DREZotomy in the Treatment of Cancer Pain: A Review

Abstract

Background: Cancer-related pain is a common problem that may be intractable by medical and neuromodulatory treatment. The dorsal root entry zone (DREZ) is a hyperactive focus in neuropathic pain syndromes, and DREZotomy has been used in selective cases of neuropathic cancer pain. Objective: The aim of this study was to describe the technique of spinal DREZotomy in the treatment of cancer pain and review the relevant published literature. Methods: A PubMed database search for ‘DREZ’, ‘dorsal root entry zone’ and ‘cancer’, and a search of the references of these manuscripts, was undertaken. Results: 14 papers were identified and reviewed that described a total of 123 patients with cancer pain or radiation-induced pain who have been treated with DREZotomy. Though heterogeneous, these studies reported an overall favorable outcome in carefully selected patients with topographically limited pain syndromes. Conclusion: For patients with well-localized neuropathic cancer pain intractable to medical and first-line surgical management, DREZotomy is a viable treatment option. Further prospective studies are needed to evaluate the outcomes of this procedure.

Dorsal Rhizotomy for Pain from Neoplastic Lumbosacral Plexopathy in Advanced Pelvic Cancer

“…DREZ lesioning can be considered for cancer pain patients with predominantly neuropathic pain [29,30]. Sindou [30] reported a good result (>75% pain relief) in 87 and 78% of 81 cancer pain patients at the cervicothoracic and lumbosacral level, respectively.…”

“…Although detailed descriptions of patient characteristics and selection were not provided, they suggested that good candidates for DREZotomy were patients with ‘topographically limited pain caused by local lesions', as seen in Pancoast tumor, invasion of the thoracic or abdominal wall, or limited involvement of the lumbosacral nerves. In a recent review on DREZotomy in the treatment of cancer pain, Gadgil and Viswanathan [29] suggested judicious use of DREZotomy in Pancoast tumor and radiation-induced plexopathy.…”

A Retrospective Review and Treatment Paradigm of Interventional Therapies for Patients Suffering from Intractable Thoracic Chest Wall Pain in the Oncologic Population

“…For intractable pain not response to the above therapies (or intrathecal drug delivery is not indicated), both percutaneous cervical cordotomy and dorsal root entry zone (DREZ) procedure may be considered. Cordotomy has been reported to be effective in patients suffering from mesothelioma, and DREZ has been efficacious for pain related to Pancoast tumors [31,32].…”

Anatomy of the spinal dorsal root entry zone: its clinical significance

“…In the spinal cord, these nociceptive fibers do not synapse immediately with the second-order neurons of the gray mater. Instead, they ascend 1-2 segments in Lissauer's tract (dorsolateral tract) located proximal to the dorsal horn [3,5,19]. Lissauer's tract has a function of increasing or inhibiting the pain signals before they reach the Rexed laminae I-V [3,19].…”

“…During DREZ, the dorsal rootlets must be carefully elevated, the PLS should be defined, and the lesion should be made in the appropriate direction. There have been numerous surgical and gross anatomical studies of the DREZ, however, there are no studies on the anatomy of the PLS itself [1,5,10,16,21,27]. The aim of the present study is to provide insight on three topics: (1) to describe the PLS and its variations using histological sections, (2) to report the variability in the number of dorsal rootlets of the spinal nerves, (3) to measure the height and width of the dorsal horn on histological sections for cervical, thoracic, and lumbar levels.…”