scholarly journals Radiosurgery for multiple sclerosis–related trigeminal neuralgia: retrospective review of long-term outcomes

2019 ◽  
Vol 131 (5) ◽  
pp. 1583-1590 ◽  
Author(s):  
Colin J. Przybylowski ◽  
Tyler S. Cole ◽  
Jacob F. Baranoski ◽  
Andrew S. Little ◽  
Kris A. Smith ◽  
...  
Keyword(s):  
Multiple Sclerosis ◽  
Trigeminal Neuralgia ◽  
Retrospective Review ◽  
Pain Control ◽  
Facial Pain ◽  
Salvage Treatment ◽  
Long Term Outcomes ◽  
Facial Numbness

OBJECTIVEThe objective of this study was to assess long-term outcomes of facial pain and numbness after radiosurgery for multiple sclerosis (MS)–related trigeminal neuralgia (MS-TN).METHODSThe authors conducted a retrospective review of their Gamma Knife radiosurgeries (GKRSs) to identify all patients treated for MS-TN (1998–2014) with at least 3 years of follow-up. Treatment and clinical data were obtained via chart review and mailed or telephone surveys. Pain control was defined as a facial pain score of I–IIIb on the Barrow Neurological Institute (BNI) Facial Pain Intensity Scale. Kaplan-Meier analysis was performed to determine the rates of pain control after index and first salvage GKRS procedures. Patients could have had more than 1 salvage procedure. Pain control rates were based on the number of patients at risk during follow-up.RESULTSOf the 50 living patients who underwent GKRS, 42 responded to surveys (31 women [74%], median age 59 years, range 32–76 years). During the initial GKRS, the trigeminal nerve root entry zone was targeted with a single isocenter, using a 4-mm collimator with the 90% isodose line completely covering the trigeminal nerve and the 50% isodose line abutting the surface of the brainstem. The median maximum radiation dose was 85 Gy (range 50–85 Gy). The median follow-up period was 78 months (range 36–226 months). The rate of pain control after the index GKRS (n = 42) was 62%, 29%, 22%, and 13% at 1, 3, 5, and 7 years, respectively. Twenty-eight patients (67%) underwent salvage treatment, including 25 (60%) whose first salvage treatment was GKRS. The rate of pain control after the first salvage GKRS (n = 25) was 84%, 50%, 44%, and 17% at 1, 3, 5, and 7 years, respectively. The rate of pain control after the index GKRS with or without 1 salvage GKRS (n = 33) was 92%, 72%, 52%, 46%, and 17% at 1, 3, 5, 7, and 10 years, respectively. At last follow-up, 9 (21%) of the 42 patients had BNI grade I facial pain, 35 (83%) had achieved pain control, and 4 (10%) had BNI grade IV facial numbness (very bothersome in daily life).CONCLUSIONSIndex GKRS offers good short-term pain control for MS-TN, but long-term pain control is uncommon. If the index GKRS fails, salvage GKRS appears to offer beneficial pain control with low rates of bothersome facial numbness.

The Treatment of Trigeminal Neuralgia in Patients with Multiple Sclerosis using Percutaneous Radiofrequency Rhizotomy

2003 ◽  
Vol 30 (3) ◽  
pp. 220-223 ◽  
Author(s):  
Caglar Berk ◽  
Constantine Constantoyannis ◽  
Christopher R. Honey
Keyword(s):  
Multiple Sclerosis ◽  
Trigeminal Neuralgia ◽  
Recurrence Rate ◽  
Pain Control ◽  
Bilateral Presentation ◽  
Facial Numbness ◽  
Poor Tolerance ◽  
Percutaneous Rhizotomy ◽  
Pain Distribution

ABSTRACT:Background:Trigeminal neuralgia (TN) has a higher incidence among patients with multiple sclerosis (MS) than in the general population. This cohort of MS patients with TN presents a series of management challenges including poor tolerance of antineuralgic medications and occasional bilateral presentation. We analyzed our surgical series of MS patients presenting with TN who were treated with percutaneous radiofrequency rhizotomy to estimate the success, failure and recurrence rate of this procedure for those patients.Methods:Surgical reports were retrospectively reviewed between the years 1996-2000. Patients with MS and TN who received a percutaneous rhizotomy during that time were included in the study and followed until the end of 2002. Data regarding age, sex, duration of MS and pain, response to medical treatment, pain distribution and surgical outcome were evaluated.Results:There were thirteen patients with MS and medically refractory TN treated with percutaneous radiofrequency rhizotomy. The average age at diagnosis for MS was 41 with TN beginning an average of eight years later. Following rhizotomy, complete pain relief without the need for any medication was achieved in 81% of the patients. The addition of medications resulted in pain control in the remaining patients. During a mean follow-up period of 52 months, there was a 50% recurrence rate. There were no complications related to the procedure and the associated facial numbness was well-tolerated.Conclusions:Percutaneous radiofrequency rhizotomy is a safe and effective method for the treatment of TN in patients with MS. The unique susceptibility of this cohort to the side effects of antineuralgic medications may require early consideration of rhizotomy.

Long-Term Outcomes in the Treatment of Classical Trigeminal Neuralgia by Gamma Knife Radiosurgery

Neurosurgery ◽  
2016 ◽  
Vol 79 (6) ◽  
pp. 879-888 ◽  
Author(s):  
Nuria E. Martínez Moreno ◽  
Jorge Gutiérrez-Sárraga ◽  
Germán Rey-Portolés ◽  
Adolfo Jiménez-Huete ◽  
Roberto Martínez Álvarez
Keyword(s):  
Trigeminal Neuralgia ◽  
Gamma Knife ◽  
Gamma Knife Radiosurgery ◽  
Response Rates ◽  
Complete Response ◽  
Long Term Outcomes ◽  
Classical Trigeminal Neuralgia ◽  
Facial Numbness

Abstract BACKGROUND: Gamma knife radiosurgery (GKRS) is one of the alternatives for treatment for classical trigeminal neuralgia (TN). OBJECTIVE: To retrospectively analyze long-term outcomes for TN using GKRS achieved at our institution. METHODS: One hundred seventeen patients with medically refractory TN treated by GKRS at our institution were followed up between 1993 and 2011. Mean maximum dose was 86.5 Gy (range: 80-90 Gy; median: 90 Gy). Clinical response was defined based on the Burchiel classification. We considered classes I and II as a complete response. For toxicity, we use the Barrow Neurological Institute facial numbness scale. Mean duration of follow-up was 66 months (range: 24-171 months). RESULTS: Complete response at last follow-up in our patients was 81%, with an excellent response while off medication in 52%. Pain-free rates without medication (class I) were 85% at 3 years (confidence interval [CI]: 78%-94%), 81% at 5 years (CI: 72%-91%), and 76% at 7 years (CI: 65%-90%). Complete response rates (classes I-II) were 91% at 3 years (CI: 86%-97%), 86% at 5 years (CI: 79%-93%), and 82% at 7 years (CI: 72%-93%). Poor treatment response rates differed significantly between patients who had undergone previous surgery and were refractory to management with medication prior to GKRS. New or worsening facial numbness was reported in 32.5% (30% score II and 2.5% score III). No anesthesia dolorosa was reported. Permanent recurrence pain rate was 12%. CONCLUSION: GKRS achieved favorable outcomes compared with surgery in terms of pain relief and complication rates in our cohort of patients, notwithstanding decreasing pain-free survival rates over time. We consider GKRS to be an initial treatment in the management of medically intractable TN in selected patients.

Linear accelerator–based radiosurgery for trigeminal neuralgia: comparative outcomes of frame-based and mask-based techniques

2021 ◽  
pp. 1-10
Author(s):  
Jenny C. Kienzler ◽  
Stephen Tenn ◽  
Srinivas Chivukula ◽  
Fang-I Chu ◽  
Hiro D. Sparks ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Pain Control ◽  
Linear Accelerator ◽  
Initial Response ◽  
Time To Recurrence ◽  
Facial Numbness ◽  
The Mean

OBJECTIVE Precise and accurate targeting is critical to optimize outcomes after stereotactic radiosurgery (SRS) for trigeminal neuralgia (TN). The aim of this study was to compare the outcomes after SRS for TN in which two different techniques were used: mask-based 4-mm cone versus frame-based 5-mm cone. METHODS The authors performed a retrospective review of patients who underwent SRS for TN at their institution between 1996 and 2019. The Barrow Neurological Institute (BNI) pain score and facial hypesthesia scale were used to evaluate pain relief and facial numbness. RESULTS A total of 234 patients were included in this study; the mean age was 67 years. In 97 patients (41.5%) radiation was collimated by a mask-based 4-mm cone, whereas a frame-based 5-mm cone was used in the remaining 137 patients (58.5%). The initial adequate pain control rate (BNI I–III) was 93.4% in the frame-based 5-mm group, compared to 87.6% in the mask-based 4-mm group. This difference between groups lasted, with an adequate pain control rate at ≥ 24 months of 89.9% and 77.8%, respectively. Pain relief was significantly different between groups from initial response until the last follow-up (≥ 24 months, p = 0.02). A new, permanent facial hypesthesia occurred in 30.3% of patients (33.6% in the frame-based 5-mm group vs 25.8% in the mask-based 4-mm group). However, no significant association between the BNI facial hypesthesia score and groups was found. Pain recurrence occurred earlier (median time to recurrence 12 months vs 29 months, p = 0.016) and more frequently (38.1% vs 20.4%, p = 0.003) in the mask-based 4-mm than in the frame-based 5-mm group. CONCLUSIONS Frame-based 5-mm collimator SRS for TN resulted in a better long-term pain relief with similar toxicity profiles to that seen with mask-based 4-mm collimator SRS.

scholarly journals Long-Term Results after Glycerol Rhizotomy for Multiple Sclerosis-Related Trigeminal Neuralgia

1994 ◽  
Vol 21 (2) ◽  
pp. 137-140 ◽  
Author(s):  
Douglas Kondziolka ◽  
L. Dade Lunsford ◽  
David J. Bissonette
Keyword(s):  
Multiple Sclerosis ◽  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Surgical Procedures ◽  
Pain Control ◽  
Long Term Results ◽  
Sensory Loss ◽  
Single Patient

Abstract:Percutaneous retrogasserian glycerol rhizotomy (PRGR) was used during an 11-year interval in 53 patients with typical trigeminal neuralgia associated with multiple sclerosis. All patients had failed extensive medical trials prior to PRGR. Long-term (median follow-up, 36 months) complete pain relief (no further medication) was achieved in 29 (59%) of 49 evaluable patients. Eight patients (16%) had satisfactory pain control but required occasional medication. Twelve patients (25%) had initial unsatisfactory results with inadequate pain relief; nine underwent alternative surgical procedures. Sixteen patients (30%) subsequently required repeat glycerol rhizotomies to reachieve pain control. Twenty-seven patients (60% of 45 patients evaluated for this finding) retained normal trigeminal sensation after injection. Major trigeminal sensory loss developed in a single patient who had four glycerol rhizotomies over a 25-month interval. No patient developed deafferentation pain. We believe that PRGR is a low-morbidity, effective, and repeatable surgical procedure for the management of trigeminal neuralgia in the setting of multiple sclerosis.

Microvascular Transposition Without Teflon: A Single Institution's 17-Year Experience Treating Trigeminal Neuralgia

2021 ◽  
Vol 20 (4) ◽  
pp. 397-405
Author(s):  
Andrew R Pines ◽  
Richard J Butterfield ◽  
Evelyn L Turcotte ◽  
Jose O Garcia ◽  
Noel De Lucia ◽  
...  
Keyword(s):  
Multiple Sclerosis ◽  
Postoperative Pain ◽  
Trigeminal Neuralgia ◽  
Fibrin Glue ◽  
Microvascular Decompression ◽  
Inclusion Criteria ◽  
Kaplan Meier ◽  
Trigeminal Nerve Root

Abstract BACKGROUND Trigeminal neuralgia (TN) refractory to medical management is often treated with microvascular decompression (MVD) involving the intracranial placement of Teflon. The placement of Teflon is an effective treatment, but does apply distributed pressure to the nerve and has been associated with pain recurrence. OBJECTIVE To report the rate of postoperative pain recurrence in TN patients who underwent MVD surgery using a transposition technique with fibrin glue without Teflon. METHODS Patients were eligible for our study if they were diagnosed with TN, did not have multiple sclerosis, and had an offending vessel that was identified and transposed with fibrin glue at our institution. All eligible patients were given a follow-up survey. We used a Kaplan-Meier (KM) model to estimate overall pain recurrence. RESULTS A total of 102 patients met inclusion criteria, of which 85 (83%) responded to our survey. Overall, 76 (89.4%) participants responded as having no pain recurrence. Approximately 1-yr pain-free KM estimates were 94.1% (n = 83), 5-yr pain-free KM estimates were 94.1% (n = 53), and 10-yr pain-free KM estimates were 83.0% (n = 23). CONCLUSION Treatment for TN with an MVD transposition technique using fibrin glue may avoid some cases of pain recurrence. The percentage of patients in our cohort who remained pain free at a maximum of 17 yr follow-up is on the high end of pain-free rates reported by MVD studies using Teflon. These results indicate that a transposition technique that emphasizes removing any compression near the trigeminal nerve root provides long-term pain-free rates for patients with TN.

Efficacy of Internal Neurolysis for Trigeminal Neuralgia without Vascular Compression

2021 ◽  
Author(s):  
Ming-Wu Li ◽  
Xiao-feng Jiang ◽  
Chaoshi Niu
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Chart Review ◽  
Vascular Compression ◽  
Internal Neurolysis ◽  
Facial Numbness ◽  
Relief Rate

Abstract Background and Objective Trigeminal neuralgia is a common neurologic disease that seriously impacts a patient's quality of life. We retrospectively investigated the efficacy and safety of internal neurolysis (nerve combing) for trigeminal neuralgia without vascular compression. Patients and Methods This study was a retrospective review of all patients with trigeminal neuralgia who were admitted between January 2014 and February 2019. A subgroup of 36 patients had no vascular compression at surgery and underwent internal neurolysis. Chart review and postoperative follow-up were performed to assess the overall outcomes of internal neurolysis. Results Thirty-six patients were identified, with a mean age of 44.89 ± 7.90 (rang: 31–65) years and a disease duration of 5.19 ± 2.61 years. The immediate postoperative pain relief (Barrow Neurological Institute [BNI] pain score of I or II) rate was 100%. The medium- to long-term pain relief rate was 91.7%. Three patients experienced recurrence. Facial numbness was the primary postoperative complication. Four patients with a score of III on the BNI numbness scale immediately after surgery had marked improvement at 6 months. No serious complications occurred. Conclusion Internal neurolysis is a safe and effective treatment for trigeminal neuralgia without vascular compression or clear responsible vessels.

Patterns of opioid use in patients with trigeminal neuralgia undergoing neurosurgery

2019 ◽  
Vol 131 (6) ◽  
pp. 1805-1811
Author(s):  
Andrew I. Yang ◽  
Brendan J. McShane ◽  
Frederick L. Hitti ◽  
Sukhmeet K. Sandhu ◽  
H. Isaac Chen ◽  
...  
Keyword(s):  
Trigeminal Neuralgia ◽  
Facial Pain ◽  
Opioid Use ◽  
Exact Test ◽  
Fisher's Exact Test ◽  
Fisher’S Exact Test ◽  
Long Term Follow Up ◽  
Neurosurgical Intervention

OBJECTIVEFirst-line treatment for trigeminal neuralgia (TN) is pharmacological management using antiepileptic drugs (AEDs), e.g., carbamazepine (CBZ) and oxcarbazepine (OCBZ). Surgical intervention has been shown to be an effective and durable treatment for TN that is refractory to medical therapy. Despite the lack of evidence for efficacy in patients with TN, the authors hypothesized that patients with neuropathic facial pain are prescribed opioids at high rates, and that neurosurgical intervention may lead to a reduction in opioid use.METHODSThis is a retrospective study of patients with facial pain seen by a single neurosurgeon. All patients completed a survey on pain medications, medical comorbidities, prior interventions for facial pain, and a validated pain outcome tool (the Penn Facial Pain Scale). Patients subsequently undergoing neurosurgical intervention completed a survey at the 1-month follow-up in the office, in addition to telephone interviews using a standardized script between 1 and 6 years after intervention. Univariate and multivariate logistic regression were used to predict opioid use.RESULTSThe study cohort consisted of 309 patients (70% Burchiel type 1 TN [TN1], 18% Burchiel type 2 [TN2], 6% atypical facial pain [AFP], and 6% TN secondary to multiple sclerosis [TN-MS]). At initial presentation, 20% of patients were taking opioids. Of these patients, 55% were receiving concurrent opioid therapy with CBZ/OCBZ, and 84% were receiving concurrent therapy with at least one type of AED. Facial pain diagnosis (for diagnoses other than TN1, odds ratio [OR] 2.5, p = 0.01) and facial pain intensity at its worst (for each unit increase, OR 1.4, p = 0.005) were predictors of opioid use at baseline. Neurosurgical intervention led to a reduction in opioid use to 8% at long-term follow-up (p < 0.01, Fisher’s exact test; n = 154). Diagnosis (for diagnoses other than TN1, OR 4.7, p = 0.002) and postintervention reduction in pain at its worst (for each unit reduction, OR 0.8, p < 10−3) were predictors of opioid use at long-term follow-up. On subgroup analysis, patients with TN1 demonstrated a decrease in opioid use to 5% at long-term follow-up (p < 0.05, Fisher’s exact test), whereas patients with non-TN1 facial pain did not. In the nonsurgical group, there was no statistically significant decrease in opioid use at long-term follow-up (n = 81).CONCLUSIONSIn spite of its high potential for abuse, opioid use, mostly as an adjunct to AEDs, is prevalent in patients with facial pain. Opportunities to curb opioid use in TN1 include earlier neurosurgical intervention.

scholarly journals Peripheral nerve field stimulation in medically refractory trigeminal neuralgia attributed to multiple sclerosis

2020 ◽  
pp. 1-7
Author(s):  
Johann Klein ◽  
Timo Siepmann ◽  
Gabriele Schackert ◽  
Tjalf Ziemssen ◽  
Tareq A. Juratli
Keyword(s):  
Multiple Sclerosis ◽  
Adverse Events ◽  
Trigeminal Neuralgia ◽  
Peripheral Nerve ◽  
Case Reports ◽  
Pain Severity ◽  
Field Stimulation ◽  
Peripheral Nerve Field Stimulation

OBJECTIVECase reports and small patient series have suggested peripheral nerve field stimulation (PNFS) as a treatment for refractory trigeminal neuralgia attributed to multiple sclerosis (MS). Here, the authors aimed to assess the effects of this technique on long-term pain severity.METHODSData were prospectively collected on patients with refractory trigeminal neuralgia attributed to MS who underwent PNFS between July 2013 and August 2017 at the authors’ neurosurgical department. Patients were evaluated before and after the first treatment as well as at follow-up at least twice a year. Patients underwent assessment of their pain severity using the Barrow Neurological Institute (BNI) Scale before treatment and at follow-up and were questioned about adverse events following cranial MRI performed after implantation of a permanent PNFS system.RESULTSEight patients (3 women) underwent PNFS trials and their median age was 61 years (IQR 73.75 − 46.5 years). Seven patients proceeded to permanent implantation of the stimulation system. At a median follow-up of 33 months (IQR 42 − 24 months), pain severity decreased from baseline to the last follow-up (BNI score decrease from V [IQR V − V] to III [IQR V − III], p = 0.054). Four patients experienced long-lasting benefit (at 48, 33, 24, and 15 months’ follow-up, respectively), while in 3 patients the treatment eventually failed after an initially successful period. One patient had an infection, requiring system removal and subsequent reimplantation. No other complications occurred. No adverse events were noted in the patients undergoing MRI postimplantation.CONCLUSIONSThis analysis indicates a possibly beneficial long-term effect of PNFS on refractory trigeminal neuralgia attributed to MS in some patients.

scholarly journals Surgical Outcomes After Microvascular Decompression With Internal Neurolysis and Partial Neurectomy for Patients With Trigeminal Neuralgia and Negative Neurovascular Compression

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Amanda Carpenter ◽  
James K Liu
Keyword(s):  
Trigeminal Neuralgia ◽  
Microvascular Decompression ◽  
Neurovascular Compression ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Root Entry Zone ◽  
Internal Neurolysis ◽  
Facial Numbness

Abstract INTRODUCTION Microvascular decompression (MVD) is an effective and durable treatment for patients with trigeminal neuralgia (TN) due to neurovascular compression (NVC). In the absence of NVC, the traditional MVD is less effective in achieving long-term pain relief. Internal neurolysis at the root entry zone (REZ) of the trigeminal nerve has been described in the literature; however, there are few reports of long-term outcome after this procedure. Furthermore, this is the first study to combine this procedure with additional partial neurectomy. METHODS This is a retrospective review of the senior author's patients with TN who underwent retrosigmoid craniectomy for MVD with internal neurolysis and partial neurectomy. Primary indications were patients with TN and no evidence of NVC intraoperatively. A total of 9 patients were included in the analysis. Three cases were of recurrent TN. The technique was performed with an 11-blade or arachnoid knife to open the perineurium in a longitudinal fashion at the REZ. A disc dissector was used to comb the fascicles along the longitudinal course, and a partial neurectomy was performed with a microscissors to make three selective cuts into the fascicles at the REZ. Barrow Neurological Institute (BNI) facial pain and numbness scales were used as postoperative assessment. RESULTS At median follow up of 12 mo (range: 2 to 34), 8 of 9 patients (89%) had a BNI-pain score of I (no trigeminal pain, no medications). Two of nine patients (22%) had a BNI-numbness score of I (no numbness); seven (78%) had a BNI-numbness score of II (mild facial numbness that is not bothersome). CONCLUSION Internal neurolysis with partial neurectomy appears to be an effective and potentially durable treatment option for patients with TN (primary or recurrent) without NVC. Larger series with longer follow-up is indicated to further evaluate the utility of this procedure.

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