CE: Alpana; ACO/290501; Total nos of Pages: 6;

ACO 290501

REVIEW

CURRENT
OPINION Regional anesthesia in pain management
Michele Curatolo

Purpose of review
The study focuses on neural blocks with local anesthetics in postoperative and chronic pain. It is prompted
by the recent publication of several systematic reviews and guidelines.
Recent findings
For postoperative pain, the current evidence supports infusions of local anesthetics at the surgical site,
continuous peripheral nerve blocks, and neuraxial analgesia for major thoracic and abdominal procedures.
Ultrasound guidance can improve the performance of the blocks and different patient outcomes, although the
incidence of peripheral nerve damage is not decreased. For chronic pain, the best available evidence is on
nerve blocks for the diagnosis of facet joint pain. Further research is needed to validate diagnostic nerve blocks
for other indications. Therapeutic blocks with only local anesthetics (greater occipital nerve and sphenopalatine
ganglion) are effective in headache. A possible mechanism is modulation of central nociceptive pathways.
Therapeutic nerve blocks for other indications are mostly supported by retrospective studies and case series.
Summary
Recent literature strongly supports the use of regional anesthesia for postoperative pain, whereby infusions
at peripheral nerves and surgical site are gaining increasing importance. Local anesthetic blocks are valid
for the diagnosis of facet joint pain and effective in treating headache. There is a need for further research
in diagnostic and therapeutic blocks for chronic pain.
Keywords
chronic pain, nerve blocks, postoperative pain, regional analgesia, regional anesthesia

INTRODUCTION and the American Society of Anesthesiologists pub-

Regional anesthesia is the only pharmacological lished an evidence-based guideline on the manage-
&&

approach that is able to stop pain. This is because
of the unique ability of local anesthetics to provide
deep block of sensory input. This study focuses on
the use of neural blocks with local anesthetics for the
management of acute and chronic pain. Injections
of steroid, as well as injection of any medication at
joints, ligaments, or tendons are not discussed. In
line with this journal policy, the study is not a
comprehensive review of the practice of regional
anesthesia for pain management; it rather discusses
topics of current interest in this field and focuses on
research published in the last 12–18 months, based
on my selection and appraisal of the literature.
ACUTE POSTOPERATIVE PAIN
The main rationale for using regional anesthesia in
acute postoperative pain is its superiority to
systemic analgesia in terms of pain relief [1–5].
Recent recommendations
Recently, the American Pain Society, the American
Society of Regional Anesthesia and Pain Medicine,
ment of postoperative pain [6 ]. Based on a
structured systematic review of the available liter-
ature, an interdisciplinary panel developed recom-
mendations to guide clinical practice. In the field of
regional anesthesia, the panel recommended to:
consider surgical site-specific local anesthetic infil-
tration (weak recommendation, moderate-quality
evidence); consider surgical site-specific peripheral
regional anesthetic techniques in adults and chil-
dren (strong recommendation, high-quality evi-
dence); use continuous, local anesthetic-based
peripheral regional analgesic techniques when the
need for analgesia is likely to exceed the duration of
effect of a single injection (strong recommendation,
Department of Anesthesiology and Pain Medicine, University of Wash-
ington, Seattle, USA
Correspondence to Michele Curatolo, MD, PhD, Department of Anes-
thesiology and Pain Medicine, University of Washington, 1959 NE Pacific
Street, Box 356540, Seattle, WA 98195-6540, USA. Tel: +1 206 543
2673; e-mail: curatolo@uw.edu
Curr Opin Anesthesiol 2016, 29:000–000
DOI:10.1097/ACO.0000000000000353

0952-7907 Copyright ß 2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-anesthesiology.com

Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: Alpana; ACO/290501; Total nos of Pages: 6;
ACO 290501
Regional anesthesia
KEY POINTS
 For postoperative pain, the current evidence supports
infusions of local anesthetics at the surgical site,
continuous peripheral nerve blocks, and neuraxial
analgesia for major thoracic and abdominal
procedures.
 Ultrasound guidance can improve the performance of
the blocks and different patient outcomes, although the
incidence of peripheral nerve damage is not decreased.
 For chronic pain, the best available evidence is on
nerve blocks for the diagnosis of facet joint pain, and
further research is needed to validate diagnostic nerve
blocks for other indications.
 Therapeutic blocks with only local anesthetics (greater
occipital nerve and sphenopalatine ganglion) are
effective in headache, whereas their efficacy for other
chronic pain conditions has not been adequately
studied.
moderate-quality evidence); and offer neuraxial
analgesia for major thoracic and abdominal pro-
cedures, particularly in patients at risk for cardiac
complications, pulmonary complications, or pro-
longed ileus (strong recommendation, high-quality
evidence).
The same panel identified several research gaps in
postoperative pain management and published an
additional study highlighting areas where future
&&
research is needed [7 ]. In the field of regional anes-
thesia, the review found that most trials were not
designed to assess the risk of uncommon compli-
cations. Because the sample size would be prohibitive
for a randomized controlled trial (RCT), the review
highlighted the need for databases or registries that
capture data of large patient populations to address
occurrence and risk factors for uncommon, but
potentially disastrous, complications. Although
there is a reasonable amount of evidence suggesting
that the use of epidural analgesia is associated with a
decrease in perioperative morbidity, the review
found a lack of similar data for continuous peripheral
regional analgesia. In addition, there are few data on
the efficacy of regional analgesia on patient-reported
outcomes (e.g., satisfaction, quality of recovery, qual-
ity of life, and sleep). The use of perioperative regional
anesthesia/analgesia may decrease the incidence or
severity of chronic postsurgical pain, but there is a
need for further research in this field.
Alternatives to neuraxial analgesia
The use of neuraxial analgesia undoubtedly led to
dramatic improvements in perioperative pain care.
2 www.co-anesthesiology.com
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
However, a wide application of this practice has
been challenged in recent years. Some surgical tech-
niques have become less invasive, requiring less
aggressive analgesic regimens. Improved periopera-
tive care has reduced the risk of postoperative com-
plications, reducing the effect of epidural analgesia
on postoperative morbidity over time [8]. Severe
neurological complications, although very rare,
remain a concern.
The above considerations led to a progressively
lesser use of neuraxial blocks, in favor of peripheral
nerve blocks. These procedures, when performed
either as single shot or as continuous infusion, are
particularly suited for surgery on the upper and
lower limb, and for some procedures on the trunk.
The main advantages over neuraxial analgesia are
the avoidance of potentially catastrophic neurologic
complications associated with spinal procedures,
the higher hemodynamic stability and the lesser
impairment of motor function. A recent narrative
review based on a systematic literature search and
prospectively defined appraisal criteria came to the
conclusion that the majority of peripheral regional
anesthetic techniques produce benefits for patients
and hospital efficiency: they reduce postoperative
pain and opioid consumption and/or increase
patient satisfaction; for selected surgical procedures,
the use of blocks can avoid general anesthesia and is
associated with increased efficiency of the surgical
pathway [9]. An exception is the transversus abdom-
inis plane block, where the evidence for efficacy was
conflicting. This is confirmed by a recent meta-
analysis, which found marginal postoperative anal-
gesic efficacy of transversus abdominis plane block
after abdominal laparotomy/laparoscopy and cesar-
ean delivery [10]. Consistent with the aforemen-
&&
tioned study by the multisociety panel [7 ], the
review [9] found that the evidence for the impact
of peripheral nerve blocks on longer-term outcomes
was inadequate to inform clinical decision-making.
Ultrasound guidance has gained enormous pop-
ularity in the last decade. Multiple recently pub-
lished systematic reviews found ultrasound
guidance to improve the performance of the blocks
and different patient outcomes [11–14]. Impor-
tantly, the expectation that direct visualization of
the neural structures would reduce the incidence of
neurologic complications has not been confirmed,
but ultrasound guidance has been found to reduce
the risk of local anesthetic systemic toxicity and
possibly pneumothorax [15 ].
&
An alternative to neuraxial and peripheral
blocks is infiltration of local anesthetics at the sur-
gical site, which has been the focus of several inves-
tigations in the last decade. A recent meta-analysis
found continuous local anesthetic infusion to be
Volume 29  Number 00  Month 2016
CE: Alpana; ACO/290501; Total nos of Pages: 6;
ACO 290501
more effective than placebo in controlling pain after
total knee arthroplasty, but the incidence of infection
was increased [16]. However, a previous meta-
analysis on heterogeneous types of surgery had found
efficacy of continuous local anesthetic infusion,
without an increase in the incidence of infections
[17]. Another systematic review and meta-analysis on
wound infiltration of bupivacaine or ropivacaine in
breast cancer surgery found no difference from
placebo in postoperative pain scores; of notice, the
medication was injected perioperatively, with no
following continuous infusion via a catheter [18].
It seems that a continuous local anesthetic infusion
at the site of surgery may be a valuable alternative to
neuraxial or peripheral nerve blocks. Although this
treatment seems to be more effective than placebo,
the relevant question is whether it produces superior
or at least an equivalent effect on patient outcomes
compared with continuous epidural or peripheral
nerve infusions. Clinical trials will unlikely have
enough power to detect differences in rare compli-
cations, but it would be desirable to have more data
on how infusions at surgical sites compare with
traditional analgesic techniques in terms of analgesia
and common side-effects.
CHRONIC PAIN
Blocks with local anesthetics are offered to chronic
pain patients for either diagnostic or therapeutic
purposes.
Diagnostic blocks
Many chronic pain conditions have no morphologi-
cal correlate that can be detected by clinical exam-
ination or medical imaging. For some such
conditions, nerve blocks can be used to identify
the source of pain [19]. The rationale is that if a
structure is the source of pain, then anesthetizing it
or its nerve supply should relieve the pain. If the
suspected structure is not the source of pain, anaes-
thetizing it should not relieve the pain.
Nerve blocks of the facet joints have shown face
validity and construct validity for the diagnosis of
cervical and lumbar facet joint pain (medial branch
blocks) [20–24]. The validity of medial branch
blocks has been thoroughly studied in the 90s, open-
ing a new era in the evidence-based practice of
interventional pain medicine. Regrettably, research
on validation of diagnostic nerve blocks has almost
stopped since then. This leaves us with only specu-
lation on the possible validity of blocks performed
for indications other than facet joint pain.
Nerve blocks cannot identify the specific patho-
logical process underlying a pain condition. For
0952-7907 Copyright ß 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Regional anesthesia in pain management Curatolo
instance, they cannot tell us whether pain stem-
ming from a facet joint has an inflammatory origin,
is the result of a joint capsule tear, a microfracture,
or other lesions. However, they can provide infor-
mation on the anatomical structure that is the
primary source of nociception; specifically, medial
branch blocks can tell us with a reasonable degree of
confidence whether the pain stems primarily from a
facet joint or not. This conclusion cannot be made
for a block of nerves that supply multiple structures
that are potential sources of nociception. For
instance, pain relief after a block of the ilioinguinal
and iliohypogastric nerves in a patient with groin
pain cannot differentiate between neuropathy of
those nerves and pain arising from damaged tissues
supplied by the nerves. Block of nerves supplying
multiple structures that are potential sources of
nociception should not be called diagnostic. A
possible better term is test block, as the aim is testing
the possible involvement of nerves in the trans-
mission of pain [19,25].
Therapeutic blocks
The use of therapeutic nerve blocks with local anes-
thetics has a long tradition but a weak literature. The
term therapeutic is used when a long-term effect is
expected by the procedure. On a first glance, it
seems irrational to expect a therapeutic effect by
the injection of a local anesthetic, as the effect on
nerve conduction is short lasting. However, a sys-
tematic review found consistent evidence for an
effect of local anesthetic injections that exceeds
the duration of the conduction blockade [26]. No
study included in the review had negative results,
but all reviewed articles were single case reports or
case series, preventing reliable conclusions.
The best available literature on therapeutic
nerve blocks is on the use of greater occipital nerve
(GON) blocks in headache. Different studies using
local anesthetics alone or in combination with a
steroid have been performed. They have mostly
shown efficacy in reducing pain intensity and/or
frequency of pain attacks in different forms of head-
ache. Most of the studies were prospective case series
or audits, either using single injections or a series of
procedures at variable intervals [27–29]. An obser-
vational study evaluated the effect of repeated GON
and supraorbital nerve blocks on migraine patients,
performed a maximum 10 times on alternate days:
85% of patients had a positive response during a
6-month observation period [30]. Of notice, only
bupivacaine without a steroid was injected. The
efficacy of GON blocks has been evaluated also by
RCTs. One RCT on cervicogenic headache found
occipital nerve blocks to be superior to placebo at
www.co-anesthesiology.com 3
CE: Alpana; ACO/290501; Total nos of Pages: 6;
ACO 290501
Regional anesthesia
2-week follow-up; a mixture of local anesthetic,
opioid, and clonidine was injected [31]. A GON
steroid injection without local anesthetic was
superior to placebo in preventing cluster headache
attacks [32]. Another RCT compared a local anes-
thetic alone with a mixture of a local anesthetic and
a steroid in chronic daily headache: pain was sig-
nificantly reduced, with no difference between the
two groups up to 4 weeks after the injection [33].
The most recent placebo-controlled trial was con-
ducted on chronic headache using a series of GON
injections and showed superiority of local anes-
thetic injections to placebo at 4-week follow-up
&
[34 ]. A limitation of placebo-controlled trials is
the limited ability to blind patients to the group
allocation, as the GON block produces cutaneous
numbness.
A recent placebo-controlled study evaluated
transnasal sphenopalatine ganglion blocks with
0.5% bupivacaine, performed 12 times during 6
weeks in patients with chronic migraine [35]. The
bupivacaine group had statistically significant lower
pain scores up to 24 h after the block, with an
improvement during the overall treatment period.
The patients were re-evaluated at 1 and 6 months
after procedure, but no data on pain were
provided. This study shows that a series of transnasal
Functional
connections
Headache
Trigeminal
pathways
Trigemino-cervical
nucleus
C1–2–3
pathways
FIGURE 1. Possible mechanisms of action of greater occipital nerve blocks in headache. Left: functional connection between
trigeminal and cervical pathways. Right: possible modulating effect of blocking neural transmission from the greater occipital
nerve on trigeminocervical pathways involved in headache.
4 www.co-anesthesiology.com
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
sphenopalatine ganglion blocks may be useful for the
acute management of headache. The literature on
different approaches to block the sphenopalatine
&
ganglion was recently reviewed [36 ]: it was found
that the published data support efficacy of the block
for cluster headache and migraine in both the short
and long term, although the data are not very robust.
Different mechanisms may underlie a possible
therapeutic effect of local anesthetic nerve blocks in
chronic pain conditions. The literature on headache
is important in this respect. The GON supplies the
skin of the occipital region, which is not a primary
source of nociception in headache. So why should
anesthesia of this nerve reduce headache? Further-
more, why should the effect be long-lasting, given
the fact that the conduction blockade is of short
duration? The most widely accepted explanation for
a possible effect of GON block on headache is the
presence of anatomical and functional connections
between cervical and trigeminal pathways involved
in headache [37,38]. Block of sensory input from the
tissues supplied by the GON may lead to reduced
activity of central neural pathways responsible for
headache, ultimately producing pain relief (Fig. 1).
Two studies on healthy volunteers and cluster head-
ache patients analyzed the effect of unilateral GON
block on the nociceptive blink reflex [39,40]. The
Possible mechanism for
greater occipital nerve block
Reduced headache
Reduced nociceptive
trigeminal transmission
Reduced nociceptive
transmission
Nerve
block
Volume 29  Number 00  Month 2016
CE: Alpana; ACO/290501; Total nos of Pages: 6;
ACO 290501
nociceptive blink reflex is a measure of central
nociceptive trigeminal transmission. In both studies
GON block produced a decrease in the reflex
responses that was statistically significant only for
reflexes measured at the side of the block [39,40],
supporting a reduction in nociceptive trigeminal
transmission by block of afferent input from cervical
pathways. Cutaneous allodynia is common in
migraine and is the result of central sensitization
[41]. GON block reduces cutaneous allodynia in
trigeminal and cervical areas [42]. This suggests that
a block of afferent input from cervical pathways
leads to attenuation of hypersensitivity of both
trigeminal and cervical nociceptive pathways. These
considerations may apply also to nerve blocks per-
formed for conditions other than headache, but to
my knowledge, no mechanistic studies have been
conducted in this area.
Another possible mechanism for a long-term
effect is facilitation of functional and mental health
rehabilitation following the temporary pain
reduction induced by the block. Patients who
experience pain relief may be encouraged to
increase their level of activity and their mood
may be improved, with following long-term
reduction in their pain. It is also possible that the
effect of local anesthetic blocks is explained by
placebo, at least in part: most studies did not include
a placebo control group; for those that did, group
allocation is difficult to blind, exposing these studies
to the risk of observer bias.
It is clear that the above considerations on
mechanisms are largely speculative. More research
on therapeutic nerve blocks in terms of efficacy and
mechanisms of action is highly desirable to establish
their role in the management of chronic pain.
Ultrasound guidance
The use of ultrasound as guidance for nerve blocks
in chronic pain is increasing. Most of the published
studies have focused on techniques, namely, aimed
at describing how to perform blocks under ultra-
sound guidance. Although this is very valuable
research, feasibility of a block under ultrasound
does not prove that the procedure benefits patients
more than techniques that do not use this technol-
ogy. The literature on ultrasound-guided blocks for
chronic pain that addresses patient outcomes or
compares it with other imaging techniques is
sparse, but emerging. An RCT comparing fluoro-
scopy-guided with ultrasound-assisted epidural
steroid injections has found no significant differ-
ence between the two groups in mean procedure
time, number of needle insertion attempts or needle
passes, mean pain intensity, and degree of disability
0952-7907 Copyright ß 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Regional anesthesia in pain management Curatolo
scores before at 1 and 3 months after procedure [43].
When compared with fluoroscopy, ultrasound
imaging was found to be an accurate technique
for performing cervical facet joint nerve blocks,
except for the C7 medial branch blocks [44].
In two randomized controlled studies on diagnostic
nerve blocks for facet joint pain, fluoroscopy and
ultrasound guidance provided similar success
rates, but ultrasonography was associated with
improved efficiency (decreased performance time
&
and fewer needle passes) [45,46 ]. Ultrasound-
guided piriformis injections provided similar out-
comes to fluoroscopically guided injections with-
out differences in imaging, needling, or overall
procedural times [47].
CONCLUSION
Recent literature strongly supports the use of
regional anesthesia for postoperative pain, whereby
infusions at peripheral nerves and surgical site are
gaining increasing importance. Nerve blocks have
diagnostic validity in chronic facet joint pain.
Blocks of the GON and of the sphenopalatine
ganglion are effective in headache. More research
is definitely needed to validate diagnostic blocks for
indications other than facet joint pain and to study
the potential therapeutic value of nerve blocks in
chronic pain. Ultrasound guidance improves the
performance of peripheral nerve blocks and differ-
ent patient outcomes, but does not increase the
incidence of neurologic complications.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
The author has provided occasional consulting for Sono-
Site, Bothell, USA.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Wu CL, Cohen SR, Richman JM, et al. Efficacy of postoperative patient-
controlled and continuous infusion epidural analgesia versus intravenous
patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology
2005; 103:1079–1088.
2. Schnabel A, Reichl SU, Kranke P, et al. Efficacy and safety of paravertebral
blocks in breast surgery: a meta-analysis of randomized controlled trials. Br J
Anaesth 2010; 105:842–852.
3. Ilfeld BM. Review article: continuous peripheral nerve blocks: a review of the
published evidence. Anesth Analg 2011; 113:904–925.
www.co-anesthesiology.com 5
CE: Alpana; ACO/290501; Total nos of Pages: 6;
ACO 290501
Regional anesthesia
4. Paul JE, Arya A, Hurlburt L, et al. Femoral nerve block improves analgesia
outcomes after total knee arthroplasty: a meta-analysis of randomized con-
trolled trials. Anesthesiology 2010; 113:1144–1162.
5. Richman JM, Liu SS, Courpas G, et al. Does continuous peripheral nerve
block provide superior pain control to opioids? A meta-analysis. Anesth Analg
2006; 102:248–257.
6. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of post-
&& operative pain: a clinical practice guideline from the American Pain Society,
the American Society of Regional Anesthesia and Pain Medicine, and the
American Society of Anesthesiologists’ Committee on Regional Anesthesia,
Executive Committee, and Administrative Council. J Pain 2016; 17:131–157.
Based on a structured systematic review of the available literature, an interdisci-
plinary panel developed recommendations to guide clinical practice for post-
operative pain.
7. Gordon DB, de Leon-Casasola OA, Wu CL, et al. Research gaps in practice
&& guidelines for acute postoperative pain management in adults: findings from a
review of the evidence for an American Pain Society Clinical Practice Guide-
line. J Pain 2016; 17:158–166.
Based on a structured systematic review of the available literature, an interdisci-
plinary panel identified gaps in knowledge to guide clinical future research in
postoperative pain.
8. Popping DM, Elia N, Marret E, et al. Protective effects of epidural analgesia on
pulmonary complications after abdominal and thoracic surgery: a meta-
analysis. Arch Surg 2008; 143:990–999.
9. Kessler J, Marhofer P, Hopkins PM, Hollmann MW. Peripheral regional
anaesthesia and outcome: lessons learned from the last 10 years. Br J
Anaesth 2015; 114:728–745.
10. Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The analgesic efficacy of
ultrasound-guided transversus abdominis plane block in adult patients: a
meta-analysis. Anesth Analg 2015; 121:1640–1654.
11. Salinas FV. Evidence basis for ultrasound guidance for lower-extremity
peripheral nerve block: update 2016. Reg Anesth Pain Med 2016;
41:261–274.
12. Perlas A, Chaparro LE, Chin KJ. Lumbar neuraxial ultrasound for spinal and
epidural anesthesia: a systematic review and meta-analysis. Reg Anesth Pain
Med 2016; 41:251–260.
13. Choi S, McCartney CJL. Evidence base for the use of ultrasound for upper
extremity blocks: 2014 update. Reg Anesth Pain Med 2016; 41:242–250.
14. Abrahams M, Derby R, Horn J-L. Update on ultrasound for truncal blocks: a
review of the evidence. Reg Anesth Pain Med 2016; 41:275–288.
15. Neal JM. Ultrasound-guided regional anesthesia and patient safety: update of
& an evidence-based analysis. Reg Anesth Pain Med 2016; 41:195–204.
The systematic literature appraisal found ultrasound guidance to reduce the risk of
local anesthetic systemic toxicity and possibly pneumothorax, while not affecting
the incidence of neurologic complications.
16. Sun XL, Zhao ZH, Ma JX, et al. Continuous local infiltration analgesia for pain
control after total knee arthroplasty: a meta-analysis of randomized controlled
trials. Medicine (Baltimore) 2015; 94:e2005.
17. Liu SS, Richman JM, Thirlby RC, Wu CL. Efficacy of continuous wound
catheters delivering local anesthetic for postoperative analgesia: a quantita-
tive and qualitative systematic review of randomized controlled trials. J Am Coll
Surg 2006; 203:914–932.
18. Tam KW, Chen SY, Huang TW, et al. Effect of wound infiltration with
ropivacaine or bupivacaine analgesia in breast cancer surgery: a meta-
analysis of randomized controlled trials. Int J Surg 2015; 22:79–85.
19. Curatolo M, Bogduk N. Diagnostic blocks for chronic pain. Scand J Pain
2010; 1:186–192.
20. Barnsley L, Lord S, Bogduk N. Comparative local anaesthetic blocks in the
diagnosis of cervical zygapophysial joint pain. Pain 1993; 55:99–106.
21. Barnsley L, Bogduk N. Medial branch blocks are specific for the diagnosis of
cervical zygapophyseal joint pain. Reg Anesth 1993; 18:343–350.
22. Lord SM, Barnsley L, Bogduk N. The utility of comparative local anesthetic
blocks versus placebo-controlled blocks for the diagnosis of cervical zyga-
pophysial joint pain. Clin J Pain 1995; 11:208–213.
23. Dreyfuss P, Schwarzer AC, Lau P, Bogduk N. Specificity of lumbar medial
branch and L5 dorsal ramus blocks. A computed tomography study. Spine
1997; 22:895–902.
24. Kaplan M, Dreyfuss P, Halbrook B, Bogduk N. The ability of lumbar medial
branch blocks to anesthetize the zygapophysial joint. A physiologic challenge.
Spine 1998; 23:1847–1852.
6 www.co-anesthesiology.com
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
25. Curatolo M, Bogduk N. Diagnostic and therapeutic nerve blocks. In: Fishman
SM, Ballantyne JC, Rathmell JP, editors. Bonica’s management of pain, 4th ed
Philadelphia: Lippincott William & Wilkins; 2010. pp. 1401–1423.
26. Vlassakov KV, Narang S, Kissin I. Local anesthetic blockade of peripheral
nerves for treatment of neuralgias: systematic analysis. Anesth Analg 2011;
112:1487–1493.
27. Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater occipital nerve injection
in primary headache syndromes: prolonged effects from a single injection.
Pain 2006; 122:126–129.
28. Peres MF, Stiles MA, Siow HC, et al. Greater occipital nerve blockade for
cluster headache. Cephalalgia 2002; 22:520–522.
29. Jurgens TP, Muller P, Seedorf H, et al. Occipital nerve block is effective in
craniofacial neuralgias but not in idiopathic persistent facial pain. J Headache
Pain 2012; 13:199–213.
30. Caputi CA, Firetto V. Therapeutic blockade of greater occipital and supraor-
bital nerves in migraine patients. Headache 1997; 37:174–179.
31. Naja ZM, El-Rajab M, Al-Tannir MA, et al. Occipital nerve blockade for
cervicogenic headache: a double-blind randomized controlled clinical trial.
Pain Pract 2006; 6:89–95.
32. Ambrosini A, Vandenheede M, Rossi P, et al. Suboccipital injection with a
mixture of rapid- and long-acting steroids in cluster headache: a double-blind
placebo-controlled study. Pain 2005; 118:92–96.
33. Ashkenazi A, Matro R, Shaw JW, et al. Greater occipital nerve block using
local anaesthetics alone or with triamcinolone for transformed migraine: a
randomised comparative study. J Neurol Neurosurg Psychiat 2008; 79:415–
417.
34. Inan LE, Inan N, Karadas O, et al. Greater occipital nerve blockade for the
& treatment of chronic migraine: a randomized, multicenter, double-blind, and
placebo-controlled study. Acta Neurol Scand 2015; 132:270–207.
The randomized trial showed superiority of GON blocks to placebo at 4-week
follow-up conducted in patients with chronic headache.
35. Cady R, Saper J, Dexter K, et al. Placebo-controlled study of repetitive
transnasal sphenopalatine ganglion blockade with Tx360 as acute treatment
for chronic migraine. Headache 2015; 55:529–542.
36. Robbins MS, Robertson CE, Kaplan E, et al. The sphenopalatine ganglion:
& anatomy, pathophysiology, and therapeutic targeting in headache. Headache
2016; 56:240–258.
A comprehensive review on the sphenopalatine ganglion and its block in head-
ache.
37. Bartsch T, Goadsby PJ. The trigeminocervical complex and migraine: current
concepts and synthesis. Curr Pain Headache Rep 2003; 7:371–376.
38. Piovesan EJ, Kowacs PA, Oshinsky ML. Convergence of cervical and trigem-
inal sensory afferents. Curr Pain Headache Rep 2003; 7:377–383.
39. Busch V, Jakob W, Juergens T, et al. Functional connectivity between
trigeminal and occipital nerves revealed by occipital nerve blockade and
nociceptive blink reflexes. Cephalalgia 2006; 26:50–55.
40. Busch V, Jakob W, Juergens T, et al. Occipital nerve blockade in chronic
cluster headache patients and functional connectivity between trigeminal and
occipital nerves. Cephalalgia 2007; 27:1206–1214.
41. Burstein R, Yarnitsky D, Goor-Aryeh I, et al. An association between migraine
and cutaneous allodynia. Ann Neurol 2000; 47:614–624.
42. Schwedt TJ. Chronic migraine. BMJ 2014; 348:g1416.
43. Evansa I, Logina I, Vanags I, Borgeat A. Ultrasound versus fluoroscopic-
guided epidural steroid injections in patients with degenerative spinal dis-
eases: a randomised study. Eur J Anaesthesiol 2015; 32:262–268.
44. Siegenthaler A, Mlekusch S, Trelle S, et al. Accuracy of ultrasound-guided
nerve blocks of the cervical zygapophysial joints. Anesthesiology 2012;
117:347–352.
45. Finlayson RJ, Etheridge JP, Vieira L, et al. A randomized comparison between
ultrasound- and fluoroscopy-guided third occipital nerve block. Reg Anesth
Pain Med 2013; 38:212–217.
46. Finlayson RJ, Etheridge JP, Tiyaprasertkul W, et al. A randomized comparison
& between ultrasound- and fluoroscopy-guided c7 medial branch block. Reg
Anesth Pain Med 2015; 40:52–57.
The study validated ultrasound guidance using fluoroscopy as control for diag-
nostic nerve blocks of the facet joints.
47. Fowler IM, Tucker AA, Weimerskirch BP, et al. A randomized comparison of
the efficacy of 2 techniques for piriformis muscle injection: ultrasound-guided
versus nerve stimulator with fluoroscopic guidance. Reg Anesth Pain Med
2014; 39:126–132.
Volume 29  Number 00  Month 2016