Digesting the Moose Jaw adventure: Part II (NERVES, baby..)

This is the third in a series of digestion posts about the Neuropathic Pain Conference in Moose Jaw this weekend. Today is the day after.

Here is the intro post.
Here is Digestion Part I.

This post is about how nerves were discussed.
Yay! Nerves! Finally discussed as if they actually existed and can have feelings!

SAPHENOUS NERVE

My ears first pricked up when Dr. Squire described a patient with persisting medial knee pain, way long-time post-op arthroscopy. She asked for ideas on what it might be. I suggested it might be irritation of the saphenous nerve secondary to minor damage caused by the arthroscopy. She agreed.

From Thieme

CLUNEAL NERVES? OR ILIOHYPOGASTRIC?

WikimediaCommons

A bit later she talked about cluneal nerves, and my ears pricked up. She was pointing to a spot directly lateral at the top of the iliac crest, and calling that a cluneal nerve. I had to object. I said, out loud, "I think you're pointing to iliohypogastric nerve - I think the cluneal nerves are further posterior." A guy sitting behind, a family physician who does trigger point injecting, spoke up in support of her, even had a picture to show me that showed the cluneal nerves coming out the sides of the pelvis, not the back.


ILIOHYPOGASTRIC NERVE
Iliohypogastric nerve comes out the side over iliac crest, with subcostal just in front, and a bit more superiorly, as in this picture to the right.


Iliohypogastric nerve supplies the skin on the side of the pelvis, while cluneal nerves drape down over the back of it, supplying skin at the top of the buttock.

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SUPERIOR CLUNEAL NERVES
See also this image of superior cluneal nerves (below). It shows cluneal nerves further back, posterior to iliohypogastric.

Via http://jiepou.shmu.edu.cn/

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Anyway, I insist I'm less wrong than they, about this. They inject, I don't. One wonders what exactly they think they are injecting...
Have I ever mentioned how against needling for pain I am? Or injecting stuff into other stuff? Unless it's to get a tooth pulled? Or a nerve literally frozen in order to stop its activity and have a surgical procedure (a life-saving surgical procedure!) done? 
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AXILLARY NERVE
A woman attending volunteered to have sensory testing done as a demo to the audience. She fell ten years ago and wrenched her upper limb. To this day she has pain on the outside of that arm, and her movement is restricted.

There was a practical small group session where we practiced asking each other questions related to neuropathic pain. I overheard Squire talking to a table about meralgia paresthetica, entrapment of lateral cutaneous nerve of the thigh, and I guess my ears must have gone straight up in the air, because she spotted me and came over and asked me what I thought. I said I thought it might be axillary nerve entrapment. She asked me how I would know. I said, there would be a very sore spot in the region of the posterior axilla, and her movement would be restricted at the shoulder.

I didn't know that her next move would be to invite me up on the platform to observe the woman's movement or to test her tender spot, but that's exactly what happened. And I was given the mike to explain the quadrilateral space through which the nerve emerges, which can scissor against it.
I did my best. I was nervous and felt like a bit of a smarty-pants being hauled to the front of the class. But nothing bad happened. I do think I got one of the muscular boundaries of the quadrilateral space wrong; however I don't think enough people in the room knew what I was talking about to even stop and correct me. 

Right scapula, quadrilateral space, axillary nerve, lateral cutaneous branch to outside of upper arm
Wikimedia Commons

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MY PRESENTATION

I had to zoom through it 3 times in three half hour slots.

People seemed interested but it was really hard to know where the material landed and how. There were a number of comments and questions. I was feeling pretty jangled, actually. It was just me, not anything whatsoever to do with the organizers, who could not have been more gracious and helpful and supportive.

One guy, an MD, an injector type I'm sure, asked me, "Isn't what you're doing the same thing as myofascial release?" I said, "No." He said, "Then what are you doing?" I replied, "Lateral skin stretch." He said, "But isn't it the same?" I replied, "Fascia doesn't release." Someone else asked something and we moved on.

I summed it up by saying that even though my layout and connecting of dots was merely conjecture at this point, and the only evidence consisted of a tiny case series with modest display of help over an 8-week post treatment period, I thought that my explanatory model was less wrong than others floating around out there in manual therapy land.

That was about all I had the nerve to say about that. I hope it was enough.

One very thoughtful guy in front seemed pretty interested in the cutaneous rami angle. Maybe something can come from that. I guess we'll find out some day. Or not.

A few people came up later and wondered if they could have a card. I think the people there who actually have pain might be somewhat interested in checking out treatment some day. I'm certainly available. And I'm willing to travel.




Next post - sensory testing.