Dorsal Root Entry Zone Lesioning for Brachial Plexus Avulsion Pain

Abstract

Brachial plexus avulsion is often seen after motorcycle accidents or with high-speed ejection injuries. Rehabilitation focuses on regaining motor and sensory function, but the detrimental effect of pain is often underappreciated. Up to 90% of patients with avulsion injury will experience deafferentation pain, which until relatively recently has been difficult to treat medically or surgically. DREZotomy, the ablation of neurons in the dorsal root entry zone of the spinal cord, was introduced in the 1970s and has since changed how we treat brachial plexus avulsion and other forms of neuropathic pain. The procedure is straightforward: with a standard cervical approach, a hemilamiotomy is used to expose the area of interest. The dura is opened, and areas of root avulsion are identified. Using bipolar cautery, RF ablation, or ultrasound, the 2nd order neurons in dorsal horn are destroyed for the affected dermatomes. Complications include standard cervical spinal approach-related issues, such as infection, hematoma, CSF leak, and kyphosis. Risks specific to the procedure include post-operative motor or sensory deficits, due to the proximity of the corticospinal tracts and the dorsal columns to dorsal horn. As many as 18% of patients report a long-term neurological deficit post-operatively, but despite these complications, 80% of patients say they would repeat the procedure. Multiple outcomes series have been published since the procedure was introduced, and typically 70–80% of patients receive benefit from the procedure.