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Chronic pain and driving: proceed with caution . Pain , 122 , 6 \200\2237. CHAPTER 46 Interventional pain management techniques for chronic pain Navil F. Sethna , Pra deep Dinakar, and Karen R. Boretsky Summary As part of multidisciplinary management of pediatric chronic pain, interventional p ain management techniques can play an important role when pain is unrelieved by conventiona l treatment modali- ties. Many procedures and indications are extrapolated from adult studi es, and evidence for long-term effi cacy in pediatric popula- tions is limited. Interventio ns range from injection techniques with local anesthetic and/or corticosteroids to neuraxia l blockade with implanted catheters. Pediatric case series have reported benefi t in select ed patients with complex regional pain syndrome and cancer- related pain. standard textbooks for detailed technical information (Cousins et al., 2009 ; Fishman et al ., 2010 ; Prithvi Raj, 2008 ). Th is chapter focuses on commonly useful procedures that are increasingly used in pediatric patients with chronic pain syndromes. Physicians who perfor m IPM techniques in children should be familiar with dif- ferences in developmental anatomy and pharmacology and trained and experienced in regional nerve blocks in adults and childr en. As a general principle all IPM procedures for chronic pain disor- ders must be performe d as adjunct to multimodal therapies in the setting of interdisciplinary program. General patient considerations Interventional pain management techniques are widely used in the pediatric population in acute postoperative pain, but also have a role in chronic pedi atric pain management. Patients and families should be fully informed about the benefi t an d risks of the IPM procedure, how a particular procedure is conducted, potential rare but s erious complications, and alternative options should be reviewed. Th e patients and guardia ns should be informed that IPM techniques have limitations, and responses may vary for diff erent patients and diff erent chronic pain conditions. Th e details of proce- dures, setti ng appropriate expectations, long-term benefi ts and risks must be explained in days or wee ks before the scheduled procedure rather than on the day of the planned procedure. Dependin g on his/her age, the procedure should be discussed with the child, who is encouraged to ex press concerns and ask questions. Th e guard- ians must provide a written informed consent for the procedure and when appropriate (usually over age of 7 years) the child should provi de assent, not only to protect the patient \200\231s right to autonomy but also to protect the physician from medical malpractice. Th e analgesic eff ect of a single intervention is typically temporary and may off er little to no long-term pain relief. Th ese IPM technique s are oft en performed in a series to achieve longer duration of anal- gesia or discontinue d if no benefi t obtained. Younger children and anxious adolescents may require intravenous sedation or general Introduction Signifi cant improvement in our understanding of pediatric pain neurobiology a nd its adverse eff ects has increased awareness for the need for early analgesic interventi on to mitigate the acute and long- term consequences of pain. As part of multidisciplinary manage- ment of pediatric chronic pain, interventional pain management (IPM) techniques pla y an important role when pain is unrelieved by conventional treatment modalities. Although these techniques have long been the mainstay of adult chronic pain management, the lack of outcome data in pediatric populations has limited its utility. As with adults, pediatric ch ronic pain requires multidisci- plinary management, combining psychosocial support and phar - macotherapy, and including IPM when required to provide the best possible options for man aging pain and improving quality of life. Several textbooks and manuals have been published describing detailed applied anatomy and a pproaches and techniques of IPM in adults (Peng and Tumber, 2008 ) but only a few case repo rts and case series are described in children. Th e experience with appli- cation of these blockades in pediatric population is very limited and citation of references in this chapte r refers to adult literature unless specifi ed for children. It is not the intention of thi s chapter to duplicate these technical details and readers are referred to adult CHAPTER 46 interventional pain management techniques for chronic pain 475 anesthesia, which will require additional preparation. Th e abso- lute contraindications fo r IPM technique are same as in adults including presence of infections at the site of the p rocedure, intake of anticoagulants, a history of coagulopathy, and hyperglycaemia. number of options may now be utilized to improve accuracy and safety of the procedures: \231 Nerve stimulation aims to stimulate the motor component of a mixed peripheral nerve to elicit painless muscle contraction. A current of usually between 0.4 and 0.5 mA is the t hreshold cur- rent at lowest twitch response. Higher current intensity should not be used t o avoid stimulating the sensory component and causing painful paraesthesia. Responses at lo wer currents may indicate contact with the neural tissue and potential for inadvert- ent in traneural injection (Abrahams et al., 2009 ). Pharmacology of agents The most common medications used in pediatric inter- ventional pain management include local anesthetics and corticosteroids. Local anesthetics Local anesthetics are reversible voltage-gated sodium channel blockers, a nd blockade of (Na + ) ion infl ux leads to inhibition of nociceptive impulse propagation. Th e success and safety of a nerve blockade depends on delivery of the optimal dose and vol ume of a local anesthetic, preferably at the precise site of the suspected pain generator f oci of a nerve or plexus. Adding 1 ml of sodium bicarbonate 8.4% to each 10 ml of a local a nesthetic (e.g. lidocaine or mepivacaine) or 0.1 ml to 10 ml of bupivacaine can hasten the onset of the nerve blockade and lessen the discom- fort associated with the local anestheti c injection. Amide local anesthetics, such as lidocaine, bupivacaine, and ropivacaine have delayed hepatic clearance in infants less than 2 months and vari- able clearance between 3 and 6 months. Reduced plasma proteins (albumin and alpha-1 glycoproteins) in this age group increase the unbound and free local anesthetic concentration that is potentially available to cause central nervous system (CNS) and cardiac toxicity. Similarly, ester local anesthe tics such as chlo- roprocaine are metabolized at a lower rate in infants under the age of 6 months due to decreased plasma cholinesterase activity (Mazoit and Dalens, 2004 ) \231 Fluoroscopic guidance (i.e. X-ray image intensifi er or a C-arm X-ray system with in jection of radiopaque contrast to confi rm needle tip position) for epidural steroid inject ions and other IPM techniques enhances accuracy of locating the target tissue and reduces t he potential injury to the surrounding structures. Safe and effi cient use of these modalit ies requires formal train- ing, skills and experience, with attention to minimizing radia- tion exposure to patients \200\231 vital organs and clinicians (Eckel and Bartynski, 2009 ; Hodge, 2005 ). \231 Ultrasound imaging allows visualization of soft tissue, bony, vas- cular, and neural structures, and can diff erentiate various tissue planes and spaces (e.g. epidural, intrat hecal, pleural and perito- neal). Th e operator can confi rm desirable spread of the inject ate in real time. Ultrasound imaging avoids radiation and is virtually without side eff ect s (Peng and Narouze, 2009 ). Interventional pain management for CRPS Sympathetic ganglion blockade Sympathetic ganglia b lockade with local anesthetics may be used as a diagnostic test, and a positive response is interpreted as sym- pathetically mediated pain (SMP), however, this view is not shared by all researchers and is not supported by rigorous investigation. Although favorable response s to sympathetic blockade has been used to predict pain relief from implanted spinal cord s timulators in adult patients with CRPS, the evidence is weak (Bogduk, 2002 ; Sharma et al., 2006 ). Response to sympathetic ganglion blockade success could not be predicted from any of the presenting signs or symptoms (Sethna and Berde, 2012 ; van Eijs et al., 2012 ). Steroids Glucocorticoids are commonly used anti-infl ammatory drugs and suppress infl ammat ory process through many routes despite its limited effi cacy. It is most frequently used v ia lumbar and cau- dal epidural routes for targeting the radicular pain of L5, S1, and othe r nerve roots. Th ey exert their action by blocking the synthe- sis of prostaglandins, leuk otrienes, and platelet activating factor. Steroids also stabilize the neuronal membrane and so are used to reduce pain from neural irritability and diminish perineural infl am- matio n and oedema. Th ere is no supporting scientifi c evidence in children, but a maximum serie s of three nerve blocks are proposed, to achieve longer-term relief. Th ere is no consensus on the type or optimal dose of steroids that should be used for various central and periph eral nerve blocks in adults and no data in children. Th e most common steroid preparations used include triamcinolone, meth- ylprednisolone acetate, and dexamethasone. Even though th e fi rst two are particulate steroids with better effi cacy, the potential risk of vascular injury and infarction makes their use undesirable. Th e main risks of repeat injections of steroids are systemic absorption and Cushing \200\231s syndrome, skin atrophy, and poor he aling. Th e use of steroid for interventional chronic pain in children is not approved by F ederal Drug Administration in US (Eckel and Bartynski, 2009 ). Sympathetic ganglia blockade and/or epidural analgesia must be off ered in the context of m ultidisciplinary management of chronic pain disorders. Preliminary experience in rehabilita tion of chil- dren and adolescents with intractable CRPS reported signifi cant improvement in many domains of the child \200\231s quality of life includ- ing pain reduction, function al improvement to remission, return to normal activities, and improvement of school attenda nce aft er a 3-week outpatient intensive interdisciplinary rehabilitative pro- gramme, cons isting of physical and occupational therapies, cogni- tive-behavioral therapy, and child an d family education (Logan et al., 2012 ). Stellate ganglion blockade Th e stellate ganglion is located on the anterior surface of C7 trans- verse process. Sympathetic innervation to the head and neck arises from T1/T2 and pa sses through the stellate ganglion; and the sym- pathetic innervation to the upper extremit y arises from T2 to T8, but some fi bres synapse at the second thoracic ganglion and may no t be fully interrupted by a stellate ganglion blockade (Tong and Correct needle placement technique Although many axial and peripheral nerve blockades have tra- ditionally been performed without aids to correct placement a SECTION 6 pharmacological interventions 476 Complications Potential serious infectious complications can occur with tempo- rary epidura l catheters and SCS, particularly in immune suppressed children due to malignancy, chronic steroid therapy, chronic pain disorders or those with coexisting infection (Aram et al., 20 01 ; Olsson et al., 2008 ; Sethna et al., 2010 ; Straff ord et al., 1995 ). In a large pedi atric population the incidence of externalized (through a short subcutaneous tunnel) tunnel ed epidural catheter-associ- ated cellulitis, paravertebral muscle, and epidural space infe ctions was evaluated and signifi cantly higher rate of infection was found in children with CRPS when compared to postoperative children: 3.2% versus 0.06% (Sethna et al., 2010 ). Th e median duration of epidural infusion was similar in the two groups of patients (3 versus 4 days, ranging 1 \200\22312 days). Th e diagnosis of the infection in CRPS children (10 \200\22316 years) was made between 3 and 5 days aft er inser- tion of the catheters. All CR PS children were otherwise healthy whereas the children who developed postoperative epidura l cath- eter-associated infection were immunosuppressed due to malig- nancy and/or chronic steroid therapy. Th e most common pathogen was Staphylococcus aureus . Th e reasons for the higher incidence of infection in otherwise healthy CRPS children are not entirely understo od, but are attributed to impaired immune response caused by chronic pain and stress. Nelson, 2000 ). Blockade is achieved by injection of 3 to 5 ml of local anesthetic; larger volumes may spread to the somatic nerve via epidural sleeves, or cause serious systemic tox icity if inadvertently injected in a vessel (particularly the nearby vertebral artery). Sig ns of successful sympathetic blockade include: ipsilateral Horner \200\231s syndrome, nasal congestion, cutaneous vasodilation, and increased cutaneous temperature in the arm. Stella te ganglion blockade is infrequently performed in children because CRPS aff ects pre- domin antly the lower extremity. Recent cases report use for post- traumatic headache, and pain m anagement of acute herpes zoster ophthalmicus using an indwelling catheter for injection of a series stellate ganglion blockade (Agarwal and Joseph, 2006 ; Chan and Chalkiadis, 2010 ; Elias and Chakerian, 1994 ).