Persistent occipital neuralgia can produce severe headaches that may not be controllable by conservative or surgical approaches. We describe a case series of 6 patients who had chronic headaches over an average of 4.9 yr who underwent occipital nerve electrical stimulation lead implantation using a modified midline approach. The patients had received conservative and surgical therapies in the past including oral antidepressants, membrane stabilizers, opioids, occipital nerve blocks, and radiofrequency ablations. Significant decreases in pain visual analog scale (VAS) scores and drastic improvement in functional capacity were observed during the occipital stimulation trial and during the 3-mo follow-up after implantation. The mean VAS score changed from 8.66 +/- 1.0 to 2.5 +/- 1.3 whereas pain disability index improved from 49.8 +/- 15.9 to 14.0 +/- 7.4. Our midline approach has several advantages compared with the submastoid approach used elsewhere. There is only one small midline incision over the upper neck and the strain on the lead extension occurs only with flexion and is minimal with lateral flexion and rotation, which contributes to overall stability of this system.

This study shows significant improvement in pain scores and patients' PDI following IDTA but not after RFA of the intervertebral disks. IDTA appears to be more efficacious than RFA based on PDI and VAS scores measured at 1 year following procedure.

P Pu ur rp po os se e: : Even though clinical safety has been established in large studies, ondansetron has been reported to cause adverse cardiovascular events. We present a case of atrial fibrillation in association with ondansetron in the postoperative period.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : A 47-yr-old, 81 kg female presented with a benign lump in her left breast for lumpectomy. Her past medical history was unremarkable. Physically she was very active, nonsmoker and had no allergies. She underwent the procedure under general anesthesia. She received 4 mg of ondansetron intravenously for postoperative nausea and vomiting prophylaxis at the end of the procedure and an additional 4 mg in the recovery room for nausea. Within 15 min after the second dose she was noted to be in atrial fibrillation that required admission to the hospital and procainamide infusion for conversion to normal sinus rhythm. She did not have any evidence of myocardial ischemia, valvular abnormality or pulmonary embolism.

Spontaneous cerebrospinal fluid (CSF) leak is a rare clinical entity that may result in disabling headaches. It occurs as a result of dural defects, and the initial symptoms resemble those of postdural puncture headache. However, the positional headache can later evolve into a persistent chronic daily headache. The diagnosis of spontaneous CSF leak can be very challenging, but increasing awareness and improved diagnostic techniques are yielding ever more cases. When conservative management fails, the pain management clinician is called upon to administer an epidural blood patch. The success of this technique is dependent upon accurate diagnosis of the site of leakage and targeted epidural administration of the blood patch to this area. In this report, we describe four consecutive cases that were referred to our pain management department over an 18-month period and were successfully treated with site-directed epidural blood patches.