Hesch Seminars and Physical Therapy, LLC 1609 Silver Slipper Ave Henderson, NV 89002 USA Email: jerryhesch@cox.net Phone 702-558-6011 Pacific Time 9:00am-8:00pm

 

 

This is an email I sent recently to a renowned hernia surgeon. His reply is below. I am certainly delighted with his reply.

 

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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.

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     "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.