Abstract / Summary
Trigeminal neuralgia affects approximately 3% of patients with multiple sclerosis - a far higher prevalence than in the general population. The associated pain often proves refractory to medication, prompting consideration of neurosurgical intervention. The variable efficacy, tolerability, and durability of available procedures, compounded by factors such as multiple sclerosis subtype and neuroimaging findings, require evidence to guide personalised surgical decision-making. This systematic review evaluates surgical interventions for trigeminal neuralgia in multiple sclerosis, analysing how patient and disease-specific variables influence outcomes. A systematic review with narrative synthesis was performed. Following PRISMA guidelines, Embase, PubMed, and Scopus were searched (January 2000 - April 2026). Studies assessing pain relief from surgical procedures for trigeminal neuralgia in multiple sclerosis using the Barrow Neurological Institute Pain Scale were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. Thirty-two studies, encompassing 1617 patients, met the inclusion criteria. Microvascular decompression in cases with demonstrable neurovascular conflict provided durable outcomes offset by higher risks of serious complications (including one fatality), despite inherent diagnostic uncertainty regarding whether pain was specifically driven by multiple sclerosis. Partial sensory rhizotomy displayed favourable pain relief (initial success range: 95.3-100%) and durability (recurrence ranging from 20.1 to 79 months). Whilst some studies noted a lack of major complications, some cases of severe trigeminal dysfunction including anaesthesia dolorosa were reported (n = 3; 7.5%). Percutaneous ablative procedures (initial success ranging from 58 to 100%) and gamma knife radiosurgery (initial success ranging from 52.7 to 97.3%) achieved comparable pain control rates to classical trigeminal neuralgia cohorts. They also featured a mild complication profile, though durability was suboptimal (recurrence ranging from 7.4 to 74.5 months for gamma knife radiosurgery and 8-60 months for percutaneous procedures) and repeat procedures were typically tolerable. Differing gamma knife radiosurgery dosages (</>80 Gy) were not associated with significant differences in pain control. Preliminary outcomes of arachnoid-trigeminal nerve release from a 2025 study highlighted promising results with 75% of patients achieving Barrow Neurological Institute Pain Scale I at final follow-up. Gamma knife radiosurgery and percutaneous ablative procedures represent well-tolerated surgical options with comparable outcomes to primary trigeminal neuralgia cohorts regardless of plaque burden. Partial sensory rhizotomy demonstrated notable efficacy and durability in refractory multiple sclerosis-associated trigeminal neuralgia, particularly in the absence of neurovascular conflict, and warrants earlier consideration in the surgical pathway. Microvascular decompression may offer long-term durability where neurovascular conflict is demonstrated. However, its higher procedural risk and the diagnostic uncertainty inherent in multiple sclerosis-associated trigeminal neuralgia cases with concurrent neurovascular conflict necessitate cautious patient selection. High-resolution preoperative imaging is therefore recommended to guide personalised modality selection. Prospective studies are needed to further validate surgical decision-making and establish standardised outcome reporting in this population.