Diagnostic injections

[tig5]

I am trying to decide on having obturator and ilioiguinal surgery with Dr. Conway to relieve pain I have bilaterally in the front inner thigh/groin area of my legs. Worse on the left. However, I am not sure if the genital femoral nerve is also involved in this pain syndrome.

I am currently seeing a new pain management doctor, whom I like very much so, who suggested he block all three groin nerves including the iliohypogastric and see if it provides any relief. If so, then going back and blocking each one individually and seeing which one(s) is the real culprit. Dr. Conway did do and eMG on my obturator and that was an 10.17 on the left leg.

Dr. conway and Dr. Williams both recommended first blocking the ilioiguinal nerve to see how much relief I get from my groin pain, and then have the doctor then block the genitofemoral nerve or at least the genital branch of the genitofemoral nerve at the external left in the groin. If they also know how to block the femoral branch of the GFN then they could try that too. They suggested basically the same thing but eliminating doing all three together and getting to doing each one individually right at the start to better diagnosis that true pain generator that way I would know 1) what nerves need to be surgically addressed and 2) what surgeon I need to go to as Dr. Conway does not do the genital femoral nerve.

I was just wondering what you guys would do. I did put a phone call into my new pain management doctor to discuss this with him, but I only got a call back from a PA who said she would relay the message. So I guess I will have to wait and see what happens the day of the block and ultimately it will be the pain doc's decision.

Again, I really do like and trust him so either way it will by fine. I think he is just looking at it has giving me the most pain relief and the surgeons are looking at it as more diagnostic purposes. Honestly, I am in so much pain but also want the right surgery ASAP that either way will be fine with me. I think I am kind of hoping he will do it the way the surgeons are recommending, however I think I would like to start with the genital femoral nerve as I think that my be the main source of my pain and then do the ilioiguinal.

Again, any thoughts you have would be greatly appreciated. My block is Wednesday.

Sincerely,
Annmarie

[helenlegs 11]

Had to go away and sleep on this one Annemarie ; Well was up in the night anyway .
I can understand the dilemma! At first it sounded clear cut;. . . I decided, speaking personally, that I would do each one separately without a doubt, although the temptation for all three and pain relief would be difficult to deny oneself. . . . but that would be my plan of action, as I would prefer to know the answer sooner rather than later (after all of this time )
Then I got to wondering well what if there are 2 or even three nerves that are problematic?? would you be able differentiate between them, still having some symptoms ? We all have ups and downs pain wise. if you were not altogether (front of pelvis) pain free but did feel an improvement post block, would this be due to the shot or a fluctuation in your pain? You would need to analyse things carefully. Would there be repeat shots if the first round brought no clear cut answers?
I am probably over complicating things when they are already complicated enough!!!

I am not familiar with these nerves (although I do get one anterior pelvic nerve 'stuck' and nipped every now and again, it always manages to free itself. . .)
So I looked them up. I'm sure that you know all of this below but thought I'd throw it in anyway. Not sure if it will help??

Ilioinguinal, iliohypogastric and genitofemoral nerves. Injury to these nerves or their roots may occur from
thoracolumbar pathology, abdominal posterior wall conditions, surgery, and entrapment in the groin. The
pain may extend into the groin, anterior perineum and scrotum/labia majorum. If the femoral branch of the
genitofemoral nerve is involved, pain may extend into the inner thigh.

6.2.1 The anterior groin nerves
The iliohypogastric nerve arises from L1 and its anterior branch supplies the skin above the pubis; its lateral
cutaneous branch is distributed to the anterolateral part of the buttock.
The ilioinguinal nerve is smaller than the iliohypogastric nerve; it also arises from L1 and is distributed to the
skin of the groin and mons pubis.
The genitofemoral nerve arises from L1 and L2. It passes through the psoas muscle, then down it to emerge
through the deep inguinal ring. Its genital branch supplies the cremaster muscle and a part of the anterior and
lateral scrotum. The femoral branch passes close to the external iliac artery, the deep circumflex iliac artery and
the femoral artery to be distributed to the upper part of the femoral triangle. The two branches of the femoral
branch may separate at any level, therefore, sensory phenomena associated with nerve damage depend upon
the level of the lesion and individual variability.
The lateral cutaneous nerve of the thigh arises from L2 and L3 and eventually leaves the abdomen behind
or through the inguinal ligament at a variable distance medial to the anterior superior iliac spine. In the thigh,
it divides into an anterior branch that supplies the anterolateral skin of the thigh, approximately 10 cm down
from the inguinal ligament to the knee. The posterior branch supplies the skin more laterally from the greater
trochanter, down to the mid-thigh.
The obturator nerve arises from L2-L4, descends through the psoas muscle, runs around the pelvis in close
proximity to the obturator internus muscle and obturator vessels, and leaves the pelvis via the obturator
foramen. This nerve has significant motor innervation, and its cutaneous branch is distributed primarily to the
skin on the medial aspect of the knee.

So after all of my possibly unnecessary complications I would still opt for separate blocks, starting as you said with your 'favorite ' (I'm sure it's NOT!!!)
Take care,
Helen

[Karyn]

Hi Tig,
I guess I'm a bit confused about your new PM's rationale, too. It sounds like he wants to do injections in the abdomen first, and then do them again individually at the spinal level?

I think he is just looking at it has giving me the most pain relief and the surgeons are looking at it as more diagnostic purposes.

Personally, I didn't get any pain relief what so ever from the ilioinguinal block. It would be great if someone here could share their experience with it.

So I guess I will have to wait and see what happens the day of the block and ultimately it will be the pain doc's decision.

I don't agree with this, hon. You, and you alone are in the drivers seat in regards to your medical care. This doctor is working for you. If you're looking for pain relief, then blocking all three nerves may be helpful. If you're looking for diagnostics to justify surgery, I don't see how blocking all three nerves at the same time will provide useful information.

Honestly, I am in so much pain but also want the right surgery ASAP that either way will be fine with me.

If this is what you want, I would suggest doing the blocks individually, as Dr. Conway & Dr. Williams recommended.
Best wishes with your appointment. Please let us know what you decide and how your blocks went.

Edited to add:
http://www.ncbi.nlm.nih.gov/pubmed/6696629
I think this link may better explain what your PM is trying to accomplish. Hope it helps!
Hugs,
Karyn