Gamma Knife Radiosurgery for the Treatment of Trigeminal Neuralgia in Patients with Multiple Sclerosis: A Single-Center Retrospective Study and Literature Review

Trigeminal neuralgia management in patients with multiple sclerosis: A systematic review of approaches and outcomes

BACKGROUND

Trigeminal neuralgia (TN) is a debilitating condition characterized by recurrent, intermittent episodes of severe facial pain. Approximately 1-2% of patients with multiple sclerosis (MS) experience trigeminal neuralgia during their lifetime. The management of such condition necessitates a multimodal approach that addresses both the symptoms of trigeminal neuralgia and underlying multiple sclerosis. Therefore, we aim to systematically compare the medical, surgical, and stereotactic radiosurgery (SRS) approaches and their efficacy in the management of trigeminal neuralgia in patients with multiple sclerosis.

METHODS

A comprehensive database search was conducted utilizing Medline, CENTRAL, Science Direct, and Web of Science databases. Only Randomized controlled trials (RCT), retrospective, or prospective cohort studies reporting the outcomes of interest were included. The main outcomes were acute pain relief, pain relief at follow-up, and recurrence rate. Risk of bias assessment was conducted using the ROBINS-I and NOS tools for non-randomized and cohort studies, respectively.

RESULTS

Out of the 33 studies included, 3 were assessing medical management, 17 were for surgical interventions, and 13 were for SRS, with a combined sample size of 1469 patients. Out of 193 reported patients who underwent radiofrequency ablation, 124 (64 %) patients had pain relief at the last follow-up. 76 (37.4 %) out of 203 reported patients who underwent glycerol rhizotomy (GR) had pain relief at last follow-up with either a BNI score of I-IIIB or complete pain relief with or without medication. After following up with the patients in the ballon compression cohort, 101 (60 %) out of 168 of them had pain relief after a mean duration of 27.8 months. Among the patients who underwent microvascular decompression, 71 % of them had pain relief at follow up. 280 (43 %) out of 651 patients had acute pain relief after SRS and were followed up for a mean duration of 42 months.

CONCLUSION

This is a comprehensive review on the current evidence of managing trigeminal neuralgia in multiple sclerosis patients. Although medical management is still the first line of management, finding the most effective drug was not approachable due to the high heterogeneity and small sample size. While glycerol rhizotomy showed a superior outcome of acute pain relief among percutaneous ablative approaches, radiofrequency ablation resulted in a better pain relief outcome at last follow up. Results from microsurgical rhizotomy and peripheral neurectomy were not conclusive enough to withdraw recommendations. Due to the lack of high-quality studies, rigorous randomized controlled trials are warranted to assess the efficacy and safety of different interventions for TN management in MS patients.

Efficacy and clinical outcomes of percutaneous treatments for trigeminal neuralgia secondary to multiple sclerosis

BACKGROUND

People with Multiple Sclerosis (MS) have a 20-fold higher risk of developing trigeminal neuralgia compared to the general population. Treating trigeminal neuralgia in these patients is particularly challenging due to reduced tolerance and increased side effects from medications. When no neurovascular conflict exist, percutaneous treatments are usually the first option after drug therapy. According to the literature, treatment outcomes for MS-associated trigeminal neuralgia show higher relapse rates and lower rates of sustained pain relief compared to primary trigeminal neuralgia, often necessitating multiple procedures.

METHODS

We conducted a retrospective cohort study of patients who underwent percutaneous procedures for trigeminal neuralgia between 2010 and 2021 at Rouen University Hospital. The patients were divided into two groups based on the presence or absence of multiple sclerosis. The primary endpoint was the postoperative Barrow Neurological Institute (BNI) pain score, categorized as favourable (I-III) or unfavourable (IV-V) at 3 months postoperatively and at the last date of follow-up.

RESULTS

Patients with multiple sclerosis were younger, had fewer comorbidities, and experienced more bilateral trigeminal pain compared to those without multiple sclerosis. BNI score evaluations at 3 months and at the last follow-up did not differ significantly between the two groups, with 81 % and 77 % of patients, showing favourable outcomes. However, the recurrence of pain after percutaneous procedures was significantly higher in patients with multiple sclerosis (p < 0.05).

CONCLUSION

Percutaneous rhizotomies achieve satisfactory clinical outcomes in patients with MS, despite a higher incidence of recurrences and subsequent percutaneous procedures compared to the general population.

Bibliometric analysis of research developments in oral and maxillofacial neuralgia from 2004 to 2023

This study employs bibliometric techniques to dynamically represent the research landscape of oral and maxillofacial neuralgia. Its goal is to pinpoint research hotspots and delineate forthcoming trends. A systematic search of the Web of Science Core Collection was performed using targeted keywords to retrieve literature from January 2004 to December 2023. Citespace version 6.2.6 was utilized to analyze countries, institutions, authors, co-cited journals, and keywords. The analysis indicates an annual increase in research literature on oral and maxillofacial neuralgia, albeit with a decline observed in the past 2 years. In the last 5 years, a total of 279 publications have been produced, predominantly by developed countries. The average betweenness centrality exceeds 0.1. Analysis of co-cited literature revealed 100 nodes, with research frontiers closely associated with trigeminal neuralgia, gamma knife radiosurgery, percutaneous balloon compression, among others. Keyword clustering analysis generated 61 nodes, primarily concentrated on 3 research areas: gamma knife, microvascular decompression, and hemifacial spasm. The emergence of keywords closely correlates with trigeminal neuralgia. Research frontiers in the field of oral and maxillofacial neuralgia are primarily focused on trigeminal neuralgia, with major therapeutic approaches including gamma knife radiosurgery and percutaneous balloon compression. These areas, along with botulinum toxin, represent current hotpots and are likely to drive the future direction of research in treating oral and maxillofacial neuralgia.

Gamma Knife radiosurgery for multiple sclerosis-associated trigeminal neuralgia

BACKGROUND

Gamma Knife radiosurgery (GKRS) has well-known efficacy in the treatment of idiopathic trigeminal neuralgia (TN). However, few studies have evaluated the effects of GKRS in the treatment of multiple sclerosis (MS)-related TN. This study analyzed the efficacy and complications of GKRS for MS-related TN.

METHODS

This retrospective study included 28 MS-related TN patients who underwent GKRS with a median follow-up of 27 (range, 12-181) months. The cisternal segment of the trigeminal nerve was targeted with a median radiation dose of 80 (80-90) Gy. Pain intensity was assessed using Barrow Neurological Institute (BNI)-Pain Intensity Scores (BNI-PIS). Before GKRS, all patients suffered from BNI pain levels of 4 or 5. A reduction in pain to BNI 3b or below was deemed as adequate pain relief.

RESULTS

The initial proportion of patients who experienced adequate pain relief was 71.4%, with a median interval of 21 (1-45) days. At the final follow-up, 50% of patients had achieved adequate pain relief. Ten patients (35.7%) suffered from complications, including four with facial sensorial dysfunctions, four with a decline in their corneal reflexes, and two with jaw weakness. Among the 20 initial responders, six (30%) patients suffered pain recurrence after a median interval of 35 (12-180) months.

CONCLUSIONS

GKRS is an effective means of pain relief in MS-related TN, but has side effects that are relevant to other ablative treatments. The benefits and risks of GKRS should be discussed with patients who wish to avoid surgery or when previous treatments fail.

Efficacy and Challenges: Minimally Invasive Procedures for Trigeminal Neuralgia Treatment in Multiple Sclerosis - A Systematic Review and Meta-Analysis

INTRODUCTION

Trigeminal neuralgia (TGN) poses a therapeutic challenge, particularly within the context of multiple sclerosis (MS). This study aimed to conduct a comprehensive meta-analysis and systematic review of four less-invasive treatment modalities for TGN in MS patients, namely, gamma knife radiosurgery (GKRS), glycerol rhizotomy (GR), balloon compression (BC), and radiofrequency ablation (RFA).

METHODS

Single-armed meta-analyses were employed to assess the overall efficacy of each treatment, while double-armed analyses compared the efficacy between different treatment options in double-armed studies. Outcome evaluations included acute pain relief (within 1 month post-procedure), recurrence rates throughout 18 months of follow-up, and reported complication rates.

RESULTS

The meta-analysis revealed diverse outcomes for each intervention. GKRS demonstrated favorable outcomes, achieving a 77% success rate in alleviating pain among a pooled cohort of 863 patients, reinforcing its status as a viable therapeutic option. Additionally, GR, BC, and RFA exhibited efficacy, with success rates of 77%, 71%, and 80%, respectively, based on outcomes observed in 611, 385, and 203 patients. Double-armed analyses highlighted distinctions between the treatments, providing nuanced insights for clinical decision-making.

CONCLUSION

This meta-analysis provides a comprehensive overview of less-invasive treatments for TGN in MS patients. GKRS emerges as a leading option with comparable efficacy and fewer complications. However, the study underscores the nuanced efficacy and considerations associated with GR, BC, and RFA. The findings offer valuable insights for clinicians navigating treatment choices in this challenging patient population, considering acute pain relief, recurrence rates, and complication profiles.

Frame navigation guided percutaneous balloon compression for intractable trigeminal neuralgia secondary to multiple sclerosis

Background

Patients with multiple sclerosis (MS) are more likely to develop trigeminal neuralgia (TN) compared to the regular population, due to scarring of the nerve and development of a demyelination plaque. Despite treatment, approximately 10% of MS patients treated for TN experience symptom recurrence, including the development of MS-like symptoms such as optic neuritis and bilateral facial pain.

Methods

A computed tomography (CT) scan was performed preoperatively on two patients diagnosed with multiple sclerosis (MS) who experienced secondary trigeminal neuralgia (TN). A precise reference frame was strapped firmly to the patient's forehead during the intraoperative procedure. Preliminary CT images were registered using the navigation system and the bony landmarks were set.

Case description

Two patients diagnosed with multiple sclerosis (MS) who experienced refractory trigeminal neuralgia (TN) underwent percutaneous balloon compression. Initial conservative treatment and one dosage of Gamma Knife Radiosurgery (GKR) resulted in symptom control for a few weeks. Both patients had an acute recurrence of pain; thus, percutaneous retrogasserian balloon compression was performed. During follow-up, the patients reported a 70% decrease in pain after the procedure, with minimal recurrence of shooting episodes.

Conclusion

Management of trigeminal neuralgia secondary to drug-resistant multiple sclerosis presents a persistent challenge. The percutaneous technique for retrogasserian balloon compression may offer a solution for some patients, but it presents unique challenges for neurosurgeons. Given the complexity of the pathogenesis, target identification, and the potential absence of neurovascular conflict, microvascular decompression remains a debated approach for this patient population. While stereotactic radiosurgery may be a promising alternative.

Pharmacological and Non-pharmacological Approaches for the Management of Neuropathic Pain in Multiple Sclerosis

Multiple sclerosis is a chronic inflammatory disease that affects the central nervous system and can cause various types of pain including ongoing extremity pain, Lhermitte's phenomenon, trigeminal neuralgia, and mixed pain. Neuropathic pain is a major concern for individuals with multiple sclerosis as it is directly linked to myelin damage in the central nervous system and the management of neuropathic pain in multiple sclerosis is challenging as the options available have limited efficacy and can cause unpleasant side effects. The literature search was conducted across two databases, PubMed, and Google Scholar. Eligible studies included clinical trials, observational studies, meta-analyses, systematic reviews, and narrative reviews. The objective of this article is to provide an overview of literature on pharmacological and non-pharmacological strategies employed in the management of neuropathic pain in multiple sclerosis. Pharmacological options include cannabinoids, muscle relaxants (tizanidine, baclofen, dantrolene), anticonvulsants (benzodiazepines, gabapentin, phenytoin, carbamazepine, lamotrigine), antidepressants (duloxetine, venlafaxine, tricyclic antidepressants), opioids (naltrexone), and botulinum toxin variants, which have evidence from various clinical trials. Non-pharmacological approaches for trigeminal neuralgia may include neurosurgical methods. Non-invasive methods, physical therapy, and psychotherapy (cognitive behavioral therapy, acceptance and commitment therapy and mindfulness-based stress reduction) may be recommended for patients with neuropathic pain in multiple sclerosis. The choice of treatment depends on the severity and type of pain as well as other factors, such as patient preferences and comorbidities. There is a pressing need for healthcare professionals and researchers to prioritize the development of better strategies for managing multiple sclerosis-induced neuropathic pain.

Repeat Gamma Knife radiosurgery for recurrent trigeminal neuralgia in patients with multiple sclerosis: a single-center retrospective study

PURPOSE

Gamma Knife radiosurgery (GKRS) has emerged as an effective treatment option for trigeminal neuralgia (TN) in patients with multiple sclerosis (MS). To date, the outcomes of repeat GKRS for patients with TN and MS with recurrent pain have been investigated in a few patients. This study aims to report the outcomes and predictive factors of pain reduction for MS patients undergoing repeat GKRS for recurrent TN.

METHODS

Eighteen patients with MS underwent repeat GKRS for recurrent TN. A retrospective chart review and telephone interviews were conducted to determine background medical history, dosimetric data, and outcomes of the procedure. Facial pain and sensory function were evaluated using the Barrow Neurological Institute (BNI) scales.

RESULTS

Fifteen patients achieved a BNI pain score of IIIa or better, indicating pain reduction, within a median period of 21 days after repeat GKRS. The maximum dose for repeat GKRS ranged from 70 to 85 Gy. Pain recurred in 5 patients after a median period of 12 months after GKRS. Percentages of patients with pain reduction at 1, 2, 3, 5, and 7 years were 60%, 60%, 50%, 50%, and 50%, respectively. Older age at repeat GKRS predicted sustained pain reduction (P = 0.01). Seven patients developed facial sensory disturbances, which were bothersome in two patients.

CONCLUSIONS

Repeat GKRS may be used as an effective treatment modality for prolonging the duration of pain reduction time in patients with MS and TN. After repeat GKRS, facial sensory disturbances are common; however, they are often not bothersome.

[Surgical treatment of secondary trigeminal neuralgia]

OBJECTIVE

To present a case series analysis of surgical treatment of patients with secondary trigeminal neuralgia.

MATERIAL AND METHODS

The treatment of 8 patients with secondary trigeminal neuralgia who underwent surgery since 2021 was analyzed. All records, neuroimaging archive, and follow-up observations were reviewed.

RESULTS

There were 5 patients with trigeminal neuralgia associated with multiple sclerosis; with neurosarcoidosis (n=1); with tumor (n=1); with unspecified degenerative disease (n=1). The mean age was 61 years (from 48 to 73), the mean duration of disease was 7.2 years (from 5 to 13). Radiofrequency ablation (RF) was performed in 4 cases, balloon compression in 3 cases, tumor removal in 1 case. Relief of trigeminal neuralgia after surgery was observed in 7 patients, partial reduction in 1 patient. A complication was noted in a patient with neurosarcoidosis after RF with the appearance of dysesthesia, dry eye. The mean follow-up was 10 months (1 to 29). Pain recurrence occurred in 2 patients, one of them underwent the surgery twice.

CONCLUSION

Surgical treatment of patients with secondary trigeminal neuralgia contributes to pain relief.

Effectiveness of gamma knife radiosurgery in the management of trigeminal neuralgia associated with multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

Trigeminal neuralgia (TN) is a chronic condition characterized by intense facial pain akin to electric shocks, often associated with the trigeminal nerve. It can be either idiopathic or secondary, with multiple sclerosis (Ms) being a significant contributing factor. Non-responsive patients may opt for minimally invasive procedures, such as gamma knife radiosurgery (GKRS), which offers precise, non-invasive treatment and is frequently chosen as a primary approach. This meta-analysis evaluates the long-term efficacy of GKRS in TN management in Ms patients.

METHODS

We conducted a focused search across various databases. Inclusion criteria encompassed studies with ≥ 30 patients using GKRS for TN in Ms, reporting pertinent clinical outcomes. Primary outcomes assessed GKRS efficacy through Barrow Neurological Institute Pain scores. Secondary outcomes encompassed bothersome numbness, facial numbness, and recurrence. Data analysis employed OpenMeta, random effect models, and odds ratios with 95% confidence intervals. Heterogeneity was assessed using I2 statistics.

RESULTS

Fourteen studies with 752 cases of GKRS for TN were included. Regarding the outcomes, 83% of patients experienced a positive initial pain response, while the overall treatment success rate was 51%. Additionally, 19.6% of patients reported facial numbness, 4.1% experienced bothersome numbness, and 40% faced recurrence. The odds ratio for positive initial pain response was 0.83 (95% CI, 0.76-0.89), while for treatment success, it was 0.51 (95% CI, 0.379-0.639). Facial numbness had an odds ratio of 0.196 (95% CI, 0.130-0.262), bothersome numbness had an odds ratio of 0.041 (95% CI, 0.013-0.069), and recurrence had an odds ratio of 0.403 (95% CI, 0.254-0.551).

CONCLUSIONS

In conclusion, treating trigeminal neuralgia in multiple sclerosis patients remains challenging. GKRS shows promise, but customized treatment approaches tailored to individual patient characteristics are urgently needed to address the unique challenges of this condition.

Gamma Knife Radiosurgery Targeting the Trigeminal Nerve for Tumor-Related Trigeminal Neuralgia: A Case Series

BACKGROUND

Tumor-related trigeminal neuralgia (TN) is a challenging condition to manage that is commonly treated by surgical resection of the tumor. Stereotactic radiosurgery targeting the tumor is used to control pain and tumor growth in patients unsuitable for surgery. Stereotactic radiosurgery targeting the trigeminal nerve has been explored as a viable treatment for patients with tumor-related TN who are unsuitable for surgical removal of the tumor or whose pain is refractory to radiation therapy targeting the tumor. Information regarding the efficacy of this procedure is limited to only a few studies. We report the outcomes of Leskell Gamma Knife radiosurgery (GKRS) targeting the trigeminal nerve for tumor-related TN from a case series.

METHODS

A retrospective review of our GKRS database identified 6 patients with unilateral tumor-related TN treated with GKRS targeting the trigeminal nerve between 2014 and 2020. Five patients had undergone previous radiation therapy targeting the tumor. Facial pain and sensory function were evaluated using the Barrow Neurological Institute scales.

RESULTS

Three patients achieved a Barrow Neurological Institute score of IIIb or better, indicating pain reduction, within a mean period of 4.3 months after GKRS. The maximum dose for GKRS ranged from 80 to 88 Gy. Pain recurred in 1 patient at 64 months after GKRS. No patient developed permanent facial sensory disturbances. No adverse event was recorded.

CONCLUSIONS

GKRS targeting the trigeminal nerve could be a safe and effective treatment for a subset of patients with tumor-related TN who are unsuitable for surgical removal of the tumor or whose pain is refractory to radiation therapy targeting the tumor.