The Effect of Local Analgesia on Postoperative Gluteal Pain in Patients Undergoing Sacrospinous Ligament Fixation
The Effect of Local Analgesia on Postoperative Gluteal Pain in Patients Undergoing Sacrospinous Ligament Fixation
This study will randomize patients to either receive intraoperative administration of local
 anesthetic and corticosteriod at time of sacrospinous ligament fixation compared to placebo
 to determine if intraoperative trigger point injection (TPI) improves postoperative gluteal
 and sciatic pain scores along with use of narcotic pain medications.

 There is a paucity of data examining interventions to potentially ameliorate the
 postoperative gluteal pain often associated with sacrospinous ligament colpopexy. Our study
 aims to determine if a compounded TPI improves postoperative pain scores and minimizes use of
 narcotic pain medications by 20% compared to controls.
Sacrospinous ligament fixation (SSLF) is commonly performed to treat apical prolapse. Pelvic
 organ prolapse (POP) is a complaint for which as many as 11% of women seek surgical
 intervention in their lifetimes (2). SSLF is associated with shorter operating time, improved
 patient recovery time, fewer complications and decreased costs compared to an abdominal
 approach (3).This procedure is associated with postoperative nerve pain in 6.1% to 15.3% of
 SSLF procedures, due to impingement of the S3 to S5 nerve roots that course over the
 mid-portion of the coccygeus muscle-sacrospinous ligament (C-SSL) complex (1). 89% of the
 nerve fibers to the coccygeus and/or levator ani muscles (S3) course over the midportion of
 the C-SSL complex, just proximal to the intended location for suspension (4). This resulting
 nerve entrapment or injury may then lead to gluteal and perineal pain, parasthesias and
 muscle weakness (1). This pain may persist 6 weeks in up to 15% of patients,but most patients
 can be managed with conservative therapies, such as medications, TPIs and/or pelvic floor
 physical therapy (3).

 A myofascial trigger point is a hyperirritable area in skeletal muscle that is painful on
 compression and can give rise to characteristic referred pain and tenderness, motor
 dysfunction and autonomic phenomena (5). TPIs are a treatment used in cases of chronic
 myofascial nerve pain and involve injection of the involved muscle(s), typically with local
 anesthetics and corticosteroids (5). The mechanism of action of TPIs occurs by mechanical
 disruption of abnormal contractile elements, dilution of nociceptive substances by the
 infiltrated anesthetic, and induction of muscle fiber trauma that subsequently releases
 intracellular potassium. Additionally, injections interrupt the positive feedback loop that
 perpetuates pain and a vasodilatory effect of anesthetic helps to remove excess metabolites
 (5). The benefits of this local combined pain control method are two-fold: the local
 anesthetic offers rapid pain relief for several hours while the corticosteroid provides
 delayed pain control, often lasting three to five weeks (6). The use of such local analgesia
 is not typically standard of care at the time of a sacrospinous ligament fixation, but may be
 a helpful adjunct therapy.

 A recent case report noted significant improvement in a patient's pelvic pain after she
 received three therapeutic pudendal nerve perineal injections using the combination of a
 local anesthetic and steroid (bupivicaine 0.25% and triamcinolone 40 mg); two injections were
 placed at the ischial spine and one in Alcock's canal (7). Similarly, another randomized
 controlled trial found that injection of slow-release corticosteroid (triamcinolone) and
 lidocaine in the anatomic region around the sacrospinous ligament's insertion on the ischial
 spine (i.e., also in the area of SSL colpopexy) significantly reduced pain intensity and
 number of pain locations in women with persistent, debilitating sacral low back pain, even
 spanning up to two years after pregnancy and childbirth (8).

 There is a paucity of data examining interventions to potentially ameliorate the
 postoperative transient gluteal pain often associated with sacrospinous ligament colpopexy.
 The only comparable study to date examined the injection of 0.25% bupivicaine at the time of
 sacrospinous ligament colpopexy and found that such an intervention did not reduce patient's
 perceptions of postoperative gluteal pain, but did potentially reduce the need for medication
 after surgery (1). Our study aims to determine if a compounded TPI (9cc 0.5% marcaine and 1cc
 Kenalog) improves postoperative gluteal pain scores and minimizes use of narcotic pain
 medications in the postoperative period.
Inclusion Criteria:

 -  21yo or older

 -  English speaking

 -  Stage II or greater pelvic organ prolapse

 -  Sacrospinous Ligament Fixation (SSLF) used as apical suspension

 -  SSLF scheduled to be performed by Dr. Janelle Evans or Dr. Marc Ashby

 Exclusion Criteria:

 -  Under 21yo

 -  Non English speaking

 -  Patient consented, but SSLF not performed at time of surgery

 -  Patient on chronic opiates preoperatively (greater than three months of use)

 -  Contraindication to Marcaine or Kenalog

 -  Prisoners and those involuntarily confined

 -  Patients with cognitive impairment or those using a legally-authorized representative

 -  Hysterectomy performed at time of suspension