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6 Articles in this Series
Introduction
A Challenging Case of Postoperative Hyperalgesia
Are Serum Bupivacaine Levels a Concern During Postoperative Analgesia?
Postoperative Shoulder Pain: Which Analgesic Block Is Best?
TAP Block Could Help Diagnose Nerve Entrapment Syndrome
Ultrasound-Guided Injections for Pregnant Women with Sacroiliac Joint Pain
Using Intrathecal Patient-Controlled Analgesia in the Postop Setting: Case Report

TAP Block Could Help Diagnose Nerve Entrapment Syndrome

Interview with Sachin Jha, MD, MS

One common analgesic technique can help provide temporary relief of chronic abdominal wall pain, but also diagnose the source of the pain itself.

A new case study suggests anterior cutaneous nerve entrapment syndrome could be an overlooked etiology behind chronic abdominal wall pain. By treating a patient with transversus abdominus plane block (TAP), doctors could be able to confirm this diagnosis while providing analgesia to the patient.1

The case study was presented at this year’s annual meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA).1 The case involved a 73-year-old patient who was admitted to surgical service suffering from an acute exacerbation of chronic abdominal wall pain. The patient had a long history of abdominal surgeries, which had led doctors to suspect she was suffering from anterior cutaneous nerve entrapment syndrome.

“Scarring, fibrosis, herniation, and disruption of the abdominal wall have all been cited as risk factors that increase the incidence of anterior cutaneous nerve entrapment. Surgical manipulation can result in all of the previously aforementioned items occurring and one could suspect this likely led to or contributed to her condition,” said Sachin Jha, MD, MS, from the department of anesthesiology and perioperative medicine at the David Geffen School of Medicine at the University of California (UCLA).

While TAP blocks have been used before to manage acute postoperative pain in patients receiving surgery on their abdominal wall, it is not typically used to treat chronic abdominal wall pain.

“Our goal was to provide the patient with a diagnosis and it was important to distinguish the pain as being visceral in nature or from the actual abdominal wall. TAP blocks have traditionally been associated with relief of abdominal wall pain and can quickly and safely be performed at the bedside. Hence, it was trialed on her with a successful result,” Dr. Jha said.

The patient reported significant pain relief lasting about 24 hours, “which was a bit longer than typical TAP blocks last with a long acting local anesthetic,” Dr. Jha noted.

“She did notice a dramatic improvement in her pain after the TAP block was administered and was significantly more functional, being able to ambulate and breathe deeply without difficulty,” Dr. Jha said.

The patient had an extensive history of surgical interventions, including an open cholecystectomy, open appendectomy, partial right nephrectomy, total abdominal hysterectomy, exploratory laparotomy with lysis of adhesions 6 times, and ventral hernia repair with mesh 12 times.

According to Dr. Jha, the TAP only provided temporary pain relief for the patient, but it also served as a diagnostic tool for future treatment strategies.

“This is a patient who was admitted frequently over the past few years due to her pain being poorly characterized, was on a significant narcotic regimen with sub-optimal results, and was essentially without a distinct diagnosis. She also underwent additional surgical procedures in an attempt to better characterize her pain and unfortunately, this may have actually worsened the underlying pathology,” Dr Jha said.

“Thus, it is important to distinguish chronic abdominal pain as being visceral or associated with the abdominal wall. Interventional techniques, such as the TAP block, can be effective in reducing this patient's dependence on opioids and can improve her overall function. Perhaps, had these techniques been explored before, it may have resulted in significant cost savings by preventing readmission's or extra surgical procedures.”

According to Dr. Jha, repeating the TAP block with a steroid perhaps could have provided longer pain relief to the patient. “Further treatment strategies certainly can include chemical neurolysis, surgical neurectomy as well as radiofrequency ablation, spinal cord stimulation, intrathecal pump, or implanted epidural."

Reference

1. Jha S, Majidian S, Naim M, et al. Transversus abdominus plane block for the treatment of chronic abdominal wall pain. Poster presented at: Regional Anesthesiology and Acute Pain Medicine Meeting. April 6-8, 2017; San Francisco, CA. Poster 3169.

Next summary: Ultrasound-Guided Injections for Pregnant Women with Sacroiliac Joint Pain
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