tag:blogger.com,1999:blog-61647057904629485352024-03-20T04:38:34.185-04:00Iliosacral Nodule Induced Pain of the Lower BackUnknownnoreply@blogger.comBlogger1125tag:blogger.com,1999:blog-6164705790462948535.post-33101258853449560072010-03-19T13:01:00.003-04:002012-05-16T17:25:25.411-04:00A Forgotten or Often Overlooked Cause of Lower Back Pain- Iliosacral Nodules<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-weight: bold;">Anatomy</span><br />
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a) Single or multiple fatty nodules along the superior border of the posterior iliac crest 4 to 6 cm from the midline of the back.<br />
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b) Posterior branches of the lumbar plexus penetrate the fascia in the same area.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgivwTKyjwwsCzdwJJbtMJfF3dmPzRcDSN-P9m2_pYr_GNywenuuYLzN2FoNL5JUPNEsLu7vPdTy5_QI0m6KFw34lMz1XtWUY95ERXHVnQdbhl6OGOxXJd5RXrwcB039m84GtboEh5B7Dn1/s1600/Episacral-Incision.gif" imageanchor="1" linkindex="15" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgivwTKyjwwsCzdwJJbtMJfF3dmPzRcDSN-P9m2_pYr_GNywenuuYLzN2FoNL5JUPNEsLu7vPdTy5_QI0m6KFw34lMz1XtWUY95ERXHVnQdbhl6OGOxXJd5RXrwcB039m84GtboEh5B7Dn1/s320/Episacral-Incision.gif" /></a></div>
<span style="font-weight: bold;">Pain Mechanism</span><br />
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Compression of/or stretching of these neurofibrils as they pass through the fascia or in the subcutaneous area give local or referred pain & tenderness.<br />
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Referred pain may be felt locally in the buttock in the lower areas of the abdomen, in the groin, in the testicles or in the anterior & medial aspect of the upper thigh.<br />
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<span style="font-weight: bold;">Syndrome</span><br />
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1) Local and referred pain initially intermittent becomes progressive in frequency and severity.<br />
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2) Increased by posture changes-squatting, recumbency (often on arising in the am), twisting as in golf, tennis or work activity.<br />
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3) History of mattress changes<br />
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4) History of multiple investigations & specialist referrals.<br />
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5) History of multiple forms of therapy non-surgical such as physiotherapy, massage, acupuncture, analgesics, etc.<br />
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6) History of inappropriate surgical procedures such as laparoscopes, colonoscopies, groin explorations and even major back operations.<br />
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<span style="font-weight: bold;">Diagnostic Test</span><br />
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Objective: To avoid delay in diagnosis and inappropriate treatment.<br />
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Technique: Injection of a long acting local anaesthetic directly into the tender nodules.<br />
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<span style="font-weight: bold;">Results</span>:<br />
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A) If no relief of discomfort look for an alternative cause of pain.<br />
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B) If immediate relief of the local and referred pain occurs and lasts for the duration of the anaesthetic or longer, consider this as a positive test. A repeat diagnostic test with a similar dramatic success is an absolute indication to proceed to definitive treatment.<br />
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<span style="font-weight: bold;">Definitive Treatment</span>- Excising Iliosacral Nodules<br />
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A minor operation under local anaesthetic<br />
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1) Mark the skin over a 1 ½ “ – 2” where the painful nodules are palpated.<br />
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2) Infiltrate with local anaesthesia<br />
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3) Incise and deepen incision to the fascia exposing the iliosacral nodules.<br />
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4) Remove iliosacral nodules<br />
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5) Palpate for fine neurofibrils penetrating the fascia and transect them.<br />
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6) Close wounds in two layers once hemostasis is achieved.<br />
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7) Compression dressing with betadine or iodine<br />
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<span style="font-weight: bold;">Results</span><br />
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Over 200 patients highly selected by means of the diagnostic test underwent the surgical procedure to remove iliosacral nodules. 98% experienced full relief. 2% were better.<br />
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Contralateral procedures were done later in about 20%.<br />
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Ipsilateral recurrent nodules were excised in 5% of patients.<br />
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<span style="font-weight: bold;">Complications</span><br />
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The procedure is fairly simple but one should remain aware of the general risks of surgery. There is a small chance of seroma formation, infection and wound separation. In this study none of the 200 patients contracted an infection.<br />
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<span style="font-weight: bold;">Comment</span><br />
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A large percentage of individuals with chronic low back pain due to a simple treatable cause have been misdiagnosed and/or mistreated. The cost to society is enormous in terms of unnecessary pain and suffering and the resultant financial implications.<br />
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In summary therefore by following this simple approach in the diagnosis and treatment of the this common cause of chronic low back pain a great deal of suffering will be eliminated.<br />
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The loss of man hours alone may save billions of dollars to our overstretched medial costs world wide.<br />
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Dr. Joseph P. McKenna, FRCSC<br />
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Toronto, Ontario<br />
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March, 2010</div>Unknownnoreply@blogger.com0