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    DREZ-? for Dr. Young

    What is your opinion of the DREZ procedure? If someone had it done, would it have any impact on their chance for a future cure? Thanks for your input.

    #2
    Phillis, in my opinion, the DREZ procedure should be a procedure of last resort because it is destructive. I also think that it should be restricted to the localized pain. Wise.

    Comment


      #3
      Originally posted by Phillis:

      What is your opinion of the DREZ procedure? If someone had it done, would it have any impact on their chance for a future cure? Thanks for your input.
      Ive had the DREZ over 7 yrs now with 100% relief of pain. I had pain from the waist down. It was the best thing I have ever done. Contact me for info if you want Sirdzoker@aol.com

      Comment


        #4
        In other words, with my all over pains, I wouldn't be a candidate for this.
        Alan

        Proofread carefully to see if you any words out.

        Comment


          #5
          Alan, you could be a good candidate. My pain was from the waist down. You really need the advice of more than one doctor in regards to this type of surgery. You also need the advice from a doctor who has had sucessful results of the drez. Also the patients who have had it done with good results, like myself. I recommend it any day over all the narcotics the Drs are giving for this pain. Because anyone knows who suffers from it knows that these meds do not deaden the pain, they only deaden the patient so they can accept pain. Just food for thought.

          Comment


            #6
            Here are some recent articles on the subject:


            • Burchiel KJ and Hsu FP (2001). Pain and spasticity after spinal cord injury: mechanisms and treatment. Spine 26:S146-60. Summary: STUDY DESIGN: A comprehensive survey of literature on the proposed mechanisms and treatment of pain and spasticity after spinal cord injury (SCI) was completed. OBJECTIVES: To define the current understanding of these entities and to review various treatment options. SUMMARY OF BACKGROUND DATA: The neurophysiologic basis of spasticity after SCI is well established. The mechanism of neuropathic pain after SCI remains conjectural, although considerable new data, much of it from animal models, now add to our understanding of this condition. METHODS: A comprehensive search and review of the published literature was undertaken. RESULTS: Treatment options for spasticity are effective and include oral medication (baclofen, tizanidine), intrathecal baclofen, and rarely, surgical rhizotomy or myelotomy. Selected patients with post-SCI pain can respond to surgical myelotomy (DREZ lesions) or intrathecal agents (e.g., morphine + clonidine), but the majority continue to suffer. CONCLUSIONS: Medical and surgical treatments for spasticity are established and highly successful. Management of post-SCI pain remains a clinical challenge, as there is no uniformly successful medical or surgical treatment. Department of Neurological Surgery, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97201, USA. burchiek@ohsu.edu

            • Mertens P and Sindou M (2000). [Surgery in the dorsal root entry zone for treatment of chronic pain]. Neurochirurgie 46:429-46. Summary: Microsurgical drezotomy (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 35 ventro-medially, and to 2-3 mm deep according to the pre-operative neurological status and the desired effects. MDT i) interrupts the small (nociceptive) fibres regrouped laterally and the large (myotatic) afferents which runs centrally, whilst sparing part of the large medial (lemniscal) fibres, ii) destroys the (excitatory) medial part of the Lissauer's tract, iii) 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: i) well-localized cancer pain, such as Pancoast syndrome; ii) 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); iii) excess of spasticity, especially when associated with severe pain. Service de Neurochirurgie A, Hopital Neurologique et Neurochirurgical P. Wertheimer, Universite de Lyon, 59, boulevard Pinel, 69003 Lyon.

            • Sindou M (1995). Microsurgical DREZotomy (MDT) for pain, spasticity, and hyperactive bladder: a 20-year experience. Acta Neurochir (Wien) 137:1-5. Summary: 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. Department of Neurosurgery, Neurological Hospital P. Wertheimer, University of Lyon, France.

            • Sindou M, Mertens P and Wael M (2001). Microsurgical DREZotomy for pain due to spinal cord and/or cauda equina injuries: long-term results in a series of 44 patients. Pain 92:159-71. Summary: According to the literature estimations, 10-25% of patients with spinal cord and cauda equina injuries eventually develop refractory pain. Due to the fact that most classical neurosurgical methods are considered of little or no efficacy in controlling this type of pain, the authors had recourse to microsurgery in the dorsal root entry zone (DREZ). This article reports on the long-term results of the microsurgical approach to the dorsal root entry zone (DREZotomy) in a series of 44 patients suffering from unbearable neuropathic pain secondary to spine injury. The follow-up ranged from 1 to 20 years (6 years on average). The series includes 25 cases with conus medullaris, 12 with thoracic cord, four with cauda equina and three with cervical cord injuries. Surgery was performed in 37 cases at the pathological spinal cord levels that corresponded to the territory of the so-called 'segmental pain', and in seven cases, on the spinal cord levels below the lesion for 'infralesional pain' syndromes. The post-operative analgesic effect was considered to be 'good' when a patient's estimation of pain relief exceeded 75%, 'fair' if pain was reduced by 25-75%, and 'poor' when the residual pain was more than 75% of preoperative estimations. Immediate pain relief was obtained in 70% of patients and was long-lasting in 60% of the total series. The results varied essentially according to the distribution of pain. Good long-term results were obtained in 68% of the patients who had a segmental pain distribution, compared with 0% in patients with predominant infralesional pain. Regarding pain characteristics, a good result was obtained in 88% of the cases with predominantly paroxysmal pain, compared with 26% with continuous pain. There were no perioperative mortalities. Morbidity included cerebrospinal fluid leak (three patients), wound infection (two patients), subcutaneous hematoma (one patient) and bacteremia (in one patient). The above data justify the inclusion of DREZ-lesioning surgery in the neurosurgical armamentarium for treating 'segmental' pain due to spinal cord injuries. Department of Neurosurgery, Hopital Neurologique Pierre Wertheimer, University of Lyon, 69003, Lyon, France. marc.sindou@chu-lyon.fr

            • Spaic M, Markovic N and Tadic R (2002). Microsurgical DREZotomy for pain of spinal cord and Cauda equina injury origin: clinical characteristics of pain and implications for surgery in a series of 26 patients. Acta Neurochir (Wien) 144:453-62. Summary: The result of the DREZotomy procedure used for the treatment of chronic intractable neuropathic pain caused by injuries at the T9-L4 spine level in 26 patients has been reported. For the purpose of identifying the most favorable pain pattern for DREZ surgery we retrospectively analyzed the effectiveness of surgical treatment on different forms of pain in the follow-up period of 13-50 months, 37 months on average. All pain forms were classified according to subjective sensory pain expression including the rhythm and topography of the pain. Three groups of pain were formed according to subjective sensory equivalents: pain of thermal quality (burning, boiling, baking, warm etc.), pain of mechanical-nonthermal quality (shooting, cutting, stabbing, sharp, incisive, cramping, constriction, distraction, throbbing etc.). The third group was the combination of the previous two. Success in pain relief has been defined as a 50% or greater reduction in pain after surgery such that pain no longer interferes with patient activities of daily living and sleeping pattern and no longer requires routine analgesic pain medication. Our results revealed that the pain of mechanical-nonthermal nature and intermittent rhythm, confined to segmental topography was the most responsive to the DREZ surgical treatment so that 90% patients suffering from this pain pattern experienced a good long-term pain relief (70% had complete long term pain relief). Neuropathic pain of thermal quality with the diffuse infralesional distribution and steady rhythm was the most resistant to the DREZ surgical treatment: neither patient had long-term relief of this pain pattern. In the group of patients suffering from pain consisting of combined mechanical and thermal sensory components with confined pain territory, 75% experienced a good long-term pain relief (50% had complete long-term pain relief). Immediate pain relief was obtained in 88% of patients and was long lasting in 69% of the total series. Our results pointed to confined territory, intermittent rhythm and mechanical nature of the pain as the most relevant predictors of the expected pain relief achieved by the DREZ surgery. Department of Neurosurgery, Military Medical Academy, Belgrade, Serbia, Yugoslavia.

            Comment


              #7
              I am so glad that I found this link in New Mobility magazine. I have had chronic pain for the past 16 years and I have not been able to find relief. I was prescribed Elavil (low dose) for three years, but it made me numb and sleepy and I couldn't function in school. Since then (13 years), I haven't taken anything except something over the counter at times when I couldn't sleep. The burning, stinging hasn't gone away at all, but I have noticed that as I am aging I am getting other pains and at times it is unbearable. I have had a few doctors recommend DREZ and my reasons for not having the procedure done were more based on sensation and balance and less on cure. I wanted to know how much of what I have would be lost with the procedure or is there any way to know?

              What else to you suggest for pain management? I have done well basically ignoring it for all this time, but there are really times that I need relief.

              Comment


                #8
                Originally posted by Sir Dzoker:

                Alan, you could be a good candidate. My pain was from the waist down. You really need the advice of more than one doctor in regards to this type of surgery. You also need the advice from a doctor who has had sucessful results of the drez. Also the patients who have had it done with good results, like myself. I recommend it any day over all the narcotics the Drs are giving for this pain. Because anyone knows who suffers from it knows that these meds do not deaden the pain, they only deaden the patient so they can accept pain. Just food for thought.
                My pains are from the upper chest and back down.
                Alan

                Proofread carefully to see if you any words out.

                Comment


                  #9
                  Originally posted by Sir Dzoker
                  Ive had the DREZ over 7 yrs now with 100% relief of pain. I had pain from the waist down. It was the best thing I have ever done. Contact me for info if you want Sirdzoker@aol.com
                  Hi I don't know if u got my first message?I would like learn more of
                  DREZ.And where it's possible to take one.I feel I have nothing to loose.
                  They have giving up on me here in Norway.My injured is from t9-10 comlete.My pain is so terrible from waist down.It's like my legs is
                  wrapped up in barbed wire.The only thing they can give me is meds,but they
                  have not much effect on me anymore.I'm longing for a long good sleep.It's been a while.I tried to send u a mail,but i didn't work out.If u can't help me,is there anybody else who can?I have suffer enough now in the past 8 years since my injury.

                  Comment


                    #10
                    http://www.newmobility.com/review_ar...&action=browse

                    "The Duke DREZ procedure that Snow contemplated simply burned the sensory nerves two levels above the original injury and one level below it. This procedure was eventually undertaken and improved upon by Craig Hospital's Dr. Robert Edgar, now retired, and Dr. Scott Falci."

                    Contact Dr. Scott Falci at Craig Hospital http://www.craighospital.com/ in Denver (actually Englewood, Denver suburb), Colorado.

                    Scott Falci, M.D., Neurosurgeon
                    Charlotte Starnes, R.N. 303-761-5281
                    CStarnes@craighospital.org
                    Last edited by cass; 7 Aug 2006, 8:30 PM.

                    Comment


                      #11
                      Originally posted by Wise Young
                      Phillis, in my opinion, the DREZ procedure should be a procedure of last resort because it is destructive. I also think that it should be restricted to the localized pain. Wise.

                      I am glad to see Wise take this position, since I do not know of any cases where DREZ has relieved OTHER THAN the level of injury pain, although I have talked to some people who felt it helped spasticity, but that is not pain.

                      Lissauer's tract is traditionally defined as a layer OUTSIDE Lamina I. It contains both afferent and efferent fibers, (those going up as well as down.) As early as 1978, it was known that DREZ mainly helped lemniscal (posterior column) pain. It was also known that lesioning of Lissauer's tract did NOT diminish the dorsal root currents above the lesion. See eg. The Journal of Physiology, Vol 282, Issue 1 295-305,.

                      From the limited correspondence I have had with those undergoing DREZ, its utility seemed more for peripheral pain than central pain. An example of peripheral pain might be brachial plexus injury like motorcyclists get from traction on the shoulder, when they hit the pavement, and stretch the nerves. Just considering the basic physiology, I do not see why DREZ should be more than what Wise says, a measure of last resort for LOCALIZED pain.
                      Last edited by dejerine; 8 Aug 2006, 12:00 AM.

                      Comment


                        #12
                        sorry, dej, i disagree. even barry corbet had this surgery and it is for central pain. did you read the article i cited? they cauterize the hyperactive nerve endings in the spinal cord. this is most definitely not addressing peripheral pain according to those i know who have had it. wise's comments are from 2003. i'm interested to hear if he has anything more recent, though this procedure has been around for years. i do not see how anybody can say cauterizing nerve endings in the spinal cord is addressing the peripheral system. the drawback is possible loss of function and/or sensation.

                        it worked for barry, it worked for the guy in this article and i know of others. and, for those who don't know, barry corbet was the editor of new mobility. he reported on his surgery years ago. unf., he passed away a year or two ago (nothing to do with the DREZ surgery).

                        wise is, obviously, correct in saying it is a last resort. the neurosurgeon i cited says the same thing. some of us are reaching the last resort. last i heard, because of the risk, they would not do this on anybody injured above T4 or so. this was yrs ago.

                        i would suggest, for those interested, corresponding with craig hospital and the doctor whose contact info i gave. craig is a highly reputable sci center.

                        "The pre-op testing tells us where to look," Falci explains. "Once the cord is exposed in surgery, we can hook up electrodes, measure responses, record activity and analyze for painful and non-painful responses. The difference between pain and normal signals is quite clear, and we use that information to direct our surgery. We can now knock out the pain 85 percent of the time."

                        "Mechanical pain -- the kind experienced in bones, joints or muscles and normally caused by overuse and exacerbated by movement -- usually responds well to anti-inflammatory drugs such as ibuprofen, as well as narcotics, and will cease when the damage heals or the source of the strain is removed. However, Snow's nemesis wasn't mechanical pain, but an entirely different animal called neuropathic pain, a type that many SCI survivors know all too well."

                        from the article.
                        Last edited by cass; 8 Aug 2006, 12:38 AM.

                        Comment


                          #13
                          Cass,

                          There has been precious little progress in this area. I list some papers on the subject since 2003. Basically, there is progress in three areas that I can see. First, the combination of DREZ and stimulation may be helpful. Second, the procedure appears to be useful in some cases of brachial plexus avulsion pain. Third, there may be new and less destructive methods. Fourth, Ivanovic, et al. in Serbia claims to be getting "excellent" results in 80% of patients although I must say that I am skeptical about chordotomy as a procedure for pain since much experience suggests that the pain returns after about a year. The results may be related to the timing of the assessment after the surgery.

                          When I said that the treatment should be considered a last resort, I think that a person should exhaust the drug therapies (amitryptaline, gabapentin, etc.) and spinal cord stimulation before considering DREZ.

                          Wise.
                          1. Prestor B (2006). Microcoagulation of junctional dorsal root entry zone is effective treatment of brachial plexus avulsion pain: long-term follow-up study. Croat Med J 47: 271-8. AIM: To analyze long-term clinical results of coagulation lesions of the dorsal root entry zone (DREZ) in patients with deafferentation pain due to brachial plexus avulsion and to correlate the pain relief after DREZ coagulation with pain duration before the DREZ coagulation. METHODS: Twenty-six patients with intractable deafferentation pain after brachial plexus avulsion lesion were treated for pain at the Department of Neurosurgery. Junctional coagulation lesion was made with bipolar forceps along the DREZ. The patients assessed post-operative analgesic effect using a visual analog scale at 1 week, 1 year, 3 years, and 5 years after the surgery. RESULTS: The greatest pain relief was reported immediately after the DREZ procedure. Over the 5-year follow-up period, the pain relief effect gradually and significantly decreased. There were no significant differences between the pain relief evaluated at 1 week and after 1 year and between the pain relief evaluated at 1 week and after 3 years. There was a correlation between the pain duration before the surgery and pain relief after the surgery, with best correlation found between pain duration before surgery and pain relief 5 years after DREZ procedure (r = 0.623, P = 0.007). CONCLUSION: The long-term follow up showed that the pain relief gradually decreased over 5 years after surgery. However, the pain relief still did not significantly decrease after 3 years. Department of Neurosurgery, Ljubljana University Medical Center, Ljubljana, Slovenia. borut.prestor@kclj.si http://www.ncbi.nlm.nih.gov/entrez/q..._uids=16625692
                          2. Yearwood TL (2006). Neuropathic extremity pain and spinal cord stimulation. Pain Med 7 Suppl 1: S97-S102. ABSTRACT Neuropathic pain of the extremities can be well treated with neurostimulation techniques. Over the past decade, spinal cord stimulation (SCS) has become more elegant and sophisticated, especially as technological improvements have enabled newer techniques of neurostimulation and more precise targeting of electrically excitable neuronal structures within the spinal canal. These structures include the dorsal columns, the dorsal root entry zone (DREZ), and spinal nerve roots (traversing and/or exiting nerve roots). It is thus more appropriate now to think in terms of intraspinal neurostimulation (INS) rather than SCS, per se. The balanced application of neurostimulation techniques at more than one intraspinal neuronal structure can significantly augment the therapeutic efficacy of INS. A type of "Dual Modality" stimulation technique can be particularly efficacious, as seen with combined nerve root stimulation and dorsal column stimulation (DCS). It is believed that this improved therapeutic effect may stem from the application of neurostimulatory pulses to influence pain pathways other than the dorsal columns (e.g., the lateral spinothalamic tract). In this way, neurostimulation influences a greater number of neuronal systems within the central nervous system (CNS) to effect both stimulatory and inhibitory modulation of the pain signals. New technologies have enabled implanters the opportunity to explore new horizons of neurostimulation therapy for the treatment of chronic neuropathic extremity pain. Comprehensive Pain and Rehabilitation, Daphne, Alabama, USA. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=16640772
                          3. Sindou MP, Blondet E, Emery E and Mertens P (2005). Microsurgical lesioning in the dorsal root entry zone for pain due to brachial plexus avulsion: a prospective series of 55 patients. J Neurosurg 102: 1018-28. OBJECT: Most patients with preganglionic lesions after brachial plexus injuries suffer pain that is hard to control through medication or neuromodulation. Lesioning in the dorsal root entry zone (DREZ) is undeniably effective. Fifty-five patients who had undergone the so-called microsurgical DREZotomy (MDT) procedure were studied with the two following objectives: 1) to describe the anatomical lesions observed during MDT in correlation with sensory deficits and pain features; and 2) to analyze the results in the 44 patients who were followed for more than 1 year (mean 6 years). METHODS: The observed lesions were severe: 79.6% of ventral and 78.2% of dorsal roots from C5-T1 were impaired. Damage extended to all five roots in 42% of patients. Strong arachnoiditis was present in 38.2%, pseudomeningoceles in 31%, spinal cord distortion and/or atrophy in 49%, and abundant gliotic tissue and/or microcavitations within the dorsal horn at the avulsed segments in 36.4% of cases. Sensory deficit corresponded to the entire territory of the dorsal root lesions in 52% of patients, but was larger in 30% most certainly due to the associated extrarachidian lesions. At the last evaluation after MDT, 66% of patients showed excellent (total relief without medication) or good (total relief with medication) pain relief and 71% experienced an improvement in activity level. CONCLUSIONS: Apart from other indications not addressed in this article, MDT can be performed to treat refractory pain due to brachial plexus avulsions. The long-term efficacy of this procedure strongly indicates that pain after brachial plexus avulsion originates from the deafferented (and gliotic) dorsal horn. Department of Neurosurgery, Pierre Wertheimer Neurological Hospital, University of Lyon, France. marc.sindou@chu-lyon.fr http://www.ncbi.nlm.nih.gov/entrez/q..._uids=16028760
                          4. Spaic M, Mikicic D, Ilic S, Milosavljevic I, Ivanovic S, Slavik E and Antic B (2004). [Biomechanical characteristics of spinal cord tissue--basis for the development of modifications of the DREZ (dorsal root entry zone) operation]. Acta Chir Iugosl 51: 59-64. Mechanical properties of the spinal cord tissue--biological basis for the development of the modality of the DREZ surgery lesioning technique Succesful treatment of the chronic neurogenic pain of spinal cord and cauda equina injury origin remains a significant management problem. The mechanism of this pain phenomenon has been shown to be related to neurochemical changes that lead to the state of hypereactivity of the second order dorsal horn neurons. The DREZ surgery (Dorsal Root Entry Zone lesion), designed to destroy anatomy structures involved in pain generating thus interrupting the neurogenic pain mechanism, as a causative procedure in treating this chronic pain, has been performed by using different technical modalities: Radiofrequency (RF) coagulation technic, Laser, Ultrasound and Microsurgical DREZotomy technic. The purpose of the study was to assess the possibility for the establishment of the lesioning technic based on the natural difference in the mechanical properties between the white and gray cord substance. We experimentally deteminated mechanical properties of the human cadaveric cord white versus gray tissue for the purpose of testing possibility of selective suction of the dorsal horn gray substance as a DREZ lesioning procedure. Based on the fact of the difference in tissue elasticity between white and gray cord substance we established a new and simple DREZ surgical lesioning technique that was tested on cadaver cord. For the purpose of testing and comparing the size and shape of the DREZ lesion axchieved the DREZ surgery has been performed on cadaver cord by employing selective dorsal horn suction as a lesioning method. After the procedure cadaver cord underwent histological fixation and analysis of the DREZ lesions achieved. Our result revealed that the white cord substance with longitudinal fiber structure had four time higher dynamical viscosity than gray substance of local neuronal network structure (150 PaS versus 37.5 PaS) that provided possibility for the safe and selective suction of the gray substance of the dorsal horn. Technic includes incision of the dorsolateral sulcus according to Sindous Microsurgical DREZotomy technic than suction under visual control of the dorsal horn gray matter using succer adopted from the lumbar puncture nidle. Operative experimental testing and hystological analysis confirmed expected size and shape of the DREZ lesion performed by dorsal horn suction as DREZ lesioning technique. The utility, selectivity and safety of this technic has been provided by the natural mechanical properties of the cord tissue itself. Application of the Dorsal horn suction as a DREZ lesioning in humans confirmed this technic as a safe and reliable DREZ lesioning method. Klinika za neurohirurgiju, Vojnomedicinska akademija, Beograd. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=16018411
                          5. Spaic M, Ivanovic S, Slavik E and Antic B (2004). [DREZ (dorsal root entry zone) surgery for the treatment of the postherpetic intercostal neuralgia]. Acta Chir Iugosl 51: 53-7. Postherpetic intercostal neuralgia proved to be an incapacitating pain often recalcitrant to therapy. Acute pain that accompanied Herpes zoster usually subsides spontaneously but in 10% of patients the pain persists and intensifies. The incidence of postherpetic neuralgia incrises up to 50% among elder patients. We report the case of the two 42 and 48 yers old male patient who were succesfuly relieved from the chronic postherpetic intercostal neuralgia employing the DREZ surgery (Dorzal Root Entry Zone lesion). DREZ surgicall treatment of this pain should be considered when medical therapies failed in controling pain. Subjective sensory nature of the pain should play an important role in setting the indication for DREZ surgical treatment. The most favourable pain pattern for DREZ operation is the pain of intermittent rhythm, confined theritory accompanied with the phenomenon of alodinic pain that could be provoked from the pain theritory. Klinika za neurohirurgiju, Vojnomedicinska akademija, Beograd. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=16018410
                          6. Ivanovic S, Slavik E, Spaic M, Antic B, Samardzic M and Rasulic L (2004). [Cordotomy in the treatment of pain conditions]. Acta Chir Iugosl 51: 49-51. During the time interval from January 1978 to January 2003, total of 128 chordotomy procedures have been done due to cancer's pain at the Institute of neurosurgery in Clinical Centre of Serbia. That pain has been mostly of uncontrolled intensity and it was resistant on applieed conservative treatment. Bilateral chordotomy has been performed in 6 patients only in exceptional cases when fixed paraplegia has proved; unilateral chordotomy has been performed in 122 cases. Bilateral chordotomy is much more dangerous than unilateral one because of greater posibility of appearance of motor deficits, sphincteral disturbances or subsequent formed pain. This procedure has several negative aspects. Firstly, it is an opened surgical intervention in general anesthesia and therefore, there is no communication with patient. We had a habit to perform DREZ surgery rather than chordotomy when ever it has been indicated. In 80.1% of all cases, the successfulness of surgery has been marked as excellent, in 15.2% of all cases, it has been marked as good, and in 4.7% of all cases, bad outcome has been detected. The rate of complication was 4.4%. Institut za neurohirurgiju KCS. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=16018409
                          7. Ivanovic S, Slavik E, Antic B, Spajic M and Rasulic L (2004). [Indications for surgical treatment of pain and types of operations]. Acta Chir Iugosl 51: 25-30. During the period from 1978 to 2003 in Institut for neurosurgery CCS and Neurosurgical hospital of MA in Belgrade, 3057 patients with pain syndroms in different localisations were operated. Before operation all conservative methods were exhausted. We made 248 microvacular decompressions in fossa cranii posterior, 1600 radiophrequent lessions of ggl.Gasseri and 64 avulsions of distal trigeminal branches in patients with trigeminal and glossopharingeal neuralgia, 128 chordotomies in patients with neurogenic and cancer pain, 62 DREZ operations in patients with paraplegia, cancer pain and postherpetic intercostal neuralgia. More than 900 patients have been operated because of neuropathic pain and trauma of peripheral nerves, and 48 patients were operated due to Phantomzs pain. We compared results of two alternative methods in treatment of trigeminal neuralgia (radiophrequent lesion of ggl. Gasseri and microvascular decompression in posterior fossa). Institut za neurohirurgiju KCS. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=16018405
                          8. Tomas R and Haninec P (2005). Dorsal root entry zone (DREZ) localization using direct spinal cord stimulation can improve results of the DREZ thermocoagulation procedure for intractable pain relief. Pain 116: 159-63. The dorsal root entry zone (DREZ) thermocoagulation for intractable pain after brachial plexus avulsion was performed in 21 patients. Good results in pain relief (relief of more than 75% of preoperative pain) were achieved in 62% of patients, whereby fair results (relief of 25-75% of preoperative pain) in 38% of patients. There was no patient with poor result (relief of less than 25% of preoperative pain). Complication rate was 14%. The whole patient population was subdivided into two groups (Group 1 and Group 2). Direct spinal cord bipolar stimulation and registration with the goal to localize DREZ was performed in the Group 2 consisting of 12 patients (n=12). The point on the spinal cord surface where no response after stimulus of low intensity was obtained was the site (the posterolateral sulcus) we identified as the most suitable point for the placement of radiofrequency thermocoagulation electrode. Comparing with the Group 1 consisting of nine patients (n=9), where the localization of DREZ by evoked potentials was not performed, significantly better effect of pain relief was recorded (P<0.05, odds ratio 10). There was no statistically significant difference (P>0.7) in complication rate in Group 1 and Group 2. Described electrophysiological technique is very helpful in identifying of DREZ and, in combination with microsurgical technique, can create DREZ thermocoagulation more effective. Department of Neurosurgery, 3rd Faculty of Medicine, Faculty Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic. robert.tomas@volny.cz http://www.ncbi.nlm.nih.gov/entrez/q..._uids=15936886
                          9. Ivanovic S, Slavik E, Antic B, Spajic M and Rasulic L (2004). [Indications for surgical treatment of pain and types of operations]. Acta Chir Iugosl 51: 25-30. During the period from 1978 to 2003 in Institut for neurosurgery CCS and Neurosurgical hospital of MA in Belgrade, 3057 patients with pain syndroms in different localisations were operated. Before operation all conservative methods were exhausted. We made 248 microvacular decompressions in fossa cranii posterior, 1600 radiophrequent lessions of ggl.Gasseri and 64 avulsions of distal trigeminal branches in patients with trigeminal and glossopharingeal neuralgia, 128 chordotomies in patients with neurogenic and cancer pain, 62 DREZ operations in patients with paraplegia, cancer pain and postherpetic intercostal neuralgia. More than 900 patients have been operated because of neuropathic pain and trauma of peripheral nerves, and 48 patients were operated due to Phantomzs pain. We compared results of two alternative methods in treatment of trigeminal neuralgia (radiophrequent lesion of ggl. Gasseri and microvascular decompression in posterior fossa). Institut za neurohirurgiju KCS. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=16018405
                          10. Koszewski W, Jarosz J and Pernak-De Gast J (2003). [The DREZ lesion as an effective treatment for chronic hypothetically post-herpetic neuropathic pain. Case report and review of literature]. Neurol Neurochir Pol 37: 943-53. The authors present a case of a 54-year-old woman with a 3-year history of chronic pain syndrome, probably of postherapeutic origin, with diffuse segmentary dermatome characteristics, both somatic and autonomic. The former were exemplified by a constant "burning" skin pain in the representation of Th8-LI dermatomes unilaterally, while the latter by a unilateral visceral pain within the abdominal cavity. Electrophysiological examination indicated a neuropathic origin of the pain, despite the lack of clinically evident sensory deficits and/or hypersensitivity. The pain was so intense that normal walking was difficult for the patient and ineffectiveness of her treatment made her suicidal. Since both pharmacological treatment (non-steroid analgesics, opioids, antidepressants, and anticonvulsants including gabapentin) and minimally invasive methods of treatment (blockades, thermolesions) failed to control pain, she was subjected to surgery. A right-sided DREZ lesion within the Th8-LI dermatomes resulted in a complete pain relief, both within the somatic and autonomic innervation projections, and in the patient's functional recovery. Kliniki Neurochirurgii A.M. w Warszawie. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=14746252

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                            #14
                            Dr. Young, perhaps you could clarify a little about what you meant by "destructive" to let folks know what sort of risk they're running. You know I've always cautioned people to use great caution when seeking surgical solutions to their pain, and this is a good example of that.

                            Dejerine, my memory may be way off here, but I thought once a few years ago you mentioned having communicated with Barry Corbet some time after his surgery and after a year or two there was a change in his status. Am I completely off on this?

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                              #15
                              David,
                              I communicated with Barry a bit. He lost some sensation but got enough pain relief he felt it was worth it. That's what I remember him saying anyway.
                              I imagine Wise is talking about them cauterizing (or whatever method they're currently using to kill the nerve ending) the hyperactive nerve endings in the cord when he says destructive. I don't know how that would impact any future therapies. But, obviously, Wise can speak for himself
                              The bottom line is, the people that turn to this surgery pretty much have exhausted other means, I think. Last I heard they wouldn't do it on higher SCI levels (above T4) so it wasn't an option for me. Over the years they may have refined that. This recent article in NM doesn't say.
                              Last edited by cass; 8 Aug 2006, 5:54 PM.

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