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

[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.

[Violet M]

Thanks for posting this Shawn. I find it very interesting because I was in the situation where my SI ligaments were bad before surgery which is exactly why I went to Bautrant to have surgery -- so I could have just the SS ligament but not the ST ligament cut.

The independent insurance reviewer conceded that the TIR surgery was the right one for me -- but with only Bautrant's article published on the TIR approach, they didn't pay for it. Of course, now we have all these other docs sparing the ST ligament during TG surgery but that option wasn't available 7 years ago when I had surgery.

The problem is......I don't know if anyone has developed a reliable way to predict ahead of time which patients will develop instability from having both the ST and SS ligaments cut. Is there are reliable way to determine if the SI ligaments are disrupted prior to surgery?