Dr. Mark Conway MD FACOG V.P. Society for Pudendal Neuralgia · Dr. Mark Conway MD FACOG V.P....
Transcript of Dr. Mark Conway MD FACOG V.P. Society for Pudendal Neuralgia · Dr. Mark Conway MD FACOG V.P....
Dr. Mark Conway MD FACOGV.P. Society for Pudendal Neuralgia
Published on www.pudendal.com the 5th February 2009
About 60 Kilometers North of BostonCommunity HospitalPopulation of surrounding area 150,000Several Teaching and University hospitals within one hour driveStill a tremendous lack of treatment options for these patients
Published on www.pudendal.com the 5th February 2009
Neuropathic pain condition involving the areas enervated by the Ilioinguinal nerve.Often seen in conjunction with neuropathies of the Iliohypogastric and Genitofemoral nerves
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PainLancinatingBurningIncreased with hip flexion or activation of abdominal muscles
Hypo and Hyper-esthesiaTemporal relationship to surgeryPelvic floor dysfunction,Myofacial pain
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IliohypogastricVentral Rami L1 and small contribution T12Between int. oblique and transversalisPierces ext. oblique 2-3 cm cephalad to superficial inguinal ringEnervates skin superior to pubis
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Ilioinguinal NerveFusion of T12 and L1 nerve roots,similar course to ilioinguinalPierces the transversalis and int.oblique adjacent to iliac crest. Then runs on the anterior surface of the internal oblique. Sensory branches to pubis,superior and medial aspect femoral triangle,base of penis and anterior scrotum or labia majoraOverlap with other nerves
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GenitofemoralVentral rami L1 and L2Decends on the ventral surface of psoas muscle. Then splits into Femoral and Genital Branch.Femoral Branch runs lateral to femoral artery and inferior to inguinal ligamentGenital Branch inguinal canal usually inferior to spermatic cord.
Labia majora or scrotum and adjacent thigh
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Starling J.R. 1989
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Ndiaye A. 2007Published on www.pudendal.com the 5th February 2009
Ndiaye A. 2007
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Ndiaye A. 2007
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Ndiaye A. 2007
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Several authors have shown significant variationRab M. 2001
4 major groups of variation A-DNdiaye A. et al 2007
100 disections great color pictures
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Ndiaye A. 2007
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The majority of cases result from surgical injury
Inguinal hernia repairMesh,laparoscopic,staples
Pfannenstiel incisionsAppendectomyLaparoscopy (lower quadrant port placement)Iliac bone harvestingNode dissection etc.
Non surgicalMuscle tear,Sportsman Hernia
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Nerve damage from direct surgical traumaInflammation and scar formationInflammation and retraction from permanent meshSuture encirclementTack impingementFascial tear (external oblique aponeurosis)
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Pathological Study ShowedGranuloma formationInflammationDemyelination
Also up stream from entrapmentFindings may be exacerbated by mesh
Miller et al 2008
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Pfannenstiel Incision8.8% had moderate-severe painOdds ration increased by 2.95 > 2 incisions70% patients had pain at corners of incision
Loos M.J. et al 2008
Inguinal herniaMultiple studies ranging from 0.35%-10% for moderate to severe pain
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Primarily ClinicalHistoryExam
Iliohypogastric: pain and tenderness at the scarIlioinguinal: pain and tenderness at exit of inguinal canal,and medial to anterior iliac crestGenitofemoral: hypo-esthesia anterior thigh below inguinal ligamentCarnett’s Sign
Abdominal wall flexion increases or does not change pain. With intra-abdominal pathology flexion will decrease pain.
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EMG ilioinguinal nerveDescribed by Ellis et al 1992
Limited published dataSpecificity and Sensitivity is lowIf used must be interpreted along with clinical data
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Ellis R.J. 1992
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Nerve BlocksOffice procedureAnterior abdominal wall just medial to anterior superior iliac spineAlso can use point of maximal tendernessPatient will feel radiation to affected areas
Ultrasound guided described Gofeld 2006Possibly safer to avoid femoral block
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Re exam after block to confirm benefitIf no benefit from anterior block consider Genitofemoral neuropathy and proceed with L1L2 nerve root block to confirm diagnosisSignificant overlap can make differentiation difficult
Starling J. 1989
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HerniorrhaphyLaparoscopic approach widely abandonedAvoid fixation of mesh with tacks,?avoid plugs and flat mesh.Careful disection,anatomy matters,preserveposterior aspect of spermatic cord where the genitofemoral n. usually lies. Described by Lichtenstein 1998Several studies on prophylactic neurectomy
Meta analysis no benefit for pain, increased paresthesiaGravante et al 2008
RCT showed significant decreased pain and no change in paresthesia
Mui et al 2006 Published on www.pudendal.com the 5th February 2009
PfannenstielIncision length is risk factor
Avoid extending incision beyond rectus borderPosition of incision
The higher above the pubis the betterNumber of incisions is risk factor
After two incisions risk increasedWould a vertical incision work?
Only close the external oblique aponeurosis when incision extends beyond the lateral border of the rectus.
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Physical TherapyLittle published dataTissue mobilizationEarly intervention may help prevent scar entrapmentHelpful for associated myofascial pain and muscle dysfunction
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Neuropathic pain modulatorsTricyclic antidepressantsNeurolepticsCase reports on Gabapentin
Very effective and well toleratedBenito-Leon J. 2001
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If a diagnostic block is effective a series may provide chronic relief
Marcaine +/- anti-inflamatoryEffects can be cumulativeAnywhere from 4 -7 blocksIntervals varyMay require retreatment
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Open post herniorrhaphyMost reports involve mesh removal with genitofemoral and or ilioinguinal neurectomiesResults overall were favorable with low complication rateStudies can’t be compared due to poor design
Aasvang E. 2005
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Starling et all 198917 of 19 patients curedFlank incision for genitofemoral neurectomy
Loss of cremasteric reflex and Hypo-esthesiaInguinal incision for ilioinguinal
Hypo-esthesia
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Amid P.K. 2004Triple neurectomy from anterior approach
Genitofemoral hard to find but usually could be accessed at the lateral crus of the internal ring,withinthe ring or along the spermatic cord89 % success rate
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Kim D. et al 2005Ilioinguinal and iliohypogatric
Anterior approach91% success rateNo significant complications
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Post PfannenstielAnterior approachComplete scar excisionLoos et al 2008
73% good to excellent14% moderateNo significant complications
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LaparoscopicMost reports use a retroperitoneal approachLateral incision and retroperitoneal space is created with a balloonGenitofemoral and ilioinguinal nerves are identified and divided
Both branches of the genitofemoral
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Krahenbuhl L. 1997Published on www.pudendal.com the 5th February 2009
Krahenbuhl et al 19973 patients all curedNo complications
Muto et al 20056 patientsAll cured
No complications
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Pulsed radiofrequency nerve ablationRozen D. 2006
5 patients post inguinal herniorrhaphyVertebral T12,L1,L2 nerve root
42 degrees C for 120 seconds per level4 of 5 patients with pain relief lasting 4-9 months
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NeuromodulationSeveral case reports publishedMost using a peripheral placementTwo eight contact leads placed parallel above and below inguinal scarAll patients had significant reduction in painSmall numbers and limited follow up
Rauchwerger et al 2008
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Rauchwerger J.J. 2008
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Laparoscopic Placement of Neuroprothesis(LION) ProcedurePossover M. et al 2007
3 patients with different neuropathiesIlioinguinal +pudendalSciaticSacral nerve root
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Conventional LaparoscopyRetroperitoneum accessed medial to cecum and incised up the level of the ovarian origin from the inferior vena cavaSingle contact lead placed near the origin of the nerves(ilioinguinal ,iliohypogastric and lateral femoral cutaneous)Same approach to place leads at S2-S4 and the sciatic
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Operative time 2.5 hoursNo complicationsAll three patients report excellent results
Small numbersLimited follow up
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These disorders are much more common than are recognizedWe now have a variety of effective treatmentsChallenges for the future is comparing these alternativesExpanding availability for treatment
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Finis
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