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Dorsal Rhizotomy

Dorsal rhizotomy is a procedure where the sensory roots are divided either intradurally or extradurally. According to Nashold (1991) a single one or two level root rhizotomy may be appropriate when the pain is localized as in those patients with paraparesis and single root pain. Moreover, Nashold (1991) reported the Dorsal Root Entry Zone (DREZ) procedure was more likely to be successful in these patients.

Table 37 Dorsal Root Entry Zone Procedure Post-SCI Pain

Author Year

Country
PEDro Score
Research Design
Total Sample Size

MethodsOutcome
Falci et al. 2002

USA

PCT

N=41

Population: Type of pain=neuropathic.

Intervention: The first nine patients were placed in group 1 and the next 32 in group 2. Individuals in group 1 underwent Dorsal Root Entry Zone (DREZ) microcoagulation using recorded spontaneous neuroelectrical hyperactivity in DREZ as a guide. While the second group underwent DREZ microcoagulation using the above recorded spontaneous nuroelectrical hyperactivity in the DREZ as well as recorded evoked hyperactivity during TCS of the DREZ.

Outcome Measures: Visual Analogue Scale (VAS)

1.     Seven patients in the first group achieved at least 50% pain relief post treatment while five patients achieved 100%.

2.     In the second group, 84% of patients reported 100% pain relief post treatment; while 88% reported at least 50%.

3.     In patients in the second group that experienced below level pain, 81% of patients reported 100% pain relief; while 19% that experienced above level pain all achieved 100% pain relief.

4.     The intervention did not result in any deaths.

5.     82% of patients lost partial or complete pinprick sensation in the corresponding DREZ.

6.     68% experienced partial or complete loss of light touch sensation.

Chun et al. 2011

Korea

Pre-post

N=38

Population: Age: 49 yr, Level of injury: T=5, Conus Medullaris=33. Severity of Injury: AIS A=27; B11; Type of pain=neuropathic.

Treatment: MDT was performed according to Sindou’s technique

Outcome Measures: Visual Analogue Scale (VAS)

1.     Overall patients achieved good (79.0%), fair (10.5%) and poor (10.5%) poor pain relief.

2.     Good pain relief was achieved in 82.5% of those with mechanical pain and 100% with combined pain, vs. 20% with thermal pain

3.     Good pain relief was achieved in those with diffuse pain (73.3%) and segmental pain (82.6%).

4.     Good pain relief was achieved in those with intermittent pain (78.2%) and continuous pain (80.0%)

Spaic et al. 2002

Yugoslavia (Serbia)

Case series

N=26

Population: Type of pain=neuropathic.

Treatment: Dorsal Root Entry Zone (DREZ) surgical treatment

Outcome Measures: Visual Analogue Scale (VAS)

1.     DREZ surgical treatment was found to be effective at reducing pain in the majority of patients, more so for those with mechanical and combined vs. thermal pain.

2.     Long-term pain relief was achieved in 90% of those with mechanical pain and 25% of those with combined pain.

Sindou et al. 2001

France/Egypt

Case series

N=44

Population: Type of pain=neuropathic and musculoskeletal.

Treatment: Patients underwent Dorsal Root Entry Zone (DREZ) procedure to reduce pain.

Outcome Measures: Visual Analogue Scale (VAS)

1.     By 10 days, 70% of patients had experienced good pain relief, 18.5% fair pain relief, and 11.5% poor pain relief.

2.     3 months later, 66% reported continued good pain relief.

3.     Better pain relief was seen in those with segmental vs. below-lesion pain and in those with conus medullaris vs. higher injuries.

Spaic et al. 1999

Yugoslavia (Serbia)

Case series

N=6

Population: Type of pain=neuropathic.

Treatment: DREZotomy surgical procedure.

Outcome Measures: Self-reported pain relief.

1.     4/6 patients reported complete pain relief; 2/6 reported 80% pain relief.

2.     Two patients who had been using pain medication reported no longer needing them.

Rath et al. 1997

Germany

Case series

N=23

Population: Type of pain=neuropathic

Treatment: Patients underwent Dorsal Root Entry Zone (DREZ) procedure.

Outcome Measures: Patients were asked to judge postoperative pain relative to preoperative pain (%).

1.     Of the 23 patients who underwent the procedure, 11 were judged to have experienced good pain relief; the remaining 12 were said to have had a fair or poor result.

2.     Better results were seen for those with ‘end-zone’ vs. diffuse pain.

Sampson et al. 1995

USA

Case series

N=39

Population: Type of pain=neuropathic and musculoskeletal.

Treatment: Patients received Dorsal Root Entry Zone (DREZ) procedures from 1978 to 1992.

Outcome Measures: Pain relief, as indicated by subsequent treatment and activity levels.

1.     21 of the 39 reported good results, while the remaining 18 reported fair results at a mean of 3 yr.

2.     30/39 had no post-operative complications.

Nashold et al. 1990

USA

Case series

N=18

Population: Type of pain=neuropathic and musculoskeletal.

Treatment: Patients who had a SCI and Dorsal Root Entry Zone (DREZ) procedures and drainage to remove cysts that had developed <1 post injury.

Outcome Measures: Pain relief, as indicated by subsequent treatment and activity levels.

1.     14/18 patients reported good pain relief with combined cyst drainage. Good pain relief was defined as not requiring any analgesics and activities not limited because of pain.
Friedman & Nashold 1986

USA

Case series

N=56

Population: Type of pain=not stated.

Treatment: Patients underwent Dorsal Root Entry Zone (DREZ) procedure.

Outcome Measures: Pain relief, as indicated by subsequent productivity levels.

1.     50% of patients reported good pain relief, 9% fair, 4% poor following DREZ procedure.

2.     Better results were obtained for those with segmental vs. diffuse pain.

Discussion

In the Falci et al. (2002) study, individuals were divided into two treatment groups: the first nine patients underwent DREZ micro-coagulation using recorded spontaneous neuro-electrical hyperactivity in as a guide; while the second group underwent DREZ micro-coagulation using both the recorded spontaneous and evoked hyperactivity as a guide. Individuals were followed up to six years post-surgery and pain was measured using the VAS. The study found that more participants (50% vs. >80%) in the second group reported 100% pain relief than those in the first group.

Chun et al. (2011) reported on 38 individuals treated with the procedure, between 2003 and 2008. These individuals suffered from various types of neuropathic pain including segmental versus diffuse, mechanical versus thermal or a combination of both, and intermittent versus continuous pain. Previous management with medication had proven unsuccessful. After surgery, individuals were followed for a period ranging between 19 and 84 months (average of 42 months) to measure the degree of pain relief. At follow-up, individuals were asked to rate the intensity of their pain using the VAS. Pain relief was considered by the authors to be “good” if pain was reduced by more than 75%, “fair” if it was reduced by 25-75% and “poor” if pain was reduced less than 25%. Individuals with intermittent pain and continuous pain achieved high rates of good pain relief (78% and 80%, respectively).9

Notably, Nashold et al. (1990) reported 14 of 18 individuals (77%) with paraplegia who underwent cyst drainage and the DREZ surgical procedure reported pain relief following surgery. In general, approximately 50% or more of the patients across these case series achieved greater than 50% pain relief or experienced no pain-related activity limitations and no need for narcotics following the surgery (Friedman & Nashold 1986; Nashold et al. 1990; Rath et al. 1997; Sampson et al. 1995; Sindou et al. 2001; Spaic et al. 1999; Spaic et al. 2002). However, all of these were retrospective, uncontrolled reports with obvious methodological limitations, such as ill-defined eligibility criteria (i.e., potential selection bias) and inadequate outcome measurement which limits the generalizability of the results.

Conclusion

There is level 2 evidence (from one prospective controlled trial, one pre-post study, and seven case series studies; Falci et al. 2002; Chun et al. 2011; Sindou et al. 2001; Spaic et al. 1999, 2002; Rath et al. 1997; Sampson et al. 1995; Bashold et al. 1990; Friedman & Nashold 1986) to support the use of the DREZ surgical procedure to reduce pain post SCI. It may be that some populations (segmental pain) are more likely to benefit from this procedure.

  • DREZ surgical procedure reduces pain post SCI.