Trigeminal interfascicular neurolysis (nerve combing) for refractory recurrent neuralgia in multiple sclerosis.

Paolo Ferroli,Morgan Broggi,Marco Schiariti,Paolo Confalonieri,Luisa Chiapparini,Francesco Acerbi,Gabriella Raccuia,Ignazio G Vetrano

doi:10.3171/2020.5.focvid203

Abstract

In multiple sclerosis (MS) patients, trigeminal neuralgia (TN) represents a challenging syndrome to treat, often refractory to medical therapy and percutaneous techniques. Despite the frequent lack of a neurovascular conflict, the trigeminal nerve’s axons are often damaged, with the myelin sheath permanently degenerated, thus explaining the difficulty in treating TN in MS.The authors illustrate trigeminal interfascicular neurolysis (the combing technique) to control refractory recurrent TN in MS: the nerve is longitudinally divided along its fibers from the root entry zone, determining good pain relief.The video can be found here: https://youtu.be/o1XksPW5fMY

Highlights

We present a case of a 58-year-old woman affected by recurrent, drug-resistant trigeminal pain and multiple sclerosis diagnosed in 2003.1 Two previous percutaneous balloon compressions and a microvascular decompression obtained only transient pain relief
The trigeminal nerve is longitudinally divided with a microknife along its fascicula in the root entry zone area, allowing for an accurate interfascicular cleavage plane
Interfascicular neurolysis is performed with a blunt round dissector

Summary

Introduction

We present a case of a 58-year-old woman affected by recurrent, drug-resistant trigeminal pain and multiple sclerosis diagnosed in 2003.1 Two previous percutaneous balloon compressions and a microvascular decompression obtained only transient pain relief. MR did not reveal any new vascular cross compression, and surgical exploration of the trigeminal root with interfascicular neurolysis was proposed.2 The preoperative T2 and T1 axial MR showed multiple demyelinating lesions. The red arrow points at plaque into the pons, along the trigeminal intrapontine fibers; the blue arrow shows a vessel running close to the trigeminal nerve (yellow arrow).

Results

Conclusion