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Kato N, Kambe T, Chiba T, Taguchi K, Abe K. Analgesic effect of a cholinergic agonist (carbachol) in a sural nerve ligation-induced hypersensitivity mouse model. Neurol Res 2024; 46:505-515. [PMID: 38569563 DOI: 10.1080/01616412.2024.2337512] [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: 09/14/2023] [Accepted: 03/26/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVES Neuropathic pain is characterized by long-lasting, intractable pain. Sciatic nerve ligation is often used as an animal model of neuropathic pain, and the spared nerve injury (SNI) model, in which the common peroneal nerve (CPN) and tibial nerve (TN) are ligated, is widely used. In the present study, we evaluated the analgesic effect of a cholinergic agonist, carbachol, on a neuropathic pain model prepared by sural nerve (SN) ligation in mice. METHODS The SN was tightly ligated as a branch of the sciatic nerve. Mechanical and thermal allodynia, and hyperalgesia were assessed using von Frey filaments and heat from a hot plate. The analgesic effects of intracerebroventricularly-administered morphine and carbachol were compared. RESULTS SN ligation resulted in a significant decrease in pain threshold for mechanical stimulation 1 day after ligation. In response to thermal stimulation, allodynia was observed at 50°C and hyperalgesia at 53 and 56°C 3 days after ligation. Content of thiobarbituric acid reactive substances (TBARS) in the spinal cord increased significantly at 6 and 12 h after ligation. Acetylcholine content of the spinal cord also increased at 5 and 7 days after ligation. Intracerebroventricular administration of carbachol at 7 days after ligation produced a marked analgesic effect against mechanical and thermal stimuli, which was stronger and longer-lasting than morphine at all experimental time points. CONCLUSION These findings suggest that cholinergic nerves are involved in allodynia and hyperalgesia of the SN ligation neuropathic pain model.
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Affiliation(s)
- Nodoka Kato
- Department of Pharmacology, School of Pharmaceutical Sciences, Ohu University, Koriyama, Fukushima, Japan
| | - Toshie Kambe
- Department of Medicinal Pharmacology, Showa Pharmaceutical University, Machida, Tokyo, Japan
| | - Terumasa Chiba
- Faculty of Pharmaceutical Sciences, Nihon Pharmaceutical University, Saitama, Japan
| | - Kyoji Taguchi
- Department of Pharmacology, ShowaPharmaceutical University, Machida, Tokyo, Japan
| | - Kenji Abe
- Department of Pharmacology, School of Pharmaceutical Sciences, Ohu University, Koriyama, Fukushima, Japan
- Faculty of Pharmaceutical Sciences, Nihon Pharmaceutical University, Saitama, Japan
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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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Neurochirurgia del dolore. Neurologia 2023. [DOI: 10.1016/s1634-7072(22)47347-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Duraffourg M, Brinzeu A, Sindou M. How to Do It: Microsurgical DREZotomy for Pain After Brachial Plexus Injury: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E294-E295. [PMID: 33412582 DOI: 10.1093/ons/opaa380] [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: 01/15/2020] [Accepted: 09/06/2020] [Indexed: 11/14/2022] Open
Abstract
More than three-quarters of victims of brachial plexus injury suffer from refractory neuropathic pain.1-6 Main putative mechanism is paroxysmal hyperactivity in the dorsal horn neurons at the dorsal root entry zone (DREZ) as demonstrated by microelectrode recordings in animal models7 and patients.8 Pain relief can be achieved by lesioning the responsible neurons in the spinal cord segments with avulsed rootlets.9,10 This video illustrates the technique for microsurgical DREZotomy.11,12 A C3-C7 hemilaminectomy is performed to access the C4-Th1 medullary segments. After opening the dura and arachnoid, and freeing the cord from arachnoid adhesions, the dorsolateral sulcus is identified. Identification can be difficult when the spinal cord is distorted and/or has a loss of substance. The dorsolateral sulcus is then opened with a microknife, so that microcoagulations are performed: 4 mm deep, at 35° angle in the axis of the dorsal horn, every millimeter in a dotted fashion along the avulsed segments. Care should be taken not to damage the corticospinal tract, laterally, and the dorsal column, medially. The patient consents to the procedure. In the presented case, surgery led to complete disappearance of the paroxysmal pain and reduced the background of burning pain to a bearable level without the need of opioid medication. There was no motor deficit or ataxia in the ipsilateral lower limb postoperatively. According to Kaplan-Meier analysis at 10 yr follow-up, in our overall series, microsurgical DREZotomy achieved total pain relief without any medication in 60% of patients, and in 85% without the need for opioids.10,13-15 Microelectrode recording at 1:26 reproduced from Guenot et al7 with permission from JNSPG.
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Affiliation(s)
- Manon Duraffourg
- Department of Neurosurgery, CHU Saint Etienne, Saint Priest en Jarez, France
| | - Andrei Brinzeu
- University of Lyon 1, Lyon, France.,University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
| | - Marc Sindou
- University of Lyon 1, Lyon, France.,University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
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Comparison of Different In Vivo Animal Models of Brachial Plexus Avulsion and Its Application in Pain Study. Neural Plast 2020; 2020:8875915. [PMID: 33273909 PMCID: PMC7676973 DOI: 10.1155/2020/8875915] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/26/2020] [Accepted: 10/29/2020] [Indexed: 01/11/2023] Open
Abstract
Brachial plexus injuries (BPIs) are high-energy trauma that can result in serious functional problems in the affected upper extremities, and brachial plexus avulsion (BPA) could be considered the most severe type of them. The booming occurrence rate of BPA brings up devastating impact on patients' life. Complications of muscle atrophy, neuropathic pain, and denervation-associated psychological disorders are major challenges in the treatment of BPA. Animal models of BPA are good vehicles for this kind of research. Full understanding of the current in vivo BPA models, which could be classified into anterior approach avulsion, posterior approach avulsion, and closed approach avulsion groups, could help researchers select the appropriate type of models for their studies. Each group of the BPA model has its distinct merits and demerits. An ideal BPA model that can inherit the advantages and make up for the disadvantages is still required for further exploration.
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Guo J, Gao K, Zhou Y, Zhao X, Lao J. Comparison of neuropathic pain characteristics associated with total brachial plexus injury before and after surgical repair: A retrospective study. Clin Neurol Neurosurg 2020; 191:105692. [PMID: 32087463 DOI: 10.1016/j.clineuro.2020.105692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/15/2019] [Accepted: 01/22/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The goal of this study was to compare clinical characteristics of neuropathic pain associated with total brachial plexus injury before and after surgeries and to correlate possible contributing factors concerning to the pain prognosis. PATIENTS AND METHODS Thirty patients with both total brachial plexus injury and neuropathic pain were included. Neuropathic pain was evaluated in terms of pain intensities, symptoms and regions. Pain intensities were evaluated by a visual analogue scale. The Neuropathic Pain Symptoms Inventory questionnaire and body maps were used to compare the pain symptoms and regions. Demographic data, injury and repair information were evaluated to analyze the possible factors influencing the prognosis. RESULTS The average pain score of all participants was 7.13 ± 2.46 preoperatively and 5.40 ± 2.08 postoperatively. All patients were divided into Pain Relief Group and Pain Aggravation Group. Older age (p = 0.042), machine traction injury (p = 0.019)and nerve transplantation(p = 0.015) seemed to be related with pain aggravation. Paroxysmal pain was aggravated after surgical repairs (p = 0.041), while paresthesia/dysesthesia improved after surgery (p = 0.003). The permanent component of the pain (spontaneous pain) did not show any significant change (p = 0.584). Pain in C5 (p < 0.001) and C6 (p = 0.031) dermatomes got relieved after surgery. CONCLUSION This study revealed the neuropathic pain of most patients with total brachial plexus injury was alleviated after neurosurgery, and the pain prognosis of different symptoms and regions varied after the nerve repair.
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Affiliation(s)
- Jinding Guo
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Kaiming Gao
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China; Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, People's Republic of China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China
| | - Yingjie Zhou
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China; Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, People's Republic of China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China
| | - Xin Zhao
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China; Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, People's Republic of China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China
| | - Jie Lao
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China.
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North RY, Lazaro TT, Dougherty PM. Ectopic Spontaneous Afferent Activity and Neuropathic Pain. Neurosurgery 2018; 65:49-54. [PMID: 31076785 DOI: 10.1093/neuros/nyy119] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/04/2018] [Indexed: 12/17/2022] Open
Affiliation(s)
- Robert Y North
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Tyler T Lazaro
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Patrick M Dougherty
- The Departments of Pain Medicine Research, The Division of Anesthesia, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Bipolar dual-lead spinal cord stimulation between two electrodes on the ventral and dorsal sides of the spinal cord: consideration of putative mechanisms. Acta Neurochir (Wien) 2018; 160:639-643. [PMID: 29224084 DOI: 10.1007/s00701-017-3421-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 11/29/2017] [Indexed: 10/18/2022]
Abstract
We have applied bipolar dual-lead spinal cord stimulation (SCS) between two cylinder-type electrodes placed on the ventral and dorsal sides of the spinal cord (dual-VD-SCS). A 36-year-old man suffered from burning pain from his right elbow down to his hand after brachial plexus avulsion. The areas with paresthesia induced by conventional SCS did not include the painful hand area. However, dual-VD-SCS completely induced paresthesia in the painful hand area. We speculate that dual-VD-SCS can be applied to stimulate deeper sites of the dorsal column and dorsal horn than conventional SCS and is useful for pain reduction.
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Hruby LA, Pittermann A, Sturma A, Aszmann OC. The Vienna psychosocial assessment procedure for bionic reconstruction in patients with global brachial plexus injuries. PLoS One 2018; 13:e0189592. [PMID: 29298304 PMCID: PMC5751989 DOI: 10.1371/journal.pone.0189592] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 11/13/2017] [Indexed: 01/01/2023] Open
Abstract
Background Global brachial plexopathies cause major sensory and motor deficits in the affected arm and hand. Many patients report of psychosocial consequences including chronic pain, decreased self-sufficiency, and poor body image. Bionic reconstruction, which includes the amputation and prosthetic replacement of the functionless limb, has been shown to restore hand function in patients where classic reconstructions have failed. Patient selection and psychological evaluation before such a life-changing procedure are crucial for optimal functional outcomes. In this paper we describe a psychosocial assessment procedure for bionic reconstruction in patients with complete brachial plexopathies and present psychosocial outcome variables associated with bionic reconstruction. Methods Between 2013 and 2017 psychosocial assessments were performed in eight patients with global brachial plexopathies. We conducted semi-structured interviews exploring the psychosocial adjustment related to the accident, the overall psychosocial status, as well as motivational aspects related to an anticipated amputation and expectations of functional prosthetic outcome. During the interview patients were asked to respond freely. Their answers were transcribed verbatim by the interviewer and analyzed afterwards on the basis of a pre-defined item scoring system. The interview was augmented by quantitative evaluation of self-reported mental health and social functioning (SF-36 Health Survey), body image (FKB-20) and deafferentation pain (VAS). Additionally, psychosocial outcome variables were presented for seven patients before and after bionic reconstruction. Results Qualitative data revealed several psychological stressors with long-term negative effects on patients with complete brachial plexopathies. 88% of patients felt functionally limited to a great extent due to their disability, and all of them reported constant, debilitating pain in the deafferented hand. After bionic reconstruction the physical component summary scale increased from 30.80 ± 5.31 to 37.37 ± 8.41 (p-value = 0.028), the mental component summary scale improved from 43.19 ± 8.32 to 54.76 ± 6.78 (p-value = 0.018). VAS scores indicative of deafferentation pain improved from 7.8 to 5.6 after prosthetic hand replacement (p-value = 0.018). Negative body evaluation improved from 60.71 ± 12.12 to 53.29 ± 11.03 (p-value = 0.075). Vital body dynamics increased from 38.57 ± 13.44 to 44.43 ± 16.15 (p-value = 0.109). Conclusions Bionic reconstruction provides hope for patients with complete brachial plexopathies who have lived without hand function for years or even decades. Critical patient selection is crucial and the psychosocial assessment procedure including a semi-structured interview helps identify unresolved psychological issues, which could preclude or delay bionic reconstruction. Bionic reconstruction improves overall quality of life, restores an intact self-image and reduces deafferentation pain.
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Affiliation(s)
- Laura Antonia Hruby
- Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Anna Pittermann
- General Hospital of Vienna, Department of Clinical Psychology, Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Agnes Sturma
- Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Health Assisting Engineering, University of Applied Sciences FH Campus, Vienna, Austria
| | - Oskar Christian Aszmann
- Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
- * E-mail:
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10
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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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11
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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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Teixeira MJ, da Paz MGDS, Bina MT, Santos SN, Raicher I, Galhardoni R, Fernandes DT, Yeng LT, Baptista AF, de Andrade DC. Neuropathic pain after brachial plexus avulsion--central and peripheral mechanisms. BMC Neurol 2015; 15:73. [PMID: 25935556 PMCID: PMC4429458 DOI: 10.1186/s12883-015-0329-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 04/21/2015] [Indexed: 02/03/2023] Open
Abstract
REVIEW The pain that commonly occurs after brachial plexus avulsion poses an additional burden on the quality of life of patients already impaired by motor, sensory and autonomic deficits. Evidence-based treatments for the pain associated with brachial plexus avulsion are scarce, thus frequently leaving the condition refractory to treatment with the standard methods used to manage neuropathic pain. Unfortunately, little is known about the pathophysiology of brachial plexus avulsion. Available evidence indicates that besides primary nerve root injury, central lesions related to the abrupt disconnection of nerve roots from the spinal cord may play an important role in the genesis of neuropathic pain in these patients and may explain in part its refractoriness to treatment. CONCLUSIONS The understanding of both central and peripheral mechanisms that contribute to the development of pain is of major importance in order to propose more effective treatments for brachial plexus avulsion-related pain. This review focuses on the current understanding about the occurrence of neuropathic pain in these patients and the role played by peripheral and central mechanisms that provides insights into its treatment. Pain after brachial plexus avulsion involves both peripheral and central components; thereby it is characterized as a mixed (central and peripheral) neuropathic pain syndrome.
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Affiliation(s)
- Manoel Jacobsen Teixeira
- Pain Center, Department of Neurology, University of São Paulo, São Paulo, Brazil.
- Pain Center, Instituto do Câncer de São Paulo, São Paulo, Brazil.
- Service of Interdisciplinary Neuromodulation (SIN), Department and Institute of Psychiatry, University of São Paulo, São Paulo, Brazil.
| | | | - Mauro Tupiniquim Bina
- Functional Electrostimulation Laboratory, Federal University of Bahia, São Paulo, Brazil.
| | | | - Irina Raicher
- Pain Center, Department of Neurology, University of São Paulo, São Paulo, Brazil.
- Pain Center, Instituto do Câncer de São Paulo, São Paulo, Brazil.
| | - Ricardo Galhardoni
- Pain Center, Department of Neurology, University of São Paulo, São Paulo, Brazil.
- Service of Interdisciplinary Neuromodulation (SIN), Department and Institute of Psychiatry, University of São Paulo, São Paulo, Brazil.
| | | | - Lin T Yeng
- Pain Center, Department of Neurology, University of São Paulo, São Paulo, Brazil.
- Centro de Dor, Instituto de Ortopedia e Traumatologia, University of São Paulo, São Paulo, Brazil.
| | - Abrahão F Baptista
- Functional Electrostimulation Laboratory, Federal University of Bahia, São Paulo, Brazil.
| | - Daniel Ciampi de Andrade
- Pain Center, Department of Neurology, University of São Paulo, São Paulo, Brazil.
- Pain Center, Instituto do Câncer de São Paulo, São Paulo, Brazil.
- Service of Interdisciplinary Neuromodulation (SIN), Department and Institute of Psychiatry, University of São Paulo, São Paulo, Brazil.
- Divisão de Clínica Neurocirúrgica do Hospital das Clínicas da FMUSP, Secretaria da Neurologia, Instituto Central, Av. Dr. Enéas de Carvalho Aguiar, 255, 5° andar, sala 5084 - Cerqueira César, 05403-900, São Paulo, SP, Brazil.
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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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Ali M, Saitoh Y, Oshino S, Hosomi K, Kishima H, Morris S, Shibata M, Yoshimine T. Differential efficacy of electric motor cortex stimulation and lesioning of the dorsal root entry zone for continuous vs paroxysmal pain after brachial plexus avulsion. Neurosurgery 2012; 68:1252-7; discussion 1257-8. [PMID: 21307799 DOI: 10.1227/neu.0b013e31820c04a9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pain after traumatic brachial plexus avulsion (BPA) has 2 distinct patterns: continuous burning pain and paroxysmal shooting pain. Lesioning of the dorsal root entry zone (DREZotomy) is more effective for paroxysmal than continuous pain. It is unknown, however, whether electric motor cortex stimulation (EMCS) has a differential effect on continuous vs paroxysmal BPA pain. OBJECTIVE To analyze the differential effect of EMCS and DREZotomy on continuous vs paroxysmal BPA pain in a series of 15 patients. METHODS Fifteen patients with intractable BPA pain underwent DREZotomy alone (n = 7), EMCS alone (n = 4), or both procedures (n = 4). Pain intensity was evaluated with the Visual Analog Scale, and separate ratings were recorded for paroxysmal and continuous pain. Pain relief was categorized as excellent (> 75% pain relief), good (50%-75%), or poor (< 50%). Favorable outcome was defined as good or better pain relief. RESULTS Eight patients had EMCS; 7 were followed up for an average of 47 months. Of those 7 patients, 3 (42%) with continuous pain had favorable outcomes compared with no patients with paroxysmal pain. Eleven patients had DREZotomy; 10 were followed up for an average of 31 months. Of those 10 patients, 7 (70%) with paroxysmal pain had favorable outcomes compared with 2 (20%) with continuous pain. CONCLUSION EMCS was ineffective for paroxysmal pain but moderately effective for continuous pain. DREZotomy was highly effective for paroxysmal pain but moderately effective for continuous pain. It may be prudent to use EMCS for residual continuous pain after DREZotomy.
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Affiliation(s)
- Mohamed Ali
- Neurosurgery Department, Mansoura University, Mansoura, Egypt
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15
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Abe K, Fujii Y, Nojima H. Evaluation of hyperalgesia in spared nerve injury model using mechanical, thermal, and chemical stimuli in the mouse. Neurol Res 2012; 33:656-62. [PMID: 21708075 DOI: 10.1179/1743132810y.0000000019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Neuropathic pain results from multiple etiological factors and is a debilitating condition often resulting from partial injury to a peripheral nerve. However, the mechanism underlying this syndrome remains unclear. The aim of the present study is to investigate whether a spared nerve injury model with transection of both the common peroneal nerve (CPN) and tibial nerve (TN) branches of the sciatic nerve is associated with pain or hypersensitivity in the mouse. METHODS A skin and muscle incision was made, and we tightly ligated CPN+TN or the sural nerve (SN) alone as branches of the sciatic nerve. Mechanical and thermal allodynia were tested using von Frey filaments and radiant heat at -1, 1, 3, 5, and 7 days after surgery. RESULTS The thresholds of mechanical and thermal stimuli were increased and decreased in the CPN+TN-ligated and SN-ligated groups, respectively. Chemical hyperalgesia was estimated using two doses of intraplantar administration of formalin (0.1 and 1%) 1 week after surgery. Then behaviors were videotaped and playback was used to measure time of licking of the hind paws. The licking time induced by 0.1% formalin was significantly shortened in the CPN+TN-ligated group and significantly prolonged in the SN-ligated group. Number of c-Fos-immunoreactive cells in the spinal cord was not affected by CPN+TN ligation, but was significantly increased in the SN-ligated group. DISCUSSION These findings suggest that changing the combination of nerves in sciatic branch ligation produces different sensitivities to stimuli and SN ligation will be useful for inducing allodynia and hyperalgesia in the mouse.
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Affiliation(s)
- Kenji Abe
- Department of Pharmacology, School of Pharmaceutical Sciences, Ohu University, Fukushima, Japan
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16
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Chew DJ, Carlstedt T, Shortland PJ. A comparative histological analysis of two models of nerve root avulsion injury in the adult rat. Neuropathol Appl Neurobiol 2011; 37:613-32. [DOI: 10.1111/j.1365-2990.2011.01176.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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17
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Dorsal root entry zone lesioning for pain after brachial plexus avulsion: Results with special emphasis on differential effects on the paroxysmal versus the continuous components. A prospective study in a 29-patient consecutive series. Pain 2011; 152:1923-1930. [DOI: 10.1016/j.pain.2011.03.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 03/27/2011] [Accepted: 03/28/2011] [Indexed: 02/03/2023]
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Fouad W. Management of generalized spasticity of lower limbs by selective posterior rhizotomy. ALEXANDRIA JOURNAL OF MEDICINE 2011. [DOI: 10.1016/j.ajme.2011.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Wael Fouad
- Alexandria Faculty of Medicine Neurosurgery Department Alexandria Egypt
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19
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Abstract
Pain, motor, and sensory deficits characterize patients with a traumatic lesion of the brachial plexus. Frequently, more severe injuries co-exist that require immediate surgical attention. Early rehabilitation and physical therapy are the cornerstones of treatment. Pharmacological management can be difficult. Surgical reconstruction is frequently advised when nerves are disrupted. The results, mostly from small historical reports, vary greatly. Neurostimulation may have an additional beneficial effect, especially if the pathophysiology of nociception and neuropathic pain becomes evident in these complex patients.
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Affiliation(s)
- Robert van Dongen
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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20
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Surgery in the DREZ for Refractory Neuropathic Pain After Spinal Cord/Cauda Equina Injury. World Neurosurg 2011; 75:447-8. [DOI: 10.1016/j.wneu.2011.01.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 01/27/2011] [Indexed: 11/24/2022]
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21
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Wu A, Lauschke JL, Morris R, Waite PM. Characterization of Rat Forepaw Function in Two Models of Cervical Dorsal Root Injury. J Neurotrauma 2009; 26:17-29. [DOI: 10.1089/neu.2008.0675] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Ann Wu
- Neural Injury Research Unit, School of Medical Sciences, University of New South Wales, New South Wales, Sydney, Australia
| | - Jenny L. Lauschke
- Neural Injury Research Unit, School of Medical Sciences, University of New South Wales, New South Wales, Sydney, Australia
| | - Renée Morris
- Neural Injury Research Unit, School of Medical Sciences, University of New South Wales, New South Wales, Sydney, Australia
| | - Phil M.E. Waite
- Neural Injury Research Unit, School of Medical Sciences, University of New South Wales, New South Wales, Sydney, Australia
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22
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Kanpolat Y, Tuna H, Bozkurt M, Elhan AH. Spinal and Nucleus Caudalis Dorsal Root Entry Zone Operations for Chronic Pain. Oper Neurosurg (Hagerstown) 2008; 62:235-42; discussion 242-4. [DOI: 10.1227/01.neu.0000317398.93218.e0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objective:
Dorsal root entry zone (DREZ) operations came into medical practice after the demonstration of increased electrical activity in the dorsal horn of the spinal cord and brainstem in patients with deafferentation of the central nervous system after injury to these areas. The aim of the study was to describe the technique and the effectiveness of spinal DREZ and nucleus caudalis (NC) DREZ operations, which may be the treatments of choice in unique chronic pain conditions that do not respond to medical therapy or any other surgical methods.
Methods:
Fifty-five patients (44 spinal, 11 NC DREZ) underwent 59 (48 spinal, 11 NC DREZ) operations. There were 44 men and 11 women with a mean age of 46.4 years (range, 24–74 yr). The mean follow-up period was 72 months (range, 6 mo–20 yr). Follow-up assessments were performed with clinical examination on the first day and in the sixth and twelfth months postoperatively. Patients' pain scores and Karnofsky Performance Scale scores were also evaluated pre- and postoperatively.
Results:
The initial success rates for spinal and NC DREZotomy procedures were 77 and 72.5%, respectively. In the spinal DREZotomy group, mortality occurred in one patient (2.2%). There were two cases of transient muscle weakness (4.4%) and two of cerebrospinal fluid fistulae (4.4%). In the NC DREZotomy group, mortality occurred in one patient (9%). There were two cases of transient ataxia (18%) and two of transient hemiparesis (18%).
Conclusion:
Spinal and trigeminal NC DREZ operations are effective in the treatment of intractable pain syndromes, especially in traumatic brachial plexus avulsions, segmental pain after spinal cord injury, postherpetic neuralgia, topographically limited cancer pain, and atypical facial pain.
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Affiliation(s)
- Yucel Kanpolat
- Department of Neurosurgery, Ankara University School of Medicine, Ankara, Turkey
| | - Hakan Tuna
- Department of Neurosurgery, Ankara University School of Medicine, Ankara, Turkey
| | - Melih Bozkurt
- Department of Neurosurgery, Ankara University School of Medicine, Ankara, Turkey
| | - Atilla Halil Elhan
- Department of Biostatistics, Ankara University School of Medicine, Ankara, Turkey
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23
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Garcia-Larrea L, Magnin M. Physiopathologie de la douleur neuropathique : revue des modèles expérimentaux et des mécanismes proposés. Presse Med 2008; 37:315-40. [DOI: 10.1016/j.lpm.2007.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2007] [Accepted: 07/02/2007] [Indexed: 01/22/2023] Open
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24
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Cell death after dorsal root injury. Neurosci Lett 2008; 433:231-4. [PMID: 18280043 DOI: 10.1016/j.neulet.2008.01.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 01/09/2008] [Accepted: 01/10/2008] [Indexed: 01/03/2023]
Abstract
Flow cytometry and terminal deoxynucleotidyl transferase-mediated biotinylated uridine triphosphate nick end-labelling (TUNEL) immunohistochemistry have been used to assess cell death in the dorsal root ganglia (DRG) or spinal cord 1, 2 or 14 days after multiple lumbar dorsal root rhizotomy or dorsal root avulsion injury in adult rats. Neither injury induced significant cell death in the DRG compared to sham-operated or naïve animals at any time point. In the spinal cord, a significant increase in death was seen at 1-2 days, but not 14 days, post injury by both methods. TUNEL staining revealed that more apoptotic cells were present in the dorsal columns and dorsal horn of avulsion animals compared to rhizotomised animals. This suggests that avulsion injury, which can often partially damage the spinal cord, has more severe effects on cell survival than rhizotomy, a surgical lesion which does not affect the spinal cord. The location of TUNEL positive cells suggests that both neuronal and non-neuronal cells are dying.
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25
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Guenot M, Lee JW, Nasirinezhad F, Sagen J. Deafferentation Pain Resulting from Cervical Posterior Rhizotomy is Alleviated by Chromaffin Cell Transplants into the Rat Spinal Subarachnoid Space. Neurosurgery 2007; 60:919-25; discussion 919-25. [PMID: 17460528 DOI: 10.1227/01.neu.0000255435.29118.3d] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Deafferentation pain is common after posttraumatic brachial plexus avulsion in humans. Alleviation of such pain is poorly achieved by most therapeutic interventions; the only efficient neurosurgical procedure currently available is lesioning of the dorsal root entry zone. Previous work has demonstrated that adrenal medullary transplants into the lumbar spinal subarachnoid space can alleviate neuropathic pain behavior resulting from peripheral nerve or spinal cord injury. The purpose of this study was to evaluate the potential effects of adrenal medullary transplants on brachial plexus deafferentation pain. METHODS The cervical posterior rhizotomy model was selected as an upper segmental deafferentation model because it mimics the pathological situation after traumatic brachial plexus avulsion in humans. Animals underwent a right posterior cervical rhizotomy extending from C5 to T1 and received either adrenal medullary transplants or control striated muscle transplants into the cervical subarachnoid space. The clinical evolution was evaluated daily for self-directed behaviors indicative of ongoing pain, including onset, dermatomal extent, and severity. RESULTS In animals with muscle control transplants, self-directed behaviors appeared in 83.3% of the group, with a mean delay between rhizotomy and onset of self-directed behaviors of 8 days. In contrast, only 30.8% of the animals implanted with chromaffin cells exhibited any signs of self-directed behaviors, and these had a mean onset delay of 14 days. CONCLUSION The suppression of self-directed behaviors by adrenal medullary transplants is similar to that observed after dorsal root entry zone lesioning and suggests that this approach may offer a nonablative alternative in the management of deafferentation pain resulting from dorsal root avulsion.
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Raslan AM, McCartney S, Burchiel KJ. Management of chronic severe pain: spinal neuromodulatory and neuroablative approaches. ACTA NEUROCHIRURGICA. SUPPLEMENT 2007; 97:33-41. [PMID: 17691354 DOI: 10.1007/978-3-211-33079-1_4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The spinal cord is the target of many neurosurgical procedures used to treat pain. Compactness and well-defined tract separation in addition to well understood dermatomal cord organization make the spinal cord an ideal target for pain procedures. Moreover, the presence of opioid and other receptors involved in pain modulation at the level of the dorsal horn increases the suitability of the spinal cord. Neuromodulative approaches of the spinal cord are either electrical or pharmacological. Electrical spinal cord modulation is used on a large scale for various pain syndromes including; failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), neuropathic pain, angina, and ischemic limb pain. Intraspinal delivery of medications e.g. opioids is used to treat nociceptive and neuropathic pains due to malignant and cancer pain etiologies. Neuroablation of the spinal cord pain pathway is mainly used to treat cancer pain. Targets involved include; the spinothalamic tract, the midline dorsal column visceral pain pathway and the trigeminal tract in the upper spinal cord. Spinal neuroablation can also involve cellular elements such as with trigeminal nucleotomy and the dorsal root entry zone (DREZ) operation. The DREZ operation is indicated for phantom type pain and root avulsion injuries. Due to its reversible nature spinal neuromodulation prevails, and spinal neuroablation is performed in a few select cases.
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Affiliation(s)
- A M Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland 97239, USA.
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27
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Kanpolat Y, Savas A, Ugur HC, Bozkurt M. The trigeminal tract and nucleus procedures in treatment of atypical facial pain. ACTA ACUST UNITED AC 2005; 64 Suppl 2:S96-100; discussion S100-1. [PMID: 16256853 DOI: 10.1016/j.surneu.2005.07.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2005] [Indexed: 11/23/2022]
Abstract
BACKGROUND Atypical facial pain (AFP) is a throbbing pain situated deep in the eye and malar region, often radiating to the ear, neck, and shoulders. The pain generally is not within any dermatomal or anatomical boundaries. Atypical facial pain is distinct from trigeminal neuralgia and its variants. Therefore, the treatment of AFP should be specified. There is also no consensus in the treatment of AFP. Two different treatment procedures on the trigeminal tract and nucleus in a series of cases with AFP are presented. METHODS Between 1989 and 2005, 17 patients with AFP, in whom previous therapies had failed, underwent computed tomography (CT)-guided percutaneous trigeminal tractotomy-nucleotomy (TR-NC). One patient with unfavorable response to TR-NC underwent trigeminal dorsal root entry zone (DREZ) operation. RESULTS In the series with AFP, pain relief was achieved in all of the 17 cases. TR-NC provided maximum to inadequate degrees of pain relief in 16 of 17 patients. Dorsal root entry zone operation provided partial relief in 1 case. Neither mortality nor serious permanent complication was observed in the series. CONCLUSION Neurosurgical procedures such as TR-NC or trigeminal DREZ operation may be effective in the treatment of intractable AFP. The primary choice of operation should be TR-NC because this procedure is minimally invasive. Trigeminal DREZ operation, which affects a larger spread area, may follow if TR-NC fails. The indications and procedure of choice should be individually tailored, depending on the type of pain, underlying pathology, and experience of the surgeon.
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Affiliation(s)
- Yücel Kanpolat
- Department of Neurosurgery, School of Medicine, Ankara University, Ankara 06100, Turkey.
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28
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Sindou MP, Blondet E, Emery E, Mertens P. Microsurgical lesioning in the dorsal root entry zone for pain due to brachial plexus avulsion: a prospective series of 55 patients. J Neurosurg 2005; 102:1018-28. [PMID: 16028760 DOI: 10.3171/jns.2005.102.6.1018] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECT Most patients with preganglionic lesions after brachial plexus injuries suffer pain that is hard to control through medication or neuromodulation. Lesioning in the dorsal root entry zone (DREZ) is undeniably effective. Fifty-five patients who had undergone the so-called microsurgical DREZotomy (MDT) procedure were studied with the two following objectives: 1) to describe the anatomical lesions observed during MDT in correlation with sensory deficits and pain features; and 2) to analyze the results in the 44 patients who were followed for more than 1 year (mean 6 years). METHODS The observed lesions were severe: 79.6% of ventral and 78.2% of dorsal roots from C5-T1 were impaired. Damage extended to all five roots in 42% of patients. Strong arachnoiditis was present in 38.2%, pseudomeningoceles in 31%, spinal cord distortion and/or atrophy in 49%, and abundant gliotic tissue and/or microcavitations within the dorsal horn at the avulsed segments in 36.4% of cases. Sensory deficit corresponded to the entire territory of the dorsal root lesions in 52% of patients, but was larger in 30% most certainly due to the associated extrarachidian lesions. At the last evaluation after MDT, 66% of patients showed excellent (total relief without medication) or good (total relief with medication) pain relief and 71% experienced an improvement in activity level. CONCLUSIONS Apart from other indications not addressed in this article, MDT can be performed to treat refractory pain due to brachial plexus avulsions. The long-term efficacy of this procedure strongly indicates that pain after brachial plexus avulsion originates from the deafferented (and gliotic) dorsal horn.
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Affiliation(s)
- Marc P Sindou
- Department of Neurosurgery, Pierre Wertheimer Neurological Hospital, University of Lyon, France.
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