Multiple sclerosis surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D., Julinka Auta Fernandes
Overview
The surgical procedures used in multiple sclerosis are symptomatic treatments and do not modify the underlying disease. Surgery or implantation of a therapeutic device may be considered only for carefully selected patients with severe, functionally disabling symptoms that remain refractory to appropriate non-surgical treatment.
Current guideline-supported indications include medically refractory trigeminal neuralgia, severe medication-refractory tremor, and selected cases of severe spasticity. Ataxia alone is not a surgical indication.[1]
Because MS-specific evidence for several surgical procedures is limited, recommendations generally state that an intervention may be considered rather than recommending routine surgery. Selection should be individualized and undertaken by an experienced multidisciplinary team.[1]
Indications
Surgical or implanted interventions may be considered for:
- Medically refractory or medication-intolerant trigeminal neuralgia.[1][2]
- Severe, functionally disabling tremor when medication is ineffective or causes intolerable adverse effects, for evaluation at an experienced deep brain stimulation center.[1]
- Severe generalized or multisegmental spasticity that remains inadequately controlled, for possible implantation of an intrathecal baclofen pump.[1]
- Rare, highly selected cases of refractory spasticity when established treatments are ineffective or contraindicated.[1]
Surgery
Trigeminal neuralgia
Surgical treatment of MS-associated trigeminal neuralgia is reserved for patients whose pain remains inadequately controlled by appropriate medication or who cannot tolerate medical treatment.[1][2]
The 2026 DGN living guideline, recommendation E56 (strong consensus), states that percutaneous operative procedures or stereotactic radiosurgery may be considered for medically refractory trigeminal neuralgia. Microvascular decompression may be considered when definite neurovascular contact is demonstrated.[1]
Guideline-supported procedures include:
- Percutaneous radiofrequency thermocoagulation of the trigeminal nerve at the trigeminal ganglion
- Percutaneous glycerol rhizolysis
- Percutaneous balloon compression
- Stereotactic radiosurgery
- Microvascular decompression when definite neurovascular contact is present[1]
Surgical outcomes are generally less favorable and recurrence is more frequent in patients with MS-associated trigeminal neuralgia than in patients with classical trigeminal neuralgia without MS. Patients should be counseled about sensory complications, recurrence, and the possible need for repeat procedures.[1]
Deep brain stimulation for tremor
Deep brain stimulation may improve severe MS-associated tremor but does not treat the underlying MS.
The 2026 Deutsche Gesellschaft für Neurologie (DGN; German Neurological Society) living guideline, recommendation E17 (consensus), states that referral to a deep brain stimulation center may be considered when tremor causes severe functional impairment and medication is ineffective or produces intolerable adverse effects.[1]
Deep brain stimulation can improve tremor but is not effective for ataxia. Therefore, ataxia alone should not be listed as a surgical indication.[1]
Because MS-related tremor may have cerebellar, postural, kinetic, and intention components, candidacy, stimulation target, expected benefit, and operative risk should be evaluated individually at an experienced functional-neurosurgery center.[1]
Intrathecal baclofen pump implantation
Surgical implantation of an intrathecal baclofen pump may be considered for carefully selected patients with severe generalized or multisegmental spasticity that remains inadequately controlled or when systemic treatment causes intolerable adverse effects.[1][3]
The procedure involves placement of a programmable subcutaneous pump connected to an intrathecal catheter. Patient selection should be undertaken by an experienced multidisciplinary spasticity team after establishing individualized functional, positioning, comfort, or caregiving goals.[4][5]
Patients should be counseled about operative and device-related risks, including pump or catheter complications, the possible need for surgical revision or replacement, and the requirement for regular refills and long-term specialist monitoring.[3][4]
Last-resort surgery for spasticity
When established treatments are ineffective or contraindicated, the DGN living guideline identifies the following possible last-resort operations:
- Selective peripheral neurotomy
- Nerve transfer
- Selective dorsal rhizotomy[1]
Selection should be interdisciplinary and individualized. Large studies evaluating these operations specifically in patients with MS are lacking; therefore, they should not be presented as routine treatment.[1]
Surgical and interventional procedures not recommended
Venoplasty for chronic cerebrospinal venous insufficiency
Percutaneous venoplasty for alleged chronic cerebrospinal venous insufficiency, sometimes called "liberation therapy," should not be used to treat multiple sclerosis.
The National Institute for Health and Care Excellence concluded that the procedure provides no clinical benefit and can cause serious complications.[6]
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 Deutsche Gesellschaft für Neurologie (27 April 2026). "Diagnose und Therapie der Multiplen Sklerose, Neuromyelitis-optica-Spektrum-Erkrankungen und MOG-IgG-assoziierten Erkrankungen: S2k-Living Guideline, Version 9.0, AWMF Registry Number 030-050" (in German). Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften. Retrieved 30 August 2026.
- ↑ 2.0 2.1 Bendtsen L, Zakrzewska JM, Abbott J, Braschinsky M, Di Stefano G, Donnet A; et al. (2019). "European Academy of Neurology guideline on trigeminal neuralgia". European Journal of Neurology. 26 (6): 831–849. doi:10.1111/ene.13950. PMID 30860637.
- ↑ 3.0 3.1 Solari A, Giordano A, Sastre-Garriga J, Köpke S, Rahn AC, Kleiter I; et al. (2020). "EAN guideline on palliative care of people with severe, progressive multiple sclerosis". European Journal of Neurology. 27 (8): 1510–1529. doi:10.1111/ene.14248. PMID 32469447 Check
|pmid=value (help). - ↑ 4.0 4.1 Verduzco-Gutierrez M, Raghavan P, Pruente J, Moon D, List CM, Hornyak JE; et al. (2024). "AAPM&R consensus guidance on spasticity assessment and management". PM&R. 16 (8): 864–887. doi:10.1002/pmrj.13211. PMID 38770827 Check
|pmid=value (help). - ↑ Biering-Sørensen B, Stevenson VL, Bensmail D, Grabljevec K, Martínez Moreno M, Pucks-Faes E, Wissel J, Zampolini M (2022). "European expert consensus on improving patient selection for the management of disabling spasticity with intrathecal baclofen and/or botulinum toxin type A". Journal of Rehabilitation Medicine. 54: jrm00241. doi:10.2340/16501977-2877. PMID 34608495 Check
|pmid=value (help). - ↑ National Institute for Health and Care Excellence (2019). "Percutaneous venoplasty for chronic cerebrospinal venous insufficiency in multiple sclerosis". National Institute for Health and Care Excellence. Retrieved 30 August 2026.