inguinal pain

[Pain_doc]

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Any suggestions for the following?
38 yo obese F with 1 year history of left inguinal/left lower quadrant pain. Has had no prior abd/inguinal surgery when pain started. Neg abd CT. Underwent diagnostic laparoscopy to rule out gyn causes. Neg lumbar MRI. Had multiple ESIs without success. Local infiltration did provide some relief. Area involved seems to be that of ilioinguinal/iliohypogastric. Given body habitus (morbid obesity with pannus overhanging), I didn't feel I could block the individual nerves with certainty with a small quantity of local, so I peformed selective NBs of L1 & L2, figuring she'd get at least some relief. No relief at all. Next?

 

[spondy14]

I would get an MRI arthrogram of the hip, and a diagnostic intra-articular hip injection, to rule out labral tear. I see it all the time, with patient that has groin pain, and obesity seems to agravate the issue.

 

[Ligament]

Would consider a diagnostic ultrasound to eval for tear of the abdominal musculature (since its in the LLQ and responded to local infiltration). Have them scan over the tender areas. Does the pain get worse with trunk flexion? Have had a couple similar patients, one of them had a rectus tear.

 

[lobelsteve]

Broad differential...

Femoral hernia more likely than any ilioinguinal or GF neuropathy. Hip is also high on the differntial. More H&P needed.....

ESI's? Multiple ESI's? WTF! Hope you didn't do that and she came to you after some jackass said- how about ESI for belly pain. And we wonder why they want to cut payments.....

 

[Ligament]

This sounds good too, labral tears are often overlooked for a long time. Although, I have not seen them respond to local infiltration (I assume you mean infiltration in the LLQ). Often the patient has had a fall and due to obesity and awkward landing forces tear the labrum. A lot of times they will not remember any trauma as the pain is not immediate. Have you stressed the hip capsule on exam?

I would get an MRI arthrogram of the hip, and a diagnostic intra-articular hip injection, to rule out labral tear. I see it all the time, with patient that has groin pain, and obesity seems to agravate the issue.

 

[Pain_doc]

The patient was referred to me after the "3 ESIs". Hip ROM essentially normal and pain free. Neg FABER. Pain to palp over area above inguinal crease and most painful to palp where pannus overlaps abd. + allodynia. No sign of infection. No history of skin lesions. Non-diabetic. Patient states that the local infiltrated into the area is the only thing that has given her some relief. Sounds like it was a rather indiscriminate injection of 20ml of local ("it was a big syringe"). No pain to palp of superior thigh. Given size of patient, I can't really palpate any difference between R & L sides.

 

[Pain_doc]

Pain is aggravated by flexion, extension & lateral movement. Recumbent position with legs flexed is most comfortable.

 

[octrode]

psoas bursitis?

 

[spondy14]

Pain is aggravated by flexion, extension & lateral movement. Recumbent position with legs flexed is most comfortable.

Diagnostic hip injection...still think it is a labral tear with this PE, unless you or she can put her finger on it.

 

[Mister Mxyzptlk]

Femoral hernia gets my vote. Could be psoas bursitis, but that is usually the result of DJD of the hip and the hip exam sounds normal.

Inject the hip joint with a mix of local and steroid. You can catch the psoas bursa during the injection easily enough.

1. If the groin pain goes away with the local you have a diagnosis and just need to wait and see the results of the steroid.

2. If local relieves the pain but the steroid doesn't work then get an ortho eval.

3. If the local doesn't block the pain refer to a surgeon for femoral hernia.

 

[axm397]

How about pelvic floor related pain? Lots of OB/Gyns are NOT familiar with how to examine the musculature of the pelvic floor. Any bowel bladder issues? does she have children? pain assoc w menstrual cycle?

I know, UGH but could be on the differential...

 

[Disciple]

How about pelvic floor related pain? Lots of OB/Gyns are NOT familiar with how to examine the musculature of the pelvic floor.

Neither are 99.9% of interventional pain doctors.

 

[Pain_doc]

Has had a couple of children. Youngest now eight. Patient evaluated by gyn, including diagnostic laparoscopy prior to the gyn sending her to local pain doc. No bowel or bladder issues other than occasional constipation with narcotics.

 

[Pain_doc]

Well I am "out of network" and the prior injection cost the patient alot, so she opted to have MRIs of hip and pelvis vs the hip injection. (out of network facility cost for SNRB over $5000!, kind of sad that its cheaper to get two MRIs than one diagnostic hip injection...) The MRIs are both normal. No hernias, no pelvic/adnexal abnormalities. Hips normal, no labral tear. No muscle abnormalities, no masses....nada. Any other suggestions? She's asking me about SCS. I'm considering sending her to another local general surgeon for eval. thanks

 

[spondy14]

Was it an MRI arthogram of the hip?

 

[Pain_doc]

Yes. I have not seen the films but received a report from the radiologist (and he knew what I was looking for...)