Efficacy and factors determining the outcome of dorsal root entry zone lesioning procedure (DREZotomy) in the treatment of intractable pain syndrome

Abstract The authors report the results of DREZ thermocoagulation in 35 patients since March 1980. This technique was applied not only in patients with deafferentation pain after brachial plexus avulsion, but also for postamputation phantom limb pain and pain caused by injury to the spine and spinal cord, by peripheral nerve lesions, and by multiple sclerosis. Independent of etiology, the duration of the pain syndrome, and the quality and projection of the pain, the overall results have been satisfactory and long-lasting.

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Treatment of Refractory Pain after Brachial Plexus Avulsion with Dorsal Root Entry Zone Lesions

Neurosurgery ◽

10.1097/00006123-200106000-00016 ◽

2001 ◽

Vol 48 (6) ◽

pp. 1269-1277 ◽

Cited By ~ 5

Author(s):

Madjid Samii ◽

Steffani Bear-Henney ◽

Wolf Lüdemann ◽

Marcos Tatagiba ◽

Ulrike Blömer

Keyword(s):

Brachial Plexus ◽

Dorsal Root ◽

Intractable Pain ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Root Entry Zone ◽

Long Term Follow Up ◽

Cervical Root

Abstract OBJECTIVE Significant numbers of patients experience intractable pain after brachial plexus root avulsions. Medications and surgical procedures such as amputation of the limb are often not successful in pain treatment. METHODS Forty-seven patients with intractable pain after traumatic cervical root avulsions were treated with dorsal root entry zone coagulation between 1980 and 1998. The dorsal root entry zone coagulation procedure was performed 4 months to 12 years after the trauma, and patients were monitored for up to 18 years (average follow-up period, 14 yr). RESULTS Immediately after surgery, 75% of patients experienced significant pain reduction; this value was reduced to 63% during long-term follow-up monitoring. Nine patients experienced major complications, including subdural hematomas (n = 2) and motor weakness of the lower limb (n = 7). Improved coagulation electrodes with thermistors that could produce smaller and more-accurate lesion sizes, which were introduced in 1989, significantly reduced the number of complications. CONCLUSION Central deafferentation pain that persists and becomes intractable among patients with traumatic cervical root avulsions has been difficult to treat in the past. Long-term follow-up monitoring of patients who underwent the dorsal root entry zone coagulation procedure in the cervical cord indicated that long-lasting satisfactory relief is possible for the majority of individuals, with acceptable morbidity rates.

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Spinal cord mapping with evoked responses for accurate localization of the dorsal root entry zone

Journal of Neurosurgery ◽

10.3171/jns.1995.82.4.0587 ◽

1995 ◽

Vol 82 (4) ◽

pp. 587-591 ◽

Cited By ~ 15

Author(s):

Mahmood Fazl ◽

David A. Houlden ◽

Zelma Kiss

Keyword(s):

Spinal Cord ◽

Dorsal Root ◽

Neurological Deficits ◽

Intractable Pain ◽

Specific Stimulus ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Accurate Localization

✓ Direct spinal cord stimulation and recording techniques were used intraoperatively to localize the dorsal root entry zone (DREZ) in four patients with brachial plexus avulsion and severe intractable pain. The spinal cord was stimulated by a cordotomy needle placed on the pia-arachnoid at the DREZ or the dorsal or dorsolateral aspect of the spinal cord. Recordings were obtained from a subdural silver ball electrode placed rostral or caudal to the stimulation site. Spinal cord conduction velocity was significantly faster following dorsolateral stimulation than dorsal stimulation (mean = 66 and 45 m/sec respectively). The spinal cord evoked potential was significantly larger in amplitude following dorsolateral stimulation than dorsal stimulation at a specific stimulus intensity. Stimulation at the DREZ failed to evoke a response. These neurophysiological phenomena helped to accurately localize the DREZ before DREZ lesioning was undertaken. There were no untoward neurological deficits related to the DREZ lesions and all patients had satisfactory pain relief following the procedure. Intraoperative spinal cord mapping facilitates accurate DREZ localization when the DREZ cannot be visually identified.

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Central Neuropathic Pain and Complex Regional Pain Syndrome Following Brachial Plexus Injury Treated Successfully With Dorsal Root Entry Zone Lesioning

Neurosurgery ◽

10.1093/neuros/nyz310_703 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Erin McCormack ◽

Mansour H Mathkour ◽

Lora Wallis Kahn ◽

Reda Tolba ◽

Maged Guirguis ◽

...

Keyword(s):

Neuropathic Pain ◽

Pain Relief ◽

Brachial Plexus ◽

Dorsal Root ◽

Brachial Plexus Injury ◽

Pain Syndrome ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Central Neuropathic Pain ◽

Root Entry Zone

Abstract INTRODUCTION Central neuropathic pain (CNP) and complex regional pain syndrome (CRPS) present as chronic, unrelenting, and disabling pain resulting from central and peripheral nervous system injuries. For patients who have failed conservative management, dorsal root entry zone (DREZ) lesioning may serve as an alternative for the management of intractable pain. METHODS A 36-yr-old male presented with complete right brachial plexus injury and avulsion of nerve roots following a motorcycle accident. He developed disabling type I CRPS of the right upper extremity. After failing medical therapy, he underwent a trial of conventional SCS using 2 percutaneous leads in the upper cervical spine but did not get topographical coverage. He underwent a second SCS trial with the placement of a paddle lead using burst therapy, but his initial partial pain relief subsided after 3 d. Subsequently, he underwent SCS removal, C2 to T1 right DREZ lesioning, and C4 to T1 laminoplasty. The patient gained a significant pain relief and became more functional. Five months postoperatively, he experienced an improvement in his pain and narcotic consumption. RESULTS Using an insulated neurotomy electrode, 2-mm-deep lesions were made at 75°C for 15 s. A total of 83 lesions were made from T2 to C3. Each lesion was spaced 1 mm apart. The impedance was less than 1000 ohms, which was consistent within an area of injury. Somatosensory and motor-evoked potentials were at baseline during the case without significant changes. CONCLUSION When SCS fails, lesioning of the dorsal root entry zone is a useful tool in the armamentarium for the management of refractory brachial plexus neuropathic pain.

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Dorsal root entry zone (DREZ) localization using direct spinal cord stimulation can improve results of the DREZ thermocoagulation procedure for intractable pain relief

Pain ◽

10.1016/j.pain.2005.03.015 ◽

2005 ◽

Vol 116 (1) ◽

pp. 159-163 ◽

Cited By ~ 18

Author(s):

Robert Tomáš ◽

Pavel Haninec

Keyword(s):

Spinal Cord ◽

Pain Relief ◽

Spinal Cord Stimulation ◽

Dorsal Root ◽

Intractable Pain ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Root Entry Zone

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Dorsal root entry zone lesions for intractable pain after trauma to the conus medullaris and cauda equina

Journal of Neurosurgery ◽

10.3171/jns.1995.82.1.0028 ◽

1995 ◽

Vol 82 (1) ◽

pp. 28-34 ◽

Cited By ~ 39

Author(s):

John H. Sampson ◽

Robert E. Cashman ◽

Blaine S. Nashold ◽

Allan H. Friedman

Keyword(s):

Dorsal Root ◽

Cauda Equina ◽

Conus Medullaris ◽

Intractable Pain ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Relieve Pain ◽

Fine Print

✓ This review was undertaken to determine the efficacy of using dorsal root entry zone (DREZ) lesions to treat intractable pain caused by trauma to the conus medullaris and cauda equina. Traumatic lesions of this area are unique in that both the spinal cord and the peripheral nerve roots are injured. Although DREZ lesions have been shown to relieve pain of spinal cord origin in many patients, they have been shown not to relieve pain of peripheral nerve origin. Therefore, 39 patients with trauma to the conus medullaris and cauda equina who underwent DREZ lesioning for intractable pain were reviewed retrospectively. The results of this review demonstrate the efficacy of DREZ lesions in these patients. At a mean follow-up period of 3.0 years, 54% of patients were pain-free without medications, and 20% required only nonnarcotic analgesic drugs for pain that no longer interfered with their daily activities. Better outcomes were noted in patients with an incomplete neurological deficit, with pain having an “electrical” character, and with injuries due to blunt trauma. Operative complications included weakness (four patients), bladder or sexual dysfunction (three), cerebrospinal fluid leak (two), and wound infection (two), but overall, 79.5% of patients (31 of 39) were without serious complications. Complications were limited to patients with prior tissue damage at the surgical exploration site and were most prevalent in patients who underwent bilateral DREZ lesions. In conclusion, this preliminary report suggests that DREZ lesions may be useful in combating intractable pain from traumatic injuries to the conus medullaris and cauda equina, with some risk to neurological function that may be acceptable in this group of patients.

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Dorsal Root Entry Zone Coagulation for Control of Intractable Pain Due to Brachial Plexus Injury

Peripheral Nerve Lesions ◽

10.1007/978-3-642-75611-5_67 ◽

1990 ◽

pp. 422-426 ◽

Cited By ~ 2

Author(s):

M. Samii ◽

E. Kohmura ◽

H. Khalil ◽

C. Matthies

Keyword(s):

Brachial Plexus ◽

Dorsal Root ◽

Brachial Plexus Injury ◽

Intractable Pain ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Root Entry Zone

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Modified dorsal root entry zone lesioning for pain relief in cervical root avulsion injury

Neurosurgical Focus: Video ◽

10.3171/2020.7.focvid2020 ◽

2020 ◽

Vol 3 (2) ◽

pp. V11

Author(s):

Keisuke Takai ◽

Makoto Taniguchi

Keyword(s):

Pain Relief ◽

Dorsal Root ◽

Substantia Gelatinosa ◽

Intractable Pain ◽

Root Avulsion ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Avulsion Injury ◽

Root Entry Zone ◽

Cervical Root

Neuropathic pain in the upper extremity due to cervical root avulsion injury is refractory to medical treatments. Superficial layers in the posterior horn of spinal gray matter, including the substantia gelatinosa, are the main target of dorsal root entry zone (DREZ) lesioning, which has been the most effective surgical treatment for the relief of intractable pain; however, residual pain and a decrease in pain relief during the long-term follow-up period have been reported. Based on pain topography in the most recent basic studies, the conventional DREZ lesioning procedure was modified to improve clinical outcomes.The video can be found here: https://youtu.be/PyaAGmAE7Og

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Laser-induced dorsal root entry zone lesions for pain control

Journal of Neurosurgery ◽

10.3171/jns.1983.59.5.0884 ◽

1983 ◽

Vol 59 (5) ◽

pp. 884-886 ◽

Cited By ~ 53

Author(s):

Walter J. Levy ◽

Alan Nutkiewicz ◽

Q. Michael Ditmore ◽

Clark Watts

Keyword(s):

Spinal Cord ◽

Dorsal Root ◽

Scar Tissue ◽

Intractable Pain ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Cord Injury ◽

Alternative Means

✓ Dorsal root entry zone lesions have been documented as effective for control of intractable pain in patients with brachial plexus avulsion or severe spinal cord injury. These lesions are usually made with the radiofrequency technique. The authors report three cases in which the CO2 laser was used as an alternative means of making the lesions. This latter technique provided effective pain relief in two of the patients and was efficient to use. It was noted that the presence of overlying scar tissue can be deceptive in judging the depth of the lesion made with the laser. The CO2 laser provided a means of producing controlled spinal cord lesions which may be more precise than the radiofrequency method.

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