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Pelvic and Perineal Pain Due to inflammation in the Lumbosacral Epidural Space

Fabricio Dias Assis on March 1, 2020 at 11:35 am
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    • Fabricio Dias AssisFabricio Dias Assis
      Joined: Sep 6, 2016
      Posts: 5

      Wanna share a case of a 58 y/o female who presented a history of pelvic and perineal pain for the last 3 years. VAS 8/10. The pain was worse in the perineal area, bilateral, but mainly left sided, from the vulvar region running into the vagina and pelvic area. The patient complained also of dyspareunia and dysuria. Low back pain was a secondary complain. The patient had been in many urologists and gynecologists during this period, made lots of image and functional urogeninital exams that did not show anything that could explain her pain. A comprehensive sensory and motor neurological examination of the lumbar and sacral nerve roots was carried out with any abnormal findings. The patient had a decreased range of motion of the lumbar spine, pain and limitation on its flexion, and a very painful palpation around the lumbosacral midline area. Lumbosacral MRI showed the presence of S1-S2, S2-S3 and S3-S4 discs. All the discs from L1-L2 to S3-S4 had a preserved height (including the sacral ones that were similar to the lumbar) with a Pfirmann classification between C and D.
      The patient was first submitted to a x-Ray guided Superior Hypogastric Plexus + Impar Ganglion block with 20% pain relief.
      In the next day the patient came back and a x-ray guided pudendal nerve injection was performed. The patient got completely anesthetized around the pain area but with not pain relief. A caudal epidurogqram was the carried out followed by an epidural block. The epidurogram showed a whole left sided filling effect, from S4 all the way up to the lumbar roots. After the injection of Ropi 0,2% + Depomedrol 80mg 20cc the patient had 80% pain relief that lasted for few days.
      Pelvic and perineal pain are many times a very challenging condition to treat. We have to keep in mind that not only local problems could be the source of pain. Maybe an epidurogram should be a very important diagnostic tool to be addressed in this group of patients.

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