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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 32  |  Issue : 2  |  Page : 113-115

Radio-frequency ablation of trigeminal ganglion for refractory pain of bilateral trigeminal neuralgia in a patient with multiple sclerosis


Department of Pain Management, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India

Date of Web Publication31-Aug-2018

Correspondence Address:
Dr. Preeti P Doshi
Department of Pain Management, Jaslok Hospital and Research Centre, 15, Dr. G. Deshmukh Road, Mumbai, Maharashtra 400026
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_42_18

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  Abstract 

Trigeminal neuralgia (TN) is one of the most excruciating variety of craniofacial neuralgias with 12% prevalence in general population. It can be either primary (idiopathic, 90% cases) or secondary (due to pathology such as tumor, multiple sclerosis [MS], and arteriovenous malformation, 10% of cases). TN has a 20 times higher risk of prevalence in patients with MS with an average incidence of 2%. Bilateral TN is significantly more common in patients with MS (18%) when compared to the normal population (5%). Pharmacotherapy is the first line and mainstay of management, but a small percentage of patients continue to have unremitting pain requiring other management modalities such as minimally invasive percutaneous techniques, microvascular decompression, or stereotactic radiosurgery. There is, however, no consensus at present regarding its selection for an individual patient. This case report highlights successful application of radio-frequency ablation in a patient with MS who had bilateral presentation with different timings.

Keywords: Bilateral trigeminal neuralgia, multiple sclerosis, pain management, percutaneous intervention, radio-frequency thermal ablation Keymessage: Radio-frequency ablation is a useful minimally invasive treatment modality, which is effective and relatively safer as compared to other options for medically refractory TN in patients with MS, especially the ones with bilateral presentation.


How to cite this article:
Doshi PP, Parikh NH. Radio-frequency ablation of trigeminal ganglion for refractory pain of bilateral trigeminal neuralgia in a patient with multiple sclerosis. Indian J Pain 2018;32:113-5

How to cite this URL:
Doshi PP, Parikh NH. Radio-frequency ablation of trigeminal ganglion for refractory pain of bilateral trigeminal neuralgia in a patient with multiple sclerosis. Indian J Pain [serial online] 2018 [cited 2018 Dec 19];32:113-5. Available from: http://www.indianjpain.org/text.asp?2018/32/2/113/240286


  Introduction Top


Trigeminal neuralgia (TN) is an excruciating variety of craniofacial neuralgias in the distribution of trigeminal nerve. It can be either primary (idiopathic, 90% cases) or secondary (as a consequence of a primary pathology such as tumor, multiple sclerosis [MS], arteriovenous malformation, 10% cases). MS is a disease more frequently associated with TN, affecting 1%–5% of the patients with TN and conversely, 3.8% of patients with MS have TN.[1] In approximately 18% of patients with MS having TN, it is bilateral.[2] The pharmacotherapy for TN secondary to MS is similar to that of primary TN, carbamazepine being the drug of choice. When associated with MS, TN is often bilateral and more refractory to treatment, especially the drugs.[2] For these patients, the interventional options available are percutaneous ablation techniques, microvascular decompression (MVD), and stereotactic radiosurgery (SRS). None of the procedures have proven superiority over the other in terms of acute pain relief.[3] The right timing for surgical intervention is yet to be determined.[4]

This case report highlights successful application of radio-frequency ablation (RFA) in a patient with MS who had bilateral presentation at different times with good outcome.


  Case History Top


A 71-year-old woman having MS for 6 years presented with the complaint of pain in the (L) V2 distribution of trigeminal nerve of 2 year duration with acute exacerbation in the past 2 weeks. Initially she responded to oxcarbamazepine. When the pain recurred, pregabalin was added. However, this gave her side effects of somnolence and dizziness. At the time of presentation, her pain was paroxysmal, sharp, shooting, and severe in intensity (numeric rating score, 10/10) and lasting for approximately 20–30 s. It was triggered by trivial daily activities such as touching, brushing, chewing, and washing the face. She was completely pain-free in between the attacks of pain, which were up to 40–50 per day.

A contrast-enhanced magnetic imaging resonance (MRI) scan confirmed the diagnosis of MS with plaques involving root entry zones of both trigeminal nerves. No obvious vascular loops at root entry zone were reported.

As the pain was refractory to medical treatment, the patient was offered RFA. Foramen ovale was cannulated under fluoroscopic guidance using a 5-mm exposed tip of 18-G radio-frequency needle. The needle on a lateral fluoroscopic view can be observed [Figure 1] 2-mm deeper to the profile of the clivus and in the middle portion of the buttonhole-shaped foramen ovale [Figure 2] on the ipsilateral fronto-mental oblique view.
Figure 1: Lateral fluoroscopic view with RF needle in situ

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Figure 2: Ipsilateral oblique view with RF needle in foramen ovale

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Sensory stimulation at 0.2 V triggered concordant paresthesia in (L) V2 distribution. Following this, the patient was administered three lesions under general anaesthesia at 65°C, 70°C, and 75°C for 60 s each. The patient was woken up between each lesion to check for hypesthesia in V2 and the presence of corneal reflex. On discharge, 50% hypesthesia was recorded on the treated side with complete pain relief. Medications were tapered and stopped over the following 2 weeks. As per telephonic follow-up, every 2 weeks for the first 8 weeks and then every month for the first 8 months, she reported being completely pain-free.

Seventeen months later, the patient developed classical V2 TN on the contralateral side. This too was refractory to medical treatment. A fresh MRI scan was performed to rule out any new changes. In view of excruciating severity, she opted once again for the RFA. During stimulation, the patient reported concordant paresthesia only in (R) V2 distribution at a voltage of 0.27 V. She underwent RFA after this in a manner identical to the first side. The patient had good pain relief and 50% hypesthesia in the (R) V2 distribution at the time of discharge. She tapered all medications and stopped after 2 weeks. She is free from pain at the last follow-up at 6 months. She does not report any side effects of the therapy and is not disturbed by the hypesthesia.


  Discussion Top


The exact pathophysiology of TN associated with MS is not fully understood. It has been suggested that demyelinating plaques in the entry zones of the trigeminal roots are responsible for the lancinating pain by ephaptic conduction. However, suggestions involving other central changes of demyelination, which may potentially contribute to the pain, are available.[5] It is known that treating patients with MS with antiepileptic medications, even at low dosages, may cause an elevated incidence of adverse effects, mimicking clinical worsening suggestive of MS relapse.[6] Surgical outcomes also are less predictable and less durable in MS, presumably because of ill-understood central pain mechanisms that are often unaddressed.

A systematic review to evaluate the clinical efficacy of different treatment modalities in patients with MS and TN showed that the data of evidence, to support any one medical therapy, were insufficient and so earlier surgery may be preferable.[7] These patients respond differently to various surgical procedures. MVD, which is usually recommended as the first line of treatment in idiopathic TN with immediate pain relief (IPR) in 90% of patients with 10 years of pain-free interval (PFI) in around 65% of patients, is not considered the first line of treatment in MS-related TN.[8] In a large, single-center study, Mohammad-Mohammadi et al.[9] found that most patients required repeat procedures (66%), and the outcome following repeat procedures was inferior as the number of procedures increased. They also noted that the IPR was lower following SRS than following percutaneous procedures, but the recurrence rate was higher with percutaneous procedures. Zakrzewska et al.[7] found that the median PFI for all types of surgical procedures is shorter with 50% recurring at 2 years.

RFA is a safe and effective method for the treatment of TN. The mortality risk is extremely low with this modality, making it very appealing for elderly, frail patients, or the ones where other comorbidities enhance the risk of open neurosurgical therapy. After RFA, IPR can be achieved in 98% patients. Although 15%–20% of patients may experience recurrence of pain in 12 months, recurrence rate is the lowest among all the percutaneous techniques. The most common side effects are hypesthesia (50%), dysesthesias (6%), anesthesia dolorosa (4%), and corneal anesthesia with risk of keratitis (4%). Berk et al.[10] found that to be the case even in patients with MS. In their series, the IPR was 81% with remaining patients getting relief after addition of medical management. The recurrence rate was 50%. At our institute, the patients have generally preferred RFA over other surgical procedures. This particular patient had complete pain relief lasting for more than 2 years on one side. When the pain occurred on contralateral side and she failed to get adequate relief with medications, she chose to undergo RFA on the other side. Once again RFA has offered her complete relief from the pain. The advantage of this modality is precise ablation of the involved division and reproducibility of the results in majority of the patients.


  Conclusion Top


We conclude that RFA is an effective interventional modality in patients of MS with TN and can be safely offered bilaterally for medically intractable TN.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Foley PL, Vesterinen HM, Laird BJ, Sena ES, Colvin LA, Chandran S, et al. Prevalence and natural history of pain in adults with multiple sclerosis: systematic review and meta-analysis. Pain 2013;154:632-42.  Back to cited text no. 1
    
2.
Berk C. Bilateral trigeminal neuralgia: a therapeutic dilemma. Br J Neurosurg 2001;15:198.  Back to cited text no. 2
    
3.
Montano N, Papacci F, Cioni B, Di Bonaventura R, Meglio M. What is the best treatment of drug-resistant trigeminal neuralgia in patients affected by multiple sclerosis? A literature analysis of surgical procedures. Clin Neurol Neurosurg 2013;115: 567-72.  Back to cited text no. 3
    
4.
Spatz AL, Zakrzewska JM, Kay EJ. Decision analysis of medical and surgical treatments for trigeminal neuralgia: how patient evaluations of benefits and risks affect the utility of treatment decisions. Pain 2007;131:302-10.  Back to cited text no. 4
    
5.
Cruccu G, Biasiotta A, Di Rezze S, Fiorelli M, Galeotti F, Innocenti P, et al. Trigeminal neuralgia and pain related to multiple sclerosis. Pain 2009;143:186-91.  Back to cited text no. 5
    
6.
Ramsaransing G, Zwanikken C, De Keyser J. Worsening of symptoms of multiple sclerosis associated with carbamazepine. BMJ 2000;320:1113.  Back to cited text no. 6
    
7.
Zakrzewska JM, Wu J, Brathwaite TS. A systematic review of the management of trigeminal neuralgia in patients with multiple sclerosis. World Neurosurg 2018;111:291-306.  Back to cited text no. 7
    
8.
Jannetta PJ. Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia. J Neurosurg 1967;26: 159-62.  Back to cited text no. 8
    
9.
Mohammad-Mohammadi A, Recinos PF, Lee JH, Elson P, Barnett GH. Surgical outcomes of trigeminal neuralgia in patients with multiple sclerosis. Neurosurgery 2013;73:941-50; discussion 950.  Back to cited text no. 9
    
10.
Berk C, Constantoyannis C, Honey CR. The treatment of trigeminal neuralgia in patients with multiple sclerosis using percutaneous radiofrequency rhizotomy. Can J Neurol Sci 2003;30: 220-3.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2]



 

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