Abstract
ACNES is a pain syndrome caused by entrapment of distal branches of the intercostal nerves. Literature is heterogeneous in the management of this condition, and no standard of care is available. This study aims to provide a systematic review and meta-analysis of available treatments for ACNES, propose standardized nomenclature and a management algorithm.
We systematically searched PubMed, Embase, and Cochrane Library from inception to August 2024 for studies analyzing interventions for ACNES. We analyzed non-operative and surgical outcomes, primary outcomes including treatment success, recurrence, and need for re-intervention, as well as complication rates, and proposed a standardized nomenclature and management flowchart. Our robotic approach was described.
Non-operative success rate was 35%. Surgery success rate was 94.45%, and recurrence after first surgery was 34.6%. Significant heterogeneity was observed in the definitions of different neurectomies, and our proposed definition incorporates the relationship of the dissection with the anterior sheath, and includes a robotic approach.
Non-operative therapy for ACNES can provide both symptom relief and diagnostic clarity, but recurrence rate remains high. Despite surgery presented a superior efficacy, no direct comparative superiority between treatment modalities can be established based on the available evidence. Patients might fare better when care is individualized according to symptom severity, expectations, and predicted disability.
•ACNES management is highly heterogeneous, with no established standard of care across non-operative and surgical treatments.•Non-operative therapies achieve symptom relief in approximately 35% of patients but are associated with a high recurrence rate.•Surgical treatment demonstrates high initial success (>94%), though pain recurrence after first surgery remains common.•Significant variability exists in the anatomical definitions of surgical neurectomy in the literature, and we propose the definition based on the relation to the anterior rectus sheath and associated comorbidity.•Standardized nomenclature, an anatomy-based management algorithm, and a novel totally extraperitoneal robotic neurectomy technique may improve outcome assessment and patient selection.•An introduction to the robotic totally extraperitoneal neurectomy is proposed.