13-3-211 Pain patterns in disc herniation Hanne B. Albert, Peter Kent Jeanette Hansen, Helle Søgård Deffinition of a dermatom A dermatome is the cutaneus area receiving nerve supply from a specific dorsal nerve root and the corresponding ganglion Why are dermatomes interesting? Dermatomes are commonly used in clinical practise to identify the spinal level involved in radiculopathy. Pain science suggests that pain referral can be non-dermatomal. Is a dermatome a dermatome? Identification of dermatomes The aim of this study was to identify the distribution and overlap of pain reported by people who had an MRI-identified single level L4, L5 or S1 nerve root compromise. Sherrington 1892 He cut the nerve root above and below of the nerve root he wanted to examine. Kept one root and mapped the left over sensitivity. The study was performed on monkeys. 1
13-3-211 Very thorough dissection of one single person. Bolk 1898 Foerster cut the nerve roots on live people, (the isolation method). There after, he stimulated the cut nerve root ending in the dorsal root with strychnine and observed the vasodilatation at UE. Foerster (1933) Observed patients with active Herpes Zoster and from this made a chart of the dermatomes. Head (19) Keegan (194) Mapped the painful areas with lumbar herniation. Cutting of the posterior lumbar roots, mapping of the areas of hypoalgesy. Keegan emphasises that his charts are charts of hypoalgesy. Methods 188 patients with radicular pain All made a drawing of the distribution of pain. Thereafter a MRI the same day. 2
13-3-211 Pain drawings Pain drawings are tested for intra-tester reliability, it is evaluated to being high. Ohnmeeisiss 2,Pande 25,Mann 1993 Exclusion 9 patients were excluded Herniations and/or protrusions at several levels Uncertain herniation Other reason for nerve root compression Included 98 patients with a certain herniation only on one level. Group 1: direct compression of the nerve root Group 2: touch or pushing of the nerve root Group 3: no contact between the nerve root and the herniation Group 1 Direct compression Group 2 Touch/push Group 3 No contact L4 root L5 root S1 root I total 1 6 15 22 3 3 34 67 1 3 5 9 I total 5 39 54 98 The pain drawings were digitised in a standardised manner using computer software (Adobe Photoshop) All people who had the same level nerve root compromise Stacked them electronically, and make composite images of the pain distribution. The darkest parts of these composite drawings indicated where most patients experienced pain. L4-L5, L5 nerve root, compression n=5 3
13-3-211 L4-L5, L5 nerve root, touch/pushed, n=3 L4-L5, L5 nerve root, no contact, n=6 L4-L5, L5 nerve root. Total, n=39 L5-S1, S1 nerve root, compressed, n=15 L5-S1, S1 nerve root, touch/push, n=34 L5-S1, S1 nerve root, no contact, n=5 4
13-3-211 L5-S1, S1 nerve root, total, n=5 L5 nerve root, S1 nerve root Conclusion The variation in location of experienced pain between patients with a single level herniation of people is large Pain distribution from compromise of the L4, L5, S1 nerve roots is not concordant with the sensory distribution of common dermatome charts. The most clinically useful sign for determining if pain is associated with a root compromise may be that the distribution follows a continuous straight line. However, using the location of this line as a tool to identify a particular spinal level of nerve root compromise does not appear to be a valid practice. The efficacy of active conservative treatments for patients with severe sciatica. A randomized clinical controlled trial Aim To evaluate and compare the efficacy of two active conservative treatment methods to patients suffering from severe sciatica 5
13-3-211 Setting Patients were referred to The Back Centre, a specialist centre ALL patients had received some kind of conservative treatment before referral Inclusion criteria Radicular pain of dermatonal distribution below the knee Current leg pain intensity > 3 (-1) Duration of leg pain between two weeks and one year Exclusion criteria Not having Danish as first language Pending workers compensation litigation Inability to follow the rehabilitation program due to other disease Previous back surgery At baseline and follow-up MRI Physical examination Questionnaires Treatment Common in both treatments The patients were randomized into either Symptom guided exercises and rehabilitation program (n=91) Sham exercises and rehabilitation program (n=86) Thorough information Optional medication 8 weeks treatment, 4 to 8 treatments 6
13-3-211 Difference in treatment Compulsory symptom guided exercises and optional mobilization/manipulation. Flow 2 patients did not complete treatment 6 patients were referred to neurosurgeons during treatment period Optional sham exercises Follow-up 1 year after treatment Symptom guided exercises and rehabilitation program (n=81) Sham exercises and rehabilitation program (n=76) Baseline Baseline data were compared and found similar in both groups 65 % had 3 or 4 positive signs of root compression 3 % had 2 positive signs of root compression Likely surgical candidates Duration of symptoms Patients in percent 7 6 5 4 3 2 1 1/2-1 month 1-3 months 3-6 months 6-12 months P atien ts in p ercen t General improvement 9 8 7 6 5 4 3 2 1 Excellent Better Unchanged Worse Much worse Symptom guided ex. Sham exercises General improvement Both groups had a highly significant improvement (p<.1). Symptom guided exercise treatment program improved significantly (p<.5) more than Sham exercise treatment program. At end of treatment 89 % of the Symptom guided exercise treatment program were much better or better, 91 % at 1 year follow up 7
13-3-211 Improvement in mean RMQ, baseline to 1-year follow-up Present leg pain at 1-year followup Roland Morris Disability scale (-23) 16 14 12 1 8 6 4 2 Baseline 1 year follow up Symptom guided ex. Sham exercises Patients in percent 9 8 7 6 5 4 3 2 1 No leg pain Leg pain Symptom guided ex. Sham exercises Root compression signs at baseline and 1 year follow-up Sick leave Patients in p ercent 5 45 4 35 3 25 2 15 1 5 1 2 3 4 Symptom guided ex. Sham exercises Patients in p ercent 6 5 4 3 2 1 1 2 3 4 Symptom guided ex. Sham exercises The symptom depended exercises treatment group had fewer days of sick leave, mean = 69 days (n=22) A group of patients who received Sham exercises had many days of sick leave, mean = 11 days (n=16) Sick leave Conclusion Percent of patients on sick leave 7 6 5 4 3 2 1 1-1 days 11-199 days 2 + days Symptom guided ex. Sham exercises These patients who are likely candidates to surgery improved considerably by active conservative treatment 8
13-3-211 Conclusion The symptom depended exercise treatment group was better than the sham exercise treatment group Predictors Type of herniation Type of personality Centralization http://www.sygehuslillebaelt.dk/wm34575 The intervertebral area seen from oblique behind Does size matters?? 1: Normal 2. Bulge 3. Focal protrusion 4. Broad-based protrusion 5. Extrusion 6. Sequestration Change in size 4 1 3 75 Percent 2 Percent 5 Worsened Unchanged Improved 1 25 Normal (n=15) Bulge (n=33) Focal protrusion (n=52) Broad-based protrusion (n=1) Extrus ion (n=36) Sequestration (n=8) Bulge (n=33) Focal (n=52) Broad-based Extr us ion Sequestration (n=1) (n=36) (n=8) 9
13-3-211 Change in nerve root compression B 1 75 Percent 5 Worsened Unchanged Improved Baseline C D 14 måneders follow-up 25 Bulge (n=33) Focal (n=52) Broad-based (n=1) Extr us ion (n=36) Sequestration (n=8) B Conclusion Baseline Baseline 14 måneders follow-up Does size matters in herniation?? Yes, big is best Type of personality Antal patienter 7 6 5 4 3 2 1 Fordelingen af patienttyper efter psykosociale risikofaktorer 1 Fear avoiders 5 Depressed supressors 5 Happy supressors 59 "Copers" 1
13-3-211 Fald i RMQ 9 8 7 6 5 4 3 2 1 Reduktion i Roland Morris funktions scala Fear avoiders Depressed supressors Happy supressors "Copers" Fald i bensmerter -1 3,5 3 2,5 2 1,5 1,5 Reduktion i bensmerter efter behandling Fear avoiders Depressed supressors Happy supressors "Copers" Reduktion i RMQ efter behandling fordelt på behandlingsgrupper Centralization in patients with sciatica. Fald i RMQ 1 9 8 7 6 5 4 3 2 1 Hands on Hands off Fear avoiders Depressed supressors Happy supressors "Copers" Background Centralisation is a predictor for good outcome in low back pain Centralisering is a part of the examination and treatment system; Mechanical Diagnostic and Therapy (MDT) System developed by New Zealand Physiotherapist R. McKenzie The theory behind is the disc model; by exercises or positioning it is possible to change the position of the nucleus material i discus, To be able to centralise the hydrostatics pressure in discus must be present, therefore annulus must be intact. 11
13-3-211 Definition of centralization The phenomenon by which distal limb pain emanating from the spine is immediately or eventually abolished in response to the deliberate application of loading strategies. Such loading caused reduction, then abolition of peripheral pain that appears to progressively retreat in a proximal direction. Prevalence of centralisation in low back pain. Reviews: 58% - 64.5 % Intertester realibility: literature review, mean Kappa.75). (Aina et al 24). (Aina et al 24) Aim To determine the prevalence of different types of pain responses in patients with sciatica To determine associations between pain responses, baseline MRI findings, and treatment outcome. Centralization procedures A physiotherapist with a Diploma provided the training in centralization and standardization the procedures. The examiner was a physiotherapist with ten years of clinical experience but no formal McKenzie education. Operationalization The intent was to determine whether the patients did centralize or not not allocating patients into different syndromes i.e. derangement, postural syndrome etc. Operationalization A thorough pain history The patient recorded on a pain drawing 1) the exact location of the pain; 2) the pain intensity (-1) for each region Directional movement and position The patient moved freely around for one minute The patient filled out the second pain drawing. 12
13-3-211 Abolishment centralization Reduction centralization Unstable centralization Peripheralization No effect Pain response 85.7 % of patients reported experiencing one of the three forms of centralization, 6.9 % experienced peripheralization 7.4 % had no effect. 13
13-3-211 Pain response at baseline Mean RMDQ at baseline, end of treatment, and 12 months after end of treatment Number of patients 9 8 7 6 5 4 3 2 1 Abolisment centralization Reduction centralization Unstable centralization Peripheralization No effect 2 18 16 14 12 1 8 6 4 2 (p<.1), Baseline 8 weeks 1 year Any type centralisation Peripheralization No effekt Reduction in RDQ 12 1 8 6 4 2 Reduction in RDQ score from baseline to post treatment Function limitation Difference in improvement between the centralization groups + peripheralization group and the no effect group was highly significant (p<.1) Abolisment centralization Reduction centralization Unstable reduction Peripheralization No Effect Leg pain at baseline, end of treatment, and 12 months after end of treatment Average reduction in leg pain intensity from baseline to post treatment 25 2 15 1 5 Baseline 8 weeks 1 year Any type centralisation Peripheralization No effekt R eduction in leg pain scale -1 4 3 2 1 Abolisment centralization Reduction centralization Unstable reduction Peripheralization No Effect 14
13-3-211 Leg pain The Intervertebral space seen in an oblique view from behind Difference in improvement between the centralization groups + peripheralization group and the no effect group was significant (p<.5) Normal Bulge, 36 Focal protrusion, -9 Broad based protrusion 9-18 Extrusion Sequestration Number of patients in % 4 35 3 25 2 15 1 5 Distribution of disc lesions Centralization and disc lesion Extruded and sequestrated discs 93.5 % centralized Normal and bulge discs 83.7 % centralized Normal Bulge Focal protrusion Broad based protrusion Extrusion Sequestration Conclusion A large proportion of patients with herniated disc were able to centralize their pain Any type of centralization was found to be a positive prognostic factor for functional capacity. Both centralization and peripheralization predicted a good outcome as regards the reduction on leg pain, while the no effect group demonstrated a less favorable outcome. Conclusion There was no correlation between the type of disc lesion observed on MRI and the reported pain responses. It is possible to centralize even if the annulus is not intact. 15
13-3-211 Thank you for your attention 16