Microsurgical DREZ-otomy for the Treatment of Spasticity and Pain in the Lower Limbs

Neurosurgery ◽  
1989 ◽  
Vol 24 (5) ◽  
pp. 655-670 ◽  
Author(s):  
Marc Sindou ◽  
Daniel Jeanmonod
Keyword(s):  
Dorsal Root ◽  
Lower Limbs ◽  
Lateral Part ◽  
Entry Zone ◽  
Dorsal Root Entry Zone ◽  
Root Entry Zone ◽  
Afferent Fibers ◽  
Disabled Patients

ABSTRACT The authors report on a series of 53 bedridden patients suffering from harmful spasticity in one (6) or both (47) lower limbs, who were treated with microsurgical DREZ-otomy. Surgery was performed to treat fixed abnormal postures in flexion in 49 patients and hyperextension in 3, and, additionally, to treat pain in 37 patients. Microsurgical DREZ-otomy was introduced in 1972, on the basis of anatomical studies of the human dorsal root entry zone (DREZ) showing a topographical segregation of the afferent fibers according to their size and functional destinations. It consists of a 2 mm deep microsurgical lesion directed at a 45° angle in the posterolateral sulcus and penetrating the dorsal root entry zone in its ventrolateral aspect, at the level of all the rootlets considered involved in spasticity (and pain). It destroys mainly the lateral (nociceptive) and central (myotatic) afferent fibers as well as the facilitatory medial part of the Lissauer tract, while sparing most of the medial (lemniscal) fibers, the suppressor lateral part of the Lissauer tract, and more or less of the dorsal horn (DH). The postoperative results were evaluated after a mean follow-up period of 3 years and 4 months. Both spasticity and spasms were significantly decreased or suppressed in 75% and 88.2% of the patients, respectively. When present, pain was relieved without abolition of sensation in 91.6%. These benefits-combined with complementary orthopedic surgery in 23 patients-resulted in either disappearance or marked reduction of the abnormal postures in 85.3% of the patients and of articular limitations in 96.8%. Mid-to-severe complications occurred in 25 patients and precipitated or were responsible for death in 5. This is explained by the fact that the general and neurological conditions of most of the patients-especially those affected by multiple sclerosis-were precarious. MDT has, however, enabled a majority of these severely disabled patients to sit and lie comfortably, and has allowed them to reach a significantly improved quality of life.

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

Neurosurgery ◽  
2001 ◽  
Vol 48 (6) ◽  
pp. 1269-1277 ◽  
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.

Dorsal root entry zone lesions to control central pain in paraplegics

1981 ◽  
Vol 55 (3) ◽  
pp. 414-419 ◽  
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.

scholarly journals Microsurgical DREZ lesions for the control of cancer-related pain

2020 ◽  
Vol 3 (2) ◽  
pp. V14 ◽  
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

Follow-up 26 years after dorsal root entry zone thermocoagulation for brachial plexus avulsion and phantom limb pain

2011 ◽  
Vol 114 (1) ◽  
pp. 196-199 ◽  
Author(s):  
Nestor D. Tomycz ◽  
John J. Moossy
Keyword(s):  
Brachial Plexus ◽  
Upper Extremity ◽  
Pain Control ◽  
Dorsal Root ◽  
Phantom Limb ◽  
Entry Zone ◽  
Dorsal Root Entry Zone ◽  
Brachial Plexus Avulsion ◽  
Root Entry Zone

Brachial plexus avulsion and limb amputation are often associated with intractable chronic pain. Dorsal root entry zone (DREZ) thermocoagulation is an effective surgical treatment for upper-extremity deafferentation pain. The authors describe the clinical follow-up and imaging in a patient who underwent DREZ thermocoagulation 26 years ago for postamputation phantom limb syndrome with associated brachial plexus avulsion. This patient continues to have successful pain control without phantom limb sensation and has never experienced a recurrence of his left upper-extremity pain syndrome. This report lends credibility to the notion that, among ablative neurosurgical pain operations, DREZ thermocoagulation may provide the greatest durability of pain control.

Dorsal Root Entry Zone Lesions for the Treatment of Brachial Plexus Avulsion Injuries: A Follow-up Study

Neurosurgery ◽  
1988 ◽  
Vol 22 (2) ◽  
pp. 369-373 ◽  
Author(s):  
Allan H. Friedman ◽  
Blaine S. Nashold ◽  
Peter R. Bronec
Keyword(s):  
Pain Relief ◽  
Brachial Plexus ◽  
Dorsal Root ◽  
Entry Zone ◽  
Dorsal Root Entry Zone ◽  
Avulsion Injury ◽  
Brachial Plexus Avulsion ◽  
Root Entry Zone ◽  
Good Pain Relief

Abstract Dorsal root entry zone (DREZ) lesions have been shown to yield short term relief from the pain associated with a brachial plexus avulsion injury. Because of the propensity of pain to recur after neuroablative procedures, 39 patients with pain after a brachial plexus avulsion injury were observed for 14 months to 10 years after DREZ lesions were made. Fifty-four per cent of these patients were afforded good pain relief. Of 21 patients who had multiple small lesions made within the DREZ, 15 (72%) were afforded good pain relief. (Neurosurgery 22:369-373, 1988)

scholarly journals Correlation of preoperative MRI with the long-term outcomes of dorsal root entry zone lesioning for brachial plexus avulsion pain

2016 ◽  
Vol 124 (5) ◽  
pp. 1470-1478 ◽  
Author(s):  
Andrew L. Ko ◽  
Alp Ozpinar ◽  
Jeffrey S. Raskin ◽  
Stephen T. Magill ◽  
Ahmed M. Raslan ◽  
...  
Keyword(s):  
Pain Relief ◽  
Brachial Plexus ◽  
Dorsal Horn ◽  
Dorsal Root ◽  
Entry Zone ◽  
Dorsal Root Entry Zone ◽  
Root Entry Zone ◽  
Pain Outcomes

OBJECT Lesioning of the dorsal root entry zone (DREZotomy) is an effective treatment for brachial plexus avulsion (BPA) pain. The role of preoperative assessment with MRI has been shown to be unreliable for determining affected levels; however, it may have a role in predicting pain outcomes. Here, DREZotomy outcomes are reviewed and preoperative MRI is examined as a possible prognostic factor. METHODS A retrospective review was performed of an institutional database of patients who had undergone brachial plexus DREZ procedures since 1995. Preoperative MRI was examined to assess damage to the DREZ or dorsal horn, as evidenced by avulsion of the DREZ or T2 hyperintensity within the spinal cord. Phone interviews were conducted to assess the long-term pain outcomes. RESULTS Between 1995 and 2012, 27 patients were found to have undergone cervical DREZ procedures for BPA. Of these, 15 had preoperative MR images of the cervical spine available for review. The outcomes were graded from 1 to 4 as poor (no significant relief), good (more than 50% pain relief), excellent (more than 75% pain relief), or pain free, respectively. Overall, DREZotomy was found to be a safe, efficacious, and durable procedure for relief of pain due to BPA. The initial success rate was 73%, which declined to 66% at a median follow-up time of 62.5 months. Damage to the DREZ or dorsal horn was significantly correlated with poorer outcomes (p = 0.02). The average outcomes in patients without MRI evidence of DREZ or dorsal horn damage was significantly higher than in patients with such damage (3.67 vs 1.75, t-test; p = 0.001). A longer duration of pain prior to operation was also a significant predictor of treatment success (p = 0.004). CONCLUSIONS Overall, the DREZotomy procedure has a 66% chance of achieving meaningful pain relief on long-term follow-up. Successful pain relief is associated with the lack of damage to the DREZ and dorsal horn on preoperative MRI.

Predictive Variables for the Successful Treatment of Trigeminal Neuralgia With Gamma Knife Radiosurgery

Neurosurgery ◽  
2011 ◽  
Vol 70 (3) ◽  
pp. 566-573 ◽  
Author(s):  
Kopriva Marshall ◽  
Michael D. Chan ◽  
Thomas P. McCoy ◽  
Adam C. Aubuchon ◽  
J. Daniel Bourland ◽  
...  
Keyword(s):  
Trigeminal Neuralgia ◽  
Dorsal Root ◽  
Gamma Knife Radiosurgery ◽  
Dominant Factor ◽  
Entry Zone ◽  
Dorsal Root Entry Zone ◽  
Root Entry Zone ◽  
Facial Numbness ◽  
The Mean

Abstract Background: Gamma Knife radiosurgery (GKRS) has been reported to be an effective modality to treat trigeminal neuralgia. Objective: To determine predictive factors for the successful treatment of trigeminal neuralgia with GKRS. Methods: Between 1999 and 2008, 777 GKRS procedures for patients with trigeminal neuralgia were performed at our institution. Evaluable follow-up data were obtained for 448 patients. Median follow-up time was 20.9 months (range, 3–86 months). The mean maximum prescribed dose was 88 Gy (range, 80–97 Gy). Dosimetric variables recorded included dorsal root entry zone dose, pons maximum dose, dose to the petrous dural ridge, and cisternal nerve length. Results: By 3 months after GKRS, 86% of patients achieved Barrow Neurologic Institute I to III pain scores, with 43% of patients achieving a Barrow Neurologic Institute I pain score. Twenty-six percent of patients reported posttreatment facial numbness; 28% of patients reported a post-GKRS procedure for relapsed pain, and median time to next procedure was 4.4 years. Multivariate analysis revealed that the development of postsurgical numbness (odds ratio [OR], 2.76; P = .006) was the dominant factor predictive of efficacy. Longer cisternal nerve length (OR, 0.85; P = .005), prior radiofrequency ablation (OR, 0.35; P = .028), and diabetes mellitus (OR, 0.38; P = .013) predicted decreased efficacy. The mean dose delivered to the dorsal root entry zone dose in patients who developed facial numbness (57.6 Gy) was more than the mean dose (47.3 Gy) given to patients who did not develop numbness (P = .02). Conclusion: The development of post-GKRS facial numbness is a dominant factor that predicts for efficacy of GKRS. History of diabetes mellitus or previous radio-frequency ablation may portend worsened outcome.

Nucleus caudalis dorsal root entry zone lesioning for the treatment of anesthesia dolorosa

2013 ◽  
Vol 118 (3) ◽  
pp. 534-538 ◽  
Author(s):  
Stephen E. Sandwell ◽  
Amr O. El-Naggar
Keyword(s):  
Dorsal Root ◽  
Facial Pain ◽  
Evidence Base ◽  
Current Evidence ◽  
Entry Zone ◽  
Dorsal Root Entry Zone ◽  
Root Entry Zone ◽  
Current Evidence Base ◽  
History Of

Deafferentation facial pain (anesthesia dolorosa) can occur after injury of the first-order trigeminal nerve. It is often debilitating and difficult to treat. The authors report the treatment of anesthesia dolorosa in a 69-year-old man with a 7-year history of pain. The pain occurred after an open resection of a right trigeminal neuroma. After treatment with medications failed, the patient was treated with nucleus caudalis (dorsal root entry zone) lesioning. His facial pain was immediately and completely eliminated. The authors describe the technique of this central neuroablative procedure, and they review the available literature regarding this procedure as well as the current evidence base for neuromodulatory surgeries. After the 1-year follow-up, the authors conclude that the patient attained lasting relief.

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