Femoral Artery Hematoma-Induced Scarring
Patients needed transfemoral arterial placement of radiofrequency electrodes for cardiac arrhythmia. The procedure took several hours, the patient returned at night complaining of pain in the groin and numbness, weakness in right leg. Ultrasound study in the ER was negative for hematoma. Subsequent CAT scan study showed a hematoma. A couple of years later, the patient had pain, weakness and wasting of the quadriceps which led to further studies. An EMG showed silent vastus-lateralis muscle. MRI of the back was reasonable for the patient’s age and was considered negative for causation. Hydrodissection of the femoral sheath was followed by recovery of strength and a couple of months later the EMG showed reinnervation. Interestingly there was one sided significant lower extremity varicosity possibly from venous congestion from the area of the pelvis. The recovery following the procedure has been uneventful and none of the patients needed repeat hydrodissection of the three in one area. We meticulously avoided any injections with sharp needles because of the work of Dr. Doug Selander because of his work on longitudinal intraneural eye pressure spread from sharp needle injections(1).
Sacral Lysis of Adhesions
Sacral lysis of adhesions (neuroplasty) has been extremely helpful in sacral fractures and CRPS like pain. Some of these patients need to go onto neuromodulation; for example, a patient that fell on the crossbar of an exercise cycle, fracturing her sacrum, has suffered extremely severe, multiyear pain. After following the outlines in the above cases, we trial stimulated for sacral nerve stimulation but were not able to get good coverage. Next electrode placements were done through the sacral hiatus with two 8 lead contact electrodes; that provided excellent coverage. The anticipated problems with anchoring has led us to use a new system for anchoring where the two electrodes were placed 2 inches down and 1 inch from the midline of the gluteal cleft with 3 incisions; one over the sacral hiatus and the 2 electrodes were sutured and tied together. On the gluteal incisions we used an extended length silastic anchor that allowed reinforcement and mobility, we placed the IPG system in the usual spot above the gluteal muscles below the iliac crest.
Neuromodulation of the Sacral Nerve Roots
The patient had very good pain relief and had no issues with migration or movement. I have had many years’ experience with neuromodulation of the sacral nerve roots and it must be considered as an important part of some of the patients that fail to respond to lesser measures. The pain of pelvic origin can be extremely severe; one of the patients that responded very nicely to the hydrodissection after multiple abdominal surgeries was bedridden for 6 years. The patient reported “I would have killed myself if I knew how”. The above described approach short of neuromodulation resulted in the patient regaining mobility, activity and satisfaction in life.
Neuromodulation does not approach pathology and the recovery of the EMG in the last patient that chose hydrodissection is worthy of consideration prior to neuromodulation. Furthermore, repeat neuropathic pain with pudendal nerve involvement has been gratifyingly helpful in the increasing duration of procedures where one of these patients recently went 2 ½ years before repeating the procedure. As mentioned before hydrodissection should not be performed with sharp needles. Intraneural injections can travel a long distance longitudinally into the spinal cord as was shown by the great work and co-worker with Alon Winnie and Doug Selander.
