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Re: radiating pain after appendectomy

Posted By W. D. on May 06, 1999 at 10:52:07
My sister began experiencing right sided pelvic pain which didn't carry the classic symptoms of appendicitis.  After an ultra sound and a cat scan she had a colonoscopy which revealed an area of the colon which seemed to exhude some fluid.  She had the appendectomy done laparascopicaly about five weeks ago.  The doctor resected a portion of the bowel that seemed thickened along with taking out the appendix...he also cut down adhesions which had resulted from a previous ectopic pregnancy.  Two weeks after surgery my sister still had sharp right sided pain and in addition pain in her right side cheek and pain traveling to three areas of her thigh down to knee.  At first surgeon dismissed problem and told her to do stretching exercises. Pain persisted, he referred her to a neurologist. Her right leg made no movement when hit to test reflex. It is now five weeks after surgery.  Pain continues and is more intense and right leg feels a little weak.  She has had another CAT Scan and just had an MRI done.  The neurolgist said that if MRI shows nothing, he would do nothing more than put her on nerve medicine.  Is there another test that could diagnose the source of her difficulty.  She is a flight attendant with 27 year seniority who will never be able to go back to work in this shape.  

6 Responses
Avatar universal
Posted By CCF MD mdf on May 06, 1999 at 11:41:04
Sounds like a "pinched nerve" at the lumbosacral spine, probably around L2-3-4 given the distribution of the pain and absence of knee jerk.
The surgical exploration or instrumentation itself would not have damaged anything there. However, if your sister had degenerative spine disease (wear and tear, quite common and quite probable as a pre-existing condition), lying on the operating table may have led to compression of the nerve root at the point where it exits the spine.
An MRI of the lumbosacral spine should show whether there is much disc bulging or other sign of wear and tear. I wouldn't be a bit surprised if mild degen changes are shown, but there may not be much more than that. Occasionally you find a real herniated (not just bulging) disc and sufficient debris to be convinced of the source of compression injury.
If degenerative spine disease is extensive, she may wish to see a spine surgeon but be sure you know all your options prior to consenting to surgical decompression. In any case, physical therapy is often quite helpful. Certain medications like nortriptyline (an old antidepressant) can be very useful for chronic pain even if depression has nothing to do with the problem.
I hope this helps. As you know, this information is provided for educational purposes only. Any comment regarding diagnosis, prognosis, and treatment options must come from your physician after appropriate evaluation. CCF MD mdf.

Avatar universal
Posted By W.D. on May 06, 1999 at 12:26:01
Thank you doctor for your response.  Just spoke to my sister and the MRI of the lumbar spine came back all normal.  Could this problem with the leg be caused by the nerve being pinched or hurt once it has left the spine?  This morning she reports that in addition to the thigh pain, her leg is tingling down to her foot.  

Avatar universal
Posted By CCF MD mdf on May 06, 1999 at 13:02:43
A normal MRI does not mean the nerve root couldn't be irritated and cause pain and tingling. But it does mean that there isn't anything ugly that might require surgical decompression (in the spine). This is a situation which is likely to improve with PT and/or medications such as what I mentioned.
One other thing that I didn't mention the first time. There is a small nerve which travels in the shallow surface under the skin and supplies sensation to the front and side part of the thigh (lateral femoral cutaneous nerve). It travels under the inguinal ligament - feel the junction between your leg and your pelvis in the front - that's where it is. In some people, that gets smashed and you get numbness on the front and side of the thigh, NOT below the knee, and not in the back of the thigh. That is called meralgia paresthetica, and it is completely harmless (if a bit annoying). The thing is, it usually doesn't result in pain, and there is never any weakness (no motor fibers are in that nerve, and nothing else branches off it). Knee reflex would not be lost.
Meralgia paresthetica has nothing to do with degenerative spine disease or pinched nerve roots or even any other nerve compression syndrome. It just happens that that nerve is so vulnerable that it is a common problem. Pregnancy, obesity, perhaps abdominal surgery in the right circumstances. If this pattern seems to fit, get a neurologist to confirm it so you can know and not worry about it. If symptoms are bothersome, I usually suggest nortriptyline or similar medications.
I hope this helps. CCF MD mdf.

Avatar universal
Posted By W.D. on May 08, 1999 at 05:37:00
Doctor, I don't know if you will go back this far.  Yesterday the neurologist my sister went to put her on Neurontin 3X a day and said he would see her in a month.  He said there was nothing more that could be done, time would tell.  Can you tell me what the difference between Neurontin and the Nortryptyline you mentioned is?  He didn't recommend P/T.  If there is to be recovery from this problem, does it take weeks, months, years.  Is there any chance that adhesions could have formed so quickly that might be causing her pain?  I guess it is just hard to accept that there isn't more that can be done.  Thanks for the valuable info in your previous responses.

Avatar universal
Posted By CCF MD mdf on May 09, 1999 at 13:16:34
Neurontin is gabapentin, which is a medication originally designed as an anti-seizure medication. It turns out that it helps people with numbness, tingling, and pain from nerve compression injury. It's not perfect, but it is in my list of medications to use.
Neurontin is not the same as nortriptyline. The mechanism of action is probaby different, and if one does not work, then the other one (or related) should be tried.
If you are not sure whether PT should be tried, ask the doctor. If you get a well-considered rational answer, then you can make your decision what to do next based on that. If you are not certain you have all the answers, a second opinion is a reasonable thing to seek.
I hope this helps. CCF MD mdf.

Avatar universal
Posted By W.D. on May 11, 1999 at 19:17:26
Thank you for your responses.  I don't know if you will see this last one, but I do have one more question.  The neurologist my sister saw has diagnosed her problem as Traumatice Lumbar Radiculopathy.  He said it is a pinched nerve.  The MRI was normal.  He said it is a result of the surgery and indicates that there is no reason to do an EMG or any other test because there's nothing that can be done.  On the chance there's been injury or some kind of entrapment of the femoral nerve or any other nerve, maybe from an adhesion, would there be any advantage to pursuing this with any other tests.  I have offered to bring my sister who lives in NYC (I live in PA) to Cleveland Clinic or U of P or really anywhere there's a possibility of a better chance for her returning to normal and somehow I feel time is ticking here.  Thank you so much, doctor.

Follow Ups:

Re: radiating pain after appendectomy CCF MD mdf 5/12/1999

radiating pain after appendectomy W.D. 5/31/1999

Re: radiating pain after appendectomy W.D. 7/05/1999

radiating pain after appendectomy CCF MD GS 7/20/1999

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