Anatomic Pathways Related to Pain in Face and Neck

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    Diagram of the origins and terminations of the descending tract of V. The fibers shown are those carrying impulses of pain and temperature.

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    Cross sections of human brain stem after total retrogasserian rhizotomy to show the descending tract of V. (A) The level of cranial nerve XII. (B) A level 6. mm. below the obex at sensory decussation which we believe to be the optimal site for medullary tractotomy. Note position of the dorsal spinocerebellar tract superficial to the descending tract of V at this level.

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    Cross sections of medulla of monkey stained by technique of Weil. (A) Total degeneration in the descending tract of V at level of sensory decussation following total retrogasserian rhizotomy. Note position of the dorsal spinocerebellar tract superficial to the descending tract of V and the bulbar accessory rootlet which serves as a landmark for the anterior extent of the tractotomy incision. (B) Level of beginning motor decussation showing degeneration in descending tract of V following retrogasserian rhizotomy of mandibular fibers only. Note dorsal location of the degeneration and its proximity to fasciculus cuneatus.

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    Cross section of the human medulla 6 mm. below the obex.

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    Photograph following left medullary tractotomy in a patient with intractable pain in the face from carcinoma of the tongue which is shown. The patient is free from pain. Except for sparing of the left upper lip, which is slightly more than usual, there is analgesia of entire left face including faucial tonsil and tympanic membrane.

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    Diagram of the second- and third-order neurons mediating facial and cervical pain.

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    Cross section of lower medulla of human following medullary tractotomy. This section is stained by Marchi technique. The operation resulted in relief of the intractable facial pain from a carcinoma of the tongue. The patient had excellent analgesia of the face, auditory canal, tympanic membrane, and faucial tonsil with sparing only in the vermilion border of the lip. There was a mild ataxia of the ipsilateral upper extremity. Note particularly the crossing bundles of the ventral secondary ascending tract of V as indicated by the arrows.

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    Diagram of region of overlap between dorsalhorn gray and caudal part of nucleus of descending tract of V.

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