Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

Is it true that because I’ve had RFA to my occipital nerves, that I’m not a candidate for surgery?

This statement represents a common misconception. First of all, let’s define ‘RFA’ or radiofrequency ablation. Simply put, this treatment modality uses radio waves at a high frequency to ablate a structure, in this case a nerve. The term ‘ablation’ actually means to surgically remove a body part or organ, but since RFA is performed with probes through the skin (i.e. percutaneously) it essentially means to destroy the nerve. The probe tip is hopefully placed close enough to the nerve in one or more places such that when the radio waves are passed through it, the tip heats up and completely destroys the nerve which theoretically should be equivalent to surgically excising the nerve.

In reality however, this approach has a number of significant drawbacks. First, if the RFA probe tip is not placed in the exact correct position, the nerve is not completely destroyed. As a peripheral nerve surgeon who routinely uses high powered loupe magnification and operative microscopes in the operating room to find, decompress and/or repair nerves I can emphatically state that nerves are often small and very difficult to find, even when looking at them directly with magnification. Moreover, they are often encased in scar tissue which is tough and can be difficult to penetrate with a scalpel or scissors, much less a tiny probe. Thus if the RFA probe tip doesn’t target the nerve just right to completely destroy it, it creates a thermal zone of injury around the nerve. Sometimes this “stuns” the nerve (i.e. neurapraxia) and there is temporary relief (a few days, weeks or months) until the nerve recovers at which point the pain can return. Other times the thermal zone of injury is far enough away from the nerve that the nerve itself is not affected. In this case, not only can the original pain remain unchanged, but other structures around the nerve can be damaged secondary to formation of scar tissue thus leading to more pain. In addition, one of the maneuvers required when intentionally cutting a nerve is to bury the proximal nerve end into muscle because doing so can significantly reduce the chances of a painful neuroma forming. A neuroma is a regenerating nerve that can cause significant pain. Think of a downed power line in the middle of the street writhing like a snake with high voltage sparks coming out of it. Hence, even if the RFA probe successfully ablates a nerve, but does so in an area where the remaining viable nerve is not surrounded by muscle, a painful neuroma can form leading to more pain.
Now, no procedure is fool proof and peripheral nerve surgery for headaches requires general anesthesia and all the risks that the former and latter entail. But, performed in an accredited institution by a properly trained surgeon, the rates of complications are very low and the complications that do occur are relatively minor. I also believe that the best way to determine whether a nerve is salvageable and can be decompressed or is too injured and must be either excised and buried or reconstructed is to look at it directly in the operating room. So what to do if you’ve had RFA and still have pain? See a peripheral nerve surgeon for a formal evaluation to determine whether surgery is possible and if so, have a frank discussion of the operative plan beforehand. After all, even if the nerve is found to be severely damaged in the operating room, there are still options which can lead to significant pain relief.

For more information about peripheral nerve surgery, rfa, and other ways to relieve your migraine and headache pain, visit today, and call (415) 751-0583 to schedule an appointment.
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