I posted over on tipna a lengthy story about my pudendal nerve saga (too many details), typical symptoms of perineal branch + horrific autonomic symptons. Short summary is: I fell skating 2+ years ago (was wearing a coccyx 'protector'- ha!
) and that was all the clinical info given to the radiologists, to try and get a 'blind' read on the films. I'll post my symptoms in another section on this site.The information I hoped to get from the MRI was: if entrapped at ST or SS, then that would point in one direction if surgery--TG-- but if clear 'back there' and only injured/scarred/entrapped down low where the coccyx protector hit, then that does open other options (like local injections, TIR, etc or doing nothing, waiting...) FYI: PT was a fiasco this second time around.
Dr Potter was gracious enough to read an outside film, also 3T and discuss with the neuroradiologist 1 hr from my home, the protocol for images she needed.
There was always the possibility the images would be inferior and she could not read the films-- waste of time/trip and minor flareup I got from just travelling 1 hr (lying down in minivan-- it's the getting in and out that is the problem). But she was able to! and here is her report:
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Submitted outside MR examination of the pelvis was performed utilizing coronal and oblique axial inversion recovery followed by coronal, sagittal, axial and oblique axial fast spin echo techniques. Clinical concern is pudendal nerve entrapment. There is a history of a fall 2 years previously.
The inferior margin of the coccyx is deviated to the left with scarring of the anococcygeal ligament. The branches of the pudendal nerves to the rectum are well visualized without scar enhancement. There is, however, asymmetry of the fat planes surrounding the pudendal nerves, particularly on the left with scarring of the anterioinferior margin adjacent to the perineal muscles. This is noted on series 5 image 6, where there is linear scar entrapping the left pudendal nerve. A focal pelvic floor varix is identified at the anterioinferior margin of the left Alcock’s canal, extending to the margin of the left dorsal nerve to the penis. No extensive scarring of the pubic symphysis is seen. More posteriorly, the fat planes around the sacrotuberous ligaments are preserved and there is no scar enhancement of the pudendal nerves at that point. The sacrospinous ligaments also appear symmetric. There is no soft tissue mass in the precoccygeal space. There is no occult fracture. No pelvic adenopathy is appreciated.
Impression:
Submitted outside MR examination of the pelvis demonstrates focal scar entrapment of the left pudendal nerve at the anterioinferior margin of Alcock’s canal, adjacent to a focally prominent felvic floor varix. The pudendal nerves more posteriorly appear symmetric and there is no scar encasement appreciated at the branches of the pudendal nerves to the rectum. There is post-traumatic deviation of the coccyx, with scarring of the anococcygeal ligament.
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I checked to make sure the images were not accidentally inverted and at least in NY they were not; perhaps in the facility where I went? Or, I'm crazy. Or, I'm entrapped on both sides and the pathology on my R could not be seen on the MRI, ie too distal? What she is seeing on the "L" is exactly where I thought the problem was on my Right. Or, there are numerous other possibilities.
My autonomic symptoms have been largely absent in the past 3 months, only briefly, if I forget, in the middle of the night if one of our kids wakes me up and I jump up without thinking, I'll get zapped.
Well, thanks for reading. And I am very thankful to Dr Potter for even agreeing to read an outside scan. Her assistant, Amanda, was so kind, and prompt with the email replies. From her report she doesn't diss the quality of the films at all and even comments on the inferior rectal branches, and able to see the fat planes of ST areas. So, I'm thinking that if there was scarring deep inside at the ST or falciform process impingement, I would think she would have been able to see it.
Don S
