Home Medicine A new treatable chronic pain diagnosis? Flank pain caused by entrapment of posterior cutaneous branch of intercostal nerves, lateral ACNES coined LACNES
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A new treatable chronic pain diagnosis? Flank pain caused by entrapment of posterior cutaneous branch of intercostal nerves, lateral ACNES coined LACNES

  • Harald Breivik EMAIL logo and Audun Stubhaug
Published/Copyright: October 1, 2017
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 17 Issue 1

In this issue of the Scandinavian Journal of Pain Robbert Maatman, and his co-workers in The Netherlands publish their retrospective observational study on 21 women and 9 men presenting with flank pain in whom they were able to make a diagnosis of lateral cutaneous entrapment syndrome (LACNES) [1]. These authors have long experience diagnosing and treating chronic abdominal pain due to entrapment in the abdominal wall of terminal endings of intercostal nerves (ACNES, anterior abdominal cutaneous nerve entrapment syndrome) [2,3].

These syndromes occur only occasionally, many physicians and even pain specialists are not familiar with these entrapment phenomena and the pain they generate. Therefore these patients may suffer prolonged periods from undiagnosed abdominal or flank pain, often with a diagnosis of “idiopathic” pain, “functional” pain, or even “psychogenic” pain. Such diagnoses are just expressions of failure to find any somatic cause of the pain. Patients may often have the impression that the health care providers consider them to have “imagined” pain. They have been exposed to several failed treatments. They risk being prescribed opioid analgesics in increasing doses. This adds to the patients’ problems, risking opioid use disorder.

Specific ACNES characteristics include a small area (several square centimetres) of maximum pain, altered skin sensation covering this tender point, a positive “pinch test” and a positive Carnett’s test (increased local tenderness by tensing the abdominal muscles) [1]. It is interesting that these authors described a novel variant of ACNES associated with severe localized (lower) back pain, and it was found that posterior branches of the intercostal nerve were entrapped in the region of the thoracolumbar muscle group [2].

Similar to the procedure to diagnose ACNES, when LACNES is suspected because of a constant area of flank tenderness, a small area of maximal pain, and locally altered skin sensation, a specific localized point of pressure-generated intense pain, increases the likelihood of LACNES: Injection of a small amount of a local anaesthetic will confirm the diagnosis if the pain intensity decreases at least 50% [1]. Injections of a local anaesthetic caused prolonged or permanent pain relief in about 50% of the patients, and minimally invasive surgery to relieve the entrapped nerve was necessary in about 1/3 of the LACNES patients [1].

It is important that the surgical relief of an entrapped nerve is done as “atraumatically” as possible. Rough handling of the already damaged entrapped nerve can aggravate the nerve damage and the patient’s pain problem.

We recommend our readers to study this article from the surgeons in Veldhoven and the specialized Center of Excellence for Chronic Abdominal Wall and Groin Pain in Eindhoven, The Netherlands [1], as well as their recent publications on the more frequently occurring ACNES [3,4].

1 Why does local injections in ACNES and LACNES cause prolonged pain relief?

There is one great mystery in these optimistic reports of long- lasting or even permanent relief of ACNES or LACNES pain by injection of a small amount of lidocaine, or even only saline [1,2].

Patrick Wall in 1990 in his Editorial in the December issue of PAIN recommended highly [5] the study by the “Karolinska Pain Troika”, Staffan Arner, Ulf Lindblom, and Bjorn Meyerson, in addition to Carl Molander who reported prolonged relief of neuralgia after regional anaesthetic blocks [6]. Patrick Wall clearly was fascinated by their observations, especially of the puzzling finding that some patients reported that the pain returned after the anaesthetic block, but then a second phase of prolonged pain relief followed [6]. Patrick Wall strongly recommended more clinical research on the prolonged effect of the frequently performed local/regional injections, for which evidence of mechanisms of prolonged relief was lacking [5].

Patrick Wall and Clifford Woolf discussed this conundrum in Nature already in 1980: why can a blank injection cause analgesia? [7]. At that time, with the endorphins recently discovered, the hope was that somehow endorphins were mobilized; creating analgesia that in some circumstances could be reduced by injecting a large dose of naloxone. It is more complex than that, but we have to admit that even today “What we don’t know about pain” [7] is a huge “black box”. Clinical pain researchers should be busy for a long time to come.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2017.10.007.

Oslo University Hospital, Department of Pain Management and Research, Pbox 4956 Nydalen, 0424 Oslo, Norway

  1. Conflict of interest None declared.

References

[1] Maatman RC, Papen-Botterhuis NE, Scheltinga MRM, Roumen RMH. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): a previously unrecognized cause ofintractable flank pain. Scand J Pain 2017;17:211–7.Search in Google Scholar

[2] Boelens OB, Maatman RC, Scheltinga MR, van Laarhoven K, Roumen RM. Chronic localized back pain due to posterior cutaneous nerve entrapment syndrome (POCNES): a new diagnosis. Pain Phys 2017;20:E455–8.Search in Google Scholar

[3] Boelens OB, Scheltinga MR, Houterman S, Roumen RM. Randomized clinicaltrial oftrigger point infiltrationwith lidocaine to diagnose anteriorcutaneous nerve entrapment syndrome. Br J Surg 2013;100:217–21.Search in Google Scholar

[4] Boelens OB, van Assen T, Houterman S, Scheltinga MR, Roumen RM. A doubleblind, randomized, controlled trial on surgery for chronic abdominal pain due to anterior cutaneous nerveentrapment syndrome. Ann Surg 2013;257: 845–9.Search in Google Scholar

[5] Wall PD. Neuropathic pain. Pain 1990;43:287–8.Search in Google Scholar

[6] Arner S, Lindblom U, Meyerson BA, Molander C. Prolonged relief of neuralgia after regional anesthetic blocks. A call for further experimental and systematic clinical studies. Pain 1990;43:287–97.Search in Google Scholar

[7] Wall PD, Woolf CJ. What we don’t know about pain. Nature 1980;287:185–6.Search in Google Scholar
Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain

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https://doi.org/10.1016/j.sjpain.2017.10.006

Articles in the same Issue

  1. Observational study
  2. Perceived sleep deficit is a strong predictor of RLS in multisite pain – A population based study in middle aged females
  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
  5. Clinical pain research
  6. The Functional Barometer — An analysis of a self-assessment questionnaire with ICF-coding regarding functional/activity limitations and quality of life due to pain — Differences in age gender and origin of pain
  7. Clinical pain research
  8. Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain
  9. Observational study
  10. Chronic disruptive pain in emerging adults with and without chronic health conditions and the moderating role of psychiatric disorders: Evidence from a population-based cross-sectional survey in Canada
  11. Educational case report
  12. Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
  13. Clinical pain research
  14. Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain
  15. Observational study
  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
  17. Original experimental
  18. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic
  19. Topical review
  20. New evidence for a pain personality? A critical review of the last 120 years of pain and personality
  21. Clinical pain research
  22. A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain
  23. Clinical pain research
  24. Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome
  25. Observational study
  26. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy
  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
  29. Original experimental
  30. Quantitative sensory tests fairly reflect immediate effects of oxycodone in chronic low-back pain
  31. Editorial comment
  32. Spatial summation of pain and its meaning to patients
  33. Original experimental
  34. Effects of validating communication on recall during a pain-task in healthy participants
  35. Original experimental
  36. Comparison of spatial summation properties at different body sites
  37. Editorial comment
  38. Behavioural inhibition in the context of pain: Measurement and conceptual issues
  39. Clinical pain research
  40. A randomized study to evaluate the analgesic efficacy of a single dose of the TRPV1 antagonist mavatrep in patients with osteoarthritis
  41. Editorial comment
  42. Quantitative sensory tests (QST) are promising tests for clinical relevance of anti–nociceptive effects of new analgesic treatments
  43. Educational case report
  44. Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl
  45. Editorial comment
  46. Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations
  47. Editorial comment
  48. Opioids in chronic pain – Primum non nocere
  49. Editorial comment
  50. Finally a promising analgesic signal in a long-awaited new class of drugs: TRPV1 antagonist mavatrep in patients with osteoarthritis (OA)
  51. Observational study
  52. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain
  53. Clinical pain research
  54. Opioid tapering in patients with prescription opioid use disorder: A retrospective study
  55. Editorial comment
  56. Sleep, widespread pain and restless legs — What is the connection?
  57. Editorial comment
  58. Broadening the fear-avoidance model of chronic pain?
  59. Observational study
  60. Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic
  61. Editorial comment
  62. The burden of central anticholinergic drugs increases pain and cognitive dysfunction. More knowledge about drug-interactions needed
  63. Editorial comment
  64. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities
  65. Editorial comment
  66. Why can multimodal, multidisciplinary pain clinics not help all chronic pain patients?
  67. Topical review
  68. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics
  69. Editorial comment
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  71. Clinical pain research
  72. PhKv a toxin isolated from the spider venom induces antinociception by inhibition of cholinesterase activating cholinergic system
  73. Clinical pain research
  74. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain
  75. Editorial comment
  76. Towards a structured examination of contextual flexibility in persistent pain
  77. Clinical pain research
  78. Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance
  79. Editorial comment
  80. Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
  81. Editorial comment
  82. Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation
  83. Editorial comment
  84. A glimpse into a neglected population – Emerging adults
  85. Observational study
  86. Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
  87. Clinical pain research
  88. Randomized, double-blind, placebo-controlled, dose-escalation study: Investigation of the safety, pharmacokinetics, and antihyperalgesic activity of L-4-chlorokynurenine in healthy volunteers
  89. Clinical pain research
  90. Prevalence and characteristics of chronic pain: Experience of Niger
  91. Observational study
  92. The use of rapid onset fentanyl in children and young people for breakthrough cancer pain
  93. Original experimental
  94. Acid-induced experimental muscle pain and hyperalgesia with single and repeated infusion in human forearm
  95. Original experimental
  96. Swearing as a response to pain: A cross-cultural comparison of British and Japanese participants
  97. Clinical pain research
  98. The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy
  99. Clinical pain research
  100. Central sensitization associated with low fetal hemoglobin levels in adults with sickle cell anemia
  101. Topical review
  102. Targeting cytokines for treatment of neuropathic pain
  103. Original experimental
  104. What constitutes back pain flare? A cross sectional survey of individuals with low back pain
  105. Original experimental
  106. Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
  107. Clinical pain research
  108. Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?
  109. Original experimental
  110. The impact of the Standard American Diet in rats: Effects on behavior, physiology and recovery from inflammatory injury
  111. Educational case report
  112. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series
  113. Original experimental
  114. Hyperbaric oxygenation alleviates chronic constriction injury (CCI)-induced neuropathic pain and inhibits GABAergic neuron apoptosis in the spinal cord
  115. Observational study
  116. Predictors of chronic neuropathic pain after scoliosis surgery in children
  117. Clinical pain research
  118. Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
  119. Clinical pain research
  120. A novel miniature, wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study
  121. Clinical pain research
  122. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending
  123. Original experimental
  124. Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
  125. Original experimental
  126. Initial validation of the exercise chronic pain acceptance questionnaire
  127. Clinical pain research
  128. Exploring patient experiences of a pain management centre: A qualitative study
  129. Clinical pain research
  130. Narratives of life with long-term low back pain: A follow up interview study
  131. Observational study
  132. Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption
  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
  135. Original experimental
  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
  137. Observational study
  138. Impact of analgesics on executive function and memory in the Alzheimer’s Disease Neuroimaging Initiative Database
  139. Clinical pain research
  140. Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
  141. Original experimental
  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
  143. Topical review
  144. Psychoneuroimmunological approach to gastrointestinal related pain
  145. Letter to the Editor
  146. Do we need an updated definition of pain?
  147. Narrative review
  148. Is acetaminophen safe in pregnancy?
  149. Book Review
  150. Physical Diagnosis of Pain
  151. Book Review
  152. Advances in Anesthesia
  153. Book Review
  154. Atlas of Pain Management Injection Techniques
  155. Book Review
  156. Sedation: A Guide to Patient Management
  157. Book Review
  158. Basics of Anesthesia
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