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ORIGINAL RESEARCH |
From the 1Department of Plastic Surgery and the 2Department of Obstetrics and Gynecology, Georgetown University Hospital, Washington, DC.
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ABSTRACT |
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 ABSTRACT PARTICIPANTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: Neuromas of the ilioinguinal, iliohypogastric, and/or genitofemoral nerves were suspected clinically and confirmed intraoperatively.
RESULTS: After neuroma resection, all patients reported complete and durable pain relief.
CONCLUSION: Intractable pain after obstetric or gynecologic surgery can be due to neuroma formation, and resection is therapeutic. We suggest an algorithm for the management of women with chronic intractable suprapubic or groin pain after major obstetric and gynecologic surgery.
LEVEL OF EVIDENCE: II-3
A neuroma is a damaged part of a peripheral nerve that will form after trauma or transection. It can also form when a peripheral nerve becomes engulfed in scar tissue (including that after surgical incision or manipulation). Treatment of a neuroma includes its resection and implantation of the proximal peripheral nerve stump into muscle to avoid neuroma recurrence. When the peripheral nerve becomes encased within a fibrous scar, neurolysis (nerve decompression) can release external pressure that causes symptoms of pain and burning. If intraoperative findings include hardening of the nerve itself, then internal nerve microdissection (neurolysis) could further improve the outcome.
We present a series of seven consecutive patients with intractable pain after major obstetric and gynecologic surgeries, all of whom had exhausted medical therapy with frustration to both themselves and their physicians. After exclusion of other pathologic etiologies for their pain, these women were referred to a plastic surgeon who identified and excised their surgical site neuromas, with complete eradication of symptoms. We suggest an algorithm for the management of intractable postoperative pain at the incision site after major obstetric surgery.
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PARTICIPANTS AND METHODS |
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ABSTRACTPARTICIPANTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Peripheral nerve surgery was performed by a single surgeon at Georgetown University Hospital. After induction of general anesthesia, the dissection was performed under loupe magnification for identification of the ilioinguinal, iliohypogastric, and/or genitofemoral nerves or their branches (Fig. 1). The incision was usually made within the old scar and extended laterally if needed. Ilioinguinal and iliohypogastric nerves were identified under the external oblique fascia, whereas the genital branch of the genitofemoral nerve had to be dissected within the inguinal canal because it comes out from the retroperitoneum through the internal inguinal ring. Neuroma detection was based on the gross identification of a fibrotic widening along a peripheral nerve, with confirmation from permanent pathologic specimen (Fig. 2). Identified neuromas were resected and then more proximally buried in skeletal muscle (to prevent neuroma recurrence). It should be noted that anatomical variations within these nerves are more common than appreciated. Thus, knowledge of its variations, especially when dealing with previously operated scarred tissues, becomes critical for proper execution of the surgery. Furthermore, it is mandatory to use delicate instruments suitable for peripheral nerve surgery as well as 3.5 or 4.0 loop magnification.
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Patients were followed after surgery for 3–17 months. Subjective evaluation of pain was documented for each patient, as well as any adverse effects or morbidities from the neurectomy procedure. A chart review of these patients was conducted under a protocol approved by the Institutional Review Board at Georgetown University.
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RESULTS |
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ABSTRACTPARTICIPANTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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It is of note that these seven patients represent all of the patients who have been referred to the peripheral nerve clinic at Georgetown University Hospital with this constellation of complaints and physical findings. Only patients with the appropriate history, examination, and negative diagnostic studies described above were taken to the operating room. All of these patients were found to have neuromas, and all demonstrated symptomatic relief after peripheral nerve surgery.
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DISCUSSION |
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ABSTRACTPARTICIPANTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Neuroma formation can follow any surgical incision, and its excision has previously been reported to relieve intractable postoperative pain in numerous chronic pain syndromes, particularly in the groin and on the anterior abdominal wall.6,8,9,10 Neuromas of the ilioinguinal and iliohypogastric nerves have been well documented after various anterior abdominal wall incisions for herniorrhaphy, iliac bone crest harvest, laparoscopic port placement, and appendectomy.5,7,11,12 Although transaction of a peripheral nerve can lead to neuroma formation, more frequently the cause is development of scar tissue that then entraps the peripheral nerve, with subsequent traction leading to neuroma formation. Therefore, neuroma formation by itself cannot be attributed only to poor surgical technique.
The clinical evaluation of the patient with postoperative pain needs to be comprehensive and is best performed by the operating obstetrician or gynecologist. Because most postoperative incisional pain is transient and self-resolves, the management strategy of postoperative pain can be broadly divided into pain that lasts less than 6 months as opposed to pain lasting more than 6 months. The differential diagnosis of postoperative incisional pain within the first 6 months includes pain from local scar formation, local infection including cellulitis or abscess, wound dehiscence, foreign body reaction against retained material (such as suture), and isolated secondary pathology that is independent from the preceding surgery (such as unrelated malignancy). Appropriate investigation for these patients includes a thorough history and physical examination, including inspection of the wound for signs of infection or dehiscence, focused abdominal and pelvic exams, and judicious laboratory and radiologic studies as warranted. In the majority of patients whose postoperative pain is due to local scar formation, narcotic and nonnarcotic pain relief almost always adequately controls their pain.
In contrast, the evaluation of the patient whose postoperative pain exceeds 6 months focuses on etiologies with different mechanisms. At the top of the differential diagnosis are processes independent of the surgery, including abdominal or pelvic masses (malignancy), endometriosis, spinal radiculopathy, or other independent pathology that is presenting as unrelated postoperative pain. Thorough examination and imaging (particularly CT scan) will usually diagnose any independent medical disorder. However, once abdominal/pelvic malignancy, gynecologic disease, or other organic medical problems have been excluded, most patients with chronic postoperative pain have historically been referred to a psychiatrist or have been placed on empiric antidepressant medication. Unfortunately, we found that this approach had been attempted in four of the seven patients in our series. We suggest that once the patient with prolonged postoperative pain has been evaluated for latent pathology, a peripheral nerve-related disorder should be considered.
Certain diagnostic features that are particularly suggestive of neuroma include 1) delayed onset of postoperative pain, 2) hyperesthesia surrounding the incision, 3) immediate or delayed occurrence of areas of numbness, 4) referred pain into the groin or along a nerve’s sensory distribution, and 5) reproduction of pain with point percussion (Tinel’s sign). These findings in patients whose postoperative pain lasts 6 months beyond their surgery and whose search for alternate pathology has been unrewarding raise high suspicion for neuroma formation (Fig. 1).
Further diagnostic testing can include electromyography, nerve conduction studies, and diagnostic nerve blocks.13,14 Electromyography and nerve conduction studies are not routinely indicated and are often inconclusive in this anatomic region. Diagnostic nerve blocks have been advocated by earlier authors before proceeding with neuroma excision. Briefly, once the diagnosis of neuroma has been suspected, selective percutaneous nerve blockade is used to decide which nerves are involved. However, our experience with this and other peripheral nerve surgeries has been that diagnostic nerve blocks are unnecessary in a groin pain patient with an appropriately diagnostic history and physical examination and that the additional cost and morbidity are unwarranted. Caution must be exercised in the interpretation of any nerve block testing in this clinical situation because the ilioinguinal, iliohypogastric, and genitofemoral nerves have a particularly high incidence of anatomic variability in their respective distributions, creating a predisposition for false-positive and false-negative results.4 We suggest an algorithm in Figure 3 for the management of the patient with prolonged postoperative incisional groin pain after obstetric or gynecologic surgery.
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Footnotes |
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doi:10.1097/01.AOG.0000223864.63747.ce
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REFERENCES |
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