Benefits of Innovative Enhanced Recovery Protocol After Trigeminal Neuralgia Surgery

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: November 1, 2025
Expiration Date: October 31, 2026

Estimated Time of Completion: 30 minutes

Benefits of Innovative Enhanced Recovery Protocol After Trigeminal Neuralgia Surgery
Havid Borghei-Razavi, MD

Description
Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience
Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

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• American Medical Association (AMA)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  
  Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

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  A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

• American Board of Surgery (ABS)
  Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Credit will be reported within 30 days of claiming credit.

Podcast Series Director
Andreas Alexopoulos, MD, MPH
Epilepsy Center

Additional Planner/Reviewer
Cindy Willis, DNP

Faculty
Hamid Borghei-Razavi, MD
Brain Tumor and Neuro-Oncology Center

Host
Glen Stevens, DO, PhD
Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Benefits of Innovative Enhanced Recovery Protocol After Trigeminal Neuralgia Surgery
Hamid Borghei-Razavi, MD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

Glen H Stevens, DO	DynaMed Consulting
Hamid Borghei-Razavi, MD	Johnson & Johnson Consulting

All other individuals have indicated no relationship which, in the context of their involvement, could be perceived as a potential conflict of interest.

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

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Go to: Neuro Pathways Podcast November 1, 2025 to log into myCME and begin the activity evaluation and print your certificate If you need assistance, contact the CME office at myCME@ccf.org

Copyright © 2025 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuropathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab and psychiatry.

Glen Stevens, DO, PhD: Trigeminal neuralgia is a chronic pain condition, often described as one of the most excruciating disorders known to medicine, but behind the sharp electric shock-like pain lies a story of innovation, one that includes evolving surgical protocols and multidisciplinary collaboration.

In this episode we'll explore how treatment for trigeminal neuralgia has advanced in recent years, what it means for patient recovery and quality of life, and how a culture of continuous improvement is reshaping care. I'm your host Glenn Stevens, neurologist neuro oncologist in Cleveland Clinic's Neurological Institute. And joining me for today's conversation is Dr. Borghei-Razavi. Dr. Razavi is a neurosurgeon at Cleveland Clinic Westin Hospital whose practice has evolved to focus on innovative comprehensive management of trigeminal neuralgia. Hamid, welcome to Neural pathways.

Hamid Borghei-Razavi, MD: Thank you so much for introduction. I love to be with you and I have been always impressed with the good vibe you bring to the practice of medicine, which is very important and I'm happy to talk to you.

Glen Stevens, DO, PhD: So, Hamid, I've known you for a long time, but for those that aren't familiar with you, tell us a little bit about yourself, where you did your training and what you do down in Florida.

Hamid Borghei-Razavi, MD: So, I did my residency actually in Europe and then I was at University of Pittsburgh for fellowship and then at Cleveland Clinic I was very lucky to have two years at Cleveland Clinic. One year I did neurosurgical oncology fellowship and one year skull-based fellowship. And then with combination of these two I got hired at Cleveland Clinic, Florida, my new home.

Glen Stevens, DO, PhD: Excellent. We're happy to have you, of course you're primarily what kind of surgeries you're doing down there.

Hamid Borghei-Razavi, MD: So, I think my practice is focused on brain tumor practice and obviously trigeminal neurology and pituitary tumors and obviously because of the old population of Florida I have also a shunt practice here.

Glen Stevens, DO, PhD: So, we're going to talk today about trigeminal neuralgia or what we used to call tic douloureux, our audience, what trigeminal neuralgia is.

Hamid Borghei-Razavi, MD: So, if I want to make it easy technique is face pain, but this is not just a face pain that comes and goes one time. These are like a chronic face pain that has a lot of appearances and a lot of models of coming. But the typical one is like electric shock, stabbing pain comes and goes and really debilitating pain that affects significantly patient's quality of life. And a lot of these patients really the pain is so bad that they are thinking about suicide. So this is not just the easy pain to handle, it's a severe pain that is very difficult for a patient to tolerate it.

Glen Stevens, DO, PhD: So as the name suggests, trigeminal, the fifth cranial nerve, and I would say the same thing when I would see patients in the old days that you just said that they would call a suicide type pain you know patients would have such bad pain and could be worsened with brushing their teeth eating and I'm sure you see it as well. Sometimes patients lose weight, they don't want to eat or any of those types of things.

Hamid Borghei-Razavi, MD: Exactly. As my practice goes more toward trigeminal nausea, I see more appearance of trigeminal neuralgia. One of them is the patient almost actually I did a study on my patients, half of them they pull the tooth or they don't have any teeth on that side because of the dentist. Technically they didn't think about it or they were not aware about such a disease and that's also my job to make awareness for dental practices too.

Glen Stevens, DO, PhD: Yeah, I'm not sure how many dentists listened to the podcast, but maybe they should because back in the day I had similar experiences to you in that it would be a dentist that would finally refer the patient or as you said, I had two teeth taken out and didn't get better and they said well you should go see somebody else. Maybe there's something else going on here. And as you know, these things can get very difficult. So somebody comes to see you, they say they having this very lancinating electric type pain on the right side worse with brushing their teeth, chewing that type of stuff. Do you image them? Do you not image them? It sounds like trigeminal neuralgia.

Hamid Borghei-Razavi, MD: I think a lot of them come already from the neurologist. Actually they are expert neurologists that they knew already tried all medical therapy for this trigeminal neurology. As a surgeon, when we receive them, normally they have been always seeing neurologists or primary doctor. They tried multiple medications and they are resistant to all of this. So we received them normally and the end stage, although there are new research that say it is better to offer surgery to them sooner because as trigeminal neuralgia stays longer than the prognosis of the surgery is worse. But normally we make sure they have imaging and then we make sure they are classic trigeminal nausea because the meaning of classic is the pains that they are really sharp, they are not constant, they are not burning pain, they are like electric shortcoming and going as you mentioned, getting worse with brushing, eating, talking, sometimes touching the face. So then next step for us is looking at the images and see what kind of treatment is the best option for them and there are multiple treatment options.

Glen Stevens, DO, PhD: So, what are you looking for on the imaging?

Hamid Borghei-Razavi, MD: So, first of all, this is also another issue that we have here because a lot of even neurologists, we received the patient from them but they didn't order the right images. So they ordered just the MRI to rule out the tumor but we know like 95% of them or 99% of them, there is no tumor there. So we want a special MRI sequence, we call it fiesta or key sequence CISS sequence or MR angiogram to see if the vessels compressing the nerve at the entry zone. It means at the area that the nerve is coming out from the brain stem. We want to make sure we see exactly what's going on there, especially in vascular compression we see there.

Glen Stevens, DO, PhD: And the percent that are related to vascular compression versus something else? Is it 10%, is it 80%?

Hamid Borghei-Razavi, MD: No, I think it is very common to have vascular compression. There is probably 20 30% they have severe compression but is very common to see some kind of contact or some kind of compression there in the MRI. It is very uncommon not to see anything, just the nerve there. But normally we see some kind of compression, but a tumor is rare. As I mentioned it's more like vascular compression rather than tumors or any other pathology.

Glen Stevens, DO, PhD: And I think it's important for our audience to realize that if you see young patients with trigeminal neuralgia, the imaging is very important to make sure they don't have multiple sclerosis.

Hamid Borghei-Razavi, MD: Exactly, exactly. I had patient with severe face pain, it was no vascular compression but it was like a plug sitting at the brain stem and then the treatment obviously is different.

Glen Stevens, DO, PhD: Alright. And then as you mentioned, a small percent will have a tumor and then idiopathic, which really just means we're not really sure why you got it.

Hamid Borghei-Razavi, MD: Exactly. That's also a question for the future research, we don't know really a lot. We see patients that there's nothing there but the patient, I think it's probably a genetic component of nerve threshold to pain or nerve producing TIC shocks by itself.

Glen Stevens, DO, PhD: And maybe we'll get to this after you tell us about your surgical approaches, but I do hear conversations occasionally about should we just do not really a sham surgery but an exploratory surgery to see if there could be a vascular loop and even though we can't obviously see one.

Hamid Borghei-Razavi, MD: Exactly. This is interesting because at CNS, the biggest conference in neurosurgery, the director of the trigeminal neurology symposium and then it was a very hard discussion between even the masters, there is no clear answer. But I think a lot of people really don't recommend to do surgery because the outcome is not good if there is nothing there. So, with this new imaging that we have like case sequence MRI, MRA, it is very hard to miss the vessels there. I think I wouldn't offer someone that I don't see anything surgery because anyway this surgery and is risk involving it. I think probably the ones that we don't see any vessels, they are a good candidate for radiosurgery or even more conservative stuff like ganglion block or something like that.

Glen Stevens, DO, PhD: Yeah, so for completeness I'll just mention that as you said, a lot of these people will come from a headache specialist or a neurologist, they'll have been on carbamazepine, oxcarbazepine, gabapentin, these types of medications that aren't doing the trick enough but before we go to the microvascular decompression, other surgical options or things that can be done?

Hamid Borghei-Razavi, MD: I think before going to surgical option, I mean you mentioned carbamazepine, it's very interesting at the beginning I have had patients they are super happy with carbamazepine but better than me is I think it's a resistance to this medication over the time and a lot of patients experience side effects, especially sodium drops and we have had even patient coming to the ER because of the low sodium. I think these medications over the time I barely have seen the patient that they are happy with these medications. I might be biased because I see the ones that they are not happy but overall even if I started the medication over the time they are not very happy with this medication. The other surgical option, before going to microvascular competition, is rhizotomy, which I learned in Ohio actually from Dr. Barnett is balloon compression rhizotomy that we go through the face and then we inflate the balloon for two minutes around the ganglion and technically we punish the nerve. Then the nerve gets very upset and instead of producing electric shock then I don't produce anything. Then the patient get numb completely for one to three years.

I keep this normally for the patients that they are very old and then they are not tolerating the big surgery or the ones that they failed initial treatment. The other option is radiosurgery, which we do a stereotactic radiosurgery for the nerve. Technically we burn the nerve, burn the outer layer of the nerve and normally the outcome is not as good as microvascular. The compression is about 65 to 70% success. The effect of the radiosurgery, normally it comes later, not right away. After doing it it takes up to eight weeks and then it's not long standing. Normally after three years majority of the patient the pain start to come back.

Glen Stevens, DO, PhD: So, another form of rhizotomy where you're affecting the nerve fibers themselves. Are you doing any glycerin or glycerol injections?

Hamid Borghei-Razavi, MD: No, I think glycerol is maybe out of market now, but there is also radio ablation. That's also another option. The problem with that, actually we started to do it but the patient is awake and is like a torture for patient. The patient don't like it, they prefer numbness rather than being awake when you do that. But if the patient don't want to have numbness, we discuss that and this is another option we can do.

Glen Stevens, DO, PhD: And does the numbness, I mean you see these patients, do they complain about the numbness a lot? Does it become a bigger problem?

Hamid Borghei-Razavi, MD: You after the rhizotomy?

Glen Stevens, DO, PhD: Yes.

Hamid Borghei-Razavi, MD: So, after rhizotomy they should have numbness, otherwise the precision was not successful. They are candidate for rhizotomy. I always ask them, do you prefer numbness to pain? And always if they say we don't care about numbness, we just want the pain goes away, then I offer them this. But the ones that they say, oh we are not sure about numbness then I never do rhizotomy.

Glen Stevens, DO, PhD: But you know how it is. They want the pain gone and numbness is okay, but then they have the pain's gone. Now the numbness, it's the number one problem they have and then they're less excited about it.

Hamid Borghei-Razavi, MD: But they are super happy with numbness. You mean at that level that the pain is so bad. They also be super happy with numbness. I always tell them this is going to the dentist. The feeling that you have after going to you might bite your tongue. You might not be able even to eat from that side because you feel not comfortable but they are happy with it and then this is much, much better than the pain that they have been experiencing.

Glen Stevens, DO, PhD: So, tell us a little bit about the surgery that you're doing, the microvascular decompression and the enhanced recovery after surgery that you've been looking at probably for the last four or five years.

Hamid Borghei-Razavi, MD: Exactly. So obviously microvascular decompression is known from the year 1970, I think seven or eight that Peter John Etta started in Pittsburgh and he realized the vascular compression is the cause of trigeminal neural and he did the first time. So this technique has been available for years. But the thing that we came here and we realized that maybe we can start to do a little bit more minimally invasive that the patient can tolerate this surgery better because technically this surgery is not a big surgery but it's not like a tumor surgery or something like that. We are able to make it to the smaller version of the surgery that they can tolerate better and then they can go home earlier. So we have been talking to do a smaller incision, a smaller craniotomy, then doing the nerve blocks before surgery and then doing TIVA anesthesia like complete intravenous anesthesia and then don't using any opioid after surgery to make the patients going home faster.

So, we put this protocol and then we designed it and six seven components. And then we did it for 40 to 50 patients. And then we came back. We compared this 40 50 patient to the traditional patient that we did bigger incision, bigger craniotomy, always gave them Percocet after surgery if they had pain and then normal anesthesia, no nerve block. Then we realized this patient, I would say like 60 70 patients of this patient went home same day next day, I mean in 24 hours and then few of them stayed two days and that was when I look at that data, most of these two days patients they were because they didn't have a ride or they lived far from here, they said, okay, let me stay one more night. My son cannot pick me up or something like, but really one day they were ready to go home and then compared to three to four days in other group. So technically we saw a very significant difference between discharge days with also patient satisfaction. So that's the reason we said this protocol is really we have to do for all of the patients. And then when we publish our data about this 40 patient compared to the cohort of the other 40 patients, then it got published actually in red journal neurosurgery journal, which is the best neurosurgery journal in the market now.

Glen Stevens, DO, PhD: So, talk to me about the surgical approach. You use a retro approach for all your patients?

Hamid Borghei-Razavi, MD: Exactly. We do a small incision behind the ear and then we drill the bone, we open the envelope of the brain, which is dura and then we reach to the trigeminal nerve and then we see the vessels and then we dissect the vessel out from the nerve and then we put piece of Teflon between the nerve and artery and interestingly the pain normally goes away right away when they wake up from surgery the pain is gone. And the other interesting thing that we saw, I had two, three patients that this pain, despite complete decompression, the pain didn't go away. Very interesting. I mean I said I did everything. I look at the video even like there's no compression and then after one to two months the pain has started to go away. So then we published a paper actually about it. We call it delayed response to microvascular decompression.

And I look at the literature actually it reported more in Asian population that 10% of the patient with microvascular decompression, they don't get better right away. But the thing is a lot of surgeon don't know that and then they get disappointed and then they send the patient for gamma knife right away. I had a patient actually from other institution came for gamma knife because she didn't get better than they told her, okay, go to gamma knife now. But it was like three weeks after surgery I told her to wait. So she waited two months and the pain gone and we published that paper I call it when the nerve keeps firing actually published in neurosurgical review. And then I wanted to make awareness for the surgeons that it is possible that they don't get better right away. Just wait a little bit before doing another procedure.

Glen Stevens, DO, PhD: I guess the problem with making a smaller incision, is does it affect your visualization? Is it more difficult? Do you have to use other equipment?

Hamid Borghei-Razavi, MD: I think really not because now with this new technique that we have, I mean it is not really new but in last few years, maybe in last 10 years, we are not using retractor anymore. We are doing retractor less surgery. So it means we don't put anything to retract the cerebellum for us. And the reason for that because we go to the system of the brain and we drain CSF and we use also gravity in the positioning of the patient combination of gravity and draining the CSF let the cerebellum falls and if the cerebellum falls then you have a very nice view even with the smaller craniotomy.

Glen Stevens, DO, PhD: And when you look at it, the nerve and the blood vessel, what do you see? Do you see connections between the two? What do you actually do with the blood vessel to decompress it?

Hamid Borghei-Razavi, MD: Yeah, normally we see the nerve and artery or vein, I mean it's mostly artery but sometimes it's vein. They are contacting each other and in a lot of patients we see the artery severely made the deformation or indentation in the nerve. So when we elevate the artery, we see still the effect and indentation of the artery over the nerve. So it is really displaced. Sometimes it's also displaced the nerve. So we have different type, we have contact, we have indentation or displacement or deformity of the nerve.

Glen Stevens, DO, PhD: But how do you keep the vessel away from the nerve?

Hamid Borghei-Razavi, MD: Well, we dissect the arachnoid. Sometimes when you push the artery away it stays away and sometimes it doesn't stay away. Then we put obviously the Teflon to make the artery doesn't come back over the nerve and we don't want the artery pulsate over the nerve because it's like a shearing for the nerve over the time. So we keep it, but in very advanced cases we need to do transposition. It means really they move the artery to another spot. And there is another technique, you can use a fenestrated clip to keep the artery away from the nerve, but these are extreme cases.

Glen Stevens, DO, PhD: Do you ever have to go back and repeat a microvascular decompression on a patient?

Hamid Borghei-Razavi, MD: Unless it is like a real compression in the MRI you do another MRI over the year and see it is real compression. We prefer not to go back. I recommend normally rhizotomy and I think rhizotomy is a good option instead of going back if it's no vessel in the MRI.

Glen Stevens, DO, PhD: Now in the study that you did, as you sort of mentioned, I think you saw a decrease in length of stay even though the regular length of stay is short. I think you also found changes in one technique versus the other affecting hearing.

Hamid Borghei-Razavi, MD: Exactly. So, when you don't open the mastoid cells too much, then if you do a smaller craniotomy. Obviously, if you don't open the mastoid itself, then there's less fluid going to the mastoid cells. A lot of patients after the surgery get muffled hearing at least for a short time because the mastoid cells get full of fluid and CSF obviously it goes away over time. But this patient, because we did a smaller craniotomy then we didn't open that much mastoid and make sense that they have less muffled hearing after surgery.

Glen Stevens, DO, PhD: Are you seeing other centers adopt what you are doing?

Hamid Borghei-Razavi, MD: I got a lot of contact after we publish this from other institutions that they asked me the details of this and I think that people try to especially experienced people, they are more comfortable to do a smaller craniotomy. I think they like to adapt, especially like this injection, the nerve block before surgery, no opioid use. Actually this is a very easy technique to adapt. It's not very difficult or complicated or need extra thing. And then the hospital love it because it is less financial. It makes more sense for the hospital. Actually the other thing that we are doing, we are going back to our finance department to see how much we saved in each patient in sending them home sooner. I mean you save money and patient are happier. So what is better than that?

Glen Stevens, DO, PhD: Yeah, I guess the barrier to implementation is probably just the surgeon's unwillingness to change.

Hamid Borghei-Razavi, MD: Yeah, exactly. But normally the younger generation they want to try.

Glen Stevens, DO, PhD: But you know how it is you're comfortable with what you do, less excited about changing but yes, certainly, certainly seems that that patients should. Negatives of the technique or anything?

Hamid Borghei-Razavi, MD: I think obviously smaller craniotomy sometimes you have to struggle a little bit because of the smaller. Obviously if I see is not safe I increase the size of craniotomy but I didn't see any negative. Especially is interesting because in older age that we have more older patient in Florida the cerebellum is smaller and there is a big CSF space. It's much easier to implement this in Florida because you have patients that they have bigger CSF space which help us to have better view of the nerve.

Glen Stevens, DO, PhD: But I guess that's important, right? If you have a non-MS patient that's young that has a vascular loop that needs surgery, they've got a lot more tissue, it's probably a little more difficult surgery. Right?

Hamid Borghei-Razavi, MD: Exactly. Young patients is more difficult because they have a very full brain and you don't have that big access that you have in older patients.

Glen Stevens, DO, PhD: And I assume that the application for other types of surgical techniques adapting the same general strategy would make sense as well. Right?

Hamid Borghei-Razavi, MD: It is very interesting you asked because my first idea of ERAs enhanced recovery after surgery came from shunt and the reason for that was because a lot of patients that we do shunt, they are over 80 years old and they get very delirious in the hospital at night. Then it came to my mind why we don't send the patients home same day. So the first time I did, we started to do this ERAs for the shunt patients and we published that one first. So we did nerve block, a smaller incision, laparoscopic placement of the distal catheter and no opioid. And then I have been able to send to any patient home same day after shunt and the patient were home very happy because they don't get delirious at home. There's a very known environment that they compare it to the patient that they stayed in the hospital two nights or three nights. So this idea came actually from other procedure. So I think that's possible for every procedure. Brain tumor also has been in a lot of publications. But there is a key in this and the patient needs to be psychological ready for that. So I mean you have to talk to patient and make the patient ready before surgery. Patient and family, a lot of family, they don't want to go home early. So that's the problem. You have to make them really ready for that.

Glen Stevens, DO, PhD: Yeah, I think we can't understate that with everything that we do that we need to set expectations at the start. And recovery of expectations is always poor for everybody.

We need to be very clear with what the expectation is and what we want patients to do and I think they'll then understand, and they'll comply.

Hamid Borghei-Razavi, MD: Exactly. That's the most important thing because if you tell them after surgery, okay, you have to go home now they don't accept it, but if they make them ready and then it is very acceptable for the patient.

Glen Stevens, DO, PhD: If we could get in the time machine and go back 30 years to the Cleveland Clinic and you looked at who's in the hospital, we would have patients that were post myelogram patients in the hospital for three or four days. You couldn't even now we're doing fairly major surgery and sending people home, which is good and bad. It requires a lot on the outpatient group.

Hamid Borghei-Razavi, MD: That's true. I mean the outpatient takes a route. But AI is helping a lot because it gives us a warning to patients that they shouldn't go home same day. I don’t know if you have seen in Epic that it gives us a warning if you want to send the patient home and the patient is sick and is still not ready, it gives us a warning, okay, this patient is a high chance that the patient comes back if you're sent home. So this is I mean, application of AI in our practice.

Glen Stevens, DO, PhD: Yes. Now everybody's interested in readmission rates. So these are important because it means that we've not done something we should for the patient and they're at risk and we should have been looking at things in a better way. Collaboration, who are you working with down there on these patients?

Hamid Borghei-Razavi, MD: So, anesthesia are very important in trigeminal neuralgia in putting the patient in sleep and do the nerve blocks. And then ICU team are important. For rhizotomy is very interestingly I wanted to just advertise for culture of Cleveland Clinic in multidisciplinary approach to patients because when I came here I learned balloon compression from Ohio and then when I came here I was talking discussing with one of neuro neurointerventional neuroradiologist who told me why instead of x-ray you are not using Dyna CT in the IR that you can make a trajectory and make it nicer. So then we start to work together and then now we change our practice to use Dyna CT in the IR and then we change technically the rhizotomy to the higher level of accuracy and then better outcomes. Because with Dyna CT, technically you don't need that much radiation. You do the trajectory and then you go directly to the foramen and then you do rhizotomy. We publish our data, we publish two papers out of this. So this is multidisciplinary practice that you'd learn from the other disciplines in your practice.

Glen Stevens, DO, PhD: Yeah, it's amazing how much we learn when we actually talk to our colleagues. Right?

Hamid Borghei-Razavi, MD: Exactly.

Glen Stevens, DO, PhD: Suddenly we're all a lot smarter as things go away. Are you refining the technique or were you going next with this? Little nuances?

Hamid Borghei-Razavi, MD: The other thing that I'm very interested in trigeminal neuralgia is because 10 years ago it was a taboo to do microvascular decompression for over 80 years old. I remember I was listening to neurosurgery called Atlas. The interviewer said, okay, if the patient is older than 75, I never do microvascular decompression, but it is like most of our practice here is over 75 years. So we went back and then we are publishing our data about older patient with trigeminal neuralgia and microvascular decompression and we felt it's more important the KPS of the patient or our fit is the patient not the age. I mean we can offer to older patient if they are in a good shape and this will be also a change in the practice for us and therefore the other institutions.

Glen Stevens, DO, PhD: For those out there who aren't familiar KPS is a kowsky performance status. We use it a lot in the tumor field. It's a score from zero to a hundred, a hundred, they're perfect, zero, they're dead. Generally patients are functioning at an independent level around 70 or so, but it can help us screen patients for surgeries and risk what their outcomes might be. Any closing statements or things that we didn't discuss that are important?

Hamid Borghei-Razavi, MD: This is what I learned from my mentor Pablo Recinos, who has been my mentor. So he always told me, don't accept whatever they tell you to do. So you need to follow up six months, three months, you don't need to do this. Always think about it, is there any other way? Are we doing the right thing or is there any resources we are wasting in this? So always think if you can make something better. So don't follow everything that they tell you. I think this is important when someone start the practice, always thinking about doing some innovative thing. The other thing I want to make sure is the culture of Cleveland Clinic in asking each other, talk to each other, multidisciplinary approach, doing, working with other disciplines. This is a very unique culture at Cleveland Clinic. So that's made me to think about using other techniques and talk to other people. I think this is very important part of Cleveland Clinic culture. Why I wanted to advertise on this.

Glen Stevens, DO, PhD: Well, Hamid, it's great to see you again. I think about you more in the winter than the summer, I have to admit. But it's great to see. I appreciate your educating our audience and great to see you innovating and bringing new things to patients because what we all need in everything that we do. So wish you well and get some rest.

Hamid Borghei-Razavi, MD: Thank you so much. Thank you. Great to see you and hope to see you soon.

Closing: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And for further learning, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website, that's consultqd.clevelandclinic.org/neuro, or follow the Cleveland Clinic Neurological Institute on LinkedIn. And thank you for listening.