Minimally Invasive Surgical Treatment of Intractable Trigeminal Neuralgia in Multiple Sclerosis

Abstract

Background: Retrograssean balloon compression of the trigeminal nerve is a common treatment modality used for the treatment of trigeminal neuralgia in patients without multiple sclerosis (MS), but is not commonly used in patients diagnosed with MS, where the facial pain is a result of scar tissue or demyelinating plaques. Approximately 10 percent of patients with MS have a diagnosis of trigeminal neuralgia (TN). Most patients develop other symptoms of multiple sclerosis and optic neuritis before the facial pain and the diagnosis of MS is usually established before they develop chronic facial pain. These patients are more likely to develop the symptoms on both sides of the face than those without MS, but rarely anyone has both sides of the face are affected at the same time. This cases report an efficient method to treat an acute episode of intractable trigeminal neuralgia in multiple sclerosis patients. Case Description: We report the cases of two women with a primary diagnosis of MS that presented with secondary trigeminal neuralgia. The patients were 38 and 56 years old. Patients presented to the ER with pain that was described as a “shooting” sensation in the V1-V2 and V3 distributions, with an intensity of 10/10, and not relieved by pharmacologic or Radiosurgical treatment. Both cases were treated by retrograssian balloon compression by neuro-navigation based on the difficulty to foramen ovale puncture. Conclusion: The treatment of TN in patients with MS presents a dilemma. The difficulty of demyelinating disease is identifying the source of pain and finding the best treatment for the symptoms. This is the primary challenge for neurosurgeons in treating MS patients with atypical facial pain. Micro vascular decompression should not be considered as primary treatment of trigeminal neuralgia in this patient population, where the target plate and not the neurovascular conflict related trigeminal neuralgia. Stereotactic Radiosurgery can be a good treatment option, but there is a lack of published data to support the treatment in acute setting after failure of treatment by Radiosurgery. Retrograssean balloon compression by neuro-navigation could be a successfully rescue technique in acute complex trigeminal neuralgia in MS patient.