Lindsey B Armstrong1, Pradeep Dinakar2, David P Mooney3. 1. Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA. Electronic address: lindsey.armstrong@childrens.harvard.edu. 2. Department of Anesthesiology, Boston Children's Hospital, Harvard Medical School, Boston, MA. 3. Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA.
Abstract
INTRODUCTION: Anterior cutaneous nerve entrapment syndrome (ACNES) is an underrecognized etiology of chronic abdominal pain that causes great morbidity to those affected. We sought to determine the outcome of neurectomy for ACNES in children. METHODS: Demographic and clinical data on children who underwent neurectomy for ACNES by a single surgeon from 10/2011 to 01/2017 were reviewed. RESULTS: Twenty-six patients underwent neurectomy for ACNES. Five were male and average age was 15years (10-21). Median (IQR) preoperative pain duration was 15 (8-29) months and 19 reported their pain was 10/10 (6-10). Thirteen patients were taking antidepressants, 12 Gabapentin, and 4 narcotics. Most had been hospitalized at least once secondary to the pain. All 26 had undergone diagnostic studies including: nuclear medicine scan, fluoroscopy, computed tomography, magnetic resonance imaging, sonography, endoscopy and surgery. Once the diagnosis was suspected, all underwent at least one ultrasound-directed nerve block, which provided relief lasting from 6h to 14days. Patients then underwent outpatient surgery with division of the involved nerve(s). There were no perioperative complications. Most patients reported incisional discomfort for 3-14days afterward, and immediate resolution of the nerve pain without cutaneous numbness. Postoperatively, 15 patients (58%) were pain free long-term; pain recurred to a lesser severity in 8 (31%) and recurred to the same extent in 3 (11%), with average time to recurrence of 6.7months. Of those whose pain recurred to a lesser extent, all achieved long term relief, 4 improved with time, 1 through repeat neurectomy, 2 through medical treatment for underlying psychiatric disorders and 1 through treatment for newly diagnosed inflammatory bowel disease. Of those children with pain recurring to the same extent, all underwent repeat neurectomy, none of whom achieved pain relief. CONCLUSION: ACNES should be considered in children with chronic abdominal pain. Neurectomy is safe and relieves pain in around 88% of selected children. Further investigation is necessary to optimize patient selection. LEVEL OF EVIDENCE: IV.
INTRODUCTION:Anterior cutaneous nerve entrapment syndrome (ACNES) is an underrecognized etiology of chronic abdominal pain that causes great morbidity to those affected. We sought to determine the outcome of neurectomy for ACNES in children. METHODS: Demographic and clinical data on children who underwent neurectomy for ACNES by a single surgeon from 10/2011 to 01/2017 were reviewed. RESULTS: Twenty-six patients underwent neurectomy for ACNES. Five were male and average age was 15years (10-21). Median (IQR) preoperative pain duration was 15 (8-29) months and 19 reported their pain was 10/10 (6-10). Thirteen patients were taking antidepressants, 12 Gabapentin, and 4 narcotics. Most had been hospitalized at least once secondary to the pain. All 26 had undergone diagnostic studies including: nuclear medicine scan, fluoroscopy, computed tomography, magnetic resonance imaging, sonography, endoscopy and surgery. Once the diagnosis was suspected, all underwent at least one ultrasound-directed nerve block, which provided relief lasting from 6h to 14days. Patients then underwent outpatient surgery with division of the involved nerve(s). There were no perioperative complications. Most patients reported incisional discomfort for 3-14days afterward, and immediate resolution of the nerve pain without cutaneous numbness. Postoperatively, 15 patients (58%) were pain free long-term; pain recurred to a lesser severity in 8 (31%) and recurred to the same extent in 3 (11%), with average time to recurrence of 6.7months. Of those whose pain recurred to a lesser extent, all achieved long term relief, 4 improved with time, 1 through repeat neurectomy, 2 through medical treatment for underlying psychiatric disorders and 1 through treatment for newly diagnosed inflammatory bowel disease. Of those children with pain recurring to the same extent, all underwent repeat neurectomy, none of whom achieved pain relief. CONCLUSION: ACNES should be considered in children with chronic abdominal pain. Neurectomy is safe and relieves pain in around 88% of selected children. Further investigation is necessary to optimize patient selection. LEVEL OF EVIDENCE: IV.