OBJECTIVE: This study compares tender point infiltration (TPI) and a tailored neurectomy as the preferred treatment for chronic inguinodynia after inguinal herniorraphy.
BACKGROUND: Some 11% of patients develop chronic discomfort after open inguinal herniorraphy. Both TPI and neurectomy have been suggested as treatment options, but evidence is conflicting.
METHODS: Patients with chronic neuropathic pain after primary Lichtenstein repair and >50% pain reduction after a diagnostic TPI were randomized for repeated TPI (combined Lidocaine/corticosteroids /hyaluronic acid injection) or for a neurectomy. Primary outcome was success (>50% pain reduction using Visual Analog Scale, VAS) after 6 months. Cross-over to neurectomy was offered if TPI was unsuccessful.
RESULTS: A total of 54 patients were randomized in a single center between January 2006 and October 2013. Baseline VAS was similar (TPI: 55, range 10-98 vs neurectomy: 53, range 18-82, P = 0.86). TPI was successful in 22% (n = 6), but a neurectomy was successful in 71% (n = 17, P = 0.001). After unsuccessful TPI, 19 patients crossed over to neurectomy and their median VAS score dropped from 60 to 14 (P = 0.001). No major complications after surgery were reported. Two-thirds of patients on worker's compensation returned to work.
CONCLUSION: A tailored neurectomy is 3 times more effective than tender point infiltration in chronic inguinodynia after anterior inguinal hernia mesh repair. A step up treatment stratagem starting with tender point infiltration followed by a tailored neurectomy is advised.
This is the first RCT to compare tender point infiltration (TPI) and neurectomy in patients with chronic inguinodynia after Lichtenste ininguinal herniorraphy and intitial TPI treatment. Although sample size is not enough, the treatment effect is large in neurectomy group. The results may provide the new therapeutic algorithm in future.