
Contents
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Case Presentation Case Presentation
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Questions Questions
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What Is the Differential Diagnosis for the Etiology of the Pain in This Case? What Is the Differential Diagnosis for the Etiology of the Pain in This Case?
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What Further History May Be Useful in Establishing the Diagnosis? What Further History May Be Useful in Establishing the Diagnosis?
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Preoperative Risk Factors Preoperative Risk Factors
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Age Age
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Preexisting Preoperative Pain Preexisting Preoperative Pain
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Psychological Factors Psychological Factors
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Employment Status Employment Status
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Surgical Risk Factors Surgical Risk Factors
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Surgical Technique Surgical Technique
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Mesh and Fixatives Mesh and Fixatives
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What Other Exam Findings May Be Pertinent? What Other Exam Findings May Be Pertinent?
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What Diagnostic Studies May Be Helpful? What Diagnostic Studies May Be Helpful?
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Ultrasound Ultrasound
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Magnetic Resonance Imaging (MRI) Magnetic Resonance Imaging (MRI)
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Computed Tomography (CT) Computed Tomography (CT)
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Herniography Herniography
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Fluoroscopy Fluoroscopy
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Electromyography (EMG) and Quantitative Sensory Testing (QST) Electromyography (EMG) and Quantitative Sensory Testing (QST)
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Selective Nerve Blocks Selective Nerve Blocks
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What Is the Pathophysiology of Persistent Postoperative Pain? What Is the Pathophysiology of Persistent Postoperative Pain?
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Mechanism of Acute Pain Mechanism of Acute Pain
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Mechanism of Persistent Pain Mechanism of Persistent Pain
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Mechanism of Chronic Pain Mechanism of Chronic Pain
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Neuropathic Pain Neuropathic Pain
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Inflammatory Pain Inflammatory Pain
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How Would You Manage the Patient’s Medications? How Would You Manage the Patient’s Medications?
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First-Line Medication Therapy First-Line Medication Therapy
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Calcium Channel Ligands (Gabapentin, Pregabalin) Calcium Channel Ligands (Gabapentin, Pregabalin)
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Topical Lidocaine Topical Lidocaine
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TCAs: Nortriptyline, Desipramine, Amitriptyline, Imipramine TCAs: Nortriptyline, Desipramine, Amitriptyline, Imipramine
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SNRIs: Duloxetine, Venlafaxine SNRIs: Duloxetine, Venlafaxine
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Second-Line Medication Therapy Second-Line Medication Therapy
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Opioid Analgesics Opioid Analgesics
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Tramadol Tramadol
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Third-Line Medication Therapy Third-Line Medication Therapy
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Pre-emptive and Preventative Analgesia Pre-emptive and Preventative Analgesia
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What Other Approaches Would You Consider for Managing this Patient? What Other Approaches Would You Consider for Managing this Patient?
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Behavioral Behavioral
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Alcohol Use Alcohol Use
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Surgery Surgery
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Interventional Pain Treatments Interventional Pain Treatments
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Nerve Blocks Nerve Blocks
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Radiofrequency (RF) Ablation Radiofrequency (RF) Ablation
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Cryoablation Cryoablation
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Neuromodulation Neuromodulation
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Rehabilitation Rehabilitation
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References References
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Cite
Abstract
This chapter presents a clinical case of post-herniorrhaphy pain. Pain after a hernia repair is either neuropathic pain due to nerve injury or non-neuropathic pain, which is the result of either somatic or visceral nociceptive signaling, typically from the presence of excessive scar tissue, pressure from bulky or heavy mesh used in repair, or mechanical distortion of viscera due to recurrent hernia and adhesions. The chapter discusses the differential diagnosis, useful diagnostic studies, and pathophysiology of the condition. Techniques for managing post-herniorrhaphy pain include pharmacotherapy, cognitive behavior therapy (CBT), surgical re-exploration, and interventional treatments including nerve blocks, radiofrequency ablation, cryoblation, and neuromodulation.
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