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Microsurgical DREZotomy (MDT) for pain, spasticity, and hyperactive bladder: a 20-year experience
1Department of Neurosurgery, Neurological Hospital P. Wertheimer, University of Lyon, France.
Abstract:
Since 1972, micro-DREZ-tomy has been performed in 367 patients: with cancer pain in 81, neurogenic pain in 139, hyperspasticity in 135, and hyperactive neurogenic bladder in 12. MDT consists of an incision and bipolar coagulations performed ventro-laterally in the Dorsal Root Entry Zone (DREZ) at the entrance of the rootlets into the dorso-lateral sulcus. The lesion is directed at 45 degrees ventro-medially, and 2-3 mm deep according to the pre-operative neurological status and the desired effects. MDT 1 degree interrupts the small (nociceptive) fibres regrouped laterally and the large (myotatic) afferents which runs centrally, whilst sparing part of the large medial (lemniscal) fibres. 2 degrees destroys the (excitatory) medial part of the Lissauer's tract, 3 degrees and the cells of the dorsalmost layers of the dorsal horn, which can be the site of hyperactivity, as we were able to record in patients with deafferentation pain. Best indications are: 1) well localized cancer pain, such as Pan-coast syndrome; 2) neuropathic pain due to: brachial plexus injuries, cauda equina and/or spinal cord lesions especially for pain corresponding to segmental lesions, peripheral nerve injuries-amputation-herpes zoster-(especially when the predominant component of pain is of the paroxysmal type and/or corresponds to provoked hyperalgesia/allodynia); 3) excess of spasticity and 4) neurogenic hyperactive bladder.
Insights
Micro-DREZ-tomy (MDT) is a surgical procedure that treats chronic pain and spasticity by targeting specific nerve fibers in the spinal cord. This technique has shown effectiveness in managing various neuropathic pain conditions and hyperspasticity.
Area of Science:
- Neurosurgery
- Pain Management
- Neurology
Background:
- Micro-DREZ-tomy (MDT) has been utilized since 1972 to address complex neurological conditions.
- The procedure involves precise lesions within the Dorsal Root Entry Zone (DREZ) to modulate pain and spasticity signals.
Purpose of the Study:
- To evaluate the efficacy and indications of micro-DREZ-tomy in a large patient cohort.
- To detail the surgical methodology and anatomical targets of MDT.
- To identify optimal patient candidates for MDT.
Main Methods:
- Performed on 367 patients for cancer pain, neurogenic pain, hyperspasticity, and hyperactive neurogenic bladder.
- Involved creating precise lesions in the Dorsal Root Entry Zone (DREZ) using bipolar coagulation.
- Lesion depth and angle adjusted based on neurological status and desired therapeutic effect, targeting specific fiber tracts and dorsal horn layers.
Main Results:
- MDT effectively targets nociceptive and myotatic fibers while sparing crucial lemniscal pathways.
- Different degrees of MDT (1, 2, or 3) allow for selective interruption of specific neural components.
- Successful application in localized cancer pain, neuropathic pain (brachial plexus, spinal cord lesions, peripheral nerve injuries), spasticity, and bladder dysfunction.
Conclusions:
- Micro-DREZ-tomy is a versatile neurosurgical technique for managing refractory neuropathic pain and spasticity.
- Careful patient selection based on pain characteristics and neurological deficits is crucial for optimal outcomes.
- MDT offers a targeted approach to modulate aberrant neural activity contributing to pain and hyperreflexia.