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

Differentiating multiple sclerosis and neuromyelitis optica spectrum disorders through pontine trigeminal nerve lesions: A comparative MRI study

PURPOSE

Multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) are two major demyelinating diseases affecting the central nervous system (CNS). The objective of this study is to evaluate the prevalence of pontine trigeminal nerve lesions in patients diagnosed with MS and NMOSD using MRI.

METHODS

This retrospective study included patients diagnosed with MS or NMOSD between July 2018 and July 2023. MS patients were clinically diagnosed using the 2017 McDonald criteria, while NMOSD patients were those who met the 2015 International Panel for NMO Diagnosis (IPND) criteria and were positive for Aquaporin-4 Antibody (AQP4-Ab).

RESULTS

The study included a total of 90 patients, with 45 diagnosed with MS and another 45 with NMOSD. Pontine trigeminal nerve lesions were observed in both MS and NMOSD, but were more prevalent in MS patients (20 % vs. 2 %, p = 0.008). Root entry zone (REZ) lesions were found in 4 of 45 MS patients, accounting for 9 % (95 % CI: 3 %-17 %), and were absent in the NMOSD group; however, there was no significant difference between the two groups (p = 0.12). Of the MS patients with pontine trigeminal nerve lesions, 6 out of 9 (63 %; 95 % CI, 36 %-98 %) exhibited bilateral lesions, which was significantly more prevalent compared to the NMOSD group (13 % vs. 0 %, p = 0.03).

CONCLUSIONS

The presence of pontine trigeminal nerve lesions, particularly when bilateral, are significantly more prevalent in MS patients than in those with NMOSD, suggesting their utility as a distinctive marker and potential diagnostic indicator specifically for MS.

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.

Atlas orthogonal chiropractic management of trigeminal neuralgia: A series of case reports

CONTEXT

Trigeminal neuralgia is a debilitating facial pain condition. Upper cervical chiropractic care has been mentioned as a possible solution OBJECTIVE: To determine the effects of Atlas Orthogonal upper cervical chiropractic technique adjustments on trigeminal neuralgia sufferers DESIGN: Case series SETTING: A private chiropractic practice PARTICIPANTS: Five persons with chronic, severe, daily trigeminal neuralgia pain, radiological findings of significant head tilt, pain upon upper cervical palpation, and supine leg length inequality INTERVENTIONS: Up to two consultations and/or Atlas Orthogonal adjustments a week for eight weeks OUTCOME MEASURES: Self-reported reduction in trigeminal neuralgia pain and changes in radiological findings, sensitivity to upper cervical palpation, and leg length inequality RESULTS: Four participants reported reduced trigeminal neuralgia pain, including two with complete cessation of pain. Three participants reduced medication dosages. One reported no change.

Trigeminal neuralgia in multiple sclerosis: Association with demyelination and progression

BACKGROUND

Trigeminal neuralgia (TN) is a well-recognized symptom of multiple sclerosis (MS), yet its clinical characteristics related to MS subtype is poorly studied. Our aim was to evaluate whether development and clinical outcome of TN are influenced by MS phenotype.

METHODS

In this retrospective cohort study, our database from 2007 to 2022 was reviewed to identify patients who had both the diagnosis of MS and TN, whether TN was an initial symptom of MS or developed later in diagnosis. A detailed medical history and treatment outcome was obtained. Pain status was assessed retrospectively using the Barrow Neurological Institute Pain Scale (BNI-PS), with BNI-PS I-III considered as good pain control and BNI-PS IV-V as poor pain control.

RESULTS

58 patients had MS-related TN. 44 patients had relapsing remitting multiple sclerosis (RRMS) at the time of TN diagnosis, 11 had secondary progressive multiple sclerosis (SPMS) at the time of TN diagnosis, and type of MS was not clear in 3 patients at the time of TN diagnosis (either RRMS or SPMS). Over a mean follow up of 18.8 (SD=10.9) years, 30 transitioned to SPMS. TN was refractory to medical management in 9 RRMS and 22 SPMS patients (p = 0.001). TN patients with RRMS required lower median number of pain medications compared to SPMS (p = 0.014). Brain MRI was available in 41 of the entire cohort. Of these, 27 patients had demyelinating lesions in the trigeminal sensory pathway and 14 did not. Patients with existing lesions had a higher chance of failure of medical management (74% versus 36%, p = 0.017) and required surgical intervention (55% versus 7%, p = 0.003).

DISCUSSION

TN was not seen in primary progressive multiple sclerosis (PPMS). In patients who transitioned to SPMS, TN was more likely to be refractory to medical management. TN was more refractory in the presence of demyelinating plaque involving trigeminal sensory pathway.

Central Neuropathic Pain Syndromes: Current and Emerging Pharmacological Strategies

Central neuropathic pain is caused by a disease or lesion of the brain or spinal cord. It is difficult to predict which patients will develop central pain syndromes after a central nervous system injury, but depending on the etiology, lifetime prevalence may be greater than 50%. The resulting pain is often highly distressing and difficult to treat, with no specific treatment guidelines currently available. This narrative review discusses mechanisms contributing to central neuropathic pain, and focuses on pharmacological approaches for managing common central neuropathic pain conditions such as central post-stroke pain, spinal cord injury-related pain, and multiple sclerosis-related neuropathic pain. Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and gabapentinoids have some evidence for efficacy in central neuropathic pain. Medications from other pharmacologic classes may also provide pain relief, but current evidence is limited. Certain non-pharmacologic approaches, neuromodulation in particular, may be helpful in refractory cases. Emerging data suggest that modulating the primary afferent input may open new horizons for the treatment of central neuropathic pain. For most patients, effective treatment will likely require a multimodal therapy approach.

The journeys of patients with trigeminal neuralgia on a background of multiple sclerosis

Aim: Multiple sclerosis (MS) is well recognized as a secondary cause for trigeminal neuralgia (TN). In this case series, we detail the management of all the patients with TN and MS (pwTNMS) presenting to a specialist unit. Materials & methods: A prospective patient database was used to extract key clinical data on pharmacological, psychometric and surgical management of 20 pwTNMS. Results: 65% of pwTNMS underwent surgical interventions for management of their pain.12/20 achieved remission periods, through surgery and/or medication. Significant improvement was noted on the global impression of change illustrated by a p < 0.001. Conclusion: pwTNMS require a multifaceted approach combining polypharmacy, surgical interventions and psychological support. Developing self-management skills is crucial if patients are to live well with pain.

Cranial Neuralgias

PURPOSE OF REVIEW

This article discusses the differential diagnosis, evaluation, and management of trigeminal neuralgia and reviews other neuralgias of the head and neck, including those that contribute to neuralgic ear pain.

RECENT FINDINGS

Most cases of trigeminal neuralgia are related to vascular compression, a demyelinating plaque, or a compressive mass affecting the trigeminal nerve. However, recent studies have shown that up to 11% of patients have a family history of trigeminal neuralgia, suggesting that some patients may have a genetic predisposition to demyelination or nerve hyperexcitability. In these patients, trigeminal neuralgia may occur at a younger age, on both sides of the face, or in combination with other neuralgias.

SUMMARY

When a patient presents with neuralgic pain, the diagnosis is made by careful history and neurologic examination, with attention to the dermatome involved, the triggers, and the presence of any associated sensory deficit. All patients with new neuralgia or neuropathic facial pain warrant a careful evaluation for a secondary cause. The presence of sensory deficit on bedside examination is particularly concerning for an underlying secondary etiology.

[Pain in multiple sclerosis and neuromyelitis optica spectrum disorders]

Multiple sclerosis and neuromyelitis optica spectrum disorders are autoimmune inflammatory diseases of the central nervous system, which can lead to a multitude of neurological complaints and pain syndromes. Pain may be an acute symptom during disease exacerbation as well as a chronic symptom, whereby the latter sometimes substantially reduces the quality of life. The etiology of pain is very heterogeneous but the rapid differential diagnostic classification is decisive in order to be able to initiate a differentiated treatment strategy. Chronic pain must be differentiated from pain as a possible (early) symptom of an acute disease exacerbation, classified in more detail and individually treated. These include central neuropathic pain, pain associated with spasticity, musculoskeletal pain due to excess loading and pain as a side effect of immunotherapy and in the context of comorbidities. The treatment strategies are often insufficiently evidence-based due to the lack of data.

Neurovascular contact plays no role in trigeminal neuralgia secondary to multiple sclerosis

INTRODUCTION

A demyelinating plaque and neurovascular contact with morphological changes have both been suggested to contribute to the etiology of trigeminal neuralgia secondary to multiple sclerosis (TN-MS). The aim of this study was to confirm or refute whether neurovascular contact with morphological changes is involved in the etiology of TN-MS.

METHODS

We prospectively enrolled consecutive TN-MS patients from the Danish Headache Center. Clinical characteristics were collected systematically. MRI scans were done using a 3.0 Tesla imager and were evaluated by the same experienced blinded neuroradiologist.

RESULTS

Sixty-three patients were included. Fifty-four patients were included in the MRI analysis. There was a low prevalence of neurovascular contact with morphological changes on both the symptomatic side (6 (14%)) and the asymptomatic side (4 (9%)), p = 0.157. Demyelinating brainstem plaques along the trigeminal afferents were more prevalent on the symptomatic side compared to the asymptomatic side (31 (58%) vs. 12 (22%), p < 0.001). A demyelinating plaque was highly associated with the symptomatic side (odds ratio = 10.6, p = 0.002).

CONCLUSION

The primary cause of TN-MS is demyelination along the intrapontine trigeminal afferents. As opposed to classical trigeminal neuralgia, neurovascular contact does not play a role in the etiology of TN-MS. Microvascular decompression should generally not be offered to patients with TN-MS.The study was registered at ClinicalTrials.gov (number NCT04371575).

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.

Chronic Facial Pain: Trigeminal Neuralgia, Persistent Idiopathic Facial Pain, and Myofascial Pain Syndrome-An Evidence-Based Narrative Review and Etiological Hypothesis

Trigeminal neuralgia (TN), the most common form of severe facial pain, may be confused with an ill-defined persistent idiopathic facial pain (PIFP). Facial pain is reviewed and a detailed discussion of TN and PIFP is presented. A possible cause for PIFP is proposed. (1) Methods: Databases were searched for articles related to facial pain, TN, and PIFP. Relevant articles were selected, and all systematic reviews and meta-analyses were included. (2) Discussion: The lifetime prevalence for TN is approximately 0.3% and for PIFP approximately 0.03%. TN is 15-20 times more common in persons with multiple sclerosis. Most cases of TN are caused by neurovascular compression, but a significant number are secondary to inflammation, tumor or trauma. The cause of PIFP remains unknown. Well-established TN treatment protocols include pharmacotherapy, neurotoxin denervation, peripheral nerve ablation, focused radiation, and microvascular decompression, with high rates of relief and varying degrees of adverse outcomes. No such protocols exist for PIFP. (3) Conclusion: PIFP may be confused with TN, but treatment possibilities differ greatly. Head and neck muscle myofascial pain syndrome is suggested as a possible cause of PIFP, a consideration that could open new approaches to treatment.

Harmonization of real-world studies in multiple sclerosis: Retrospective analysis from the rirems group

BACKGROUND

Worldwide multiple sclerosis (MS) centers have coordinated their efforts to use data acquired in clinical practice for real-world observational studies. In this retrospective study, we aim to harmonize outcome measures, and to evaluate their heterogeneity within the Rising Italian Researchers in MS (RIReMS) study group.

METHODS

RIReMS members filled in a structured questionnaire evaluating the use of different outcome measures in clinical practice. Thereafter, thirty-four already-published papers from RIReMS centers were used for heterogeneity analyses, using the DerSimonian and Laird random-effects method to compute the between-study variance (τ²).

RESULTS

Based on questionnaire results, we defined basic modules for diagnosis and follow-up, consisting of outcome measures recorded by all participating centers at the time of diagnosis, and, then, at least annually; we also defined more detailed/optional modules, with outcome measures recorded less frequently and/or in the presence of specific clinical indications. Looking at heterogeneity, we found 5-year variance in age at onset (ES=27.34; 95%CI=26.18, 28.49; p<0.01; τ²=4.76), and 7% in female percent (ES=66.42; 95%CI=63.08, 69.76; p<0.01; τ²=7.15). EDSS variance was 0.2 in studies including patients with average age <36.1 years (ES=1.96; 95%CI=1.69, 2.24; p<0.01; τ²=0.19), or from 36.8 to 41.1 years (ES=2.70; 95%CI=2.39, 3.01; p<0.01; τ²=0.18), but increased to 3 in studies including patients aged >41.4 years (ES=4.37; 95%CI=3.40, 5.35; p<0.01; τ²=2.96). The lowest variance of relapse rate was found in studies with follow-up duration ≤2 years (ES=9.07; 95%CI=5.21, 12.93; p = 0.02; τ²=5.53), whilst the lowest variance in EDSS progression was found in studies with follow-up duration >2 years (ES=5.41; 95%CI=3.22, 7.60; p = 0.02; τ²=1.00).

DISCUSSION

We suggest common sets of biomarkers to be acquired in clinical practice, that can be used for research purposes. Also, we provide researchers with specific indications for improving inclusion criteria and data analysis, ultimately allowing data harmonization and high-quality collaborative studies.

Pharmacotherapeutic Options for Managing Pain in Multiple Sclerosis

Pain is a major matter for patients with multiple sclerosis; treatment response is frequently inadequate, with a significant impact on quality of life. The estimated prevalence of pain in multiple sclerosis ranges widely (26-86%), and different subtypes of pain, mediated by specific pathophysiological mechanisms, are described. The aim of this narrative review, performed using a systematic search methodology, was to provide current, evidence-based, knowledge about the pharmacological treatment of the different kinds of pain in multiple sclerosis. We searched for relevant papers within PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Clinical Trials database (ClinicalTrials.gov), considering publications up to November 2019. Two authors independently selected studies for inclusion, data extraction, and bias assessment. A total of 27 randomized controlled trials were identified, but in only a few cases, patients with different pain qualities were stratified. Following a mechanism-based approach, treatment of paroxysmal pain and painful tonic spasms should be based on sodium-channel blockers, whereas treatment of ongoing extremity pain should be based on gabapentinoids and antidepressants.