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Have a patient with long term history of pain and numbess in the pelvis/groin region that can be partially relieved by arching his back in certain ways, with mid back and lower back pain. Very tender psoas muscle and pain/numbness around the anterior greater trochanter .
Patient was given a transforaminal L1-L2 nerve root block twice which reduced his pain in most areas by 90%+ for a week afterwards.
Unfortunately, patient was given a recent laminectomy at the L1-L2 for a suspected spinal cause, and has had no improvement in his pain.
Patient researched nerve entrapments and seems to believe that he has genitofemoral nerve entrapment and the symptoms seem to match up. In fact, a L1-L2 transforminal nerve root block SHOULD help someone with a pinched genitofemoral nerve. The patient seems to have pain along the entire route of the nerve from the L1-L2 facet (seems like the facet) to the psoas on downwards to the pelvis, to the scrotum.
1. If he is having pain along the entire length of the nerve, then the genitofemoral nerve is likely pinched at the L1-L2 facet?
"The genitofemoral nerve arises from the L1 and L2 ventral primary rami, which fuses into the psoas muscle". If a spinal cause has been ruled out, then where else except the facet can the nerve be pinched?
2. Since nerve root blocks at the l1 to l2 formen are used to diagnose genitofemoral nerve entrapment (I believe) and he has already had two very successful blocks that work short term, a week- what should this patient's next step be?
3. Patient experiences increased pelvic pain, but increased genital sensation after doing piriformis stretches, but he has already had the piriformis release surgery.
Would the likely series of events be that through an injury, his genitofemoral nerve became pinched, which explains the mid back pain, and then this also causes a severe psoas muscle spasm, through which the nerve passes, and then causes a very tightened piriformis muscle, out of compensation? The pudental nerve runs under the piriformis, thus the patient's piriformis stretching increases room for that nerve, thus the increased sensation?
Thank for any informed advice,
Patient was given a transforaminal L1-L2 nerve root block twice which reduced his pain in most areas by 90%+ for a week afterwards.
Unfortunately, patient was given a recent laminectomy at the L1-L2 for a suspected spinal cause, and has had no improvement in his pain.
Patient researched nerve entrapments and seems to believe that he has genitofemoral nerve entrapment and the symptoms seem to match up. In fact, a L1-L2 transforminal nerve root block SHOULD help someone with a pinched genitofemoral nerve. The patient seems to have pain along the entire route of the nerve from the L1-L2 facet (seems like the facet) to the psoas on downwards to the pelvis, to the scrotum.
1. If he is having pain along the entire length of the nerve, then the genitofemoral nerve is likely pinched at the L1-L2 facet?
"The genitofemoral nerve arises from the L1 and L2 ventral primary rami, which fuses into the psoas muscle". If a spinal cause has been ruled out, then where else except the facet can the nerve be pinched?
2. Since nerve root blocks at the l1 to l2 formen are used to diagnose genitofemoral nerve entrapment (I believe) and he has already had two very successful blocks that work short term, a week- what should this patient's next step be?
3. Patient experiences increased pelvic pain, but increased genital sensation after doing piriformis stretches, but he has already had the piriformis release surgery.
Would the likely series of events be that through an injury, his genitofemoral nerve became pinched, which explains the mid back pain, and then this also causes a severe psoas muscle spasm, through which the nerve passes, and then causes a very tightened piriformis muscle, out of compensation? The pudental nerve runs under the piriformis, thus the patient's piriformis stretching increases room for that nerve, thus the increased sensation?
Thank for any informed advice,
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