OBJECTIVE: This study compares tender point infiltration (TPI) and a tailored neurectomy as the preferred treatment for chronic inguinodynia after inguinal herniorraphy. BACKGROUND: Some 11% of patients develop chronic discomfort after open inguinal herniorraphy. Both TPI and neurectomy have been suggested as treatment options, but evidence is conflicting. METHODS:Patients with chronic neuropathic pain after primary Lichtenstein repair and >50% pain reduction after a diagnostic TPI were randomized for repeated TPI (combined Lidocaine/corticosteroids /hyaluronic acid injection) or for a neurectomy. Primary outcome was success (>50% pain reduction using Visual Analog Scale, VAS) after 6 months. Cross-over to neurectomy was offered if TPI was unsuccessful. RESULTS: A total of 54 patients were randomized in a single center between January 2006 and October 2013. Baseline VAS was similar (TPI: 55, range 10-98 vs neurectomy: 53, range 18-82, P = 0.86). TPI was successful in 22% (n = 6), but a neurectomy was successful in 71% (n = 17, P = 0.001). After unsuccessful TPI, 19 patients crossed over to neurectomy and their median VAS score dropped from 60 to 14 (P = 0.001). No major complications after surgery were reported. Two-thirds of patients on worker's compensation returned to work. CONCLUSION: A tailored neurectomy is 3 times more effective than tender point infiltration in chronic inguinodynia after anterior inguinal hernia mesh repair. A step up treatment stratagem starting with tender point infiltration followed by a tailored neurectomy is advised.
RCT Entities:
OBJECTIVE: This study compares tender point infiltration (TPI) and a tailored neurectomy as the preferred treatment for chronic inguinodynia after inguinal herniorraphy. BACKGROUND: Some 11% of patients develop chronic discomfort after open inguinal herniorraphy. Both TPI and neurectomy have been suggested as treatment options, but evidence is conflicting. METHODS:Patients with chronic neuropathic pain after primary Lichtenstein repair and >50% pain reduction after a diagnostic TPI were randomized for repeated TPI (combined Lidocaine/corticosteroids /hyaluronic acid injection) or for a neurectomy. Primary outcome was success (>50% pain reduction using Visual Analog Scale, VAS) after 6 months. Cross-over to neurectomy was offered if TPI was unsuccessful. RESULTS: A total of 54 patients were randomized in a single center between January 2006 and October 2013. Baseline VAS was similar (TPI: 55, range 10-98 vs neurectomy: 53, range 18-82, P = 0.86). TPI was successful in 22% (n = 6), but a neurectomy was successful in 71% (n = 17, P = 0.001). After unsuccessful TPI, 19 patients crossed over to neurectomy and their median VAS score dropped from 60 to 14 (P = 0.001). No major complications after surgery were reported. Two-thirds of patients on worker's compensation returned to work. CONCLUSION: A tailored neurectomy is 3 times more effective than tender point infiltration in chronic inguinodynia after anterior inguinal hernia mesh repair. A step up treatment stratagem starting with tender point infiltration followed by a tailored neurectomy is advised.
Authors: Elisabeth Kjær Jensen; Thomas K Ringsted; Joakim M Bischoff; Morten A Petersen; Jacob Rosenberg; Henrik Kehlet; Mads U Werner Journal: Medicine (Baltimore) Date: 2019-08 Impact factor: 1.817