Brisman R: Treatment of Trigeminal Neuralgia associated with
Multiple Sclerosis. World Neurosurg 2013 Oct 14 [Epub ahead of print].
The following is a revised personal version of the text of the final journal article.
Perspective Statement by Ronald Brisman, M.D.
on Outcomes after Microvascular Decompression for Patients with
Trigeminal Neuralgia and Suspected Multiple Sclerosis by Ariai MS, et
al. World Neurosurg 2013 Oct 14 [Epub ahead of print].
is more difficult to treat in patients with multiple
sclerosis (MS) than in those without MS. Patients with TN and MS are
more likely to be medically intractable because their MS symptoms are
often worsened by the antiseizure medicines used to treat TN, especially
when used in higher doses. The cause of pain in those with TNMS is in
the brainstem and the denervating lesion that we make is in the nerve
before it enters the brainstem. TNMS is often bilateral and may require
bilateral treatment with special care to avoid profound bilateral
sensory or motor trigeminal denervation, which can be functionally
devastating. Patients with TNMS are often younger and have more years to
Fortunately, we have effective, minimally
invasive neurosurgical techniques to treat TN, such as percutaneous
denervations (2, 5, 6, 7) and radiosurgery (7, 10, 13), which are
particularly helpful for patients with TN and MS.
microvascular decompression (MVD) is effective for patients with
idiopathic TN without MS, the question has been raised as to whether or
not it would help patients with TN and MS, some of whom will have a
blood vessel in contact with the trigeminal nerve. Several studies
suggest that MVD is not very helpful for TN with MS as the recurrence
rate is high (1, 4, 9) (and much higher than in those without MS) and
complications are not infrequent (4, 8, 12).
resolution MRI will show blood vessel contact with the trigeminal nerve
less often with TNMS than with idiopathic TN, many of the patients with
TNMS (3) and TN with suspected MS (1) who are operated on will
demonstrate vascular/nerve contact under the operating microscope.
However, when microvascular decompression is done without rhizotomy,
pain relief is not likely to be sustained and the presence or absence of
a neurovascular contact does not seem to influence the result (3). This
suggests that the temporary pain relief is due to partial denervation
done during manipulation of the nerve. If a partial rhizotomy is
explicitly done, pain relief is more likely, but so is numbness.
the present issue of World Neurosurgery (1), Ariai et al report
outcomes in 10 patients after MVD for patients with TN and suspected MS.
Nine patients had symptoms characteristic of typical trigeminal
neuralgia. All these patients had medically intractable face pain and an
ipsilateral brainstem T2 hyperintensity. Five had additional clinical
features consistent with MS. Three patients had a neurovascular contact
demonstrated on pre-operative MRI. At surgery, a clear neurovascular
contact was found in 9 cases. Actuarial rates of being pain-free off
medications were 50% at 3 months and 15% at 2 years and this one good
result may have been the one patient who was treated with partial
rhizotomy (although this is not clearly stated). The poor results
regarding pain relief in these patients with suspected MS and a
brainstem demyelinating lesion who had microvascular decompression of a
nerve/vessel contact suggest that the brainstem lesion is the primary
cause of the TN pain and not the vascular contact or compression. The
brainstem lesion is similarly the cause of the TN and not the vascular
contact or compression in patients with confirmed MS.
MVD is a
particularly unattractive option for treating TN with MS or TN with
suspected MS: it does not usually provide long-term relief of pain and
is a major operation that has the potential for many complications.
Patients with MS are more vulnerable to the effects of such surgery with
3 of 9 patients in one study suffering from significant morbidity
associated with worsening of their MS (4); mortality (5 days after
surgery from pulmonary infection) occurred in 1 of 2 cases (8); and
lasting problems occurred in 5 of 15 MVDs (33%) (12) compared with 20 of
135 (15%) patients without MS (11).
According to Jannetta and
colleagues, “Microvascular decompression of the trigeminal nerve is not
an adequate or reliable cure for trigeminal neuralgia in patients with
MS. Because these patients have intrinsic abnormalities of the myelin at
the nerve root entry zone, destructive lesions appear to be necessary
for the effective alleviation of pain (9).”
While an open
operation in the posterior fossa can sometimes give relief of TNMS or
suspected MS with an ipsilateral T2 brainstem hyperintensity on MRI (1),
it does so by denervation and not by relieving vascular compression.
There are much safer ways of doing this denervation. These include
percutaneous denervations with radiofrequency electrocoagulation (RFE),
glycerol or balloon. (The percutaneous procedure that I prefer is RFE
and/or glycerol as it is easily repeated, if necessary, and has fewer
complications than the balloon microcompression.) Also effective and
even less invasive is Gamma Knife radiosurgery (7, 10, 13). By having
available multiple, minimally invasive procedures such as RFE, glycerol
and Gamma Knife radiosurgery, the neurosurgeon has a powerful
armamentarium for safely relieving pain in the otherwise difficult
situation of TNMS, which may need more than one procedure either because
of recurrence or bilaterality in patients who are often medically or
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