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The interruption, interference, or blockade of painful stimuli has been used in the management of pain for several decades. Acute, chronic, and postoperative pain can be diminished with various types of regional anesthesia or specific nerve blocks. In the setting of chronic pain management, various peripheral nerve blocks can be diagnostic, prognostic, or therapeutic in nature. A nerve block involves the injection or infusion of a short- or long-acting local anesthetic around a peripheral sensory nerve, motor nerve, or sympathetic nerve plexus. In addition to local anesthetic, a steroid preparation may be added to decrease any suspected inflammatory process. Neurolytic nerve blocks can be performed utilizing various techniques including chemical, heat, or cold. Chemical agents such as alcohol or phenol are used for the selective destruction of nerves. Pulsed radiofrequency and cryoanalgesia cause neurolysis via heat or cold lesioning. Advances in fluoroscopic imaging and computed tomography (CT) scanning allow direct visualization and targeting of specific nerves and nerve plexuses. Other improvements include the use of nerve stimulators during interscalene and axillary blocks or sensory and motor nerve stimulation performed during radiofrequency procedures to assist in accurate needle placement.

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Nerve blocks are generally most useful when a specific nerve or limb is affected. Neuropathies with bilateral or multiple areas of involvement may benefit from other forms of neuromodulation including pharmacologic management, transcutaneous electrical stimulation (TENS), or spinal cord stimulation.1,2

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Successful treatment outcomes involve numerous factors including proper patient selection, understanding the anatomy, side effects, and potential complications of each specific nerve block. A comprehensive approach to chronic pain management has been shown to produce superior outcomes.3 Nerve blocks, when appropriate, should be considered part of the overall multidisciplinary treatment plan.

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Patients selected for nerve block therapy or regional anesthesia should have an accurate diagnosis for the origin of their pain. In some instances nerve blocks may aid in the diagnosis of certain acute and chronic conditions. The relief of pain comes from the interruption of nociceptive or pain sensory pathways, sympathetic blockade, or somatosensory blockade. Regional anesthesia may be used to interrupt the afferent limb of abnormal reflexes that contribute to the pathogenesis of some pain syndromes. Regional anesthesia may block efferent sympathetic outflow, which contributes to postoperative, post-traumatic, and chronic pain syndromes with sympathetic involvement such as complex regional pain syndrome (CRPS) or postherpetic neuralgia.4

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A complete history and physical evaluation of the patient should be performed including review of laboratory studies, imaging studies, medications, and allergies. Psychiatric and psychosomatic assessment should be carried out when appropriate. Special attention should be paid to anticoagulant medications, sensory loss or motor weakness on physical examination. Complaints of sexual dysfunction, and bowel or bladder problems should also be noted. Any abnormal findings should be documented and may require further evaluation prior to any interventional nerve blocks.

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The choice of local anesthetic (LA) used will affect the density of the nerve ...

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