, Volume 22, Issue 3, pp 507–516 | Cite as

Anterior cutaneous nerve entrapment syndrome (ACNES)

  • M. R. ScheltingaEmail author
  • R. M. RoumenEmail author


The abdominal wall is frequently overlooked as a potential source of chronic abdominal pain. In anterior cutaneous nerve entrapment syndrome (ACNES), irritated intercostal nerves cause severe abdominal pain. Current textbooks fail to acknowledge ACNES. Aim of the present review is to provide detailed information on patient history, physical examination, and a three-step treatment protocol including abdominal wall injections and a localized removal of terminal branches of intercostal nerves.


Nerve entrapment Neuropathic pain Abdominal wall Neurectomy 


Author contributions

Both authors, MS and RR, declare that they substantially and equally contributed to the conception and design of the work, revised it both very critically, they both give the final approval of the version to be submitted and published, and they agree to be equally accountable for all aspects of the work.

Compliance with ethical standards

Conflict of interest

Both authors, MS and RR, declare no conflicts of interest.

Ethical approval

This review was performed under compliance with all ethical standards.

Human and animal rights

This article does not contain any study with humans or animals performed by the authors.

Informed consent

Considering the design of this review patient informed consent was not required.


  1. 1.
    Carnett JB (1926) Intercostal neuralgia as a cause of abdominal pain and tenderness. Surg Gyn Obstet 42:625–632Google Scholar
  2. 2.
    Applegate WV (1972) Abdominal cutaneous nerve entrapment syndrome. Surgery 71:118–124PubMedGoogle Scholar
  3. 3.
    Spinner RJ (2006) Outcomes for peripheral nerve entrapment syndromes. Clin Neurosurg 53:285–294PubMedGoogle Scholar
  4. 4.
    Boelens OB, Scheltinga MR, Houterman S, Roumen RM (2013) Randomized clinical trial of trigger point infiltration with lidocaine to diagnose anterior cutaneous nerve entrapment syndrome. Br J Surg 100(2):217–221CrossRefPubMedGoogle Scholar
  5. 5.
    Boelens OB, van Assen T, Houterman S, Scheltinga MR, Roumen RM (2013) A double-blind, randomized, controlled trial on surgery for chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome. Ann Surg 257(5):845–849CrossRefPubMedGoogle Scholar
  6. 6.
    Boelens OB, Scheltinga MR, Houterman S, Roumen RM (2011) Management of anterior cutaneous nerve entrapment syndrome in a cohort of 139 patients. Ann Surg 254(6):1054–1058CrossRefPubMedGoogle Scholar
  7. 7.
    van Assen T, Boelens OB, van Eerten PV, Perquin C, Scheltinga MR, Roumen RM (2015) Long-term success rates after an anterior neurectomy in patients with an abdominal cutaneous nerve entrapment syndrome. Surgery 157(1):137–143CrossRefPubMedGoogle Scholar
  8. 8.
    Siawash M, Maatman R, Tjon A Ten W, van Heurn E, Roumen R, Scheltinga M (2017) Anterior neurectomy in children with a recalcitrant anterior cutaneous nerve entrapment syndrome is safe and successful. J Pediatr Surg 52:478–480CrossRefPubMedGoogle Scholar
  9. 9.
    Thome J, Egeler C (2006) Abdominal cutaneous nerve entrapment syndrome (ACNES) in a patient with a pain syndrome previously assumed to be of psychiatric origin. World J Biol Psychiatry 7(2):116–118CrossRefPubMedGoogle Scholar
  10. 10.
    Mackenzie J (1892) Contribution to the study of sensory symptoms associated with visceral disease. Med Chron XVI:293–322Google Scholar
  11. 11.
    Head H (1893) On disturbances of sensation with especial reference to the pain of visceral disease, Part I. Brain 16(1–2):1–133CrossRefGoogle Scholar
  12. 12.
    Lewis T, Kellgren JH (1939) Observations relating referred pain, visceromotor reflexes and other associated phenomena. Clin Sci 4:47Google Scholar
  13. 13.
    Cyriax EF (1919) On various conditions that may simulate the referred pains of visceral disease, and the consideration of these from the point view of cause and effect. Practioner 102:314–319Google Scholar
  14. 14.
    Carnett JB, Bates W (1933) The treatment of intercostal neuralgia of the abdominal wall. Ann Surg 98(5):820–829CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Thompson H, Francis DM (1977) Abdominal-wall tenderness: a useful sign in the acute abdomen. Lancet 2:1053–1054CrossRefGoogle Scholar
  16. 16.
    Srinivasan R, Greenbaum DS (2002) Chronic abdominal wall pain: a frequently overlooked problem. Practical approach to diagnosis and management. Am J Gastroenterol 97:824–830PubMedGoogle Scholar
  17. 17.
    Takada T, Ikusaka M, Ohira Y, Noda K, Tsukamoto T (2011) Diagnostic usefulness of Carnett’s test in psychogenic abdominal pain. Intern Med 50:213–217CrossRefPubMedGoogle Scholar
  18. 18.
    Gray DW, Dixon JM, Seabrook G et al (1988) Is abdominal wall tenderness a useful sign in the diagnosis of non-specific abdominal pain? Ann R Coll Surg Engl 70:233–234PubMedPubMedCentralGoogle Scholar
  19. 19.
    Greenbaum DS, Joseph JG (1991) Abdominal wall tenderness test. Lancet 337:1606–1607Google Scholar
  20. 20.
    Murray GM, Durh DCL (1929) An address on: myofibrositis as a simulator of other maladies. Lancet 19:113–116Google Scholar
  21. 21.
    Harman JB, Young RH (1940) Muscle lesions simulating visceral disease. Lancet 235(6095):1111–1113. CrossRefGoogle Scholar
  22. 22.
    Judovitch B, Bates W (1946) Segmental neuralgia in painful syndromes, 2nd edn. Davis Company, PhiladelphiaGoogle Scholar
  23. 23.
    Mehta M, Ranger I (1971) Persistent abdominal pain. Anaesthesia 26:330–333CrossRefPubMedGoogle Scholar
  24. 24.
    Vogl A (1972) Nerve pain from fascial lacunae. Zentralbl Chir 97(1):31 (Article in German) PubMedGoogle Scholar
  25. 25.
    Meier W (1988) Experiences with the “epigastric pain syndrome”. Helv Chir Acta 55:731–736Google Scholar
  26. 26.
    Langdon DE (2002) Abdominal wall pain will be missed until examinations change! Am J Gastroenterol 97:3207–3208CrossRefPubMedGoogle Scholar
  27. 27.
    Lindsetmo RO, Stulberg J (2009) Chronic abdominal wall pain—a diagnostic challenge for the surgeon. Am J Surg 198(1):129–134CrossRefPubMedGoogle Scholar
  28. 28.
    van der Graaf T, Verhagen PC, Kerver AL, Kleinrensink GJ (2011) Surgical anatomy of the 10th and 11th intercostal, and subcostal nerves: prevention of damage during lumbotomy. J Urol 186(2):579–583CrossRefPubMedGoogle Scholar
  29. 29.
    Copyright © 2006 Pearson Education, Inc., Publishing as Benjamin cummings spinal nerve innervation: back, anterolateral thorax, and abdominal wall figure 13.7bGoogle Scholar
  30. 30.
    Applegate WV, Buckwalter NR (1997) Microanatomy of the structures contributing to abdominal cutaneous nerve entrapment syndrome. J Am Board Fam Pract 10:329–332PubMedGoogle Scholar
  31. 31.
    Applegate WV (2002) Abdominal cutaneous nerve entrapment syndrome(ACNES): a commonly overlooked cause of abdominal pain. Perm J 6:20–27Google Scholar
  32. 32.
    McGarrity T, Peters DJ, Thompson C, McGarrity SJ (2000) Outcome of patients with chronic abdominal pain referred to chronic pain clinic. Am J Gastroenterol 95:1812–1816CrossRefPubMedGoogle Scholar
  33. 33.
    Hall PN, Lee AP (1988) Rectus nerve entrapment causing abdominal pain. Br J Surg 75:917CrossRefPubMedGoogle Scholar
  34. 34.
    Graff LG, Robinson D (2001) Abdominal pain and emergency department evaluation. Emerg Med Clin North Am 19(1):123–136CrossRefPubMedGoogle Scholar
  35. 35.
    van Assen T, de Jager-Kievit JW, Scheltinga MR, Roumen RM (2013) Chronic abdominal wall pain misdiagnosed as functional abdominal pain. J Am Board Fam Med 26(6):738–744CrossRefPubMedGoogle Scholar
  36. 36.
    van Assen T, Boelens OB, Kamphuis JT, Scheltinga MR, Roumen RM (2012) Construction and validation of a questionnaire distinguishing a chronic abdominal wall pain syndrome from irritable bowel syndrome. Frontline Gastroenterol 3(4):288–294CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    van Assen T, Brouns JAGM, Scheltinga MR, Roumen RM (2015) Incidence of abdominal pain due to the anterior cutaneous nerve entrapment syndrome in an emergency department. Scand J Trauma Resusc Emerg Med 23:19. CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Körner H, Söndenaa K, Söreide JA, Andersen E, Nysted A, Lende TH, Kjellevold KH (1997) Incidence of acute nonperforated and perforated appendicitis: age-specific and sex-specific analysis. World J Surg 21(3):313–317CrossRefPubMedGoogle Scholar
  39. 39.
    Sarbandi HS, Pruss-Kaddatz U, Dohmann R (1989) Abdominal intercostal nerve pain. A contribution to differential diagnosis of acute abdominal pain. Chirurg 60:886–889 (discussion 890) PubMedGoogle Scholar
  40. 40.
    Scheltinga MR, Boelens OB, Ten Tjon A (2011) WE, Roumen RM. Surgery for refractory anterior cutaneous nerve entrapment syndrome (ACNES) in children. J Pediatr Surg 46(4):699–703CrossRefPubMedGoogle Scholar
  41. 41.
    Davis JH (1936) Segmental neuralgia in childhood simulating visceral disease. JAMA 107:1620–1626CrossRefGoogle Scholar
  42. 42.
    Hughes GS (1985) Syndrome of the rectus abdominis muscle mimicking the acute abdomen. Ann Emerg Med 14:694–695CrossRefPubMedGoogle Scholar
  43. 43.
    Choi YK, Chou S (1995) Rectus syndrome. Another cause of upper abdominal pain. Reg Anesth 20:347–351PubMedGoogle Scholar
  44. 44.
    Oesch A, Kupfer K, Bodoky A (2001) Intercostal nerve syndrome. Swiss Surg 7:82–85CrossRefPubMedGoogle Scholar
  45. 45.
    Feurle GE (2007) Abdominal wall pain—classification, diagnosis and treatment suggestions. Wien Klin Wochenschr 119:633–638CrossRefPubMedGoogle Scholar
  46. 46.
    McGrady EM, Marks RL (1988) Treatment of abdominal nerve entrapment syndrome using a nerve stimulator. Ann R Coll Surg 70:120–122Google Scholar
  47. 47.
    Luz ZZ, Fernandes EC, Sivado M, Kokai E, Szucs P, Safranov BV (2015) Monosynaptic convergence of somatic and visceral C-fiber afferents on projection and local circuit neurons in lamina I: a substrate for referred pain. Pain 156:2024–2051CrossRefGoogle Scholar
  48. 48.
    (1991) Abdominal wall tenderness test: could Carnett cut costs? Lancet 337:1134Google Scholar
  49. 49.
    Costanza CD, Longstreth GF, Liu AL (2004) Chronic abdominal wall pain: clinical features, health care costs, and long-term outcome. Clin Gastroenterol Hepatol 2:395–399CrossRefPubMedGoogle Scholar
  50. 50.
    Greenbaum DS, Greenbaum RB, Joseph JG, Natale JE (1994) Chronic abdominal wall pain, diagnostic validity and costs. Digest Dis Sci 39:1935–1941CrossRefPubMedGoogle Scholar
  51. 51.
    Cimen A, Celik M, Erdine S (2004) Myofascial pain syndrome in the differential diagnosis of chronic abdominal pain. Agri 16(3):45–47PubMedGoogle Scholar
  52. 52.
    Facco E, Ceccherelli F (2005) Myofascial pain mimicking radicular syndromes. Acta Neurochir Suppl 92:147–150CrossRefPubMedGoogle Scholar
  53. 53.
    Montenegro ML, Gomide LB, Mateus-Vasconcelos EL, Rosa-e-Silva JC, Candido-dos-Reis FJ, Nogueira AA, Poli-Neto OB (2009) Abdominal myofascial pain syndrome must be considered in the differential diagnosis of pelvic pain. Eur J obstet Gyn Reprod Biol 147:21–24CrossRefGoogle Scholar
  54. 54.
    Nazareno J, Ponich T, Gregor J (2005) Long-term follow-up of trigger point injections for abdominal wall pain. Can J Gastroenterol 19(9):561–565CrossRefPubMedGoogle Scholar
  55. 55.
    Muscolino JE (2013) Abdominal wall trigger point case study. J Bodyw Mov Ther 17(2):151–156CrossRefPubMedGoogle Scholar
  56. 56.
    Sharp HT (2003) Myofascial pain syndrome of the abdominal wall for the busy clinician. Clin Obstet Gynecol 46:783–788CrossRefPubMedGoogle Scholar
  57. 57.
    Sharpstone D, Colin-Jones DG (1994) Chronic, non visceral abdominal pain. Gut 35:833–836CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Clearfield HR (1982) Diagnosing parietal abdominal pain. Hosp Pract 17:219–227CrossRefGoogle Scholar
  59. 59.
    Gschossmann JM, Häuser W, Wesselmann U, Holtmann G (2002) Diagnostic criteria and therapeutic strategies of abdominal pain syndromes. Schmerz 16:476–480CrossRefPubMedGoogle Scholar
  60. 60.
    Amir R, Argoff CE, Bennett GJ, Cummins TR, Durieux ME, Gerner P, Gold MS, Porreca F, Strichartz GR (2006) The role of sodium channels in chronic inflammatory and neuropathic pain. J Pain 7(5 Suppl 3):S1–S29CrossRefPubMedGoogle Scholar
  61. 61.
    Vlassakov KV, Narang S, Kissin I (2011) Local anesthetic blockade of peripheral nerves for treatment of neuralgias: systematic analysis. Anesth Analg 112(6):1487–1493CrossRefPubMedGoogle Scholar
  62. 62.
    Glissen Brown JR, Bernstein GR, Friedenberg FK, Ehrlich AC (2016) Chronic abdominal wall pain: an under-recognized diagnosis leading to unnecessary testing. J Clin Gastroenterol 50:828–835CrossRefPubMedGoogle Scholar
  63. 63.
    Doouss TW, Boas RA (1975) The abdominal cutaneous nerve entrapment syndrome. N Z Med J 81:473–475PubMedGoogle Scholar
  64. 64.
    Jeynes LC, Gauci CA (2008) Evidence for the use of botulinum toxin in the chronic pain setting—a review of the literature. Pain Pract 8(4):269–276CrossRefPubMedGoogle Scholar
  65. 65.
    Skinner AV, Lauder GR (2007) Rectus sheath block: successful use in the chronic pain management of pediatric abdominal wall pain. Paediatr Anaesth 17:1203–1211CrossRefPubMedGoogle Scholar
  66. 66.
    Simpson DM, Tyrrell J, De Ruiter J, Campbell FA (2011) Use of ultrasound-guided subcostal transversus abdominis plane blocks in a pediatric patient with chronic abdominal wall pain. Paediatr Anaesth 21(1):88–90CrossRefPubMedGoogle Scholar
  67. 67.
    Kanakarajan S, High K, Nagaraja R (2011) Chronic abdominal wall pain and ultrasound-guided abdominal cutaneous nerve infiltration: a case series. Pain Med 12(3):382–386CrossRefPubMedGoogle Scholar
  68. 68.
    Batistaki C, Saranteas T, Adoni A, Kostopanagiotou G (2013) Ultrasound-guided anterior abdominal cutaneous nerve block for the management of bilateral abdominal cutaneous nerve entrapment syndrome (ACNES). Pain Phys 16(6):E799–E801Google Scholar
  69. 69.
    Alnahhas MF, Oxentenko SC, Locke GR 3rd, Hansel S, Schleck CD, Zinsmeister AR, Farrugia G, Grover M (2016) Outcomes of ultrasound-guided trigger point injection for abdominal wall pain. Dig Dis Sci 61:572–577CrossRefPubMedGoogle Scholar
  70. 70.
    Hong MJ, Kim YD, Seo DH (2013) Successful treatment of abdominal cutaneous entrapment syndrome using ultrasound guided injection. Korean J Pain 26(3):291–294CrossRefPubMedPubMedCentralGoogle Scholar
  71. 71.
    Haynsworth RF Jr, Noe CE (1990) An unusual presentation of intercostal neuralgia. Anesthesiology 73(4):779–780CrossRefPubMedGoogle Scholar
  72. 72.
    Luis Téllez Villajos BHO, Moreira Vicente V, de la Calle Reviriego JL, Senosiain Lalastra C, Foruny Olcina JR (2015) Radiofrecuencia pulsada en el tratamiento del síndrome de atrapamiento del nervio cutáneo abdominal. Gastroenterologia y hepatologia 38(1):14–16CrossRefPubMedGoogle Scholar
  73. 73.
    Hershfield NB (1992) The abdominal wall. A frequently overlooked source of abdominal pain. J Clin Gastroenterol 14:199–202CrossRefPubMedGoogle Scholar
  74. 74.
    Towfigh S, Anderson S, Walker A (2013) When it is not a Spigelian hernia: abdominal cutaneous nerve entrapment syndrome. Am Surg 79(10):1111–1114PubMedGoogle Scholar
  75. 75.
    Solmaz I, Talay M, Tekindur Ş, Kurt E (2012) A commonly seen cause of abdominal pain: abdominal cutaneous nerve entrapment syndrome. Agri 24(3):139–141CrossRefPubMedGoogle Scholar
  76. 76.
    Zganjer M, Bojić D, Bumči I (2013) Surgery for abdominal wall pain caused by cutaneous nerve entrapment in children-a single institution experience in the last 5 years. Iran Red Crescent Med J 15(2):157–160CrossRefPubMedPubMedCentralGoogle Scholar
  77. 77.
    Roumen RM, Scheltinga MR (2006) Abdominal intercostal neuralgia: a forgotten cause of abdominal pain.[Article in Dutch]. Ned Tijdschr Geneeskd 150(35):1909–1915PubMedGoogle Scholar
  78. 78.
    van Assen T, Boelens OB, van Eerten PV, Scheltinga MR, Roumen RM (2014) Surgical options after a failed neurectomy in anterior cutaneous nerve entrapment syndrome. World J Surg 38(12):3105–3111CrossRefPubMedGoogle Scholar
  79. 79.
    Chrona E, Kostopanagiotou G, Damigos D, Batistaki C (2017) Anterior cutaneous nerve entrapment syndrome: management challenges. JPR 10:145–156CrossRefGoogle Scholar
  80. 80.
    Suleiman S, Johnston DE (2001) The abdominal wall: an overlooked source of pain. Am Fam Phys 64:431–438Google Scholar
  81. 81.
    Thompson C, Goodman R, Rowe WA (2001) Abdominal wall syndrome: a costly diagnosis of exclusion. Gastroenterology 120:A637CrossRefGoogle Scholar
  82. 82.
    Garcia-Larrea L (2012) Objective pain diagnostics: clinical neurophysiology. Neurophysiol Clin 42(4):187–197CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2017

Authors and Affiliations

  1. 1.Department of SurgeryMáxima Medical CenterEindhoven/VeldhovenThe Netherlands
  2. 2.SolviMáx DepartmentCenter of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin PainEindhoven/VeldhovenThe Netherlands

Personalised recommendations