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

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.

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.

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.

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.