Pulsed radiofrequency for occipital neuralgia.

BACKGROUND: The clinical application of pulsed radiofrequency (PRF) by interventional pain physicians for a variety of chronic pain syndromes, including occipital neuralgia, is growing. As a minimally invasive percutaneous technique with none to minimal neurodestruction and a favorable side effect profile, use of PRF as an interventional neuromodulatory chronic pain treatment is appealing. Occipital neuralgia, also known as Arnold's neuralgia, is defined by the International Headache Society as a paroxysmal, shooting or stabbing pain in the greater, lesser, and/or third occipital nerve distributions. Pain intensity is often severe and debilitating, with an associated negative impact upon quality of life and function. Most cases of occipital neuralgia are idiopathic, with no clearly identifiable structural etiology. Treatment of occipital neuralgia poses inherent challenges as no criterion standard exists. Initially, conservative treatment options such as physical therapy and pharmacotherapy are routinely trialed. When occipital neuralgia is refractory to conservative measures, a number of interventional treatment options exist, including: local occipital nerve anesthetic and corticosteroid infiltration, botulinum toxin A injection, occipital nerve subcutaneous neurostimulation, and occipital nerve PRF. Of these, PRF has garnered significant interest as a potentially superior, safe, non-invasive treatment with long-term efficacy. OBJECTIVE: The objective of this article is to provide a concise review of occipital neuralgia; and a concise, yet thorough, evidence-based review of the current literature concerning the use of PRF for occipital neuralgia. STUDY DESIGN: Review of published medical literature up through April 2013. SETTING: The Center for Pain Medicine and Regional Anesthesia, the University of Iowa Hospitals and Clinics. RESULTS: A total of 3 clinical studies and one case report investigating the use of PRF for knee occipital neuralgia have been published worldwide. Statistically significant improvements in pain, quality of life, and adjuvant pain medication usage have been demonstrated. LIMITATIONS: Lack of randomized control trials, small study sample sizes, an absence of diagnostic block imaging guidance, and the use of outcome measures that are inherently subjective, limiting objectivity and introducing an unquantifiable degree of bias. CONCLUSION: Clinical studies to date examining the efficacy of PRF as a treatment for occipital neuralgia have yielded promising results, demonstrating sustained improvement in pain, quality of life, and adjuvant pain medication usage. Despite these encouraging clinical studies, conclusive evidence in support of PRF as an interventional treatment option for occipital neuralgia awaits to be seen.

Mental nerve neuropathy following dental extraction.

Mental nerve neuropathy (MNN), colloquially referred to as numb chin syndrome, is an uncommon neurologic condition that may arise secondary to multiple local and systemic etiologies, and may mimic other pain conditions affecting the mandible. Early recognition of mental nerve neuropathy in conjunction with accurate etiologic identification is crucial, as early pain management may prevent the transition from an acute to a chronic pain condition. In this article, we will describe the clinical courses of 2 patients who presented to the pain clinic with chronic painful numbness in the mental nerve sensory distribution following dental extraction. After a period of failed conservative medical management and repetitive successful nerve blocks at the mental foramen, we decided to proceed with radiofrequency nerve ablation. In both cases, performance of radiofrequency nerve ablation demonstrated a significant decrease in pain. Within interventional pain medicine, nerve blocks are often utilized to assist with pain generator identification, and resultantly also play an integral role in treatment planning. For instance, nerve blocks are often utilized to establish accurate identification of nerve tissue viability, a preliminary role essential for the determination of whether to proceed with an ablative peripheral nerve procedure. In this article, we will additionally review these important usages of nerve blocks within interventional pain medicine. The objective of our article is to help clinicians identify and properly manage early stage mental nerve neuropathy. Moreover, we aim to advance general medical knowledge of this important pain medicine topic. During the process of preparing this article we reviewed all existing pertinent medical literature related to MNN.