Treatment for Spinal Segmental Sensitization

in Spinal Cord Injury Patient with Chronic Pain

Fatmawati General Hospital –Spinal Cord Injury Rehabilitation Unit

Dr. Ronald E. Pakasi, SpRM

(Presented in Indonesian Pain Society Congress 2008)

Introduction

Spinal Segmental Sensitization (SSS): proposed by Andrew A. Fischer, MD, PhD &Marta Imamura, MD, PhD

Introduced in the Asia-Oceania Physical Medicine and Rehabilitation Congress in May 2008

Introduction

Hyperactivity in the spinal segments marked by their dermatomal sensory distribution throughout the body

Noxious stimuli ⇒ persistent bombardment to the sensory nerves ⇒ hypersensitivity & hyperreactivity responses irritative foci along the segmental spinal distribution

Observed in various types of chronic pain (i.e. musculoskeletal, neurological, visceral origins, etc.)

Spinal Cord Injury (SCI) Patients in Fatmawati Hospital

January - September 2008: 59 SCI patients Two most common etiologies: trauma (i.e. traffic

accidents) and infection (tuberculosis) 12 patients w/ post SCI pain Most frequent origins: musculoskeletal and/or

neurological Case report: 1st case evaluated with SSS model

and treated with paraspinous injection

Case Report

Male, 44-y.o., admitted on February 2008 Vertebral compression fractures on T3-T4 levels Prior to admission: internal fixation on vertebral

levels T2-T4 Dx/: T4 incomplete SCI ASIA class C Pain complained from the first admittance Pain on the post-op area Full passive shoulder ROM but limited in active

movement

Case Report

No Paresthesia / hypesthesia on both UE Pain Visual Analog Scale [VAS] = 9-10 ⇒

decreased to 5 when treated with morphine sulphate

Radiograph: no internal fixation misalignment, no vertebral misalignment

Dx/: suspected musculoskeletal pain on shoulder musculatures

In the past 4 months, medications changedfrom: Paracetamol ⇒ (to) Ketoprofen + Amitriptyline, Eperisone HCl ⇒ Paracetamol + Tramadol ⇒ Morphine Sulphate (VAS = 5)

SSS Model

Scratch test Pinch & roll test Result: (+) T2-T5

bilateral Pain medications:

discontinued for 3 days Replaced with

Transcutaneous Electrical Nerve Stimulation (TENS)

VAS scale = 9 (after 3 days w/o. meds)

A

B

SSS Desensitization: Paraspinous Injection

T3 level bilaterally (most painful level)

VAS = 3 Increased active

shoulder movement Resumed rehabilitation

program on the next day

Follow Up Procedure

Needling & infiltration (lidocaine 2%) VAS = 1 Patient was able to follow the

program for the next 4 weeks w/o. significant disturbances (VAS = 1-2)

Discussion: Concept of SSS

Concept of SSS: similar w/ peripheral sensitization

Different characteristics: hyperreactivity in a dermatomal sensory pattern

Two clinical features: hyperalgesia or allodynia

Associated reactions: muscle spasm in the correlated myotomes & generation of tender spots / trigger points

Discussion: Case

Case: origin of pain was unclear, more likely from musculoskeletal origin

Clinical findings: hyperalgesia → below T4? (T5) was unclear

Major drawback: no skin conduction measurements

SSS Desensitization Paraspinous injection Lidocaine 2%

Conclusion

SSS: new point of view to understand pain SSS can also be found in spinal cord injury cases Use of lidocaine: have an important role to

desensitize the SSS.

Still need further study to determine the long term efficacy of lidocaine injection as a treatment of SSS

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