32 Dorsal Root Entry Zone: Nucleus Caudalis

Abstract Dorsal root entry zone (DREZ) lesioning is a neurosurgical procedure that aims to relieve severe neuropathic pain in patients with brachial plexus avulsion by selectively destroying nociceptive neural structures in the posterior cervical spinal cord. Since the introduction of the procedure over 4 decades ago, the DREZ lesioning technique has undergone numerous modifications, with a variety of center- and surgeon-dependent technical differences and patient outcomes. We have reviewed the literature to discuss reported methods of DREZ lesioning and outcomes.

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Dorsal root entry zone lesions for the treatment of post-herpetic neuralgia

Journal of Neurosurgery ◽

10.3171/jns.1984.60.6.1258 ◽

1984 ◽

Vol 60 (6) ◽

pp. 1258-1262 ◽

Cited By ~ 43

Author(s):

Allan H. Friedman ◽

Blaine S. Nashold ◽

Janice Ovelmen-Levitt

Keyword(s):

Pain Relief ◽

Dorsal Root ◽

Post Herpetic Neuralgia ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Adequate Pain Relief ◽

Good Pain Relief ◽

Transcutaneous Nerve Stimulation

✓ Post-herpetic pain was treated in 12 patients using dorsal root entry zone (DREZ) lesions. All patients had failed to receive adequate pain relief from conservative therapy consisting of transcutaneous nerve stimulation, carbamazepine, and/or amitriptyline. Dorsal root entry zone lesions were made to include the involved dermatomes plus one-half of the dermatomes above and below the painful areas. Eight patients reported good pain relief with follow-up periods ranging from 6 to 21 months. A ninth patient obtained satisfactory pain relief, but the superior 1 cm of the original painful area was not included in the distribution of the DREZ lesions. Patients whose lesions were performed using a thermally controlled lesion probe suffered no significant postoperative neurological deficit. Dorsal root entry zone lesions appeared to be a satisfactory treatment for post-herpetic neuralgia in patients who have failed to respond to more conservative modes of therapy.

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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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Theoretical Aspects of Radiofrequency Lesions in the Dorsal Root Entry Zone

Neurosurgery ◽

10.1227/00006123-198412000-00035 ◽

1984 ◽

Vol 15 (6) ◽

pp. 945-950 ◽

Cited By ~ 114

Author(s):

Eric R. Cosman ◽

Blaine S. Nashold ◽

Janice Ovelman-Levitt

Keyword(s):

Dorsal Root ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Root Entry Zone ◽

Radiofrequency Lesions

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Dorsal root entry zone lesions to control central pain in paraplegics

Journal of Neurosurgery ◽

10.3171/jns.1981.55.3.0414 ◽

1981 ◽

Vol 55 (3) ◽

pp. 414-419 ◽

Cited By ~ 74

Author(s):

Blaine S. Nashold ◽

Elizabeth Bullitt

Keyword(s):

Dorsal Root ◽

Central Pain ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Cord Injury ◽

Fine Print

✓ Thirteen patients with intractable long-term pain following spinal cord injury and paraplegia were treated with dorsal root entry zone lesions placed at the level just above the transection. Pain relief of 50% or more was achieved in 11 of the 13 patients, with follow-up periods ranging from 5 to 38 months. A previous report showed that central pain from brachial plexus avulsion could be relieved by dorsal root entry zone lesions, and this technique has been extended to the central pain phenomena associated with spinal trauma and paraplegia.

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Microsurgical DREZ lesions for the control of cancer-related pain

Neurosurgical Focus: Video ◽

10.3171/2020.7.focvid2033 ◽

2020 ◽

Vol 3 (2) ◽

pp. V14 ◽

Cited By ~ 1

Author(s):

Edoardo Mazzucchi ◽

Andrei Brinzeu ◽

Patrick Mertens ◽

Marc Sindou

Keyword(s):

General Condition ◽

Dorsal Root ◽

Lateral Part ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Patients With Cancer ◽

Root Entry Zone ◽

Refractory Pain ◽

Pain Pathways ◽

Good General Condition

Pain in patients with cancer is a major problem, and sometimes it is necessary to surgically interrupt pain pathways to effectively control refractory pain. Surgical lesion of the dorsal root entry zone (DREZ) was first performed in 1972 for the treatment of pain related to a Pancoast-Tobias tumor. The rationale of DREZotomy is to preferentially interrupt the nociceptive inputs in the lateral part of the DREZ and the ventrolateral (excitatory) part of the dorsal horn. Microsurgical DREZotomy is one technique for DREZ lesioning that is suited for tailored control of pain in patients in good general condition who are experiencing pain in a well-defined territory.The video can be found here: https://youtu.be/JtLQDP7gYSQ

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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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