Repeat intrathecal triamcinolone acetonide application reduces acute occurring painful dysesthesia in patients with relapsing remitting multiple sclerosis

Predictors for Therapy Response to Intrathecal Corticosteroid Therapy in Multiple Sclerosis

Objective: The autoimmune disease Multiple Sclerosis (MS) represents a heterogeneous disease pattern with an individual course that may lead to permanent disability. In addition to immuno-modulating therapies patients benefit from symptomatic approaches like intrathecal corticosteroid therapy (ICT), which is frequently applied in a growing number of centers in Germany. ICT reduces spasticity, which elongates patient's walking distance and speed, thus improves quality of life.

Methods: In our study we set out to investigate cerebrospinal fluid (CSF) parameters and clinical predictors for response to ICT. Therefore, we analyzed 811 CSF samples collected from 354 patients over a time period of 12 years. Patients who received ICT were divided in two groups (improving or active group) depending on their EDSS-progress. As control groups we analyzed data of ICT naïve patients, who were divided in the two groups as well. Additionally we observed the clinical progress after receiving ICT by comparison of patients in both groups.

Results: The results showed clinical data had a significant influence on the probability to benefit from ICT. The probability (shown by Odds Ratio of 1.77–2.43) to belong to the improving group in contrast to the active group is significantly (p < 0.0001) higher at later stages of disease with early disease onset (< 35 years, OR = 2.43) and higher EDSS at timepoint of ICT-initiation (EDSS > 6, OR = 2.06). Additionally, we observed lower CSF cell counts (6.68 ± 1.37 μl) and lower total CSF protein (412 ± 18.25 mg/l) of patients who responded to ICT compared to patients who did not (p < 0.05). In the control group no significant differences were revealed. Furthermore analyses of our data revealed patients belonging to the improving group reach an EDSS of 6 after ICT-initiation less often than patients of the active group (after 13 years 39.8% in the improving group, 67.8% in the active group).

Conclusion: Our study implies two relevant messages: (i) although the study was not designed to prospectively assess clinical data, in this cohort no severe side effects were observed under ICT; (ii) disease onset, EDSS, CSF cell count, and total protein may serve as predictive markers for therapy response.

Atypical facial pain in multiple sclerosis caused by spinal cord seizures: a case report and review of the literature

Background

Pain is a very commonly reported symptom and often drives patients to seek medical attention; however, it can prove a very difficult diagnostic conundrum and even more challenging to treat effectively. Accurately determining the primary pain generator is key, as certain conditions have efficacious medical and surgical treatments. We present a rare case of a man with multiple sclerosis presenting with spinal cord seizures causing dermatomal pain. While pain has been reported in the context of motor symptoms attributed to spinal cord seizures in a small number of spinal cord conditions, this case represents the first report of pain exclusively associated with spinal cord demyelination in multiple sclerosis.

Case presentation

We present the case of a 60-year-old Caucasian male patient with multiple sclerosis who reported a 5-year history of progressive pain in his left retroauricular region and superior left shoulder. He described this pain as sharp, episodic, and unrelenting and he was referred for consideration for surgical treatment of trigeminal neuralgia. He had no evidence of trigeminal nerve root pathology on magnetic resonance imaging, but did show dorsolateral spinal cord demyelination at the C3–4 level. His symptoms therefore represent an unusual presentation of spinal cord seizures.

Conclusions

Spinal cord seizures are rarely reported in multiple sclerosis and typically present with focal motor seizures. These have been reported to present with cramping dysesthesia and pruritus, though rarely with primary pain. Knowledge of uncommon pain presentations is critical for the increasing number of primary care physicians caring for patients with such chronic neurological diseases as it will guide management and referral patterns. This knowledge is also important for the treating neurologists and neurosurgeons. Neurosurgical intervention for trigeminal neuralgia poses considerable surgical risk, and it should be avoided where possible. Identifying the primary pain generator is, therefore, critical for accurate diagnosis and management.

Pain in multiple sclerosis: a systematic review of neuroimaging studies

Introduction

While pain in multiple sclerosis (MS) is common, in many cases the precise mechanisms are unclear. Neuroimaging studies could have a valuable role in investigating the aetiology of pain syndromes. The aim of this review was to synthesise and appraise the current literature on neuroimaging studies of pain syndromes in MS.

Methods

We systematically searched PubMed and Scopus from their inception dates to the 2nd of April 2013. Studies were selected by predefined inclusion and exclusion criteria. Methodological quality was appraised. Descriptive statistical analysis was conducted.

Results

We identified 38 studies of variable methodology and quality. All studies but one used conventional structural magnetic resonance imaging, and the majority reported a positive association between location of demyelinating lesions and specific neuropathic pain syndromes. Most investigated headache and facial pain, with more common pain syndromes such as limb pain being relatively understudied. We identified a number of methodological concerns, which along with variable study design and reporting limit our ability to synthesise data. Higher quality studies were however less likely to report positive associations of lesion distribution to pain syndromes.

Conclusions

Further high quality hypothesis-driven neuroimaging studies of pain syndromes in MS are required to clarify pain mechanisms, particularly for the commonest pain syndromes.

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We reviewed neuroimaging studies of pain syndromes in multiple sclerosis (MS).

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All studies investigated neuropathic pain or headache, mainly using structural MRI.

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Most reported associations between location of demyelinating lesions and pain.

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Culprit lesions were most commonly reported in the brainstem.

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High quality hypothesis-driven neuroimaging studies of pain in MS are still needed.

Symptomatic treatment and management of multiple sclerosis

The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.

Benefit of repetitive intrathecal triamcinolone acetonide therapy in predominantly spinal multiple sclerosis: prediction by upper spinal cord atrophy

Intrathecal injection of triamcinolone acetonide (TCA) has been shown to provide substantial benefit in a subset of progressive multiple sclerosis (MS) patients with predominant spinal symptoms. We examined whether atrophy of the upper spinal cord (USC) as measured by MRI can serve as a predictive marker for response to repetitive intrathecal TCA application. Repetitive administration of 40 mg TCA was performed in 31 chronic progressive MS patients up to six times within 3 weeks. Expanded Disability Status Scale (EDSS) and maximum walking distance (WD) were assessed before and after the treatment cycle. Cervical 3D T1-weighted images were acquired on a 1.5T scanner at baseline. Mean cross-sectional area of the USC was determined using a semi-automated volumetry method. Results were compared with a group of 29 healthy controls to group patients into those with and without atrophy. Results show a negative correlation between the degree of USC atrophy and treatment benefit. A higher treatment benefit in patients with little USC atrophy but short initial maximum WD was observed. Absence of USC atrophy as measured on MRI is a predictive marker for intrathecal TCA therapy outcome in progressive MS. Patients with initial poor walking abilities, but only little or no atrophy, benefited most from TCA therapy.

Role of intraspinal steroid application in patients with multiple sclerosis

Clinical trials on patients with progressive multiple sclerosis (MS) have shown no clear evidence of an effective symptomatic treatment with improving disability. Immunomodulatory compounds efficaciously reduce the relapse rate. Numerous earlier papers exist on the pros and cons and/or on the efficacy of intrathecal administration of differing dosages of various conventional released steroids. Furthermore, this treatment approach was nearly abondoned owing to a debate on side effects and a missing proven superiority over intravenous systemic high dosage steroid administration. However, recent open-label studies in progressive MS patients with predominant spinal symptomatology investigated the repeated intraspinal application of the sustained-release compound triamcinolone acetonide (TCA). A distinct improvement of walking distance and MS scores in the short term and stabilization of this beneficial effect after repeat TCA application every 6-12 weeks was found. Moreover, patients with a relapse with acute onset of painful sensations showed a marked pain improvement after repeated TCA application following prior unsuccessful treatment with intravenous steroids. The available data from open studies ask for the performance of a randomized clinical trial, comparing intravenous with intrathecal steroid administration, to confirm the higher efficacy of the more invasive therapy with repeated lumbar puncture.

Corticosteroids and plasma exchange in multiple sclerosis

Corticosteroids (CS) remain a mainstay of treatment for relapses in multiple sclerosis (MS) and optic neuritis. Currently, there is not enough evidence that long-term corticosteroid treatment delays progression of long-term disability in patients with MS. Likewise, it is unclear whether there are, in fact, true differences among the various CS agents, doses, and their applications in specific pulse and tapering regimens.In some patients suffering from severe steroid-resistant relapses, the clinical response to CS treatment may be insufficient. Such patients may obtain clinical benefit from subsequent plasma exchange (PE). PE is increasingly considered as an individual treatment decision in patients with severe relapses not properly responding to CS. Because of the lack of appropriate studies, PE is not recommended as a permanent disease-modifying strategy in MS patients.

Current management of pain associated with multiple sclerosis

While pain is a common problem in patients with multiple sclerosis (MS), it is not frequently mentioned by patients and a more direct approach is required in order to obtain information about pain from patients. Many patients with MS experience more than one pain syndrome; combinations of dysaesthesia, headaches and/or back or muscle and joint pain are frequent. For each pain syndrome a clear diagnosis and therapeutic concept needs to be established. Pain in MS can be classified into four diagnostically and therapeutically relevant categories: (i) neuropathic pain due to MS (pain directly related to MS); (ii) pain indirectly related to MS; (iii) MS treatment-related pain; and (iv) pain unrelated to MS. Painful paroxysmal symptoms such as trigeminal neuralgia (TN), or painful tonic spasms are treated with antiepileptics as first choice, e.g. carbamazepine, oxcarbazepine, lamotrigine, gabapentin, pregabalin, etc. Painful 'burning' dysaesthesias, the most frequent chronic pain syndrome, are treated with TCAs such as amitriptyline, or antiepileptics such as gabapentin, pregabalin, lamotrigine, etc. Combinations of drugs with different modes of action can be particularly useful for reducing adverse effects. While escalation therapy may require opioids, there are encouraging results from studies regarding cannabinoids, but their future role in the treatment of MS-related pain has still to be determined. Pain related to spasticity often improves with adequate physiotherapy. Drug treatment includes antispastic agents such as baclofen or tizanidine and in patients with phasic spasticity, gabapentin or levetiracetam are administered. In patients with severe spasticity, botulinum toxin injections or intrathecal baclofen merit consideration. While physiotherapy may ameliorate malposition-induced joint and muscle pain, additional drug treatment with paracetamol (acetaminophen) or NSAIDs may be useful. Moreover, painful pressure lesions should be avoided by using optimally adjusted aids. Treatment-related pain associated with MS can occur with subcutaneous injections of interferon-beta or glatiramer acetate, and may be reduced by optimizing the injection technique and by local cooling. Systemic (particularly 'flu-like') adverse effects of interferons, e.g. myalgias, can be reduced by administering paracetamol, ibuprofen or naproxen. A potential increase in the frequency of pre-existing headaches after starting treatment with interferons may require optimization of headache attack therapy or even prophylactic treatment. Pain unrelated to MS, such as back pain or headache, is common in patients with MS and may deteriorate as a result of the disease. In summary, a careful analysis of each pain syndrome will allow the design of the appropriate treatment plan using various medical and nonmedical options (multimodal therapy), and will thus help to improve the quality of life (QOL) of the patients.