To clarify the role of a surgical neurectomy on pain in refractory patients after conservatively treated anterior cutaneous nerve entrapment syndrome (ACNES).
ACNES is hardly ever considered in the ...differential diagnosis of chronic abdominal pain. Treatment is usually conservative. However, symptoms are often recalcitrant.
Patients older than 18 years with a diagnosis of ACNES were randomized to undergo a neurectomy or a sham procedure via an open surgical procedure in day care. Both the patient and the principal investigator were blinded to the nature of surgery. Pain was recorded using a visual analog scale (1-100 mm) and a verbal rating scale (score 0-5; 0 = no pain, 5 = severe pain) before surgery and 6 weeks postoperatively. A reduction of at least 50% in the visual analog scale score and/or 2 points on the verbal rating scale was considered a "successful response."
Forty-four patients were randomized between August 2008 and December 2010 (39 women, median age = 42 years; both groups, n = 22). In the neurectomy group, 16 patients reported a successful pain response. In contrast, significant pain reduction was obtained in 4 patients in the sham group (P = 0.001). Complications associated with surgery were hematoma (n = 5, conservative treatment), infection (antibiotic and drainage, n = 1), and worsened pain (n = 1).
Neurectomy of the intercostal nerve endings at the level of the abdominal wall is an effective surgical procedure for pain reduction in ACNES patients who failed to respond to a conservative regimen.
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.
Breast cancer treatment depends on human epidermal growth factor receptor-2 (HER2) status, which is often determined using dual probe fluorescence in situ hybridisation (FISH). Hereby, also loss and ...gain of the centromere of chromosome 17 (CEP17) can be observed (HER2 is located on chromosome 17). CEP17 gain can lead to difficulty in interpretation of HER2 status, since this might represent true polysomy. With this study we investigated whether isolated polysomy is present and how this effects HER2 status in six breast cancer cell lines and 97 breast cancer cases, using HER2 FISH and immunohistochemistry, DNA ploidy assessment and multiplex ligation dependent probe amplification. We observed no isolated polysomy of chromosome 17 in any cell line. However, FISH analysis did show CEP17 gain in five of six cell lines, which reflected gains of the whole chromosome in metaphase spreads and aneuploidy with gain of multiple chromosomes in all these cases. In patients' samples, gain of CEP17 indeed correlated with aneuploidy of the tumour (91.1%; p < 0.001). Our results indicate that CEP17 gain is not due to isolated polysomy, but rather due to widespread aneuploidy with gain of multiple chromosomes. As aneuploidy is associated with poor clinical outcome, irrespective of tumour grade, this could improve future therapeutic decision making.
Purpose
Patients with anterior cutaneous nerve entrapment syndrome (ACNES) often require a step‐up treatment strategy including abdominal wall injections, pulsed radiofrequency (PRF) or a neurectomy. ...Long‐term success rates of PRF and surgery are largely unknown. The aim of the current study was to report on the long‐term efficacy of PRF and neurectomy in ACNES patients who earlier participated in the randomized controlled PULSE trial.
Methods
Patients who completed the PULSE trial were contacted about pain status and additional treatments in the following years. Treatment success was based on numerical rating scale (NRS) following IMMPACT recommendations and Patient Global Impression of Change (PGIC) scores.
Results
A total of 44 of the original 60 patients were eligible for analysis (73.3%). Median follow‐up was 71.5 months. One patient (4.3%) was still free of pain after a single PRF session, and five additional patients (21.7%) were free of pain by repetitive PRF treatments. By contrast, 13 patients (61.9%) in the neurectomy group were still free of pain without additional treatments. All pain recurrences and therefore primary re‐interventions occurred in the first 2 years after the initial treatment.
Conclusion
Approximately one in five ACNES patients undergoing PRF treatment reports long‐term success obviating the need of surgical intervention. Surgery for ACNES is long‐term effective in approximately two of three operated patients. Recurrent ACNES beyond 2 years after either intervention is rare.
Some patients with chronic abdominal pain suffer from an anterior cutaneous nerve entrapment syndrome (ACNES). This somewhat illusive syndrome is thought to be caused by the entrapment of end ...branches of the intercostal nerves residing in the abdominal wall. If ACNES is suspected, a local injection of an anesthetic agent may offer relief. If pain is recurrent following multiple-injection therapy, an anterior neurectomy entailing removal of the entrapped nerve endings may be considered. After 1 year, a 70% success rate has been reported. Research on minimally invasive alternative treatments is scarce. Pulsed radiofrequency (PRF) treatment is a relatively new treatment for chronic pain syndromes. An electromagnetic field is applied around the nerve in the hope of leading to pain relief. This randomized controlled trial compares the effect of PRF treatment and neurectomy in patients with ACNES.
Adult ACNES patients having short-lived success following injections are randomized to PRF or neurectomy. At the 8-week follow-up visit, unsuccessful PRF patients are allowed to cross over to a neurectomy. Primary outcome is pain relief after either therapy. Secondary outcomes include patient satisfaction, quality of life, use of analgesics and unanticipated adverse events. The study is terminated 6 months after receiving the final procedure.
Since academic literature on minimally invasive techniques is lacking, well-designed trials are needed to optimize results of treatment for ACNES. This is the first large, randomized controlled, proof-of-concept trial comparing two therapy techniques in ACNES patients. The first patient was included in October 2015. The expected trial deadline is December 2017. If effective, PRF may be incorporated into the ACNES treatment algorithm, thus minimizing the number of patients requiring surgery.
Nederlands Trial Register (Dutch Trial Register), NTR5131 ( http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5131 ). Registered on 15 April 2015.
Most patients with chronic back pain suffer from degenerative thoracolumbovertebral disease. However, the following case illustrates that a localized peripheral nerve entrapment must be considered in ...the differential diagnosis of chronic back pain. We report the case of a 26-year-old woman with continuous excruciating pain in the lower back area. Previous treatment for nephroptosis was to no avail. On physical examination the pain was present in a 2 x 2 cm area overlying the twelfth rib some 4 cm lateral to the spinal process. Somatosensory testing using swab and alcohol gauze demonstrated the presence of skin hypo- and dysesthesia over the painful area. Local pressure on this painful spot elicited an extreme pain response that did not irradiate towards the periphery. These findings were highly suggestive of a posterior version of the anterior cutaneous nerve entrapment syndrome (ACNES), a condition leading to a severe localized neuropathic pain in anterior portions of the abdominal wall. She demonstrated a beneficial albeit temporary response after lidocaine infiltration as dictated by an established diagnostic and treatment protocol for ACNES. She subsequently underwent a local neurectomy of the involved superficial branch of the intercostal nerve. This limited operation had a favorable outcome resulting in a pain-free return to normal activities up to this very day (follow-up of 24 months).We propose to name this novel syndrome "posterior cutaneous nerve entrapment syndrome" (POCNES). Each patient with chronic localized back pain should undergo simple somatosensory testing to detect the presence of overlying skin hypo- and dysesthesia possibly reflecting an entrapped posterior cutaneous nerve.Key words: Chronic pain, back pain, posterior cutaneous nerve entrapment, peripheral nerve entrapment, surgical treatment for pain, anterior cutaneous nerve entrapment.
Chronic back pain (CBP) may be caused by a variety of conditions including dysfunctional muscles, ligaments or intervertebral discs, improper movement of vertebral column joints, or nerve root ...compression. Recently, CBP was treated successfully in a patient having an entrapment of cutaneous branches of the posterior rami of the thoracic nerves, termed posterior cutaneous nerve entrapment syndrome (POCNES). Our aim is to describe clinical presentation, differential diagnosis, and management of patients with such a neuropathic pain syndrome.
This study analyzed prospectively obtained data from consecutive patients suspected of having POCNES, presenting to two Dutch hospitals between January 2013 and September 2016. Patients received a diagnostic 2-5 mL 1% lidocaine injection just below the thoracolumbar fascia. Pain was scored using a numerical rating scale (0 = no pain to 10 = worst possible pain). A >50% pain reduction was defined as success. A neurectomy was proposed if pain reduction was temporary or insufficient after one to three injections. Long-term treatment effect was determined using a verbal rating scale (VRS; 1 = very satisfied, no pain, to 5 = pain worse).
Fourteen patients (12 women, median age 26, age range 18-73) were diagnosed with POCNES. Eighty-one percent (n=11) reported a >50% pain drop after injection (NRS pain scores of median 8.0 IQR 7.0-8.0 to median 3.0 IQR 1.5-3.5,
<0.001). In one patient, repeated injections were successful long-term (VRS score of 2). Two patients declined surgery, whereas the remaining eleven underwent a neurectomy that was successful in seven (64%). A 57% long-term efficacy (median 29 months follow-up, range 5-48, VRS score 1-2) was attained in the entire study population.
POCNES should be considered in the differential diagnosis of chronic localized back pain. A treatment regimen including injections and neurectomy of the specific cutaneous branch results in long-term pain relief in more than half of these patients.
Pain after Anterior Mesh Hernia Repair Nienhuijs, Simon Willem; Boelens, Oliver B.A.; Strobbe, Luc J.A.
Journal of the American College of Surgeons,
06/2005, Letnik:
200, Številka:
6
Journal Article
Recenzirano
The results of a randomized clinical trial comparing the Lichtenstein procedure, mesh plug repair, and the Prolene Hernia System provided a database for analyzing chronic pain after anterior mesh ...hernia repair to determine the characteristics and identify risk factors.
A total of 334 patients with primary inguinal hernia were randomly allocated to receive one of the three meshes. Data on patient characteristics, hernia, and procedure were collected. Longterm followup was completed for 319 of 333 (95.8 %) patients with a postal questionnaire that included a Visual Analog Scale pain score, pain descriptions, and questions about numbness and prosthesis awareness. Chronic pain was analyzed irrespective of the technique used.
With increasing age, significantly less intense chronic pain was reported (
R = −0.267, p < 0.001) and pain descriptors were used less frequently (p < 0.001). This indirectly reflected the significance of employment (p = 0.019) and body mass index (
R = −0.166, p = 0.005) in a univariate analysis because the elderly were, for the most part, unemployed and had a higher body mass index. Longterm Visual Analog Scale pain score correlated significantly with pain directly after an operation (
R = 0.253, p = < 0.001). Reported pain increased with the presence of numbness (p < 0.001) and the number of descriptions used (
R = 0.389, p < 0.001). Patients using only neuropathic descriptions (n = 56) suffered significantly more intense pain (Visual Analog Scale 26.5 versus 16.6, p = 0.014) than those using only words indicating nociceptive pain (n = 47).
Chronic pain after anterior mesh hernia repair is determined by younger age and stronger pain directly after the operation. Especially in patients with chronic neuropathic pain, its intensity is aggravated when numbness is present and the number of words to describe pain increases.
Abstract Background Chronic abdominal pain (CAP) in children may be caused by entrapment of cutaneous branches of intercostal nerves (anterior cutaneous nerve entrapment syndrome, or ACNES). Local ...injection of anesthetics may offer relief, but pain is persistent in some children. This study is the first to describe the results of a ‘cutaneous neurectomy’ in children with refractory ACNES. Methods Chronic abdominal pain children with suspected ACNES refractory to conservative treatment received a cutaneous neurectomy in a day care setting. They were interviewed postoperatively using an adapted quality of life questionnaire (testing quality of life in children). Results All subjects (n = 6; median age, 15 years; range, 9-16 years) were previously healthy school-aged children without prior illness or earlier surgery. Each presented with intense abdominal pain and a positive Carnett sign. Blood, urine tests, and abdominal ultrasound investigations were normal. Delay in seeing a physician was 16 weeks, and school absence was 25 days. Before surgery, quality of life (pain, daily activities, and sports) was greatly diminished. After the neurectomy, all children were free of pain and had resumed their normal daily routine (follow-up at 6 months). Conclusions The role of the abdominal wall as the source of childhood CAP is underestimated. Some children with CAP have ACNES. Children with refractory ACNES should be offered a cutaneous neurectomy, as this simple technique is effective in the short and long term.
Background and aims Anterior cutaneous nerve entrapment syndrome (ACNES) may result in chronic abdominal pain. Therapeutic options include local injection therapy. Data on the efficacy of adding ...corticosteroids to these injections is lacking. Methods Patients ≥18 years with ACNES were randomized to receive an injection of lidocaine with (LC-group) or without (LA-group) the addition of methylprednisolone into the point of maximal abdominal wall pain. Pain was recorded using a numeric rating scale (NRS: 0-10) and a verbal rating scale (VRS: 0=no pain, 5=unbearable pain) at baseline and 6 weeks after the start of a bi-weekly injection regimen consisting of a total of three injections. A minimal 50% reduction on NRS and/or two points on VRS were considered successful responses. Results Between February 2014 and August 2016, 136 patients (median age 46 year, range 18-79, 75% females) were randomized (68 vs. 68). The proportion of patients demonstrating a successful response after 6 weeks did not significantly differ between groups (LA 38%, LC 31%, p=0.61). At 12 weeks, the number of patients still experiencing a minimal 50% pain relief had decreased but no group difference was observed (LA 20%, LC 18%, p=0.80). Minor side effects included temporary increase of pain, tenderness at injection sites or transient malaise (LA23/68, LC 29/68, p=0.46). Conclusions Adding corticosteroids to a lidocaine does not increase the proportion of ACNES patients with a successful response to injection therapy. Lidocaine alone can provide long term pain relief after one or multiple injections, in approximately 1 of 5 patients.
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