Re: Superior cluneal nerve entrapment

[Guest guest]

Hi Bonnie and All,

Here is the basic information I have from Martha. I know she doesn't

want to get anyones hopes up ...this may be a " dead end " , but because

we all know how many of us are having ongoing SI area issues.... on

the chance that it will pan out or at least further the knowledge (or

just underscore the fact that everything related to this surgery

is " newish " and things are still changing and there is hope) I will

share what Martha shared with me.

As some of you may recall, she is about 3 years from revision with

DrBridwell and she has had that persistent pain over her left iliac

crest with walking still a burning that made it difficult to walk as

much as she needs to in order to get through her busy day. Anyway,

Dr. Mardjetko (who started out as her daughters doctor and now cares

for her as well since he is closer to home and Bridwell's friend, and

who took out her iliac screws in Nov.) highly recommended this pain

management doctor in the same building as he, and it took her quite

awhile to get into him. He's triple board certified in Pain

Management, Anesthesiology and Internal Medicine. She really like

this guy was very thorough, plus when he was an anesthesiologist at

Rush, he saw many spine surgeries, including revisions, so he's

familiar with what we have done. Anyway, long and short of it is

that he felt that this was nerve pain, and had her see this

specialist in musculokeletal ultrasounds, to look at scar

tissue/adhesions that may be causing nerve entrapment.

She had this done early in August, and the doctor who did the

ultrasound found superior cluneal nerve entrapment. This nerve goes

right over the iliac crest. He said that ultrasounds show this much

better than MRI or CT scans. Next she had a diagnostic injection

with lidocaine of that superior cluneal nerve to see if when she

walked the pain was gone. If it is gone, then they schedule for

radio-frequency of the nerve to destroy it.

Martha talked with Dr. Mardjetko about the procedure and he advised

her to go for it. He said that it will be such a learning experience

for Dr. Bridwell and for him, if after all this time it turns out

that the pain was from that nerve entrapment, and not the iliac

screws. He said that he could go in surgically and free up that

nerve or destroy it, but if they can do it using radio-frequency

instead of an incision and surgery, then that's the way to go. Dr.

M. seemed to be really interested in what is going on here, as not

all patients are relieved of their pain after iliac screws are

removed.

Then, apparently at Marthas visit Drs. Konowitz (the pain guy) and

(the ultrasound guy) talked out the plan and changed it a

little bit, so what she actually had done was a little different than

what Dr. had suggested at the last ultrasound. They decided to

use the ultrasound guiding them and the lidocaine needle to go in

and " pulse " or break up the scar tissue around that nerve. Konowitz

also decided that instead of jumping to the radiofrequency treatment

right now, he'd put in some steroid to keep the inflammation down

around the nerve while the area is healing where he broke up the

tissue. So, he said that she would get more sore over the ensuing

several days from the bit of trauma that he caused in that area, and

then hopefully, she should get some relief as the nerve is freed up.

If not, then they can see about the RF treatment.

As of my last corespondence with Martha, which was about 4 weeks ago

she was feeling like it was working ...as the swelling was subsiding

she was noticing a big difference. She told me on the phone that the

notion that adhesions can form around nerves as you heal from this

surgery can't really be determined except by this musculokeletal

ultrasounds method Dr is using and its pretty new...he travels

around the country teaching the technique.

I know Martha doesn't want any false hopes...and I know she doesn't

get here to this site all that much these days...but hopefully she

will chime in and update her progress soon or I will get in touch and

let you know how she is doing now that almost a month has passed. I

am sure if you want to contact her directly she will be glad to tell

you what she can.

Of course, you can also seach under those key words and you will get

a lot on info too! Some info is below.

Take Care,

Cam

Here is the bio of Dr, the Musculoskeletal Sonologist. Martha

says he is in Chicago a few days a month and lectures all over the

country..I think he is based in CA:

http://mskus.com/allpages/aboutus.htm

and here is an article Martha sent to kind of explain the technique

of breaking up of scar tissue using ultrasound/needle technique and

this is one that I found that explains it, using it for a variety of

things like tennis elbow, etc. But, you'll get the general idea on

the technique she had done:

Contact: Baxt

jeffrey.a.baxt@...

215-955-5507

Jefferson University

Jefferson researchers find that ultrasound helps in treating tennis

elbow and other tendon problems

Minimally-invasive ultrasound-guided needle therapy may help treat a

wide variety of sports injuries, said Jefferson radiologist

Researchers at Jefferson University Hospital have found that

they can successfully treat chronic tendon problems such as " tennis

elbow, " " jumper's knee " and Achilles tendon, with the help of

diagnostic ultrasound, as an alternative to surgery.

The ultrasound is used to better visualize abnormal tendons, identify

areas of the tendon containing scar tissue and determine if the scar

tissue is infiltrated with calcification, explained radiologist Lev

N. Nazarian, M.D., professor of Radiology, Jefferson Medical College

of Jefferson University, Philadelphia, one of the

investigators. Then needle therapy is applied to treat the problem.

The study is co-authored by McShane, M.D., clinical assistant

professor of Family Medicine, Jefferson, and sports medicine

specialist at the Rothman Institute at Jefferson, who performs the

procedure with Dr. Nazarian.

Many of the 400 patients who participated in the trial were able to

resume athletic and other activities after 12 weeks, Dr. Nazarian

said. " These are small abnormalities that a surgeon wouldn't touch,

but can still cause considerable symptoms, " the Jefferson radiologist

said. " It's the kind of problem that falls between the cracks, so to

speak, when it come to treatment. This procedure provides effective

treatment to patients who may not have been able to get relief

before, with minimal disruption to a patient's life. "

The study's findings will be presented at the 88th Scientific

Assembly and Annual Meeting of the Radiological Society of North

America (RSNA) on Wed., Dec. 4, in Chicago. The study is also

authored by Jefferson Family Medicine/Sports Medicine specialist Marc

I. Harwood, M.D., of the Rothman Institute at Jefferson.

Athletes and non-athletes alike are prone to chronic tendon problems

that can be caused by a wide variety of activities and can range in

severity from mildly annoying to completely debilitating.

" Tendons are sinewy, somewhat elastic connective tissue that attach

muscle to bones, " Dr. Nazarian said. " They are vulnerable to wear and

tear, particularly as we get older. Over time, tendons become weaker

than normal and become subject to tiny breaks and tears in their

fibers. When the tendon is overused, strained, or injured, some of

the tendon tissue is replaced with scar tissue instead of normal

elastic tendon tissue.

" Scar tissue is not elastic, " he said. " It is thick and dense and it

occurs right at the location where the tendon attaches to the bone.

So when the muscle contracts, the normal tendon that is remaining

pulls on this now dense, non-elastic tissue that then pulls against

the bone. And that interface causes pain. "

Treatments to date for chronic tendon problems have been imperfect in

that they either do not fully remedy the problem-- or they entail

major orthopaedic surgery and long recovery periods, said Dr.

Nazarian.

The ultrasound-guided hypodermic needle procedure can be used to

treat a variety of problems including:

Easing inflammation by injecting corticosteroid at the site

Smoothing out bone adjacent to the tendon

Eliminate calcifications rubbing against the tendon

" Roughing up " tissue around small tears in the tendon to promote

healing

" Once we see the abnormality on the ultrasound, we can make a

diagnosis right away and tell exactly what is wrong. Additionally, we

can treat the problem immediately, " said Dr. Nazarian said.

Traditionally, physicians have used magnetic resonance imaging (MRI)

to assess problem areas. But the researchers found that

ultrasonography provides a more accurate look.

" In fact, in many ways, ultrasonography is preferable to MRI. It's

quicker, less expensive, and better tolerated by patients, " Dr.

Nazarian said. " Furthermore, because the ultrasound examination is

performed in so-called 'real-time,' any abnormalities can be directly

correlated with the physical examination. "

The study found that approximately 65 percent of the participants

(151 males, 155 females, ages 13-82) reported improvement. They

suffered from various tendon, muscle and ligament injuries, including

tennis elbow, golfer's elbow, jumper's knee, hamstring and rotator

cuff injuries and Achilles tendon problems. They had not responded to

more conservative therapies such as medication, bracing, physical

therapy or rest, and had been living with symptoms from three months

to 15 years.

To treat the identified problem, local anesthesia is administered.

Then, with the guidance of ultrasound, a needle is inserted down to

the areas that contain scar tissue. The needle tip breaks up scar

tissue and any calcifications.

Depending on the exact problem being treated, the procedure is often

completed with an injection of cortisone-like medication into the

area. " The procedure encourages blood vessels to enter the area and

enables the body to dissolve the scar tissue and lay down new,

healthier tissue. After the procedure, stretching and physical

therapy encourage this tissue to become more elastic and lengthened,

enabling the tendon to function more normally, " the Jefferson

radiologist said.

[Guest guest]

Hi Cam,

Thank you so much. I had tried to do some online research when you first mentioned this, but I found nothing and now I realize I was using the wrong search terms. I'll do more of my own research as you suggested, but am grateful for the info you wrote about. Eye opening. I will share this with my pain doc when I see him next week. I'll let you know what he says.

Bonnie