3T MRN new mathematical approaches

[janetm2]

I just wanted to post information on some newer ideas with 3T MRN that I tried to say were not Filler and included 3Tessla MRI as in my report that was signed by John Carrino MD in my reply to Jen- see excerpts from Dellon's book for the details. Thanks
Janet

Jen,
Johns Hopkins in Baltimore has an Magnetic Resonance Neurography (MRN) which listed the following at the start of my report:
RESULT:
INDICATION: Left pudendal neuralgia

TECHNIQUE: High resolution MRI was performed of the pelvis employing MR neurography techniques on a 3-Tesla system using multiplanar 3-D anatomical and fluid sensitive sequences per the descrpition on my MRN report.

To note Dr. Marvel said the MRN was being done to eliminate other problems, not to diagnose PN/PNE.
Also, this is not a Dr. Filler MRN as described in chapter 12 of Dr. Dellon's pain solution book.
It took me about a month to get in for the MRN March 2011

Janet

From chapter 12 of Dellon's Pain solutions book:
A commonly used approach today is to have radiographic imaging of the pelvis. The
best “x-ray” approach is actually with magnetic resonance imaging (MRI) which puts
energy into the tissues and records the energy given off in response to that stimulus.
Mathematical models applied to this generated energy can be used to create a
photographic image, which looks like a traditional x-ray, but can be manipulated in many
ways to highlight different tissues, such as bone versus muscle, primarily related to the
water and fat content of that tissue. Sadly, nerve as a tissue, has been traditionally hard to
image because it is similar to blood vessels in its water content. So radiologists usually
assume they know where the nerve is because the nerve is related to the blood vessel or
certain bone landmarks. In other words, traditional MRI tests do not directly image the
peripheral nerves. A neurosurgeon, Aaron Filler, MD, developed a mathematical
A. Lee Dellon, MD, PhD
Chronic Pelvic Pain 335
approach designed to identify nerves more easily and he has termed this “MR
Neurography”. There are many radiology locations in the country at which this testing
using his proprietary, patented, formula can be done. Other medical institutions are
developing their own mathematical approach to visualize these small nerves better. At
Johns Hopkins Hospital, we have a dedicated Musculoskeletal Unit, organized by John
Carino MD and Avneesh Chhabra, MD, in the department of radiology that is currently
correlating their images with intra-operative photographs that my partners in the Dellon
Institute for Peripheral Nerve Surgery® are sending to them. These clinical/radiologic
correlations already have enabled better understanding of the location of nerve
entrapment with regard to all peripheral nerve problems in the arms and legs,*, **, *** and
it is now being applied to the pudendal nerve. We, doctors and patients, must bear in
mind that this imaging is still in its infancy with regard to the pudendal nerve, and it is
still difficult to distinguish scarring from nerve entrapment from the adjacent pudendal
artery. The appearance of a nerve that is entrapped or one that is freed from entrapment
may still appear abnormal due to the scar remaining from the neurolysis surgery itself.
The good news is that, at present, I do not routinely require this test to be done in the
evaluation of my pelvic pain patients. If a patient has had previous surgery, or if a pelvic
tumor is suspected, or if there has been a pelvic fracture, a high intensity MRI with special
imaging should be recommended. An example of an MRI of the pudendal nerve using the
approach developed at Johns Hopkins is given in Figure 12-18.
* Chhabra, A, Williams, EH, Wang, KC, Dellon, AL, Carrino, JA, Magnetic
resonance neurography of neuromas related to nerve injury and entrapment with
surgical correlation, American Journal of Neuroradiology, 31:1363-1368, 2010.
** Chhabra A, Faridian-Aragh N, Chalian M, Soldatos T, Thawait SK, Williams EH,
Andreisek G. High-resolution 3-T MR neurography of peroneal neuropathy.
Skeletal Radiology, in press 2011.
*** Subhawong TK, Wang KC, Thawait SK, Williams EH, Hashemi SS, Machado AJ,
Carrino JA, Chhabra A., High resolution imaging of tunnels with magnetic
reasonance neurography, Skeletal Radiology, in press 2011.
CHRONIC PELVIC PAIN
CHAPTER 12 336
A
B
Figure12-18. MRI of the pudendal nerve in a man using a high intensity 3 Tessla protocol as
developed by the Musculoskeletal Radiology Group at Johns Hopkins Hospital, Baltimore. A: Level of
ischial spine. Pudendal nerve is between the sacrospinous and sacrotuberous ligaments (white
arrow). B: Level of Alcock’s canal, the pudendal nerve is alongside the obturator internus muscle
(white arrow). Images courtesy of John Carrino MD and Avneesh Chhabra, MD.

[seawalker]

Janet,

I found out that dr. Chhabra does mri guided pudendal injections. I'm debating on doing it with him vs. Dr. Richard just because of the CT radiation.

I'm wondering if it is worth it to get the mrn with him as well. Did you ever find out if therwas any coorelation with ur mrn and surgerical findings?

[janetm2]

Jason,
As I said the MRN was not for diagnosing PNE but to rule out other issues. I am not sure it shows a correlation but I am not sure if that may be because I am not reading it correctly. I am going to try to upload it without my name so others can see and help out. Also although it seems folks feel all MRNs are read by Dr. Filler this is not a filler MRN but a Johns Hopkins version. Hope you will get some answers soon on what is going on and what you can do about it. I think I got the pages (split page one due to sizing allowed) added. Sorry for the delay, I am now working 6 hours and going to acupuncture as well as PT weekly and the internet was offline so we could replace the vinyl flooring this weekend.
Guess I should add in something about the surgery I had. Sorry but trying to rush and so I will type in two sections of the report and can add more (another day - the detailed procedure is a very long paragraph) if you (or others) think it would help.
Procedure performed: Transgluteal left pudendal nerve decompression, neurolysis of the inferior rectal nerve, neurolysis of the pudendal nerve, fasciotomy of alcox canal, transection of the sacrospinous ligament, transection of the sacrotuberous ligament.
Findings:
Left pudendal nerve was flattened and yellowed as it traversed the intraligamentous space. There was minimal space between the ischial spine, sacrospinous ligamentand sacrotuberous ligament. The nerve densely adhered to the underside of the sacrotuberous ligament. There was a band compressing the nerve at the opening of the Alcox canal. There was tethering of the nerve to the falciform process. The inferior rectal branch split just prior to the Alcox canal.

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Janet

[Lernica]

So what you're saying is that they discovered pudendal neuropathy at your surgery even though the Johns Hopkins MRI was negative for it?

[janetm2]

Lernica,
Actually what I was told is that I had PNE because
1 two ligaments were compressing the pudendal nerve by my physical therapist
2 history sittting pain from sitting for 20+ years to compensate for chronic foot pain
3 3years pelvic muscle spasms
4 unguided nerve blocks provided some temporary relief
5 CT guided nerve blocks provided full but temporary relief
As I said the MRN was done to ensure there were no other problems so I was under the impression that meant it was not ordered to show or confirm PNE, so I was not sure if it does not show it because it was not set up for that or it did not show it and should have?
So far as I can see I had PNE and am getting some relief from the surgery.
Janet

[Lernica]

Yes it's clear from your operative findings that you did have PNE and I'm so glad you are feeling better post-surgery. On a scale of 1 - 10, how MUCH better are you feeling?

Still I am confused about the MRI because it appears indeed to have been specifically looking for PNE ("Indications - Left pudendal neuralgia") and yet didn't find any. This is clear in its final "Impression" at the bottom of the page where it concludes: "no abnormality . . . along the course of the pudendal nerve". So the MRI was basically wrong. How much did you pay for it?

[seawalker]

Janet, you are so awesome for scanning your report! thank you for taking the time to help out, you are a great recourse to me and I have been keeping you in my mind.

I just got back from a visit to that 3T bore at Hopkins today matter of fact. but.... not for my pudendal issues. I have learned a great deal about MRI. Today was the 14th time in the tube in the last year and 1/2! I met with some neuroradiologist last week and asked a lot of questions about MR neurography.

Even though Dr. Marvel ordered it to check for all possible pathology, it still would be no different course of action when targeting the pudendal. So no, there was no surgical correlation with your MRN . Thats unfortunate for the pudendal community but good info to know. Dr. Marvel must have known they wouldnt be able to see entrapment. The fact is we just arn't there yet with MRI. Its not just the pudendal nerve. Unless we really have something obvious like a big tumor or fracture they cant always tell, and radiologist all have slightly different opions just like most docs. it is an art of interpretation. Radiologist also fly through thousands of slices, report after report.

This is good to know Janet. Im emailing this radiologist at Hopkins about MR guided injections. At least it might be another option for folks in this area. Glad to see your working 6 hours a day. That would be a life long accomplishment for me! My therapist told me that results can take a year to come after surgery.

Jason

[janetm2]

Lernica and Jason,
I will try to answer both of you. I am not sure I can put a % better yet but am just crossing over past where I was before surgery. I was able to work 5 hours before and am now at six but my feet were starting to be impacted and I was not sure I could continue.As for the cost of the MRN I need to check other info but I think my portion may have been $74 and change from my checkbook. Cheaper than the MRIs ($200 each) to confirm arthritis in my large toes. I am thankful you could set me straight on reading the MRN and disappointed this won't help Jason maybe they owe me if they are using data to tweak the algorithms! I am glad to provide info to help with sorting out what can help or rule out what won't . Wow 14 tube runs and you are still going hope you get answers soon and some day reach your goals. I am very grateful and lucky to get this far. If I can get back full time and finish my last 4 and 1/2 years of work that would be great. Dr Marvel said the year was needed to determine success or failure. I will let you know if the acupuncture works and the person performing it as we need all the help we can get. I hope I covered everything my screen is out of whack I think due to the inserted report. Take care
Janet