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Aims: In laparoscopic cholecystectomy surgery (LCS), for anesthesiologist and surgeons postoperative analgesia method is still problem. The aim of this study is to evaluate the effect of preoperative paravertebral block (PVB) application as a part of multimodal analgesia on postoperative pain management in this surgery. Methods: In this prospective, randomized, single blinded study, over 18 years old, 70 (ASA I-II) patients who underwent elective LCS were included. In the control group, analgesia was managed with only traditional multimodal analgesia methods, while ultrasound- guided PVB (20 ml of 0.5% bupivacaine,T7 level) was added to multimodal anagesia in the study group. Postoperative pain reduction was evaluated using VAS at 1, 6, 12 and 24 hours postoperatively, and morphine consumption amount was caLCSulated with IV patient-controlled analgesia in the postoperative period. Results: Demographic data were similar in both groups. VAS scores at 1 and 6 hours were statistically significantly lower in the PVB group (p

Recent recommendations describe a set of core anatomical structures to identify on ultrasound for the performance of basic blocks in ultrasound-guided regional anesthesia (UGRA). This project aimed to generate consensus recommendations for core structures to identify during the performance of intermediate and advanced blocks. An initial longlist of structures was refined by an international panel of key opinion leaders in UGRA over a three-round Delphi process. All rounds were conducted virtually and anonymously. Blocks were considered twice in each round: for “orientation scanning” (the dynamic process of acquiring the final view) and for “block view” (which visualizes the block site and is maintained for needle insertion/injection). A “strong recommendation” was made if ≥75% of participants rated any structure as “definitely include” in any round. A “weak recommendation” was made if >50% of participants rated it as “definitely include” or “probably include” for all rounds, but the criterion for strong recommendation was never met. Structures which did not meet either criterion were excluded. Forty-one participants were invited and 40 accepted; 38 completed all three rounds. Participants considered the ultrasound scanning for 19 peripheral nerve blocks across all three rounds. Two hundred and seventy-four structures were reviewed for both orientation scanning and block view; a “strong recommendation” was made for 60 structures on orientation scanning and 44 on the block view. A “weak recommendation” was made for 107 and 62 structures, respectively. These recommendations are intended to help standardize teaching and research in UGRA and support widespread and consistent practice.

Lumbar disc herniation is the most common spinal disorder and various less invasive techniques such as microdiscectomy have been described. However, postoperative pain management in patients undergoing discectomy is still commonly inadequate. Erector spinae plane (ESP) block is a relatively easier technique with lower risks of complications, and can be performed to provide postoperative analgesia for various procedures. The current study aimed to determine the effect of ESP block on postoperative analgesia in patients who underwent elective lumbar disc herniation repair surgeries. Fifty-four ASA I-II patients aged 18–65 years scheduled for elective discectomy surgery were included in the study. Patients were randomized either to the ESP or control group. Ultrasound-guided ESP block with 20 mL of 0.25% bupivacaine was performed preoperatively in the ESP group patients and a sham block was performed with 20 mL normal saline in the control group patients. All the patients were provided with intravenous patient-controlled analgesia devices containing morphine. Morphine consumption and numeric rating scale (NRS) scores for pain were recorded 1, 6, 12, and 24 h after surgery. A significantly lower morphine consumption was observed at 6, 12, and 24 h timepoints in the ESP group (p

Background and objectives: documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. Methods: following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as >= 75% agreement and weak consensus as 50%-74% agreement. Results: seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. Conclusion: by means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia., European Society of Regional Anaesthesia and Pain Therapy (ESRA); ASRA Pain Medicine

Defined in the last decade, erector spinae plane block (ESPB) is one of the more frequently used interfacial plans, and it has been the most discussed block among the recently defined techniques. Lumbar ESPB administered at lumbar levels is relatively novel and is a new horizon for regional anesthesia and pain practice. In this article, we aim to explain and introduce different approaches and explain the possible mechanism of action of lumbar ESPB. The objective of this review is to analyze the case reports, clinical and cadaveric studies about lumbar ESPB that have been published to date. We performed a search in "Pubmed" and "Google Scholar" database. After a selection of the relevant studies, 59 articles were found eligible and were included in this review. While we believe that lumbar ESPB is reliable and easy, we suggest that its efficacy and indications should be verified with anatomical and clinical studies, and its safety should be confirmed with pharmacokinetic studies. Moreover, the possibility of complications must be considered.

Resumo Introducao Observa‐se aumento do numero de pacientes submetidos a cirurgia por neoplasia mamaria. Seroma e a mais frequente complicacao pos‐operatoria que aumenta a morbidade. Ha muito tempo, considera‐se o Bloqueio Paravertebral Toracico (BPVT) a tecnica padrao‐ouro para o controle da dor pos‐operatoria. O BPVT provoca, igualmente, o bloqueio da inervacao simpatica. Objetivo Identificar o efeito do BPVT na reducao de seroma em pacientes que realizaram mastectomia e disseccao dos linfonodos axilares. Metodo Foram incluidas no estudo 40 pacientes do sexo feminino ASA I – II, entre 18 e 65 anos de idade, submetidas a mastectomia eletiva unilateral com resseccao de linfonodos axilares. As pacientes foram randomizadas em grupo BPVT e grupo controle. As pacientes do grupo BPVT foram submetidas ao BPVT guiado por ultrassom no nivel de T1 e 20 mL de bupivacaina 0,25% foram administrados antes da cirurgia. Bomba de infusao IV ACP foi prescrita para todas as pacientes. Na 24a hora pos‐operatoria foram registradas a quantidade de producao de seroma, o consumo de morfina e a avaliacao da dor pela escala de avaliacao numerica (NRS – do ingles Numeric Rating Scale). Resultados A quantidade media de seroma na 24a hora pos‐operatoria foi 112,5 ± 53,3 mL no grupo controle e 74,5 ± 47,4 mL no grupo BPVT (p = 0,022). Na 24a hora pos‐operatoria a pontuacao NRS foi semelhante nos dois grupos (p = 0,367), porem o consumo medio de morfina foi 5,6 ± 4 mg no grupo BPVT e 16,6 ± 6,9 mg no grupo controle (p Conclusoes O BPVT reduz a quantidade de seroma enquanto proporciona analgesia efetiva em pacientes que se submetem a mastectomia e remocao dos linfonodos axilares.

Study objective Erector spinae plane (ESP) block is a novel regional anesthesia technique and gaining importance for postoperative pain management. Since it was first described, the clinicians wonder if this new simple technique can replace paravertebral block (PVB). We aimed to compare the postoperative analgesic effect of ESP block and PVB with a control group in breast surgeries. Design Randomized controlled trial. Setting Operating room. Patients Seventy-five ASA I–II patients aged 25–65, who were scheduled to go under elective unilateral breast surgery for breast cancer were included to the study. Interventions Patients were randomized into three groups as ESP, PVB, and Control group. Ultrasound (US) guided ESP block and PVB with 20 ml 0.25% bupivacaine was done preoperatively to the patients according to their groups. Measurements All patients were provided with iv patient-controlled analgesia device for postoperative analgesia. Morphine consumptions and numeric rating scale (NRS) scores for pain were recorded at 1st, 6th, 12th and 24th hours postoperatively. Main results There was a statistically significant difference between ESP and Control groups (p 0,05) for 24-hour morphine consumptions. There was a significant difference between PVB and Control groups for NRS at postoperative 1st and 6th hour (p = 0.018 and p = 0.027 respectively). Conclusions This study has shown that US guided ESP block and PVB provided adequate analgesia in patients undergoing breast surgery and have an opioid sparing effect by reducing morphine consumption. Clinical Trials Registry: NCT03480958 .

Epidural anesthesia and thoracic paravertebral blocks have been the mainstay of regional anesthesia for thoracic surgery for many years. Following introduction of ultrasound use during regional anesthesia practices, new blocks named interfascial plane blocks have been introduced into clinical practice. Although interfascial plane blocks fail to provide surgical anesthesia their contribution to providing analgesia is clinically important. In this review we mention the most commonly accepted blocks namely pectoral blocks, serratus anterior plane block, erector spinae plane block and rhomboid blocks.

Introduction Arthroscopic shoulder surgeries are usually performed in a sitting position. The sitting position is known to cause physiological changes related to cardiovascular adaptation. Interscalene nerve blocks (ISB) are the most commonly used techniques and are considered gold standard regional anesthesia methods for shoulder surgeries. Cerebral vessels located around sympathetic ganglia provide sympathetic system integrity. This local anesthetic spreading during ISB could be a side effect or provide a protective effect on cerebral ischemia. Our study aimed to investigate the cerebral protective effect of the ISB in arthroscopic shoulder surgeries in a sitting position. Material and methods After the approval of Koç University Clinical Research Ethics Committee (2020.020.IRB1.011), records of patients between January and December 2019 with shoulder arthroscopy at the Vehbi Koç Foundation (VKV) American hospital were retrospectively reviewed. Records of the hemodynamic response, INVOSTM (Medtronic, Minneapolis, USA) (rSO2) parameters, pain scores, and additional analgesic needs of all cases were examined in the intraoperative and postoperative period. Results Data of 40 patients who met the criteria to be included in the study was analyzed. Our study showed that the sitting position leading to hypotension coincided with a decrease in INVOS values. Nevertheless, we did not record any significant hypotension after ISB, and this may be due to the use of a minimal dose of local anesthetic. There was a certain increase in near-infrared spectroscopy (NIRS) values ​​after ISB. We saw that the value of regional oxygen saturation (rSO2) increased on both the ISB side and the non-ISB side. This shows that the ISB can have a global impact on the brain. Specificially, the increase in rSO2 values ​​in the ISB side compared to the other side suggests that ISB has possible positive effects on cerebral blood flow. Conclusion Our study has shown that ISB may transiently increase the rSO2 levels in the sitting position during shoulder surgery.

Erector spinae plane block (ESPB) is a newly described interfascial plane block, and the number of articles on the bilateral application of ESPB is increasing in the literature. In this paper, in addition to analyzing bilateral ESPB cases and studies published so far, we aimed to review the relevant anatomy, describe the mechanism of spread of the injectant, demonstrate varying approaches to ESPB, and summarize case reports and clinical trials, as well as provide current insight on this emerging and popular block. Randomized controlled studies, comparative studies of ESPB versus other methods, and pharmacokinetic studies of bilateral applications must be the next step in clearly understanding bilateral ESPB.

Introduction Various regional anesthesia techniques such as thoracic epidural, thoracic paravertebral block, erector spinae plane block (ESPB), parasternal intercostal blocks are used in cardiac surgery for postoperative analgesia. In our study, we investigated the analgesic efficacy of the dual injection technique of ESPB in beating heart coronary bypass surgeries. Methods The records of patients with coronary artery bypass (CABG) surgery in the beating heart at the VKV American Hospital between January and December 2019 were retrospectively analyzed. The data of 30 patients who met the criteria to be included in the study were analyzed. Whether any opioid use is required for maintenance of anesthesia it is recorded. The pain scores of the patients are recorded by the intensive care team and cardiovascular service nurses for the first 48 hours. Results The absence of secondary responses to pain in all surgical periods, including skin incision and sternotomy, and low number of rating scale (NRS) scores in the postoperative 0- to 24-hour period show that the technique we developed can produce effective analgesia. After the 24th postoperative hour, the patients were followed up in the cardiovascular service and there was no opioid use between 24- to 48-hour period. Conclusion Our approach, in which the local anesthetic is applied by approaching the superior costa-transverse ligament (SCTL) in the ESPB, provides an effective analgesia in coronary artery bypass surgeries in the beating heart. The main purpose of our new approach is to increase the amount of local anesthetic in the paravertebral area. We recommend using our modified technique for effective analgesia after CABG surgeries.

Sağır, Özlem (Balikesir Author), Introduction More than 300 million surgical procedures are performed each year. Acute kidney injury (AKI) is a common complication after major surgery and is associated with adverse short-term and long-term outcomes. However, there is a large variation in the incidence of reported AKI rates. The establishment of an accurate epidemiology of surgery-associated AKI is important for healthcare policy, quality initiatives, clinical trials, as well as for improving guidelines. The objective of the Epidemiology of Surgery-associated Acute Kidney Injury (EPIS-AKI) trial is to prospectively evaluate the epidemiology of AKI after major surgery using the latest Kidney Disease: Improving Global Outcomes (KDIGO) consensus definition of AKI. Methods and analysis EPIS-AKI is an international prospective, observational, multicentre cohort study including 10 000 patients undergoing major surgery who are subsequently admitted to the ICU or a similar high dependency unit. The primary endpoint is the incidence of AKI within 72 hours after surgery according to the KDIGO criteria. Secondary endpoints include use of renal replacement therapy (RRT), mortality during ICU and hospital stay, length of ICU and hospital stay and major adverse kidney events (combined endpoint consisting of persistent renal dysfunction, RRT and mortality) at day 90. Further, we will evaluate preoperative and intraoperative risk factors affecting the incidence of postoperative AKI. In an add-on analysis, we will assess urinary biomarkers for early detection of AKI. Ethics and dissemination EPIS-AKI has been approved by the leading Ethics Committee of the Medical Council North Rhine-Westphalia, of the Westphalian Wilhelms-University Münster and the corresponding Ethics Committee at each participating site. Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and used to design further AKI-related trials. Trial registration number NCT04165369. ©

Dear editor Erector spinae plane block (ESPB) was initially described at the thoracic level in 2016, with further indications subsequently reported at different vertebral levels.[1 2][1] Lumbar ESPB (L-ESPB) has been used for many indications such as chronic low back pain, spinal surgery, herpes

To the Editor We thank Nielsen et al [1][1] for their detailed comments on our article.[2][2] The inability to fully explain the mechanisms of action in the erector spinae plane block (ESPB) and efforts to further advance the effective results have been intensively studied by many researchers.[3][3

To the editor, Erector spinae plane block (ESPB) has recently become a popular regional anesthesia technique. However, local anesthetic (LA) spread and anatomical studies regarding the mechanism of effect of ESPB have been both confusing and conflicting.[1 2][1] Recently, Nielsen et al [3][2]

Erector spinae plane block is gaining popularity both for its ease of application and as its comparable effect on postoperative analgesia with central regional techniques like paravertebral block or epidural anesthesia. Its use for many indications has been reported in the literature for pediatric patients. We would like to share our experiences in a 2.5-month infant scheduled for thoracotomy for a giant congenital cyst. Single shot erector spinae plane block was done at T4 level before the start of the surgery for both surgical and postoperative analgesia. No complication was seen during both surgery and follow up period. Erector spinae plane block with the combination of paracetamol was adequate for pain relief. Resumo: O bloqueio do plano do músculo eretor da espinha está ganhando popularidade, tanto pela facilidade de aplicação quanto pelo efeito comparável em analgesia pós-operatória com técnicas regionais centrais, como o bloqueio paravertebral ou a anestesia peridural. Seu uso tem sido relatado na literatura para muitas indicações em pacientes pediátricos. Gostaríamos de compartilhar nossas experiências no caso de um bebê de 2,5 meses de idade programado para toracotomia para excisão de um cisto congênito gigante. O bloqueio do plano do eretor da espinha dorsal com injeção única foi realizado no nível de T4 antes do início da cirurgia para analgesia cirúrgica e pós-operatória. Nenhuma complicação foi observada durante a cirurgia e o período de acompanhamento. O bloqueio do plano do eretor da espinha com a combinação de paracetamol foi adequado para o alívio da dor. Keywords: Erector spinae plane block, Postoperative analgesia, Pediatric surgery, Thoracotomy pain, Epidural analgesia, Palavras-chave: Bloqueio do plano do eretor da espinha, Analgesia pós-operatória, Cirurgia pediátrica, Dor pós-toracotomia, Analgesia epidural

Resumo O bloqueio do plano do musculo eretor da espinha tem ganhado popularidade, tanto pela facilidade de aplicacao quanto pelo efeito comparavel em analgesia pos‐operatoria com tecnicas regionais centrais, como o bloqueio paravertebral ou a anestesia peridural. Seu uso tem sido relatado na literatura para muitas indicacoes em pacientes pediatricos. Gostariamos de compartilhar nossas experiencias no caso de um bebe de 2,5 meses de idade programado para toracotomia para excisao de um cisto congenito gigante. O bloqueio do plano do eretor da espinha dorsal com injecao unica foi realizado no nivel de T4 antes do inicio da cirurgia para analgesia cirurgica e pos‐operatoria. Nenhuma complicacao foi observada durante a cirurgia e o periodo de acompanhamento. O bloqueio do plano do eretor da espinha com a combinacao de paracetamol foi adequado para o alivio da dor.

Truncal blocks have a place within multimodal analgesia techniques in abdominal surgery. The quadratus lumborum block is a new abdominal truncal block used for somatic analgesia of both the upper and lower abdomen. In this prospective, double-blind, randomized study, we aimed to compare quadratus lumborum block and transversus abdominis plane block in pediatric patients undergoing lower abdominal surgery.Fifty-three children undergoing unilateral inguinal hernia repair or orchiopexy surgery were randomized into 2 groups: transversus abdominis plane block and quadratus lumborum block. All blocks were performed under general anesthesia before surgery. Pain levels were assessed using an FLACC (Face, Legs, Activity, Cry, Consolability) scale.The study included 50 patients, after excluding 3 patients who were not eligible. The number of patients who required analgesia in the first 24 hours postoperatively was significantly lower in the quadratus lumborum block group (P0.05). In the quadratus lumborum block group, the postoperative 30-minute and 1-, 2-, 4-, 6-, 12-, and 24-hour FLACC scores were lower compared with those of the transversus abdominis plane block group (P0.05). Parent satisfaction scores were higher in the quadratus lumborum block group (P0.05).The results of this study showed that in pediatric patients undergoing unilateral inguinal hernia repair or orchiopexy the quadratus lumborum block provided longer and more effective postoperative analgesia compared with the transversus abdominis plane block.The trial was registered prospectively at clinicaltrials.gov (NCT02715999).

To the Editor Although interscalene brachial plexus block is accepted as a gold standard technique in shoulder surgeries, even at low local anesthetic doses such as 5 mL, phrenic nerve involvement may result in hemidiaphragmatic paralysis (HDP).[1][1] Therefore, search for diaphragm sparing nerve

Thoracic paravertebral block (TPVB) is considered the gold standard for hemithoracic regional anaesthesia. Erector spinae plane block (ESPB) is a new posterior thoracic wall block. Multiple-injection costotransverse block (MICB) mimics TPVB but with injection points within the thoracic intertransverse tissue complex and posterior to the superior costotransverse ligament. We aimed to compare the spread of injectate into the thoracic paravertebral space (TPVS) resulting from single-injection ESPB and MICB, respectively, with TPVB.Ten soft-embalmed cadavers were utilised. In five cadavers, the right hemithorax was randomly allocated either to ultrasound-guided single-injection ESPB or single-injection TPVB; vice versa on the other side. In another five cadavers, the right hemithorax was randomly allocated either to ultrasound-guided MICB or multiple-injection TPVB. About 20 mL of dye was injected in each hemithorax with all techniques.With TPVB, the dye was consistently present in the TPVS with concomitant epidural spread in the majority of cases. The injectate spread into the TPVS with ESPB (60%) and MICB (100%). MICB consistently stained the ventral rami (T1-7), communicating rami and thoracic sympathetic trunk without epidural spread. Dissection after MICB revealed dye spread into the TPVS via the costotransverse foramina and along the dorsal branches of the posterior intercostal veins.Consistent spread of dye into the TPVS colouring the ventral rami, the communicating rami, and the sympathetic trunk was observed with MICB; in this respect equivalent to TPVB. ESPB exhibited only partial success and was not equivalent to TPVB. No epidural spread was found with neither MICB nor ESPB.

Pediatric regional anesthesia is in the verge of a new era due to both widespread use of ultrasound and new defined fascial plane blocks. But we should still discuss the controversial issues like genetics and obesity, as there are some unclear issues according to limited data. In parallel with the changes in modern lifestyles, nutrition habits, and due to decreased physical activity obesity rates throughout the world continue to increase day by day. Change in both physiology and anatomy can lead to technical difficulties for performing regional techniques along with adjusting the drug doses. Although it might not be difficult to identify a landmark such as bone and vessels in obese pediatric patients, it would be challenging to visualize muscles and fascial planes. Even though local anesthetic toxicity rates are low in pediatric patients,1 it is difficult to detect while these patients are under general anesthesia (GA).2 Due to the possibility of a changed local anesthetic distribution clinicians should be aware of its manifestations under GA. When it comes to genetic disorders, it is even more difficult to talk clearly due to lack of data. There is only limited number of case reports and diversity of genetic disorders make it difficult to generalize recommendations. While the main concern must be the patient safety, consideration of regional technique should also be done according to risk versus benefit ratio, clinical experience and conditions of the practitioner. References Walker BJ, Long JB, Sathyamoorthy M, et al. Pediatric Regional Anesthesia Network Investigators. Complications in pediatric regional anesthesia: an analysis of more than 100,000 blocks from the pediatric regional anesthesia network. Anesthesiology 2018;129:721–722. Lonnqvist, P-A, Ecoffey, C, Bosenberg, A, Suresh, S, Ivani, G. The European society of regional anesthesia and pain therapy and the American society of regional anesthesia and pain medicine joint committee practice advisory on controversial topics in pediatric regional anesthesia I and II: what do they tell us?Curr Opin Anaesthesiol 2017;30:613–620.

Chronic pain is an important and specific healthcare problem, which affects at least 10% of the world’s population.1 In 1953 Bonica made the first and simplest definition of chronic pain as: ‘pain which persists past the normal time of healing stated’.2 He just did not made the definition but also stated its importance: ‘in its late phases, when it becomes intractable, it no longer serves a useful purpose and then becomes, through its mental and physical effects, a destructive force’. In parallel to this explanation, with our current knowledge, we now name chronic pain as a disease or syndrome as it is a multidimensional health problem.3 4 The standard treatment plan of chronic pain is a multidisciplinary approach, which includes pharmacology, physical therapies as well as psychological therapies and surgical interventions.5 However, this intensive treatment modality is inadequate for many patients and because chronic pain is sometimes resistant even to opioid drugs, ‘overuse’ or ‘abuse’ of prescription opioids has turned to an ‘opioid crisis’.6 This situation leads us to opioid sparing therapies where the inevitable role of neuromodulation starts. Definition of neuromodulation, in its simplest form, is; the process of inhibition, stimulation, modification or therapeutic alteration of the activities of central, peripheral and also autonomic nervous systems by using electricity.6 In fact neuromodulation therapy has been known since 15 AD by an accidental help of a torpedo fish.7 But the modern era of neuromodulation starts after the introduction of Melzack and Wall’s gate-control theory.8 They stated that there is ‘A gate control system modulates sensory input from the skin before it evokes pain perception and response’. the balance between the activation of small and large neural fibers determines if the gate is open or closed. Stimulation of large touch fibers (like in the situation we rub the painful area) would close the gate and lessen the pain. This description leaded clinicians to perform different modalities of neuromodulation at about the same time in late 60’s. Shealy et al.9 reported that the dorsal column stimulator was used to treat pain in the light of this theory and now this technique is called spinal cord stimulation [SCS]. Deep brain stimulation [DBS] was defined for the treatment of cancer pain10 and followed by the identification of peripheral nerve stimulation [PNS] for chronic pain.11 Deep Brain Stimulation (DBS) Surgically implanted units are used for DBS. Thin electrical leads placed deep in the brain, a small battery is generally placed under collarbone and an extension wire placed under the skin from skull passing down the neck to the battery unit. DBS targets specific sites in the brain with a low electrical mono- or bipolar stimulation: ventral posterolateral nucleus and ventral posteromedial nucleus (VPL/VPM) in the thalamus; periventricular grey matter and periaquaductal grey matter (PVG/PAG) and other regions surrounding the third ventricle and aqueduct of Sylvius, and the rostral anterior cingulate cortex (ACC) posterior to the anterior horns of the lateral ventricles.12 While the stimulation of VPL/VPM pleasant paraesthesia occurs and overcomes the painful sensation, stimulation of PVG/PAG induces a sense of warmth and analgesia. Stimulation of ACC with high frequency removes the affective aspect of pain.12 Spinal Cord Stimulation (SCS) SCS stimulation can be provided either via percutaneously placed epidural electrodes or via surgical paddle leads that implanted with a laminotomy.13 Electrodes can be placed between C5 to T11 according to the type and origin of the pain. There are three types of SCS as conventional/tonic SCS, High-frequency SCS and Burst SCS. In conventional SCS main goal is to mask the sensation of pain with paresthesia or tingling. Stimulations are low frequency (40–100 Hz), high amplitude (3.6–8.5 mA) and pulse widths ranging between 300–600 μs.6 Classic SCS treatment is effective for etiologies such as complex regional pain syndrome, failed back surgery syndrome, multiple sclerosis and diabetic neuropathy. This tonic, high charge stimulations are the cause of paresthesia feeling. Although its effect on pain relief, some patients reports that they are also uncomfortable with the sensation of paresthesia. Accordingly, in recent years, two new modalities with different stimulation waveforms and stimulation paradigms have been implemented to the clinical practice. High-frequency SCS involves a different high frequency (10 kHz) stimulation with amplitude ranging between 1–5 mA and with a pulse width at 30 μs. This frequency is at a sub-threshold level and therefore does not cause paresthesia. Although there are limited data about its efficacy and superiority to conventional SCS, it is shown that high-frequency SCS is a better option for chronic low back pain.6 Burst SCS is another novel mode of stimulation where burst frequency is 40 Hz and pulse frequency is 500 Hz. the stimulations are provided in bursts of five pulses (1000 μs). With reduced amplitudes, this modality provides pain relief with either reduced or no paresthesia. Burst SCS has been shown to be superior to SCS in the treatment of lumbosacral component of pain in failed back syndrome but for other indications, there is still limited evidence to reach a conclusion. Peripheral Nerve Stimulation (PNS) Peripheral nerve stimulation is a less invasive neuromodulation therapy as it does not violate central nervous system, but works with peripheral subcutaneously placed electrode. Electrode is implanted to close proximity to targeted peripheral nerve. This procedure is similar to perineural catheter placement of regional anesthetists. There are two types of PNS; direct PNS or field PNS (PNfS). In PNfS terminal, sensory and cutaneous nerve fibers are targeted for stimulation. Headache, fascial pain, trigeminal neuropathic pain, fibromyalgia, postherpetic neuralgia and complex regional pain syndrome type I-II, coccydynia are some of the indications that PNS/PNfS have been shown to be efficacious.14 Conclusion Except for all these new treatment modalities and all newly developed technologies, yet we have limited data to compare each method with each other. Probably, over time, some neuromodulation techniques will gain value, while others will loose. There are still unanswered questions related to exact mechanism of action, potential effects of these various stimulation methods on both neuroimmune axis and gene expression, best waveform etc. Clinicians should consider treatment options depending on their clinical conditions, experiences and patient-based basis while relying on the current literature. Although neuromodulation is currently used just for the treatment of chronic pain; with the development of new technologic devices and by understanding more about the neuronal network it might be used for preventing or treating acute pain in the future by the ‘anesthesiologists not in practice’. References Jackson T, Stabile V, McQueen K. The Global Burden of Chronic Pain. [Accessed June 21, 2017]. Available from:http://monitor.pubs.asahq.org/article.aspx?articleid=2432061. Bonica JJ. The Management of Pain. Philadelphia, PA: Lea and Febirger; 1953. H. Merskey and N. Bogduk, ‘Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms/prepared by the international association for the study of pain,’ in Task Force on Taxonomy, 2nd edition, 1994, Update 2012, http://www.iasp-pain.org/PublicationsNews/Content.aspx?ItemNumber=1673 Treede RD, Rief W, Barke A, et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain 2019;160:19–27. Verrills P, Sinclair C, Barnard A. a review of spinal cord stimulation systems for chronic pain. J Pain Res 2016;9:481–492. Deer TR, Jain S, Hunter C, Chakravarthy K. Neurostimulation for Intractable Chronic Pain. Brain Sci, 2019;9:23. doi: 10.3390/brainsci9020023 Gildenberg PL. History of Electrical neuromodulation of chronic pain. Pain Medicine. 2006;7:7–13 Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150:971–979 Shealy CN, Mortimer JT, Reswick JB. Electrical inhibition of pain by stimulation of the dorsal columns. Preliminary clinical report. Anesth Analg (Cleve) 1967;46:489–491. Gol, A. Relief of pain by electrical stimulation of the septal area. J. Neurol. Sci.1967;;5:115–120. Sweet WH, Wepsic JG. Treatment of chronic pain by stimulation of fibers of primary afferent neuron. Trans Am Neurol Assoc 1968;93:103–107. Farrell S, Green A, Aziz T. the Current State of Deep Brain Stimulation for Chronic Pain and Its Context in Other Forms of Neuromodulation. Brain Sci. 2018;8. pii: E158. doi: 10.3390/brainsci8080158. Deer TR, Mekhail N, Provenzano D, et al. the appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuro- modulation Appropriateness Consensus Committee. Neuromodulation. 2014;17:515–550. Nayak R, Banik RK. Current Innovations in Peripheral Nerve Stimulation. Pain Res Treat. 2018; 2018:9091216 doi:10.1155/2018/909121