The "banana splitting DREZotomy": an atraumatic method to improve pain relief after dorsal root entry zone lesioning in brachial plexus injuries Case series and tenets for the treatment

BACKGROUND: The treatment of neuropathic deafferentation pain due to avulsion injuries of the brachial plexus is a major problem, albeit rare, in the neurosurgical practice. The aim of the paper is to present step-by-step the main principles of a surgical upgrade of the well-known Dorsal Root Entry Zone lesioning, that we named banana splitting DREZotomy. METHODS: A comparison is made among three groups of patients, two of which were treated following the classic techniques, while in the third no physical agent is applied to the spinal cord during surgery. RESULTS: The patients operated on following the well-established surgical procedures showed a short-term success rate around 70%, online with the data of the ongoing literature. The results with the banana-splitting technique, instead, have been astonishing both in terms of resolution of pain, absence of true complications and of unpleasant side effects. CONCLUSIONS: A purely dissective technical variant of the surgical procedure called DREZ lesioning has shown better results overcoming the 30% failures of all the reported series. The profound and permanent splitting of the posterior horn and the absence of any other component (heat propagation, radiofrequency, or dotted coagulation) are the major factors which may explain such outstanding results.