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CC BY-NC-ND 4.0 · Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery 2021; 40(03): e229-e237
DOI: 10.1055/s-0040-1719003
Review Article | Artigo de Revisão

Dorsal Root Entry Zone Lesioning: Systematic Review

Lesionamento da zona de entrada da raiz dorsal: Revisão sistemática
Giovanna Zambo Galafassi 
1   Faculdade de Medicina do ABC, Santo André, SP, Brazil
,
Paulo Henrique Pires Aguiar 
2   Department of Research and Innovation, Laboratório de Biologia Celular e Molecular, Faculdade de Medicina do ABC, Santo André, SP, Brazil
3   Department of Neurosurgery, Hospital Santa Paula, São Paulo, SP, Brazil
4   Department of Neurology, Pontifícia Universidade Católica de São Paulo, Sorocaba, SP, Brazil
,
André Akira Takahashi 
1   Faculdade de Medicina do ABC, Santo André, SP, Brazil
,
Jorge Roberto Pagura 
5   Department of Neurology and Neurosurgery, Faculdade de Medicina do ABC, Santo André, SP, Brazil
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Abstract

Introduction Dorsal root entry zone (DREZ) leasioning (DREZ-otomy) is considered an effective treatment for chronic pain due to spinal cord injuries, brachial and lumbosacral plexus injuries, postherpetic neuralgia, spasticity, and other conditions. The objective of the technique is to cause a selective destruction of the afferent pain fibers located in the dorsal region of the spinal cord.

Objective To identify and review the effectiveness and the main aspects related to DREZ-otomy, as well as the etiologies that can be treated with it.

Methods The PubMed, MEDLINE and LILACS databases were used as bases for this systematic review, having the impact factor as the selection criteria. The 23 selected publications, totalizing 1,099 patients, were organized in a table for systematic analysis.

Results Satisfactory pain control was observed in 70.1% of the cases, with the best results being found in patients with brachial/lumbosacral plexus injury (70.8%) and the worst, in patients with trigeminal pain (40% to 67%).

Discussion Most of the published articles observed excellent results in the control of chronic pain, especially in cases of plexus injuries. Complications are rare, and can be minimized with the use of new technologies for intraoperative monitoring and imaging.

Conclusion DREZ-otomy can be considered a great alternative for the treatment of chronic pain, especially in patients who do not tolerate the side effects of the medications used in the clinical management or have refractory pain.

Resumo

Introdução O lesionamento da zona de entrada da raiz dorsal (dorsal root entry zone, DREZ), ou DREZ-otomia, é considerado um tratamento eficaz para a dor crônica decorrente de lesões medulares, lesão dos plexos braquial e lombossacro, neuralgia pós-herpética, espasticidade, entre outras lesões. O objetivo da técnica é causar uma destruição seletiva das fibras localizadas na região dorsal da medula espinal, entre elas as fibras aferentes de dor.

Objetivo Identificar a efetividade da DREZ-otomia e as principais etiologias que podem ser tratadas por este procedimento, e revisar os principais aspectos relacionados à técnica.

Métodos As bases de dados do PubMed, MEDLINE e Lilacs foram utilizadas na realização desta revisão sistemática, tendo o impacto como critério de seleção. As 23 publicações selecionadas, totalizando 1.099 pacientes, foram organizadas numa tabela para análise sistemática.

Resultados Controle satisfatório da dor foi observado em 70,1% dos casos, sendo que os melhores resultados foram encontrados em pacientes com lesão dos plexos braquial/lombossacro (70,8%), e os piores, em pacientes com dor neuropática do nervo trigêmeo (40% a 67%).

Discussão A maioria dos artigos publicados encontrou ótimos resultados no controle da dor crônica, principalmente na dor relacionada à lesão de plexos. As complicações são raras, podendo ser minimizadas com o emprego das novas tecnologias de monitoração intraoperatória e imagem existentes.

Conclusão A drezotomia pode ser considerada uma ótima alternativa para o tratamento da dor crônica, especialmente em pacientes que não toleram os efeitos colaterais das medicações utilizadas no manejo clínico ou apresentam dor refratária.

Keywords

neuropathic pain - dorsal root entry zone - radiculopathy - spinal cord

Palavras-chave

dor neuropática - zona de entrada da raiz dorsal - radiculopatia - medula espinal


Publication History

Received: 04 May 2020

Accepted: 24 August 2020

Article published online:
26 November 2020

© 2020. Sociedade Brasileira de Neurocirurgia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Teixeira MJ, Haman C, Teixeira WGJ. Tratamento cirúrgico funcional da dor. Rev Med (São Paulo) 2001; 80: 276-289
    CrossrefPubMedGoogle Scholar
  • 2 Chivukula S, Tomycz ND, Moossy JJ. Paddle lead cervical spinal cord stimulation for failed neck surgery syndrome. Clin Neurol Neurosurg 2013; 115 (10) 2254-2256
    CrossrefPubMedGoogle Scholar
  • 3 Deer TR, Skaribas IM, Haider N. et al. Effectiveness of cervical spinal cord stimulation for the management of chronic pain. Neuromodulation 2014; 17 (03) 265-271 , discussion 271
    CrossrefPubMedGoogle Scholar
  • 4 Jensen MP, Chodroff MJ, Dworkin RH. The impact of neuropathic pain on health-related quality of life: review and implications. Neurology 2007; 68 (15) 1178-1182
    CrossrefPubMedGoogle Scholar
  • 5 Smith BH, Torrance N, Bennett MI, Lee AJ. Health and quality of life associated with chronic pain of predominantly neuropathic origin in the community. Clin J Pain 2007; 23 (02) 143-149
    CrossrefPubMedGoogle Scholar
  • 6 Inoue S, Taguchi T, Yamashita T, Nakamura M, Ushida T. The prevalence and impact of chronic neuropathic pain on daily and social life: A nationwide study in a Japanese population. Eur J Pain 2017; 21 (04) 727-737
    CrossrefPubMedGoogle Scholar
  • 7 Attal N, Lanteri-Minet M, Laurent B, Fermanian J, Bouhassira D. The specific disease burden of neuropathic pain: results of a French nationwide survey. Pain 2011; 152 (12) 2836-2843
    CrossrefPubMedGoogle Scholar
  • 8 Konrad P. Dorsal root entry zone lesion, midline myelotomy and anterolateral cordotomy. Neurosurg Clin N Am 2014; 25 (04) 699-722
    CrossrefPubMedGoogle Scholar
  • 9 Nashold Jr BS. Current status of the DREZ operation: 1984. Neurosurgery 1984; 15 (06) 942-944
    PubMedGoogle Scholar
  • 10 Sindou M. 1972; Study of the dorsal root - spinal cord junction. A target for pain surgery. These Doctorat Medecine, Lyon 182
    PubMedGoogle Scholar
  • 11 Hatch MN, Cushing TR, Carlson GD, Chang EY. Neuropathic pain and SCI: Identification and treatment strategies in the 21st century. J Neurol Sci 2018; 384: 75-83
    CrossrefPubMedGoogle Scholar
  • 12 Cardenas DD, Nieshoff EC, Suda K. et al. A randomized trial of pregabalin in patients with neuropathic pain due to spinal cord injury. Neurology 2013; 80 (06) 533-539
    CrossrefPubMedGoogle Scholar
  • 13 Amr YM. Multi-day low dose ketamine infusion as adjuvant to oral gabapentin in spinal cord injury related chronic pain: a prospective, randomized, double blind trial. Pain Physician 2010; 13 (03) 245-249
    CrossrefPubMedGoogle Scholar
  • 14 Finnerup NB, Gottrup H, Jensen TS. Anticonvulsants in central pain. Expert Opin Pharmacother 2002; 3 (10) 1411-1420
    CrossrefPubMedGoogle Scholar
  • 15 Dworkin RH, O'Connor AB, Audette J. et al. Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. Mayo Clin Proc 2010; 85 (03) S3-S14 ). Elsevier.
    CrossrefPubMedGoogle Scholar
  • 16 Lynch ME, Campbell F. Cannabinoids for treatment of chronic non-cancer pain; a systematic review of randomized trials. Br J Clin Pharmacol 2011; 72 (05) 735-744
    CrossrefPubMedGoogle Scholar
  • 17 Karst M, Salim K, Burstein S, Conrad I, Hoy L, Schneider U. Analgesic effect of the synthetic cannabinoid CT-3 on chronic neuropathic pain: a randomized controlled trial. JAMA 2003; 290 (13) 1757-1762
    CrossrefPubMedGoogle Scholar
  • 18 Colloca L, Ludman T, Bouhassira D. et al. Neuropathic pain. Nat Rev Dis Primers 2017; 3: 17002 DOI: 10.1038/nrdp.2017.2.
    CrossrefPubMedGoogle Scholar
  • 19 Rawlings III CE, el-Naggar AO, Nashold Jr BS. The DREZ procedure: an update on technique. Br J Neurosurg 1989; 3 (06) 633-642 DOI: 10.3109/02688698908992686.
    CrossrefPubMedGoogle Scholar
  • 20 Sindou M. Microsurgical DREZotomy (MDT) for pain, spasticity, and hyperactive bladder: a 20-year experience. Acta Neurochir (Wien) 1995; 137 (1-2): 1-5
    CrossrefPubMedGoogle Scholar
  • 21 Chun H-J, Kim YS, Yi H-J. A modified microsurgical DREZotomy procedure for refractory neuropathic pain. World Neurosurg 2011; 75 (3-4): 551-557 DOI: 10.1016/j.wneu.2010.12.005.
    CrossrefPubMedGoogle Scholar
  • 22 Yang F, Zhang C, Xu Q. et al. Electrical stimulation of dorsal root entry zone attenuates wide-dynamic-range neuronal activity in rats. Neuromodulation 2015; 18 (01) 33-40 , discussion 40
    CrossrefPubMedGoogle Scholar
  • 23 Takai K, Taniguchi M. Modified dorsal root entry zone lesioning for intractable pain relief in patients with root avulsion injury. J Neurosurg Spine 2017; 27 (02) 178-184 DOI: 10.3171/2017.1.spine16234.
    CrossrefPubMedGoogle Scholar
  • 24 Sindou M, Jeanmonod D. Microsurgical DREZ-otomy for the treatment of spasticity and pain in the lower limbs. Neurosurgery 1989; 24 (05) 655-670 DOI: 10.1227/00006123-198905000-00002.
    CrossrefPubMedGoogle Scholar
  • 25 Sitthinamsuwan B, Phonwijit L, Khampalikit I, Nitising A, Nunta-Aree S, Suksompong S. Comparison of efficacy between dorsal root entry zone lesioning and selective dorsal rhizotomy for spasticity of cerebral origin. Acta Neurochir (Wien) 2017; 159 (12) 2421-2430 DOI: 10.1007/s00701-017-3322-x.
    CrossrefPubMedGoogle Scholar
  • 26 Sindou M, Georgoulis G. Focal Dystonia in Hemiplegic Upper Limb: Favorable Effect of Cervical Microsurgical DREZotomy Involving the Ventral Horn - A Report of 3 Patients. Stereotact Funct Neurosurg 2016; 94 (03) 140-146 DOI: 10.1159/000446078.
    CrossrefPubMedGoogle Scholar
  • 27 Henssen DJHA, Weber RC, de Boef J. et al. 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 DOI: 10.3389/fnana.2019.00066.
    CrossrefPubMedGoogle Scholar
  • 28 Monaco BA, Lopes AJM, Teixeira MJ. Ultrasound-Guided DREZotomy: Technical Note. Stereotact Funct Neurosurg 2019; 97 (02) 127-131 DOI: 10.1159/000500491.
    CrossrefPubMedGoogle Scholar
  • 29 Friedman AH, Nashold Jr BS. DREZ lesions for relief of pain related to spinal cord injury. J Neurosurg 1986; 65 (04) 465-469
    CrossrefPubMedGoogle Scholar
  • 30 Saris SC, Iacono RP, Nashold Jr BS. Successful treatment of phantom pain with dorsal root entry zone coagulation. Appl Neurophysiol 1988; 51 (2-5): 188-197
    PubMedGoogle Scholar
  • 31 Young RF. Clinical experience with radiofrequency and laser DREZ lesions. J Neurosurg 1990; 72 (05) 715-720
    CrossrefPubMedGoogle Scholar
  • 32 Bullard DE, Nashold Jr BS. The caudalis DREZ for facial pain. Stereotact Funct Neurosurg 1997; 68 (1-4 Pt 1): 168-174
    CrossrefPubMedGoogle Scholar
  • 33 Rath SA, Seitz K, Soliman N, Kahamba JF, Antoniadis G, Richter HP. DREZ coagulations for deafferentation pain related to spinal and peripheral nerve lesions: indication and results of 79 consecutive procedures. Stereotact Funct Neurosurg 1997; 68 (1-4 Pt 1): 161-167
    CrossrefPubMedGoogle Scholar
  • 34 Samii M, Bear-Henney S, Lüdemann W, Tatagiba M, Blömer U. Treatment of refractory pain after brachial plexus avulsion with dorsal root entry zone lesions. Neurosurgery 2001; 48 (06) 1269-1275 , discussion 1275–1277
    PubMedGoogle Scholar
  • 35 Sindou M, Mertens P, Wael M. Microsurgical DREZotomy for pain due to spinal cord and/or cauda equina injuries: long-term results in a series of 44 patients. Pain 2001; 92 (1-2): 159-171
    CrossrefPubMedGoogle Scholar
  • 36 Delgado-López P, García-Salazar F, Mateo-Sierra O, Carrillo-Yagüe R, Llauradó G, López E. Trigeminal nucleus caudalis dorsal root entry zone radiofrequency thermocoagulation for invalidating facial pain. Neurocirugia (Astur) 2003; 14 (01) 25-32 , discussion 32
    CrossrefPubMedGoogle Scholar
  • 37 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 (06) 1018-1028 DOI: 10.3171/jns.2005.102.6.1018.
    CrossrefPubMedGoogle Scholar
  • 38 Spaic M, Markovic N, Mikicic D, Ilic S, Milosavljevic I. The DREZ Surgical Treatment of chronic pain in traumatic paraplegia. Indian Journal of Neurotrauma 2005; 2 (02) 111-116
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Prestor B. Microcoagulation of junctional dorsal root entry zone is effective treatment of brachial plexus avulsion pain: long-term follow-up study. Croat Med J 2006; 47 (02) 271-278
    PubMedGoogle Scholar
  • 40 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 (Wien) 2006; 99: 73-75
    CrossrefPubMedGoogle Scholar
  • 41 Teixeira MJ, Fonoff ET, Montenegro MC. Dorsal root entry zone lesions for treatment of pain-related to radiation-induced plexopathy. Spine 2007; 32 (10) E316-E319
    CrossrefPubMedGoogle Scholar
  • 42 Zhang XH, Li YJ, Hu YS, Tao W, Zheng Z. Dorsal root entry zone coagulation for treatment of deafferentation pain syndromes. Chin Med J (Engl) 2008; 121 (12) 1089-1092
    PubMedGoogle Scholar
  • 43 Hong JC, Kim MS, Chang CH, Kim SW, Kim OL, Kim SH. Long term results of microsurgical dorsal root entry zonotomy for upper extremity spasticity. J Korean Neurosurg Soc 2008; 43 (04) 182-185
    CrossrefPubMedGoogle Scholar
  • 44 Kanpolat Y, Tuna H, Bozkurt M, Elhan AH. Spinal and nucleus caudalis dorsal root entry zone operations for chronic pain. Neurosurgery 2008;62(03, Suppl 1):235–242, discussion 242–244
    PubMedGoogle Scholar
  • 45 Ruiz-Juretschke F, García-Salazar F, García-Leal R. et al. Treatment of neuropathic deafferentation pain using DREZ lesions; long-term results. Neurologia 2011; 26 (01) 26-31
    CrossrefPubMedGoogle Scholar
  • 46 Awad AJ, Forbes JA, Jermakowicz W, Eli IM, Blumenkopf B, Konrad P. Experience with 25 years of dorsal root entry zone lesioning at a single institution. Surg Neurol Int 2013; 4: 64
    CrossrefPubMedGoogle Scholar
  • 47 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 (01) 225
    CrossrefPubMedGoogle Scholar
  • 48 Liu MX, Zhong J, Zhu J, Xia L, Dou NN. Treatment of postherpetic neuralgia using DREZotomy guided by spinal cord stimulation. Stereotact Funct Neurosurg 2015; 93 (03) 178-181
    CrossrefPubMedGoogle Scholar
  • 49 Chivukula S, Tempel ZJ, Chen CJ, Shin SS, Gande AV, Moossy JJ. Spinal and nucleus caudalis dorsal root entry zone lesioning for chronic pain: efficacy and outcomes. World Neurosurg 2015; 84 (02) 494-504
    CrossrefPubMedGoogle Scholar