DREZ Lesioning for Brachial Plexus Avulsion Pain

Original Article
Retrospective Study of 57 Patients Submitted to Dorsal Root Entry Zone Lesioning by
Radiofrequency for Brachial Plexus Avulsion Pain
Marcio de Mendonça Cardoso1, Ricardo Gepp1, Henrique Caetano1, Ricardo Felipe1, Bernardo Martins2
BACKGROUND: Dorsal root entry zone (DREZ) lesioning
may be used to treat neuropathic pain in patients with
traumatic brachial plexus injuries. The clinical outcome
after surgery is variable in the medical literature. We
aimed to report the surgical outcome after DREZ lesioning
by radiofrequency and to analyze prognostic factors such
as the presence of a spinal cord injury identified before
surgery.
-
METHODS: We conducted a retrospective study that
included 57 patients who had experienced traumatic
brachial plexus injuries and exhibited neuropathic pain
that did not respond to conservative treatment methods.
They were submitted to DREZ lesioning. We defined the
inclusion and exclusion criteria, collected sociodemographic and clinical characteristics, and identified and
classified spinal cord lesions based on magnetic resonance imaging. We applied statistical tests to evaluate the
association between pain intensity after surgery and the
radiological profile and sociodemographic characteristics.
-
RESULTS: Immediately after surgery, the pain outcome
was considered good or excellent in 50 patients (89.28%).
At the last follow-up, it was good or excellent in 39 patients (68.43%). There was no association (P > 0.05) between the pain outcome and the variables analyzed (time
interval between trauma and DREZ lesioning, presence of
spinal cord injury, age, the number of avulsed roots, and the
type of pain).
-
CONCLUSIONS: DREZ lesioning using radiofrequency
represents a significant therapeutic approach for managing
neuropathic pain after a traumatic brachial plexus injury.
-
Key words
- Brachial plexus avulsion
- Dorsal root entry zone
- Neuropathic pain
- Surgery
Abbreviations and Acronyms
DREZ: Dorsal root entry zone
MRI: Magnetic resonance imaging
VAS: Visual analog scale
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Importantly, we found that the presence of a spinal cord
injury is not associated with the surgical outcome.
INTRODUCTION
R
esearchers have reported that 69%e95% of patients who
experience traumatic brachial plexus injuries present with
neuropathic pain.1-4 Depending on its intensity, neuropathic pain can be associated with depression and a lower quality
of life,5-7 and it can be refractory to conservative treatment. In this
situation, dorsal root entry zone (DREZ) lesioning can be indicated to treat neuropathic pain. There are different methods to
perform DREZ lesioning, including ultrasound, laser, radiofrequency, and microsurgery.8 The clinical outcome after surgery
is variable, and studies have reported a good prognosis in
60%e96% of cases.8-14 However, it is not clear what prognostic
factors are responsible for this outcome variation because there
are only a few studies on this subject.15 It has been suggested that
the identification of spinal cord injury by magnetic resonance
imaging (MRI) could indicate a worse prognosis after surgery.16
Our objectives were to report the surgical outcome after DREZ
lesioning by radiofrequency and to analyze prognostic factors
such as the presence of a spinal cord lesion.
MATERIAL AND METHODS
Study Design and Setting
We conducted a retrospective study of 57 patients who attended
our hospital from 2001 to 2020. The patients had experienced
traumatic brachial plexus injuries and presented with neuropathic
pain refractory to conservative treatment. The diagnosis of root
avulsion was made primarily by clinical examination, MRI,
From the 1Department of Neurological Surgery, Sarah Network of Rehabilitation Hospitals;
and 2Department of Radiology, Sarah Network of Rehabilitation Hospitals, Brasilia, Brazil
To whom correspondence should be addressed: Marcio de Mendonça Cardoso, M.Sc.
[E-mail: [email protected]]
Citation: World Neurosurg. (2023) 177:e466-e471.
https://doi.org/10.1016/j.wneu.2023.06.077
Journal homepage: www.journals.elsevier.com/world-neurosurgery
Available online: www.sciencedirect.com
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ORIGINAL ARTICLE
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neurophysiological studies, and intraoperative analysis (in patients
who had undergone brachial plexus reconstruction). We obtained
data by reviewing electronic medical records. We followed the
PROCESS Guidelines (https://www.processguideline.com) for this
case series.17
Participants
The inclusion criteria were the presence of a traumatic lesion of
the brachial plexus with pain refractory to conservative treatment,
submitted to DREZ lesioning, and age >18 years. The exclusion
criteria were the use of other surgical procedures to treat pain
besides DREZ lesioning, the absence of an outcome measure (a
visual analog scale [VAS]) before or after surgery, and repeated
DREZ lesioning. Our institution granted ethics approval, and we
obtained informed consent from all patients.
Variables
We have reported the following sociodemographic and clinical
characteristics: age, gender, and the time interval between trauma
and DREZ lesioning.
The patients reported their pain location and pain characteristics. Pain intensity was assessed using a VAS that ranged from
0 mm (no pain) to 100 mm (very intense pain). A member of the
neurosurgical team was responsible for the pain evaluation. The
VAS was applied immediately before surgery, every 6 months after
surgery during the first 3 years, and every year thereafter. We
defined pain outcomes after comparing the VAS score before
surgery, immediately after surgery, and at the last follow-up visit.
We categorized it as excellent (75% pain relief), good (50%e75%
pain relief), or fair (<50% pain relief).
We classified spinal cord lesions based on MRI. We considered
exams to be normal if there was no evidence of abnormalities on
axial T2 images of the spine. We classified lesions as: 1) focal if
there was evidence of DREZ avulsion with a shallow abnormal
signal of the dorsal horn; 2) extensive if there was evidence of an
abnormal T2 signal with deep extension in the dorsal horn; or 3)
diffuse if there was evidence of a lesion beyond the DREZ and
Figure 1. Radiological classification of spinal cord
lesions: (A) focal and superficial lesion identified in
DREZ, classified as focal. (B) Focal lesion identified in
DREZ, with deep extension, classified as extensive
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DORSAL ROOT ENTRY ZONE LESIONING
dorsal horn (Figure 1). Two independent radiologists were
responsible for the radiological evaluation. When there was not
a consensus, a neurosurgeon participated in the evaluation and
helped define the classification.
Surgical complications were described when they occurred.
Surgical Procedure
The patient was placed in a prone position, and a Mayfield head
holder was used. Hemilaminectomy from C5 to C7 or an open
door laminoplasty (in patients with extensive arachnoiditis and
spinal cord rotation, it was easier to identify the DREZ when we
could also see the normal side) was performed. After opening the
dura mater and arachnoid mater, the area of root avulsion was
located. Radiofrequency thermocoagulation was performed with
an electrode (75 C for 15 seconds). The electrode was inserted to a
depth of 2 mm and angled 30e45 in the sagittal plane. A radiofrequency lesion was repeated every 1 mm in the area of the root
avulsion. Motor- and somatosensory-evoked potentials were
monitored during surgery. Two neurosurgeons performed the
procedures.
Statistical Analysis
We used R version 4.2.0 for statistical analysis. We have presented
the qualitative variables as absolute numbers and percentages and
the quantitative variables as means and standard deviations. We
evaluated the data for normality by using the Kolmogorove
Smirnov test; only age had a normal distribution. When
comparing the sociodemographic, clinical, and radiological profiles with the intensity and variation of pain, we applied the c2
and Wilcoxon signed-rank tests. We used Spearman correlation
analysis to evaluate the relationship between pain variation before
and after surgery with age, the time interval between trauma and
surgery, and the number of avulsed roots. For all statistical tests,
the significance level was 5%.
lesion. (C) Lesion beyond the DREZ and dorsal horn
and associated with ‘pitting’ of the left lateral part of
the spinal cord classified as diffuse lesion.
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DORSAL ROOT ENTRY ZONE LESIONING
RESULTS
The study included 57 patients, most of whom were men (55 patients). The mean VAS before surgery was 90.23. Pain was located
exclusively in the forearm or hand in 34 patients (59.65%)
(Table 1). The mean follow-up evaluation was 40.3 months
(Table 1). The mean time interval between trauma and DREZ
Table 1. Demographic and Clinical-Radiological Characteristics
Variable
Number of Patients (%)
Sex
Male
55 (96.49%)
Female
2 (3.51%)
Age
40 years
28 (49.12%)
>40 years
29 (50.88%)
Spinal cord injury*
Yes
36 (72%)
No
14 (28%)
Radiological aspecty
Extensive
24 (66.67%)
Focal
10 (27.77%)
Diffuse
2 (5.56%)
Number of avulsed roots
3
25 (52.08%)
>3
23 (47.92%)
Location of avulsed roots
C4
4 (8.33%)
C5
20 (41.67%)
C6
29 (60.42%)
C7
41 (85.42%)
C8
41 (85.42%)
T1
33 (68.75%)
Pain location
Arm
1 (1.75%)
Forearm-hand
18 (31.58%)
Hand
16 (28.07)
Whole arm
22 (38.60%)
Pain characteristics
Lancinating with paroxysms
1 (1.75%)
Constant
32 (56.14%)
Both lancinating and constant
24 (42.11%)
*Diagnosed by magnetic resonance imaging.
yRadiological classification described in the manuscript.
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lesioning was 66.9 months, and the median time interval was
46.5 months (range 7.1e363.6 months).
Immediately after surgery, the pain outcome was considered
good or excellent in 50 patients (89.28%). At the last follow-up
evaluation, the pain outcome was good or excellent in 39 patients (68.43%) (Table 2). In this group, 26 patients did not take
pain medication, whereas 13 did (gabapentin or amitriptyline).
Based on MRI, 36 patients (63.16%) had a spinal cord lesion
before surgery, 14 patients (24.56%) did not, and 7 patients
(12.28%) did not have an adequate radiological evaluation and
thus, we excluded them from this analysis. There was no association (P > 0.05) between the presence of a spinal cord lesion and
the pain outcome after DREZ lesioning.
There was no association between the pain outcome and variables such as age, the number of avulsed roots, or radiological
aspect, as indicated in Table 3. Spearman’s correlation test,
conducted at a significance level of 5%, revealed no significant
difference between the pain outcome and the time interval
between trauma and surgery (r (55) ¼ 0.05, P > 0.05).
Furthermore, there was no significant correlation between the
type of pain experienced before surgery and the subsequent
relief of pain after the surgical intervention (P > 0.05).
Immediately following the surgery, 8 patients (14.04%) reported
motor paresis, while 13 (22.81%) patients reported various abnormalities or sensory deficits specifically affecting the ipsilateral
lower limb. However, during the final follow-up evaluation, only 1
patient continued to experience motor paresis. It is noteworthy
that this persistent motor paresis did not impact the patient’s
ability to walk independently or necessitate any form of assistance.
There were no general neurosurgical complications, such as
infection or cerebrospinal fluid fistula.
DISCUSSION
The most common surgical techniques used for DREZ lesioning
are radiofrequency and microsurgical lesioning using bipolar
coagulation, as described by Nashold18 and Sindou.19 Previous
studies indicate that to achieve a meaningful reduction in pain
intensity after surgery, it is necessary to reduce the pain score
(based on the VAS) by 30%e48%.20,21 Our surgical results
demonstrate the increased relevance of DREZ lesioning in the
treatment of refractory neuropathic pain, considering that most
of our patients had pain relief (68.43% of the patients had a
good or excellent outcome), and the incidence of severe
neurological complications was small. Generally, neurological
complications are caused by the entrance angle or depth of the
radiofrequency needle in the spinal cord. When the inclination
of the needle is small, there is a higher risk of lesioning the
corticospinal tract. If the entrance point of the needle is located
medially to the posterior-lateral sulcus of the spinal cord, then
the posterior funiculus can be affected. In patients with extensive
arachnoiditis and spinal cord retraction, finding the correct place
for needle insertion can be very difficult. In this situation, it is
important to release the spinal cord and to obtain a wider exposure to visualize the normal roots both above and below the
affected area on the same side, as well as on the contralateral side.
It is also important to control the temperature of the needle and
the duration of the lesion.
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DORSAL ROOT ENTRY ZONE LESIONING
Table 2. Pain Comparison Before and After Surgery
Variable
Pain (VAS) before surgery
Median (mm)
Mean (mm)
Standard Deviation
P*
100.00
90.23
9.5
<0.001
Pain (VAS) immediately after surgery
0
10.16
20.11
Pain (VAS) variation before and immediately after surgery
90.00
80.54
24.60
Pain (VAS) at last follow-up visit
20.00
30.18
30.32
Pain (VAS) variation before surgery and at last follow-up visit
70.00
60.53
34.47
<0.001
VAS, visual analog scale.
*Based on the Wilcoxon signed-rank test.
that the absence of spinal cord injury associated with root
avulsion before surgery was associated with important pain
relief. The authors proposed that patients with a spinal cord
injury have already had “DREZ lesioning” that occurred from the
trauma. In this situation, neuropathic pain would be the result
of altered activity at the supraspinal level.16
In our study, which has a larger sample than the study by Ko
et al.,16 we did not observe this relationship, probably because
there are other mechanisms besides hyperactive posterior horn
neurons that could act together to influence neuropathic pain.
First, it is important to consider that cortical reorganization is a
well-established process that occurs after peripheral nerve injury.
It is proposed that after brachial plexus injury, the corresponding
cortical area is invaded by representations of the body parts
adjacent to the missing limb, and this phenomenon may negatively influence motor recovery.24 Baruah et al.25 studied a series of
patients before and after DREZ lesioning. Functional MRI was
performed before and after surgery; they observed the
development of cortical activation areas in patients with chronic
It is crucial to highlight that pain relief at long-term follow-up
may not be as effective as immediately after surgery, but it still
represents a positive outcome when compared with other options
like spinal cord stimulation.22 Analyzing the long-term outcomes
after DREZ lesioning present challenges, primarily due to patient
attrition. Many patients may choose to discontinue their participation in the study, especially if they live far from the hospital or
have already experienced positive results from the procedure. This
attrition can potentially introduce bias and limit the comprehensive assessment of long-term outcomes in DREZ lesioning
studies.
It has been suggested that neuropathic pain after traumatic
brachial plexus root avulsion is caused by hyperactive posterior
horn spinal cord neurons under the influence of a disinhibited
lateral Lissauer tract. In line with this concept, DREZ lesioning
has been adopted to treat refractory neuropathic pain because it
will destroy these hyperactive neurons located in the posterior
horn (Rexed lamina IeV).23 Considering this information, Ko
et al.16 studied 17 patients after DREZ lesioning and observed
Table 3. Association Between Pain Outcome at the Last Follow-Up Visiting and Demographic and Clinical-Radiological Characteristics
Pain Outcome*
Characteristics
Excellent
Good
Fair
Total
Py
40 years
12 (42.86%)
6 (21.43%)
10 (35.71%)
28 (100%)
0.804
>40 years
14 (48.28%)
7 (24.14%)
8 (27.59%)
29 (100%)
3
13 (36.11%)
12 (33,33%)
2 (5.71%)
35 (100%)
>3
9 (64.29%)
2 (14.29%)
3 (21.43%)
14 (100%)
Absent
9 (64.29%)
2(14.29%)
3(21.43%)
14 (100%)
Diffuse
2 (100%)
—
—
2 (100%)
Extensive
8 (33.33%)
9 (37.50%)
7 (29.17%)
24 (100%)
Focal
3 (30%)
2 (20%)
5 (50%)
10 (100%)
Age
Number of avulsed roots
0.190
Radiological aspect
0.191
*Number of patients (percentage).
yc2.
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neuropathic pain, but after surgery, there was inactivation of this
area in patients with pain relief. They suggested that the DREZ
may send excitatory impulses to adjacent cortical areas.25
However, the mechanism by which brain plasticity influences
neuropathic pain is controversial. Yanagisawa et al.26 used a
brainemachine interface based on real-time magnetoencephalography signals to reconstruct affected hand movements with a
robotic hand. They observed improved functional control of the
amputated limb and hand prosthesis, but there was not consistent
pain relief. A convergence among studies suggests that preventing
abnormally increased or decreased activity in central areas by
regulating sensory input and motor output signals may contribute
to the treatment of neuropathic pain.27
Considering the currently available information concerning the
relationship between cortical plasticity and pain, it is possible to
find studies suggesting other treatment options for neuropathic
pain: repetitive transcranial magnetic stimulation,28 mirror
therapy, and cognitive behavioral therapy.29
We observed that during surgery, some patients had greater
degeneration in the avulsion zone, characterized by the needle
entering the spinal cord more loosely. In some cases, we noted the
presence of microcysts. We hypothesize that under this circumstance, there is reduced propagation of heat, which consequently
increases the risk of treatment failure. Unfortunately, we were
unable to carry out this evaluation in our study because not all
surgical reports presented an evaluation related to this aspect.
The correlation between the number of avulsed roots and the
pain outcome is a topic of ongoing debate and scientific inquiry.
Piyawattanametha et al.15 conducted a study where they observed
that fewer pain dermatomes were associated with a favorable
prognosis following DREZotomy. However, comparing their
findings with our own study is challenging due to differences in
the patient inclusion criteria. Their study encompassed patients
with neuropathic pain stemming from various etiologies such as
trauma, tumors, and spinal cord injury, among others, while our
study specifically focused on patients with brachial plexus
injuries resulting from trauma. It is worth noting that many
patients with flail arms experience pain primarily localized to
the hand and forearm, despite presenting with multiple root
avulsions. Consequently, the number of painful dermatomes
does not consistently correlate with the number of root
avulsions. In a separate investigation by Samii et al.,14 there was
no significant correlation between the number of painful
dermatomes and postoperative pain relief.
We did not observe a significant association between pain relief
and the time interval between trauma and DREZ lesioning. This
finding is interesting because studies based on MRI indicate that
regions related to memory and learning, such as the hippocampus
and amygdala, are involved in chronic pain, which may explain
treatment failure in some diseases such as back pain.30 We
consider that a long interval between trauma and DREZ
lesioning should not contraindicate surgery.
It has been suggested that the type of pain before surgery
could influence the pain outcome after surgery,10 but we did not
observe this phenomenon in our study. Our findings strengthen
our belief that the presence of persistent and intense burning
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pain should not be considered a contraindication for DREZ
lesioning.
Limitations
Our study has a few limitations. First, it is retrospective and may
have related bias, but it is important to consider that the previous
study on the association between spinal cord injury and outcome
after DREZ injury indicated a strong relationship.16 Therefore,
considering the large effect size, the number of patients we
evaluated may give us a better estimate of the presence or
absence of an association.
Second, we selected the laminectomy level according to Nashold,31 considering pain location, but not including T1 (because
this spinal level originates at the T2 radicular filaments), and we
cannot guarantee that a few patients had a worse prognosis
because we did not include C4. Nevertheless, our surgical
results are consistent with most of the medical literature on the
topic.8 We should also mention that according to Sindou,10 the
extent, in length, of the surgical lesioning was established based
on pain topography, which generally corresponded with the
avulsed segments as well as the altered adjacent rootlets, and in
our study, no patient complained of pain that corresponded to
C4 or C3; in fact, most of them indicated a pain location in the
forearm and hand.
Third, while grading pain using a VAS before and after surgery
provides valuable information and is the most used scale for pain
assessment, it would be beneficial to use scales that relate pain to
functionality, such as the Brief Pain Inventory,32 for a more
comprehensive assessment after surgery.
Finally, we did not evaluate the presence of depression or secondary gain among the patients, despite the potential influence of
these factors on the surgical prognosis.
CONCLUSION
DREZ lesioning using radiofrequency represents a significant
therapeutic option for managing neuropathic pain resulting from
a traumatic brachial plexus injury. This procedure often leads to
pain relief, with rare occurrences of long-term neurological complications. Interestingly, our findings indicate that spinal cord
injury, as diagnosed by MRI, and other variables examined in this
study were not linked to the surgical outcome. This finding suggests the presence of additional factors beyond hyperactive neurons in the dorsal horn of the spinal cord that may contribute to
neuropathic pain. Such factors may involve changes in cortical
sensorimotor areas and brain plasticity after brachial plexus injury.
Further investigation into these aspects is warranted to enhance
our understanding of the complex mechanisms underlying
neuropathic pain and to optimize treatment approaches.
CRediT AUTHORSHIP CONTRIBUTION STATEMENT
Marcio de Mendonça Cardoso: Conceptualization, Methodology,
Writing e original draft, Visualization, Project administration.
Ricardo Gepp: Writing e review & editing. Henrique Caetano:
Writing e review & editing. Ricardo Felipe: Investigation, Data
curation. Bernardo Martins: Data curation, Writing.
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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 15 June 2023; accepted 18 June 2023
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