Mechanism of pain:
(1) scar tissue compressing nerve
(2) suture or mesh material impinging on nerve
(3) interference with vascular supply to the nerve
Clinical features:
(1) history of surgical operation (this may be many years in the past)
(2) onset of pain after the operation
(3) pain is in the distribution of a nerve passing through the operative field
(4) relief of pain by placement of a 1% lidocaine nerve block
Management:
(1) Identify other possible causes for pain and treat.
(2) If the pain has lasted less than 6 months, manage the patient conservatively, optimizing medical management.
(3) If the pain persists then consider surgery along the course of the nerve to find and correct possible lesions. If no specific problem is identified then the nerve trunk proximal to the site of injury is excised and the nerve stump embedded in muscle. In many cases this brings rapid pain relief, but for some patients relief may take up to 2 months to occur.
(4) If surgery fails to relieve the pain then consider surgical ganglionectomy and/or optimized pain management.
The goal of management is complete relief of pain. Successful outcome was symptomatic relief in pain of at least 50%.
