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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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Sun XX, Liu H, Qin XZ, Li MR, Yan QH, Zhang GJ. The Diagnostic Value of Carnett's Test with Chronic Abdominal Pain: A Narrative Review. Curr Pain Headache Rep 2024; 28:251-257. [PMID: 38340209 DOI: 10.1007/s11916-024-01223-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 02/12/2024]
Abstract
PURPOSE OF REVIEW Chronic abdominal wall pain is a poorly recognized cause of chronic abdominal pain, and patients frequently go misdiagnosed despite a battery of medical tests. The Carnett's test is a diagnostic tool used to distinguish between abdominal wall pain and visceral pain. This review synthesizes the current literature on the Carnett's test, merges the viewpoints of diverse writers, and evaluates and reports on the Carnett's test's applicability. RECENT FINDINGS Several clinical investigations have established the usefulness of the Carnett's test in the diagnosis of chronic abdominal wall pain. Furthermore, the Carnett's test is quite useful in determining the depth of the mass and detecting psychogenic abdominal pain. However, its diagnostic use for acute abdominal pain is limited. The Carnett's test is a simple and safe point-of-care diagnostic technique, with several studies supporting its usefulness. Early detection of abdominal wall pain is critical for chronic abdominal wall pain therapy. Carnett's test is very useful in patients with chronic, unexplained local abdominal discomfort who are compliant and do not have a clear rationale for surgery.
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Affiliation(s)
- Xiao-Xiao Sun
- Department of Pain, Yanbian University Hospital, Yanji, Jilin Province, China
| | - Heng Liu
- School of Nursing, Qingdao University, Qingdao, Shandong Province, China
| | - Xiang-Zheng Qin
- Department of Anatomy, Basic Medical Sciences of Yanbian University, Yanji, Jilin Province, China
| | - Mei-Rui Li
- Department of Pain, Yanbian University Hospital, Yanji, Jilin Province, China
| | - Qing-Hua Yan
- Department of Pain, Yanbian University Hospital, Yanji, Jilin Province, China
| | - Guang-Jian Zhang
- Department of Pain, Yanbian University Hospital, Yanji, Jilin Province, China.
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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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Have TT, Geffen STV, Zwaans WAR, Maatman RC, Boelens OBA, Steegers MAH, Scheltinga MRM, Roumen RMH. Pulsed radiofrequency or surgery for anterior cutaneous nerve entrapment syndrome: Long-term results of a randomized controlled trial. Pain Pract 2024; 24:288-295. [PMID: 37823480 DOI: 10.1111/papr.13305] [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: 02/09/2023] [Revised: 05/26/2023] [Accepted: 10/01/2023] [Indexed: 10/13/2023]
Abstract
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.
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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
| | - Sem T van Geffen
- 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
| | - 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
| | - 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
| | | | - Monique A H Steegers
- Department of Anaesthesiology & Pain and Palliative Care, Amsterdam University Medical Center, Amsterdam, 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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Otsuka Y, Ishizuka K, Harada Y, Harada T, Shikino K, Shiraishi Y, Watari T. Three Subtypes of Cutaneous Nerve Entrapment Syndrome: A Narrative Review. Intern Med 2024:2927-23. [PMID: 38220195 DOI: 10.2169/internalmedicine.2927-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2024] Open
Abstract
Anterior, lateral, and posterior cutaneous nerve entrapment syndromes have been proposed as etiologies of trunk pain. However, while these syndromes are analogous, comprehensive reports contrasting the three subtypes are lacking. We therefore reviewed the literature on anterior, lateral, and posterior cutaneous nerve entrapment syndrome. We searched the PubMed and Cochrane Library databases twice for relevant articles published between March and September 2022. In addition to 16 letters, technical reports, and review articles, a further 62, 6, and 3 articles concerning anterior, lateral, and posterior cutaneous nerve entrapment syndromes, respectively, were included. These syndromes are usually diagnosed based solely on unique history and examination findings; however, the diagnostic process may be prolonged, and multiple re-evaluations are required. The most common first-line treatment is trigger point injection; however, the management of refractory cases remains unclear. Awareness of this disease should be expanded to medical departments other than general medicine.
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Affiliation(s)
- Yuki Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Kosuke Ishizuka
- Department of General Medicine, Yokohama City University School of Medicine, Japan
| | - Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Japan
| | - Taku Harada
- Division of General Medicine, Nerima Hikarigaoka Hospital, Japan
| | - Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, Japan
| | | | - Takashi Watari
- General Medicine Center, Shimane University Hospital, Japan
- Department of Medicine, University of Michigan Medical School, USA
- Division of Hospital Medicine, VA Ann Arbor Healthcare System, USA
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Newman DP, Holkup SM, Masi EL, Soto AT. A Novel Approach to Assessing and Conservatively Treating Anterior Cutaneous Nerve Entrapment Syndrome: A Case Study. Cureus 2023; 15:e44912. [PMID: 37814768 PMCID: PMC10560539 DOI: 10.7759/cureus.44912] [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: 09/08/2023] [Indexed: 10/11/2023] Open
Abstract
Anterior cutaneous nerve entrapment syndrome (ACNES) is a common source of chronic abdominal pain and is often underdiagnosed despite numerous and potentially invasive diagnostic evaluations and tests. We present a case report describing a novel, conservative, and non-invasive approach to diagnose and treat recurrent ACNES in a young and active patient. We describe a treatment-based diagnostic approach to confirm potential ACNES pain generators while recording pre- and post-treatment pain scores. After each maneuver, the patient was reassessed which allowed the working diagnosis to clinically evolve demonstrating the pathologic interrelationship between different skeletal structures and myofascial tissues contributing to irritation of the anterior cutaneous nerve. This treatment-based technique also made it possible to identify referred pain from a condition with overlapping symptoms originating from a different anatomic site. Treatment consisted of sequenced osteopathic manipulation techniques, active release techniques, instrument-assisted soft tissue mobilization, directional cupping, stretching, and strengthening exercises. The combination of sequenced treatments over the course of six physical therapy visits spanning 10 weeks resulted in 100% pain reduction and complete resolution of functional limitations. The patient was able to complete all work requirements and physical activity without pain. A sequenced treatment-based diagnostic approach to this case allowed us to more accurately identify all involved anatomic regions of pain and anatomic segments of pathology that were contributing to the abdominal pain or referring pain. No diagnostic imaging, invasive test, or injection was needed to properly diagnose and treat this case of ACNES. A proper understanding and application of osteopathic manipulation, active release techniques, instrument-assisted soft tissue mobilization, cupping, and exercises successfully resolved the contributing pain conditions and provided the patient important and useful tools and strategies to prevent recurrence.
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Affiliation(s)
- David P Newman
- Pain Management-Physiotherapy, Tripler Army Medical Center, Honolulu, USA
| | | | - Erica L Masi
- Pain Management, Tripler Army Medical Center, Honolulu, USA
| | - Adam T Soto
- Anesthesiology, Pain Management, Alexander T. Augusta Military Medical Center, Fort Belvoir, USA
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Kondo Y, Fujiwara T. Laparoscopic Surgical Options as a Minimally Invasive Procedure for a Patient With Recurrent Postoperative Pain in Anterior Cutaneous Nerve Entrapment Syndrome: A Case Report. Cureus 2023; 15:e39366. [PMID: 37362460 PMCID: PMC10285427 DOI: 10.7759/cureus.39366] [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: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
This report presents a case of a 70-year-old woman who developed anterior cutaneous nerve entrapment syndrome (ACNES) three years ago and had an anterior cutaneous neurectomy in the left Th10 region. Postoperatively, the pain had improved entirely, but 10 weeks later, she developed a recurrence in the vicinity of the wound. The anterior intercostal nerve branch (Th10), located between the transversus abdominis and internal oblique muscles, was dissected laparoscopically six months after the initial surgery. There was no re-recurrence of pain for four months postoperatively. The postoperative recurrence of ACNES was refractory to various treatments, including surgical neurectomy, and is often difficult to treat. In cases in which transversus abdominis plane block is effective, laparoscopic neurectomy through an intraperitoneal approach may be effective, and minimally invasive laparoscopic treatment may be an effective surgical option for patients with recurrent and refractory ACNES who have a low pain threshold and are prone to prolonged complaints due to wound pain.
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Affiliation(s)
- Yoshitaka Kondo
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, JPN
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, JPN
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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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Ferreira-Silva N, Ferreira-Dos-Santos G, Gupta S, Hunt CL, Eldrige JS, Pingree MJ, Clendenen SR, B Hurdle MF. A case for ultrasound-guided peripheral nerve stimulation in intractable anterior cutaneous nerve entrapment syndrome. Pain Manag 2022; 12:813-819. [PMID: 36065884 DOI: 10.2217/pmt-2022-0056] [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] [Indexed: 11/21/2022] Open
Abstract
Aim: This case report documents the use of peripheral nerve stimulation in the setting of entrapment of the anterior cutaneous branches of the intercostal nerves, with pain rated by the patient as severe during exacerbation episodes. Materials & methods: Under ultrasound guidance, two permanent leads were implanted caudad to cephalad, along and superficial to the lateral aspect of the rectus abdominis, distal to the umbilicus (1 lead per side). Results: At the 6 month follow-up, the patient reported near complete resolution of baseline pain, as well as fewer, sporadic pain exacerbation episodes, rated as mild-to-moderate. Conclusion: This case report suggests that peripheral nerve stimulation might be a valuable treatment option for previously intractable abdominal pain due to entrapment of the anterior cutaneous branches.
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Affiliation(s)
- Nuno Ferreira-Silva
- Department of Physical Medicine & Rehabilitation, Hospital Professor Doctor Fernando Fonseca, Amadora, Portugal
| | - Guilherme Ferreira-Dos-Santos
- Department of Anesthesiology & Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, M5T 2S8, Canada
| | - Sahil Gupta
- Department of Pain Medicine, Mayo Clinic Jacksonville, FL 32224, USA
| | - Christine L Hunt
- Department of Pain Medicine, Mayo Clinic Jacksonville, FL 32224, USA
| | - Jason S Eldrige
- Department of Pain Medicine, Mayo Clinic Jacksonville, FL 32224, USA
| | - Matthew J Pingree
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Steven R Clendenen
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
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Tsuchida T, Kondo Y, Ishizuka K, Matsuda T, Ohira Y. Nerve Identification Procedures Are Necessary for Complete Recovery From Recurrent Cases of Anterior Cutaneous Nerve Entrapment Syndrome: A Case Report. Cureus 2022; 14:e26497. [PMID: 35923491 PMCID: PMC9339258 DOI: 10.7759/cureus.26497] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/05/2022] Open
Abstract
Anterior cutaneous nerve entrapment syndrome (ACNES) involves pain in the abdominal wall due to nerve compression or ischemia. The diagnosis of ACNES is challenging with the pain often inclined to be diagnosed as psychological in origin. A 20-year-old woman presenting with abdominal pain was initially diagnosed with mesenteric lymphadenitis and prescribed pain relievers. However, following worsened pain, she was hospitalized. Blood examinations, abdominal and gynecological ultrasonography, and gastrocolonoscopy yielded no abnormal findings, leading to suspicions of psychological factors. As the patient experienced sharp abdominal pain on movement, but not at rest, which was temporarily relieved by lidocaine injections, she was diagnosed with ACNES. Rectus abdominal resection was performed but the pain relapsed. Laparoscopic surgery was performed to cut the nerve that caused the pain. After three surgeries, the patient was completely symptom-free. ACNES should be considered as a differential diagnosis for intractable abdominal pain. For recurrent relapses, the triggering nerves must be carefully identified for the successful treatment of ACNES.
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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: 0.5] [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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12
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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: 01/20/2022] [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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Jacobs MLYE, van den Dungen-Roelofsen R, Heemskerk J, Scheltinga MRM, Roumen RMH. Ultrasound-guided abdominal wall infiltration versus freehand technique in anterior cutaneous nerve entrapment syndrome (ACNES): randomized clinical trial. BJS Open 2021; 5:6487776. [PMID: 34964825 PMCID: PMC8715735 DOI: 10.1093/bjsopen/zrab124] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/20/2021] [Indexed: 11/14/2022] Open
Abstract
Background The optimal technique of abdominal wall infiltration for chronic abdominal wall pain due to anterior cutaneous nerve entrapment syndrome (ACNES) is unknown. The aim of this study was to compare pain reduction after an abdominal wall anaesthetic injection by use of an ultrasound-guided technique (US) or given freehand (FH). Methods In this multicentre non-blinded randomized trial, adult patients with ACNES were randomized (1:1) to an US or a FH injection technique. Primary outcome was the proportion of injections achieving a minimum of 50 per cent pain reduction on the Numeric Rating Scale (range 0–10) 15–20 min after abdominal wall infiltration (‘successful response’). Secondary outcomes were treatment efficacy after 6 weeks and 3 months, and the influence of the subcutaneous tissue thickness on treatment outcome. Results Between January 2018 and April 2020, 391 injections (US = 192, FH = 199) were administered in 117 randomized patients (US = 55, FH = 62; 76.0 per cent female, mean age 45 years). The proportion of successful responses did not significantly differ immediately after the injection regimen (US 27.1 per cent versus FH 33.2 per cent; P = 0.19) or after 3 months (US 29.4 per cent versus FH 30.5 per cent; P = 0.90). Success was not determined by subcutaneous tissue thickness. Conclusion Pain relief following abdominal wall infiltration by a US or FH technique in ACNES is similar and not influenced by subcutaneous tissue thickness. Registration number Dutch Clinical Trial Register NL8465.
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Affiliation(s)
- Monica L Y E Jacobs
- Correspondence to: Department of Surgery, Máxima Medical Center, Ds. Th. Fliednerstraat 1, 5600 PD Eindhoven, The Netherlands (e-mail: and )
| | - Rosanne van den Dungen-Roelofsen
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
| | - Jeroen Heemskerk
- Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
| | - Marc R M Scheltinga
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
| | - Rudi M H Roumen
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
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14
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Ishizuka K, Yokokawa D, Mori T, Kato T, Ikusaka M. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES). Am J Med 2021; 134:e488-e489. [PMID: 33939995 DOI: 10.1016/j.amjmed.2021.03.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Kosuke Ishizuka
- Department of General Medicine, Chiba University Hospital, Japan; Department of General Internal Medicine, Eastern Chiba Medical Center, Japan.
| | - Daiki Yokokawa
- Department of General Medicine, Chiba University Hospital, Japan
| | - Takahiro Mori
- Department of General Internal Medicine, Eastern Chiba Medical Center, Japan
| | - Tomonori Kato
- Department of General Internal Medicine, Eastern Chiba Medical Center, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, Japan
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15
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Jacobs MLYE, Scheltinga MRM, Roumen RMH. Persistent pain relief following a single injection of a local anesthetic for neuropathic abdominal wall and groin pain. Scand J Pain 2021; 21:628-632. [PMID: 34114386 DOI: 10.1515/sjpain-2021-0034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/18/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES It is our experience that a small portion of patients with neuropathic abdominal wall pain syndromes such as the anterior cutaneous nerve entrapment syndrome (ACNES) have a long term beneficial response following just one single tender point injection (TPI) with a local anesthetic agent. This report focuses on the phenomenon of ongoing pain relief following a single local anesthetic injection in neuropathic abdominal wall and groin pain syndromes. METHODS This report is an overview based on earlier studies from a center of expertise for neuropathic abdominal wall and groin pain syndromes. All studies on neuropathic abdominal wall and groin pain syndromes reporting on efficacy of a diagnostic TPI using a local anesthetic agent were included. RESULTS A total of 10 studies including 834 patients fulfilled study criteria. Each of these 10 studies found that approximately 10% (range, 4-25%) of the cases experienced persistent pain relief after a single TPI with lidocaine 1%. CONCLUSIONS Persistent pain relief after a single TPI using a local anesthetic agent may be observed in approximately one of 10 patients suffering from neuropathic abdominal wall or groin pain syndromes. When a patient is suspected of having a neuropathic abdominal wall or groin pain syndrome, a single TPI using a local anesthetic agent should be administered as long term pain relief may occasionally occur.
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Affiliation(s)
- Monica L Y E Jacobs
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands.,SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
| | - Marc R M Scheltinga
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands.,SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
| | - Rudi M H Roumen
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands.,SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
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16
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Ultrasound-guided transversus abdominis plane block vs trigger point injections for chronic abdominal wall pain: a randomized clinical trial. Pain 2021; 162:1800-1805. [PMID: 33433147 DOI: 10.1097/j.pain.0000000000002181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/28/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT The primary aim of this randomized clinical trial is to investigate the effects of ultrasound-guided transversus abdominis plane (TAP) vs ultrasound-guided trigger point injections (TPIs) on numerical rating scale pain scores at month 3 follow-up in patients with a chronic abdominal wall pain. The primary outcome measure was the difference in mean numeric rating scale pain scores between the TAP and TPI groups at month 3 in an intent-to-treat (ITT) analysis. A total of 60 patients were randomized 1:1 to receive an ultrasound-guided TAP block (n = 30) or an ultrasound-guided TPI (n = 30). No significant group differences in baseline demographic or clinical characteristics were observed. The mean baseline pain score for the TAP and TPI groups was 5.5 and 4.7, respectively. In the ITT analysis at month 3, the between-group difference in pain scores was 1.7 (95% confidence interval, 0.3-3.0) favoring the TPI group. In a secondary per-protocol analysis, the between-group difference in pain scores was 1.8 (95% confidence interval, 0.4-3.2) favoring the TPI group. For the ITT and per-protocol analyses, the group differences in pain scores were consistent with a medium effect size. The main finding of this randomized clinical trial is that adults with chronic abdominal wall pain who received a TPI reported significantly lower pain scores at month 3 follow-up compared with patients who received a TAP block.
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17
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Chalian M, Hoang D, Rozen S, Chhabra A. Role of magnetic resonance neurography in intercostal neuralgia; diagnostic utility and efficacy. Br J Radiol 2021; 94:20200603. [PMID: 33960822 DOI: 10.1259/bjr.20200603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To evaluate the utility and efficacy of MR neurography (MRN) in the diagnostic work-up for intercostal neuralgia and to assess the treatment course and outcomes in MRN-imaged clinically suspected intercostal neuropathy cases of chronic chest and abdominal wall pain syndromes. METHODS Following a retrospective cross-sectional study, a consecutive series of patients who underwent MRN of torso for suspected intercostal neuralgia were included. Patient demographics, pain location/level/duration, previous work-up for the same indication, MRN imaging results, and MRN cost per patient were recorded. An inter-reader reliability assessment was performed on the MRN findings using Cohen's weighted κ analysis. Post-MRN treatment choice, as well as success rates of MRN directed perineural injections and surgical management were also evaluated. RESULTS A total of 28 patients (mean ± SD age, 48.3 ± 18.0 years, female/male = 3.0) were included. Pain and/or numbness in the right upper quadrant were the most common complaints. The mean maximum pain level experienced was 7.4 ± 2.5 on a 1 (lowest pain level) - 10 (highest pain level) visual analog scale. The duration of pain before MRN work-up was 36.9 ± 37.9 months. The patients had seen an average of 5 ± 2.8 physicians for such syndromes. 20 (71%) patients had one or multiple other imaging studies for prior work-up. MRN identified positive intercostal nerve abnormality in 19 cases with clinical symptoms of intercostal neuralgia. From the inter-reader reliability assessment, a Cohen's weighted κ value of 0.78 was obtained. The costs of work-up was about one-third with MRN for diagnostic purposes with less financial and psychological harm. Among the MRN-positive cases, 9/19 patients received perineural injections, of which 6 reported improvement after their first round, lasting an average of 41.1 ± 83 days. Among the nine MRN-negative cases, two received perineural injections, of which none reported improvement. Surgical management was mostly successful with a positive outcome in six out of seven operated cases (85.7%). CONCLUSION MRN is useful in diagnostic algorithm of intercostal neuralgia and MRN-positive cases demonstrate favorable treatment response to perineural injections and subsequent surgical management. ADVANCES IN KNOWLEDGE The use of MRN in intercostal neuralgia is an application that has not been previously explored in the literature. This study demonstrates that MRN offers superior visualization of pathology in intercostal neuralgia and confirms that treatment directed at MRN identified neuropathy results in good outcomes while maintaining cost efficiency.
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Affiliation(s)
- Majid Chalian
- Department of Radiology, Musculoskeletal Imaging and Intervention, University of Washington, Seattle, WA, USA
| | - Diana Hoang
- Department of Radiology, Musculoskeletal Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Shai Rozen
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Avneesh Chhabra
- Department of Radiology, Musculoskeletal Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Orthopedics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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18
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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: 2.3] [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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19
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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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20
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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: 6] [Impact Index Per Article: 2.0] [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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21
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Characteristics of 1116 Consecutive Patients Diagnosed With Anterior Cutaneous Nerve Entrapment Syndrome (ACNES). Ann Surg 2021; 273:373-378. [PMID: 30817351 DOI: 10.1097/sla.0000000000003224] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to discuss patient history and subjective findings at physical examination in a large case series to validate a proposed comprehensive set of major and minor diagnostic criteria. SUMMARY BACKGROUND DATA Chronic abdominal pain in some patients is caused by the anterior cutaneous nerve entrapment syndrome (ACNES). ACNES is a clinical diagnosis as no functional testing or imaging modalities are available up to date. METHODS This study retrospectively analyzed prospectively obtained data from consecutive patients who received the diagnosis ACNES during evaluation at the SolviMáx Center of Excellence for Abdominal Wall and Groin Pain, Eindhoven, The Netherlands, between June 1, 2011 and September 1, 2016. Questionnaires, standard case forms, and digital case files containing characteristics of individuals were used for analysis. RESULTS Data of 1116 patients suspected and treated for ACNES consistently showed the presence of the following 4 characteristics: sensory disturbances at the painful abdominal area (78%), a positive pinch sign (78%), a positive Carnett's sign (87%), and a positive response to a modified rectus sheath block (>50% pain reduction, 81%). The majority of patients are female of young or middle age with a normal BMI reporting complaints that occurred spontaneously in either a sudden or gradual timeframe, developing a severe (NRS 6-8) chronic abdominal pain that was only diagnosed after a substantial doctor's delay. CONCLUSION A combination of typical findings in history and physical examination, combined with a positive modified rectus sheath block, may allow for diagnosing ACNES in patients with chronic abdominal pain.
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22
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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: 0.5] [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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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: 0.8] [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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24
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Maatman RC, Kuijk SM, Steegers MA, Boelens OB, Lim TC, Scheltinga MR, Roumen RM. 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. [DOI: 10.1111/papr.12806] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 05/28/2019] [Accepted: 05/30/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Robbert C. Maatman
- Department of Surgery Máxima Medical Center VeldhovenThe Netherlands
- SolviMáx Center of Expertise for ACNES Center of Excellence for Chronic Abdominal Wall and Groin Pain Máxima Medical Center EindhovenThe Netherlands
| | - Sander M.J. Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA) MUMC+ MaastrichtThe Netherlands
| | - Monique A.H. Steegers
- Department of Anaesthesiology & Pain and Palliative Care Radboud University Medical CentreNijmegenThe 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 VeldhovenThe Netherlands
- SolviMáx Center of Expertise for ACNES Center of Excellence for Chronic Abdominal Wall and Groin Pain Máxima Medical Center EindhovenThe Netherlands
| | - Rudi M.H. Roumen
- Department of Surgery Máxima Medical Center VeldhovenThe Netherlands
- SolviMáx Center of Expertise for ACNES Center of Excellence for Chronic Abdominal Wall and Groin Pain Máxima Medical Center EindhovenThe Netherlands
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25
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Omura D, Obika M, Iwamuro M, Nagao S, Nada T, Matsuzaki T, Kondo Y, Otsuka F. Anterior Cutaneous Nerve Entrapment Syndrome Possibly Triggered by Oral Contraceptives. Intern Med 2019; 58:1507-1509. [PMID: 30713291 PMCID: PMC6548911 DOI: 10.2169/internalmedicine.1361-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
We herein report a teenage girl who had been taking oral contraceptive pills for three months and complained of left lower abdominal pain that had continued for two months. A physical examination indicated anterior cutaneous nerve entrapment syndrome (ACNES), although no abnormality was found in various biochemical and imaging examinations. The pain was only transiently ameliorated by trigger-point injection, and neurectomy surgery was eventually effective. Sex steroids can be involved in the progress of local tissue edema causing ACNES. ACNES should be considered in cases of abdominal pain in patients taking oral contraceptives.
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Affiliation(s)
- Daisuke Omura
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Mikako Obika
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Masaya Iwamuro
- Department of Gastroenterology and Hepatology Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Satoko Nagao
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Takahiro Nada
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Takashi Matsuzaki
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Yoshitaka Kondo
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Fumio Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
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Maatman RC, Boelens OB, Scheltinga MRM, Roumen RMH. Chronic localized back pain due to entrapment of cutaneous branches of posterior rami of the thoracic nerves (POCNES): a case series on diagnosis and management. J Pain Res 2019; 12:715-723. [PMID: 30863144 PMCID: PMC6388752 DOI: 10.2147/jpr.s178492] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Introduction and aim 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. Methods 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). Results 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], P<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. Conclusion 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.
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Affiliation(s)
- Robbert C Maatman
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands,
| | - Oliver B Boelens
- Department of Surgery, Maasziekenhuis Pantein, Boxmeer, The Netherlands
| | - Marc R M Scheltinga
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands,
| | - Rudi M H Roumen
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands,
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Factors predicting outcome after anterior neurectomy in patients with chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome (ACNES). Surgery 2019; 165:417-422. [DOI: 10.1016/j.surg.2018.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 08/02/2018] [Accepted: 08/14/2018] [Indexed: 01/16/2023]
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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: 3.0] [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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Maatman RC, Werner MU, Scheltinga MRM, Roumen RMH. Bilateral distribution of anterior cutaneous nerve entrapment syndrome (ACNES): are clinical features and outcomes comparable to unilateral ACNES? Reg Anesth Pain Med 2019; 44:rapm-2018-100062. [PMID: 30635513 DOI: 10.1136/rapm-2018-100062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/06/2018] [Accepted: 11/30/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES Mirror-image pain may occur in the presence of a one-sided peripheral nerve lesion leading to a similar distribution of pain on the contralateral side of the body ("mirrored"). Anterior cutaneous nerve entrapment syndrome (ACNES) is a neuropathic pain syndrome due to entrapment of terminal branches of intercostal nerves T7-12 in the abdominal wall and sometimes presents bilaterally. This study aims to address specifics of bilateral ACNES and to determine potential differences in clinical presentation and treatment outcomes when compared with the unilateral form of ACNES. METHODS Electronic patient files and questionnaires of a case series of patients who were evaluated for chronic abdominal wall pain in a single center were analyzed using standard statistical methods. RESULTS Between June 1, 2011 and September 1, 2016, 1116 patients were diagnosed with ACNES, of which a total of 146 (13%) with bilateral ACNES were identified (female, n = 114, 78 %; median (range) age 36 (1181) years). Average NRS (Numeric Rating Scale; 0-10) scores were similar (median (range) NRS scores 6 (0-10) although peak NRS scores were significantly higher in the bilateral group (9 (5-10) vs 8 (2-10); p=0.02). After a median of 26 months (1-68), the proportion of patients with bilateral ACNES reporting treatment success was 61%. CONCLUSIONS One in eight patients with ACNES has bilateral abdominal wall pain. Characteristics are similar to unilateral ACNES cases. Further studies aimed at underlying mechanisms in mirror image pain pathogenesis could provide a more targeted approach in the management of this neuropathic pain.
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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
| | - Mads U Werner
- Multidisciplinary Pain Center, Neuroscience Center, Rigshospitalet, Copenhagen, Denmark
| | - 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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Michels T, Ahmadi S, Graf N. Treatment of peripheral pain with low-dose local anesthetics by epidermal, epithelial and periosteal application. Local Reg Anesth 2018; 11:129-136. [PMID: 30588085 PMCID: PMC6294063 DOI: 10.2147/lra.s151316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives The efficiency of local anesthetics (LAs) in the treatment of peripheral pain is commonly attributed to their capacity to block the axon conduction of sensory nerves. LAs even in non-blocking concentration suppress oscillations of the resting membrane potential. Spiking in sensory neurons is triggered by subthreshold membrane potential oscillations (SMPOs), which reach threshold and is maintained by depolarizing impulse after oscillations. The suppression of these oscillations abolishes sustained afferent discharge in sensory nerves without blocking the axon conduction. In a retrospective observational study, we examined if LAs in low concentration and very small quantities could reduce peripheral pain in patients. Design During a period of 2 years, a total of 127 consecutive patients, 43 with cervico-brachial, 12 with intercostal and 72 with lumbo-sciatic pain received an identical treatment, which consisted of LAs applied in 4–8 sessions on average to a fixed set of epidermal, epithelial and periosteal locations. The primary outcome was relief of symptoms measured by verbal analog scales at the end of therapy. Results At the end of therapy, 53 (41.7%) of all patients (127) had a complete remission (reduction of pain 100%). Twenty-three patients (18.1%) had a partial remission with >90% reduction of pain and 50 patients (39.4%) had a pain reduction of 30%–90%. One patient did not respond. Conclusion LAs in low concentration and small quantities proved to be highly efficient in the treatment of peripheral pain. An almost complete remission could be obtained in a majority of patients. Given the extent of pain reduction achieved, the method of application seems to be of major importance.
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Affiliation(s)
| | - Seifollah Ahmadi
- Institute of Physiology II, University of Bonn, 53115 Bonn, Germany
| | - Nicole Graf
- Graf Biostatistics, CH-8400 Winterthur, Switzerland
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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: 0.2] [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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Anterior Cutaneous Nerve Entrapment Syndrome in Children: A Prospective Observational Study. Clin J Pain 2018; 34:670-673. [DOI: 10.1097/ajp.0000000000000573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Maatman RC, Steegers MA, Kallewaard JW, Scheltinga MR, Roumen RM. Pulsed Radiofrequency as a Minimally Invasive Treatment Option in Anterior Cutaneous Nerve Entrapment Syndrome: A Retrospective Analysis of 26 Patients. J Clin Med Res 2018; 10:508-515. [PMID: 29707093 PMCID: PMC5916540 DOI: 10.14740/jocmr3354w] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 01/23/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Chronic abdominal pain is occasionally due to entrapped intercostal nerve endings (ACNES, abdominal cutaneous nerve entrapment syndrome). If abdominal wall infiltration using an anesthetic agent is unsuccessful, a neurectomy may be considered. Pulsed radiofrequency (PRF) is a relatively new treatment option for various chronic pain syndromes. Evidence regarding a beneficial effect of this minimally invasive technique in ACNES is lacking. The aim was to assess the effectiveness of PRF treatment in ACNES patients. METHODS A series of ACNES patients undergoing PRF treatment between January 2014 and December 2015 in two hospitals were retrospectively evaluated. Pain was recorded prior to treatment and after 6 weeks using a numerical rating scale (NRS, 0 (no pain) to 10 (worst possible pain)). Successful treatment was defined as > 50% NRS pain reduction. Patient satisfaction was scored by patient global impression of change (PGIC, 1 = very much worse, to 7 = very much improved). RESULTS Twenty-six patients were studied (17 women, median age 47 years, range 18 - 67 years). After 6 weeks, mean NRS score had dropped from 6.7 ± 1.2 to 3.8 ± 2.3 (P < 0.001). A mean 4.9 ± 1.4 PGIC score was reported by then. Short term treatment success (6 - 8 weeks) was 50% (n = 13, 95% CI: 29 - 71), while 8% was pain-free on the longer term (median 15 months). Median effect duration was 4 months (range 2 - 26). CONCLUSIONS PRF is temporarily effective in half of patients with ACNES. PRF is safe and may be favored in neuropathic pain syndromes as nerve tissue destruction is possibly limited. A randomized controlled trial determining the potential additional role of PRF in the treatment strategy for ACNES is underway.
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Affiliation(s)
- Robbert C. Maatman
- Department of Surgery, Maxima Medical Center, Veldhoven, The Netherlands
- SolviMax, Center of Expertise for ACNES and Center of Excellence for Abdominal Wall and Groin Pain, Department of Surgery, Maxima Medical Center, Eindhoven, The Netherlands
| | - Monique A.H. Steegers
- Department of Anaesthesiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Marc R.M. Scheltinga
- Department of Surgery, Maxima Medical Center, Veldhoven, The Netherlands
- SolviMax, Center of Expertise for ACNES and Center of Excellence for Abdominal Wall and Groin Pain, Department of Surgery, Maxima Medical Center, Eindhoven, The Netherlands
| | - Rudi M.H. Roumen
- Department of Surgery, Maxima Medical Center, Veldhoven, The Netherlands
- SolviMax, Center of Expertise for ACNES and Center of Excellence for Abdominal Wall and Groin Pain, Department of Surgery, Maxima Medical Center, Eindhoven, The Netherlands
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Siawash M, Roumen R, Ten WTA, van Heurn E, Scheltinga M. Diagnostic characteristics of anterior cutaneous nerve entrapment syndrome in childhood. Eur J Pediatr 2018. [PMID: 29516161 DOI: 10.1007/s00431-018-3125-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
UNLABELLED Some children suffering from chronic abdominal pain may have an abdominal wall entity such as anterior cutaneous nerve entrapment syndrome. This syndrome is largely suspected on a combination of findings at history and physical examination. The aim is to obtain clues in history and physical examinations in a selected population of children with anterior cutaneous nerve entrapment syndrome. We analyzed all children with abdominal pain visiting our hospital between January 2013 and January 2015. A total of 71 cases were identified (median age 15 years, range 8-17, 77% female). Pain was severe (median 8, range 6-9), stabbing/burning (84%), superficial (88%), aggravated by physical activity (91%), and always in one abdominal area (97%). Hypo-/hyperesthesia (87%) or a positive pinch test (89%) was often found at the skin overlying the painful spot. Increased pain was reported by 97% when the abdominal muscles were tensed (Carnett test). A single anterior rectus sheath block is successful in almost all patients (97%). CONCLUSION A combination of typical findings in history and physical examination allows for diagnosing childhood ACNES. What is Known: • Anterior cutaneous nerve entrapment syndrome (ACNES) is often overlooked in chronic abdominal pain. • Pediatric literature on diagnostic work up for ACNES is poor. What is New: • Two third reported treatment delay due to misdiagnosis as functional abdominal pain. • Medical history and physical examination revealed neuropathic pain characteristic in up to 90% of the cases.
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Affiliation(s)
- Murid Siawash
- Department of Surgery and SolviMáx, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, 7777, 5500 MB, Veldhoven, The Netherlands.
| | - Rudi Roumen
- Department of Surgery and SolviMáx, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, 7777, 5500 MB, Veldhoven, The Netherlands
| | - Walther Tjon A Ten
- Department of Pediatrics, Máxima Medical Center, Veldhoven, The Netherlands
| | - Ernst van Heurn
- Emma Children's Hospital AMC & VU University medical center, Department of Pediatric Surgery, Amsterdam, The Netherlands
| | - Marc Scheltinga
- Department of Surgery and SolviMáx, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, 7777, 5500 MB, Veldhoven, The Netherlands
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Naimer SA. Abdominal Cutaneous Nerve Entrapment Syndrome: The Cause of Localized Abdominal Pain in a Young Pregnant Woman. J Emerg Med 2018; 54:e87-e90. [DOI: 10.1016/j.jemermed.2018.01.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 12/04/2017] [Accepted: 01/25/2018] [Indexed: 01/07/2023]
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Tolmos-Estefanía M, Fernández-Rodríguez T, Bernard-de Casco Z, Grande-Díez C, Rodríguez-Lorenzo Á. Dolor abdominal recurrente. Síndrome de atrapamiento del nervio cutáneo abdominal a propósito de tres casos. Semergen 2018; 44:290-292. [DOI: 10.1016/j.semerg.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 10/24/2017] [Accepted: 11/03/2017] [Indexed: 10/18/2022]
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Mol FM, Jansen CH, Boelens OB, Stronks DL, Eerten PV, Huygen FJ, Scheltinga MR, Roumen RM. Adding steroids to lidocaine in a therapeutic injection regimen for patients with abdominal pain due to anterior cutaneous nerve entrapment syndrome (ACNES): a single blinded randomized clinical trial. Scand J Pain 2018; 18:505-512. [DOI: 10.1515/sjpain-2018-0011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 03/06/2018] [Indexed: 12/14/2022]
Abstract
Abstract
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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Affiliation(s)
- Frédérique M.U. Mol
- 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 , Veldhoven , The Netherlands
| | - Claire Heukelsfeldt Jansen
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain , Veldhoven , The Netherlands
- Department of Surgery, Máxima Medical Center , P. O. Box 7777 , 5500 MB Veldhoven , The Netherlands , Phone: +31 40 8886230
| | - Oliver B. Boelens
- Department of Surgery , Pantein Hospital Boxmeer , Beugen , The Netherlands
| | - Dirk L. Stronks
- Center of Pain Medicine, Erasmus Medical Center , Rotterdam , The Netherlands
| | - Percy Van Eerten
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain , Veldhoven , The Netherlands
- Department of Surgery, Máxima Medical Center , P. O. Box 7777 , 5500 MB Veldhoven , The Netherlands , Phone: +31 40 8886230
| | - Frank J.P.M. Huygen
- Center of Pain Medicine, Erasmus Medical Center , Rotterdam , The Netherlands
| | - Marc R. Scheltinga
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain , Veldhoven , The Netherlands
- Department of Surgery, Máxima Medical Center , P. O. Box 7777 , 5500 MB Veldhoven , The Netherlands , Phone: +31 40 8886230
| | - Rudi M. Roumen
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain , Veldhoven , The Netherlands
- Department of Surgery, Máxima Medical Center , P. O. Box 7777 , 5500 MB Veldhoven , The Netherlands , Phone: +31 40 8886230
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Zagarella S. Nerve entrapment syndromes in dermatology: Review and practical approach to treatment. Australas J Dermatol 2018; 59:286-290. [PMID: 29676437 DOI: 10.1111/ajd.12822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 03/07/2018] [Indexed: 11/28/2022]
Abstract
A good understanding of cutaneous nerve entrapment syndromes is important for physicians to provide early and accurate diagnosis and treatment. These syndromes have traditionally been managed with analgesics, antidepressants or antiepileptic medication but this approach is often inadequate and causes frequent adverse medication effects. With early diagnosis and treatment, many nerve entrapment syndromes can be successfully managed with physical, non-pharmacological approaches including stretches, exercises and physiotherapy.
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Affiliation(s)
- Samuel Zagarella
- Department of Dermatology, Concord Hospital, University of Sydney Medical School, Sydney, New South Wales, Australia
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Lam K, Vasey C. Diagnostic dilemma: think about anterior cutaneous nerve entrapment syndrome (ACNES) in patients with atypical abdominal pain and Crohn's disease. BMJ Case Rep 2018; 2018:bcr-2017-224041. [PMID: 29593000 DOI: 10.1136/bcr-2017-224041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Chronic abdominal pain can be a difficult diagnostic dilemma. Anterior cutaneous nerve entrapment syndrome (ACNES) is a potential differential diagnosis that should be considered because treatment is both easy and effective. We describe the case of a 51-year-old man presenting with 7 months of right lower quadrant abdominal pain on the background of known Crohn's disease. A circumspect surgical approach and multidisciplinary input was key to making the diagnosis of a nerve entrapment syndrome.
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Affiliation(s)
- Kenneth Lam
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Carolyn Vasey
- Gold Coast University Hospital, Southport, Queensland, Australia
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40
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Scheltinga MR, Roumen RM. Anterior cutaneous nerve entrapment syndrome (ACNES). Hernia 2017; 22:507-516. [DOI: 10.1007/s10029-017-1710-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 12/09/2017] [Indexed: 12/13/2022]
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Tanizaki R, Takemura Y. Anterior cutaneous nerve entrapment syndrome with pain present only during Carnett's sign testing: a case report. BMC Res Notes 2017; 10:503. [PMID: 29020997 PMCID: PMC5637317 DOI: 10.1186/s13104-017-2816-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 09/28/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The identification of anterior cutaneous nerve entrapment syndrome is often challenging, due to no widely accepted standard guidelines regarding laboratory and imaging tests for the diagnosis of ACNES. CASE PRESENTATION A 77-year-old Japanese man presented with mild lower abdominal pain that had been present for the past 3 years. Physical examination revealed no abdominal pain during palpation, with normal laboratory and imaging testing; therefore, conservative therapy was initiated. However, the abdominal pain continued. Re-examination 16 days later revealed three tender points in accordance with intercostal nerves Th10, Th11, and Th12, with the pain occurring only during Carnett's sign testing. A cutaneous injection of 1% lidocaine was administered, and the abdominal pain was resolved about 30 min later. Based on these results, anterior cutaneous nerve entrapment syndrome was diagnosed. CONCLUSIONS It is sometimes hard to diagnose anterior cutaneous nerve entrapment syndrome without testing for Carnett's sign. If patients present with chronic abdominal pain, clinicians should test for Carnett's sign even if no pain is elicited during regular abdominal palpation.
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Affiliation(s)
- Ryutaro Tanizaki
- Department of Community Medicine, Nabari, Mie University Graduate School of Medicine, Tsu, Mie, Japan. .,General Medicine, Nabari City Hospital, Nabari, Mie, Japan.
| | - Yousuke Takemura
- Department of Community Medicine, Nabari, Mie University Graduate School of Medicine, Tsu, Mie, Japan.,Department of Family Medicine, Mie University School of Medicine and Graduate School of Medicine, Tsu, Mie, Japan
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Mol FM, Lataster A, Scheltinga M, Roumen R. Anatomy of abdominal anterior cutaneous intercostal nerves with respect to the pathophysiology of anterior cutaneous nerve entrapment syndrome (ACNES): A case study. TRANSLATIONAL RESEARCH IN ANATOMY 2017. [DOI: 10.1016/j.tria.2017.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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van Rijckevorsel DC, Boelens OB, Roumen RM, Wilder-Smith OH, van Goor H. Treatment response and central pain processing in Anterior Cutaneous Nerve Entrapment Syndrome: An explorative study. Scand J Pain 2017; 14:53-59. [PMID: 28850430 DOI: 10.1016/j.sjpain.2016.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 08/21/2016] [Accepted: 09/30/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND 10-30% of chronic abdominal pain originates in the abdominal wall. A common cause for chronic abdominal wall pain is the Anterior Cutaneous Nerve Entrapment Syndrome (ACNES), in which an intercostal nerve branch is entrapped in the abdominal rectus sheath. Treatment consists of local anaesthetics and neurectomy, and is ineffective in 25% of cases for yet unknown reasons. In some conditions, chronic pain is the result of altered pain processing. This so-called sensitization can manifest as segmental or even generalized hyperalgesia, and is generally difficult to treat. OBJECTIVE The aim of this study was to assess pain processing in ACNES patients responsive and refractory to treatment by using Quantitative Sensory Testing, in order to explore whether signs of altered central pain processing are present in ACNES and are a possible explanation for poor treatment outcomes. METHODS 50 patients treated for ACNES with locally orientated treatment were included. They were allocated to a responsive or refractory group based on their response to treatment. Patients showing an improvement of the Visual Analogue Scale (VAS) pain score combined with a current absolute VAS of <40mm were scored as responsive. Sensation and pain thresholds to pressure and electric skin stimulation were determined in the paravertebral bilateral ACNES dermatomes and at four control areas on the non-dominant side of the body, i.e. the musculus trapezius pars medialis, musculus rectus femoris, musculus abductor hallucis and the thenar. The ACNES dermatomes were chosen to signal segmental hyperalgesia and the sum of the control areas together as a reflection of generalized hyperalgesia. Lower thresholds were interpreted as signs of sensitized pain processing. To test for alterations in endogenous pain inhibition, a conditioned pain modulation (CPM) response to a cold pressor task was determined. Also, patients filled in three pain-related questionnaires, to evaluate possible influence of psychological characteristics on the experienced pain. RESULTS Patients refractory to treatment showed significantly lower pressure pain thresholds in the ACNES dermatomes and for the sum of as well as in two individual control areas. No differences were found between groups for electric thresholds or CPM response. Duration of complaints before diagnosis and treatment was significantly longer in the refractory compared to the responsive group, and refractory patients scored higher on the pain-related psychological surveys. CONCLUSION AND IMPLICATIONS In this hypothesis-generating exploratory study, ACNES patients refractory to treatment showed more signs of sensitized segmental and central pain processing. A longer duration of complaints before diagnosis and treatment may be related to these alterations in pain processing, and both findings could be associated with less effective locally orientated treatment. In order to validate these hypotheses further research is needed. REGISTRATION NUMBER NCT01920880 (Clinical Trials Register; http://www.clinicaltrials.gov).
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Affiliation(s)
- Dagmar C van Rijckevorsel
- Pain and Nociception Neuroscience Research Group, Department of Surgery, Radboud university medical center, Nijmegen, The Netherlands
| | - Oliver B Boelens
- Pain and Nociception Neuroscience Research Group, Department of Surgery, Maasziekenhuis Pantein, Boxmeer, Boxmeer, The Netherlands
| | - Rudi M Roumen
- Pain and Nociception Neuroscience Research Group, SolviMáx, Center of Excellence for Abdominal Wall and Groin Pain, Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Oliver H Wilder-Smith
- Pain and Nociception Neuroscience Research Group, Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Nijmegen, The Netherlands.,Pain and Nociception Neuroscience Research Group, Centre for Sensory-Motor Interaction, Aalborg University, Aalborg, Denmark
| | - Harry van Goor
- Pain and Nociception Neuroscience Research Group, Department of Surgery, Radboud university medical center, Nijmegen, The Netherlands
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Stubhaug A. Why are some patients with chronic pain from anterior abdominal nerve entrapment syndrome (ACNES) refractory to peripheral treatment with neurectomy? Scand J Pain 2017; 14:80-81. [PMID: 28850439 DOI: 10.1016/j.sjpain.2016.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Audun Stubhaug
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway
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45
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Maatman RC, Steegers MAH, Boelens OBA, Lim TC, van den Berg HJ, van den Heuvel SAS, Scheltinga MRM, Roumen RMH. Pulsed radiofrequency or anterior neurectomy for anterior cutaneous nerve entrapment syndrome (ACNES) (the PULSE trial): study protocol of a randomized controlled trial. Trials 2017; 18:362. [PMID: 28768538 PMCID: PMC5541413 DOI: 10.1186/s13063-017-2110-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 07/18/2017] [Indexed: 11/10/2022] Open
Abstract
Background 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. Methods 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. Discussion 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. Trial registration Nederlands Trial Register (Dutch Trial Register), NTR5131 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5131). Registered on 15 April 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2110-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robbert C Maatman
- Department of General Surgery, Máxima Medical Centre, PO Box 7777 5500 MB, Veldhoven/Eindhoven, The Netherlands. .,SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, The Netherlands.
| | - Monique A H Steegers
- Department of Anaesthesiology and Pain and Palliative Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Toine C Lim
- Department of Anaesthesiology and Pain and Palliative Care, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Hans J van den Berg
- Department of Anaesthesiology and Pain and Palliative Care, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Sandra A S van den Heuvel
- Department of Anaesthesiology and Pain and Palliative Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marc R M Scheltinga
- Department of General Surgery, Máxima Medical Centre, PO Box 7777 5500 MB, Veldhoven/Eindhoven, 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 General Surgery, Máxima Medical Centre, PO Box 7777 5500 MB, Veldhoven/Eindhoven, 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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46
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McLaughlin C, Gandhi A, Hamner CE. Anterior cutaneous neurectomy for chronic abdominal wall pain: A case report and review of the literature. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2017. [DOI: 10.1016/j.epsc.2017.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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47
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Roumen RMH, Vening W, Wouda R, Scheltinga MM. Acute Appendicitis, Somatosensory Disturbances ("Head Zones"), and the Differential Diagnosis of Anterior Cutaneous Nerve Entrapment Syndrome (ACNES). J Gastrointest Surg 2017; 21:1055-1061. [PMID: 28411350 DOI: 10.1007/s11605-017-3417-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/27/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cutaneous nerve entrapment syndrome (ACNES) is a neuropathic abdominal wall pain syndrome typically characterized by locally altered skin sensations. On the other hand, visceral disease may also be associated with similar painful and altered skin sensations ("Head zones"). Aim of the study was to determine if patients with acute appendicitis demonstrated somatosensory disturbances in the corresponding right lower quadrant Head zone. METHODS The presence of somatosensory disturbances such as hyperalgesia, hypoesthesia, altered cool perception, or positive pinch test was determined in 100 patients before and after an appendectomy. Potential associations between altered skin sensations and various items including age, sex, history, body temperature, C-reactive protein (CRP), leukocyte count, and type of appendicopathy (normal, inflamed, necrotic, or perforated) were assessed. RESULTS A total of 39 patients demonstrated at least one right lower abdominal quadrant skin somatosensory disturbance before the laparoscopic appendectomy. However, locoregional skin sensation normalized in all but 2 patients 2 weeks postoperatively. No differences were found concerning patient characteristics or type of appendicopathy between populations with or without altered lower abdominal skin sensations. CONCLUSION A substantial portion of patients with acute appendicitis demonstrate right lower abdominal somatosensory disturbances that are similar as observed in acute ACNES. Both may be different sides of the same coin and are possibly expressions of segmental phenomena as described by Head. McBurney's point, a landmark area of maximum pain in acute appendicitis, is possibly a trigger point within a Head zone. Differentiating acute appendicitis from acute ACNES is extremely difficult, but imaging and observation may aid in the diagnostic process.
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Affiliation(s)
- Rudi M H Roumen
- Dept. of Surgery and SolviMáx, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Center, de Run 4600, P.O. Box 7777, 5500 MB, Eindhoven/Veldhoven, The Netherlands.
| | - Wouter Vening
- Dept. of Surgery and SolviMáx, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Center, de Run 4600, P.O. Box 7777, 5500 MB, Eindhoven/Veldhoven, The Netherlands
| | - Rosanne Wouda
- Dept. of Surgery and SolviMáx, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Center, de Run 4600, P.O. Box 7777, 5500 MB, Eindhoven/Veldhoven, The Netherlands
| | - Marc M Scheltinga
- Dept. of Surgery and SolviMáx, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Center, de Run 4600, P.O. Box 7777, 5500 MB, Eindhoven/Veldhoven, The Netherlands
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48
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Siawash M, Mol F, Tjon-A-Ten W, Perquin C, van Eerten P, van Heurn E, Roumen R, Scheltinga M. Anterior rectus sheath blocks in children with abdominal wall pain due to anterior cutaneous nerve entrapment syndrome: a prospective case series of 85 children. Paediatr Anaesth 2017; 27:545-550. [PMID: 28295822 DOI: 10.1111/pan.13084] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic abdominal pain in children may be caused by the anterior cutaneous nerve entrapment syndrome. Local nerve blocks are recommended as an initial treatment in adults. Evidence on effectiveness and safety of such a treatment in children is lacking. AIM Our aim was to study outcome and adverse events of anterior rectus sheath blocks in childhood anterior cutaneous nerve entrapment syndrome. METHODS Patients <18 years of age receiving anterior rectus sheath blocks were prospectively followed. Injections were administered using a free-hand technique in the outpatient department. RESULTS A total of 85 children were included (median age 15 years, range 8-17, 76% female). Eighty-three children reported immediate pain relief following a single lidocaine block and 13 achieved long-term success. Another 19 children was successfully treated with additional blocks combined with steroids. A total 38% success ratio was attained after a median 17-month follow-up (range, 4-39). Pain intensity and diagnostic delay were not associated with a beneficial outcome. However, young age predicted success. An infrequently occurring adverse event was temporarily increased pain some 6 h post injection. CONCLUSION Anterior rectus sheath blocks using local anesthetics and steroids are safe and long-term successful in more than one-third of children suffering from abdominal pain due to anterior cutaneous nerve entrapment syndrome.
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Affiliation(s)
- Murid Siawash
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Frederique Mol
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Walther Tjon-A-Ten
- Department of Pediatrics, Máxima Medical Center, Veldhoven, The Netherlands
| | - Christel Perquin
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Percy van Eerten
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Ernst van Heurn
- Department of Pediatric Surgery, Emma Children's Hospital AMC & VU University Medical Center, Amsterdam, The Netherlands
| | - Rudi Roumen
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Marc Scheltinga
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
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Mommers EHH, Leenders BJM, Leclercq WKG, de Vries Reilingh TS, Charbon JA. A modified Chevrel technique for ventral hernia repair: long-term results of a single centre cohort. Hernia 2017; 21:591-600. [PMID: 28409277 PMCID: PMC5517587 DOI: 10.1007/s10029-017-1602-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 03/30/2017] [Indexed: 11/15/2022]
Abstract
Purpose To evaluate the short- and long-term results after a modified Chevrel technique for midline incisional hernia repair, regarding surgical technique, hospital stay, wound complications, recurrence rate, and postoperative quality of life. These results will be compared to the literature derived reference values regarding the original and modified Chevrel techniques. Methods In this large retrospective, single surgeon, single centre cohort all modified Chevrel hernia repairs between 2000 and 2012 were identified. Results were obtained by reviewing patients’ medical charts. Postoperative quality of life was measured using the Carolina Comfort Scale. A multi-database literature search was conducted to compare the results of our series to the literature based reference values. Results One hundred and fifty-five patients (84 male, 71 female) were included. Eighty patients (52%) had a large incisional hernia (width ≥ 10 cm) according the definition of the European Hernia Society. Fourteen patients (9%) underwent a concomitant procedure. Median length-of-stay was 5 days. Within 30 days postoperative 36 patients (23.2%) had 39 postoperative complications of which 30 were mild (CDC I–II), and nine severe (CDC III–IV). Thirty-one surgical site occurrences were observed in thirty patients (19.4%) of which the majority were seroma (16 patients 10.3%). There was no hernia-related mortality during follow-up. Recurrence rate was 1.8% after a median follow-up of 52 months (12–128 months). Postoperative quality of life was rated excellent. Conclusions The modified Chevrel technique for midline ventral hernias results in a moderate complication rate, low recurrence rate and high rated postoperative quality of life.
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Affiliation(s)
- E H H Mommers
- Department of Surgery, Elkerliek Hospital, Helmond, The Netherlands. .,Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - B J M Leenders
- Department of Surgery, Máxima Medical Centre, Eindhoven, The Netherlands
| | - W K G Leclercq
- Department of Surgery, Máxima Medical Centre, Eindhoven, The Netherlands
| | | | - J A Charbon
- Department of Surgery, Máxima Medical Centre, Eindhoven, The Netherlands
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50
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Koop H, Koprdova S, Schürmann C. Chronic Abdominal Wall Pain. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 113:51-7. [PMID: 26883414 DOI: 10.3238/arztebl.2016.0051] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/30/2015] [Accepted: 09/30/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronic abdominal wall pain is a poorly recognized clinical problem despite being an important element in the differential diagnosis of abdominal pain. METHODS This review is based on pertinent articles that were retrieved by a selective search in PubMed and EMBASE employing the terms "abdominal wall pain" and "cutaneous nerve entrapment syndrome," as well as on the authors' clinical experience. RESULTS In 2% to 3% of patients with chronic abdominal pain, the pain arises from the abdominal wall; in patients with previously diagnosed chronic abdominal pain who have no demonstrable pathological abnormality, this likelihood can rise as high as 30% . There have only been a small number of clinical trials of treatment for this condition. The diagnosis is made on clinical grounds, with the aid of Carnett's test. The characteristic clinical feature is strictly localized pain in the anterior abdominal wall, which is often mischaracterized as a "functional" complaint. In one study, injection of local anesthesia combined with steroids into the painful area was found to relieve pain for 4 weeks in 95% of patients. The injection of lidocaine alone brought about improvement in 83-91% of patients. Long-term pain relief ensued after a single lidocaine injection in 20-30% of patients, after repeated injections in 40-50% , and after combined lidocaine and steroid injections in up to 80% . Pain that persists despite these treatments can be treated with surgery (neurectomy). CONCLUSION Chronic abdominal wall pain is easily diagnosed on physical examination and can often be rapidly treated. Any physician treating patients with abdominal pain should be aware of this condition. Further comparative treatment trials will be needed before a validated treatment algorithm can be established.
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Affiliation(s)
- Herbert Koop
- Department of General Practice, Internal Medicine and Gastroenterology, HELIOS Klinikum Berlin-Buch
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