Management of medically refractory trigeminal neuralgia in patients with multiple sclerosis

Object Trigeminal neuralgia (TN) is a painful disorder that frequently causes lancinating, electrical shock–like pain in the trigeminal distribution. Common surgical treatments include microvascular decompression (MVD), radio-surgery, and radiofrequency ablation, and complete pain relief is generally achieved with a single treatment in 70 to 85% of cases for all modalities. In a subset of patients with multiple sclerosis (MS), however, the rates of surgical treatment failure and the need for additional procedures are significantly increased compared with those in patients without MS. In this study the authors report their experience with a cohort of 11 patients with TN who also had MS, and assess the efficacy of MVD, gamma knife surgery (GKS), and radiofrequency ablation in achieving complete or partial long-term pain relief. Methods Eleven patients with TN and MS who were treated by the senior author (N.B.) at the University of California, San Francisco were included in this study. All patients underwent GKS and/or radiofrequency ablation, and four received MVD. A detailed clinical history and intraoperative findings were recorded for each patient and frequent follow-up evaluations were performed, with a mean follow-up duration of 40.6 months (range 1–96 months). Pain was assessed for each patient by using the Barrow Neurological Institute scale (Scores I–V). Conclusions Achieving complete pain relief in patients with TN and MS required significantly more treatments compared with all other patients with TN who did not have MS (p = 0.004). Even when compared with a group of 32 patients who had highly refractory TN, the cohort with MS required significantly more treatments (p = 0.05). Radiosurgery proved to be an effective procedure and resulted in fewer retreatments and longer pain-free intervals compared with MVD or radiofrequency ablation.

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Long-term Follow-up of Patients Treated with Percutaneous Radiofrequency Thermocoagulation via the Foramen Rotundum for Isolated Maxillary Nerve Idiopathic Trigeminal Neuralgia

Pain Medicine ◽

10.1093/pm/pnz006 ◽

2019 ◽

Vol 20 (7) ◽

pp. 1370-1378 ◽

Cited By ~ 3

Author(s):

Bing Ran ◽

Jun Wei ◽

Qiong Zhong ◽

Min Fu ◽

Jun Yang ◽

...

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Sagittal Plane ◽

Ct Guided ◽

Radiofrequency Thermocoagulation ◽

Complete Pain Relief ◽

Idiopathic Trigeminal Neuralgia ◽

Foramen Rotundum ◽

The Mean

Abstract Objective The purpose of this study is to evaluate the effectiveness and safety of percutaneous radiofrequency thermocoagulation (PRT) via the foramen rotundum (FR) for the treatment of isolated maxillary (V2) idiopathic trigeminal neuralgia (ITN) and assess the appropriate puncture angle through the anterior coronoid process to reach the FR. Methods Between January 2011 and October 2016, 87 patients with V2 ITN refractory to conservative treatment were treated by computed tomography (CT)–guided PRT via the FR at our institution. The outcome of pain relief was assessed by the visual analog scale (VAS) and Barrow Neurological Institute (BNI) pain grade and grouped as complete pain relief (BNI grades I–III) or unsuccessful pain relief (BNI grades IV–V). Recurrence and complications were also monitored and recorded. The puncture angle for this novel approach was assessed based on intraoperative CT images. Results Of the 87 treated patients, 85 (97.7%) achieved complete pain relief, and two patients (2.3%) experienced unsuccessful pain relief immediately after operation. During the mean follow-up period of 44.3 months, 15 patients (17.2%) experienced recurring pain. No severe complications occurred, except for hypoesthesia restricted to the V2 distribution in all patients (100%) and facial hematoma in 10 patients (11.5%). The mean puncture angle to reach the FR was 33.6° ± 5.7° toward the sagittal plane. Discussion CT-guided PRT via the FR for refractory isolated V2 ITN is effective and safe and could be a rational therapy for patients with V2 ITN.

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Systematic Review of Ablative Neurosurgical Techniques for the Treatment of Trigeminal Neuralgia

Neurosurgery ◽

10.1227/01.neu.0000114867.98896.f0 ◽

2004 ◽

Vol 54 (4) ◽

pp. 973-983 ◽

Cited By ~ 217

Author(s):

Benjamin C. Lopez ◽

Peter J. Hamlyn ◽

Joanna M. Zakrzewska

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Stereotactic Radiosurgery ◽

Quality Criteria ◽

Controlled Trials ◽

Randomized Controlled ◽

Radiofrequency Thermocoagulation ◽

Complete Pain Relief ◽

Glycerol Rhizolysis

Abstract OBJECTIVE There are no randomized controlled trials comparing retrogasserian percutaneous radiofrequency thermocoagulation, glycerol rhizolysis, balloon compression of the gasserian ganglion, and stereotactic radiosurgery, nor are there systematic reviews using predefined quality criteria. The objective of this study was to systematically identify all of the studies reporting outcomes and complications of ablative techniques for treatment of trigeminal neuralgia, from the development of electronic databases, and to evaluate them with predefined quality criteria. METHODS Inclusion criteria for the outcome analysis included thorough demographic documentation, defined diagnostic and outcome criteria, a minimum of 30 patients treated and median/mean follow-up times of 12 months, not more than 20% of patients lost to follow-up monitoring, Kaplan-Meier actuarial analysis of individual procedures, less than 10% of patients retreated because of failure or early recurrence, and a minimal dose of 70 Gy for stereotactic radiosurgery. High-quality studies with no actuarial analysis were used for the evaluation of complications. RESULTS Of 175 studies identified, 9 could be used to evaluate rates of complete pain relief on a yearly basis and 22 could be used to evaluate complications. In mixed series, radiofrequency thermocoagulation offered higher rates of complete pain relief, compared with glycerol rhizolysis and stereotactic radiosurgery, although it demonstrated the greatest number of complications. CONCLUSION Radiofrequency thermocoagulation offers the highest rates of complete pain relief, although further data on balloon microcompression are required. It is essential that uniform outcome measures and actuarial methods be universally adopted for the reporting of surgical results. Randomized controlled trials are required to reliably evaluate new surgical techniques.

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

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100049076 ◽

1994 ◽

Vol 21 (2) ◽

pp. 137-140 ◽

Cited By ~ 46

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.

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EFFECT OF MICROVASCULAR DECOMPRESSION IN TRIGEMINAL NEURALGIA PATIENTS WITH OR WITHOUT CONSTANT PAIN

Neurosurgery ◽

10.1227/01.neu.0000335075.16858.ef ◽

2008 ◽

Vol 63 (1) ◽

pp. 93-100 ◽

Cited By ~ 46

Author(s):

Tiril Sandell ◽

Per Kristian Eide

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Senior Author ◽

Total Study Population ◽

Significant Pain ◽

Constant Pain ◽

Study Population ◽

First Time

ABSTRACT OBJECTIVE To study the effect of microvascular decompression (MVD) in trigeminal neuralgia (TN) patients with or without constant pain. METHODS The study includes all first-time MVDs for facial pain performed by the senior author (PKE) during the 6-year period from 1999 to 2005 in the Department of Neurosurgery at the National Hospital. At the time of follow-up, pain relief was assessed using a standard mail questionnaire; those patients still having residual pain were further examined in the outpatient clinic or interviewed by phone. RESULTS The total study population includes 135 patients who underwent initial MVDs (67% of MVDs for TN without constant pain and 33% of MVDs for TN with constant pain). At the time of follow-up, the response rate was 95%, which provided us with 128 patients. The median observation period was 38 months (range, 12–87 mo). For episodic pain, MVD caused complete (i.e., 100%) pain relief in 78% of TN patients without constant pain and in 77% of TN patients with constant pain before MVD, and a significant pain relief (i.e., worst pain marked as 0–3 cm on a 10-cm visual analog scale) in 85 and 81%, respectively. For constant pain, MVD caused complete pain relief in 70% of the TN patients with constant pain before MVD, and significant pain relief in 77%. CONCLUSION In TN patients with constant pain before MVD, significant relief of episodic and constant pain was observed in 81 and 77%, respectively. Hence, the presence of constant pain should not prevent TN patients from being offered MVD.

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Outcomes following single-treatment Gamma Knife surgery for trigeminal neuralgia with a minimum 3-year follow-up

Journal of Neurosurgery ◽

10.3171/2009.8.jns081706 ◽

2010 ◽

Vol 112 (4) ◽

pp. 766-771 ◽

Cited By ~ 51

Author(s):

Ron I. Riesenburger ◽

Steven W. Hwang ◽

Clemens M. Schirmer ◽

Vasilios Zerris ◽

Julian K. Wu ◽

...

Keyword(s):

Treatment Outcome ◽

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Gamma Knife Surgery ◽

Good Treatment ◽

Complete Pain Relief ◽

Good Treatment Outcome

Object Gamma Knife surgery (GKS) has been shown to be effective in treating trigeminal neuralgia (TN). Existing studies have demonstrated success rates of 69.1–85% with median follow-up intervals of 19–60 months. However, series with uniform long-term follow-up data for all patients have been lacking. In the present study the authors examined outcomes in a series of patients with TN who underwent a single GKS treatment followed by a minimum follow-up of 36 months. They used a clinical scale that simplifies the reporting of outcome data for patients with TN. Methods Fifty-three consecutive patients with typical, intractable TN received a median maximum radiation dose of 80 Gy applied with a single 4-mm isocenter to the affected trigeminal nerve. Follow-up data were obtained by clinical examination and questionnaire. Outcome results were categorized into the following classes (in order of decreasing success): Class 1A, complete pain relief without medications; 1B, complete pain relief with either a decrease or no change in medications; 1C, ≥ 50% pain relief without medications; 1D, ≥ 50% pain relief with either a decrease or no change in medications; and Class 2, < 50% pain relief and/or increase in medications. Patients with Class 1A–1D outcome (equivalent to Barrow Neurological Institute Grades I–IIIb) were considered to have a good treatment outcome, whereas in patients with Class 2 outcome (equivalent to Barrow Neurological Institute Grades IV and V) treatment was considered to have failed. Results A good treatment outcome from initial GKS was achieved in 31 (58.5%) patients for whom the mean follow-up period was 48 months (range 36–66 months). Outcomes at last follow-up were reflected by class status: Class 1A, 32.1% of patients; 1B, 1.9%; 1C, 3.8%; 1D, 20.8%; and Class 2, 41.5%. Statistical analysis showed no difference in outcomes between patients previously treated with microvascular decompression or rhizotomy compared with patients with no previous surgical treatments. Thirty-six percent of patients reported some degree of posttreatment facial numbness. Anesthesia dolorosa did not develop in any patient. Conclusions Despite a time-dependent deterioration in the success rate of GKS for medically intractable TN, the authors' study showed that > 50% of patients can be expected to have a good outcome based on their scoring system, with ~ 33% having an ideal outcome (pain free with no need for medications). Long-term data, as those presented here, are important when counseling patients on their treatment options.

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Comparative study of Gamma Knife surgery and percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia in patients with multiple sclerosis

Journal of Neurosurgery ◽

10.3171/2012.6.gks12987 ◽

2012 ◽

Vol 117 (Special_Suppl) ◽

pp. 175-180 ◽

Cited By ~ 18

Author(s):

David Mathieu ◽

Khaled Effendi ◽

Jocelyn Blanchard ◽

Mario Séguin

Keyword(s):

Multiple Sclerosis ◽

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Pain Control ◽

Pain Scale ◽

Gamma Knife Surgery ◽

Sensory Loss ◽

Morbidity Rate

Object Among patients with multiple sclerosis (MS) there is a high incidence of trigeminal neuralgia (TN), and outcomes after treatment seem inferior to those in patients suffering from idiopathic TN. The goal of this study was to evaluate clinical outcomes in patients with MS-related TN after Gamma Knife surgery (GKS) and compare them with those obtained using percutaneous retrogasserian glycerol rhizotomy (PRGR). Methods The authors retrospectively reviewed the charts of 45 patients with MS-related TN. The first procedure undertaken was GKS in 27 patients and PRGR in 18 patients. Pain had been present for a median of 60 months (range 12–276 months) in patients who underwent GKS and 48 months (range 12–240 months) in patients who underwent PRGR. The following outcome measures were assessed in both groups of patients: pain relief (using the Barrow Neurological Institute [BNI] Pain Scale), procedure-related morbidity, time to pain relief and recurrence, and subsequent procedures that were performed. Results The median duration of follow-up was 39 months (range 13–69 months) in the GKS group and 38 months (range 2–75 months) in the PRGR group. Reasonable pain control (BNI Pain Scale Scores I–IIIb) was noted in 22 patients (81.5%) who underwent GKS and in 18 patients (100%) who underwent PRGR. For patients who underwent GKS, the median time to pain relief was 6 months; for those who underwent PRGR, pain relief was immediate. In the GKS group12 patients required subsequent procedures (3 patients for absence of response and 9 patients for pain recurrence), whereas in the PRGR group 6 patients required subsequent procedures (all for pain recurrence). As of the last follow-up, complete or reasonable pain control was finally achieved in 23 patients (85.2%) in the GKS group and in 16 patients (88.9%) in the PRGR group. The morbidity rate was 22.2% in the GKS group (all due to sensory loss and paresthesia) and 66.7% in the PRGR group (mostly hypalgesia, with 2 patients having corneal reflex loss and 1 patient suffering from meningitis). Conclusions Both GKS and PRGR are satisfactory strategies for treating MS-related TN. Gamma Knife surgery has a lower rate of sensory and overall morbidity than PRGR, but requires a delay before pain relief occurs. The authors propose that patients with extreme pain in need of fast relief should undergo PRGR. For other patients, both management strategies can lead to satisfactory pain relief, and the choice should be made based on patient preference and expectations.

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CyberKnife radiosurgical rhizotomy for the treatment of atypical trigeminal nerve pain

Neurosurgical FOCUS ◽

10.3171/foc-07/12/e9 ◽

2007 ◽

Vol 23 (6) ◽

pp. E8 ◽

Cited By ~ 8

Author(s):

Chirag G. Patil ◽

Anand Veeravagu ◽

Regina S. Bower ◽

Gordon Li ◽

Steven D. Chang ◽

...

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Maximum Dose ◽

Single Session ◽

Complete Pain Relief ◽

Rate Of Success ◽

Median Maximum ◽

Better Than

Object Patients with atypical trigeminal neuralgia (TN) have unilateral pain in the trigeminal distribution that is dull, aching, or burning in nature and is constant or nearly constant. Studies of most radiosurgical and surgical series have shown lower response rates in patients with atypical TN. This study represents the first report of the treatment of atypical TN with frameless CyberKnife stereotactic radiosurgery (SRS). Methods Between 2002 and 2007, 7 patients that satisfied the criteria for atypical TN and underwent SRS were included in our study. A 6–8-mm segment of the trigeminal nerve was targeted, excluding the proximal 3 mm at the brainstem. All patients were treated in a single session with a median maximum dose of 78 Gy and a median marginal dose of 64 Gy. Results Outcomes in 7 patients with a mean age of 61.6 years and a median follow-up of 20 months are reported. Following SRS, 4 patients had complete pain relief, 2 had minimal pain relief with some decrease in the intensity of their pain, and 1 patient experienced no pain relief. Pain relief was reported within 1 week of SRS in 4 patients and at 4 months in 2 patients. After a median follow-up of 28 months, pain did not recur in any of the 4 patients who had reported complete pain relief. Complications after SRS included bothersome numbness in 3 patients and significant dysesthesias in 1 patient. Conclusions The authors have previously reported a 90% rate of excellent pain relief in patients with classic TN treated with CyberKnife SRS. Compared with patients with classic TN, patients with atypical TN have a lower rate of pain relief. Nevertheless, the nearly 60% rate of success after SRS achieved in this study is still comparable to or better than results achieved with any other treatment modality for atypical TN.

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Comparison of Stereotactic Radiosurgery and Radiofrequency Ablation for Trigeminal Neuralgia in Multiple Sclerosis Patients

Stereotactic and Functional Neurosurgery ◽

10.1159/000509315 ◽

2020 ◽

Vol 98 (6) ◽

pp. 378-385

Author(s):

Anthony T. Lee ◽

Kunal P. Raygor ◽

Felicia Elefant ◽

Mariann M. Ward ◽

Doris D. Wang ◽

...

Keyword(s):

Multiple Sclerosis ◽

Radiofrequency Ablation ◽

Pain Relief ◽

Trigeminal Neuralgia ◽

Treatment Outcomes ◽

Stereotactic Radiosurgery ◽

Adequate Pain Relief ◽

Final Treatment ◽

Surgical Options ◽

Multiple Sclerosis Patients

Background: The optimal treatment for medically refractory trigeminal neuralgia in multiple sclerosis (MS-TN) patients is unknown. Objective: To compare treatment outcomes between stereotactic radiosurgery (SRS) and radiofrequency ablation (RFA). Methods: We performed a retrospective study of MS-TN patients treated with SRS or RFA between 2002 and 2019. Outcomes included degree of pain relief, pain recurrence, and sensory changes, segregated based on initial treatment, final treatment following retreatment with the same modality, and crossover patients. Results: Sixty surgical cases for 42 MS-TN patients were reviewed. Initial pain freedom outcomes and rates of retreatment were similar (SRS: 30%; RFA: 42%). RFA resulted in faster onset of pain freedom (RFA: <1 week; SRS: 15 weeks; p < 0.001). SRS patients with pain relief had longer intervals to pain recurrence at 2 years (p = 0.044). Final treatment outcomes favored RFA for pain freedom/off-medication outcomes (RFA: 44%; SRS: 11%; p = 0.031), though RFA resulted in more paresthesia (RFA: 81%; SRS: 39%; p = 0.012). Both provided at least 80% of adequate pain relief. Crossover patients did not have improved pain relief. Conclusions: SRS and RFA are both valid surgical options for MS-TN. Discussion with providers will need to balance patient preference with their unique treatment characteristics.

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The Effect of Microvascular Decompression in Patients With Multiple Sclerosis and Trigeminal Neuralgia

Neurosurgery ◽

10.1227/01.neu.0000375491.81803.5d ◽

2010 ◽

Vol 67 (3) ◽

pp. 749-754 ◽

Cited By ~ 33

Author(s):

Tiril Sandell ◽

Per Kristian Eide

Keyword(s):

Multiple Sclerosis ◽

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Senior Author ◽

Preoperative Pain ◽

Entry Zone ◽

Root Entry Zone ◽

Constant Pain ◽

First Time

Abstract BACKGROUND Trigeminal neuralgia (TN) in patients with multiple sclerosis (MS) is thought to be caused by demyelinating plaques within the nerve root entry zone, the trigeminal nucleus, or the trigeminal tracts. OBJECTIVE To review our experience of microvascular decompression (MVD) in patients with MS and symptomatic TN. METHODS All first-time MVDs for symptomatic trigeminal neuralgia in patients with MS performed by the senior author during an 8-year period (1999–2007) in this department were reviewed. The preoperative pain components were differentiated as being 100% episodic pain, > 50% episodic pain, or > 50% constant pain. At follow-up, pain relief was assessed with a standard mail questionnaire; those still having residual pain were further examined in the outpatient clinic or interviewed by phone. RESULTS Of the 19 MS patients, 15 were available for follow-up. The median observation period was 55 months (range, 17–99 months). At follow-up, 7 of 15 patients (47%) were completely free of their episodic pain, and an additional 4 (27%) had significant relief of episodic pain (ie, worst pain marked as 0 to 3 cm on a 10-cm visual analog scale). Among the subgroup of 8 patients with a constant pain component, all were free of their constant pain, and 4 (50%) were free of their episodic pain. CONCLUSION In our 8-year experience of doing MVD in MS patients with TN, we found complete and significant relief of episodic TN in a large proportion of patients. Even those with a constant pain component before MVD were completely relieved of their constant pain. Thus, in patients with TN (with or without a constant pain component), the presence of MS should not prevent patients from being offered MVD.

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Percutaneous glycerol rhizotomy for trigeminal neuralgia in patients with multiple sclerosis: a long-term retrospective cohort study

Journal of Neurosurgery ◽

10.3171/2019.1.jns183093 ◽

2020 ◽

Vol 132 (5) ◽

pp. 1405-1413 ◽

Cited By ~ 1

Author(s):

Michael D. Staudt ◽

Holger Joswig ◽

Gwynedd E. Pickett ◽

Keith W. MacDougall ◽

Andrew G. Parrent

Keyword(s):

Multiple Sclerosis ◽

Pain Relief ◽

Trigeminal Neuralgia ◽

Retrospective Chart Review ◽

Medication Usage ◽

Free Response ◽

Free Survival ◽

Time To Recurrence ◽

Significant Difference

OBJECTIVEThe prevalence of trigeminal neuralgia (TN) in patients with multiple sclerosis (MS-TN) is higher than in the general population (idiopathic TN [ITN]). Glycerol rhizotomy (GR) is a percutaneous lesioning surgery commonly performed for the treatment of medically refractory TN. While treatment for acute pain relief is excellent, long-term pain relief is poorer. The object of this study was to assess the efficacy of percutaneous retrogasserian GR for the treatment of MS-TN versus ITN.METHODSA retrospective chart review was performed, identifying 219 patients who had undergone 401 GR procedures from 1983 to 2018 at a single academic institution. All patients were diagnosed with medically refractory MS-TN (182 procedures) or ITN (219 procedures). The primary outcome measures of interest were immediate pain relief and time to pain recurrence following initial and repeat GR procedures. Secondary outcomes included medication usage and presence of periprocedural hypesthesia.RESULTSThe initial pain-free response rate was similar between groups (p = 0.726): MS-TN initial GR 89.6%; MS-TN repeat GR 91.9%; ITN initial GR 89.6%; ITN repeat GR 87.0%. The median time to recurrence after initial GR was similar between MS-TN (2.7 ± 1.3 years) and ITN (2.1 ± 0.6 years) patients (p = 0.87). However, there was a statistically significant difference in the time to recurrence after repeat GR between MS-TN (2.3 ± 0.5 years) and ITN patients (1.2 ± 0.2 years; p < 0.05). The presence of periprocedural hypesthesia was highly predictive of pain-free survival (p < 0.01).CONCLUSIONSPatients with MS-TN achieve meaningful pain relief following GR, with an efficacy comparable to that following GR in patients with ITN. Initial and subsequent GR procedures are equally efficacious.

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