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.

Department of Anesthesiology and Critical Care Medicine 3rd Faculty of Medicine Charles University Hospital Kralovske Vinohrady Prague Czech Republic

Department of Neurosurgery 3rd Faculty of Medicine Charles University Hospital Kralovske Vinohrady Srobarova 50 100 34 Prague Czech Republic

See more in PubMed

Aichaoui F, Mertens P, Sindou M. 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(8):1923–1930. doi: 10.1016/j.pain.2011.03.037. PubMed DOI

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(6):1018–1028. doi: 10.3171/jns.2005.102.6.1018. PubMed DOI

Bertelli JA, Ghizoni MF. Concepts of nerve regeneration and repair applied to brachial plexus reconstruction. Microsurgery. 2006;26(4):230–244. doi: 10.1002/micr.20234. PubMed DOI

Ambler Z, Bednařík J, Keller O. Recommended method of treatment of neuropathic pain. Cesk Slov Neurol N. 2002;65(3):135–138.

Attal N, Cruccu G, Baron R, Haanpää M, Hansson P, Jensen TS, Nurmikko T. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2009 revision. Eur J Neurol. 2010;17:1113–e88. doi: 10.1111/j.1468-1331.2010.02999.x. PubMed DOI

Bonilla G, Di Masi G, Battaglia D, Otero JM, Socolovsky M. Pain and brachial plexus lesions: evaluation of initial outcomes after reconstructive microsurgery and validation of a new pain severity scale. Acta Neurochir (Wien) 2011;153(1):171–176. doi: 10.1007/s00701-010-0709-3. PubMed DOI

Haninec P, Tomáš R, Sereghy T, Houšťava L. Drez thermocoagulation in treatment of deafferentation pain. Bolest. 2002;5(3):177–180.

Nashold BS, Ostdahl RH. Dorsal root entry zone lesions for pain relief. J Neurosurg. 1979;51:59–69. doi: 10.3171/jns.1979.51.1.0059. PubMed DOI

Sindou M. Microsurgical DREZotomy (MDT) for pain, spasticity, and hyperactive bladder: A 20-year experience. Acta Neurochir. 1995;137(1–2):1–5. doi: 10.1007/BF02188771. PubMed DOI

Tomáš R, Haninec P. Dorsal root entry zone (DREZ) localization using direct spinal cord stimulation can improve results of the DREZ termocoagulation procedure for intractable pain relief. Pain. 2005;116:159–163. doi: 10.1016/j.pain.2005.03.015. PubMed DOI

Spaić M, Ivanović S, Slavik E, Antić B. DREZ (dorsal root entry zone) surgery for the treatment of the postherpetic intercostal neuralgia. Acta Chir Iugosl. 2004;51(4):53–57. doi: 10.2298/ACI0404053S. PubMed DOI

Freynhagen R, Baron R, Gockel U, Tölle TR. painDETECT: A new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin. 2006;22(10):1911–1920. doi: 10.1185/030079906X132488. PubMed DOI

Chen HJ, Tu YK. Long term follow-up results of dorsal root entry zone lesions for intractable pain after brachial plexus avulsion injuries. Acta Neurochir Suppl. 2006;99:73–75. doi: 10.1007/978-3-211-35205-2_14. PubMed DOI

Ruiz-Juretschke F, García-Salazar F, García-Leal R, Fernández-Carballal C, Iza B, Garbizu JM, García-Duque S, Panadero T. Treatment of neuropathic deafferentation pain using DREZ lesions; long-term results. Neurologia. 2011;26(1):26–31. doi: 10.1016/j.nrl.2010.10.003. PubMed DOI

Zheng Z, Hu Y, Tao W, Zhang X, Li Y. Dorsal root entry zone lesions for phantom limb pain with brachial plexus avulsion: A study of pain and phantom limb sensation. Stereotact Funct Neurosurg. 2009;87(4):249–255. doi: 10.1159/000225978. PubMed DOI

Campbell JN, Solomon CT, James CS. The Hopkins experience with lesions of the dorsal horn (Nashold’s operation) for pain from avulsion of the brachial plexus. Appl Neurophysiol. 1988;51:170–174. PubMed

Samii M, Bear-Henney S, Ludemann W, Tatagiba M, Blomer U. Treatment of Refractory Pain after Brachial Plexus Avulsion with Dorsal Root Entry Zone Lesions. Neurosurgery. 2001;48:1269–1275. PubMed

Fazl M, Houlden DA, Kiss Z. Spinal cord mapping with evoked responses for accurate localization of the dorsal root entry zone. J Neurosurg. 1995;82:587–591. doi: 10.3171/jns.1995.82.4.0587. PubMed DOI

Aly MM, Saitoh Y, Kishima H, Hosomi K, Yoshimine T. Importance of distinction between paroxysmal and continuous patterns of pain during evaluation of pain after brachial plexus injury. Acta Neurochir (Wien) 2011;153(2):437–438. doi: 10.1007/s00701-010-0874-4. PubMed DOI

Hallström H, Norrbrink C. Screening tools for neuropathic pain: Can they be of use in individuals with spinal cord injury? Pain. 2011;152(4):772–779. doi: 10.1016/j.pain.2010.11.019. PubMed DOI

Haroutiunian S, Nikolajsen L, Finnerup NB, Jensen TS. The neuropathic component in persistent postsurgical pain: A systematic literature review. Pain. 2013;154(1):95–102. doi: 10.1016/j.pain.2012.09.010. PubMed DOI

Karatas A, Caglar S, Savas A, Elhan A, Erdogan A. Microsurgical anatomy of the dorsal cervical rootlets and dorsal root entry zones. Acta Neurochir. 2005;147(2):195–199. doi: 10.1007/s00701-004-0425-y. PubMed DOI

Gilbert A, Pivato G, Kheiralla T. Long-term results of primary repair of brachial plexus lesions in children. Microsurgery. 2006;26(4):334–342. doi: 10.1002/micr.20248. PubMed DOI

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. 2011;68(5):1252–1257. PubMed

Carlstedt T, Anand P, Htut M, Misra P, Svensson M. Restoration of hand function and so called “breathing arm” after intraspinal repair of C5-T1 brachial plexus avulsion injury, Case report. Neurosurg Focus. 2004;16(5):E7. doi: 10.3171/foc.2004.16.5.8. PubMed DOI

Bertelli JA, Ghizoni MF. Pain after avulsion injuries and complete palsy of the brachial plexus: the possible role of nonavulsed roots in pain generation. Neurosurgery. 2008;62(5):1104–1113. doi: 10.1227/01.neu.0000325872.37258.12. PubMed DOI

Bertelli JA, Ghizoni MF, Loure Iro Chaves DP. Sensory disturbances and pain complaints after brachial plexus root injury: A prospective study involving 150 adult patients. Microsurgery. 2011;31(2):93–97. doi: 10.1002/micr.20832. PubMed DOI

Tomycz ND, Moossy JJ. Follow-up 26 years after dorsal root entry zone thermocoagulation for brachial plexus avulsion and phantom limb pain. J Neurosurg. 2011;114(1):196–199. doi: 10.3171/2010.5.JNS091520. PubMed DOI

Preserved cutaneous silent period in cervical root avulsion