Thoracic Pain

Anterior cutaneous nerve entrapment syndrome: management challenges

“…ACNES should always be included in the differential diagnosis of patients suffering from chronic unilateral abdominal pain, after a thorough clinical and laboratory evaluation. The specific diagnostic steps described in the literature4,9,10,17–20 should be followed. No definitive therapy has been prescribed so far, as the literature that supports different types of treatment is mostly based on retrospective case series and a few randomized controlled trials.…”

“…However, the management of other conditions of chronic pain suggests that systemic drug administration may be used as a first step or in combination with interventional techniques, in order to facilitate patients’ recovery and improve their overall quality of life 13,17,18. Systemic pharmacotherapy must follow the World Health Organization’s analgesic ladder in addition to the guidelines for neuropathic pain management, and this may be used in the course of a multimodal and individualized management plan 17,18…”

“…Interventional techniques were the main therapeutic option employed in most of the studies on pain management in ACNES 1,2,13,14,17–20. These techniques include the trigger point injections (blind or ultrasound-guided), neurolytic techniques (chemical neurolysis or radiofrequency ablation), surgical techniques (anterior neurectomy and mesh reinforcement), and newer techniques such as botulinum toxin injection and neuromodulation 1,2,10–12…”

“…However, Van Kleef et al17 in their evidence-based guidelines for interventional pain management, rated both the pulsed and the thermal radiofrequency approaches of the DRG in the cases of intercostal neuralgia as 2C+ (effectiveness only demonstrated in observational studies). However, ACNES has a different etiology; the mechanical irritation of the nerve in its peripheral course is the main cause of injury, but it is still an intercostal neuralgia, and the efficacy of radiofrequency ablation in the refractory cases, when other interventional techniques or surgery fails to provide pain relief, is yet to be defined.…”

“…However, it might be effective in the management of the disease after the failure of all interventional and surgical therapies, as it has been found to be effective in other forms of neuropathic pain of different origin and etiology. The exact role of nerve stimulation in ACNES is yet to be unraveled, as there is no current evidence to support its use 17,18…”