Pain and Sensory Dysfunction 6 to 12 Months After
Inguinal Herniotomy
Trine Mikkelsen, MS*, Mads U. Werner, MD, PhD†,
Henrik Kehlet, MD, PhD*
*Department of Surgical Gastroenterology and †Acute Pain Service, Department of Anesthesiology, Hvidovre University
Hospital, Copenhagen, Denmark
Inguinal hernia repair is associated with a 5%–30% incidence
of chronic pain, but the pathogenesis remains unknown. We
therefore evaluated pain and sensory dysfunction by quan-
titative sensory testing 6–12 mo after open herniorrhaphy.
Before sensory testing, all patients (n ⫽ 72) completed a
short-form McGill Pain Questionnaire and a functional im-
pairment questionnaire. Sensory dysfunction in the inci-
sional area was evaluated by quantification of thermal and
mechanical thresholds, by mechanical pain responses (von
Frey/pressure algometry), and by areas of pinprick hypoes-
thesia and tactile allodynia. The incidence of chronic pain
was28%(20of72).Quantitativesensorytestingandpressure
algometry did not demonstrate differences between the pain
I
nguinal hernia repair is a common procedure with
infrequent postoperative morbidity, but it may be
followed by complaints of chronic pain in 5%–30%
of patients (1). However, most studies have not as-
sessed chronic pain as the primary aim of the study;
therefore, assessment of the functional consequences
of chronic pain after inguinal herniotomy have only
recently been reported (2– 4). In these studies, approx-
imately 10% stated that pain was interfering with
work or leisure activity (2– 4), thus emphasizing the
importance of the problem.
The development of chronic pain after inguinal her-
niotomy has been attributed to several pathogenic
mechanisms, including damage to the well defined
sensory nerves in the groin area: the iliohypogastric
nerve, the ilioinguinal nerve, and the genitofemoral
nerve. Only two studies (5,6) have discussed the asso-
ciation between late postoperative cutaneous sensory
This study was supported by Grant 22010160 from the Danish
Medical Research Council.
Accepted for publication December 11, 2003.
Address correspondence to Mads U. Werner, MD, PhD, Depart-
ment of Oncology, University Hospital, SE 221 85 Lund, Sweden.
Address e-mail to madswerner@medscape.com. Reprints will not be
available from the authors.
DOI: 10.1213/01.ANE.0000115147.14626.C5
146 Anesth Analg 2004;99:146–51
Birgit Lassen, RNA†, and
and nonpain groups, except for a small but significant in-
crease in pain response to von Frey hair and brush stimula-
tion in the pain group. Hypoesthesia, or tactile allodynia, in
the incisional area was observed in 51% (37 of 72) of the pa-
tients, but the incidence did not differ significantly between
the pain group and the nonpain group (14 of 20 versus 23 of
52; P ⬎ 0.3). We concluded that cutaneous hypoesthesia, or
tactile allodynia, is common after inguinal herniotomy but
has a low specificity for chronic postherniotomy pain. Fac-
tors other than nerve damage may be involved in the devel-
opment of chronic postherniotomy pain.
(Anesth Analg 2004;99:146–51)
disturbances and pain. However, in both these stud-
ies, the examination technique was not presented, and
patients without pain were not examined, thereby
hindering interpretation regarding the association be-
tween chronic pain and sensory dysfunction as an
indicator of neuropathic pain. Therefore, the aim of
this study was to evaluate in detail the association
between chronic pain and sensory dysfunction in her-
nia repair patients with and without pain 6 –12 mo
after surgery.
Methods
After approval from the regional ethical committee, all
patients were included who had undergone elective
uncomplicated inguinal herniotomy by the Lichten-
stein procedure 6 –12 mo before the start of the study
at our institution. Exclusion criteria were female sex, a
bilateral procedure, surgery for recurrent hernia, age
younger than 18 yr, chronic opioid medication, lan-
guage barriers, cognitive dysfunction, or known neu-
rological disease. Questionnaires with prestamped re-
turn envelopes were mailed to 171 patients (Fig. 1).
After verbal and written consent, the patients were
asked to complete two questionnaires relating to pain
and functional impairment (3). All patients were given
©2004 by the International Anesthesia Research Society
0003-2999/04
ANESTH ANALG
2004;99:146 –51
Figure 1. Chart depicting patient flow. HIV ⫽ human immunode-
ficiency virus.
detailed verbal instructions for correct completion.
The first questionnaire is a modified Danish short
form of the McGill Pain Questionnaire (3) that con-
tains a visual analog scale (VAS; 0 –100) for assessment
of pain intensity, a list of adjectives describing pain
quality, and an anatomical chart for depiction of pain
localization. In the second questionnaire, the patients
were asked to assess how the pain was interfering
with daily living and leisure activity (3).
The quantitative sensory testing was performed
with the patients resting in a comfortable semireclined
position. To get the patients well acquainted with the
testing paradigm, a preparatory testing sequence was
performed at the patient’s forearm, followed by test-
ing in the groin area. During the examination, the
patient was asked to keep his eyes closed and to
concentrate on the evoked sensations. The patient was
unaware of the test results. The quantitative sensory
testing was done by two investigators (TM and BL).
The actual sensory testing was performed starting
in a reference area (25 ⫻ 50 mm) 4 cm cephalad for the
incision. The reference area was used for all sensory
thresholds and pain assessments in patients without
any demonstrable skin hyperesthesia. In patients with
hyperesthesia, a corresponding area (25 ⫻ 50 mm) was
demarcated centrally in the hyperesthesia zone, taking
PAIN MEDICINE MIKKELSEN ET AL. 147
SENSORY DYSFUNCTION AFTER HERNIOTOMY
care not to include scar tissue. This area and an area
immediately outside were used for sensory thresholds
and pain assessments.
Hypoesthesia was determined by stimulating with a
von Frey monofilament (Senselab Aesthesiometer; So-
medic AB, Sweden; No. 17; nominal buckling force,
468 mN) well outside the sensory testing area along
eight linear paths angled at 45° and converging to-
ward the center of the area. The patients were in-
structed to report a definite decrease in tactile sensa-
tion. Tactile allodynia was evaluated by gently
stroking the skin with a soft brush perpendicular to
the linear paths, and the patients were instructed to
report any sensation of discomfort or pain.
Mechanical pain threshold was evaluated by stim-
ulation with 11 progressively rigid calibrated von Frey
monofilaments (No. 7, 2 mN; No. 8, 3 mN; No. 9, 6
mN; No. 10, 12 mN; No. 11, 22 mN; No. 12, 34 mN; No.
13, 58 mN; No. 14, 89 mN; No. 15, 212 mN; No. 16, 309
mN; and No. 17, 468 mN [calibrated at 23°C and a
relative humidity of 35%]) as previously described (7).
The mechanical pain threshold was defined as the
least force that elicited a sensation of pain or discom-
fort. If von Frey filament No. 17 did not elicit a sen-
sation of pain or discomfort, the observation was as-
signed a value of 18. Pain responses (VAS 0 –100) to
mechanical stimuli were assessed by five stimuli of a
rigid von Frey filament (No. 17) with a stimulation
rate of 0.5 Hz.
Brush (dynamic) allodynia was evaluated by appli-
cation of an electric toothbrush (Oral-B 4713; Braun,
Germany; 127-Hz oscillations) on the skin for 30 s in
the incisional area. Brush-induced pain or discomfort
was evaluated by VAS ratings after 5 and 25 s of
stimulation.
The mechanical pain threshold from deep somatic
tissues was evaluated by pressure algometry (Bridge
amplifier; Somedic AB, Sverige) with a circular probe
(0.18 cm2) applied directly over the middle of the
inguinal ligament. Pressure was applied at a constant
rate (10 kPa/s), and the patient was instructed to press
a button when a sensation of pain or discomfort ap-
peared. Assessments were made in triplicate, with an
interstimulus interval of 30 s, and the median value
was used in the analysis.
Thermal thresholds were assessed by a computer-
ized 25 ⫻ 50 mm contact thermode (Modular Sensory
Analyzer; Somedic AB, Hörby, Sweden) applied in the
incisional area. The patients were instructed to imme-
diately push a button when a change of temperature
was perceived. Assessments of warm detection
threshold, cold detection threshold, and heat pain
threshold (HPT) were made in triplicate with random-
ized interstimulus intervals of 4 – 6 s, starting from a
baseline temperature of 32°C and with a ramp rate of
148 PAIN MEDICINE MIKKELSEN ET AL.
SENSORY DYSFUNCTION AFTER HERNIOTOMY
⫾1°C/s. The cutoff limits for warm and cold meas-
urements were 50°C and 25°C, respectively. The cre-
master reflex was elicited by stroking the inside of the
thigh with a von Frey monofilament No. 18 (1584
mN), and retraction was noted.
The chronological order of testing was assessment
of hypoesthesia and tactile allodynia, cold detection
threshold, warm detection threshold, mechanical pain
threshold (skin), HPT, mechanical pain response,
brush allodynia, cremaster reflexes, and mechanical
pain threshold (pressure algometry). All patients were
examined clinically with palpation of both groin areas
with the patient in the standing position, at rest, and
during coughing.
Data were analyzed for normality by the
Kolmogorov-Smirnov test (SPSS 10.0.7; SPSS Inc., Chi-
cago, IL). Because several of the test data were not
normally distributed, only nonparametric tests were
used: the Mann-Whitney test for nonpaired data and
Wilcoxon’s signed rank test for paired data. The ␹2 test
with Yates’ continuity correction or Fisher’s exact test,
as appropriate (8), was used to assess differences in
frequencies between groups. Values are median and
interquartile range (25%–75%) unless otherwise
stated. A P value ⬍0.05 was considered to indicate
statistical significance.
Results
Between January 1 and December 31, 2000, 171 male
patients had undergone elective primary inguinal her-
niotomy by the Lichtenstein procedure at our institu-
tion. Questionnaires with prestamped return enve-
lopes were mailed to all patients (Fig. 1). The median
age of the patients was 64 yr (interquartile range,
48 –73 yr). The investigation period started April 3 and
ended August 10, 2001, and the median follow-up
time was 9.5 mo (7–13 mo).
Twenty (28%) of the 72 patients had experienced
pain in the area, and 52 patients (72%) had not. Eleven
(15%) of the patients with pain indicated that pain
significantly interfered with work or leisure activity.
The most commonly chosen descriptors of pain were
pricking (13 of 20; Fig. 2), annoying/irritating (11 of
20), tender (10 of 20), and shooting/jolting (10 of 20).
The number of descriptors was 4 (interquartile range,
3– 8). The spontaneous VAS pain intensity in the pain
group was 22 (interquartile range, 12–30).
Mechanical hypoesthesia or tactile allodynia in the
incisional area was observed in 51% (37 of 72) of the
patients. Three patients in the pain group and six
patients in the nonpain group had areas with both
hypoesthesia and tactile allodynia in the incisional
area. The overall incidence of sensory dysfunction was
not different among pain patients (14 of 20) compared
with nonpain patients (23 of 52) (P ⬎ 0.3).
ANESTH ANALG
2004;99:146 –51
Figure 2. Pain descriptors reported from the pain questionnaire
(short form of the McGill Pain Questionnaire) (12). Categories are 1,
evaluative; 2–14, sensory; and 15–18, affective. The most commonly
chosen descriptors were 1, 3, 5, and 13.
There was no significant difference between the
pain group and the nonpain group in mechanical pain
thresholds for punctate stimuli (P ⬎ 0.4; Mann-
Whitney test; Table 1). In contrast, the pain response to
five repeated von Frey hair stimuli was significantly
higher (P ⬍ 0.002) in the pain patients, but the VAS
scores were very low (10 versus 2; Table 1). Pain to
brush-evoked stimulation (5 and 25 s) was also more
frequent in the pain group than in the nonpain group
(P ⬍ 0.02 and P ⬍ 0.03; Mann-Whitney test; Table 1),
but again with very low VAS scores, between 2 and 5
of 100 (Table 1). There was no difference in mechanical
pain perception (von Frey or brush) among the pain
patients with or without sensory dysfunction (P ⬎
0.3).
Mechanical pain threshold assessed by pressure al-
gometry in the incisional area did not differ between
the pain and the nonpain groups (P ⬎ 0.1; Mann-
Whitney test; Table 1). Warm detection, cold detec-
tion, and HPT did not differ between the pain group
and the nonpain group (P ⬎ 0.6; Mann-Whitney test;
Table 1).
The cremaster reflex was elicitable on the incisional
side in 14 of 20 patients in the pain group and in 44 of
52 patients in the nonpain group (P ⬎ 0.2; ␹2 Yates’
correction; Table 1). The physical examination did not
reveal any recurrent or new hernias. Anatomical pain
charts for the 20 pain patients are illustrated in Figure
3. In addition, two patients (Patients 29 and 52) spon-
taneously reported that they experienced severe ejac-
ulatory pain that led to sexual dysfunction and im-
pairment. Neither of these patients reported pain in
the incisional area.
Post hoc statistical analysis showed that the power of
the study (n ⫽ 72) ranged between 80% and 95% (␣ ⫽
0.05; ␤ ⫽ 0.05– 0.20) in regard to detection of a 2.5⫻
ANESTH ANALG
2004;99:146 –51
Table 1. Summary of Results from Quantitative Sensory Testing in the Incisional Area
Variable
Incidence of hypoesthesia (fraction of patients)
Incidence of tactile allodynia (fraction of patients)
Mechanical pain threshold (von Frey)
Mechanical pain response (von Frey ⫻ 5) (VAS 0–100)
Brush allodynia after 5 s of stimulation (VAS 0–100)
Brush allodynia after 25 s of stimulation (VAS 0–100)
Mechanical pain threshold in area (pressure algometry; kPa)
Warm detection threshold (°C)
Cold detection threshold (°C)
Heat pain threshold (°C)
Cremaster reflex (elicitable/total number)
VAS ⫽ visual analog scale.
Figure 3. Anatomical charts with patients’ localization of pain (n ⫽
20).
increased incidence of hypoesthesia or tactile allo-
dynia, a 10% change in thermal thresholds, a 40%
change in mechanical pain threshold (pressure algom-
etry), or a 40% change in the incidence of elicitation of
the cremaster reflex in the pain group compared with
the nonpain group.
Discussion
This study is the first to investigate chronic pain and
sensory dysfunction by quantified sensory testing in
PAIN MEDICINE MIKKELSEN ET AL. 149
SENSORY DYSFUNCTION AFTER HERNIOTOMY
Pain versus nonpain group
7/20 vs 12/52: P ⬎ 0.2
10/20 vs 17/52: P ⬎ 0.2
18 vs 18: P ⬎ 0.4
10 vs 2: P ⬍ 0.002
2 vs 0: P ⬍ 0.02
5 vs 0: P ⬍ 0.03
145 vs 178: P ⬎ 0.1
36.9 vs 37.0: P ⬎ 0.9
28.5 vs 28.4: P ⬎ 0.7
46.9 vs 47.2: P ⬎ 0.6
14/20 vs 44/52: P ⬎ 0.2
hernia repair patients 6 –12 months after elective un-
complicated surgery. A total of 28% of the patients
reported pain, and 15% stated that the pain interfered
with work or social activities; this is in agreement with
previous follow-up studies (2– 4,9). The quantitative
sensory testing showed that sensory disturbances, i.e.,
mechanical hypoesthesia and tactile allodynia, were a
common finding (37 of 72 patients; 51%) in the her-
niotomy area, but these sensory aberrations did not
seem to occur more often in patients with pain than in
patients without pain. Also, detailed, quantified sen-
sory testing did not demonstrate differences between
pain and nonpain patients except for minor, but sig-
nificant, increased VAS responses in pain patients to
von Frey and brush stimulation.
Chronic pain after herniotomy has primarily been
assumed to be of neuropathic origin (1), and it has
been hypothesized that the nerve injury could be at-
tributed either to direct surgical trauma or to delayed
injury caused by postoperative inflammatory changes.
A previously observed relationship between chronic
pain and late postoperative sensory dysfunction sup-
ports this interpretation (5,6), but in these studies no
detailed sensory assessments were performed, and no
information was provided from patients without pain.
In the Cunningham et al. study (5), pain and sensory
disturbances were followed up in 276 patients with
315 hernia repairs. At 12 months control, 31% of the
patients reported numbness in the incisional area, and
a significant correlation with pain was observed. On
physical examination, 90% of patients with sensory
impairment had hypoesthesia, whereas dysesthesia
was uncommon and allodynia was not noted. In a
large long-term follow-up questionnaire-based study,
8% of the patients indicated hypoesthesia and 2%
indicated touch- or movement-related paresthesia in
the incisional area (6).
In the study by Cunningham et al. (5), three distinct
types of pain were suggested but not analyzed: a
somatic pain localized to the common ligamentous
insertion to the pubic tubercle, a neuropathic pain
150 PAIN MEDICINE MIKKELSEN ET AL.
SENSORY DYSFUNCTION AFTER HERNIOTOMY
referable to the ilioinguinal or genitofemoral nerve
distribution, and a visceral, ejaculatory-related pain.
In the anatomical chart (Fig. 3) in this study, 9 of the 20
pain patients indicated pain near the incision, 6 indi-
cated discrete pain points near the inguinal ligament,
and 6 indicated a more circumscribed pain area (Fig.
3). As previously mentioned, two patients reported
ejaculatory pain. The discrete pain markings could
represent a somatic pain component or a neuroma
formation, whereas the circumscribed areas would
seem to suggest involvement of one or more nerve
branches. An anatomical study indicated a complex
innervation pattern of the three cutaneous nerves sup-
plying the groin area (10), and a detailed nerve lesion
interpretation is therefore not possible. In support of a
neuropathic component, we observed that 10 of the
pain patients, including 3 of 6 patients with circum-
scribed pain areas, used a combination of 2 or more
neuropathic pain descriptors (11–13), i.e., shooting,
pricking, burning, or tender (Fig. 2). The most fre-
quent pain descriptors belonged to the sensory or
evaluative category (pricking, annoying/irritating,
tender, and shooting/jolting), which is in close agree-
ment with a previous study (3).
A number of studies have evaluated chronic cuta-
neous sensory impairment after tissue injury, by using
quantitative testing methods: in postherpetic neural-
gia (14 –17), in neuropathy (18), in postmastectomy
pain (19), in osteoarthritis (20), and in whiplash injury
(21). In a prospective study of herpes zoster patients,
the presence in the acute stage of brush-induced allo-
dynia (gain of sensory function) and pinprick hypoes-
thesia (loss of sensory function) correlated with devel-
opment of postherpetic neuralgia (15). In a recent
study, it was suggested that two distinct mechanisms
may be operational in neuropathic pain: central sensi-
tization in patients with minor cutaneous sensory dys-
function (painful hyperalgesia) and partial nociceptive
deafferentation in patients with major sensory dys-
function (painful hypoalgesia) (18). In this study of 20
pain patients, 14 had tactile allodynia or hypoesthesia,
and 3 of these presented with a combination of allo-
dynia and hypoesthesia.
In a study of postmastectomy pain, sensory abnor-
malities were studied with a quantitative sensory test-
ing technique in pain patients (n ⫽ 15) and nonpain
patients (n ⫽ 11). The inclusion criterion was abnor-
mal sensitivity, painful (allodynia or dysesthesia) or
nonpainful (hypoesthesia or dysesthesia), in or
around the incisional area. Sensory thresholds to pin-
prick and thermal stimuli were significantly increased
on the operated side, with no difference between
groups. There was no difference in HPT in the pain
group, but a significant decrease was observed in the
nonpain group in the hypoesthetic/dysesthetic area.
The mechanical pain threshold for pinprick was sig-
nificantly lower in pain patients on the operated side
ANESTH ANALG
2004;99:146 –51
compared with control. Repetitive pinprick stimula-
tion was associated with higher pain ratings in the
pain group, indicating a prominent sensitization com-
ponent. Data from this study corroborate these find-
ings, bearing in mind that all pain patients in the study
by Gottrup et al. (19) had an abnormal hypersensitiv-
ity in the incisional area. In this area we observed no
difference in thermal detection thresholds and HPTs
between pain and nonpain patients, but we did ob-
serve an increased pain response to pinprick and
brush stimulation in patients with pain compared
with those without pain, although these differences
were quantitatively very minor (VAS ⬍10 on a 100-
point scale).
The lack of a clear relationship in sensory distur-
bances between pain and nonpain patients may at first
seem surprising. However, sensory disturbances may
be related to damage to the ilioinguinal and iliohypo-
gastric nerves, and studies with intraoperative cryo-
analgesia of these nerves have demonstrated sensory
dysfunction but no effect on acute pain for up to four
weeks after herniotomy (22). Therefore, chronic pain
after inguinal herniotomy may be related to damage to
deeper nerve structures (musculofascial layer) rather
than damage to the nerves traversing the surgical
field. Findings after herniotomy may therefore differ
from those after herpes zoster and mastectomy, both
of which include superficial tissue damage and there-
fore may be more closely related to cutaneous sensory
disturbances.
In conclusion, we studied pain and sensory dys-
function in 72 patients 6 –12 months after herniotomy
with a quantitative sensory testing technique. The in-
cidence of chronic pain was 28% (20 of 72) and that of
sensory dysfunction was 51% (37 of 72), but there were
no differences between the pain group and the non-
pain group. Quantitative sensory testing had a low
specificity for chronic pain after inguinal herniotomy.
Future studies should therefore include a detailed as-
sessment of all preoperative, intraoperative, and post-
operative factors to elucidate the pathogenesis of
chronic postherniotomy pain (23).
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