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

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

Download Full-text

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.

Download Full-text

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

Download Full-text

Neuropharmacology of the Dorsal Root Entry Zone

Neurosurgery ◽

10.1097/00006123-198412000-00026 ◽

1984 ◽

Vol 15 (6) ◽

pp. 900-903 ◽

Cited By ~ 1

Author(s):

Major Bennett Blumenkopf

Keyword(s):

Dorsal Root ◽

Root Avulsion ◽

Endogenous Opiates ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Avulsion Injury ◽

Root Entry Zone ◽

Neural Transmission ◽

The Central Nervous System ◽

Nerve Root Avulsion

Abstract The finding of a number of peptides in the central nervous system and the discovery of the endogenous opiates represent major recent advances in the understanding of neural transmission. A number of these neuropeptides are found in the dorsal root entry zone and may play a role in pain. An analysis of changes in distribution of substance P, methionineenkephalin, and somatostatin after simulated nerve root avulsion injury suggested a possible mechanism for deafferentation pain. A review of the localizations and actions of these peptides in the dorsal root entry zone is included.

Download Full-text

Pain Relief by Dorsal Root Entry Zone Lesions in Intractable Pain due to Partially Injured Tibial Nerve

Clinical Journal of Pain ◽

10.1097/00002508-198712000-00009 ◽

1987 ◽

Vol 3 (4) ◽

pp. 227-232

Author(s):

Masaru Matsumura ◽

Tohru Shibasaki ◽

Masatoshi Negishi ◽

Masafumi Hirato ◽

Tatsuo Hirai ◽

...

Keyword(s):

Pain Relief ◽

Dorsal Root ◽

Tibial Nerve ◽

Intractable Pain ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Root Entry Zone

Download Full-text

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

Neurosurgery ◽

10.1227/00006123-198802000-00016 ◽

1988 ◽

Vol 22 (2) ◽

pp. 369-373 ◽

Cited By ~ 53

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)

Download Full-text

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.

Download Full-text

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.

Download Full-text

Pain Relief After Dorsal Root Entry Zone Lesions

Advances in Stereotactic and Functional Neurosurgery 4 - Acta Neurochirurgica Supplementum ◽

10.1007/978-3-7091-8592-6_48 ◽

1980 ◽

pp. 383-389 ◽

Cited By ~ 10

Author(s):

B. S. Nashold ◽

R. H. Ostdahl

Keyword(s):

Pain Relief ◽

Dorsal Root ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Root Entry Zone

Download Full-text

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.

Download Full-text