Trigeminal neuralgia in multiple sclerosis: proposal of surgical flowchart and long-term outcome evaluation in a mono-istitutional cohort

Trigeminal neuralgia (TN) is a chronic pain syndrome more prevalent in patients with multiple sclerosis (MS), often presenting with earlier onset and more intense pain compared to non-MS patients. The management of TN in MS is complex due to the interaction between demyelination and neurovascular factors.

A retrospective analysis of 35 MS patients treated for TN with 65 procedures between 2010 and 2023 was conducted. Patients underwent surgical treatments guided by a flowchart and based on the presence of NVC and patient risk factors. Procedures included MVD, PBC, SRS and TRZ. Outcomes were assessed using BNI pain and hypoesthesia scales, focusing on pain recurrence and changes in antineuralgic medication.

After first treatment, MVD (13 procedures) achieved a 100% success rate with a mean pain-free interval of 59.4 months, and 77% of patients reduced or stopped medication. PBC (16) had a 93.8% success rate and a recurrence time of 34 months. SRS showed an 80% success rate with a recurrence time of 7.4 months, while TRZ had a 50% success rate with 24 months of pain-free duration. After the first surgical intervention, 30.5% of patients were pain-free, increasing to 40% after the third treatment. At last follow-up (77,0 ± 68.7 months) it was demonstrated high pain-free rates (61.1%) and good long-term pain control.

The use of a tailored flowchart significantly improves outcomes in TN-MS patients. MVD provides the longest pain-free intervals when NVC is present, while PBC, SRS, and TRZ remain viable alternatives for those with contraindications. Personalized approaches enhance pain control and reduce recurrence.