Intraoperative Ultrasound for Post-Lesion Confirmation in Cervical DREZ Surgery: Technical Feasibility and Clinical Outcomes

Microsurgical dorsal root entry zone (DREZ) lesioning is an established treatment for refractory pain following brachial plexus avulsion. However, lesion depth and trajectory are critical technical variables that may influence safety and outcomes. We report our single-center experience using intraoperative ultrasound for systematic post-lesion confirmation during cervical DREZ lesioning. Between January 2016 and March 2025, 23 consecutive patients with complete or partial brachial plexus avulsion and severe neuropathic pain (VAS ≥ 6) refractory to optimized pharmacological therapy underwent cervical DREZ lesioning with ultrasound-based post-lesion confirmation. Serial microcoagulations were performed along the posterolateral sulcus to a depth of approximately 3 mm with medial angulation of 25°–45°, under multimodal neuromonitoring. Ultrasound was used after each lesion to confirm depth and medial–lateral trajectory. Pain intensity was assessed using the visual analog scale (VAS) at baseline and during serial follow-up. Mean preoperative VAS was 9.6. At a median follow-up of 36 months (range 6–108), 13 patients (57%) achieved excellent pain relief (VAS ≤ 3), 6 (26%) had good relief (VAS 4–6), and 4 (17%) had poor outcomes (VAS ≥ 7). One patient (4%) developed a transient motor deficit lasting three months, 2 (9%) required revision for laminotomy reconstruction subsidence, and 1 patient (4%) died from postoperative pulmonary embolism. Intraoperative ultrasound for post-lesion confirmation during cervical DREZ lesioning is feasible and may enhance depth and trajectory verification. Durable pain relief was achieved in the majority of patients. Further studies are needed to define its incremental benefit.