Diagnostic characteristics of anterior cutaneous nerve entrapment syndrome in childhood

Background: Anterior cutaneous nerve entrapment syndrome (ACNES) is a frequently overlooked cause of chronic abdominal pain in children. Currently, both nonsurgical and surgical treatment options are available to treat this disease. The objective was to give insight into the success rate of different treatment strategies for children with ACNES, and provide treatment recommendations for physicians based on the published evidence. Method: A literature search of PubMed, Embase.com and the Wiley/Cochrane Library was conducted for studies published up to 25 February 2020. Randomized controlled trials, prospective or retrospective cohort studies, meta-analyses and literature reviews describing the outcome of different treatment strategies for children (b18 years old) with ACNES with a follow-up duration of at least four weeks were included. Results: Six studies, involving 224 patients, were included with an overall quality reported to be between fair and poor. Treatment success of local injections with an anesthetic agent into the trigger point ranged from 38% to 87% with a follow-up ranging from 4 weeks to 39 months. In addition, treatment success of anterior neurectomy ranged from 86% to 100%, with a follow-up duration ranging from 4 weeks to 36 months. Conclusion: A step-up treatment strategy should be applied when treating pediatric patients with ACNES. This strategy starts with an injection with a local anesthetic agent, reserving surgery (anterior neurectomy) as a viable option in case of persistent pain. Level of evidence: II.

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“…In addition, one can inject a local anesthetic into the trigger point. Pain relief for several hours or days confirms the diagnosis [11,17,18].…”

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confidence: 69%

“…At physical examination painful abdominal palpation, positive pinch test and Carnett's sign may be found [11,16]. Furthermore, altered skin sensibility demonstrated by a swab or alcohol-soaked gauze strongly supports to the diagnosis [11,16,17]. In addition, one can inject a local anesthetic into the trigger point.…”

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confidence: 91%

Treatment strategies for anterior cutaneous nerve entrapment syndrome in children: A systematic review

Markus

Sibbing

Ket

et al. 2021

Journal of Pediatric Surgery

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“…Para el tratamiento del ACNES en la edad pediátrica se barajan dos estrategias: -La utilización de inyecciones en el punto gatillo con un agente anestésico local. Se han utilizado las inyecciones subfasciales guiadas por ecografía con 40 mg de lidocaína al 1% y 4 mg de dexametasona, y las inyecciones con 50 mg de lidocaína al 1% utilizando la técnica de manos libres y agregando 40 mg de metilprednisolona si se necesita tratamiento adicional [3][4][5][6][7][8][9] . El éxito de este tratamiento (con un número de inyecciones por paciente entre uno y siete) oscila entre el 38 y el 87% con una duración de seguimiento de cuatro semanas a 39 meses, según las series 3,5,9 .…”

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Anterior cutaneous nerve entrapment syndrome: a frequently overlooked cause of chronic abdominal pain in children

2021

An Sist Sanit Navar

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Resumen El síndrome de atrapamiento del nervio cutáneo anterior (ACNES) con frecuencia no se tiene presente en el diagnóstico diferencial del dolor abdominal crónico (DAC). Presentamos el caso de un varón de 11 años con DAC estudiado previamente en servicios de urgencia y digestivo sin detectar patología orgánica, sugiriéndose un origen psicosomático. En la exploración mostró dolor en la pared abdominal localizado en el área de la rama terminal del nervio intercostal T11, con signo de Carnett positivo y respuesta favorable a la inyección con anestésico local en el punto gatillo. Los potenciales evocados somatosensoriales revelaron neuropatía del nervio del músculo recto anterior derecho. Se diagnosticó de ACNES. Como tratamiento se administró en el punto gatillo una inyección subfascial ecoguiada de lidocaína y dexametasona. Tras cuatro meses, permanece asintomático. Para el tratamiento de ACNES en población pediátrica, recomendamos una estrategia terapéutica escalonada comenzando con inyecciones en el punto gatillo y reservar la neurectomía anterior para cuando estas fracasan.

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“…In addition, coughing, body stretching, or any type of movement or more intense use of abdominal muscles may aggravate the pain [2]. At physical examination, painful abdominal palpation, positive pinch test and Carnett's sign may be found [2,3]. The Carnett's sign helps to distinguish if the pain originates from the abdominal wall or from abdominal viscera.…”

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confidence: 99%

“…If the pain increases during palpation with flexed abdominal muscles, the Carnett's sign is positive indicating the pain originates from the abdominal wall [4]. Furthermore, altered skin sensibility demonstrated by a swab or alcohol-soaked gauze strongly supports the diagnosis [2,3,5]. In addition, one can inject a local anesthetic into the trigger point with or without corticosteroids and with or without ultrasound guidance [2,[6][7][8].…”

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confidence: 99%

Histopathologic examination of resected nerves from children with anterior cutaneous nerve entrapment syndrome: Clues for pathogenesis?

Markus

Montfoort

Jong

et al. 2020

Journal of Pediatric Surgery

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a b s t r a c tBackground: Anterior cutaneous nerve entrapment syndrome (ACNES) has been described as a possible cause for chronic pain in the pediatric population. However, the exact pathophysiology of ACNES is unknown. It may be caused by compression or traction of cutaneous nerve branches of intercostal nerves, or it may be the result of an infection. Therefore, we present histopathological evidence to determine the pathophysiology of ACNES. Methods: A total of seven pediatric patients underwent a neurectomy for ACNES. All specimens were sent for histopathological evaluation, including immunohistochemical staining, to evaluate if there were any signs of infection, inflammation or compression. Results: Seven out of seven (100%) histopathological specimens showed non-specific nerve degeneration. Immunohistochemical evaluation showed there were several CD68-positive macrophages present in the specimens. Four out of seven (57%) specimens showed the presence of a few CD3-positive T-cells, however, this was not suggestive for inflammation or infection. Conclusion: Our study supports the hypothesis that ACNES is caused by compression of the nerves rather than inflammation. Level of evidence: III

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Diagnostic characteristics of anterior cutaneous nerve entrapment syndrome in childhood

Cited by 22 publications

References 22 publications

Treatment strategies for anterior cutaneous nerve entrapment syndrome in children: A systematic review

Treatment strategies for anterior cutaneous nerve entrapment syndrome in children: A systematic review

Anterior cutaneous nerve entrapment syndrome: a frequently overlooked cause of chronic abdominal pain in children

Histopathologic examination of resected nerves from children with anterior cutaneous nerve entrapment syndrome: Clues for pathogenesis?

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