1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
2Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota; and.
J Neurosurg Spine. 2023 Mar 31;39(1):101-112. doi: 10.3171/2023.2.SPINE221252. Print 2023 Jul 1.
Patients with brachial plexus avulsion (BPA) experience chronic deafferentation pain characterized by two patterns: continuous background pain and electrical shooting paroxysmal attacks. The authors' aim was to report the effectiveness and safety of dorsal root entry zone (DREZ) lesioning in relieving the two forms of pain over short and long periods.
All patients who underwent DREZ lesioning performed by the senior author for medically refractory BPA-related pain between July 1, 2016, and June 30, 2020, in Johns Hopkins Hospital were followed up. The intensity levels for continuous and paroxysmal pains were evaluated using the numeric rating scale (NRS) preoperatively and at 4 time points postsurgery, including the day of discharge, with a mean hospital stay of 5.6 ± 1.8 days; first postoperative clinic visit (33.0 ± 15.7 days); short-term follow-up (4.0 ± 1.4 months); and long-term follow-up (3.1 ± 1.3 years). The percent of pain relief according to the NRS was categorized into excellent (≥ 75%), fair (25%-74%), and poor (< 25%).
A total of 19 patients were included, with 4 (21.1%) lost to long-term follow-up. The mean age was 52.7 ± 13.6 years; 16 (84.2%) were men, and 10 (52.6%) had left-sided injuries. A motor vehicle accident was the most common etiology of BPA (n = 16, 84.2%). Preoperatively, all patients had motor deficits, and 8 (42.1%) experienced somatosensory deficits. The greatest pain relief was observed at the first postoperative and short-term follow-up visits, with the lowest proportions of patients having continuous pain (26.3% and 23.5%, respectively) and paroxysmal pain (5.3% and 5.9%, respectively). Also, the highest reductions in mean NRS scores were observed for first postoperative and short-term follow-up visits (continuous 1.1 ± 2.1 and 1.1 ± 2.3; paroxysms 0.4 ± 1.4 and 0.5 ± 1.7, respectively) compared to the preoperative symptomatology (continuous 6.7 ± 3.0; paroxysms 7.9 ± 4.3) (p < 0.001). Most patients had excellent relief of continuous pain (82.4% and 81.3%) and of paroxysms (90.9% and 90.0%) at the first postoperative visit and short-term follow-up visit, respectively. The pain relief benefits had diminished by 3 years after surgery but remained significantly better than in the preoperative assessment. At the last evaluation, the proportion of patients achieving excellent relief of paroxysmal pain (66.7%) was double that for continuous pain (35.7%) (p < 0.001). New sensory phenomena were observed among 10 patients (52.6%), and 1 patient developed a motor deficit.
DREZ lesioning is an effective and safe option for relieving BPA-associated pain, with good long-term outcomes and better benefits for paroxysmal pain than for the continuous pain component.
臂丛神经撕脱伤（BPA）患者经历以两种模式为特征的慢性去传入性疼痛：持续的背景疼痛和电激阵发性发作。作者的目的是报告在短期和长期内，通过背根入髓区（DREZ）消融术缓解这两种疼痛形式的有效性和安全性。
在约翰霍普金斯医院，由资深作者对 2016 年 7 月 1 日至 2020 年 6 月 30 日期间因医学难治性 BPA 相关疼痛而行 DREZ 消融术的所有患者进行了随访。使用数字评分量表（NRS）在术前和术后 4 个时间点（包括出院当天）评估连续和阵发性疼痛的强度水平，平均住院时间为 5.6 ± 1.8 天；术后首次就诊（33.0 ± 15.7 天）；短期随访（4.0 ± 1.4 个月）；长期随访（3.1 ± 1.3 年）。根据 NRS 评估的疼痛缓解百分比分为优秀（≥75%）、良好（25%-74%）和差（＜25%）。
共纳入 19 例患者，其中 4 例（21.1%）长期随访丢失。平均年龄为 52.7 ± 13.6 岁；16 例（84.2%）为男性，10 例（52.6%）为左侧损伤。机动车事故是 BPA 最常见的病因（n=16，84.2%）。术前所有患者均有运动障碍，8 例（42.1%）有感觉障碍。在术后第一次和短期随访时观察到最大的疼痛缓解，连续疼痛（分别为 26.3%和 23.5%）和阵发性疼痛（分别为 5.3%和 5.9%）的患者比例最低。同样，术后第一次和短期随访时 NRS 评分的平均降低幅度最大（连续为 1.1 ± 2.1 和 1.1 ± 2.3；阵发性为 0.4 ± 1.4 和 0.5 ± 1.7），与术前症状相比（连续为 6.7 ± 3.0；阵发性为 7.9 ± 4.3）（p＜0.001）。大多数患者在术后第一次就诊和短期随访时，连续疼痛（82.4%和 81.3%）和阵发性疼痛（90.9%和 90.0%）均有极好的缓解。术后 3 年疼痛缓解效果有所下降，但仍明显优于术前评估。在最后一次评估时，阵发性疼痛（66.7%）获得极好缓解的患者比例是连续疼痛（35.7%）的两倍（p＜0.001）。10 例患者（52.6%）出现新的感觉现象，1 例患者出现运动障碍。
DREZ 消融术是缓解 BPA 相关疼痛的有效且安全的选择，具有良好的长期效果，对阵发性疼痛的缓解效果优于持续性疼痛。
