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2. medicine
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How to diagnose patients with
low backache & Sciatica
Satishchandra Gore
Gore System
www.drgoreonline.com
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How to increase our certainty??
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Patient talks,narrates, blabbers, tells stories > Dr. listens
Pain has no objective sign!! So IT may be all narration
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Best advice to patient : tell me what
not why!!!!
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Listen, Visualize and Palpate
What your
mind does not
know eyes
don’t see
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Don’t see
visualize
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Fundamental question
• Where is the pain coming from?
• Why is it persisting?
• Kuslich study under local anesthesia but
traditional surgery
• Yeung & Gore “surgery in awake aware patients
by transforaminal stitchless endoscopy under LA”
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In vivo visualization paradigm
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Unified law of pain
• All pain is inflammation or end result of
inflammation
• Detect confirm and monitor inflammation and
pain!
• 3 cytokines prostaglandins, inter leukins, TNF
alpha
• PAIN IS
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Healthy aging degenerating
• Simplified definitions. validated. Published.
• Irrespective of calendar age
• Healthy is structure and function is normal
• Aging function starts slowing changing due to
decreased diffusion
• Degeneration is additional structural failure eg:
annular tear
• Which becomes symptomatic and vocal and “visible” to
the seer. NERVE SUPPLY
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What makes patient vocal and pain
“visible” : nerve supply
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Red flags
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Common Problems in spine
•
•
•
•
Back pain : discogenic and facet origin
Leg pain: sciatica: chemical and mechanical
Leg pain as claudication
VCF and osteoporosis
• S P I N E solutions
– Safe precise innovative novel enabling!!! SPINE
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Back pain presentation axial
Axial back pain
Horizontal or vertical
Associated spasm
Posture induced changes in pain
Assessing root mobility , where root is sensitised!!
Examination in standing and lying down
Static examination can not bring out dynamic complaints
Dynamic in time and location
Red flags: unrelenting , pain at night
Investigations need and interpretation
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Back pain targets I
• Annular tear central non healing
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Paraspinal back pain: MB of DR
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II
• Facet bilateral two level for MB of DR
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Leg pain 6 questions
L5
S1
knee
Is pain along dermatomes?
If yes which root?
Is it disc?
If yes which disc?
Non invasive imaging
Invasive imaging
Answering:
Where is pain coming from?
Why is it persisting?
calf
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CENTRALISATION
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Limitations of dermatomes:
old unreliable dogma etc.
Can be OVERCOME: PALPATE
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Limitations of “mute” imaging
• Image symptom paradox
• 30% either way
• Images look same but presentations are
different
• How to overcome this uncertainty
• Deciphering images with added knowledge
from our studies. See <- Visualize
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Sciatica targets I
• Mechano sensitized root : SNRB and PALPATE
for gore sign … Sodium channel upregulation.
L5
s1
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PALPATE elicit tenderness AND BLOCK LTDPN at sinus tarsi for L5 or sural for S1 sciatica pain
L5
S1
L5
Accepted for publication in IJASS Sep 2014 special miss spine surgery issue
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Change from image and dermatome paradigm to NERVE paradigm : PALPATE
Staging of sciatica 3 stages progressive, may jump.
Stage 1 of mechano [pressure] sensitization 80% outpatient
Stage 2 of mechanical compression 15 % SLR
Stage 3 of nerve dysfunction 5% standard neuro examination
limitation of Root mobility
Indicates stretch sensitivity
**May improve if it is only
Inflammatory
And
2
Not mechanical
Listen
Visualize
Palpate
Increase certainty
Predictability
Dependability
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2 sub sets
LATERAL Knee pain: BE AWARE
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Heel pain: ouch after zzz
Maximum in morning
There is no way
bone grows
to cause pain!!
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How to select patients for
conservative treatment or surgery
Satishchandra Gore
Gore System
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Outcome of discogenic sciatica
& Pain generators
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Conservative therapy and intervention
• Natural resolution and its monitoring
• Using anti inflammatory forces and improve
functional rehab
• Intervention to mask pain
• Intervention to correct structural failure
• Monitor our treatment and its outcome
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Conservatively treated massive prolapsed discs: a 7-year follow-up.
Benson RT, Tavares SP, Robertson SC, Sharp R, Marshall RW.
Ann R Coll Surg Engl. 2010 Mar;92(2):147-53
• A massive disc herniation can pursue a
favourable clinical course.
• If early progress is shown, the long-term
prognosis is very good and even massive disc
herniations can be treated conservatively.
• Who will show the progress? Images??
• How will it be shown?
• Unanswered questions!!!
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The spine journal Review Article
Neurological examination of the peripheral nervous system to diagnose
lumbar spinal disc herniation with suspected radiculopathy: a systematic
review and meta-analysis
Nezar H. Al Nezari, PT, MPhty, Anthony G. Schneiders, PT, PhD*,
Paul A. Hendrick, PT, MPhty, PhD
• diagnostic ability of NEURO examination has
not been explicitly investigated.
• *** 6 QUESTIONS
– IS IT SCIATICA
– IF YES WHICH ROOT?
– IS IT DISC IF YES WHICH?
– NON INVASIVE TEST THEN INVASIVE
– WHERE IS PAIN COMING FROM?
– WHY IS IT PERSISTING?
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ii
• limited overall diagnostic accuracy in detecting
disc herniation with radiculopathy.
• Pooled diagnostic accuracy values of the tests
were poor
– lack of a standardized classification criterion for disc
herniation,
– variable psychometric properties of testing
procedures,
– complex pathoetiology of lumbar disc herniation with
radiculopathy
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Mechanism of sciatica
• Effects of nucleus pulposus on nerve root activity,
mechanosensitivity, axonal morphology, sodium
channel expression: Chen et al: spine 2004 29:1:1725
– Seven days' exposure of nerve root to nucleus pulposus
potential neural conduction block +++ higher intensity of
ectopic discharges on compression due to mechanical
sensitization of nerve root.
– whereas 42 days' exposure resulted in desensitization.
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Chen et al.
– Numbness: Loss of neural activity propagated to the
central nervous system
– intense pain and paresthetia: Higher ectopic discharge rate
– More severe symptoms clinically during the acute stage of
disc herniation.
– Abnormal accumulation of sodium channels at the tip of
injured axons-> increases conductance of voltage-gated
sodium channels.
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Chen et al.
• Increased conductance ->lower voltage
threshold rather than pressure threshold
>neurons ectopic discharges.
• Hyperexcitability -> spontaneous and
movement-evoked neuropathic
paraesthesias, dysesthesias, and pain.
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Clinical Relevance
• Nerve roots become sensitive to mechanical
compression 7 days after exposure to NP.
• Mechanical stimulation to the nerve root can
provoke abnormal neural activity that can manifest
as pain and paresthetia.
• Mechanical stimulation includes compression from
herniated disc and stretch of the nerve root as in the
straight leg raising test.
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Purpose: intensity and location
• Sciatica is proposed to be staged based on its
mechanism of development or time wise evolution
and intensity.
– Inflammation
– Mechanical compression
– Loss of function
• Subsets based on location of pain in partial [subtotal]
evolving or resolving sciatica.
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Methods
• 70 consecutive Patients were recruited with
acute [less than 3 to 6 weeks] sciatica in
various stages of development. Early, late and
resolving. 10 endoscopically operated patients
recruited.
• Routine focused examination and palpation of
sciatic nerve done.
• Use of distal block done at ankle.
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Use of 2% plain lidocaine done distally
• Use of 2% plain lidocaine for a distal block at sinus
tarsi over lateral branch of deep peroneal nerve or
sural nerve.
• Response partial or total was noted.
• Follow-up was maintained for 1 month.
• Patients were investigated with imaging.
• Imaging findings were correlated with symptoms.
• Lack of correlation noted.
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Results
• Nerve tenderness was noted in all patients of acute sciatica L5
or S1 at time frame <3-6 wks.
• Every patient had a positive change in clinical status with
distal block.
• All post operative patients had full resolution of nerve
tenderness by 6 weeks. Flare ups were correlated well with
recurrent symptoms.
• Stages based on total relief of pain, partial relief with or
without improvement in SLR, partial or no relief with
neurodeficit.
• Subsets based on initial location of partial sciatica but tender
nerve and full relief of pain with distal block.
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Stage 1
• Sensitization:
– 80% of patients
– Severe nerve tenderness
– SLR negative
– NO significant sensory or motor loss.
– Imaging study negative.
– full relief of pain on distal block
– Partial sensory motor loss relieved.
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Stage 2
• Mechanical compromise:
– 15 % patients
– Moderate nerve tenderness
– positive SLR
– 6% of them had relief of pain with increased range
SLR after distal block.
– Images positive that May or may not correlate
well with symptoms.
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Stage 3
• Nerve Dysfunction:
– Nerve Desensitized
– 5% Patients
– Neurodeficit
– SLR stretch may be positive.
– changes after distal blocks like relief of tingling or
and total reversal of motor deficit.
– Images may correlate well.
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significance
• Staging helps in treatment planning.
• Chemical sciatica can be clinically monitored and
treated.
• Residual INFLAMMATION/pain post op?
• Inflammation part of Sciatica can be blocked by
sodium channel blocker used distally.
• Probably if inflammation alone best responds to non
operative conservation where natural resolution
alone can relieve pain.
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Locational subsets knee, heel.
• KNEE PAIN
pain over lateral aspect of either knee.
in spots or over limited area along lateral knee.
Inability to flex Knee fully.
associated tingling numbness on sitting cross legged.
Pain increasing with walking and then radiating along calf and lower
leg.
– Stiffness at knee and urge to extend knee after sitting for few minutes
with legs crossed.
– Stiff in morning for few minutes after getting up.
– Presence or absence of low back pain.
–
–
–
–
–
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Nerve supply of knee
• Knee is supplied in lateral aspect by 3
branches of common peroneal nerve,
• CPN is most affected component of sciatic
nerve may be tender.
• Supply is through superior, inferior and
recurrent genicular nerve.
• DPN Nerve is tender responds to distal block.
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Heel pain
• Exclude trauma, organic local lesions in heel.
• When local nociception can be ruled out
nerve mediated pain is commonest, well
correlated with sural nerve, S1.
• Heel pain in significant numbers follows or
precedes back ache.
• Sural block relieves pain in heel.
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Advanced application of endoscopic
technique
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Patients for conservation
• Centralisation of pain on extension indicating
a good annular integrity
• Inflammatory radicular pain with positive gore
sign , responding to distal block
• Resolution of symptoms
• Sustained resolution and return to function
• May have relevant image resolution
• Natural history does not change
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Indications for intervention
Pain and inflammation not resolving naturally
Resolution reaches a pleateu
Functional limitations in activities of daily life
Specific complaints in sit, stand, walk and lay
down and neuro deficit
• Symptoms match images
• Medical co morbidities are under control
• Patient FIT or ready to work towards functional
rehab
•
•
•
•
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In FBSS we target hidden zone of McNab. In the foramen and axilla.
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Stitchless surgery under local anesthesia
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Sciatica target II
• Herniated disc with migrated fragments: **
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Target Claudication III
• Degenerative canal with SAP causing stenosis
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GORE SYSTEM animation
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CT MOVIE
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Beating drg surgery
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Literature
1. Jeremy Walsh , Toby Hall, Reliability, validity and diagnostic accuracy of palpation of the sciatic,
tibial and common peroneal nerves in the examination of low back related leg pain Manual
Therapy 14 (2009) 623–629
1. Epstein NE. The risks of epidural and transforaminal steroid injections in the Spine: Commentary
and a comprehensive review of the literature. Surg Neurol Int 2013;4:S74-93.
1. Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and sciatica: a report of
pain response to tissue stimulation during operations on the lumbar spine using local
anesthesia. Orthop Clin North Am. 1991 Apr;22(2):181-7.
1. Chaoyang Chen, MD, John M. Cavanaugh, MD,* Zheng Song, MS, et al Effects of Nucleus
Pulposus on Nerve Root Neural Activity, Mechanosensitivity, Axonal Morphology, and Sodium
Channel Expression Spine 2004;29:17–25
1. Allan I. Basbaum et al. Cellular and Molecular Mechanisms of Pain Cell. 2009 October 16; 139(2):
267–284.
NOCICEPTOR IS A PSEUDO UNIPOLAR AXON
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GORE
SYSTEM
Stitchless under local anesthesia.
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How to speak with patient so they listen!!
Guide for Drs.
•
•
•
•
•
•
You set agenda for discussion
Objectively identify pain.
Remove uncertainty from clinical diagnosis,
over come image symptom paradox,
be certain about treatment outcomes.
Answer queries on YOUR terms:
• what is cause of my pain, how can I improve, do I need more
than medication?, best surgery solution?
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Summary
• Listen visualize and palpate
• Pain in back and leg is caused as a response of
nervous system to degenerative changes
[includes structural failure].
• Detection, confirmation and monitoring of
sciatica is possible with gore sign.
• Stitchless disc surgery under local anesthesia
is possible with high degree of success [up to
93%] with gore system.
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