Genitofemoral Neuralgia Research Articles

Implantation of a Genitofemoral Nerve Peripheral Nerve Stimulator for the Treatment of Refractory Groin Pain: A Case Report

Implantable peripheral nerve stimulators (PNS) are a neuromodulation technique for those suffering from neuropathic pain from peripheral nerve origin. Genitofemoral (GF) neuralgias are difficult to treat yet common pain disorder after surgical procedures (inguinal herniorrhaphy, appendectomy, caesarean sections). To date, there are limited reports of PNS for GFN.

Genitofemoral peripheral nerve stimulator implantation for refractory groin pain: a case report.

Genitofemoral neuralgia (GFN) is a chronic pain condition that may be refractory to commonly employed treatment modalities. Implantation of a peripheral nerve stimulator (PNS) may provide significant pain relief; however, few reports have described placement of and response to a GFN PNS implant. We implanted a StimRouter® PNS in a 42-yr-old male with severe GFN that did not respond to pharmacologic and interventional pain management modalities and impaired all aspects of his function and quality of life. The often-challenging sonographic visualization of the genitofemoral nerve was aided by intraprocedural sensory mapping using a stimulating probe. Preoperatively, the patient's average pain was rated as 7 on a 0 to 10 numeric rating scale. Following the procedure, the patient experienced over 90% pain relief after one week. At one and five months post implantation, the patient's average pain scores were 1 and 0.5, respectively. The patient also reported substantial improvement in the physical component scores on the 12-Item Short Form Survey (SF-12), which remained similar at the five-month follow-up (from 26.1 preop to 57.2 at one month and 49.7 at five months). Peripheral nerve stimulator implantation may be a promising intervention when other analgesic modalities fail to manage refractory GFN. Further research to verify the effectiveness of this intervention and evaluate for appropriate integration in patient care is required.

ID:16316 PNS for Chronic Ilioinguinal and Genitofemoral Neuralgia: A Light at the End of the Tunnel

A 40 year old female who came to the pain clinic for evaluation of long standing right lower abdominal, hip, groin, and medial thigh pain. Her discomfort was debilitating, and affected several aspects of her everyday life including standing, bending, and even mild physical activity and exercise. Over the course of fifteen years, she had tried several treatment modalities including acupuncture, physical therapy, occupational therapy, massage, medications, and steroid injections to no avail. She underwent radiofrequency ablation of the right ilioinguinal and genitofemoral nerves which did provide her relief for almost one year, but she was in search of a more permanent solution to her pain as she found repeat procedures quite uncomfortable.

Surgical Management of Genitofemoral Neuralgia

Video Objective This video reviews the etiology, diagnosis, and management of genitofemoral neuralgia which is defined as pain along the distribution of the genitofemoral nerve. Setting The patient in this video began having symptoms of genitofemoral neuralgia following a laparotomy. A common mechanism of iatrogenic injury to this nerve is crush injury from poorly placed self-retaining retractors during abdominopelvic surgery. A neurectomy can be offered because the genitofemoral nerve has only sensory function and no motor function. Interventions We review the surgical technique for resection of the genital branch of the genitofemoral nerve. This technique involves retroperitoneal dissection over the psoas muscle, identification of the bifurcation of the nerve into its femoral and genital branches, isolation of the nerve, resection of the nerve, and implantation of the proximal nerve ending into the psoas muscle for nerve regeneration and neuroma prevention. Conclusion This technique is 66-100% in successful in relieving symptoms including the case of this patient.

Role of MR Neurography in Groin and Genital Pain: Ilioinguinal, Iliohypogastric, and Genitofemoral Neuralgia.

Chronic neuralgia of the border nerves (ilioinguinal, iliohypogastric, and genitofemoral) is difficult to diagnose and treat clinically. We examined the role of MR neurography (MRN) in the evaluation of border nerve abnormalities and the results of treatments directed at the MRN-detected nerve abnormalities. This retrospective cross-sectional study included 106 subjects with groin or genital pain (mean [± SD] age, 50.7 ± 15.4 years) who showed mono- or multifocal neuropathy of the border nerves at 3-T MRN. Subjects who underwent CT-guided perineural injection were assessed for pain response. Injection responses were categorized as positive, possible positive, and negative. Subjects who received hyaluronidase, continuous radiofrequency ablation, or surgery were also evaluated for treatment outcomes. One hundred forty abnormal nerves were positive for neuropathy in 106 studies. Eighty of 106 subjects had single neuropathy, and 26 had multifocal neuropathy. Fifty-eight subjects underwent CT-guided perineural injections, with five receiving bilateral injections (63 injections). Improvement in subjective pain was seen in 53 of 63 cases (84.2%). A statistically significant improvement in pain response was noted in the isolated ilioinguinal nerve block group as compared with the isolated genitofemoral nerve block group (p = 0.0085). Thirteen of 58 subjects received multiple nerve injections at the same sitting. Both groups receiving single or multiple nerve injections had similar improvement in pain scores of 84% and 85%, respectively, although this difference was not statistically significant. Our retrospective analysis showed improved pain relief in subjects who underwent CT-guided nerve blocks on the basis of a positive MRN.

Efficacy of intraoperative local administration of 0.5% bupivacaine on postoperative pain control following anterior abdominal wall hernia repair-A prospective case-control study

Introduction: With current technological advancement and availability of synthetic materials used in inguinal hernia repair, a recurrence after first intervention is not a common and important adverse event [1, 2]. On the other hand, however, some patients complain about chronic pain of the operated site after surgeries using a polypropylene mesh [3]. Many patients are constrained to a prolonged use of analgesics and increased frequency of control visits, which may even­tually result in loss of trust in the operator [3]. Every surgical intervention is associated with the risk of immediate or delayed complications [4, 5]. Genitofemoral neuralgia is associated with dysfunction of peripheral nerves passing through the inguinal canal or the surround­ing tissue and it is a chronic, troublesome and undesired complication of an inguinal hernia repair [5]. The possibility of minimizing chronic inguinal pain by proper management during herniorrhaphy should be considered in all cas­es of an inguinal canal reconstruction [6]. Objectives: To assess the efficacy of intraoperative injection of 0.5% bupivacaine (analgesic) into the operated site on the postoperative pain over operated site, assessed on the day of operation as well as the 1st and 2nd postoper­ative day after anterior abdominal wall hernia repair. Materials and methods: A prospective analysis of patient data compiled by assessment of Post-Operative pain at operated site documented and patient follow up recorded over the period from March 2018 and December 2018 at RL Jalappa hospital and research centre, Tamaka, Kolar. Results: All complications of the surgical wound significantly increased pain level on postoperative day 2. The NRS score for complicated surgical wound was 2.1 on av­erage. In the case of uncomplicated wounds, it was 0.72 (2.1 vs. 0.72 on day 2). Presence of blood in the surgical wound manifesting itself by ecchymosis and hematoma increased pain level assessed on postoperative day 2 (NRS score 2.0 vs. 0.79 in day 2). Duration of procedure did not influence pain sensation on post­operative day 0, 1, 2. In the group with inguinal hernias, postoperative complications of the wound occurred in 8.3% (n=3). Skin and subcutaneous tissue oedema of the wound was found in 10% (n=5) of patients.

Selective Spinal Nerve Block in Ilioinguinal, Iliohypogastric and Genitofemoral Neuralgia.

To seek the efficacy of selective spinal nerve blocks in the treatment of groin pain that are irresponsive to peripheral nerve blocks. This retrospective study comprised 17 patients with ilioinguinal, iliohypogastric, and genitofemoral neuralgias treated between 2017 and 2018. All patients received diagnostic peripheral nerve blocks and/or TAP blocks with blind or ultrasound-guided techniques. Four patients had ineffectual peripheral nerve blocks, after which they underwent T12 and L1 selective spinal nerve blocks. All four patients had satisfactory results. If distal peripheral nerve blocks are ineffective, an upper level nerve lesion, a lesion in the lumbar plexus or an L1 radiculopathy should be considered in ilioinguinal, iliohypogastric, and genitofemoral neuralgias. Upper level nerve blocks should be performed before deciding on surgery.

Diagnostic Accuracy of Selective 3-T MR Neurography-guided Retroperitoneal Genitofemoral Nerve Blocks for the Diagnosis of Genitofemoral Neuralgia.

Purpose To determine if 3-T magnetic resonance (MR) neurography-guided retroperitoneal genitofemoral nerve (GFN) blocks are safe and effective for the diagnosis of genitofemoral neuralgia. Materials and Methods Following institutional review board approval and informed consent, 26 subjects (16 men, 10 women; mean age, 42 years [range, 24-78 years]; mean body mass index, 28 kg/m2 [range, 20-35 kg/m2]) with intractable groin pain were included. By using a 3-T MR imaging system, intermediate-weighted turbo spin-echo pulse sequences, and MR-conditional needles, diagnostic MR neurography-guided GFN blocks were performed in the retroperitoneum. Outcome variables included technical success, procedure time, complications, and rates of positive and negative GFN blocks in association with therapeutic outcomes. For the assessment of a learning curve, Mann-Whitney test was used. P values ≤ .05 were considered to indicate a statistically significant difference. Results In 26 subjects, 30 retroperitoneal GFN blocks were performed. Twelve (40%) were performed with an anterior needle path, 12 (40%) with a lateral needle path, and six (20%) with a posterior needle path. GFN blocks were technically successful in 24 of 26 (92%) subjects, achieving appropriate scrotal anesthesia. No complications occurred. The time required for a GFN block was 40 minutes (range, 18-67 minutes). The rate of a successful GFN intervention after a positive GFN block was 88% (14 of 16). The rate of a successful intervention of an alternative target after a negative GFN block was 71% (five of seven). Conclusion Selective retroperitoneally directed MR neurography-guided GFN blocks are safe and effective with high technical success and positive effect on surgical decision making in patients with presumed genitofemoral neuralgia. © RSNA, 2017 Online supplemental material is available for this article.

Fluoroscopically-Guided Pulsed Radiofrequency Neurotomy Technique for the Treatment of Genitofemoral Neuralgia

Fluoroscopically-Guided Pulsed Radiofrequency Neurotomy Technique for the Treatment of Genitofemoral Neuralgia

Sandwich technique, peripheral nerve stimulation, peripheral field stimulation and hybrid stimulation for inguinal region and genital pain

Objective: Ilioinguinal neuralgia (IG) and genitofemoral (GF) neuralgia following inguinal hernia repair is a chronic and debilitating neuropathic condition. Recently, peripheral nerve stimulation has become an effective and minimally invasive option for the treatment of refractory pain. Here we present a retrospective case series of six patients who underwent placement of peripheral nerve stimulation electrodes using various techniques for treatment of refractory post-intervention inguinal region pain.Methods: Six patients with post-intervention inguinal, femoral or GF neuropathic pain were evaluated for surgery. Either octopolar percutaneous electrodes or combination of paddle and percutaneous electrodes were implanted in the area of their pain. Pain visual analog scores (VAS), surgical complication rate, preoperative symptom duration, degree of pain relief, preoperative and postoperative work status, postoperative changes in medication usage, and overall degree of satisfaction with this therapy was assessed.Results: All six patients had an average improvement of 62% in the immediate post-operative follow-up. Four patients underwent stimulation for IG, one for femoral neuralgia, and another for GF neuralgia. Peripheral nerve stimulation provided at least 50% pain relief in all the six patients with post-intervention inguinal region pain. 85% of patients indicated they were completely satisfied with the therapy overall. There was one treatment failure with an acceptable complication rate.Conclusion: Peripheral nerve or field stimulation for post-intervention inguinal region pain is a safe and effective treatment for this refractory and complex problem for patients who have exhausted other management options.

(397) Fluoroscopically-guided radiofrequency neurotomy technique for the treatment of genitofemoral neuralgia

Genitofemoral neuralgia (GFN) is a pain syndrome that causes burning, tingling, and numbness along the groin and medial thigh. The etiology is thought to be nerve entrapment or iatrogenic injury. GFN has been noted following surgeries such as inguinal herniorraphy, appendectomy, caesarian section, lymph node biopsy, hysterectomy, vasectomy, and urethral sling surgery. GFN has been treated with medications, surgical neurotomies, and with various ablative interventional procedures. These interventional procedures have been performed blindly, with CT guidance, or with ultrasound guidance. In this article we present the case of a 48-year-old-woman with GFN who responded to anesthetic nerve blockade of the genitofemoral nerve and subsequent fluoroscopically-guided genitofemoral radiofrequency neurotomy. She experienced complete relief of her symptoms immediately post-procedure and had 95% pain relief at 1.5 month-follow-up. To the knowledge of the authors, this is the first technical description of a fluoroscopic guidance technique for genitofemoral neurotomy.

The Diagnostic Dilemma of a Genitofemoral-ilioinguinal Overlap Syndrome

Background: It is sometimes difficult to clinically delineate genitofemoral and ilioinguinal neuralgias because of the overlap in the clinical symptomatology. Case description: A young male with a past history of transurethral removal of ureteral calculi presented with severe, debilitating neuropathic pain in the groin. He had hyperpathia and allodynia in the distribution of genitofemoral nerve, and hence a clinical diagnosis of genitofemoral neuralgia was made. An ultrasound guided diagnostic block of the genitofemoral nerve with local anesthetic produced only a mild reduction in pain (VAS 2 reduction). A repeat diagnostic block of the ilioinguinal nerve produced complete resolution of pain. Literature search showed a limited number of case reports of ultrasound guided blocks for genitofemoral neuralgia; and overlap syndromes have been addressed with differential nerve blocks. Clinical relevance: Our hypothesis is that an aberrant reinnervation from the ilioinguinal to genitofemoral nerve may present with features favoring a genitofemoral neuralgia. In situations where radiofrequency treatment is being considered, such cases may pose a failed intervention if both nerves are not separately targeted.

Genitofemoral neuralgia: a review.

Genitofemoral neuralgia is a cause of neuropathic pain that is often debilitating in nature. It is characterized by chronic neuropathic groin pain that is localized along the distribution of the genitofemoral nerve. The symptoms include groin pain, paresthesias, and burning sensation spreading from the lower abdomen to the medial aspect of the thigh. It may present with scrotal pain in male, while females experience symptoms radiating to the labia majora and mons pubis. Genitofemoral neuropathy has been attributed to iatrogenic nerve injury occurring during inguinal and femoral herniorrhaphy, with cases developing after both open and laparoscopic techniques. Diagnosis of genitofemoral neuralgia can be challenging, due to the overlap in sensory distribution the nerve shares with the ilioinguinal and iliohypogastric nerve. Differential nerve blocks are recommended in effort to differentiate the nerves when patients present with lower abdominal and groin pain. Once a diagnosis has been made, there exist several treatment options for genitofemoral neuralgia ranging from medical management, non-invasive injections, and surgery. Literature has also brought light to radiofrequency ablation and cryoablation performed under ultrasound guidance as emerging treatments. The aim of the current article is to review the anatomy, diagnostic techniques, and treatment options for patients with genitofemoral neuralgia.

Successful treatment of genitofemoral neuralgia using ultrasound guided injection: a case report and short review of literature.

A young male patient developed chronic, severe, and disabling right sided groin pain following resection of his left testicular cancer. Since there is considerable overlap, ultrasound guided, selective diagnostic nerve blocks were done for ilioinguinal, iliohypogastric, and genitofemoral nerves, to determine the involved nerve territory. It was revealed that genitofemoral neuralgia was the likely cause. As a therapeutic procedure, it was injected with local anesthetic and steroid using ultrasound guidance. The initial injection led to pain relief of 3 months. Subsequent blocks reinforced the existing analgesia and were sufficient to allow for maintenance with the use of analgesic medications. This case report describes the successful use of diagnostic selective nerve blocks for the assessment of groin pain, subsequent to which an ultrasound guided therapeutic injection of genitofemoral nerve led to long term pain relief. As a therapeutic procedure, genitofemoral nerve block is done in patients with genitofemoral neuralgia. Ultrasound allows for controlled administration and greatly enhances the technical ability to perform precise localization and injection. There are very few case reports of such a treatment in the published literature. Apart from the case report, we also highlight the relevant anatomy and a brief review of genitofemoral neuralgia and its treatment.

Trajectory avoiding kidney and ureter injury for percutaneous lumbar sympathetic block.

Trajectory avoiding kidney and ureter injury for percutaneous lumbar sympathetic block.

A Novel CT-Guided Transpsoas Approach to Diagnostic Genitofemoral Nerve Block and Ablation

Inguinal hernia repair is associated with a high incidence of chronic postsurgical pain. This pain may be caused by injury to the iliohypogastric, ilioinguinal, or genitofemoral nerves. It is often difficult to identify the specific source of the pain, in part, because these nerves are derived from overlapping nerve roots and closely colocalize in the area of surgery. It is therefore technically difficult to selectively block these nerves individually proximal to the site of surgical injury. In particular, the genitofemoral nerve is retroperitoneal before entering the inguinal canal, a position that puts anterior approaches to the proximal nerve at risk of transgressing into the peritoneum. We report a computed tomography (CT)-guided transpsoas technique to selectively block the genitofemoral nerve for both diagnostic and therapeutic purposes while avoiding injury to the nearby ureter and intestines. A 39-year-old woman with chronic lancinating right groin pain after inguinal hernia repair underwent multiple pharmacologic interventions and invasive procedures without relief. Using CT and Stimuplex nerve stimulator guidance, the genitofemoral nerve was localized on the anterior surface of the psoas muscle and a diagnostic block with local anesthetic block was performed. The patient had immediate relief of her symptoms for 36 hours, confirming the diagnosis of genitofemoral neuralgia. She subsequently underwent CT-guided radiofrequency and phenol ablation of the genitofemoral nerve but has not achieved long-term analgesia. CT-guided transpsoas genitofemoral nerve block is a viable option for safely and selectively blocking the genitofemoral nerve for diagnostic or therapeutic purposes proximal to injury caused by inguinal surgery.

(222) Treatment of Genitofemoral Neuralgia After Laparoscopic Inguinal Herniorrhaphy with Fluoroscopically-Guided Tack Injection

Nerve entrapment syndromes involving the genital branch of the genitofemoral nerve, the ilioinguinal nerve, or the iliohypogastric nerve occur in an estimated 1–2% of conventional, open herniorrhaphies [3], and can also occur with laparoscopic herniorrhaphies [1]. A 48-year-old man with a recurrent right-sided inguinal hernia underwent a laparoscopic hernia repair using Prolene mesh and titanium tacks. Two weeks post-operatively, the patient spontaneously developed severe, intermittent, lancinating pain in a genitofemoral nerve distribution. Infection and recurrent hernia were ruled out. Treatment with non-steroidal anti-inflammatory drugs, muscle relaxants and ilioinguinal nerve blocks using traditional anatomic landmarks were unsuccessful. A focal point of tenderness at the inferolateral portion of the pubic ramus was investigated under fluoroscopy and was found to be directly overlying a surgical tack. Palpation over this site produced a Tinel's sign reproducing the patient's pain. A diagnostic injection using local anesthetic was performed at this site. The patient was pain-free for two months following the injection. When the pain returned, the injection was repeated using local anesthetic with corticosteroid, using the same fluoroscopically-guided technique. The patient has been asymptomatic since that time. Laparoscopic hernia repair may pose increased risk of nerve injury than conventional hernia repair [1]. With a conventional repair the nerves at risk are generally visible and may be dissected free, thus avoiding nerve injury. In contrast, with the laparoscopic repair the staples are placed preperitoneally and the nerves cannot be visualized. In a patient with suspected nerve entrapment syndrome following laparoscopic hernia repair, injection therapy may be effective treatment. As illustrated in this paper, fluoroscopy can be useful during physical exam and as an aid in localizing and for performing the injection. If an injection offers significant but transient relief, surgical removal of the staple or neurectomy at a site proximal to the lesion may be indicated [2].

Iatrogenic ureteral injury due to lumbar sympathetic block

Lumbar sympathetic block (LSB) is used in the management of sympathetically maintained pain states. Complications of LSB may include infection, injury of spinal cord or somatic nerve, kidney trauma, hypotension, paraplegia and genitofemoral neuralgia. We present a case of a 53-year-old woman who had undergone LSB for the relief of reflex sympathetic dystrophy and subsequently a disrupted right proximal ureter. She was treated with ureteroureterostomy and an indwelling ureteral stent.

Iatrogenic ureteral injury due to lumbar sympathetic block

Lumbar sympathetic block (LSB) is used in the management of sympathetically maintained pain states. Complications of LSB include infection, injury of spinal cord or somatic nerve, kidney trauma, hypotension, paraplegia and genitofemoral neuralgia. This report presents the case of a 53-year-old woman who had undergone LSB for relief of reflex sympathetic dystrophy and subsequently disrupted right proximal ureter. She was treated with ureteroureterostomy and indwelling ureteral stent.

The outcome of percutaneous computed tomography-guided chemical lumbar sympathectomy for patients with causalgia after lumbar discectomy

Background Coldness, numbness, or causalgia usually affects the lower limbs in patients after back surgeries. The treatment of causalgia is still the source of continuing debate. We treated patients presenting with causalgia secondary to LD with CT-guided CLS and determined the therapeutic outcome at long-term follow-up. Methods From January 2002 to December 2002, a total of 15 patients (16 limbs) with causalgia after LD underwent the percutaneous CT-guided CLS. There were 7 male patients and 8 female patients, with an average age of 49.1 years. A total of 14 patients underwent unilateral procedures, and 1 patient underwent staged bilateral procedures. We followed up our patients for at least 24 months (24-36 months). Results There were 13 patients (14 limbs) diagnosed as Drucker stage I and 2 patients as stage II. There were 88% (14 limbs) that had an early satisfactory outcome after CLS and 75% (12 limbs) that had a late satisfactory outcome (more than 24 months after CLS). Stage I patients had more satisfying early and late outcome than stage II patients ( P = .014 and P = .039, respectively). Female patients were more likely to have satisfactory late outcome than male patients ( P = .034). There was no operative mortality. A patient had a complication of genitofemoral neuralgia, which had recovered in a month. Conclusions We concluded that the percutaneous CT-guided CLS is an easy, safe, and reproducible technique, and it carries long-term benefit to patients with pain after LD presenting with causalgia, especially for patients with Drucker stage I and female patients.