Cite as: Kashiwagi Y, Grzybowski J, Krakowski JC, et al. Literature review - November 2026. ASRA Pain Medicine News 2026;51. https://doi.org/10.52211/asra110126.017.

Acute Pain

Early Percutaneous Cryoneurolysis for Pain Control After Rib Fracture for Older Patients: A Prospective Randomized Clinical Trial

Forrester JD et al. J Am Coll Surg 2026;243(1):36-46. https://doi.org/10.1097/XCS.0000000000001856

Summary by Yuta Kashiwagi, MD

Introduction: Pain control after rib fractures in older adults is critical for patient comfort and preventing respiratory complications.

Methods: This prospective, non-blinded randomized clinical trial evaluated whether CT-guided percutaneous cryoneurolysis (CT-PCN) improved outcomes when added to a multimodal standard-of-care (SoC) analgesic regimen in patients aged 65 years or older with rib fractures. Patients were randomized within 72 hours of admission to receive CT-PCN plus SoC or SoC alone. The primary outcome was the highest pain score with deep inspiration within 24 hours before discharge, while secondary outcomes included hospital length of stay, opioid use, and McGill pain scores.

Results: A total of 110 patients were enrolled (56 CT-PCN, 54 SoC). Cryoneurolysis was performed a median of 31 hours after admission, treating a median of five intercostal nerves. Although fewer patients in the CT-PCN group required subsequent nerve blocks (13% vs 35%, p=0.005), there was no significant difference in discharge pain scores (intervention: 5.6 ± 2.4 vs SoC: 5.9 ± 2.4; p = 0.49), hospital length of stay, or opioid consumption (intervention median MME 24 [IQR 6-45] vs SoC 15 [IQR 4-34]; p = 0.29). Intervention patients were more likely to continue using NSAIDs, gabapentin, lidocaine patches, and opioids after discharge and reported higher sensory and affective pain scores at 1 month. No differences were observed at later follow-up.

Key point: Despite recent enthusiasm for the technique, CT-PCN provided no short- or long-term analgesic benefit and may worsen pain-related outcomes during the first month after rib fracture recovery.

Comparison of Ultrasound-Guided Erector Spinae Plane Block to Intrathecal Morphine for Postoperative Analgesia in Patients Undergoing Elective Lumbar Fusion Operations Under General Anesthesia: A Randomized Controlled Trial

Ashoor T et al. BMC Anesthesiol 2026;26(1):430. https://doi.org/10.1186/s12871-026-04030-4

Summary by Jeffrey Grzybowski, MD

Introduction: Postoperative pain management after spine surgery is challenging, and no single approach is considered the “gold standard.” This clinical trial assessed the efficacy and safety of ultrasound (US)-guided bilateral single-injection erector spinae plane block (ESPB) compared with a single dose of 0.2 mg intrathecal morphine (ITM) for the first 24 hours of postoperative analgesia in patients undergoing lumbar fusion.

Methods: Patients were randomized to three groups: ESPB (E-group), ITM (M-group), or control (C-group). E-group received bilateral ESPBs at T10 under general anesthesia (GA) with 20 mL of 0.25% bupivacaine per side and a sham block at the lumbar puncture site. The M-group received 0.2 mg ITM after induction of GA, with bilateral sham ESPBs. C-group received sham blocks in all locations. Intraoperative GA technique and postoperative analgesia were standardized; rescue analgesia in the form of 30 mg intravenous ketorolac was given on patient request or with pain visual analog scale > 3 at rest.

Results: The final analysis included 104 patients: 35 in the E-group, 34 in the M-group, and 35 in the C-group. The primary endpoint was the time to first rescue analgesic. The M-group showed a significantly longer time to the first analgesic request (22.4±1.4 h) compared to the E-group (20.9±1.9 h) and the C-group (1.3±0.5 h) (p < 0.001). The M-group had higher incidences of pruritus and nausea within 24 hours (p = 0.004 and p < 0.001, respectively).

Key Point: ITM after lumbar fusion provided lower analgesic demands than ESPB, but with a higher incidence of ITM side effects within the first 24 hours postoperatively.

Opioid-Sparing Anesthesia Based on Opioid-Free Principles for Early Recovery after Total Knee Arthroplasty: A Randomized Controlled Trial

Liu J et al. J Clin Anesth 2026;114:112307. https://doi.org/10.1016/j.jclinane.2026.112307

Summary by James C. Krakowski, MD, FASA

Introduction: Total knee arthroplasty (TKA) is associated with substantial perioperative pain, inflammation, and opioid exposure, which may adversely affect recovery. This trial evaluated whether an opioid-sparing anesthesia (OSA) strategy based on opioid-free principles could improve early recovery compared with conventional opioid-based anesthesia (OBA).

Methods: This single-center randomized controlled trial enrolled 98 adults undergoing elective unilateral TKA and allocated 49 patients per group. Patients, surgeons, and outcome assessors were blinded. Both groups received preoperative femoral nerve block, sevoflurane, oxycodone at skin incision and closure, and identical postoperative multimodal analgesia with patient-controlled analgesia. OSA used dexmedetomidine and esketamine as the primary analgesic regimen; OBA used sufentanil and remifentanil. The primary outcome was QoR-15 at 24 hours. Secondary outcomes included 48-hour QoR-15, Oxford Knee Score (OKS), EQ-5D-3L, and postoperative pain through 3 months.

Results: All 98 patients were included in the modified intention-to-treat analysis; 90 and 88 completed 1- and 3-month follow-up, respectively. QoR-15 at 24 hours was higher with OSA than OBA (118.4±11.5 vs 113.3±12.2; adjusted difference 5.12, 95% CI 0.51–9.74; P=0.029), with a similar difference at 48 hours (5.54, 95% CI 1.57–9.52; P=0.007). OSA reduced postoperative nausea and vomiting (4% vs 18%; P=0.025) and postoperative blood C-reactive protein level (P=0.001), and improved 1-month OKS (difference 2.31, 95% CI 0.34–4.27; P=0.022). QoR-15 differences remained below the predefined 6-point minimal clinically important difference (MCID), and functional benefit was absent at 3 months.

Key Point: OSA modestly improved early recovery after TKA, but the QoR-15 benefit did not reach the predefined MCID threshold.

Chronic Pain

Sustained Relief of Chronic Headache Using Percutaneous 60-Day Peripheral Nerve Stimulation Treatment: 12-Month Results from a Multicenter, Prospective Clinical Study

McCormick ZL, Gilmore CA, Gutierrez GG, et al. Interv Pain Med 2026;5(3):100806. https://doi.org/10.1016/j.inpm.2026.100806

Summary by Enas Kandil, MD, MSc

Introduction: Cervicogenic headache (CGH) and occipital neuralgia (ON) are difficult-to-treat headache conditions that impair function and quality of life. Occipital nerve blocks offer short-lived relief, while conventional permanently implanted stimulation systems have shown high complication rates. This study examines 12-month durability data on a percutaneous 60-day peripheral nerve stimulation (PNS) system designed to resist lead migration and fracture.

Methods: This was a multicenter, prospective, single-arm feasibility study. Twenty participants with CGH or ON (without migraine) diagnosed based on International Classification of Headache Disorders 3 criteria received bilateral percutaneous lead implantation targeting the greater and third occipital nerves under imaging guidance. Leads remained indwelling for up to 60 days before removal. Participants were followed through 12 months, with key effectiveness outcome examining proportion of participants with >50% reduction in average pain intensity and/or pain interference (Brief Pain Inventory Short Form 5 and 9 respectively), and secondary outcomes including Neck Disability Index, Headache Impact Test (HIT-6), Patient Global Impression of Change, and headache days/week.

Results: Sixteen participants completed the 12-month follow-up, of whom 82% (95% CI 63%–100%) had sustained ≥50% reduction in pain and/or pain interference, comparable to the 85% response at 3 months. The mean pain and pain interference decreased by 59%±8% and 70%±7%, respectively. Neck disability, headache impact, and headache days/week all showed sustained, clinically meaningful improvement. No new device-related adverse events occurred after 3 months.

Key Point: Percutaneous 60-day PNS of the occipital nerves produced durable, clinically meaningful relief of refractory CGH/ON through 12 months without permanent implantation.

Dual Stellate Ganglion Blocks for Managing Treatment-Resistant Anxiety Disorder: A Randomized, Double-Blind, Placebo-Controlled Trial

Niraj G, Karanth V, Charan N, et al. Pain Physician 2026;29(5):327-34.

Summary by Howard Meng MD, FRCPC

Introduction: Treatment-resistant anxiety disorders are associated with a high burden of disease. Stellate ganglion block (SGB) has been reported to reduce anxiety symptoms in post-traumatic stress disorder (PTSD). This study aims to determine the effectiveness of SGB for reducing anxiety symptoms in treatment-resistant anxiety disorder.

Methods: A randomized, double-blind, sham-controlled trial involved adults with GAD-7 scores >10 who had failed first-line psychotherapy and pharmacotherapy. Participants were randomized 2:1 to dual ultrasound-guided SGB (n=42) or sham treatment (n=21). Patients with PTSD were excluded. SGB consisted of local anesthetic and 20 mg of methylprednisolone. A right-sided SGB was performed, followed by a left-sided SGB between 24 hours and 7 days. The primary outcome was change in GAD-7 score at 4 weeks. Secondary outcomes included GAD-7, Hamilton Anxiety Rating Scale (HAM-A) scores, and Patient Global Impression of Change (PGIC).

Results: Sixty-two participants completed the study. The mean total GAD-7 score change at 4 weeks post-intervention was -9.6 points for the SGB group and -3.6 points for the sham group (mean difference of -6.2; 95% CI, -9.3 to -3.2; p<0.001). This difference persisted at 12 weeks (p<0.001). HAM-A score change also significantly favored the SGB group at 4 and 12 weeks post-intervention. No serious adverse events occurred. Transient hoarseness was the most common adverse effect.

Key Point: Dual SGB significantly reduced treatment-resistant anxiety symptoms for up to 12 weeks, although larger, longer-term studies are needed to confirm durability and generalizability.

High-Voltage Fluoroscopic Guided Pulsed Radiofrequency Compared to Standard-Voltage Pulsed Radiofrequency on the Dorsal Root Ganglion for Chronic Lumbosacral Radicular Pain: A Double-Blinded, Randomized Controlled Trial

Hashem EY, Habib MN, Elkaradawy S, et al. Pain Physician 2026;29(3):259-67

Summary by Vandana Sharma MD, FASA

Introduction: Dorsal root ganglion (DRG) can be modulated via pulsed radiofrequency (PRF). PRF is a non-neurodestructive treatment for the treatment of neuropathic pain. This study compares the effects of DRG-adjacent high-voltage pulsed radiofrequency (HV-PRF) with standard-voltage (SV-PRF) for chronic radicular pain.

Methods: This was a prospective, double-blind, randomized controlled trial. Ninety-six adults with lumbar radicular pain caused by disc prolapse were divided into two groups to receive

HV-PRF at 55 -75 volts (Group I) or SV-PRF at 45 volts (Group II) adjacent to the corresponding DRG. Other PRF parameters (temperature 42°C, frequency 2 Hz, and pulse width 20 msec) were the same in both groups. We evaluated the numeric rating scale and Oswestry Low Back Disability Questionnaire at 1 week and at 1, 2, 3, and 6 months after the intervention.

Results: In both groups, numeric rating scale scores decreased at all post-intervention time points (P ≤ 0.001), with the decline significantly greater in Group I than in Group II (P ≤ 0.001). Oswestry Low Back Disability scores decreased significantly in both groups at all post-intervention times (P ≤ 0.001); the reduction was significantly greater in Group I than in Group II (P ≤ 0.001). No major complications were recorded for either group.

Key Point: Both HV-PRF and SV-PRF provided pain relief and improved functional status in lumbosacral radicular pain; however, HV-PRF provided superior results compared to SV-PRF.