A 25-year-old, 55 kg male presented with severe pain on the right side of the abdomen that radiated to the testicle and the inner side of the thigh, was aggravated on walking and incapacitated him to perform routine work. Other complaints were daytime sedation and loss of job since 5 months. The past history revealed inguinal hernia surgery 6 months back. The patient developed severe pain after 1-month of surgery which progressively increased to hyperalgesia and allodynia. Patient was on regular medical management including per oral diclofenac, paracetamol-tramadol combination, and gabapentin with no relief in pain and had received several interventional pain injections earlier. Systemic and neurological examination was unremarkable. Blood and other investigations were acceptable. After explaining the procedure to the patient, a written informed consent was taken. In the pain management theater, intravenous access was secured, and noninvasive blood pressure, oxygen saturation, and electrocardiograph monitoring were monitored.
Under strict asepsis and a linear high-frequency ultrasound probe (Sonosite, Inc., Bothell, WA 98021 USA) was placed medial and inferior to anterior superior iliac spine. Ilioinguinal-iliohypogastric (II-IH) nerves were identified between the internal oblique and transverses abdominis muscle and a 5 cm, 22 G RF cannula (Cosman Medical Inc., Burlington, MA, USA) was inserted using the in-plane technique. The correct placement of needle tip was verified with sensory stimulation at 50-Hertz frequency and 0.5 volts. Extended duration PRF was applied at 42 C with four cycles of 120 s each (8 min). After negative aspiration for blood, a mixture of 5 ml of 0.2% ropivacaine and 20 mg of triamcinolone was injected. The visual analog scale (VAS) reduced from 100 to 0 in the II-IH territory.
Under strict asepsis, high-frequency ultrasound probe was placed in the right inguinal area. The femoral artery was followed cranially until the spermatic cord was located (above the inguinal ligament) just lateral to the symphysis pubis. On gentle traction of the testis, the spermatic cord was confirmed. The testicular and vas deferens vessels were located with color Doppler. Using an in-plane technique, a 5 cm, 22 G RF cannula was advanced toward the genital branch of the genitofemoral nerve (GGFN) using the in-plane technique. Correct needle positioning was verified with sensory stimulation and motor stimulation. A diagnostic block in GGFN with 5 ml of 0.2% ropivacaine and 20 mg of triamcinolone resulted in preblock VAS of 100 to zero in the right testicular area. However, after 2 weeks, the VAS increased to 50 on movement and after 1-month PRF of GGFN was performed (8 min) using the same methodology described above. The procedure reduced VAS from preblock VAS of 50 on movement to postblock VAS of zero. Thereafter, the patient received Amitriptyline 10 mg once daily at night, Gabapentin 100 mg twice daily and occasional analgesics for 5 months. At present, the patient has resumed his earlier job after a gap of more than 1-year and is now currently not on any analgesics from the past 4 months. The World Health Organization Quality of Life BREF score increased from an initial score of 32 ( first visit in pain management center) to 106 at follow-up of 9 months.