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1174 Canadian Family PhysicianLe Médecin de famille canadienVOL 47: JUNE • JUIN 2001

Another source might explain the pain

I

would like to suggest another expla- nation for the findings reported by Drs Peleg and Shvar tzman in “Case report: Cutaneous nerve entrapment.”1 Although cutaneous nerve entrapment might cause musculoskeletal pain in cer tain locations, it is an unlikely mechanism in the case of most scars.

Scars are frequently overlooked as a source of pain and not just in the abdominal region. The fact that infil- tration with local anesthetic provides lasting relief does not prove that the problem is one of ner ve entrapment.

A more likely cause of pain emanat- ing from a scar is an “inter ference field” or localized area of autonomic ner vous system dysfunction.

Inter ference fields develop in scars when some interruption has occurred in the usual healing process (eg, infec- tion). There is often local tenderness, change in tissue texture, or slight ery- thema. Galvanic measurements will show either higher or lower electric potentials than in the surrounding tis- sues. Surrounding somatic tissue (eg, abdominal wall) might exhibit changes consistent with sympathetic arousal. Infiltration of the scar with diluted procaine or lidocaine (without steroid) will provide pain relief for much longer than would be expected from an anesthetic ef fect: days, weeks, months, or even permanent resolution (as occurred in Peleg and Shvartzman’s case).

Treating scars in this way is a small part of a German system of treating disorders of the autonomic ner vous system, called “neural therapy.” It has been developed in Germany over the last 70 years, is taught in medical schools, but is virtually unknown in the English-speaking medical community.

Unfortunately nearly all the pertinent scientific literature has been published in German or Russian and is difficult

for English speakers to access. The one opening into this fascinating area of med- icine is an English translation of the stan- dard German textbook,2now out of print.

—Robert Kidd, MD, CM

Renfrew, Ont by e-mail

References

1. Peleg R, Shvartzman P. Case report: cutaneous nerve entrapment. Abdominal wall pain in an elderly patient. Can Fam Physician2001;47:788-9.

2. Dosch P. Manual of neural therapy according to Huneke. 1st English ed, (11th German ed). Heidelberg, Ger: Haug Publishers; 1984.

Response

T

he explanation presented by Dr Kidd is interesting; however, we have found no basis for it in the acknowledged literature. In examining two recent textbooks, Practical Management of Pain1 and Bonica’s Management of Pain,2 we found that both provide the same explanation as ours for painful scars—either neuroma or nerve entrapment.

All our explanations of these cases are limited and not evidence based. The literature does not provide an explana- tion for this common phenomenon, and we can only hope that future studies will help find and clarify the proper treat- ment to ease these patients’ suffering.

—Dr Pesach Shvartzman

—Dr Roni Peleg Beer-Sheva, Israel

References

1. Raj PP. Practical management of pain. 3rd ed. St Louis, Mo:

Mosby; 2000.

2. Loeser JD, Butler SH, Chapman CR, Turk DC. Bonica’s management of pain.3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000.

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