Keywords
neuropathic pain
anterior cutaneous nerve
iliohypogastric nerve
ilioinguinal nerve.
Abstract
Introduction: Neuropathic abdominal pain is an underdiagnosed and undertreated pathology, it is frequently confused with visceral, somatic or psychiatric disorders, delaying correct diagnosis, timely treatment and increasing significant costs for the health system. The causes of abdominal neuropathic pain can be due to damage to the sensory branches of the nerves of the abdominal wall caused by partial or complete resection, stretching, contusion or compression. Case description: 31-year-old female patient with a history of twin pregnancy and cesarean delivery with subsequent chronic abdominal pain who underwent multiple medical examinations in search of gastrointestinal pathology. Physical examination revealed abdominal pain with neuropathic characteristics associated with a positive Carnett sign and diastasis recti abdominis, for which it was considered an anterior abdominal cutaneous nerve entrapment syndrome. In addition, evoked potentials of iliohypogastric and ilioinguinal nerves showed alteration of the somatosensory pathway, a transverse abdominal plane block was performed, which added physical therapy and neuromodulatory medication significantly improved pain and quality of life. Discussion: Neuropathy of the ilioinguinal and iliohypogastric nerves can be a complication of lower hemiabdomen surgeries; in the reported case, cesarean section is a potential cause of injury to these nerves. However, his pain and neuropathic sensory symptoms extended to an area that went beyond the territory of these nerves, so it was considered that the diastasis recti abdominis had a compressive effect, additionally causing an anterior cutaneous abdominal nerve entrapment syndrome. Conclusion: In the presence of chronic abdominal or pelvic pain, a clinical history and a complete physical examination should be performed, identifying the characteristics of the pain to determine the precise and targeted diagnostic aids and thus be able to clarify the cause of the pain and treat it appropriately.References
1. Costanza CD, Longstreth GF, Liu AL. Chronic abdominal wall pain: Clinical features, health care costs, and long-term outcome. Clin Gastroenterol Hepatol. 2004;2(5):395-9.
2. Bouhassira D. Neuropathic pain: Definition, assessment and epidemiology. Rev Neurol (Paris). 2019;175(1-2):16-25.
3. Hawksworth DJ, Dellon AL, Herati AS. Ilioinguinal and iliohypogastric neuralgia as an etiology of bladder pain syndrome. Urol Case Rep. 2019;28:101056.
4. Sabo CM, Grad S, Dumitrascu DL. Chronic abdominal pain in general practice. Dig Dis. 2021;39(6):606-14.
5. Shian B, Larson ST. Abdominal wall pain: Clinical evaluation, differential diagnosis, and treatment. Am Fam Physician. 2018;98(7):429-36.
6. Gangopadhyay N, Pothula A, Yao A, Geraghty PJ, Mackinnon SE. Retroperitoneal approach for ilioinguinal, iliohypogastric, and genitofemoral neurectomies in the treatment of refractory groin pain after inguinal hernia repair. Ann Plast Surg. 2020;84(4):431-5.
7. Fuentes Aparicio L, Rejano-Campo M, Donnelly GM, Vicente-Campos V. Self-reported symptoms in women with diastasis rectus abdominis: A systematic review. J Gynecol Obstet Hum Reprod. 2021;50(7):101995.
8. Scheltinga MR, Roumen RM. Anterior cutaneous nerve entrapment syndrome (ACNES). Hernia. 2018;22(3):507-16.
9. García-Carmona JA, Sánchez-Lucas J. Role of Carnett's maneuver in the diagnosis of an anterior cutaneous nerve syndrome confused with a somatic symptom disorder: A case report. Neurologia (Engl Ed). 2021;36(2):179-80.
10. Hidalgo Paz ML. Valores normales de potenciales evocados somatosensoriales del nervio iliohipogástrico en una muestra de adultos sanos. [Tesis de maestría, Universidad Nacional de Colombia]. 2020.
11. Papazian O, Alfonso I, Luzondo R. Indicaciones médicas y quirúrgicas de los potenciales evocados. Medicina (B. Aires). 2007;67(6 Pt 1):647-60.
12. Kohan L, McKenna C, Irwin A. Ilioinguinal neuropathy. Curr Pain Headache Rep. 2020;24(1):2.
13. Radhakrishnan M, Ramamurthy K. Efficacy and challenges in the treatment of diastasis recti abdominis-A scoping review on the current trends and future perspectives. Diagnostics (Basel). 2022;12(9):2044.
14. Thomassen I, van Suijlekom JA, van de Gaag A, Ponten JE, Nienhuijs SW. Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks for chronic pain after inguinal hernia repair. Hernia. 2013;17(3):329-32.
15. Kastler A, Aubry S, Piccand V, Hadjidekov G, Tiberghien F, Kastler B. Radiofrequency neurolysis versus local nerve infiltration in 42 patients with refractory chronic inguinal neuralgia. Pain Physician. 2012;15(3):237-44.
16. Zacest A, Magill S, Anderson V, Burchiel K. Long-term outcome following ilioinguinal neurectomy for chronic pain. Clinical article. J Neurosurg. 2010;112(4):784-9.
17. Tran DQ, Bravo D, Leurcharusmee P, Neal JM. Transversus Abdominis Plane Block: A narrative review. Anesthesiology. 2019;131(5):1166-90.
18. Vilchis-Rentería JS, Zaragoza-Lemus MG. Bloqueo en el plano transverso abdominal. Rev Mex de Anestesiol. 2017;40(1):334-6.
19. Sellam S, Nguyen AT, Pogu M, Kianmanesh R, Malinovsky JM, Renard Y. Transversus abdominis plane block in the treatment of chronic postsurgical abdominal wall pain improves patient quality of life: A retrospective study and literature review. Pain Physician. 2023;26(2):E91-100.