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Background: Trigeminal neuralgia (TN) is the most common cause of facial pain, leading to significant disability and impacting a patient's quality of life. Percutaneous procedures like continuous radiofrequency, pulsed radiofrequency (PRF), and combined continuous and pulsed radiofrequency have been studied in past years comparing different voltages in order to find more effective therapies with fewer complications (eg, numbness and masseter muscle weakness). With regard to young patients, there is still insufficient evidence on the most appropriate procedure in this patient population. PRF does not cause thermal damage. The mechanism of action involves delivering an electrical field to targeted nerves or tissues, modulating pain. We propose that bipolar pulsed radiofrequency (2 parallel cannulas) in the trigeminal ganglion produce a denser and larger field resulting in more effective controlled pain. Case Presentation: We present 2 cases of 40‐ and 48‐year‐old men with severe V2 to V3 TN who underwent bipolar PRF. We performed bipolar PRF on the trigeminal ganglion through the foramen ovale using two 22‐gauge 100‐mm cannulas with 10‐mm active tips. Parameters used were voltage of 85 V, pulse width of 20 milliseconds, and total duration time of 6 minutes. Both patients reported complete relief of pain after the procedure, and at 2‐year follow‐up they were pain free and experienced a better quality of life. No complications were reported. Conclusion: Bipolar PRF could be a non‐neurodestructive option for young people with TN and deserves further investigation as a treatment option. [ABSTRACT FROM AUTHOR]

▪ Abstract: The sympathetic nervous system has been implicated in numerous pain syndromes ranging from neuropathic pain to vascular pain to visceral pain. In light of this, sympathetic ganglia have been the target of local anesthetic blockade to determine the sympathetic role in the transmission of pain. If analgesia is afforded with local anesthetic blockade, chemical or thermal neurolysis have been utilized to attempt to provide long-term relief. Despite frequent use of minimally invasive sympathetic blocks and neurolysis by pain practitioners, their efficacy for providing analgesia has been sparsely reported in the literature. Many case reports and case series have been published, but few placebo-controlled, blinded studies exist. This manuscript will review the literature on sympathetic blocks and summarize existing studies for each of the sympathetic blocks. The goal is to provide past, current, and future pain physicians with evidence that they can use to provide appropriate care for their patients. ▪ [ABSTRACT FROM AUTHOR]

Focuses on the emergence of pain medicine as a medical specialty. Criteria established by the American Board of Medical Specialties for the approval of new specialty boards; History of the Medical Specialty Board in the U.S.; Subspecialty certification granted by the board for pain medicine; Criteria for approval of new examining boards.

An obituary for Miles Day of the Department of Anesthesiology, Texas Tech University Health Sciences Center, is presented.

A response by Miles Day to a letter to the editor about his article on the description of the blockade of the ganglion of Walther published in the previous issue.

Introduction: Adverse reactions to radiopaque contrast media (RCM) are well documented with a wide range of incidences reported. The objective of this study was to determine how many patients in a sample of 200 who presents for interventional pain treatments report a history of adverse reactions to RCM. Methods: Data from 200 outpatients were collected using a self-administered questionnaire. The questionnaire was designed to obtain information about prior exposure to RCM and any adverse events plus other general information about allergic reactions including known risk factors for allergic reactions. Demographic data and information about past medical history were obtained from each patient. Results: Of the 200 patients surveyed, 16 reported having had an allergic reaction to RCM. The events met criteria for immediate hypersensitivity reaction. Chemotoxic reactions cannot be ruled out. Of factors associated with risk of allergic reaction, none were clearly more prevalent in subjects reporting an allergic reaction vs. subjects who did not. Atopic patients generally considered susceptible to contrast allergy reported no hypersensitivity reaction. The number of medications and foods the subjects reported caused them to have allergic reactions was extensive. Conclusion: Patients with a history suggestive of an immediate hypersensitivity reaction to RCM may report for interventional pain procedures normally performed with RCM. Patients who have experienced an immediate hypersensitivity reaction to RCM have increased risk for another reaction if injected again with contrast agent. Therefore, facilities should be prepared to implement measures to prevent recurrent reactions. [ABSTRACT FROM AUTHOR]

Study Design. A cross-sectional cadaveric examination of the mechanical effect of foraminal ligaments on cervical nerve root displacement and strain. Objective. To determine the role of foraminal ligaments by examining differences in cervical nerve root displacement and strain during upper limb neural tension testing (ULNTT) before and after selective cutting of foraminal ligaments. Summary of Background Data. Although investigators have determined that lumbar spine foraminal ligaments limit displacement and strain of lumbosacral nerve roots, similar studies have not been conducted to prove that it is true for the cervical region. Because the size, shape, and orientation of cervical spine foraminal ligaments are similar to those in the lumbar spine, it is hypothesized that foraminal ligaments in the cervical spine will function in a similar fashion. Methods. Radiolucent markers were implanted into cervical nerve roots C5–C8 of 9 unembalmed cadavers. Posteroanterior fl uoroscopic images were captured at resting and upper limb neural tension testing positioning before and after selective cutting of foraminal ligaments. Results. Selective cutting of foraminal ligaments resulted in significant increases in inferolateral displacement (average, 2.94 mm [ligaments intact]–3.87 mm [ligaments cut], P < 0.05) and strain (average, 9.33% [ligaments intact]–16.31% [ligaments cut], P < 0.03) of cervical nerve roots C5–C8 during upper limb neural tension testing. Conclusion. Foraminal ligaments in the cervical spine limited cervical nerve root displacement and strain during upper limb neural tension testing. Foraminal ligaments seem to have a protective role, reducing displacement and strain to cervical nerve roots during tension events. [ABSTRACT FROM AUTHOR]

Study Design. A cross-sectional cadaveric examination of displacement and strain measured at the level of the cervical nerve roots during upper limb neural tension testing (ULNTT) with median nerve bias. Objective. To determine the displacement and strain of cervical nerve roots C5–C8 during ULNTT with minimal disruption of surrounding tissues. Summary of Background Data. Clinical examination of neural pathology involving cervical nerve roots is diffi cult because of the transient nature of pathologies, such as cervical radiculopathy, entrapment neuropathies, and thoracic outlet syndrome. Cadaveric studies have demonstrated signifi cant displacement and strain in lumbosacral nerve roots during neurodynamic testing of the lower extremity. Examination into the biomechanical behaviors of cervical nerve roots during ULNTT has not been performed. Methods. Eleven unembalmed cadavers were positioned supine as though undergoing ULNTT. Radiolucent markers were implanted into cervical nerve roots C5–C8. Posteroanterior fl uoroscopic images were captured at resting and ULNTT positioning. Images were digitized and displacement and strain were calculated. Results. ULNTT resulted in signifi cant inferolateral displacement (average, 2.16 mm–4.32 mm, P < 0.001) of cervical nerve roots C5– C8. There was a signifi cant difference in inferolateral displacement between the C5 and C6 nerve roots (3.15 mm vs . 4.32 mm, P = 0.009). ULNTT resulted in signifi cant strain (average, 6.80%– 11.87%, P < 0.001) of cervical nerve roots C5–C8. There was a signifi cant difference in strain between the C5 and C6 nerve roots (6.60% vs . 11.87%, P = 0.03). Conclusion. ULNTT caused signifi cant inferolateral displacement and strain in cervical nerve roots C5–C8. These results provide the mechanical foundation for the use of ULNTT in clinical evaluation of pathology in the cervical region, such as in cervical radiculopathy, entrapment neuropathies, and thoracic outlet syndrome. [ABSTRACT FROM AUTHOR]

Persistent idiopathic facial pain, previously known as atypical facial pain, is described as a persistent facial pain that does not have the classical characteristics of cranial neuralgias and for which there is no obvious cause (International Classification of Headache Disorders in 2004). According to these criteria, the diagnosis is possible if the facial pain is localized, present daily, and throughout all or most of the day. By definition, neurological and physical examination findings in persistent idiopathic facial pain should be normal. Forming a diagnosis is not simple and follows a process of elimination of other causes of facial pain. The precise incidence is unknown. The affliction is seen primarily in older adults and rarely in children. The pathophysiology is unknown. In persistent idiopathic facial pain, there is no abnormal processing of somatosensory stimuli in the pain area or facial area of the primary somatosensory cortex of the brain. The treatment is difficult and often requires a multidisciplinary approach. The most important part of the treatment is psychological counseling and pharmacological therapy. Pharmacological treatment with tricyclic antidepressants and anti-epileptic drugs can be tried. The conservative, pharmacological treatment with amitryptiline is the primary choice. Venlafaxine and fluoxetine treatment can also be considered. When the pharmacological treatment fails, pulsed radiofrequency treatment of the ganglion pterygopalatinum (sphenopalatinum) can be considered (2 C+). [ABSTRACT FROM AUTHOR]

Background and Objectives: Complications associated with interventional pain procedures have raised questions regarding the relative safety of sharp vs. blunt needles. It has been speculated that the incidence of hemorrhage, intraneural and/or intravascular injections may be reduced by the use of blunt needles. In this study we compared penetration and bleeding associated with sharp vs. blunt needle punctures. Methods: Attempts were made to insert blunt and sharp needles (18-, 20-, 22-, and 25-gauge) directly or percutaneously into kidney, liver, renal artery, intestine or spinal nerve/nerve root of anesthetized dogs. Penetration and bleeding were ascertained by direct vision through a surgical wound. Results: All attempts to directly puncture the kidney and liver with sharp needles were successful. All but one attempt to puncture a spinal nerve/nerve root with 20-, 22-, and 25-gauge sharp needles were successful but half or less attempts to puncture the intestines were successful. All attempts to puncture the renal artery with sharp needles were successful. Blunt needles never punctured the renal artery, spinal nerve/nerve root and intestines and rarely penetrated the kidney (22- and 25-gauge one time each). All attempts to puncture the liver with blunt needles were successful. Bleeding scores for kidney punctures were generally higher for larger sharp needles than for smaller ones. Bleeding scores for blunt needle punctures of the liver were generally smaller than for sharp needle puncture. Conclusion: Blunt needles are less likely than sharp ones to enter vital structures and/or produce hemorrhage. Thus, blunt needles may be preferable to sharp ones for performing interventional pain procedures. [ABSTRACT FROM AUTHOR]