Objective:

Trigeminal neuralgia affects approximately 3% of patients with multiple sclerosis - a significantly higher incidence than in the general population - and is recognised as a distinct clinical entity. Due to the challenges of treating these patients, we conducted this systematic review to provide an up-to-date assessment of surgical interventions for this debilitating condition whilst considering factors shaping personalised treatment pathways.

Background:

Trigeminal neuralgia associated with multiple sclerosis often proves unresponsive to pharmacological management, necessitating consideration of neurosurgical alternatives. Neurosurgical approaches have variable efficacy, tolerability, and response duration with additional factors such as multiple sclerosis subtype, demyelinating plaques, and neurovascular contact further complicating management decisions.

Design/Methods:

A literature search across Embase, PubMed and Scopus, using a PRISMA-guided screening protocol, included articles published post-2021 that detailed outcomes for our defined cohort. Pain relief was assessed at initial and final follow-up using the Barrow Neurological Institute (BNI) pain scale and contextualised with information regarding complications, multiple sclerosis subtype, radiation dosages, and pathophysiology.

Results:

Twelve studies, analysing 608 patients with trigeminal neuralgia associated with multiple sclerosis, met the search criteria. Microvascular decompression achieved superior, longer-lasting outcomes in cases with morphological nerve changes (70.1% BNI I-III at final follow-up). Percutaneous ablative procedures showed fewer adverse events and comparable pain control rates to those in classical trigeminal neuralgia. However, percutaneous treatments and gamma knife radiosurgery exhibited suboptimal durability (54.3% and 48.9% BNI I-III at final follow-up respectively), though repeat procedures were generally tolerable. Multiple sclerosis subtype did not show a consistent influence. 

Conclusions:

Percutaneous ablative procedures demonstrate favorable efficacy and tolerability, making them candidates for first-line surgical options, especially in trigeminal plaque-driven cases. Superior outcomes with microvascular decompression where neurovascular compression is the likely cause highlights the importance of preoperative imaging in personalised management pathways. Future prospective studies may further refine surgical decision-making in this important cohort.