Injury to the ilioinguinal nerve commonly follows during lower abdominal and pelvic surgery, especially with inguinal hernia repair, appendectomy, and hysterectomy. Other potential causes include low abdominal blunt trauma, iliac crest bone graft, psoas abscess, Pott's disease, and prolonged wearing of abdominally constrictive clothing. The actual incidence of ilioinguinal neuralgia is uncertain, as reported percentage ranges between 12% and 62%. Prompt and accurate diagnosis is critical, and appropriate treatments range from conservative pharmacologic management with nonopioid (eg, gabapentin, topiramate) as well as opioid agents, to surgical neurectomy of the proximal portion of the ilioinguinal nerve. Pharmacological treatment is frequently unsuccessful (particularly if delayed) and while surgery is successful in approximately 73% of cases, it can result in problematic paresthesias, and pain may continue to persist in some patients. Thus, minimally invasive techniques, such as peripheral nerve stimulation, may be viable in those patients who are refractory to pharmacological management, as an option to surgery, and who have not gained satisfactory pain relief through surgical intervention. We present three cases of successful pain control of ilioinguinal neuralgia with peripheral nerve stimulation. These cases demonstrate the potential benefits of neurostimulation including durable effective pain relief and decreased use of medication. Putative mechanisms of effect(s) and caveats for continued research to inform prudent employment of this technique are presented.

Spinal cord stimulation is increasingly utilized as a treatment to alleviate low back pain and lumbar radiculopathy, particularly in patients with failed back surgery syndrome. We present an illustrative case of early, rapidly progressive methicillin-resistant Staphylococcus aureus (MRSA) infection after a brief stimulator trial lead implantation. Operators should maintain a high level of suspicion for deep infection, including epidural abscess, even when only minor symptoms and signs are present. Because of the poor ability to clear infections in the presence of a retained foreign body, the device must be explanted immediately. Subsequent surgical intervention, however, may nevertheless still be needed. While a variety of bacteria may cause epidural abscess, methicillin sensitive Staphylococcus aureus, and increasingly, MRSA and community-associated MRSA, are the most likely etiologic organisms.A 46-year-old white man, who smoked and had a history of asthma and borderline hypertension, was being treated in our practice for failed back surgery syndrome. He was unresponsive to conservative therapy including methadone 10 mg, 6 tablets Q8hours, Oxycodone 15 mg, 4 tablets Q3hours prn, and pregabalin 75-mg capsule Q12hours, and presented for a spinal cord stimulator trial. Adhering to strict aseptic technique, the patient's thoracolumbar spine was prepped with 70% isopropyl rubbing alcohol followed by 10% povidone-iodine. The operative site was then surgically draped and the fluoroscopic image intensifier sterilely wrapped. Prophylactic systemic antibiotics were not administered. Wearing sterile gloves, mask, gown, and cap, we placed 2 percutaneous electrode leads (Advance Bionics, Sylmar, CA, U.S.A.) through separate insertion sites on a single attempt. After assuring successful stimulation coverage, the leads were secured to the back with steri-strips and Tegaderm. The procedure was uneventful and there was no break in sterility.

Treatment for rib fracture pain can be broadly divided into pharmacologic approaches with oral and/or parenteral medication and interventional approaches utilizing neuraxial analgesia or peripheral nerve blocks to provide pain relief. Both approaches attempt to control nociceptive and neuropathic pain secondary to osseous injury and nerve insult, respectively. Success of treatment is ultimately measured by the ability of the selected modality to decrease pain, chest splinting, and to prevent sequelae of injury, such as pneumonia. Typically, opioids and NSAIDs are the drugs of first choice for acute pain because of ease of administration, immediate onset of action, and rapid titration to effect. In contrast, neuropathic pain medications have a slower onset of action and are more difficult to titrate to therapeutic effect. Interventional approaches include interpleural catheters, intercostal nerve blocks, paravertebral nerve blocks, and thoracic and lumbar epidural catheters. Each intervention has its own inherent advantages, disadvantages, and success rates. Rib fracture pain management practice is founded on the thoracic surgical and anesthesiology literature. Articles addressing rib fracture pain are relatively scarce in the pain medicine literature. As life expectancy increases, and as healthcare system modifications are implemented, pain medicine physicians may be consulted to treat increasing number of patients suffering rib fracture pain and may need to resort to novel therapeutic measures because of financial constraints imposed by those changes. Here we present the first published case series of thoracic epidural steroid injections used for management of rib fracture pain.

Lumbar synovial cysts can be a source of low back pain with or without radiculopathy depending upon the size and location of the mass. Options for treatment range from analgesics to surgery, depending upon the degree of nerve root or spinal cord impingement. Attempts at minimally invasive treatment such as computed tomography-assisted aspiration and cyst rupture are documented in the radiology literature with varying degrees of reported success. This case report is the first to document the fluoroscopically-guided management of a lumbar synovial cyst in the pain medicine literature and highlights the knowledge and technical skills required when treating such cases.

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