Duke is one of the few centers in the U.S. to offer an ablation treatment for pain from spinal avulsion injuries. The dorsal root entry zone (DREZ) procedure can relieve the phantom pain from an injury when other pain treatment options have failed, according to Nandan Lad, MD, PhD.
“A majority of the cases we treat are patients with upper extremity, high-velocity injuries from accidents in cars, boats, jet skis, motorcycles, and the like, in which the brachial plexus is stretched or torn,” Lad says. “When the nerve is separated from the spinal cord, the spinal cord interprets that missing input as pain. Over time, the pain can worsen. When medications have stopped helping and interventional treatments aren’t doing what they need to do to maintain the patient’s quality of life, then the DREZ procedure is a viable option. It silences those missing inputs.”
The technique originated at Duke—it was often called Nashold’s procedure in the early literature because Duke neurosurgeon Blaine S. Nashold, MD, first described it in the 1970s.
The surgery involves identifying the areas of injury and ablating the injured nerves. Lad notes that few centers can offer it because it is a complicated surgery that requires an experienced team to map the spinal cord to ensure the best possible outcomes.
“We have an excellent intraoperative neuromonitoring team led by Aatif M. Husain, MD, that helps map the area where the injury has occurred,” Lad says. “I am very conservative in terms of making a lesion, because it can be permanent. We do a test stimulation and map the response on the neuromonitoring while the patient is under anesthesia. We test motor function before and after every lesion using motor evoked potentials or MEPs. We ablate the missing inputs from top to bottom of the avulsed nerve root region. It is definitely a team effort to make sure it is done as safely as possible.”
When the injury involves the lower cervical spine, Lad enlists the help of a specialist in spine surgery, such as Muhammad M. Abd-El-Barr, MD, PhD.
As major surgery, it may not be appropriate for older patients, those with too many comorbidities, or those who are too far out from their injury. It works best for younger, active patients, and is designed to provide permanent relief.
Duke is the only center in North Carolina to offer it. Lad performs 10 to 20 DREZ operations a year on patients from all around the U.S., with most patients referring themselves. “Many patients are just living with the pain. If they happen to hear about it, they find us,” Lad says.
Lad hopes to increase awareness of the procedure among providers because he believes many more patients could benefit from the relief of brachial plexus avulsion pain, for which it works quite well.
To refer a patient, log in to Duke MedLink or call 844-DUKE-LAD (844-385-3523).