Spinal Cord Stimulation and DREZ Lesioning for Refractory Postherpetic Neuralgia: An Exploratory Case Series

Refractory postherpetic neuralgia (PHN) remains one of the most challenging forms of neuropathic pain after herpes zoster infection, often resistant to conventional therapy. Neurosurgical interventions-particularly spinal cord stimulation (SCS) and dorsal root entry zone (DREZ) lesioning-offer potential benefit, yet optimal selection of surgical treatment remains unclear. This study explores the clinical evidence application of SCS and DREZ lesioning, focusing on clinical outcomes, safety, and costs.

This retrospective single-center series included ten patients with refractory PHN treated between 2011 and 2023. Eight underwent SCS trials; those achieving ≥30% pain reduction (Numeric Rating Scale, NRS) received permanent implants. Patients with insufficient response proceeded to DREZ lesioning. Pain intensity and disability were evaluated using NRS and the Pain Disability Index (PDI) after a minimum 24-month follow-up. Treatment success was defined as ≥30% reduction in NRS. Secondary outcomes included complications, hospital stay, and procedural costs.

Among the eight patients who underwent SCS trials, three achieved ≥30% pain reduction and proceed to permanent implantation, with 24-month pain relief rates of 70%, 40%, and 0, respectively. Of the five patients with inadequate SCS response, one subsequently underwent DREZ lesioning; while two additional patients who declined SCS underwent primary DREZ lesioning. At 24 months, pain relief among DREZ-treated patients was 90%, 80%, and 60%, respectively. One patient developed mild segmental sensory loss at the lesioned levels without functional impairment, and no serious complications were observed.

In this small, single-center case series, both SCS and DREZ lesioning achieved meaningful pain reduction in carefully selected patients with refractory postherpetic neuralgia. SCS offers a minimally invasive, reversible option for patients demonstrating effective trial stimulation, whereas DREZ may provide durable analgesia for those with failed SCS or central dorsal horn pathology. These findings are exploratory and hypothesis-generating, underscoring the need for prospective multicenter studies to refine patient selection based on clinical evidence and optimize neurosurgical management.