Long-term outcomes of microvascular decompression for trigeminal neuralgia in multiple sclerosis: a systematic review and meta-analysis

OBJECTIVE Trigeminal neuralgia (TN) is a debilitating condition often associated with multiple sclerosis (MS), in which the presence of demyelinating plaques in the pons can impact the trigeminal nerve. Microvascular decompression (MVD) is the gold-standard surgical treatment for classic TN but is traditionally contraindicated in TN-MS patients due to limited efficacy and concerns over neurovascular compression as the sole etiology. This systematic review aimed to evaluate the outcomes of MVD in TN-MS patients, focusing on pain relief and complications. METHODS A systematic search of the PubMed, Embase, Scopus, and Web of Science databases was conducted in June 2024, adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies reporting on MVD outcomes in TN-MS patients were included. Data on demographics, clinical characteristics, surgical outcomes, and complications were extracted. The primary outcome was long-term pain-free status (Barrow Neurological Institute [BNI] score of I) at the final follow-up. A meta-analysis of proportions was performed using a random-effects model. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies tool. RESULTS From 523 unique records, 30 studies were included, consisting of 429 TN-MS patients treated with MVD, with 265 unique patients. Neurovascular compression was identified in 96.6% of the patients. The pooled success rate of MVD, defined as achieving a BNI score of I, was 30.2% (95% CI 24.2%–36.9%). Heterogeneity was low (I 2 = 0%–25%) across analyses. The most common complication reported after MVD was transient facial numbness. Publication bias was not significant in the included studies. CONCLUSIONS MVD is less effective in TN-MS patients than in those with classic TN, with approximately 30% achieving long-term pain-free outcomes. However, MVD may still offer meaningful relief, particularly in patients with neurovascular compression. Given these findings, MVD should not be categorically excluded as a treatment option for TN-MS. Further prospective studies are needed to refine patient selection and optimize outcomes.