Anterior cutaneous nerve entrapment syndrome

Anterior cutaneous nerve entrapment syndrome (ACNES) is a condition that causes chronic pain of the abdominal wall. It occurs when terminal branches of the lower thoracic intercostal nerves (7-12) are ‘entrapped’ in abdominal muscles, causing a severe localized neuropathic pain that is usually experienced at ventral portions of the abdomen. It is frequently overlooked and unrecognized, although the incidence is estimated to be 1:2000 patients.[1]

The relative unfamiliarity with this condition often leads to significant diagnosis delays/misdiagnosis, often resulting in unnecessary diagnostic interventions and futile procedures.[2] Physicians tend to diagnose these patients with alleged "irritable bowel syndrome", or "functional disorders," as symptoms of the condition are not dispositive.[3][4]

Epidemiology

This syndrome is predominantly found in young women, but also occurs in children, teenagers and octogenarians.[5]

Signs and symptoms

Patients typically experience limited relief from standard analgesic medication, with the exception of some neuroleptic agents. Patients frequently experience ‘pseudovisceral’ phenomena or symptoms of altered autonomic nerve system function including nausea, bloating, abdominal swelling, loss of appetite with consecutively lowered body weight or an altered defecation process.[6]

Pain is typically related to tensing the abdominal wall muscles, so any type of movement is prone to aggravate pain. Lying quietly can be the least painful position. Most patients report that they cannot sleep on the painful side.[7]

Diagnosis

Once ACNES is considered based on the patient’s history, the diagnosis can easily be made via a thorough physical examination: looking for a painful spot, which worsens by tensing the abdominal muscles as in lifting the head (Carnett's sign).[8] Almost always, a small area of maximal pain is covered by a larger area of altered skin sensibility with somatosensory disturbances such as hypoesthesia as well as hyperesthesia or hyperalgesia and change of cool perception. Pinching the skin between thumb and index finger is extremely painful compared to the opposite non-involved side.[9]

Confirmation of a diagnosis of ACNES is warranted using an abdominal wall infiltration with a local anesthetic agent near the painful spot.[10]

Treatment

Treatment consists of several such anesthetic injections, sometimes combined with corticosteroids. Such an approach yields persistent pain relief in two-thirds of patients. This beneficial effect on pain has been demonstrated in a prospective double blind trial.[11] The physical volume of the injection may also break apart the adhesions or fibrosis responsible for the entrapment symptoms.[12]

Patients who do not respond to a stratagem of repetitive local trigger point injections can be offered a surgical approach. Terminal branches of an intercostal nerve are removed at the level of the anterior sheath of the rectus abdominal muscle (‘anterior neurectomy’). Several larger series demonstrated a successful response in approximately two out of three patients, which was confirmed in another prospective double blind surgical trial: 73% of the patients who underwent a neurectomy were pain free, compared to 18% in the non-nerve resected group.[13] Patients not responding to an anterior neurectomy, or those in whom the pain syndrome recurs after an initial pain free period (10%) may choose to undergo secondary surgery. This involves a repeated exploration combined with a posterior neurectomy. This procedure has been shown to be beneficial in 50% of cases.[14][15]

References

  1. ↑ Van Assen, T.; Brouns, J. A. G. M.; Scheltinga, M. R.; Roumen, R. M. (2015). "Incidence of abdominal pain due to the anterior cutaneous nerve entrapment syndrome in an emergency department". Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 23: 19. doi:10.1186/s13049-015-0096-0.
  2. ↑ Srinivasan, R; Greenbaum, D. S. (2002). "Chronic abdominal wall pain: A frequently overlooked problem. Practical approach to diagnosis and management". The American Journal of Gastroenterology 97 (4): 824–30. doi:10.1111/j.1572-0241.2002.05662.x. PMID 12003414.
  3. ↑ Van Assen, T; De Jager-Kievit, J. W.; Scheltinga, M. R.; Roumen, R. M. (2013). "Chronic abdominal wall pain misdiagnosed as functional abdominal pain". The Journal of the American Board of Family Medicine 26 (6): 738–44. doi:10.3122/jabfm.2013.06.130115. PMID 24204070.
  4. ↑ Van Assen, T; Boelens, O. B.; Kamphuis, J. T.; Scheltinga, M. R.; Roumen, R. M. (2012). "Construction and validation of a questionnaire distinguishing a chronic abdominal wall pain syndrome from irritable bowel syndrome". Frontline Gastroenterology 3 (4): 288–294. doi:10.1136/flgastro-2012-100207. PMC 3730810. PMID 23914291.
  5. ↑ Lindsetmo, R. O.; Stulberg, J (2009). "Chronic abdominal wall pain--a diagnostic challenge for the surgeon". The American Journal of Surgery 198 (1): 129–34. doi:10.1016/j.amjsurg.2008.10.027. PMID 19555786.
  6. ↑ Applegate WV (1972). "Abdominal cutaneous nerve entrapment syndrome". Surgery 71 (1): 118–24. PMID 4332389.
  7. ↑ Scheltinga, M. R.; Boelens, O. B.; Tjon a Ten, W. E.; Roumen, R. M. (2011). "Surgery for refractory anterior cutaneous nerve entrapment syndrome (ACNES) in children". Journal of Pediatric Surgery 46 (4): 699–703. doi:10.1016/j.jpedsurg.2010.08.054. PMID 21496540.
  8. ↑ Carnett J. (1926). "Intercostal neuralgia as a cause of abdominal pain and tenderness". Surg Gynecol Obstet 42: 8.
  9. ↑ Van Assen, T; Boelens, O. B.; Van Eerten, P. V.; Perquin, C; Scheltinga, M. R.; Roumen, R. M. (2015). "Long-term success rates after an anterior neurectomy in patients with an abdominal cutaneous nerve entrapment syndrome". Surgery 157 (1): 137–43. doi:10.1016/j.surg.2014.05.022. PMID 25444218.
  10. ↑ Boelens, O. B.; Scheltinga, M. R.; Houterman, S; Roumen, R. M. (2011). "Management of anterior cutaneous nerve entrapment syndrome in a cohort of 139 patients". Annals of Surgery 254 (6): 1054–8. doi:10.1097/SLA.0b013e31822d78b8. PMID 21881494.
  11. ↑ Boelens, O. B.; Scheltinga, M. R.; Houterman, S; Roumen, R. M. (2013). "Randomized clinical trial of trigger point infiltration with lidocaine to diagnose anterior cutaneous nerve entrapment syndrome". British Journal of Surgery 100 (2): 217–21. doi:10.1002/bjs.8958. PMID 23180371.
  12. ↑ Akhnikh, S; De Korte, N; De Winter, P (2014). "Anterior cutaneous nerve entrapment syndrome (ACNES): The forgotten diagnosis". European Journal of Pediatrics 173 (4): 445–9. doi:10.1007/s00431-013-2140-2. PMID 24197667.
  13. ↑ Boelens, O. B.; Van Assen, T; Houterman, S; Scheltinga, M. R.; Roumen, R. M. (2013). "A double-blind, randomized, controlled trial on surgery for chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome". Annals of Surgery 257 (5): 845–9. doi:10.1097/SLA.0b013e318285f930. PMID 23470571.
  14. ↑ Van Assen, T; Boelens, O. B.; Van Eerten, P. V.; Scheltinga, M. R.; Roumen, R. M. (2014). "Surgical options after a failed neurectomy in anterior cutaneous nerve entrapment syndrome". World Journal of Surgery 38 (12): 3105–11. doi:10.1007/s00268-014-2737-2. PMID 25189442.
  15. ↑ Roumen, R. M.; Scheltinga, M. R. (2006). "Abdominal intercostal neuralgia: A forgotten cause of abdominal pain". Nederlands tijdschrift voor geneeskunde 150 (35): 1909–15. PMID 16999272.
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