Neurectomy

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R. M. Roumen - One of the best experts on this subject based on the ideXlab platform.

  • 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 Practice, 2019
    Co-Authors: Robbert C Maatman, M. R. Scheltinga, Oliver B Boelens, Sander M J Van Kuijk, Monique A H Steegers, Toine C Lim, R. M. Roumen
    Abstract:

    BACKGROUND: Chronic abdominal pain can be due to entrapped intercostal nerves (anterior cutaneous nerve entrapment syndrome [ACNES]). If abdominal wall infiltration using an anesthetic agent is unsuccessful, a Neurectomy may be considered. Pulsed radiofrequency (PRF) applies an electric field around the tip of the cannula near the affected nerve to induce pain relief. Only limited retrospective evidence suggests that PRF is effective in ACNES. METHODS: A multicenter, randomized, nonblinded, controlled proof-of-concept trial was performed in 66 patients. All patients were scheduled for a Neurectomy procedure. Thirty-three patients were randomized to first receive a 6-minute cycle of PRF treatment, while the other 33 were allocated to an immediate Neurectomy procedure. Pain was recorded using a numeric rating scale (NRS, 0 [no pain] to 10 [worst pain possible]). Successful treatment was defined as >50% pain reduction. Patients in the PRF group were allowed to cross over to a Neurectomy after 8 weeks. RESULTS: The Neurectomy group showed greater pain reduction at 8-week follow-up (mean change from baseline -2.8 (95% confidence interval [CI] -3.9 to -1.7) vs. -1.5 (95% CI -2.3 to -0.6); P = 0.045) than the PRF group. Treatment success was reached in 12 of 32 (38%, 95% CI 23 to 55) of the PRF group and 17 of 28 (61%, 95% CI 42 to 72) of the Neurectomy group (P = 0.073). Thirteen patients were withdrawn from their scheduled surgery. Adverse events were comparable between treatments. CONCLUSIONS: PRF appears to be an effective and minimally invasive treatment option and may therefore be considered in patients who failed conservative treatment options before proceeding to a Neurectomy procedure. Anterior Neurectomy may possibly lead to a greater pain relief compared with PRF in patients with ACNES, but potential complications associated with surgery should be discussed.

  • factors predicting outcome after anterior Neurectomy in patients with chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome acnes
    Surgery, 2019
    Co-Authors: Frederique M. U. Mol, M. R. Scheltinga, P V Van Eerten, Claire Heukensfeldt M A Jansen, William Van Dijk, R. M. Roumen
    Abstract:

    Abstract Background Chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome may require surgery to provide long-term pain relief in up to 70% of patients. Factors predicting outcome after an anterior Neurectomy are unknown. The aim of the study is to identify factors associated with treatment failure to possibly allow for optimizing patient counselling and selection. Methods Characteristics of anterior cutaneous nerve entrapment syndrome patients who were unresponsive to nonsurgical therapies and underwent an anterior Neurectomy in a tertiary referral center from 2011 to 2016 were analyzed. Treatment failure was defined as Results A total of 495 patients (78% female, median age 40 years, range 8–83) undergoing an anterior Neurectomy were eligible for analysis. Pain medication use (odds ratio 1.84, P = .027, confidence interval 1.07–3.17), abdominal surgery in the past (odds ratio 1.85, P = .026, confidence interval 1.08–3.18), the presence of paravertebral tender points at exit points of intercostal nerves (odds ratio 2.58, P = .003, confidence interval 1.39–4.80), and failure to favorably respond to a diagnostic rectus sheath block (odds ratio 3.74, P = .000, confidence interval 3.74 – 7.10) were identified as factors predicting surgical failure. However, a prediction model including these 4 factors had poor accuracy with an area under the curve of 0.64 (confidence interval 0.58–0.70). Conclusion The present study identified risk factors associated with treatment failure that are useful in counseling anterior cutaneous nerve entrapment syndrome patients prior to a surgical intervention.

  • pulsed radiofrequency or anterior Neurectomy for anterior cutaneous nerve entrapment syndrome acnes the pulse trial study protocol of a randomized controlled trial
    Trials, 2017
    Co-Authors: Robbert C Maatman, M. R. Scheltinga, Oliver B Boelens, Monique A H Steegers, Toine C Lim, Hans J. Van Den Berg, Sandra A. S. Van Den Heuvel, R. M. Roumen
    Abstract:

    Some patients with chronic abdominal pain suffer from an anterior cutaneous nerve entrapment syndrome (ACNES). This somewhat illusive syndrome is thought to be caused by the entrapment of end branches of the intercostal nerves residing in the abdominal wall. If ACNES is suspected, a local injection of an anesthetic agent may offer relief. If pain is recurrent following multiple-injection therapy, an anterior Neurectomy entailing removal of the entrapped nerve endings may be considered. After 1 year, a 70% success rate has been reported. Research on minimally invasive alternative treatments is scarce. Pulsed radiofrequency (PRF) treatment is a relatively new treatment for chronic pain syndromes. An electromagnetic field is applied around the nerve in the hope of leading to pain relief. This randomized controlled trial compares the effect of PRF treatment and Neurectomy in patients with ACNES. Adult ACNES patients having short-lived success following injections are randomized to PRF or Neurectomy. At the 8-week follow-up visit, unsuccessful PRF patients are allowed to cross over to a Neurectomy. Primary outcome is pain relief after either therapy. Secondary outcomes include patient satisfaction, quality of life, use of analgesics and unanticipated adverse events. The study is terminated 6 months after receiving the final procedure. Since academic literature on minimally invasive techniques is lacking, well-designed trials are needed to optimize results of treatment for ACNES. This is the first large, randomized controlled, proof-of-concept trial comparing two therapy techniques in ACNES patients. The first patient was included in October 2015. The expected trial deadline is December 2017. If effective, PRF may be incorporated into the ACNES treatment algorithm, thus minimizing the number of patients requiring surgery. Nederlands Trial Register (Dutch Trial Register), NTR5131 ( http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5131 ). Registered on 15 April 2015.

  • anterior Neurectomy in children with a recalcitrant anterior cutaneous nerve entrapment syndrome is safe and successful
    Journal of Pediatric Surgery, 2017
    Co-Authors: Murid Siawash, R. M. Roumen, Robbert C Maatman, Walther Tjon A Ten, Ernst Van Heurn, M. R. Scheltinga
    Abstract:

    Abstract Introduction Anterior cutaneous nerve entrapment syndrome (ACNES) is a relatively unknown cause of severe neuralgic abdominal pain. Treatment includes medication, local nerve blocks or, if unresponsive, a Neurectomy of nerve endings. In children, the outcome of Neurectomy for ACNES is scantly described in retrospective studies. The objective of this first prospective study was to investigate the safety and short term success rate of anterior Neurectomy in a large pediatric population with ACNES. Methods All children Results 60 children were included (80% female, mean age 15 years ± 2 SD). 75% had right lower abdominal pain. At first follow-up, 47 children were free of pain (78% success rate). Complications other than an occasional local hematoma were not reported. Outcome was not related to demographics, preoperative pain intensity, pain duration or localization. Conclusion Anterior Neurectomy is safe and successful in most children with abdominal pain failing a conservative treatment for ACNES. Type of study Treatment study. Level of evidence IV.

  • mesh removal and selective Neurectomy for persistent groin pain following lichtenstein repair
    World Journal of Surgery, 2017
    Co-Authors: Willem A R Zwaans, Maarten J A Loos, R. M. Roumen, Christel Perquin, M. R. Scheltinga
    Abstract:

    Some patients with persistent inguinodynia following a Lichtenstein hernia repair fail all non-surgical treatments. Characteristics of mesh-related pain are not well described whereas a meshectomy is controversial. Aims were to define mesh-related pain symptoms, to investigate long-term effects of a meshectomy and to provide recommendations on meshectomy. Consecutive patients undergoing open meshectomy with/without selective Neurectomy for chronic inguinodynia following Lichtenstein repair were analysed including a follow-up questionnaire. Outcome measures were complications, satisfaction (excellent, good, moderate, poor) and hernia recurrence rate. Recommendations for meshectomy are proposed based on a literature review. Seventy-four patients (67 males, median age 56 years) underwent mesh removal (exclusively mesh, 26%; combined with tailored Neurectomy, 74%) between June 2006 and March 2015 in a single centre. Complications were intraoperatively recognized small bowel injury (n = 1) and testicular atrophy (n = 2). A 64% excellent/good long-term result was attained (median 18 months). Success rates of a meshectomy (63%) or combined with a Neurectomy (64%) were similar. Five hernia recurrences occurred during follow-up (7%). A patient with a pure mesh-related groin pain characteristically reports a ‘foreign body feeling’. Pain intensifies during hip flexion (car driving) and is attenuated following hip extension or supine position. Palpation is painful along the inguinal ligament whereas neuropathic characteristics (hyperpathic skin, trigger points) are lacking. Mesh removal either or not combined with tailored Neurectomy is beneficial in two of three patients with characteristics of mesh-related inguinodynia following Lichtenstein hernia repair who are refractory to alternative pain treatments.

M. R. Scheltinga - One of the best experts on this subject based on the ideXlab platform.

  • 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 Practice, 2019
    Co-Authors: Robbert C Maatman, M. R. Scheltinga, Oliver B Boelens, Sander M J Van Kuijk, Monique A H Steegers, Toine C Lim, R. M. Roumen
    Abstract:

    BACKGROUND: Chronic abdominal pain can be due to entrapped intercostal nerves (anterior cutaneous nerve entrapment syndrome [ACNES]). If abdominal wall infiltration using an anesthetic agent is unsuccessful, a Neurectomy may be considered. Pulsed radiofrequency (PRF) applies an electric field around the tip of the cannula near the affected nerve to induce pain relief. Only limited retrospective evidence suggests that PRF is effective in ACNES. METHODS: A multicenter, randomized, nonblinded, controlled proof-of-concept trial was performed in 66 patients. All patients were scheduled for a Neurectomy procedure. Thirty-three patients were randomized to first receive a 6-minute cycle of PRF treatment, while the other 33 were allocated to an immediate Neurectomy procedure. Pain was recorded using a numeric rating scale (NRS, 0 [no pain] to 10 [worst pain possible]). Successful treatment was defined as >50% pain reduction. Patients in the PRF group were allowed to cross over to a Neurectomy after 8 weeks. RESULTS: The Neurectomy group showed greater pain reduction at 8-week follow-up (mean change from baseline -2.8 (95% confidence interval [CI] -3.9 to -1.7) vs. -1.5 (95% CI -2.3 to -0.6); P = 0.045) than the PRF group. Treatment success was reached in 12 of 32 (38%, 95% CI 23 to 55) of the PRF group and 17 of 28 (61%, 95% CI 42 to 72) of the Neurectomy group (P = 0.073). Thirteen patients were withdrawn from their scheduled surgery. Adverse events were comparable between treatments. CONCLUSIONS: PRF appears to be an effective and minimally invasive treatment option and may therefore be considered in patients who failed conservative treatment options before proceeding to a Neurectomy procedure. Anterior Neurectomy may possibly lead to a greater pain relief compared with PRF in patients with ACNES, but potential complications associated with surgery should be discussed.

  • factors predicting outcome after anterior Neurectomy in patients with chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome acnes
    Surgery, 2019
    Co-Authors: Frederique M. U. Mol, M. R. Scheltinga, P V Van Eerten, Claire Heukensfeldt M A Jansen, William Van Dijk, R. M. Roumen
    Abstract:

    Abstract Background Chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome may require surgery to provide long-term pain relief in up to 70% of patients. Factors predicting outcome after an anterior Neurectomy are unknown. The aim of the study is to identify factors associated with treatment failure to possibly allow for optimizing patient counselling and selection. Methods Characteristics of anterior cutaneous nerve entrapment syndrome patients who were unresponsive to nonsurgical therapies and underwent an anterior Neurectomy in a tertiary referral center from 2011 to 2016 were analyzed. Treatment failure was defined as Results A total of 495 patients (78% female, median age 40 years, range 8–83) undergoing an anterior Neurectomy were eligible for analysis. Pain medication use (odds ratio 1.84, P = .027, confidence interval 1.07–3.17), abdominal surgery in the past (odds ratio 1.85, P = .026, confidence interval 1.08–3.18), the presence of paravertebral tender points at exit points of intercostal nerves (odds ratio 2.58, P = .003, confidence interval 1.39–4.80), and failure to favorably respond to a diagnostic rectus sheath block (odds ratio 3.74, P = .000, confidence interval 3.74 – 7.10) were identified as factors predicting surgical failure. However, a prediction model including these 4 factors had poor accuracy with an area under the curve of 0.64 (confidence interval 0.58–0.70). Conclusion The present study identified risk factors associated with treatment failure that are useful in counseling anterior cutaneous nerve entrapment syndrome patients prior to a surgical intervention.

  • pulsed radiofrequency or anterior Neurectomy for anterior cutaneous nerve entrapment syndrome acnes the pulse trial study protocol of a randomized controlled trial
    Trials, 2017
    Co-Authors: Robbert C Maatman, M. R. Scheltinga, Oliver B Boelens, Monique A H Steegers, Toine C Lim, Hans J. Van Den Berg, Sandra A. S. Van Den Heuvel, R. M. Roumen
    Abstract:

    Some patients with chronic abdominal pain suffer from an anterior cutaneous nerve entrapment syndrome (ACNES). This somewhat illusive syndrome is thought to be caused by the entrapment of end branches of the intercostal nerves residing in the abdominal wall. If ACNES is suspected, a local injection of an anesthetic agent may offer relief. If pain is recurrent following multiple-injection therapy, an anterior Neurectomy entailing removal of the entrapped nerve endings may be considered. After 1 year, a 70% success rate has been reported. Research on minimally invasive alternative treatments is scarce. Pulsed radiofrequency (PRF) treatment is a relatively new treatment for chronic pain syndromes. An electromagnetic field is applied around the nerve in the hope of leading to pain relief. This randomized controlled trial compares the effect of PRF treatment and Neurectomy in patients with ACNES. Adult ACNES patients having short-lived success following injections are randomized to PRF or Neurectomy. At the 8-week follow-up visit, unsuccessful PRF patients are allowed to cross over to a Neurectomy. Primary outcome is pain relief after either therapy. Secondary outcomes include patient satisfaction, quality of life, use of analgesics and unanticipated adverse events. The study is terminated 6 months after receiving the final procedure. Since academic literature on minimally invasive techniques is lacking, well-designed trials are needed to optimize results of treatment for ACNES. This is the first large, randomized controlled, proof-of-concept trial comparing two therapy techniques in ACNES patients. The first patient was included in October 2015. The expected trial deadline is December 2017. If effective, PRF may be incorporated into the ACNES treatment algorithm, thus minimizing the number of patients requiring surgery. Nederlands Trial Register (Dutch Trial Register), NTR5131 ( http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5131 ). Registered on 15 April 2015.

  • anterior Neurectomy in children with a recalcitrant anterior cutaneous nerve entrapment syndrome is safe and successful
    Journal of Pediatric Surgery, 2017
    Co-Authors: Murid Siawash, R. M. Roumen, Robbert C Maatman, Walther Tjon A Ten, Ernst Van Heurn, M. R. Scheltinga
    Abstract:

    Abstract Introduction Anterior cutaneous nerve entrapment syndrome (ACNES) is a relatively unknown cause of severe neuralgic abdominal pain. Treatment includes medication, local nerve blocks or, if unresponsive, a Neurectomy of nerve endings. In children, the outcome of Neurectomy for ACNES is scantly described in retrospective studies. The objective of this first prospective study was to investigate the safety and short term success rate of anterior Neurectomy in a large pediatric population with ACNES. Methods All children Results 60 children were included (80% female, mean age 15 years ± 2 SD). 75% had right lower abdominal pain. At first follow-up, 47 children were free of pain (78% success rate). Complications other than an occasional local hematoma were not reported. Outcome was not related to demographics, preoperative pain intensity, pain duration or localization. Conclusion Anterior Neurectomy is safe and successful in most children with abdominal pain failing a conservative treatment for ACNES. Type of study Treatment study. Level of evidence IV.

  • mesh removal and selective Neurectomy for persistent groin pain following lichtenstein repair
    World Journal of Surgery, 2017
    Co-Authors: Willem A R Zwaans, Maarten J A Loos, R. M. Roumen, Christel Perquin, M. R. Scheltinga
    Abstract:

    Some patients with persistent inguinodynia following a Lichtenstein hernia repair fail all non-surgical treatments. Characteristics of mesh-related pain are not well described whereas a meshectomy is controversial. Aims were to define mesh-related pain symptoms, to investigate long-term effects of a meshectomy and to provide recommendations on meshectomy. Consecutive patients undergoing open meshectomy with/without selective Neurectomy for chronic inguinodynia following Lichtenstein repair were analysed including a follow-up questionnaire. Outcome measures were complications, satisfaction (excellent, good, moderate, poor) and hernia recurrence rate. Recommendations for meshectomy are proposed based on a literature review. Seventy-four patients (67 males, median age 56 years) underwent mesh removal (exclusively mesh, 26%; combined with tailored Neurectomy, 74%) between June 2006 and March 2015 in a single centre. Complications were intraoperatively recognized small bowel injury (n = 1) and testicular atrophy (n = 2). A 64% excellent/good long-term result was attained (median 18 months). Success rates of a meshectomy (63%) or combined with a Neurectomy (64%) were similar. Five hernia recurrences occurred during follow-up (7%). A patient with a pure mesh-related groin pain characteristically reports a ‘foreign body feeling’. Pain intensifies during hip flexion (car driving) and is attenuated following hip extension or supine position. Palpation is painful along the inguinal ligament whereas neuropathic characteristics (hyperpathic skin, trigger points) are lacking. Mesh removal either or not combined with tailored Neurectomy is beneficial in two of three patients with characteristics of mesh-related inguinodynia following Lichtenstein hernia repair who are refractory to alternative pain treatments.

David C Chen - One of the best experts on this subject based on the ideXlab platform.

  • efficacy of retroperitoneal triple Neurectomy for refractory neuropathic inguinodynia
    American Journal of Surgery, 2016
    Co-Authors: Alexandra M Moore, Parviz K Amid, Jonathan R Hiatt, Martin F Bjurstrom, David C Chen
    Abstract:

    Abstract Background Refractory neuropathic inguinodynia following inguinal herniorrhaphy is a common and debilitating complication. This prospective study evaluated long-term outcomes associated with laparoscopic retroperitoneal triple Neurectomy. Methods Sixty-two consecutive patients (51 male; mean age, 47); all failing pain management; prior reoperation in 35, prior Neurectomy in 26; average follow-up 681 days (range: 90 days to 3 years). Measured outcomes include numeric pain ratings, dermatomal mapping, histologic confirmation, quantitative sensory testing, complications, narcotic usage, and activity level. Results Mean numerical pain scores were significantly decreased (baseline, 8.6) at all postoperative time points (POD 1, 3.6; P P P Conclusions Retroperitoneal triple Neurectomy is an effective and durable treatment for refractory neuropathic inguinodynia.

  • open triple Neurectomy
    2016
    Co-Authors: Ian T Macqueen, David C Chen, Parviz K Amid
    Abstract:

    Postherniorrhaphy chronic pain is a significant cause of morbidity following inguinal hernia repair. Patients with inguinodynia refractory to conservative treatment may be considered for operative remediation. Triple Neurectomy remains the most definitive operative modality for addressing neuropathic causes of inguinal pain. A thorough understanding of groin neuroanatomy is crucial, and successful outcomes are dependent upon choosing patients with discrete neuroanatomic problems amenable to surgical correction. Open triple Neurectomy involves segmental resection of the ilioinguinal nerve (IIN), the genital branch of the genitofemoral nerve (GFN), and the iliohypogastric nerve (IHN). Variations on this operation involve resecting the main branch of the GFN for patients whose original repair entered the preperitoneal space and resecting the paravasal nerves for patients with orchialgia in addition to inguinodynia. Triple Neurectomy is successful in greater than 90 % of carefully selected patients with postherniorrhaphy chronic pain.

  • laparoscopic triple Neurectomy
    2016
    Co-Authors: Stephanie Kingman, Parviz K Amid, David C Chen
    Abstract:

    Triple Neurectomy is the most definitive and effective remedial operation for refractory chronic postherniorrhaphy neuropathic pain. Successful outcomes are dependent on patient selection and understanding of the potential causes of pain. Laparoscopic triple Neurectomy allows for reliable identification of the nerves within the retroperitoneal lumbar plexus outside the prior scarred operative field. It reliably addresses the neuropathic component of inguinodynia with minimal operative morbidity. It is effective as primary treatment for neuropathy of the ilioinguinal, iliohypogastric, and genitofemoral nerves and as an adjunct in those with mixed nociceptive and neuropathic pain.

  • operative management of refractory neuropathic inguinodynia by a laparoscopic retroperitoneal approach
    JAMA Surgery, 2013
    Co-Authors: David C Chen, Jonathan R Hiatt, Parviz K Amid
    Abstract:

    RESULTS There were no intraoperative complications. All patients had histologic confirmation of Neurectomy and clinical confirmation with dermatomal mapping. Mean numeric pain scores were significantly decreased (baseline score, 7.8) on postoperative days 1 (score, 2.9; P < .001), 7 (score, 2.2; P < .001), 30 (score, 1.7; P < .001), and 90 (score, 1.9; P < .001). Narcotic dependence decreased and activity level increased. Five patients reported transient hypersensitivity consistent with deafferentation. All had numbness in the distribution of Neurectomy without complaint. Four had residual meshoma pain, with 2 undergoing subsequent reoperation to remove mesh. Orchialgia was not improved. CONCLUSIONS AND RELEVANCE This represents the largest series of laparoscopic retroperitoneal triple neurectomies for treatment of inguinodynia. The rate of successful intervention was better than reported for standard triple Neurectomy and open extended triple Neurectomy. The procedure allows access proximal to all potential sites of peripheral neuropathy and overcomes many of the limitations of open triple Neurectomy. In the absence of recurrence or meshoma, it is the preferred technique for definitive management of chronic inguinal neuralgia.

  • surgical treatment of chronic groin and testicular pain after laparoscopic and open preperitoneal inguinal hernia repair
    Journal of The American College of Surgeons, 2011
    Co-Authors: Parviz K Amid, David C Chen
    Abstract:

    Background Standard triple Neurectomy does not address inguinodynia secondary to neuropathy of the genitofemoral nerve and the preperitoneal segment of its genital branch seen after inguinal hernia repair performed laparoscopically or in open preperitoneal fashion. Study Design Standard triple Neurectomy was extended to include the genitofemoral nerve. Sixteen patients with chronic groin pain after laparoscopic and open preperitoneal inguinal hernia repair underwent operative triple Neurectomy, with resection of the main trunk of the genitofemoral nerve in the retroperitoneum over the psoas muscle. All patients had previously undergone unsuccessful extensive nonsurgical pain management. Results Fourteen of 16 patients had significant improvement of their pain, as evidenced by a decrease in subjectively reported postoperative pain levels as compared with their preoperative baseline, a decrease or complete elimination of daily narcotic dependence, and return to baseline activities of daily living and work. One of the nonresponder patients underwent a previous open prostatectomy, and exposure of the genitofemoral nerve was not possible due to scarring from the prostatectomy. The other nonresponder patient continues to experience subjective pain equivalent to preoperative levels due to the sensation of firmness and incisional pain that arose in the setting of a postoperative wound infection. He does, however, report that his pain is of different character and quality from his preNeurectomy pain and is primarily centered around the incision. His follow-up has not been long enough to determine if his symptoms will improve as his incision and scar remodel. Conclusions Extension of the standard triple Neurectomy to include the genitofemoral nerve for treatment of inguinodynia after open and laparoscopic preperitoneal mesh repair is a safe and effective procedure.

Parviz K Amid - One of the best experts on this subject based on the ideXlab platform.

  • efficacy of retroperitoneal triple Neurectomy for refractory neuropathic inguinodynia
    American Journal of Surgery, 2016
    Co-Authors: Alexandra M Moore, Parviz K Amid, Jonathan R Hiatt, Martin F Bjurstrom, David C Chen
    Abstract:

    Abstract Background Refractory neuropathic inguinodynia following inguinal herniorrhaphy is a common and debilitating complication. This prospective study evaluated long-term outcomes associated with laparoscopic retroperitoneal triple Neurectomy. Methods Sixty-two consecutive patients (51 male; mean age, 47); all failing pain management; prior reoperation in 35, prior Neurectomy in 26; average follow-up 681 days (range: 90 days to 3 years). Measured outcomes include numeric pain ratings, dermatomal mapping, histologic confirmation, quantitative sensory testing, complications, narcotic usage, and activity level. Results Mean numerical pain scores were significantly decreased (baseline, 8.6) at all postoperative time points (POD 1, 3.6; P P P Conclusions Retroperitoneal triple Neurectomy is an effective and durable treatment for refractory neuropathic inguinodynia.

  • open triple Neurectomy
    2016
    Co-Authors: Ian T Macqueen, David C Chen, Parviz K Amid
    Abstract:

    Postherniorrhaphy chronic pain is a significant cause of morbidity following inguinal hernia repair. Patients with inguinodynia refractory to conservative treatment may be considered for operative remediation. Triple Neurectomy remains the most definitive operative modality for addressing neuropathic causes of inguinal pain. A thorough understanding of groin neuroanatomy is crucial, and successful outcomes are dependent upon choosing patients with discrete neuroanatomic problems amenable to surgical correction. Open triple Neurectomy involves segmental resection of the ilioinguinal nerve (IIN), the genital branch of the genitofemoral nerve (GFN), and the iliohypogastric nerve (IHN). Variations on this operation involve resecting the main branch of the GFN for patients whose original repair entered the preperitoneal space and resecting the paravasal nerves for patients with orchialgia in addition to inguinodynia. Triple Neurectomy is successful in greater than 90 % of carefully selected patients with postherniorrhaphy chronic pain.

  • laparoscopic triple Neurectomy
    2016
    Co-Authors: Stephanie Kingman, Parviz K Amid, David C Chen
    Abstract:

    Triple Neurectomy is the most definitive and effective remedial operation for refractory chronic postherniorrhaphy neuropathic pain. Successful outcomes are dependent on patient selection and understanding of the potential causes of pain. Laparoscopic triple Neurectomy allows for reliable identification of the nerves within the retroperitoneal lumbar plexus outside the prior scarred operative field. It reliably addresses the neuropathic component of inguinodynia with minimal operative morbidity. It is effective as primary treatment for neuropathy of the ilioinguinal, iliohypogastric, and genitofemoral nerves and as an adjunct in those with mixed nociceptive and neuropathic pain.

  • operative management of refractory neuropathic inguinodynia by a laparoscopic retroperitoneal approach
    JAMA Surgery, 2013
    Co-Authors: David C Chen, Jonathan R Hiatt, Parviz K Amid
    Abstract:

    RESULTS There were no intraoperative complications. All patients had histologic confirmation of Neurectomy and clinical confirmation with dermatomal mapping. Mean numeric pain scores were significantly decreased (baseline score, 7.8) on postoperative days 1 (score, 2.9; P < .001), 7 (score, 2.2; P < .001), 30 (score, 1.7; P < .001), and 90 (score, 1.9; P < .001). Narcotic dependence decreased and activity level increased. Five patients reported transient hypersensitivity consistent with deafferentation. All had numbness in the distribution of Neurectomy without complaint. Four had residual meshoma pain, with 2 undergoing subsequent reoperation to remove mesh. Orchialgia was not improved. CONCLUSIONS AND RELEVANCE This represents the largest series of laparoscopic retroperitoneal triple neurectomies for treatment of inguinodynia. The rate of successful intervention was better than reported for standard triple Neurectomy and open extended triple Neurectomy. The procedure allows access proximal to all potential sites of peripheral neuropathy and overcomes many of the limitations of open triple Neurectomy. In the absence of recurrence or meshoma, it is the preferred technique for definitive management of chronic inguinal neuralgia.

  • surgical treatment of chronic groin and testicular pain after laparoscopic and open preperitoneal inguinal hernia repair
    Journal of The American College of Surgeons, 2011
    Co-Authors: Parviz K Amid, David C Chen
    Abstract:

    Background Standard triple Neurectomy does not address inguinodynia secondary to neuropathy of the genitofemoral nerve and the preperitoneal segment of its genital branch seen after inguinal hernia repair performed laparoscopically or in open preperitoneal fashion. Study Design Standard triple Neurectomy was extended to include the genitofemoral nerve. Sixteen patients with chronic groin pain after laparoscopic and open preperitoneal inguinal hernia repair underwent operative triple Neurectomy, with resection of the main trunk of the genitofemoral nerve in the retroperitoneum over the psoas muscle. All patients had previously undergone unsuccessful extensive nonsurgical pain management. Results Fourteen of 16 patients had significant improvement of their pain, as evidenced by a decrease in subjectively reported postoperative pain levels as compared with their preoperative baseline, a decrease or complete elimination of daily narcotic dependence, and return to baseline activities of daily living and work. One of the nonresponder patients underwent a previous open prostatectomy, and exposure of the genitofemoral nerve was not possible due to scarring from the prostatectomy. The other nonresponder patient continues to experience subjective pain equivalent to preoperative levels due to the sensation of firmness and incisional pain that arose in the setting of a postoperative wound infection. He does, however, report that his pain is of different character and quality from his preNeurectomy pain and is primarily centered around the incision. His follow-up has not been long enough to determine if his symptoms will improve as his incision and scar remodel. Conclusions Extension of the standard triple Neurectomy to include the genitofemoral nerve for treatment of inguinodynia after open and laparoscopic preperitoneal mesh repair is a safe and effective procedure.

Oliver B Boelens - One of the best experts on this subject based on the ideXlab platform.

  • 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 Practice, 2019
    Co-Authors: Robbert C Maatman, M. R. Scheltinga, Oliver B Boelens, Sander M J Van Kuijk, Monique A H Steegers, Toine C Lim, R. M. Roumen
    Abstract:

    BACKGROUND: Chronic abdominal pain can be due to entrapped intercostal nerves (anterior cutaneous nerve entrapment syndrome [ACNES]). If abdominal wall infiltration using an anesthetic agent is unsuccessful, a Neurectomy may be considered. Pulsed radiofrequency (PRF) applies an electric field around the tip of the cannula near the affected nerve to induce pain relief. Only limited retrospective evidence suggests that PRF is effective in ACNES. METHODS: A multicenter, randomized, nonblinded, controlled proof-of-concept trial was performed in 66 patients. All patients were scheduled for a Neurectomy procedure. Thirty-three patients were randomized to first receive a 6-minute cycle of PRF treatment, while the other 33 were allocated to an immediate Neurectomy procedure. Pain was recorded using a numeric rating scale (NRS, 0 [no pain] to 10 [worst pain possible]). Successful treatment was defined as >50% pain reduction. Patients in the PRF group were allowed to cross over to a Neurectomy after 8 weeks. RESULTS: The Neurectomy group showed greater pain reduction at 8-week follow-up (mean change from baseline -2.8 (95% confidence interval [CI] -3.9 to -1.7) vs. -1.5 (95% CI -2.3 to -0.6); P = 0.045) than the PRF group. Treatment success was reached in 12 of 32 (38%, 95% CI 23 to 55) of the PRF group and 17 of 28 (61%, 95% CI 42 to 72) of the Neurectomy group (P = 0.073). Thirteen patients were withdrawn from their scheduled surgery. Adverse events were comparable between treatments. CONCLUSIONS: PRF appears to be an effective and minimally invasive treatment option and may therefore be considered in patients who failed conservative treatment options before proceeding to a Neurectomy procedure. Anterior Neurectomy may possibly lead to a greater pain relief compared with PRF in patients with ACNES, but potential complications associated with surgery should be discussed.

  • pulsed radiofrequency or anterior Neurectomy for anterior cutaneous nerve entrapment syndrome acnes the pulse trial study protocol of a randomized controlled trial
    Trials, 2017
    Co-Authors: Robbert C Maatman, M. R. Scheltinga, Oliver B Boelens, Monique A H Steegers, Toine C Lim, Hans J. Van Den Berg, Sandra A. S. Van Den Heuvel, R. M. Roumen
    Abstract:

    Some patients with chronic abdominal pain suffer from an anterior cutaneous nerve entrapment syndrome (ACNES). This somewhat illusive syndrome is thought to be caused by the entrapment of end branches of the intercostal nerves residing in the abdominal wall. If ACNES is suspected, a local injection of an anesthetic agent may offer relief. If pain is recurrent following multiple-injection therapy, an anterior Neurectomy entailing removal of the entrapped nerve endings may be considered. After 1 year, a 70% success rate has been reported. Research on minimally invasive alternative treatments is scarce. Pulsed radiofrequency (PRF) treatment is a relatively new treatment for chronic pain syndromes. An electromagnetic field is applied around the nerve in the hope of leading to pain relief. This randomized controlled trial compares the effect of PRF treatment and Neurectomy in patients with ACNES. Adult ACNES patients having short-lived success following injections are randomized to PRF or Neurectomy. At the 8-week follow-up visit, unsuccessful PRF patients are allowed to cross over to a Neurectomy. Primary outcome is pain relief after either therapy. Secondary outcomes include patient satisfaction, quality of life, use of analgesics and unanticipated adverse events. The study is terminated 6 months after receiving the final procedure. Since academic literature on minimally invasive techniques is lacking, well-designed trials are needed to optimize results of treatment for ACNES. This is the first large, randomized controlled, proof-of-concept trial comparing two therapy techniques in ACNES patients. The first patient was included in October 2015. The expected trial deadline is December 2017. If effective, PRF may be incorporated into the ACNES treatment algorithm, thus minimizing the number of patients requiring surgery. Nederlands Trial Register (Dutch Trial Register), NTR5131 ( http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5131 ). Registered on 15 April 2015.

  • Pulsed radiofrequency or anterior Neurectomy for anterior cutaneous nerve entrapment syndrome (ACNES) (the PULSE trial): study protocol of a randomized controlled trial
    BMC, 2017
    Co-Authors: Robbert C Maatman, M. R. Scheltinga, Oliver B Boelens, Monique A H Steegers, Toine C Lim, Hans J. Van Den Berg, Sandra A. S. Van Den Heuvel, R. M. Roumen
    Abstract:

    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

  • surgical options after a failed Neurectomy in anterior cutaneous nerve entrapment syndrome
    World Journal of Surgery, 2014
    Co-Authors: T Van Assen, M. R. Scheltinga, Oliver B Boelens, P V Van Eerten, R. M. Roumen
    Abstract:

    Injection treatment followed by an anterior Neurectomy in patients insufficiently responding to an injection regimen is successful long term in three-quarters of patients with anterior cutaneous nerve entrapment syndrome (ACNES). The efficacy of secondary surgery, including re-exploration or a posterior Neurectomy in patients reporting recurrent pain after initially successful surgery or following an immediately failed anterior Neurectomy is unknown. A database of ACNES patients receiving surgery between 2004 and 2012 in the SolviMax institution was analysed. Adult patients with residual pain after an anterior Neurectomy (failures) or with recurrent pain after initially successful surgery (recurrences) were selected. Following a re-exploration or a posterior Neurectomy, pain was scored using a pain intensity numeric rating scale (PI-NRS 0–10) and a six-point verbal category rating scale (VRS). Success was defined as a ≥50 % PI-NRS reduction and/or ≥2 point VRS reduction. ACNES patients undergoing an anterior Neurectomy (n = 181) were analysed during the 8-year study period. At follow-up, 51 patients reported unacceptable pain levels following an anterior Neurectomy, whereas 20 developed recurrent abdominal wall pain. Of these 71 unsuccessful patients, 41 underwent secondary surgery, including a re-exploration (n = 10), or a posterior Neurectomy (n = 31). After a 25-month median follow-up, secondary surgical treatment regimens proved successful in 66 % (27/41). Patients with recurrent pain did better (14/15) than patients who were immediate failures after the anterior Neurectomy (13/26, p = 0.01). Secondary surgery including re-explorations and posterior neurectomies are successful in two-thirds of ACNES patients with persistent pain or recurrence of pain after an anterior Neurectomy.

  • surgical options after a failed Neurectomy in anterior cutaneous nerve entrapment syndrome
    World Journal of Surgery, 2014
    Co-Authors: T Van Assen, M. R. Scheltinga, Oliver B Boelens, P V Van Eerten, R. M. Roumen
    Abstract:

    Background Injection treatment followed by an anterior Neurectomy in patients insufficiently responding to an injection regimen is successful long term in three-quarters of patients with anterior cutaneous nerve entrapment syndrome (ACNES). The efficacy of secondary surgery, including re-exploration or a posterior Neurectomy in patients reporting recurrent pain after initially successful surgery or following an immediately failed anterior Neurectomy is unknown.

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