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

Trigeminal neuralgia is a common cause of facial pain. It has a significant impact on the quality of life and the socioeconomic functioning of the patient. The aim of this review is to provide recommendations for medical management of trigeminal neuralgia based on current evidence. Based upon the analyses of the literature combined with experience in pain management, symptoms, assessment, differential diagnosis, and treatment possibilities of trigeminal neuralgia are described and discussed. Recommendations for pain management are given and are displayed in a clinical practice algorithm. Treatment should be multidisciplinary. Various treatment options and their risks should be discussed with the patient. The first treatment of choice is carbamazepine or oxcarbazepine. In younger patients, the first choice of invasive treatment is probably microvascular decompression. For elderly patients, radiofrequency treatment of Gasserian ganglion is recommended and the technique is described in detail.

There are currently 6 reviews on (pulsed) radiofrequency (RF) for the management of spinal pain. Two reviews on interventional pain management techniques in general also discuss RF. The outcomes of those reviews depend on the type of studies included and the opinion of the reviewers, which may result in different evidence levels. Radiofrequency denervation at the cervical and lumbar level has produced the most solid evidence. The differences in treatment outcome registered in the 5 randomized controlled trials (RCTs) regarding lumbar facet denervation can be attributed to differences in patient selection and/or inappropriate technique. There is not sufficient evidence supporting the use of RF facet denervation for the management of cervicogenic headache. The studies examining the management of cervical radicular pain suggest a comparable efficacy for RF and pulsed RF (PRF). The PRF treatment is supposed to be safer and therefore should be preferred. The superiority of RF treatment adjacent to the lumbar dorsal root ganglion for the management of lumbar radicular pain has not been demonstrated in an RCT. Information regarding RF treatment of sacroiliac joint pain is accumulating. No randomized sham-controlled trials on the value of RF treatment of the Gasserian ganglion for the management of idiopathic trigeminal neuralgia have been published. One RCT indicates superiority of RF over PRF for the management of idiopathic trigeminal neuralgia. Future research to confirm or deny the efficacy of (P)RF should be conducted in carefully selected patient populations. The tests used for patient inclusion in such a trial could potentially help the clinician in selecting patients for this type of treatment. The value of PRF treatment of the peripheral nerves also needs to be confirmed in well-designed trials.

Interventional pain management techniques are considered for patients whose pain proves refractory to conventional treatment. According to the evidence-based medicine (EBM) guidelines, the highest level of evidence for efficacy and safety of a treatment is generated in high-quality randomized controlled trials and systematic reviews. A randomized controlled trial is defined as an experiment that determines the influence of an intervention on the natural history of the disease, which means that the comparative group should receive placebo, which is a sham intervention in case of the interventional pain management techniques. The systematic review summarizes in a structured way the results of the available information. When randomized controlled trials are available, observational studies will often be discarded. As new information on a treatment becomes available the perceived value may change, thus determining the survival time of clinical evidence. This survival time is not different when based on randomized or nonrandomized studies. The inclusion criteria are an important component of the randomized controlled trial and are designed to test a treatment in a homogeneous patient population. As interventional pain management techniques are mainly used for the management of spinal pain, it needs to be stressed that there is no gold standard for the diagnosis. This lack of validated standard diagnostic procedures is at the origin of different patient selection criteria, which makes the interpretation of the different randomized controlled trials and the meta-analyses very difficult. Moreover, the extrapolation of randomized controlled trials with carefully selected patient populations to daily practice is a major problem. Randomized controlled trials in interventional pain management techniques often prove to be underpowered, which can be attributed to the difficulty in motivating patients and the referring physicians to participate in a trial where there is 50% chance of receiving a placebo/sham for intractable pain. Furthermore, the validity of sham intervention as a reflection of the natural course of the disease is questioned. It is stated that any new technique should prove to be at least equally effective as the best available treatment option, which offers the possibility of comparing two groups, both receiving active treatment. The reference treatment may be pharmacological or a rehabilitation program (cognitive behavioral) in which case blinding becomes a problem. It has been demonstrated that large observational studies with a cohort or case-control design do not systematically overestimate the magnitude of the associations between exposure and outcome as compared with the results of randomized controlled trials. There is an urgent need for guidelines on performing prospective cohort trials that should be designed to confirm or refute the anecdotal findings from retrospective studies.

Background: The purpose of this study was to evaluate the effectiveness of pulsed radiofrequency (PRF) applied to the lumbar dorsal root ganglion (DRG)., Methods: A retrospective analysis of 54 consecutive patients who underwent 75 PRF procedures was performed. The patients were divided into three groups according to the etiology of the lesion (herniated disc [HD], spinal stenosis [SS], and failed back surgery syndrome [FBSS]). The analgesic efficacy of the technique was assessed using a 10-point Numeric Rating Scale (NRS) at baseline and, along with the Global Perceived Effect (GPE), at 30, 60, 90, and 180 days. The reduction in medications and the number of complications associated with the technique were assessed., Results: A decrease in the NRS score was observed in patients with HD (P < 0.05) and SS (P < 0.001), but not in those with FBSS. The GPE scores confirmed this finding. No complications were noted., Conclusions: We observed that PRF of the DRG was significantly more efficacious in HD and SS than in FBSS patients. The application of PRF was not effective in FBSS.

Cervical radicular pain affects approximately 1 on 1000 adults per year. Although many treatment modalities are described in the literature, the available evidence for efficacy is not sufficient to allow definitive conclusions on the optimal therapy to be made. The effect of pulsed radiofrequency treatment for this type of patients was evaluated in a prospective audit that showed satisfactory pain relief for a mean period of 9.2 months, justifying a randomized sham controlled trial. Twenty-three patients, out of 256 screened, met the inclusion criteria and were randomly assigned in a double blind fashion to receive either pulsed radiofrequency or sham intervention. The evaluation was done by an independent observer. At 3 months the pulsed radiofrequency group showed a significantly better outcome with regard to the global perceived effect (>50% improvement) and visual analogue scale (20 point pain reduction). The quality of life scales also showed a positive trend in favor of the pulsed radiofrequency group, but significance was only reached in the SF-36 domain vitality at 3 months. The need for pain medication was significantly reduced in the pulsed radiofrequency group after six months. No complications were observed during the study period. These study results are in agreement with the findings of our previous clinical audit that pulsed radiofrequency treatment of the cervical dorsal root ganglion may provide pain relief for a limited number of carefully selected patients with chronic cervical radicular pain as assessed by clinical and neurological examination.

Objective: Pulsed radiofrequency, where short bursts of radiofrequency energy are applied to nervous tissue, has been used by pain practitioners as a non- or minimally neurodestructive technique, alternative to radiofrequency heat lesions. Clinical advantages and mechanisms of this treatment remain unclear. The objective of this study was to review current clinical and laboratory data., Design: We systematically searched the MEDLINE database (PubMed) and tables of contents of electronically available pain journals. Reference lists of relevant reports and international scientific pain congress abstract books were also hand searched. Only those reports on pulsed radiofrequency were withheld., Results: The final analysis yielded 58 reports on the clinical use of pulsed radiofrequency in different applications: 33 full publications and 25 abstracts. We also retrieved six basic science reports, five full publications, and one abstract., Conclusions: The accumulation of these data shows that the use of pulsed radiofrequency generates an increasing interest of pain physicians for the management of a variety of pain syndromes. Although the mechanism of action has not been completely elucidated, laboratory reports suggest a genuine neurobiological phenomenon altering the pain signaling, which some have described as neuromodulatory. No side effects related to the pulsed radiofrequency technique were reported to date. Further research in the clinical and biological effects is justified.

Cervical radicular pain affects 83 per 100,000 adults annually. Diagnosis by means of physical examination, imaging, and electrophysiological studies is characterized by high specificity but low sensitivity. In this review, we focus on the role of the dorsal root ganglion and those treatment modalities that aim at pathophysiological mechanisms occurring after injury to the dorsal root ganglion. Cervical nerve injury initiates multiple events that lead to changes in nerve function and result in spontaneous firing at the dorsal root ganglion. Among these, inflammation and changes in ion-channel function play a pivotal role. Although many treatment modalities are described in the literature, the available evidence for efficacy does not allow us to formulate definitive conclusions on the optimal therapy. A lack of evidence is reported for cervical spine surgery. Interlaminar epidural steroid administration and radiofrequency techniques adjacent to the cervical dorsal root ganglion have the highest, but still weak recommendations.

Low back pain is one of the most important burdens for the patient, the health-care provider, and society. Treatment selection should target the appropriate use of the available health-care resources with the highest probability of success. When conventional treatment fails to provide satisfactory pain reduction and improvement of the quality of life, more interventional techniques can be envisioned. The degree of invasiveness of the different treatment modalities varies as well as the costs. A stepwise approach to chronic low back pain may reduce the economic burden with optimal use of the less invasive treatments. In this review, we discuss the treatment algorithm with special attention to the interventional pain management techniques. We also describe the results of a cost evaluation for the management of low back pain in Belgium compared with that in the Netherlands, two neighboring countries with different social security systems.

Background: Pulsed radiofrequency treatment has recently been described as a non-neurodestructive or minimally neurodestructive alternative to radiofrequency heat lesions. In clinical practice long-lasting results of pulsed radiofrequency treatment adjacent to the cervical dorsal root ganglion for the management of chronic radicular spinal pain have been reported without neurologic complications. However, the mode of action is unclear. An early (3 h) effect of pulsed radiofrequency as measured by an increase of c-Fos in the pain-processing neurons of the dorsal horn of rats has been described in the literature. This effect was not mediated by tissue heating. The authors investigated a possible late or long-term effect of three different radiofrequency modalities., Methods: Cervical laminectomy was performed in 19 male Wistar rats. The cervical dorsal root ganglion was randomly exposed to one of the four interventions: sham, continuous radiofrequency current at 67 centigrades, or pulsed radiofrequency current for 120 s or 8 min. The animals were sacrificed and the spinal cord was prepared for c-Fos labeling 7 days after the intervention., Results: The number of c-Fos immunoreactive cells in the dorsal horn was significantly increased in the three different radiofrequency modalities as compared with sham. No significant difference was demonstrated between the three active intervention groups., Conclusions: The authors demonstrated a late neuronal activity in the dorsal horn after exposure of the cervical dorsal root ganglion to different radiofrequency modalities, which was not temperature dependent.

Cervicogenic headache and cervicobrachialgia are frequent diagnoses of chronic cervical pain. After failure of conservative treatment, an interventional approach may be indicated in the absence of any indication for causal surgical treatment. The pulsed radiofrequency (PRF) technique exposes the nerve to a high-frequency electric field while the temperature of the electrode tip does not exceed 42°C. This method is thought to be nondestructive and almost free of neurologic side effects and complications. Our extended pilot study was performed to confirm the perceived efficacy of PRF for short- and long-term relief of chronic cervical pain. We carried out a clinical audit of the first 18 patients treated with PRF at the cervical dorsal root ganglion. An independent evaluator reviewed the medical records. Patients with good clinical results at 8 weeks were evaluated for long-term effect (> 6 months), based on a 7-point Likert scale. Thirteen patients (72%) showed short-term clinical success (≥ 50% pain relief). Mean follow-up was 19.4 months (SD 8.9 months), maximum 2.5 years. The duration of satisfactory pain relief (6 or 7 on the Likert scale) varied between 2 and over 30 months, with a mean duration of 9.2 months (SD 11.2 months). Kaplan-Meier analysis illustrated that 50% of patients experienced success 3 months after treatment. We could not identify predictive variables for clinical outcome. None of the patients reported post-treatment neuritis or other adverse events. To our knowledge, this is the first documented series of chronic cervical pain syndromes treated with PRF. Satisfactory pain relief of at least 50% was achieved in 13 of 18 (72%) patients at 8 weeks. More than one year after treatment, six patients (33%) continue to rate treatment outcome as good or very good. No side effects were reported. j.

Many therapeutic interventions for chronic pain are available, and decisions about optimal management are not easy to make. Radiofrequency (RF) treatment is classified as a percutaneous minimal invasive procedure for patients who do not respond to appropriate medical and physical therapy. Although RF treatment is widely used differences in current practice exist due to ongoing controversies.

Spinal cord stimulation is a minimally invasive mode of treatment in the management of certain forms of chronic pain that do not respond to conventional pain therapy. Several authors have reported encouraging findings with this technique. Over a 10-year period in a single centre, 254 patients were subjected to a trial period of spinal cord stimulation with an externalized pulse generator. Two hundred and seventeen of the patients showed satisfactory results justifying permanent implantation of a spinal cord stimulation system. In 1998, an independent physician invited 153 patients (155 pain cases), who still had the system in place and who could be contacted, for an interview. The aim of this study was to evaluate the efficacy of an implanted spinal cord stimulation system in terms of pain relief and quality of life and to assess the accuracy of the patient selection criteria. The results of this study demonstrate a high success rate as evaluated by the patients' own assessments--68% of the patients rated the result of the treatment as excellent to good after an average follow-up of almost 4 years. The resumption of work by 31% of patients who had been working before the onset of pain supports these positive findings., (Copyright 2001 European Federation of Chapters of the International Association for the study of Pain.)

Objective. Treatment of pain associated with failed back surgery syndrome was evaluated in a pilot clinical study of a new dual lead spinal cord stimulation (SCS) system. Methods. The following data was retrospectively sought from 20 non-randomized patients at 2 centers treated by the new SCS system, instead of an implantable drug pump: 1) prior back surgeries, 2) pain and paresthesia mapping, 3) VAS ratings, 4) medication use, 5) sleep patterns, 6) physical abilities, 7) hardware problems, and 8) willingness to repeat the procedure. Two-year follow-up was sought from all patients. Results. The new dual lead SCS system provided good low back and leg paresthesia coverage. Patients reported having less pain and using fewer analgesics and narcotics during follow-up, compared to their preimplant experience. These improvements were statistically significant. Patients also improved their sleep and physical abilities during follow-up. While external hardware problems occurred, 65% of dual lead SCS patients were willing to repeat the SCS implant procedure. Conclusions. Dual lead stimulation proved beneficial for patients with low back and leg pain associated with failed back surgery syndrome.

In a randomized double-blind study, three groups of 25 term parturients received one of the following intrathecal drugs or combinations for relief of labor pain: sufentanil 7.5 microg (1.5 ml), sufentanil 5 microg + bupivacaine 1 mg (1.5 ml) or the combination bupivacaine 1.75 mg, sufentanil 1.05 microg and epinephrine 1.75 microg, that is 1.5 ml of our standard epidural mixture. After the intrathecal injection, patients received a peridural catheter for supplementation of analgesia. Onset and duration of the three regimens were similar. Analgesia lasted for approximately 95-115 minutes which was similar to durations obtained with the subsequent epidural top-ups. Pruritus was observed significantly less frequently in the group treated intrathecally with the epidural mixture. The incidence of other maternal side-effects was extremely low and not different among the groups. Instrumental delivery, Apgar scores and umbilical blood gases were identical. More cardiotocographic changes were observed in the plain sufentanil group but this was not related to neonatal outcome. It was concluded that intrathecal injection of the standard epidural mixture offers effective and long-lasting analgesia. This may avoid side-effects and complications, manipulations of drugs with the risk for contamination, spilling of drugs and loss of time.