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Table of Contents
LETTER TO EDITOR
Year : 2021  |  Volume : 37  |  Issue : 1  |  Page : 124-125

Pulsed radiofrequency for chronic post-herniorrhaphy inguinal pain: A road less traveled


Department of Anaesthesia and Intensive care, Government Medical College and Hospital, Chandigarh, India

Date of Submission26-Feb-2020
Date of Acceptance06-Mar-2020
Date of Web Publication10-Apr-2021

Correspondence Address:
Dr. Sukanya Mitra
Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Sector 32, Chandigarh - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_90_20

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How to cite this article:
Mitra S, Singh J, Jain K, Jindal S. Pulsed radiofrequency for chronic post-herniorrhaphy inguinal pain: A road less traveled. J Anaesthesiol Clin Pharmacol 2021;37:124-5

How to cite this URL:
Mitra S, Singh J, Jain K, Jindal S. Pulsed radiofrequency for chronic post-herniorrhaphy inguinal pain: A road less traveled. J Anaesthesiol Clin Pharmacol [serial online] 2021 [cited 2021 Jun 25];37:124-5. Available from: https://www.joacp.org/text.asp?2021/37/1/124/313429

Dear Editor,

The development of chronic post-herniorrhaphy inguinal pain (CPIP) is a growing concern which impacts patient satisfaction, health care utilization and quality of life. Different treatment strategies have been proposed for chronic pain following inguinal hernia repair, though marred by the absence of a definitive appropriate management strategy in all patients.[1] Pulsed radiofrequency ablation (PRFA) is a novel therapeutic modality and we report two cases demonstrating its use in pain management.

A 68-year-old male patient, postoperative case of mesh hernioplasty was referred to a pain clinic after 4 months for persistent non-radiating groin pain (verbal categorical pain score 8/10), which increased on getting up from his bed, walking up the stairs, and starting his scooter. It was shooting in character and associated with altered sleep and appetite. He had no history of urinary retention. On examination, there was no local redness or edema. A well-healed fine scar mark was present with tenderness on deep palpation. The pain became refractory to oral diclofenac with serratiopeptidase combination after the initial response.

His pain score dropped to 4/10 with oral medications (pregabalin 150 mg bd, amitriptyline 50 mg hs, and tramadol-paracetamol combination tds). Although, the pain persisted on getting up from bed or while brisk walking. His pain scores further reduced to 2/10 with six injections of a combination of 4 mL of 0.25% bupivacaine with 20 mg of methylprednisolone in the groin area at 2-day intervals. The patient was pain-free for 6 months with marked improvement in sleep and appetite but following this period he had a recurrence of severe pain (6/10).

With his informed consent, PRFA of the ilioinguinal nerve (IIN) using the Cosman PRF machine (Cosman, MA, USA) was performed. The local point of tenderness was ascertained, and under complete asepsis, a 22-gauge 3.5-inch insulated radiofrequency needle was advanced under ultrasound guidance. The PRF probes were then inserted and sensory testing achieved at 0.5 mA. With the pulse setting, the probes were heated to 42°C for a total of 120 s, with current bursts of 20 ms.

The patient reported a marked decline in pain score to 2/10 after 2 weeks, with concomitant improvement in sleep, appetite, and daily functioning. He remained pain-free for a year, after which the procedure was repeated. Currently, he leads a gainful life.

The second case was of a 40-year-old male patient, factory worker dealing with heavy-weight equipment, referred to pain clinic 3 months after undergoing mesh hernioplasty, with persistent severe pain (verbal categorical pain score 9/10) with similar characteristics and adverse consequences as in case 1. The pain was refractory to conservative approaches including oral medications continued for 6 weeks followed by local injections of bupivacaine and methylprednisolone. He still was unable to ride his bike or continue work involving lifting heavy machines with a pain score of 5/10.

After discussion and obtaining informed consent, he was then subjected to PRFA of IIN using the same equipment and technique as mentioned above. His pain score came down significantly after a month and oral medications were tapered gradually over 2 months. He remained pain-free for 6 months, after which the second PRFA at pain score of 6/10 was repeated. His pain score dropped significantly after 2 weeks. Currently, he leads a gainful life but does feel a sensation of heaviness while lifting heavy machine parts.

PRF delivers high-intensity currents in pulses, allowing for heat (typically 42°C) to dissipate during the latent phase. Since the neurodestructive temperatures are not obtained, the risk of neuroma formation, neuritis-type reaction, and deafferentation pain are lowered. This mild heating of the nerve tissue is thought to temporarily block nerve conduction; however, the exact mechanism of analgesia is unclear. It may involve a temperature-independent pathway involving alterations in neural functioning mediated by a rapidly changing electrical field.[2] In addition, Wijayasinghe et al. demonstrated the role of peripheral afferents input in maintaining persistent pain in patients with CPIP.[3] Lee et al. also demonstrated that reduction of neuropathic pain after PRF stimulation applied proximal to the injured peripheral nerve may be associated with inhibition of the expression or anterograde transportation of TNF-α causing neuromodulation effects in an animal model study.[4]

PRFA has been reported rarely in CPIP [Table 1].
Table 1: Case reports or series illustrating use of PRFA in chronic ilioinguinal neuralgia including CPIP

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Further studies are required to firmly establish the efficacy and safety of PRFA for CPIP, especially for peripheral application, but our case reports emphasize the need for pursuing this line of approach for CPIP cases resistant to conventional treatment as a “road less traveled.”

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Andresen K, Rosenberg J. Management of chronic pain after hernia repair. J Pain Res 2018;11:675-81.  Back to cited text no. 1
    
2.
Rozen D, Parvez U. Pulsed radiofrequency of lumbar nerve roots for treatment of chronic inguinal herniorraphy pain. Pain Physician 2006;9:153-6.  Back to cited text no. 2
    
3.
Wijayasinghe N, Ringsted TK, Bischoff JM, Kehlet H, Werner MU. The role of peripheral afferents in persistent inguinal postherniorrhaphy pain: A randomized, double-blind, placebo-controlled, crossover trial of ultrasound-guided tender point blockade. Br J Anaesth 2016;116:829-37.  Back to cited text no. 3
    
4.
Lee JB, Byun JH, Choi IS, Kim Y, Lee JS. The effect of pulsed radiofrequency applied to the peripheral nerve in chronic constriction injury rat model. Ann Rehabil Med 2015;39:667-75.  Back to cited text no. 4
    
5.
Rozen D, Ahn J. Pulsed radiofrequency for the treatment of ilio-inguinal neuralgia after inguinal herniorrhaphy. Mt Sinai J Med 2006;73:716-8.  Back to cited text no. 5
    
6.
Makharita MY, Amr YM. Pulsed radiofrequency for chronic inguinal neuralgia. Pain Physician 2015;18:E147-55.  Back to cited text no. 6
    
7.
Cohen SP, Foster A. Pulsed radiofrequency as a treatment for groin pain and orchialgia. Urology 2003;61:645.  Back to cited text no. 7
    
8.
Mitra R, Zeighami A, Mackey S. Pulsed radiofrequency for the treatment of chronic ilioinguinal neuropathy. Hernia 2007;11:369-71.  Back to cited text no. 8
    



 
 
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