Percutaneous balloon compression trigeminal rhizotomy for multiple sclerosis related trigeminal neuralgia

Percutaneous balloon compression trigeminal rhizotomy for multiple sclerosis related trigeminal neuralgia

Many patients with multiple sclerosis related trigeminal neuralgia have pain that is centrally mediated, reducing the effectiveness of procedures performed on the trigeminal roottrigeminal ganglion, or divisions 1).

Balloon compression had the highest rate of initial pain-free response (IPFR) and duration of pain-free intervals (PFIs), compared with other modalities in the initial treatment of MS-related TN 2). It could be considered a useful technique for patients whose pain recurs after other procedures 3).

Percutaneous balloon compression PBC is a treatment that can be effective for many patients with MS-TN 4).

Compared with that in non-MS patients, symptom recurrence is higher and requires multiple procedures 5).

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 6).


One hundred eleven procedures with Percutaneous balloon compression (PBC) performed in 66 cases of Multiple sclerosis related trigeminal neuralgia (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.

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.

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 7).


Retrospectively collected clinical data on 80 consecutive patients who underwent 144 procedures and who received PBC for TN treatment between January 2000 and January 2010 were analyzed. The cohort included 17 MS and 63 non-MS patients.

The mean age at first operation was significantly younger in the MS group compared with the non-MS group (59 years vs 72 years, respectively, p < 0.0001). After a mean follow-up of 43 months (MS group) and 25 months (non-MS group), the symptom recurrence rate following the first operation was higher in the MS group compared with that in the non-MS group (86% vs 47%, respectively, p < 0.01). During long-term follow-up, more than 70% of MS patients required multiple procedures compared with only 44% of non-MS patients. Excellent or satisfactory outcomes were not significantly different between the MS and non-MS cohorts, respectively, at 1 day postoperatively (82% vs 91%, p = 0.35), 3 months postoperatively (65% vs 81%, p = 0.16), and at last follow-up (65% vs 76%, p = 0.34). A similar incidence of postoperative complications was observed in the 2 groups.

PBC is effective in the treatment of trigeminal neuralgia in patients with MS, but, compared with that in non-MS patients, symptom recurrence is higher and requires multiple procedures 8).


During the period 2000-2012, 10 patients with medically refractory TN and ipsilateral brainstem T2 hyperintensity underwent MVD. In 5 patients, additional clinical features suspicious for MS were present, including prior optic neuritis (n = 2), multiple disseminated lesions (n = 3), and elevated immunoglobulin G index (n = 2). One patient had failed prior percutaneous surgery; 1 patient had Burchiel type 2 TN. Follow-up (median, 14 months) was censored at the time of additional surgery (n = 6) or last clinic visit (n = 4).

Neurovascular compression was confirmed at surgery from the superior cerebellar artery (SCA) plus adjacent vein (n = 4), vein alone (n = 3), SCA alone (n = 2), and SCA plus anterior inferior cerebellar artery (n = 1). Initially after MVD, 8 patients (80%) were pain-free and subsequently tapered off medications for their facial pain. Pain recurred in 6 patients at a median of 4 months (range, 1-23 months). Actuarial rates of being pain-free off medications were 50% at 3 months and 15% at 2 years. In 6 patients, additional treatments were performed, including glycerol rhizotomy (n = 4), radiosurgery (n = 2), balloon compression (n = 2), and repeat MVD (n = 1). At last contact, 5 of the 6 patients who were retreated were pain-free.

Facial pain outcomes after MVD in patients with suspected MS-related TN are poor compared with outcomes for patients with idiopathic TN. This study provides further support that many patients with MS-related TN have pain that is centrally mediated, reducing the effectiveness of procedures performed on the trigeminal root, ganglion, or divisions 9).


Seven patients had TN related to multiple sclerosis (MS). Mean follow-up was 51.81 ± 26.63 months. 81.81 % of patients reported an acute pain relief. No major complication was observed after PBC. Eight patients (36.36 %) experienced pain recurrence and underwent one (five patients) or more (three patients) PBC. At the last follow-up, we obtained an excellent outcome (BNI I-II) in 16 patients out of 22 (72.72 %) and a good outcome (BNI III) in the remaining six. No patients had an uncontrolled pain. The lack of history of MS (p = 0.0174), the pear-like shape of the balloon at the operation (p = 0.0234) and a compression time <5 min (p < 0.05) were associated to higher pain-free survival. Considering these results PBC could be considered a useful technique for patients whose pain recurs after other procedures 10).


Balloon compression had the highest rate of initial pain-free response (IPFR) and duration of pain-free intervals (PFIs), compared with other modalities in the initial treatment of MS-related TN 11).

References

1) , 9)

Ariai MS, Mallory GW, Pollock BE. Outcomes after microvascular decompression for patients with trigeminal neuralgia and suspected multiple sclerosis. World Neurosurg. 2014 Mar-Apr;81(3-4):599-603. doi: 10.1016/j.wneu.2013.09.027. Epub 2013 Sep 19. PubMed PMID: 24056218.
2) , 11)

Mohammad-Mohammadi A, Recinos PF, Lee JH, Elson P, Barnett GH. Surgical outcomes of trigeminal neuralgia in patients with multiple sclerosis. Neurosurgery. 2013 Dec;73(6):941-50; discussion 950. doi: 10.1227/NEU.0000000000000128. PubMed PMID: 23921703.
3) , 10)

Montano N, Papacci F, Cioni B, Di Bonaventura R, Meglio M. The role of percutaneous balloon compression in the treatment of trigeminal neuralgia recurring after other surgical procedures. Acta Neurol Belg. 2014 Mar;114(1):59-64. doi: 10.1007/s13760-013-0263-x. Epub 2013 Dec 12. PubMed PMID: 24338759.
4) , 6) , 7)

Asplund P, Linderoth B, Lind G, Winter J, Bergenheim AT. One hundred eleven Percutaneous Balloon Compressions for Trigeminal Neuralgia in a Cohort of 66 Patients with Multiple Sclerosis. Oper Neurosurg (Hagerstown). 2019 Jan 23. doi: 10.1093/ons/opy402. [Epub ahead of print] PubMed PMID: 30690631.
5) , 8)

Martin S, Teo M, Suttner N. The effectiveness of percutaneous balloon compression in the treatment of trigeminal neuralgia in patients with multiple sclerosis. J Neurosurg. 2015 Dec;123(6):1507-11. doi: 10.3171/2014.11.JNS14736. Epub 2015 Jun 12. PubMed PMID: 26067615.

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