Treatment for

Spinal Segmental Sensitization

in Spinal Cord Injury Patient
with Chronic Pain

Dr. Ronald E. Pakasi, SpRM

(P resented in Indonesian P ain Society Congress 2008)

Fatmawati General Hospital –

Spinal Cord Injury Rehabilitation Unit
 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 changed
from: Paracetamol ⇒ (to) Ketoprofen +
Amitriptyline, Eperisone HCl ⇒ Paracetamol +
Tramadol ⇒ Morphine Sulphate (VAS = 5)
 SSS Model
A

 Scratch test
 Pinch & roll test
 Result: (+) T2-T5
bilateral
 Pain medications: B
discontinued for 3 days
 Replaced with
Transcutaneous
Electrical Nerve
Stimulation (TENS)
 VAS scale = 9 (after 3
days w/o. meds)
 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
THANK YOU