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The greater occipital nerve (GON) is primarily responsible for the sensory innervation of the posterior region of the scalp. GON block has been described as a safe and effective therapeutic option for various types of headaches, including occipital neuralgia, migraine, cervicogenic headache, and cluster headache. Despite its established role in headache management, there is a paucity of evidence in the literature regarding its use in the perioperative setting, particularly in surgeries involving the occipital region of the scalp. In this context, we present a case series of three patients undergoing excision of malignant tumors in the occipital scalp region, followed by reconstruction. GON block was performed following anesthetic induction to evaluate its efficacy in postoperative pain control. The results suggest that this technique may provide effective analgesia while also contributing to reduced opioid consumption.

Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)Background and Aims Preoperative optimization of anemia is particularly important in Jehovah’s Witnesses before major surgery. However, when presenting in an acute setting there are no recommendations, and a multimodal and multidisciplinary approach is necessary to safely deliver treatment. Regional anesthesia has a particular role in reducing complications.MethodsCase report.ResultsA 74-year-old male was admitted in our institution for above-knee amputation of the left lower extremity due to irreversible ischemia. His past medical history was relevant for multiple myeloma, hypertension and type 2 diabetes mellitus. His baseline hemoglobin was 7.7 g/dL. He was a Jehovah’s Witness who refused blood transfusions, having been transferred from another institution, where he was denied surgery. Two days before surgery, ferric carboxymaltose 500 mg was administered. Surgery was performed under combined spinal-epidural anesthesia, with 7 mg of intrathecal hyperbaric bupivacaine. Before the beginning of surgery, tranexamic acid 1 g was administered. Hemodynamic stability was achieved, with minimal blood loss (200 mL). The final hemoglobin was 6.4 g/dL. For postoperative analgesia a multimodal approach was implemented, with patient-controlled epidural analgesia with ropivacaine 0.2%. After surgery, darbepoetin alfa 500 micrograms was administered. He was transferred back to his original institution after two days.ConclusionsLower extremity amputation carries a significant risk of perioperative morbidity and mortality. Regional anesthesia may confer several advantages over general anesthesia, having demonstrated a reduction of blood transfusion requirements in the setting of lower extremity amputation. Therefore, it should be considered as part of a blood conservation strategy.AttachmentPatient Consent for Publication.pdf

Background and AimsChronic pelvic pain (CPP) is a frequent and often debilitating symptom of deep infiltrating endometriosis, with a complex pathophysiology involving nociceptive, neuropathic, and central sensitization mechanisms that remains a significant therapeutic challenge, often requiring a tailored, multidisciplinary, and multimodal approach. This case report illustrates the successful integration of pharmacologic, psychological, physiotherapeutic, and interventional strategies in the management of refractory CPP in a patient with rectovaginal endometriosis.MethodsA 32-year-old female with a history of bipolar disorder and previous excision of a serous cystadenoma was referred to the chronic pain clinic in 2024 for CPP characterized by dysmenorrhea, dyschezia, dyspareunia, and dysuria. She had undergone laparoscopic resection of a 3 cm rectovaginal endometriotic nodule invading the hypogastric plexus in 2021, with intraoperative evidence of frozen pelvis. Despite ongoing hormonal suppression, a complex psychopharmacological regimen, pelvic floor physiotherapy, and psychological support, her symptoms persisted. After a positive diagnostic block, thermal radiofrequency ablation (RFA) of the superior hypogastric plexus was performed using three 90-second lesions on each side.ResultsAt four-month follow-up, the patient reported significant improvement in pelvic pain and dyspareunia, with no complications observed. The intervention allowed better functional outcomes and reduced interference with daily activities.ConclusionsThis case highlights the value of a multidisciplinary and multimodal strategy in managing complex CPP secondary to endometriosis. Thermal radiofrequency ablation of the superior hypogastric plexus proved to be a safe and effective interventional option within a broader multimodal strategy, offering meaningful symptom relief, particularly when unresponsive to conservative measures. The sustained clinical improvement observed reinforces the relevance of a multimodal and multidisciplinary strategy—combining pharmacologic, psychological, physiotherapeutic, and interventional modalities—as essential to managing complex and refractory pain syndromes.

Background and AimsNotalgia paresthetica (NP) is a neuropathic syndrome that involves the unilateral infrascapular region, typically corresponding to the T2-T6 dermatomes. It is classically characterized by localized, episodic pruritus, burning, tingling, and pain, often accompanied by secondary skin lesions resulting from chronic scratching. Although the pathogenesis has not been fully elucidated, it is believed to be the result of spinal nerve impingement or nerve trauma. We aim to present an example of a successful management and highlight the importance of a multidisciplinary approach to it.MethodsA 65-year-old female patient, with a medical history of hypothyroidism, nodular thyroid disease and hypertension, started to feel a burning sensation in the left medial infrascapular area by the end of 2022. After dermatology and physical medicine and rehabilitation consultation, a diagnose of NP was done. The initial treatment involved five sessions of cervico-dorsal mesotherapy and application of 5% lidocaine patch, with limited pain control. By the end of 2023 the patient was also receiving physiotherapy twice a week. With no significative improvement, the patient was referred to the chronic pain consult. Since then, was submitted to left dorsal paravertebral block, four capsaicin applications and started 30 mg duloxetine and 50 mg pregabalin twice a day. She was also submitted to four applications of 10 mL subcutaneous ozone.ResultsSince the referral to chronic pain team and with the implemented multimodal approach, the patient had a significant clinical improvement, with less pain and fewer itching episodes in the first month.ConclusionsNP is a clinically poorly recognized syndrome. The lack of studies makes it difficult to optimize the recommendations to treatment. To date, there has been no effective treatment for this condition, decreasing the patients quality of life. This report illustrates a case of treatment success and emphasizes the need for a multidisciplinary and multimodal approach.