- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
- Lake Cumberland Neurosurgical Clinic, Somerset, KY, USA
Stephen E. Sandwell
Lake Cumberland Neurosurgical Clinic, Somerset, KY, USA
DOI:10.4103/2152-7806.85467Copyright: © 2011 Sandwell SE. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Sandwell SE, El-Naggar AO. Nucleus caudalis lesioning: Case report of chronic traumatic headache relief. Surg Neurol Int 27-Sep-2011;2:128
How to cite this URL: Sandwell SE, El-Naggar AO. Nucleus caudalis lesioning: Case report of chronic traumatic headache relief. Surg Neurol Int 27-Sep-2011;2:128. Available from: http://sni.wpengine.com/surgicalint_articles/nucleus-caudalis-lesioning-case-report-of-chronic-traumatic-headache-relief/
Background:The nucleus caudalis dorsal root entry zone (DREZ) surgery is used to treat intractable central craniofacial pain. This is the first journal publication of DREZ lesioning used for the long-term relief of an intractable chronic traumatic headache.
Case Description:A 40-year-old female experienced new-onset bi-temporal headaches following a traumatic head injury. Despite medical treatment, her pain was severe on over 20 days per month, 3 years after the injury. The patient underwent trigeminal nucleus caudalis DREZ lesioning. Bilateral single-row lesions were made at 1-mm interval between the level of the obex and the C2 dorsal nerve roots, using angled radiofrequency electrodes, brought to 80°C for 15 seconds each, along a path 1 to 1.2 mm posterior to the accessory nerve rootlets. The headache improved, but gradually returned. Five years later, her headaches were severe on over 24 days per month. The DREZ surgery was then repeated. Her headaches improved and the relief has continued for 5 additional years. She has remained functional, with no limitation in instrumental activities of daily living.
Conclusions:The nucleus caudalis DREZ surgery brought long-term relief to a patient suffering from chronic traumatic headache.
Keywords: Dorsal root entry zone, headache, nucleus caudalis, trauma, trigeminal
Every year, 1.7 million people in the United States suffer traumatic brain injuries.[
The prognosis of post-traumatic headache is generally good: many patients improve within months of their injury.[
Although the majority of patients experience a tolerable recovery, some develop medically intractable and incapacitating headaches. Such patients may be referred for pain management consult. The evaluation may be obscured by psychological factors and issues of potential secondary gain. While recognizing the complexity and diverse etiology of post-traumatic headaches,[
A 40-year-old woman was referred to our clinic with a 3-year history of chronic bi-temporal headaches. Her headaches developed after she was ejected from a motor vehicle. The injury resulted in a temporary loss of consciousness, scalp laceration, and skull fracture without cerebrospinal fluid leak. She recovered after an 8-day admission at an outside hospital. Her memory of events was limited for 1 month, preventing her from recalling the headache's onset more precisely than “within a month of the injury.” She had no prior history or family history of headaches. Her headache intensity was rated as 8-9/10, and these occurred on over 20 days per month. The headaches were exacerbated by bending forward, loud noise, and sunlight. She denied aura, visual symptoms, or food triggers. She had occasional nausea without vomiting. The pain character was described as throbbing, stabbing, and piercing. She felt a tightening pressure over a bi-temporal band-like distribution. She did not have any numbness, tingling or weakness in the face or extremities. She ambulated without difficulty and was otherwise neurologically intact. Her MRI did not show any significant intracranial abnormalities. Post-traumatic headaches must develop within seven days of an injury to meet criteria set by the International Classification of Headache Disorders,[
She failed treatments with acetaminophen, butalbital, caffeine, celecoxib, clonazepam, dihydroergotamine, gabapentin, hydrocodone, nadolol, oxycodone, paroxetine, and sumatriptan. With each medicine trial, she was followed closely by her neurologist to reduce the risk of developing medication overuse headache. She tried bilateral C2 ganglion blocks without relief. She achieved only temporary relief with botulinum toxin injections in the temporalis muscle. After 3 years of incapacitating chronic trauma-related headaches, and with no pending litigation settlements, she was referred to our neurosurgery clinic for evaluation of her headache and consideration for bilateral radiofrequency trigeminal nucleus caudalis DREZ lesioning.
The surgical exposure required a suboccipital craniectomy and C1 hemilaminectomy. The dura was opened. Single-row serial lesions were made at 1-mm intervals along the trigeminal nucleus caudalis using El-Naggar-Nashold angled radiofrequency thermocoupled DREZ electrodes (Cosman Medical®, Burlington, MA). The electrodes were brought to 80°C, for 15 s per lesion. The row began 1 mm below the level of the obex [
Surgical outcome and postoperative neurological exam
Following surgery, her headache pain was immediately improved and she had no ataxia. Over the next 5 months, she had occasional discomfort behind her left eyebrow and along the left side of her nose. Both symptoms improved with gabapentin.
Neurological exam at 5 months after surgery revealed normal sensation to touch along the face, but no sensation to pin prick in the V1 distributions, bilaterally. Pin prick was sensed at half intensity along the V2 distributions, and as 75% of normal in the V3 distributions. Perception of ice as cold was absent in the V1 distributions, less than normal in the V2 distributions, and normal in the V3 distributions. Perception of coffee as warm in the mouth and throat was normal bilaterally. Sensation to pin prick was normal at the earlobes and in the occipital C2 and C3 distributions. Vibration, temperature, and pin prick sensations were normal in all extremities. Position sense and motor strength were normal in all extremities. Her gait was normal with no difficulty walking quickly or turning. She felt her headache symptoms were 90% improved and she was glad that she had undergone surgery.
Two years after surgery, her headaches began to redevelop, especially around the left eye and forehead. Over the next 3 years, she was referred for neurology consultation to maximize nonsurgical options. Despite neurology-guided headache treatment, her headache intensity was rated as 9-10/10 on at least 24 days per month. At this time, she underwent a repeated bilateral nucleus caudalis DREZ procedure.
On her first 3 postoperative days, she had transient ataxia and mild dysmetria of the left arm. She was discharged on the fourth day after surgery with no headache, no facial pain, and only minimal ataxia. Three months after surgery, she denied frontal or parietal headache. She was weaned off all pain medication. Seven months after surgery, she was neurologically intact except for a lack of sensation to pin prick in the V1 and V2 distributions. Pin prick was perceived in the V3 distributions. She could distinguish touch, hot, and cold in all trigeminal distributions. She had no imbalance in her gait.
She continued to do well until her last follow-up (nearly 5 years since her second surgery, 10 years since her first surgery, and 13 years since her injury). She recently reported only one or two short headaches per month, which were of an intensity of 1/10 and localized to the temple and occipital regions. She was not using any pain medication other than acetaminophen. In reflection, she is extremely glad that she underwent this surgery. She has remained very functional and can carry out instrumental activities of daily living without difficulty.
Anatomy of the trigeminal pain pathway
First-order trigeminal sensory neurons enter the brainstem at the pons [
Axial brainstem schematic, 8 mm below obex, posterior shown upward. Trigeminal Tract (TT), Trigeminal Nucleus Caudalis (NC), Accessory Nerve rootlet (XI), Dorsal Spinocerebellar Tract (DSC), Fasciculus Cunneatus (FC), Pyramidal Decussation (PD), Corticospinal Tract (CS). DREZ electrode superimposed
History of dorsal root entry zone lesioning
The nucleus caudalis DREZ procedure is an extension of a concept pursued by Sjoqvist in 1937.[
Using trigeminal tractotomy, Kunc found that lesioning the descending trigeminal tract near the level of the obex interrupted the first-order afferents that supplied both the rostral and caudal portions of the nucleus caudalis. A rostral tractotomy would result in analgesia of the entire face, while more caudal lesions only resulted in analgesia of the periphery of the face. The finding correlated with the Dιjerine “onion peel” model for the segmental mapping of the nucleus caudalis, in which rostral levels convey central face pain sensation and caudal levels convey peripheral face pain sensation.[
Trigeminal tractotomy was further advanced by Crue and Hitchcock who independently designed stereotactic techniques to perform the tractotomy percutaneously.[
In 1972, Sindou developed a DREZ lesioning technique for arm pain associated with Pancoast-Tobias syndrome.[
Nashold's technique differed from Schvarcz's in that he made a series of lesions to cover the length of the nucleus caudalis rather than a single percutaneous lesion. An advantage of Nashold's open technique was that brainstem landmarks could guide lesion placement. Additionally, a range of the nucleus could be targeted, addressing deafferentation pain signals that could be emitted from the nucleus caudalis at levels above or below where a percutaneous electrode could be placed.
The nucleus caudalis DREZ procedure is similar to spinal DREZ procedures, but it does not involve lesioning the pons at the location of the trigeminal nerve entry. Instead, a series of lesions are made below the level of the fourth ventricle and extending to the C2 dorsal nerve roots. Many variations of the DREZ lesioning technique have since been used, including using laser[
Surgical indications for nucleus caudalis dorsal root entry zone lesioning
The nucleus caudalis DREZ surgery has primarily been used to improve deafferentation facial pain, as exists in post-herpetic neuralgia and anesthesia dolorosa.[
Surgical risks and technique considerations
Caudal to the obex, lesions are not expected to affect sensation to touch or affect trigeminal motor function. In older literature, the most common complication was ataxia, attributed to lesion extension to the dorsal spinocerebellar tract.[
The corticospinal tract is another neighboring structure that is vulnerable to injury [
We use the open DREZ technique because it allows visualization and protection of brainstem surface blood vessels and accessory nerve rootlets. These rootlets serve as an external landmark to localize the nucleus caudalis.[
The open technique may increase the potential risk for cerebrospinal fluid leak or wound infection, but we believe that the visualization of these structures adds safety for the placement of the electrode.
The patient must be cautioned of the possibility of pain recurrence after surgery. If pain recurs, the median time for recurrence is 3 months after surgery.[
After medical management failed to relieve our patient's trauma-related headaches, relief was achieved with the nucleus caudalis DREZ procedure. Pain relief after DREZ lesioning can be significant and long lasting. This procedure is not recommended for all patients with headaches, but in the literature, and in our experience, it has been effective for other patients that suffered from incapacitating and intractable cluster and migraine headaches.[
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