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Ilioinguinal and iliohypogastric nerve blocks for the treatment of refractory neuropathic pain following cesarean delivery
Abstract Number: S-41
Abstract Type: Case Report/Case Series
Introduction: Nerve injury and the development of neuropathic pain are known complications of cesarean delivery, and the management of these painful conditions can be challenging in the postpartum setting. We present a case of intractable left lower abdominal pain following cesarean delivery, and discuss the use of ilioinguinal/iliohypogastric nerve blocks to provide immediate and sustained relief.
Case: 30year old G4P2 with obesity (BMI=45), chronic diabetes mellitus on insulin, and two prior cesarean deliveries presented in spontaneous labor. Following combined spinal-epidural anesthesia, patient underwent unremarkable repeat cesarean delivery via low-transverse Pfannenstiel incision. The epidural catheter was removed at the end of the surgery; however, shortly after arriving in the PACU patient began to complain of severe electric, shooting pain at the left margin of her surgical incision and upper left thigh. Despite receiving IV fentanyl and bilateral transversus abdominis plane (TAP) block, the patient continued to have excruciating pain. Ultimately, a new epidural catheter was placed to provide post-operative analgesia, and our patient remained comfortable overnight. However, upon briefly discontinuing her epidural infusion on post-operative day (POD) #1, she again developed severe neuropathic pain, and the epidural infusion was restarted. Symptoms were most consistent with iliohypogastric nerve entrapment. Gabapentin or pregabalin were recommended for her neuropathic pain, but the patient refused these medications as she desired to breastfeed the infant. The patient continued to require continuous epidural infusion for adequate analgesia. On POD #2, she underwent ultrasound-guided ilioinguinal and iliohypogastric nerve blocks (10cc of 0.25% bupivacaine + 4mg dexamethasone + 1:300,000 epinephrine) with immediate relief of her left abdominal and upper thigh pain. The epidural infusion was discontinued and patient was discharged home on oral analgesics on POD #4.
Discussion: Previous reports discussing the management of iliohypogastric nerve entrapment have focused largely on surgical approaches (i.e. either release or resection of the entrapped nerve) (1) or radiofrequency ablation, although case reports of single-shot ilioinguinal and iliohypogastric nerve blocks have been described following abdominal herniorrhaphy and other abdominal surgeries (2). This quick and technically-straightforward approach is attractive in parturients with suspected iliohypogastric or ilioinguinal nerve entrapment, particularly since many pharmacologic agents for the management of neuropathic pain are contraindicated in the post-partum setting.
1. Loos MJ et al. Surgical management of inguinal neuralgia after a low transverse Pfannenstiel incision. Ann Surg. 2008 Nov;248(5):880-5.
2. Thomassen et al. Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks for chronic pain after inguinal hernia repair. Hernia. 2013 Jun;17(3):329-32.