Abstract

UNDERSTANDING SPINAL SEGMENTAL SENSITIZATION AS A NEW CONCEPT OF PAIN AND EMPLOY ITS TREATMENT

Fulltext
Ronald E. Pakasi
Medical Rehabilitation Dept., Fatmawati General Hospital – Jakarta

Spinal segmental sensitization is a brand new concept in understanding the nature of pain. It was the work of the late
Andrew A. Fischer, and has just been introduced lately by his colleagues in the Asia-Oceania Physical Medicine and
Rehabilitation Congress on May 2008. The concept of spinal segmental sensitization provides a new model to describe
the origin of pain. In this article, we will discuss the original theory of spinal segmental sensitization and how to employ
its treatment strategies.
To understand the concept of spinal segmental sensitization, we must first understand the nature of peripheral
sensitization. Peripheral sensitization exemplifies hyperreactivity of sensory fibers in the presence of chronic noxious
stimuli. The symptom derives when sensory nerve fibers become hyperexcitable in the presence of chronic pain stimuli.
This reaction can be observed when the affected sites are given sharp or painful stimuli, such as pinprick or scratching,
a strong pain sensation (sometimes severe) is perceived; hence demonstrates the hyperreactivity process. There are
two kinds of clinical findings may arise from this process: hyperalgesia, an increased response to painful stimuli; and
allodynia, a pain sensation that is perceived in the presence of stimuli that usually do not incite pain sensation (e.g.
compression). How do hyperalgesia and allodynia occur will be explained as follows:
When segments of sensory nerves are subjected to chronic noxious stimuli, i.e. chronic pain, they generate a vicious
cycle between the irritative foci and the corresponding hypersensitive spinal segments. The most common noxious
stimuli may arise from mechanical origin, i.e. musculoskeletal; and neurological causes. There are many other causes
that play a role in provoking noxious stimuli, include: degenerative processes, visceral dysfunctions, infections,
psychological disturbances, etc.
To look deeper into the matter, the noxious stimuli are actually an inflammatory reaction within the local tissues; in this
case the peripheral nerves. And as with other inflammatory reactions, it begins to produce substances that are
sensitizing and irritating such as bradykinin and prostaglandins.
The above mechanism is an initial process that will cause two major reactions.
First, the presence of inflammatory substances will incite the sympathetic nerve activity. An increase in sympathetic
discharge potentials will sensitize the sensory nerves, i.e. the peripheral nerves, in the acute phase.
Second, inflammatory reactions are always causing edema surrounding the injured tissue that will further entrap the
inflammatory substances, hence creating a vicious cycle of hypersensitivity; in this case being the nerve endings of the
peripheral nerves.
The aforementioned events are the very basis of hyperalgesia and/or allodynia mentioned earlier in the text. However,
aside from these, other clinical manifestations also occur, the associated irritative foci. There are two types of irritative
foci: tender spots and trigger points. While tender spots can sometimes develop further into trigger points, they differ in
their clinical manifestations. Tender spots are points on the muscle tissues that cause aching sensations when being
pressed; whereas trigger points are points on the muscle tissue that cause radiating pain when being pressed.
While all of these processes are the foundation of peripheral sensitization, spinal segmental sensitization is actually has
the same basis. However, spinal segmental sensitization has its own unique mechanism that makes it differs with
peripheral sensitization. We will look into this matter in further detail.
First, by its name, the spinal segmental sensitization is characterized by hyperactivity in the spinal segments marked by
their dermatomal sensory distribution throughout the body. As with the peripheral sensitization, there are also painful
stimuli that persistently bombard the sensory nerves. The hypersensitivity and hyperreactivity responses that follows,
eventually causing irritative foci to occur along the segmental spinal distribution. This reaction is different with peripheral
sensitization, because of the influence of spinal nerve distribution.
If we look further into the mechanism, we will find that when noxious stimuli are first received by the sensory endings,
they are carried up to the central nervous system. Inevitably the central nervous system becomes hypersensitive and
hyperexcitable. These reactions are spread further down to the motor nerve system of the spinal segments, generating
irritative foci marked by tender spots or trigger points. However the sites of irritative foci follow the rule of myotomal
distributions of the spinal segments; hence create its unique characteristic. In addition, these reactions also induce
muscle spasms at the affected myotomes. While this means that every muscle that belongs to the myotomes will be
involved, it serves as reflex protection by the muscles for the tissues beneath them.
The description of spinal segmental sensitization above gives us clues about what can we understand about its nature.
In essence, spinal segmental sensitization is both a symptom and a pattern. The hypersensitivity reaction is a symptom
arising from a repetitive chronic pain, so frequently that it creates a stable pattern within the spinal segments.
From that point of view, treatment strategies can be focused on two things: to eradicate the acute pain symptom by
cutting the segmental pain-pattern; and to maintain a pain-free period as long as possible. Treatment strategies for
spinal segmental sensitization can be divided into two methods: the non-invasive treatments and injection procedures.
Non-invasive treatments take longer time to achieve its goal, however, it is important – even after an injection procedure
– to keep the patient in a relatively pain-free period as long as possible. Two common methods used in non-invasive
treatments include: the MECE (move, ethylchloride, compression, elevation) approach that integrates the use of
ethylchloride to deactivate trigger points and the prescription of exercise program to encourage movement of the
affected area; and the use of medications to relieve pain.
Alternatively, the injection procedures are used if the non-invasive treatment alone is not sufficient to relieve the pain.
There are two kinds of injection procedures: (1) needling and infiltration and (2) trigger point injection.
The aforementioned approaches, non-invasive and injection procedures are the common methods that have been
practiced as a routine measures in the treatment of pain. However, a new kind of approach has been developed by
Fischer et al. (2008), called paraspinous block. This technique is essentially a desensitization procedure of the spinal
segmental sensitization. The procedure is done as follows:
1.Perform a scratch test using a sharp object (e.g. the tip of a paper clip) along the suspected dermatomes. The affected
segments would be perceived as painful sensations that could be severe.
2.Confirm the findings with pinch and roll test, on the skin along the affected dermatomes. Confirmed segments will
appear with skin redness along the dermatomal pattern.
3.As an alternative, the suspected segments can be confirmed further using micro-Ampere meter. Note that on the
affected segments, skin conduction is increased.
4.Mark the spinous process at corresponding spinal level, and mark.
5.Clean the target area (as above).
6.Inject 2 cc of 2% lidocaine diluted in 2 cc of aqua or normal saline (equal to 4 cc of 1% lidocaine), using 1.5 inch long
gauge syringe, along the area adjacent to the spinous process (paraspinous area). Spread the injection until it reaches
the posterior ligaments.
7.Stretch the affected segments after the injection procedure has been completed.
In conclusion, the concept spinal segmental sensitization offers us a new paradigm to understand the nature of pain.
While basically it has the same origin with peripheral sensitization, they differ in their clinical characteristics. It is the
pattern of dermatomal and myotomal distributions that contribute to the main characteristic of spinal segmental
sensitization. Although some of its treatment strategies (i.e. non-invasive approach, and the needling and infiltration
technique) are already well-known in the rehabilitation medicine field, the paraspinous block provides a new treatment
approach in the management of pain.

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