Trigeminal Neuralgia: Radiofrequency Ablation vs Surgery

Radiofrequency ablation (RFA) of the trigeminal ganglion is how Dr. Ashu Kumar Jain, Chief – Pain Medicine & Palliative Care, Artemis Hospitals, Gurugram, India, treats trigeminal neuralgia that medicines cannot control. Set against microvascular decompression surgery and gamma knife radiosurgery, RFA is a day-care procedure of about half an hour, with results he puts at above 95 per cent, and a vascular loop does not rule it out.

Pain in the face, head, neck and shoulder is among the most disabling a patient can carry. It can stop a patient eating, speaking or sleeping, and much of it is never traced to its true source. Dr. Jain treats most of these conditions with image-guided nerve blocks and radiofrequency procedures performed as day cases. His approach runs from the trigeminal ganglion down to the shoulder joint, and at every level it begins with proving where the pain comes from.

Trigeminal neuralgia: radiofrequency ablation vs surgery

How trigeminal neuralgia is diagnosed

The diagnosis of trigeminal neuralgia rests primarily on the history, and the character of the pain is decisive. It is a sharp, shooting, stabbing, electric-shock pain in one or more divisions of the trigeminal nerve (V1, V2 or V3), the nerve that carries sensation from the face. It is severe enough that patients cannot eat, speak, wash their face or even lie under a ceiling fan. In classical trigeminal neuralgia there is no neurological deficit.

Medicines first, then a choice of procedures

Around 80 per cent of patients can be managed medically, with carbamazepine or oxcarbazepine as the mainstays. For the remainder there are three procedural options:

• Gamma knife radiosurgery, which delivers focused radiation to the nerve. Dr. Jain notes it is expensive and takes two to three months to take effect. Most patients gain initial relief after radiosurgery, but recurrence over the following years is common.
• Microvascular decompression (MVD), which is a surgical operation.
• Radiofrequency ablation (RFA) of the trigeminal ganglion, which is a day-care procedure taking about half an hour, with results that Dr. Jain puts at above 95 per cent.

Peripheral blocks such as supraorbital and infraorbital nerve blocks have a place, but in his experience the definitive result comes from ablation of the trigeminal ganglion.

How trigeminal ganglion ablation is done

An electrode is introduced into the trigeminal fossa under imaging, with lateral, oblique and anteroposterior views used to confirm its path. Before any lesion is made, the nerve is stimulated and the patient is asked where the sensation is felt. When it reproduces the pain in exactly the territory the patient recognises, the electrode is in the right place and the ablation proceeds.

Does a vascular loop mean surgery?

Not in Dr. Jain's practice. Conventional teaching holds that a vascular loop compressing the nerve is an indication for MVD rather than ablation. Dr. Jain rejects this. His position, stated on record, is that the presence of a vascular loop is no contraindication to RFA, and his team has treated many such patients by ablation.

The stakes are illustrated by one of his patients: a man who had lived with trigeminal neuralgia in the V1 and V2 territories for 17 years and had attempted suicide twice. After ablation he reported complete relief.

Glossopharyngeal neuralgia and throat pain treatment

Glossopharyngeal neuralgia produces pain in the throat on swallowing and eating. It can be very disabling: patients may be unable to eat or swallow. Dr. Jain treats it with pulsed radiofrequency (PRF), a form of radiofrequency treatment that modulates the nerve rather than burning it, applied to the glossopharyngeal nerve under ultrasound or fluoroscopic guidance.

The same procedure serves conditions that ENT surgeons see regularly: Eagle syndrome, and pain from cancers of the tongue, pharynx and tonsillar bed. The average duration of relief after PRF is 9 to 12 months.

Sphenopalatine ganglion ablation for cluster headache and burning mouth

The sphenopalatine ganglion is a nerve cluster that lies deep in the pterygopalatine fossa, behind the nose. Ablating it is particularly useful for:

• cluster headache that has not responded to medical treatment;
• migraine;
• atypical facial pain, notably burning mouth syndrome, in which patients feel burning sensations across the tongue and mouth.

Needles are placed into the pterygopalatine fossa under lateral and anteroposterior imaging, with the needle tip positioned within the inverted-vase outline of the fossa on the lateral view. Both sides can be treated in one session.

Dr. Jain described a young man who had suffered severe bilateral burning of the tongue for many years. Electrodes were placed on both sides of the face in a single sitting, the procedure took about an hour, and the patient has remained well since.

Cervicogenic headache: when neck problems cause headaches

Headaches that start in the neck

Cervicogenic headache is headache that arises from the neck, from the C2 and C3 nerves, and it is commonly mistaken for migraine because it can be one-sided and refer pain forward to the forehead and around the eye. Neck pain is a leading cause of disability, and heavy mobile phone use is a recognisable pattern among Dr. Jain's patients. Cervicogenic headache and occipital neuralgia respond to targeted treatment of the third occipital nerve. He cited a woman who had lived with cervicogenic headache for 27 years and was treated in a single sitting.

Reading the referral map

The cervical facet joints, the small paired joints at the back of the neck, generate a wide spread of symptoms: suboccipital headache, cervicogenic headache, neck pain, shoulder pain and pain over the back of the shoulder blade. Each level has its own referral pattern. Pain from the C6-C7 facet, for example, is felt behind the scapula and in the mid-thoracic region. Without knowledge of these patterns the source is very hard to identify.

Cervical facet medial branch RFA, several levels at once

Once the pattern is clear, the treatment sequence is:

1. A diagnostic block to establish whether the patient will benefit.
2. Medial branch RFA, ablation of the small nerves that supply the facet joints, with stimulation first. Stimulating C2, for instance, should send the sensation to the back of the head; when the patient confirms that it radiates to the occipital area, the position is right.
3. Treatment of C2 through C6 in a single sitting where needed, addressing headache, neck pain, shoulder pain and scapular pain together.

Dr. Jain described these as spines that no surgeon would operate on, in patients who nonetheless live with severe pain. Performed as a day-care procedure in a catheterisation lab, medial branch RFA treats 90 per cent or more of cervicogenic headache and related neck and shoulder pain in his experience.

Cervical radiculopathy: treating arm pain without surgery

Most neck-related arm pain does not need an operation. A cervical disc prolapse that compresses a nerve root causes radicular pain down the arm, known as cervical radiculopathy. Dr. Jain's threshold for surgery is clear: if the patient has no myelopathy (compression of the spinal cord itself), no muscle weakness and no severe sensory deficit, the radicular pain can be treated with a cervical epidural injection and the patient does not need an operation. In his experience, patients with myelopathy or weakness form only a small minority. Most cervical radiculopathy improves without surgery, and epidural steroid injection is an established option when radicular pain persists despite medicines and physiotherapy.

Under imaging, an epidural needle is advanced into the epidural space; contrast shows the nerve root outlined and the space opening. Dexamethasone with normal saline is then injected. One of his patients, an international patient weighing 135 kg, was treated this way without surgery.

Cervical epidural injection is also where Dr. Jain's insistence on DSA in a catheterisation lab proved its value, when imaging revealed contrast entering a web of epidural veins in one patient. The lumbar counterpart for sciatica, transforaminal epidural adhesiolysis, is described in back pain treatment without surgery.

T2-T3 sympathectomy for upper-limb pain and CRPS

Sympathetically maintained pain of the upper limb, pain driven by the sympathetic nerves, that does not respond to conventional treatment can be treated by ablating the sympathetic chain at T2 and T3. Dr. Jain's indications include:

• complex regional pain syndrome (CRPS), including after brachial plexus injury;
• pain after surgery such as breast cancer surgery;
• post-amputation and phantom limb pain;
• peripheral vascular disease, such as Raynaud's disease;
• a range of other neuropathic pains.

Many centres still perform sympathectomy surgically, through a thoracoscope. Dr. Jain's institution performs it percutaneously, through the skin, as a day case in the cath lab: two electrodes are placed at T2 and T3, confirmed on lateral, oblique and anteroposterior views, and stimulation is used to confirm that the sensation travels down the arm before ablation.

The vascular indication can be urgent. His team was once called in the middle of the night to perform sympathectomy on a patient whose hand had turned black and who was not recovering after embolectomy. Another patient, treated for a vascular cause, reported marked relief of her pain. For brachial plexus injury, he regards T2-T3 sympathectomy as one of the most rewarding procedures in his practice.

Shoulder pain without surgery: frozen shoulder and the 3-in-1 block

Conditions managed without surgery

Adhesive capsulitis (frozen shoulder), calcific tendinosis, bursitis and suprascapular neuropathy can all be managed with interventions rather than surgery. Management of shoulder pain has changed substantially. Dr. Jain uses ultrasound-guided platelet-rich plasma (PRP) injections for tendinosis, and both ultrasound-guided and fluoroscopy-guided procedures for frozen shoulder.

Dr. Jain applies a size rule to rotator cuff tears: in his practice, a tear of less than 50 per cent does not need surgery, while a tear above 50 per cent needs the tendon fixed first. Some patients continue to have pain after tendon repair, and these are treated with suprascapular nerve RFA in a single sitting, followed by rehabilitation.

Releasing a frozen shoulder with hydrodissection

For adhesive capsulitis, a spinal needle is introduced through the acromioclavicular (AC) joint and advanced to the capsule of the shoulder joint under fluoroscopy. The capsule is then hydrodissected, stretched open with injected fluid, and contrast can be seen spreading around it as it releases. Dr. Jain follows the release with 40 mg of Kenacort, and most patients respond well.

The 3-in-1 shoulder block

On withdrawing the same needle, he injects the supraspinatus region, then the space below the AC joint, then the AC joint itself. A single pass therefore treats adhesive capsulitis, the suprascapular region, the bursa and AC joint arthritis. He calls this the 3-in-1 shoulder block and combines it, where indicated, with suprascapular nerve RFA.

Which treatment for which face, neck or shoulder pain

For a referring doctor, the practical value of this section of Dr. Jain's work lies in the thresholds he applies:

• Trigeminal neuralgia: medicines for the roughly 80 per cent who respond; ablation of the trigeminal ganglion for the rest, including patients with a vascular loop.
• Throat and tongue pain, including cancer pain in the head and neck: pulsed radiofrequency of the glossopharyngeal nerve, with relief typically lasting 9 to 12 months.
• Refractory cluster headache and burning mouth: sphenopalatine ganglion ablation, bilateral in one session if needed.
• Headache with neck pain, or pain behind the shoulder blade: suspect the cervical facets, confirm with a diagnostic block, then treat C2 to C6 by medial branch RFA in one sitting.
• Arm pain from a cervical disc: cervical epidural injection, unless there is myelopathy, weakness or a severe sensory deficit.
• Refractory sympathetic pain in the arm: percutaneous T2-T3 sympathectomy.
• Shoulder: hydrodissection and the 3-in-1 block for frozen shoulder; repair first for tears above 50 per cent; suprascapular nerve RFA when pain persists after repair.

The diagnostic discipline and the criteria for surgical referral that sit behind these choices are set out in Advances in Chronic Pain Treatment: A Complete Guide.