Neuropathic pain, resulting from an irritated or damaged nerve is normally classed as “chronic”. The levels of pain experienced though, can be classified as extremely intense, very acute and are often extremely debilitating. Patients experience this kind of pain at reported levels of between 8-10, on a pain scale of 1-10. This kind of pain is completely incompatible with leading any semblance of a normal life, both physically and mentally. Patients have trouble concentrating, loose the desire to participate in their usual activities and start to completely isolate themselves socially.
Endometriosis of the sciatic nerve falls precisely into this category of neuropathic pain. Patients suffering from endometriosis know very well what severe pain is but can generally manage their symptoms quite well with a combination of painkillers and hormones and/or a surgical procedure. Although painful, these symptoms can in no way be compared with what is experienced in the case of an endometriosis of the sciatic nerve. This type of pain is so much worse and more extreme in nature, gets even more acute during menstrual periods and strong morphine-based pain medications bring only partial relief, if any. Attempts to treat this type of pain with hormonal preparations may, in some cases, provide a little relief from pain but will not treat the underlying cause and so allow the disease to spread further, undisturbed. Patients suffering from endometriosis of the sciatic nerve will gradually retreat from leading a normally active life, not only as a result of the pain and side effects of the prescribed medication but as a result of the disease itself. Such patients have often been left very much alone with their fate for years: gynecologists will treat abdominal pain but not neuropathic pain. Pain originating deep within the pelvis and radiating down the legs, possibly as far as the feet, is not something most gynecologists are familiar with.
Endometriosis of the sciatic nerve is slowly becoming more recognizable in the field of gynecology – particularly amongst those gynecologists with training in the specialist field of endometriosis. Yet still, it is far too often dismissed as a complete rarity – which it most definitely is not. Patients experiencing these symptoms, where the pain radiates down the legs, will often seek out a specialist in neurology, orthopedics or neurosurgery. These specialists are well versed in neuropathic pain; however, they are not in a position to treat endometriosis. When it comes to treating this unusual form of endometriosis, we find the exact same problem. Neurosurgeons do indeed operate on the sciatic nerve. Their access to the nerve is approached externally via the buttock however, and as such, is quite removed from the pelvis region. Endometriosis of the sciatic nerve develops within the pelvis itself though, an area neurosurgeons are not usually familiar with and where they cannot operate – they are unable to operate through the pelvic bones after all!
By contrast, gynecologists, general surgeons and urologists all do operate in the pelvic region but are unfamiliar with procedures on the nerves and usually have trouble even locating the sciatic nerve. This region remains a real “no man`s land” in the field of pelvic surgery. Since endometriosis of the sciatic nerve can be aggressively damaging, over time it will start to attack the nerve itself and sooner or later will cause neurological impairment, producing:
If left untreated, the pain as well as the neurological symptoms, will deteriorate and in time will become permanent. Eventually, MRIs of the spine are carried out to try to determine the cause of the symptoms but nothing conspicuous is found and yet the patient is left still suffering terribly. Despite the pain growing constantly more excruciating (comparable to the pain of a dental drill without anesthetic!), no one can ascertain why. Perhaps an exploratory laparoscopy is suggested but if the surgeon is not well versed in the anatomy of the pelvic nerves he/she will likely not find anything and worse still, may remove the womb in the belief that this will solve all the problems. Yet, the patient`s symptoms continue unchanged, as before. The pain therapist will prescribe ever-stronger medication in the hopes of alleviating the symptoms, yet the patient becomes more and more dependent on them and suffers the consequences.
Neuropelveology is a relatively new branch of medicine offering the possibility to diagnose and treat unexplained chronic pelvic pain and any associated organ dysfunctions. The symptoms of this disease are varied and may present as lower back pain (lumbar region), pain may be felt in the genital area and buttocks. Often the nerve pain will radiate down the legs (sciatica) and can sometimes be felt as far down as the feet. Symptoms may also include disorders of the pelvic organs such as the womb, ovaries, bladder and bowel. The concept of Neuropleveology was first introduced more than 10 years ago and focuses on the origin and nature of these complaints specific to the pelvic nervous system. Neuropelveology combines the knowledge required for a proper neurological diagnosis for intractable sciatic pain and offers viable treatment solutions.
Chronic pelvic pain syndrome (CPPS), Sciatic Pain (SP) and Chronic Low Lumbar Pain (LLP) are conditions, which are extremely common amongst the general population. These complaints are frequently encountered in clinical practice and affect between 10% and 39% of the population. Most patients have a variety of additional ”associated” problems, including bladder or bowel dysfunction, sexual dysfunction and other systemic or constitutional symptoms. Because of the stigma and social isolation of these patients, it is not surprising that other associated problems may co-exist, such as depression, anxiety and prevalence for drug dependency. These pain conditions present a major challenge to healthcare providers because of their often-unclear origin, complex natural history and poor response to therapy. These sufferers will often approach several doctors and specialists in the hopes of finding relief. It can be an off-putting and long process as one failure after another can dash any hope of a permanent solution to their problem. In such cases, the goal then becomes to merely manage the pain and symptoms without ever seeking to investigate the root causes. Patients end up with widely varying diagnoses, depending on the particular specialty of the doctor they consult: “Idiopathic Sciatic Pain” or Chronic Low-Back Pain”, “Chronic Prostatodynia”, “Interstitial Cystitis”, “Vulvodynia” or “Irritable Bowel Syndrome” also known as IBS. With such diagnoses, patients are often sidelined and must content themselves to accept medical pain management and antidepressants, with their known side effects and risk of dependency, for the rest of their lives.
Sciatic pain of unknown origin is commonplace: the symptoms of which can include tingling, numbness and loss of feeling, weakness in the lower back, buttocks and legs, and which has not been pinpointed to any traceable spinal cause. This scenario is rather widespread, with many patients not being able to achieve an accurate diagnosis of why they are experiencing pain and symptoms. “Pseudo-sciatica” of undetermined causes, is diagnosed when there are definitely no spinal sources responsible for causing the symptoms, yet a chronic expression is present. In these circumstances, no structural or non-structural cause has been verified as the source responsible for causing the sciatica. In precisely such cases, where the cause of the sciatica is of unknown origin, careful and thorough investigation of the portion of the sciatic nerve which lies within the pelvis and/or of the nerve roots of the lower spine, may offer an explanation as to the origins of the pain and the associated pelvic organ dysfunction. As yet though, this in-depth approach is still largely unknown in modern medical practice and training. This is all the more surprising, if one considers the variety of conditions affecting the pelvis region and also the many invasive procedures, which are carried out in close proximity to the pelvic nerves that could potentially induce compression or entrapment of the nerves or damage them in other ways. The number of such cases of pelvic nerve conditions is widely underestimated, mainly because of a lack of awareness that such lesions can exist and a failure to diagnose them appropriately. In the established field of neurosurgery the techniques for dealing with nerve lesions of the upper limbs are tried and tested but as yet, surgical exploration of the pelvic nerves remains largely uninvestigated by neurosurgeons.
The only well-investigated pelvic nerve condition is pudendal neuralgia (Alcock´s Canal Syndrome) because this nerve is easily accessible for exploration and surgical decompression. By contrast, the nerves of the pelvis are notoriously difficult to access and have been less well investigated in the past. Based on recent findings in pelvic anatomy and the introduction of laparoscopy in the visualization and dissection of the pelvic nerves, Marc Possover developed the concept of “Neuropelveology”, the first medical practice focused on the conditions of the pelvic nervous system. Neuropelveology combines all the knowledge required for a proper neurological diagnosis for intractable Sciatic Pain and other Chronic Pelvic Pain Syndromes of “unknown origin” (Possover M, Forman A, Rabischong B, Lemos N, Chiantera V. Neuropelveology: New Groundbreaking Discipline in Medicine. J Minimally Invasive Gynecology 2015;22(7):1140-1).
Due to a growing interest from the medical community, the International Society of Neuropelveology (ISoN) (www.theison.org) was founded in 2014, with one major objective; to provide universal access to education in Neuropelveology. The neuropelveological approach to pelvic conditions may not only explain many cases of Sciatic Pain Syndrome of unknown origin but also enable new treatment options. (Zanatta A, Rosin MM, Machado RL, Cava L, Possover M. Laparoscopic dissection and anatomy of sacral nerve roots and pelvic splanchnic nerves. J Minim Invasive Gynecol 2014;21(6):982-3), providing the necessary visibility with magnification of the structures and possibility to work with appropriate instruments for adequate neurofunctional procedures such as nerve decompression and neurolysis (Possover M, Forman A. Pelvic neuralgias by neurovascular entrapment: anatomical findings in a series of 97 consecutive patients treated by laparoscopic nerve decompression. Pain Physician 2015;18(6):1139-43. - Lemos N., Possover M. Laparoscopic approach to intrapelvic nerve entrapments. J Hip Preserv Surg 2015; 2:92-8. - Possover M, Schneider T, Henle KP. Laparoscopic therapy for endometriosis and vascular entrapment of sacral plexus. Fertil Steril 2011;95:756-8).
For obvious reason, such complex laparoscopic procedures should be reserved for highly experienced surgeons; however, the diagnosis of pelvic nerve conditions in every day practice is accessible for all doctors! It is absolutely essential to adopt a “neurological way of thinking” here. Standard medical training teaches the concept that the location of the pain and its causes are to be found in the same location. In the case of the pelvic nerves however, the location of the patient’s pain may not necessarily correspond to the source of the pain and in fact, often doesn`t. A thorough examination and diagnosis will reveal precisely which nerves, at which level, are involved in generating the pain symptoms.
The guidelines for diagnosis always follow these 5 steps: (Possover M, Forman A. Neuropelveological assessment of neuropathic pelvic pains. Gyneco Surg 2014; 11: 139-144):
1. Is the pain coming from the internal organs or from the nerves?
2. Which pathways are involved in carrying the pain signals to the brain?
3. Determining the precise location of the origin of the pain ie. pelvis , spinal cord or brain
4. Establishing possible root causes
5. Confirmation of the diagnosis and neuropelveological treatment plan
Steps 1 to 3 are achieved by looking at the patient`s history so far and a physical, neurological examination of the pelvic nerves can confirm any diagnosis. Since Neuropelveology is now accessible for all physicians, it is no longer acceptable to ignore the condition of the pelvic nerves as a potential cause for Chronic Pelvic Pain Syndrome, Sciatic Pain and Lower Lumbar Pain.
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