Use of ultrasound-guided subcostal transversus abdominis plane blocks in a pediatric patient with chronic abdominal wall pain

How Do We Treat Children with Anterior Cutaneous Nerve Entrapment Syndrome and Is the Biopsychosocial Model Also Being Applied? A Scoping Review

Background

Evidence-based guidelines for managing anterior cutaneous nerve entrapment syndrome (ACNES) in children are absent. The primary aim of this review was to scrutinize the evidence supporting currently used treatment interventions. In accordance with the World Health Organization (WHO) guidelines for managing chronic pain in children, these patients and their families and caregivers should be treated within the context of the biopsychosocial model; pain should not be treated purely as a biomedical problem. Therefore, our second aim was to evaluate whether these interventions are applied within the context of the biopsychosocial model, utilizing an inter- or multidisciplinary approach.

Materials and Methods

A scoping review of the literature was conducted to explore treatment strategies for ACNES in children. To ensure a comprehensive overview of published literature on this topic, the search was not restricted based on study type. Two reviewers independently assessed titles and abstracts. After excluding records unrelated to children, full texts were screened for inclusion. Any discrepancies in judgement were resolved through discussion with a third reviewer.

Results

Out of 35 relevant titles, 22 were included in this review. Only 4 articles provided information on long-term outcomes. The overall quality of the review was deemed low. The majority of reports did not address treatment or education within the psychological and social domains. A structural qualitative analysis was not feasible due to the substantial heterogeneity of the data.

Conclusion

The evidence supporting current treatment strategies in children with ACNES is of low quality. More research is needed to establish an evidence-based treatment algorithm for patients with this challenging pain problem. In line with the WHO recommendation, greater emphasis should be placed on a biopsychosocial approach. The ultimate goal should be the development of a generic treatment algorithm outlining an approach to ACNES applicable to all professionals involved.

Utilization of Truncal Fascial Plane Nerve Blocks for Chronic Pain Management: A Narrative Review

PURPOSE OF REVIEW

Nerve blocks constitute an integral portion in the management of chronic pain. The widespread use of ultrasound imaging opened the door to a flood of newer blocks especially truncal plane nerve blocks. We reviewed the current medical literature for studies and case reports utilizing the two most common truncal plane nerve blocks, transversus abdominis plane and erector spinae plane blocks, to manage chronic pain.

RECENT FINDINGS

We found some evidence, mostly in case reports and retrospective observational studies, that supports the use of transversus abdominis plane and erector spinae plane nerve blocks, usually with steroids, as a safe and valuable part of interdisciplinary management of chronic abdominal and chest walls pain. Ultrasound-guided truncal fascial plane nerve blocks are safe, easy to learn, and proven to help with post-operative acute pain management. Although limited, our current review provides evidence from the current medical literature regarding the utility of these blocks to manage some of the challenging chronic and cancer-related pain conditions of the trunk region.

Functional Abdominal Pain in a Pediatric Patient After Resolution of Acute Pancreatitis: A Case Report

Children with acute pancreatitis may develop chronic abdominal wall pain after resolution of clinical, laboratory, and radiographic signs of disease. We describe a 13-year-old boy who underwent an unrevealing, complex diagnostic evaluation for persistent abdominal pain after resolution of acute pancreatitis. His pain required an extended leave of absence from school and nasogastric tube feeds. After receiving abdominal nerve blocks and trigger point injections, he experienced near-complete resolution of pain with normalization of eating habits and daily function. Pain practitioners should think critically about the signs and symptoms of visceral versus somatic pain and try newer diagnostic interventions that may be therapeutic.

Abdominal Wall Pain or Irritable Bowel Syndrome: Validation of a Pediatric Questionnaire

OBJECTIVES

A questionnaire study demonstrated that some adult patients who were diagnosed with irritable bowel syndrome (IBS) were in fact having an abdominal wall pain syndrome, such as anterior cutaneous nerve entrapment syndrome (ACNES). The aim of the present study was to investigate whether a pediatric version of this questionnaire was useful in diagnosing abdominal wall pain syndromes in children with chronic abdominal pain (CAP).

METHODS

An 18-item questionnaire was tested in 3 groups of children with CAP: group 1, children who underwent surgery for ACNES (n = 42); group 2, children who were found to have ACNES after an outpatient analysis (n = 57); and group 3, children diagnosed with IBS (n = 53). Qualities including internal consistency (Cronbach α), cut-off points and a ROC-curve were calculated using standard statistical analysis.

RESULTS

Questionnaire response rates in the three populations of CAP children ranged from 69% to 92%. When comparing ACNES and IBS groups, 17 of 18 questions were discriminative (P < 0.01, Cronbach α 0.74). Total questionnaire scores ranged from 0 (IBS likely) to 17 points (ACNES likely). A median 13-point score (range 8-17) was found in both ACNES groups. In contrast, a median 8-point score was calculated in children with IBS (range 3-13, P < 0.01). Using an 11-point cut-off score, a child with CAP was diagnosed with ACNES with 86% sensitivity and 89% specificity. A ROC curve with an AUC of 0.94 was obtained.

CONCLUSIONS

A 17-item questionnaire showed good diagnostic test properties and may aid in distinguishing ACNES from IBS in pediatric populations with chronic abdominal pain.

Chronic Abdominal Wall Pain: An Under-Recognized Diagnosis Leading to Unnecessary Testing

Chronic abdominal wall pain (CAWP) refers to a condition wherein pain originates from the abdominal wall itself rather than the underlying viscera. According to various estimates, 10% to 30% of patients with chronic abdominal pain are eventually diagnosed with CAWP, usually after expensive testing has failed to uncover another etiology. The most common cause of CAWP is anterior cutaneous nerve entrapment syndrome. The diagnosis of CAWP is made using an oft-forgotten physical examination finding known as Carnett's sign, where focal abdominal tenderness is either the same or worsened during contraction of the abdominal musculature. CAWP can be confirmed by response to trigger point injection of local anesthetic. Once diagnosis is made, treatment ranges from conservative management to trigger point injection and in refractory cases, even surgery. This review provides an overview of CAWP, discusses the cost and implications of a missed diagnosis, compares somatic versus visceral innervation, describes the pathophysiology of nerve entrapment, and reviews the evidence behind available treatment modalities.

[Chronic pain and regional anesthesia in children]

Chronic pain is usually underestimated in children, due to lack of knowledge and its specific signs. In addition to suffering, chronic pain causes a physical, psychological, emotional, social, and financial burden for the child and his family. Practitioners may find themselves in a situation of failure with depletion of medical resources. Some types of chronic pain are refractory to conventional systemic treatment and may require the use of regional anesthesia. Cancer pain is common in children and its medical management is sometimes insufficient. It is accessible to neuroaxial or peripheral techniques of regional anesthesia if it is limited to an area accessible to one of these techniques and no contraindications (e.g., thrombopenia) are present. Complex regional pain syndrome 1 is not rare in children and adolescents, but it often goes undiagnosed. Regional anesthesia may contribute to the treatment of complex regional pain syndrome 1, mainly in case of recurrence, because it provides rapid effective analgesia and allows rapid implementation of intensive physiotherapy. These techniques have also shown interest in phantom limb pain after limb amputation, but they remain controversial for erythromelalgia pain or chronic abdominopelvic pain. Finally, the treatment of postdural puncture headache due to cerebrospinal fluid leak can be treated by performing an epidural injection of the patient's blood, called a blood-patch. Finally, the management of children with chronic pain should be multidisciplinary (pediatrician, physiotherapist, psychologist, surgeon, anesthesiologist) to support the child and her problem in its entirety.

Clinical implications of the transversus abdominis plane block in pediatric anesthesia

Optimal perioperative analgesia for infants and children after major abdominal surgery poses a challenge when central neuraxial techniques are contraindicated. As a regional anesthesia technique, the transversus abdominis plane (TAP) block has been shown to reduce opioid consumption and improve pain scores compared to traditional perioperative pain strategies. Accordingly, TAP blocks may be considered as an alternative to central neuraxial analgesia to optimize perioperative pain control. Advancements in ultrasound technology have further improved the reliability and safety profile of this technique. Despite growing recognition of the diverse clinical scenarios where TAP blocks may be of benefit, its use among pediatric anesthesiologists remains limited. This article describes the history, anatomy, and a review of the current literature on TAP blocks with an emphasis on outcomes in pediatric patients.

Bilateral ultrasound transversus abdominis plane block in a patient affected from Menkes disease

This case report demonstrates the utility and safety of ultrasound transversus abdominis plane (TAP) block in a paediatric patient suffering from Menkes disease. Anaesthetists, and particularly paediatric and neonatal anaesthetists, have to make a careful assessment of these patients, who are subjected to frequent surgeries, despite their tender years. These operations are often necessary in order to improve the patient's quality of life as much as possible. The choice of anaesthetic technique must take the particular nature of the disease and the patient's medical history into consideration, while careful preparation and preoperative evaluations make it possible to administer the general or local anaesthetic safely. Official literature on the subject does not provide sufficient information about the use of local anaesthetic techniques. Moreover, the use of ultrasound TAP block in patients affected by Menkes disease has never been published in literature. In our experience, ultrasound TAP block has provided positive results, although the rarity of this childhood disease makes a detailed study difficult.