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Dervan dermatome syndrome often missed but surprisingly common coexistent spine pathology in ‘Knee Pain’, ignore at your own risk

Authors:
  • BKL Walawalkar medical college
  • BKL WALAWALKAR MEDICAL COLLEGE AND RESEARCH INSTITUTE
Article

Dervan dermatome syndrome often missed but surprisingly common coexistent spine pathology in ‘Knee Pain’, ignore at your own risk

Abstract

Introduction: Knee pain is among the commonest complaints in the outpatient orthopedic department. However the cause does not always originate from knee itself. and knee pain is used by the patient more as an umbrella term. In fact very few patients give the complete list of accompanying symptoms. They have more often than not to be coaxed out of the patient. To make matters more complex, Referred pain from the Spinal nerves, Hip and Ankle joints join the many structures around the knee to make knee pain an umbrella term for this Pandora’s Box. Misdiagnosis or partial diagnosis leads to inadequate or wrong treatment and continued suffering for patient and treating doctors Materials & Methods: 78 patients with knee pain attended the OPD of Walawalkar hospital, Dervan. On x-ray, 28 were found to have different grades of osteoarthritis. Of these 25 agreed to be part of this pilot study. They underwent standing x rays & MRI of the lumbosacral spine. Results: This study found an unusually high rate of coexistent knee and spine pathologies. All patients had some degree of disc disease accompanying medial or tricompartmental osteoarthritis. It undermines the need for investigating this important contributor to the umbrella term of knee pain. The commonest affected disc segment was L4-5 i.e 92% with two patients having L5- S1 prolapse 8%. The purpose of this pilot study is only to alert the surgical and rehabilitation colleagues of the frequent coexistence of the spine and knee conditions for Counseling, consent, surgery & rehabilitation and thus improve patient satisfaction. Keywords: knee pain, dermatome, ignorance, dervan
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International Journal of Orthopaedics Sciences 2018; 4(4): 649-653
ISSN: 2395-1958
IJOS 2018; 4(4): 649-653
© 2018 IJOS
www.orthopaper.com
Received: 19-08-2018
Accepted: 23-09-2018
Pavankumar Kohli
Professor Dept. of Orthopaedics,
BKL Walawalkar Medical
College, Dervan, Chiplun,
Ratnagiri, Maharashtra, India
Ankush Nawale
Fellow in spine surgery, Dept. of
orthopaedics, BKL Walawalkar
Medical College, Dervan,
Chiplun, Ratnagiri,
Maharashtra, India
Sushant Chavan
Fellow in joint Replacement,
Dept. of Orthopaedics, BKL
Walawalkar Medical College,
Dervan, Chiplun, Ratnagiri,
Maharashtra, India
Satishchandra Gore
Mentor Spine Surgeon Dept. of
Orthopaedics, BKL Walawalkar
Medical College, Dervan,
Chiplun, Ratnagiri,
Maharashtra, India
Sunil Nadkarni
Professor Dept. of Orthopaedics,
BKL Walawalkar Medical
College, Dervan, Chiplun,
Ratnagiri, Maharashtra, India
Correspondence
Ankush Nawale
Fellow in spine surgery, Dept. of
orthopaedics, BKL Walawalkar
Medical College, Dervan,
Chiplun, Ratnagiri,
Maharashtra, India
Dervan dermatome syndrome often missed but
surprisingly common coexistent spine pathology in
‘Knee Pain’, ignore at your own risk
Pavankumar Kohli, Ankush Nawale, Sushant Chavan, Satishchandra
Gore and Sunil Nadkarni
DOI: https://doi.org/10.22271/ortho.2018.v4.i4h.78
Abstract
Introduction: Knee pain is among the commonest complaints in the outpatient orthopedic department.
However the cause does not always originate from knee itself. and knee pain is used by the patient more
as an umbrella term. In fact very few patients give the complete list of accompanying symptoms. They
have more often than not to be coaxed out of the patient. To make matters more complex, Referred pain
from the Spinal nerves, Hip and Ankle joints join the many structures around the knee to make knee pain
an umbrella term for this Pandora’s Box. Misdiagnosis or partial diagnosis leads to inadequate or wrong
treatment and continued suffering for patient and treating doctors
Materials & Methods: 78 patients with knee pain attended the OPD of Walawalkar hospital, Dervan.
On x-ray, 28 were found to have different grades of osteoarthritis. Of these 25 agreed to be part of this
pilot study. They underwent standing x rays & MRI of the lumbosacral spine.
Results: This study found an unusually high rate of coexistent knee and spine pathologies. All patients
had some degree of disc disease accompanying medial or tricompartmental osteoarthritis. It undermines
the need for investigating this important contributor to the umbrella term of knee pain.
The commonest affected disc segment was L4-5 i.e 92% with two patients having L5- S1 prolapse 8%.
The purpose of this pilot study is only to alert the surgical and rehabilitation colleagues of the frequent
coexistence of the spine and knee conditions for Counseling, consent, surgery & rehabilitation and thus
improve patient satisfaction.
Keywords: knee pain, dermatome, ignorance, dervan
Introduction
Knee pain is among the commonest complaints in the outpatient orthopedic department.
However the cause does not always originate from the knee itself [1, 2] and knee pain is used by
the patient more as an umbrella term. In fact very few patients give the complete list of
accompanying symptoms. They have more often than not to be coaxed out of the patient. To
make matters more complex, Referred pain from the Spinal nerves, Hip and Ankle joints join
the many structures around the knee to make knee pain an umbrella term for this Pandora’s
Box [3, 4]. Misdiagnosis or partial diagnosis leads to inadequate or wrong treatment and
continued suffering for the patient treating doctors [5, 6]. We do now live in a litigious society.
This coexistence of spine and knee pathology also emphasizes need to
1. Investigate causality of knee pain and L4-5 pathology as chicken and egg syndrome.
2. Need to compulsively probe for coexistence of concomitant spine pathology with the
umbrella term knee pain as it is the one factor which will influence complete diagnosis,
counseling, legal consent taking, simultaneous treatment of both spine and knee disease
and postoperative rehabilitation protocol.
3. Further Examine possibility of simultaneous treatment of knee pain and leg pain, i.e the
entire Dermatome, by endoscopic discectomy and knee arthroplasty as a holistic and
complete treatment and long term relief to the patient.
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International Journal of Orthopaedics Sciences
There is a dire need, NOT to treat knee pain as a specialty in
itself, thereby ignoring the holistic view of considering
contributions to pain from the neighboring joints & spine.
Specialization should not lead to separation. Ignoring the role
of the Spine as a pain generator [7, 9], is hazardous in a litigant
society & may lead to erroneous labeling of mildly arthritic x
rays of the knee as the main pain causative agent.
Materials and Methods
The subjects were patients who visited Outpatient department
for primary knee pain. This study has been conducted in BKL
walawalkar rural medical college and research centre,
Dervan, dist Ratnagiri, Maharashtra, India. The study was
approved by Ethics committee. 78 patients visited the above
hospital in the month of January 2018 with the primary
complaint of knee pain. Of them 25 had confirmed
Osteoarthritis on X rays. 25 of them consented to be part of
this pilot study. Mean age of the patient was 60.4 years; there
were 11 males and 14 females. All patients complained
primarily of pain at knee joint. None of the patients
complained of back pain or radiculopathy on their own.
We evaluated AP and Lateral view radiographs of Knee joint.
Patients were further subjected to X rays and MRI of
Lumbosacral spine. Under a special research arrangement
with the local MRI center, all patients were examined
clinically for knee pain, general examination done to rule out
any systemic neurological disorder. X rays took included
Anteroposterior (AP) weight-bearing knee and standing
Anteroposterior with Lateral radiographs of Lumbosacral
spine and MRI of Lumbosacral spine axial and saggital view
T1 and T2 images.
Inclusion criteria
1. Patient who consented for above mention investigation
2. Knee pain
3. Age group between 50 to 80 years
Exclusion criteria
1. Subjects with previous neurological disorder; Cerebro
vascular attack, potts spine, charcots joints, previous
surgery
2. Subject with Osteoarthritis secondary to trauma.
3. Generalized involvement RA, ankylosing spondylosis,
Inflammatory / systemic disease.
Data was collected and analyzed by the Radiological imaging
center and reported by a senior radiologist. Results were
calibrated and presented in graphical form of pie charts.
Results
All patients showed varying degrees of disc disease. The
commonest affected disc segment was L4-5 i.e 92% with two
patients having L5- S1 prolapse 8%.
The work for further staging of the disc disease, its
anatomical classification and its correlation with the grade of
osteoarthritis is part of a larger study to be reported soon.
The purpose of this pilot study is only to alert the surgical and
rehabilitation colleagues of the frequent coexistence of the
spine and knee conditions for Counseling, consent, surgery &
rehabilitation.
Chart 1
Chart 2
Discussion
The senior contributors of our team have studied the subject
of knee pain with special reference to L5 radiculopathy [1, 2, 10].
Lateral knee pain has been shown to commonly arise from the
L5 nerve root [1, 2, 10].
Symptomatic effusion, patellofemoral pain, is common
accompanying symptoms.
Also, there are many a well done arthroplasties who still
complain of pain around the knee postoperatively [11]. We
surmise that a predominant cause for the above is missing the
element of coexistent spine pathology or not giving it due
importance in counseling, rehabilitation and treatment. This
sometimes needlessly leads to authentic doctors, well done
surgeries & a sound technique getting a bad name.
Majority of medial knee pains originate from the knee itself &
those lateral or posterolateral have a contribution of
radiculopathy from the L5 nerve root [1, 2]. All posterior or
posterolateral pain complaints are questioned for past history
of back pain and fresh, coexisting or previous radiculopathy
symptoms. We have found an extremely high incidence of
radiculopathy in the posterior & posterolateral region of knee
which correlates greatly with subsequent MRI of
Lumbosacral spine. This is so far proven & well accepted
scientifically by our senior authors.
However, there was also a correlation to medial knee pain,
often noted as L4 exiting root compression. The commonest
culprit disc prolapse was L4-5.
It is too early for us to assert that the knee arthritis may be
caused by commonly coexistent disc pathology of L4-5 disc
prolapse. We further surmise that, could central disc
herniations with traversing root L5 compression causing a
posterior & posterolateral knee pain/ calf pain cause abnormal
load patterns due to weakness of hip abductors on that side ?
Also could exiting or paracentral disc herniation may cause
Medial sided or medial joint arthrosis cause exaggerated
cartilage wear due to a subclinical hyposensitisation of the L4
sensory supply to medial side of knee ?
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International Journal of Orthopaedics Sciences
Further studies are needed to verify this theory.
Modifications in our treatment protocol are then made for
Counseling, Rehabilitation and Treatment of such patients
who may have coexistent spine and knee pathologies. We
have developed “THE DERVAN PROTOCOL” for
investigation which includes standing knee and spine x-rays
and MRI spine.
Often on deep probing and explaining the concept of knee as
a bulb, the nerve as a cable & Spine as a junction box, and
that a fault in the bulb may be from the bulb or cable or
junction box. The patient is able to relate to the pain generator
concept and does remember an episode of back pain followed
by radiculopathy etc.
The patient who has knee osteoarthritis which may need
surgery is then counseled for the causative contributors to the
pain. If required symptomatically & proved by imaging,
Patient is then offered either Knee surgery with special focus
on concomitant rehabilitation of spine, a training of day to
day correct postural ergonomics. If both knee arthritis &
spinal canal stenosis are equally severe, we offer him
concomitant surgery by the “Dervan Simultaneous Surgery
Protocol “which is also under review for publication. We are
also happy to state that we are the first team to treat
simultaneous knee and spine pathologies, in the same sitting.
i.e endoscopic decompression of spine followed by
endoscopic insertion of epidural catheter & simultaneous
surgery of the knees in an awake & aware patient. This leads
to complete readdressal of all causative pain factors
concomitantly. However this paper is to report the imperative
need for the diagnosis rather than treatment. We have called it
the “Dervan Dermatome Syndrome”
Rehabilitation of the patient is done following the “Dervan
Rehabilitation Protocol” which is also under review for
publication. To our knowledge this is the first study to report
the high incidence of knee and spine pathologies and its
ramifications.
Knee pain is commonly considered an independent and
separate clinical entity in itself. Specialization has
unfortunately led to separation. A knee pain specialist is
concerned more with the MRI and X rays of the knee and
seldom seeks to find the alternate or maybe even true pain
generator after a positive imaging finding in the knee.
Unfortunately even after proper and complete readdressal of
the image by knee surgery, many patients complain of
persistent pain, to be slowly referred to other colleagues
including counselors. Practicing as a holistic team comprising
arthroplasty and spine experts along with pain medicine
specialists, at the Rural Medical College in Dervan gave us
the opportunity to probe for all possible causes of knee pain,
confirm by radiology imaging and then redress all of them
together.
This enumeration of all causes of pain gave us a much better
and complete approach to counseling preoperatively, surgical
readdressal either concomitantly or in planned stages and
focusing simultaneously on all needy areas during
rehabilitation.
Example Case
Image 1: MRI Lumbosacral Spine
Diffuse annular disc bulge along with bilateral facetal
ligamental hypertrophy at L4-5 Levels Causing Moderate
significant impression on thecal sac and bilateral lateral recess
nerve roots and compromising bilateral neural foramina.
Patient complained of pain over lateral & medial knee. On
Questioning, He also confessed to calf pain & repeated
history of radiculopathy over past 2 years. But he insisted that
the pain was presently only Knee pain!
Image 2, 3: Bilatoral Knee Xray Anteroposterior and Lateral View
Showing Degenerative Osteoarthritis with Cartilage Thinning
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International Journal of Orthopaedics Sciences
Image 4, 5: Xray Lumbosacral Spine Anteroposterior and Lateral
view showing reduced disc space
Conclusion
The epidemiology of patients who present with radicular
complaints and symptoms of knee osteoarthritis often
overlaps and can prove difficult to correctly diagnose.
Additionally, pre-existing arthritis of an extremity can cause
imbalance in the spine, leading to mal alignment and radicular
symptoms. One must be aware of the multiple causes of hip,
knee, and back pain and how to properly examine these
patients.
A new method for Work up for these complaints to make the
correct diagnosis and guide treatment is proposed. Special
vigilance should be paid to postoperative patients with new
back pain several years after arthroplasty. With rising super
specialization, a team approach to patients with potentially
atypical presentations of their joint or back pain is best for
optimizing the appropriate care.
In our study all patients with knee pain& osteoarthritis on x
rays who underwent set of investigation as described above
have some pathology at L4-5 disc level. This concludes that
there is need for considering knee pain and back pain together
and investigation as a single functional unit & treat
accordingly with relevant set of investigations. We can
presently treating symptomatic knee arthritis and symptomatic
prolapse inter vertebral disc in a single surgical setting. This
leads to better and early Rehabilitation of patient and will
prevents dissatisfaction because of persistence of the umbrella
term “pain around the knee”. Hence we suggest following the
new investigation protocol in all patients with knee pain along
with back pain for holistic healing.
Also further avenues of research are opened by this paper on
the causation of knee pain, is the affliction of the spine &
knee a chicken & egg syndrome, if so, which precedes which?
Are there ways to quantify the contribution to knee pain, thus
prioritizing the sequence of surgical intervention?
Can specific rehabilitation protocols be developed for such
patients who focus on back care too along with knee
rehabilitation, as a more holistic approach?
Can we also further develop minimally invasive techniques to
address the entire dermatome simultaneously, in a single
sitting, thereby giving complete relief to the patient?
The future looks exciting & we are also reminded of the
wisdom of our ancient wise ones who called the spine
“MERUDANDA or the AXIS OF THE UNIVERSE”, where
every man is a universe in himself & the axis is the human
spine.
Acknowledgement
We are grateful to Dr Ravishankar Vedantam, Spine Surgeon,
and USA for his guidance in preparing this manuscript.
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... The exact cause of pain, the origin of the main pain generator has confused many an astute clinician. To confuse matters more, coexistence of the pain generator in both knee joints & spine is often noted [1][2][3][4] . The surgeons practicing specialized knee Arthroplasty are often faced with dissatisfied patients complaining of lingering pain in the knee, often behind the knee [5,6] . ...
... It was thereafter made mandatory for all patients of knee osteoarthritis to undergo spine investigations & detailed clinical examination preoperatively. Furthermore it was found that great concomitant affliction existed between spinal disc disease & knee Osteoarthritis [1] . Cost savings, Ease of rehabilitation, Skill development, Propagation of a holistic attitude to patient care& a deeper understanding of the integrated functioning of the human body are promoted [2] . ...
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Abstract Introduction: Surgery has made tremendous advances in the fields of joint Arthroplasty & Spine. Major advances in both these fields have made patient care more nature friendly & less morbid, thus allowing smaller incisions, day care procedures like endoscopic spine surgeries, minimally invasive joint replacement and so on. However, both these specialties have remained diverse and separate. Thus, in the typical modern-day specialty-based practice era, a patient consulting an Arthroplasty surgeon will seldom have a detailed spine examination or vice versa. This may lead to scenarios where the pain generator is from for example radiculopathy to the knee and below & the recommended procedure is a joint replacement due to incidental wear of the joints seen on the X ray. (1) The international data shows that there are 20% dissatisfied arthroplasty patients worldwide. (2) We have found concomitant knee & spine pathologies in more than 90% of our patients& published our research on the same topic. (1, 3, 4, 5) Thus the need arises for taking care of both pain generators i.e. from the spinal stenosis (central & or lateral) & knee arthritis for complete pain relief to the lower limbs. The developed protocol is the first of its kind for a more Holistic diagnosis & treatment of lower limb pain. It also saves interval dissatisfaction of the patient, healthcare costs & is a step towards a more team based surgical care between specialized spine & arthroplasty surgeons. Specialization should no more be a cause of separation between treating surgical teams & continued pain for the patient. A more Holistic clinical & surgical approach is hereby proposed. Methods: In this pilot study, twenty two patients were selected who underwent simultaneous & single sitting surgical treatment for leg pain, unilateral or bilateral. After detailed clinical examination & imaging studies, Simultaneous, Single stage Surgery was carried out in needy patients. Step one was Transforaminal Endoscopic Lumbar discectomy of the L4-5 disc in 17 patients, 2 level L3-4 & L4-5 in 3 patients & L5-S1 in 2 patients under local anesthesia in an awake & aware patient. After completion of the Percutaneous Endoscopic Lumbar Discectomy, an epidural catheter was inserted through the endoscope under vision in the epidural space by the spine surgeon (Dr. Sunil Nadkarni) & patient turned supine after checking the position of the catheter with radiolucent dye & securing the catheter. The anesthetist pushed the drug, patient was turned supine and painting & draping was done to begin the second part of the procedure i.e. single side or bilateral unicondylar joint replacement. Results: Results were classified by VAS, ODI, Oxford knee score, SF 12 before & after the procedure. Conclusion: The proposed “Dervan Simultaneous Surgical protocol “for Lower Limb pain, is a satisfying procedure with good to excellent outcomes in more than 90% patients. It provides the way for a holistic patient centered approach to treating all the main pain generators of the lower limb in one sitting. It is time saving & cost effective. Rehabilitation can start for the entire physiological neuromuscular unit and provide more holistic therapy.
... Arthroplasty surgeries are doneroutinely now for osteoarthritis knee; however, arthroplasty surgeons are often faced with dissatisfied patients complaining of lingering knee pain, often behindthe knee [1] . This may be due to the fact that sources of knee pain can also be secondary to pain generators in lumbar spine [2][3][4][5] . Most of the causes of non-traumatic knee pain and swelling can be diagnosed based on clinical and radiological examination (Xray's and MRI's'). ...
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DOI: https://doi.org/10.22271/ortho.2021.v7.i1n.2588 Abstract Introduction: Knee pain and swelling are known amongst orthopedic surgeons as symptoms of a local pathology arising from the knee joint area. It is also often used by patients as an ‘umbrella term’. Although in most cases the causative pathology may be the knee joint itself, however, this umbrella term can cause prejudice among clinicians to look at only locally and not think of a lumbar pathology as a cause of knee pain and swelling. The objective of this pilot study was to make clinicians aware that causes knee pain and swelling may be beyond the anatomical confinements of the knee. Material and Methods: This is a prospective study in which we evaluated consecutive patients with non-traumatic knee joint pain and effusion coming in our hospital from 1st January to 1st February 2020. Detailed history and clinical examination were taken. After ruling out obvious causes of non-traumatic knee pain and effusion in these patients, we included 38 patients based on our inclusion and exclusion criteria. Written informed consent was taken. They were evaluated for knee joint with radiographs and lumbar spine with radiographs and MRI. Arthrocentesis and synovial fluid evaluation were done. Results: After synovial fluid examination, 2 patients were found to have subclinical inflammatory arthritis and were excluded out of the study. 36 of the 38 patients had a normal study on arthrocentesis. 2 out of these 36 patients had no abnormalities on spine MRI. Out of the remaining 34, 30 had disc degenerative disease at L45 or L5S1 (25 patient L4-5, 3 patient L5-S1, 4 patients with both L4-5 and L5- S1), 1 patient had a L34 disc degenerative disease, 3 patients had Grade 2 L45 spondylolisthesis with mild or no back pain. Conclusion: Although a disc degeneration can be seen incidentally in many asymptomatic patients, based on our observations we think that causes like “autonomic” overload can be one of the unheard reasons of knee pain and effusion. The clinician must be aware of possible causes of knee pain and swelling beyond the anatomical confinements of knee and that lumbar spine pathology need also to be ruled out. The clinician must not let prejudice rule his clinical judgement. We don’t claim direct association of lumbar disc degeneration and knee pain and swelling in this study. Further studies are needed. Keywords: knee effusion, knee Swelling, lumbar disc, degenerative disc
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