Radiofrequency Lesion for Trigeminal Neuralgia

Radiofrequency Lesion for Trigeminal Neuralgia (CPT 64600) 

General: This procedure involves insertion of a probe transcutaneously into an orifice (foramen ovale) in the base of the skull under sedation. Probe position will be verified several times using fluoroscopy, and by using the probe to stimulate the nerve (needs patient cooperation). Unilateral thermal lesion of the trigeminal nerve will be done under heavy sedation.
Preop: Patient needs to remain cooperative during the procedure, so no sedative preoperative medication should be given.
Monitors: Routine monitors. Nasal cannula O2, taped away from the ipsilateral cheek.
Anesthesia: Patient will remain supine. Titrate up to 100 μg of fentanyl for baseline analgesia as long as the patient remains completely cooperative. Surgeon will apply local anesthesia for percutaneous application of the radiofrequency probe. Fluoroscope will be used to aid in positioning the probe. Sedation for probe placement will consist of several brief but relatively deep periods of IV sedation. Sedation should be brief as the location of the probe will be tested immediately, and requires patient cooperation (increased current in the probe resulting in facial sensation). Having the patient in a relatively deep state facilitates probe placement as patient movement changes the fluoroscopic image and will increase the length of the procedure. Sedation is best achieved by use of a combination of remifentanil (10-20 μg) and propofol (30-50 mg) boluses. The response to the initial doses used during probe placement should guide the decision on how much sedation to use for the thermal lesioning. It is usually necessary to reach a state of apnea in order to avoid excessive movement in response to this intense pain stimulus. In fact, patients usually begin breathing as the probe temperature approaches the intended level for lesioning. Heavy sedation with ramifentanil and propofol after good preoxygenation with blow by oxygen (can’t use the mask because of the location of the probe). Lesioning takes about 3- 4 minutes (time for the probe to reach appropriate temperature, 120 seconds at that temperature, and time for the probe to cool). Oxygen saturation will most likely start to decrease during this time. Administer oxygen with face mask as soon as the probe is removed.
Potential complications: Potential for desaturation and hypertension during thermal lesioning of the nerve. Communicate with surgeon. Hypertension should be avoided by adequate anesthesia and potential prophylactic use of labetalol.
Recovery: Typically in the recovery room. Should be rapid due to use of short acting drugs. Patients go home when fully recovered from anesthesia.

Last revised 05/2013 Talke 

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This information is meant to serve as an educational resource. Clinicians should use their own professional judgment in the care of any individual patient as the guidance contained in this document may not be appropriate for all patients or all situations.