Functional Neurosurgery Department, Neurology and Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France; University of Lyon, University Claude Bernard Lyon I, Lyon, France.
Functional Neurosurgery Department, Neurology and Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France; University of Lyon, University Claude Bernard Lyon I, Lyon, France; University of Medicine and Pharmacy "Victor Babes" Timisoara, Romania.
World Neurosurg. 2021 Apr;148:177. doi: 10.1016/j.wneu.2021.01.054. Epub 2021 Jan 28.
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). 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). 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. 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. 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).
一位 63 岁男性，42 年前曾遭遇摩托车事故导致左侧臂丛神经撕脱伤。其左侧上肢 C6-C7-C8 皮区出现神经性疼痛。行“DREZ 切开术”的基本原理是优先中断背根进入区（DREZ）外侧的伤害性传入。对于如臂丛神经撕脱伤所见的完全去传入性疼痛，目标是破坏背角（DH）尖端深处的过度活跃伤害性神经元。手术在全身麻醉下进行，患者取俯卧位。一旦硬脑膜打开，蛛网膜需要广泛解剖以打开背外侧和外侧脊髓腔。在臂丛神经撕脱伤的情况下，可能难以识别背外侧沟。三个解剖学元素可以帮助识别它。首先，未受损的神经根（在撕脱段上方和下方）允许我们通过连接这些颅侧和尾侧正常神经根大致定位背外侧沟。其次，沿脊髓运行的血管穿透背外侧沟，通常可描绘出该沟。第三，沿着沟可以看到瘢痕，神经根曾经穿过脊髓的地方有小孔。使用逐渐变细的双极锐器进行 DREZ 切开术，以允许对 DH 进行精确的微凝。术前手术计划通过给出 DH 与正中平面之间的角度来帮助外科医生。在术后即刻，患者描述其左侧上肢的神经性疼痛完全消失，在最后一次随访（1 年）时仍持续存在（视频 1）。
