PATIENTS' GUIDE TO THE RFL
This is a description
of what is called a radiofrequency lesion ("RFL" for short).
This is a treatment for your condition that is called tic douloureux
(French for "painful spasm"). It occurs most commonly
when the nerve that travels to the face (called "the fifth
nerve") is pressed on by an artery as it leaves the brain.
Of the many options for this, an RFL has been recommended to you.
Preparation for the
Procedure: There is very little in the way of preparation
for this procedure. The only request is that you eat nothing after
midnight before the procedure. If you take medications in the morning,
take them with a sip of water prior to leaving for the hospital.
lesions take approximately 45 minutes, and are done as an outpatient.
The day starts with arrival in the Operating Room after having an
intravenous placed. When on the operating table, an X-ray machine
will be positioned next to you that assists us during the procedure.
You will receive one medication that will make you sleepy, and then
another that will put you completely asleep for about two or three
minutes. During that time, an approximately 2 ½ in. probe
will be passed through the cheek just to the side of the mouth.
With the use of the X-ray machine, we will guide it so that the
tip ends in the fibers of the nerve which is causing your discomfort.
When you awake from the medication we have given you, we will run
a small amount of electricity into the probe. You will feel a buzzing
or warmness either in the chin, the cheek, or the forehead. It is
vital that you relay to us precisely where you feel this because
these are the same nerve fibers that are causing your pain. We might
re-position the needle several times so that you get the buzzing
or warmness in the part of your face where you feel your tic
douloureux. We will then put you back to sleep for another few
that time, we will run a different form of electricity that will
treat the nerve fibers which are causing your pain. This will cause
them to be altered such that you will feel numbness in the part
of your face where you previously felt your pain. When you awake
again, we will test that part of your face with a safety pin. The
goal is that you are able to feel pressure, but that the sharpness
or prickliness of the needle is no longer felt. When we achieve
this goal, we are finished. The needle will be removed and a Band-Aid
placed on it. After a short stay in the Recovery Room, you will
After-effects of an
RFL: It is important to know that an RFL will usually eliminate
the pain, but at some cost. The intent is to give you numbness in
the part of your face where you have been feeling pain. This numbness
is annoying, but usually minimal and well tolerated. You may notice
that your speech is slightly slurred, and this can last a few weeks
before going away. You may also notice that the side of your tongue
is numb and that you tend to bite it when eating.
Some people lose food
on the inside of that cheek. You might not know it is there because
you cannot feel it. Again, this usually gets better as time goes
on because one gets used to it, and the numbness can diminish over
is important to note that this annoying numbness is almost always
preferred to the excruciating pain it replaces. On rare occasion,
however, people actually find that this numbness is more annoying
than the pain it replaced. This is a rare medical condition called
anesthesia dolorosa and can be difficult to treat when it
Complications of the
RFL: The main complication that we have seen is that the
numbness is either more extensive in intensity or location than
desired. I am very careful in making sure the needle is in the correct
fibers prior to treating them. However, even with the most careful
preparation, sometimes the numbness can spread to other parts of
the face. For example, we have had a few patients who had tic
douloureux in the cheek. Despite standard placement of the needle
and conservative nerve fiber treatment, they developed numbness
that spread to the forehead, eye, and chin as well. Although it
is difficult to explain why, this can be extremely annoying, though
in general is reasonably well tolerated.
Other complications are
extremely rare. In over 25 years of performing this procedure, in
one instance, a patient developed an infection that spread into
the temporal lobe that required prolonged antibiotics. Fortunately,
this completely resolved. In another instance, the nerve treatment
included fibers of a nerve that went to the eye. This resulted in
double vision that also fortunately resolved in about two months.
One undesirable feature
of an RFL is that the pain often comes back. The cure rate is about
80%, but the pain can come back in a few weeks or up to many years.
If it returns, the options are more medication, another RFL, or
the below-described MVD.
There are many alternatives to an RFL, but the most common
is called a microvascular decompression (MVD for short).
An MVD is a safe, but more extensive procedure involving at least
2 days in the hospital. It is done under general anesthesia, and
involves making an incision behind the ear, and under a microscope
identifying where the blood vessel is pressing on the nerve. The
vessel is then gently separated from it with a small piece of material.
This usually results in excellent pain relief, and its advantage
is that there is generally no numbness as a result. Should you wish
to speak to a neurosurgeon that specializes in this, I will arrange
this for you.
RFLs are extremely safe procedures. They are a desirable alternative
to open brain surgery done under general anesthesia, though they
are not for everyone. There are risks, though are generally minor
Stephen Saris, M.D.