Persistent Post-Surgical Pain — FRCA Final MCQ

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ModeratePain MedicinePersistent Post-Surgical PainFRCA Final

A 35-year-old man has persistent neuropathic groin pain 2 years after inguinal hernia repair. Surgical review has excluded recurrent hernia, infection and a correctable mesh complication. He has allodynia and hyperalgesia confined to the cutaneous distribution of the ilioinguinal nerve, with pain reproduced by pressure along its course. Multimodal conservative treatment has failed. What is the most appropriate next interventional procedure?

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Correct answer: B — Ilioinguinal nerve block

The correct answer is B. The focal allodynia, hyperalgesia and provocation of pain along the ilioinguinal nerve indicate neuropathic chronic postoperative inguinal pain involving that nerve. After structural causes and recurrent hernia have been excluded and conservative management has failed, an image-guided selective ilioinguinal nerve block is an appropriate diagnostic and potentially therapeutic next step. Local anaesthetic is used; a non-particulate corticosteroid may be added, although the evidence for sustained benefit is limited and heterogeneous. A transversus abdominis plane block is less selective. A genitofemoral block targets a different, although overlapping, sensory distribution. Trigger-point injection is appropriate for focal myofascial or scar pain rather than nerve-territory allodynia. Lumbar sympathetic block is used for sympathetically maintained pain and is not anatomically targeted to an isolated ilioinguinal neuropathy.

Reference: Benzon HT et al. Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections. Regional Anesthesia and Pain Medicine. 2026;51:642-659. https://pubmed.ncbi.nlm.nih.gov/25956797/