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PATIENTS’ GUIDE TO THE RFL
You have been asked to consider a procedure called a radiofrequency lesion (RFL). 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 irritated by an artery as it leaves the brain.
PREPARATION: There is little in the way of preparation for this procedure. You should not eat or drink anything after midnight before the day of the surgery. You will be instructed if you need to stop any medications prior to your surgery by our office staff, and which medications to take the morning of your procedure, by the nurse at your pre-operative appointment.
PROCEDURE: Radiofrequency lesions take approximately 45 minutes, and are done as an outpatient. When you come to the Operating Room, you will first enter the Holding Area. You will meet the nursing staff, the anesthesia staff, and have an intravenous placed. You will then be transported to the operating room. There 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 a few minutes. During that time, an approximately 2½ inch probe will be passed through the cheek just to the side of your 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 warmth either in the chin, the cheek, or the forehead. It is important that you tell us precisely where you feel this buzzing because these are the same nerve fibers that are causing your pain. We will then put you back to sleep for another few minutes.
During that time, we will run a different form of electricity that will destroy the nerve fibers which are causing your pain. As you awaken, you will often feel immediate numbness in the part of your face where you previously felt your pain. When we achieve this goal, we are finished. The probe will be removed and a Band-Aid placed on your cheek. After a short stay in the Recovery Room, you will be sent home.
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.
It 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 occurs.
COMPLICATIONS OF THE RFL: The main complication that we have seen is that the numbness is either more extensive than planned, or in a different location, than desired. I am very careful in making sure the probe 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 well tolerated.
Other complications are extremely rare. In over 25 years of performing this procedure, I’ve two or so infections. In another instance, the nerve treatment affected fibers of a nerve that went to the eye. This resulted in double vision that also fortunately resolved in a few months.
One undesirable feature of an RFL is that the pain can come back. The cure rate is about 80%, but the pain can come back in weeks to years. If it returns, the options are more medication, radiation (gamma knife), another RFL, or open surgery called a microvascular decompression.
ALTERNATIVES: 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. The other is the gamma knife which is another section on this website you may read about.
Summary: An RFL is an extremely safe procedure. It is a desirable alternative to open brain surgery and radiation.