Trigeminal Neuralgia: Radiofrequency Ablation vs Surgery

In India, opioids are scheduled drugs — you need a prescription from a competent doctor: a pain specialist, anaesthesiologist or neurologist, not a general surgeon or ENT. For morphine and fentanyl specifically, the hospital needs a government licence to hold a certain quantity, and we use a special designated government form that we stamp, with patients required to bring a consumption chart we submit to the drug controller. Tramadol, tapentadol and buprenorphine don't need special licensing, but you do need a valid prescription from a competent doctor.

The first issue is simply diagnosis — ninety per cent of doctors not trained for this kind of spinal pain can't diagnose facetogenic pain. We call it axial pain, which includes facetogenic and discogenic pain, and gabapentinoids are of no use for it whatsoever — yet eight out of ten patients with axial pain are given these drugs with no results. It's a diagnostic challenge first: specific questions in the history, a specific examination, then a diagnostic block to confirm the pain is coming from the facet before proceeding to facet joint RFA.

If the femoral head is involved, we can perform radiofrequency ablation of the hip joint, ablating the articular nerves supplying the joint — it's a very rewarding procedure. But if the pain is arising from the bone itself or visceral involvement, the best approach is opioid analgesics rather than high-dose NSAIDs, which will damage the kidneys. Primary management is opioid-based — morphine or tramadol with paracetamol and a neuropathic agent — and where there is a specific anatomical target, we address that interventionally as well.

According to international Spine Society guidelines, any pain coming from the spine where the primary problem is pain alone does not require surgery. The indications for surgery are disability — foot drop, motor or sensory deficit — or more than moderate to severe canal stenosis on MRI, where pain intervention can buy time but can't treat the disease. If a patient comes to me with a neurological deficit, I immediately refer to the spine surgeon and don't proceed with intervention. If pain is the only presenting symptom, we treat it — there's a very clear demarcation.

If you use opioids for chronic low back pain, knee pain or musculoskeletal pain, yes, they are habit-forming. But for cancer pain, and for pain like sickle cell disease — which we manage on the same lines as cancer pain — they are never habit-forming. Visceral pain is mediated by the sympathetic nervous system and doesn't respond to conventional NSAIDs, so it needs neuropathic agents and opioids in combination; back pain, knee pain and shoulder pain are peripheral musculoskeletal or neuropathic pain and don't carry the same opioid receptor expression, which is why the risk profile is so different between the two.

Sharp, shooting, electric-shock-like pain in one of the three divisions of the trigeminal nerve, severe enough that patients cannot eat, speak, wash their face, or sit under a fan.

No. Eighty per cent of patients respond to medical management alone. For those who do not, radiofrequency ablation of the trigeminal ganglion is the first-line intervention, a day-care procedure taking about half an hour with results above 95%.

No. This is a persistent misconception. The claim that a neurovascular loop rules out radiofrequency ablation in favour of the open surgical procedure microvascular decompression is not supported by clinical evidence, and many patients with a neurovascular loop have been treated successfully with radiofrequency ablation alone.

By stimulating the nerve first and checking that the patient feels it in their usual pain distribution, before proceeding with ablation.