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Background Nutcracker syndrome is a rare disorder caused by compression of the left renal vein, usually between the aorta and the superior mesenteric artery. It typically presents with left-sided abdominal pain and hematuria. Left renal vein transposition is the most commonly employed surgical technique to alleviate the compression. Case presentation A 22-year-old Caucasian man with a known diagnosis of nutcracker syndrome had undergone left renal vein transposition 1 year before presentation without any subsequent pain relief. In addition, his surgery was complicated by massive blood loss and a 1-week-long stay in an intensive care unit (ICU); as such, he was not amenable to further surgical intervention or stenting to treat his underlying pathology. His symptoms included constant sharp left-sided flank, perineal, and testicular pain. A series of ganglion impar blocks were performed every 3–4 months over the course of 5 years with substantial pain relief achieved. Conclusions Our case report highlights a treatment option that has not yet been described for patients with pain secondary to nutcracker syndrome refractory to surgical intervention.

INTRODUCTION: The Neuromodulation Appropriateness Consensus Committee (NACC) is dedicated to improving the safety and efficacy of neuromodulation and thus improving the lives of patients undergoing neuromodulation therapies. With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion (DRG) stimulation has significantly improved the treatment of complex regional pain syndrome (CRPS), among other conditions. Through funding and organizational leadership by the International Neuromodulation Society (INS), the NACC reconvened to develop the best practices consensus document for the selection, implantation and use of DRG stimulation for the treatment of chronic pain syndromes. METHODS: The NACC performed a comprehensive literature search of articles about DRG published from 1995 through June, 2017. A total of 2538 article abstracts were then reviewed, and selected articles graded for strength of evidence based on scoring criteria established by the US Preventive Services Task Force. Graded evidence was considered along with clinical experience to create the best practices consensus and recommendations. RESULTS: The NACC achieved consensus based on peer-reviewed literature and experience to create consensus points to improve patient selection, guide surgical methods, improve post-operative care, and make recommendations for management of patients treated with DRG stimulation. CONCLUSION: The NACC recommendations are intended to improve patient care in the use of this evolving therapy for chronic pain. Clinicians who choose to follow these recommendations may improve outcomes.

Introduction Spinal cord stimulation (SCS) devices are cost effective and improve function as well as quality of life. Despite the demonstrated benefits of SCS, some patients have the device explanted. We are interested in exploring the patient characteristics of those explanted. Methods This is a retrospective chart review of neurostimulation patients who underwent explantation at 18 centers across the United States within the previous five years. Results Data from 352 patients were collected and compiled. Failed Back Surgery syndrome was the most common diagnosis (38.9%; n = 136/350) and over half of the patients reported numerical rating scale (NRS) scores ≥8 prior to implant (64.3%; n = 207/322). All patients reported changes in NRS scores across time, with an initial decrease after implant followed by a pre-explant increase (F (2, 961) = 121.7, p

Objectives The objective of this study was to present results from a multicenter registry designed to obtain longitudinal clinical outcome data for patients implanted with a neuromodulation system for the management of chronic pain of the trunk and/or limbs. Materials and Methods Interim data from 579 patients across 40 study sites were analyzed from a prospective, observational, noninterventional registry. Institutional review board approval was obtained prior to enrollment. The following were recorded at baseline and at 3, 6, and 12 months postimplant: patient-reported pain relief, categorical ratings of pain relief, Pain Disability Index (PDI) scores, quality of life, medication usage, and patient satisfaction. Pain relief among (tobacco) smokers was also assessed. Descriptive statistics were compiled for all patient outcome measurements, and data are reported as mean (±standard deviation). All statistical analysis was conducted using one-sided t-tests with a significance level of α = 0.05. Device-related adverse events were captured and are reported. Results Patient-reported pain relief was 58.0% (±26.2%) at 3 months, 58.1% (±28.7%) at 6 months, and 57.0% (±29.4%) at 12 months. Mean PDI scores were reduced from 47.7 points at baseline to 33.3, 32.4, and 31.9 points, respectively (p ≤ 0.001). The majority of patients categorized their pain relief as “excellent” or “good” and reported their overall quality of life as “greatly improved” or “improved” at all time points. In addition, greater than 79% of patients were “satisfied” or “very satisfied” with the therapy at all time points assessed, and 47.1% of patients “stopped” or “decreased” use of narcotics/opioids. Pain relief was significantly attenuated by smoking (p = 0.042). The most common adverse event was persistent pain and/or numbness at implantable pulse generator/lead site, which accounted for 18.6% of all events in 3.2% of all patients. Conclusions These results provide evidence to further support the safety, efficacy, and sustainability of neuromodulation in clinical practice.

Objective This longitudinal, clinical outcome study was a multicenter, prospective, observational, registry with a 24-month assessment of patients implanted with spinal cord stimulation (SCS) systems for the management of chronic pain of the trunk and/or limbs. Methods On informed consent and institutional review board approval, 614 patients from 39 sites were enrolled within 30 days following permanent SCS system implantation. Medication usage, patient-reported pain relief (PRP), categorical ratings of pain relief, pain disability index scores (PDI), quality of life (QoL), and patient satisfaction were assessed at enrollment, 3-, 6-, 12-, 18-, and 24-month postimplant. Device-related adverse events (AEs) were recorded and reported. Results Across all visits, statistically significant improvements were reported on all outcome measures. Mean PRP was 58.5% (± 26.4) at 3 months, 56.8% (± 29.2) at 6 months, 57.7% (± 28.9) at 12 months, 55.6% (± 29.8) at 18 months, and 56.3% (± 30.3) at 24 months. More than 65% of patients at any visit reported a PRP ≥ 50%. Mean PDI scores reduced from 46.9 points at baseline to 32.7, 31.8, 31.5, 32.1, 32.1 points at 3, 6, 12, 18, and 24 months (p ≤ 0.0001), respectively. Greater than 76% of patients at any visit were satisfied with their therapy. The majority of patients categorized pain relief as excellent or good on a 5-item scale and reported overall QoL as greatly improved or improved on a 5-item scale. An average of 88% of patients stopped, decreased, or did not change dose of narcotics/opioids. The most common AE was diminished or loss of pain relief in 11.4% of enrolled patients. Conclusions Most patients experienced substantial pain relief and a significant improvement in all outcome measures. These results further support the safety, efficacy, and sustainability of SCS in clinical practice.

Objective: To show the value of computed tomography (CT) in selectively blocking the pudendal nerve in patients with long-term anogenital pain of uncertain etiology. We report a technique to selectively block the pudendal nerve using CT guidance in 2 patients with long-term anogenital pain. Case Report: In 1 patient, a competitive cyclist, the diagnosis of pudendal neuralgia was substantiated by blocking the nerve under CT. The procedure relieved the pain for approximately 24 hours. In the other patient, pudendal nerve block produced perineal analgesia but no pain relief. Superior hypogastric plexus block relieved the pain significantly for about 4 weeks on 2 separate occasions, suggesting sympathetically maintained pain. Conclusion: The use of CT to guide the procedure allowed precision in performing the procedure and in making a differential diagnosis. Reg Anesth Pain Med 2000;25:420-423.

Objectives: Charcot-Marie-Tooth (CMT) disease is one of the most common hereditary neuropathies affecting one in 2500 people in the United States. CMT disease is associated with moderate to severe chronic extremity pain. We present the case of a young man with chronic intractable lower extremity pain associated with CMT disease treated with spinal cord stimulation (SCS). Materials and Methods: This was an Institutional Review Board-approved case study involving a 37-year-old man diagnosed with CMT disease with pain of more than 20 years. He was implanted with an SCS device and patient pain and quality of life was assessed one and six months later using the SF-McGill Pain Questionnaire, Visual Analog Scale, Oswestry Disability Questionnaire, Pain Disability Index, and SF-36. Baseline measures were obtained retrospectively. Qualitative data were collected from the medical record. Results: SCS was effective in decreasing pain, improving quality of life and reducing medication consumption at both one and six months post-implant. In addition, the patient was satisfied with SCS treatment. Conclusion: SCS produced favorable results in a patient with CMT and should be considered a treatment option for pain resulting from this condition.

The sacroiliac joint as a source of chronic pain has been a subject of debate for a long period of time. This controversy stems from the inherent anatomic location of the sacroiliac joint. Adjacent spinal structures may cause pain to be referred to the sacroiliac joint, thus making a precise diagnosis difficult. The most reliable method to establish the diagnosis of sacroiliac arthralgia is fluoroscopic-guided intra-articular injection of a local anesthetic preceded by a sacroiliac arthrogram. Although there are many therapeutic options for sacroiliac joint syndrome, the ideal treatment has not yet been discovered. There is evidence that intra-articular viscosupplementation of the sacroiliac joint with hylan can consistently and reliably induce a prolonged analgesic response in sacroiliac joint syndrome. Viscosupplementation restores joint homeostasis, allows increased joint motion, and induces analgesia. Hylan is highly viscoelastic hyaluronan (hyaluronic acid), and is capable of increasing the viscoelastic properties of synovial fluid.

Introduction Occipital peripheral nerve stimulation is an interventional pain management therapy that provides beneficial results in the treatment of refractory chronic occipital neuralgia. Herein we present a first-of-its-kind case study of a patient with neurofibromatosis type 1 and bilateral occipital neuralgia treated with occipital peripheral nerve stimulation. Case presentation A 42-year-old Caucasian woman presented with bilateral occipital neuralgia refractory to various conventional treatments, and she was referred for possible treatment with occipital peripheral nerve stimulation. She was found to be a suitable candidate for the procedure, and she underwent implantation of two octapolar stimulating leads and a rechargeable, programmable, implantable generator. The intensity, severity, and frequency of her symptoms resolved by more than 80%, but an infection developed at the implantation site two months after the procedure that required explantation and reimplantation of new stimulating leads three months later. To date she continues to experience symptom resolution of more than 60%. Conclusion These results demonstrate the significance of peripheral nerve stimulation in the management of refractory occipital neuralgias in patients with neurofibromatosis type 1 and the possible role of neurofibromata in the development of occipital neuralgia in these patients.