Numb's MRI

Discussion of magnetic resonance imaging and magnetic resonance neurography

Numb's MRI

Postby numb » Tue Sep 25, 2012 5:48 am

Hi All,
I had Potter's MRI result and would like your input/feedback. I can not upload the report so i will just type out the impression portion. It said MRI of the pelvis demonstrates pelvic vein congestion, effacing the inferior perineal branches of pudendal distribution in the anteroinferior margin of alcock's canal, coursing with the dorsal nerves to the clitoris and extending aroud the urethra and between the vulvar region and lower anus. There is no scar entrapment of the pudendal nerves in the posterior margin of alcock's canal nor adjacent to the SS/ST ligaments. Incidental note is made of a cyst in the left vulvar region, possibly a smalll bartholin gland cyst.
Please help me to understand what Dr. Potter was saying. Did she say my pelvic veins effacing the inferior perineal branches in the front/low margin of alcock's, dorsal nerves as well. Is effacing meaning compressing? She said no scar entrapment of pn in the posterior margin of alcock's nor in between the SS/ST ligaments. Does it mean no entrapment in the posterior margin of alcock's and SS/ST ligaments?
My pelvic pain was initially started in my sacral, S3 area, spreading to the sit bone areas w/in 10 days and then to my genital areas more the surface, not in the deep part after a few months. I also had some feet pain ( ball). My pain has the burning feature and numbness depending how long i stay seated. My pain will get reduced and or relief when i stand up. I went to see OB/GYN re: pelvic vein congestion who said my symptoms and the painful sites are not consistent with the pelvic congestion syndrome which is the fullness a and feeling heavy in the pubic/low abdominal areas. I also research online and it said the pain is dull and achy when standing. So I am very confused and not sure what am i dealing with. Dr. Weiss in SF said i have PNE. When he did the internal exam via vagina, i had the sharp burning pain in between the ligaments and alcock's. When he did the first PN block it numbed the pain in these areas but it did nothing to ease my sacral/butt/feet pain. My genital areas did not bother me at that time. Another doc did a S3 block which numbed all of my pains except the pain around the sit bone areas.
I really appreciated if you folks can give me some feedback. I need to sort this out soon as my pains are getting worse.
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Re: Numb's MRI

Postby helenlegs 11 » Tue Sep 25, 2012 12:09 pm

I would never consider myself the best at this but will give it a go. Hopefully others will chip in.
Firstly take a look at this ... veBeco.jpg it is from the home pages and 3 shows Alcocks canal
ANTERIOR means in front (opposite, posterior is behind)
INFERIOR means below or more towards the feet (opposite, superior is above/ more towards top of head) Sorry I'm sure you know all of this, it is more for me ;)
On that home page diagram [b]4, 5[/b] and 6 show the separate branches of the pudendal nerve.
4 is the dorsal branch to the clitoris/penis (here is is branched before alcocks canal)
5 is the perineal branch
6 is the inferior rectal branch (in many diagrams this one is branched before alcocks, although not here)
Everyone is different.
I have no clue about effacing, sorry, other than it should?? mean to be inconspicuous (also rub out, thin?? but I can't imagine veins having this effect on the nerve, so don't worry) It must mean that the veins are covering and hiding the nerve in this area. The area being after the perineal and dorsal branches have travelled thru' alcocks canal. So I take it that the rectal branch may have separated off before alcocks in your case maybe?
From the results here it is showing that this is the only feature on the scan than could be responsible for your pain. Just remember that this scan will not necessarily give you a definitive answer. Imaging may show something where there is the no doubt as to what THE cause , or one of THE causes, must be. Sometimes it can compliment a diagnosis and further cement it. Sometimes it can show something that isn't widely accepted in medicine at that time, as 'the culprit' and sometimes it shows nothing, or nothing conclusive, at all.
Maybe the fact that the varices are covering the nerve, if there was anything else going on behind that, it can't be seen??
Might it be the fact that your numbness (saddle area?) may stop or rule out (some of) the heavy feeling usually associated with congestion syndrome?? Just a thought.
Personally I would trust a clinical examination rather than imaging. Many PN surgeons don't find imaging helpful at the moment, although hopefully that will change soon. It is just unfortunate that you have had varying degrees of success with blocks.

You may have seen this already but Violets post here gives some further insight into varices and PN.

Edited to add;
Have you had anyone look (PT) at your piriformis muscles? Just because you mention butt and feet pain) Often that muscle is a problem, tight or prone to spasm as a secondary effect from PN. Some people do have the sciatic nerve running thru' this muscle making them more prone to feet and/or sciatic pain. Piriformis stretches (only very easy ones) can help evaluate this or knowledgeable PT. The other theory for foot pain being problematic with PN is that in the homunculus the genitals are next to the feet in the cerebral cortex. If the pain system to one area (genitals in our case) is messed up and highly sensitised there can be some sensory crossover effect to adjacent cerebral areas. Not saying I agree with this at all, and I would definitely not mention it for fear of the 'crazy' tag :) but it has been mooted as a theory.
Take care,
Fall 2008. Misdiagnosed with lumber spine problem. MRN June 2010 indicated pudendal entrapment at Alcocks canal. Diagnosed with complex variant piriformis syndrome with sciatic, pudendal and gluteal entrapment's by Dr Filler 2010.Guided piriformis botox injection 2011 Bristol. 2013, Nerve conduction test positive; new spinal MRI scan negative, so diagnosed for the 4th time with pelvic nerve entrapment, now recognised as Sciatic, pudendal, PFCN and cluneal nerves at piriformis level.
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Re: Numb's MRI

Postby Violet M » Sun Oct 07, 2012 4:18 am

numb wrote:Please help me to understand what Dr. Potter was saying. Did she say my pelvic veins effacing the inferior perineal branches in the front/low margin of alcock's, dorsal nerves as well. Is effacing meaning compressing? She said no scar entrapment of pn in the posterior margin of alcock's nor in between the SS/ST ligaments. Does it mean no entrapment in the posterior margin of alcock's and SS/ST ligaments?

According to the dictionary, effacing means to make indistinct. So it sounds like your pelvic veins may be enlarged for some reason and since the blood vessels typically follow the same path as the nerves it may have blurred the image of the nerves. I'm not sure what the significance of this is other than there are some types of neuralgia that can be caused by blood vessels impinging on them such as trigeminal neuralgia. But I have also seen MRN reports showing a back-up of blood in the blood vessels likely due to compression of those vessels by ligaments and I have spoken with an RN who had an MRN that showed a back-up of blood in some of the veins that was actually caused by a compression. Dr. Bautrant's dopplar tests were based on the fact that the blood vessels and nerves run together and if the dopplar studies of the blood vessels were abnormal (blood flow was not normal) it could mean that the nerves were compressed.

I'm assuming your MRI checked the lumbo-sacral area and that problems such as cauda-equina syndrome were ruled out? Some of your sciatic-type symptoms affecting your feet may be a result of piriformis involvement or sacral root involvement. Have you been evaluated for sacro-iliac joint dysfunction?

PNE since 2002. Started from weightlifting. PNE surgery from Dr. Bautrant, Oct 2004. Pain now is usually a 0 and I can sit for hours on certain chairs. No longer take medication for PNE. Can work full time and do "The Firm" exercise program. 99% cured from PGAD. PNE surgery was right for me but it might not be for you. Do your research.
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Re: Numb's MRI

Postby numb » Sun Jan 13, 2013 5:45 am

Hi Everybody,
Hope you are all have less pain and Happy New Year! I have gone to see Dr. Hiner in December. He had reviewed my pelvis MRI written report and recommended embolism for my enlarged veins, a nerve block for my perineal branches and botox. Did anyone has this type of procedures done by Dr. Hibner. What was your experience? I thought embolism of the veins should be done by an interventional radiologist or should it be done by the pelvic surgeon. How experience is Dr. Hibner re: embolism, perineal block and or botox.
Thanks for your feedback!
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Re: Numb's MRI

Postby nyt » Sun Jan 13, 2013 2:02 pm

Dr. Hibner has done at least 200 botox injections under anesthesia and probably alot more since he is a big believer in botox and does several botox injections a week. I know one of the last times I had mine done I think he did 4 other patients. He has done about 6 botox injections on me and I do quite well with them and they last me just about 3 months before I need more. Each time they wear off I'm not quite as bad as before. Like all procedures some people do very well but I do know a couple of people who they did not help and at least one person on this forum is worse. Dr. Howard now does the botox like Dr. HIbner and at my last visit to see Dr. Howard (2 weeks ago) he said now that he does botox like Dr. Hibner he is getting much better results with pain control than how he use to do them. Not sure how many perineal nerve blocks he has done but he did mine about 1.5 years ago. The embolism is done under ultrasound and I know he always looks at the vein when he does the dorsal nerve block. From the couple of people I know there have been mixed results with the embolism, I know one women cured, others better, some no difference. When it comes to experience with these procedures Hibner probably has done more than anyone and developed the ultrasound guided embolism of the dorsal vein procedure. When it comes to outcomes, Dr. Hibner, has never published his outcomes, I don't know if he has any exact numbers or not. I only know what people have posted on this forum when it comes to outcomes and it is mixed.
2/07 LAVH and TOT 7/07 TOT right side removed 9/07 IL, IH and GN neuropathy 11/07 PN - Dr. Howard
6/08 Obturator neuralgia - Dr. Conway 11/08 Disability, piriformis syndrome - Dr. Howard
4/09 Bilateral obturator decompression surgery, BLL RSD - Dr. Howard
9/10 Removed left side TOT, botox, re-evaluate obturator nerve - Dr. Hibner
2/11 LFCN and saphenous neuralgia - Dr. Dellon 2/11 MRI with Dr. Potter - confirmed entrapment
5/11 Right side TG - Dr. Hibner 2012 Left side TG - Dr. Hibner
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