Microsurgical DREZotomy for Treatment of Brachial Plexus Avulsion Pain

A 63-year-old man with a history of motorcycle accident 42 years ago suffered a left brachial plexus avulsion (BPA). Neuropathic pain in his left upper limb was felt in the C6-C7-C8 dermatomes. The rationale for performing "DREZotomy" is to preferentially interrupt the nociceptive inputs in the lateral part of the dorsal root entry zone (DREZ).^1-3 For pain with complete deafferentation, as observed in BPA, the aim is to destroy the hyperactive nociceptive neurons deep in the apex of the dorsal horn (DH).⁴ Surgery is performed under general anesthesia, with the patient in prone position. Once the dura mater is opened, the arachnoid needs extensive dissection to open the dorsolateral and lateral spinal cisterns.⁵ In cases of BPA, the dorsolateral sulcus may be difficult to identify. Three anatomic elements can facilitate its recognition. Firstly, the remaining intact rootlets (above and below the avulsed segments) allow us to roughly localize the dorsolateral sulcus by joining these cranial and caudal normal rootlets. Secondly, blood vessels running on the spinal cord penetrate into the dorsolateral sulcus and often delineate the sulcus. Thirdly, scarring can be seen along the sulcus with small holes where the rootlets used to penetrate the cord. DREZotomy is performed using a graduated sharp bipolar instrument to allow precise microcoagulations of the DH. Preoperative surgical planning helps the surgeon by giving the angle between the DH and median plane.⁶ In the immediate postoperative period, the patient described the complete disappearance of neuropathic pain in his left upper limb, persistent at last follow-up (1 year) (Video 1).