Microsurgical lesioning in the dorsal root entry zone for pain due to brachial plexus avulsion: a prospective series of 55 patients.
OBJECTIVE
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.
Sindou
Marc P
MP
Department of Neurosurgery, Pierre Wertheimer Neurological Hospital, University of Lyon, France. marc.sindou@chu-lyon.fr
Blondet
Eric
E
Emery
Evelyne
E
Mertens
Patrick
P
D000293:Adolescent; D000328:Adult; D000368:Aged; D001917:Brachial Plexus / Q000293:injuries / Q000473:pathology / Q000601:surgery*; D020516:Brachial Plexus Neuropathies / Q000150:complications / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D009437:Neuralgia / Q000209:etiology / Q000473:pathology / Q000601:surgery*; D009460:Neurologic Examination; D019635:Neurosurgical Procedures / Q000379:methods; D020671:Posterior Horn Cells / Q000473:pathology; D011446:Prospective Studies; D013126:Spinal Nerve Roots / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome