Surgical management of chronic inguinal pain syndromes - Liespijn

effect of neurectomy on occupational disability is annoyingly insufficient. Non-surgicaltreatment results with reference to return to work in chronic postherniorrhaphy painpatients are virtually nonexistent. In general, these effects on occupational disabilityare not mentioned at all. In a recent retrospective study by Bright et al. the majority ofpatients attending a pain clinic were discharged pain-free after a 1-year period 35 . It isobvious that due to a lack of major studies on non-surgical treatment regimes theeffect on chronic pain resolution and occupational disability also remains unclear.The present study demonstrates that, based on a recently published registry of neurectomypatients 18 , over 50% of the patients went back to work. Moreover a lot of patientswere occupationally disabled even before their inguinal hernia repair due to otherreasons. So, on the one hand there is a definite pain reductive effect of our treatment,but on the other it does not always result in alleviation of the occupational disability ineach patient. Moreover, some patients continued to work despite severe pain complaints.Our success rate may seem somewhat lower compared to earlier mentioned successrates, but is probably a more realistic one. An overestimation in previous studies due toabsence of in- and exclusion criteria as well as inaccurate measurement of disability orincomplete follow-up may possibly explain this discrepancy. In contrast, a 50% successrate is much higher when compared to percentages observed in other causes of occupationaldisability (e.g. chronic musculoskeletal problems). In the Netherlands, only 10%of the occupationally disabled patients will eventually get back to work, often by meansof an intensively subsidized reintegration project 36 . Despite the lack of large and uniformlyconducted studies, operative neurectomy appears to provide a substantial reduction inoccupational disability in most patients suffering from severe postoperative inguinal pain.Occupational disability due to inguinal neuralgia is associated with major workerscompensational costs. A tailored neurectomy can save over €1.6 million per year in theNetherlands alone. As most patients are disabled for many years, these costs arecumulative. Since chronic postherniorrhaphy neuralgia is encountered all over the world,an enormous cost reduction can be accomplished globally with adequate treatment.Another aspect of occupational disability is the increased medical consumption forother health issues, which generates high costs as well 21 .The present study has certain limitations. A drawback includes the small number ofstudied patients. Moreover, a totally reliable cost-benefit analysis is impossible due toabsence of previous studies on this subject. In future studies occupational disabilityshould be taken into account as a standard outcome measure for treatment regimes.We also strongly feel that most patients are currently inadequately treated for severeinguinal pain complaints. A ‘tailored neurectomy’ is obvious beneficial for most patientsalthough some issues remain unsolved including timely referral patterns to painclinics as well as the effects of non-surgical treatment on occupational disability. Theoretically,it may be possible that some patients are treated with adequate pain reductionwithin one year of non-surgical treatment.In conclusion, neurectomy is an effective treatment modality for the resolution ofoccupational disability due to postherniorrhaphy inguinal neuralgia. Results on nonsurgicaltreatment options are unavailable. Neurectomy probably greatly reducesworkers’ compensational costs. Worldwide an enormous cost-reduction can be accomplishedwith adequate treatment.REFERENCES1 Bay-Nielsen M, Perkins FM, Kehlet H. Pain and functional impairment 1 year after inguinalhernior-rhaphy: a nationwide questionnaire study. Ann Surg 2001; 233: 1-72 Loos MJ, Roumen RM, Scheltinga MR. Chronic sequelae of common elective groin hernia repair.Hernia 2007; 11: 169-1733 Nienhuijs S, Staal E, Strobbe L, Rosman C, Groenewoud H, Bleichrodt R. Chronic pain after meshrepair of inguinal hernia: a systematic review. Am J Surg 2007; 194: 394-4004 Loos MJ, Roumen RM, Scheltinga MR. Classifying post-herniorrhaphy pain syndromes followingelective inguinal hernia repair. World J Surg 2007; 31: 1760-17655 Hindmarsh AC, Cheong E, Lewis MP et al. Attendance at a pain clinic with severe chronic painafter open and laparoscopic inguinal hernia repairs. Br J Surg 2003; 90: 1152-11546 Hameroff SR, Carlson GL, Brown BR. Ilioinguinal pain syndrome. Pain 1981; 10: 253-2577 Maaliki H, Naja Z, Zeidan A. Repeated ilioinguinal block using a catheter technique for painrelief in inguinal neuralgia. Pain Pract 2008; 8: 144-1468 Rauchwerger JJ, Giordano J, Rozen D, Kent JL, Greenspan J, Closson CW. On the therapeuticviability of peripheral nerve stimulation for ilioinguinal neuralgia: putative mechanisms andpossible utility. Pain Pract 2008; 8: 138-1439 Cohen SP, Foster A. Pulsed radiofrequency as a treatment for groin pain and orchialgia. Urology2003; 61: 64510 Rho RH, Lamer TJ, Fulmer JT. Treatment of genitofemoral neuralgia after laparoscopic inguinalherniorrhaphy with fluoroscopically guided tack injection. Pain Med 2001; 2: 230-23311 Rozen D, Parvez U. Pulsed radiofrequency of lumbar nerve roots for treatment of chronic inguinalherniorraphy pain. Pain Physician 2006; 9: 153-15612 Aasvang EK, Kehlet H. The effect of mesh removal and selective neurectomy on persistent postherniotomypain. Ann Surg 2009; 249: 327-33413 Amid PK. Causes, prevention, and surgical treatment of postherniorrhaphy neuropathic inguinodynia:triple neurectomy with proximal end implantation. Hernia 2004; 8: 343-34914 Bower S, Moore BB, Weiss SM. Neuralgia after inguinal hernia repair. Am Surg 1996; 62: 664-66715 Giger U, Wente MN, Buchler MW, Krähenbühl S, Lerut J, Krähenbühl L. Endoscopic retroperitonealneurectomy for chronic pain after groin surgery. Br J Surg 2009; 96: 1076-108116 Heise CP, Starling JR. Mesh inguinodynia: a new clinical syndrome after inguinal herniorrhaphy?J Am Coll Surg 1998; 187: 514-518132 Chapter 9Occupational disability due to chronic postherniorrhaphy neuralgia: a plea for tailored neurectomy 133