Takai Keisuke, Taniguchi Makoto
Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan.
J Neurosurg Spine. 2017 Aug;27(2):178-184. doi: 10.3171/2017.1.SPINE16234. Epub 2017 Jun 2.
OBJECTIVE Dorsal root entry zone (DREZ) lesioning has been the most effective surgical treatment for the relief of intractable pain due to root avulsion injury, but residual pain and a decrease in pain relief in the follow-up period have been reported in 23%-70% of patients. Based on pain topography in the most recent studies on neuropathic pain, the authors modified the conventional DREZ lesioning procedure to improve clinical outcomes. The presumed rationale for this procedure is to eliminate the spontaneous discharges of neurons in the superficial spinal dorsal horn as well as wide dynamic range neurons in the deep spinal dorsal horn. METHODS Ten patients with avulsion-related pain underwent surgery between 2011 and 2015. The surgical procedure was described and postoperative pain relief was assessed as follows: excellent (residual pain never exceeded 3 on the visual analog scale [VAS] without medication), good (residual pain never exceeded 5 on the VAS with medication), and poor (residual pain was greater than 5 with medication). Specific perioperative complications were assessed. RESULTS The aim of this surgical procedure was to destroy the deeper layers of the posterior horn of spinal gray matter, which was in contrast to the procedures of Nashold and Sindou, which were to destroy the superficial layers. All patients achieved excellent (n = 7, pain relief without medication) or good (n = 3, pain relief with medication) pain relief postoperatively, and the recurrence of pain was not reported in any patients (median 29 months after surgery, range 12-64 months). Nine patients (90%) achieved complete pain relief (a score of 0 or 1 on the VAS) with or without medication. No surgical site complications such as infection or CSF leakage were noted. No motor deficit was observed in any patient. A sensory deficit was observed in 2 patients and disappeared within 1 month in 1 patient. New pain at the adjacent level of DREZ lesioning was observed in 3 patients and disappeared within 1 month in 2 patients. In the other patient, new pain persisted and required analgesics. CONCLUSIONS These preliminary results demonstrated that total and persistent global pain relief was achieved with the modified DREZ lesioning procedure in 90% of patients without major neurological deficits. The clinical improvements achieved by this modified surgical procedure support the hypothesis that not only the superficial layers, but also deeper layers of the spinal dorsal horn are associated with intractable pain due to root avulsion injury.
目的 背根入髓区（DREZ）毁损术一直是缓解因神经根撕脱伤所致顽固性疼痛最有效的外科治疗方法，但据报道，23% - 70%的患者在随访期间存在残留疼痛且疼痛缓解程度下降。基于最近关于神经性疼痛研究中的疼痛分布图，作者对传统的DREZ毁损术进行了改良，以改善临床疗效。该手术的推测原理是消除脊髓背角浅层神经元以及脊髓背角深层广动力范围神经元的自发放电。方法 2011年至2015年间，10例患有与撕脱相关疼痛的患者接受了手术。描述了手术过程，并按以下方式评估术后疼痛缓解情况：优（视觉模拟量表[VAS]评分在未用药时残留疼痛从未超过3分）、良（用药时VAS评分残留疼痛从未超过5分）、差（用药时残留疼痛大于5分）。评估了特定的围手术期并发症。结果 该手术的目的是破坏脊髓灰质后角的深层，这与Nashold和Sindou的手术不同，他们的手术是破坏浅层。所有患者术后均实现了优（n = 7，未用药时疼痛缓解）或良（n = 3，用药时疼痛缓解）的疼痛缓解，且未报告任何患者疼痛复发（术后中位时间29个月，范围12 - 64个月）。9例患者（90%）无论是否用药均实现了完全疼痛缓解（VAS评分为0或1分）。未发现手术部位并发症，如感染或脑脊液漏。未观察到任何患者出现运动功能障碍。2例患者出现感觉功能障碍，其中1例在1个月内消失。3例患者在DREZ毁损部位相邻水平出现新的疼痛，2例患者在1个月内消失。另1例患者新的疼痛持续存在，需要使用镇痛药。结论 这些初步结果表明，改良的DREZ毁损术使90%的患者实现了完全且持久的整体疼痛缓解，且无重大神经功能缺损。这种改良手术所取得的临床改善支持了以下假设：不仅脊髓背角的浅层，而且深层也与神经根撕脱伤所致的顽固性疼痛相关。
