NEURAL PROLOTHERAPY LOW BACK/HIP/GROIN

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1 NEURAL PROLOTHERAPY LOW BACK/HIP/GROIN LIZA M. SMIGEL, MD November 9, 2013

2 Chronic Constriction Injuries (CCIs) These are key areas to inject

3 Neural Prolotherapy Steps Identify area of pain. Ask patient to show with both hands. Feel for warmth/swelling/tissue texture changes/ lumps Use neural atlas to help identity nerves. Identify the CCIs Inject the painful CCIs about ¼ to 1/2 inch deep. Instruct patient to move around and point to any painful area left that remain painful. Inject any painful CCI s left Procedure complete once patient is painfree.

4 HOW OFTEN DO YOU TREAT? Treatment is given weekly, then reduced to biweekly,then monthly On average, 4-6 treatments are needed for cure.

5 INSTRUCTIONS TO PATIENTS PAIN RELIEF WILL LAST 1-4 DAYS,THEN WILL RECUR BUT NOT AS SEVERE. IN SOME,IT MAY INC MORE THAN YOU WILL HAVE GOOD DAYS AND BAD DAYS MONITOR FOR PAIN THAT HAS RECURRED OR AREAS THAT WERE MISSED. MONITOR FOR NEW AREAS SINCE THE TREATMENT. EXERCISE TO TOLERANCE. NOT NECESSARY TO STOP NSAIDS OR OTHER INFLAMMATORIES DUE TO RISK OF REBOUND PAIN, INSTEAD WEAN SLOWLY. USE OF VITAMIN D SUPPLEMENTS AND TRANSDERMAL CREAM /PROLOPHORESIS BETWEEN TREATMENTS ARE HELPFUL.

6 CONDITIONS TREATED Herniated disc Spinal Stenosis Facet Syndrome Chronic nonspecific low back pain SI joint pain Restless bu^ syndrome Coccydynia Piriformis syndrome Complex Regional Pain Syndrome (CRPS) low back Trochanteric bursibs Illio Tibial Tract pain CECS erector spine muscles Gluteus Medius/ Maximus dysfuncbon Labssimus Dorsi pain?discogenic pain Hip pain

7 Gray s Anatomy Cutaneous innervabon Note: NO L 4-5 pepddergic cutaneous innervadon in the low back

8 Low Back & Hip/Groin REVIEW Cutaneous branches T Superior cluneal nerves L Illio hypogastric nerve Posterior femoral nerve (aka lesser sciabc nerve) Medial cluneal nerves Inferior cluneal nerves Lateral femoral cut nerve Anterior femoral cut nerve Ilioinguinal nerve Genitofemoral nerve Obturator nerve Abdominal Pain/ Coccygodynia

9 Superior cluneal nerves L Illio hypogastric nerve Posterior femoral nerve (aka lesser sciabc nerve) Medial cluneal nerves Inferior cluneal nerves

10 Spalteholz CLUNEAL PLEXUS Superior cluneal nerves L Cutaneous branches T Illio hypogastric nerve Illio inguinal nerve Posterior femoral nerve (aka lesser sciabc nerve) Medial cluneal nerves Lateral femoral nerve

11 INFERIOR CLUNEAL AND POSTERIOR FEMORAL CUTANOUS NERVE CCI S

12

13 Superior Cluneal Plexus (L 1 or 2 or 3) nerve entrapment The underlying cause of almost all recurrent lumbago

14 60 % 25 % 15 %

15 Superior Cluneal Nerve Entrapment -- An Overlooked Cause of Low Back Pain By Warren Hammer, MS, DC, DABCO Evaluation of soft tissue often reveals nerve entrapment distal from the spine. When this occurs, we may find that the vertebral subluxation that we think is the cause of the referred pain is not directly related to the patient's pain. Complaints of pain over the medial portion of the iliac crest and in the gluteal or lumbosacral area are often diagnosed as a facet syndrome, lower lumbar disc problem or an iliolumbar syndrome (involvement of the iliolumbar ligament). Lu et al. 1 described for the first time the anatomic relationship of the superior cluneal nerve to the posterior iliac crest and thoracolumbar fascia. They dissected 15 cadavers and found that the medial branch of the superior cluneal nerve is confined within a tunnel consisting of the thoracolumbar fascia and the superior rim of the iliac crest as the nerve passes over the iliac crest (see Figures 1A and 1B). The location is 7-8 cm lateral to the midline (sacral spinouses) on the iliac crest just lateral and superior to the posterior superior iliac spine (PSIS). "The medial branch of the superior cluneal nerve passes superficially over the iliac crest, and is covered by two layers of dense fibrous fascia." 1 References Lu J, Ebraheim NA, Huntoon M, et al. Anatomic considerabons of superior cluneal nerve at posterior iliac crest region. Clin Orth & Rel Res 1998;347: Drury BJ. Clinical evaluabon of back and leg pain due to irritabon of the superior cluneal nerve. J Bone Joint Surg 1967;49A(1):199. Abstract.

16 Roger Wyndham Mason Diagram Gluteus injury to Superior/Middle Cluneal Nerves Neuropraxia injury preceding CCI

17 Brian Shiple, M.D. Sup Cluneal Nerve Ultrasound On US they look like li^le ellipbcal balls of connecbve bssue very superficial. When you line up on them perfectly they are connected to a nerve. I put the numbing needle into the center of it and blow them up a li^le and her pain goes away instantly, then I hit them w/ D5. It's interesbng I've now seen the cluneals go thru the fibro- osseus tunnel as well as over it. There are more than one nerve in that small geographic area which then go in different direcbons just distal to it. Fascinabng stuff.

18 Upper Low Back Cutaneous branches T

19 Bifurcabon Medial and Lateral Branch

20 R Spinal nerves CCI s and relabonship to Iliac crest and osteofibrous tunnel Superior Cluneal Nerve L3 (older version)

21 Thoracic/lumbar dorsal rami branches

22 Robert Maigne: DIAGNOSIS and TREATMENT of PAIN of VERTEBRAL ORIGIN 2 nd EDITION

23 Robert Maigne: DIAGNOSIS and TREATMENT of PAIN of VERTEBRAL ORIGIN 2 nd EDITION Study involved 30 dissecbons by J Y Maigne and R Maigne Pepbdergic cutaneous branches that cross over the Iliac crest. Nociceptor class: silent mechano- insensibve C- fibers During some dissecbons J Y Maigne nobced a typical case: the nerve ramus uncovered demonstrated evidence of a severe stenosis with supra- and substenobc swelling hourglass injury

24 Osteofibrous Tunnels Cluneal Plexus & T10 IH X2 T10 L1 L3 T10 Iliohypogastric nerve(s) run in a groove over iliac crest Sup cluneal

25 Axial Thoracic & Lumbar Pain Spalteholz Cutaneous nerves of the back

26

27

28

29

30 Abdominal Pain/ Osteoibs Pubis

31 Abdominal Pain/ Osteibs Pubis iliohypogastric ilioinguinal

32 LFC IH X2 T10 LATERAL HIP Sup cluneal SUPERIOR CLUNEAL T10 ILIOHYPOGASTRIC (X2) LATERAL FEMORAL CUT (meralgia paresthedca)

33 Iliohypogastric nerve

34 ANATOMY LUMBAR PLEXUS

35 Right groin sensory innervabon according to Jean- Pierre Barral ILIOINGUINAL GENITOFEMORAL L23 ILIOHYPOGASTRIC SUBCOSTAL T12 LAT FEM CUT ANT FEM CUT OBTURATOR

36 ilioinguinal GENITOFEMORAL Spalteholz IH LFC Anterior Femoral nerve AFC Lateral femoral nerve OBUTRATOR Genitofemoral nerve Illiohypogastric nerve Cutaneous branches Obturator nerve

37 LFC ilioinguinal genitofem AFC obturator

38 Obturator Nerve Distribubon

39 Ilioinguinal & Genitofemoral Nerves ILIOHYPOGSTRIC ILIOINGUINAL GENITOFEMORAL RIC

40 Groin Pain Anterior Hip and Groin Lateral Hip Genitofemoral IH/ilioinguinal LFC ilioinguinal LFC IHX2 ilioinguinal

41 GROIN PAIN Anterior view Lateral view iliohypogastric ilioinguinal ilioinguinal genitofemoral Lat fem cut Aant fem cut

42 ILIOINGUINAL LFC AFC Pepbdergic cutaneous innervabon right PERONEAL SAPHENOUS anterior leg and hip (from Spalteholz)

43 Overview Anterior Cutaneous Femoral Nerve Right Groin and Anterior Femoral Cutaneous Nerves

44 INF CLUNEAL & POSTERIOR FEMORAL CUTANEOUS NERVES

45 Coccygodynia and Perineal Pain

46 THANK YOU FOR YOUR ATTENTION

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