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".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Thompson C, Goodman R, Rowe WA, et al. Abdominal wall syndrome: A costly diagnosis of exclusion (abstract). Gastroenterology 2001; 120:A637.
- Hershfield NB. The abdominal wall. A frequently overlooked source of abdominal pain. J Clin Gastroenterol 1992; 14:199.
- Applegate WV. Abdominal cutaneous nerve entrapment syndrome. Surgery 1972; 71:118.
- Greenbaum DS, Greenbaum RB, Joseph JG, Natale JE. Chronic abdominal wall pain. Diagnostic validity and costs. Dig Dis Sci 1994; 39:1935.
- Srinivasan R, Greenbaum DS. Chronic abdominal wall pain: a frequently overlooked problem. Practical approach to diagnosis and management. Am J Gastroenterol 2002; 97:824.
- Sharpstone D, Colin-Jones DG. Chronic, non-visceral abdominal pain. Gut 1994; 35:833.
- Costanza CD, Longstreth GF, Liu AL. Chronic abdominal wall pain: clinical features, health care costs, and long-term outcome. Clin Gastroenterol Hepatol 2004; 2:395.
- van Assen T, Brouns JA, Scheltinga MR, Roumen RM. Incidence of abdominal pain due to the anterior cutaneous nerve entrapment syndrome in an emergency department. Scand J Trauma Resusc Emerg Med 2015; 23:19.
- Thomson H, Francis DM. Abdominal-wall tenderness: A useful sign in the acute abdomen. Lancet 1977; 2:1053.
- Peleg R. Abdominal wall pain caused by cutaneous nerve entrapment in an adolescent girl taking oral contraceptive pills. J Adolesc Health 1999; 24:45.
- Peleg R, Gohar J, Koretz M, Peleg A. Abdominal wall pain in pregnant women caused by thoracic lateral cutaneous nerve entrapment. Eur J Obstet Gynecol Reprod Biol 1997; 74:169.
- Boelens OB, Scheltinga MR, Houterman S, Roumen RM. Randomized clinical trial of trigger point infiltration with lidocaine to diagnose anterior cutaneous nerve entrapment syndrome. Br J Surg 2013; 100:217.
- Carnett JB. Intercostal neuralgia as a cause of abdominal pain and tenderness. SGO Surg Gynecol Obstet 1926; 42:625.
- Takada T, Ikusaka M, Ohira Y, et al. Diagnostic usefulness of Carnett's test in psychogenic abdominal pain. Intern Med 2011; 50:213.
- McGrady EM, Marks RL. Treatment of abdominal nerve entrapment syndrome using a nerve stimulator. Ann R Coll Surg Engl 1988; 70:120.
- Gallegos NC, Hobsley M. Recognition and treatment of abdominal wall pain. J R Soc Med 1989; 82:343.
- Tung AS, Tenicela R, Giovanitti J. Rectus abdominis nerve entrapment syndrome. JAMA 1978; 240:738.
- Nazareno J, Ponich T, Gregor J. Long-term follow-up of trigger point injections for abdominal wall pain. Can J Gastroenterol 2005; 19:561.
- Skinner AV, Lauder GR. Rectus sheath block: successful use in the chronic pain management of pediatric abdominal wall pain. Paediatr Anaesth 2007; 17:1203.
- Thomson WH, Dawes RF, Carter SS. Abdominal wall tenderness: a useful sign in chronic abdominal pain. Br J Surg 1991; 78:223.
- Gray DW, Dixon JM, Seabrook G, Collin J. Is abdominal wall tenderness a useful sign in the diagnosis of non-specific abdominal pain? Ann R Coll Surg Engl 1988; 70:233.
- van Assen T, de Jager-Kievit JW, Scheltinga MR, Roumen RM. Chronic abdominal wall pain misdiagnosed as functional abdominal pain. J Am Board Fam Med 2013; 26:738.
- Hensen JH, Van Breda Vriesman AC, Puylaert JB. Abdominal wall endometriosis: clinical presentation and imaging features with emphasis on sonography. AJR Am J Roentgenol 2006; 186:616.
- Whitcomb DC, Martin SP, Schoen RE, Jho HD. Chronic abdominal pain caused by thoracic disc herniation. Am J Gastroenterol 1995; 90:835.
- Longstreth GF, Newcomer AD. Abdominal pain caused by diabetic radiculopathy. Ann Intern Med 1977; 86:166.
- Longstreth GF. Diabetic thoracic polyradiculopathy: ten patients with abdominal pain. Am J Gastroenterol 1997; 92:502.
- Streib EW, Sun SF, Paustian FF, et al. Diabetic thoracic radiculopathy: electrodiagnostic study. Muscle Nerve 1986; 9:548.
- Palmer E. Xyphoid cartilage syndrome (quoted in Calabro JJ. Costochondritis. N Engl J Med 1977; 296:946).
- The hypersensitive xiphoid. Lancet 1955; 2:1182.
- Scobie BA. Costochondral pain in gastroenterologic practice. N Engl J Med 1976; 295:1261.
- Heinz GJ, Zavala DC. Slipping rib syndrome. JAMA 1977; 237:794.
- Simpson C, Greenough WB 3rd. Abdominal pain in an elderly osteoporotic patient: ribs on pelvis syndrome. J Am Geriatr Soc 2004; 52:1039.
- Boelens OB, Scheltinga MR, Houterman S, Roumen RM. Management of anterior cutaneous nerve entrapment syndrome in a cohort of 139 patients. Ann Surg 2011; 254:1054.
- Koop H, Koprdova S, Schürmann C. Chronic Abdominal Wall Pain. Dtsch Arztebl Int 2016; 113:51.
- Devor M, Govrin-Lippmann R, Raber P. Corticosteroids suppress ectopic neural discharge originating in experimental neuromas. Pain 1985; 22:127.
- Bourne IH. Treatment of painful conditions of the abdominal wall with local injections. Practitioner 1980; 224:921.
- Mehta M, Ranger I. Persistent abdominal pain. Treatment by nerve block. Anaesthesia 1971; 26:330.
- Hahn L. Clinical findings and results of operative treatment in ilioinguinal nerve entrapment syndrome. Br J Obstet Gynaecol 1989; 96:1080.
- Oor JE, Ünlü Ç, Hazebroek EJ. A systematic review of the treatment for abdominal cutaneous nerve entrapment syndrome. Am J Surg 2016; 212:165.
- van Assen T, Boelens OB, van Eerten PV, et al. Long-term success rates after an anterior neurectomy in patients with an abdominal cutaneous nerve entrapment syndrome. Surgery 2015; 157:137.
- Boelens OB, van Assen T, Houterman S, et al. A double-blind, randomized, controlled trial on surgery for chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome. Ann Surg 2013; 257:845.
- 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