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With the ongoing opioid epidemic in the United States there has been a strong transition towards utilizing multi-modal analgesia, interventional procedures, and non-opioid medications when managing acute and chronic pain. There has also been an increased interest in utilizing buprenorphine. Buprenorphine is a novel long-acting analgesic with partial mu-opioid agonist activity that can be utilized for analgesia as well as opioid use disorder. Buprenorphine also has a unique set of side effects as well pharmacodynamic and pharmacokinetic properties that require special attention, especially if these patients require future surgical interventions. Given the increased interest in this medication we believe that there needs to be increased education and awareness regarding this medication amongst physicians, specifically pain management physicians and trainees.

Purpose of Review Headaches, especially migraines, are one of the most pervasive neurological disorders affecting up to 15.9% of the population. Current methods of migraine treatment include lifestyle changes, pharmacologic, and minimally invasive techniques such as peripheral nerve stimulation (PNS) and pericranial nerve blocks (PNB). Recent Findings PNBs are used to treat and prevent migraines and involves injection of local anesthetics with or without corticosteroids. PNBs include the greater occipital, supraorbital, supratrochlear, lesser occipital, auriculotemporal, sphenopalantine ganglion, and cervical root nerve blocks. Of the PNBs, the most extensively studied is the greater occipital nerve block (GONB) which has been shown to be an efficacious treatment for migraines, trigeminal neuralgia, hemi-crania continua, and post-lumbar puncture, post-concussive, cluster, and cervicogenic headaches but not medication overuse and chronic tension type headaches. Summary In this review, we aim to summarize the recent literature on PNBs and their efficacy in the treatment of migraines including a brief discussion of peripheral nerve stimulation.

This is a review of the latest and seminal evidence in pediatric migraine. It covers the etiology and pathophysiology known today, and then will review treatment options, efficacy and safety, quality of data and indications. Though migraine is usually regarded as an infliction in adults, it is not uncommon in the pediatric population and affects up to 8% of children. Children may experience migraine differently than adults, and present not only with headache but also frequent gastrointestinal symptoms. They are frequently shorter in duration than in adults. Traditional migraine treatment in adults is less effective in children. In this population, adjunct therapies – such as interventional techniques – should be considered when traditional treatment fails, including Botulinum Toxin A (BTA) injections, peripheral nerve and ganglion blocks. BTA injections are FDA approved for migraine prophylaxis in adults, but currently not in children; however, recent evidence shows efficacy and safety in pediatric migraine management. Nerve blocks stop nociceptive afferent fibers through injection of local anesthetics, and it may be associated with the local injection of corticosteroids. Although more common in adults, recent data suggests they are safe and effective in children and adolescents. Blocking the sphenopalatine ganglion can be achieved through nasal approach, and achieves a similar action by blocking the entire ganglion. Interventional techniques may provide a key component in the alleviation of this otherwise debilitating chronic migraine pain. Though most studies have been performed in adults, new studies provide encouraging results for treatment in children.

Management of mental health illnesses and needs are important in fostering psychosocial support, interprofessional coordination, and greater adherence to treatment protocols in the field of urology. This can be especially true for mental health conditions that may greatly impact the presentation of a patient in the healthcare setting with urologic symptoms. This review describes the history, epidemiology, pathophysiology, clinical presentation, and treatment of somatic symptom disorder, illness anxiety disorder, compulsive sexual behavior/hypersexuality, factitious disorder, malingering symptoms, and conversion disorder in the realm of urology. Given the newly updated psychiatric diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, there has been a lack of studies reviewing how these illnesses may present in a urology patient encounter. Additionally, as these mental health illnesses may carry a rare incidence compared to other well-known mental health illness such as generalized depression or generalized anxiety disorder, we have found that the lack of provisions and recognition of the diseases can prolong the timeline for diagnosis and lead to an increased cost in both healthcare and quality of life of patients with these mental health illnesses. This review provides awareness on these mental health conditions which may greatly impact patient history and presentation within the field of urology. Additionally, urologic care providers may have an improved understanding of interdisciplinary management of such illnesses and the common symptoms patients may present with such diseases.

Background Vasectomy is a procedure that results in permanent yet reversible sterility and remains a great contraceptive option for many. Previous research studies have highlighted frequency of vasectomy utilization, defining characteristics of individuals who opt for this method, various surgical techniques, and the risks and benefits associated with the procedure. What remains to be defined is why or why not individuals may experience post-vasectomy regret and whether the previous characteristics correlate. Objective The objective of this review is to synthesize information regarding reasons individuals may regret their vasectomy and seek reversal, what options exist for accomplishing the reversal, and patients’ fertility prognosis post-vasovasostomy. Methods This review utilized a combination of secondary and tertiary data analysis across a wide scope of academic databases pertaining to the topic of interest. Results Typically, most males who have sought a vasectomy are satisfied with their decision, however, approximately 6% of this population seeks reversal. Key factors influencing vasectomy regret include age at the time of vasectomy, parental status, pre- and post-operative relationship status, unresolved physical and psychosexual problems, and development of chronic scrotal pain following the procedure. Few options exist for vasectomy reversal including microsurgical reconstructive vasectomy reversal (VR) and sperm extraction for in vitro fertilization. There is no guarantee that fertility will be restored in any case but a major predictive factor for success is the time interval prior to reversal. Conclusion Vasectomy is intended to be a permanent form of contraception; however, a minor chance remains that individuals may experience post-operative regret due to various factors. This warrants proper comprehensive counseling by the patient’s provider regarding benefits and risks, procedural outcomes, opportunities for reversal, and fertility prognosis.

Chronic shoulder pain affects millions of patients each year. Various conditions can result in shoulder pain ranging from rotator cuff injury, subacromial impingement, post-surgical pain, bursitis, adhesive capsulitis, and osteoarthritis. Typically, rotator cuff pathology is diagnosed by physical exam maneuvers along with advanced imaging modalities. Initial treatment for rotator cuff injury typically consists of physical therapy, NSAIDs, and possible injections depending on the extent of the injury. If conservative measures fail or the injury is too substantial, surgery is typically the appropriate treatment for healthy patients. For patients who are not surgical candidates or refuse surgery, peripheral nerve stimulation (PNS) can be considered. With the use of PNS, the suprascapular and axillary nerves can be targeted to provide pain relief for a variety of chronic shoulder pain issues. We describe the use of PNS in 2 patients with significant rotator cuff pathology who were not surgical candidates.

Sacroiliac joint (SIJ) pain is responsible for approximately a third of reported back pain. Patients with SIJ pain report some of the lowest quality of life scores of any chronic disease. Understanding of the physiology and pathology of the SI joint has changed dramatically over the years, and SI joint pain and injury can now be thought of in two broad categories: traumatic and atraumatic. Both categories of SI joint injury are thought to be caused by inflammation or injury of the joint capsule, ligaments, or subchondral bone in the SI joint. Treatment of SI joint pain usually involves a multi-pronged approach, utilizing both, multi-modal medical pain control and interventional pain/surgical techniques such as steroid injections, radiofrequency nerve ablation, and minimally invasive sacroiliac arthrodesis. Though conservative management through multi-modal pain control and physical therapy have their role as first line therapies, an increasing body of evidence supports the use of minimally invasive procedures, both as adjuvant treatments to conservative management and as second line therapies for patient’s that fail first line treatment.

Chronic pain affects roughly 50 million Americans, or 20.4% of the national population, and is a huge economic burden on society. Spinal cord stimulation (SCS) is a cost-effective interventional treatment modality for patients with chronic neuropathic and radicular pain. It is traditionally reserved for patients suffering from post-laminectomy syndrome, complex regional pain syndrome, or chronic back pain that is refractory to other less invasive techniques. There have been a few cases describing the use of SCS at higher levels to successfully obtain coverage of visceral abdominal pain. Here we describe an interesting case of a patient who suffered from chronic back pain and radiculopathy with post-laminectomy syndrome as well as chronic abdominal pain. We describe the use of high-frequency SCS to alleviate the patient’s post-laminectomy pain as well as his abdominal pain. Our case describes SCS use with multi-level lead placement targeting both post-laminectomy pain and abdominal pain. We describe a strategy that can be useful to patients with concurrent pain from more than one source. Our case also adds to the growing evidence supporting the use of SCS for treating chronic visceral pain syndromes.

Previously used as anti-arrhythmic, intravenous lidocaine infusion is becoming popular for use in management of acute pain. There is still much to be understood about its pharmacokinetics and pharmacodynamics, especially with regard to optimal dosing to avoid side effects. In this article, we selected and reviewed randomized controlled trials to summarize the pharmacokinetics, antinociceptive effects, anti-hyperalgesic effects, anti-inflammatory effects, side effects, and role of intravenous lidocaine in the management of early postoperative pain. The mechanisms of action of lidocaine are still unclear but there are many theories postulated. Optimal dosing of lidocaine is not known but general consensus indicates that a loading dose of 1-2 mg/kg, followed by 1-2 mg/kg/hr continuous infusion during early postoperative pain control while recovering from anesthesia to achieve therapeutic levels of 0.5-5 mcg/kg clearly improves analgesia in the immediate postoperative period. Although lidocaine was initially studied and proven to have clear analgesic effects following laparoscopic and open abdominal surgeries, it has now been shown to be applicable in different clinical settings perioperatively including following spinal, breast, ENT and other surgeries. It is generally safe, with hypotension, headache and vomiting being the more common side effects. Serious adverse effects include cardiovascular block and arrhythmias, neuro-excitability and hypersensitivity, although the frequency of these are not known.

PURPOSE OF REVIEW: This is a comprehensive review and update on advances in the understanding and treatment of slipping rib syndrome. It covers the physiology and pathophysiology at the basis of the syndrome, epidemiology and clinical presentation as well as diagnosis. It goes on to review the available literature to provide description and comparison of the available methods for alleviation. RECENT FINDINGS: Slipping rib syndrome stems from irritation of intercostal nerves. It is caused by slipping of the costal cartilage and the resulting displacement of a false rib and pinning underneath the adjacent superior rib and nerve irritation. It is rare and spans genders and ages; most evidence about epidemiology is conflicting and mostly anecdotal. Risk factors include trauma and high intensity athletic activity. Presentation is of a sudden onset of pain with jerking motion; the pain can be localized, radiating or diffuse visceral. It is often alleviated by positions that offload the impinged nerve. Diagnosis is clinical, and can be aided by Hooking maneuver and dynamic ultrasound. Definitive diagnosis is with pain relief on nerve block, visualization of altered anatomy during surgery and relief after surgical correction. Initial treatment includes rest, ice and NSAIDs, as well as screening for co-morbid conditions, as well as local symptomatic relief. Injection therapy with local anesthetics and steroids can provide a diagnosis as well as symptomatic relief. Surgical correction remains the definitive treatment. SUMMARY: Slipping rib syndrome is a rare cause of chest pain that could be perceived as local or diffuse pain. Diagnosis is initially clinical and can be confirmed with nerve blocks and surgical visualization. Initial treatment is symptomatic and anti-inflammatory, and definitive treatment remains surgical. More recently, advanced surgical options have paved way for cure for previously hard to treat patients.

BACKGROUND: Post dural puncture headache (PDPH) is a known complication which may occur in the setting of patients undergoing lumbar punctures (LP) for diagnostic or therapeutic purposes. The gold standard for treating a PDPH is an epidural blood patch (EBP). There have been few publications evaluating the long-term outcomes of PDPH treated with EBP. The aim of this pilot study was to examine the incidence of chronic headaches in dural puncture patients who received EBP versus those who did not. METHODS: A retrospective case control study was performed at a single large center institution. Forty-nine patients who had intentional dural puncture were identified on chart review and completed a survey questionnaire via phone interview: twenty-six of these patients required a subsequent EBP, while twenty-three did not. The primary outcomes were the development and prevalence of chronic headaches after the procedures. There was no statistically significant difference in the prevalence of current headaches between the EBP group and Non-EBP group (54% vs. 52% p = 0.91). There were no significant differences in the rates of severity and descriptive qualities of headache between the EBP and non-EBP groups. There was higher incidence of tinnitus in the PDPH patients. SUMMARY: This pilot study demonstrates that patients who received an EBP for treatment of a PDPH following LP are no more likely to experience chronic headaches compared to patients who do not receive an EBP. However, both the EBP group and Non-EBP group had high incidence of chronic headaches which may be related to dural puncture or a baseline trait of this cohort given the recall bias. There is a suggestion that tinnitus could be a long-term residual symptom of PDPH treated with EBP.

PURPOSE OF REVIEW: This is a comprehensive review of the literature regarding the use of asenapine for the treatment of schizophrenia (SZ) in adults. It covers an introduction, epidemiology, risk factors, pathophysiology, and current treatment modalities regarding SZ, provides a background on the mechanism of action of asenapine, and then reviews the existing evidence for use of asenapine in both its sublingual and transdermal formulation in the treatment of SZ. RECENT FINDINGS: SZ is a complex and multifactorial mental disorder which is thought to combine several genetic, epigenetic, and environmental factors causing abnormalities in the dopaminergic system. Symptoms are categorized in delusions, hallucinations, disorganization, and negative presentations like affective flattening and apathy. Current treatment focuses on antipsychotic medications by means of oral administration or long-acting injection. Asenapine is a second-generation antipsychotic with 5HT-2A antagonist and 5HT-1A/1B partial agonist properties, which provides a favorable profile in targeting schizophrenic symptoms, while reducing motor side effects and improving mood and cognition. Asenapine in its sublingual formulation was FDA approved for treatment of SZ and bipolar I disorder in adults in August of 2009 and has been proven to be both effective and safe. Transdermal patch of asenapine (Secuado) was FDA approved in October of 2019, the first and only FDA approved patch for SZ in adults, which offers another strategy for treatment to improve compliance and ease of administration. SUMMARY: SZ is a chronic and debilitating disease which is still not well understood and comes at great cost with regards to the quality of life for patients. Medication side-effects and compliance are enormous issues which take a toll on health care systems in industrialized nations and keep patients from achieving stability with their disease. Transdermal asenapine is a new first-in-class dosage form and provides a novel modality of administration. It has been shown to be effective in reducing positive, as well as negative symptoms, while still maintaining a favorable side-effect profile.

PURPOSE OF REVIEW: This is a comprehensive review of the literature regarding the use of Lofexidine for opiate withdrawal symptoms. It covers the background and necessity of withdrawal programs and the management of withdrawal symptoms and then covers the existing evidence of the use of Lofexidine for this purpose. RECENT FINDINGS: Opiate abuse leads to significant pain and suffering. However, withdrawal is difficult and often accompanied by withdrawal symptoms and renewed cravings. These symptoms are driven mostly by signaling in the locus coeruleus and the mesolimbic system and a rebound increase in noradrenaline, producing symptoms such as anxiety, gastrointestinal upset, and tension. Lofexidine, an alpha-2 agonist, can be used to manage acute withdrawal symptoms before starting maintenance treatment with either methadone or buprenorphine. Lofexidine, if FDA approved for management of withdrawal symptoms and has been proved to be both effective and safe. SUMMARY: Opiate addiction is increasing and plaguing the western world and specifically the U.S. It takes a large toll on both a personal and societal level and carries a high cost. Withdrawal is difficult, both related to withdrawal symptoms and renewed cravings. Lofexidine has been shown to be effective in reducing the former and could potentially aid in recovery and withdrawal.

Amnon A Berger,1 Jamal Hasoon,1 Ivan Urits,1 Omar Viswanath,2– 4 Jatinder Gill1 1Beth Israel Deaconess Medical Center and Harvard Medical School, Department of Anesthesia, Critical Care and Pain Medicine, Boston, MA, USA; 2Valley Anesthesiology and Pain Consultants – Envision Physician Services, Phoenix, AZ, USA; 3University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA; 4Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USACorrespondence: Jamal HasoonBeth Israel Deaconess Medical Center and Harvard Medical School, Department of Anesthesia, Critical Care and Pain Medicine, Boston, MA, USAEmail Jhasoon@bidmc.harvard.eduAbstract: Chronic pain affects roughly 50 million Americans, or 20.4% of the national population, and is a huge economic burden on society. Spinal cord stimulation (SCS) is a cost-effective interventional treatment modality for patients with chronic neuropathic and radicular pain. It is traditionally reserved for patients suffering from post-laminectomy syndrome, complex regional pain syndrome, or chronic back pain that is refractory to other less invasive techniques. There have been a few cases describing the use of SCS at higher levels to successfully obtain coverage of visceral abdominal pain. Here we describe an interesting case of a patient who suffered from chronic back pain and radiculopathy with post-laminectomy syndrome as well as chronic abdominal pain. We describe the use of high-frequency SCS to alleviate the patient’s post-laminectomy pain as well as his abdominal pain. Our case describes SCS use with multi-level lead placement targeting both post-laminectomy pain and abdominal pain. We describe a strategy that can be useful to patients with concurrent pain from more than one source. Our case also adds to the growing evidence supporting the use of SCS for treating chronic visceral pain syndromes.Keywords: abdominal pain, chronic pain, neuromodulation, spinal cord stimulation