Nucleus caudalis dorsal root entry zone lesioning for the treatment of anesthesia dolorosa

Deafferentation facial pain (anesthesia dolorosa) can occur after injury of the first-order trigeminal nerve. It is often debilitating and difficult to treat. The authors report the treatment of anesthesia dolorosa in a 69-year-old man with a 7-year history of pain. The pain occurred after an open resection of a right trigeminal neuroma. After treatment with medications failed, the patient was treated with nucleus caudalis (dorsal root entry zone) lesioning. His facial pain was immediately and completely eliminated. The authors describe the technique of this central neuroablative procedure, and they review the available literature regarding this procedure as well as the current evidence base for neuromodulatory surgeries. After the 1-year follow-up, the authors conclude that the patient attained lasting relief.

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Treatment of Refractory Pain after Brachial Plexus Avulsion with Dorsal Root Entry Zone Lesions

Neurosurgery ◽

10.1097/00006123-200106000-00016 ◽

2001 ◽

Vol 48 (6) ◽

pp. 1269-1277 ◽

Cited By ~ 5

Author(s):

Madjid Samii ◽

Steffani Bear-Henney ◽

Wolf Lüdemann ◽

Marcos Tatagiba ◽

Ulrike Blömer

Keyword(s):

Brachial Plexus ◽

Dorsal Root ◽

Intractable Pain ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Root Entry Zone ◽

Long Term Follow Up ◽

Cervical Root

Abstract OBJECTIVE Significant numbers of patients experience intractable pain after brachial plexus root avulsions. Medications and surgical procedures such as amputation of the limb are often not successful in pain treatment. METHODS Forty-seven patients with intractable pain after traumatic cervical root avulsions were treated with dorsal root entry zone coagulation between 1980 and 1998. The dorsal root entry zone coagulation procedure was performed 4 months to 12 years after the trauma, and patients were monitored for up to 18 years (average follow-up period, 14 yr). RESULTS Immediately after surgery, 75% of patients experienced significant pain reduction; this value was reduced to 63% during long-term follow-up monitoring. Nine patients experienced major complications, including subdural hematomas (n = 2) and motor weakness of the lower limb (n = 7). Improved coagulation electrodes with thermistors that could produce smaller and more-accurate lesion sizes, which were introduced in 1989, significantly reduced the number of complications. CONCLUSION Central deafferentation pain that persists and becomes intractable among patients with traumatic cervical root avulsions has been difficult to treat in the past. Long-term follow-up monitoring of patients who underwent the dorsal root entry zone coagulation procedure in the cervical cord indicated that long-lasting satisfactory relief is possible for the majority of individuals, with acceptable morbidity rates.

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Dorsal root entry zone lesions to control central pain in paraplegics

Journal of Neurosurgery ◽

10.3171/jns.1981.55.3.0414 ◽

1981 ◽

Vol 55 (3) ◽

pp. 414-419 ◽

Cited By ~ 74

Author(s):

Blaine S. Nashold ◽

Elizabeth Bullitt

Keyword(s):

Dorsal Root ◽

Central Pain ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Cord Injury ◽

Fine Print

✓ Thirteen patients with intractable long-term pain following spinal cord injury and paraplegia were treated with dorsal root entry zone lesions placed at the level just above the transection. Pain relief of 50% or more was achieved in 11 of the 13 patients, with follow-up periods ranging from 5 to 38 months. A previous report showed that central pain from brachial plexus avulsion could be relieved by dorsal root entry zone lesions, and this technique has been extended to the central pain phenomena associated with spinal trauma and paraplegia.

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Follow-up 26 years after dorsal root entry zone thermocoagulation for brachial plexus avulsion and phantom limb pain

Journal of Neurosurgery ◽

10.3171/2010.5.jns091520 ◽

2011 ◽

Vol 114 (1) ◽

pp. 196-199 ◽

Cited By ~ 6

Author(s):

Nestor D. Tomycz ◽

John J. Moossy

Keyword(s):

Brachial Plexus ◽

Upper Extremity ◽

Pain Control ◽

Dorsal Root ◽

Phantom Limb ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Brachial Plexus Avulsion ◽

Root Entry Zone

Brachial plexus avulsion and limb amputation are often associated with intractable chronic pain. Dorsal root entry zone (DREZ) thermocoagulation is an effective surgical treatment for upper-extremity deafferentation pain. The authors describe the clinical follow-up and imaging in a patient who underwent DREZ thermocoagulation 26 years ago for postamputation phantom limb syndrome with associated brachial plexus avulsion. This patient continues to have successful pain control without phantom limb sensation and has never experienced a recurrence of his left upper-extremity pain syndrome. This report lends credibility to the notion that, among ablative neurosurgical pain operations, DREZ thermocoagulation may provide the greatest durability of pain control.

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Microsurgical DREZ-otomy for the Treatment of Spasticity and Pain in the Lower Limbs

Neurosurgery ◽

10.1227/00006123-198905000-00002 ◽

1989 ◽

Vol 24 (5) ◽

pp. 655-670 ◽

Cited By ~ 60

Author(s):

Marc Sindou ◽

Daniel Jeanmonod

Keyword(s):

Dorsal Root ◽

Lower Limbs ◽

Lateral Part ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Root Entry Zone ◽

Afferent Fibers ◽

Disabled Patients

ABSTRACT The authors report on a series of 53 bedridden patients suffering from harmful spasticity in one (6) or both (47) lower limbs, who were treated with microsurgical DREZ-otomy. Surgery was performed to treat fixed abnormal postures in flexion in 49 patients and hyperextension in 3, and, additionally, to treat pain in 37 patients. Microsurgical DREZ-otomy was introduced in 1972, on the basis of anatomical studies of the human dorsal root entry zone (DREZ) showing a topographical segregation of the afferent fibers according to their size and functional destinations. It consists of a 2 mm deep microsurgical lesion directed at a 45° angle in the posterolateral sulcus and penetrating the dorsal root entry zone in its ventrolateral aspect, at the level of all the rootlets considered involved in spasticity (and pain). It destroys mainly the lateral (nociceptive) and central (myotatic) afferent fibers as well as the facilitatory medial part of the Lissauer tract, while sparing most of the medial (lemniscal) fibers, the suppressor lateral part of the Lissauer tract, and more or less of the dorsal horn (DH). The postoperative results were evaluated after a mean follow-up period of 3 years and 4 months. Both spasticity and spasms were significantly decreased or suppressed in 75% and 88.2% of the patients, respectively. When present, pain was relieved without abolition of sensation in 91.6%. These benefits-combined with complementary orthopedic surgery in 23 patients-resulted in either disappearance or marked reduction of the abnormal postures in 85.3% of the patients and of articular limitations in 96.8%. Mid-to-severe complications occurred in 25 patients and precipitated or were responsible for death in 5. This is explained by the fact that the general and neurological conditions of most of the patients-especially those affected by multiple sclerosis-were precarious. MDT has, however, enabled a majority of these severely disabled patients to sit and lie comfortably, and has allowed them to reach a significantly improved quality of life.

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Long-term follow up of dorsal root entry zone lesions in brachial plexus avulsion.

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp.57.6.737 ◽

1994 ◽

Vol 57 (6) ◽

pp. 737-738 ◽

Cited By ~ 49

Author(s):

D G Thomas ◽

N D Kitchen

Keyword(s):

Brachial Plexus ◽

Dorsal Root ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Brachial Plexus Avulsion ◽

Root Entry Zone ◽

Long Term Follow Up

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Postherpetic Neuralgia

Pain Neurosurgery ◽

10.1093/med/9780190887674.003.0006 ◽

2019 ◽

pp. 41-50

Author(s):

Sebastian Rubino ◽

Roy S. Hwang ◽

Julie G. Pilitsis

Keyword(s):

Postherpetic Neuralgia ◽

Dorsal Root ◽

Facial Pain ◽

Age Group ◽

Motor Cortex Stimulation ◽

Trigeminal Nucleus ◽

Herpes Zoster Ophthalmicus ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Root Entry Zone

Postherpetic neuralgia (PHN) after acute herpes zoster ophthalmicus involves unilateral pain persisting or recurring for at least 3 months in the distribution of one or more branches of the trigeminal nerve. Patients often describe the pain associated with PHN as a deep aching or burning, dysesthetic, hyperesthetic, or electric shock-like sensation. The incidence of PHN increases with age and varies from 7 to 27%, depending on age group. 1 A subset of these patients develops medication-refractory PHN and should be referred for neurosurgical evaluation. Motor cortex stimulation (MCS) and trigeminal nucleus caudalis dorsal root entry zone (NC DREZ) lesioning are two therapies that may provide substantial relief to patients suffering from medication-refractory, postherpetic neuropathic facial pain.

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An Anatomical Study of the Human Trigeminal Nucleus Caudalis as It Relates to Facial Pain and the Dorsal Root Entry Zone Operation

Neurosurgery ◽

10.1227/00006123-199205000-00033 ◽

1992 ◽

Vol 30 (5) ◽

pp. 801-802

Author(s):

B. S. Nashold ◽

A. El-Naggar ◽

M. M. Abdulhak ◽

J. Ovelmen-Levitt ◽

E. Cosman

Keyword(s):

Dorsal Root ◽

Facial Pain ◽

Anatomical Study ◽

Trigeminal Nucleus ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Trigeminal Nucleus Caudalis ◽

Root Entry Zone

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A new design of radiofrequency lesion electrodes for use in the caudalis nucleus DREZ operation

Journal of Neurosurgery ◽

10.3171/jns.1994.80.6.1116 ◽

1994 ◽

Vol 80 (6) ◽

pp. 1116-1120 ◽

Cited By ~ 17

Author(s):

Blaine S. Nashold ◽

Amr O. El-Naggar ◽

Janice Ovelmen-Levitt ◽

Muwaffak Abdul-Hak

Keyword(s):

Dorsal Root ◽

Facial Pain ◽

Anatomical Study ◽

New Right ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Radiofrequency Lesion ◽

Fine Print

✓ Two new right-angled electrodes have been designed for use at the dorsal root entry zone (DREZ) of the caudalis nucleus to provide relief of chronic facial pain. The electrode design was based on an anatomical study of the human caudalis nucleus at the cervicomedullary junction. Previously, caudalis nucleus DREZ operations were often followed by ipsilateral ataxia, usually in the arm. The new electrodes have significantly reduced this complication. A group of 21 patients with varied types of chronic facial pain have been treated, with pain relief in 70%.

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Facial pain due to vascular lesions of the brain stem relieved by dorsal root entry zone lesions in the nucleus caudalis

Journal of Neurosurgery ◽

10.3171/jns.1992.77.3.0473 ◽

1992 ◽

Vol 77 (3) ◽

pp. 473-475 ◽

Cited By ~ 11

Author(s):

John H. Sampson ◽

Blaine S. Nashold

Keyword(s):

Dorsal Root ◽

Facial Pain ◽

Artery Aneurysm ◽

Vascular Lesions ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Radiofrequency Lesions ◽

The Brain

✓ One patient with a pontine infarct due to a fusiform basilar artery aneurysm and one with an arteriovenous malformation within the tectum of the mesencephalon developed intractable facial pain. This pain was relieved in both patients by radiofrequency lesions in the dorsal root entry zone of the trigeminal nucleus caudalis.

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