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Shaw Chiropractic Scerotomal vs Dermatomal Referred Pain "My client says he has pain shooting into his leg but the neurologist said that the EMG and MRI are normal. Is my client embellishing?" The answer is probably no. While it is true that some patients magnify their symptoms they are usually not sophisticated enough to feign symptoms into a specific reproducible pattern. Why then were the imaging and electrodiagnostic tests negative? The answer is simple. The tests are either not sensitive enough to demonstrate the lesion, not designed to find the existing lesion or improperly performed and interpreted For example, a negative MRI may suggest that there is no visualized compression of neural structures by discs or bone spurs. A negative EMG may suggest that either there was insufficient compression or no compression at all of the large diameter nerves which would result in a measurable abnormality. In fact, patients with referred pain do not necessarily have nerve compression. Life would be simple if this was the case but life is rarely simple. The most common referred pains seen in trauma cases are vascular, neurologic, visceral and sclerotomal. Neurologic referred pain, such as seen with disc herniations and carpal tunnel syndromes, is the most frequently looked for. Less common are the vascular referred pains such as those seen with thoracic outlet syndromes. Visceral referred pain can happen with contusion to the bodies organ systems. The most common and frequently overlooked origin of referred pain is the somatic referred pain also known as sclerotomal or sclerotogenous pain. An exampe of sclerotomal pain would be the referred pain experienced with myofascial trigger points. While trigger points are common they are only one of the many sources of sclerotomal pain. Other sources would include disc (discogenic pain), joint capsules, tendons, ligaments, etc As suggested by the name sclerotomal, the pain can come from any tissue of the same embyonic origin. A sclerotome is a embryonic region which during fetal development differentiates into a variety of different body structures. These parts may or may not be neurologically connected but are understood to have some physiological relationship. Researchers have demonstrated these relationships repeatedly over the years and mapped out their referral distributions quite well. In fact, sclerotomal referral patterns have been published in many indexed medical journals beginning with the early work of Kellgren in 1939, Inman and Saunders 1944, Feinstein et al 1954, Bogduk in 1988. Sclerotomal referred pain has some unique characteristics. For example, in the lower back a sclerotomal referred pain is usually more severe than dermatomal pain. Sclerotomal pain may not radiate down the entire leg and will usually stop at the knee or calf. There is no weakness or atrophy with scerotomal pain. Somatic referred pain can often be reproduced by touching the referral site. In the cervical spine referral patterns to the cranium, chest, upper extremities and thoracic spine are common. The concept of scerotomal pain has been overlooked as a source of pain by many clinicians because it is one of the more difficult types of pain to treat and diagnose. Often times, patients are classified as malingerers, conversion hysterics or magnifiers by defense doctors and carriers who have little or no experience with managing these type of injuries. Over time these patients may become chronic pain patients and eventually develop symptoms consistent with Fibromyalgia and Chronic Fatigue Syndrome. (Both upcoming topics for our newsletter) What then should be done by the attending physician to document the somatic referred pain? The first thing is to identify that the condition exists and look for a pattern consistent with the tissues damaged. The diagnosis is done by elimination of the other reasons for the referred pain such as nerve, organ and vascular origins. If treatment is directed towards the damaged soft tissue structures there should be regular and consistent decrease in referred symptoms .This improvement supports the diagnosis of sclerotogenous pain. Rule out of the other sources of referred pain may be necessary if symptoms persist unchanged. However, the physician should understand that a normal imaging or electrodiagnostic test is supportive of the diagnosis of somatic referred pain. The prognosis for sclerotogenous pain from traumatic insult is dependent upon many factors. The extent of tissues damage, pre-exiting illnesses, compliance with care and early detection by the physician all contibute to the potential outcome. Damaged soft tissues tend to heal in a disorganized manner even with regular management. The fibrotic replacement tissue is never as competent as the original tissue and is prone towards reinjury and hypersensitivity. Even with prompt attention the prognosis for complete recovery is poor, |
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