I can't say I am too clear about where I am at, other than I'll probably be having another MRI soon.
I have had a response to your questions from surgeon, as follows:
Q: What dose of anaesthetic and steroid was given and was this a “stronger” dose? - The two injections in the past have not affected the pain experienced when she sits down and this one did. Why? Also, why did the pain she gets when she sits down never go away after her hip arthroscopy?
A: 2ml Depo-medrol 80mg and 8ml of Marcaine. I wouldn’t call that a strong dose but a normal dose for a hip injection. I am not sure if Louisa is referring to the two previous hip injections that she has had in the past or to the hamstring injections. If she is referring to the hamstring injections then I would conclude that the hamstrings are not causing the problem. If I knew exactly why the original pain had never completely disappeared I would be able to treat it, but unfortunately her response is not a typical response that is seen in the majority of the hip arthroscopy patients with this type of pathology and therefore more difficult to pin down.
Q: Louisa’s range of motion is quite good. Would this be expected if she has developed scar tissue?
A: The number of patients that I have treated so far with adhesions post hip arthroscopy is very small. But in the group with this problem I didn’t feel that a reduction in ROM was the problem. Because we are talking about 1-2% of the hip arthroscopies as a group it is too small to see patterns and be able to identify possible causes for residual problems.
Q: The effect of the recent injection lasted no more than 4 hours. You said it would possibly last for 5-6 hours. Is this because Louisa’s pain is now so chronic and nothing will have a longer-lasting effect?
A: Each patient’s reaction to an anesthetic is individual. If I specify 5-6 hours then this means that this can be expected in the majority of patients, but it can last a shorter or longer amount of time as well and we have no way of knowing this with each patient. Chronic pain is unfortunately much more difficult to resolve because the permanent stimulus to the nerve roots telling the brain that there is pain might still continue even though the original problem has been solved.
Q: Louisa said that the injection took away the pain she feels when she sits down and was replaced by a sensation of deep-seated “itching” within her hip. Does this tell you anything?
A: It tells me that there could be an intra-articular cause which is at least partially responsible for her pain.
Q: Do you feel that Louisa has some residual impingement, or has she likely developed scar tissue?
A: That I can’t answer at this moment. As I discussed with her, if we felt that the injection gave her a positive response (i.e. blocked the pain), which I think she has had, at least partially, it would probably be a good idea to re-scan her hip.
I would say that the diary of symptoms over the past week is what could be expected from the effect of the local anesthetic firstly, and then subsequently, when the steroid kicks in, her symptoms start to improve again.
Q: Louisa has noticed that her gluteus on the right side seems to increase and decrease in size and she is able to induce “impingement” symptoms in the right hip herself in some positions. Can you explain this?
A: What Louisa is able to induce is pain, but there is no evidence at present that this is “impingement” and this should not automatically be assumed.
Q: Louisa seems quite convinced that there is some residual impingement remaining. Is this a possibility?
A: We have discussed in clinic how I treat a pincer abnormality and I have confirmed that she doesn’t have a coxa profunda, which is the more global-type of over-coverage.
I assessed the zone where Louisa had a wave sign and then decompressed the acetabulum in the area of unstable cartilage followed by a labral repair. Assessment of the impingement is done dynamically during the operation.
Can there still be residual impingement? - nothing is impossible; however her outcome scores and assessment do show that she is deviating from the pattern that the standard group of patients with this type of pathology follow (call it disproportionate symptoms) and we therefore have to start to look realistically at would could be achieved with further surgery if permanent stimulus to the nerve roots continues.
I hope the above information is of some help. If you are amenable to a re-scan I can ask the MRI department to arrange an appointment with you. I know you said that you were not keen on another arthrogram, but your surgeon would not consider a second arthroscopy without a scan, as the results of the scan will be important in deciding further appropriate treatment options if something does show up. I understand it is difficult and frustrating for you not to have a definitive answer, but I think he has been as informative as he can at this stage. If you have a think about things over the weekend and let us know if you would like an MRI scan arranging.