Can Multiple Sclerosis Be Treated Surgically?

Frank J. Veith, MD


February 22, 2013

This feature requires the newest version of Flash. You can download it here.

Hi. I am Frank Veith, Professor of Vascular Surgery at New York University and the Cleveland Clinic. Today's topic is chronic cerebral spinal venous insufficiency (CCSVI) and its relationship to multiple sclerosis. This relationship is based on the premise that narrowing of the major veins in the neck and thorax can increase venous pressure in the brain and spinal cord, and this increased pressure is a major cause of multiple sclerosis. It is further maintained that this condition can be treated interventionally by dilating the stenosis and relieving the venous obstruction.

This is one of the most controversial areas in medicine today, and it became apparent at our last VEITHsymposium™, held late in November 2012, that there are very strong opinions on both sides of this controversy. Many very reputable, well-established, and prestigious physicians believe that this relationship is real and that balloon dilatation to relieve venous obstruction also improves multiple sclerosis. Of interest, on the other side of the debate, equally prestigious and well-established investigators believe that the relationship is not real and that therapy with balloon dilatation is overused.

There are many reasons for this controversy. One is the nature of multiple sclerosis, which is a disease that has ups and downs, exacerbations and remissions without any therapy, making it difficult to evaluate whether the balloon dilatation improves multiple sclerosis more than what is offered by the natural history of the disease. Another reason that the controversy exists is that patients with multiple sclerosis are often desperate and seek out this therapy even though evidence for the impact of the venous obstruction has not been established.

Some patients with multiple sclerosis don't have any venous obstruction, and some patients with venous obstruction don't have multiple sclerosis. So the controversy continues, and it is fair to say that it probably will continue because it is very difficult to organize a randomized comparison of the therapy against some form of placebo. The patients will not give permission to be randomized because they are so desperate that they want the treatment.

This is a very interesting as well as controversial area in medicine, and the controversy will likely continue. We will hear new evidence next year at our meeting in New York in November. It may not be settled in the near future, but it remains an area of great interest to physicians, interventionalists, neurologists, and patients.