Trigeminal Neuralgia
Ronald Brisman, M.D.

Trigeminal Neuralgia Multiple Sclerosis

Brisman R: Treatment of Trigeminal Neuralgia associated with Multiple Sclerosis. World Neurosurg 2013 Oct 14 [Epub ahead of print]. http://dx.doi.org/10.1016/j.wneu.2013.10.018.

The following is a revised personal version of the text of the final journal article.

Perspective Statement by Ronald Brisman, M.D.
Commentary 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]. http://dx.doi.org/10.1016/j.wneu.2013.09.027 .
 
Trigeminal neuralgia (TN) 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 develop recurrence.

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.

Since 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).

Although high 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.

In 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 neurologically fragile.  

REFERENCES

1.      Ariai MS, Mallory GW, Pollock BE: Outcomes after microvascular decompression for patients with trigeminal neuralgia and suspected multiple sclerosis. World Neurosurg 2013 Oct 14 [Epub ahead of print], http://dx.doi.org/10.1016/j.wneu.2013.09.027.
   
2.    Brisman R: Trigeminal neuralgia and multiple sclerosis. Arch Neurol 44:379-381, 1087.

3.    Broggi G, Ferroli P, Franzini A, Nazzi V, Farina L, La Mantia L, Milanese C: Operative findings and outcomes of microvascular decompression for trigeminal neuralgia in 35 patients affected by multiple sclerosis. Neurosurgery 55:830-839, 2004.

4.    Eldridge PR, Sinha AK, Javadpour M, Littlechild P, Varma TRK: Microvascular decompression for trigeminal neuralgia in patients with multiple sclerosis. Stereo Funct Neurosurg 81:57-64, 2003.

5.    Kanpolat Y, Berk C, Savas A, Bekar A: Percutaneous controlled radiofrequency rhizotomy in the management of patient with trigeminal neuralgia due to multiple sclerosis. Acta Neurochirurgica (Wien) 142:685-690, 2000.
 
6.    Kondziolka D, Lunsford LD, Bissonette DJ: Long-term results after glycerol rhizotomy for multiple sclerosis-related trigeminal neuralgia. Can J Neurol Sci 21:137-140, 1994.

7.    Mathieu D, Effendi K, Blanchard J, Seguin M: Comparative study of Gamma Knife surgery and percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia in patients with multiple sclerosis. J Neurosurg (Suppl) 117:175-180, 2012.

8.    Meaney JFM, Watt JWG, Eldridge PR, Whitehouse GH, Wells JCDE, JB Miles: Association between trigeminal neuralgia and multiple sclerosis: role of magnetic resonance imaging. J Neurol Neurosurg Psych 59:253, 259, 1995.

9.    Resnick DK, Jannetta PJ, Lunsford LD, Bissonette DJ: Microvascular decompression for trigeminal neuralgia in patients with multiple sclerosis. Surg Neurol 46:358-362, 1996.

10.    Rogers CL, Shetter AG, Ponce FA, Fiedler JA, Smith KA, Speiser BL: Gamma knife radiosurgery for trigeminal neuralgia associated with multiple sclerosis. J Neurosurg (Suppl 5) 97:529-532, 2002.

11.    Sandell T, Eide PK: Effect of microvascular decompression in trigeminal neuralgia patients with or without constant pain. Neurosurg 63:93-100, 2008.

12.    Sandell T, Eide PK: The effect of microvascular decompression in patients with multiple sclerosis and trigeminal neuralgia. Neurosurg 67:749-754, 2010.

13.    Zorro O, Lobato-Polo J, Kano H, Flickinger JC, Lunsford LD, Kondziolka D: Gamma knife radiosurgery for multiple sclerosis-related trigeminal neuralgia. Neurology 73:1149-1154, 2009.
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