Percutaneous glycerol rhizotomy for trigeminal neuralgia in patients with multiple sclerosis: a long-term retrospective cohort study

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OBJECTIVE

The prevalence of trigeminal neuralgia (TN) in patients with multiple sclerosis (MS-TN) is higher than in the general population (idiopathic TN [ITN]). Glycerol rhizotomy (GR) is a percutaneous lesioning surgery commonly performed for the treatment of medically refractory TN. While treatment for acute pain relief is excellent, long-term pain relief is poorer. The object of this study was to assess the efficacy of percutaneous retrogasserian GR for the treatment of MS-TN versus ITN.

METHODS

A retrospective chart review was performed, identifying 219 patients who had undergone 401 GR procedures from 1983 to 2018 at a single academic institution. All patients were diagnosed with medically refractory MS-TN (182 procedures) or ITN (219 procedures). The primary outcome measures of interest were immediate pain relief and time to pain recurrence following initial and repeat GR procedures. Secondary outcomes included medication usage and presence of periprocedural hypesthesia.

RESULTS

The initial pain-free response rate was similar between groups (p = 0.726): MS-TN initial GR 89.6%; MS-TN repeat GR 91.9%; ITN initial GR 89.6%; ITN repeat GR 87.0%. The median time to recurrence after initial GR was similar between MS-TN (2.7 ± 1.3 years) and ITN (2.1 ± 0.6 years) patients (p = 0.87). However, there was a statistically significant difference in the time to recurrence after repeat GR between MS-TN (2.3 ± 0.5 years) and ITN patients (1.2 ± 0.2 years; p < 0.05). The presence of periprocedural hypesthesia was highly predictive of pain-free survival (p < 0.01).

CONCLUSIONS

Patients with MS-TN achieve meaningful pain relief following GR, with an efficacy comparable to that following GR in patients with ITN. Initial and subsequent GR procedures are equally efficacious.

ABBREVIATIONS BNI = Barrow Neurological Institute; GR = glycerol rhizotomy; ITN = idiopathic TN; MS = multiple sclerosis; MS-TN = MS-related TN; TN = trigeminal neuralgia.

Article Information

Correspondence Michael D. Staudt: London Health Sciences Centre, Western University, London, ON, Canada. michael.staudt@londonhospitals.ca.

INCLUDE WHEN CITING Published online April 12, 2019; DOI: 10.3171/2019.1.JNS183093.

M.D.S. and H.J. contributed equally to this work.

Disclosures Dr. Joswig received speaker honoraria from UCB Canada and travel grants from Medtronic. Dr. Parrent is an advisory board member for Medtronic.

© AANS, except where prohibited by US copyright law.

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Figures

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    Kaplan-Meier curve of pain-free survival after initial or repeat GR for TN with or without MS among 383 cases. First-time GR MS-TN patients had a similar median time to recurrence (2.7 ± 1.3 years) as the first-time GR ITN patients (2.1 ± 0.6 years; p = 0.87) and as the patient groups with repeat GR (p = 0.18 and p = 0.57). However, among patients who had undergone repeat GR, the MS-TN patients had statistically significant better pain-free survival than the ITN patients (2.3 ± 0.5 and 1.2 ± 0.2 years, respectively; p < 0.05). Figure is available in color online only.

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    Kaplan-Meier curve for 371 cases (follow-up data available in 371 of 385 cases) undergoing GR for TN, illustrating statistically different (p < 0.01) pain-free survival with or without the presence of hypesthesia during the procedure. Figure is available in color online only.

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    Patient use of first-tier (carbamazepine, oxcarbazepine) and second-tier (pregabalin, gabapentin, valproate, lamotrigine) medications, as well as baclofen, prior to GR and at follow-up. **p < 0.01; *p < 0.05; +p < 0.1 (statistical trend). Figure is available in color online only.

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