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Multiple Sclerosis
This information is designed only to help patients talk with their physicians about Multiple Sclerosis (MS) and is not intended to provide treatment guidelines.
Most of the symptoms caused by MS are well treated with appropriate medications under the guidance of Neurologists. The MS Clinic at the University of British Columbia has an international reputation for the medical treatment and research of this condition. Occasionally there are symptoms that do not respond to medications and patients need to consider the pros and cons of surgical intervention. Three of these symptoms are:
- Tremor
- Trigeminal neuralgia
- Lower limb spasticity
Tremor
Tremor is rhythmic shaking. Arm tremor can be particularly disabling because the shaking prevents patients from using their arms for the activities of daily living. Tremor can be quite difficult to treat with medications. One option available for patients at the University of British Columbia is thalamic deep brain stimulation. This operation is designed to “turn off” the area of the brain causing the tremors. We have published our work with this technique (see our Research page).
The surgery will reduce tremor by approximately 80% but will have no beneficial effect on ataxia, weakness or sensory loss. Ataxia is incoordination of the limb. It can be difficult to decide how much ataxia a patient has if there is a lot of tremor. If a patient has a lot of tremor and little ataxia, the operation will be very effective. If the patient has a lot of ataxia and a little tremor the operation will not be helpful.
Surgical Treatment
Trigeminal Neuralgia
Trigeminal Neuralgia is more than 100 times more common in MS than within the general population. Detailed information about about this condition is presented on our Trigeminal Neuralgia page.
The medical treatments of trigeminal neuralgia are the same for patients with MS patients BUT they seem to suffer more side effects from the typical anti-neuralgia medications (e.g. reduced mental quickness or sedation). Patients who continue to have pain despite their medications or those who can not tolerate their medications can consider a surgical treatment. We have published our experience with the treatment of trigeminal neuralgia in MS (see our Research page).
The cause of the pain is thought to be due to a demyelinated plaque (see picture above) in the trigeminal pathway inside the brainstem not a vessel compressing the trigeminal nerve. We therefore recommend percutaneous rhizotomy not microvascular decompression for MS patients with trigeminal neuralgia.
Surgical treatment
Lower Limb Spacticity
Lower limb spasticity can be treated with a variety of oral medications (e.g. Baclofen, Tizanadine or Dantrolene). When any of these medications are taken as a pill, they are absorbed through the gut and circulate around the entire body through the bloodstream. They produce their desired effect (reduced spasticity) when they reach the spinal cord. They produce unwanted effects (e.g. sedation) when the reach the brain. As the dosage level is increased, both the benefits and the side-effects increase. Occasionally patients can not tolerate the side-effects of the medications required to reduce their spasticity.
One solution to this problem is to concentrate the medication where it is needed – around the spinal cord. This is the concept that underlies Intrathecal Baclofen Therapy or ITB.
These pumps contain a refillable reservoir of this anti-spasticity medication and are connected to a small tube which delivers the drug to the space around the spinal cord. The pump is about the size of a hockey puck and sits under the skin of the lower abdomen. The drug is delivered directly to where it is needed (around the spinal cord) and therefore has less systemic sedative side-effects. The benefits and potential complications of this therapy must be discussed with your surgeon.
Surgical Treatment
The picture below is of a freeze from Persepolis (Takht-e-Jashid) depicting the lion and the bull. Persepolis was the ceremonial capital of the Persian Empire before it was destroyed by Alexander the Great in 330 BCE. Much is written about the symbolism with one interpretation suggesting the lion, representing the spring and the beginning of a new year, overcoming the bull, representing winter and the old year. The lost of function of the bull’s legs and the sudden new pain is reminiscent of some of our patients with multiple sclerosis.
