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Anterior cutaneous nerve entrapment syndrome (ACNES)

Updated: Jul 23, 2022



Description:

Anterior cutaneous nerve entrapment syndrome is described as actually one of the most common chronic abdominal wall pain conditions and is often underdiagnosed.


Pathophysiology:

The cutaneous branches of sensory nerves from T7-T12 travel through channels in the abdominal wall fascia at the linea semilunaris and do a 90 degree turn to innervate the cutaneous surface of the abdomen


Usually this neurovascular bundle is protected by fat however in times of trauma, surgery, or idiopathic causes, the nerve can be entrapped causing significant discomfort across the abdominal wall


Risk factors:

  • Tight clothing

  • Belts

  • Increased abdominal pressure

  • Scarring

  • Obesity

  • Previous surgery

  • Women 4:1 Men

History features:

Patients often describe a fairly localised pain with tenderness within a small area of the abdominal wall

The pain is typically at the lateral edge of the rectus abdominis muscles and is more common on the R than the left (though the pain can be felt anywhere over the abdomen due to referral)

The pain is typically sharp in nature and worse with different postures and positions


Physical examination:

  • Palpation - Typical pressure with a Q-tip can show an area of max tenderness

  • Carnett's sign - Patient lifts their head and shoulders while you apply pressure over the area of pain on the abdomen. Tightening of the abdominal muscles can protect internal organs from palpation pressure whereas abdominal wall pathology will remain as tender as before, or worse.

Management:

Trigger point injections can be both a treatment and confirm diagnosis

It provides relief in 80-90% of patients

Injections can be repeated as required

Hydrodissection and steroidal thinning of connective tissue is thought to help

Chemical neurolysis and/or surgical neurolysis can be considered

Need to avoid stomach crunches and pressure on the area


Reference:



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