Radiofrequency thermoablation of the infraorbital nerve for posttraumatic trigeminal neuropathic pain: illustrative case

BACKGROUND: Trigeminal neuropathic pain (TNP), particularly posttraumatic TNP (PTTN), is often refractory to medical therapy and difficult to manage surgically. Although radiofrequency thermoablation (RFA) of the gasserian ganglion is established, peripheral nerve RFA remains underutilized, particularly in anatomically complex cases. OBSERVATIONS: A 62-year-old man developed severe left maxillary (V2) facial pain following sinus surgery, refractory to multiple pharmacological therapies and prior gasserian balloon rhizotomy. A diagnostic infraorbital nerve block produced significant temporary relief, supporting a peripheral pain generator and RFA consideration. An initial infraorbital nerve RFA performed with fluoroscopic guidance failed to provide durable benefit. A subsequent CT-guided infraorbital nerve RFA resulted in marked pain reduction. The patient later developed localized recurrent dysesthesia, prompting a third CT-guided, navigation-assisted RFA with sustained improvement. At the last follow-up (8, 6, and 3 months after the first, second, and third RFAs, respectively), his visual analog scale pain score improved from 10 to 2, with approximately 80% reduction in pain flares and significant quality of life improvement. LESSONS: CT-guided infraorbital nerve RFA is a minimally invasive and effective option for refractory PTTN. Peripheral RFA, particularly when combined with advanced image guidance and potentially awake mapping, should be considered when central interventions fail or are contraindicated. https://thejns.org/doi/10.3171/CASE25553.