The effect of repetitive infiltrations as a part of a new multidisciplinary algorithm for chronic postoperative groin pain

1. The effect of repetitive infiltrations as a part of a new multidisciplinary
algorithm for chronic postoperative groin pain
Nijs Y, Peeters E, Verbeke H, Bruyninckx F, Theys T, Morlion B, Miserez M

2. Department Abdominal Surgery, University Hospitals
Gasthuisberg, Leuven, Belgium

3.  Introduction
- Chronic postoperative groin pain
• 11% to 54% of patients
• Subgroup moderate to severe in 1,9% to 3%
• Severe impact
• QoL/Social/ Physical/Mental/ Sexual
• No standardisation
• Diagnosis/Work-up/Treatment
• Aim
- Multidisciplinary standardised protocol
• Surgeons, pain therapists, neurosurgery, physical medicine
Loos et al, Chronic sequelae of common elective
groin hernia repair , Hernia 2007

4.  Material and methods
 Inclusion criteria
 Chronic post-operative groin pain > 6 months and suggestive
neuropathic pain (DN4 ≥ 4 and/or LANSS ≥ 12)
 Exclusion criteria
 Nociceptive pain, meshoma, hernia relapse, complex pain
problems, previous surgery infra-umbilical M. rectus
abdominis
 EMG intake
 4 Repetitive injections
 EMG at 3 months
 Multidisciplinary decision
=> Outcome

5. Uitsluiten centrale
sensitisatie ?
Intake EMG 1ste infiltratie 2de infiltratie 3de infiltratie
Maand 1
2 weken 2 weken 2 weken
4de infiltratie EM Chirurgie of pijntherapie
Maand 2 Maand 3 INTERVENTIE
2 weken 1 maand 2 maanden
Evaluatie pijntherapie
EMG EMG
Maand 3 na interventie Maand 6 Maand 12
1 maand 3 maanden 6 maanden
Nadien 6 maandelijkse FU tot jaar 2 met jaarlijkse controle EMG
•History
•Anamnesis
•Clinical
examination
•Questionnaires

6.  Multidisciplinary work-up
 EMG
 Why ?
 Sensible nerve conduction studies not possible
 Selective nerve stimulation unfeasible
 Inguinal region unfavorable anatomy
 Severity and chronicity nerve damage
 Radiculopathy
 Carpal tunnel
 Prognostic factor CRD’s ?
 Crampy contractions
 Local muscle ischaemia
 How ?
 Blinded EMG
 Rest / Contraction
 Subcategorized

7. • Repetitive injections
• Ultra-sound and/or nerve-
stimulation guided
• Lidocaïn hydrochloride 2% 5ml
• Interval 2 weeks
• 1st injection ilio-
inguinal/ilio-hypogastric
nerve
• 2nd injection
genitofemoral nerve
 3rd injection repetition of
the most successful
 4th injection differential
epidural block or
transforaminal infiltration
 Central sensitisation ?
Ilioinguinal nerve
Iliohypogastric
nerve
ter Meulen et al, Clin Neurol Neurosurg
2007
Gucev et al, Anesth Analg 2008

8.  Material and methods
 VASmax scores
 Pre-injection, 30 and 60 minutes post-injection, clinical visits
 Individual plots
 VASmax post/pre ratio
Nijs et al, Long-term outcome of surgical treatment of chronic postoperative groin pain, Hernia 2013

9.  Material and methods
 10 patients
 Median age 49,4 (30-72)
 8 male, 2 female
Patient Sex Age
Previous
Surgery
Hernia location Lap/Open
Previous
neurecto
my ?
Previous
mesh
resection ?
1 F 27 Pfannenstiel NA Open 0 0
2 M 31 TAPP Right Lap 0 0
3 M 50 Lichtenstein Left Open 0 0
4 M 38 TEP Right Lap 0 1
5 M 53 Stoppa Bilateral Open 0 1
6 M 46 TEP Right Lap 0 0
7 M 30 Lichtenstein Right Open 0 0
8 V 73 Lichtenstein Right Open 0 0
9 M 60 Lichtenstein Right Open 0 0
10 V 59 TEP Right Lap 0 0

10.  Results
 2 patients complete pain relief
 Long term result
 After 3 injections
 Long-term follow-up
VASmax post/pre ratio 0 0
Mean ratio = Median ratio 0
Mean FU 10,80 months (10,45 – 11,16)
VASmax post/pre 0 0

11. • Results
 6 patients intermittent pain relief
 After each injection
 No permanent effect
VASmax post/pre 1,5 1,625 7
VASmax post/pre 1,25 1,14 0,93
Median ratio 1,37 (0,93 – 7)
Mean FU 14,14 months
(10,13-16,47)

12.  Results
 2 patients no pain relief
 Follow-up
VASmax post/pre 1,14 0,93
Median ratio = Mean ratio 1,03
Mean FU 14,79 months (10,13 – 19,46)
VASmax post/pre 1,14 0,92

13.  Conclusions
 Multidisciplinary standardised protocol
 Repetitive injections
 Small subset 20% permanent pain
relief
 Long-term effect
 1st injection no effect => non-
responder
 Preliminary results
 Larger prospective multi-center
studies needed

14. Thank You !!