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Thread: DREZ for brachial plexus avulsions

  1. #1

    DREZ for brachial plexus avulsions

    I was just recently asked a question concerning dorsal root entry zone (DREZ) lesions to treat deafferentation after brachial plexus avulsions. It seems to be effective for some cases, as the following selected abstracts over the past 10 years suggest:

    • Dreval ON (1993). Ultrasonic DREZ-operations for treatment of pain due to brachial plexus avulsion. Acta Neurochir (Wien) 122:76-81. Summary: One, if not the only effective way of treating pain due to preganglionic avulsion of the brachial plexus is the Dorsal Root Entry Zone (DREZ) lesion procedure. In 1985 the author began to use ultrasound as a lesion-maker for operations in the DREZ. Since then, 127 (3 patients were operated on twice) DREZ-Operations have been carried out on 124 patients suffering from chronic pain due to brachial plexus avulsion. Different technical lesioning modalities were employed: ultrasonic discontinuous DREZ lesions in 20 cases and a new modality: ultrasonic DREZ-sulcomyelotomy in 107 cases. Analysis of the results after ultrasonic DREZ-operations revealed that ultrasonic DREZ-sulcomyelotomy was the most effective technical modality. Immediately after operation good pain relief was obtained in 103 (96%) out of the 107 patients operated on with the ultrasonic DREZ-sulcomyelotomy method, and in 15 (75%) out of the 20 patients with ultrasonic discontinuous DREZ-lesions. The total follow-up study (47.5 months on average) revealed 87% good results overall. Department of Neurosurgery, Central Institute of Postgraduate Training of Doctors, Moscow, Russia.

    • Guenot M, Bullier J and Sindou M (2002). Clinical and electrophysiological expression of deafferentation pain alleviated by dorsal root entry zone lesions in rats. J Neurosurg 97:1402-9. Summary: OBJECT: The aims of this study were to construct an animal model of deafferentation of the spinal cord by brachial plexus avulsion and to analyze the effects of subsequent dorsal root entry zone (DREZ) lesions in this model. To this end, the authors measured the clinical and electrophysiological effects of total deafferentation of the cervical dorsal horn in rats and evaluated the clinical efficacy of cervical DREZ lesioning. METHODS: Forty-three Sprague-Dawley rats were subjected to total deafferentation of the right cervical dorsal horn by performing a posterior rhizotomy from C-5 to T-1. The clinical effects of this deafferentation, namely self-directed mutilations consisting of scraping and/or ulceration of the forelimb skin or even autotomy of some forelimb digits, were then evaluated. As soon as some of these clinical signs of pain appeared, the authors performed a microsurgical DREZ rhizotomy ([MDR], microincision along the deafferented DREZ and dorsal horn). Before and after MDR, single-unit recordings were obtained in the deafferented dorsal horn and in the contralateral (healthy) side. The mean frequency of spontaneous discharge from the deafferented dorsal horn neurons was significantly higher than that from the healthy side (36.4 Hz compared with 17.9 Hz, p = 0.03). After deafferentation, 81.4% of the rats developed clinical signs corresponding to pain following posterior rhizotomy. Among these animals, scraping was observed in 85.7% of cases, ulceration (associated with edema) in 37.1%, and autotomy in 8.5%. These signs appeared a mean 5.7 weeks (range 1-12 weeks) after deafferentation. Thirteen rats benefited from an MDR; nine (69%) experienced a complete cure, that is, a total resolution of scraping or ulceration (a mean 4.6 weeks after MDR). In contrast, only one of 11 sham-operated animals showed signs of spontaneous recovery (p = 0.01). CONCLUSIONS: These results emphasize the role of the spinal dorsal horn in the genesis of deafferentation pain and suggest that dorsal horn deafferentation by cervical posterior rhizotomy in the rat provides a reliable model of chronic pain due to brachial plexus avulsion and its suppression by MDR. Department of Functional Neurosurgery, P. Wertheimer Hospital, Lyon, France.

    • Pagni CA, Canavero S, Bonicalzi V and Nurisso C (2002). The important role of pain in neurorehabilitation. The neurosurgeon's approach or (neurorehabilitation: the neurosurgeon's role with special emphasis on pain and spasticity). Acta Neurochir Suppl 79:67-74. Summary: Pain syndromes due to peripheral or central nervous system damage, or both, may hinder neurorehabilitation. Control of pain may be obtained by ablative or augmentative procedures. Of the ablative modes only DREZ and Cordectomy are still being employed in cases of pain due to Brachial Plexus Avulsion and conus and cauda damage at T9-L1: in both pain is not simply due to "deafferentiation". The augmentative procedures include spinal cord, deep brain and cortical stimulation. Subarachnoid infusion of drugs (midazolam, clonidine, baclofen, etc.) is a new avenue open to control pain. Indications, results and mechanisms of action of those procedures in neuropathic pain are discussed on the basis of literature and personal experience. Neurosurgical Clinic, University of Torino, Italy.

    • Prestor B (2001). Microsurgical junctional DREZ coagulation for treatment of deafferentation pain syndromes. Surg Neurol 56:259-65. Summary: BACKGROUND: In the treatment of intractable deafferentation pain, different procedures in the DREZ have proved most effective. For most of the spot-like techniques special equipment is mandatory. In this study the technique and the results of junctional DREZ coagulation for treatment of different pain syndromes with the help of bipolar forceps is presented. METHODS: In 40 patients with intractable deafferentation pain syndromes a junctional DREZ coagulation lesion along the entire dorsolateral fissure of the involved spinal cord segments was made using bipolar forceps. Etiologies of the pain included avulsion of the brachial plexus (21 cases), postherpetic pain (4 cases), phantom pain (3 cases), peripheral nerve injury (3 cases), reflex sympathetic dystrophy (2 cases), spinal cord transsection (1 case), and syringomyelia (6 cases). RESULTS: Of 21 patients who underwent junctional DREZ surgery for pain because of brachial plexus avulsion 10 (47.6%) had complete, 7 (33.3%) excellent, 3 (14.3%) good, and 1 (4.7%) fair pain relief (follow-up 20 to 120 months). In the group of 19 patients (follow-up 6 to 84 months) with pain syndromes other than postavulsion pain we achieved excellent results in 10 cases (52.6%), good in 8 (42.1%) and no pain relief in 1 case (5.3%). Transient sensory neurological disturbances lasting up to 8 weeks were observed in 6 (15%) cases; permanent sensory and motor deficit in 1 (2.5%) case. CONCLUSIONS: Clinical results of junctional coagulation DREZ lesion for the treatment of deafferentation pain syndromes are promising. There is no need for special equipment for creating DREZ lesions. The lesions are precisely placed with only a bipolar electrode. Postoperative complications are rare and transient. We believe that the junctional coagulation includes the entire dorsolateral sulcus and DREZ structures important for deafferentation pain. Department of Neurosurgery, University Hospital Center, Zaloska 7, 1525 Ljubljana, Slovenia.

    • Rath SA, Braun V, Soliman N, Antoniadis G and Richter HP (1996). Results of DREZ coagulations for pain related to plexus lesions, spinal cord injuries and postherpetic neuralgia. Acta Neurochir (Wien) 138:364-9. Summary: The results of 58 dorsal root entry zone (DREZ) thermocoagulation procedures in 51 patients are reported. The postoperative analgesic effect was judged by the patients as being good (more than 75% pain reduction), fair (25-75% pain reduction) or poor (less than 25% pain reduction). Of the 14 patients who underwent surgery for pain due to cervical root avulsion, 10 (77%) had permanently good (8) or fair (2) pain relief after a mean follow up period of 76 months, another 2 (15%) experienced recurrence to the preoperative level (initially 1 good, 1 fair) after more than 2 and 4 years, respectively. Twenty two paraplegics were operated upon, 3 of whom twice, for intractable pain. After a mean observation time of 54 months, continuing pain relief was reported by 12 (55%) patients (11 good, 1 fair), and one (initially fair) had recurrent pain after 8 months. All 3 (early) re-operations remain successful for an average period of 75 months. Poor results were seen especially in cases of associated spinal cord cysts (5 out of 7), despite combined drainage, and in patients with diffuse pain distribution (5 out of 6). Continuous marked improvement for longer periods (mean follow up: 52 months) after DREZ lesions was reported only by 2 out of 10 patients with postherpetic neuralgia (12 procedures) and by 1 out of 5 with painful states due to radiation-induced brachial plexopathy (2), previous surgery (2) and malignant tumour infiltration of the brachial plexus (1). Three patients died postoperatively due to acute cardiac failure (2) and pulmonary embolism (1). Major complications, especially permanent gait disturbances were observed in 6 patients (12%) following primary procedures and in 2 out of 7 patients after re-operations, most of them suffering from postherpetic neuralgia. Minor neurological deficits were noted in 9 cases (18%). DREZ lesions revealed to be an effective procedure in patients with pain related to root avulsion and paraplegia. In contrast, it seems to be less successful for painful states due to other plexus lesions or postherpetic neuralgia. Department of Neurosurgery, University of Ulm, Gunzburg, Federal Republic of Germany.

    • Rath SA, Seitz K, Soliman N, Kahamba JF, Antoniadis G and Richter HP (1997). DREZ coagulations for deafferentation pain related to spinal and peripheral nerve lesions: indication and results of 79 consecutive procedures. Stereotact Funct Neurosurg 68:161-7. Summary: During a 16 years' period, a total of 79 dorsal root entry zone coagulations were performed in 68 patients for deafferentation pain. Of the 23 patients who underwent surgery for pain due to cervical root avulsion, 18 (82%) had a good (12) or fair (6) pain relief (mean follow-up period 51 months). Twelve (57%) patients with spinal cord injuries noted continuous pain reduction (10 good, 2 fair; mean follow-up 52 months). Continuous marked improvement for longer periods was reported only by 2 out of 10 patients with postherpetic neuralgia and 1 out of 7 patients with painful states due to other brachial plexus lesions and none out of 5 with spinal cord lesions (3) and phantom limb pain (2). Department of Neurosurgery, University of Ulm, Gunzburg, Germany.

    • Thomas DG (1993). Brachial plexus injury: deafferentation pain and dorsal root entry zone (DREZ) coagulation. Clin Neurol Neurosurg 95 Suppl:S48-9. Summary: The nature of deafferentation pain in cases of brachial plexus injury is described. The natural course of the symptoms together with conservative treatment is outlined. The theoretical background of the dorsal root entry zone (DREZ) coagulation, and its clinical indications, operative techniques and results are presented. National Hospital for Neurology and Neurosurgery, London, UK.

    • Thomas DG and Kitchen ND (1994). Long-term follow up of dorsal root entry zone lesions in brachial plexus avulsion. J Neurol Neurosurg Psychiatry 57:737-8. Summary: The long-term results of 44 patients who underwent dorsal route entry zone (DREZ) lesioning for pain secondary to brachial plexus avulsion are reported with a mean clinical follow up period of 63 months. The postoperative analgesic effect was judged by the patients as being good (greater than 75% pain reduction), fair (25-75% pain reduction), or poor (0-25% pain reduction). With these criteria 35 patients (77%) had continuing good (30 cases, 68%) or fair (five cases, 11%) pain relief at the time of final follow up. Eight cases (18%) had persisting neurological deficits, although these were generally mild. DREZ thermocoagulation is an effective procedure for relieving deafferentation pain. The analgesic effect which is produced in the early postoperative period seems to be maintained in the long-term. Gough-Cooper Department of Neurological Surgery, National Hospital for Neurology and Neurosurgery, London, UK.

    • Zeidman SM, Rossitch EJ and Nashold BS, Jr. (1993). Dorsal root entry zone lesions in the treatment of pain related to radiation-induced brachial plexopathy. J Spinal Disord 6:44-7. Summary: Radiation-induced brachial plexopathy (RBP) is a rare (1-2% of irradiated patients) but serious disorder associated with supramaximal irradiation of the brachial plexus. Nerve compression by radiation-induced fibrosis in the absence of tumor recurrence is the hypothesized mechanism of RBP. It appears as severe pain in up to 20% of cases. Current medical and surgical therapies are ineffective in obtaining long-term pain control. Dorsal root entry zone (DREZ) lesions represent a potential therapy for the pain associated with RBP. The records of two patients with RBP with severe pain successfully treated with DREZ lesions are reviewed. Each received supramaximal radiation to the brachial plexus following resection of the malignancy and had pain within the irradiated area approximately 1 year following radiation without evidence of tumor recurrence by either computed tomography or magnetic resonance imaging. Electromyography patterns consistent with RBP were detected within the irradiated area in both patients. Pain was in the C8-T1 distribution and described as sharp and burning. Both patients failed to obtain pain relief with prior medical and/or surgical procedures. Histologic sections of nerves were taken at surgery and confirmed the diagnosis of radiation-induced injury. Within the immediate postoperative period both patients experienced excellent pain relief and continue to be pain free at 29-48-month follow-up observation. The DREZ lesions provide a safe and effective therapy for the pain associated with RBP. Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland 21205.

  2. #2

    Can I get some help?

    Dear Sir,
    My brother had brachial Plexus injury in 2003, and there is still to remain severe pain , can you give any suggestion of any doctor or hospital can help him??
    Thank you very much!
    I'm looking forward to hearing from you!
    my email add:

  3. #3

    Pedicle subtraction osteotomy

    i had harrington rod surgey in 81 for scoliosis , instrumention still intact, past 3 yrs treated for intractable pain from diagnosed flatback syndrome and fixed kyphosis and ddd etc.

    Positive ct disco, had 5 epidurals and finally RF ablation of medial branches all without ANY relief. Three diff surgeons agree i need the PSO surgery. I am thinking of Larry Lenke in St Louis. I am moving from VA back home to Vegas, no specialist there for this condition

    I want to know how long ill be out of work because i forced myself to return to work to save so i can pay bills whiel recovering. Im 41 f no kids and good health otherwise. any ideas and is this surgery too new to trust

  4. #4
    I recommend doing a search on DREZ on this forum dedicated to Brachial Plexus Injuries. There have been mixed responses on how the treatments worked. You can also post any questions your brother might have there.

    Best of luck,

    It is my understanding that Dr. Osenbach at Duke University is one of the best surgeons regarding this operation for Brachial Plexus Injuries, but have also read of a patient having very bad outcome from surgery w/Osenbach.

    Quote Originally Posted by hanye
    Dear Sir,
    My brother had brachial Plexus injury in 2003, and there is still to remain severe pain , can you give any suggestion of any doctor or hospital can help him??
    Thank you very much!
    I'm looking forward to hearing from you!
    my email add:

  5. #5

    DREZ surgery receipient

    Hello, following a gun shot wound at the T-12 level in 1976 I lived with the deaffereniation pain with burning, lancinating pain for twenty years. In 1996 I found a neurosurgeon Dr. Scott Falci out of Boulder and Craig Hospital who performed a computer assisted DREZ(CADREZ) using radio frequency ablation. I have been pain free since. I think the difference between the DREZ and the CADREZ was the assessment instruments used to detect the "hot spots" or the ganglia responsible for firing off. I am a rehabilitation counselor for the state of Pennsylvania and have recommended consultations with this group.

    Steven Schindler

  6. #6

    DREZ or - Dorsal Root??????

    My life like many of you is a bitch and great at the same time but over the past 15 years the chronic pain has reached the stage of me just wanting to get out of here even thought of ways to do this.

    I used Lyrica for 3 months and it caused extreme sleepiness, tried Neurotin for 5 months, no go, use Oxyconode usually every day but this doesn't work for nerve pain. I wear the Fentynal Transdermal patch 50 mg 24/7 and these do work I know because if I stop using them the pain goes out of hand an 8 or 9! I supplement this with 1 or 2 Diazepam daily. It is the burning pain that is whats getting to me.

    WHAT ABOUT DREZ? Who does on the west coast. I am ready to go for it or even the Dorsal Root surgery!

    Gary Is = L-1 Para for 34 years.....................

  7. #7

    CADREZ Surgery

    Have my initial consult set for the end of this moth. Tried to find SOMEONE on the West Coast who will perform this surgery, and all paths still lead to Colorado. Guess that is as close as I'm gonna get. Hoping that the surgery relieves the burning nerve pain cause I can't take it. Will keep this thread updated on progress.

  8. #8
    Senior Member Cowboys_Place's Avatar
    Join Date
    Dec 2005
    Northern California
    RCbear, yes please keep us all informed so many of us are desperate for relief! Like Garyis posted two years ago for the last couple of weeks I have just been ready to check out pain has gotten so bad.

    I'm currently in process of trying to get into the spinal cord clinic at UC Davis medical center to see if they can help.

    I hope you're able to find of relief so desperately need we also desperately need.

    Take Care
    Courage is being scared to death but saddling up anyway. .(John Wayne)

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