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Lesioning of Nucleus Caudalis Dorsal Root Entry Zone Strong Option for Intractable Headache Pain: Presented at AANS

By W. A. Thomasson

Special to DG News

CHICAGO, IL -- April 11, 2002 -- The nucleus caudalis dorsal root entry zone procedure is a viable treatment option for some patients with intractable headache who do not respond to conservative treatments, researchers report.

Amr O. El-Naggar, MD, a private-practice pain consultant in Somerset, Kentucky, and Blaine Nashold, MD, of Duke University, in Durham, North Carolina, reported the findings here yesterday at the annual meeting of the American Association of Neurological Surgeons.

In support of this conclusion, Dr. El-Naggar presented a series of 12 patients from his practice.

The nucleus caudalis dorsal root entry zone (DREZ) operation is generally used for treatment of the most challenging intractable craniofacial pain syndromes. Carefully placed electrodes create lesions in selected areas of the nucleus caudalis, a medulla oblongata structure devoted to transmission of pain signals.

Dr. El-Naggar noted that the operation for intractable headache differs slightly from that for trigeminal pain. Since the pain has no central facial component, there is no need to place lesions above the level of the obex. This significantly increases safety of the procedure. Safety is also increased by use of a series of electrodes Dr. El-Naggar has recently designed, with each electrode specifically sized and shaped to place lesions at a different level of the nucleus.

Dr. El-Naggar's patient series presented with headache of a variety of origins: seven migraine cases (four with and three without aura), one case of cluster headache, and one case each of headache secondary to trauma, to multiple sinus operations, to periorbital cellulitis, and to radiation treatment for pituitary adenoma. In every case, the pain was debilitating and all conservative options had proven ineffective. Follow-up to date ranges from four months to 11. Mean patient age was 42 years (range 25-45).

Overall, six patients experienced excellent relief, five patients experienced good relief, and only the patient with post-traumatic headache obtained little relief. Relief was seen primarily in frequency and duration of headache, with limited effects on severity of those headaches that still occurred. Quality of life improved dramatically, Dr. El-Naggar said.

Eight of the patients had temporary ataxia lasting three or four days, but there was no residual ataxia in any patient. Dysesthetic pain was sometimes seen in Dr. El-Naggar's early experience, but is minimal since he began using the new electrodes. Aside from facial numbness of a few months' duration, there have been no other significant complications.

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