80.4%, and 72.9%, respectively. In our group, postoperative diplopia was reported in 1 case, masticatory muscle weakness in 3 cases, and herpes labialis in 19 cases. A total of 100% of pain-cured patients exhibited facial numbness and facial hypoesthesia. No serious complications occurred in this group of patients. PBC is an effective and safe procedure for TN treatment and can be employed as the preferred regimen for elderly TN patients aged above 80 years in poorer physical condition.

Subcutaneous Trigeminal Nerve Field Stimulation for Refractory Facial Pain

Chronic or neuropathic trigeminal facial pain can be challenging to treat. Neurosurgical procedures should be applied when conservative treatment fails. Neuromodulation techniques for chronic facial pain include deep brain stimulation and motor cortex stimulation, which are complex to perform. Subcutaneous nerve field stimulation is certified for chronic back pain and is the least invasive form of neuromodulation. We applied this technique to treat chronic and neuropathic trigeminal pain as an individual therapy concept. First, trial stimulation is performed. Subcutaneous leads are placed in the painful trigeminal dermatome under local anesthesia. The leads are connected to an external neurostimulator that applies constant stimulation. Patients undergo a 12 day outpatient trial to assess the effect of the stimulation. Electrodes are removed after the trial. If the patient reports pain reduction of at least 50% in intensity and/or attack frequency, a reduction in medication or increase in quality of life, permanent implantation is scheduled. New electrodes are implanted under general anesthesia and are subcutaneously tunneled to an infraclavicular internal pulse generator. Patients are able to turn stimulation on and off and to increase or decrease the stimulation amplitude as needed. This technique represents a minimal invasive alternative to other more invasive means of neuromodulation for trigeminal pain such as motor cortex stimulation or deep brain stimulation.

Neurological deficit following stereotactic radiosurgery for trigeminal neuralgia

We report a unique case of neurological deficit from late onset multiple sclerosis (MS), in a 65-year-old woman, after stereotactic radiosurgery (SRS) for trigeminal neuralgia (TN). At 3.5months post-SRS for TN, the patient developed ataxia and left leg paraesthesiae and brain MRI showed altered signal and enhancement in the vicinity of the right trigeminal root entry zone (REZ). The symptoms remitted following treatment with intravenous methylprednisolone, however, 10months post-SRS, the patient developed gait ataxia and left lower limb weakness. MRI showed persistent T2 changes at the REZ and multiple new non-enhancing white matter lesions in the cerebrum and spinal cord; and oligoclonal bands were present in the cerebrospinal fluid but not serum. A diagnosis of multiple sclerosis (MS) was made. This report raises the issue of whether the risk of radiation-induced toxicity is increased in patients with MS treated with SRS. We hypothesise that breakdown in the blood brain barrier secondary to the radiosurgery may have triggered a vigorous local inflammatory response.

Laser speckle imaging to improve clinical outcomes for patients with trigeminal neuralgia undergoing radiofrequency thermocoagulation

OBJECTIVE

Percutaneous treatments for trigeminal neuralgia are safe, simple, and effective for achieving good pain control. Procedural risks could be minimized by using noninvasive imaging techniques to improve the placement of the radiofrequency thermocoagulation probe into the trigeminal ganglion. Positioning of a probe is crucial to maximize pain relief and to minimize unwanted side effects, such as denervation in unaffected areas. This investigation examined the use of laser speckle imaging during probe placement in an animal model.

METHODS

This preclinical safety study used nonhuman primates, Macaca nemestrina (pigtail monkeys), to examine whether real-time imaging of blood flow in the face during the positioning of a coagulation probe could monitor the location and guide the positioning of the probe within the trigeminal ganglion.

RESULTS

Data from 6 experiments in 3 pigtail monkeys support the hypothesis that laser imaging is safe and improves the accuracy of probe placement.

CONCLUSIONS

Noninvasive laser speckle imaging can be performed safely in nonhuman primates. Because improved probe placement may reduce morbidity associated with percutaneous rhizotomies, efficacy trials of laser speckle imaging should be conducted in humans.

Symptomatic management in multiple sclerosis

Multiple sclerosis (MS) is the commonest cause of disability in young adults. While there is increasing choice and better treatments available for delaying disease progression, there are still, very few, effective symptomatic treatments. For many patients such as those with primary progressive MS (PPMS) and those that inevitably become secondary progressive, symptom management is the only treatment available. MS related symptoms are complex, interrelated, and can be interdependent. It requires good understanding of the condition, a holistic multidisciplinary approach, and above all, patient education and empowerment.

The effectiveness of percutaneous balloon compression in the treatment of trigeminal neuralgia in patients with multiple sclerosis

OBJECT

Trigeminal neuralgia (TN) is more common in multiple sclerosis (MS) patients than in the general population and among the former has an incidence of approximately 2%. The pathophysiology of TN in MS patients is believed to be caused by a demyelinating plaque at the root entry zone, and therefore procedures that cause direct nerve damage are thought to be the most effective surgical modality. The authors aimed to compare the efficacy of percutaneous balloon compression (PBC) in TN patients with and without MS.

METHODS

Retrospectively collected clinical data on 80 consecutive patients who underwent 144 procedures and who received PBC for TN treatment between January 2000 and January 2010 were analyzed. The cohort included 17 MS and 63 non-MS patients.

RESULTS

The mean age at first operation was significantly younger in the MS group compared with the non-MS group (59 years vs 72 years, respectively, p < 0.0001). After a mean follow-up of 43 months (MS group) and 25 months (non-MS group), the symptom recurrence rate following the first operation was higher in the MS group compared with that in the non-MS group (86% vs 47%, respectively, p < 0.01). During long-term follow-up, more than 70% of MS patients required multiple procedures compared with only 44% of non-MS patients. Excellent or satisfactory outcomes were not significantly different between the MS and non-MS cohorts, respectively, at 1 day postoperatively (82% vs 91%, p = 0.35), 3 months postoperatively (65% vs 81%, p = 0.16), and at last follow-up (65% vs 76%, p = 0.34). A similar incidence of postoperative complications was observed in the 2 groups.

CONCLUSIONS

PBC is effective in the treatment of trigeminal neuralgia in patients with MS, but, compared with that in non-MS patients, symptom recurrence is higher and requires multiple procedures.

Advances in diagnosis and treatment of trigeminal neuralgia

Various drugs and surgical procedures have been utilized for the treatment of trigeminal neuralgia (TN). Despite numerous available approaches, the results are not completely satisfying. The need for more contemporaneous drugs to control the pain attacks is a common experience. Moreover, a number of patients become drug resistant, needing a surgical procedure to treat the neuralgia. Nonetheless, pain recurrence after one or more surgical operations is also frequently seen. These facts reflect the lack of the precise understanding of the TN pathogenesis. Classically, it has been related to a neurovascular compression at the trigeminal nerve root entry-zone in the prepontine cistern. However, it has been evidenced that in the pain onset and recurrence, various neurophysiological mechanisms other than the neurovascular conflict are involved. Recently, the introduction of new magnetic resonance techniques, such as voxel-based morphometry, diffusion tensor imaging, three-dimensional time-of-flight magnetic resonance angiography, and fluid attenuated inversion recovery sequences, has provided new insight about the TN pathogenesis. Some of these new sequences have also been used to better preoperatively evidence the neurovascular conflict in the surgical planning of microvascular decompression. Moreover, the endoscopy (during microvascular decompression) and the intraoperative computed tomography with integrated neuronavigation (during percutaneous procedures) have been recently introduced in the challenging cases. In the last few years, efforts have been made in order to better define the optimal target when performing the gamma knife radiosurgery. Moreover, some authors have also evidenced that neurostimulation might represent an opportunity in TN refractory to other surgical treatments. The aim of this work was to review the recent literature about the pathogenesis, diagnosis, and medical and surgical treatments, and discuss the significant advances in all these fields.

The role of percutaneous balloon compression in the treatment of trigeminal neuralgia recurring after other surgical procedures

Trigeminal neuralgia (TN) recurring after surgery can be difficult to treat. Treatment algorithms have not been standardized or universally accepted. Here we investigated the effectiveness of percutaneous balloon compression (PBC) in the treatment of patients with TN recurrence after other surgical techniques and analyzed the role of some clinical and operative factors in determining the prognosis. The records of 22 patients (13 M and 9 F) suffering recurrent TN after one (2 gamma knife surgery, 5 percutaneous radiofrequency rhizotomy, 6 percutaneous retrogasserian glycerol rhizotomy, 3 microvascular decompression) or more (6 patients) procedures and submitted to PBC at our institution from January 2003 to February 2012 were reviewed. Seven patients had TN related to multiple sclerosis (MS). Mean follow-up was 51.81 ± 26.63 months. 81.81 % of patients reported an acute pain relief. No major complication was observed after PBC. Eight patients (36.36 %) experienced pain recurrence and underwent one (five patients) or more (three patients) PBC. At the last follow-up, we obtained an excellent outcome (BNI I-II) in 16 patients out of 22 (72.72 %) and a good outcome (BNI III) in the remaining six. No patients had an uncontrolled pain. The lack of history of MS (p = 0.0174), the pear-like shape of the balloon at the operation (p = 0.0234) and a compression time <5 min (p < 0.05) were associated to higher pain-free survival. Considering these results PBC could be considered a useful technique for patients whose pain recurs after other procedures.

Symptomatic treatment and management of multiple sclerosis

The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.

Surgical Outcomes of Trigeminal Neuralgia in Patients With Multiple Sclerosis

BACKGROUND:

Trigeminal neuralgia (TN) is relatively frequent in multiple sclerosis (MS) patients and can be extremely disabling. Surgical interventions are less effective for the treatment of MS-related TN compared with classic TN, and higher recurrence rates are observed.

OBJECTIVE:

To evaluate initial pain-free response (IPFR), duration of pain-free intervals (PFIs), and factors predictive of outcome in different surgical modalities used to treat MS-related TN.

METHODS:

A total of 96 MS patients underwent 277 procedures (range, 1–11 procedures per patient) to treat TN at our institution from 1995 to 2011. Of these, 89 percutaneous retrogasserian glycerol rhizotomies, 82 balloon compressions, 52 stereotactic radiosurgeries, 28 peripheral neurectomies, 15 percutaneous radiofrequency rhizotomies, and 10 microvascular decompressions were performed as upfront or repeat treatments.

RESULTS:

Bilateral pain was observed in 10% of patients during the course of disease. During the follow-up period (median, 5.7 years), recurrence of symptoms was seen in 66% of patients, and 181 procedures were performed for symptom recurrence. As an initial procedure, balloon compression had the highest IPFR (95%; P = .006) and median PFI (28 months; P = .05), followed by percutaneous retrogasserian glycerol rhizotomy (IPFR, 74%, P = .04; median PFI, 9 months; P = .05). In general, repeat procedures had lower effectiveness compared with initial procedures, with no statistically significant difference seen across the various treatment modalities.

CONCLUSION:

Treatment failure occurs in most of the MS-related TN patients independently of the type of treatment. However, balloon compression had the highest rate of IPFR and PFI compared with other modalities in the initial treatment of MS-related TN.