Trigeminal neuralgia affects approximately 3% of patients with multiple sclerosis (MS), a prevalence notably higher than in the general population. The pain in MS-associated trigeminal neuralgia is frequently refractory to medication, prompting consideration of neurosurgical interventions. Variability in efficacy, tolerability, and long-term durability across available surgical procedures, together with patient- and disease-specific factors such as MS subtype and neuroimaging findings, complicate personalised treatment decisions.
This systematic review followed PRISMA guidance. Embase, PubMed, and Scopus were searched for the period January 2000 to April 2026. Included studies assessed pain relief from surgical procedures for trigeminal neuralgia in MS and reported outcomes using the Barrow Neurological Institute (BNI) Pain Scale. Risk of bias for included observational studies was evaluated using the Newcastle-Ottawa Scale. The review employed a narrative synthesis of the identified literature.
Thirty-two studies met inclusion criteria, encompassing a total of 1,617 patients. Studies varied in surgical modality, reported outcomes, follow-up duration, and complication reporting. The review synthesised results across modalities including microvascular decompression, partial sensory rhizotomy, percutaneous ablative procedures, Gamma Knife radiosurgery, and a more recent series reporting arachnoid-trigeminal nerve release.
When neurovascular conflict was demonstrable on preoperative imaging, microvascular decompression (MVD) provided durable pain relief in selected MS patients. However, MVD was associated with higher rates of serious complications relative to less invasive procedures; the included literature reported at least one fatality associated with MVD. The authors highlight diagnostic uncertainty in MS: it can be difficult to determine whether trigeminal pain is driven by demyelinating lesions, neurovascular compression, or both. This uncertainty complicates attribution of benefit and necessitates careful case selection.
Partial sensory rhizotomy (PSR) demonstrated high initial success rates (reported range 95.3–100%) and favourable durability, with reported recurrence intervals spanning a median or range of 20.1 to 79 months in included studies. While some series reported an absence of major complications, instances of severe trigeminal dysfunction were documented, including cases of anaesthesia dolorosa (n = 3; reported as 7.5% in that report). The review suggests PSR may merit earlier consideration for refractory MS-associated trigeminal neuralgia, particularly when neurovascular conflict is absent.
Percutaneous ablative procedures achieved initial pain control rates ranging from 58% to 100% across studies. These procedures generally featured a mild complication profile compared with open surgery. Durability of pain relief was variable, with recurrence intervals reported between 8 and 60 months. Repeat percutaneous procedures were commonly tolerable in practice according to the reviewed literature.
Gamma Knife radiosurgery (GKRS) yielded initial success rates ranging from 52.7% to 97.3% in the included studies, with a mostly mild complication profile. However, durability was suboptimal in several series: reported recurrence intervals ranged from 7.4 to 74.5 months. Studies examining different GKRS dosages (below or above an 80 Gy threshold) did not find consistent, significant differences in pain control across cohorts included in the review. Overall, GKRS outcomes in MS-associated trigeminal neuralgia were comparable to those reported in primary trigeminal neuralgia cohorts in many studies, and plaque burden did not predict clearly worse results in the aggregated data.
A 2025 study included in the review reported preliminary outcomes for arachnoid-trigeminal nerve release, with 75% of patients achieving BNI I at final follow-up. These results are promising but are based on limited data and require replication and longer follow-up before broader conclusions can be drawn.
The review synthesises evidence suggesting that Gamma Knife radiosurgery and percutaneous ablative procedures represent well-tolerated surgical options for MS-associated trigeminal neuralgia, with outcomes broadly comparable to primary trigeminal neuralgia cohorts and generally mild complication profiles. Partial sensory rhizotomy demonstrated notable efficacy and durability, particularly in refractory cases without demonstrable neurovascular conflict, and may warrant earlier consideration in the surgical pathway for selected patients.
Microvascular decompression may offer the best long-term durability when clear neurovascular conflict is present on high-resolution imaging, but it carries a higher risk of serious complications and there remains diagnostic uncertainty in attributing pain to neurovascular conflict versus MS lesions. Therefore, cautious patient selection and detailed preoperative imaging are emphasised.
The authors recommend the use of high-resolution preoperative imaging to inform personalised selection of surgical modality. For many patients, GKRS and percutaneous procedures offer a reasonable balance between efficacy and tolerability; PSR may be particularly effective for refractory cases without neurovascular compression. MVD can be considered when neurovascular conflict is clearly demonstrated, but only after weighing the increased procedural risks and diagnostic ambiguity in MS-related pain.
Prospective studies are needed to validate surgical decision-making pathways and to establish standardised outcome reporting measures for this population.
The review highlights heterogeneity across studies in patient selection, operative technique, outcome reporting, and follow-up duration. Risk of bias was assessed but observational study designs predominate. The authors call for prospective, standardized studies to better define comparative effectiveness, long-term durability, and optimal patient selection criteria in MS-associated trigeminal neuralgia.