Chronic post-herniorrhaphy groin pain (CPGP)
Chronic post-herniorrhaphy groin pain (CPGP) is a common and debilitating condition that occurs with a prevalence of 15%–53% of patients undergoing inguinal hernia repair. It is associated with significant disability and is often refractory to conservative care. While the mechanism of CPGP neuropathic groin pain has not been defined, several theories exist and include direct intraoperative nerve injury, tension on the ilioinguinal and iliohypogastric nerves created by postsurgical changes, and an inflammatory reaction to implanted mesh. Independent risk factors for the development of CPGP included younger age (<40 years), body mass index greater than 25 kg/m2, and the use of a surgical propylene radomesh.
There are no specific guidelines on the treatment of CPGP but the European Federation of Neurological Societies (EFNS) recommends initial treatment with a neuropathic pain medication such as anticonvulsants (gabapentin and pregabalin) or the tricyclic antidepressants (amitriptyline, nortriptyline, etc.). When these medications fail, more aggressive interventions may be indicated.
The providers at Denver Back Pain Specialists (DBPS) specialize in both conservative treatment and advanced procedural interventions to treat CPGP. Dr. Drew Trainor has done extensive research on CPGP during his residency and fellowship at the Mayo Clinic in the department of Physical Medicine and Rehabilitation (PM&R) and department of Anesthesia- Pain Medicine Division.
The general approach taken by our providers is to start conservatively and work to more aggressive interventions if indicated. This includes the use of medications such as anticonvulsants, TCAs, and SNRIs. The use of non-steroidal anti-inflammatories, and even opioid-based medications can complement the affects of the neuropathic pain medications when appropriate. Behavioral health is an important part of the multi-modal treatment plan in any chronic pain condition. Denver Back Pain Specialists are fortunate to have Joy Simpson, MA, LPC as part of the team. Injections can be an effective treatment as well. Dr. Trainor uses ultrasound-guidance to precisely deliver the medication to the targeted location. Common injections in the treatment of CPGP include ilioinguinal/iliohypogastric or genitofemoral nerve and peripheral field blocks.
For patients who continue to have debilitating pain that does not response to medications, therapies, behavioral health, and injections, Dorsal Root Ganglion (DRG) spinal cord stimulation is a new and promising advanced intervention. It involves placing tiny electrical leads out of the appropriate neural foramen via epidural access. These leads are used to deliver energy to the DRG and effectively block the pain signal transmission at the DRG level. Recent studies have shown this to be an extremely effective treatment in patients with refractory CPGP.