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Re: Ilioinguinal Neuralgia?
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Re: Ilioinguinal Neuralgia? - June 25, 2004 1:06:00 PM
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FlaDC
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[URL=http://www.emedicine.com/neuro/topic589.htm]www.emedicine.com/neuro/topic589.htm[/URL]
consider this, it can happen of a suture was wrapped around the femoral nerve. no amount of PT will help if thats the case.
Dr. Wagner; don't be so fast to say that nothing about the surgical procedure could have been the cause.."Iatrogenic causes of femoral mononeuropathy include direct pressure or trauma to the nerve during pelvic or abdominal surgery or focal damage at the femoral triangle due to a difficult femoral line placement".
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Re: Ilioinguinal Neuralgia? - June 26, 2004 3:32:00 PM
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Dr.Wagner
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Give me a break my man...common things being common, this was likely a routine appendectomy, the only thing NOT routine is that this is a 20ish female. Sorry, but this is seen way to often and is VERY likely supratentorial. That is a more common diagnosis (tying off a nerve? come on...might as well say she stepped on a stone, created an upslip and on up the kinetic chain went the force and now you need to manipulate her OA...neither excuse do I buy).
Furthermore, this is likely a laparoscopy and no where NEAR the common femoral nerve. Ain't a whole lotta suturing in this procedure. She didn't have a femoral line placed, and the procedure takes place in a different area.
I have a case study of a hair tourniquet of the uvula, but not all cases of pharyngitis are due to hair tourniquets...common things are common.
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Re: Ilioinguinal Neuralgia? - June 26, 2004 4:58:00 PM
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FlaDC
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http://www.neuroland.com/spine/le_neuropathy.htm
http://health.allrefer.com/health/femoral-nerve-dysfunction-info.html
I quote from this source "One common risk factor is lying in the "lithotomy" position (on the back with thighs and legs flexed) during surgery or diagnostic procedures. In some cases, no detectable cause can be identified".
http://www.medhelp.org/forums/neuro/archive/16463.html
another quote: "Injury to the femoral nerve is a recognized complication during abdominal, pelvic, inguinal and hip operations. The most common surgical cause associated with femoral nerve injury has been abdominal hysterectomy, (7.5-10% incidence quoted). I don't have the number for appendectomy but I'm sure the figure is lower. The nerve usually is inadvertently damaged (either cut, snared by suture, stretch or pressure from retractors) during the procedure. Post op complication such as a large blood clot (iliacus hematoma) can also injure the nerve. Infection (abscess) my develop post op and cause injury".
Dr. Wagner, I am not here to piss in the sand with you. Someone asked a clinical question and I tried to help. I suffered from this complication 2 years ago myself. I had to do all my own research because all those in the "know" said it wasn't possible.
I assume since my reference is from a neuro-surgeon from the Cleveland Clinic it is less credible then someone who claims to be able to perform an appendectomy "blindfolded".
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Re: Ilioinguinal Neuralgia? - June 27, 2004 4:44:00 AM
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Dr.Wagner
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Appendectomies are done completely supine...sure lots of things are possible, but this is not a question of possibilities rather commonalities. Treat this patient academically, with known causes, don't go chasing zebras. If an answer presents itself, don't go looking for another. Appendectomies are not inguinal surgeries, they are abdominal, done laparoscopically...nothing like hysterectomies (review anatomy regarding vascular and ligamentous supply and support to the uterus vs. appendix).
This PT is working hard with a 20 yr old female, whom the surgeon, PCP, and PT are spinning their wheels on WHY she is in pain. Perhaps this patient WANTS to be in pain, or wants others to think that she is. Supratentorial. This is FAR more common of a cause than tying off a femoral nerve (with what? THere generally is one suture other than skin/fascia closure).
Common things are common...don't argue like a lawyer, argue with reason and rational thought. Don't go chasing zebras when horses are all around you.
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Re: Ilioinguinal Neuralgia? - June 27, 2004 7:20:00 AM
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FlaDC
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Lord Wagner; excuse my ignorance for butting in. Continue please.
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Re: Ilioinguinal Neuralgia? - June 27, 2004 8:29:00 AM
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Diane
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Hi, me again:
Dr. Wagner, I wonder if you took a moment to peek at the link I provided above;
http://xnet.kp.org/permanentejournal/sum02/acnes.html
To tempt you, here is the title and the first few lines of text:
[QUOTE]Abdominal Cutaneous Nerve Entrapment Syndrome (ACNES): A Commonly Overlooked Cause of Abdominal Pain
By William V Applegate, MD, FABFP
Introduction
Abdominal cutaneous nerve entrapment syndrome (ACNES) may sound like an esoteric condition rarely seen by clinicians but is a common condition. When a patient is seen for abdominal pain without other clinically significant symptoms, ACNES should be high on the list of likely diagnoses. ..[/QUOTE]This info is provided about the author of the article:
[QUOTE]Author information
William V Applegate, MD, FABFP
William V Applegate, MD, FABFP, is a retired SCPMG Family Practice physician from San Diego. He is an Associate Clinical Professor at UCSD Medical School in San Diego, CA.[/QUOTE]I hope his credentials pass your inspection.
Presumably he has examined thousands of bellies in a long career. Note he doesn't assume that because someone is a. young and b. female, that they are automatically operating from a supratentorial agenda, seeking attention for the sake of seeking attention.
As a soft tissue manual therapist I very much appreciate this article. It has freed up my own methods of practice and way of thinking about nerves, where they run (diagonally down and forward around the trunk), made me realize that they can be "trapped" anywhere, not just at the vertebral exits, how they exit deep layers into superficial layers, made me realize that the whole trunk needs treating including belly walls, and that my job doesn't end at some mythical dividing point between the anterior border of the lat and the posterior border of the obliques.
I think you might agree, after taking a look at the article, that there are probably way more 'horses' out there than you suspected, that require some wrangling by one means or another.(I prefer to consider other means of 'horse wrangling' these nerves other than injecting them.)
Respectfully,
Diane
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Re: Ilioinguinal Neuralgia? - June 27, 2004 2:29:00 PM
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Dr.Wagner
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Why do you people take criticism so much to heart?? Good Lord I feel like this is an episode of Oprah.
The article was interesting...not as interesting as the bibliography, which cited some esoteric but a few good sources. All of which seem to point to this as an absolute diagnosis of exclusion.
Listen, I have seen patients as a PT then as a physician I see the same patients...and sometimes people simply WANT to be in pain (not talking about secondary gain), but rather the psyche of "pain".
I am not doubting any author, but if you look long enough, you can find a supporter of ANYTHING...
I just saw a patient who is pregnant and is seen in the ED weekly for "cramping" or "discomfort"...she is a documented malingerer...why, who the hell knows. There is nothing really to be gained by "faking" contractions, she "just does". It is pathetic, but not uncommon. All I am saying, is that if a an accomplished surgeon, FP, and PT are having a hard time finding a rational reason for discomfort...maybe there is no rational reason. Maybe it is IRRATIONAL. Maybe, someday it will just go away, without any reason. Or perhaps, she simply amplifies post surgical discomfort (hmmmm boy never saw that before). Perhaps it just isn't politically correct to say it happens MORE OFTEN in young females (they NEVER are known for high drama...never).
If you ask a hard core DO into manual medicine, you will likely convince him this is a Chapmans point for the adrenals...or a tenderpoint treated with positional release.
Ask a psychiatrist about this case...guarantee they may get to the point of the issue pretty fast.
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Re: Ilioinguinal Neuralgia? - June 27, 2004 3:32:00 PM
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pablo w
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And if the only tool we have is a hammer, soon everything starts to look like a nail.
Neuropathic pain syndromes are extremely common. I think far more common than people "wanting" to be in pain. "supratentorial" doesn't really explain anything. Dr Wagner, you say that supratentorial pain is more common than other causes for unresolved pain, but I think it would be nice to be able to exclude other possibilities before we can jump to that conclusion.
The surgery was performed through the abdominal wall, which has a cutaneous innervation. Cutaneous nerves can be damaged in surgery, and often do. I'm not talking about the femoral nerve here. Sensory nerve damage can lead to plastic changes in dorsal horn networks, leading to situation like allodynia and hyperalgesia, as well as spontaneous pain. This is obviously "felt" or perceived by the brain, so we could argue that all pain is supratentorial, but that doesn't really solve the problem.
Pablo
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Re: Ilioinguinal Neuralgia? - June 27, 2004 5:29:00 PM
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Dr.Wagner
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come on my man...you wouldn't last a second in the Emergency Department or in medicine for that matter over-anylizing and looking for "deeper meanings". Somethings just "are". These cases are a dime a dosen...every once and a while they get past good PT's who BUST their ass trying to figure out a problem that is irrational. Supratentorial is a term used to describe psychogenic pain.
Do you realize how many lacerations are seen DAILY without any cutaneous long lasting effects? But this one does...despite good professional consultation?
As for this patient, I suggest continuation on the current track of therapy. If it fails, refer to a massage therapist or myofascial therapist that will perform manual therapy until her problems are resolved. This patient NEEDS one on one care, primarily for pyschological benefit.
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Re: Ilioinguinal Neuralgia? - June 27, 2004 10:47:00 PM
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pablo w
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Thank you, Dr Wagner. Fortunately the patient under discussion does not seem to be in need of emergency medical treatment. You are right, I wouldn't last in an emergency department, so I have not chosen that path.
Would it be fair to say that if the patient in question improves, it was because of psychological benefits? And if she doesn't, because she has deep-seated psychological problems which are not amenable to therapy?
You suggetsed looking for horses. The horse I see is called "cutaneous nerve injury". I'll leave the zebras of psychogenic pain to the experts.
Pablo
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Re: Ilioinguinal Neuralgia? - June 28, 2004 5:53:00 AM
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Diane
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Dr. Wagner:
[QUOTE]If it fails, refer to a massage therapist or myofascial therapist that will perform manual therapy until her problems are resolved. This patient NEEDS one on one care, primarily for pyschological benefit.[/QUOTE]I actually agree with you. I think this patient wil be much better served by someone who takes her worries/complaints seriously.
While it's true she's not in any danger of dying just this minute, and has no need of your highly skilled capability of saving her life, and you probably, from that standpoint, cannot help but see someone with her ailment as a pest to be gotten rid of, she is a fully conscious human, worried about a pain in her abdomen. If it's "just" a cutaneous nerve entrapment, then the "best" practitioner for the job is a "pain wrangler", someone who has figured out how to deal with people who have pain, who can gauge if the pain is centralized (which overlaps with the supratentorial possibility) or is a simple peripheral issue in the tissue, and can apply some slick hands-on manouver to help her brain eliminate it.
DOs used to be famous for being able to do this. I guess it's a job skill that has eroded with time, or has been fobbed off to PTs and others.
Cheers,
Diane
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Re: Ilioinguinal Neuralgia? - June 29, 2004 3:48:00 AM
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Dr.Wagner
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No...sometimes one must realize that not EVERYONE can or wants to be completely pain free. I see psychogenic pain/disorders 20:1 over cutaneous nerve entrapment...that does NOT make it a zebra. It is a diagnosis of exclusion. I can't believe you guys are buying into this bunk. Too bad. Pablo, I think you are a bit naive my man...doctors often fall into this trap the "vague pain syndromes" that defy professional evaluation. More often than not, these individuals have ALOT of issues. Alot. If you want similar examples as this patient, I have a ton. I am not trying to be confrontational, its just that many of you are SOO resistent to the idea that psychogenic pain PLAGUES medicine. I gave you the example of hundreds of lacerations treated daily in EVERY hospital...not a single return for "nerve entrapment". This patient MAY have a true musculoskeletal disorder...but if you exclude the fact that hmmmm multiple good professionals have seen her, and hmmmm it has been many many months since her surgery, and hmmmm are there outside forces influencing her healing (enjoys the attention, lawsuit pending, workers compensation, not returning to work, restricted activity) then you aren't fully considering the differential.
Sure, there are articles written on "nerve entrapment syndromes" just like there are articles written on tenderpoints, trigger points, chapman points etc the unfortunate thing is that these areas are so poorly proven and are ONLY supported by case studies with a n=1 and rarely have objective proof.
Haven't you figured out that manual therapists don't get success stories necessarily from technique, but many times just from touch? One on one manual treatment treats more than tissue, it treats the patients DESIRE to be believed or taken seriously (supratentorial), and often leads to success primarily as a result of pyshcological factors. As for "Pain wranglers"Well, I suppose there is a market for anything, and if someone is buying...sounds like you are selling.
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Re: Ilioinguinal Neuralgia? - June 29, 2004 5:37:00 AM
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Diane
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Guess you are still a tad Cartesian in your thoughts about pain Dr. Wagner.
[QUOTE]As for "Pain wranglers"Well, I suppose there is a market for anything, and if someone is buying...sounds like you are selling.[/QUOTE](Really, is it necessary to sound so condescending?)
Not to worry. Someday the medical world will start to realize what pain therapists of all stripes are starting to realize, that the body is just a large and distracting bump on the bottom of the brain, and that what is going on in that brain is a lot more important (in a conscious patient) than what is or isn't going on in their body.
To expand the conversation for a moment away from this particular woman's sore belly, I know all too well what you are saying about all the secondary gains issues, as a PT who is out there in the world with a cash practice, those are exactly the people I see. (Mind you, it's a cash practice. They are paying for my time and expertise, and finding me by word of mouth.)
I am at the end of the trail for most of those who live with chronic pain (and hopefully am keeping them out of your ER). I spend most of my waking hours dealing with it; either working with those who have it, or reading about it, thinking about it, puzzling about it, discussing it with others on forums like this one. It is a phenomenon all on its own. And yes, it doesn't kill anyone except by degrees, by eroding away any pleasure they might have felt living in a body. It is definitely a brain/mind issue, no one argues that it isn't.
How does one access the "brain" in a conscious aware patient who lives with some form of pain? One first of all does no harm. One teaches the patient about how their brain makes pain, how pain is a movie the brain makes, and projects out on the movie screen of the body. That the body is not the source of the pain, it is merely a reflective surface upon which the "projector" is operating. (This is all "hard science" by now. No worries about being off the page..)
Then one considers the bits that are extensions of the brain, i.e: nerves. One addresses/treats those, and one can affect the output of the brain, noodle it into behaving a bit or a lot less "painfully." Much of the time. Most of the time.
I guess your worldview goggles are so very different from mine that you won't ever see my point; you are rushing around saving lives and misinterpreting pain therapy on forums.. and we love you for that! If any of us were to be in a horrible accident with 14 compound fractures and a collapsed airway, arteries spurting, and completely unconscious, I know most of us would rather be in the ER than in a pain therapists office. I see your point quite well I think.
In your example of 20:1, you see all the '20s', and I end up seeing the '20s + ones'.
[QUOTE]Haven't you figured out that manual therapists don't get success stories necessarily from technique, but many times just from touch?[/QUOTE]Yup. I figured that out before I ever went into physiotherapy.
Cheers,
Diane
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Re: Ilioinguinal Neuralgia? - June 29, 2004 1:39:00 PM
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Dr.Wagner
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I am not attempting to sound condesending, but in a world where there are people wanting to treat anything and everything...myofascial unwinding...this and that, and when people come to the ED SPECIFICALLY to recieve a work excuse, one becomes slightly more jaded. I have seen everything heard everything. I have been lied to, and spit on. I have seen immaculate conceptions, errors in drug screens (yeah right), and even have seen vibrators in the rectum that got their because "I slipped and fell". When I smell a rat, I call the rat out. When I see a pattern consistant with supratentorial behavior and patterns...I name it. I despise those who begin treating anyting without validating their methods, I have a hard time buying what many are selling.
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Dr. Wagner DO
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Re: Ilioinguinal Neuralgia? - June 29, 2004 3:24:00 PM
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pablo w
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Dr Wagner,
I appreciate what you are saying, and I agree with you, that there are a lot of issues that influence people's pain. Maybe in the ED the ratios are different to what I see, so I like to give people the benefit of the doubt. There is little harm done in considering a neuropathic pain syndrome with a dominant peripheral mechanism, and finding it when it is present. I can't dismiss the possibility from the information provided. We're just trying to offer some advice, and Mickey can evaluate each theory on its merits.
On the topic of references, there's probably a heap of them on psychogenic pain, but I haven't really read anything that was particularly enlightening.
Pablo
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Re: Ilioinguinal Neuralgia? - June 29, 2004 4:06:00 PM
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Diane
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Dr. Wagner,
[QUOTE]in a world where there are people wanting to treat anything and everything...myofascial unwinding...this and that,... [/QUOTE]I don't disagree with you that this is a perceptual fantasy on the part of the originators of the term.
[QUOTE]...and when people come to the ED SPECIFICALLY to recieve a work excuse, one becomes slightly more jaded. I have seen everything heard everything. I have been lied to, and spit on. I have seen immaculate conceptions, errors in drug screens (yeah right), and even have seen vibrators in the rectum that got their because "I slipped and fell". When I smell a rat, I call the rat out. When I see a pattern consistant with supratentorial behavior and patterns...I name it.[/QUOTE]Fair enough. You are a gatekeeper and I'm sure lots of people try to storm the gate. Your job is to be selective.
[QUOTE]I despise those who begin treating anyting without validating their methods, I have a hard time buying what many are selling.[/QUOTE]I guess you mean all the lovely hands-on techniques your forebearers(DOs) came up with, to treat conscious people with, to relieve pain and improve function, that are called strange things that sound downright quaint by today's language standards, and defy RCT type methods because ultimately there's no getting around the placebo effect they all elicit. Are those the methods you despise? Like the "myofascial unwinding"(sic) you referred to earlier? "A rose by any other name would smell as sweet." I agree, these weird names should all be dumped, as they mean nothing real and are intensely provocative.
As Pablo said, [QUOTE]There is little harm done in considering a neuropathic pain syndrome with a dominant peripheral mechanism, and finding it when it is present. I can't dismiss the possibility from the information provided.[/QUOTE]One cannot dump all the pain science that has surfaced in the last 10-15 years, all the pain physiology that has been worked out, all the brain fMRIs that indicate which pathways are working under what conditions, all the neurochemistry going on that suggests that in many instances, (e.g.: chronic pain) the opioids made by the brain itself are way more effective than any introduced from the outside, for kicking the system over into a better level of function. And I refuse to abandon soft tissue manual treatment.
I realize none of this interests you in the slightest, but I just thought I'd come back on one more time to reassure you I'm not a Barnes-o-phile.
Battle on Dr. Wagner,
Diane
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Re: Ilioinguinal Neuralgia? - June 29, 2004 4:30:00 PM
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Dr. Perkins
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I think we should take a moment to review the situation with this patient.
1)Pain present since September 2003 (9 months).
2)Resting pain 6/10, spiking to 9/10 with activity.
3)Passive and active hip extension illicit pain
4)Pulling sensation with motions that stretch the area lateral to the navel in standing and sitting.
5)Ober’s negative, Thomas test negative.
a.I don’t understand how this patient is complaining of pulling in the abdomen in sitting but is able to get into a Thomas test position and not have significant complaints of abdominal pain or significant sensation of strain?
6) Femoral nerve stretch test positive.
a. How does this person get into the Thomas test position again?
7) Pain lateral to the navel and also in the ipsilateral thigh.
a. There is no likely dermatomal or peripheral nerve relationship between these areas.
With the lack of a common peripheral or dermatomal relationship between the periumbilical area and the anterior thigh in combination with the lack of any objective or subjective neurological deficits leads me to be very skeptical of any nerve entrapment here.
This patient is complaining of a slew of confusing active and passive findings of the hip and trunk without any real supporting orthopedic tests. This patient is also complaining of resting pain at 6/10 (as in constant 6/10 pain?) with pain spiking to 9/10 (after 9 months?). This scenario does not lead us to any diagnoses that would be likely to directly benefit from a manual intervention.
In my opinion, it is likely that Dr. Wagner is correct in this case.
Also, if treatment is initiated in a case like this there should be a significant active component and a disability index should be used. The appropriateness of further treatment should be based on functional improvements in the absence of other objective measurable findings.
Good luck.
_____________________________
Aaron W. Perkins D.C., P.T., M.S.
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Re: Ilioinguinal Neuralgia? - June 29, 2004 7:16:00 PM
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Diane
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Hi Aaron W. Perkins,
[QUOTE]This patient is complaining of a slew of confusing active and passive findings of the hip and trunk without any real supporting orthopedic tests. This patient is also complaining of resting pain at 6/10 (as in constant 6/10 pain?) with pain spiking to 9/10 (after 9 months?). This scenario does not lead us to any diagnoses that would be likely to directly benefit from a manual intervention.[/QUOTE]Welcome to the world of chronic pain, where people have symptoms that don't fit, pain that spreads outside the nice lines on dermatome charts, and are therefore considered cranks or crocks or crazy or attention seeking.
At least this patient still has pain that is in a pattern, even if the pattern is an odd one. There is probably still some hope for turning it around with some intelligent handling.
[QUOTE]This scenario does not lead us to any diagnoses that would be likely to directly benefit from a manual intervention.[/QUOTE]I will take the liberty of translating this into paintherapy-ese: "This pain pattern will not likely change using the rationale/application of joint manipulation."
Or exercise therapy. No amount of theraband/weight training/stretching is likely to produce reduction in this pain pattern, because no one is willing to consider the soft tissue or the way it is structured, or the nervous system innervating it, or how feedback from said nervous system may sound like microphone squeal to the brain. No one wants to know, I guess, that every nerve, incuding every cutaneous nerve to the abdomen, has its own nerve supply, the nervi nervorum, which, if its own blood flow is even a little bit impaired, can be raising a huge pain ruckus even if all seems perfectly normal in the world of outer appearances.
Or modalities probably. Electrotherapy might push it down for a bit. Ultra sound etc., but she'll more than likely be back before long.
No protocols will fit this patient, no insurer will pay for any creative approach to helping her. She is stuck sideways in the system, between the medical system on one hand who think she's crazy/young/female therefore bogus by definition, and a system that rewards the theraputic handling of bones and joints, so you better not use up any valuable cognitive space learning about any other systems of the body. Too many quacks out there, too scary. Don't want to be suspected of being one of THEM!
Treating pain in people/people in pain is like working in a hall of distorting mirrors. You have to be ready for anything, in good communication with your patient, and willing to be wrong in your assumptions, frequently. Pain is a wiley foe; it has no shape, it can't be imaged (well, that's starting to change but it's still a ways away).
Pain won't stay inside the lines, comes and goes as it likes, baffles the best intentions. That's life outside the ER and outside everyone's nice neat bone&joint mentality. Good luck Mickey.
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Re: Ilioinguinal Neuralgia? - June 30, 2004 2:45:00 AM
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Barrett
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Diane,
Wonderful post. I agree entirely.
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Ilioinguinal Neuralgia? - June 30, 2004 3:57:00 AM
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Oaks
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Diane,
Great response, very accurate description of a large percentage of what we see daily.
Aaron,
The original post said the THomas test was negative but painful
Scott
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