A Case of Dentatotomy for Pain and Spasticity and Systematic Review.

BACKGROUND: Surgical interventions for spasticity aim to improve motor function and pain in cases that are refractory to medical treatment. Ablation of the cerebellar dentate nucleus (dentatotomy) may be a useful alternative. CASE REPORT: A 55-year-old male patient with spasticity, secondary to a traumatic cervical spinal cord injury with quadriparesis, had bilateral lumbar DREZotomy with an improvement that lasted for 6 years. Ten years after the DREZotomy, a progressive increased spasticity manifested as spastic diplegia (Ashworth 4) and spontaneous muscle painful spasms (Penn 4), as well as spasticity in the upper extremities, predominantly on the right side (Ashworth 3). A right radio frequency dentatotomy was performed with intraoperative electrophysiological monitoring. Spasticity scales were applied at the following times: preoperative and at 1 and 8 months after surgery. During the first month, the patient presented a clear decrease in spasticity ipsilateral to the side of lesioning (Ashworth 1) and of painful spasms in the lower extremities (Penn 1). After 8 months, spasticity ipsilateral to the injury decreased even more to Ashworth (0), but a progressive increase in muscle spasms of lower extremities was observed (Penn 2). CONCLUSION: Stereotactic dentatotomy may be an effective surgical alternative for management of spasticity associated with painful spasms in selected patients.

Neuropathic Pain Relief after Surgical Neurolysis in Patients with Traumatic Brachial Plexus Injuries: A Preliminary Report.

Objective: To evaluate the usefulness of surgical neurolysis for neuropathic pain relief in patients with posttraumatic brachial plexus injury (BPI). Methods: A prospective, longitudinal, nonrandomized, self-controlled before and after study was performed to evaluate the pain changes according to their intensity using the Visual Analogue Scale (VAS), and the sensory recovery after surgery using the British Medical Research Council (BMRC) scale for sensory recovery. To establish significant changes, a paired T-test was performed, and in order to determine the magnitude of these changes, an effect size was measured. α = 0.05. Results: Ten patients were included with an average follow-up of 61.9 ± 53.62 months. The main mechanism of injury was vehicular trauma (70%). A significant decrease in pain after the surgical intervention was observed resulting from an average preoperative state according to VAS of 8.4 ± 1.58, to a postoperative state of 3.4 ± 3.27 (59.52%, p = 0.005, Δ = 1.572), added to a mean sensory improvement (25%) from 2.8 ± 1.62 to 3.5 ± 0.97 after surgery according to BMRC, without statistically significant changes (p=0.062), showing a moderate effect size (Δ = 0.413). Almost all patients showed improvement in the continuous and paroxysmal pattern of pain. No postoperative complications were observed. Discussion. These results suggest that in cases of BPI that originates from a compressive syndrome secondary to the posttraumatic fibrosis that surrounds the nerve structures causing strangulation and inducing hypernociception, the use of surgical neurolysis is an appropriate alternative for patients with medically refractory neuropathic pain.