The Outcomes of Primary Anterior and Posterior Neurectomy for Anterior Cutaneous Nerve Entrapment Syndrome
Madi El Haj, MD1, Elyad Davidson, MD2, Sofia Anastasia Vorobeitchik, Medical Student3, Tal Eliav, Medical Student4, Tal Harel, MD5 and Rami David, MD6, 1Hadassah Hebrew University medical school, Jerusalem, Israel, 2Hadassah Hebrew University Medical Center, Jerusalem, Israel, Israel, 3Hadassah Hebrew University Medical Center, Jerusalem, Jerusalem, Israel, 4Ben-Gurion University, Beer Sheva, Israel, Israel, 5Safra Children's Hospital, Petah Tikva, Israel, Israel, 6Meir Medical Center, Kfar Saba, Israel, Israel
Objective: Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) is known to be caused by the trapping of end twigs of intercostal nerves at the level of the rectus abdominis muscle. This diagnosis is suggested by the patient’s history and physical examination (circumscribed pain localization and abnormal sensibility) and the absence of objective abnormalities (laboratory and imaging), as well as diagnostic intercostal nerve block. Following failed nonoperative treatment, anterior neurectomy is the treatment of choice with an efficacy rate of 61%. Combined anterior and posterior neurectomy (AP-neurectomy) is used after anterior neurectomy failure. We aimed to evaluate the efficacy rate of primary combined anterior and posterior neurectomy for failed nonoperative treatment of ACNES.
Materials & Methods: A retrospective review was conducted between March 2021 and April 2023, including 25 patients (18 females and 7 males) diagnosed with ACNES, who were treated with primary anterior and posterior neurectomy following failed nonoperative treatment (Figure 1). Patients were preoperatively evaluated using a 10-point visual analog scale (VAS) for pain, Pain Rating Index (PRI), Brief Pain Inventory index (BPI), and Pain Catastrophizing Scale (PCS).
Results: 16.3 months postoperatively, 20 patients (80%) reported a successful pain response (Responders), 4 patients (16%) reported poor results (non-Responders), and 1 patient moderate improvement. The pre- and postoperative VAS score in the responders was (8.05±1.398) and (0.78±1.39) respectively, (p<0.0001). There was no correlation between age, preoperative PCS, course of pain, and postoperative VAS score. 59 intercostal nerves were involved in the 25 patients. The most frequently affected nerves (40%) were the right T11, T12 and T10 intercostal nerves associated with right lower quadrant abdominal pain followed by the left T10, T11 and T12 (22%).
Conclusion: Primary anterior and posterior neurectomy are successful in 80% of ACNES patients with persistent symptoms following failed nonoperative treatment.
Figure 1. A: A transverse incision over the rectus sheath and the T8 rectus foramen. B: the anterior intercostal nerve cutaneous branch (AICB). C: The hourglass deformity of the (AICB). D: The left T10 intercostal nerve is marked with a vessel loop. E: The hourglass deformity of the left T10 intercostal nerve at the lateral rectus foramen.
Figure-1.png
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