Obturator nerve block/neurolysis

[clubdeac]

Got a nice 70 y/o guy with advanced parkinsons who has been battling bilateral adductor pain and spasticity for several years. He has been referred to me by my neurology colleagues and has failed multiple meds including TCAs, AEDs, opiates, SNRIs etc as well as botox injections into the adductors, 150U bilaterally. I was thinking of doing an obturator block and if successful, phenol or PRFA. Any thoughts? Anyone with experience on US guidance of this block that could offer up some pearls?

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[ultm8frisbee]

baclofen pump?

 

[bedrock]

baclofen pump?

Need to first ask if the botox decreased his tone in any real way. Otherwise, I would double the dose before giving up on botox (You can do 600units spread between both sides). Maybe they didn't do a very good job with the botox. Are the adductors all that's involved? . Sound like his pain is primarily due to tone, and I would still try to correct the main problem, before frying the obturator nerve.

Also has he been on PO baclofen? Need to try to try that if not. If fails a better botox injection + PO baclofen, I would also vote for botox/phenol of obturator before considering a pump. His symptoms are way to focal to consider a baclofen pump.

 

[lobelsteve]

Is he ambulatory? Phenol to obturator may put him at increased fall risk.

 

[clubdeac]

Good thoughts. He's tried and failed baclofen and tizanidine. Botox was EMG guided by my partner so I think it was done well. Only recommendation along those lines would be a higher dose like you suggested. He is ambulatory and I do fear increasing instability and falls w/neurolysis. I've discussed this with the referring neurologist who thought it wouldn't be a bad idea if he responds well to blocks. Would do one side first. Will do the blocks and see if he even gets temporary relief and will then consider phenol if substantial relief and he and family are well aware and accepting of the risks.

 

[drf]

Look for the obturator artery deep to pectineus then stim for the nerve next to it. If you do it a bit lower it is easy to find the brevis, longus, and magnus. Anterior branch is between longus and brevis. Posterior branch between brevis and magnus.

 

[clubdeac]

Look for the obturator artery deep to pectineus then stim for the nerve next to it. If you do it a bit lower it is easy to find the brevis, longus, and magnus. Anterior branch is between longus and brevis. Posterior branch between brevis and magnus.

Thanks drf! Thought you'd have some good suggestions on US