In this example, we meet a 30-year-old, right-handed male with reports of bilateral testicular pain with pressure, achiness, tightness and burning also with intermittent shooting pain down the right lower extremity.
The patient notes there was no known accident, trauma or injury prior to the onset when he developed intermittent shooting pain from the sacrum into the right lower extremity. Then he had a sudden onset of testicular pain that became constant, the right greater than left, but one month later the symptoms would travel from the right to the left and cause him to have left greater than right pain, especially with increased activity, sitting from the perineum to rectal region. He was treated with some superficial inguinal block with no change and referred to Pain Management for a cord block at which time they also performed epidurals and a discography. He then underwent a fusion of the L4-L5. Postoperatively he developed intermittent tingling to the lateral feet with no changes in his preoperative symptoms.
Based on this history, exam, data and findings, this is very likely a subtype of Pudendal nerve syndrome. He has both genital pain and perineal region pain exacerbated by sitting. In addition, he has radiating leg pain and pain in the bottom of both feet. Some of these symptoms developed or progressed after the fusion surgery, but most were present prior to the surgery and there was no benefit after surgery. The presence of sensitivity to palpation at both the piriformis level and at the location of the obturator internus is a typical pattern left with significant percentage of Pudendal nerve patients. An MR Neurography study of the pelvis, which would look for evidence of pudendal impingements is planned, followed by Interventional MRI-guided injection, which in his case involved the piriformis and obturator internus muscles. First the piriformis muscle on the right side would be injected and then the obturator internus left and right would be injected in order to assess the differential effect dealing with regard to foot symptoms.
The MR Neurography findings illustrate the general pelvic course is abnormal in that there was tortuosity and increased image intensity affecting the pudendal neurovascular elements affecting the pudendal veins, right greater than left in the medial aspect of the obturator internus muscle. Also significant irritative change and some tortuosity affecting the pudendal nerve elements. The abnormality appears to commence above the level of the ischial spine. The MRI guided interventional plan is to treat the obturator internus muscle bilaterally and the right piriformis muscle in order to establish a differential effect.
Following the Interventional MR procedure the patient has reported a complete suppression of the symptoms and then over the succeeding three weeks he also had very significant relief. He was able to greatly increase his activity level. The patient reports that following the MRI guided injection he had significant numbness to the right from the hip to the foot that has completely resolved. He notes that during that period he had minimal to no pain. Currently he notes that he continues to maintain improvements especially to the testicular area with a 75% improvement from initial pain symptoms.
He notes that his pain level has notably decreased from a 6-7 out of 10 to a 2.5 out of 10. He also notes that his general energy level and appetite have notably improved.