S01: TRANSVERSUS ABDOMINIS PLANE BLOCK FOR CHRONIC ABDOMINAL PAIN AFTER CESAREAN DELIVERY
Maria Rathore, DO; Jason Lefkof, DO; Noushad Mamun, DO; Danielle Bodzin Horn, MD; University of Miami
Introduction: Of all U.S. births, 31.9% are via Cesarean delivery (CD)(1). The incidence of chronic postsurgical pain (CPSP) ranges from 5-85%(2), and may be severe in 2-10% of cases(3, 4). One prospective study found incidence of CPSP (>12 months) following CD was 6.8%(5). This risk increases with each subsequent CD(6). Complications following CD like scar tissue, adhesions, and nerve dysfunction or injury (particularly the iliohypogastric, ilioinguinal, and genitofemoral nerve(s)) may contribute to chronic pain syndromes(6). Often times this chronic pain is somatic and neuropathic, and associated with decreased quality of life. Treatment options may range from conservative measures to surgery.
Case Presentation: A 43-year-old woman presented with chronic right-sided lower abdominal pain attributed to previous CD in 1994. Her pain was described as a constant throbbing and burning sensation in her lower abdomen/pelvis radiating cephalad, exacerbated by movement and palpation. She had multiple emergency room visits and underwent a total of 8 surgeries including multiple lysis of adhesions, partial hysterectomy, and oopherectomy. She failed to improve with these surgeries, physical therapy and multiple medications including, but not limited to opioids and antidepressants.
On examination, she endorsed abdominal tenderness to palpation, without sensory changes or erythema. Pain was worsened with head lift. She was started on amitriptyline and returned for a transversus abdominis plane (TAP) block under ultrasound guidance. A mixture of local anesthetic and steroid was infiltrated into the fascial plane between the internal oblique muscle and the transversus abdominis muscle. She reported 100% pain relief following the procedure.
Discussion: CPSP following CD is rare, but may be life-altering, and there is limited guidance regarding management. A patient with intractable CPSP following CD refractory to multiple treatments including surgeries underwent successful ultrasound guided TAP block with local anesthetic and steroid offering excellent relief. Traditionally, TAP blocks are utilized for management/prevention of acute abdominal wall pain following surgery, however, studies have described efficacy of TAP block in the treatment of refractory chronic abdominal pain (7, 8). Further studies elucidate whether TAP blocks play a role in the treatment algorithm for refractory CPSP following CD.
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