Management of Chronic Post-Herniorrhaphy Pain: A Systematic Review

Abstract:

Background: Chronic post-herniorrhaphy inguinal pain (CPIP) is a significant complication following inguinal hernia repair, affecting 2-5% of patients with severe pain. The condition is characterized by persistent pain lasting more than 3 months and often involves neuropathic mechanisms caused by nerve damage or inflammatory responses. CPIP exerts a substantial impact on patients' quality of life, and the management of the condition remains controversial and challenging. Objectives: To evaluate recent literature on various interventions for treating chronic inguinal pain after inguinal hernia repair, including the outcomes thereof, and to suggest an evidence-based algorithmic approach to managing post-herniorrhaphy chronic pain. Study Design: Systematic literature review with qualitative data synthesis. Setting: Published studies from January 2012 to February 2023 of patients with chronic postherniorrhaphy inguinal pain. Methods: A systematic review was conducted under PRISMA guidelines, analyzing studies published throughout a period of 11 years and 2 months from the MEDLINE/PubMed and EMBASE databases. The review included randomized controlled trials, prospective and retrospective studies, case series, and case reports focusing on CPIP treatments. We collected the demographic data (gender, age), main etiologies, and specific treatments applied in each study. Based on the reviewed evidence, we propose an algorithmic approach to managing patients with CPIP. Results: The review incorporated 10 studies involving 152 patients, who were predominantly male (88.2%) with an average age of 49.7 years. Treatment approaches were classified into 3 main categories: nerve blocks or pulsed radio frequency, neurectomy, and neurostimulation/ablation techniques. Nerve blocks demonstrated the highest efficacy (up to 98.1% pain relief), followed by neurostimulation and ablation (approximately 92.8%). Neurectomy, though reported widely, showed variable success and higher invasiveness. Limitations: A publication bias might have been present due to the inclusion of studies published only in English. The included studies also had heterogeneous methodologies. Additionally, we excluded gray literature, which could have caused publication limitation. Conclusions: Despite significant advances in the understanding of CPIP, there remains no universally accepted treatment algorithm. Minimally invasive techniques, including nerve blocks, pulsed radio frequency, and neurostimulation, show promising results and should be prioritized before clinicians resort to such surgical interventions as neurectomy. This review highlights the need for multidisciplinary evaluation and proposes an evidence-based treatment algorithm to optimize CPIP management. (Summary); del Prado, Gema Ruiz Lopez (Author of contact); del Prado, Gema Ruiz Lopez, Pain Clinic, Hospital Sanitas La Moraleja, Madrid, Madrid, Spain; Ferreiro, Antonio, Department of Radiology, Universidad CEU San Pablo, Madrid, Spain; Avellanal, Martín, Pain Clinic, Hospital Sanitas La Moraleja, Madrid, Madrid, Spain (Authors with Filk)