Jerry Hesch Inguinal Neuropathy Test
This is an email I sent recently to a renowned hernia surgeon. His reply is below. I am certainly delighted with his reply.
---- Original Message ----- From: jerry hesch, mhs To: [email protected] Sent: Thursday, February 12, 2009 12:17 PM Dear Dr. Amid,
Today I received a copy of your published study on post hernia neuropathy, from Deena Goodman, PT, who lives in the Los Angeles area. It is a very informative and encouraging paper.
The topic is near and dear to me as I went 32 years with moderate to severe pain before getting a triple neurectomy, very similar to what you describe.
The light bulb went on when my new Family Physician did an internal hernia screen and serendipitously, it felt like she turned on a 220 volt current. I then realized that it was possibly a peripheral neuropathy as opposed to believing it was a generalized soft tissue pain and pursued treatment aggressively. Protracted conservative care failed.
I have described a test I use to scour the inguinal canal circumferentially (symptom provocation), including palpation of the spermatic cord, to screen for traumatic neuropathies. I did an extensive literature search a few years ago and looked at textbooks in many medical specialties including a large volume on hernia repair and did not find the test described. For me, it was very informative, as I learned that all 3 nerves were involved. I do think it might be of value in athletics, perhaps with non-responsive non-hernia “sportsman’s hernias”.
Would you happen to know if this test is utilized in non English speaking countries?
I would be very grateful for a brief comment, or suggestion, if you have the time. I wonder if I should pursue it re publication, presentation or research.
Thank you very much for sharing your work.
Sincerely Yours,
Jerry Hesch, MHS, PT
Dear Mr.Hesch, To my knowledge there is no scientific publication in the surgical literature regarding your approach. Regards, Parviz K. Amid, M.D., F.A.C.S., F.R.C.S.
Professor of Clinical Surgery
David Geffen School of Medicine at UCLA
Director, Lichtenstein Hernia Institute at UCLA
---- Original Message ----- From: jerry hesch, mhs To: [email protected] Sent: Thursday, February 12, 2009 12:17 PM Dear Dr. Amid,
Today I received a copy of your published study on post hernia neuropathy, from Deena Goodman, PT, who lives in the Los Angeles area. It is a very informative and encouraging paper.
The topic is near and dear to me as I went 32 years with moderate to severe pain before getting a triple neurectomy, very similar to what you describe.
The light bulb went on when my new Family Physician did an internal hernia screen and serendipitously, it felt like she turned on a 220 volt current. I then realized that it was possibly a peripheral neuropathy as opposed to believing it was a generalized soft tissue pain and pursued treatment aggressively. Protracted conservative care failed.
I have described a test I use to scour the inguinal canal circumferentially (symptom provocation), including palpation of the spermatic cord, to screen for traumatic neuropathies. I did an extensive literature search a few years ago and looked at textbooks in many medical specialties including a large volume on hernia repair and did not find the test described. For me, it was very informative, as I learned that all 3 nerves were involved. I do think it might be of value in athletics, perhaps with non-responsive non-hernia “sportsman’s hernias”.
Would you happen to know if this test is utilized in non English speaking countries?
I would be very grateful for a brief comment, or suggestion, if you have the time. I wonder if I should pursue it re publication, presentation or research.
Thank you very much for sharing your work.
Sincerely Yours,
Jerry Hesch, MHS, PT
Dear Mr.Hesch, To my knowledge there is no scientific publication in the surgical literature regarding your approach. Regards, Parviz K. Amid, M.D., F.A.C.S., F.R.C.S.
Professor of Clinical Surgery
David Geffen School of Medicine at UCLA
Director, Lichtenstein Hernia Institute at UCLA
Inguinal Neuropathy Letter
RE Inguinal Neuropathy
My Published Letter to the Editor regarding the article: Low Back Pain and Leg Symptoms: Another Differential Diagnostic Possibility
Letter published online: J Man Manip Ther. 2007; 15(3): E71–E72.
Pinto D, Cleland J, Palmer J, Eberhart S. Management of low back pain: A case series illustrating the pragmatic combination of treatment-and mechanism-based classification systems. J Manual Manipulative Ther 2007;15:111–122
This letter is in response to the recent article by Pinto et al1. The authors are to be congratulated on a very successful presentation of a case series. My comments are directed at some of the symptoms of patients 1 and 2, because they apply to other clients seen in a typical PT clinic. Patient 1 had chief complaints of low back and groin pain, whereas patient 2 reported left buttock pain and pins and needles down the left medial leg. The examination addressed many things, including testing for altered sensation to pinprick in the lower extremity dermatomes. However, I would like to suggest that for these and similar patients the inclusion of the lower abdominal wall in the sensory screen might be of value because of the possibility of a para-inguinal neuropathy. A recent male patient had experienced painful traumatically induced neuropathies of 33 years duration involving the accessory obturator, ilioinguinal, and iliohypogastric nerves and the genital portion of the genitofemoral and vesicular portion of the hypogastric nerves. All these nerves are involved in the sensory innervation of the lower abdominal wall and genito-urinary region, but may also cause hypersensitivity in the groin and paraesthesiae and/or dysaesthesia in the medial calf (saphenous portion of femoral sensory nerve). Sensory alterations in the saphenous distribution of the medial leg are at times misinterpreted due to its overlap with the S1 dermatome. In this patient a reduced sensation to pin prick was not present but rather sensory hyperaesthesia and allodynia were noted in the lower abdominal and lower extremity dermatomes. Of differential diagnostic importance is that the ilioinguinal and iliohypogastric nerves and the genital portion of the genitofemoral nerve can be palpated proximal to and/or within the inguinal canal. All three nerves take a primary origin from the T12-L2 nerve roots. The ilioinguinal nerve innervates the inguinal ligament, the anterior inner wall of the inguinal canal, and the spermatic cord and can be palpated within and outside the inguinal canal. The iliohypogastric nerve supplies the roof of the inguinal canal and innervates superficial skin. The genital portion of the genitofemoral nerve—despite its very small diameter—can be screened by applying pressure onto the floor of the inguinal canal, located at the top of the pubic bone just medial to the spermatic cord. There is however, considerable variation in the pathway of this nerve. These palpatory tests have not been described in the literature. In the case of my recent patient, these intra-inguinal palpatory tests proved to be diagnostic: after failing previous conservative care including PT and interventional pain management, a triple neurectomy was successful in relieving long-standing complaints and in allowing a return to exercise. Although these comments do not directly seem to apply to the case series in which all patient had a very successful outcome, I present this differential diagnostic possibility and the associated palpatory tests for the benefit of the small percentage of clients who present with similar findings but who do not make significant gains with PT.
Jerry Hesch, MHS, PT
Reference
1. Pinto D, Cleland J, Palmer J, Eberhart S. Management of low back pain: A case series illustrating the pragmatic combination of treatment-and
mechanism-based classification systems. J Manual Manipulative Ther 2007;15:111–122.
My Published Letter to the Editor regarding the article: Low Back Pain and Leg Symptoms: Another Differential Diagnostic Possibility
Letter published online: J Man Manip Ther. 2007; 15(3): E71–E72.
Pinto D, Cleland J, Palmer J, Eberhart S. Management of low back pain: A case series illustrating the pragmatic combination of treatment-and mechanism-based classification systems. J Manual Manipulative Ther 2007;15:111–122
This letter is in response to the recent article by Pinto et al1. The authors are to be congratulated on a very successful presentation of a case series. My comments are directed at some of the symptoms of patients 1 and 2, because they apply to other clients seen in a typical PT clinic. Patient 1 had chief complaints of low back and groin pain, whereas patient 2 reported left buttock pain and pins and needles down the left medial leg. The examination addressed many things, including testing for altered sensation to pinprick in the lower extremity dermatomes. However, I would like to suggest that for these and similar patients the inclusion of the lower abdominal wall in the sensory screen might be of value because of the possibility of a para-inguinal neuropathy. A recent male patient had experienced painful traumatically induced neuropathies of 33 years duration involving the accessory obturator, ilioinguinal, and iliohypogastric nerves and the genital portion of the genitofemoral and vesicular portion of the hypogastric nerves. All these nerves are involved in the sensory innervation of the lower abdominal wall and genito-urinary region, but may also cause hypersensitivity in the groin and paraesthesiae and/or dysaesthesia in the medial calf (saphenous portion of femoral sensory nerve). Sensory alterations in the saphenous distribution of the medial leg are at times misinterpreted due to its overlap with the S1 dermatome. In this patient a reduced sensation to pin prick was not present but rather sensory hyperaesthesia and allodynia were noted in the lower abdominal and lower extremity dermatomes. Of differential diagnostic importance is that the ilioinguinal and iliohypogastric nerves and the genital portion of the genitofemoral nerve can be palpated proximal to and/or within the inguinal canal. All three nerves take a primary origin from the T12-L2 nerve roots. The ilioinguinal nerve innervates the inguinal ligament, the anterior inner wall of the inguinal canal, and the spermatic cord and can be palpated within and outside the inguinal canal. The iliohypogastric nerve supplies the roof of the inguinal canal and innervates superficial skin. The genital portion of the genitofemoral nerve—despite its very small diameter—can be screened by applying pressure onto the floor of the inguinal canal, located at the top of the pubic bone just medial to the spermatic cord. There is however, considerable variation in the pathway of this nerve. These palpatory tests have not been described in the literature. In the case of my recent patient, these intra-inguinal palpatory tests proved to be diagnostic: after failing previous conservative care including PT and interventional pain management, a triple neurectomy was successful in relieving long-standing complaints and in allowing a return to exercise. Although these comments do not directly seem to apply to the case series in which all patient had a very successful outcome, I present this differential diagnostic possibility and the associated palpatory tests for the benefit of the small percentage of clients who present with similar findings but who do not make significant gains with PT.
Jerry Hesch, MHS, PT
Reference
1. Pinto D, Cleland J, Palmer J, Eberhart S. Management of low back pain: A case series illustrating the pragmatic combination of treatment-and
mechanism-based classification systems. J Manual Manipulative Ther 2007;15:111–122.
Traumatic Inguinal Neuropathies Article by Jerry Hesch, MHS, PT
"Necessity is the Mother of Invention." In diagnosing my own parainguinal neuropathies, I developed a palpatory evaluation of the nerves which are accessible within the inguinal canal. This type of injury is very difficult to diagnose and it can be brutal in limiting physical activities, enhancing severe insomnia, etc. I had a very successful surgery clipping the ilioinguinal, iliohypogastric and genital portion of genitofemoral nerves in July, 2007. The initial injury occurred when I fractured my pelvis in 1974 from a severe motorcycle wreck, and sustained internal bleeding. The fracture healed in time, the painful neuropathies did not. In fact, they became increasingly symptomatic in the past few years.
My family physician performed a digital examination of my inguinal canal in order to rule out hernia, and it was remarkably painful. It apparently is not normative to screen the inguinal canal for neuropathies, per extensive literature search. I reviewed the anatomy of the region, in fact did so several times over the course of a year or more. I did literature searches and looked in textbooks on many medical disciplines such as general surgery, ob-gyn, sports medicine, neurology, orthopedics, PM&R, PT, neurosurgery, etc. Nowhere did I find any discipline that palpated the nerves within the inguinal canal. The 3 nerves that can be palpated within the inguinal canal are the ilioinguinal, the iliohypogastric and the genital portion of the genitofemoral. If not directly, you can palpate portions of structures that are innervated by the afore mentioned nerve. The iliohypogastric is palpated by pinching the roof of the canal with internal index finger and eternal thumb pad. For the sake of being thorough, pinch the "top" of the roof and then repeat with slight anterior and then slight posterior migration. I then palpated the ilioinguinal which is contained in the anterior wall. Same technique regarding thumb and index finger, and migrate slightly superiorly and slightly inferiorly. Then palpate the spermatic cord, as the ilioinguinal nerve wraps around it and innervates it. It is a thick ropey like structure that is very distinct. In females the analogue is the round ligament, which does not descend very far, and the canal in females is much narrower and therefore much stronger. We don't think of our insides as having the same touch receptors as we do on our skin, yet this is an area of the body that is internal and does in fact have sensory nerves. I firmly believe that inguinal/lower abdominal neuropathies are under-diagnosed and therefore under treated.
I have explained this method of palpation to 5 pain specialists and they all seemed unfamiliar with the concept, though one asked me to show him, and I did. The literature seems to encourage evaluation via sensory palpation of the skin over the lower abdomen. However; there is considerable sensory overlap, and my sense of light touch was NOT impaired. It was however, hypersensitive, provoking dyesthesia and allodynia. I can press on a spot just above the femoral triangle and feel referral into medial calf (often confused with S1 dermatome) which is in fact terminal sensory innervation of the femoral nerve (T12-L1-L2-L3) give or take a segment. I also feel enhancing warmth in my foot in a glove-distribution, most likely a sympathetic phenomenon. When very symptomatic I had enhanced sensitivity and dysesthesia in the anterior thigh and enhancing in the obturator distribution. Otherwise the neuropathies involve the intra-canal nerves. Once I was able to define the problem, I was able to seek care. Injection provided significant, albeit short-lived relief. Pulsed cold ablation provided some help, lidocaine patches and external creams seemed futile. Application of ice and heat provided some benefit. Somewhat helpful though has been the medication Pregabalin (Lyrica). However, activity level remained severely limited.
The inguinal ligament can be palpated externally as it is innervated by the ilioinguinal nerve. There is a small patch of skin lateral to the ASIS which receives a sensory branch from the inguinal nerve. I prefer light scratching of the skin here and throughout the lower abdomen as it seems more provocative than light touch. Furthermore, I have noted a delay between light touch and processing any sensory abnormality, such that quick testing of multiple areas could easily overlook a subtle yet pathological response. My 33 year old left abdominal neuropathies are so ingrained that if I scratch anywhere on the opposite right abdominal wall I provoke the left-sided distal dysesthesias. The pain from para-inguinal neuropathies can be very vague, yet severe. It can be very hard to isolate them and medical providers do not routinely screen for them internally. My self-diagnosis took ~30 years! It is relevant for screening in persons with unresolved pelvic/SI/low back pain. I hope to contribute to the knowledge base on this topic. It can be a very devastating type of pain, so much so, that some feel suicidal (I read that on a web site related to a pressure evaluation device and a surgical technique to release scar tissue, developed by a plastic surgeon). As it is difficult to diagnose, people may suffer profoundly. The vague (albeit severe) nature of the deep pain does not end itself to clear communication from client to practitioner. The abdominal muscles are fundamental to standing, sitting, lifting, bending, twisting, etc. Thus many ADL's can enhance pain and suffering. The old expression "kicked in the groin" speaks of a very tender area, speaks of significant acute pain, but language fails to communicate what it is to have this for 3 decades. The pain can be perceived by the person as being very deep and ill defined. However, it misses the clinical radar. I asked the J____M_______ neuropathy center if they would be interested in researching it, and they said no. Probably because it affects only a minority of the population, whereas other neuropathies such as diabetic neuropathy are funded. When I evaluated myself with intra-inguinal palpation I was certainly quite tender at several structures. However, when coming off the spermatic cord at the entrance to the canal, onto the top of the pubic bone (floor of canal) where the genital portion of the genitofemoral nerve is located, I cannot say that I could actually feel the nerve, however I did feel an abrupt "electric ice pick" severe lancinating pain. Thus, I suspect that in spite of the nerves very narrow diameter at that location, I was probably directly on it. The accessory obturator nerve is external to the canal, but can be palpated over the mid region of the top of the obturator canal.again, you may not actually feel the nerve due to small fiber diameter, but if symptomatic, rubbing medial to lateral, one should easily reproduce pain, abnormal sensation. I look forward to developing this as a formal case study with an extensive reference of the medical literature. Thankfully, I am significantly improved.
My family physician performed a digital examination of my inguinal canal in order to rule out hernia, and it was remarkably painful. It apparently is not normative to screen the inguinal canal for neuropathies, per extensive literature search. I reviewed the anatomy of the region, in fact did so several times over the course of a year or more. I did literature searches and looked in textbooks on many medical disciplines such as general surgery, ob-gyn, sports medicine, neurology, orthopedics, PM&R, PT, neurosurgery, etc. Nowhere did I find any discipline that palpated the nerves within the inguinal canal. The 3 nerves that can be palpated within the inguinal canal are the ilioinguinal, the iliohypogastric and the genital portion of the genitofemoral. If not directly, you can palpate portions of structures that are innervated by the afore mentioned nerve. The iliohypogastric is palpated by pinching the roof of the canal with internal index finger and eternal thumb pad. For the sake of being thorough, pinch the "top" of the roof and then repeat with slight anterior and then slight posterior migration. I then palpated the ilioinguinal which is contained in the anterior wall. Same technique regarding thumb and index finger, and migrate slightly superiorly and slightly inferiorly. Then palpate the spermatic cord, as the ilioinguinal nerve wraps around it and innervates it. It is a thick ropey like structure that is very distinct. In females the analogue is the round ligament, which does not descend very far, and the canal in females is much narrower and therefore much stronger. We don't think of our insides as having the same touch receptors as we do on our skin, yet this is an area of the body that is internal and does in fact have sensory nerves. I firmly believe that inguinal/lower abdominal neuropathies are under-diagnosed and therefore under treated.
I have explained this method of palpation to 5 pain specialists and they all seemed unfamiliar with the concept, though one asked me to show him, and I did. The literature seems to encourage evaluation via sensory palpation of the skin over the lower abdomen. However; there is considerable sensory overlap, and my sense of light touch was NOT impaired. It was however, hypersensitive, provoking dyesthesia and allodynia. I can press on a spot just above the femoral triangle and feel referral into medial calf (often confused with S1 dermatome) which is in fact terminal sensory innervation of the femoral nerve (T12-L1-L2-L3) give or take a segment. I also feel enhancing warmth in my foot in a glove-distribution, most likely a sympathetic phenomenon. When very symptomatic I had enhanced sensitivity and dysesthesia in the anterior thigh and enhancing in the obturator distribution. Otherwise the neuropathies involve the intra-canal nerves. Once I was able to define the problem, I was able to seek care. Injection provided significant, albeit short-lived relief. Pulsed cold ablation provided some help, lidocaine patches and external creams seemed futile. Application of ice and heat provided some benefit. Somewhat helpful though has been the medication Pregabalin (Lyrica). However, activity level remained severely limited.
The inguinal ligament can be palpated externally as it is innervated by the ilioinguinal nerve. There is a small patch of skin lateral to the ASIS which receives a sensory branch from the inguinal nerve. I prefer light scratching of the skin here and throughout the lower abdomen as it seems more provocative than light touch. Furthermore, I have noted a delay between light touch and processing any sensory abnormality, such that quick testing of multiple areas could easily overlook a subtle yet pathological response. My 33 year old left abdominal neuropathies are so ingrained that if I scratch anywhere on the opposite right abdominal wall I provoke the left-sided distal dysesthesias. The pain from para-inguinal neuropathies can be very vague, yet severe. It can be very hard to isolate them and medical providers do not routinely screen for them internally. My self-diagnosis took ~30 years! It is relevant for screening in persons with unresolved pelvic/SI/low back pain. I hope to contribute to the knowledge base on this topic. It can be a very devastating type of pain, so much so, that some feel suicidal (I read that on a web site related to a pressure evaluation device and a surgical technique to release scar tissue, developed by a plastic surgeon). As it is difficult to diagnose, people may suffer profoundly. The vague (albeit severe) nature of the deep pain does not end itself to clear communication from client to practitioner. The abdominal muscles are fundamental to standing, sitting, lifting, bending, twisting, etc. Thus many ADL's can enhance pain and suffering. The old expression "kicked in the groin" speaks of a very tender area, speaks of significant acute pain, but language fails to communicate what it is to have this for 3 decades. The pain can be perceived by the person as being very deep and ill defined. However, it misses the clinical radar. I asked the J____M_______ neuropathy center if they would be interested in researching it, and they said no. Probably because it affects only a minority of the population, whereas other neuropathies such as diabetic neuropathy are funded. When I evaluated myself with intra-inguinal palpation I was certainly quite tender at several structures. However, when coming off the spermatic cord at the entrance to the canal, onto the top of the pubic bone (floor of canal) where the genital portion of the genitofemoral nerve is located, I cannot say that I could actually feel the nerve, however I did feel an abrupt "electric ice pick" severe lancinating pain. Thus, I suspect that in spite of the nerves very narrow diameter at that location, I was probably directly on it. The accessory obturator nerve is external to the canal, but can be palpated over the mid region of the top of the obturator canal.again, you may not actually feel the nerve due to small fiber diameter, but if symptomatic, rubbing medial to lateral, one should easily reproduce pain, abnormal sensation. I look forward to developing this as a formal case study with an extensive reference of the medical literature. Thankfully, I am significantly improved.
New Intra-Inguinal Peripheral Neuropathy Test
PRESENTED AT 7TH INTERDISCIPLINARY WORLD CONGRESS ON LOW BACK AND PELVIC PAIN:
This case describes a novel internal sensory evaluation of three intra/para-inguinal* nerves, in order to screen for painful, traumatic, peripheral neuropathies (PN). Although rare, a few peripheral sensory nerves innervate both superficial and deep regions of the body and are accessible digitally. This case describes severe, progressive, traumatic para-inguinal PN. Pain in the inguinal region has frequently been described as a component of sacroiliac joint dysfunction (SIJD). Perhaps the earliest reference is the description of Baer’s point (early 1900’s). Baer’s point is a tender point in the lower abdominal wall, which is a location of pain referral, perhaps from the anterior capsule of the SIJ, or the iliopsoas muscle. Clinician’s should be mindful of other medical conditions that share myotomal, dermatomal and peripheral nerve sensory regions, with SIJD referred pain. For example, McBurney’s point is oftentimes contrasted with Baer’s point, the former indicative of gall bladder disease. Other medical conditions with lower abdominal/inguinal pain are: inguinal hernia, psoas abcess, micro or macro tears of the external oblique abdominal tendon, iliopsoas injury, traumatic PN, osteitis pubis, sportsman’s hernia, referred hip pain, etc., among others. The overlapping dermatomes and sensory nerves makes for considerable complexity, further complicated by the fact that this region has contributions from the T12, L1, L2, L3 levels, and medially; the S2-3-4 levels from the pudendal nerve distribution.
In response to a very painful digital exam to rule out inguinal hernia, this author was astonished to recognize immediately and empirically, that the problem was one of a traumatic deep and superficial PN, involving the ilioinguinal, iliohypogastric and genitofemoral nerves (see Fig 3, 4). This insight was antithetical to a long held belief, perhaps reinforced by inadequate diagnostic work up and failed treatment of 32 years duration. Attempts at self treatment were equally vexatious, and part of the sensory interpretation was that of SIJ and symphysis pubis instability. It seemed that the injury was a non-treatable damage to the sacral plexus, or ganglion (see fig 5), with both deep and superficial expression. However, the internal hernia screen defined a very specifically localized tangible, tactile-available, intra-inguinal PN pathology. This serendipitous discovery greatly enhanced the author’s optimism for recovery. The condition had worsened over time in response to several traumatic events and removal of bone from the anterior ilium proximal to the ASIS, which has been reported to contribute to a lateral sensory branch ilioinguinal neuropathy.[1] Diagnosis had been elusive, in spite of consultation with many clinicians and specialists over the course of 32 years. These nerves are formed in very close proximity of the psoas muscle and biomechanical dysfunction of the pelvis and SIJ, enhanced the pain. For a period of time, addressing the movement dysfunctions of the pelvis and SIJ helped to reduce PN pain, though over time it became progressively worse, and ultimately became non-responsive to conservative care. This pain is profound due to the significant sensitivity of the region, which innervates the inguinal ligament, spermatic cord, symphysis pubis and proximal skin, and partial innervation of the testicle. Furthermore, there is no motion that does not involve the abdominal wall, thus pain is unyielding. Even turning in bed would awaken one, thus interfering with restorative sleep.
A very successful surgical intervention was performed; a triple neurectomy. This was superficial and it was performed proximally to Baer’s point, where the 3 para-inguinal nerves enter the lesser opening of the inguinal canal. The three year post-operative status boasts continued significant improvement with no regrets, and with occasional mild, proximal deep abdominal discomfort only, and occasional peripheral paraesthesia in the distribution of the femoral portion of the genitofemoral nerve. Noteworthy is the fact that the denervation is not a hinderance to ADL’s, or normative function. The pelvic and SIJD is now much more manageable with respect to movement dysfunction, pain, and stability.
Muscle guarding associated with a para-inguinal PN can mimic SIJD with a symptomatic Baer’s Point. Clinicians are encouraged to consider other proximal causes when screening for SIJD, and to consider screening the superficial and deep para-inguinal nerves when in the presence of the apparent pelvic, symphysis pubis and SIJD; in which pain control of the inguinal region is vexaciously elusive. It is hoped that this novel diagnostic tool will prevent protracted suffering, as successful surgical techniques are indeed available, yet not commonly appreciated by many medical practitioners. It is also hoped that the www.YouTube.com video titled: Iilioinguinal Iliohypogastric and Genitofemoral Nerve Eval, will assist in these goals. The author scoured the literature and a major textbook on hernias to determine whether or not the novel test was already in use. Communication with a well published expert on hernia surgery and para-inguinal neurectomy supported the novel nature of the test, stating “To my knowledge there is no scientific publication in the surgical literature regarding your approach.”[2] This author ponders whether or not deep somatic representation on a pain drawing would more readily communicate these types of pathologies. To that end work is being conducted to develop a 3-dimensional pain drawing; to be announced.
*Sometimes the genital portion of the genitofemoral nerve bypasses the inguinal canal, other times it accompanies the pathway of the ilioinguinal and iliohypogastric nerves throughout the inguinal canal. Much variation within these three nerves is the norm. If a peripheral neuropathy of these nerves lies proximal and external to the inguinal canal, it is appropriately referred to as para-inguinal, otherwise referred to as intra-inguinal.
1Greenman PE. Principles of Manual Medicine. Baltimore, MD: Williams & Wilkins; 1989:225-270.
2 Hesch J. Course workbook: The Hesch Method of Treating Sacroiliac Joint Dysfunction: Integrating the SI, Symphysis Pubis, Pelvis, Hip, and Lumbar Spine. Hesch Institute,Henderson, NV USA 2010.
3 Hesch J. Evaluating sacroiliac joint play with spring tests. J ObGyn PT. 1996;20:3 4-7.
4 Olson L. Effects from the Hesch Method Pelvic Mobilization on Lumbar flexion, Straight Leg Raise Performance, and Standing Pelvic Inclination Angles in Patients With Low Back Pain. Chicago, Il: Finch University of Health Sciences/The Chicago Medical School; 1998, Thesis.
5 Hesch J. The Hesch Method Advanced Course: Distance Learning. Hesch institute 2010 Henderson, Nevada, USA.
6 Hesch J. Evaluation and treatment of the most common pattern of sacroiliac joint dysfunction: In: Movement, Stability & Low Back Pain: The Essential Role of the Pelvis. Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R, eds. London:Churchill Livingstone 1997: chap. 42; 535-552.
7 http://erikdalton.com/article_LowBack_Piriformis_SIjointpain.htm
8 Swenson MR, Rothrock JF. Ilioinguinal neuropathy after iliac crest biopsy. Mayo Clin Proc. 1986 Jul;61(7):604.
9Parviz K.Amid, MD, FACS, FRCS. Personal communication, February 28, 2009.
This case describes a novel internal sensory evaluation of three intra/para-inguinal* nerves, in order to screen for painful, traumatic, peripheral neuropathies (PN). Although rare, a few peripheral sensory nerves innervate both superficial and deep regions of the body and are accessible digitally. This case describes severe, progressive, traumatic para-inguinal PN. Pain in the inguinal region has frequently been described as a component of sacroiliac joint dysfunction (SIJD). Perhaps the earliest reference is the description of Baer’s point (early 1900’s). Baer’s point is a tender point in the lower abdominal wall, which is a location of pain referral, perhaps from the anterior capsule of the SIJ, or the iliopsoas muscle. Clinician’s should be mindful of other medical conditions that share myotomal, dermatomal and peripheral nerve sensory regions, with SIJD referred pain. For example, McBurney’s point is oftentimes contrasted with Baer’s point, the former indicative of gall bladder disease. Other medical conditions with lower abdominal/inguinal pain are: inguinal hernia, psoas abcess, micro or macro tears of the external oblique abdominal tendon, iliopsoas injury, traumatic PN, osteitis pubis, sportsman’s hernia, referred hip pain, etc., among others. The overlapping dermatomes and sensory nerves makes for considerable complexity, further complicated by the fact that this region has contributions from the T12, L1, L2, L3 levels, and medially; the S2-3-4 levels from the pudendal nerve distribution.
In response to a very painful digital exam to rule out inguinal hernia, this author was astonished to recognize immediately and empirically, that the problem was one of a traumatic deep and superficial PN, involving the ilioinguinal, iliohypogastric and genitofemoral nerves (see Fig 3, 4). This insight was antithetical to a long held belief, perhaps reinforced by inadequate diagnostic work up and failed treatment of 32 years duration. Attempts at self treatment were equally vexatious, and part of the sensory interpretation was that of SIJ and symphysis pubis instability. It seemed that the injury was a non-treatable damage to the sacral plexus, or ganglion (see fig 5), with both deep and superficial expression. However, the internal hernia screen defined a very specifically localized tangible, tactile-available, intra-inguinal PN pathology. This serendipitous discovery greatly enhanced the author’s optimism for recovery. The condition had worsened over time in response to several traumatic events and removal of bone from the anterior ilium proximal to the ASIS, which has been reported to contribute to a lateral sensory branch ilioinguinal neuropathy.[1] Diagnosis had been elusive, in spite of consultation with many clinicians and specialists over the course of 32 years. These nerves are formed in very close proximity of the psoas muscle and biomechanical dysfunction of the pelvis and SIJ, enhanced the pain. For a period of time, addressing the movement dysfunctions of the pelvis and SIJ helped to reduce PN pain, though over time it became progressively worse, and ultimately became non-responsive to conservative care. This pain is profound due to the significant sensitivity of the region, which innervates the inguinal ligament, spermatic cord, symphysis pubis and proximal skin, and partial innervation of the testicle. Furthermore, there is no motion that does not involve the abdominal wall, thus pain is unyielding. Even turning in bed would awaken one, thus interfering with restorative sleep.
A very successful surgical intervention was performed; a triple neurectomy. This was superficial and it was performed proximally to Baer’s point, where the 3 para-inguinal nerves enter the lesser opening of the inguinal canal. The three year post-operative status boasts continued significant improvement with no regrets, and with occasional mild, proximal deep abdominal discomfort only, and occasional peripheral paraesthesia in the distribution of the femoral portion of the genitofemoral nerve. Noteworthy is the fact that the denervation is not a hinderance to ADL’s, or normative function. The pelvic and SIJD is now much more manageable with respect to movement dysfunction, pain, and stability.
Muscle guarding associated with a para-inguinal PN can mimic SIJD with a symptomatic Baer’s Point. Clinicians are encouraged to consider other proximal causes when screening for SIJD, and to consider screening the superficial and deep para-inguinal nerves when in the presence of the apparent pelvic, symphysis pubis and SIJD; in which pain control of the inguinal region is vexaciously elusive. It is hoped that this novel diagnostic tool will prevent protracted suffering, as successful surgical techniques are indeed available, yet not commonly appreciated by many medical practitioners. It is also hoped that the www.YouTube.com video titled: Iilioinguinal Iliohypogastric and Genitofemoral Nerve Eval, will assist in these goals. The author scoured the literature and a major textbook on hernias to determine whether or not the novel test was already in use. Communication with a well published expert on hernia surgery and para-inguinal neurectomy supported the novel nature of the test, stating “To my knowledge there is no scientific publication in the surgical literature regarding your approach.”[2] This author ponders whether or not deep somatic representation on a pain drawing would more readily communicate these types of pathologies. To that end work is being conducted to develop a 3-dimensional pain drawing; to be announced.
*Sometimes the genital portion of the genitofemoral nerve bypasses the inguinal canal, other times it accompanies the pathway of the ilioinguinal and iliohypogastric nerves throughout the inguinal canal. Much variation within these three nerves is the norm. If a peripheral neuropathy of these nerves lies proximal and external to the inguinal canal, it is appropriately referred to as para-inguinal, otherwise referred to as intra-inguinal.
1Greenman PE. Principles of Manual Medicine. Baltimore, MD: Williams & Wilkins; 1989:225-270.
2 Hesch J. Course workbook: The Hesch Method of Treating Sacroiliac Joint Dysfunction: Integrating the SI, Symphysis Pubis, Pelvis, Hip, and Lumbar Spine. Hesch Institute,Henderson, NV USA 2010.
3 Hesch J. Evaluating sacroiliac joint play with spring tests. J ObGyn PT. 1996;20:3 4-7.
4 Olson L. Effects from the Hesch Method Pelvic Mobilization on Lumbar flexion, Straight Leg Raise Performance, and Standing Pelvic Inclination Angles in Patients With Low Back Pain. Chicago, Il: Finch University of Health Sciences/The Chicago Medical School; 1998, Thesis.
5 Hesch J. The Hesch Method Advanced Course: Distance Learning. Hesch institute 2010 Henderson, Nevada, USA.
6 Hesch J. Evaluation and treatment of the most common pattern of sacroiliac joint dysfunction: In: Movement, Stability & Low Back Pain: The Essential Role of the Pelvis. Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R, eds. London:Churchill Livingstone 1997: chap. 42; 535-552.
7 http://erikdalton.com/article_LowBack_Piriformis_SIjointpain.htm
8 Swenson MR, Rothrock JF. Ilioinguinal neuropathy after iliac crest biopsy. Mayo Clin Proc. 1986 Jul;61(7):604.
9Parviz K.Amid, MD, FACS, FRCS. Personal communication, February 28, 2009.
Inguinal Neuropathy Test Videos
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