Pains Of Primary Neurogenic Origin Paroxysmal

Trigeminal neuralgia occurs in multiple sclerosis approximately 300 times more often than in the general population. It is generally similar in its presentation to the idiopathic condition, but tends to occur at a younger age and is more likely to be bilateral (which is extremely rare in the idiopathic disorder). It is generally responsive to treatment along similar lines to idiopathic tic doulour-eux,13 although microvascular decompression (in a small series) appeared less effective,14 and there also appears to be relative refractoriness to neurolytic surgical proce-dures.15 A 1994 study7 suggests a prevalence in the order of

5 percent (rather higher than formerly believed). Unlike most pain syndromes in MS, trigeminal neuralgia may be a presenting symptom of the disease, and the underlying diagnosis should therefore be considered particularly in a young patient or one with bilateral symptoms. The clinical manifestations and treatment of trigeminal neuralgia are discussed at greater length in Chapter 35, Facial pain.

Lhermitte's phenomenon is a classical finding in MS. It consists of rapidly evolving paresthesiae or dysesthesiae, provoked by neck flexion, and typically spreading down the back and into the extremities. It is suggested that traction on the dorsal columns actively involved in the inflammatory process is the trigger. A recent study indicates that it may occur in over 41 percent of individuals with MS at some point in the course of their disease, and is significantly correlated with magnetic resonance imaging (MRI) signal change in the cervical cord.16

Epileptiform seizures are rare in MS, and in general are a rare cause of pain. However, a syndrome of spreading dysesthesiae and muscle spasm, either spontaneous or evoked by trivial stimuli such as light touch, active or passive movement, or a startling event, is recognized. The prevalence of this symptom complex varies in the limited literature describing it.7'17

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