Health Organization for Pudendal Education

paulette wrote:Faith,
I was wondering who did your injections. Will Dr. Hibner accept them, or will you have to have them done again?

Thanks for sharing your experiences Paulette. I too am not big fans of injections. I sort of want an SI injection before I see Dr. Hibner just to rule that out, but I think it's probably a waste. My PT doesn't think my pain is coming from my SI. I don't know that my pain management doc will give me an SI injection because he doesn't feel I have sacroilitis, but I am going to try to talk him into it. He thinks my sacral pain is referred from my PN.

I had my pudendal injections done in TN. I don't know if Dr. Hibner will accept them. I have a feeling he may make me have one done under CT since mine were done uner Xray and ultrasound. Guess I'll see. Hope your appointment with Antolak goes well.

Faith,
I have heard of SI joint problems causing problems with the pudendal nerve, but I have not heard of the pudendal nerve causing SI problems, which your PT seems to suggest. Does he think our piriformis may be the cause of your pain? I have researched and researched and have never read that the pudendal nerve can cause piriformis spasm, but I have read that the piriformis can compress the pudendal nerve. Yet Violet has written that after her surgery for PNE, her piriformis calmed down. How do you argue with that? I really want to know what is the underlying cause, because I don't want the wrong thing cut. If the piriformis is the culprit, and I have surgery, they will cut the piriformis. If the the pudendal nerve is the culprit, they will cut the SS ligament. If I ended up having to have both cut, I would end walking with a cane, if at all. Have you had EMG's done? If so, what did they show? I'm sure you are getting excited for your appt. with Dr. Hibner.

Paulette, I have zero problems with the piriformis now but it used to be a huge annoyance before PNE surgery. I think what happened was that due to the PN pain many pelvic muscles went into spasm. I can see how PN might cause SIJD if you just have pain on one side and you tend to guard that side and sit/walk differently than you normally would. Over time it seems possible that the pelvis could become misaligned causing stress on various ligaments and joints but this is just my speculation.

If I had to choose between sacrificing the piriformis or the SS ligament I would choose the SS ligament because from my own experience, even with an unstable pelvis, I have not had additional problems after having both SS ligaments cut. Of course I haven't had the piriformis cut so I don't know how that would feel but the SS ligament is not a major ligament in the pelvis.

I agree with you, Violet. I just don't know if Dr. Antolak would be willing to cut the SS ligament if the pudendal nerve wasn't entrapped in the ST ligament. Cutting the piriformis muscle would be the absolutely last resort for me.

paulette wrote:Cutting the piriformis muscle would be the absolutely last resort for me.

Does anyone even cut the piriformis? I wouldn't think you'd be able to walk without the piriformis hardly.

Also about your SI injection. Did it relieve your pain as long as the anesthetic was in effect? Isn't that how they officially diagnose Sacroilits (like they use PN injections to help diagnose PN)?

Yes, they do cut the piriformis muscle. Sometimes they cut it where the tendon attaches to the greater trochanter. If the sciatic nerve is entrapped in the piriformis, they cut the belly of the muscle. Dr. Filler in LA does it with a minimally invasive approach. I have heard different opinions on cutting the muscle. Some say it is a small muscle, and the larger gluteal muscles will take over the function of adduction and outward rotation of the hip. But I talked to a man who had his piriformis cut, and he said it affected the way he walks.

I have not had a SI injection. The way my surgeon diagnosed my SI problem was by several manual tests, such as Patrick's test. But what convinced me was to do the fusion was when he showed me the SI joint on the CT scan. The arthritis was very visible. I even had a tiny bone spur in the joint.

Next week I am going to have EMG's done. The following week I have an appt. with Dr. Antolak. I am going to ask him if I can get my injections from Dr. Chris Centenno in Denver. He uses a MSK ultrasound to do the pudendal nerve injections, because he can see the nerve. He also does piriformis injections. I am even considering seeing Dr. Centenno and cancelling my appt. with Antolak, because I dont' believe I have true PN. But we will see what the EMG's show.

Paulette, you have a complicated situation and I hope your will be able to figure out what is the source of your problem.

I would love to hear more about the msk ultrasound with Dr. Centenno and how well he can see the nerve. I wish more of the PNE docs would use ultrasound because you don't have the radiation accumulation. My understanding is the fluoroscopy isn't so much radiation but the CT scans worry me a bit.

The PN anaesthetist in Toronto, Dr. Peng, uses the ultrasound-guided block, too.

My Dr used ultrasound as well but I don't know how accurate it is because each time he did it I was numb in a different area.

I had the EMG's done yesterday. The physician performing them said he could not elicit the H reflex to determine if I have piriformis syndrome. The reason for this is because my back surgeries. He said spine fusions usually make it impossible to elicit this reflex. He said I definitely have pudendal nerve denervation on both sides, right more than the left. I was feeling so good on the trip to and from Denver that I sat most of the way. Now I am in pain and don't know if I will feel well enough to make the trip to Minneapolis to see Dr. Antolak. Maybe that is just as well. The more I read about people's reactions to pudendal nerve injections, the less willing I am to have one. I have two symptoms: pain with sitting and numbness in the rt. saddle area. The only thing that worries is the numbness in the saddle area. The physician who did the EMG's said I have 40% the strength in the anal sphincter as a normal person. Isn't there any surgeon in this whole world who will do surgery without pudendal nerve injections???? Would a neurostimulator take away the numbness?