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Long-Term Pain Relief following ACNES Injection in a patient with MESH surgery

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Patient Background

A 78-year-old lady presented with longstanding severe pain over the left lower abdomen, radiating to the left groin and hip. Her symptoms began following a Spigelian hernia repair with mesh insertion performed five years ago. Since the surgery, she had experienced persistent discomfort in the area, describing the sensation of a lump, along with a constant pulling pain that significantly limited her daily activities. The pain was particularly exacerbated by standing and walking, making it difficult for her to walk even the length of a supermarket aisle. Her symptoms had a profound impact on her mobility, mood, and overall quality of life.

Investigations

She underwent extensive investigations, including an MRI scan that revealed degenerative scoliosis and possible L1 nerve root impingement on the left side. An ultrasound scan also identified a stitch granuloma in the area, though this was not visible on MRI. She was reviewed by the surgical team, who ruled out the need for further surgical intervention.

Previous Treatments

The patient was initially managed by another pain specialist who administered nerve blocks, including a rectus sheath block and a transversus abdominis plane (TAP) block. Unfortunately, these only provided short-lived relief. She also trialled multiple anti-neuropathic medications, none of which improved her symptoms and some of which led to unpleasant side effects.

Treatment with Dr Krishna

She was subsequently reviewed by Dr. Krishna at Pain Spa, who, after a detailed clinical assessment, concluded that her pain was most likely due to Anterior Cutaneous Nerve Entrapment Syndrome (ACNES), rather than lumbar nerve root compression. He discussed the option of an ultrasound-guided abdominal cutaneous nerve block using local anaesthetic and steroid. The patient underwent this procedure and experienced almost complete and immediate pain relief.

  • At 3-month and 6-month follow-ups, she remained pain-free.

  • At 2-year follow-up, she continued to report complete resolution of pain, with significant improvements in function, mood, and wellbeing.

This case highlights the value of a targeted, ultrasound-guided intervention in managing chronic abdominal wall pain in elderly patients. ACNES is often underdiagnosed and misattributed to intra-abdominal pathology or spinal pathology. In this patient’s case, early recognition and precise treatment of the abdominal nerve entrapment led to excellent long-term outcomes, sparing her the continued use of medications that had proven ineffective and were associated with adverse effects. It also prevented any repeat surgical interventions which could prove harmful.

Dr. Krishna has significant expertise in diagnosing and managing Anterior Cutaneous Nerve Entrapment Syndrome (ACNES), a frequently overlooked cause of chronic abdominal pain. He has extensive experience in performing ultrasound-guided nerve blocks, which allow for accurate and safe delivery of medication with minimal discomfort. In elderly patients, such targeted interventions can be far more effective and better tolerated than prolonged trials of systemic antineuropathic medications, which often carry a high risk of side effects including dizziness, drowsiness, cognitive impairment, and falls.

This case underscores the importance of specialist pain assessment and tailored interventions in improving outcomes for patients with chronic, complex pain conditions.

Conclusion

This case exemplifies how a focused diagnostic approach and the use of targeted, minimally invasive treatments can dramatically improve outcomes in elderly patients with chronic pain. Despite years of persistent abdominal and groin pain following hernia mesh surgery—and limited benefit from conventional medications and nerve blocks—this patient experienced complete and sustained pain relief following an ultrasound-guided abdominal cutaneous nerve block performed by Dr. Krishna. The successful outcome highlights the importance of recognising Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) as a distinct clinical entity and the value of ultrasound-guided interventions in achieving safe, effective, and long-term relief. This case reinforces the role of specialist pain assessment in complex presentations, particularly where conventional treatments have failed.

For more details please visit www.painspa.co.uk.