Dr. Dellon's New Publication about PNE and Surgery Approach

[shawnmellis]

Dr. Dellon, who is one of the best Peripheral Nerve Surgeons in the U.S. at Johns Hopkins Hospital, talks about a lot of interesting new things regarding PNE, pelvic pain in this new publication from his website, including other areas of nerve compression such as the cluneal nerve in the but, the dorsal nerve in the upper perineum, which I feel I am entrapped at in the Dorsal Nerve area. He also does not believe that neurawrap is not necessary and may be harmful, which Hibner uses for PNE surgery. He gives the surgery results for all of the major PNE Surgeons who have performed PNE surgeries. He also states that he believes that at least one of the ligaments must remain cut open in some way, such as in carpel tunnel surgery, tarsel tunnel surgery, some PNE surgeries, and others in order to prevent future scar tissue formation. Here is the link to his publication that you can download here http://dellon.com/ps/chapter12.pdf Some of this publication was taken from his lecture in 2010 at the International Pelvic Pain Society. Let me know if you have any thoughts on it after reading it. After reading it, I am not too sure about the neurawrap as far as if it is a good thing or not because according to him it appears that it can sometimes actually stay adhered to the nerve and can prevent gliding of the nerve, even after the normal time it is supposed to dissolve away. I guess the question is what type of neurawrap is it that was shown in this picture and for doctors that use it what are the chances of this happening? Take care and let me know if you have any thoughts or comments.

[shawnmellis]

I'm still confused on the whole cutting of the ligaments without suture thing as I"m sure a lot of you are. If anybody has a publication or study to show that cutting these ligaments do lead to Piriformis Syndrome or Sacroillliac Joint Dysfunction, please post them here. I've been only to so far find information that shows that these ligaments support the Sacroiliac Joint and Piriformis Muscle Here is one thing I found here at
http://en.wikipedia.org/wiki/Pelvis
The most important accessory ligaments of the sacroiliac joint are the sacrospinous and sacrotuberous ligaments which stabilize the hip bone on the sacrum and prevent the promonotory from tilting forward. Additionally, these two ligaments transform the greater and lesser sciatic notches into the greater and lesser foramina, a pair of important pelvic openings

and also here:
I found a Study from Vleeming in 1989, linking the sacrotuberous ligament to being the important ligament is stabilization of the SI joint and that without the sacrotuberous ligament's support that you can have Piriformis Syndrome and Sacro Iliac Joint Dysfunction. The website for this article is http://www.sidysfunction.com/generalinfo.php and here is what is says below:

The piriformis muscle, like the gluteus maximus, originates from the sacrotuberous ligament (Vleeming et al., 1989). It runs from the front of the sacrum to the femur and its action is to outwardly rotate the femur. It is a stabilizer of the SI joint via the sacrotuberous ligament. It is often the source of deep buttock pain associated with a sacroiliac dysfunction.

[PaulSa]

Wow, after reading that it sounds like he has it down to a science! How much is fact or opinion is my question?

What I found interesting was this comment,

THE PUDENDAL NERVE DOES NOT GO TO THE BUTTOCK OR THE ISCHIAL
TUBEROSITY, AND SO PUDENDAL NERVE PROBLEMS CANNOT CAUSE PAIN IN
THOSE AREAS.

I guess I don't have pudendal then...............................

[shawnmellis]

Paul, Dr. Dellon is probably the best peripheral nerve surgeon in the U.S. and maybe the world and he studied at the best Med School at Johns Hopkins and worked there also and also teaches at Johns Hopkins as a professor. He knows his stuff and this publication educated us all a lot about the different causes of pudendal and pelvic and butt bone pain. I wish every doctor, urologist, orthopedic doctor would see this publication to educate them that nerves can cause a lot of problems in the pelvis, because there are so few doctors familiar with nerves in the pelvis, including Neurosurgeons and Neurologists, and because you can not see a nerve well on even the best MRI, but ruling everything else out with mris, cystoscopys, blood tests, length of time you have had it, your symptoms, pain source, a physical exam by him, and his PSSD test are good enough to help diagnose whether you have neuralgia or entrapment in your pelvis and where it is. You first should have all of the basic tests done such as mri, blood tests, prostate, etc to make sure it's not something else. If you have pain in your buttock and not your perineum, then it could be your cluneal nerve that is entrapped or damaged as discussed in his publication.

[shawnmellis]

If you have pain or numbness that radiates down your legs to your feet, then it could be your sciatic nerve caused by something else such as your Sacroiliac Joint, Piriformis Muscle, or a herniated disc or pinched nerve in your lumbar or sacral spine area

[calluna]

Wow, after reading that it sounds like he has it down to a science! How much is fact or opinion is my question?

What I found interesting was this comment,

THE PUDENDAL NERVE DOES NOT GO TO THE BUTTOCK OR THE ISCHIAL
TUBEROSITY, AND SO PUDENDAL NERVE PROBLEMS CANNOT CAUSE PAIN IN
THOSE AREAS.

I guess I don't have pudendal then...............................

Yes, I noticed that bit. I don't have buttock pain, nor do I have 'sit bone' pain. My pain is all in the pudendal distribution, and the situation for me is pretty straightforward, if a bit difficult to fix.

I think that what this implies is that those of us with buttock or sit bone pain have a more complicated situation, with more than one nerve involved. The cluneal nerves, if I recall correctly, have the buttocks in their distribution. If you have neuropathic pain in the pudendal distribution, then yes you do have PN. If you have neuropathic pain elsewhere, then you've got something else going on as well.....

[shawnmellis]

Hi Calluna, I think that if your source of pain is just on your buttocks or sitting bone and not in your perineum, that you may just have cluneal nerve entrapment, which I think based on reading the publication is actually easier to fix than pudendal nerve entrapment, which causes pain in the perineum. With cluneal nerve entrapment or damage to it, because it is not really an important nerve as far as motor function, you can have it disected or ablated to cease your pain, or remove the entrpment or scar tissue around it without having to cut either the sacrotuberous or sacrospinous ligaments, which is usually the only way for pudendal nerve entrapment surgery. This is seriously the best publication, most detailed publication, and interesting publication, which I think anybody who thinks they have PNE or pelvic pain in general should read and more than once because it is long and complex. If anybody needs any help understanding any of this terminology in this publication, let me know and I will be more than glad to help. There's Always Hope!

[shawnmellis]

Hi guys and gals, I just wanted to also just say one last thing regarding this Dellon publication I posted. As far as Pudendal Nerve Surgeries (Not Dorsal) but typical Transgluteal Pudendal (alcocks, rectal branch, etc), he has not done a whole lot of these surgeries so far, so we need to hear more feedback on his success rates for pudendal surgery. Hibner has done more of the transgluteal surgeries than most surgeons in the US and his results should be out this year. Dellon is pretty much the only one besides Aszmann doing dorsal surgery or cluneal nerve surgery at this time and they both have good success rates for that. Take care.

[shawnmellis]

I just read Dr. Dellon's updated version of his publication in which he explains further the whole Pelvic Stability from cutting the Sacrotuberous or Sacrospinous ligaments. I am not a doctor or expert, but I would tend to agree with him that there may be some cases where cutting the ligaments may be necessary. Here is the part of his publication I am referring to.
"In some people, the symptoms of chronic pelvic pain
may come from compression of the pudendal nerve being caused to sag and pull against
the SS ligament, or the nerve may be caught between the SS and ST ligaments, or be
compressed just beneath the ST ligament. From the peripheral nerve point of view, any
and all structures compressing a nerve must be released."
*End of quote*


I also agree where Dellon said that "people should be tested for SIJD prior to having surgery where these two ligaments may be cut."

If they do not show any signs of SIJD and If cutting one or both of these ligaments to relieve the compression because it is the actual cause of the compression then it may be the best and only option. Here is his strong, compelling, evidence below which is further explained in his publication with Figure 12-30 regarding it being okay and not problematic and maybe the best thing to do is to cut these ligaments without suturing them back together, especially in some situations:

“Definitions of pelvic stability arose from the orthopedic surgeons who operated upon
pelvic fractures, and these definitions are well established now. About thirty years ago,
Marvin Tile, MD, Professor of Orthopedic Surgery at the University of Toronto in Canada,
developed an approach to fractures related to the strength of the ligaments. Disruption of
the pubic symphysis with or without division of the ST and ST ligaments were in his Type A
group, and were stable.* These were the weakest of the pelvic ligaments. J.W. Young and
Andrew R. Burgess, both Professors of Orthopedic Surgery at the University of Maryland,
Shock Trauma Unit, in Baltimore, developed an approach related to the mechanism of the
pelvic injury, either lateral (side) crush, or anterior-posterior (front to back) crush. Their
stable category, Type I, included division of the ST & SS ligaments as long as the pubic
symphysis disruption did not exceed 2.5 cm.** Therefore, a pelvic fracture is stable even if
the ST & SS ligaments are ruptured unless the pubic symphysis is widely separated or the
ligaments related to the sacroiliac joints are disrupted. Unless a patient with chronic pelvic
pain sustained a previous pelvic fracture, it is most likely they do not have pelvic instability.
In the pelvis that has not had a fracture, such as in the typical patient with chronic
pelvic pain, will dividing the ST and the SS ligament cause pelvic instability? There are
four research publications done using the pelvis from human cadavers. These are
reviewed in Table 12-3. See Figure 12-30.
From the review of scientific literature, I have concluded that ST & SL ligaments are not
necessary for pelvic stability in the adult. Therefore, if a patient with chronic pelvic pain
needs to have the ligament(s) divided to decompress the pudendal nerve, then it is safe to
divide them. It is also concluded that a divided ligament does not need to be reconstructed.”

All I am saying by this updated publication from Dr. Dellon with this information given, and his studies is that if the actual source of entrapment is the from compression of the pudendal nerve being caused to sag and pull against the SS ligament, or the nerve may be caught between the SS and ST ligaments, (which is the the majority of the cases), or be compressed just beneath the ST ligament, then if cutting the ligaments decompresses the nerve, then that may be the best and only option. As far as the whole pelvic stability thing, none of us are experts, doctors, or surgeons with true scientific case studies to show exactly what percentage of patients that have had these ligaments cut from PNE surgery did cause SIJD or Piriformis Syndrome, without having been tested for SIJD prior to surgery, although I wish there was one, so that is all I have to say about this subject until there is any true study done or scientific evidence on this and none of us really know what percentage of people get SIJD or Piriformis Syndrome or any Pelvic Floor Instability after having these ligaments cut. We can rely on the research done, which includes the best orthopedic surgeons and actual published studies of results of patients such that Dr Dellon mentioned, which included people with Pelvic fractures and cut ligaments.

So, I am not sure how common this to actually occur, because I do not know what actual percentage of PNE surgery patients got this and if they previously already had SIJD before the surgery or not because there have been no published studies from any surgeons who have done this surgery on this subject, and it may be very well be possibly very uncommon. If the source of compression is being caused by the nerve being compressed beneath the SS ligament or being caught in between the SS and ST ligaments then sometimes maybe, I am not a surgeon or expert, but I'm just saying it's possible that this may be the best and only solution to leave at least one or possibly both of the ligaments cut to decompress it. The surgeons are the experts on this, and certainly not me, so I have to rely more on them than myself for the understanding of anatomy and surgery approaches for PNE, because I am not a surgeon and most of us here are not either.

[Poppy]

I'm new to all this and have no idea about surgery success rates or cutting ligaments etc but I just read this book and I have to say it's the most informative and comprehensive thing I have ever found on pelvic pain. He mentions Pubic Ramus synrome which I have never seen mentioned anywhere else and which describes a problem I have now had for 11 years. He could be writing about me. I was diagnosed 11 years ago with compression of either the iliohypogastric or ilioinguinal nerve but no one could do anything about it. As a result I ended up in a wheelchair as standing was impossible. I've now developed what sounds like PN but with no allodynia and since I now can't sit and haven't been able to stand or walk for more than a couple of minutes for 11 years this leaves me totally bedbound. Reading his article had me in tears to at last find someone who really understands and with such an amazing knowledge of pelvic anatomy. Now all I have to do is find someone in the UK with similar knowledge. Am I asking the impossible? Just to meet someone who actually knows what they are talking about, even if they couldn't do anything would be a miracle.