Surgical management of chronic inguinal pain syndromes - Liespijn

Diagnostic pathwayTreatment modalitiesIncisional pain after Pfannenstiel procedure> 3 monthsYes, nerve blockade (10 cc lidocain)Significantpain reductionPeripheralneuropathiccause:(Neuroma/nerveentrapment)Transient painreduction aftera nerve block?Repeat nerveblock (+ corticosteroids)Neuropathic pain symptomatology?- Sharp, stabbing, burning- Neurophysiological abnormalities- Trigger point at lateral corner(s)No painreductionPersistent painreduction aftera nerve blockNo, evaluate nonneuropathiccauses andtreat them accordingly:- Lymphoma/ lipoma- Incisional hernia- Cutaneous endometriosis- Musculotendinous- Diffuse scar pain- Intra-abdominal pathologyCNS sensitization?- Pain team/anaesthesiologist- Drugs: antidepressants,anti-epileptics, gabapentin- Alternative treatmentoptionsPATIENT AND METHODSA retrospective database search was performed extracting all consecutive patients ofthe Máxima Medical Center (Veldhoven, The Netherlands), who were treated for neuralgiaof the iliohypogastric and/ or ilioinguinal nerve following a Pfannenstiel incisionsince 2000. All medical charts were reviewed for pain history, physical examination,additional tests, co-morbidities (defined as endometriosis and lumbosacral radicularsyndrome) and previously received pain treatments. Patients were excluded if otherknown causes of pain such as cutaneous endometriosis were suspected.Treatment algorithm 12All patients were evaluated according to a standard algorithm (figure 2). If pain ofneuropathic origin was suspected, patients received a nerve block using a local anaestheticinto the trigger point. A substantial but temporary pain reduction led to a repeatnerve block also using corticosteroids. If these nerve blocks did not result in long-termpain reduction, patients were offered a neurectomy of the affected nerve (ilioinguinaland/or iliohypogastric). This procedure was performed in day-care setting under spinalor general anaesthesia by general surgeons specialized in groin and abdominal wallpain pathology (RR and MS). Prior to operation, the responsible nerve was localized bymarking the skin overlying the trigger point. A portion of the scar was incised andlateralized if deemed necessary. The overlying subcutaneous tissue and external obliquefascia were dissected and the nerve was identified and removed up to the anteriorsuperior iliac spine (figure 3). For haemostatic purposes nerve endings were cauterised.In an attempt to prevent to recurrent fibrotic encasement the proximal nerve end wasburied in healthy muscular tissue. Nearly all removed specimens underwent pathologicalexamination (figure 4).QuestionnaireBetween September 2007 and November 2007 all treated patients received a questionnairethat was composed of parts of previously published pain studies 13-15 . The followingitems were assessed: pain reduction (expressed in a 5-point Verbal Rating Scale andpercentages), complaints associated with sexual activities, perceived complications,overall satisfaction 14 , and current need for pain medication.Long-termineffective?NeurectomyRESULTSFigure 2 Diagnostic and therapeutic algorithm for neuropathic post-Pfannenstiel pain.From January 2000 to September 2007 twenty-seven women presenting at the surgicaloutpatient department were diagnosed with neuralgia following a Pfannenstiel incision.During the standard workup 5 patients attained long-lasting pain relief with a single112 Chapter 8Surgical management of inguinal neuralgia after a low transverse Pfannenstiel incision 113