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16 Articles in Volume 19, Issue #2
Analgesics of the Future: Inside the Potential of Glial Cell Modulators
APPs as Leaders in Pain Management
Cases in Urine Drug Monitoring Interpretation: How to Stay in Control
Complex Chronic Pain Disorders
Efficacy of Chiropractic Care for Back Pain: A Clinical Summary
Hydrodissection for the Treatment of Abdominal Pain Caused by Post-Operative Adhesions
Letters: The Word "Catastrophizing;" AIPM Ceases Operations; Patient Questions
Management of Severe Radiculopathy in a Pregnant Patient
Managing Pain in Adults with Intellectual Disabilities
Pain in the Courtroom: An Excerpt
Q&A with Howard L. Fields: How Patients’ Expectations May Control Pain
Special Report: CGRP Monoclonal Antibodies for Chronic Migraine
The Management of Chronic Overlapping Pain Conditions
Vibration for Chronic Pain
What are the dangers of loperamide abuse?
When Patient Education Fails to Improve Outcomes: A Low Back Pain Case

Hydrodissection for the Treatment of Abdominal Pain Caused by Post-Operative Adhesions

In this case report, ultrasound-guided hydrodissection provided relief of painful abdominal adhesions that appeared after multiple breast surgeries.
Pages 53-55

Post-operative adhesions often lead to chronic debilitating pain after major abdominal surgery. It is estimated that intra-abdominal adhesions occur in at least 55% of women following pelvic or abdominal surgery, and the risk increases with each additional surgical procedure.1 Adhesions are fibrous tissue bands that form between structures (ie, tissue and organs) in the intra-abdominal cavity as a result of surgery, injury, or inflammation.2 It has been theorized that adhesions form from an imbalance between fibrinolytic and fibrin-forming activities in the peritoneum.3 Abdominal and pelvic adhesions may increase the risk of infertility, small bowel obstruction, and chronic pelvic pain due to loss of flexion, distortion or twisting of affected internal organs, and traction on the nerve endings that may become entrapped within a developing adhesion.1,4 Although the risk of adhesions and the potential adverse effects that may arise are well known to surgeons, it is not always included as part of informed consent.5

Laparoscopic exploration and adhesion lysis is a standard method used to remove painful abdominal adhesions, but like other surgical procedures, it is not always effective and may even lead to more adhesions.5,6 The process of hydrodissection, however, involves introducing saline and/or lidocaine under pressure to planes of dissection.2 Not only has hydrodissection been shown to successfully treat carpal tunnel syndrome, symptomatic sural neuromas, and ophthalmological procedures, but it has also been considered for preoperative therapy for removing adhesions.7,8

The aim of this case study is to introduce the efficacious use of hydrodissection as a method for treating abdominal pain due to post-operative adhesions in women. We introduce a female patient who presented with incapacitating pain after developing adhesions from a partially failed, bilateral transverse rectus abdominus musculocutaneous (TRAM) flap reconstruction, which was significantly relieved after six courses of treatment of hydrodissection.

In a TRAM flap breast reconstruction, the blood vessels of the flap remain attached to their original blood supply, and fat, blood vessels, and muscle from the abdomen are collectively transferred to the breast and anastomosed to either the thoracodorsal or internal mammary arteries.8,10

(Source: 123RF)

The Patient

A 53-year-old female with a history of breast cancer, presented for unremitting pain following a bilateral mastectomy and breast reconstruction, in addition to a revision of a TRAM flap reconstruction of her right breast, and five subsequent corrective surgeries to address post-operative complications. Of note, she also has a surgical history of spinal fusion in L5-S1 segments about 33 years prior with subsequent associated mild episodic pain.

As the respective post-operative recovery periods elapsed, she experienced steadily worsening abdominal pain, and limited range of motion of the trunk and upper extremities, particularly in her right shoulder. Over the course of the next three years, she visited various hospitals and clinics, trying numerous treatments in search of pain relief, including medications and supplements, physical therapy, dry needling, negative G treadmill, yoga, pilates, cupping, hot stones, whirlpools, and various manual therapies including visceral manipulation, myofascial release, chiropractic manipulation, Rolfing, deep tissue massage, and trigger point release. After trying myriad modalities to lessen her pain without success, she was referred to our outpatient clinic by her primary care physician for pain management.

Upon arriving for her initial appointment, she described suffering from crushing, “vice-like” pain in her abdomen and was experiencing severe muscle spasms throughout her trunk musculature. The patient had lost significant mobility, had become chronically short of breath, and had developed severe urge incontinence. She was a retired Air Force jet pilot, and had been an athlete, but at present, she reported limited ability across all activities of daily living (ADL), requiring additional time for dressing, bathing, and toileting.

Her right shoulder active range-of-motion was limited to 70 degrees of abduction and 80 degrees of flexion, while internal and external rotation remained full. She had several regions of firm, dense scar tissue that resisted translation in all planes, most notably along the right breast-line from the sternum to the mid-axillary line following the contour of the fifth rib; circumferentially around her umbilicus; and, one transverse running from one anterior superior iliac spine to the other.

Initiating Hydrodissection to Relieve Pain in Upper Right Chest

Given that the most pressing limitation was in her upper extremity range-of-motion, the decision was made to apply hydrodissection to the right breast incision. Before initiating treatment, a discussion of the procedure and possible risks were explained and consent was obtained.

The patient was placed in a supine position. Adhesions were identified with ultrasound guidance along her right breast tissue. Ten milliliters of 1% lidocaine were injected into the medial border of the adhesion with a 25-gauge needle, creating a bolus. This was followed by two minutes of manual scar mobilization, applying firm, deep pressure on the bolus in a medial to lateral fashion, forcing the fluid to further separate the fibers in the adhesion. This procedure was immediately repeated with another 10 milliliters of 1% lidocaine bolus into the lateral border of the scar, followed by scar mobilization with lateral to medial pressure. The injection sites were dressed with a bandage and she was discharged home uneventfully. This procedure was repeated six times, every two weeks for a total of 12 weeks, treating the right breast tissue with each treatment focused on the borders of a specific area of scar tissue in the region, namely the deep chest wall, superficial soft tissue, parasternal region, and axillary region.

Assessment of Treatment for Changes in Reported Pain and Mobility

After the first six rounds of ultrasound-guided hydrodissection to the adhesions around her right shoulder girdle and sternum, the patient’s upper extremity active range-of-motion increased to 170 degrees of flexion and abduction, and her functional limitations were dramatically improved. However, she continued to suffer from significant abdominal pain and felt as though she was “carrying a 16-pound bowling ball” in her abdomen. The hydrodissection procedure was repeated in the superficial and deep layers of fascia within the abdominal wall of the periumbilical region, and along the transverse scar from one anterior superior iliac spine to the other, progressively working on a different layer with each round, spaced every two to three weeks over an 11-month period. Images of the abdominal adhesions were captured before (see Figure 1) and after (see Figure 2) a round of hydrodissection and mobilization to demonstrate the process.

Figure 1. Transverse abdominal view with noted hyperechoic adhesions within the deep fascial layer (red arrow).

Figure 2. Tissue status post 2 minutes of manual scar mobilization. Note extension of bolus through previous adhesions (red circle)

After targeting every region of adhesion in the chest and abdominal walls, the patient no longer needed tramadol and was fully independent with all ADLs without any reported pain. Most significantly, since the end of the nearly year-long treatments, the patient was able to return to work, following completion of a rigorous training course to become a commercial cargo pilot. Residual symptoms included a feeling of fullness and tightness in the midline just beneath her umbilicus where the root of the TRAM flap is located and some occasional back pain if she sits for prolonged periods of time. However, these issues have been manageable, and have not impacted her daily mobility or ability to fly.

Review of Treatment Efficacy and Patient Satisfaction

With a growing awareness of patients suffering from extreme pain due to surgical adhesions, the need to provide safe and efficacious treatment has become a clinical imperative. To present, the only recognized potential surgical treatment for abdominal adhesions has been removal via laparoscopy.3 Whereas this option requires that patients undergo another surgical procedure, it raises the risk of resulting in more adhesions.

As such, trialing a non-surgical method with injected lidocaine to bring pain relief to patients with post-surgical adhesions was deemed successful. The application of ultrasound-guided hydrodissection enabled dissection of the adhesions in a minimally invasive way so as to avoid the risk of initiating additional adhesions in this patient. Of note, this case utilized 1% lidocaine as the medium for hydrodissection based on previous literature;2 however, other solutions such as bupivacaine or normal saline may be equally or more efficacious given the need to limit lidocaine to 20 milliliters per round due to the concern for cardiac toxicity.

Certainly, further research of this method with a larger number of participants in a randomized control trial would be a reasonable next step to more fully assess the benefits of ultrasound-guided hydrodissection as a pain-relieving treatment due to post-operative adhesions. This therapy is easy to apply in an outpatient setting and has the potential to significantly improve the quality of life for patients suffering from an otherwise debilitating pain condition.

Given the limited array of options for treating unremitting pain caused by post-surgical adhesions, the use of hydrodissection represents a possible method for pain practitioners to offer patients who present with abdominal pain unresponsive to traditional forms of pain relief.

Last updated on: April 12, 2019
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Analgesics of the Future: Inside the Potential of Glial Cell Modulators
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