Pain Physician 2012; 15:237-244 • ISSN 1533-3159

Retrospective Study

Radiofrequency Neurolysis Versus Local Nerve

Infiltration in 42 Patients with Refractory
Chronic Inguinal Neuralgia

Adrian Kastler, MD1,3, Sebastien Aubry, MD, PhD2,3, Veronique Piccand, MD4,
Georges Hadjidekov, MD2, Florence Tiberghien, MD4, and Bruno Kastler, MD, PhD2,3

Background: Chronic inguinal neuralgia involving ilioinguinal and iliohypogastric nerves is a

From: 1Radiology Department
frequent complication of surgical procedures involving a lower abdominal incision such as hernia
CHU Gabriel Montpied, repair, appendicitis surgery, or cesarean sections. Chronic inguinal neuralgia is a very painful condition
Clermont-Ferrand, France; and diagnosis can be challenging as it is an overlooked impairment. Existing specific treatments are
2
Interventional Pain inefficient and often fail.
Management Unit, CHU Jean
Minjoz. Besancon, France;
3
I4S Laboratory, IFR 133 UA Objective: The purposes of this study are to describe, evaluate, and compare ilioinguinal and
4268 Franche Comté Univerity iliohypogastric radiofrequency neurolysis (RFN) and local injection.
Besançcon, France; 4Pain
Evaluation and Treatment Study Design: Retrospective comparison cohort study from 2005 to 2011.
Unit, CHU Jean Minjoz.
Besancon, France.
Setting: A single center, Academic Interventional Pain Management Unit
Address correspondence:
Adrian Kastler, MD Methods: Forty-two patients suffering from chronic inguinal pain refractory to specific medication
Hôpital Jean Minjoz
CHU Besançon were included. A total of 18 RFN procedures (14 patients) and 28 injections (28 patients) were
Bvd Fleming performed. Pain was assessed in both groups using Visual Analog Scale (VAS) scores (0-10)
25000 Besançon, Francee measured immediately before and after the procedure and at one, 3, 6, 9, and 12 months after
E-mail: adriankastler@gmail. the procedure. Mean duration of pain prior to the procedure and mean duration of pain relief were
com
noted. Moreover, mean maximum early pain relief was assessed. All procedures were ambulatory
under computed tomography (CT) guidance. Injections contained 1.5 mL of cortivazol and 3 mL of
Disclaimer: There was lidocaine-ropivacaine (30%-70%). Radiofrequency neurolysis was performed using a Neurotherm
no external funding in RF Generator. In both cases, 22-gauge needles were used. After needle retrieval, control slices were
the preparation of this
taken and the patient was supervised for 30 minutes at the CT unit.
manuscript.
Conflict of interest: None.
Results: The mean age in both groups was 48.7 years. Forty-two patients (97.6%) presented
Manuscript received: postsurgical inguinal pain, 62% of which occurred after hernia repair. All included patients had
05/31/2011 undergone previously unsuccessful pain therapies. Mean VAS scores were 7.72 in the RF group and
Revised manuscript received:
01/07/2012 7.46 in the infiltration group. Maximum early pain relief did not statistically differ (77% in the RFN
Accepted for publication: group and 81.5% in the injection group). Mean duration of pain relief was statistically significant
02/09/2012 (P = .005) in the RF group (12.5 months) compared to the infilitration group (1.6 months). Mean
VAS scores during the year following the procedure were all significantly in favor of radiofrequency
Free full manuscript:
www.painphysicianjournal. neurolysis management.
com
Limitations: Those inherent to small study samples and retrospective studies.

Conclusion: Radiofrequency neurolysis appears to be significantly more effective than local nerve
infiltrations. It is a safe and effective treatment for chronic inguinal pain. Local steroid injection along
with local injection of anesthetics should be used as a confirmation of ilioinguinal neuropathy before
performing radiofrequency neurolysis.

Key words: Radiofrequency, Ilioinguinal, Iliohypogastric, neuropathy, infiltration, computed

tomography guidance.

Pain Physician 2012; 15:237-244

www.painphysicianjournal.com
 Pain Physician: May/June 2012; 15:237-244

C hronic inguinal neuralgia involving ilioinguinal

and iliohypogastric nerves is a very painful
condition with a high socioeconomic impact
(1-4). It is a well-known complication of surgical
procedures involving a lower abdominal incision
was tried. In some cases, topical antineuralgics were
used. Local Institutional Review Board approval was
obtained. The data were collected from patients’ medi-
cal records and included information on demographics,
clinical, and pain management history.
(1,2,5,6). The diagnosis of these neuralgias can be
challenging and existing conservative treatments often Pain
fail. Ilioinguinal and iliohypogastric nerve blocks are Pain was assessed using Visual Analog Scale scores
well described in the literature and are often used in (0-10) measured immediately before and after the pro-
pediatric surgery (7). Local infiltration of anesthetics cedure and at one, 3, 6, 9 and 12 month follow-up ex-
and steroids is widely used in pain management and aminations. Mean maximum early pain relief and mean
has been described in this indication with satisfactory duration of pain prior to the procedure were assessed
results (8). Moreover, radiofrequency neurolysis (RFN) in both groups. Pain was defined as chronic when it
has become a common procedure in interventional lasted for at least 6 months. A score of less than 2 was
pain management. We therefore studied the efficacy, graded as mild pain, a score between 2 and 5 was grad-
safety, and feasibility of both local nerve infiltration ed as moderate pain, and a score above 5 was graded
and RFN for the management of chronic ilioinguinal as severe pain (9). Pain distribution and etiology were
and iliohypogastric pain. The purposes of this study are also noted.
to describe, evaluate, and compare these 2 treatments.
Procedure
Methods All procedures were accomplished on an outpa-
Forty-two patients suffering from chronic ingui- tient basis by one of several authors (AK, SA, BK) with
nal pain were included in this single center retrospec- computed tomography (CT) guidance (Philips Brilliance
tive study from 2005 to 2011. Only patients who had CT 64-channel scanner, Eindhoven, The Netherlands,
failed specific neuropathic oral therapy were included and Siemens Somatom Sensation CT 64-channel scan-
in the study. The same treatment algorithm was always ner, Erlangen, Germany). An initial planning CT was
followed prior to the procedure: antiepileptic drug performed at the level of the anterior superior iliac
therapy was the first line treatment; in case of failure, spine and the target was located between the trans-
tricyclc antidepressant therapy was introduced. In case verse abdominal muscle and the lesser oblique muscle
of failure of either treatments, a combination of both (Fig. 1). After accurate marking of the skin, local subcu-

Fig. 1. Planning axial CT scan showing target location prior to needle insertion. Black arrow : transverse abdominal muscle.
White arrows : internal oblique muscle. Arrowhead: ilioinguinal-iliohypogastric nerves

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 Management of Inguinal Neuralgia: Radiofrequency Versus Infiltration

taneous infiltration of lidocaine hydrochloride 1% was For steroid injection, diluted iodinated contrast
performed at the defined skin entry point. A safe step- media was injected first in order to control accurate
by-step progression of the needle (22-gauge) was per- needle positioning. Once the contrast media diffused
formed under CT guidance until the needle tip artifact between the transverse abdominal muscle and the less-
was located at the defined target (Fig. 2). er oblique muscle (Fig. 3), a mixture of fast and slow

Fig. 2. CT slice showing needle tip artifact (black circle) at defined target.

Fig. 3. CT slice after injection of contrast media (arrowhead) at defined target.

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 Pain Physician: May/June 2012; 15:237-244

acting anesthetic (1 mL lidocaine hydrochloride 1% and RFN procedures and 28 local nerve infiltrations were
2 mL ropivacaine chlorhydrate were injected followed performed. The mean duration of the RFN procedures
by 1.5 mL of cortivazol [3.75 mg]). was 25.4 minutes (range 19 - 33 minutes). No side ef-
One of 2 radiofrequency (RF) generators was used fects were noted.
for RFN (RF 3FG, Radionics, Burlington, NJ and NT1100
RF Generator Neurotherm, Wilmington, MA). Once the Pain
RF needle tip artifact was located at the defined tar- The patients’ description of pain included elec-
get (Fig. 2) (22-gauge, 50-100 mm, 5 mm exposed tip), tric sensation (85%), hypoesthesia (32%), allodynia
stimulation mode was used to obtain the exact needle (14%), stabbing (24%) or irritation (10%). In 62% of
position immediately adjacent to the nerve. The needle cases, pain consisted of paroxysmal attacks of short,
orientation could be modified until the patient de- sharp pain superimposed on a dull background of
scribed a tingling sensation in the painful territory. This pain that was responsible for multiple nights of inter-
was considered as a technical success for the needle po- rupted sleep. Painful regions, as shown in Fig. 4, were
sitioning. One mL of lidocaine hydrochloride 1% was the lateral cutaneous branch of the iliohypogastric
then injected before RFN was started. Three 90 second nerve, 11 cases; inguinal region, 13 cases; scrotal re-
RF cycles were performed in lesion mode at 70°C, 80°C, gion, 6 cases; lateral cutaneous branch and inguinal
and 90°C. After needle retrieval, a control axial CT scan regions, 7 cases; and inguinal and scrotal regions, 5
was performed and the patient was supervised for 30 cases.
minutes at the CT Unit. Pain was present for an average of 2.8 years (range
2 – 5 years) prior to the initial procedure with a mean
Results VAS score of 7.6/10 and was therefore classified as se-
vere. Mean VAS scores were 7.72 in the RF group and
Patients 7.46 in the infiltration group. Immediate pain relief was
A total of 42 patients were included in our study:
14 in the RFN group and 28 in the infiltration group.
The mean age in the whole population was 48.7 years:
43.9 years in the RFN group and 49.5 years in the infil-
tration group. All but one patient (97.6%) presented
with postsurgical-induced chronic inguinal pain and
62% of patients presented with pain after hernia re-
pair. The etiologies of inguinal neuralgia are detailed
in Table 1. The local pain management unit referred
90% of the patients, surgeons referred 7%, and general
practitioners referred 2.5%.
Three patients in the RF group benefited from re-
peated RFN because of satisfactory initial results (2 RFN
in 2 patients and 3 RFN in one patient). As a result, 18

Table 1. Etiologies of inguinal neuralgia.

ETIOLOGY PATIENTS
Hernia Repair 19 (46.4%)
Multiple Hernia Repair 6 (14.3%)
Fig. 4. Anatomical routes of both ilioinguinal (white arrow)
Testicular Surgery 5 (12.2%) and iliohypogastric (black arrow) nerves and their regions of
Gynecological Surgery 5 (12.2%) distribution.
Blue: Common to both nerves
Appendicitis Surgery 3 (7.3%) * Light : Inguinal region
Other Surgery 2 (4.9%) * Dark : Scrotal region
Green: Lateral cutaneous branch (black arrowhead) of
Testicular and Hernia Surgery 1 (2.4%) iliohypogastric nerve distributing in upper and lateral part
Trauma 1 (2.4%) of thigh.

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 Management of Inguinal Neuralgia: Radiofrequency Versus Infiltration

≥ 95% in all patients, thereby confirming the diagno- Fig. 5 for both groups. Two patients treated with RFN
sis. Technical success rate was 100%. Mean maximum had long-term (> 36 months) pain relief and treatment
early pain relief did not statistically differ between the was therefore considered definitive. We report only
2 techniques (RF group, 77%; infiltration group, 81.5%; one failure of RFN, lasting for 15 days. Important pain
P = 0.54). reduction (≥ 80%) was obtained in 72% of RFN proce-
In the RF group, mean duration of pain relief (12.5 dures (13/18) at 6 months follow-up and in 44% of cases
months) was significantly higher (P = 0.005) than in the at 12 months (8/18).
infiltration group (1.6 months). VAS scores at one, 3, 6, In the infiltration group, mean duration of pain
9, and 12 month follow-up examinations were statisti- relief was 1.6 months and ranged from 3 hours to 12
cally inferior for those in the infiltration group (Table months. We report 7 cases of pain relief lasting for one
2). The evolution of mean VAS scores is represented in day or less.

Table 2. VAS scores at one, 3, 6, 9 and 12 months

Mean VAS Scores (/10) Mean

Mean Maximum
Before duration
M1 M3 M6 M9 M12 Early Pain Relief
procedure (months)
RF Group 7.72 1.4 1.6 1.7 4.0 4.8 12.5 77%
Infiltration Group 7.46 4.8 6.1 6.5 6.9 6.9 1.6 81.5%
t-test P = 0.273 P <0.001 P < 0.001 P <0.001 P = 0.004 P = 0.021 P = 0.005 P = 0.54

Fig. 5. Evolution of mean VAS scores in both groups during the 12 months following procedure.

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 Pain Physician: May/June 2012; 15:237-244

Discussion
Our study showed significantly longer lasting pain lower abdominal incision. Our study showed that 97.5%
relief after RFN compared to local nerve infiltration in of the included patients had postsurgical inguinal neu-
patients with refractory inguinal neuralgia. Indeed, a ralgia and that 62% followed hernia repair. Reports of
mean pain reduction of 12.5 months was obtained with inguinal neuralgia rates from open mesh hernia surgery
a mean maximum early pain relief of 77%. Only one range from 10% to 25%, especially when a Pfannenstiel
patient was a failure in the RFN group. This patient was incision is performed (1,2,5). Five patients (12.2%) {this
the first to undergo RFN in our center, and we there- percentage would be based on 41 patients, not 42}in
fore think that the failure of this RFN is partly explained this study presented postgynecological surgery neural-
by our lack of expertise in this first procedure. A previ- gia. The literature reports complication rates of 1.8%
ous study showed satisfactory pain reduction in 75% of especially after caesarian section (6). Other nonsurgical
patients treated with 4 to 5 repeated local infiltrations etiologies are described in the literature: local com-
(8). However, no details were given about long-term pression mechanisms secondary to tight clothing (e.g.,
results. Moreover, satisfactory long-term results were belts and weapon holsters), obesity (13) and pregnancy.
obtained in all but one patient with one minimally Chronic inguinal pain is also described secondary to
invasive procedure. Even though mean pain relief du- muscular trauma or tears of the lower abdominal mus-
ration after local infiltration (1.6 months) appeared cles in athletes (14,15). Finally, lumbar spinal disorders
significantly inferior to RFN in our study, it remains use- by compression mechanisms at the emerging L1 root
ful as a block test for diagnosis and may furthermore are also described in inguinal neuropathic pain. In our
induce beneficial short- to mid-term pain relief (up to study only one patient presented nonsurgical inguinal
12 months). We therefore always perform a diagnostic neuropathy (posttraumatic).
block with a local infiltration of steroids prior to RFN in Existing treatments for inguinal neuralgia are quite
our institution to establish the diagnosis and rule out limited and have fair results at best. Specific oral medi-
central pain. Patients are re-evaluated and RFN is per- cations, including anti-inflammatory and neuropathic
formed in case of pain recurrence only after a positive treatments, are faced with the difficulties of neuro-
initial diagnostic block test . pathic pain management, which is a common problem
Anatomical knowledge of the ilioinguinal and ilio- in medical care (16).
hypogastric nerves is a necessary condition to success- Blockades of these nerves are commonly performed
ful image-guided inguinal RFN or infiltrations (Fig. 5). in pediatric surgery (7). It is established that the use of
Both the ilioinguinal and iliohypogastric nerves arise imaging guided techniques has increased the success
from the L1 root (common trunk in 35% of cases). Their rate of ilioinguinal and iliohypogastric nerve blocks
course is quite similar. They descend on the quadratus (7,17,18). This is particularly true with RF procedures,
lumborum muscle along the parietal peritoneum, per- as precise needle location immediately adjacent to the
forate the transverse abdominal muscle, and course be- nerve is mandatory to ensure the success of the proce-
tween the transverse abdominal muscle on the inside dure. Indeed, the thermoablation radius at the tip of
and the lesser oblique on the outside at the level of the needle is quite small (1-2 mm) (19,20) and therefore
the anterior superior iliac spine. The iliohypogastric the conventional blind technique used in nerve block-
nerve has a branch called the lateral cutaneous branch ades is insufficient (17). In our study we used CT guid-
at this level that distributes in the upper lateral part ance because of the experience and expertise acquired
of the thigh. Both the ilioinguinal and iliohypogastric with this guidance technique in our unit. However, we
nerves then pass along the inguinal canal to become think that both local nerve infiltrations and RFN could
subcutaneous in their territories of distribution (ingui- also be completed under ultrasound guidance (Fig. 6),
nal, groin, scrotal region, and upper medial part of the as is the case with inguinal blockades (7,17,18). Recent
thigh). Numerous anatomical variants are described in interventional pain management techniques include
the literature (up to 60%) (10,11) but these variations cryoablation and RFN. Cryoablation seems promising
mainly concern the penetrating site of the muscle layers but only a few studies exist in the literature (13,21) and
(12). The distributions of the 2 nerves are quite constant no information on long-term results is available. RFN
and overlapping. has become a specialized technique commonly used in
Because of the superficial nature of these nerves, interventional pain management but to our knowledge
they are often injured in surgical procedures involving a has never been described for this indication with im-

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 Management of Inguinal Neuralgia: Radiofrequency Versus Infiltration

Fig. 6. Ultrasound picture taken at level of anterior superior iliac spine (black arrow head) showing the 3 layers of abdominal
wall. Blue: External oblique muscle . Green: Internal oblique Muscle. Pink: Transverse abdominal muscle. Peritoneum appears
as a hyperechoic ligne (black arrow). Ilioinguinal and iliohypogastric nerves (white arrow) are seen between internal oblique
and transverse abdominal muscles. Hypothetic needle pathway is shown on figure to the right.

aging guidance. A case report describing RF manage- plained by anatomical variability which makes it dif-
ment of inguinal neuralgia showed satisfactory results ficult for surgeons to identify ilioinguinal and iliohy-
at the 3-month follow-up examination (22). Another pogastric nerves (32). On the other hand, re-operative
study that included 5 cases of RFN at the L1 origin of neurectomy seem to have satisfactory results (60% to
the nerve reported satisfactory results, lasting from 4 80% success rates) (33,34), but it remains an invasive
to 5 months (23). In these reports, no imaging guidance technique not easily accessible for patients since it re-
techniques were used; follow-up was quite limited (3 quires referral to specific surgeons. The limitations of
to 5 months) and only a few patients were included (5 our study are those inherent to small study samples and
at best). retrospective studies.
Peripheral nerve stimulation methods (TENS, spinal
cord stimulation) seem to have poor long-term efficacy
Conclusion
due to stimulation desensitization (24,25). Our study showed excellent technical success rates
Finally, surgical management of inguinal neural- and similar important early pain intensity reduction in
gia includes both division of the nerve during hernia both groups. However, RFN showed significantly longer
repair and re-operative neurectomy. There seems to be lasting pain relief compared to local infiltration. Lo-
no consensus on whether or not the nerve should be cal nerve infiltration may, however, still be performed
resected during surgical procedures, as some studies prior to RFN in order to confirm an accurate inguinal
report significant pain reduction (26-28) whereas oth- neuralgia diagnosis. RFN should be considered as an al-
ers report no improvement after intraoperative nerve ternative treatment to surgery for the management of
division (29-31). These conflicting results are partly ex- inguinal neuralgia.

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 Pain Physician: May/June 2012; 15:237-244

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