case report of Chinese Neurosurgical Journal describe a new salvage surgical approach for refractory multiple sclerosis-associated trigeminal neuralgia. In one patient who failed medical, percutaneous, and radiosurgical treatments, a procedure combining internal neurolysis (neurocombing) with targeted glycerol delivery to the proximal trigeminal nerve was performed. Patients experienced immediate pain relief, with no recurrence for 43 months on the treated side, preserved sensation, and reduced drug use.
Multiple sclerosis-related trigeminal neuralgia (MS-TN) is one of the most painful neurological complications experienced by people with multiple sclerosis. Compared to classic trigeminal neuralgia, MS-TN is often more difficult to treat, more likely to recur, and often less responsive to both medical and surgical interventions. This condition is thought to occur due to demyelination affecting trigeminal nerve pathways within the brainstem, causing abnormal nerve signaling and severe episodes of facial pain. Treatment options are becoming increasingly limited for patients who do not respond to conventional treatments.
A case report by Dr. Thomas Patrick Short and Dr. Chandrasekaran Kaliaperumal from the Department of Neurosurgery at the Royal Infirmary of Edinburgh, UK, was published in Volume 12, Issue 14 of this journal. Chinese Neurosurgical Journal on May 14, 2026, describe a novel salvage surgical approach to provide durable pain relief to patients with severe, treatment-resistant MS-TN. “Our study reports a salvage surgical approach that combines internal neurolysis and targeted proximal trigeminal nerve root glycerol injections for refractory MS-associated trigeminal neuralgia.” explains Dr. Short.
The patient was a 50-year-old woman with relapsing-remitting multiple sclerosis who suffered from debilitating right-sided facial pain affecting the maxillary and mandibular branches of the trigeminal nerve. Her symptoms significantly interfered with daily activities such as speaking, eating, and touching her face. Despite extensive treatment, including anticonvulsants, two percutaneous glycerol rhizectomies, and Gamma Knife radiosurgery, she continued to suffer from severe breakthrough pain and required ongoing medical management. Advanced magnetic resonance imaging demonstrated multiple demyelinating lesions consistent with multiple sclerosis, including abnormalities extending to the entry area of the trigeminal nerve roots. Importantly, no evidence of neurovascular compression was identified. Because traditional microvascular decompression relies on the presence of compressed vessels and was not appropriate, the patient was evaluated by a multidisciplinary team to consider alternative treatment strategies. The surgical team performed exploration of the posterior sigmoid fossa.
During the surgery, no neurovascular impingement involving the trigeminal nerve was identified. Internal neurolysis, commonly referred to as “nerve combing,” was performed to mechanically isolate the trigeminal nerve bundle without intentionally cutting nerve fibers, thereby disrupting aberrant signaling pathways that may contribute to pain generation. Subsequently, a small amount of anhydrous glycerol was targeted and delivered to the proximal cisternal portion of the trigeminal nerve root adjacent to the radiologically relevant demyelinating lesion. The goal was to provide localized chemical neurolysis at a more proximal anatomical location than those targeted with previous percutaneous procedures. The patient experienced improvement in facial pain immediately postoperatively. Importantly, sensation of the trigeminal nerve distribution was preserved and there was no new neurological deficit, corneal dysfunction, or clinically significant facial numbness. Her early postoperative recovery was complicated by a wound infection that required surgical flushing and antibiotic treatment, but no trigeminal nerve-related complications were observed.
Long-term follow-up demonstrated durable responses. Five months after surgery, the patient reported significant improvement with only occasional residual pain. One year later, she had no recurrence of trigeminal neuralgia on the treated side, her pain had improved from a preoperative Barrow Neurological Institute (BNI) pain intensity score of V to a postoperative score of I, and her medication requirements had significantly decreased. Follow-up assessments after 19, 26, and 43 months continued to show sustained pain relief on the operated side. She subsequently developed intermittent facial pain on the contralateral side, which was well controlled with low doses of medication and no recurrence of the original symptoms was observed. According to the authors, this case highlights the potential role of root-level surgical strategies in carefully selected patients with refractory MS-TN who have exhausted medical, percutaneous, and radiosurgical options. However, they caution that the study results should be interpreted with caution. “To our knowledge, this is the first published report of this combination technique in trigeminal neuralgia secondary to multiple sclerosis.” Dr. Short said.
The authors conclude that this new approach should be seen as hypothesis-generating rather than practice-defining. Nevertheless, the sustained analgesia observed in this very difficult case suggests that further studies may be warranted to assess whether the combination of internal neurolysis and targeted glycerol delivery to the proximal trigeminal nerve root can provide a future salvage option for selected patients with treatment-resistant multiple sclerosis-associated trigeminal neuralgia.
sauce:
Chinese Neurosurgical Journal
Reference magazines:
Short, TP, & Kaliaperumal, C. (2026) Combination of internal neurolysis and glycerol delivery to targeted proximal trigeminal nerve roots for refractory multiple sclerosis-associated trigeminal neuralgia: a case report. Chinese Journal of Neurosurgery. DOI: 10.1186/s41016-026-00433-x. https://link.springer.com/article/10.1186/s41016-026-00433-x
