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Abdominal wall pain at the linea semilunaris is classically the result of a Spigelian hernia. If no hernia is detected, these patients may be leftwith chronic pain without a diagnosis or treatment. A retrospective review was performed of patients presenting with abdominal wall pain at the linea semilunaris between 2009 and 2012. Of the 14 patients, three (21%) were diagnosed with a Spigelian hernia confirmed by imaging. The remaining patients were eventually diagnosed with abdominal cutaneous nerve entrapment syndrome (ACNES). The average delay in diagnosis was 4 years with patients with ACNES suffering twice as long with chronic pain. Patients with a Spigelian hernia and ACNES had different demographics and presenting complaints. Physical examination findings were nondiagnostic. Of the patients with ACNES, five (50%) had resolution of pain with serial nerve blocks alone; another five proceeded to surgical neurectomy with resolution of their pain. Thus, to prevent delay in diagnosis and treatment, patients with chronic abdominal wall pain at the linea semilunaris should first be ruled out for Spigelian hernia. Then, they should be evaluated and treated for ACNES.
A BDOMINAL WALL PAIN localized at the lateral border of the rectus abdominis muscle is most often attributed to a Spigelian hernia. This hernia is classically noted as a defect in the transversus aponeurosis occurring at the junction of the rectus abdominis and linea semilunaris. Most often, these hernias occur at or below the linea arcuata, because the posterior rectus sheath is lacking in this area. Spigelian hernias are rare and many are obscure. The true incidence of Spigelian hernias is unknown but is estimated to be at least 0.12 per cent of all diagnosed abdominal wall hernias and perhaps up to 1 to 2 per cent in the healthy population. 1 Patients may or may not present with a bulge in the area of the defect. Localized abdominal pain without a palpable bulge is the most common presentation in the outpatient setting.1, 2
Abdominal cutaneous nerve entrapment syndrome (ACNES) is a separate entity that also presents with pain at the lateral border of the rectus abdominis. The abdominal cutaneous nerve runs anterior to the transversus abdominis muscle for most of its course. At the anterior abdominal wall, it splits into an anterior and posterior...