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

Riveting technique in percutaneous balloon compression for trigeminal neuralgia remedy

BACKGROUND

The percutaneous balloon compression (PBC) is a safe and simple treatment for trigeminal neuralgia. It works by compressing the Gasserian ganglion to block pain signals from the trigeminal nerve. To ensure effectiveness, it is important to focus the compression on the lower part of the balloon.

OBJECTIVE

To validate the efficacy of a riveting technique, specifically pulling an inflated balloon, in order to apply enhanced compression on the ganglion.

METHODS

To compare this novel technique with the conventional approach, a retrospective investigation was conducted on consecutive PBCs performed in our department between 2019 and 2022. For postoperative outcome assessment, efficacy was defined as achieving a VAS score of 0 or an improvement exceeding 5 points. Postoperative numbness was graded as none, mild, or severe based on its impact on daily life and tolerance level.

RESULTS

Excluding cases with missed follow-up, a total of 179 participants were included in the study, and their follow-up period ranged up to 40 months. Postoperatively, symptomatic remission was achieved by 98.1% (52/53) of patients in the riveting technique group compared to 87.3% (110/126) in the conventional group (P<0.05). At the last follow-up period, with recurrence observed over time, the long-term efficacy of riveting and conventional groups were 94.3% and 74.6%, respectively (P<0.05). The majority of cases in both groups experienced ipsilateral facial numbness immediately following PBC, which appeared to diminish after 3 months in both groups without significant difference between them (P>0.05).

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.

Pharmacological and Non-pharmacological Approaches for the Management of Neuropathic Pain in Multiple Sclerosis

Multiple sclerosis is a chronic inflammatory disease that affects the central nervous system and can cause various types of pain including ongoing extremity pain, Lhermitte's phenomenon, trigeminal neuralgia, and mixed pain. Neuropathic pain is a major concern for individuals with multiple sclerosis as it is directly linked to myelin damage in the central nervous system and the management of neuropathic pain in multiple sclerosis is challenging as the options available have limited efficacy and can cause unpleasant side effects. The literature search was conducted across two databases, PubMed, and Google Scholar. Eligible studies included clinical trials, observational studies, meta-analyses, systematic reviews, and narrative reviews. The objective of this article is to provide an overview of literature on pharmacological and non-pharmacological strategies employed in the management of neuropathic pain in multiple sclerosis. Pharmacological options include cannabinoids, muscle relaxants (tizanidine, baclofen, dantrolene), anticonvulsants (benzodiazepines, gabapentin, phenytoin, carbamazepine, lamotrigine), antidepressants (duloxetine, venlafaxine, tricyclic antidepressants), opioids (naltrexone), and botulinum toxin variants, which have evidence from various clinical trials. Non-pharmacological approaches for trigeminal neuralgia may include neurosurgical methods. Non-invasive methods, physical therapy, and psychotherapy (cognitive behavioral therapy, acceptance and commitment therapy and mindfulness-based stress reduction) may be recommended for patients with neuropathic pain in multiple sclerosis. The choice of treatment depends on the severity and type of pain as well as other factors, such as patient preferences and comorbidities. There is a pressing need for healthcare professionals and researchers to prioritize the development of better strategies for managing multiple sclerosis-induced neuropathic pain.

The role of multiple sclerosis subtype in microvascular decompression outcomes for patients with trigeminal neuralgia

OBJECTIVES

While patients with concomitant trigeminal neuralgia (TN) and multiple sclerosis (MS) are understood to experience a more intractable pain phenotype, whether TN pain outcomes differ by the presenting MS subtype is not well characterized. This study's objective is to compare post-operative pain and numbness outcomes following microvascular decompression (MVD) in TN patients with either relapsing-remitting MS (RRMS) or progressive MS.

METHODS

We retrospectively reviewed all TN patients who underwent MVDs at our institution from 2007 to 2020. Of the 1044 patients reviewed, 45 (4.3%) patients with MS were identified. Patient demographics, procedural characteristics, and post-operative pain and numbness scores were recorded and compared. Factors associated with pain recurrence were assessed using survival analyses and multivariate regressions.

RESULTS

Of the resulting 45 MS patients, 34 (75.6%) patients presented with the RRMS subtype, whereas 11 (24.4%) patients exhibited progressive MS. Using an adjusted multivariate ordinal regression, the subtype of MS was not significantly associated with the Barrow Neurological Institute (BNI) pain score at final follow-up. Using a Kaplan-Meier survival analysis and a multivariate Cox proportional hazards regression, respectively, RRMS was significantly associated with a shorter post-operative pain-free interval (p = 0.04) as well as a greater risk for pain recurrence (p = 0.02).

CONCLUSIONS

Although the degree of pain at final follow-up may not differ, RRMS patients are at increased risk for pain recurrence following MVD for TN. These results align with a growing understanding that neuroinflammation may play a significant role in TN pain.

A retrospective study to examine the association of different pear-shaped balloons with efficacy and postoperative complications in percutaneous balloon compression for trigeminal neuralgia

Percutaneous balloon compression is a safe and effective therapeutic modality for trigeminal neuralgia. It is widely recognized that the pear-shaped balloon is the key to the success of the procedure. This study aimed to analyze the effect of different pear-shaped balloons on the duration of the treatment outcome. In addition, the relationship between individual variables and the duration and severity of complications was analyzed. The clinical data and intraoperative radiographs of 132 patients with trigeminal neuralgia were reviewed. We classify pear-shaped balloons into type A, type B, and type C balloons depending on the size of their heads. The collected variables were correlated with prognosis by univariate and multivariate analyses. The efficiency of the procedure was 96.9%. There was no significant difference in pain relief rates between the different pear-shaped balloons. Median pain-free survival time was longer for type B and C balloons, which were significantly different from type A balloons. In addition, pain duration also was a risk factor for recurrence. There was no significant difference in the duration of numbness between the different types of pear-shaped balloons, but type C balloons resulted in longer-lasting masticatory muscle weakness. Duration of compression and balloon shape can also significantly influence the severity of complications. Different pear-shaped balloons have been shown to have a significant effect on the efficacy and complications of the PBC procedure, with type B balloons (head ratio: 10-20%) appearing to be the ideal pear shape. However, its clinical application remains to be validated.

Multivariate models to predict pain recurrence and sensitive complications after percutaneous balloon compression in trigeminal neuralgia

OBJECTIVE

Percutaneous balloon compression (PBC) is a popular treatment option for trigeminal neuralgia. However, the efficacy of PBC is widely considered to be associated with the occurrence of sensitive complications, although neither this correlation nor the underlying mechanisms have been established. The objectives of the present study were to identify factors predicting time to pain recurrence after PBC and identify factors predicting a severe sensitive complication.

METHODS

The authors conducted a retrospective study on patients who underwent PBC for the first time between 1985 and 2019 in two French hospitals. Data were retrieved from patients' medical records. Potential clinical and radiological predictors for time to pain recurrence and severe sensitive complication were evaluated using a Cox model and a logistic regression, respectively.

RESULTS

A total of 131 patients were included in the study, with a median follow-up of 3.0 years. Pain recurrence occurred in 77 patients, and the median time to pain recurrence was 2.0 years. In the multivariate analysis, six independent factors predicting pain recurrence were identified: 1) longer duration of presurgical symptoms; 2) localization of the pain along the mandibular branch of the trigeminal nerve (V3); 3) atypical pain; 4) diagnosis of multiple sclerosis; 5) use of a medical device not specifically adapted for trigeminal neuralgia surgery; and 6) duration of balloon compression > 60 seconds. Regarding the secondary objective, 26 patients presented a severe sensitive complication after PBC, which the authors defined as the development of a new sensitivity disorder of the cornea, deafferentation pain known as anesthesia dolorosa, and/or long-lasting hypoesthesia augmentation characterized by the new appearance or increase in size or intensity of an area of hypoesthesia in the face for at least 3 months. The only predictor associated with a severe sensitive complication in the multivariate analysis was compression duration > 60 seconds.

CONCLUSIONS

These results show that the risk of postoperative complications can be assessed at the patient level, the most important modifiable parameter being the time of compression by the balloon. Although this study shows the relevance of a personalized medicine approach, its clinical application remains to be validated.

Trigeminal Neuralgia: Current Approaches and Emerging Interventions

Trigeminal neuralgia (TN) has been described in the literature as one of the most debilitating presentations of orofacial pain. This review summarizes over 150 years of collective clinical experience in the medical and surgical treatment of TN. Fundamentally, TN remains a clinical diagnosis that must be distinguished from other types of trigeminal neuropathic pain and/or facial pain associated with other neuralgias or headache syndromes. What is increasingly clear is that there is no catch-all medical or surgical intervention that is effective for all patients with trigeminal neuralgia, likely reflective of the fact that TN is likely a heterogenous group of disorders that jointly manifests in facial pain. The first-line treatment for TN remains anticonvulsant medical therapy. Patients who fail this have a range of surgical options available to them. In general, microvascular decompression is a safe and effective procedure with immediate and durable outcomes. Patients who are unable to tolerate general anesthesia or whose medical comorbidities preclude a suboccipital craniectomy may benefit from percutaneous methodologies including glycerol or radiofrequency ablation, or both. For patients with bleeding diathesis due to blood thinning medications who are ineligible for invasive procedures, or for those who are unwilling to undergo open surgical procedures, radiosurgery may be an excellent option-provided the patient understands that maximum pain relief will take on the order of months to achieve. Finally, peripheral neurectomies continue to provide an inexpensive and resource-sparing alternative to pain relief for patients in locations with limited economic and medical resources. Ultimately, elucidation of the molecular mechanisms underlying trigeminal neuralgia will pave the way for novel, more effective and less invasive therapies.

[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.

Comparison of first-time microvascular decompression with percutaneous surgery for trigeminal neuralgia: long-term outcomes and prognostic factors

Objective

Common surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD) and percutaneous procedures (glycerol rhizolysis; thermocoagulation; and balloon compression). Although the efficacy of each procedure has been documented, direct comparisons of their relative efficacies for TN are lacking. We aimed to directly compare long-term outcomes after first-time MVD with percutaneous surgery in primary (idiopathic and classical) TN and identify predictors of outcome.

Methods

We conducted a retrospective analysis of prospectively collected data on 185 patients undergoing MVD and 129 undergoing percutaneous surgery. Procedures were performed by one of two neurosurgeons in a single centre; an independent observer collected long-term follow-up data by interviews, using the same outcome measures for all procedures.

Results

MVD patients were younger than those undergoing percutaneous surgery (P <.001). MVD provided superior initial pain relief (P <.001): 87.0% had Barrow Neurological Institute class I or II pain scores after MVD compared with 67.2% after percutaneous surgery. The complication rate for percutaneous procedures was 35.7% and for MVDs was 24.9% (P =.04), including minor and transient complications. Kaplan-Meier analysis demonstrated that MVD provided longer pain relief than percutaneous procedures (P <.001); 25% of patients had recurrence at 96 months following MVD compared with 12 months after percutaneous surgery. Subgroup analysis showed that balloon compression provided more durable relief amongst percutaneous procedures. Multivariate analysis revealed that post-operative numbness and age were prognostic factors for percutaneous procedures (P =.03 and .01, respectively).

Conclusions

MVD provides better initial pain relief and longer durability of relief than percutaneous surgery, although carrying a small risk of major complications. Amongst percutaneous procedures, balloon compression gave the most durable relief from pain. Older age and post-operative numbness were predictors of good outcome from percutaneous surgery. These results can help clinicians to counsel patients with primary TN on neurosurgical treatment selection for pain relief.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-021-04793-4.

Does the Surgical Intervention for Trigeminal Neuralgia Refractory to Pharmacotherapy Improve Quality-of-Life? - A Systematic Review

PURPOSE

Trigeminal neuralgia (TN) refractory to pharmacotherapy requires surgical interventions which vary from percutaneous procedure to microvascular decompression (MVD). The aim of the systematic review is to find evidence for the surgical treatment for TN with high success rate and low complications which improves the quality-of-life (QOL).

METHODS

A systematic literature search was made on published studies from MEDLINE, SCOPUS, Science direct, and Cochrane Library databases that report the available surgical treatment for TN up to March 2020 and studies referred in the selected papers. Relevant studies were selected based on predefined eligibility criteria. The primary outcome measured was success rate, pain relief and secondary outcome measured was QOL, recurrence and complication rate.

RESULTS

Ten studies with a sum of 11,154 individuals were included in this qualitative analysis. Seven studies compared MVD whereas 4 studies compared Gamma knife radiosurgery with other techniques like percutaneous balloon compression, percutaneous glycerol rhizotomy etc. The result showed that MVD has a considerable higher rate of initial pain-free outcomes (96.6%) followed by Gamma knife radiosurgery (96.2%), cryotherapy (95.4%), percutaneous balloon compression (87%), percutaneous glycerol rhizotomy (85%) and the lowest rate of cohorts who were never pain-free (1.7%).QOL was improved to 100% as a result of pain relief which was evaluated in only 2 studies . Overall the recurrence rate was 0.45 to 52%. MVD has lower rate of long-term recurrence 0.45 and 6.1% for 2 years and 8 years, respectively, and cryotherapy has the highest rate of 52% at 6 months.

CONCLUSION

Outcomes of the literature search showed that it lacks the knowledge to generally support 1 or the other treatment. Each type of TN requires individualized protocols to treat based on pain response which ultimately improve the QOL. We also propose there should be more reliable data reporting by using a universally acceptable pain scale for better analysis of treatment outcome.

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.

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.

One Hundred Eleven Percutaneous Balloon Compressions for Trigeminal Neuralgia in a Cohort of 66 Patients with Multiple Sclerosis

BACKGROUND

Trigeminal neuralgia associated with multiple sclerosis (MS-TN) is comparatively rare and larger series of percutaneous balloon compression (PBC) in such cases are few in the literature.

OBJECTIVE

To evaluate the results after PBC for MS-TN with regards to therapeutic effect, side effects, and complications.

METHODS

One hundred eleven procedures with PBC performed in 66 cases of MS-TN were analyzed. Therapeutic effect was measured as postoperative time to pain recurrence without medication. All complications were compiled and the sensory function was evaluated in a subgroup of cases.

RESULTS

The initial pain free rate was 67% and the median time to pain recurrence was 8 mo. Thirty-six patients were treated with PBC only, and among them, the results were worse if treated 3 to 4 times before, compared to first treatment (P = .009-.034). Patients who had several PBCs had worse results already after the first surgery (P < .001). A significant number of patients had impaired sensation to light touch directly after surgery, which was normalized at the late follow-up. Sensimetric testing showed raised thresholds for perception and pain directly after surgery (P = .004-.03), but these were also normalized at the late follow-up.

CONCLUSION

PBC is a treatment that can be effective for many patients with MS-TN. Repeated previous surgeries is a risk factor for an unsatisfactory outcome. However, the patients with multiple surgeries had less satisfactory results already at the first procedure, indicating that a therapy resistant disease can be predicted after the first two PBCs. Postoperative sensory deficits were common but not lasting.

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.

Microsurgical rhizotomy for trigeminal neuralgia in MS patients: technique, patient satisfaction, and clinical outcomes

OBJECTIVE

Patients with multiple sclerosis (MS)-associated trigeminal neuralgia (TN) have higher recurrence and retreatment rates than non-MS patients. The optimal management strategy and role for microsurgical rhizotomy (MSR) for MS-TN remains to be determined. The aim of this study was to report time to treatment failure (TTF) and pain scores following MSR compared to percutaneous and Gamma Knife procedures.

METHODS

Time to treatment failure was analyzed after MSR (n = 14) versus prior procedures (n = 53) among MS-TN patients. Kaplan-Meier curves and log-rank test were utilized to compare TTF after MSR versus prior procedures using the same cohort of patients as their own control group. Subsequent analysis compared TTF after MSR to TTF after 93 other procedures among a second cohort of 18 MS-TN patients not undergoing MSR. BNI pain scores were compared between MSR and other procedures among the MS-TN cohort using a chi-square test.

RESULTS

TTF was significantly longer after MSR than after other procedures in the MSR cohort (median TTF 79 vs 10 months, respectively, p < 0.0001). Similarly, TTF was longer after MSR than after prior procedures in the non-MSR cohort (median TTF 79 vs 13 months, respectively, p < 0.001). MSR resulted in a higher proportion of excellent pain scores when compared to other procedures in the non-MSR cohort (77% vs 29%, p < 0.001). Probability of treatment survival was higher after MSR than after other procedures at all time points (3, 6, 12, 24, 36, and 48 months). There were no deaths or major complications after MSR.

CONCLUSIONS

TTF was significantly longer following MSR compared to prior procedures in MS-TN patients. Additionally, a higher proportion of patients achieved excellent BNI pain scores after MSR.

The Effectiveness of Percutaneous Balloon Compression, Thermocoagulation, and Glycerol Rhizolysis for Trigeminal Neuralgia in Multiple Sclerosis

BACKGROUND

Balloon compression (BC), thermocoagulation (TC), and glycerol rhizolysis (GR) are percutaneous surgical options for trigeminal neuralgia (TN). Whether the outcomes of these procedures in multiple sclerosis -related TN (MS-TN) are as effective as in idiopathic TN (ITN) is unknown.

OBJECTIVE

To retrospectively compare pain relief, complications, and durability achieved by these 3 types of procedures in MS-TN and ITN.

METHODS

Two hundred and four patients with typical TN were treated percutaneously: 33 had MS-TN (64 procedures) and 171 had ITN (329 procedures). All were performed by 1 of 2 neurosurgeons; interviews enabled long-term data to be gathered by an independent observer.

RESULTS

MS-TN patients (53.1%) had Barrow Neurological Institute pain scores of I or II after a percutaneous procedure, compared with 59.3% in the ITN cohort; there was no difference in initial relief between the 2 groups overall (P = .52). There was a trend toward fewer complications in MS-TN compared with ITN (23.4% vs 33.7%, respectively; P = .058). Kaplan–Meier analysis demonstrated no difference in durability of relief in MS-TN (median 23.0 mo) compared with ITN overall (median 24.0 mo; P = .75). Subgroup analysis demonstrated longer relief from BC and TC compared with GR in MS-TN (P = .013). Multivariate analysis confirmed that although the presence of MS does not predict durability of outcome, postoperative numbness (P = .0046) and undergoing a repeat procedure (P = .037) were significant predictors.

CONCLUSION

BC and TC are safe and effective in MS-TN. Postoperative numbness is the strongest prognostic factor in MS-TN.

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.

[Experience of the use of gasserian ganglion balloon compression in patients with trigeminal neuralgia associated with multiple sclerosis]

AIM

To evaluate the efficacy of gasserian ganglion balloon compression in patients with trigeminal neuralgia associated with multiple sclerosis (MS).

MATERIAL AND METHODS

Eight patients (3 men, 5 women), aged from 46 to 66 years (mean age 55 years), with trigeminal neuralgia associated with MS underwent surgery. An average duration of the pain syndrome was 8,4 years. Six patients had previous surgeries due to facial pain. Percutaneous balloon compression of gasserian ganglion was performed to all patients. Follow up period was from 2 to 24 months.

RESULTS

Six patients (75%) reported 100% of pain relief right after the surgery, 2 patients (25%) reported a significant decrease of pain (2-3 points on VAS). Pain recurrence occurred in 3 patients: in 4 months, in 12 months and in 6 months. All of them were operated repeatedly. After the surgery, hypoesthesia on the side of surgery was observed in all patients with a trend towards regression. There was no keratopathy or any complications.

CONCLUSION

Percutaneous balloon compression of gasserian ganglion is an effective and minimally invasive method which can be performed repeatedly in patients with trigeminal neuralgia associated with MS.

Long-term follow-up of multimodality treatment for multiple sclerosis-related trigeminal neuralgia

BACKGROUND

The treatment for multiple sclerosis-related trigeminal neuralgia (MS-TN) is less efficacious and associated with higher recurrence rates than classical TN. No consensus has been reached in the literature on the choice procedure for MS-TN patients. The aim of this study was to assess the incidence and surgical outcomes of medically refractory MS-TN.

METHODS

Patient records were retrospectively reviewed for all Manitobans undergoing first procedure for medically refractory MS-TN between 2000 and 2014. Subsequent procedures were then recorded and analyzed in this subgroup of patients. The primary outcome measure was time to treatment failure.

RESULTS

The incidence of medically refractory MS-TN was 1.2/million/year. Twenty-one patients with 26 surgically treated sides underwent first rhizotomy including 13 GammaKnife and 13 percutaneous rhizotomies comprised of ten glycerol injections and three balloon compressions. Subsequent procedures were required on 23 sides (88%), including 24 GammaKnife, 19 glycerol injections, 25 balloon compressions, two microvascular decompressions, and four open partial surgical rhizotomies with a total of 99 surgeries on 26 sides (range, 1-12 each).

CONCLUSIONS

The majority of MS-TN patients become medically refractory and require multiple repeat surgical procedures. MS-TN procedures were associated with high rates of pain recurrence and our data suggests reoperation within 1 year is often necessary. Optimal management strategy in this patient population remains to be determined. Patients need to be counseled on managing expectations as treatments commonly afford only temporary relief.

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.

Trigeminal Neuralgia Commonly Precedes the Diagnosis of Multiple Sclerosis

BACKGROUND

Trigeminal neuralgia (TN) is a well-recognized cause of facial pain in the general population, and multiple sclerosis (MS) accounts for some of these cases. However, the prevalence of TN in MS is poorly understood. We investigated the prevalence of TN and how often TN is the initial presentation of MS in a large MS cohort.

METHODS

In 2009, we surveyed participants in the North America Research Committee on Multiple Sclerosis Registry regarding TN, including date of onset and pharmacologic and nonpharmacologic treatments used. We estimated the frequency of TN and the frequency with which TN preceded the diagnosis of MS. We compared the demographic and clinical characteristics of participants who reported TN with those of participants who did not using descriptive statistics and logistic regression.

RESULTS

Among 8590 eligible survey respondents, the prevalence of TN was 830 (9.7%). Of these respondents, 588 reported the year when TN was diagnosed. The diagnosis of TN preceded that of MS in 88 respondents (15.0%), and the mean ± SD age at diagnosis of TN was 45.3 ± 11.0 years. The odds of reporting TN were higher in women and those with greater disability and longer disease duration. Pharmacologic treatments were used by 88.3% of respondents; 9.7% underwent surgical interventions.

CONCLUSIONS

In MS, TN occurs frequently and precedes the diagnosis of MS in 15.0% of individuals. Given the frequency of TN in MS, further epidemiological studies and clinical trials to identify effective pharmacologic and nonpharmacologic therapies for TN in MS are warranted.