Utilization of Concurrent Dorsal Root Ganglion Stimulation and Dorsal Column Spinal Cord Stimulation in Complex Regional Pain Syndrome.

INTRODUCTION: Complex regional pain syndrome (CRPS) can be effectively treated with spinal cord stimulation (t-SCS). There is also evidence that dorsal root ganglion (DRG) stimulation may be superior to t-SCS in CRPS. However, there has been no published data, to our knowledge, that looked at the concurrent use of t-SCS and DRG stimulation for treatment of CRPS. METHODS: Our study includes four patients with severe CRPS who had all been implanted with a t-SCS. While all these patients had positive results from their t-SCS, they all had areas which lacked coverage, giving them incomplete pain relief. These patients also underwent successful trial and implantation of DRG-S. All four patients reported further improvement in their residual pain and function with DRG-S (>60%), and even superior pain relief (>80%) with concurrent use of t-SCS and t-SCS. RESULTS: All patients had a diagnosis of lower extremity CRPS-1. After DRG-S implantation, multiple attempts were made in each patient to use DRG-S alone by temporarily turning the t-SCS off. However, in each attempt, all patients consistently reported superior pain relief and improvement in function with the concurrent use of t-SCS and DRG, as compared to DRG alone. The average numeric rating scale pain score decreased from approximately 7 in the regions not covered by t-SCS to 3 after DRG-S implantation, and to 1.25 with concurrent use t-SCS and DRG-S. CONCLUSION: Both t-SCS and DRG-S have been shown to be effective in treatment of patients with CRPS. In our study, concurrent use of t-SCS and DRG-S provided significant improvement in pain and function as compared to using either device alone. This suggests the potential that combination therapy with t-SCS and DRG-S may be beneficial in patients with CRPS. Further prospective studies are required to evaluate this concept.

Treatment of Chronic Pain With Various Buprenorphine Formulations: A Systematic Review of Clinical Studies.

Clinical studies demonstrate that buprenorphine is a pharmacologic agent that can be used for the treatment of various types of painful conditions. This study investigated the efficacy of 5 different types of buprenorphine formulations in the chronic pain population. The literature was reviewed on PubMed/MEDLINE, EMBASE, Cochrane Database, clinicaltrials.gov, and PROSPERO that dated from inception until June 30, 2017. Using the population, intervention, comparator, and outcomes method, 25 randomized controlled trials were reviewed involving 5 buprenorphine formulations in patients with chronic pain: intravenous buprenorphine, sublingual buprenorphine, sublingual buprenorphine/naloxone, buccal buprenorphine, and transdermal buprenorphine, with comparators consisting of opioid analgesics or placebo. Of the 25 studies reviewed, a total of 14 studies demonstrated clinically significant benefit with buprenorphine in the management of chronic pain: 1 study out of 6 sublingual and intravenous buprenorphine, the only sublingual buprenorphine/naloxone study, 2 out of 3 studies of buccal buprenorphine, and 10 out of 15 studies for transdermal buprenorphine showed significant reduction in pain against a comparator. No serious adverse effects were reported in any of the studies. We conclude that a transdermal buprenorphine formulation is an effective analgesic in patients with chronic pain, while buccal buprenorphine is also a promising formulation based on the limited number of studies.

Cervical Epidural Injection in the Management of Refractory Pain and Stiffness in Spondyloarthropathy: A Case Report Series.

OBJECTIVES: The primary objective of this case series was to report the use of cervical epidural steroid injection in the management of neck pain and stiffness secondary to spondyloarthropathy in cases refractory to conservative therapy. METHODS: This was a case report series on three patients with diagnosis of spondyloarthropathy who presented with severe stiffness and non-radicular axial neck pain refractory to conservative therapy. All patients received cervical epidural steroid injections with significant improvement of their axial neck pain and stiffness. RESULTS: Cervical epidural steroid injections may be effective to improve the axial neck pain and stiffness in patients with diagnosis of spondyloarthropathy refractory to conservative management. Thus, we believe that epidural steroid injections should be considered in the management of patients with spondyloarthopathies.

Changes in the Skin Conductance Monitor as an End Point for Sympathetic Nerve Blocks.

OBJECTIVE: There is a lack of objective methods for determining the achievement of sympathetic block. This study validates the skin conductance monitor (SCM) as an end point indicator of successful sympathetic blockade as compared with traditional monitors. METHODS: This interventional study included 13 patients undergoing 25 lumbar sympathetic blocks to compare time to indication of successful blockade between the SCM indices and traditional measures, clinically visible hyperemia, clinically visible engorgement of veins, subjective skin temperature difference, unilateral thermometry monitoring, bilateral comparative thermometry monitoring, and change in waveform amplitude in pulse oximetry plethysmography, within a 30-minute observation period. Differences in the SCM indices were studied pre- and postblock to validate the SCM. RESULTS: SCM showed substantially greater odds of indicating achievement of sympathetic block in the next moment (i.e., hazard rate) compared with all traditional measures (clinically visible hyperemia, clinically visible engorgement of veins, subjective temperature difference, unilateral thermometry monitoring, bilateral comparative thermometry monitoring, and change in waveform amplitude in pulse oximetry plethysmography; P ≤ 0.011). SCM indicated successful block for all (100%) procedures, while the traditional measures failed to indicate successful blocks in 16-84% of procedures. The SCM indices were significantly higher in preblock compared with postblock measurements (P < 0.005). CONCLUSIONS: This preliminary study suggests that SCM is a more reliable and rapid response indicator of a successful sympathetic blockade when compared with traditional monitors.

A Case of Spinal Cord Stimulator Recharging Interruption in Wound Healing.

OBJECTIVES: To illustrate the obstacles and problems with electrical fields (EFs) in treatment and management of skin wounds. Unlike the literature that gives evidence for EF promoting wound healing, there is relatively little research to illustrate the interference of wound healing with EFs. MATERIALS AND METHODS: This is a case report of a patient who underwent spinal cord stimulator implantation, and presented with delayed wound healing postoperatively. Postoperative workup for infection was negative. Spinal cord stimulator was programmed to use higher frequencies than traditional settings, which required recharging the pulse generator daily. There was spontaneous improvement of the clinical presentation resulting in adequate wound healing after changing the programming to less frequent recharging requirements. RESULTS: In our case, despite the presence of clinical signs similar to a surgical site infection, the wound healing was most likely interrupted and delayed secondary to the electric field generated due to the frequent recharges of the pulse generator. CONCLUSIONS: It is possible that EF can also negatively impact healing of a wound, and thus should be a consideration to clinicians when a delay in proper wound healing is encountered postoperatively. Therefore, in the postoperative period, when the wound healing is most active, we recommend avoiding programs that require frequent pulse generator recharges.

A Computed Tomography-Guided Demonstration of the Unilateral Distribution of Low-Volume Epidural Injectate.

OBJECTIVES: The primary objective of this case report was to demonstrate the unilateral distribution of the low volume injectate given in the epidural space when paramedian interlaminar approach is utilized under computed tomography guidance. METHODS: This was a case report on a single patient with history of unilateral epidural contrast distribution under fluoroscopy views, who presented with bilateral lumbar radicular symptoms, and underwent epidural injections via bilateral paramedian interlaminar approach under computed tomography guidance. Multiple-level computed tomography scans were obtained for demonstration purposes. RESULTS: There was primarily unilateral distribution of low-volume injectate in the epidural space when paramedian interlaminar approach is utilized.

Traditional versus cooled-radiofrequency neurotomy for the treatment of chronic lumbar facet (zygapophyseal) joint pain.

Aim: Traditional radiofrequency ablation (TRFA) effectively treats facet joint-related pain, while water-cooled radiofrequency ablation (CRFA) may offer benefits like larger lesions and easier nerve access. Our goal is to assess the effectiveness of TRFA and CRFA for facet joint-related pain.Materials & methods: This retrospective study included an evaluation of 346 RFA interventions performed on 190 patients suffering from long-term low-back pain. The primary outcome was defined as a decrease of ≥50% of the mean numeric rating scale.Results: The primary outcome was achieved at the first follow-up (FU) for both TRFA and CRFA, with pain relief of 55.2 and 60.5%, respectively. At the second FU, the primary outcome was achieved only in the CRFA group (54.1%), although the TRFA group also showed a good improvement (48.6%). In both groups, pain relief was under 50% during the third FU.Conclusion: Our study indicates that both CRFA and TRFA modalities are effective and safe treatments.

What is this article about? In this study, the effectiveness of two different techniques of facet radiofrequency neurotomy (TRFA and CRFA) is compared. The study involved patients with facet joint-related back pain who did not improve with regular treatments but showed positive results with diagnostic blocks. The pain levels are recorded before and after treatment using a numeric rating scale at various times. The main goal was to see if pain decreased by 50% or more after the treatment. Second, the duration of time until patients need another treatment is investigated.What were the results? Both TRFA and CRFA reduced pain significantly in the first 4­8 weeks. TRFA patients had a 55.2% pain reduction, and CRFA patients had a 60.5% reduction. By 2­6 months, only the CRFA group maintained a 54.1% reduction, while the TRFA group had a 48.6% reduction. By 6­12 months, pain relief in both groups was found below 50%. Out of 81 treatments (44 TRFA and 37 CRFA), many patients needed another procedure within 6­12 months.What do the results of this study mean? Both TRFA and CRFA are effective and safe for treating chronic low back pain from facet joints. Although CRFA has some theoretical advantages over TRFA, the study found no significant difference in the outcomes between the two methods.

Temperature difference between the affected and unaffected limbs in complex regional pain syndrome.

Background: Complex regional pain syndrome (CRPS) is classified into two subtypes based on clinical presentation: warm or cold.Methods: We examined the distribution of warm and cold subtypes in CRPS patients before they received lumbar sympathetic block. We retrospectively analyzed 81 prelumbar sympathetic block Forward Looking InfraRed images obtained from 30 patients to study temperature asymmetry between affected and unaffected limbs.Results: In 23 of the 30 patients (77%), the temperature difference between the affected and affected limbs was within the normal range (<0.6°C difference). Of the remaining seven cases, six (20%) were diagnosed with cold-CRPS and one (3%) with warm-CRPS. During subsequent interventions, 74% of the patients maintained a temperature difference within the normal range (<0.6°C difference).Conclusion: Retrospective analysis of Forward Looking InfraRed thermal camera images in CRPS patients showed that 77% of patients did not exhibit significant temperature asymmetry (<0.6°C difference) between affected and unaffected limbs.

What is the article about? The article discusses a condition called complex regional pain syndrome (CRPS), a type of chronic pain that affects arms or legs. CRPS can potentially make the affected limb colder or warmer compared with the other limb. This study investigated temperature differences between the affected and nonaffected limbs in CRPS patients to be treated with a procedure called lumbar sympathetic nerve blocks. Researchers used an infrared thermal camera to take pictures of the patients' feet to measure these temperature differences.What were the results? The study found that 77% of the patients, who were about to have their initial nerve block treatments, did not show a significant (greater than 0.6°C) temperature difference between their affected and nonaffected limbs.What do the results mean? The study suggests that most CRPS patients demonstrated only a small temperature difference between their affected and nonaffected limbs. This result is different from earlier studies, which suggested that warm CRPS occurs in about 70% and cold CRPS in about 30% of cases at the time of diagnosis.

Epidural spread of surgical site infection from spinal cord stimulation trial.

We present a case of deep surgical site infection (SSI) at a spinal cord stimulator (SCS) trial implantation site, resulting from an allergic reaction to an unknown agent. A 38-year-old female with complex regional pain syndrome began an SCS trial, noting 100% pain relief for 5 days. Fluid drainage from the surgical site was reported on POD6 and trial leads were removed the following day. The patient was hospitalized with sepsis. Blood cultures revealed Staphylococcus aureus. MRIs showed skin breakdown and cellulitis of the paraspinal musculature extending into the epidural space. The patient was maintained with antibiotics and rigorous wound care for 9 days and the surgical site infection resolved. The patient proceeded to SCS implantation, and reported good pain relief with the implanted device.

This case report describes the treatment of an infection developed during a spinal cord stimulator (SCS) trial period. SCS are medical devices used to treat pain, they work by applying electrical current to the areas of the spinal cord that cause patients' pain. Before patients get an SCS device implanted, they often undergo a trial period first. During a trial, the stimulator device stays outside the body, and only the wires carrying electricity to the spinal cord are implanted. Typically, SCS trial and implantation procedures are safe and result in effective pain relief. However, infections are a dangerous potential complication that can result from these procedures. In our case, the patient developed an infection during an SCS trial period, likely resulting from an allergic reaction to their surgical dressings. The infection traveled down the wires and nearly reached the spinal cord. Since the infection was quickly identified and managed, devastating complications were avoided. The patient was able to get a permanent SCS after the infection was resolved, and had effective pain relief. Our report emphasizes the importance of using strict infection prevention techniques, and monitoring patients for signs of infection throughout SCS trials.

Novel use of propranolol for management of pain in children with vertebral hemangioma: report of two cases.

INTRODUCTION: Vertebral hemangioma (VH) is an exceedingly rare neoplasm in pediatric population with less than 10 cases reported in the literature. It is usually asymptomatic in adults and diagnosed incidentally at radiographic investigations of other medical conditions. In this report, we describe two children who presented to our institution with severe back pain and were diagnosed with VH. CASE REPORTS: Case 1 was an 8-year-old male with a pain score of 10 out of 10 at presentation. Clinical investigations eliminated the possibility of a neoplasm or infectious process and MRI findings were highly suggestive of an aggressive vertebral hemangioma. Case 2 was a 17-year-old female who presented with back pain radiating to shoulders. Her pain score was 4 out of 10 and she was diagnosed with vertebral hemangioma due to the specific findings on MRI studies. DISCUSSION: Both patients received propranolol with a dose of 20 and 40 mg per day, respectively. They were free of pain at 2 months follow-up. There are different invasive treatment modalities for the management of VH, including vertebroplasty, kyphoplasty, radiotherapy, alcohol injection, embolization, and surgery. These methods have been used in adult patients for several years, but each of them has potential risks which make these options unsuitable for children. CONCLUSION: Propranolol is a beta blocker which is safely used in the management of infantile hemangiomas. This is the first report demonstrating its efficacy in symptomatic treatment of childhood VH. The lesions did not show any regression, but the pain relief obtained was very significant under propranolol therapy.

Spinal cord stimulator malfunction as a result of lead fracture: a case report.

Spinal cord stimulation is a successful and thoroughly documented procedure in treating chronic refractory pain. Complications are rare and usually mild, but hardware complications such as electrode dysfunction have been shown to be detrimental in treatment efficacy and patient outcome. We report a case in which a patient diagnosed with complex regional pain syndrome underwent spinal cord stimulation for pain management and experienced lead migration and fracture, resulting in loss of paresthesia and increased pain. This case provides useful clinical information on identifying electrode dysfunction in patients with implanted spinal cord stimulators and emphasizes the importance of preventative measures to reduce the risk of similar complications.

Acute worsening of clinical presentation in CRPS after SARS-CoV-2 (COVID-19) vaccination: a case series.

We present the acute worsening of clinical presentation in complex regional pain syndrome (CRPS), following mRNA-based COVID-19 vaccination. We report the case series of three patients diagnosed with CRPS type I who presented with acute worsening of symptoms after mRNA-based COVID-19 vaccination and their medical management. The acute clinical worsening after mRNA-based COVID-19 vaccination was transient and effectively managed with adjustment of individualized therapy in all three patients. The mortality and morbidity of COVID-19 infection are serious, and vaccination is recommended in the general population, including patients with a diagnosis of CRPS. However, clinicians should be aware of the possibility that there may be a clinical worsening CRPS after mRNA-based COVID-19 vaccination.

This case series presents the worsening of symptoms in complex regional pain syndrome (CRPS), following mRNA-based COVID-19 vaccination. We report on three patients diagnosed with CRPS who presented with worsening of symptoms after mRNA-based COVID-19 vaccination and their medical management. The worsening of symptoms was temporary and managed with adjustment of individualized therapy in all three patients. The dangers of COVID-19 infection are serious, and vaccination is highly recommended in the general population, including patients with a diagnosis of CRPS. However, healthcare providers should be aware of the possibility of clinical worsening of CRPS after mRNA-based COVID-19 vaccination.

Cooled-radiofrequency neurotomy for the treatment of chronic lumbar facet (zygapophyseal) joint pain: A retrospective study.

ABSTRACT: Cooled-radiofrequency (CRFA) is a newer technique and may have some theoretical advantages over traditional radiofrequency ablation (TRFA). In this study, we aimed to investigate the efficacy and safety of CRFA for the treatment of lumbar facet joint-mediated pain. In this retrospective study, we evaluated 185 CRFA performed on 105 patients. All patients with axial lower back who received the preliminary diagnosis of lumbar facet joint-mediated pain and refractory to conservative therapy underwent diagnostic medial branch blocks. CRFA was recommended to those patients who responded favorably to two sets of diagnostic medial branch blocks. Pain scores in numeric rating scale (NRS) were recorded pre-treatment and post-treatment at different time-points. The primary outcome measure was to report descriptive NRS score and average % improvement from baseline at each time point. A significant pain relief was determined by a decrease of ≥50% of mean NRS. Secondary outcome measure was the time to repeat treatment with subsequent CRFA. Adverse events were also recorded.Primary outcome measure determined as the improvement in NRS, for at least 50% or more, was achieved in both 1st (4-8 weeks) and 2nd (>2-6 months) follow-up (FU) with 60.5% and 53.6% reduction in NRS respectively. Our subgroup analysis comparing the younger (<50) and older (≥50) age groups showed superior pain relief with CRFA in the older (≥50) age group, both in the 1st (4-8 weeks) and 2nd (>2-6 months) FU time points (63.4% and 58.4% reduction in NRS, respectively). Cooled-radiofrequency ablation is an effective and safe procedure for the treatment of chronic lumbar facet joint related pain. The duration of pain relief was comparable to traditional radiofrequency ablation as reported in the literature.

Treatment of knee osteoarthritic pain with platelet-rich plasma: a systematic review of clinical studies.

Introduction: Knee osteoarthritis is a degenerative joint disease that is secondary to degradation of articular cartilage, reformation of subchondral bone through degradation and proliferation as well as presence of synovitis. Materials & methods: This systematic review was conducted and reported as per Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Results: A total of 30 of the 48 comparators showed statistically significant superiority with platelet-rich plasma (PRP) compared with a control, while the other 16 comparators showed no significant difference between PRP and the comparator. Conclusion: We can only recommend PRP for patients with early-stage osteoarthritis (I or II) and who are aged below 65, based on our findings. Based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) recommendations, while studies reviewed were randomized controlled studies, and therefore, high grade, due to variance in imprecision, risk of bias and inconsistency among the 37 studies, it would be reasonable to rate this paper as subjectively moderate.

The efficacy and safety of cooled-radiofrequency neurotomy in the treatment of chronic thoracic facet (zygapophyseal) joint pain: A retrospective study.

Anatomic course of medial branches in the thoracic spine is significantly different. Cooled RFA (CRFA) is a newer technique that can create a larger spherical lesion with a potential to compensate for the anatomic variability of the medial branches in the thoracic spine. Our retrospective study aimed to investigate the efficacy and the adverse effects of the CRFA in the treatment of thoracic facet-related pain.For this retrospective study, we evaluated 40 CRFA performed on 23 patients. The patients with diagnosis of thoracic facet joint-related pain underwent CRFA. Pain scores in numeric rating scale (NRS) were recorded at pretreatment and posttreatment at different time-points. The primary outcome measure was to report descriptive NRS score and average % improvement from baseline at each time point. A significant pain relief was determined by a decrease of ≥ 50% of mean NRS. Secondary outcome measure was the time to repeat treatment with subsequent CRFA. Adverse events were also recorded.Improvement of average pain level was 20.72% in the 1st follow-up (FU) (4-8 weeks), 53% in the 2nd FU (2-6 months), and 37.58% in the 3rd FU (6-12 months). Subgroup analysis was done based on age cutoff (age in years ≤ 50 versus >50), and pretreatment NRS (≤7 versus >7). Patients with age ≤50 and NRS score >7 experienced the best pain relief in the 2nd FU period (2-6 months). The patients with age > 50 and NRS pain level ≤7 showed steadily increased benefit both in the 2nd FU (2-6 months) and 3rd FU (6-12 months).This is the first clinical study to evaluate the efficacy and adverse effects of CRFA in the thoracic spine for facet joint-related pain. Our results suggest that CRFA procedure is an effective treatment modality for thoracic facet-related pain. Our subgroup analysis demonstrated that the pain relief and duration varies with the age and the pretreatment pain levels.

Ultrasound-guided caudal epidural steroid injection for successful treatment of radiculopathy during pregnancy.

Aim: The aim of this case report is to describe ultrasound guidance for caudal epidural steroid injection during pregnancy. Case report: A 29-year-old, 32-week parturient presented with severe back and leg pain with MRI demonstrating herniation of the L5-S1 level. The disabling pain was refractory to conservative therapy, and an ultrasound-guided caudal epidural steroid injection was performed. There was significant pain relief in the first week with an uneventful subsequent pregnancy. Following delivery, the patient had no further recurrence of her presenting symptoms. Conclusion: Severe radiculopathy may be encountered during pregnancy, complicated by a limited number of treatment options. Ultrasound guidance should be considered during performance of caudal epidural injections in feasible cases.

[The effect of emotional stressors on postoperative skin conductance indices: a prospective cohort pilot study]. / Efeito dos estressores emocionais nos índices de condutância cutânea no pós­operatório: estudo piloto de coorte prospectivo.

BACKGROUND: Skin conductance response reflects the activity of the sympathetic nervous system and is used to measure acute pain. This pilot study examines correlations of skin conductance response with emotional stressors postoperatively. METHODS: The correlation of skin conductance response with pain, anxiety, nausea and intellectual task performance was analyzed in postoperative patients. RESULTS: Significant correlations were observed between anxiety and pain during physical activity on both postoperative day 1 and 2. No significant correlations were found between skin conductance response versus mild pain, nausea, anxiety or intellectual task performance. CONCLUSION: This pilot study suggests that when the pain is well-controlled in the early postoperative period, skin conductance response monitoring may not be influenced by other emotional stressors.

Detection of unrecognized pregnancy prior to a fluoroscopy-guided interventional procedure: A case report.

The aim of this case report is to increase the awareness about patient and fetus safety through preprocedure assessment and screening of unrecognized pregnancy for fluoroscopy-guided procedures.

Incidence and risk factors for development of persistent postsurgical pain following total knee arthroplasty: A retrospective cohort study.

Persistent postsurgical pain (PPP) is defined as the discomfort that lasts >3 months postoperatively. The primary aim of this retrospective study was to estimate the risk of developing moderate-to-severe PPP after primary total knee arthroplasty (TKA). The secondary goal was to explore potential predictors of this outcome.Data were collected via hospital arthroplasty registry and chart review. The risk of moderate-to-severe PPP, defined as ≥4 on the numerical rating scale (NRS) at minimum of 3 months post-surgery, was calculated. Multivariable logistic regression was used to estimate the association of patient demographics, diagnoses, length of hospital stay, and preoperative NRS with the odds of developing PPP. Exploratory, simple logistic regression was used to estimate the association of perioperative factors with the odds of developing PPP on a subset of patients (n = 72).The risk of PPP after TKA was 31.3% (95% confidence interval [CI]: 27.5-35.0) (n = 578). Every 2-point increase in baseline NRS was associated with 1.66 (95% CI: 1.37-2.03) times the odds of developing PPP (P < .001). African-Americans (vs whites) had 1.82 (95% CI: 1.03-3.22) times the odds of developing PPP (P = .040). Exploratory analysis suggested that the adductor canal saphenous nerve (vs femoral nerve) blocks were associated with 2.87 (95% CI: 1.00-8.26) times the odds of developing PPP (P = .049).This study estimated a high risk (31.3%) of moderate-to-severe PPP after primary TKA. This study suggested that higher preoperative pain scores might be associated with greater odds of developing PPP. Moreover, this study suggested the possibility that racial differences and types of peripheral nerve blocks might be associated with greater odds of developing moderate-to-severe PPP after TKA surgery. However, the evidence obtained from our exploratory analysis of limited data certainly requires further exploration in large-scale studies.

Epidural approach to paravertebral thoracic sympathetic block as an alternative to stellate ganglion block: A case report.

RATIONALE: Evidence from cadaveric studies note that the sympathetic nerves from the second and third thoracic ganglia bypass the stellate ganglion in 20% of the population. We present a novel alternative technique for sympathetic blockade of upper extremity via thoracic epidural approach. PATIENT CONCERNS: The patient-reported anxiety about "the placement of the needle in the front of the neck" and severe pain secondary to complex regional pain syndrome. DIAGNOSES: Complex regional pain syndrome type-1 with involvement of upper extremity. INTERVENTIONS: A patient with upper extremity complex regional pain syndrome underwent sympathetic blockade of the upper extremity via thoracic epidural approach with advancement of a catheter through neural foramen and positioning the catheter tip in the upper thoracic paravertebral space. OUTCOMES: Clinical signs of successful sympathetic blockade of upper extremity were consistently observed after each block utilizing this alternative technique multiple times in a single patient. LESSONS: Thoracic paravertebral block via thoracic epidural approach and catheter use may be an alternative technique for upper extremity sympathetic blockade. Potential advantages of this technique include complete sympathetic blockade of upper extremity for both diagnostic and therapeutic purposes, patient comfort with more effective local anesthetic administration for needle entry site, and potentially reduced risk of pneumothorax and inadvertent intravascular injection.