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Background Occipital neuralgia is a form of neuropathic type of pain in the distribution of the greater, lesser, or third occipital nerves. Patients with intractable occipital neuralgia do not respond well to conservative treatment modalities. This group of patients represents a significant therapeutic challenge and may require interventional or invasive therapeutic approaches. Purpose Occipital neuralgia frequently occurs as a result of nerve entrapment or irritation by a tight muscle or vascular structure, or nerve trauma during whiplash injury. Although the entrapment theory is most commonly accepted, it lacks strong clinical evidence to support it. Accordingly, the available interventional approaches have been targeting the accessible part of the occipital nerve rather than the entrapped part. Conclusion Bedside sonography is an excellent imaging modality for soft tissue structures. Ultrasound not only allows distinguishing normal from abnormal entrapped occipital nerves, it can identify the level and the cause of entrapment as well. Ultrasound guidance allows precise occipital nerve blocks and interventions at the level of the 'specific' entrapment location rather than into the site of 'presumed' entrapment. [ABSTRACT FROM AUTHOR]

Objectives The aim of this trial was to determine risk factors for chronic saphenous neuralgia ( SN) following harvesting of the great saphenous vein ( GSV) for coronary artery bypass graft ( CABG) surgery. Methods In a prospective observational trial, 526 patients with no history of chronic painful disorders or surgery in the lower limbs were followed up for 13 weeks after undergoing CABG surgery in which GSV grafts were used. The primary outcome measure was persistence of clinically significant pain of neuropathic type in the territory supplied by the saphenous nerve beyond 12 weeks after surgery. Results Eighty-one (15.4%) patients consistently had probable neuropathic pain of clinically significant severity throughout the follow-up period and were labeled as suffering from chronic SN. Multivariable binary logistic regression analysis showed that younger age ( OR, 0.92; 95% CI, 0.88-0.95; P-value, < 0.0001), female gender ( OR, 2.28; 95% CI, 1.21-4.29; P-value, 0.011), higher body mass index ( OR, 1.25; 95% CI, 1.17-1.35; P-value, < 0.0001), diabetes mellitus ( OR, 2.13; 95% CI, 1.13-4.01; P-value, 0.020), distal-to-proximal dissection of the GSV ( OR, 7.28; 95% CI, 3.62-14.66; P-value, < 0.0001), and closure of the leg wound in two layers ( OR, 3.28; 95% CI, 1.81-5.95; P-value, 0.0001) were independent risk factors for chronic SN. Conclusions Chronic SN after CABG surgery utilizing GSV grafts is not uncommon. Risk factors identified in this trial are younger age, female gender, higher body mass index, diabetes mellitus, distal-to-proximal dissection of the GSV, and closure of the leg wound in two layers. [ABSTRACT FROM AUTHOR]

Background Goals Intrathecal drug delivery is an effective method to treat intractable pain. However, intrathecal catheter tip granuloma ( ICTG) is a devastating complication of intrathecal drug delivery systems. It typically occurs in the thoracic region; particularly, in patients receiving high doses or high concentrations of intrathecal drug infusions. Materials and Methods The PUBMED/ MEDLINE and Cochrane databases were also systematically searched for all reports on ICTG published in any language. The key words included 'intrathecal,' 'granuloma,' and 'spine surgery,' and all related publications between the earliest available date (the first granuloma-related chronic complication of intrathecal infusion reported in PUBMED/ MEDLINE in 1996) and June (week 1) of 2012 were searched. This case report is unique because it describes the formation of an intrathecal granuloma in the lumbar region of a patient who received a low-dose intrathecal infusion. Results and Conclusion Cerebrospinal fluid flow dynamics within the spinal canal along with the physical, chemical, and immunological properties of intrathecal medications have been suggested to be responsible for the growth of inflammatory mass lesions at the tips of intrathecal drug delivery catheters. Our literature review supports the possible role of certain factors, specifically previous spine surgery or spinal injury, in granuloma formation. The rate of development of ICTG appears to be higher in patients who have had previous spine surgery or spinal injury (68%) than in a general cohort of patients (48%), with an intrathecal pump. Therefore patients with a history of spine surgery or injury may be at increased risk of ICTG when receiving chronic intrathecal analgesia. [ABSTRACT FROM AUTHOR]

Objectives.— Chronic cluster headache patients are often resistant to pharmacological management. Percutaneous radiofrequency ablation (RFA) of the sphenopalatine ganglion (SPG) was shown before to improve episodic cluster headache but not chronic cluster headache. We were interested to examine the effect of such intervention in patients with intractable chronic cluster headache who failed pharmacological management. Methods.— Fifteen patients with chronic cluster headache, who experienced temporary pain relief following SPG block, underwent percutaneous RFA via the infrazygomatic approach under fluoroscopic guidance. Collected data include demographic variables, onset and duration of the headache, mean attack intensity (MAI), mean attack frequency (MAF), and pain disability index (PDI) before and up to 18 months after procedure. Results.— At 1-, 3-, 6-, 12-, 18-month follow-up, the MAI was 2.6, 3.2, 3.2, 3.4, 4.2, respectively ( P < .0001, P < .0001, P < .0001, P < .0005, P < .003, respectively). The PDI improved from 55 (baseline) to 17.2 and 25.6 at 6 and 12 months respectively ( P < .001). The MAF improved from 17 attacks/week to 5.4, 6.4, 7.8, 8.6, 8.3 at 1-, 3-, 6-, 12-, 18-month follow-up visits ( P < .0001, P < .0001, P < .0001, P < .002, P < .004, respectively). Conclusion.— Our data showed that percutaneous RFA of the SPG is an effective modality of treatment for patients with intractable chronic cluster headaches. Precise needle placement with the use of real-time fluoroscopy and electrical stimulation prior to attempting radiofrequency lesioning may reduce the incidence of adverse events. [ABSTRACT FROM AUTHOR]

The article discusses the diagnosis and treatment for cervicogenic headache. Cervicogenic headache has been initially defined as unilateral headache that is provoked by neck movement or pressure over tender points in the neck with associated reduced range of movement of the cervical spine. The article discusses the diagnostic criteria for the diagnosis of cervicogenic headache developed by the International Headache Society in 2004.

Objective. The most accepted mechanism of cervicogenic headache is referred pain from cervical structures innervated by the upper three cervical spinal nerves. The lateral atlantoaxial joint is not an uncommon cause of cervicogenic headache. In this retrospective study, we examined the effect of lateral atlantoaxial intra-articular steroid injection in managing 32 patients with cervicogenic headache who have a clinical picture suggestive of atlantoaxial joint pain. Design and Setting. The data were collected retrospectively by reviewing the patient’s medical records and pain questionnaires. Patients and Interventions. A total of 115 patients with cervicogenic headache who were referred to our institute were identified. Of those patients, 32 had a clinical picture suggestive of atlantoaxial joint pain and subsequently underwent a diagnostic/therapeutic intra-articular block. Results. Fifteen of the 32 patients (46.8%) had a postprocedure pain score of 0 (95% CI = 17.5–72.1%). Twenty-six of the 32 patients (81.2%) had a decrease in their postprocedure pain score of 50% or more (95% CI = 62.4–97.6%). The mean preprocedure pain score was 6.8 and postprocedure was 2.2 (Bonferroni-adjusted P < 0.001). At 1 and 3 months, the mean pain scores were 1.9 ( P < 0.001) and 3.6 ( P < 0.008), respectively. However, at 6 months, the mean pain score was 3.7, and this was not statistically significant ( P = 0.208). Conclusions. Lateral atlantoaxial intra-articular corticosteroid injections may provide short-term analgesia for patients with pain originating from the lateral atlantoaxial joint. [ABSTRACT FROM AUTHOR]

Objective. Recent studies have demonstrated significant involvement of dorsal column pathways in transmission of visceral pelvic pain. Spinal cord stimulation (SCS) suppresses visceral response to colon distension in an animal model and therefore may be an effective therapy for chronic pelvic pain of visceral origin. We are reporting on the value of neurostimulation for chronic visceral pelvic pain in six female patients with the diagnosis of long-standing pelvic pain (history of endometriosis, multiple surgical explorations, and dyspareunia). Design and Settings. Case-series report. All patients received repeated hypogastric blocks (in an average of 5.3 blocks) with a significant pain relief for a period ranging from 1 to 6 weeks. Three received neurolytic hypogastric block with the pain relief of 3, 8, and 12 months, respectively. Following psychological evaluation and clearance by our Multidisciplinary Committee on Implantable Devices, they all underwent SCS trial for 7-14 days. All patients received SCS systems with dual leads (Compact or Quad leads, Medtronic Inc., Minneapolis, MN, USA). Results. The average follow-up was 30.6 months. Median visual analog scale pain score decreased from 8 to 3. All patients had more than 50% of the pain relief. Pain Disability Index changed from an average of 57.7 ± 12 to 19.5 ± 7. Opiate use decreased from an average 22.5 mg to 6.6 mg of morphine sulfate milligram equivalents per day. Conclusion. It appears that SCS may have a significant therapeutic potential for treatment of visceral pelvic pain. [ABSTRACT FROM AUTHOR]

The article reports on the ultrasound guidance for peripheral nerve blocks as an instituted form in the area of regional anesthesia. It discusses that the possible advantages of ultrasonography are period visualization of needle tip advancement, neural and vascular structures, and local anesthetic (LA) spread.

Intrathecal baclofen is an invaluable therapeutic modality in the management of severe spasticity, especially in patients with cerebral palsy, multiple sclerosis, and spinal cord and brain injuries. This case report presents a rare complication of long-term intrathecal infusion with the development of a huge anterior abdominal wall hematoma with extension to the retroperitoneal space as a result of a repeated blunt trauma to the site of the intrathecal pump with erosion of the inferior epigastric artery. This inferior epigastric artery erosion could be avoided by implanting the intrathecal pump laterally away from the rectus abdominus muscle sheath. [ABSTRACT FROM AUTHOR]

We describe a patient with intractable chronic cluster headache that responded well to supraorbital nerve electric stimulation. [ABSTRACT FROM AUTHOR]

Abstract: Minor complications of inadvertent dural puncture during attempted epidural anesthesia are common, related to the size of the needle and the incidence of postdural puncture headache. Serious complications are much less common. We report a case where inadvertent dural puncture with an 18-gauge epidural needle was associated with the creation of intracranial and spinal subdural hematoma. [Copyright &y& Elsevier]

This report highlights transient Horner’s syndrome and trigeminal nerve palsy following labor epidural analgesia. A 29-year-old primigravida had a lumbar epidural catheter placed for analgesia in labor. The analgesia was maintained by infusion of a dilute local anesthetic/opioid mixture and turned off after achieving complete cervical dilation. Approximately 1 hour after delivery she complained of heaviness in her left eyelid, and was noted to have left-sided ptosis and paresthesia within the distribution of the ophthalmic and maxillary divisions of the trigeminal nerve, which resolved over the next 2 hours. There were no other neurologic changes. Horner’s syndrome and cranial nerve palsies can occur as a consequence of epidural analgesia for labor. [Copyright &y& Elsevier]

The article offers information on the use of virtual reality (VR) for pain therapy and the challenges associated with VR-induced cybersickness. Topics include the growing interest in VR for pain management, highlighting its potential to immerse patients in a computer-generated world to distract them from pain.

The authors discuss the article by Douglas R. A. McKendrick and colleagues on the effectiveness of preoperative preparation clinic in decreasing the number of cancellation rates (CRs) of surgery. Topics include the potential benefits of preoperative preparation clinic, the reduction of hospital, patient, and caregiver costs after the implementation of preoperative preparation clinic, and the increase in the number of patients who called and cancelled their surgeries.

The article presents a case study of a 33-year-old man with a headache disorder, called refractory unilateral occipital neuralgia. Via ultrasound scan a greater occipital nerve (GON) entrapment within the semispinalis capitis muscle was revealed and the patient was treated with the medication botulinum toxin type-A. It is suggested that the treatment provided pain relief and increased the quality of life of the patient.

The authors discuss issues concerning the need for anesthesiologists to acquire formal training. They provide an overview about regional anesthesia (RA), which offers postoperative analgesia, moderates stress responses, and diminishes postoperative cognitive dysfunction as well as shortens hospital stay. They highlight the importance of ultrasound-guided RA.

Background: Chronic daily headaches (CDH) are common and associated with significant morbidity, poor quality of life, and substantial burden on the healthcare system. CDH tends to be refractory to conventional medical management and/or patients cannot afford expensive treatments. It is stipulated that CDH share a mechanism of central sensitization in the trigeminocervical complex, mediated by activation of the N-methyl-d-aspartate (NMDA) receptors. Ketamine, a non-competitive NMDA antagonist, has been used in the treatment of chronic pain, but its role in CDH has not been completely established. This trial aims to evaluate the effect of high-dose IV ketamine infusions (compared to placebo) on the number of headache days at 28 days post-infusion. Methods: A multicenter, placebo-controlled, randomized controlled trial will be conducted with two parallel groups and blinding of participants and outcome assessors. The study will include 56 adults with a CDH diagnosis as per ICHD-3 criteria. Participants will be randomized (1:1) to either ketamine (1 mg. kg−1 bolus followed by infusion of 1 mg. kg−1. h−1 for 6 h) or placebo (0.9% saline in the same volume and infusion rate as the trial medication) bolus and infusion for 6 h. The impact on the number of monthly headache days, headache intensity, physical activity, mood, sleep, quality of life, analgesic consumption, and adverse effects will be recorded at baseline, immediately post-infusion, and from 1 to 28 days, 29 to 56 days, and 57 to 84 days after the infusion Discussion: Despite advancements in treatment, many patients continue to suffer from CDH. This trial investigates whether high-dose IV ketamine infusions can effectively and safely improve the CDH burden as compared to a placebo infusion. This treatment could become a safe, affordable, and widely available option for patients living with refractory headache. Trial registration: ClinicalTrials.gov NCT05306899. Registered on April 1, 2022 [ABSTRACT FROM AUTHOR]

The article discusses that chronic pain interventionalists' duty is to do no harm to the environment. Pain physicians should implement sustainability practices by using a systematic "Triple R: Reduce, Replace, Rethink" approach to greening the healthcare sector. The aim of reducing carbon footprint can be achieved while providing exceptional care for vulnerable patients with pain. The curricula for interventional pain fellowships should incorporate sustainability education.

Background The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial. Methods In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4–5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement. Results Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation. Conclusions Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice. [ABSTRACT FROM AUTHOR]

Background. Age and gender may exert important influences on opioid responsiveness and chronic pain. These effects have not been explored in the setting of chronic intrathecal (IT) opioid therapy. The objective of this study was to evaluate the effect of age and sex on IT opioid requirements during the first year after implantation of an intrathecal drug delivery system (IDDS) in chronic noncancer pain patients. Design. Retrospective study. Methods and Patient Population. In this retrospective study, 135 chronic noncancer pain patients consecutively implanted with IDDSs for opioid therapy had their first year postimplant records examined. Results. Similar pain relief was achieved at 12 months after implant in both age groups. Relative to the dose at implant, younger patients had significantly higher rates of IT opioid dose escalation compared with older patients at 12 months (750 ± 450% in patients ≤50 years old vs 195 ± 120% in patients >50 years old, P < 0.001). Oral opioid consumption was significantly decreased at 12 months in the older patient population (140 ± 89 to 62 ± 35 mg/day at 12 months, P < 0.001, n = 85), while in the younger patient group, there was no change in oral opioid consumption (128 ± 81 mg/day to 105 ± 140 mg/day at 12 months, P = 0.65, n = 50). Gender-based analysis (55% males and 45% females) revealed similar reductions in pain scores during the first year postimplant. Oral opioid consumption was significantly higher in females (126 ± 138 mg) vs males (79 ± 89 mg) at 12 months postimplant; however, IT opioid dose escalation at 12 months postimplant was not statistically different between males and females. Conclusion. IT opioid dose escalation occurs more steeply in the younger (under 50 years old) IDDS patient population without a concomitant significant decrease in oral consumption of opioids. Age-dependent changes may have important clinical implications on the effectiveness of IT opioid therapy in noncancer pain and its potential complications. [ABSTRACT FROM AUTHOR]

Cervicogenic headache is mainly characterized by unilateral headache symptoms which arise from the neck radiating to the fronto-temporal and possibly to the supra-orbital region. Physical examination to find evidence of a disorder known to be a valid cause of headache encompasses movement tests of the cervical spinal column and segmental palpation of the cervical facet joints and soft tissues of the neck. Injection of the nervus occipitalis major is recommended after unsatisfactory results with conservative treatments (1 B+). In the case of an unsatisfactory outcome after injection of the nervus occipitalis major, radiofrequency treatment of the ramus medialis (medial branch) of the cervical ramus dorsalis can be considered (2 B±). If the result is unsatisfactory pulsed radiofrequency treatment of the ganglion spinale (dorsal root ganglion) of C2 and/or C3 can be considered in a study context (O). [ABSTRACT FROM AUTHOR]

With the recent technological advances, neurostimulation has provided new hope for millions of patients with debilitating chronic pain conditions that respond poorly to other therapies. Outcome research demonstrated that patients with failed back surgery syndrome and complex regional pain syndromes benefit significantly from neurostimulation in pain reduction, functional capacity, and quality of life. Increasing clinical evidence supports the use of neurostimulation in post-herpetic neuralgia, peripheral neuropathy, occipital neuralgia, and other neuropathic pain conditions. Strong clinical evidences indicate that neurostimulation offers less invasive and more effective therapies for many patients with ischemic pain caused by cardiovascular and peripheral vascular diseases. A growing body of literature supports neurostimulation for visceral pain in general and interstitial cystitis in particular. As a basic principle, patient selection for the appropriate neurostimulation modalities is essential for safe, efficacious, and cost-effective applications of this therapy. Research with more vigorous designs is needed to establish evidence-based applications of neuromodulation therapy in emerging indications of pain management. [ABSTRACT FROM AUTHOR]

Cluster headache is a strictly unilateral headache that is associated with ipsilateral cranial autonomic symptoms and usually has a circadian and circannual pattern. Prevalence is estimated at 0.5 to 1.0/1,000. The diagnosis of cluster headache is made based on the patient's case history. There are two main clinical patterns of cluster headache: the episodic and the chronic. Episodic is the most common pattern of cluster headache. It occurs in periods lasting 7 days to 1 year and is separated by at least a 1-month pain-free interval. The attacks in the chronic form occur for more than 1 year without remission periods or with remission periods lasting less than 1 month. Conservative therapy consists of abortive and preventative remedies. Ergotamines and sumatriptan injections, sublingual ergotamine tartrate administration, and oxygen inhalation are effective abortive therapies. Verapamil is an effective and the safest prophylactic remedy. When pharmacological and oxygen therapies fail, interventional pain treatment may be considered. The effectiveness of radiofrequency treatment of the ganglion pterygopalatinum and of occipital nerve stimulation is only evaluated in observational studies, resulting in a 2 C+ recommendation. In conclusion, the primary treatment is medication. Radiofrequency treatment of the ganglion pterygopalatinum should be considered in patients who are resistant to conservative pain therapy. In patients with cluster headache refractory to all other treatments, occipital nerve stimulation may be considered, preferably within the context of a clinical study. [ABSTRACT FROM AUTHOR]

Background.— We report preliminary results of a novel acute treatment for intractable migraine. The sphenopalatine ganglion (SPG) has sensorimotor and autonomic components and is involved in migraine pathophysiology. Methods.— In 11 patients with medically refractory migraine, the sphenopalatine fossa was accessed with a 20-gauge needle using the standard infrazygomatic transcoronoid approach under fluoroscopy. Patients underwent temporary unilateral electric stimulation of the SPG with a Medtronic 3057 test stimulation lead after induction of full-blown migraine. Both sham and active stimulations with different settings were carried out for ≤60 minutes, and then the lead was removed. Results.— In 11 evaluations, 2 patients were pain-free within 3 minutes of stimulation. Three had pain reduction; 5 had no response; 1 was not stimulated. Five patients had no pain relief. Stimulation settings: mean amplitude of 1.2V, mean pulse rate of 67 Hz, mean pulse width of 462 µs. Lack of headache relief appeared linked to suboptimal lead placement, poor physiologic sensory response to localization stimulation, and diagnosis of medication overuse headache. Conclusion.— This study suggests a possible role for SPG stimulation in the treatment of refractory migraine headaches. [ABSTRACT FROM AUTHOR]

Discogenic back pain is frequently present in patients after discectomy. Here, we describe a case of young woman, previously discectomized, who was treated by a novel annuloplasty procedure, intradiscal biacuplasty (IDB). The improvement in functional capacity and pain scores were profound 12 months after the IDB. Visual analog pain scores (0–10) changed from 5 to 3. Oswestry scale showed functional improvement from 52%, or severe disability, to 14%, or minimal disability, and the SF-36 physical function scale score changed from 55 to 95. IDB may be an effective treatment for patients with discogenic pain from previously discectomized discs. [ABSTRACT FROM AUTHOR]

Abstract Background: Recent studies evaluated short-term efficacy and safety of peripheral nerve stimulation (PNS) of the occipital nerves for managing chronic migraine. We present 52-week safety and efficacy results from an open-label extension of a randomized, sham-controlled trial. Methods: In this institutional review board-approved, randomized, multicenter, double-blinded study, patients were implanted with a neurostimulation system, randomized to an active or control group for 12 weeks, and received open-label treatment for an additional 40 weeks. Outcomes collected included number of headache days, pain intensity, migraine disability assessment (MIDAS), Zung Pain and Distress (PAD), direct patient reports of headache pain relief, quality of life, satisfaction and adverse events. Statistical tests assessed change from baseline to 52 weeks using paired t-tests. Intent-to-treat (ITT) analyses of all patients (N=157) and analyses of only patients who met criteria for intractable chronic migraine (ICM; N=125) were performed. Results: Headache days were significantly reduced by 6.7 (±8.4) days in the ITT population (p<0.001) and by 7.7 (±8.7) days in the ICM population (p<0.001). The percentages of patients who achieved a 30% and 50% reduction in headache days and/or pain intensity were 59.5% and 47.8%, respectively. MIDAS and Zung PAD scores were significantly reduced for both populations. Excellent or good headache relief was reported by 65.4% of the ITT population and 67.9% of the ICM population. More than half the patients in both cohorts were satisfied with the headache relief provided by the device. A total of 183 device/procedure-related adverse events occurred during the study, of which 18 (8.6%) required hospitalization and 85 (40.7%) required surgical intervention; 70% of patients experienced an adverse event. Conclusion: Our results support the 12-month efficacy of PNS of the occipital nerves for headache pain and disability associated with chronic migraine. More emphasis on adverse event mitigation is needed in future research. Trial registration: Clinical trials.gov (NCT00615342). [ABSTRACT FROM AUTHOR]

Background: Chronic migraine (CM) is a debilitating neurological disorder with few treatment options. Peripheral nerve stimulation (PNS) of the occipital nerves is a potentially promising therapy for CM patients. Methods: In this randomized, controlled multicenter study, patients diagnosed with CM were implanted with a neurostimulation device near the occipital nerves and randomized 2:1 to active (n = 105) or sham (n = 52) stimulation. The primary endpoint was a difference in the percentage of responders (defined as patients that achieved a ≥50% reduction in mean daily visual analog scale scores) in each group at 12 weeks. Results: There was not a significant difference in the percentage of responders in the Active compared with the Control group (95% lower confidence bound (LCB) of −0.06; p = 0.55). However, there was a significant difference in the percentage of patients that achieved a 30% reduction (p = 0.01). Importantly, compared with sham-treated patients, there were also significant differences in reduction of number of headache days (Active Group = 6.1, baseline = 22.4; Control Group = 3.0, baseline = 20.1; p = 0.008), migraine-related disability (p = 0.001) and direct reports of pain relief (p = 0.001). The most common adverse event was persistent implant site pain. Conclusion: Although this study failed to meet its primary endpoint, this is the first large-scale study of PNS of the occipital nerves in CM patients that showed significant reductions in pain, headache days, and migraine-related disability. Additional controlled studies using endpoints that have recently been identified and accepted as clinically meaningful are warranted in this highly disabled patient population with a large unmet medical need. Trial registration: Clinical trials.gov (NCT00615342). [ABSTRACT FROM AUTHOR]

Objective. The purpose of this study was to examine the effect of intrathecal (IT) coadministration of bupivacaine with opioids during the initial phase of opioid titration and up to 1 year after implantation of an IT drug delivery system (IDDS). Design. The study was designed as a retrospective study. Outcomes Analyzed. The outcomes analyzed for this study were pain relief, oral opioid consumption, IT opioid, and bupivacaine dosage. Methods and Patient Population. The patient population for this study were consecutively implanted patients over a period of 6 years in a tertiary single center with multiple practitioners. In this retrospective study, 126 consecutive noncancer intractable pain patients were implanted with IDDS and initiated with an IT opioid (O) as a single medication or an IT opioid and bupivacaine (O + B). Pain intensity, amount of oral opioids, dose, rate, and concentration of IT opioids and bupivacaine, and number and type of IT medication used were recorded at preimplant, implant, and at 3, 6, and 12 months postimplant. Intervention. The intervention used for the study was the IT delivery device implant. Results. Significant reduction in pain intensity was observed in both groups at 12 months postimplant (O group: baseline 7.42 ± 2.1 to 5.85 ± 2.8 [n = 72, P < 0.001]; O + B group 7.35 ± 2 to 5.03 ± 2.4 (n = 54; P < 0.001]). The combination of opioids with bupivacaine from the start of IT infusion treatment resulted in a reduced progression of opioid dose escalation in comparison to patients started with opioids (O group). The rate of increase of IT opioids in the O group at 12 months was 535 ± 180%, whereas in the O + B, the dose increase was significantly lower at 185 ± 85% ( P < 0.004). In both groups, there was a statistically significant decrease in oral opioid consumption compared with preimplant doses. Conclusion. Concomitant initial coadministration of IT bupivacaine with opioids blunts the rate of IT opioid dose escalation during the first year after implant of an IDDS. More studies are necessary to thoroughly examine IT opioid dose escalation and the effects of addition of bupivacaine to IT opioids. Blunting IT opioid dose escalation may be a beneficial long-term effect of IT bupivacaine. [ABSTRACT FROM AUTHOR]

( Headache 2010;50:1164-1174) Introduction.— Cluster headaches (CH) are primary headaches marked by repeated short-lasting attacks of severe, unilateral head pain and associated autonomic symptoms. Despite aggressive management with medications, oxygen therapy, nerve blocks, as well as various lesioning and neurostimulation therapies, a number of patients are incapacitated and suffering. The sphenopalatine ganglion (SPG) has been implicated in the pathophysiology of CH and has been a target for blocks, lesioning, and other surgical approaches. For this reason, it was selected as a target for an acute neurostimulation study. Methods.— Six patients with refractory chronic CH were treated with short-term (up to 1 hour) electrical stimulation of the SPG during an acute CH. Headaches were spontaneously present at the time of stimulation or were triggered with agents known to trigger clusters headache in each patient. A standard percutaneous infrazygomatic approach was used to place a needle at the ipsilateral SPG in the pterygopalatine fossa under fluoroscopic guidance. Electrical stimulation was performed using a temporary stimulating electrode. Stimulation was performed at various settings during maximal headache intensity. Results.— Five patients had CH during the initial evaluation. Three returned 3 months later for a second evaluation. There were 18 acute and distinct CH attacks with clinically maximal visual analog scale (VAS) intensity of 8 (out of 10) and above. SPG stimulation resulted in complete resolution of the headache in 11 attacks, partial resolution (>50% VAS reduction) in 3, and minimal to no relief in 4 attacks. Associated autonomic features of CH were resolved in each responder. Pain relief was noted within several minutes of stimulation. Conclusion.— Sphenopalatine ganglion stimulation can be effective in relieving acute severe CH pain and associated autonomic features. Chronic long-term outcome studies are needed to determine the utility of SPG stimulation for management and prevention of CH. [ABSTRACT FROM AUTHOR]

( Headache 2010;50:937-942) Background.— Many clinicians use peripheral nerve blocks (NBs) and trigger point injections (TPIs) for the treatment of headaches. Little is known, however, about the patterns of use of these procedures among practitioners in the USA. Objectives.— The aim of this study was to obtain information on patterns of office-based use of peripheral NBs and TPIs by headache practitioners in the USA. Methods.— Using an Internet-based questionnaire, the Interventional Procedures Special Interest Section of the American Headache Society (AHS) conducted a survey among practitioners who were members of AHS on patterns of use of NBs and TPIs for headache treatment. Results.— Electronic invitations were sent to 1230 AHS members and 161 provided useable data (13.1%). Of the responders, 69% performed NBs and 75% performed TPIs. The most common indications for the use of NBs were occipital neuralgia and chronic migraine (CM), and the most common indications for the use of TPIs were chronic tension-type headache and CM. The most common symptom prompting the clinician to perform these procedures was local tenderness at the intended injection site. The most common local anesthetics used for these procedures were lidocaine and bupivacaine. Dosing regimens, volumes of injection, and injection schedules varied greatly. There was also a wide variation in the use of corticosteroids when performing the injections. Both NBs and TPIs were generally well tolerated. Conclusions.— Nerve blocks and TPIs are commonly used by headache practitioners in the USA for the treatment of various headache disorders, although the patterns of their use vary greatly. [ABSTRACT FROM AUTHOR]

( Headache 2010;50:943-952) Interventional procedures such as peripheral nerve blocks (PNBs) and trigger point injections (TPIs) have long been used in the treatment of various headache disorders. There are, however, little data on their efficacy for the treatment of specific headache syndromes. Moreover, there is no widely accepted agreement among headache specialists as to the optimal technique of injection, type, and doses of the local anesthetics used, and injection regimens. The role of corticosteroids in this setting is also debated. We performed a PubMed search of the literature to find studies on PNBs and TPIs for headache treatment. We classified the abstracted studies based on the procedure performed and the treated condition. We found few controlled studies on the efficacy of PNBs for headaches, and virtually none on the use of TPIs for this indication. The most widely examined procedure in this setting was greater occipital nerve block, with the majority of studies being small and non-controlled. The techniques, as well as the type and doses of local anesthetics used for nerve blockade, varied greatly among studies. The specific conditions treated also varied, and included both primary (eg, migraine, cluster headache) and secondary (eg, cervicogenic, posttraumatic) headache disorders. Trigeminal (eg, supraorbital) nerve blocks were used in few studies. Results were generally positive, but should be taken with reservation given the methodological limitations of the available studies. The procedures were generally well tolerated. Evidently, there is a need to perform more rigorous clinical trials to clarify the role of PNBs and TPIs in the management of various headache disorders, and to aim at standardizing the techniques used for the various procedures in this setting. [ABSTRACT FROM AUTHOR]

Background and Objectives. Ganglion impar block is an uncommon procedure that has been performed traditional with fluoroscopy. One approach is the trans-sacrococcygeal approach. Sometimes this can be difficult because the sacrococcygeal joint (SCJ) cannot be readily seen on anteroposterior (AP) and lateral fluoroscopy. This technical report describes the feasibility of ultrasound in assisting ganglion impar blocks. Methods. We performed ganglion impar block using ultrasound as the primary imaging tool, with fluoroscopic confirmation in 15 patients. We used a linear array transducer (5–12 MHz) to obtain sonographic transverse and longitudinal views at the sacral cornua; we identified the first cleft below the sacral hiatus as the SCJ. Then we inserted a 23-gauge (7 cm in length) needle into the SCJ under sonographic guidance. Then we confirmed proper needle depth by lateral fluoroscopy and injection of contrast agent. Results. In all 15 procedures, we accurately located and passed the needle into the patients' SCJs under real time sonographic guidance. Conclusions. In cases where the cleft cannot be readily seen on AP and lateral fluoroscopy, we have found ultrasound to be of assistance. Ultrasound does not replace fluoroscopy, because lateral fluoroscopy is still required to establish safe depth, and correct site of injection. However, ultrasound can be helpful when fluoroscopy alone is insufficient. [ABSTRACT FROM AUTHOR]

▪ Abstract: Sacroiliitis and sacroiliac (SI) joint dysfunction are frequent causes of the chronic lower back pain. Therapeutic solutions include intra-atricular injections with short-term pain relief and surgical fusion, which appears ineffective. Radiofrequency (RF) of the joint capsule or lateral branches has been previously reported with variable successes. Cooling tissue adjacent to the electrode (cooled RF) increases the radius of lesion. We present here the first retrospective data on pain relief and changes in function after such RF denervation. We reviewed electronic records of 27 patients with chronic low back pain (median 5 years) who underwent cooled RF of S1, S2, and S3 lateral branches and of dorsal ramus (DR) L5 following two diagnostic SI joint blocks (>50% of pain relief). Patient sample consisted of 20 women and 7 men, 38 to 92 years old. Pain disability index (PDI), visual analog scale (VAS) pain scores, global patient satisfaction (GPE) and opioid use before and 3–4 months after the procedure were analyzed. One patient had an incomplete chart. Observed were improvements in function (PDI) from 32.7 ± 9.9 to 20.3 ± 12.1 ( P < 0.001) and VAS pain scores 7.1 ± 1.6 to 4.2 ± 2.5 ( P < 0.001) at 3–4 months after the procedure. Opioid use decreased from median 30 to 20 mg morphine equivalent. Eighteen patients rated their improvement in pain scores using GPE as improved or much improved, while eight claimed minimal or no improvement. The majority of patients with chronic SI joint pain experienced a clinically relevant degree of pain relief and improved function following cooled RF of sacral lateral branches and DR of L5 at 3–4 months follow-up. ▪ [ABSTRACT FROM AUTHOR]

• During the COVID-19 pandemic, many conferences were converted to virtual formats. • Online offerings should allow for conference panels to include more female speakers. • We conducted a cross-sectional observation of webinars at the beginning of the COVID-19 pandemic. • Webinars organized by industry (vs professional societies) included fewer women (10% vs 28%). • Webinar organizers must be intentional with the gender distribution of panel speakers. [ABSTRACT FROM AUTHOR]