How to Do It: Microsurgical DREZotomy for Pain After Brachial Plexus Injury: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Manon Duraffourg ◽  
Andrei Brinzeu ◽  
Marc Sindou
Keyword(s):  
Spinal Cord ◽  
Pain Relief ◽  
Brachial Plexus ◽  
Dorsal Horn ◽  
Brachial Plexus Injury ◽  
Dorsal Column ◽  
Motor Deficit ◽  
Complete Disappearance ◽  
Burning Pain ◽  
Root Entry Zone

Abstract More than three-quarters of victims of brachial plexus injury suffer from refractory neuropathic pain.1-6 Main putative mechanism is paroxysmal hyperactivity in the dorsal horn neurons at the dorsal root entry zone (DREZ) as demonstrated by microelectrode recordings in animal models7 and patients.8 Pain relief can be achieved by lesioning the responsible neurons in the spinal cord segments with avulsed rootlets.9,10  This video illustrates the technique for microsurgical DREZotomy.11,12 A C3-C7 hemilaminectomy is performed to access the C4-Th1 medullary segments. After opening the dura and arachnoid, and freeing the cord from arachnoid adhesions, the dorsolateral sulcus is identified. Identification can be difficult when the spinal cord is distorted and/or has a loss of substance. The dorsolateral sulcus is then opened with a microknife, so that microcoagulations are performed: 4 mm deep, at 35° angle in the axis of the dorsal horn, every millimeter in a dotted fashion along the avulsed segments. Care should be taken not to damage the corticospinal tract, laterally, and the dorsal column, medially.  The patient consents to the procedure. In the presented case, surgery led to complete disappearance of the paroxysmal pain and reduced the background of burning pain to a bearable level without the need of opioid medication. There was no motor deficit or ataxia in the ipsilateral lower limb postoperatively. According to Kaplan-Meier analysis at 10 yr follow-up, in our overall series, microsurgical DREZotomy achieved total pain relief without any medication in 60% of patients, and in 85% without the need for opioids.10,13-15  Microelectrode recording at 1:26 reproduced from Guenot et al7 with permission from JNSPG.

Dorsal root entry zone lesions for pain relief

1979 ◽  
Vol 51 (1) ◽  
pp. 59-69 ◽  
Author(s):  
Blaine S. Nashold ◽  
Roger H. Ostdahl
Keyword(s):  
Spinal Cord ◽  
Pain Relief ◽  
Brachial Plexus ◽  
Dorsal Root ◽  
Dorsal Column ◽  
Entry Zone ◽  
Dorsal Root Entry Zone ◽  
Content Type ◽  
Arm Pain ◽  
Root Entry Zone

✓ Arm pain due to avulsion of the cervical dorsal roots of the brachial plexus may become intractable, ameliorated little, if at all, by contemporary medical or surgical treatment. Severe and sudden trauma to the neck, shoulder, or arm is the usual cause of avulsion of the cervical rootlets. The injury may result in complete sensorimotor paralysis of the involved extremity, or a partial deficit if only a few rootlets are involved. Previous therapies have included stellate block, sympathectomy, high cervical cordotomy, rhizotomy, transcutaneous stimulation, dorsal column stimulation, mesencephalic tractotomy, cingulotomy, and the use of narcotics. The extent of the pathological change in the spinal cord following root avulsion is not completely known; at the time of operation, abnormalities frequently noted included ipsilateral atrophy of the dorsal aspect of the cord, dense arachnoid scarring, microcyst formation, and loss of both dorsal and ventral roots. The cervical myelogram is abnormal, although not necessarily pathognomonic of the extent of injury. The surgical technique of coagulation of the dorsal root entry zone is discussed, and the results and morbidity in 21 patients are reviewed. Thirteen patients (67%) continue to have good pain relief, with follow-up periods ranging from 6 months to 3½ years. Three patients with extremity pain from other causes are included in the series. Clinical observations suggest the possibility that pain resulting from brachial plexus avulsion originates from pathophysiological changes in the injured dorsal horn of the spinal cord. This report is a discussion of a new technique aimed at destruction of the dorsal root entry zone for relief of chronic extremity pain.

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

Neurosurgery ◽  
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.

scholarly journals Neuromodulation in the Management of Pain from Brachial Plexus Injury

2008 ◽  
Vol 1;11 (1;1) ◽  
pp. 81-85
Author(s):  
Silviu Brill
Keyword(s):  
Spinal Cord ◽  
Pain Relief ◽  
Brachial Plexus ◽  
Spinal Cord Stimulation ◽  
Brachial Plexus Injury ◽  
Key Words Spinal Cord ◽  
Motorcycle Accidents ◽  
Plexus Lesion

We are presenting a paper on the effectiveness of spinal cord stimulation (SCS) in 2 patients suffering pain from brachial plexus injury (BPI). After a traumatic brachial plexus lesion about 80% of patients develop pain in the deafferentated arm. This pain is considered very resistant to many forms of therapy. In the early 1970s, SCS was introduced in the treatment of BPI pain with disappointing results. There are only about 20 published cases of BPI pain treated with SCS. Many injuries are due to motorcycle accidents, so that patients are often young and require long-term pain relief. During the SCS trial the pain relief was more than 50% with an absolute improvement in the quality of life and significant drug reduction. The results of the SCS were excellent in these 2 patients, defined as more than 50% pain relief at 6 and 18 months. Key words: Spinal cord stimulation, brachial plexus injury, neurophatic pain.

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.

Tardy Spinal Cord Tumor Following Avulsive Brachial Plexus Injury: Coincidental or Causal?

2010 ◽  
Vol 74 (2-3) ◽  
pp. 368-373 ◽  
Author(s):  
Marie-Noëlle Hébert-Blouin ◽  
Allen T. Bishop ◽  
Alexander Y. Shin ◽  
Cynthia Wetmore ◽  
Robert J. Spinner
Keyword(s):  
Spinal Cord ◽  
Brachial Plexus ◽  
Brachial Plexus Injury ◽  
Spinal Cord Tumor

Expression of c-Fos Protein in the Spinal Cord after Brachial Plexus Injury: Comparison of Root Avulsion and Distal Nerve Transection

Neurosurgery ◽  
1998 ◽  
Vol 42 (6) ◽  
pp. 1357-1362 ◽  
Author(s):  
Shurun Zhao ◽  
Ying Pang ◽  
Roger W. Beuerman ◽  
Hilary W. Thompson ◽  
David G. Kline
Keyword(s):  
Spinal Cord ◽  
Brachial Plexus ◽  
Brachial Plexus Injury ◽  
Nerve Transection ◽  
Root Avulsion ◽  
Fos Protein ◽  
Distal Nerve

Effects of early nerve repair on experimental brachial plexus injury in neonatal rats

2017 ◽  
Vol 43 (3) ◽  
pp. 275-281 ◽  
Author(s):  
Gráinne Bourke ◽  
Aleksandra M. McGrath ◽  
Mikael Wiberg ◽  
Lev N. Novikov
Keyword(s):  
Spinal Cord ◽  
Brachial Plexus ◽  
Brachial Plexus Injury ◽  
Neuroprotective Effect ◽  
Nerve Repair ◽  
Neonatal Rats ◽  
Spinal Motoneurons ◽  
Muscle Weight ◽  
Retrograde Degeneration ◽  
Dendritic Branches

Obstetrical brachial plexus injury refers to injury observed at the time of delivery, which may lead to major functional impairment in the upper limb. In this study, the neuroprotective effect of early nerve repair following complete brachial plexus injury in neonatal rats was examined. Brachial plexus injury induced 90% loss of spinal motoneurons and 70% decrease in biceps muscle weight at 28 days after injury. Retrograde degeneration in spinal cord was associated with decreased density of dendritic branches and presynaptic boutons and increased density of astrocytes and macrophages/microglial cells. Early repair of the injured brachial plexus significantly delayed retrograde degeneration of spinal motoneurons and reduced the degree of macrophage/microglial reaction but had no effect on muscle atrophy. The results demonstrate that early nerve repair of neonatal brachial plexus injury could promote survival of injured motoneurons and attenuate neuroinflammation in spinal cord.

Current Status of the DREZ Operation: 1984

Neurosurgery ◽  
1984 ◽  
Vol 15 (6) ◽  
pp. 942-944 ◽  
Author(s):  
Blaine S. Nashold
Keyword(s):  
Pain Relief ◽  
Brachial Plexus ◽  
Therapeutic Effect ◽  
Brachial Plexus Injury ◽  
Medical Center ◽  
Current Status ◽  
Neural Basis ◽  
Deafferentation Pain ◽  
Drez Lesion

Abstract The DREZ operation was introduced in 1976 as a method to control deafferentation pain associated with brachial plexus injury. Since then, 250 DREZ operations have been done at Duke Medical Center. At present, the best results of pain relief occur in brachial and lumbosacral root avulsions, paraplegia, and postherpetic pain. Post-DREZ complications have been reduced by the introduction of new lesion techniques, including the recent use of the laser. The neural basis of deafferentation pain is still not solved, nor is the therapeutic effect of the DREZ lesion known.

Intraoperative evoked potentials recorded in man directly from dorsal roots and spinal cord

1985 ◽  
Vol 62 (5) ◽  
pp. 680-693 ◽  
Author(s):  
Blaine S. Nashold ◽  
Janice Ovelmen-Levitt ◽  
Robbin Sharpe ◽  
Alfred C. Higgins
Keyword(s):  
Spinal Cord ◽  
Dorsal Root ◽  
Mean Amplitude ◽  
Dorsal Column ◽  
Intractable Pain ◽  
Neurosurgical Procedures ◽  
Negative Wave ◽  
Content Type ◽  
Root Entry Zone ◽  
Dorsal Columns

✓ Direct spinal cord surface recordings of evoked spinal cord potentials have been made in 26 patients during neurosurgical procedures for intractable pain. Monopolar recordings at the dorsal root entry zone after peripheral nerve stimulation have been made at multiple levels for segmental localization and to monitor the state of the afferent path and dorsal horn. Dorsal root and dorsal column conduction has been tested on diseased and intact sides. Normal afferent conduction velocity was found to have an overall mean of 61.33 m/sec for cervicothoracic and lumbosacral peripheral nerves, and 50 m/sec for the dorsal columns. The normal mean amplitude for the slow negative wave (N1) recorded at the root entry was 52.54 µV, while that for the dorsal column conducted response recorded within 4 cm of the stimulus point on the dorsal columns was 347.5 µV. Several different placements of stimulating and recording electrodes are described, as well as their application. An interpretation of the resulting data is proposed.

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