The patient came to the clinic 17-September-2023 complaining of agonizing left trigeminal neuralgia of all divisions for 25 days. He performed MRI of the brain of bad quality and not complete in 03-September-2023. The patient receiving Gabatrex 400 mg twice daily and Tegretol CR 400 mg twice daily without any improvement of his pain. The patient had head injury 2018 for what he was operated for right maxillary fracture. He had migraine for several years, which disappeared after accident.

On examination he was neurologically free. He was sent for new MRI with special protocols for posterior fossa and MRA, which were done 18-September-2023 ruling out presence of tumor, arteriovenous malformation, but showing the left trigeminal nerve compressed by SCA.

Using lazy S-shaped incision behind the left ear, craniotomy was done to expose the left transverse sinus and sigmoid. The dura was opened in C-shaped fashion and minimal traction was applied subtentorially. The left superior petrosal vein was preserved and identification of the left trigeminal nerve was achieved. Dissection of the arachnoid cistern caused release of the tortuous SCA. The superior petrosal nerve was an obstacle the work area and the trigeminal nerve was smaller than usual, for what exposure of the left facial nerve below the vein was achieved. Stimulation both nerve confirmed their identity and a bipolar pulsed mode RF with 42 Celsius, 240 sec, 2 Hz and 20 msec duration to the trigeminal nerve and 2 pieces of muscle were inserted between the trigeminal nerve and the tortuous left SCA. Strict hemostasis was achieved and water tight closure of the wound.  He was sent to the ward.

The patient showed immediate relief of his neuralgia without any deficit. There is gross horizontal nystagmus and the patient is walking the next operative day.

This case is the second one using BPRF of the trigeminal nerve after MVD.

This is the 264th case using the MultiGen. This procedure regained routine acceptance.  It became a usual part of the spine and peripheral nerves surgery. Click here for reference.

With accumulation of data, it became clear that the irritated nerve with aberrant currents running in the C fibers up, not only causing no change or elevation of the required voltage to achieve motor response, but they could cause the preoperative weakness. Ablation of such currents results in facilitation of the motor response and improvement of function with disappearance of pain.

It is unclear why the roots have several motor response with different patients, despite the fact that the neurological status was the same and the anesthesia protocol also the same.

It could be that the nerve is recovering minute by minute after decompression and this can explain why the motor conductivity is improving after the BPRF application, which require 5 minute session in most cases.

After the 172d case, the elevation of motor stimulation above 5 V was abandoned to avoid delayed dural tear with subsequent CSF leak, which take place at the contact at the lower electrode shaft with the dura below or above the level of the axilla.

Before doing motor stimulation in peripheral nerve surgery with tourniquet. always remove the tourniquet before performing motor stimulation.