Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

39 Patient with Groin Pain After a Lichtenstein…
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for cure. This includes a combination of nerve blocks and neuromodulating
medications and anti-inflammatories. If these provide short-term
success, they are continued with the goals of long-term success. In our
experience, most patients who respond to local injections require 3–5
cycles of nerve blocks and tend to have weeks to months of pain-free
episodes after each block as well as overall reduction in their pain score.
Only those that have short-term response but no long-term cure are
offered surgical options.
Nonoperative Management Options
I first offered the patient a diagnostic nerve block in the office, which
was performed with 0.5 % bupivacaine, injected medial and inferior to
the anterior superior iliac spine. This resulted in near-complete resolution
of the patient’s pain. Wiping the area clean after the injection
resulted in no pain. As per our protocol among patients with purely
neuropathic pain, if they respond positively to local nerve blocks, they
are offered serial blocks, no more than every 2 weeks, as their primary
mode of treatment. The therapeutic nerve blocks include steroids (10 mg
Kenalog). The patient indeed had a very clear improvement with the
blocks. These were continued and resulted in reduction of his pain such
that he was able to return to work, which involved sitting and standing.
The scrotal sensitivity resolved. He did have continued pain along his
groin and would even pass out at times due to the pain.
The patient already was under the care of a pain management specialist.
He did not tolerate duloxetine, due to rash, and did not tolerate gabapentin
due to its side effects. He was using Traumeel topically and 5 %
lidocaine patch with no major improvement in symptoms.
The patient did not wish to undergo an operation unless absolutely necessary.
After five cycles, the patient was agreeable to surgical exploration.
Operative Treatment
The patient was offered targeted ilioinguinal neurectomy. This was
performed in open fashion, anteriorly, with identification of the nerve as
it coursed anteriorly and just proximal to the lateral edge of the mesh.