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Slavin KV. Commentary: The Safety and Efficacy of Dorsal Root Entry Zone Lesioning for Pain Management in Patients With Brachial Plexus Avulsion: A Systematic Review and Meta-Analysis. Neurosurgery 2024; 95:e37-e38. [PMID: 38661356 DOI: 10.1227/neu.0000000000002971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024] Open
Affiliation(s)
- Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago , Illinois , USA
- Neurology Service, Jesse Brown Veterans Administration Medical Center, Chicago , Illinois , USA
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Shekouhi R, Chen X, Taylor J, Marji FP, Chim H. The Safety and Efficacy of Dorsal Root Entry Zone Lesioning for Pain Management in Patients With Brachial Plexus Avulsion: A Systematic Review and Meta-Analysis. Neurosurgery 2024; 95:259-274. [PMID: 38465954 DOI: 10.1227/neu.0000000000002906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 01/12/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Persistent neuropathic pain after brachial plexus avulsion (BPA) is common and generally nonresponsive to medical management. Dorsal root entry zone (DREZ) lesioning is the last resort for pain management in patients with BPA. This study aims to investigate and compare the outcomes and complications of DREZ procedures. METHODS A systematic literature search was conducted to identify all related studies. Comparisons were based on the number of patients with preoperative pain vs postoperative pain, with the effect size calculated using the risk ratio. Mean visual analog scale (VAS) scores were extracted and analyzed between interventions. A meta-regression analysis was performed to identify risk factors for final outcomes. The rates of complications were also assessed and analyzed between interventions. RESULTS A total of 30 studies with 917 patients (90.0% male and 10.0% female, mean age: 42.9 ± 16.6) were included in this systematic review. Of the 917 patients who underwent surgery, 655 (71.4%) patients had significant pain reduction at the last follow-up ( P < .05). The weighted mean preoperative VAS score was 8.3 ± 1.3, compared with postoperative VAS scores (1.9 ± 2.2); a significant improvement was observed ( P < .05). The subgroup analysis showed that microsurgical DREZotomy (MDT) is associated with better outcomes in terms of VAS score improvements compared with radiofrequency (RF)-assisted DREZ lesioning ( P < .05). Meta-analysis showed that the relative risk of motor deficits was significantly lower in the MDT group, compared with the RF-assisted group ( P < .05). Meta-regression showed that older age is correlated with an elevated risk of postoperative motor deficits compared with the incidence of sensory loss. CONCLUSION DREZ lesioning is effective for intractable pain alleviation after BPA. Compared with RF-assisted DREZ lesioning, MDT is associated with better VAS score improvements and a lower rate of postoperative motor weakness.
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Affiliation(s)
- Ramin Shekouhi
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Florida, Gainesville , Florida , USA
| | - Xizhao Chen
- Department of Surgery, University of Florida, Gainesville , Florida , USA
| | - Justin Taylor
- College of Medicine, University of Central Florida, Orlando , Florida , USA
| | - Fady P Marji
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Florida, Gainesville , Florida , USA
| | - Harvey Chim
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Florida, Gainesville , Florida , USA
- Lilian S. Wells Department of Neurosurgery, University of Florida, Gainesville , Florida , USA
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Vijayendra V, Bhargava D, Pridgeon M, Szylak R, Eldridge P, Osman-Farah J. Dorsal root entry zone lesioning for brachial plexus avulsion - technical evolution and long-term follow-up. Acta Neurochir (Wien) 2024; 166:241. [PMID: 38814478 DOI: 10.1007/s00701-024-06132-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/20/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Brachial plexus avulsion (BPA) injuries can cause severe deafferentation pain. This has been successfully treated with dorsal root entry zone (DREZ) lesioning. Distortions in anatomy following a BPA injury can make identifying neural structures challenging. We describe a modification to the operative technique that improves the surgical view and the advanced intraoperative neuromonitoring (IONM) employed to identify DREZ. We have analysed the long-term outcomes for pain, quality of life, and complications in patients undergoing DREZ lesioning. METHODS This is a single-centre retrospective case series including patients who underwent DREZ lesioning with IONM for brachial plexus avulsion between 2012 and 2022. Analysed data included pre- and postoperative pain (VAS), quality of life score for chronic pain, and complications. The evolution of the surgical approach is discussed. RESULTS 44 consecutive patients underwent a DREZ lesioning procedure with intraoperative monitoring and mapping. In these patients the mean VAS score improved from 8.9 (7-10) to 1.87 (0-6) (p < 0.0001) at the time of discharge. 31 patients were followed-up for more than 12 months with a mean duration of follow-up of 41 months and their results were as follows: the mean VAS improved from 9.0 (7-10) to 4.1 (0-9) (p < 0.0001) at the last follow-up and the mean QOL values improved from 3.7 (2-6) to 7.4 (4-10) (p < 0.0001). The long-term outcomes were 'good' in 39%, 'fair' in 29% and 'poor' in 32% of patients. 55% of the patients were able to stop or reduce pain medications. CONCLUSIONS Modifications of surgical technique provide better exposure of DREZ, and IONM aids in identifying DREZ in the presence of severe intra-dural changes. Long-term outcomes of DREZ lesioning indicate not only a reduction in pain but also a significant improvement in quality of life.
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Affiliation(s)
- Vishwas Vijayendra
- Departament of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Lower Lane, Liverpool, L9 7LJ, UK.
| | - Deepti Bhargava
- Departament of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Lower Lane, Liverpool, L9 7LJ, UK
| | - Michael Pridgeon
- Departament of Neurophysiology, The Walton Centre for Neurology and Neurosurgery, Lower Lane, Liverpool, L9 7LJ, UK
| | - Rafal Szylak
- Departament of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Lower Lane, Liverpool, L9 7LJ, UK
| | - Paul Eldridge
- Retired, Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Lower Lane, Liverpool, L9 7LJ, UK
| | - Jibril Osman-Farah
- Departament of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Lower Lane, Liverpool, L9 7LJ, UK
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Georgoulis G, Neromyliotis E, Sindou M. Anatomical damages in the spinal nerve roots and the spinal cord after brachial plexus injury: descriptive study from a cohort of consecutive patients who underwent DREZ-lesioning for pain-practical implications. Acta Neurochir (Wien) 2024; 166:201. [PMID: 38698241 DOI: 10.1007/s00701-024-06063-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 03/29/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Systematic descriptions of anatomical damage after brachial plexus injury (BPI) at the intradural level have been scarcely reported in detail. However, considering these damages, not only in the spinal nerve roots but also in the spinal cord itself, is crucial in determining the appropriate surgical approach to restore upper limb function and address refractory pain. Therefore, the authors present a descriptive study focusing on intradural findings observed during microsurgical DREZ-lesioning. METHODS This study enrolled 19 consecutive patients under the same protocol. Microsurgical observation through exposure of C4 to Th1 medullary segments allowed to describe the lesions in spinal nerve roots, meninges, and spinal cord. Electrical stimulation of the ventral roots checked the muscle responses. RESULTS Extensive damage was observed among the 114 explored roots (six roots per patient), with only 21 (18.4%) ventral (VR) and 17 (14.9%) dorsal (DR) roots retaining all rootlets intact. Damage distribution varied, with the most frequent impairments in C6 VRs (18 patients) and the least in Th1 VRs (14 patients), while in all the 19 patients for the C6 DRs (the most frequently impaired) and in 14 patients for Th1 DRs (the less impaired). C4 roots were found damaged in 12 patients. Total or partial avulsions affected 63.3% and 69.8% of DRs and VRs, respectively, while 15.8% and 14.0% of the 114 DRs and VRs were atrophic, maintaining muscle responses to stimulation in half of those VRs. Pseudomeningoceles were present in 11 patients but absent in 46% of avulsed roots. Adhesive arachnoiditis was noted in 12 patients, and dorsal horn parenchymal alterations in 10. CONCLUSIONS Knowledge of intradural lesions post-BPI helps in guiding surgical indications for repair and functional neurosurgery for pain control.
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Affiliation(s)
- George Georgoulis
- Department of Neurosurgery, General Hospital of Athens "G. Gennimatas", Mesogeion Avenue 154, 11527, Athens, Greece.
| | | | - Marc Sindou
- University of Lyon, Lyon, France
- Department of Neurosurgery, Groupe ELSAN, Clinique Bretéché, Nantes, France
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Du T, Ni B, Shu W, Ren Z, Guo S, Zhang X, Zhu H, Hu Y. Dorsal Root Entry Zone Lesioning Following Unresponsive Spinal Cord Stimulation for Post-Traumatic Neuropathic Pain. World Neurosurg 2023; 178:e300-e306. [PMID: 37473865 DOI: 10.1016/j.wneu.2023.07.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Spinal cord stimulation (SCS) and dorsal root entry zone (DREZ) lesioning are important therapeutic options for intractable post-traumatic neuropathic pain (PNP). However, surgical choice is controversial due to the need to maximize pain relief and reduce complications. This study aims to retrospectively analyze the effect and complications of DREZ lesioning for patients with PNP who were unresponsive to SCS and provide a surgical reference. METHODS Demographic data and surgical characteristics of patients with PNP who underwent DREZ lesioning after an unresponsive SCS were reviewed. Long-term outcomes including numeric rating scale, global impression of change, and long-term complications were assessed. Kaplan-Meier analysis was used to evaluate pain-free survival. RESULTS Of 19 patients with PNP, 8 had brachial plexus injury (BPI), 7 had spinal cord injury, 2 had cauda equina injury, 1 had intercostal nerve injury, and 1 had lumbosacral plexus injury. All patients were unresponsive or had a recurrence of pain after SCS, with an average pain-relief rate of 9.3%. After DREZ lesioning, the mean numeric rating scale scores significantly decreased from 7.6 ± 1.5 to 1.8 ± 1.7, with an average pain-relief rate of 75.3%. Seven patients (36.8%) experienced worsened neurologic dysfunction at the last follow-up. Patients with BPI had a significantly better outcome than other pathologies (P < 0.001) after DREZ lesioning. CONCLUSIONS DREZ lesioning is an effective alternative procedure to SCS for patients with PNP who have lost limb function. Particularly for those with BPI, DREZ lesioning has shown good efficacy and can be considered a preferred surgical option.
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Affiliation(s)
- Tao Du
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bing Ni
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei Shu
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhiwei Ren
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Song Guo
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaohua Zhang
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongwei Zhu
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongsheng Hu
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Gebreyohanes A, Ahmed AI, Choi D. Dorsal root entry zone lesioning for brachial plexus avulsion pain: a case series. Spinal Cord Ser Cases 2023; 9:6. [PMID: 36894525 PMCID: PMC9998452 DOI: 10.1038/s41394-023-00564-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 03/11/2023] Open
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVES Dorsal root entry zone (DREZ) lesioning can be performed in patients with intractable pain following brachial plexus avulsion (BPA). However, post-operative outcomes are variable and it is uncommonly used. We sought to determine the pain outcomes and complication profile of DREZ lesioning for BPA. SETTING Quaternary neurosurgical centre. METHODS All patients that had undergone DREZ lesioning for BPA pain over a 13-year period were included. Patients were assessed for outcome with regard to degree of pain relief and presence of complications. RESULTS Fourteen patients were reviewed, with a median post-operative follow-up duration of 27 months (1-145 months). Of these, ten were contactable for long-term telephone review, with a median post-operative duration of 37 months (11-145 months). At earliest review post-operatively, 12 of 14 patients (86%) had some level of pain relief: complete pain relief in four patients (29%) and partial pain relief in eight patients (57%). At most recent post-operative review, ten of 14 patients (71%) reported lasting significant pain relief: four (29%) had complete pain relief, six (43%) had partial pain relief and four (29%) had insignificant pain relief. Complications were predominantly sensory, including ataxia, hypoaesthesia and dysaesthesia. Four patients (29%) reported persistent motor complications at final follow-up. CONCLUSIONS DREZ lesioning is uncommonly performed. It remains a reasonable option for relief of refractory BPA pain in selected cases, though there is a significant complication rate. Future prospective studies may enable quantification of pre- and post-lesioning analgesic use, another important determinant of procedure success.
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Affiliation(s)
- Axumawi Gebreyohanes
- Complex Spine & Anterior Skull Base Team, Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
- University College London (UCL) Medical School, London, UK.
| | | | - David Choi
- Complex Spine & Anterior Skull Base Team, Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Kimoto Y, Hosomi K, Ohnishi Y, Emura T, Mori N, Nishi A, Yanagisawa T, Tani N, Oshino S, Saitoh Y, Kishima H. Tight adhesions after spinal cord stimulation observed during dorsal root entry zone lesioning for pain after spinal root avulsion: illustrative cases. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22145. [PMID: 36281477 PMCID: PMC9592961 DOI: 10.3171/case22145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/09/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients often experience strong shooting pains after spinal root avulsion. The efficacy of spinal cord stimulation (SCS) for this type of pain is inconsistent; however, dorsal root entry zone (DREZ) lesioning (DREZ-lesion) has often proven to be an effective treatment modality. The authors report two cases in which DREZ-lesion was performed to treat pain after spinal root avulsion after implantation of SCS, but the operations were challenging due to strong adhesions. OBSERVATIONS The authors present two cases of patients with pain after spinal root avulsion in whom SCS implantation was only temporarily effective. Patients complained of persistent and paroxysmal shooting pains in the upper extremities. SCS removal and DREZ-lesion were performed, but adhesions in the epidural and subdural space contacting the leads were strong, making it difficult to expose the DREZ. LESSONS Although adhesions around the spinal cord can be caused by trauma, the authors believe that in these cases, the adhesions could have been caused by the SCS leads. There are few previous reports confirming the efficacy of SCS in treating pain after spinal root avulsion; therefore, caution is required when considering SCS implantation.
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Affiliation(s)
- Yuki Kimoto
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Koichi Hosomi
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan,Center for Pain Management, Osaka University Hospital, Suita, Osaka, Japan
| | - Yuichiro Ohnishi
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan,Department of Neurosurgery, Osaka Gyoumeikan Hospital, Osaka, Japan
| | - Takuto Emura
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Nobuhiko Mori
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan,Center for Pain Management, Osaka University Hospital, Suita, Osaka, Japan
| | - Asaya Nishi
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takufumi Yanagisawa
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan,Institute for Advanced Co-Creation Studies, Osaka University, Suita, Osaka, Japan
| | - Naoki Tani
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Satoru Oshino
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan,Center for Pain Management, Osaka University Hospital, Suita, Osaka, Japan
| | - Youichi Saitoh
- Osaka University Graduate School of Engineering Science, Toyonaka, Osaka, Japan; and ,Tokuyukai Rehabilitation Clinic, Toyonaka, Osaka, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan,Center for Pain Management, Osaka University Hospital, Suita, Osaka, Japan
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Khalifeh JM, Lubelski D, Ochuba A, Belzberg AJ. Dorsal Root Entry Zone Lesioning for the Treatment of Pain After Brachial Plexus Avulsion Injury: 2-Dimensional Operative Video and Technical Report. Oper Neurosurg (Hagerstown) 2022; 22:e252-e258. [DOI: 10.1227/ons.0000000000000149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022] Open
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Success with dorsal root entry zone lesioning after a failed trial of spinal cord stimulation in a patient with pain due to brachial plexus avulsion. Pain Rep 2021; 6:e973. [PMID: 34841182 PMCID: PMC8613335 DOI: 10.1097/pr9.0000000000000973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 09/10/2021] [Accepted: 09/30/2021] [Indexed: 10/28/2022] Open
Abstract
Pain caused by brachial plexopathy (BP) represents a challenging clinical problem with few effective therapeutic options. Here, we present a patient with severe, painful BP after a high-impact motor vehicle accident who failed conservative treatments. A trial of cervical spinal cord stimulation was completed using multiple waveforms (tonic, BurstDR, and 10 kHz) over 14 days with only 30% to 40% pain reduction. Subsequently, he underwent dorsal root entry zone lesioning with a significant decrease in his pain 1 year later. Surgical exploration revealed extensive damage and avulsion of his cervical roots that was not observed on a previous brachial plexus magnetic resonance imaging. We discuss the etiology and diagnosis of traumatic BP, possible reasons for the failed spinal cord stimulation trial, and implications for management.
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Chalil A, Wang Q, Abbass M, Santyr BG, MacDougall KW, Staudt MD. Dorsal Root Entry Zone Lesioning for Brachial Plexus Avulsion Injuries: Case Series and Literature Review. FRONTIERS IN PAIN RESEARCH 2021; 2:749801. [PMID: 35295454 PMCID: PMC8915773 DOI: 10.3389/fpain.2021.749801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/26/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Brachial plexus avulsion (BPA) injuries commonly occur secondary to motor vehicle collisions, usually in the young adult population. These injuries are associated with significant morbidity, and up to 90% of patients suffer from deafferentation pain. Neuromodulation procedures can be efficacious in the treatment of refractory neuropathic pain, although the treatment of pain due to BPA can be challenging. Dorsal root entry zone (DREZ) lesioning is a classical and effective neurosurgical technique which has become underutilized in treating refractory root avulsion pain. Methods: A systematic review of the different technical nuances, procedural efficacy, and complication profiles regarding DREZ lesioning for BPA injuries in the literature is included. We also present an institutional case series of 7 patients with BPA injuries who underwent DREZ lesioning. Results: In the literature, 692 patients were identified to have undergone DREZ lesioning for pain related to BPA. In 567 patients, the surgery was successful in reducing pain intensity by over 50% in comparison to baseline (81.9%). Complications included transient motor deficits (11%) and transient sensory deficits (11%). Other complications including permanent disability, cardiovascular complications, infections, or death were rare (<1.9%). In our case series, all but one patient achieved >50% reduction in pain intensity, with the mean pre-operative pain of 7.9 ± 0.63 (visual analog scale) reduced to 2.1 ± 0.99 at last follow-up (p < 0.01). Conclusion: Both the literature and the current case series demonstrate excellent pain severity reduction following DREZ ablation for deafferentation pain secondary to BPA.
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Affiliation(s)
- Alan Chalil
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada
| | - Qian Wang
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada
| | - Mohamad Abbass
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada
| | - Brendan G. Santyr
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada
| | - Keith W. MacDougall
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada
| | - Michael D. Staudt
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Rochester, MI, United States
- Michigan Head and Spine Institute, Southfield, MI, United States
- *Correspondence: Michael D. Staudt
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Mongardi L, Visani J, Mantovani G, Vitali C, Ricciardi L, Giordano F, Cavallo MA, Lofrese G, D'andrea M, Roblot P, De Bonis P, Scerrati A. Long term results of Dorsal Root Entry Zone (DREZ) lesions for the treatment of intractable pain: A systematic review of the literature on 1242 cases. Clin Neurol Neurosurg 2021; 210:107004. [PMID: 34739884 DOI: 10.1016/j.clineuro.2021.107004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Different Dorsal root entry zone (DREZ) lesion techniques have been reported as effective treatment for intractable painful conditions, though with contradictory results. Overall, good results were reported especially in specific conditions, such as pain due to brachial plexus avulsion, spinal cord injuries and oncological pain management. However, data on long term results in different clinical conditions are still missing. OBJECTIVE This study aims to systematically review the pertinent literature to evaluate indications, clinical outcomes, and complications of DREZ lesion (DREZotomy), in chronic pain management. METHODS A systematic literature review was conducted according to the PRISMA statement. Papers on DREZotomy for chronic pain in cancer, brachial plexus avulsion, spinal cord injury, post herpetic neuralgia, and phantom limb pain were considered for eligibility. For each category we further identified two sub-group according to the length of follow up: medium term and long term follow up (more than 3 years) respectively. RESULTS 46 papers, and 1242 patients, were included in the present investigation. When considering long term results DREZotomy provided favorable clinical outcomes in brachial plexus avulsion and spinal cord injury, in 60.8% and 55.8% of the cases respectively. Conversely, the success rate was 35.3% in phantom limb pain and 28.2% in post herpetic neuralgia. A poor clinical outcome was reported in over than 25% of the patients suffering from phantom limb pain, post herpetic neuralgia and spinal cord injury. The mean complications rate was 23.58%. While BPA and SCI patients presented stable improvement over time, good outcomes among PHN and PLP groups dropped by - 46.2%; and - 14.7% at long term follow up respectively. CONCLUSION DREZotomy seems to be an effective treatment for chronic pain conditions, especially for brachial plexus avulsion, spinal cord injury and intractable cancer/post-radiation pain. According to the low level of evidence of the pertinent literature, further studies are strongly recommended, to better define potential benefits and limitations of this technique.
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Affiliation(s)
- Lorenzo Mongardi
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy.
| | - Jacopo Visani
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
| | - Giorgio Mantovani
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
| | - Costanza Vitali
- Department of Morphology, Surgery and Experimental Medicine, Section of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Luca Ricciardi
- UO di Neurochirurgia, Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, LE, Italy
| | - Flavio Giordano
- Department of Neurosurgery, Children's Hospital A. Meyer, University of Florence, Florence, Italy
| | - Michele Alessandro Cavallo
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy; Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Italy
| | | | | | - Paul Roblot
- Department of Neurosurgery, University Hospital of Bordeaux, Bordeaux, France
| | - Pasquale De Bonis
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy; Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Italy
| | - Alba Scerrati
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy; Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Italy
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Doddamani RS, Garg S, Agrawal D, Meena RK, Sawarkar D, Singh PK, Verma S, Chandra SP. Microscissor DREZotomy for post brachial plexus avulsion neuralgia: A single center experience. Clin Neurol Neurosurg 2021; 208:106840. [PMID: 34418706 DOI: 10.1016/j.clineuro.2021.106840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Brachial neuralgia is a dreaded sequelae which substantially impairs the quality of life in patients with brachial plexus avulsion (BPA) injuries. Dorsal Root Entry Zone (DREZ) lesioning of the cervical spinal cord is the most utilized procedure for alleviating this painful condition. In this study, we share a single center experience of surgically managing post BPA neuropathic pain. The efficacy, results and complications of the modified technique of DREZ, called the Microscissor DREZotomy (MDZ) are discussed along with the review of relevant literature. METHODS This retrospective analysis included all the patients undergoing MDZ for post BPA brachialgia over 5 years period (2012-2018) at our institution. The pain was quantified using the Numeric rating Scale (NRS) between 0 and 10 scale and was graded as 'Excellent' in patients with more than 75% pain relief, 'Good' with 50-75% relief, 'Fair' between 25% and 50% and 'Poor' if less than 25%. RESULTS A total of 56 patients underwent MDZ and a mean follow up of 32 months (range 18-69 months) available for 47 patients. Thirty three patients (70.4%) judged pain relief as Excellent, Five (10.6%) as Good, 3 (7%) as Fair and 6 (12%) having poor pain relief. Overall, in 38 (81%) patients long term analgesic effect (> 50%) was noted and 3 (7%) patients had more than 25% pain relief, making up an overall 41 (87%) of patients with some relief from pain. CONCLUSION MDZ is a safe, efficacious technique with good long term pain relief and quality of life. This technique entails utilization of routine surgical instruments and can be performed with ease even in resource limited settings.
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Affiliation(s)
| | - Sharat Garg
- Max Superspeciality Hospital, Department of Neurosurgery, New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery& Gamma-Knife, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Rajesh Kumar Meena
- Department of Neurosurgery& Gamma-Knife, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Dattaraj Sawarkar
- Department of Neurosurgery& Gamma-Knife, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Pankaj Kumar Singh
- Department of Neurosurgery& Gamma-Knife, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Satish Verma
- Department of Neurosurgery& Gamma-Knife, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Sarat P Chandra
- Department of Neurosurgery& Gamma-Knife, All India Institute of Medical Sciences, New Delhi 110029, India
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Gebreyohanes AMH, Ahmed AI, Choi D. Dorsal Root Entry Zone Lesioning for Brachial Plexus Avulsion: A Comprehensive Literature Review. Oper Neurosurg (Hagerstown) 2021; 20:324-333. [PMID: 33469654 DOI: 10.1093/ons/opaa447] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/23/2020] [Indexed: 11/14/2022] Open
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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Affiliation(s)
- Axumawi Mike Hailu Gebreyohanes
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom.,University College London (UCL) Medical School, London, United Kingdom
| | - Aminul Islam Ahmed
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - David Choi
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Dauleac C, Brinzeu A, Fenniri I, Sindou M, Mertens P. Microsurgical DREZotomy for Treatment of Brachial Plexus Avulsion Pain. World Neurosurg 2021; 148:177. [PMID: 33515797 DOI: 10.1016/j.wneu.2021.01.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
Abstract
A 63-year-old man with a history of motorcycle accident 42 years ago suffered a left brachial plexus avulsion (BPA). Neuropathic pain in his left upper limb was felt in the C6-C7-C8 dermatomes. The rationale for performing "DREZotomy" is to preferentially interrupt the nociceptive inputs in the lateral part of the dorsal root entry zone (DREZ).1-3 For pain with complete deafferentation, as observed in BPA, the aim is to destroy the hyperactive nociceptive neurons deep in the apex of the dorsal horn (DH).4 Surgery is performed under general anesthesia, with the patient in prone position. Once the dura mater is opened, the arachnoid needs extensive dissection to open the dorsolateral and lateral spinal cisterns.5 In cases of BPA, the dorsolateral sulcus may be difficult to identify. Three anatomic elements can facilitate its recognition. Firstly, the remaining intact rootlets (above and below the avulsed segments) allow us to roughly localize the dorsolateral sulcus by joining these cranial and caudal normal rootlets. Secondly, blood vessels running on the spinal cord penetrate into the dorsolateral sulcus and often delineate the sulcus. Thirdly, scarring can be seen along the sulcus with small holes where the rootlets used to penetrate the cord. DREZotomy is performed using a graduated sharp bipolar instrument to allow precise microcoagulations of the DH. Preoperative surgical planning helps the surgeon by giving the angle between the DH and median plane.6 In the immediate postoperative period, the patient described the complete disappearance of neuropathic pain in his left upper limb, persistent at last follow-up (1 year) (Video 1).
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Affiliation(s)
- Corentin Dauleac
- Functional Neurosurgery Department, Neurology and Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France; University of Lyon, University Claude Bernard Lyon I, Lyon, France.
| | - Andrei Brinzeu
- Functional Neurosurgery Department, Neurology and Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France; University of Lyon, University Claude Bernard Lyon I, Lyon, France; University of Medicine and Pharmacy "Victor Babes" Timisoara, Romania
| | - Inès Fenniri
- Functional Neurosurgery Department, Neurology and Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France; University of Lyon, University Claude Bernard Lyon I, Lyon, France
| | - Marc Sindou
- Centre de la douleur, Clinique Bretéché, Nantes, France
| | - Patrick Mertens
- Functional Neurosurgery Department, Neurology and Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France; University of Lyon, University Claude Bernard Lyon I, Lyon, France; Anatomy Laboratory, University of Lyon, Université Claude Bernard Lyon I, Lyon, France
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Abstract
Neuropathic pain caused by a lesion or disease of the somatosensory nervous system is a common chronic pain condition with major impact on quality of life. Examples include trigeminal neuralgia, painful polyneuropathy, postherpetic neuralgia, and central poststroke pain. Most patients complain of an ongoing or intermittent spontaneous pain of, for example, burning, pricking, squeezing quality, which may be accompanied by evoked pain, particular to light touch and cold. Ectopic activity in, for example, nerve-end neuroma, compressed nerves or nerve roots, dorsal root ganglia, and the thalamus may in different conditions underlie the spontaneous pain. Evoked pain may spread to neighboring areas, and the underlying pathophysiology involves peripheral and central sensitization. Maladaptive structural changes and a number of cell-cell interactions and molecular signaling underlie the sensitization of nociceptive pathways. These include alteration in ion channels, activation of immune cells, glial-derived mediators, and epigenetic regulation. The major classes of therapeutics include drugs acting on α2δ subunits of calcium channels, sodium channels, and descending modulatory inhibitory pathways.
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Affiliation(s)
- Nanna Brix Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Aarhus, Denmark; and Department of Pharmacology, Heidelberg University, Heidelberg, Germany
| | - Rohini Kuner
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Aarhus, Denmark; and Department of Pharmacology, Heidelberg University, Heidelberg, Germany
| | - Troels Staehelin Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Aarhus, Denmark; and Department of Pharmacology, Heidelberg University, Heidelberg, Germany
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Montalvo Afonso A, Ruiz Juretschke F, González Rodrigálvarez R, Mateo Sierra O, Iza Vallejo B, García Leal R, Valera Melé M, Casitas Hernando V, Hernández Poveda JM, Fernández Carballal C. DREZotomy in the treatment of deafferentation pain: review of results and analysis of predictive factors for success. Neurocirugia (Astur) 2020; 32:1-9. [PMID: 32376193 DOI: 10.1016/j.neucir.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/08/2020] [Accepted: 02/16/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The treatment of deafferentation pain by spinal DREZotomy is a proven therapeutic option in the literature. In recent years, use of DREZotomy has been relegated to second place due to the emergence of neuromodulation therapies. The objectives of this study are to demonstrate that DREZotomy continues to be an effective and safe treatment and to analyse predictive factors for success. PATIENTS AND METHODS A retrospective study was conducted of all patients treated in our department with spinal DREZotomy from 1998 to 2018. Bulbar DREZotomy procedures were excluded. A visual analogue scale (VAS) and the reduction of routine medication were used as outcome variables. Demographic, clinical and operative variables were analysed as predictive factors for success. RESULTS A total of 27 patients (51.9% female) with a mean age of 53.7 years underwent DREZotomy. The main cause of pain was brachial plexus injury (BPI) (55.6%) followed by neoplasms (18.5%). The mean time of pain evolution was 8.4 years with a mean intensity of 8.7 according to the VAS, even though 63% of the patients had previously received neurostimulation therapy. Favourable outcome (≥50% pain reduction in the VAS) was observed in 77.8% of patients during the postoperative period and remained in 59.3% of patients after 22 months average follow-up (mean reduction of 4.9 points). This allowed for a reduction in routine analgesic treatment in 70.4% of them. DREZotomy in BPI-related pain presented a significantly higher success rate (93%) than the other pathologies (41.7%) (p=.001). No association was observed between outcome and age, gender, DREZ technique, duration of pain or previous neurostimulation therapies. There were six neurological complications, four post-operative transient neurological deficits and two permanent deficits. CONCLUSION Dorsal root entry zone surgery is effective and safe for treating patients with deafferentation pain, especially after brachial plexus injury. It can be considered an alternative treatment after failed neurostimulation techniques for pain control. However, its indication should be considered as the first therapeutic option after medical therapy failure due to its good long-term results.
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Affiliation(s)
| | | | | | - Olga Mateo Sierra
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Begoña Iza Vallejo
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Roberto García Leal
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Marc Valera Melé
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España
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Moisset X, Bouhassira D, Avez Couturier J, Alchaar H, Conradi S, Delmotte MH, Lanteri-Minet M, Lefaucheur JP, Mick G, Piano V, Pickering G, Piquet E, Regis C, Salvat E, Attal N. Pharmacological and non-pharmacological treatments for neuropathic pain: Systematic review and French recommendations. Rev Neurol (Paris) 2020; 176:325-352. [PMID: 32276788 DOI: 10.1016/j.neurol.2020.01.361] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 01/07/2020] [Indexed: 02/08/2023]
Abstract
Neuropathic pain remains a significant unmet medical need. Several recommendations have recently been proposed concerning pharmacotherapy, neurostimulation techniques and interventional management, but no comprehensive guideline encompassing all these treatments has yet been issued. We performed a systematic review of pharmacotherapy, neurostimulation, surgery, psychotherapies and other types of therapy for peripheral or central neuropathic pain, based on studies published in peer-reviewed journals before January 2018. The main inclusion criteria were chronic neuropathic pain for at least three months, a randomized controlled methodology, at least three weeks of follow-up, at least 10 patients per group, and a double-blind design for drug therapy. Based on the GRADE system, we provide weak-to-strong recommendations for use and proposal as a first-line treatment for SNRIs (duloxetine and venlafaxine), gabapentin and tricyclic antidepressants and, for topical lidocaine and transcutaneous electrical nerve stimulation specifically for peripheral neuropathic pain; a weak recommendation for use and proposal as a second-line treatment for pregabalin, tramadol, combination therapy (antidepressant combined with gabapentinoids), and for high-concentration capsaicin patches and botulinum toxin A specifically for peripheral neuropathic pain; a weak recommendation for use and proposal as a third-line treatment for high-frequency rTMS of the motor cortex, spinal cord stimulation (failed back surgery syndrome and painful diabetic polyneuropathy) and strong opioids (in the absence of an alternative). Psychotherapy (cognitive behavioral therapy and mindfulness) is recommended as a second-line therapy, as an add-on to other therapies. An algorithm encompassing all the recommended treatments is proposed.
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Affiliation(s)
- X Moisset
- Université Clermont Auvergne, Inserm, Neuro-Dol, 63000 Clermont-Ferrand, France; CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France.
| | - D Bouhassira
- INSERM U987, CETD, Ambroise-Paré Hospital, AP-HP, Boulogne-Billancourt, France; Université Versailles - Saint-Quentin-en-Yvelines, Versailles, France
| | - J Avez Couturier
- Service de Neuropédiatrie, Consultation Douleur Enfant, CIC-IT 1403, CHU de Lille, Lille, France
| | - H Alchaar
- 73, boulevard de Cimiez, Nice, France
| | - S Conradi
- CETD, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - M H Delmotte
- GHU, Paris site Ste-Anne, Structure Douleurs, 1, rue Cabanis, Paris 14, France
| | - M Lanteri-Minet
- Université Clermont Auvergne, Inserm, Neuro-Dol, 63000 Clermont-Ferrand, France; Département d'Évaluation et Traitement de la Douleur, Centre Hospitalier Universitaire (CHU) de Nice, Fédération Hospitalo-Universitaire InovPain, Université Côte d'Azur, Nice, France
| | - J P Lefaucheur
- EA 4391, Faculté de Médecine, Université Paris Est Créteil, Créteil, France; Service de Physiologie, Explorations Fonctionnelles, Hôpital Henri-Mondor, Assistance publique-Hôpitaux de Paris, Créteil, France
| | - G Mick
- Centre d'Évaluation et Traitement de la Douleur du Voironnais, Centre Hospitalier de Voiron, Laboratoire P2S, Université de Lyon, Lyon, France
| | - V Piano
- Centre Hospitalier de Draguignan, Service Algologie 4(e), route de Montferrat, 83007 Draguignan cedex, France
| | - G Pickering
- Université Clermont Auvergne, Inserm, Neuro-Dol, 63000 Clermont-Ferrand, France; Clinical Pharmacology Department, CPC/CIC Inserm 1405, University Hospital CHU, Clermont-Ferrand, France
| | - E Piquet
- Département d'Évaluation et Traitement de la Douleur, Centre Hospitalier Universitaire (CHU) de Nice, Fédération Hospitalo-Universitaire InovPain, Université Côte d'Azur, Nice, France
| | - C Regis
- CETD, CHU Montpellier, Montpellier, France
| | - E Salvat
- Centre d'Évaluation et de Traitement de la Douleur, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, Strasbourg, France
| | - N Attal
- INSERM U987, CETD, Ambroise-Paré Hospital, AP-HP, Boulogne-Billancourt, France; Université Versailles - Saint-Quentin-en-Yvelines, Versailles, France
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Henssen DJHA, Weber RC, de Boef J, Mollink J, Kozicz T, Kurt E, van Cappellen van Walsum AM. Post-mortem 11.7 Tesla Magnetic Resonance Imaging vs. Polarized Light Imaging Microscopy to Measure the Angle and Orientation of Dorsal Root Afferents in the Human Cervical Dorsal Root Entry Zone. Front Neuroanat 2019; 13:66. [PMID: 31312124 PMCID: PMC6614433 DOI: 10.3389/fnana.2019.00066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 06/18/2019] [Indexed: 11/18/2022] Open
Abstract
Background: Destruction of the afferents by dorsal root entry zone (DREZ) surgery may be an effective treatment of intractable neuropathic pain, though it remains a high-risk surgical intervention. Potential complications due to the lesioning of structures within the cervical spinal cord other than the DREZ can be minimized by accurate knowledge of the optimal insertion angle [i.e., the angle between the DREZ and the posterior median sulcus (PMS)]. The employed insertion angle was based on measurements between the DREZ and the PMS on post-mortem transverse slices. However, new, more sophisticated imaging techniques are currently available and are thought to yield higher spatial resolution and more accurate images. Obejctive: This article measures the angle between the DREZ and the PMS on 11.7T post-mortem magnetic resonance images and compares these findings with polarized light imaging (PLI) microscopy images of the same specimens in order to quantify fiber orientation within the DREZ. Methods: To visualize the anatomy of the cervical DREZ, magnetic resonance imaging (MRI), diffusion-weighted MRI (dMRI), probabilistic tractography, and PLI were performed on three post-mortem human cervical spinal cords at level C5–C6. The MR data was used to measure the angle between the DREZ and the PMS. MR images were complemented by probabilistic tractography results. Then, the orientation of fibers within the DREZ was quantified by use of PLI microscopy. Results: Median angle between the DREZ and the PMS, as measured on MR-images, was found to be 40.1° (ranging from 34.2° to 49.1°) and 39.8° (ranging from 31.1° to 47.8°) in the left and right hemicord, respectively. Median fiber orientation within the DREZ, as quantified by PLI, was 28.5° (ranging from 12.0° to 44.3°) and 27.7° (ranging from 8.5° to 38.1°) in the left and right hemicord, respectively. Conclusion: Our study, which provides an improved understanding of the anatomy of the DREZ, the angle between the DREZ and the PMS and the median fiber orientation within the DREZ, could contribute to safer DREZ-lesioning surgery to treat chronic neuropathic pain in the future.
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Affiliation(s)
- Dylan Jozef Hendrik Augustinus Henssen
- Department of Anatomy, Donders Institute for Brain, Cognition & Behavior, Radboud University Medical Center, Nijmegen, Netherlands.,Unit of Functional Neurosurgery, Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rosanna Christina Weber
- Department of Anatomy, Donders Institute for Brain, Cognition & Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jesse de Boef
- Department of Anatomy, Donders Institute for Brain, Cognition & Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jeroen Mollink
- Department of Anatomy, Donders Institute for Brain, Cognition & Behavior, Radboud University Medical Center, Nijmegen, Netherlands.,Nuffield Department of Clinical Neurosciences, Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain (FMRIB), University of Oxford, Oxford, United Kingdom
| | - Tamas Kozicz
- Department of Clinical Genomics, Mayo Clinic Minnesota, Rochester, MN, United States
| | - Erkan Kurt
- Unit of Functional Neurosurgery, Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Netherlands
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Dauleac C, Jacquesson T, Mertens P. Anatomy of the human spinal cord arachnoid cisterns: applications for spinal cord surgery. J Neurosurg Spine 2019; 31:756-763. [PMID: 31299646 DOI: 10.3171/2019.4.spine19404] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/29/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The goal in this study was to describe the overall organization of the spinal arachnoid mater and spinal subarachnoid space (SSAS) as well as its relationship with surrounding structures, in order to highlight spinal cord arachnoid cisterns. METHODS Fifteen spinal cords were extracted from embalmed adult cadavers. The organization of the spinal cord arachnoid and SSAS was described via macroscopic observations, optical microscopic views, and scanning electron microscope (SEM) studies. Gelatin injections were also performed to study separated dorsal subarachnoid compartments. RESULTS Compartmentalization of SSAS was studied on 3 levels of axial sections. On an axial section passing through the tips of the denticulate ligament anchored to the dura, 3 subarachnoid cisterns were observed: 2 dorsolateral and 1 ventral. On an axial section passing through dural exit/entrance of rootlets, 5 subarachnoid cisterns were observed: 2 dorsolateral, 2 lateral formed by dorsal and ventral rootlets, and 1 ventral. On an axial section passing between the two previous ones, only 1 subarachnoid cistern was observed around the spinal cord. This compartmentalization resulted in the anatomical description of 3 elements: the median dorsal septum, the arachnoid anchorage to the tip of the denticulate ligament, and the arachnoid anchorage to the dural exit/entrance of rootlets. The median dorsal septum already separated dorsal left and right subarachnoid spaces and was described from C1 level to 3 cm above the conus medullaris. This septum was anchored to the dorsal septal vein. No discontinuation was observed in the median dorsal arachnoid septum. At the entrance point of dorsal rootlets in the spinal cord, arachnoid trabeculations were described. Using the SEM, numerous arachnoid adhesions between the ventral surface of the dorsal rootlets and the pia mater over the spinal cord were observed. At the ventral part of the SSAS, no septum was found, but some arachnoid trabeculations between the arachnoid and the pia mater were present and more frequent than in the dorsal part. Laterally, arachnoid was firmly anchored to the denticulate ligaments' fixation at dural points, and dural exit/entrance of rootlets made a fibrous ring of arachnoidodural adhesions. At the level of the cauda equina, the arachnoid mater surrounded all rootlets together-as a sac and not individually. CONCLUSIONS Arachnoid cisterns are organized on each side of a median dorsal septum and compartmentalized in relation with the attachments of denticulate ligament and exit/entrance of rootlets.
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Affiliation(s)
- Corentin Dauleac
- 1Department of Neurosurgery, Hôpital Neurologique et Neurochirurgical Pierre Wertheimer, Hospices Civils de Lyon
- 2University of Lyon, Université Claude Bernard Lyon I; and
| | - Timothée Jacquesson
- 1Department of Neurosurgery, Hôpital Neurologique et Neurochirurgical Pierre Wertheimer, Hospices Civils de Lyon
- 2University of Lyon, Université Claude Bernard Lyon I; and
- 3Laboratory of Anatomy, Université Claude Bernard Lyon I, Lyon, France
| | - Patrick Mertens
- 1Department of Neurosurgery, Hôpital Neurologique et Neurochirurgical Pierre Wertheimer, Hospices Civils de Lyon
- 2University of Lyon, Université Claude Bernard Lyon I; and
- 3Laboratory of Anatomy, Université Claude Bernard Lyon I, Lyon, France
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Efficacy and factors determining the outcome of dorsal root entry zone lesioning procedure (DREZotomy) in the treatment of intractable pain syndrome. Acta Neurochir (Wien) 2017; 159:2431-2442. [PMID: 28993994 DOI: 10.1007/s00701-017-3345-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/29/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Chronic pain is a disabling condition that adversely affects patient quality of life. The dorsal root entry zone lesioning procedure (DREZotomy) is a modality used to treat intractable pain caused by insults to neural structures. This study aimed to investigate the efficacy of and the factors that determine the outcome of microsurgical DREZotomy (MDT). METHOD All consecutive patients who underwent MDT for treatment of intractable pain during September 2008 to December 2016 were enrolled. Demographic data, clinical characteristics, intraoperative findings, and postoperative outcomes were analyzed. RESULTS The 40 included patients underwent MDT for relief of intractable pain caused by 27 brachial plexus injuries (BPIs), 6 spinal cord injuries, 3 neoplasms, and 4 other causes. A significant reduction in pain was observed post-MDT for both average (p < 0.001) and maximal pain (p < 0.001). Favorable outcome (≥50% pain reduction) was observed in 67.5% of patients, with the best outcome in BPI-related pain. In multivariate analysis, injury of the spinal nerve root (root avulsion or injury) was significantly associated with good average pain relief (OR, 5.8; 95% CI, 1.2-27.5; p = 0.026) and pain freedom (OR, 5.0; 95% CI, 1.12-22.30; p = 0.035). Electrical pain (OR, 6.49; 95% CI, 1.20-35.19; p = 0.030) and lower number of painful dermatomes (OR, 1.30; 95% CI, 1.01-1.67; p = 0.039) were significantly associated with good maximal pain relief. CONCLUSIONS MDT is an effective procedure for treatment of intractable pain in well-selected patients, particularly in cases with brachial plexus avulsion pain. Injury of the spinal nerve root (brachial plexus avulsion and cauda equina injury) was associated with good average pain relief and pain freedom, and electrical pain and lower number of painful dermatomes were associated with good maximal pain relief. The results are useful in the selection of candidates for DREZotomy and prediction of surgical outcome.
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21
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The Associated Factors and Clinical Features of Neuropathic Pain After Brachial Plexus Injuries. Clin J Pain 2017; 33:1030-1036. [DOI: 10.1097/ajp.0000000000000493] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abreu V, Vaz R, Rebelo V, Rosas MJ, Chamadoira C, Gillies MJ, Aziz TZ, Pereira EAC. Thalamic Deep Brain Stimulation for Neuropathic Pain: Efficacy at Three Years' Follow-Up. Neuromodulation 2017. [PMID: 28631870 DOI: 10.1111/ner.12620] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECT Chronic neuropathic pain is estimated to affect 3-4.5% of the worldwide population, posing a serious burden to society. Deep Brain Stimulation (DBS) is already established for movement disorders and also used to treat some "off-label" conditions. However, DBS for the treatment of chronic, drug refractory, neuropathic pain, has shown variable outcomes with few studies performed in the last decade. Thus, this procedure has consensus approval in parts of Europe but not the USA. This study prospectively evaluated the efficacy at three years of DBS for neuropathic pain. METHODS Sixteen consecutive patients received 36 months post-surgical follow-up in a single-center. Six had phantom limb pain after amputation and ten deafferentation pain after brachial plexus injury, all due to traumas. To evaluate the efficacy of DBS, patient-reported outcome measures were collated before and after surgery, using a visual analog scale (VAS) score, University of Washington Neuropathic Pain Score (UWNPS), Brief Pain Inventory (BPI), and 36-Item Short-Form Health Survey (SF-36). RESULTS Contralateral, ventroposterolateral sensory thalamic DBS was performed in sixteen patients with chronic neuropathic pain over 29 months. A postoperative trial of externalized DBS failed in one patient with brachial plexus injury. Fifteen patients proceeded to implantation but one patient with phantom limb pain after amputation was lost for follow-up after 12 months. No surgical complications or stimulation side effects were noted. After 36 months, mean pain relief was sustained, and the median (and interquartile range) of the improvement of VAS score was 52.8% (45.4%) (p = 0.00021), UWNPS was 30.7% (49.2%) (p = 0.0590), BPI was 55.0% (32.0%) (p = 0.00737), and SF-36 was 16.3% (30.3%) (p = 0.4754). CONCLUSIONS DBS demonstrated efficacy at three years for chronic neuropathic pain after traumatic amputation and brachial plexus injury, with benefits sustained across all pain outcomes measures and slightly greater improvement in phantom limb pain.
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Affiliation(s)
- Vasco Abreu
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Rui Vaz
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,Departmento de Neurocirugia, Hospital de São João, Porto, Portugal.,Center for Neurosciences CUF Porto, Porto, Portugal
| | - Virgínia Rebelo
- Departamento de Psicologia, Hospital São João, Porto, Portugal
| | - Maria José Rosas
- Center for Neurosciences CUF Porto, Porto, Portugal.,Departamento de Neurologia, Hospital São João, Porto, Portugal
| | - Clara Chamadoira
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,Departmento de Neurocirugia, Hospital de São João, Porto, Portugal
| | - Martin J Gillies
- Department of Neurosurgery and Nuffield Department of Surgery, Oxford University Hospitals, Oxford, United Kingdom
| | - Tipu Z Aziz
- Departmento de Neurocirugia, Hospital de São João, Porto, Portugal.,Department of Neurosurgery and Nuffield Department of Surgery, Oxford University Hospitals, Oxford, United Kingdom
| | - Erlick A C Pereira
- Departmento de Neurocirugia, Hospital de São João, Porto, Portugal.,Academic Neurosurgery Unit, St. George's, University of London, London, United Kingdom
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24
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Nadi M, Midha R. Editorial. Myoelectric functional hand prosthesis for total brachial plexus injury. J Neurosurg 2017; 127:1160-1162. [PMID: 28093032 DOI: 10.3171/2016.7.jns161501] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Mustafa Nadi
- Peripheral Nerve Surgery, Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary; and
| | - Rajiv Midha
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
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25
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Hruby LA, Sturma A, Mayer JA, Pittermann A, Salminger S, Aszmann OC. Algorithm for bionic hand reconstruction in patients with global brachial plexopathies. J Neurosurg 2017; 127:1163-1171. [PMID: 28093018 DOI: 10.3171/2016.6.jns16154] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Global brachial plexus lesions with multiple root avulsions are among the most severe nerve injuries, leading to lifelong disability. Fortunately, in most cases primary and secondary reconstructions provide a stable shoulder and restore sufficient arm function. Restoration of biological hand function, however, remains a reconstructive goal that is difficult to reach. The recently introduced concept of bionic reconstruction overcomes biological limitations of classic reconstructive surgery to restore hand function by combining selective nerve and muscle transfers with elective amputation of the functionless hand and its replacement with a prosthetic device. The authors present their treatment algorithm for bionic hand reconstruction and report on the management and long-term functional outcomes of patients with global brachial plexopathies who have undergone this innovative treatment. METHODS Thirty-four patients with posttraumatic global brachial plexopathies leading to loss of hand function consulted the Center for Advanced Restoration of Extremity Function between 2011 and 2015. Of these patients, 16 (47%) qualified for bionic reconstruction due to lack of treatment alternatives. The treatment algorithm included progressive steps with the intent of improving the biotechnological interface to allow optimal prosthetic hand replacement. In 5 patients, final functional outcome measurements were obtained with the Action Arm Research Test (ARAT), the Southampton Hand Assessment Procedure (SHAP), and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS In all 5 patients who completed functional assessments, partial hand function was restored with bionic reconstruction. ARAT scores improved from 3.4 ± 4.3 to 25.4 ± 12.7 (p = 0.043; mean ± SD) and SHAP scores improved from 10.0 ± 1.6 to 55 ± 19.7 (p = 0.042). DASH scores decreased from 57.9 ± 20.6 to 32 ± 28.6 (p = 0.042), indicating decreased disability. CONCLUSIONS The authors present an algorithm for bionic reconstruction leading to useful hand function in patients who lack biological treatment alternatives for a stiff, functionless, and insensate hand resulting from global brachial plexopathies.
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Affiliation(s)
- Laura A Hruby
- Christian Doppler Laboratory for Restoration of Extremity Function.,Department of Physical Medicine and Rehabilitation; and
| | - Agnes Sturma
- Christian Doppler Laboratory for Restoration of Extremity Function.,Department of Physical Medicine and Rehabilitation; and.,Master Degree Program, Health Assisting Engineering, University of Applied Sciences FH Campus, Vienna, Austria
| | - Johannes A Mayer
- Christian Doppler Laboratory for Restoration of Extremity Function
| | - Anna Pittermann
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna; and
| | - Stefan Salminger
- Christian Doppler Laboratory for Restoration of Extremity Function.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna; and
| | - Oskar C Aszmann
- Christian Doppler Laboratory for Restoration of Extremity Function.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna; and
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26
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Simon NG, Spinner RJ, Kline DG, Kliot M. Advances in the neurological and neurosurgical management of peripheral nerve trauma. J Neurol Neurosurg Psychiatry 2016; 87:198-208. [PMID: 25922080 DOI: 10.1136/jnnp-2014-310175] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 04/03/2015] [Indexed: 12/31/2022]
Abstract
Peripheral nerve trauma frequently affects younger people and may result in significant and long-lasting functional disability. Currently, diagnosis and monitoring of peripheral nerve injury relies on clinical and electrodiagnostic information, supplemented by intraoperative electrophysiological studies. However, in a significant proportion of nerve injuries, the likelihood of spontaneous regeneration resulting in good functional outcome remains uncertain and unnecessary delays to treatment may be faced while monitoring for recovery. Advances in non-invasive imaging techniques to diagnose and monitor nerve injury and regeneration are being developed, and have the potential to streamline the decision-making process. In addition, advances in operative and non-operative treatment strategies may provide more effective ways to maximise functional outcomes following severe peripheral nerve trauma. This review discusses these advances in light of the current state of the art of management of peripheral nerve trauma.
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Affiliation(s)
- Neil G Simon
- Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia Brain and Mind Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
| | - Robert J Spinner
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David G Kline
- Department of Neurosurgery, Louisiana State University Health Science Center, New Orleans, Louisiana, USA
| | - Michel Kliot
- Department of Neurological Surgery, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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Ko AL, Ozpinar A, Raskin JS, Magill ST, Raslan AM, Burchiel KJ. Correlation of preoperative MRI with the long-term outcomes of dorsal root entry zone lesioning for brachial plexus avulsion pain. J Neurosurg 2015; 124:1470-8. [PMID: 26406799 DOI: 10.3171/2015.2.jns142572] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Andrew L Ko
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Alp Ozpinar
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Jeffrey S Raskin
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Stephen T Magill
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
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Shankar H, Hansen J, Thomas K. Phantom pain in a patient with brachial plexus avulsion injury. PAIN MEDICINE 2014; 16:777-81. [PMID: 25529640 DOI: 10.1111/pme.12635] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Phantom limb pain is a painful sensation perceived in the absent limb following surgical or traumatic amputation. Phantom limb sensations, which are nonpainful, occur in nearly all amputees. Deafferentation can also produce similar symptoms. Here we report the presence of phantom pain in a deafferented limb. DESIGN Case report. SETTING Hospital-based outpatient clinic. PATIENT A 65-year-old man was referred to the pain clinic for management of upper extremity pain secondary to brachial plexus avulsion (BPA) following a motor vehicle accident. Initially he noticed a feeling of growing and shrinking of his arm. Following this, the pain started gradually from his elbow extending to his fingertips covering all dermatomes. He described the pain as continuous, severe, and sharp. He also described the arm as being separate from his existing insensate arm and felt as though the fist was closed with the thumb pointing out. On physical examination, he had no sensation to fine touch or pressure below the elbow. There were no consistent areas of allodynia. He had diffuse muscle wasting in all the muscle groups of his left upper extremity, besides winging of the scapula. Electrodiagnostic studies showed a left brachial plexopathy consistent with multilevel nerve root avulsion sparing the dorsal rami. CONCLUSION This is a report of phantom limb sensations and phantom pain following BPA in an intact but flaccid and insensate limb.
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Affiliation(s)
- Hariharan Shankar
- Department of Anesthesiology, Clement Zablocki VA Medical Center, Milwaukee, Wisconsin, USA; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Haninec P, Kaiser R, Mencl L, Waldauf P. Usefulness of screening tools in the evaluation of long-term effectiveness of DREZ lesioning in the treatment of neuropathic pain after brachial plexus injury. BMC Neurol 2014; 14:225. [PMID: 25487537 PMCID: PMC4264322 DOI: 10.1186/s12883-014-0225-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 11/12/2014] [Indexed: 02/02/2023] Open
Abstract
Background Despite high success rate of DREZ lesioning in the treatment of intractable central pain, there is still a significant incidence of patients without satisfactory post-operative effect. The aim of the study was to evaluate the long-term effect of DREZ lesioning using both a subjective assessment using a visual analog scale (VAS) to quantify residual pain and an assessment using the screening tool (painDETECT Questionnaire, PD-Q). Methods DREZ lesioning was performed in 52 patients from a total 441 cases with brachial plexus injury (11.8%) during a 17-year period (1995–2011). The effect of surgery was retrospectively assessed in 48 patients. Results A decrease in pre-operative pain by more than 75% (Group I) was achieved in 70.8% of patients and another 20.8% reported significant improvement (Group II). The surgery was unsucessful in 8.4% (Group III). We found a significant correlation between ‘improvement’ groups from both methods of assessments. Patients from Group I usually complained of residual nociceptive pain according to PD-Q, patients from Group II typically had pain of unclear origin, and all cases those in Group III suffered from neuropathic pain, Cramer’s V = .66, P < .001. Overall, 66.7% of patients had resolved neuropathic pain, 20.8% patients had more serious complaints and may also suffer from residual neuropathic pain, while 12.5% had unresolved neuropathic pain. Conclusion DREZ lesioning is a safe and effective method with success rates of about 90%. PD-Q scores correspond to subjective satisfaction with the surgery and it seems to be a suitable screening tool for finding patients with residual neuropathic pain after surgery.
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Affiliation(s)
- Pavel Haninec
- Department of Neurosurgery, Third Faculty of Medicine, Charles University, Hospital Kralovske Vinohrady, Srobarova 50 100 34, Prague, Czech Republic.
| | - Radek Kaiser
- Department of Neurosurgery, Third Faculty of Medicine, Charles University, Hospital Kralovske Vinohrady, Srobarova 50 100 34, Prague, Czech Republic.
| | - Libor Mencl
- Department of Neurosurgery, Third Faculty of Medicine, Charles University, Hospital Kralovske Vinohrady, Srobarova 50 100 34, Prague, Czech Republic.
| | - Petr Waldauf
- Department of Anesthesiology and Critical Care Medicine, Third Faculty of Medicine, Charles University, Hospital Kralovske Vinohrady, Prague, Czech Republic.
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30
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Cervical Spinal Cord Stimulation Treatment of Deafferentation Pain from Brachial Plexus Avulsion Injury Complicated by Complex Regional Pain Syndrome. ACTA ACUST UNITED AC 2014; 3:29-34. [DOI: 10.1213/xaa.0000000000000041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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31
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Pereira EAC, Boccard SG, Linhares P, Chamadoira C, Rosas MJ, Abreu P, Rebelo V, Vaz R, Aziz TZ. Thalamic deep brain stimulation for neuropathic pain after amputation or brachial plexus avulsion. Neurosurg Focus 2014; 35:E7. [PMID: 23991820 DOI: 10.3171/2013.7.focus1346] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Fifteen hundred patients have received deep brain stimulation (DBS) to treat neuropathic pain refractory to pharmacotherapy over the last half-century, but few during the last decade. Deep brain stimulation for neuropathic pain has shown variable outcomes and gained consensus approval in Europe but not the US. This study prospectively evaluated the efficacy at 1 year of DBS for phantom limb pain after amputation, and deafferentation pain after brachial plexus avulsion (BPA), in a single-center case series. METHODS Patient-reported outcome measures were collated before and after surgery, using a visual analog scale (VAS) score, 36-Item Short-Form Health Survey (SF-36), Brief Pain Inventory (BPI), and University of Washington Neuropathic Pain Score (UWNPS). RESULTS Twelve patients were treated over 29 months, receiving contralateral, ventroposterolateral sensory thalamic DBS. Five patients were amputees and 7 had BPAs, all from traumas. A postoperative trial of externalized DBS failed in 1 patient with BPA. Eleven patients proceeded to implantation and gained improvement in pain scores at 12 months. No surgical complications or stimulation side effects were noted. In the amputation group, after 12 months the mean VAS score improved by 90.0% ± 10.0% (p = 0.001), SF-36 by 57.5% ± 97.9% (p = 0.127), UWNPS by 80.4% ± 12.7% (p < 0.001), and BPI by 79.9% ± 14.7% (p < 0.001). In the BPA group, after 12 months the mean VAS score improved by 52.7% ± 30.2% (p < 0.001), SF-36 by 15.6% ± 30.5% (p = 1.000), UWNPS by 26.2% ± 40.8% (p = 0.399), and BPI by 38.4% ± 41.7% (p = 0.018). Mean DBS parameters were 2.5 V, 213 microseconds, and 25 Hz. CONCLUSIONS Deep brain stimulation demonstrated efficacy at 1 year for chronic neuropathic pain after traumatic amputation and BPA. Clinical trials that retain patients in long-term follow-up are desirable to confirm findings from prospectively assessed case series.
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Affiliation(s)
- Erlick A C Pereira
- Department of Neurosurgery and Nuffield Department of Surgery, Oxford University Hospitals, Oxford, United Kingdom.
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Truini A, Garcia-Larrea L, Cruccu G. Reappraising neuropathic pain in humans--how symptoms help disclose mechanisms. Nat Rev Neurol 2013; 9:572-82. [PMID: 24018479 DOI: 10.1038/nrneurol.2013.180] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Neuropathic pain--that is, pain arising directly from a lesion or disease that affects the somatosensory system--is a common clinical problem, and typically causes patients intense distress. Patients with neuropathic pain have sensory abnormalities on clinical examination and experience pain of diverse types, some spontaneous and others provoked. Spontaneous pain typically manifests as ongoing burning pain or paroxysmal electric shock-like sensations. Provoked pain includes pain induced by various stimuli or even gentle brushing (dynamic mechanical allodynia). Recent clinical and neurophysiological studies suggest that the various pain types arise through distinct pathophysiological mechanisms. Ongoing burning pain primarily reflects spontaneous hyperactivity in nociceptive-fibre pathways, originating from 'irritable' nociceptors, regenerating nerve sprouts or denervated central neurons. Paroxysmal sensations can be caused by several mechanisms; for example, electric shock-like sensations probably arise from high-frequency bursts generated in demyelinated non-nociceptive Aβ fibres. Most human and animal findings suggest that brush-evoked allodynia originates from Aβ fibres projecting onto previously sensitized nociceptive neurons in the dorsal horn, with additional contributions from plastic changes in the brainstem and thalamus. Here, we propose that the emerging mechanism-based approach to the study of neuropathic pain might aid the tailoring of therapy to the individual patient, and could be useful for drug development.
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Affiliation(s)
- Andrea Truini
- Department of Neurology and Psychiatry, Sapienza University, Viale Università 30, 00185 Rome, Italy
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33
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Fridman GY, Della Santina CC. Safe direct current stimulation to expand capabilities of neural prostheses. IEEE Trans Neural Syst Rehabil Eng 2013; 21:319-28. [PMID: 23476007 DOI: 10.1109/tnsre.2013.2245423] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
While effective in treating some neurological disorders, neuroelectric prostheses are fundamentally limited because they must employ charge-balanced stimuli to avoid evolution of irreversible electrochemical reactions and their byproducts at the interface between metal electrodes and body fluids. Charge-balancing is typically achieved by using brief biphasic alternating current (AC) pulses, which typically excite nearby neural tissues but cannot efficiently inhibit them. In contrast, direct current (DC) applied via a metal electrode in contact with body fluids can excite, inhibit and modulate sensitivity of neurons; however, chronic DC stimulation is incompatible with biology because it violates charge injection limits that have long been considered unavoidable. In this paper, we describe the design and fabrication of a Safe DC Stimulator (SDCS) that overcomes this constraint. The SCDS drives DC ionic current into target tissue via salt-bridge micropipette electrodes by switching valves in phase with AC square waves applied to metal electrodes contained within the device. This approach achieves DC ionic flow through tissue while still adhering to charge-balancing constraints at each electrode-saline interface. We show the SDCS's ability to both inhibit and excite neural activity to achieve improved dynamic range during prosthetic stimulation of the vestibular part of the inner ear in chinchillas.
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Affiliation(s)
- Gene Y Fridman
- Department of Otolaryngology Head and Neck Surgery, Johns Hopkins University, Baltimore, MD 21208, USA.
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34
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Chew DJ, Murrell K, Carlstedt T, Shortland PJ. Segmental spinal root avulsion in the adult rat: a model to study avulsion injury pain. J Neurotrauma 2013; 30:160-72. [PMID: 22934818 DOI: 10.1089/neu.2012.2481] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Road traffic accidents are the most common cause of avulsion injury, in which spinal roots are torn from the spinal cord. Patients suffer from a loss of sensorimotor function, intractable spontaneous pain, and border-zone hypersensitivity. The neuropathic pains are particularly difficult to treat because the lack of a well-established animal model of avulsion injury prevents identifying the underlying mechanisms and hinders the development of efficacious drugs. This article describes a hindlimb model of avulsion injury in adult rats where the L5 dorsal and ventral spinal root are unilaterally avulsed (spinal root avulsion [SRA]), leaving the adjacent L4 spinal root intact. SRA produced a significant ipsilateral hypersensitivity to mechanical and thermal stimulation by 5 days compared with sham-operated or naïve rats. This hypersensitivity is maintained for up to 60 days. No autotomy was observed and locomotor deficits were minimal. The hypersensitivity to peripheral stimuli could be temporarily ameliorated by administration of amitriptyline and carbamazepine, drugs that are currently prescribed to avulsion patients. Histological assessment of the L4 ganglion cells revealed no significant alterations in calcitonin gene-related peptide (CGRP), IB4, transient receptor potential cation channel subfamily V member 1 (TrpV1), or N52 staining across groups. Immunohistochemistry of the spinal cord revealed a localized glial response, phagocyte infiltration, and neuronal loss within the ipsilateral avulsed segment. A comparable response from glia and phagocytes was also found in the intact L4 spinal cord, supporting the role for central mechanisms within the L4-5 spinal cord in contributing to the generation of the pain-related behavior. The SRA model provides a platform to investigate possible new pharmacological treatments for avulsion injuries.
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Affiliation(s)
- Daniel J Chew
- Centre for Neuroscience and Trauma, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Newark Street, London, United Kingdom.
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35
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Dong S, Hu Y, Du W, Tao W, Zhang X, Zhuang P, Li Y. Changes in Spontaneous Dorsal Horn Potentials after Dorsal Root Entry Zone Lesioning in Patients with Pain after Brachial Plexus Avulsion. J Int Med Res 2012; 40:1499-506. [PMID: 22971502 DOI: 10.1177/147323001204000429] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES: This study investigated spontaneous dorsal horn potentials in patients with pain after brachial plexus avulsion and determined the effect of dorsal root entry zone (DREZ) lesioning on these potentials and on pain levels. METHODS: Electrospinography (ESG) recordings were undertaken in seven patients using a noninvasive electrocorticography strip electrode. Measurements were taken from the DREZ on the intact side of the spinal cord before lesioning of the injured DREZ and from the injured DREZ before and after lesioning. RESULTS: DREZ lesioning had a significant positive effect on pain at 12 months postoperatively. At 15.0 Hz, the mean ESG power from the injured DREZ before lesioning was significantly higher than that from the intact DREZ. In addition, the mean ESG power from the injured DREZ after successful DREZ lesioning was significantly lower than that from the intact DREZ and that from the injured DREZ before lesioning. CONCLUSIONS: The ESG power from the injured DREZ increases in patients with pain after brachial plexus avulsion compared with that of the intact DREZ; this increase is reduced by successful DREZ lesioning.
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Affiliation(s)
- S Dong
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ys Hu
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - W Du
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - W Tao
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xh Zhang
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - P Zhuang
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yj Li
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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36
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Nguyen JP, Nizard J, Keravel Y, Lefaucheur JP. Invasive brain stimulation for the treatment of neuropathic pain. Nat Rev Neurol 2011; 7:699-709. [DOI: 10.1038/nrneurol.2011.138] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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