And on a completely different topic, MRI’s, pain and spreading the word

Good Morning

I feel compelled to occasionally blog about my hernia, which is turning into quite the saga, not just because I ramble on about all topics, myself included, but because I have managed to get a better diagnosis through detailed research and I want to share those results to help others who may be suffering from chronic undiagnosed pain and who have been told it is all psychosomatic, or neuropathic, and that nothing can be done to help them but pharmaceuticals for life.

There are many reasons that our health care system tends towards prescription drugs over more intensive, investigative methods, and it mostly comes down to money.  But I do not intend to rant here about why it has taken so long to get to a diagnosis of another potential source of my pain, rather to explain how and why I was able to get to this next phase in my quest and to offer hope to anyone out there in a similar situation.

Last summer, after considerable effort, I found myself in the very capable hands of a general surgeon in Montreal, who was, no kidding, an Associate Physician to the Montreal Canadiennes (Go Habs Go!), and you can read a very succinct account of it all in this post of mine, Well, how very odd if you are me …

However, the whole pain free thing seems to have been a bit premature, and I failed to recover properly from the operation.  Initially I just thought I must have been sicker than I realised beforehand, but as time went by I knew I still didn’t feel right.  The old grinding  internal pain that sickened my stomach, and pain in my groin and down my right leg.  Not the old insane nerve pain that made me say I just wanted to saw my own leg off, that was truly gone.  As was my back pain.  A miracle, and yes, the bulge is a bit sore where the mesh is, but fixing my recurrent inguinal hernia and re-sectioning my inguinal nerve was a success.

So I felt like a whiner.  But the harder I tried to get moving, the worse the pain would become.  A pattern developed where a week ignoring the problem and trying to behave like a normal, if recovering, human – just walking the dog and doing groceries – meant a week on the couch moaning and medicating.  Back to the GP, and amongst my symptoms he decided that I might as well see a gastroenterologist because I have had some alarming if infrequent gastric moments as well as the endless nausea.  A great idea for the wrong reasons it turned out.

And I got to experience the joys of an upper gastrointestinal endoscopy, while finding out there was nothing apparently wrong with me, again.

What is upper gastrointestinal (GI) endoscopy? [I hear you ask, ed.]

Upper GI endoscopy is a procedure that uses a lighted, flexible endoscope to see inside the upper GI tract. The upper GI tract includes the esophagus, stomach, and duodenum—the first part of the small intestine.*

The trick is to only swallow once, to get the camera going down, and then drool without swallowing for two minutes.  They offered sedation, but I figured two minutes couldn’t be that bad.  It was a very, very, long two minutes.  And the doctor was fairly handsome but what can you do?  He gathered some stomach stuff, lucky guy, to send off to the lab, and then it was but a memory.  But no luck with having a diagnosable gastrointestinal problem.  Yippee, and I mean it!

The only other thing I could find that matched my symptoms was a very rare kind of hernia, called an obturator hernia.  They are unfortunately found in autopsies of emaciated elderly women, who have often been misdiagnosed with arthritis of the right hip.  Multi-parous (one of my favourite new words) elderly women.  Athletic, multi-parous elderly women.  Except for the elderly part, as I am a sprightly 50 and hope to stave off ‘elderly’ until about 65 while clinging tightly to ‘a woman of a certain age’ for as long as possible, it began to sound like me!

The reason obturator hernias are fatal is because they can entrap your bowel and then you usually die.  Let me let the medical world explain this in unfortunate detail:

The obturator foramen is the largest in the human body. It is formed by the rami of the ischium and the pubic bone. The foramen is partially closed by a strong musculoaponeurotic barrier consisting of an internal and an external obturator membrane and an internal and an external obturator muscle. The obturator canal is situated in the cranial portion of this membrane with the pubic bone above and the membrane below. This tunnel measures approximately 0.2-cm to 0.5-cm wide and 2-cm to 3-cm long through which traverse the obturator nerve, artery, and vein.

[I think this deserves a picture, ed., and please note the adductor magnus on the right hand image, as it is going to play a starring role in this tale.]

Obturator hernia (OH) formation was first described by Ronsil in 1724.¹ Although it is considered a relatively rare hernia (0.07% of all hernias), it is the most common in the pelvic floor (obturator, sciatic, and perineal). Three types of obturator hernias have been described based on the anatomical defect that is present. Type I OH occurs when preperitoneal fat and connective tissue (pilot tag) enter the pelvic orifice of the canal. Type II OH causes dimpling of the peritoneum over the canal, leading to the formation of an empty peritoneal sac. Type III OH occurs on entrance of an organ (bowel, ovary, or bladder) that eventually fails to reduce spontaneously. A partial or complete small bowel obstruction [and my GP believes, I still can’t get over this, that partial bowel obstructions don’t exist and hence can’t reduce spontaneously!  Arghh, ed.] has historically been responsible for the diagnosis of most obturator hernias (88% of all OH).²

The incidence of OH is significantly higher in females (6:1) and may be due to their larger foraminal diameter. Bowel obstructions from OH are usually in elderly (average age 70), thin patients. In fact, it has been called the “little old lady hernia.” However, with the advent of computerized tomography and magnetic resonance imaging, these hernias are being diagnosed more accurately in younger patients before the onset of bowel obstruction.²

A small proportion of patients may present with chronic pelvic pain and inner-thigh neuralgia. Symptoms are the result of compression of the obturator nerve in its tunnel. Patients may initially consult the neurologist, neurosurgeon, or orthopedist. Obturator hernia was first proposed as a cause of isolated neuropathy in 1969.³ Somell⁴ later reported a series of 7 patients with OH presenting with chronic pelvic pain in the groin and hyperesthesia over the obturator nerve distribution. A small preperitoneal fat plug was surgically removed from the canal alleviating symptoms in 5 of 7 patients.⁴Subsequently, more cases have been reported, and some investigators believe the condition is more common than previously recognized.⁵ Pilot tags of fat have been reported in up to 64% of female cadaver dissections.⁶ It is not known how many of these women suffered from chronic pelvic pain. [This was not going to be me!, ed.] The frequency of pilot tags and rarity of obturator neuralgia would suggest that most OH do not progress beyond this first stage.⁶

Pain in the medial thigh with radiation behind the knee and into the hip is most common. The pain may be dull, sharp, shooting, or burning. [Lions and tigers and bears, oh my!, ed.]  Adductor motor weakness may be present. Most patients complain of increased pain on exercise, prolonged standing, and prolonged sitting. Crossing the legs while sitting may exacerbate the pain. [This leaves little, when both sitting and standing are not be tolerated, nor movement.  Arghh, again.  ed.]

The physical diagnosis of obturator neuralgia includes the observation of the patient’s abnormal gait and internal palpation of the obturator canal. Adductor weakness may cause the patient to walk with an abnormally abducted hip.**

Well, having read that and another excellent article Obturator hernia as a cause of recurrent pain in a patient with previously diagnosed endometriosis (and I had even had exploratory laparoscopic surgery in 2008, looking for and not finding endometriosis) I was determined to rule out such a potentially deadly hernia.

I had managed to book myself into the Shouldice Clinic in Toronto, a private (don’t get me started) hernia clinic, having decided I must have yet another hernia, as it is actually very common, especially after having had 2 previous repairs, to have problems with inguinal hernias.  But they had never actually seen me, just reports of my previous surgeries, etc., and the surgery wasn’t booked until this October.  Luckily for me my excellent hubby suggested that I go to their drop in clinic when I was in Toronto earlier in the summer.  Well, they don’t “do” obturator hernias, as they so nicely told me, as if I were a window to be washed, and then I was unfortunately “examined” by a dinosaur of a doctor who asked me to cough after basically telling my I was a woman with a surgical past and I should just live with my pain.  The third surgeon of a certain type, if I am counting correctly, who has mistakenly told me the exact same thing.  “You need to find a different modality to cope with your pain,” is a quote that irritates me to this day, said to me by a surgeon I waited 8 long months to see, who failed to detect my new hernia or any of the things I have subsequently been correctly diagnosed as suffering from.  I guess he was right after all, as I did find a different modality – a very competent other doctor.

This disappointment at the Shouldice clinic, leaving me once again with no diagnosis and considerable pain and discomfort, caused me to write a fairly impassioned letter to the nice gastro fellow, as he had seemed interested in my tale and I thought he should know more about this as his office is full of women with chronic lower quadrant pain.  I asked him if the CT scan I had received during an emergency room visit in the spring could actually rule out an obturator hernia.  He got me to get the scan, and then found a radiologist he trusted who said no, a CT scan could not see such a thing, and that what was called for was a “sports protocol MRI”.  Would I want him to order such a thing for me?

Damn straight I would!

And so it was, that almost to the day of the non-surgery un-booked at the Shouldice clinic, I ended up getting a sports protocol MRI.  Before going, I carefully researched what this should entail, and went to the hospital appearing to be well-informed.  The technician was very willing to read what I had brought, and did perform almost exactly this test, which is described in detail in an excellent article with the exciting title: Athletic Pubalgia and “Sports Hernia”: Optimal MR Imaging Technique and Findings.

This is the introduction, and please bear with me, as I am hoping to up the searchability of this detailed diagnosis, in the hopes that others find it:

Groin pain is a common result of athletic injury, but it poses a diagnostic challenge for radiologists, athletic trainers, team physicians, and consulting surgeons. Athletes in sports that rely on quick acceleration, rapid changes in direction, kicking, and frequent side-to-side motions (eg, soccer, ice hockey, American- and Australian-rules football, fencing, track and field events such as high jumping, and baseball) may be particularly subject to injuries that lead to groin pain. Between 2% and 8% of all athletic injuries involve the groin, and up to 13% of soccer injuries are groin related (1–3). According to one report, 58% of soccer players had a history of groin injury (4).

Clinically, athletes frequently present with pain in the inguinal region, which may radiate to the thigh adductor muscle origins or to the scrotum and testicles. At physical examination, point tenderness is often localized to the external ring of the inguinal canal and the pubic tubercle, the lower rectus abdominis musculature, or the pubic symphysis, but there is no palpable hernia. Although groin injuries may be acute, they more often have an insidious onset and progress over a period of weeks or months. They are a significant cause of missed practice and playing time (5,6). Although many acute groin injuries are successfully treated with a conservative regimen including rest and a nonsteroidal anti-inflammatory drug (NSAID), groin injuries often recur and may lead to the premature termination of athletic careers.

The pathophysiologic conditions that cause groin pain are complicated and poorly understood. Misunderstandings may easily occur, leading to misdiagnoses, for several reasons. To begin with, the anatomy of the pubic symphyseal region includes a number of interrelated muscle attachments that are located in close proximity to one another. The interrelation of these muscle attachments causes complex interactions between the forces exerted through the muscles across the pubic symphysis. Furthermore, the differential diagnosis of groin pain in athletes is extensive because various pathologic entities may cause similar clinical signs and symptoms and overlapping findings at physical examination (Table 1). In addition, patients may be unable to precisely identify the location of their pain or to recall the mechanism of injury. Moreover, they may present with multiple coexisting injuries that could cause groin pain, a circumstance that makes it difficult to establish which injury is the major contributor. Given these complexities, it is not surprising that both conservative management and numerous invasive therapies, including herniorrhaphy, adductor tenotomy, pelvic floor relaxation, and surgical repair of the posterior wall of the inguinal ring, have been applied with variable success to treat refractory groin pain. It also stands to reason that injuries with a poor surgical response may have been incorrectly or incompletely diagnosed, leading to a suboptimal treatment plan. The variety of terms used in the medical literature to describe entities that are either identical or at least close neighbors in the same spectrum of disease—including sports hernia, sportsman’s hernia, pubalgia, Gilmore groin, hockey goalie syndrome,adductor dysfunction, and osteitis pubis —likely adds to confusion in the diagnosis and treatment of groin pain

And the wonderful punchline of all of this, is that I do seem to have something wrong where my adductor magnus attaches to my pelvis, and it is the obturator nerve that operates that muscle.  I produced “minimal T2 signal intensity” at the proximal (close to the trunk not knee) adductor magnus.

Here is a slightly unfocused, but good picture of the anatomy of the thigh showing the adductor muscles:

As my daughter said, I get full marks for proximity.

Nobody knows yet what my minimally intense T2 signal from my proximal adductor magnus means exactly, and whether this is fixable or not, but the gastro guy was terribly excited to be able to tell me that it really did mean something, having feared, he said, that I would burst into tears in his office if he had to tell me they found nothing, once again.  He said he asked the radiologist if they scanned a hundred healthy people could they get that result and he said no, it really is something.  So I have now been referred to a sports medicine doctor, and after prodding the system again (thanks to the prodding of my aforementioned excellent hubby) and rescuing my file from a dusty pile, am seeing him on the 30th.  A trifecta of injuries?  I sure hope there isn’t a quadfecta lurking in my future!

* http://digestive.niddk.nih.gov/ddiseases/pubs/upperendoscopy/

** http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015584/