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

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Regional anesthesia

However, a wide application of this practice has

KEY POINTS been challenged in recent years. Some surgical tech-
 For postoperative pain, the current evidence supports niques have become less invasive, requiring less
infusions of local anesthetics at the surgical site, aggressive analgesic regimens. Improved periopera-
continuous peripheral nerve blocks, and neuraxial tive care has reduced the risk of postoperative com-
analgesia for major thoracic and abdominal plications, reducing the effect of epidural analgesia
procedures. on postoperative morbidity over time [8]. Severe
 Ultrasound guidance can improve the performance of neurological complications, although very rare,
the blocks and different patient outcomes, although the remain a concern.
incidence of peripheral nerve damage is not decreased. The above considerations led to a progressively
lesser use of neuraxial blocks, in favor of peripheral
 For chronic pain, the best available evidence is on
nerve blocks. These procedures, when performed
nerve blocks for the diagnosis of facet joint pain, and
further research is needed to validate diagnostic nerve either as single shot or as continuous infusion, are
blocks for other indications. particularly suited for surgery on the upper and
lower limb, and for some procedures on the trunk.
 Therapeutic blocks with only local anesthetics (greater The main advantages over neuraxial analgesia are
occipital nerve and sphenopalatine ganglion) are
the avoidance of potentially catastrophic neurologic
effective in headache, whereas their efficacy for other
chronic pain conditions has not been adequately complications associated with spinal procedures,
studied. 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
moderate-quality evidence); and offer neuraxial conclusion that the majority of peripheral regional
analgesia for major thoracic and abdominal pro- anesthetic techniques produce benefits for patients
cedures, particularly in patients at risk for cardiac and hospital efficiency: they reduce postoperative
complications, pulmonary complications, or pro- pain and opioid consumption and/or increase
longed ileus (strong recommendation, high-quality patient satisfaction; for selected surgical procedures,
evidence). the use of blocks can avoid general anesthesia and is
The same panel identified several research gaps in associated with increased efficiency of the surgical
postoperative pain management and published an pathway [9]. An exception is the transversus abdom-
additional study highlighting areas where future inis plane block, where the evidence for efficacy was
research is needed [7 ]. In the field of regional anes- conflicting. This is confirmed by a recent meta-
thesia, the review found that most trials were not analysis, which found marginal postoperative anal-
designed to assess the risk of uncommon compli- gesic efficacy of transversus abdominis plane block
cations. Because the sample size would be prohibitive after abdominal laparotomy/laparoscopy and cesar-
for a randomized controlled trial (RCT), the review ean delivery [10]. Consistent with the aforemen-
highlighted the need for databases or registries that &&
tioned study by the multisociety panel [7 ], the
capture data of large patient populations to address review [9] found that the evidence for the impact
occurrence and risk factors for uncommon, but of peripheral nerve blocks on longer-term outcomes
potentially disastrous, complications. Although was inadequate to inform clinical decision-making.
there is a reasonable amount of evidence suggesting Ultrasound guidance has gained enormous pop-
that the use of epidural analgesia is associated with a ularity in the last decade. Multiple recently pub-
decrease in perioperative morbidity, the review lished systematic reviews found ultrasound
found a lack of similar data for continuous peripheral guidance to improve the performance of the blocks
regional analgesia. In addition, there are few data on and different patient outcomes [11–14]. Impor-
the efficacy of regional analgesia on patient-reported tantly, the expectation that direct visualization of
outcomes (e.g., satisfaction, quality of recovery, qual- the neural structures would reduce the incidence of
ity of life, and sleep). The use of perioperative regional neurologic complications has not been confirmed,
anesthesia/analgesia may decrease the incidence or but ultrasound guidance has been found to reduce
severity of chronic postsurgical pain, but there is a the risk of local anesthetic systemic toxicity and
need for further research in this field. possibly pneumothorax [15 ].

An alternative to neuraxial and peripheral

blocks is infiltration of local anesthetics at the sur-
Alternatives to neuraxial analgesia gical site, which has been the focus of several inves-
The use of neuraxial analgesia undoubtedly led to tigations in the last decade. A recent meta-analysis
dramatic improvements in perioperative pain care. found continuous local anesthetic infusion to be

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Regional anesthesia in pain management Curatolo

more effective than placebo in controlling pain after instance, they cannot tell us whether pain stem-
total knee arthroplasty, but the incidence of infection ming from a facet joint has an inflammatory origin,
was increased [16]. However, a previous meta- is the result of a joint capsule tear, a microfracture,
analysis on heterogeneous types of surgery had found or other lesions. However, they can provide infor-
efficacy of continuous local anesthetic infusion, mation on the anatomical structure that is the
without an increase in the incidence of infections primary source of nociception; specifically, medial
[17]. Another systematic review and meta-analysis on branch blocks can tell us with a reasonable degree of
wound infiltration of bupivacaine or ropivacaine in confidence whether the pain stems primarily from a
breast cancer surgery found no difference from facet joint or not. This conclusion cannot be made
placebo in postoperative pain scores; of notice, the for a block of nerves that supply multiple structures
medication was injected perioperatively, with no that are potential sources of nociception. For
following continuous infusion via a catheter [18]. instance, pain relief after a block of the ilioinguinal
It seems that a continuous local anesthetic infusion and iliohypogastric nerves in a patient with groin
at the site of surgery may be a valuable alternative to pain cannot differentiate between neuropathy of
neuraxial or peripheral nerve blocks. Although this those nerves and pain arising from damaged tissues
treatment seems to be more effective than placebo, supplied by the nerves. Block of nerves supplying
the relevant question is whether it produces superior multiple structures that are potential sources of
or at least an equivalent effect on patient outcomes nociception should not be called diagnostic. A
compared with continuous epidural or peripheral possible better term is test block, as the aim is testing
nerve infusions. Clinical trials will unlikely have the possible involvement of nerves in the trans-
enough power to detect differences in rare compli- mission of pain [19,25].
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 Therapeutic blocks
and common side-effects. 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
CHRONIC PAIN expected by the procedure. On a first glance, it
Blocks with local anesthetics are offered to chronic seems irrational to expect a therapeutic effect by
pain patients for either diagnostic or therapeutic the injection of a local anesthetic, as the effect on
purposes. nerve conduction is short lasting. However, a sys-
tematic review found consistent evidence for an
effect of local anesthetic injections that exceeds
Diagnostic blocks the duration of the conduction blockade [26]. No
Many chronic pain conditions have no morphologi- study included in the review had negative results,
cal correlate that can be detected by clinical exam- but all reviewed articles were single case reports or
ination or medical imaging. For some such case series, preventing reliable conclusions.
conditions, nerve blocks can be used to identify The best available literature on therapeutic
the source of pain [19]. The rationale is that if a nerve blocks is on the use of greater occipital nerve
structure is the source of pain, then anesthetizing it (GON) blocks in headache. Different studies using
or its nerve supply should relieve the pain. If the local anesthetics alone or in combination with a
suspected structure is not the source of pain, anaes- steroid have been performed. They have mostly
thetizing it should not relieve the pain. shown efficacy in reducing pain intensity and/or
Nerve blocks of the facet joints have shown face frequency of pain attacks in different forms of head-
validity and construct validity for the diagnosis of ache. Most of the studies were prospective case series
cervical and lumbar facet joint pain (medial branch or audits, either using single injections or a series of
blocks) [20–24]. The validity of medial branch procedures at variable intervals [27–29]. An obser-
blocks has been thoroughly studied in the 90s, open- vational study evaluated the effect of repeated GON
ing a new era in the evidence-based practice of and supraorbital nerve blocks on migraine patients,
interventional pain medicine. Regrettably, research performed a maximum 10 times on alternate days:
on validation of diagnostic nerve blocks has almost 85% of patients had a positive response during a
stopped since then. This leaves us with only specu- 6-month observation period [30]. Of notice, only
lation on the possible validity of blocks performed bupivacaine without a steroid was injected. The
for indications other than facet joint pain. efficacy of GON blocks has been evaluated also by
Nerve blocks cannot identify the specific patho- RCTs. One RCT on cervicogenic headache found
logical process underlying a pain condition. For occipital nerve blocks to be superior to placebo at

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2-week follow-up; a mixture of local anesthetic, sphenopalatine ganglion blocks may be useful for the
opioid, and clonidine was injected [31]. A GON acute management of headache. The literature on
steroid injection without local anesthetic was different approaches to block the sphenopalatine
superior to placebo in preventing cluster headache ganglion was recently reviewed [36 ]: it was found
attacks [32]. Another RCT compared a local anes- that the published data support efficacy of the block
thetic alone with a mixture of a local anesthetic and for cluster headache and migraine in both the short
a steroid in chronic daily headache: pain was sig- and long term, although the data are not very robust.
nificantly reduced, with no difference between the Different mechanisms may underlie a possible
two groups up to 4 weeks after the injection [33]. therapeutic effect of local anesthetic nerve blocks in
The most recent placebo-controlled trial was con- chronic pain conditions. The literature on headache
ducted on chronic headache using a series of GON is important in this respect. The GON supplies the
injections and showed superiority of local anes- skin of the occipital region, which is not a primary
thetic injections to placebo at 4-week follow-up source of nociception in headache. So why should
[34 ]. A limitation of placebo-controlled trials is anesthesia of this nerve reduce headache? Further-
the limited ability to blind patients to the group more, why should the effect be long-lasting, given
allocation, as the GON block produces cutaneous the fact that the conduction blockade is of short
numbness. duration? The most widely accepted explanation for
A recent placebo-controlled study evaluated a possible effect of GON block on headache is the
transnasal sphenopalatine ganglion blocks with presence of anatomical and functional connections
0.5% bupivacaine, performed 12 times during 6 between cervical and trigeminal pathways involved
weeks in patients with chronic migraine [35]. The in headache [37,38]. Block of sensory input from the
bupivacaine group had statistically significant lower tissues supplied by the GON may lead to reduced
pain scores up to 24 h after the block, with an activity of central neural pathways responsible for
improvement during the overall treatment period. headache, ultimately producing pain relief (Fig. 1).
The patients were re-evaluated at 1 and 6 months Two studies on healthy volunteers and cluster head-
after procedure, but no data on pain were ache patients analyzed the effect of unilateral GON
provided. This study shows that a series of transnasal block on the nociceptive blink reflex [39,40]. The

Functional Possible mechanism for

connections greater occipital nerve block

Headache Reduced headache

Trigeminal Reduced nociceptive

pathways trigeminal transmission
Reduced nociceptive


C1–2–3 Nerve
pathways block

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.

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Regional anesthesia in pain management Curatolo

nociceptive blink reflex is a measure of central scores before at 1 and 3 months after procedure [43].
nociceptive trigeminal transmission. In both studies When compared with fluoroscopy, ultrasound
GON block produced a decrease in the reflex imaging was found to be an accurate technique
responses that was statistically significant only for for performing cervical facet joint nerve blocks,
reflexes measured at the side of the block [39,40], except for the C7 medial branch blocks [44].
supporting a reduction in nociceptive trigeminal In two randomized controlled studies on diagnostic
transmission by block of afferent input from cervical nerve blocks for facet joint pain, fluoroscopy and
pathways. Cutaneous allodynia is common in ultrasound guidance provided similar success
migraine and is the result of central sensitization rates, but ultrasonography was associated with
[41]. GON block reduces cutaneous allodynia in improved efficiency (decreased performance time
trigeminal and cervical areas [42]. This suggests that and fewer needle passes) [45,46 ]. Ultrasound-
a block of afferent input from cervical pathways guided piriformis injections provided similar out-
leads to attenuation of hypersensitivity of both comes to fluoroscopically guided injections with-
trigeminal and cervical nociceptive pathways. These out differences in imaging, needling, or overall
considerations may apply also to nerve blocks per- procedural times [47].
formed for conditions other than headache, but to
my knowledge, no mechanistic studies have been
conducted in this area. CONCLUSION
Another possible mechanism for a long-term Recent literature strongly supports the use of
effect is facilitation of functional and mental health regional anesthesia for postoperative pain, whereby
rehabilitation following the temporary pain infusions at peripheral nerves and surgical site are
reduction induced by the block. Patients who gaining increasing importance. Nerve blocks have
experience pain relief may be encouraged to diagnostic validity in chronic facet joint pain.
increase their level of activity and their mood Blocks of the GON and of the sphenopalatine
may be improved, with following long-term ganglion are effective in headache. More research
reduction in their pain. It is also possible that the is definitely needed to validate diagnostic blocks for
effect of local anesthetic blocks is explained by indications other than facet joint pain and to study
placebo, at least in part: most studies did not include the potential therapeutic value of nerve blocks in
a placebo control group; for those that did, group chronic pain. Ultrasound guidance improves the
allocation is difficult to blind, exposing these studies performance of peripheral nerve blocks and differ-
to the risk of observer bias. ent patient outcomes, but does not increase the
It is clear that the above considerations on incidence of neurologic complications.
mechanisms are largely speculative. More research
on therapeutic nerve blocks in terms of efficacy and Acknowledgements
mechanisms of action is highly desirable to establish None.
their role in the management of chronic pain.
Financial support and sponsorship
Ultrasound guidance
The use of ultrasound as guidance for nerve blocks Conflicts of interest
in chronic pain is increasing. Most of the published
The author has provided occasional consulting for Sono-
studies have focused on techniques, namely, aimed
Site, Bothell, USA.
at describing how to perform blocks under ultra-
sound guidance. Although this is very valuable
research, feasibility of a block under ultrasound REFERENCES AND RECOMMENDED
does not prove that the procedure benefits patients READING
Papers of particular interest, published within the annual period of review, have
more than techniques that do not use this technol- been highlighted as:
ogy. The literature on ultrasound-guided blocks for & of special interest
&& of outstanding interest
chronic pain that addresses patient outcomes or
compares it with other imaging techniques is
1. Wu CL, Cohen SR, Richman JM, et al. Efficacy of postoperative patient-
sparse, but emerging. An RCT comparing fluoro- controlled and continuous infusion epidural analgesia versus intravenous
scopy-guided with ultrasound-assisted epidural patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology
2005; 103:1079–1088.
steroid injections has found no significant differ- 2. Schnabel A, Reichl SU, Kranke P, et al. Efficacy and safety of paravertebral
ence between the two groups in mean procedure blocks in breast surgery: a meta-analysis of randomized controlled trials. Br J
Anaesth 2010; 105:842–852.
time, number of needle insertion attempts or needle 3. Ilfeld BM. Review article: continuous peripheral nerve blocks: a review of the
passes, mean pain intensity, and degree of disability published evidence. Anesth Analg 2011; 113:904–925.

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4. Paul JE, Arya A, Hurlburt L, et al. Femoral nerve block improves analgesia 25. Curatolo M, Bogduk N. Diagnostic and therapeutic nerve blocks. In: Fishman
outcomes after total knee arthroplasty: a meta-analysis of randomized con- SM, Ballantyne JC, Rathmell JP, editors. Bonica’s management of pain, 4th ed
trolled trials. Anesthesiology 2010; 113:1144–1162. Philadelphia: Lippincott William & Wilkins; 2010. pp. 1401–1423.
5. Richman JM, Liu SS, Courpas G, et al. Does continuous peripheral nerve 26. Vlassakov KV, Narang S, Kissin I. Local anesthetic blockade of peripheral
block provide superior pain control to opioids? A meta-analysis. Anesth Analg nerves for treatment of neuralgias: systematic analysis. Anesth Analg 2011;
2006; 102:248–257. 112:1487–1493.
6. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of post- 27. Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater occipital nerve injection
&& operative pain: a clinical practice guideline from the American Pain Society, in primary headache syndromes: prolonged effects from a single injection.
the American Society of Regional Anesthesia and Pain Medicine, and the Pain 2006; 122:126–129.
American Society of Anesthesiologists’ Committee on Regional Anesthesia, 28. Peres MF, Stiles MA, Siow HC, et al. Greater occipital nerve blockade for
Executive Committee, and Administrative Council. J Pain 2016; 17:131–157. cluster headache. Cephalalgia 2002; 22:520–522.
Based on a structured systematic review of the available literature, an interdisci- 29. Jurgens TP, Muller P, Seedorf H, et al. Occipital nerve block is effective in
plinary panel developed recommendations to guide clinical practice for post- craniofacial neuralgias but not in idiopathic persistent facial pain. J Headache
operative pain. Pain 2012; 13:199–213.
7. Gordon DB, de Leon-Casasola OA, Wu CL, et al. Research gaps in practice 30. Caputi CA, Firetto V. Therapeutic blockade of greater occipital and supraor-
&& guidelines for acute postoperative pain management in adults: findings from a bital nerves in migraine patients. Headache 1997; 37:174–179.
review of the evidence for an American Pain Society Clinical Practice Guide- 31. Naja ZM, El-Rajab M, Al-Tannir MA, et al. Occipital nerve blockade for
line. J Pain 2016; 17:158–166. cervicogenic headache: a double-blind randomized controlled clinical trial.
Based on a structured systematic review of the available literature, an interdisci- Pain Pract 2006; 6:89–95.
plinary panel identified gaps in knowledge to guide clinical future research in 32. Ambrosini A, Vandenheede M, Rossi P, et al. Suboccipital injection with a
postoperative pain. mixture of rapid- and long-acting steroids in cluster headache: a double-blind
8. Popping DM, Elia N, Marret E, et al. Protective effects of epidural analgesia on placebo-controlled study. Pain 2005; 118:92–96.
pulmonary complications after abdominal and thoracic surgery: a meta- 33. Ashkenazi A, Matro R, Shaw JW, et al. Greater occipital nerve block using
analysis. Arch Surg 2008; 143:990–999. local anaesthetics alone or with triamcinolone for transformed migraine: a
9. Kessler J, Marhofer P, Hopkins PM, Hollmann MW. Peripheral regional randomised comparative study. J Neurol Neurosurg Psychiat 2008; 79:415–
anaesthesia and outcome: lessons learned from the last 10 years. Br J 417.
Anaesth 2015; 114:728–745. 34. Inan LE, Inan N, Karadas O, et al. Greater occipital nerve blockade for the
10. Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The analgesic efficacy of & treatment of chronic migraine: a randomized, multicenter, double-blind, and
ultrasound-guided transversus abdominis plane block in adult patients: a placebo-controlled study. Acta Neurol Scand 2015; 132:270–207.
meta-analysis. Anesth Analg 2015; 121:1640–1654. The randomized trial showed superiority of GON blocks to placebo at 4-week
11. Salinas FV. Evidence basis for ultrasound guidance for lower-extremity follow-up conducted in patients with chronic headache.
peripheral nerve block: update 2016. Reg Anesth Pain Med 2016; 35. Cady R, Saper J, Dexter K, et al. Placebo-controlled study of repetitive
41:261–274. transnasal sphenopalatine ganglion blockade with Tx360 as acute treatment
12. Perlas A, Chaparro LE, Chin KJ. Lumbar neuraxial ultrasound for spinal and for chronic migraine. Headache 2015; 55:529–542.
epidural anesthesia: a systematic review and meta-analysis. Reg Anesth Pain 36. Robbins MS, Robertson CE, Kaplan E, et al. The sphenopalatine ganglion:
Med 2016; 41:251–260. & anatomy, pathophysiology, and therapeutic targeting in headache. Headache
13. Choi S, McCartney CJL. Evidence base for the use of ultrasound for upper 2016; 56:240–258.
extremity blocks: 2014 update. Reg Anesth Pain Med 2016; 41:242–250. A comprehensive review on the sphenopalatine ganglion and its block in head-
14. Abrahams M, Derby R, Horn J-L. Update on ultrasound for truncal blocks: a ache.
review of the evidence. Reg Anesth Pain Med 2016; 41:275–288. 37. Bartsch T, Goadsby PJ. The trigeminocervical complex and migraine: current
15. Neal JM. Ultrasound-guided regional anesthesia and patient safety: update of concepts and synthesis. Curr Pain Headache Rep 2003; 7:371–376.
& an evidence-based analysis. Reg Anesth Pain Med 2016; 41:195–204. 38. Piovesan EJ, Kowacs PA, Oshinsky ML. Convergence of cervical and trigem-
The systematic literature appraisal found ultrasound guidance to reduce the risk of inal sensory afferents. Curr Pain Headache Rep 2003; 7:377–383.
local anesthetic systemic toxicity and possibly pneumothorax, while not affecting 39. Busch V, Jakob W, Juergens T, et al. Functional connectivity between
the incidence of neurologic complications. trigeminal and occipital nerves revealed by occipital nerve blockade and
16. Sun XL, Zhao ZH, Ma JX, et al. Continuous local infiltration analgesia for pain nociceptive blink reflexes. Cephalalgia 2006; 26:50–55.
control after total knee arthroplasty: a meta-analysis of randomized controlled 40. Busch V, Jakob W, Juergens T, et al. Occipital nerve blockade in chronic
trials. Medicine (Baltimore) 2015; 94:e2005. cluster headache patients and functional connectivity between trigeminal and
17. Liu SS, Richman JM, Thirlby RC, Wu CL. Efficacy of continuous wound occipital nerves. Cephalalgia 2007; 27:1206–1214.
catheters delivering local anesthetic for postoperative analgesia: a quantita- 41. Burstein R, Yarnitsky D, Goor-Aryeh I, et al. An association between migraine
tive and qualitative systematic review of randomized controlled trials. J Am Coll and cutaneous allodynia. Ann Neurol 2000; 47:614–624.
Surg 2006; 203:914–932. 42. Schwedt TJ. Chronic migraine. BMJ 2014; 348:g1416.
18. Tam KW, Chen SY, Huang TW, et al. Effect of wound infiltration with 43. Evansa I, Logina I, Vanags I, Borgeat A. Ultrasound versus fluoroscopic-
ropivacaine or bupivacaine analgesia in breast cancer surgery: a meta- guided epidural steroid injections in patients with degenerative spinal dis-
analysis of randomized controlled trials. Int J Surg 2015; 22:79–85. eases: a randomised study. Eur J Anaesthesiol 2015; 32:262–268.
19. Curatolo M, Bogduk N. Diagnostic blocks for chronic pain. Scand J Pain 44. Siegenthaler A, Mlekusch S, Trelle S, et al. Accuracy of ultrasound-guided
2010; 1:186–192. nerve blocks of the cervical zygapophysial joints. Anesthesiology 2012;
20. Barnsley L, Lord S, Bogduk N. Comparative local anaesthetic blocks in the 117:347–352.
diagnosis of cervical zygapophysial joint pain. Pain 1993; 55:99–106. 45. Finlayson RJ, Etheridge JP, Vieira L, et al. A randomized comparison between
21. Barnsley L, Bogduk N. Medial branch blocks are specific for the diagnosis of ultrasound- and fluoroscopy-guided third occipital nerve block. Reg Anesth
cervical zygapophyseal joint pain. Reg Anesth 1993; 18:343–350. Pain Med 2013; 38:212–217.
22. Lord SM, Barnsley L, Bogduk N. The utility of comparative local anesthetic 46. Finlayson RJ, Etheridge JP, Tiyaprasertkul W, et al. A randomized comparison
blocks versus placebo-controlled blocks for the diagnosis of cervical zyga- & between ultrasound- and fluoroscopy-guided c7 medial branch block. Reg
pophysial joint pain. Clin J Pain 1995; 11:208–213. Anesth Pain Med 2015; 40:52–57.
23. Dreyfuss P, Schwarzer AC, Lau P, Bogduk N. Specificity of lumbar medial The study validated ultrasound guidance using fluoroscopy as control for diag-
branch and L5 dorsal ramus blocks. A computed tomography study. Spine nostic nerve blocks of the facet joints.
1997; 22:895–902. 47. Fowler IM, Tucker AA, Weimerskirch BP, et al. A randomized comparison of
24. Kaplan M, Dreyfuss P, Halbrook B, Bogduk N. The ability of lumbar medial the efficacy of 2 techniques for piriformis muscle injection: ultrasound-guided
branch blocks to anesthetize the zygapophysial joint. A physiologic challenge. versus nerve stimulator with fluoroscopic guidance. Reg Anesth Pain Med
Spine 1998; 23:1847–1852. 2014; 39:126–132.

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