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Pratka HW, Martinez M. Anterior Cutaneous Nerve Entrapment Syndrome Presenting as Chronic Abdominal Pain. Cureus 2024; 16:e74921. [PMID: 39742162 PMCID: PMC11687920 DOI: 10.7759/cureus.74921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2024] [Accepted: 12/01/2024] [Indexed: 01/03/2025] Open
Abstract
Abdominal pain is one of the most common chief complaints that patients present with to healthcare facilities across specialties. Unfortunately for clinicians, the differential diagnosis for abdominal pain is vast. Abdominal pain can be broken down into two broad categories: visceral and non-visceral causes. One of the most common causes of non-visceral abdominal pain is anterior cutaneous nerve entrapment syndrome (ACNES). This report describes the case of a formerly active male in his 20s, who has been suffering from chronic abdominal pain for half of his life. Because of the broad differential and the overall lack of familiarity with ACNES, many patients face prolonged suffering and the psychological anguish of uncertainty. This report seeks to illuminate the importance of considering ACNES in a patient with chronic abdominal pain.
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Affiliation(s)
- Holden W Pratka
- Anesthesiology, Baylor Scott and White Allsaints, Fort Worth, USA
| | - Mike Martinez
- Anesthesiology, Baylor Scott and White Allsaints, Fort Worth, USA
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ten Have T, Jacobs MLYE, Scheltinga MRM, Zwaans WAR, Roumen RMH. Long-Term Efficacy of Posterior Neurectomy in Anterior Cutaneous Nerve Entrapment Syndrome. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2024; 3:13508. [PMID: 39421025 PMCID: PMC11484248 DOI: 10.3389/jaws.2024.13508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 09/11/2024] [Indexed: 10/19/2024]
Abstract
Objective To analyze long-term treatment outcomes of a posterior neurectomy in a large cohort of patients with anterior cutaneous nerve entrapment syndrome (ACNES). Summary Background Data The current step-up treatment approach for ACNES involves abdominal wall tender point injections, pulsed radiofrequency, and neurectomy. If an anterior neurectomy fails or pain reoccurs, a posterior neurectomy is considered as a final surgical option. Data on posterior neurectomy treatment outcomes are scarce. Methods ACNES patients who underwent a unilateral posterior neurectomy between 2012 and 2022 in a single institution completed a questionnaire regarding their current pain status. Primary outcomes were short- and long-term treatment success, defined as ≥50% pain relief. Patients were stratified whether the operative indication was recurrent pain (>3 months) after an initially successful anterior neurectomy or ongoing pain after an anterior neurectomy. Results Data from 260 of 379 patients (77% female, mean age 42 years) were analyzed (68.6% response rate). Sensitivity analysis found that short-term outcomes were similar between responders and non-responders. The recurrent pain group demonstrated significantly better treatment outcomes compared to the ongoing pain group, both in the short-term (7 weeks; treatment success 79.2% vs. 53.2%, p < 0.001) and long-term (58 months; treatment success 61.1% vs. 42.0%, p = 0.001). Sixteen (minor) complications (6.2%) were reported, resulting in three surgical re-interventions (1.2%). Conclusion A posterior neurectomy is long-term beneficial in approximately half of patients although treatment success is better for recurrent pain than ongoing pain. These findings aid in optimizing preoperative patient counseling.
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Affiliation(s)
- Tom ten Have
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
- SolviMáx, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands
| | - Monica L. Y. E. Jacobs
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
- SolviMáx, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands
| | - Marc R. M. Scheltinga
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
- SolviMáx, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, Netherlands
| | - Willem A. R. Zwaans
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
- SolviMáx, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands
| | - Rudi M. H. Roumen
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
- SolviMáx, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, Netherlands
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Saito Y, Takeuchi H, Tokumine J, Sawada R, Watanabe K, Yorozu T. Ultrasound-guided peripheral nerve blocks for anterior cutaneous nerve entrapment syndrome after robot-assisted gastrectomy: A case report. World J Gastrointest Surg 2024; 16:2719-2723. [PMID: 39220055 PMCID: PMC11362933 DOI: 10.4240/wjgs.v16.i8.2719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 07/17/2024] [Accepted: 07/23/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Anterior cutaneous nerve entrapment syndrome (ACNES) is a condition manifesting with pain caused by strangulation of the anterior cutaneous branch of the lower intercostal nerves. This case report aims to provide new insight into the selection of peripheral nerve blocks for the ACNES treatment. CASE SUMMARY A 66-year-old woman manifested ACNES after a robot-assisted distal gastrectomy. An ultrasound-guided rectal sheath block was effective for pain triggered by the port scar. However, the sudden severe pain, which radiated laterally from the previous site, remained. A transversus abdominis plane block was performed for the remaining pain and effectively relieved it. CONCLUSION In this case, the trocar port was inserted between the rectus and transverse abdominis muscles. The intercostal nerves might have been entrapped on both sides of the rectus and transversus abdominis muscles. Hence, rectus sheath and transverse abdominis plane blocks were required to achieve complete pain relief. To the best of our knowledge, this is the first report on use of a combination of rectus sheath and transverse abdominis plane blocks for pain relief in ACNES.
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Affiliation(s)
- Yukiko Saito
- Department of Anesthesiology, Kyorin University School of Medicine, Tokyo 181-8611, Japan
| | - Hirohisa Takeuchi
- Department of Surgery, Kyorin University School of Medicine, Tokyo 181-8611, Japan
| | - Joho Tokumine
- Department of Anesthesiology, Kyorin University School of Medicine, Tokyo 181-8611, Japan
| | - Ryuji Sawada
- Department of Anesthesiology, Kyorin University School of Medicine, Tokyo 181-8611, Japan
| | - Kunitaro Watanabe
- Department of Anesthesiology, Kyorin University School of Medicine, Tokyo 181-8611, Japan
| | - Tomoko Yorozu
- Department of Anesthesiology, Kyorin University School of Medicine, Tokyo 181-8611, Japan
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Ten Have T, Zwaans WAR, Scheltinga MRM, Roumen RMH. Lidocaine patch as noninvasive alternative treatment option in children with anterior cutaneous nerve entrapment syndrome: A retrospective case series. Paediatr Anaesth 2024; 34:638-644. [PMID: 38572969 DOI: 10.1111/pan.14890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/13/2024] [Accepted: 03/19/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Chronic abdominal pain in children is occasionally caused by anterior cutaneous nerve entrapment syndrome (ACNES). Diagnosing and treating this typical peripheral abdominal wall neuropathy is challenging. Management usually starts with minimally invasive tender point injections. Nevertheless, these injections can be burdensome and might even be refused by children or their parents. However, a surgical neurectomy is far more invasive. Treatment with a Lidocaine 5% medicated patch is successfully used in a variety of peripheral neuropathies. AIMS This single center retrospective case series aimed to evaluate the effectiveness and tolerability of lidocaine patches in children with ACNES. METHODS Children aged under 18 diagnosed with ACNES who were treated with a 10 day lidocaine patch treatment between December 2021 and December 2022 were studied. Patient record files were used to collect treatment outcomes including pain reduction based on NRS and complications. RESULTS Twelve of sixteen children (mean age 13 years; F:M ratio 3:1) diagnosed with ACNES started the lidocaine patch treatment. Two patients achieved a pain free status and remained pain free during a 4 and 7 months follow-up. A third child reported a lasting pain reduction, but discontinued treatment due to a temporary local skin rash. Five additional patients reported pain reduction only during application of the patch. The remaining four children experienced no pain relief. No adverse effects were reported. CONCLUSION Lidocaine patches provides pain relief in a substantial portion of children with ACNES.
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Affiliation(s)
- Tom Ten Have
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
- SolviMáx Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, the Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Willem A R Zwaans
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
- SolviMáx Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, the Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Marc R M Scheltinga
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
- SolviMáx Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, the Netherlands
| | - Rudi M H Roumen
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
- SolviMáx Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, the Netherlands
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Miyamatsu Y, Tanizaki R, Ninomiya T, Yoshida K. Anterior Cutaneous Nerve Entrapment Syndrome Caused by a Fixation Device: A Case Report. A A Pract 2024; 18:e01789. [PMID: 38785372 DOI: 10.1213/xaa.0000000000001789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Anterior cutaneous nerve entrapment syndrome (ACNES) is characterized by abdominal wall neuralgia. We report an 85-year-old woman with ACNES caused by a fixation device during the bipolar hip arthroplasty. To prevent ACNES as a perioperative peripheral nerve injury, it is important to maintain patients in the appropriate position during the operation. A positive Carnett's sign means the abdominal pain originates from the abdominal wall and is useful in diagnosing ACNES. Thus, physicians should examine Carnett's sign to differentiate ACNES in patients with abdominal pain developing after an operation.
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Affiliation(s)
- Yayoi Miyamatsu
- From the Departments of Internal Medicine and General Medicine
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Gritli A, Ramirez DC, Decavel P. Parietal abdominal pain with lower leg discrepancy: a case report. J Med Case Rep 2024; 18:175. [PMID: 38605402 PMCID: PMC11010276 DOI: 10.1186/s13256-024-04489-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 03/01/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND This report involves the first publication describing a case of parietal abdominal pain due to lower limb length discrepancy. CASE PRESENTATION A Caucasian male patient in his 50s was referred to our rehabilitation department with chronic abdominal pain that began in childhood. This chronic pain was associated with episodes of acute pain that were partially relieved by grade 3 analgesics. The patient was unable to sit for long periods, had recently lost his job, and was unable to participate in recreational activities with his children. Investigations revealed contracture and hypertrophy of the external oblique muscle and an limb length discrepancy of 3.8 cm (1.5 inches) in the left lower limb. The patient was effectively treated with a heel raise, physiotherapy, intramuscular injection of botulinum toxin, and lidocaine. The patient achieved the therapeutic goals of returning to work, and reducing analgesic use. CONCLUSIONS Structural misbalances, as may be caused by lower leg discrepancy, may trigger muscular compensations and pain. Complete anamnesis and clinical examination must not be trivialized and may reveal previously ignored information leading to a proper diagnosis.
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Affiliation(s)
- Agnès Gritli
- Department of Readaptation, HFR Fribourg Hôpital cantonal, chemin des pensionnats 2-6, 1708, Fribourg, Switzerland.
| | - David Cadavid Ramirez
- Department of Readaptation, HFR Fribourg Hôpital cantonal, chemin des pensionnats 2-6, 1708, Fribourg, Switzerland
| | - Pierre Decavel
- Department of Readaptation, HFR Fribourg Hôpital cantonal, chemin des pensionnats 2-6, 1708, Fribourg, Switzerland
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Bisciotti GN, Zini R, Aluigi M, Aprato A, Auci A, Bellinzona E, Benelli P, Bigoni M, Bisciotti A, Bisciotti A, Bona S, Brustia M, Bruzzone M, Canata GL, Carulli C, Cassaghi G, Coli M, Corsini A, Costantini A, Dallari D, Danelli G, Danesi G, Della Rocca F, DE Nardo P, DI Benedetto P, DI Marzo F, DI Pietto F, Eirale C, Ferretti A, Fogli M, Foglia A, Guardoli A, Guglielmi A, Lama D, Maffulli N, Manunta AF, Massari L, Mazzoni G, Moretti B, Moretti L, Nanni G, Niccolai R, Occhialini M, Panascì M, Parra MF, Pigalarga G, Randelli F, Sacchini M, Salini V, Santori N, Tenconi P, Tognini G, Vegnuti M, Zanini A, Volpi P. Groin Pain Syndrome Italian Consensus Conference update 2023. J Sports Med Phys Fitness 2024; 64:402-414. [PMID: 38126972 DOI: 10.23736/s0022-4707.23.15517-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Groin pain syndrome (GPS) is a controversial topic in Sports Medicine. The GPS Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes was organized by the Italian Society of Arthroscopy in Milan, on 5 February 2016. In this Consensus Conference (CC) GPS etiology was divided into 11 different categories for a total of 63 pathologies. The GPS Italian Consensus Conference update 2023 is an update of the 2016 CC. The CC was based on a sequential, two-round online Delphi survey, followed by a final CC in the presence of all panelists. The panel was composed of 55 experts from different scientific and clinical backgrounds. Each expert discussed 6 different documents, one of which regarded the clinical and imaging definition of sports hernias, and the other 5 dealt with 5 new clinical situations thought to result in GPS. The panelists came to an agreement on the definition of a sports hernia. Furthermore, an agreement was reached, recognizing 4 of the 5 possible proposed pathologies as causes to GPS. On the contrary, the sixth pathology discussed did not find consensus given the insufficient evidence in the available scientific literature. The final document includes a new clinical and imaging definition of sports hernia. Furthermore, the etiology of GPS was updated compared to the previous CC of 2016. The new taxonomic classification includes 12 categories (versus 11 in the previous CC) and 67 pathologies (versus 63 in the previous CC).
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Affiliation(s)
| | - Raul Zini
- Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | | | | | | | | | | | | | | | - Andrea Bisciotti
- Kinemove Rehabilitation Centers, Pontremoli, La Spezia, Italy
- Humanitas Research Hospital, Milan, Italy
| | | | | | - Marco Bruzzone
- University of Brescia, Brescia, Italy
- University of Modena and Reggio Emilia, Modena, Italy
- Unione Sportiva Sassuolo Calcio, Sassuolo, Modena, Italy
| | - Gian L Canata
- Center of Sports Traumatology, Koelliker Hospital, Turin, Italy
| | | | | | | | | | | | - Dante Dallari
- Reconstructive Orthopedic Surgery and Innovative Techniques Musculoskeletal Tissue Bank, Rizzoli IRCCS Orthopedic Institute, Bologna, Italy
| | | | | | | | | | | | | | | | | | - Andrea Ferretti
- Istituto Medicina e Scienza dello Sport Comitato Olimpico Nazionale Italiano, Rome, Italy
| | | | - Andrea Foglia
- Centers of Rehabilitative Phisiotherapy, Civitanova Marche, Macerata, Italy
| | | | | | | | - Nicola Maffulli
- La Sapienza University, Rome, Italy
- Centre for Sport and Exercise Medicine, Queen Mary University of London, London, UK
- Barts and the London School of Medicine, Surgery and Dentistry, London, UK
- Keele University School of Medicine, Stoke on Trent, UK
| | - Andrea F Manunta
- Orthopedic Clinic Sassari, Fondo Ateneo Ricerca 2020, Sassari, Italy
| | | | | | - Biagio Moretti
- Unit of Orthopedics and Traumatology, Polyclinic University Hospital, Bari, Italy
| | - Lorenzo Moretti
- Unit of Orthopedics and Traumatology, Polyclinic University Hospital, Bari, Italy
| | | | | | | | - Manlio Panascì
- Nancy Gvm Care and Research, S. Carlo Hospital, Rome, Italy
| | - Maria F Parra
- Kinemove Rehabilitation Centers, Pontremoli, La Spezia, Italy
| | | | - Filippo Randelli
- Hip Department (CAD), Gaetano Pini-CTO Orthopaedic Institute, University of Milan, Milan, Italy
| | | | | | | | | | | | - Marco Vegnuti
- Kinemove Rehabilitation Centers, Pontremoli, La Spezia, Italy
| | - Antonio Zanini
- San Clemente Nursing Home, S. Anna Clinica Institute, Brescia, Italy
| | - Piero Volpi
- Humanitas Research Hospital, Milan, Italy
- FC Internazionale Milano, Milan, Italy
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Jacobs MLYE, Janssen L, Stassen LPS, Scheltinga MRM, Roumen RMH. Visceral symptoms in patients with anterior cutaneous nerve entrapment syndrome (ACNES): expression of viscerosomatic reflexes? Hernia 2024; 28:127-134. [PMID: 37393208 PMCID: PMC10891241 DOI: 10.1007/s10029-023-02827-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 06/18/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE Anterior cutaneous nerve entrapment (ACNES) is characterized by neuropathic pain in a predictable, circumscript abdominal area. The diagnostic delay is long, with half of ACNES-affected individuals reporting nausea, bloating, or loss of appetite mimicking visceral disease. The aim of this study was to describe these phenomena and to determine whether treatment could successfully reverse the visceral symptoms. METHODS This prospective observational study was conducted between July 2017 and December 2020 at SolviMáx, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven. Adult patients who fulfilled published criteria for ACNES and reported at least one visceral symptom at intake were eligible for the study. A self-developed Visceral Complaints ACNES Score (VICAS) questionnaire that scores several visceral symptoms (minimum 1 point, maximum 9 points) was completed before and after therapy. The success of treatment was defined as at least 50% reduction in pain. RESULTS Data from 100 selected patients (86 females) aged 39 ± 5 years were available for analysis. Frequently reported symptoms were abdominal bloating (78%), nausea (66%) and altered defecation (50%). Successful treatment significantly reduced the number of visceral symptoms, with a VICAS before of 3 (range 1-8) and after of 1 (range 0-6) (p < 0.001). A low baseline VICAS was associated with successful treatment outcome (OR 0.738, 95% CI 0.546-0.999). CONCLUSION Patients with ACNES may report a variety of visceral symptoms. Successful treatment substantially reduces these visceral symptoms in selected patients.
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Affiliation(s)
- Monica L Y E Jacobs
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands.
- Centre of Expertise for ACNES, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, SolviMáx, Eindhoven, The Netherlands.
- Department of Surgery and NUTRIM, Maastricht University, Maastricht, The Netherlands.
| | - Loes Janssen
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Marc R M Scheltinga
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
- Centre of Expertise for ACNES, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, SolviMáx, Eindhoven, The Netherlands
| | - Rudi M H Roumen
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
- Centre of Expertise for ACNES, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, SolviMáx, Eindhoven, The Netherlands
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Jacobs MLYE, Ten Have T, Schaap L, Scheltinga MRM, Roumen RMH. A positive scratch collapse test in anterior cutaneous nerve entrapment syndrome indicates its neuropathic character. Scand J Pain 2024; 24:sjpain-2024-0026. [PMID: 39215453 DOI: 10.1515/sjpain-2024-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/24/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVES Chronic abdominal pain is occasionally caused by an abdominal wall entity such as anterior cutaneous nerve entrapment syndrome (ACNES). This syndrome is thought to occur due to intercostal nerve branches (T7-12) that are entrapped in the rectus abdominis muscles. The diagnosis is largely based on subjective clues in patient history and physical examination. A test referred to as the scratch collapse test (SCT) is used as an additional diagnostic tool in peripheral nerve entrapment syndromes such as the carpal tunnel syndrome. The aim of the present study is to investigate whether an SCT was positive in patients with suspected ACNES. If so, this finding may support its hypothesized neuropathic character. METHODS A prospective, case-control study was performed among patients with ACNES (n = 20) and two control groups without ACNES (acute intra-abdominal pathology n = 20; healthy n = 20), all were consecutively included. ACNES was diagnosed based on previously published criteria. The SCT test was executed at the painful abdominal area in both patient groups and at a corresponding area in healthy controls. Predictive values, sensitivity, and specificity were calculated. Videos of tests were evaluated by blinded observers. RESULTS SCT was judged positive in 19 of 20 ACNES patients but not in any of the 40 controls. A 95% sensitivity (confidence interval [CI]: 75-99) and optimal specificity (100%; CI: 83-100) were calculated. CONCLUSIONS The positive SCT supports the hypothesis that ACNES is an entrapment neuropathy. A positive SCT should be considered a major diagnostic criterion for ACNES.
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Affiliation(s)
- Monica L Y E Jacobs
- Department of Surgery, Máxima Medical Centre, De Run 4600, P.O. Box 7777, 5500 MB, Eindhoven/Veldhoven, The Netherlands
- SolviMáx, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, The Netherlands
| | - Tom Ten Have
- Department of Surgery, Máxima Medical Centre, De Run 4600, P.O. Box 7777, 5500 MB, Eindhoven/Veldhoven, The Netherlands
- SolviMáx, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, The Netherlands
| | - Lotte Schaap
- SolviMáx, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, The Netherlands
| | - Marc R M Scheltinga
- Department of Surgery, Máxima Medical Centre, De Run 4600, P.O. Box 7777, 5500 MB, Eindhoven/Veldhoven, The Netherlands
- SolviMáx, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, The Netherlands
| | - Rudi M H Roumen
- Department of Surgery, Máxima Medical Centre, De Run 4600, P.O. Box 7777, 5500 MB, Eindhoven/Veldhoven, The Netherlands
- SolviMáx, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, The Netherlands
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Schaap L, Jacobs MLYE, Scheltinga MRM, Roumen RMH. The Scratch Collapse Test in patients diagnosed with Anterior Cutaneous Nerve Entrapment Syndrome (ACNES): A report of three cases. Int J Surg Case Rep 2023; 105:108099. [PMID: 37018947 PMCID: PMC10112164 DOI: 10.1016/j.ijscr.2023.108099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/04/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The Scratch Collapse Test (SCT) is currently used as a supportive tool diagnosing peripheral nerve neuropathies including carpal tunnel syndrome or peroneal nerve entrapment. Some patients with chronic abdominal pain suffer from entrapment of terminal branches of intercostal nerves (anterior cutaneous nerve entrapment syndrome, ACNES). ACNES is characterized by a severe disabling pain at a predictable area of the anterior abdomen. Clinical examination shows altered skin sensation and painful pinching at the area of pain. However, these findings may be subjective. CASE PRESENTATION In three female patients aged 71, 33, and 43 years with suspected ACNES, the SCT was positive when scratching over the skin of the affected nerve-ending at the abdominal wall. The diagnosis ACNES was confirmed with a local abdominal wall infiltration at the tenderpoint in all three patients. In case three, the SCT turned negative after lidocaine infiltration. CLINICAL DISCUSSION ACNES was hitherto a clinical diagnosis just based on clues in medical history and physical examination. Performing a SCT in patients possibly having ACNES may additionally contribute to the diagnosis. CONCLUSION The SCT may serve as an additional tool for diagnosing patients with possible ACNES. A positive SCT in patients with ACNES supports the hypothesis that ACNES is indeed a peripheral neuropathy of terminal branches of the lower thoracic intercostal nerves. Controlled research is necessary to confirm the role of a SCT in ACNES.
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Affiliation(s)
- Lotte Schaap
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Monica L Y E Jacobs
- Máxima Medical Centre, Department of Surgery, Eindhoven/Veldhoven, the Netherlands; SolviMáx, Centre of Expertise for ACNES, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, the Netherlands.
| | - Marc R M Scheltinga
- Máxima Medical Centre, Department of Surgery, Eindhoven/Veldhoven, the Netherlands; SolviMáx, Centre of Expertise for ACNES, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, the Netherlands.
| | - Rudi M H Roumen
- Máxima Medical Centre, Department of Surgery, Eindhoven/Veldhoven, the Netherlands; SolviMáx, Centre of Expertise for ACNES, Centre of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, the Netherlands.
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Yamada K, Shimazaki K, Inomata S, Owada Y. Successful Nerve Block Therapy for Lateral Cutaneous Nerve Entrapment Syndrome (LACNES) Triggered by Exercise. Cureus 2023; 15:e36151. [PMID: 37065397 PMCID: PMC10101725 DOI: 10.7759/cureus.36151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/16/2023] Open
Abstract
This report presents a case of a 59-year-old man who experienced pain in the left abdomen during abdominal exercises, which gradually improved. Pain recurred in the same area one year later and gradually worsened, rendering him unable to work. The strongest tender point, with a positive Carnett's sign, was noted on the flank. Ultrasonography revealed a 5 × 10 mm mass shadow in the internal oblique muscle. Trigger point injection at the same site was remarkably effective. Lateral cutaneous nerve entrapment syndrome caused by a crush injury due to abdominal exercises was diagnosed. Nerve block therapy provided effective pain relief.
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12
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The role of a simple questionnaire predicting treatment success in children with ACNES. Hernia 2023; 27:15-20. [PMID: 36482227 DOI: 10.1007/s10029-022-02721-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/13/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Some children with chronic abdominal wall pain or groin pain do not have an inguinal hernia but suffer from anterior cutaneous nerve entrapment syndrome (ACNES). Diagnosing ACNES is challenging, especially in children as a diagnostic gold standard is lacking. A paediatric questionnaire containing 17 simple items was earlier found to discriminate between abdominal pain due or ACNES or IBS. Scores range from 0 points (ACNES very unlikely) to 17 points (ACNES very likely). The present study investigates whether this 17-item questionnaire predicted treatment success in children receiving therapy for ACNES. METHODS Children < 18 years who presented in a single institute between February 2016 and October 2021 with symptoms and signs suggestive of ACNES completed the questionnaire before intake and treatment. Treatment success after 6-8 weeks was defined as self-reported 'pain-free' (group 1), ' > 50% less pain' (group 2) and ' < 50% less pain' (group 3). Group differences regarding sex, age, BMI, symptoms duration and questionnaire scores were analysed. RESULTS Data of 145 children (female 78%, mean age 14.7 ± 2.3 years, mean BMI 21.1 ± 3.9) were analysed. All children received a diagnostic trigger point injection using an anaesthetic agent, and 75.5% underwent subsequent surgery for untractable pain. The three groups were comparable regarding sex distribution, age, BMI and symptoms duration. In addition, questionnaire scores were not different (group 1: n = 89, mean score 13.4 ± 2.7, group 2: n = 24, 13.4 ± 2.3 and group 3: n = 32, 13.0 ± 2.7, p > 0.05). CONCLUSIONS Treatment success was attained in 78% of children undergoing surgery for ACNES. A simple questionnaire scoring items associated with abdominal pain did not predict treatment success.
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13
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Iio K, Ishida Y. Abdominal Pain in a 15-Year-Old Adolescent Girl. JAMA 2022; 328:2357-2358. [PMID: 36441545 DOI: 10.1001/jama.2022.20402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 15-year-old adolescent girl taking an oral contraceptive had 3 days of pain in a 1-cm area of the lower left abdominal quadrant. She had no nausea/vomiting, diarrhea, hematochezia, bloating, or anorexia; no precipitating factors for the pain; and no history of pregnancy, abdominal surgery, or abdominal trauma. Results from laboratory tests, endoscopy, and abdominal computed tomography were normal. What is the diagnosis and what would you do next?
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Affiliation(s)
- Kazuki Iio
- Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
- Department of Pediatrics, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Yu Ishida
- Department of Pediatrics, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
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Muacevic A, Adler JR. A Case Report on Abdominal Pain Treated With a New Technique of Ultrasound-Guided Transversus Abdominis Plane Hydrodissection Using a Low Concentration of Local Anesthetics. Cureus 2022; 14:e31966. [PMID: 36582553 PMCID: PMC9795083 DOI: 10.7759/cureus.31966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2022] [Indexed: 11/29/2022] Open
Abstract
Hydrodissection, a technique for performing morphological dissection between the target tissues via injection, has attracted attention in recent years. However, high-quality evidence is available only for a few entrapment neuropathies, such as carpal tunnel syndrome, and further case studies are needed for other diseases. This case report presents the first case of hydrodissection of the ventral ramus of the spinal nerve, which innervates the abdominal wall, to improve abdominal pain. A 59-year-old Japanese man with a history of cerebral infarction and dyslipidemia presented to the emergency department with the chief complaint of left upper abdominal pain that began two days earlier. The pain radiated to the left side of the back and left axilla. The abdomen was flat and soft with no tenderness on examination, and the pinch test was negative. However, Carnett's sign was observed in the left upper abdomen, and the location of the left upper abdominal pain and that of the radiating pain were consistent with the ninth thoracic vertebra (Th9) dermatome; thus, the cause of the left upper abdominal pain was determined to be the ventral ramus of the spinal nerve of Th9. Two weeks of physical therapy and lifestyle guidance were ineffective; therefore, hydrodissection of the transversus abdominis plane (TAP) between the myofascia of the internal oblique muscle and that of the transversus abdominis at the Th9 level using a 23G 60 mm needle under ultrasound guidance was planned. The abdominal pain immediately improved after hydrodissection, and the patient was able to work without pain. Thus, ultrasound-guided TAP hydrodissection with a low-concentration local anesthetic is effective in the treatment of abdominal pain caused by the entrapment of the ventral ramus of the spinal nerve due to adhesions between the myofascia of the internal oblique muscle and that of the transversus abdominis. This condition should be termed ventral ramus of spinal nerve entrapment syndrome (VERNES), and this concept and TAP hydrodissection must be made known to the public.
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15
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Endo T, Watari T. A Rare Presentation of a Compression Fracture or a Typical Presentation of Lateral Cutaneous Nerve Entrapment Syndrome: A Diagnostic Error? Intern Med 2022; 61:1453-1455. [PMID: 34645766 PMCID: PMC9152874 DOI: 10.2169/internalmedicine.8256-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/30/2021] [Indexed: 11/22/2022] Open
Abstract
A 78-year-old woman complained of severe pain in the left costal region. Her body mass index was 23.1 kg/m2. Lateral cutaneous nerve entrapment syndrome (LACNES) was the suspected diagnosis because the affected area was 2×2 cm and positive for pinch sign. Seventeen days later, the patient again presented with complaints of lower back pain accompanied by back pain upon extending the spine. Magnetic resonance imaging of the spine showed a fracture of the vertebral body of T11. We herein discuss our errors in the diagnostic process and critical tactics for avoiding such errors in the future.
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Affiliation(s)
- Takeshi Endo
- General Medicine Center, Shimane University Hospital, Japan
- Department of General Medicine, Okuizumo Hospital, Japan
| | - Takashi Watari
- General Medicine Center, Shimane University Hospital, Japan
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16
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Wolfhagen FH. Endoscopy-induced anterior cutaneous nerve entrapment syndrome: a case series. Endosc Int Open 2022; 10:E544-E548. [PMID: 35433229 PMCID: PMC9010097 DOI: 10.1055/a-1784-0504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/14/2021] [Indexed: 11/25/2022] Open
Abstract
Background and study aims Anterior cutaneous nerve entrapment syndrome (ACNES) is a common but frequently overlooked disorder. Here we report on a series of patients with ACNES following endoscopy. Patients and methods This case series included consecutive patients with localized abdominal pain following an endoscopic procedure that was consistent with ACNES who presented to the author's Gastroenterology Outpatient Clinic from February 2019 to February 2021. Results Six patients presented with complaints compatible with ACNES. All of them were successfully managed with local injection therapy (n = 5) or pulsed radiofrequency (PRF) (n = 1). Conclusions It appears that ACNES can be induced by endoscopy. Early recognition is important to avoid unnecessary diagnostics and delayed pain relief in patients. Most patients can be managed with local injection therapy.
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Affiliation(s)
- Frank H.J. Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
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17
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Sawada R, Watanabe K, Tokumine J, Lefor AK, Ando T, Yorozu T. Ultrasound-guided rectus sheath block for anterior cutaneous nerve entrapment syndrome after laparoscopic surgery: A case report. World J Clin Cases 2022; 10:2357-2362. [PMID: 35321172 PMCID: PMC8895180 DOI: 10.12998/wjcc.v10.i7.2357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 12/18/2021] [Accepted: 01/19/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Anterior cutaneous nerve entrapment syndrome is defined as abdominal pain due to entrapped intercostal nerves. This is the first report of a patient successfully treated for anterior cutaneous nerve entrapment syndrome after laparoscopic surgery with an ultrasound-guided rectus sheath block. The rectus sheath block physically lysed adhesions and relieved pain from anterior cutaneous nerve entrapment syndrome. CASE SUMMARY The patient is a 44-year-old man who presented with severe left upper abdominal pain at an operative scar one month after laparoscopic ulcer repair. Diagnosis and treatment were performed using an ultrasound-guided rectus sheath block with 0.1% lidocaine 20 mL. The pain was relieved after the block. The diagnosis was anterior cutaneous nerve entrapment syndrome. Rectus sheath block may be effective for patients with anterior cutaneous nerve entrapment syndrome. CONCLUSION Ultrasound-guided rectus sheath block is a promising treatment modality for patients with postoperative anterior cutaneous nerve entrapment syndrome due to adhesions.
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Affiliation(s)
- Ryuji Sawada
- Department of Pain Clinic, NTT Medical Center Tokyo, Higashigotanda 141-8625, Tokyo, Japan
| | - Kunitaro Watanabe
- Department of Anesthesiology, Hino Municipal Hospital, Tamadaira 191-0062, Tokyo, Japan
| | - Joho Tokumine
- Department of Anesthesiology, Kyorin University School of Medicine, Mitaka 181-8611, Tokyo, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Jichi Medical University, Shimotsuke 329-0498, Tochigi, Japan
| | - Tadao Ando
- Department of Anesthesiology, Kyorin University School of Medicine, Mitaka 181-8611, Tokyo, Japan
| | - Tomoko Yorozu
- Department of Anesthesiology, Kyorin University School of Medicine, Mitaka 181-8611, Tokyo, Japan
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Puleo RM, Barreveld A, Rice S, Althausen Plante AM, Kotler DH. Unique Concerns of the Woman Cyclist. Phys Med Rehabil Clin N Am 2021; 33:61-79. [PMID: 34799003 DOI: 10.1016/j.pmr.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Previously a male-dominated activity, female cyclists now make up nearly half of all cyclists in the United States. Although cycling provides a significant number of health benefits, it is an activity that carries risk of injury, both traumatic and nontraumatic. Sex differences are seen in chest trauma and breast injury, as well as pelvic, given the inherent differences in anatomy. Understanding the relationship of the bicycle to the anatomy of the rider can help mitigate risks for injury.
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Affiliation(s)
- Rozanne M Puleo
- Sports Medicine, Lynn Community Health Center, 269 Union Street, Lynn, MA 01902, USA.
| | - Antje Barreveld
- Anesthesiology, Tufts University School of Medicine, Pain Management Services, Newton-Wellesley Hospital, 2014 Washington St, Newton, MA 02462, USA
| | - Sarah Rice
- Athletico Physical Therapy, 2143 W Division St, Chicago IL 60622-3006, USA
| | - Anne M Althausen Plante
- Obstetrics and Gynecology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Dana H Kotler
- Department of Physical Medicine & Rehabilitation, Harvard Medical School, Spaulding Outpatient Center - Wellesley, 65 Walnut Street, Wellesley, Boston, MA 02481, USA
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Surgical Treatment of Abdominal Wall Neuromas. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3585. [PMID: 34046291 PMCID: PMC8143781 DOI: 10.1097/gox.0000000000003585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/27/2021] [Indexed: 12/11/2022]
Abstract
Neuromas are an under-recognized contributor to chronic abdominal pain. Other than after mesh inguinal hernia repair, surgical management of painful abdominal wall neuromas has not been well established in the literature.
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20
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Jansen CMAH, Bonouvrie DS, Jacobs MLYE, Janssen N, Leclercq WKG, Scheltinga MRM, Roumen RMH. Chronic Abdominal Pain After Previous Bariatric Surgery: Consider the Abdominal Wall. Obes Surg 2021; 30:2942-2948. [PMID: 32337643 DOI: 10.1007/s11695-020-04629-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Up to 30% of patients who undergo bariatric surgery experience recurrent abdominal pain within 3 years after the operation. Although some causes for persisting discomfort are well known, a small portion of patients may suffer from an abdominal wall pain associated with Anterior Cutaneous Nerve Entrapment Syndrome (ACNES). Aim of the present study is to discuss incidence, clinical presentation, and treatment outcome in patients with ACNES after bariatric surgery. METHODS This retrospective observational cohort study analyzed electronically stored data of patients with ACNES having a history of bariatric surgery. All were treated for ACNES between 2011 and 2017 in a Dutch center of excellence for abdominal wall and groin pain. Success after treatment was defined as a minimal 50% drop in pain level using a Numeric Rating Scale. RESULTS A total of 49 patients (female n = 44, median age 45 (25-63) years) were identified. Four (8%) experienced long-term pain relief after just one abdominal wall infiltration with lidocaine. Ten additional patients reported success after 2-5 injections. A total of 35 unresponsive patients chose to undergo a neurectomy that was successful in 27. Therefore, this step-up approach conferred an 84% success rate. Occurrence of ACNES after bariatric surgery was estimated at 1 in 100 patients. CONCLUSION ACNES should be considered in the differential diagnosis of ongoing pain following previous bariatric surgery. A treatment regimen including abdominal wall infiltrations using an anesthetic agent or a neurectomy is successful in a vast majority of these patients.
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Affiliation(s)
- Claire M A Heukensfeldt Jansen
- Department of Surgery, Máxima Medical Center, P.O. Box 7777, 5500 MB, Eindhoven/Veldhoven, The Netherlands.,SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, The Netherlands
| | - Daniëlle S Bonouvrie
- Obesity Center Máxima, Máxima Medical Centre, Eindhoven/Veldhoven, The Netherlands
| | - Monica L Y E Jacobs
- Department of Surgery, Máxima Medical Center, P.O. Box 7777, 5500 MB, Eindhoven/Veldhoven, The Netherlands. .,SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, The Netherlands.
| | - Nicky Janssen
- NUTRIM, Maastricht University, Maastricht, the Netherlands
| | - Wouter K G Leclercq
- Obesity Center Máxima, Máxima Medical Centre, Eindhoven/Veldhoven, The Netherlands
| | - Marc R M Scheltinga
- Department of Surgery, Máxima Medical Center, P.O. Box 7777, 5500 MB, Eindhoven/Veldhoven, The Netherlands.,SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, The Netherlands
| | - Rudi M H Roumen
- Department of Surgery, Máxima Medical Center, P.O. Box 7777, 5500 MB, Eindhoven/Veldhoven, The Netherlands.,SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, The Netherlands
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21
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Surgical Management of Abdominal Anterior Cutaneous Nerve Entrapment Syndrome: Case Report, Surgical Technique, and Literature Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3453. [PMID: 33786258 PMCID: PMC7997119 DOI: 10.1097/gox.0000000000003453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 11/23/2020] [Indexed: 11/25/2022]
Abstract
Background: Abdominal anterior cutaneous nerve entrapment syndrome (ACNES) is an emerging diagnosis, with estimated incidence of 13%–30% of the adult population. It is a syndrome characterized by chronic abdominal pain caused by entrapment of cutaneous branches of thoracoabdominal nerves at the lateral border of the rectus abdominis muscle. If conservative treatment with pain medication, botulinum toxin, or lidocaine injections is inadequate, surgical management is indicated. Methods: We present a case of a 40-year-old woman presenting with a 1-year history of daily right anterior abdominal wall pain, consistent with a diagnosis of ACNES. We describe our approach for an anterior neurectomy of the intercostal nerve with closure of its fascial foramen. Results: Three months after surgery, she remained pain free and was back to work full time. At a 13-month follow-up, the patient reported that her pain had resolved completely following surgery. Conclusions: Results are encouraging following anterior neurectomy for ACNES. Surgical descriptions in the literature are brief, with limited pictorial account. Our detailed surgical approach is provided along with a review of the existing literature on the management of ACNES.
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22
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Govender I, Rangiah S, Bongongo T, Mahuma P. A Primary Care Approach to Abdominal Pain in Adults. S Afr Fam Pract (2004) 2021; 63:e1-e5. [PMID: 33764143 PMCID: PMC8378095 DOI: 10.4102/safp.v63i1.5280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/15/2021] [Indexed: 11/20/2022] Open
Abstract
Abdominal pain is a common presenting problem with multiple aetiologies that often pose diagnostic and therapeutic dilemmas for primary care practitioners. The vague symptomatology and difficult correlation to specific organ pathology obscures clinical findings leading to incorrect diagnoses. Although most presentations of abdominal pain are benign, a significant number of patients have life-threatening conditions that require a meticulous approach to management in order to prevent morbidity and mortality. The skill in assessing patients presenting with abdominal pain is fundamental for all primary care doctors. This review will discuss an approach to the assessment and diagnosis of abdominal pain in the primary care setting.
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Affiliation(s)
- Indiran Govender
- Department of Family Medicine, School of Health Sciences, University of Pretoria, Pretoria.
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Markus J, Sibbing IC, Ket JCF, de Jong JR, de Beer SA, Gorter RR. Treatment strategies for anterior cutaneous nerve entrapment syndrome in children: A systematic review. J Pediatr Surg 2021; 56:605-613. [PMID: 32553455 DOI: 10.1016/j.jpedsurg.2020.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 05/05/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anterior cutaneous nerve entrapment syndrome (ACNES) is a frequently overlooked cause of chronic abdominal pain in children. Currently, both nonsurgical and surgical treatment options are available to treat this disease. The objective was to give insight into the success rate of different treatment strategies for children with ACNES, and provide treatment recommendations for physicians based on the published evidence. METHOD A literature search of PubMed, Embase.com and the Wiley/Cochrane Library was conducted for studies published up to 25 February 2020. Randomized controlled trials, prospective or retrospective cohort studies, meta-analyses and literature reviews describing the outcome of different treatment strategies for children (<18 years old) with ACNES with a follow-up duration of at least four weeks were included. RESULTS Six studies, involving 224 patients, were included with an overall quality reported to be between fair and poor. Treatment success of local injections with an anesthetic agent into the trigger point ranged from 38% to 87% with a follow-up ranging from 4 weeks to 39 months. In addition, treatment success of anterior neurectomy ranged from 86% to 100%, with a follow-up duration ranging from 4 weeks to 36 months. CONCLUSION A step-up treatment strategy should be applied when treating pediatric patients with ACNES. This strategy starts with an injection with a local anesthetic agent, reserving surgery (anterior neurectomy) as a viable option in case of persistent pain. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Jasper Markus
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam, The Netherlands.
| | - Iris C Sibbing
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam, The Netherlands
| | | | - Justin R de Jong
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam, The Netherlands
| | - Sjoerd A de Beer
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam, The Netherlands
| | - Ramon R Gorter
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam, The Netherlands
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24
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Endo T, Watari T. Endoscopic anisakis removal induced anterior cutaneous nerve entrapment syndrome. BMJ Case Rep 2021; 14:e241455. [PMID: 33608346 PMCID: PMC7896586 DOI: 10.1136/bcr-2020-241455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 11/03/2022] Open
Affiliation(s)
- Takeshi Endo
- Department of Internal Medicine, Unnan City Hospital, Unnan, Shimane, Japan
| | - Takashi Watari
- General Medicine Center, Shimane University Hospital, Izumo, Shimane, Japan
- Master of Healthcare Quality and Safety, Harvard Medical School, Boston, Massachusetts, USA
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A Comprehensive Review and Update of Post-surgical Cutaneous Nerve Entrapment. Curr Pain Headache Rep 2021; 25:11. [PMID: 33547511 DOI: 10.1007/s11916-020-00924-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW This is a comprehensive review of the literature regarding post-surgical cutaneous nerve entrapment, epidemiology, pathophysiology, and clinical presentation. It focuses mainly on nerve entrapment leading to chronic pain and the available therapies. RECENT FINDINGS Cutaneous nerve entrapment is not an uncommon result (up to 30% of patients) of surgery and could lead to significant, difficult to treat chronic pain. Untreated, entrapment can lead to neuropathy and damage to enervated structures and musculature, and significant morbidity and financial loss. Nerve entrapment is defined as pressure neuropathy from chronic compression. It causes changes to all layers of the nerve tissue. It is most significantly associated with hernia repair and other procedures employing a Pfannenstiel incision. The initial insult is usually incising of the nerve, followed by formation of a neuroma, incorporation of the nerve during closing, or constriction from adhesions. The three most commonly involved nerves are the iliohypogastric, ilioinguinal, and genitofemoral nerves. Cutaneous abdominal nerve entrapment could occur during thoracoabdominal surgery. The presentation of nerve entrapment usually involved post-surgical pain in the territory innervated by the trapped nerve, possibly with radiation that tracks the nerve course. Once a suspected neuropathy is identified, it can be diagnosed with relief in pain after a nerve block has been instilled. Treatment is usually started with pharmaceutical solutions, topical first and oral if those fail. Most patients require escalation to a second line of treatment and see good result with injection therapy. Those that require further escalation can choose between ablation and surgical therapies. Post-surgical nerve entrapment is not uncommon and causes serious morbidity and financial loss. It is underdiagnosed and thus undertreated. Preventing nerve entrapment is the best treatment; when it does occur, options include topical and oral analgesics, nerve blocks, ablation therapy, and repeat surgery.
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Markus J, van Montfoort M, de Jong JR, de Beer SA, Aronica EMA, Gorter RR. Histopathologic examination of resected nerves from children with anterior cutaneous nerve entrapment syndrome: Clues for pathogenesis? J Pediatr Surg 2020; 55:2783-2786. [PMID: 32156426 DOI: 10.1016/j.jpedsurg.2020.01.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Anterior cutaneous nerve entrapment syndrome (ACNES) has been described as a possible cause for chronic pain in the pediatric population. However, the exact pathophysiology of ACNES is unknown. It may be caused by compression or traction of cutaneous nerve branches of intercostal nerves, or it may be the result of an infection. Therefore, we present histopathological evidence to determine the pathophysiology of ACNES. METHODS A total of seven pediatric patients underwent a neurectomy for ACNES. All specimens were sent for histopathological evaluation, including immunohistochemical staining, to evaluate if there were any signs of infection, inflammation or compression. RESULTS Seven out of seven (100%) histopathological specimens showed non-specific nerve degeneration. Immunohistochemical evaluation showed there were several CD68-positive macrophages present in the specimens. Four out of seven (57%) specimens showed the presence of a few CD3-positive T-cells, however, this was not suggestive for inflammation or infection. CONCLUSION Our study supports the hypothesis that ACNES is caused by compression of the nerves rather than inflammation. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jasper Markus
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam, The Netherlands.
| | - Maurits van Montfoort
- Department of Neuropathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Justin R de Jong
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam, The Netherlands
| | - Sjoerd A de Beer
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam, The Netherlands
| | - Eleonora M A Aronica
- Department of Neuropathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ramon R Gorter
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam, The Netherlands
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McGee R. Abdominal Pain in Primary Care. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Okamoto T, Fukuda K. Anterior Cutaneous Nerve Entrapment Syndrome Occurring after Endoscopy. Case Rep Gastroenterol 2020; 14:377-382. [PMID: 32884514 PMCID: PMC7443681 DOI: 10.1159/000508440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/01/2020] [Indexed: 12/24/2022] Open
Abstract
A 45-year-old lady presented for a follow-up endoscopy examination for mild abdominal pain due to gastric ulcers. She experienced a severe, markedly different type of pain with labor-like contractions 3 days later. Physical examination revealed tenderness confined to a 1 × 1-cm area and positive Carnett's sign. The pain completely resolved 10 min after a subcutaneous lidocaine injection. The patient was diagnosed with anterior cutaneous nerve entrapment syndrome. The pain returned within several hours and anterior neurectomy was performed several days later. The pain subsided immediately and no recurrence was seen during 3 years of follow-up.
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Affiliation(s)
- Takeshi Okamoto
- Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan
| | - Katsuyuki Fukuda
- Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan
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29
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Smelt H, Pouwels S, Apers JA, Said M, Smulders J. Anterior Cutaneous Nerve Entrapment Syndrome: Two Case Reports of the Forgotten Diagnosis After Bariatric Surgery. Cureus 2020; 12:e8499. [PMID: 32656015 PMCID: PMC7343311 DOI: 10.7759/cureus.8499] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Unexplained abdominal pain is an increasing phenomenon after laparoscopic bariatric surgery, with an occurrence of 7.4%. The pain could be explained by the anterior cutaneous nerve entrapment syndrome (ACNES). However, the incidence of ACNES after laparoscopic bariatric surgery is unclear. We report the cases of two patients with unexplained abdominal pain after laparoscopic bariatric surgery and a significant delay in the diagnosis of ACNES. In both cases, clinical signs of ACNES were demonstrated by a centralized trigger point in the abdominal wall and specific neuropathic aspects during examination. Both patients were temporary pain-free after a diagnostic local lidocaine injection. A neurectomy was performed in both cases, after which they remained pain-free. There was a significant delay (six months and three years, respectively) in the diagnosis of ACNES, and many additional imaging procedures including a diagnostic laparoscopy were performed. ACNES is difficult to diagnose due to its relatively unknown entity. This case report confirms that the diagnosis of ACNES is still frequently overlooked as a cause of chronic abdominal pain. Earlier diagnosis recognition can probably prevent unnecessary investigations and may improve the quality of life in bariatric patients with unexplained abdominal pain.
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Affiliation(s)
| | - Sjaak Pouwels
- Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, NLD
| | - J A Apers
- Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, NLD
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30
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A forgotten cause of chronic abdominal pain in children: anterior cutaneous nerve entrapment syndrome. PEDIATRU.RO 2020. [DOI: 10.26416/pedi.59.3.2020.3897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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31
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Affiliation(s)
- Takashi Watari
- Postgraduate Clinical Training Center, Shimane University Hospital, Izumo, Japan
| | - Yasuharu Tokuda
- Okinawa Muribushi Project for Teaching Hospitals, Okinawa, Japan
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32
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Incidence of arcuate line hernia in patients with abdominal complaints: radiological and clinical features. Hernia 2019; 23:1199-1203. [DOI: 10.1007/s10029-019-02067-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
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Maatman RC, van Kuijk SMJ, Steegers MAH, Boelens OBA, Lim TC, Scheltinga MRM, Roumen RMH. A Randomized Controlled Trial to Evaluate the Effect of Pulsed Radiofrequency as a Treatment for Anterior Cutaneous Nerve Entrapment Syndrome in Comparison to Anterior Neurectomy. Pain Pract 2019; 19:751-761. [PMID: 31188514 DOI: 10.1111/papr.12806] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 05/28/2019] [Accepted: 05/30/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic abdominal pain can be due to entrapped intercostal nerves (anterior cutaneous nerve entrapment syndrome [ACNES]). If abdominal wall infiltration using an anesthetic agent is unsuccessful, a neurectomy may be considered. Pulsed radiofrequency (PRF) applies an electric field around the tip of the cannula near the affected nerve to induce pain relief. Only limited retrospective evidence suggests that PRF is effective in ACNES. METHODS A multicenter, randomized, nonblinded, controlled proof-of-concept trial was performed in 66 patients. All patients were scheduled for a neurectomy procedure. Thirty-three patients were randomized to first receive a 6-minute cycle of PRF treatment, while the other 33 were allocated to an immediate neurectomy procedure. Pain was recorded using a numeric rating scale (NRS, 0 [no pain] to 10 [worst pain possible]). Successful treatment was defined as >50% pain reduction. Patients in the PRF group were allowed to cross over to a neurectomy after 8 weeks. RESULTS The neurectomy group showed greater pain reduction at 8-week follow-up (mean change from baseline -2.8 (95% confidence interval [CI] -3.9 to -1.7) vs. -1.5 (95% CI -2.3 to -0.6); P = 0.045) than the PRF group. Treatment success was reached in 12 of 32 (38%, 95% CI 23 to 55) of the PRF group and 17 of 28 (61%, 95% CI 42 to 72) of the neurectomy group (P = 0.073). Thirteen patients were withdrawn from their scheduled surgery. Adverse events were comparable between treatments. CONCLUSIONS PRF appears to be an effective and minimally invasive treatment option and may therefore be considered in patients who failed conservative treatment options before proceeding to a neurectomy procedure. Anterior neurectomy may possibly lead to a greater pain relief compared with PRF in patients with ACNES, but potential complications associated with surgery should be discussed.
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Affiliation(s)
- Robbert C Maatman
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), MUMC+, Maastricht, The Netherlands
| | - Monique A H Steegers
- Department of Anaesthesiology & Pain and Palliative Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Toine C Lim
- Department of Anaesthesiology & Pain and Palliative Care, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Marc R M Scheltinga
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
| | - Rudi M H Roumen
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
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Sweetser S. Abdominal Wall Pain: A Common Clinical Problem. Mayo Clin Proc 2019; 94:347-355. [PMID: 30711130 DOI: 10.1016/j.mayocp.2018.04.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/19/2018] [Accepted: 04/24/2018] [Indexed: 11/30/2022]
Abstract
Abdominal wall pain (AWP) is a common and underrecognized cause of chronic abdominal pain. The etiology of AWP varies. History and physical examination are critical to an accurate diagnosis of AWP. Trigger point injection using either a corticosteroid, a local anesthetic, or a combination of both often gives relief of pain and is of diagnostic and therapeutic value. Increased awareness of AWP as a cause of chronic, nonvisceral abdominal pain can prevent fruitless searches for intra-abdominal pathology and reduce medical costs.
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Affiliation(s)
- Seth Sweetser
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Frumkin K, Delahanty LF. Peripheral neuropathic mimics of visceral abdominal pain: Can physical examination limit diagnostic testing? Am J Emerg Med 2018; 36:2279-2285. [PMID: 30170933 DOI: 10.1016/j.ajem.2018.08.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The emergency department evaluation of patients with abdominal pain is most appropriately directed at identifying acute inflammation, infection, obstruction, or surgical disease. Doing so commonly involves "routine" (and often extensive) diagnostic imaging and laboratory testing. Benign mimics of serious visceral abdominal pain that can be diagnosed by physical exam and confirmed with local anesthetic injections have been identified over the last century. These syndromes derive from painful irritation of the intercostal nerves by a mobile rib below, or from impingement of the cutaneous branches of those same intercostal nerves as they penetrate the abdominal wall. These peripheral neuropathic mimics of visceral abdominal pain continue to go unrecognized and underdiagnosed. METHODS Our purpose is to review the affirmative diagnosis of non-visceral abdominal pain by physical examination. RESULTS The consequences of failure to identify these conditions are considerable. In the search for a diagnosis that is literally at the provider's fingertips, patients frequently undergo months to years of fruitless and often invasive diagnostic tests, not uncommonly including unsuccessful surgeries. CONCLUSIONS With proper consideration of and appropriate testing for visceral etiologies, a carefully directed physical examination may yield an affirmative diagnosis in a percentage of these common emergency department patients.
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Affiliation(s)
- Kenneth Frumkin
- Emergency Medicine Department, Naval Medical Center, Portsmouth, VA, USA.
| | - Liam F Delahanty
- Emergency Medicine Department, Naval Medical Center, Portsmouth, VA, USA
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