Abstract
BackgroundSome 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.MethodsAdult 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.DiscussionSince 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 registrationNederlands Trial Register (Dutch Trial Register), NTR5131 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5131). Registered on 15 April 2015.
Highlights
Some patients with chronic abdominal pain suffer from an anterior cutaneous nerve entrapment syndrome (ACNES)
Anterior cutaneous nerve entrapment syndrome (ACNES) is caused by the entrapment of end branches of the intercostal nerves that are residing in the abdominal wall
Patients suffer from severe abdominal pain that is often not recognized as most physicians are focused, when confronted with abdominal pain, on a visceral source of the pain [1, 2]
Summary
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. 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. If ACNES is suspected, current treatment options include analgesics, subfascial injections of a local anesthetic (whether or not combined with a long-acting corticosteroid), transcutaneous electrical nerve stimulation (TENS) and surgical interventions such as anterior and posterior neurectomy. A neurectomy is usually considered in the remaining two thirds with a reported 70% success rate [5]
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