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

Case report

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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.

Abbreviation used in this paper:DREZ = dorsal root entry zone.

Article Information

Address correspondence to: Stephen E. Sandwell, M.D., Department of Neurosurgery, University of Rochester, 601 Elmwood Avenue, Box 670, Rochester, New York 14642. email: Stephen_Sandwell@URMC.Rochester.edu.

Please include this information when citing this paper: published online December 14, 2012; DOI: 10.3171/2012.11.JNS121395.

© AANS, except where prohibited by US copyright law.

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Figures

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    Illustration of the left cerebral hemisphere, posterior brainstem, and right face showing the trigeminal pain pathway carrying facial pain sensation to the pons, caudal as the spinal trigeminal tract, deep to the nucleus caudalis, across the midline, and rostral to the ventroposteromedial (VPM) nucleus of the thalamus, then to the sensory cortex. The V1 distributions descend the spinal trigeminal tract anterior to the V2 and V3 distributions. Pathways for the central face cross midline at levels rostral to those of the peripheral face.

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    Contrast-enhanced axial (A), coronal (B), and sagittal (C and D) MR images. The arrows indicate the residual of right trigeminal neuroma after prior resection.

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    Intraoperative image showing the electrode at the C-1 level, placed in the right trigeminal nucleus caudalis. The rostral direction is to the left.

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    Axial Luxol fast blue–stained slide of the medulla, 2 mm caudal to the obex. Overlaid image of the DREZ electrode within the nucleus caudalis at a 120° angle to the sagittal plane. The posterior aspect appears at the top.

References

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