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Posterior Cervicothoracic Fusion During Dorsal Root Entry Zone Lesioning for Brachial Plexus Avulsion: Sagittal
Stephen M Bergin1, Joshua Woo1, Mohamed Alwadai1
1Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.
Background And Objectives:
Dorsal root entry zone (DREZ) lesioning is an established treatment of refractory deafferentation pain after brachial plexus avulsion. Exposure often requires multilevel cervical or cervicothoracic laminectomy, which may predispose to postoperative kyphosis. We evaluated whether concurrent posterior instrumented fusion preserves sagittal alignment and reduces delayed deformity after DREZ lesioning.
Methods:
We retrospectively reviewed patients undergoing cervical or cervicothoracic DREZ lesioning at a single institution from 2013 to 2025. Patients were grouped by concurrent posterior fusion vs nonfusion DREZ. Radiographic outcomes included C2-C7 Cobb angle, cervical sagittal vertical axis (CSVA), T1 slope, C2 slope, and T1 slope minus cervical lordosis. Nonfusion patients with paired standing radiographs underwent exploratory comparison. Clinical outcomes included pain relief, complications, and reoperation.
Results:
Twenty-three patients were included: 8 fusion and 15 nonfusion. In the fusion cohort, median follow-up was 16.0 (IQR: 10.9-21.4). Paired standing radiographs were available in 7 of 8 fusion patients and 3 of 15 nonfusion patients. In the fusion cohort, mean C2-C7 Cobb improved from 2.5° ± 23.1° to 18.3° ± 20.8°, whereas CSVA remained stable. All fusion patients maintained postoperative CSVA ≤40 mm, and 7 of 8 maintained T1 slope minus cervical lordosis ≤20°. No fusion patient developed new or progressive postoperative kyphosis. Durable pain relief occurred in 5 of 8 fusion patients and 10 of 15 nonfusion patients. In the nonfusion cohort, postoperative kyphosis was documented in 8 of 15 patients, new or progressive kyphosis/deformity in 5 of 12 evaluable patients, and reoperation for deformity, instability, or radiographic failure in 5 of 15.
Conclusion:
Concurrent posterior fusion during cervicothoracic DREZ lesioning was associated with preserved sagittal alignment and absence of new progressive postoperative kyphosis. Fusion should be considered when DREZ requires extensive multilevel exposure, particularly across the cervicothoracic junction.