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

Case report

Restricted access

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:

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.



  • View in gallery

    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.

  • View in gallery

    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.

  • View in gallery

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

  • View in gallery

    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.



Broggi GFranzini ALeone MBussone G: Update on neurosurgical treatment of chronic trigeminal autonomic cephalalgias and atypical facial pain with deep brain stimulation of posterior hypothalamus: results and comments. Neurol Sci 28:Suppl 2S138S1452007


Brown JAPilitsis JG: Motor cortex stimulation for central and neuropathic facial pain: a prospective study of 10 patients and observations of enhanced sensory and motor function during stimulation. Neurosurgery 56:2902972005


Bullard DENashold BS Jr: The caudalis DREZ for facial pain. Stereotact Funct Neurosurg 68:1681741997


Cruccu GAziz TZGarcia-Larrea LHansson PJensen TSLefaucheur JP: EFNS guidelines on neurostimulation therapy for neuropathic pain. Eur J Neurol 14:9529702007


El-Naggar AONucleus caudalis dorsal root entry zone lesioning for intractable facial pain. Starr PABarbaro NMLarson PS: Neurosurgical Operative Atlas: Functional Neurosurgery ed 2New YorkThieme2008. 112117


El-Naggar AONashold BS JrRossitch E JrYoung JNTrigeminal nucleus caudalis lesioning for pain relief. Wilkins RHRengachary SS: Neurosurgery ed 2New YorkMcGraw-Hill1996. Vol 3:40474053


Gorecki JPNashold BS: The Duke experience with the nucleus caudalis DREZ operation. Acta Neurochir Suppl 64:1281311995


Kanpolat YKahilogullari GUgur HCElhan AH: Computed tomography-guided percutaneous trigeminal tractotomy-nucleotomy. Neurosurgery 1 Suppl 163:ONS147ONS1552008


Nashold BSEl-Naggar AOGorecki JPThe microsurgical trigeminal caudalis nucleus DREZ procedure. Nashold BSPearlstein RDFriedman AH: The DREZ Operation Park Ridge, ILThieme1996. 159188


Nashold BSRossitch E JrAnesthesia dolorosa and the trigeminal caudalis nucleus DREZ operation. Rovit RLMurali RJannetta PJ: Trigeminal Neuralgia BaltimoreWilliams & Wilkins1990. 223237


Nashold BS Jrel-Naggar AOOvelmen-Levitt JAbdul-Hak M: A new design of radiofrequency lesion electrodes for use in the caudalis nucleus DREZ operation. Technical note. J Neurosurg 80:111611201994


Nashold BS JrFriedman AHSampson JHNashold JRBEl-Naggar AODorsal root entry zone lesions for pain. Youmans JR: Youmans Neurological Surgery ed 4PhiladelphiaSaunders1996. 5:34523462


Olivecrona H: The syndrome of painful anesthesia following section of the sensory root of the fifth nerve in tic douloureux. Acta Chir Scand 82:991061939


Rasche DRinaldi PCYoung RFTronnier VM: Deep brain stimulation for the treatment of various chronic pain syndromes. Neurosurg Focus 21:6E82006


Raslan AMNasseri MBahgat DAbdu EBurchiel KJ: Motor cortex stimulation for trigeminal neuropathic or deafferentation pain: an institutional case series experience. Stereotact Funct Neurosurg 89:83882011


Rozen TD: Relief of anesthesia dolorosa with gabapentin. Headache 39:7617621999


Sandwell SEEl-Naggar AONettleton GSAcland RD: Trigeminal nucleus caudalis anatomy: guidance for radiofrequency dorsal root entry zone lesioning. Stereotact Funct Neurosurg 88:2692762010


Young JNNashold BS JrCosman ER: A new insulated caudalis nucleus DREZ electrode. Technical note. J Neurosurg 70:2832841989


Zakrzewska JM: Medical management of trigeminal neuropathic pains. Expert Opin Pharmacother 11:123912542010




All Time Past Year Past 30 Days
Abstract Views 88 88 35
Full Text Views 163 163 24
PDF Downloads 166 166 15
EPUB Downloads 0 0 0


Google Scholar