Anterior cutaneous nerve entrapment syndrome
- George W Meyer, MD, MACP, MACG
George W Meyer, MD, MACP, MACG
- Clinical Professor of Medicine
- University of California Davis, School of Medicine
Chronic pain emanating from the abdominal wall is frequently unrecognized or confused with visceral pain, often leading to extensive diagnostic testing before an accurate diagnosis is established [1-7]. Anterior cutaneous nerve entrapment syndrome is one of the most frequent causes of chronic abdominal wall pain. The diagnosis is suspected based on history and physical examination. Injection of a local anesthetic agent and a long-acting corticosteroid is effective for most patients, and can help to confirm the diagnosis.
This topic review will review the clinical manifestations, diagnosis, and management of anterior cutaneous nerve entrapment syndrome. Other causes of abdominal pain and the evaluation of patients with abdominal pain are discussed in detail, separately. (See "Causes of abdominal pain in adults" and "Evaluation of the adult with abdominal pain".)
The estimated incidence of abdominal wall pain is 1 in 1800 individuals . In one retrospective study, 2 percent of patients who presented to the emergency room for evaluation of abdominal wall pain had anterior cutaneous nerve entrapment syndrome . Among patients with abdominal pain and a negative prior diagnostic evaluation, the prevalence of abdominal wall pain ranges from 15 to 30 percent [5,9]. Women appear to be four times more likely to have anterior cutaneous nerve entrapment syndrome as compared with men. The peak incidence is between the ages of 30 to 50 years, although cases have been reported in children and the elderly.
Anterior cutaneous nerve entrapment syndrome is caused by entrapment of the cutaneous branches of sensory nerves supplying the abdominal wall . The cutaneous branches of sensory nerves arising from T7 to T12 make a 90-degree angle as they progress anteriorly through the posterior rectus sheath, passing through a fibrous ring within the lateral border of the rectus abdominis medial to the linea semilunaris. Once the nerves reach the overlying aponeurosis, the nerves divide again at 90-degree angles beneath the skin. Normally, fat in the neurovascular bundle permits the nerve to slide unimpeded within the fibrous ring . Entrapment of the nerve can be caused by intra- or extra-abdominal pressure, ischemia, compression by herniation of the fat pad that normally protects it into the fibrous canal surrounding the nerve, or localized scarring. Other mechanical causes of nerve compression such as obesity and tight clothing may also be important in individual cases. Oral contraceptives and pregnancy have been associated with exacerbation of entrapment syndromes, possibly due to tissue edema from estrogen and progesterone [10,11]. (See "Anatomy of the abdominal wall".)
Pain can usually be localized to a highly discrete region of the abdomen. This can be explained by the characteristics of the nerves causing the pain. There are two kinds of pain receptors: A-delta and C nociceptors. The A-delta nociceptors, comprising up to 25 percent of nociceptors, are found in skin and muscle, and mediate the sharp, sudden pain that is associated with injury such as a cut, trauma, or pain in the abdominal wall. The C type nociceptor (approximately 50 percent of nociceptors) innervates periosteum, parietal peritoneum, and viscera and mediates the dull, difficult to localize pain of intraperitoneal disease. With most causes of intraabdominal pain, localization is therefore difficult and the patient often waves the hand over a relatively wide area of the abdomen. In contrast, when the pain is in the abdominal wall and, therefore, mediated by A-delta nociceptors, the patient usually points to the location with one finger. (See "Causes of abdominal pain in adults".)
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- CLINICAL FEATURES
- DIAGNOSTIC APPROACH
- Physical examination
- Red flags for additional evaluation
- Trigger point injection
- DIFFERENTIAL DIAGNOSIS
- Overall approach
- Conservative therapy
- Anesthetic, glucocorticoid injection
- - Technique
- Chemical neurolysis
- Surgical treatment
- Other therapies
- SUMMARY AND RECOMMENDATIONS