BUILDING ON BLOCKS In addition to surgical numbing and post-op relief, regional anesthesia can combat chronic conditions.

The benefits of peripheral nerve blocks are well known. Their lasting analgesic effect decreases the need for opioids and their minimal recovery complications all but guarantee patient satisfaction, making them an effective option for numbing the surgical site and managing post-op pain, even in painful joint repair procedures. But that's not all they're good for. Anesthesia providers and pain management practitioners are also placing peripheral nerve blocks to diagnose and treat chronic conditions that trouble their patients. Are you aware of these 4 alternative applications?

1. Shingles
Referrals from primary care physicians and surgeons to the anesthesia providers or other clinicians who run pain management services are perhaps the main route through which patients might receive non-surgical peripheral nerve blocks at your facility.

Pain management doesn't always involve lumbar spine injections for workers' comp injuries. Shingles, a disease sparked by the varicella zoster virus (the same virus responsible for chicken pox), causes a painful rash and in some cases leaves post-herpetic neuralgia, a burning or aching sensation on the affected nerves and skin, for months or years afterwards.

Traditional palliative remedies have included oral narcotic and non-narcotic medications, antidepressants and transdermal lidocaine patches. However, since the shingles rash and subsequent neuralgia often occur along an area of skin served by a particular neural pathway, pain management practitioners have successfully provided patients with relief from the painful aftermath through intercostal nerve blocks. Ultrasound or electrical nerve stimulation can assist providers in determining and reaching the affected nerve roots.

For patients suffering from shingles, pain management practitioners advocate blocking the nerves early, even before the outbreak has subsided, says Pam Wrobleski, CRNA, MPM, DNAP(c), CASC, administrator of the Southwestern Ambulatory Surgery Center in Pittsburgh, Pa. "You don't know who will develop the neuralgia, and they've found success in administering the nerve block early on," she says, noting that it might even ease the outbreak's symptoms as well. "Patients will do better if they're blocked earlier rather than later."

2. Phantom limb pain
Ms. Wrobleski has even seen demonstrations of nerve blocks to quiet the "phantom limb pain" experienced by patients who have lost extremities.

"For a long time, phantom limb pain was believed to be a psychiatric issue," she notes, "but research has shown that amputation disrupts the nervous system on the peripheral level and disrupts signals to the spinal cord."

In the July 2014 issue of the journal Pain, a team of Israeli and Albanian researchers reported on the peripheral nerve origins of phantom limb sensations (tinyurl.com/lr29udk). They concluded that they are not the result of the loss of sensory input and the brain's failure to adapt, but instead caused by exaggerated input from the dorsal root ganglia that once served the limb. In their experiments, intraforaminal epidural blocks "rapidly and reversibly extinguished" the phantom pain, while control injections didn't. "We recommend the [dorsal root ganglia] as a target for treatment of [phantom limb pain] and perhaps also other types of regional neuropathic pain," they write.

To locate the nerve root source of shingles' neuralgia or phantom limb pain, physicians can use transcutaneous electrical nerve stimulation (TENS) units to test out the possibilities, says Ms. Wrobleski. The external devices, which utilize electrodes temporarily affixed to the skin, are the same technology that's used to verify surgical plans for implanting subcutaneous nerve stimulators into chronic pain patients. "In each case you're asking, 'Did you get any relief? For how long?'"

3. Headaches
Headaches are a persistent symptom among patients who suffer traumatic brain injuries such as concussions. They're challenging to treat and they run the risk of becoming a chronic condition.

Peripheral nerve blocks administered into the scalp provide a therapeutic effect not only to adult patients with post-traumatic headaches, but also to pediatric patients, with safe and effective results, according to Canadian researchers writing in the May 2014 issue of the journal Headache (tinyurl.com/oa4ofpk).

For the study, the researchers observed the cases of 28 patients with an average age of 14.6 years who received their first blocks, on average, 70 days after injury. Ninety-three percent saw good outcomes, with 71% seeing rapid and complete relief.

"The ease with which peripheral nerve blocks of the scalp can be performed," they write, "combined with the immediate relief experienced by patients, makes them a potential addition to the armamentarium of headache management strategies for children and adolescent with post-traumatic headaches."

4. Save a case from cancellation
Occasionally your discussions with pre-op patients will uncover other aches and pains, unrelated to the surgery at hand, that they're feeling. Sometimes they can be quite substantial, but sometimes a well-placed nerve block can save the day.

Mike MacKinnon, MSN, CRNA, an independent practice nurse anesthetist from Show Low, Ariz., remembers a patient who was in agony before a hand surgery. "As she laid on the stretcher, she complained of weird pains radiating up her abdomen, a flare-up from a past spinal injury. Just to touch the skin would make her come off the bed," he says. "That's all she could think about. She'd actually considered cancelling the surgery."

That was one possibility, letting the patient go home and rescheduling the necessary surgery, hoping that there wouldn't be another flare-up next time. In the meantime, Mr. MacKinnon notes, she'd have to live with the inconvenience and the anxiety that her condition caused. Alternatively, she could go ahead with the surgery, suffering through the pain and through recovery with it.

Or, the source of her pain could be identified and temporarily treated. "A lot of times what chronic pain management is, is a decision pathway," he says. An understanding of the mechanics of pain, of neuropathic causes and effects and not just anesthesia's traditional focus on surgical pain, can open your clinical options.

He administered a bilateral transversus abdominis plane (TAP) block and the patient's pain receded. It was a temporary solution, of course: a more lasting fix would require the ablation of the nerve roots responsible for the pain signals, but "it got us through surgery," he says. "I don't know how long it lasted. At least a day, because when we called her, she was still feeling good."

Mr. MacKinnon admits it was an unusual situation. Almost all of the blocks he places in pre-op are intended to support post-op pain management, and for outpatient pain management services he generally employs lumbar steroid injections. "That's the first time I ever saw something like that, and I don't expect to see it again," he says. Like all nerve blocks, it generated no income for the facility and its primary benefit was to the patient's care.

But look at it this way, he adds. "It took me 5 minutes to do the bilateral TAP block. It cost me nothing, it cost the facility maybe $10 in supplies. And it saved them the lost revenue and inconvenience of a cancelled case."