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Interventional pain management is a subspecialty of medicine devoted to the use of invasive techniques such as joint injections, nerve blocks/or neurolysis, neuromodulation, and epidural and selective nerve blocks to provide diagnosis and treatment of pain syndromes unresponsive to conventional medical management.

Pain and loss of function is routine following breast cancer surgeries. The perception that these issues will always resolve over time, or even worse, cannot be treated at all is unfortunately commonplace among members of the cancer care team. Important points in doing a history and physical exam on the patient with breast pain are described. Options to treat postmastectomy and postreconstruction pain, as well as radiation fibrosis, using a multimodal approach are discussed. Pain management in this population strategically employs the use of conventional analgesics, interventional procedures, regional blocks, and botulinum toxin, among other modalities. A clinician attuned to the important principles outlined in this chapter can make a significant impact on the quality of life of patients affected by this most common cancer.

Intrathecal drug delivery has expanded since the inception of this technology in the 1980s and is utilized for a number of different conditions including pain control and management of spasticity. The use of intrathecal pumps is less common than most other techniques for interventional pain management but is essential in such conditions as refractory pain, cancer pain, multifocal pain, severe spasticity, and in patients who are not candidates for surgical correction of their underlying condition. Intrathecal drug delivery is usually considered when analgesics or antispasmodics administered via the oral, transdermal, or intravenous routes are ineffective or are associated with unacceptable side effects. The intrathecal delivery of medications bypasses the blood–brain barrier, which produces much higher concentrations of medication within the cerebrospinal fluid. This higher concentration can serve to dramatically reduce the effective dose of the medication and can be associated with higher rates of pain and spasm reduction compared to other routes of medication delivery. Although intrathecal drug delivery has been shown to be effective and cost-effective this less utilized pain management tool is less well understood regarding its implantation and management than other technologies. This chapter will serve to highlight the proper clinical use and appropriate management of intrathecal pumps for the management of spasticity and pain.

Background: Neurosurgeons and orthopedists, who have received specific training, should be the ones performing spinal surgery. Here, we present a case in which spinal surgeons secondarily (e.g., 6 months later) found that a patient’s first lumbar discectomy, performed by an interventional specialist, had been a “sham” procedure. Case Description: A 30-year-old male presented with sciatica attributed to a magnetic resonance imaging documented large, extruded disc at the L4-5 level. An interventional pain management specialist (IPMS) performed two epidural steroid injections; these resulted in an exacerbation of his pain. The IPMS then advised the patient that he was a surgeon and performed an “interventional” microdiscectomy. Secondarily, 6 months later, when the patient presented to a spinal neurosurgeon with a progressive cauda equina syndrome, the patient underwent a bilateral laminoforaminotomy and L4-L5 microdiscectomy. Of interest, at surgery, there was no evidence of scarring from the IPMS’ prior “microdiscectomy;” it had been a “sham” operation. Following the second surgery, the patient’s cauda equina syndrome resolved. Conclusion: IMPS, who are not trained as spinal surgeons should not be performing spinal surgery/ microdiscectomy.

Introduction: Lumbar zygopophyseal joint arthropathy is one of the most common causes of low back pain in adults. Historically, C-arm/Fluoroscopy has served as an image guidance tool in intra-articular facet joint injections, however, now ultrasound guidance is also a viable option. Aim: To compare ultrasonography (USG) and fluoroscopy as therapeutic imaging modalities on the basis of time taken for intervention, Visual Analogue Score (VAS) for pain and Oswestry Disability Index (ODI) at 2, 4 and 12 weeks. Materials and Methods: It was a prospective interventional study done with 62 patients who satisfied the inclusion and exclusion criteria and randomly allocated into two groups. Groups were compared on the basis of time taken for intervention, VAS for pain and ODI at 2, 4 and 12 weeks. Independent sample student t-test/Mann-Whitney U test was applied. Confidence Interval (CI) was taken as 95% and p-value

Background: Interventional procedures are offered routinely to patients seen in McGill University’s interdisciplinary cancer pain management program. However, publications on these procedures are scarce, making it difficult to predict which patients may benefit from them. Objectives: We hypothesized that interventional pain procedures offered to cancer patients could provide relief of pain as well as other symptoms. Furthermore, some variables may predict the efficacy of such procedures. Study Design: We conducted a retrospective chart review of interventional pain management procedures. Setting: The procedures reviewed were conducted at the Cancer Pain Program and performed at the interventional suites of the McGill University Health Centre. Methods: The retrospective chart review included interventional pain management procedures performed between June 2015 and March 2017. Demographic data, details about the underlying cancer and about the procedure and peripTrocedural patients’ reported outcomes were recorded for analysis. Results: Eighty-two of 126 procedures were included for analysis. Most patients presented with metastatic disease (75%). Eighty percent of the patients reported pain relief, with the average pain severity decreasing by more than 2 points on a 0-to-10 Numeric Rating Scale for pain (from 6.5 of 10 to 4.2 of 10). Forty-three percent of patients were considered responders (≥ 50% pain relief). Responders also reported a significant decrease in fatigue, depression, anxiety, drowsiness, and improved well-being. Among responders, average daily opioid use decreased significantly, by 60% on average. None of the analyzed variables correlated with the response; however, psychosocial variables like anxiety and depression showed a nonsignificant trend towards predicting procedure failure. Limitations: The core limitations of this study are its size and retrospective nature. Conclusions: In this cohort of cancer pain patients, interventional cancer pain procedures provided effective pain relief and other benefits, including pain relief, reduced burden of symptoms, and reduction of opioid intake, while demonstrating a favorable safety profile. Patients with poorer ratings of depression and fatigue derived less benefit from procedures, suggesting that offering such procedures as part of patients’ treatment plan would be sensible, rather than leaving interventions for later stages. Key words: Cancer pain, pain management, pain intractable, treatment outcomes, palliative care, advanced cancer, cancer, evidence-based madicine

This report describes a case involving a balloon kyphoplasty bone tamp becoming lodged inside the vertebral body and unable to be withdrawn, the first report of its kind in the literature. A board certified interventional pain management physician was performing a balloon kyphoplasty for an L3 osteoporotic vertebral compression fracture using a bipedicular approach with two bone tamps. Cannulation and cavity formation were completed without complication; however, upon removal of the balloons it was noted that one had become lodged in the vertebral body. Several attempts were made to remove the balloon. Neurosurgery and the balloon manufacturer were consulted intraoperative, and it was decided to leave the balloon fragments in situ and complete the interventional fixation of the vertebral body with bone cement. The patient followed up in the clinic several months later without neurologic complications. Postoperative radiography confirmed the presence of a retained foreign body consistent with balloon fragments. Balloon kyphoplasty and its various procedural complications will be discussed, as well as the intraoperative decision making faced when encountering a complication.

Background: The coronavirus disease 2019 (COVID-19) pandemic has drastically altered daily living and medical care for Ohio residents and the practice of medicine for the interventional pain management physician. As a state, Ohio tends to be demographically representative of the broader US population. Objective: Reviewing the efforts deployed by Ohio to flatten the COVID-19 infection curve and reduce the spread of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an important component of determining optimal procedures for mitigating the effects of the COVID-19 pandemic. Methods: Over the course of several announcements and orders during the months of March and April, new policies were put into place to prevent COVID-19 transmission, which included efforts to facilitate social distancing and ensure the health care system could manage the number of COVID-19 cases at peak infection rate. Efforts directed toward medical providers included delay of elective procedures, expansion of telehealth options, and new temporary guidance for prescribing controlled substances. Results: The Ohio COVID-19 containment approach resulted in a substantial reduction in COVID-19 cases compared with early models of disease spread, and the state has begun a phased reopening. Continued vigilance in applying social distancing and infection control measures will be a critical component of preventing or reducing the impact of a second wave of COVID-19 in Ohio. Limitations: A narrative review with paucity of literature. Key words: COVID-19, infection rates, mitigating effects, pandemic, infection control

Background: Since the late 1940s, corticosteroids have been a mainstay class of agents in multiple interventional techniques and intra-articular injections. Exogenous glucocorticoids are structurally and pharmacologically similar to the endogenous hormones. As such, multiple actions of corticosteroids are exhibited, including those of anti-inflammatory and immunosuppressive effects. Epidural injections, with or without steroids, have been extensively used throughout the world. There are reports of epidural injections starting in 1901, with steroids being added to the local anesthetic since 1952, when steroids were administered into the sacral foramen. Purpose: Due to the extensive side effects of steroids in various injections, some have proposed limiting their use in epidurals and intraarticular injections. With the COVID-19 pandemic, the multiple side effects of the steroids have elevated the level of concern and recommendations have been made to utilize local anesthetic alone or the lowest dose of steroids. Fashioned from common expressions of the day, the term “steroid distancing” began to be used and proposed for intraarticular injections of the knee. Consequently, we sought to evaluate the evidence and feasibility of steroid distancing in interventional pain management. Methods: This focused review of local anesthetics and steroids utilized in interventional pain management for epidural injections, peripheral nerve blocks, and intraarticular injections by multiple database searches. This is a focused narrative review and not a systematic review. Consequently, evidence synthesis was not performed traditionally, but was based on an overview of the available evidence. Results: No significant difference was identified based on whether steroids are added to local anesthetic or not for epidural as well as facet joint injections. However, there was not enough evidence to compare these 2 groups for peripheral intraarticular injections. Limitations: The present review is limited by the paucity of literature with bupivacaine alone or bupivacaine with steroids local anesthetic alone or with steroids of intraarticular injections of knee, hip, shoulder and other joints, and intraarticular facet joint injections. Conclusion: This review shows an overall lack of significant difference between lidocaine alone and lidocaine with steroids in epidural injections. However, available evidence is limited for bupivacaine alone or with steroids. Evidence is also not available comparing local anesthetic alone with steroids for facet joint or peripheral joint intraarticular injections. Thus, it is concluded that local anesthetic with lidocaine may be utilized for epidural injections, with appropriate patient selection and steroids reserved for non-responsive patients with local anesthetic and with significant radiculitis. Key words: Steroid distancing, chronic pain, steroids, epidural injections, local anesthetic alone, local anesthetic with steroid, steroid distancing, physical distancing

To assess the effectiveness of pain management with superior hypogastric plexus block (SHPB) compared to epidural anesthesia (EDA) in women requiring uterine artery embolization (UAE). In this retrospective, single-center, non-randomized trial we included 79 women with symptomatic uterine fibroids who were scheduled for percutaneous, transcatheter UAE. According to their informed decision, the women were assigned to two different approaches of pain management including either SHPB or EDA. The effectiveness outcome measure was patient reported pain using a numeric rating scale ranging from 1 to 10. The pain score was assessed at UAE, 2 hours thereafter, and at subsequent intervals of 6 hours up to 36 hours after intervention. Treatment groups did not differ significantly regarding age, pain score for regular menstrual cramps, uterine fibroid size, location, and symptoms of uterine fibroids. During UAE and up to 6 hours thereafter, women who received SHPB experienced stronger pain than those who received EDA (mean pain score during UAE: 3.3 vs. 1.5, p 0.001; at 2 hours: 4.4 vs. 2.8, p = 0.012; at 6 hours: 4.4 vs. 2.6, p = 0.021). The maximum pain level was 5.8 ± 2.9 with SHPB and 4.5 ± 2.9 with EDA (p = 0.086). Women with a history of severe menorrhagia tended to experience worse pain than those without (regression coefficient 2.5 [95 % confidence interval -0.3 to 5.3], p = 0.076). Among women who underwent UAE, pain management including SHPB resulted in stronger pain during and after the procedure than pain treatment including EDA.· Pain control with superior hypogastric plexus block was worse than epidural anesthesia.. · Peak of pain was at 12 hours after uterine artery embolization.. · Maximum pain was independent from uterine fibroid size or location..· Malouhi A, Aschenbach R, Erbe A et al. Effectiveness of Superior Hypogastric Plexus Block for Pain Control Compared to Epidural Anesthesia in Women Requiring Uterine Artery Embolization for the Treatment of Uterine Fibroids - A Retrospective Evaluation. Fortschr Röntgenstr 2021; 193: 289 - 297.ZIEL: Bestimmung der Wirksamkeit der Schmerzbehandlung durch Blockade des Plexus hypogastricus superior (superior hypogastric plexus block; SHPB) verglichen mit einer Epiduralanästhesie (EDA) bei Embolisation der Uterusarterien (uterine artery embolization; UAE). In diese retrospektive, monozentrische, nicht randomisierte Studie wurden 79 Frauen mit symptomatischem Uterusmyom eingeschlossen, für die eine perkutane UAE geplant war. Die Schmerzkontrolle erfolgte entweder mit Unterstützung des SHPB oder der EDA. Ergebnisparameter zur Wirksamkeit war die Schmerzstärke auf einer Skala von 1 bis 10. Abgefragt wurde die Schmerzstärke während sowie 2 Stunden nach UAE und jeweils im Abstand von 6 Stunden bis 36 Stunden nach der UAE. Die Behandlungsgruppen unterschieden sich nicht signifikant in Hinblick auf Alter, Schmerzstärke bei vorangegangenen Menstruationen, Größe und Lage der Myome sowie Symptome. Frauen, bei denen ein SHPB vorgenommen wurde, hatten stärkere Schmerzen als diejenigen, die eine EDA erhielten (mittlere Schmerzstärke während der UAE: 3,3 vs. 1,5, p 0,001; nach 2 Stunden: 4,4 vs. 2,8, p = 0,012; nach 6 Stunden: 4,4 vs. 2,6, p = 0,021). Die maximale Schmerzstärke betrug 5,8 ± 2,9 mit SHPB und 4,5 ± 2,9 mit EDA (p = 0,086). Patientinnen, mit Menorrhagien in der Vorgeschichte neigten zu stärkeren Schmerzen als andere (Regressionskoeffizient 2,5 [95 %-Konfidenzintervall –0,3 bis 5,3], p = 0,076). Frauen, bei denen eine Embolisation der Uterusarterien durchgeführt wurde, empfanden während und nach dem Eingriff unter einem SHPB stärkere Schmerzen als mit EDA.· Die Schmerzkontrolle durch Blockade des Plexus hypogastricus superior war der Epiduralanästhesie unterlegen.. · Die Schmerzen erreichten 12 Stunden nach Embolisation ihren Höhepunkt.. · Die maximale Schmerzstärke war unabhängig von der Größe und Lage des Myoms..

INTRODUCTION The situation generated in the health system by the COVID-19 pandemic has provoked a crisis involving the necessity to cancel non-urgent and oncologic activity in the operating room and in day-to-day practice. As the situation continues, the need to reinstate attention for patients with chronic pain grows. The restoration of this activity has to begin with on-site appointments and possible surgical procedures. On-site clinical activity has to guarantee the safety of patients and health workers. OBJECTIVES The objective of this review was to evaluate how to manage activity in pain units, considering the scenario generated by the pandemic and the implications of chronic pain on the immune system and proposed pharmacological and interventional therapies. METHODS Besides the established general recommendations (physical distance, surgical masks, gloves, etc.), we established specific recommendations that will allow patient treatment and relieve the disruption of the immune response. It is important to highlight the use of opioids with the least influence in the immune system. Further, individualized corticoid use, risk assessment, reduced immune suppression, and dose adjustment should take patient needs into account. In this scenario, we highlight the use of radiofrequency and neuromodulation therapies, techniques that do not interfere with the immune response. CONCLUSIONS We describe procedures to implement these recommendations for individual clinical situations, the therapeutic possibilities and safety guidelines for each center, and government recommendations during the COVID-19 pandemic.

ObjectiveTo conduct a systematic literature review of peripheral nerve stimulation (PNS) for pain.DesignGrade the evidence for PNS.MethodsAn international interdisciplinary work group conducted a literature search for PNS. Abstracts were reviewed to select studies for grading. Inclusion/exclusion criteria included prospective randomized controlled trials (RCTs) with meaningful clinical outcomes that were not part of a larger or previously reported group. Excluded studies were retrospective, had less than two months of follow-up, or existed only as abstracts. Full studies were graded by two independent reviewers using the modified Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the US Preventative Services Task Force level-of-evidence criteria.ResultsPeripheral nerve stimulation was studied in 14 RCTs for a variety of painful conditions (headache, shoulder, pelvic, back, extremity, and trunk pain). Moderate to strong evidence supported the use of PNS to treat pain.ConclusionPeripheral nerve stimulation has moderate/strong evidence. Additional prospective trials could further refine appropriate populations and pain diagnoses.

Pain is a universal phenomenon;every human being has experienced some type of and some degree of pain during his or her life span Roughly one third to one half of the whole population has suffered from chronic pain During the recent past the approach towards management of chronic pain has dramatically changed The opioid epidemic created alarm in the developed countries, and forced the clinicians to seek new pharmaceutical agents with less side effects and less potential for abuse The interventional pain management developed itself as an advanced branch of the pain management, thanks to the development of new and better technologies, e g , radiological imaging including ultrasound use as well as fluoroscopic and even CT and MRI use for guided neural interventions COVID-19 forced us initially to cease all interventions, only after a few months to modify patient selection and our routine management protocols This editorial offers a glimpse of this transformation to ‘the new normal’

Background Chronic pain is a widespread problem that is usually approached by focusing on its psychological aspects or on trying to reduce the pain from the pain generator. Patients report that they feel responsible for their pain and that they are disempowered and stigmatized because of it. Here, we explored interventional pain management from the patient’s perspective to understand the process better. Methods A purposive sample of 19 subjects was interviewed by an independent interviewer. The interviews were transcribed into text and thematic analysis was performed. Results The subjects’ perceptions covered three key themes: themselves as objects; the caregivers, including the process of tests and retests, the encounters and interactions with professionals, and the availability of the caregivers; and finally the outcomes, including the results of the tests and treatments and how these inspired them to think of other people with pain. Linking these themes, the subjects reported something best described as “gained empowerment” during interventional pain management; they were feeling heard and seen, they gained knowledge that helped them understand their problem better, they could ask questions and receive answers, and they felt safe and listened to. Conclusions Many of the themes evolved in relation to the subjects’ contact with the healthcare services they received, but when the themes were merged and structured into the model, a cohesive pattern of empowerment appeared. If empowerment is a major factor in the positive effects of interventional pain management, it is important to facilitate and not hinder empowerment. Trial registration Clinicaltrials.gov 2013-04-24 (Protocol ID SE-Dnr-2012-446-31 M-3, ClinicalTrials ID NCT01838603).

ObjectiveTargeted intrathecal drug delivery (TIDD) is an effective interventional pain management modality often used in postlaminectomy patients with refractory chronic low back pain. A combination of intrathecal bupivacaine with an opioid is often used. However, intrathecal catheter tip granulomas have occurred with use of morphine or hydromorphone but generally not with fentanyl. The objective of this study was to compare the efficacy of TIDD using bupivacaine/fentanyl vs bupivacaine/hydromorphone in patients with chronic intractable low back pain postlaminectomy.Materials and MethodsA retrospective comparative analysis of consecutive patients with lumbar postlaminectomy syndrome who were trialed and later received TIDD with a combination of bupivacaine/hydromorphone or bupivacaine/fentanyl between June 2009 and May 2016 at a single tertiary medical center.ResultsWe identified a cohort of 58 lumbar postlaminectomy patients receiving a TIDD admixture of either hydromorphone/bupivacaine (30 patients) or low-dose fentanyl/bupivacaine (28 patients) with at least two years of follow-up. The fentanyl group had significantly lower baseline opioid consumption and a lower rate of intrathecal opioid dose escalation. Both groups had similar and significant reductions in pain scores over the two-year follow-up period. No granulomas were observed.ConclusionTIDD using a low-dose fentanyl admixture with bupivacaine in patients with postlaminectomy syndrome and refractory chronic low back pain results in similar pain relief to TIDD with hydromorphone and bupivacaine. Low-dose intrathecal fentanyl leads to a lower rate of opioid escalation and may be safer than hydromorphone.

BACKGROUND: Coeliac plexus block (CPB) is an interventional pain management option for patients with pancreatic or other upper abdominal malignancy. AIMS: To assess the safety, utilization, and outcomes of CPBs in the local context. METHODS AND RESULTS: We conducted a retrospective case series of all patients with cancer who underwent CPB at 4 Sydney teaching hospitals from March 2010 to February 2016. We recorded baseline demographic data, details of the injectate, procedural approach and survival, as well as pain scores and analgesic use at 4 time points of interest. Thirty‐nine procedures were performed during the study period. Twenty‐four were performed endoscopically, 14 were performed via a bilateral percutaneous posterior approach by Pain Specialists or Radiologists and 1 was performed intraoperatively by a Surgeon. Patients had experienced pain for a mean of 17 weeks prior to CPB. Prior to CPB, the mean pain score was 8.8 out of 10. The mean pain score was reduced at 48 hours, 2 weeks, and 4 weeks following CPB (P

Total knee arthroplasty is a common and successful treatment modality for knee arthritis that is refractory to conservative management strategies. Over 600,000 arthroplasties are performed per year in the United States, and this number is expected to increase in the coming years. Unfortunately, 8% to 34% of patients experience chronic pain after having a total knee arthroplasty. These patients should undergo an appropriate work-up by the orthopedic surgeon, but many times a surgical problem is not uncovered. In these situations, a thorough and specific plan for pain management should be sought. In this article, we outline the work-up of a painful total knee arthroplasty. Then we provide a thorough review of interventional pain management strategies and highlight the pertinent literature. Lastly, we hypothesize future developments in the field that may provide better outcomes for patients suffering from painful total knee arthroplasty.

Background and objectivesMastectomy has many potential sources of pain. Rhomboid intercostal block (RIB) is a recently described plane block. The primary hypothesis of the study is that ultrasound-guided RIB combined with general anesthesia would accelerate global quality of recovery scores of patients following mastectomy surgery. Secondary hypothesis is that RIB would reduce postoperative opioid consumption, pain scores, and the need for rescue analgesia.MethodsPatients aged between 18 and 70 years, with American Society of Anesthesiologists physical status I–II and scheduled for an elective unilateral modified radical mastectomy surgery with axillary lymph node dissection were enrolled to the study. Following endotracheal intubation, patients were randomly allocated into two groups. Patients in the first group (group R) received ultrasound-guided RIB with 30 mL 0.25% bupivacaine. In the control group (group C), no block intervention was applied. All patients received intravenous dexamethasone 8 mg, dexketoprofen trometamol 50 mg intraoperatively and tramadol 1 mg/kg 30 min before the end of surgery for postoperative analgesia. All patients received intravenous morphine patient-controlled analgesia device at the arrival to the recovery room.ResultsThe descriptive variables of the patients were comparable between group R and group C. Mean quality of recovery-40 score at 24 hours was 164.8±3.9 in group R and 153.5±5.2 in group C (mean difference 11.4 (95% CI 8.8 to 13.9; pConclusionsIn the current study, ultrasound-guided RIB promoted enhanced recovery and decreased opioid consumption after mastectomy surgery.Trial registration numberACTRN12619000879167.

ObjectiveTo conduct a systematic literature review of spinal cord stimulation (SCS) for pain.DesignGrade the evidence for SCS.MethodsAn international, interdisciplinary work group conducted literature searches, reviewed abstracts, and selected studies for grading. Inclusion/exclusion criteria included randomized controlled trials (RCTs) of patients with intractable pain of greater than one year’s duration. Full studies were graded by two independent reviewers. Excluded studies were retrospective, had small numbers of subjects, or existed only as abstracts. Studies were graded using the modified Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the US Preventative Services Task Force level-of-evidence criteria.ResultsSCS has Level 1 evidence (strong) for axial back/lumbar radiculopathy or neuralgia (five high-quality RCTs) and complex regional pain syndrome (one high-quality RCT).ConclusionsHigh-level evidence supports SCS for treating chronic pain and complex regional pain syndrome. For patients with failed back surgery syndrome, SCS was more effective than reoperation or medical management. New stimulation waveforms and frequencies may provide a greater likelihood of pain relief compared with conventional SCS for patients with axial back pain, with or without radicular pain.

Background and objectivesSeveral clinical studies have focused on assessing the effectiveness of different radiofrequency ablation (RFA) modalities in pain management. While a direct head-to-head clinical study is needed, results from independent studies suggest that water-cooled RFA (CRFA) may result in longer lasting pain relief than traditional RFA (TRFA). The primary purpose of this study was, therefore, to investigate in a preclinical model, head-to-head differences between the two RFA technologies.MethodsRFA was performed in a rat sciatic nerve model (n=66) in two groups: (1) TRFA or (2) CRFA. The surgeon was not blinded to the treatment; however, all the physiological endpoints were assessed in a blinded fashion which include histological, MRI, and nerve function assessment via electromyography.ResultsThe energy delivered by the generator for CRFA was significantly higher compared with TRFA. Histological staining of nerves harvested immediately following CRFA exhibited extended length and multiple zones of thermal damage compared with TRFA-treated nerves. MRI scans across 4 weeks following treatment showed edematous/inflammatory zones present for longer times following CRFA. Finally, there was greater attenuation and prolonged loss of nerve function measured via electromyography in the CRFA group.ConclusionsThis study shows that CRFA has greater energy output, as well as more pronounced structural and functional changes elicited on the peripheral nerves compared with TRFA. While these preclinical data will need to be confirmed with a large clinical randomized controlled trial, we are encouraged by the direction that they may have set for those trials.

The working mechanism of neurostimulation for pain management is originally based on the gate control theory. The low intensity and low frequency stimulation as used with conventional stimulation of the dorsal columns elicits paresthesia to part of the body corresponding to the stimulated neural tissue. Recently novel targets (the dorsal root ganglion) and novel SCS-paradigms (Burst or High Frequency) were developed and tested. The stimulation of the dorsal root ganglion was documented to have advantages over the stimulation of the dorsal column for some indications. Neurostimulation has proven to be of use in failed back surgery syndrome, complex regional pain syndrome and painful diabetic polyneuropathy. Pulsed radiofrequency treatment relies on the application of a high intensity electric field close to the nerve. PRF is used for the treatment of different types of neuropathic pain.

Advanced interventional pain management techniques are safe, effective procedures for a number of pain syndromes, including radicular pain, occipital headaches, sympathetically mediated pain, pancreatic cancer, pelvic pain, and facial pain. The techniques developed and refined by Dr. Gabor Racz are described with systematic instructions. Detailed medical illustrations are included to clarify the text. Experienced practitioners will be able to incorporate this information into their practice, and trainees will be able to learn enough to gain more from their training and laboratory conferences.

The primary care provider can manage various aspects of care for the patient with chronic pain. This is a multidisciplinary approach. Management of chronic pain involves the coordination of care from various organ specialists, physical therapists, and behavioral health specialists. It also involves the psychosocial aspects of pain which the primary care provider can address. Goal settings, expectation setting, positive affect interventions can be done in the primary care setting. Identifying negative affects such as depression, catastrophizing, and solicitous relationships can also be done by the primary care provider. Lastly, the primary care provider can refer to various pain specialists which may recommend procedures to improve chronic pain. Pain management techniques and interventions can be summarized as the combination of three components: a stimulus that alters nerve function, a delivery method, and a nervous system target (i.e. brain, spinal cord, or peripheral nerve).

To the editor, Despite of the use of multimodal analgesia, total knee replacement (TKR) causes severe postoperative acute pain and can lead to persistent pain, interfering with rehabilitation and quality of life, in at least 20% of the patients. For that reason, we read with great interest the

Interventional pain management (IPM) is frequently utilized to treat pain syndromes in the adult chronic pain population (Smith et al., Med Clin North Am 100(1):103–115, 2016). Such techniques can reduce sensitization, provide regional pain relief, and are often performed in an effort to decrease systemic analgesic requirements. The standard of care in pediatric pain medicine harbors a multidisciplinary approach to restoring physical and social function while minimizing disability. Appropriately performed procedures often serve as diagnostic tools and, in select cases, may facilitate successful participation in rehabilitative programs. Procedural approaches are particularly useful for malignancy-related pain conditions, neuropathic pain syndromes, and chronic pain that is refractory to conservative treatment (Shah et al., Pain Pract 16(3):359–369, 2016). IPM encompasses a wide variety of techniques, including neuraxial injections, peripheral nerve blocks, joint infiltrations, neuromodulation, botulinum toxin application, and radiofrequency denervation. Although pediatric efficacy data are limited, appropriately performed procedures can play an important role in a child’s treatment plan, particularly after conservative measures have failed (Vega et al., Paediatr Anaesth 28:999, 2018). This chapter will provide an overview of commonly utilized interventional approaches to treat pediatric chronic pain.

Background: Several cell-based therapies have been proposed in recent years the management of low back pain, including the injection of medicinal signaling cells or mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP). However, there is only emerging clinical evidence to support their use at this time. Purpose: To assess the effectiveness of MSCs or PRP injections in the treatment of low back and lower extremity pain. Study Design: A systematic review and metaanalysis of the effectiveness of PRP and MSCs injections in managing low back and lower extremity pain. Data Sources: PubMed, Cochrane Library, US National Guideline Clearinghouse, prior systematic reviews, and reference lists. The literature search was performed from 1966 through June 2018. Study Selection: Randomized trials, observational studies, and case reports of injections of biologics into the disc, epidural space, facet joints, or sacroiliac joints. Data Extraction: Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR). The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Data Synthesis: Twenty-one injection studies met inclusion criteria. There were 12 lumbar disc injections, 5 epidural, 3 lumbar facet joint, and 3 sacroiliac joint studies Results: Evidence synthesis based on a single-arm metaanalysis, randomized controlled trials (RCTs), and observational studies, disc injections of PRP and MSCs showed Level 3 evidence (on a scale of Level I through V). Evidence for epidural injections based on single-arm metaanalysis, a single randomized controlled trial and other available studies demonstrated Level 4 (on a scale of Level I through V) evidence. Similarly, evidence for lumbar facet joint injections and sacroiliac joint injections without metaanalysis demonstrated Level 4 evidence (on a scale of Level I through V).. Limitations: Lack of high quality RCTs. Conclusion: The findings of this systematic review and single-arm metaanalysis shows that MSCs and PRP may be effective in managing discogenic low back pain, radicular pain, facet joint pain, and sacroiliac joint pain, with variable levels of evidence in favor of these techniques. Key Words: Chronic low back pain, regenerative therapy, medicinal signaling or mesenchymal stem cells, platelet-rich plasma, disc injection, lumbar facet joint injections, sacroiliac joint injections

Background: Radiofrequency neurotomy (RFN) is a therapy aimed at providing lasting back pain relief for sacroiliac joint (SIJ) pain. A recent advancement in RFN is a strip lesioning technique that involves placement of a single curved electrode and a 3-pole design that facilitates the creation of 5 overlapping lesions. These lesions form one long strip lesion accessible through a single entry point, without the need for multiple punctures. Although the early case series data looks promising, there is lack of long-term, randomized, controlled study evaluating the strip-lesioning system for SIJ pain. Objectives: The purpose of this study was to examine the safety and effectiveness of RFN using a strip lesioning device for reduction of SIJ pain. Study Design: Prospective, double-blind, randomized, sham-controlled trial with 6-month follow-up Setting: A tertiary care interventional pain management center in the UK Methods: Patients with SIJ pain with positive diagnostic local anesthetic blocks were randomly assigned (2:1) to either the sham (no RF lesions performed) or the active group (RF lesions performed). The primary endpoint was improvement of pain using the Numeric Rating Scale (NRS-11) at 3 months. Results were analyzed using nonparametric tests. Safety, secondary, and long-term outcome data were also collected. Results: Seventeen of 30 enrolled patients were randomly assigned to active treatment (n = 11) or sham treatment (n = 6). At 3 months, the mean NRS-11 score for the active group had decreased significantly, from 8.1 (± 0.8) at baseline to 3.4 (± 2.0) (P < 0.001). The sham group did not experience a statistically or clinically meaningful decrease in mean NRS-11 score from baseline (7.3 ± 0.8) to 3 months (7.0 ± 1.7). On average, patients in the active group moved from borderline anxiety at baseline (9.4 ± 5.9) to no anxiety (6.6 ± 6.3) at 3 months. Results were similar at 6 months. Limitations: Recruitment was stopped at 30 enrolled patients, only 17 of whom were randomly assigned to active or sham treatment, after the interim analysis indicated a statistically significant (P < 0.001) difference in the pain outcome between the treatment and the sham groups. Conclusions: This study demonstrated that radiofrequency neurotomy using a strip lesioning device is an appropriate therapy to treat SIJ pain. Key words: Radiofrequency, sacroiliac joint pain, low back pain, neurotomy, randomized controlled trial, simplicity

The objective of this article is to review literature on the history, proposed mechanism, and clinically relevant information on pulsed radiofrequency neuromodulation (PRF). We collected a variety of publications reviewing the safety and efficacy of PRF for various conditions commonly encountered in the field of pain management. Numerous randomized control trials, prospective series, and case reports have been published studying PRF. Many of the publications used for this review were case reports and clinical trials evaluating the safety and efficacy of PRF. Although there is evidence in some studies of the efficacy of PRF, results are occasionally conflicting or inconclusive. PRF is a safe and effective modality with a rapidly growing body of evidence to support its use in a number of clinical conditions. These conditions include headaches, radicular pain, chronic shoulder pain, axial low back pain, knee and hip pain, and peripheral nerve pain. Further studies are needed to determine which clinical conditions respond best to this therapy.

Background: Interventional pain management is essential for patients with cancer who experience medically uncontrollable chest wall pain to help control their symptoms and improve their quality of life. However, there is a lack of data on this topic, so there is an urgent need for further research. Objectives: To identify the effects of radiofrequency ablation (RFA) of the thoracic nerve roots on pain outcomes in patients with cancer and intractable chest wall pain. Study Design: Retrospective, observational cohort study. Setting: National Cancer Center in Korea. Methods: The medical records of patients with cancer who were referred to the pain clinic at our National Cancer Center for intractable chest wall pain and who underwent thoracic nerve root RFA between Jan. 1, 2011 and Dec. 31, 2015 were analyzed. The primary outcome was the change in Numeric Rating Scale (NRS) scores between pre-procedure and one week, one month, and 6 months post-procedure. The secondary outcomes were the change in morphine equivalent daily dose (MEDD) between pre-procedure and one week, one month, and 6 months post-procedure, and whether the primary cancer type (lung vs. non-lung) or radiotherapy to the chest within one month affected the outcomes of RFA. The Wilcoxon signed-rank test was used to compare RFA data between pre and post-procedure and P values less than 0.05 were considered statistically significant. Results: One hundred patients were included in the final analysis. The median NRS score in patients who underwent RFA decreased from 7 (range 3–10) pre-procedure to 4 (0–9) at one week and one-month post-procedure (both P < 0.001) and 4 (1–8) at 6 months post-procedure (P < 0.001). The median MEDD value decreased from 200 (range 30–1800) mg pre-procedure to 180 (10–1600) mg at one week post-procedure (P < 0.001), but there was no statistically significant change at one month (P = 0.699) or 6 months (P = 0.151) post-procedure. There was no difference in RFA outcome according to type of primary cancer or radiotherapy to the chest within one month. Limitations: Retrospective design. Conclusion: Radiofrequency thermocoagulation of the thoracic nerve roots achieved effective short-term pain control in patients with cancer and intractable chest wall pain. Key words: Radiofrequency ablation, thermocoagulation, thoracic nerve root, cancer, chest wall pain, radiotherapy, pain relief

Background: Among the various causes of vertigo, the so-called cervicogenic vertigo (CV) has been the most controversial. However, perturbations of proprioceptive signals and abnormal activity of the cervical afferents can induce vertigo. Medial branch blocks (MBBs) are a diagnostic tool designed to test whether a patient’s neck pain is mediated by one or more of the medial branches of the dorsal rami of the spinal nerve. It is unknown whether MBBs are also suitable for testing symptoms other than pain. Objectives: The purpose of this study was to test whether MBBs of the cervical spine can be used as a diagnostic tool to identify patients with CV. Study Design: A retrospective practice audit (clinical observation). Setting: An interventional pain management and spine practice. Methods: An electronic medical record system was used to identify patients in a single spine center. Included were consecutive patients with neck pain and vertigo, who had received cervical MBBs in a period from July 2001 to April 2016. The patients were tested with a MBB of about 1 mL of bupivacaine (0.25%) and 20 mg triamcinolone. Injections were performed with fluoroscopic visualization using established techniques in 2 or 3 levels on one or both sides. Vertigo was analyzed through the global clinical impression of the patient (i.e., “gone,” “better,” “the same,” or “worse”). Results: One-hundred seventy-eight patients met the inclusion criteria. One-hundred eleven patients (62.4%) experienced a significant improvement of the vertigo. In 47 patients (26.4%), no information about the vertigo was available at follow-up; these patients were assumed to have no improvement (worst-case scenario). Hence, altogether 67 patients (37.6%) had a negative result. The median relief of the vertigo was 2 months. Differences in age, gender, level of treatment, or pain duration between patients with relief of the vertigo and without relief were not found. Nine patients with a whiplash injury in their medical history were also tested. They experienced a lower success rate and had longer duration of pain before the treatment; however, these differences are not statistically significant. Limitations: It was the primary intention to treat neck pain; the assessment of vertigo was an additional aim. Therefore, the history taken and the clinical examination were not targeted specifically to vertigo. A placebo effect cannot be excluded. Further studies with the primary focus on CV are necessary to prove the significance of MBBs. Conclusions: This is the first study to demonstrate that MBBs of the cervical spine can be a useful tool for the diagnosis of CV, because they temporarily block cervical afferents. In 63.4% of patients with neck pain and suspected CV, the vertigo was significantly improved. Further placebo-controlled studies with the primary intention on CV are necessary to prove the significance of MBBs. Key words: Cervicogenic vertigo, medial branch block, facet joint, zygapophysial joint, neck pain, differential diagnosis

Pudendal neuralgia is a pronounced pain in pudendal nerve dermatomes, most often aggravated in the sitting position. This condition is characterized by such symptoms as pain in the perineum, genitals, anus. The onset of pudendal nerve neuralgia can occur after surgery, cycling, trauma or without a provocative factor. Today, there is no ideal method for treating pudendal neuralgia. Treatment includes medication, blockade, decompressive surgery, or radiofrequency intervention. The article presents the clinical case of a patient who received a stable positive result due to radiofrequency pulse ablation (PRF) of the pudendal nerves after unsuccessful long-term conservative treatment. 44 years age patient complained of a pronounced pulling and throbbing pain in the perineum from the anus to the pubis, which was strengthened in the sitting position. The manifestation of the disease occurred several years ago for no apparent reason. Over time, the pain acquired signs of neuropathic, that is, burning and baking, sometimes unbearable. Conservative treatment included non-steroidal, anti-inflammatory drugs, physiotherapy procedures, massage and antidepressants. But it turned out to be ineffective: the patient’s condition worsened, she was forced to resign from the work (office clerk). After a comprehensive examination (MRI, SCT, ultrasound, physical examination), a diagnosis was established: chronic neuropathy of the pudendal nerves. Under the fluoroscopic and ultrasound-guided treatment-diagnostic block of the pudendal nerves. Received a positive result – for the duration of the action of the anesthetic pain was stopped. After this a pulse radiofrequency ablation of the pudendal nerves was performed at a frequency of 2 Hz (20 millisecond pulses) at 42°C, duration 120 seconds. Observation for 2 months confirmed the correctness of the chosen strategy. The pain significantly decreased, reaching a level of temporary discomfort, the patient returned to professional activity. The success of the treatment in such way: from medical-diagnostic block under X-rays and ultrasound-control to destructive radio-frequency procedures.

Exposure to interventional pain procedures is now a required component of training in physical medicine and rehabilitation residencies as mandated by the Accreditation Council for Graduate Medical Education. Data regarding resident exposure and competency in these procedures remain limited. Objectives were to determine the volume and type of exposure physical medicine and rehabilitation residents have to interventional pain procedures and to obtain faculty-perceived opinions regarding competency of incoming fellows as it pertains to interventional pain management. Online surveys were sent to program directors of physical medicine and rehabilitation residencies and fellowship directors of interventional spine, sports medicine, and pain medicine fellowships. Surveys inquired about educational methods, the volume of procedures in which residents actively participate, and faculty-perceived competency of trainees performing procedures. Thirty-nine residency programs and 27 fellowships responded to the surveys. Of the 39 residencies that responded, there was great variation in the exposure residents receive. Most programs reported that residents have moderate exposure to common procedures such as ultrasound-guided knee injections and lumbar epidural injections. In addition, while most residency program directors report graduates to be "fairly prepared" (33%) to "well prepared" (20.5%) with regard to spine procedures, most fellowship directors (63%) describe incoming fellows to be at the "beginner" level.

To date, no case studies specifically reporting an electrode dislodging from its lead wire have been reported. Here we describe a case involving an electrode shearing from the spinal cord stimulator lead, and lodging into the ligamentum flavum during implantation. In this case, an experienced board certified interventional pain management specialist was performing the implantation procedure of a magnetic resonance imaging (MRI) compatible spinal cord stimulator with MR conditional leads. After successful placement of the first lead, the epidural space was accessed via a T11/12 interlaminar approach using loss of resistance technique. When the lead would not advance past the tip of the needle, it was removed in order to reposition the needle slightly. Upon removal of the lead, it was discovered that the first electrode was no longer attached to the wire. Subsequent fluoroscopic imaging revealed that the electrode had lodged within the ligamentum flavum. Upon discussion with the medical director of the device company, it was agreed upon that the electrode should be left in place. The decision was made to proceed with only one lead in place and the remainder of the procedure was completed uneventfully. The patient followed up two weeks later in clinic, and no adverse effect related to the dislodged electrode was reported. The indications and common complications associated with spinal cord stimulation are discussed, followed by factors to consider to help guide decision making in the event of a retained foreign body during a procedure.

One complication associated with recombinant human bone morphogenetic protein (rhBMP-2) use in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is heterotopic bone growth at the neural foramen which results in the compression of neural structures. Here we present an awake, minimally invasive surgical approach for treating the radiculopathy that results from this excessive bone growth in the foramen. A 42-year-old male underwent a lumbar 4–sacral 1 MIS-TLIF by another surgeon. He did well in the initial postoperative period, but he began to note right leg pain and numbness in an L5 dermatomal pattern. The pain continued for 2 years despite interventional pain management, and he began to note left foot dorsiflexion weakness. An electromyography (EMG) showed a left L5 radiculopathy and a CT Lumbar spine demonstrated excessive bone growth in the right L4–5 neural foramen. The patient underwent an awake, endoscopic foraminotomy procedure utilizing a blunt tipped manual shaver drill system. The patient’s radicular symptoms improved immediately, and he remained asymptomatic at the 1 year follow up. Heterotopic foraminal bone growth is one potential complication of rhBMP-2 use in the MIS-TLIF procedure. The endoscopic procedure described here is a minimally invasive surgical option that can be performed in an awake patient and is suggested a unique salvage or rescue procedure to be considered for the treatment of this potential rhBMP-2 complication.

Cancer pain is a multi-dimensional experience, varies from person to person both physically and psycho-socially, and impacts all aspects of the patients' quality of life. Majority of patients with an advanced or metastatic cancer will experience pain. It is estimated that as many as half of cancer patients are under-treated and as many as 20% experience pain refractory to the conventional WHO ladder of pain management. The McGill University Health Centre (MUHC) Cancer Pain Clinic (CPC) was created to meet the needs of those patients with a diagnosis of cancer whose pain had become a main symptom and those who failed to respond to conventional treatment. The clinic offers a unique interdisciplinary approach with a core team that includes an anesthesiologist, a palliative care physician, a radiation oncologist, a nurse clinician specialist in oncology and palliative care, and, recently, also an interventional radiologist. A cancer pain clinical fellowship was offered for the first time in July 2016. It provides intense training in the classification, epidemiology, pathophysiology, and treatment of cancer pain. Through our education program, the fellow learns to appreciate, weigh, and respond to the full spectrum of factors influencing a specific patient's condition and to develop a tailor-made care plan. To our knowledge, it is the only fellowship program in existence that focuses exclusively on cancer pain. We see it as a beacon and hope that our graduate fellows become professional leaders with a quest not only to provide the best possible care but also to raise awareness of the humanitarian need to control cancer pain.

Objective: To assess the prevalence of opioid-related deaths in patients in an interventional pain management tertiary referral center.Methods: Patient deaths from March 2003 to February 2007 were evaluated.Results: From March 2003 to February 2007, 2,179 patients were receiving opioids in 2003, 2,445 in 2004, 2,804 in 2005, and 2,965 in 2006, respectively. Overall, 86 percent of the patients were referred by a physician and 90 percent of patients received interventional techniques. There were a total of 91 deaths, of which 60 were categorized as natural deaths, 25 were characterized as accidental deaths, and 6 were characterized as suicidal. Of the 18 drug poisoning deaths, 5 deaths were positively related to prescription drugs, 7 deaths were probably related to prescription drugs, and 6 deaths had no relation to the prescription drugs provided. Total opioidrelated deaths were 12 over this 4-year period with 0.46 in 2003, 2.04 in 2004, 2.85 in 2005, and 1.35 in 2006 per 1,000 population. In contrast, deaths definitely related to prescription opioids were 5 (0.92 per 1,000) over a period of 4 years. In the suicidal group, there were a significantly higher proportion of patients with generalized anxiety disorder.Conclusions: In an interventional pain management practice (a tertiary referral center), the total prevalence of opioid-related deaths varied from 0.46 to 1.78 per 1,000 from 2003 to 2006 with a total of 12 deaths over a period of 4 years. The deaths definitely related to opioid prescriptions were 5 with a rate of 0 to 1.43 per 1,000 over a period of 4 years.

Background: low back pain (LBP) is related to disability and work absence and accounts for high economical costs. The management of LBP comprises a range of different intervention strategies including surgery, drug therapy, and non-medical interventions. Failed back surgery syndrome is a common problem with enormous costs to patients, insurers, and society, defined as persistent back and/ or leg pain after spine surgery. The etiology of failed back surgery can be poor patient selection, incorrect diagnosis, suboptimal selection of surgery, poor technique, failure to achieve surgical goals, and/or recurrent pathology. Aim of the Work: to evaluate the efficacy, safety and outcome of radiofrequency as a method for management of patients with chronic low back pain. Subjects and Methods: thisprospective study was conducted at El Galaa Military Hospital starting from January 2017. Twenty-five patients with chronic low back pain with mal-response to medical treatment justified for receiving interventional pain management as a conservative method of treatment of low back pain. They were subjected to radiofrequency neurotomy as a method for managing low back pain. Results: there was highly statistically significant decrease in pain score immediately, 1 week, 1 month and 3 months than pain score before RF with p-value < 0.01and there was highly statistically significant difference between daily living activities before RF and daily living activities at different times of measurement with p-value < 0.01. Conclusion: low back pain is a medical, social and economical problem. Radiofrequency neurotomy had advantage regarding the long term follow up but the costs and equipment-wised problem still make it less prevailed. Recommendations: longer follow up and randomized study if could be conducted the results may indicate much clues.

Musculoskeletal conditions become the leading contributor of the total years lived disability (YLD) by causing 21.3% of the YLDs, after mental and behavioral problems. Several musculoskeletal conditions give a disproportional impact on low back pain, one of the leading causes of disability. Lateral epicondylitis with a prevalence of 1-2%, commonly suffered by adults in their 30-65 years old. Epicondylitis was also suffered by a small population of athletes, such as professional tennis players (10% of epicondylitis population). The severe repetitive injuries that affect the individual daily activity also increase the daily health care cost. Osteoarthritis and tendinopathy often become the cause of pain and musculoskeletal disability. However, the etiology of pain in osteoarthritis is multifactorial. The incidence of osteoarthritis reaches 6% in 30 years old population and increases due to aging. Degenerative disease, the reduction of function or structure of the tissue or organ due to aging, encourages the pain specialist to perform a reliable pain management/therapy. Prolotherapy, especially dextrose prolotherapy, has become a promising technique by providing a safe degenerative therapy, easy to performed, and highly available in health facilities. Nowadays, it is necessary to pay more attention to causative-based treatment strategies than symptom-based treatment. A multidisciplinary team is also needed to provide appropriate treatment.

Traumatic brain injuries (TBI) and chronic post-traumatic headaches (PTH) have affected many military personnel. The increasing use of improvised explosive devices have made blast- and explosive-related head injuries more common than in previous wars [1, 2]. Data from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn demonstrate that a significant portion of military TBIs are caused by blast-related injuries [3, 4]. From 2000 to 2016 more than 350,000 military service members were diagnosed with a TBI [4]. Military troops are at greater risk of developing PTH from head injuries that arise during deployment to combat zones. These patients can be extremely challenging because they often suffer from comorbid conditions including depression and post-traumatic stress disorder (PTSD). Additionally, there is a lack of high-quality studies on the treatment of PTH [5]. This brief report describes a patient who suffered from chronic PTH after sustaining a mild TBI, and our results with greater occipital and auriculotemporal nerve blocks.