Rather than using a nerve probe to see if needle is in right position to refer to painful area, ultasound was done. In only 1 case was the right nerve area hit by injecting ilioinguinal and iliohypogastric nerves seen so they assumed nerve blocks of no value… Do others see a problem with this?
Anesth Analg. 2012 Mar 30. [Epub ahead of print]
Ultrasound-Guided Ilioinguinal/Iliohypogastric Nerve Blocks for Persistent
Inguinal Postherniorrhaphy Pain: A Randomized, Double-Blind, Placebo-Controlled, Crossover Trial.
Bischoff JM, Koscielniak-Nielsen ZJ, Kehlet H, Werner MU. abstract here
- In only 1 case was ultrasound guided nerve blocks able to numb painful area
- They felt this represented an issue with various nerve being involved in innervation and hitting one or two of little value.
- they however concluded by saying “Conclusion:Ultrasound-guided lidocaine blocks of the ilioinguinal and iliohypogastric nerves, at the level of the anterior superior iliac spine, are not useful in diagnosis and management of persistent inguinal postherniorrhaphy pain”.
- This conclusion is fine if emphasis is put on relying on ultrasound no good however they to put the emphasis on nerve blocks being no good. Anybody in their right mind is going to block all nerve areas to obtain appropriate block so that conclusion cannot be made.
Other things to consider:
1) these cases had pain over 6 months old and are going to have considerable abdominal and psoas muscle knots, paraspinous spasms, spinal sensitivity, and central sensitization.
2) I have an expression – Didn’t anybody bother turning out the lights? When I inject nerves and knots, I will work the painful area until all the muscles are released and painfree. I remember when Dr. Janet Travell changed the the emphasis from spray to one of stretch in the spray/stretch technique for muscle triggers. The spray is only useful as a technique for stretching out the knots. It is the same for injections – the injection is only useful as an aid for taking out the knots and pain in area. Not working the painful areas, while local is in, is MORONIC. I do lidocaine nerve blocks to ribs for early shingles pains (use a 30 guage needle) but find I have to include local injections into more front locations to residual sore areas missed by blocks.
3) Some of the painful areas will have surprising innervation – – abdominal muscles innervated higher up, and even from sympathetic nervous system. I remember Dr. Travell (OK – I’m showing my age) describing a case of mid back pain that had multiple level nerve root rhizotomies without any relief because the pain was actually coming from the neck – (the midback lattisimus dorsi is innervated from C6-7-8)
4) In reality, one would inject the nerves and then inject any triggers that are left. I would use 5% lidocaine because of it’s semi-neurolytic properties; in most cases you are restricted to 2 mls. so patient does not get dizzy. No one in their right mind would expect to see results from a one shot session. I call studies that do, ONE SHOT MORON STUDIES – I tell patients that expect to see great results from one shot to go 3 blocks down to the building with a cross on top – maybe miracles there… I would do a series of 3 shots or more at weekly intervals using semineurolytic lidocaine and maybe add some steroid initially as well.
5) Underneath, iliacus and psoaas might be tender – as might pubis as well – and need dealing with. The paraspinous muscles of the affected level will also be tender and Dr. Chen Gunn has developed a program of Intramuscluar stimulation (IMS) to deal with paraspinous as well as the peripheral triggers. If paraspinous is in spasm – is the quadratus lumborum as well? – and has it dragged down the ribs so they rub on iliac crst – creating an occult very tender spot on the far lateral iliac crest where a cluneal nerve crosses?
Bottom line – any injection is going to have to involve alot of massage and muscle work – and areas that don’t come out are going to have to be nerve blocked or locally injected as well and then unknotted/worked out until painfree. The Process is going to have to be repeated multiple times. Any vitamin deficiencies etc. will have to be dealt with and I don’t know if it is worth trying to desensitize nerves in a smoker – they just don’t seem to do well. Chances of a complete recovery after pain has set in over 6 months is not going to be likely because of spinal and central sensitizaiton.