Abdominal Wall Pain That Isn’t ACNES: A Case Study With Dr. Tim Tollestrup
Stanley’s pain was 10 out of 10. It sent him to the emergency room more than 20 times, often by ambulance. Over the course of his search for answers, he saw 25 to 30 different physicians. The pain was in his right upper abdomen, and no one could explain it.
In this case study, Dr. Tim Tollestrup explains what was causing Stanley’s abdominal wall pain, how he found it, and why it wasn’t the condition most people think of first.
When Abdominal Pain Comes From Nerves
Most people with severe abdominal pain are evaluated for problems with their organs: the gallbladder, liver, stomach or intestines. When those tests come back normal, patients are often left without answers.
Sometimes the problem is in the abdominal wall itself, in the nerves that run through the muscles and skin of the abdomen. The best-known form is ACNES, anterior cutaneous nerve entrapment syndrome, where the end branch of a nerve gets trapped as it passes through the front of the abdominal wall.
Stanley’s case was different.
Finding the Source
When Stanley came to Las Vegas, Dr. Tollestrup examined him and found something specific. “He was very tender to direct palpation right over this specific location along the costal margin in the right upper quadrant,” Dr. Tollestrup explains. The costal margin is the lower edge of the rib cage.
Stanley had earlier surgeries on his abdominal wall, which left scar tissue around the nerves in that area. Dr. Tollestrup believes the pain began with a sudden twisting motion. “Probably something he did that day, either working out or playing golf, the swinging and sort of violent motion that the torso goes through,” he says. “The nerve is probably caught in some scar and just became injured again.”
A later repeat surgery made the problem worse by further irritating those nerves.
Confirming It With Diagnostic Nerve Blocks
Before surgery, Dr. Tollestrup sent Stanley for diagnostic nerve blocks. The blocks completely relieved his pain for several hours, a strong sign that those nerves were the source.
Surgery on the T7 and T8 Nerves
Based on that result, Dr. Tollestrup explored the area in surgery. He removed two intercostal nerves, T7 and T8, which were both involved in scar tissue.
He explains why he takes a thorough approach: “In the operating room, you want to be more aggressive rather than less aggressive, because there’s nothing worse than leaving a nerve behind and then having that nerve still being a pain generator.”
The result: “He did excellent from that. Really totally knocked his pain out.”
Does Removing These Nerves Weaken the Abdomen?
It’s a common question. According to Dr. Tollestrup, several nerves supply the rectus muscle, so there is overlap in that coverage.
“You can remove several levels of these nerves without seeming to really impact the patient’s abdominal wall function,” he says. “They can still do sit-ups. There’s no bulging of the abdominal wall or any aesthetic problems.” For patients with debilitating pain, he calls it “a good trade-off.”
Why This Wasn’t Classic ACNES
In classic ACNES, only the terminal branch of the nerve is trapped at the anterior rectus sheath, near the front of the abdomen. Stanley’s nerves were compressed much further back, closer to the side of the body.
“His problem was much further upstream than that,” Dr. Tollestrup says. That difference matters, because treating only the end branch of the nerve wouldn’t have solved the problem.
Life After Surgery
“After surgery with Dr. Tollestrup, my quality of life has changed significantly,” Stanley says. “The abdominal nerve pain is gone. I am no longer taking pain medication or opioids. I would not hesitate to recommend Dr. Tollestrup for anyone suffering from nerve pain.”
Living With Unexplained Abdominal Pain?
If you have chronic abdominal wall pain, especially after abdominal surgery, and tests haven’t found a cause, it may be worth having your nerves evaluated. Dr. Tollestrup is one of only four peripheral nerve surgeons in the United States performing pain-focused nerve surgery.
You may be suffering from nerve pain, and there are solutions.
Request a consultation: https://nevadanervesurgery.org/contact-us/
Call: (702) 666-0463
Individual results vary. This article describes one patient’s case and is not medical advice.