Prolotherapy
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I examined a 45-year-old woman who underwent laparoscopic distal Pancreatectomy in 2015 and she has felt somatic pain from abdominal wall just after few hours the end of the procedure.
She was treated with TAP blocks and PENS therapy by another Pain Therapy Clinic. During the physical examination I couldn’t see any surgical scar in an area of 10 cm around the exact point indicated by the lady. I could appreciate a little (inferior of 1 cm) swelling in the abdominal wall, and, by using US I saw an inhomogeneities of 6 mm of muscular fibers of the left rectus abdominis muscle, but it wasn’t a cyst. I used a needle to inject local anesthetic inside this structure, I observed a different consistency from the other part of the muscle: pain decreased from 7 to 2 using NRS, but it completely returned the day after. In your opinion, could prolotherapy be useful?
Thank you very much. -
I don’t think so. I would recommend first examining the patient with gentle palpation comparing the left and right side. The painful side likely will have painful dysesthesia and is very likely related to a iliohypogastric nerve injury. You will find the nerve when you go from anterior medial to the anterior superior iliac spine. I use Cryo lesioning to treat this type of painful condition. First we usually do a nerve block, but you have done that. I have the patient for the Cryo therapy tense the abdomen, I then perforate the external oblique muscle going parallel to the iliac crest with sensory stimulation until I find the painful nerve. Once I have located the painful nerve, I perform a double Cryo lesion for 3 minutes followed by defrosting and refreezing for 3 minutes. Important to note is that the second lesion should not be painful. Defrost and advance the probe in the same space with sensory stimulation and find the second part of the nerve which should respond with a familiar pain. I then repeat the double lesioning as was done on the first part of the nerve. Otherwise, if it is not the iliohypogastric nerve you have to identify the painful nerve that is coming around between the muscle layers. Cryo lesioning for neuromas has also been very helpful. What you may have faced is likely to be a direct entrapment or actual nerve injury. Please let me know. If you do a google search you will find a couple of articles on iliohypogastric nerve Cryo lesioning. The advantage of Cryo lesioning is it is more cost effective and does not create neuritis.
Best of luck,
Dr. Gabor B. Racz
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Prolotherapy is a great treatment for ligament laxity/insufficiency. Very different patient. This sounds like nerve entrapment, as prof Gabor Racz explained above.
Neural prolo with D5 maybe an option. Some say it works. I have no experience with it.
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Gabor, could we use a perineural low dose of betamethasone or other steroid prior to cryo? Is that reasonable?
The articles in the literature that may also help guide therapy are by searching “ACNES” – anterior cutaneous nerve entrapment syndrome.
I do not personally like to say the word “entrapment” if I cannot prove a physical compression or friction syndrome, but that may help frame treatment options also.
Agnes, I have experience with D5W in dozens of patients and it seems to be less potent than low dose cortisone in my hands. But I do agree that is an option (and very popular in the pacific NW too it seems)
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Hello Frank, sorry for just noticing your question. I have been using Cryo for around 35 years now. Cryoneurolysis and injection of steroids is followed by pain usually overnight. One newly realized particular injectate in entrapment cases is hyaluronidase which reduces edema and pain. I think it would be of interest to collect your series and focus on the post procedure pain. Pretreat half of the patients with betamethasone, although I prefer triamcinolone, and the other half with a small diluted dose of hylenex (human recombinant hyaluronidase). More specific safety and pain treatment studies I’ve had favorable outcomes with the spinal canal use of hyaluronidase. Good luck!
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