Interlaminar epidural steroid injections may be performed in the cervical and lumbar spine using the traditional loss of resistance technique. For accurate placement of the needle, w ithin the epi- dural space and close to the aff ected nerve fl uoroscopic guidance is recom mended to avoid misplacement of the needle and con- fi rm spread of contrast medium in prox imity to the target spinal nerve. In adults, typical injectate is 80 mg (2ml) of triamcinol one. In the lumbar region a small amount of local anesthetic is added to produce pain relie f. In the cervical spine local anesthetics are avoided to minimize excessive cephalad sprea d of the injectate (Manchikanti et al., 2012 ). Interventional pain management for intractable acute and chronic pain Neuraxial blockade Sa fe and eff ective (defi ned as decrease in mean dose of opioid requirement) use of short-te rm caudal, lumbar and thoracic epi- dural infusions via tunneled catheters are also reporte d in a small number of 14 children and adolescents, a mean age 4.4 years, and a mean durati on of 16 days (range 5 \200\22314 days) for management of pain following trauma, extensive surgery and CRPS type I (Aram et al., 2001 ). Long-term continuous peripheral nerve block h as also been used for management of severe pain from pathological fracture of the femur in 3 children, aged 8, 13, and 14 years, with osteosarcoma while awaiting chemotherapy and sur gical treatment. Th e duration of the externalized catheters was 22 to 41 days with signifi cant reduction in pain and opioid use, and without complica- tions related to the catheter , infection or local anesthetic toxicity (Burgoyne et al., 2012b ). Transforaminal epidural steroid injections is intended to deposit the medication around the nerve root sleeve for more accurate tar- geting of the aff ected nerve in the anterior epi dural space where disc herniation occurs. It is primarily performed in the lumbar spine und er fl uoroscopic guidance. In adults, typical dose is 40 mg (1ml) of triamcinolone, with or without a small amount of local anesthetic (Manchikanti et al., 2012 , Quraishi, 2012 ). Selective spinal nerve blockade (SNRB) is a diagnostic technique to determine if a specifi c nerve root is the source of pain prior to surgical removal of the off ending ruptured int ervertebral disc. Th e needle tip is placed just outside of the neural foramen, lateral to the position for transforaminal ESI site but outside the foramina. Phantom limb pain (PLP) In children, the clinical characteristics, preventive measures and treatment of PLP have not been investigated rigorously, with only CHAPTER 46 interventional pain management techniques for chronic pain 481 Peripheral nerve blockade Many diff erent types of peripheral nerve blockade have been uti- lized for either diagnosis or management of various chronic pain syndromes. Local anesthet ic blockade can provide several hours of pain relief, and may aid in diagnosis or predict r esponses to sus- tained pain relief following prolonged nerve blockade techniques. Steroid provides lasting relief in cases of perineural infl ammation from entrapment syndromes. Com mon peripheral nerve blockade used in management of adult chronic pain are described below, but for the majority evidence is limited. For many, pediatric use is pre- dominantly for a cute or perioperative pain, and the role for chronic pain management is unclear. Caudal epidural steroid injection is performed by a technique similar to that performed for caudal anesthesia, with lateral fl uor- oscopy to visualize the spread of contrast medium (Parr et al., 2012 ). Facet joint pain Th e facet joint is formed by articulation of processes of two adja- cent vertebrae and the joint capsule is innervated by a medial nerve branch. Th e joint is susce ptible to chondral damage (e.g. whiplash injury, repetitive strain, sports injury), infl am mation and degenera- tion (e.g. congenital, post-surgical spinal fusion, old age). Estimati on of the true incidence of facet joint pain is diffi cult because the diag- nosis cannot b e made by history, physical examination or imaging, and the most reliable diagnostic test i s response to intra-articular or medial nerve branch blockade (Schwarzer et al., 1994a , 19 94b ). Although some studies report pain relief up to one year, the lack of RCT crossover s tudies precludes drawing defi nitive conclusions about specifi city of this blockade. Trigeminal nerve blockade Th e sensory aff erent inputs from the orofacial structures that sense mechanical, thermal and pain stimuli are served by the fi ft h (trigeminal) cranial n erve, and divided into: \231 Ophthalmic branch innervates nasal and frontal sinuses Intra-articular facet blockade is performed with local anaes- thetic and steroid, and repea t injections may be required to relief fl are-ups. If the pain recurs some practitioners co nsider positive response to steroid injection a criterion to perform radiofrequency lesioni ng for providing prolonged pain relief (Atluri et al., 2008 ; Boswell et al., 2007 ). mucosa. \231 Maxillary branch innervates the nares, upper teeth and gums, nasal mucosa, palate an d roof of the pharynx, maxillary, eth- moid, and sphenoid sinuses. \231 Mandibular branch innervates the lower teeth and gums. Th e trigeminal system is the main source of sensory innervations to the supra-tentorial dura, venous sinuses and mening eal arteries. Medial branch nerve blockade (MBB) interrupt pain conduction by nerves that innervate the f acet joints. MBB is performed using a local anesthetic alone or in combination with steroid s, potentially followed by a series of blocks, or radiofrequency lesioning to pro- vide pro longed pain relief. Th e sensory aff erent input projects to the trigeminal (Gasserian) ganglion. Th e trigemin al brainstem sensory neuron complex receives descending inhibitory modulation from higher c enters (periaqueductal gray, reticular formation and sensory-motor cor- tex) mediated throu gh release of neuropeptides including endog- enous opioids, noradrenaline, 5-HT, and GABA t hrough synaptic connections (Sessle, 2000 ). Radiofrequency nerve lesioning (RFNL) (thermo-coagulation or thermal injury) is utilized to interrupt nerve conduction for 6 to 9 months. Although RFNL is used for interruption of va ri- ous nerves, e.g. peripheral (e.g. occipital neuralgia), visceral (e.g. splanchnic) and sympathetic (e.g. CRPS), presently it is prima- rily used for the treatment of axial back p ain produced by facet and sacroiliac joint arthropathy, and therefore is most oft en used i n adults (van Boxem et al., 2008 ). Pulsed RFNL was introduced recently because of a wider margin of safety, and to expand the application of this therapy to various peripheral neuro pathies, joints arthropathy and painful trigger points as well as treatment of facet joints , sacroiliac joints, dorsal root ganglion, stellate gan- glion, Gasserian ganglion and inte rvertebral disks (van Boxem et al., 2008 ). Th e classic presentation of trigeminal neuralgia (TN) is parox- ysms of lancinating pain, which occur in the territory of one or more trigeminal nerve branches, associated with musc le spasms in the absence of sensory and motor defi cit. Th e pain is easily trig- gered by non-noxious stimuli such as minor mechanical stimula- tion or light touch. Trigeminal neura lgia is rare in the pediatric age group, with case reports of typical (at ages 1.5, 6, 9, a nd 12 years) and atypical (at 9 years) TN described. Th e youngest child in whom TN was ret rospectively suspected was 13 months of age; the child suff ered pain attacks for years bef ore TN was fi nally diagnosed at age 7 years (Bender et al., 2011 ). Sacroiliac joint injection Th e sacroiliac joint connects the pelvis to spine, has limited mobil- ity and is a major source of low back pain in aged adults secondary to degenerative processes of the intra-articular cartilage. In adoles- cents, sacroiliac joint pain may fol low trauma, particularly sports injury. Th ere is no one clinical test that reliably confi rms that the pain emanates specifi cally from the sacroiliac joint and diagnosis is based o n a combination of clinical tests of the sacroiliac joint and radiographic imaging. Most pa tients benefi t from anti-infl am- matory drugs and physical therapy. Some support performa nce of diagnostic/therapeutic blockade with a local anesthetic alone or in combination with steroid. If repeated treatment is required radiof- requency nerve lesioning has been utili zed in adults (Hansen et al., 2012 ; Simopoulos et al., 2012 ). As in adults, children in whom the medical treatment of TN is ineff ective or the side eff ects prove unacceptable, microvascular decompression of the trigeminal nerves in the poster ior cranial fossa may be indicated (Kalkanis et al., 2003 ; Resnick et al., 1998 ). Th ere is no satisfactory long-term medical or ablative treatment for TN. In 18 children, percutan eous retro-Gasserian glycerol injection resulted in complete pain relief in 72%, good in 11 %, poor 11%, and recurrence in 22%. None of the children experi- enced a permanent facial s ensory defi cit. Although this procedure is less invasive than a microvascular decompressio n craniotomy, its performance requires the full cooperation of an awake and non-sedated chi ld and the long-term benefi t is not known (Yue, 2004 ). SECTION 6 pharmacological interventions 482 Greater occipital nerve Occipital nerve irritation or infl ammation can produce localized p ain or ipsilateral tension-type headache or intractable neuropathic headache. Perineural in jection of a combination of local anesthetic and steroid can relieve pain. Best results are reported for occipital nerve neuralgia presenting with shooting, stinging or burning pain and the symptoms are reproducible by pressure palpation of the occipital nerve at its exist from the skull. Some degree of temporary success is also reported for patients with unilat eral migraines, clus- ter headaches and cervical facet arthropathy. Blockade is usually per formed using surface landmarks in children and adolescents (Suresh and Voronov, 2012 ). Car e is needed to avoid direct needle trauma of the nerve or puncturing the occipital artery, which runs lateral and parallel to the nerve. To improve safety occipital nerve block can b e performed with use of ultrasound guide as described for adults (Shim et al., 2011 ). and bowel injury (Bhalla et al., 2012 ; Gurnaney et al., 2011 ; Skinner and Lauder, 2007 ). Ilioinguinal and iliohypogastric nerve blockade Th e ilioinguinal and iliohypogastric nerve s are branches of the fi rst L1 root, occasionally with contribution from T12. Th e ilioing uinal nerve exits from the abdomen through the obliqus internus and accompanies the spermat ic cord through superfi cial inguinal ring. Th e iliohypogastric anterior branch perforates the external oblique muscle just medial to the anterior superior iliac spine and pro- vide s cutaneous sensory innervation to the abdominal skin above the pubis. Ilioinguinal neuralg ia can cause lower abdominal and pelvic pain in adults (oft en following direct blunt traum a, inguinal herniorrhaphy or pelvic surgery), and has been reported in ado- lescent athlete s. Th e nerve is compressed as it exits the transverse abdominis muscle just lateral to ant erior superior iliac spine, pre- senting as burning pain, paraesthesia, and infrequent numb ness over the nerve \200\231s lower abdominal distribution, with radiation to the scrotum o r labia and sometimes the inner upper thigh. Slouching forward may improve, and extension o f the spine worsens the pain. Suprascapular nerve blockade Th e suprascapular nerve arises from C5 and C6 and innervates the supraspinatus and infraspinatus muscles and gives of twigs to shoulder joint. In a rand omized control trial of adults with chronic shoulder pain this blockade has improved pain, range of motion and disability (Shanahan et al., 2003 ). Th is nerve blockade has been perf ormed in adults with aid of anatomical landmarks, electromy- ography, computed tomography s can, ultrasound guide, or with fl uoroscopy (Fernandes et al., 2012 ). In children both these nerves are in close proximity between transversus abdominis and inte rnal oblique muscle and are ame- nable to blockade with a single injection medial and cepha lad to anterior superior iliac spine. Possible complications are perforation of the bowel i f the needle further posteriorly and femoral nerve blockade if the local anesthetic tracks down caudad. Th is block- ade can be easily and safely performed with ultrasound guidance ( Ecoff ey et al., 2010 ; Jansen et al., 2008 ; Peng and Tumber, 2008 ; Stark et al., 1999 ). Intercostal nerve blockade Intercostal nerve blockade is performed for management of inter- costal neuralgia following nerve injury or infl ammation. It is also performed for diagnos is of painful conditions such as post-thora- cotomy pain syndrome, and slipping rib syndrom e. Th is procedure is commonly performed in children with the use of anatomical landmarks b ut ultrasound imaging may improve safety (Bhalla et al., 2012 ) as pneumothorax can occur i f the needle is advanced deep beyond the internal intercostal muscles. Lateral femoral cutaneous neuropathy (LFCN) LFCN neuropathy, also known as meralgia paraest hetica, presents with paraesthesia (tingling, pins and needles), burning, cutaneous hyperse nsitivity to warm shower, groin pain or numbness over the distribution of the nerve on the anterolateral area of the thigh. Th e symptoms are aggravated by prolonged walking, standin g or bik- ing. Compression of the nerve may be due to tight clothing or belt, obesity or fa st weight gain, pregnancy, pelvic pathology, local injury from direct trauma or aft er ingu inal hernia repair. Conservative therapy includes elimination of the off ending compression cause. Neuropathic pain pharmacotherapy is eff ective in most patients with mild pain (see Rastogi and Campbell, Chapter 48, this vol- ume). In some patients nerve blockade at the i nguinal ligament with a combination of a local anesthetic and corticosteroid may provide pa in relief for days to weeks (Fernandez-Mayoralas et al., 2010 ). Rectus abdominis sheath blockade Th e rectus sheath consists of anterior and posterior laye rs that envelop the rectus abdominis muscle, which is innervated by T7 to T12. Th e interco stal nerves enter the rectus sheath through the posterior rectus sheath, and pierce the rec tus muscles and the ante- rior sheath to innervate the anterior abdominal wall. In one-thir d of the population the intercostal nerve bypasses the rectus sheath compartment and innerv ates the overlying skin directly (Skinner and Lauder, 2007 ) and subcutaneous infi ltration should be used to supplement the posterior rectus sheath blockade. Entrapment of the nerves may occur aft er trauma, repetitive and excessive abdominal crunch es in athletes, rectus sheath hematoma, postsurgical entrapment in a scar or suture ligatio n. Th is presents with intermittent pain at the edge of the rectus muscle sheath (entry sit e of the intercostal nerves), which is aggravated with contraction of the rectus muscles an d alleviated by lying down and fl exion of the ipsilateral hip. Diff erential diagnoses inc lude hernia, irritation of intercostal nerve roots, rib-tip syndrome, myofascial pain and t rigger points of the recuts muscles. Pudendal nerve blockade Th e pudendal nerve arises from S2 to S4 nerve roots, passes out th e pelvis through lesser sciatic foramen and crosses the ischial spine to innervate the rect um, perineum and the penis or clitoris and posterior aspect of the penis or labia majora. I njury to these nerves occurs following trauma, injury during surgery, infl amma- tion, comp ression/entrapment, or due to invasion by malignancy. Pain is aggravated by sitting and all eviated by standing, sitting on toilet seat or lying on the painful side. Pudendal nerve bl ockade has been described in children using percutaneous transperineal approach and nerve s timulator for management of postoperative pain management (Kfoury et al., 2008 ; Naja et al ., 2011 ). Block with local anesthetic with or without steroid can be per- formed with loss of resista nce technique and feel of posterior rectus sheath as an end point, ultrasound imaging clear ly defi nes the end- point and reduces the risk of perforating the posterior rectus sheath CHAPTER 46 interventional pain management techniques for chronic pain 483 Conclusion In adults and now in pediatric patients there have been concerns about effi cacy and acceptability of the various interventional tech- niques for management of chronic pai n disorders due to the lack of well-designed randomized control trials. Interventional tech - niques for management of chronic pain in children and adoles- cents are still being devel oped and there are no controlled trials on their long-term eff ectiveness. Th e best availa ble evidence syn- thesized here is primarily extrapolation from adult interventional proced ures for chronic pain management literature, pediatric case reports and case series, and th e authors \200\231 experience. Th e authors of this chapter are of the view that the practi tioners of pediatric interventional techniques must have a basic understanding of pae- diat ric development, pharmacology, resuscitation skills, and com- petency in performing pediatr ic regional anesthesia techniques as well as experience with specifi c adult interventional techniques for chronic pain management before applying these techniques in young patients. Th e readers are also advised to review the adult controlled trials and evidence-based dat a before integrating these techniques into pediatric practice. 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