Ilioinguinal Nerve Entrapment

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Ilioinguinal Nerve Entrapment: Pelvic 2016 Springer International Publishing Switzerland Family Name Murinova Particle Given Name

Natalia

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Author

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Neurology

Organization/University

Headache Clinic, University of Washington

City

Seattle

State

WA

Country

USA

Email Family Name

[email protected] Krashin

Particle Given Name

Daniel

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Author

Division

Pain and Anesthesia and Psychiatry Departments

Organization/University

Chronic Fatigue Clinic, University of Washington

City

Seattle

State

WA

Country

USA

Email Family Name

[email protected] Trescot

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Andrea M.

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Pain and Headache Center

Q1

Abstract

Keywords (separated by “ - ”)

City

Wasilla

State

AK

Country

USA

Email [email protected] Ilioinguinal nerve entrapment is a common cause of groin or inguinal area pain. The ilioinguinal nerve can become entrapped after pelvic or hernia surgery, which can result in disabling pain in the inguinal area, lateral genitalia, or abdominal wall. The distribution and features of this pain can vary between patients, depending on anatomic variations in the course of the ilioinguinal nerve and the location of the entrapment. The pain can be diagnosed with nerve blocks and treated with neurolysis or neurectomy. Ilioinguinal entrapment causing abdominal pain is discussed in Chap. 40; this chapter discusses ilioinguinal entrapment causing groin and pelvic pain. Ilioinguinal nerve - Ilioinguinal nerve entrapment - Groin pain - Post-hernia pain - Pelvic pain - Inguinodynia

AUTHOR QUERIES

Q1 Please provide department name for Andrea M. Trescot.

1

Ilioinguinal Nerve Entrapment: Pelvic

2

Natalia Murinova, Daniel Krashin, and Andrea M. Trescot

3

Introduction

4

Ilioinguinal nerve (IIN) entrapment causing chronic pelvic pain syndrome is considered part of the “border nerve syndrome” [1] (ilioinguinal, iliohypogastric, and genitofemoral nerve neuropathy) [2]. The role of the ilioinguinal, iliohypogastric, and genitofemoral nerves in abdominal wall pain is discussed in Chaps. 40 and 41. The IIN has several areas of entrapment and has a different pain pattern based on each of the sites of entrapment.

5 6 7 8 9 10 11

12

Clinical Presentation (Table 44.1)

13

The pain of ilioinguinal nerve entrapment is described as burning, sometimes accompanied by paresthesias or altered sensation, in the inguinal area and ipsilateral scrotum and testis/labia (Figs. 44.1, 44.2, and 44.3). It may present in either sex, and, while it is commonly associated with surgical injury, it may occur spontaneously. In a study of 46 women with abdominal and pelvic pain who were diagnosed with IIN entrapment, only 6 were found to have a clear cause for this condition, suggesting that this

14 15 16 17 18 19 20 21

Electronic supplementary material The online version of this chapter (doi:10.1007/978-3-319-27482-9_44) contains supplementary material, which is available to authorized users. N. Murinova, MD (*) Neurology, Headache Clinic, University of Washington, Seattle, WA, USA e-mail: [email protected] D. Krashin, MD Pain and Anesthesia and Psychiatry Departments, Chronic Fatigue Clinic, University of Washington, Seattle, WA, USA e-mail: [email protected] [AU1]

A.M. Trescot, MD Pain and Headache Center, Wasilla, AK, USA e-mail: [email protected]

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condition may frequently go unsuspected and undiagnosed. These women were noted to have dysesthesia, pain with pressure at the nerve exit, and hyperesthesia in the nerve distribution [10]. IIN entrapment is easily mistaken for other pain syndromes involving the lower GI tract and the genitourinary tract, as well as orthopedic conditions of the pelvis and hip. The sensory distribution of this nerve is wide, ranging from the inferior margin of the abdominal muscles to the cutaneous innervation of the inguinal crease, as well as the scrotum or labia majora and superior-medial thigh (Figs. 44.2 and 44.3). Therefore, depending on the location of the entrapment, the clinical picture may vary. The pain pattern of the IIN can also mimic the pattern of the genitofemoral nerve (Fig. 44.2). Patients with ilioinguinal neuralgia will complain of groin pain, which becomes worse with sitting, lifting, and bending. Benes et al. [11] suggested using the term abdominoinguinal pain syndrome, to describe the combination of these nerve pathologies.

22

Anatomy (Table 44.2)

42

The IIN arises from the anterior ramus of L1 with some contributions from T12 and L2, similar to the iliohypogastric nerve (IHN) (Fig. 44.4), as part of the lumbar plexus (see Chap. 49). Emerging from the lateral border of the psoas major muscle, both nerves run subperitoneally in front of quadratus lumborum before piercing the transverse abdominis muscle above the iliac crest to become superficial [12]. The IIN shares dermatomes with the proximal fallopian tubes and the uterine fundus, and therefore IIN entrapment can mimic uterine and ovarian pathology. It pierces the internal oblique muscle mediocaudally to the anterior superior iliac spine (ASIS). The nerve enters the inguinal canal approximately 2 cm medial to the ASIS and exits through the superficial inguinal ring to function as a sensory nerve for the overlying skin (Fig. 44.5). From

43

© Springer International Publishing Switzerland 2016 A.M. Trescot (ed.), Peripheral Nerve Entrapments: Clinical Diagnosis and Management, DOI 10.1007/978-3-319-27482-9_44

23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

44 45 46 47 48 49 50 51 52 53 54 55 56 57

N. Murinova et al. t1.1 t1.2 t1.3

Table 44.1 Occupation/exercise/trauma history relevant to i lioinguinal and iliohypogastric nerve entrapment Surgery

t1.4 t1.5 t1.6 t1.7 t1.8 t1.9 t1.10

Trauma

t1.11 t1.12 t1.13 t1.14 t1.15

Stretch injury Entrapment

t1.16 t1.17 t1.18

Spontaneous

Inguinal hernia repair [3] Pelvic open and laparoscopic surgeries [4] Trochar trauma from laparoscopic surgery [5] Appendectomy, hysterectomy [6], abdominoplasty Pfannenstiel incision Orchiectomy Blunt abdominal trauma [7] Femoral catheter placement Tearing of the lower external oblique aponeurosis (reported in hockey players) [8] Pregnancy At the rectus border (ACNE) At the iliac crest Variations in the musculo-aponeurotic connective tissue [9] Fig. 44.2 Pain patterns from iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, and anterior femoral cutaneous nerves (Image courtesy of Andrea Trescot, MD)

Fig. 44.1 Patient pain complaint from ilioinguinal nerve entrapment (Image courtesy of Andrea Trescot, MD)

58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73

there, it supplies innervation to the inner thigh and either scrotum or labia. The IIN usually terminates approximately 3 cm lateral to the midline and 2 cm superior to the pubic symphysis. The IIN is highly variable in its course and innervation, with multiple potential connections with the IHN and the genitofemoral nerves (see Chap. 45), and it sometimes assumes the role of the genital branch of the genitofemoral nerve. The site where the IIN penetrates the different layers of abdominal muscle is also highly variable [5]. It generally pierces the lower border of the internal oblique medially and below the ASIS and then passes through the superficial inguinal ring in front of the spermatic cord. Rab et al. [13] described the dissection of 32 cadavers and identified 4 different types of branching of the ilioin-

Fig. 44.3 Innervation of perineum: A genitofemoral nerve, B obturator nerve, C inferior cluneal nerve, D peroneal branch of the posterior femoral cutaneous nerve, E ilioinguinal nerve, and F pudendal nerve (Image inspired by Hibner et al. [39], courtesy of Andrea Trescot, MD)

guinal nerve. Type A (43.7 %) had no sensory contribution in the groin from the IIN, with sensation to the groin supplied instead by the genitofemoral nerve. Type B (28.1 %) had a dominant IIN with motor fibers to the cremaster muscle but no sensation to the groin. Type C (20.3 %) had a dominant genitofemoral nerve, with an IIN providing sensory branches to the inguinal crease and the mons pubis, as well as the root of the penis/labia majora; the IIN also shared a branch with the IHN in this pattern. Type D (7.8 %) had cutaneous branches from both the ilioinguinal and genitofemoral nerves, with the IIN

74 75 76 77 78 79 80 81 82 83 84

44 Ilioinguinal Nerve Entrapment: Pelvic t2.1 t2.2 t2.3 t2.4 t2.5

Table 44.2 Ilioinguinal nerve anatomy Origin General route

t2.6 t2.7

Sensory distribution

t2.8

Motor innervation Anatomic variability Other relevant structures

t2.9 t2.10

Anterior ramus of L1 (occasionally L2) Exits L1 (sometimes L2), passes through psoas, leaves internal oblique, past ASIS, travels below aponeurosis of external oblique along spermatic cord/round ligament through superficial abdominal ring Ribbon-shaped area over inguinal region up to iliac crest, over symphysis, root of the penis, proximal scrotum/labia, and small area of the anterior and medial thigh Transverse abdominis and external oblique muscles There is an inverse size of the IIN and IHN; they may be joined or one may be absent ASIS, inguinal canal, spermatic cord/round ligament

Subcostal nerve Iliohypogastric nerve Genitofemoral nerve (cut) Ilioinguinal nerve

Lumbar plexus

Lateral femoral cutaneous nerve

Psoas major muscle Genitofemoral nerve

Obturator nerve Lumbosacral trunk Femoral nerve

Fig. 44.4 Anatomy of the lumbar plexus (Image by Springer)

innervating the inguinal crease and the mons, as well as the most anteroproximal portion of the root of the penis/ labia majora.

Entrapment The IIN is commonly trapped at the rectus border, the iliac crest, and the paravertebral area. However, it can also be entrapped at the inguinal region, and patients with Pfannenstiel incisions or inguinal hernia repairs are at an increased risk

for IIN entrapment anywhere between the ASIS and the pubis, due to tissue scarring or fibrosis [14]. Hernia repair using mesh has a risk factor for entrapment of the IIN in the fibrotic tissue surrounding and adhering to the mesh.

85 93 86 94 87 95 96 88

Physical Exam

97 89

For the physical exam of the rectus border entrapment, position the patient supine or standing. Patients will often walk flexed at the hips to avoid tension on the abdominal

90 98 91 99 92 100

N. Murinova et al. Fig. 44.5 Anatomy of the ilioinguinal nerve (Image by Springer)

T7 T8 T9

Thoracoabdominal nerves

T10 Anterior cutaneous nerves

T11 Subcostal nerve (T12) Iliohypogastric nerve (L1)

Ilioinguinal nerve (L1) Femoral branch of the genitofemoral nerve Genital branch of the genitofemoral nerve

101 102 103 104 105 106 107 108

Fig. 44.6 Ilioinguinal nerve exam at the rectus border (Image courtesy of Andrea Trescot, MD)

Fig. 44.7 Ilioinguinal nerve exam at the iliac crest (Image courtesy of Andrea Trescot, MD)

wall. Check for point tenderness at the rectus border (Fig. 44.6). This occurs approximately 10 cm inferior to the umbilicus, in a position similar to anterior cutaneous nerve entrapment (see Chap. 42). To check for iliac crest entrapment, stand in front of the patient and place hands on the iliac crest laterally (Fig. 44.7). Feel the edge of the external oblique with your thumbs (Video 44.1). Tenderness at the external oblique tendon attachment can indicate

ilioinguinal nerve e ntrapment (Fig. 44.8). For paravertebral entrapment, palpate the paravertebral L1 vertebrae. Tenderness here can indicate ilioinguinal entrapment. This exam is helpful if the treatment needs to be more proximal. A focal bulging of the abdominal wall due to loss of muscle tone in the external and internal oblique muscles may be visible in some cases of ilioinguinal neuropathy (Fig. 44.9).

109 110 111 112 113 114 115 116

44 Ilioinguinal Nerve Entrapment: Pelvic

Fig. 44.9 Abdominal bulge due to proximal ilioinguinal entrapment (Image courtesy of Andrea Trescot, MD) t3.1 Fig. 44.8 Ilioinguinal nerve entrapment at the iliac crest (modified from an image from Bodies, The Exhibition, with permission). A ilioint3.2 guinal nerve, B iliohypogastric nerve, C site of ilioinguinal nerve t3.3 entrapment at the external oblique, D ilioinguinal nerve over the inguit3.4 nal ligament, E lateral femoral cutaneous nerve, F genitofemoral nerve, G genital branch of the genitofemoral nerve, H femoral branch oft3.5 the genitofemoral nerve, I femoral nerve, J saphenous nerve, K inferior t3.6 hypogastric plexus, L obturator nerve (Image courtesy of Andrea t3.7 Trescot, MD) t3.8

Table 44.3 Differential diagnosis of lower abdominal pain

117 iliohypogastric

Potential distinguishing features Palpable abdominal wall defect Scrotal venous distension or fluid collection Testicular tenderness (male), bimanual exam (female) History, examination with local tenderness Injection of individual nerves at the ASIS

119

Symphysis pubis osteophytes on X-ray

Inguinal hernia Varicocele, hydrocele Transient testicular or ovarian torsion Myofascial injury

t3.9

Differential Diagnosis (Table 44.3)

t3.10 t3.11 t3.12

Entrapment of

or genitofemoral nerves Osteoarthritis t3.13 118 There are many conditions resulting in groin pain that

t3.14 mimic ilioinguinal entrapment, including inguinal hernia, tumor, varicocele, hydrocele, spermatocele, transient testicular or ovarian torsion, and myofascial injury. Entrapment of the iliohypogastric or genitofemoral nerve (see Chap. 45) needs to be included in the differential diagnosis as well. Other diseases that can clinically present with chronic inguinal pain (including hip osteoarthritis, disk hernia, recurrent inguinal hernia, and tumor) can be ruled out by selective radiological examinations including ultrasonography (US), computed tomography (CT), and

120 121 magnetic

129

122 laparoscopy

resonance imaging (MRI). Diagnostic can also be considered for further diagnosis 123 [15]. If a diagnostic nerve injection in the region of the 124 digital exam did not provide relief, then one needs to 125 consider the possible aberrant innervation of the nerve and 126 using ultrasound for better localization for improved 127 results of the nerve block. The diagnostic tests for IIN 128 entrapment are found on Table 44.4.

130 131 132 133 134 135 136

N. Murinova et al. t4.1

Table 44.4 Diagnostic tests for ilioinguinal nerve entrapment

t4.2 t4.3 t4.4 t4.5

Physical exam

t4.6 t4.7

Diagnostic injection

t4.8

Ultrasound MRI Arteriography X-ray Electrodiagnostic studies

t4.9 t4.10 t4.11 t4.12

137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157

Potential distinguishing features Tenderness over the lateral rectus border (ACNE syndrome – see Chap. 42), ASIS, external oblique At rectus border, ASIS, external oblique Localization of IN at ASIS Not useful Not useful Not useful Not useful

I dentification and Treatment of Contributing Factors Perimenstrual fluid retention can lead to monthly episodes of abdominal pain. Pfannenstiel incisions [16] can lead to ilioinguinal entrapment at the lateral corner of the incision. Inguinal hernia repairs, especially with mesh, can lead to early (immediately postoperatively) as well as late (sometimes years after the surgery) entrapment. Ilioinguinal nerve entrapment (INE) is one of the most significant complications following inguinal hernia repair. In 2003, Poobalan et al. [14] reviewed the literature and found that chronic groin pain after inguinal herniorrhaphy was as high as 54 %, at least in the first 3 months. The incidence of postoperative ilioinguinal neuralgia ≥1 year reported after inguinal herniorrhaphy ranges from 6 to 29 % [17–20]. Desensitization exercises have been reported to provide relief in some patients. Unfortunately, this nerve entrapment is often triggered by abdominal wall exercises. Giving diuretics (HCTZ or furosemide) 5 days before scheduled menses can sometimes prevent the perimenstrual edema that may trigger entrapment.

158

Injection Techniques

159

Landmark-Guided Technique

160

For entrapment that occurs at the rectus border, advance a 25-gauge 2-in. needle to the lateral rectus border (Fig. 44.10) (Video 44.2). Inject 2 cc maximum volume of local anesthetic with or without deposteroid. Using a peripheral nerve stimulator to identify the nerve may help. Relying on a “fascial click” as indication that the needle has pierced the fascia is associated with increased complications [12]. For an iliac crest entrapment, position the patient in either the supine or lateral decubitus position. After identifying the lateral edge of the external oblique muscle at the iliac crest, advance a 25 g 2-in. needle onto the tendon attachment (Fig. 44.8 site C). Inject a 2 cc maximum volume of local anes-

161 162 163 164 165 166 167 168 169 170 171

Fig. 44.10 Injection of the ilioinguinal nerve at the rectus border (Image courtesy of Andrea Trescot, MD)

Fig. 44.11 Injection of the ilioinguinal nerve at the iliac crest (Image courtesy of Andrea Trescot, MD)

thetic with or without deposteroid. In a third technique, the anterior superior iliac spine (ASIS) is palpated in the supine position; the injection point is 2 in. medial and 2 in. inferior to that point (Fig. 44.11). If the patient’s physique makes body landmarks difficult to identify by palpation, consider using ultrasound or fluoroscopy for the iliac crest injection.

172

Fluoroscopic-Guided Technique

178

There are no specific bony landmarks for IIN entrapment, but fluoroscopy may help to identify the iliac crest and the ASIS in the morbidly obese (Fig. 44.12). The proximal approach at T12, L1, and L2 can be done under fluoroscopic control. The procedure is done in a manner very similar to a transforaminal epidural. Position the patient prone under fluoroscopy and identify the foramen (Fig. 44.13). A peripheral nerve stimulator is used to confirm the level of p athology, since the origin of this nerve is sometimes variable. Stimulation should allow

179

173 174 175 176 177

180 181 182 183 184 185 186 187


Fig. 44.14 Location of the ultrasound probe to evaluate the ilioinguinal nerve (Image courtesy of Andrea Trescot, MD) Fig. 44.12 Fluoroscopic identification of the anterior superior iliac spine (Image courtesy of Andrea Trescot, MD)

Fig. 44.13 Location of the proximal injection of the ilioinguinal nerve at its origin at T12 and L1 (Image courtesy of Andrea Trescot, MD) 188 189 190 191 192 193 194 195

the patient to identify the “that’s it” site. If you notice twitching in the patient’s lower back ( representing the cluneal nerve) instead of the groin, reposition the needle slightly more anteriorly. After injection of contrast under live fluoroscopy, inject a 1 cc maximum volume of local anesthetic with or without steroid. Because of concerns regarding possible anterior spinal artery infarcts from particulate steroids, it may be prudent to use non-particulate steroids.

Ultrasound-Guided Technique

196

The ultrasound localization of the ilioinguinal and iliohypogastric nerves is best seen at the anterior superior iliac spine (ASIS). Eichenberger et al. [21] described one of the first US approaches to the ilioinguinal and iliohypogastric nerves. The high-frequency linear probe is placed slightly rotated from a transverse to an oblique plane to be perpendicular to the anatomical course of both the IIN and the IHN, with the lateral/caudal part of the transducers brought into contact with the iliac crest (Fig. 44.14). The fascial layers between the external oblique, the internal oblique, and the transverse abdominus should be visible as bright hypoechoic white lines; the IHN and IIN will be hypoechoic oval structures between the internal oblique and the transverse abdominus muscles (Fig. 44.15). Bischoff et al. [22] described a randomized, double-blind, placebo-controlled crossover trial in 12 patients with severe, persistent inguinal pain after herniorrhaphy and 12 normal controls. The authors felt that ultrasound-guided lidocaine injections of the ilioinguinal and iliohypogastric nerves, at the level of the ASIS, were not useful in diagnosis and management of persistent inguinal post-herniorrhaphy pain. The authors offered several possible explanations for these findings: first, the sensory innervation of the groin is complex, consisting of branches of the ilioinguinal, iliohypogastric, and genitofemoral nerves, which share origins from the T12 to L2 spinal nerves. Communicating branches between these nerves and anatomic variations is common, meaning that interruption of one nerve may not abolish sensory transmission from a specific area [13]. Second, in some patients, sensory branches to the painful area may leave the main nerves proximal to the ASIS, so that even a properly performed

197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227

N. Murinova et al.

Fig. 44.15 Ultrasound image of ilioinguinal and iliohypogastric nerves at the iliac crest. ASIS anterior superior iliac spine, EOM external oblique muscle, IOM internal oblique muscle, TAM transverse abdominis muscle (Image courtesy of Thiago Nouer Frederico, MD, modified by Charles de Oliveira, MD)

228 229 230 231 232 233 234

nerve block in that area will have no effect on the pain. Third, a more prominent role of the genitofemoral nerve in persistent post-herniorrhaphy pain has recently been suggested (see Chap. 45) [15]. Fourth, a peripheral nerve block of short duration may not be adequate to affect persistent postsurgical pain, which is thought to be maintained by central sensitization [23].

235

Neurolytic Technique

236

Cryoneuroablation

237

For the ilioinguinal, iliohypogastric, and genitofemoral nerves (Chap. 45), cryoneuroablation is a common further therapy. After superficial infiltration with local anesthetic and deep infiltration with saline containing epinephrine 1:200,000, a 12-gauge intravenous catheter is used as the introducer for the 2.0 mm cryoprobe, usually trying to place the probe parallel to the nerve from lateral to medial. Location may be optimized with the use of US guidance (Fig. 44.16) as well as with the peripheral nerve stimulator. Fanelli et al. [24] described ten patients with ilioinguinal, genitofemoral, or combined neuralgia after inguinal hernia repair treated with cryoneuroablation. After cryotherapy, patients reported overall pain reduction of 0–100 % (mean, 77.5 %; median, 100 %), 80 % reported decreased analgesic use, and 90 % reported increased physical capacity. Two patients underwent additional cryotherapy, one for incomplete relief and one for recurrent pain, both with 100 % efficacy. Wound infection (n = 1) was the only complication.

238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256

Phenol/Alcohol

257

Phenol has been used [25] to treat persistent ilioinguinal neuralgia, but there is the possibility of tissue necrosis around the nerve and a significant risk of neuritis. Absolute alcohol provides good relief with the possibility of nerve and surrounding tissue necrosis and damage [25].

258

Radio-Frequency Lesioning

263

Standard, neurodestructive heat radio-frequency ablation (RFA) has been evaluated for the treatment of ilioinguinal neuralgia. Kastler et al. [26] compared local anesthetic blockade to radio-frequency ablation. CT guidance was utilized at the level of the ASIS. A 22-gauge 5 mm active tip needle was used. There was no mention of threshold, but stimulation was used to finalize needle position. Three ablations were performed, each for 90 s, at 70, 80, and 90 °C. Results showed 12.5 months relief in the RFA arm, compared to 1.6 months in the local anesthetic/steroid arm. Several groups have used pulsed radio frequency (PRF) for ilioinguinal neuralgia. For instance, Mitra et al. [27] described PRF for the treatment of chronic ilioinguinal neuropathy. PRF has been used at the vertebral level (dorsal root ganglion); Rozen and Ahn [28] described five patients treated with PRF at T12, L1, and L2, noting that four of the five patients had relief for 4–9 months. Kastler et al. [26] compared local anesthetic blockade to pulsed radio-frequency ablation for the treatment of 42 patients with postsurgical ilioinguinal neuralgia after hernia repair. A total of 18 PRF procedures (14 patients) and 28 steroid/local anesthetic injections (28 patients) were performed under CT guidance at the ASIS. Injections contained 1.5 mL of cortivazol (a high-affinity glucocorticoid) and 3 mL of a lidocaine-ropivacaine mixture. Mean duration of pain relief in the RF group was 12.5 months, compared to 1.6 months in the injection group. Rozen and Parvez in 2006 [29] described a case series of PRF at the DRG, while in 2015 Makharita and Amr [30] performed a randomized, double-blind controlled trial of PRF at the DRG. Both groups noted significant improvement.

264

Neurostimulation

297

Peripheral nerve stimulation has been used for chronic groin pain [30, 32]. The trial electrodes are placed percutaneously through introducers, and, if there is significant temporary relief, the leads can be placed permanently. Banh et al. described the use of a peripheral nerve stimulator for a

298

259 260 261 262

265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296

299 300 301 302


Fig. 44.16 Cryoneuroablation of the ilioinguinal nerve. EOM external oblique muscle, IOM internal oblique muscle, TAM transverse abdominus muscle, ASIS anterior superior iliac spine (Image courtesy of Agnes Stogicza, MD

a

b

Fig. 44.17 Peripheral nerve stimulation of the ilioinguinal nerve. Ultrasound image: anterior superior iliac spine (yellow star), ilioinguinal/iliohypogastric nerves (thick yellow arrows), and the percutaneous

nerve stimulator lead (thin yellow arrows) (Images from Elahi et al. [33]. Reprinted with permission from American Society of Interventional Pain Physicians)

patient with combat injury-related ilioinguinal damage [32], and Elahi et al. [33] described a peripheral nerve stimulator

placed under US guidance to treat ilioinguinal neuralgia after an inguinal herniorrhaphy (Fig. 44.17).

303 305 304 306

N. Murinova et al. 307

Surgical Technique

Summary

353

308

Ilioinguinal entrapment can cause abdominal pain, as seen in Chap. 40, as well as pelvic pain. The variable location of the ilioinguinal nerve and the variable pattern of sensation can make diagnosis difficult. Recognition of the ilioinguinal nerve as a cause of pelvic pain can save patients from unnecessary surgery.

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References

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Entrapment neuralgia arising from the ilioinguinal nerve is also often treated by the surgical release of the entrapped nerve. Entrapment neuralgia arising from the ilioinguinal nerve can be treated by the surgical release of the entrapped nerve. Kim et al. [6] were able to retrospectively review charts on 33 patients; 23 had ilioinguinal neuralgia, while 10 had combined ilioinguinal and iliohypogastric neuralgia. All had a positive preoperative local anesthetic injection; 30 of the 33 had “considerable” pain relief after surgical release. Zacest and colleagues [34] noted complete or partial pain relief in 13 of 19 (66.7 %) patients undergoing ilioinguinal nerve release, with a mean followup of 35 months. Hahn [35], in a crossover prospective study, randomized 19 women to medication management or surgical release of the ilioinguinal nerve. The surgery patients noted good relief. Nine of the ten women initially randomized to the medication arm discontinued the medications due to side effects; they were then offered surgery and also noted good relief. A prerequisite for any operation should be a positive result of a block with local anesthesia. Excision of the scar neuroma can give relief, but the neuroma is often difficult to localize. One technique that has been successful (Trescot, personal correspondence) is mixing local anesthetic with methylene blue. If the local anesthetic abolishes the pain, then the neuroma is within the dye tissue, and the surgeon is instructed to “take out everything blue.”

335

Complications

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Because proper performance of ilioinguinal/iliohypogastric blocks requires small volume injections, the possibility of local anesthetic toxicity is remote. Because the injection is limited to the lower abdominal wall and inguinal region, any hemodynamic changes would be unusual. As with other injections, the patient is advised to protect the anesthetized area from trauma. Even properly performed ilioinguinal/iliohypogastric blocks can result in transient femoral anesthesia, with a reported incidence of 3.7–5 % [36]. The mechanism of femoral anesthesia with these methods is the tracking of local anesthetic along the iliac fascia. Perforations of the bowels [37] and pelvic hematomas [38] have been reported after ilioinguinal/iliohypogastric blocks. This illustrates the importance of using blunt needles to appreciate the loss of resistance as the needle traverses the layers of the abdominal wall. Damage to the L1 nerve root can leave an abdominal wall weakness (Fig. 44.9).

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Author Queries Chapter No.: 44

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Please provide department name for Andrea M. Trescot.

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Please provide citation for Ref. [31].

AU3

Refs. [34] and [35], [14] and [24], and [5] and [13] were same based on the original manuscript. Since the duplicate references have been deleted and renumbered accordingly. Please check.

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