The development of accurate techniques for spinal stereotaxic surgery facilitates the difficult management of post-herpetic facial pain by making possible destruction of both the spinal trigeminal nucleus and descending tract; it also elminates excitation from the nuclear overlap between cervical and facial segments and intranuclear pathways. The technique is described and three cases reported. Stereotaxic trigeminal tractotomy relieves both the hyperpathia and deep background pain of herpes.KEy WoRDs herpes zoster facial neuralgia trigeminal nucleus tractotomy stereotaxis LTHOUGH post-herpetic neuralgia is not an invariable concomitant of shingles, its incidence increases with age and its management is often difficult. It occurs in 10% to 15% of all post-herpetic neuralgias, 19,~5 second only in frequency to truncal pain. Although pain may be experienced in any portion of the head or face ~ it almost invariably involves the area served by the ophthalmic division of the fifth nerve. ~,28 Tatlow,~8 however, reported only seven of 47 patients with ophthalmic herpes who developed pain or abnormal sensations, and only one of these required surgical treatment.Among the diverse medical treatments are the use of vitamin B12, Diphenylhydantoin, Tegretol, and analgesics; electric massage or percussion ~1 has produced equivocal results. Surgical therapy has been equally diverse, including such peripheral measures as undermining the skin, excision of the scarred area, and avulsion of sensory nervesY 9 White and Sweet ~~ have concluded that conservative therapy should be attempted first with electrical massage or subcutaneous infiltration of the painful skin with steroids; if this fails they suggest the elevation of a large flap of the painful skin or avulsion of its sensory nerve supply provided that preliminary regional anesthesia stops the pain. Sympatheetomy has been helpful in some cases? ,11The results of thalamotomy have been uncertain? 6 Sensory cortical excision has not been very successful, za,~G and is attended by a high risk of epilepsy. The poor results of many of these treatments is shown by Sugar and Bucy's ~6 review; their final conclusion was that only bifrontal lobotomy was successful in relieving the pain of post-herpetic ncuralgia.Almost without exception the results of direct attack on the trigeminal nerve, its branches, or central connections have failed. :~,~,,~,~5,~ White and Sweet 3~ suggest that bulbar tractotomy or trigeminal rhizotomy should be considered for cases where peripheral neurectomy gives some months of adequate relief, and for the most intractable group advise stereotaxic thalamotomy or upper mesencephalotomy.Our own experience 9,~~ has been that pc-412 1. Neurosurg. / Volume 37 / October, 1972
