Bilateral facial pain is associated with temporomandibular joint dysfunction and rarely, trigeminal neuralgia. In the absence of clinical and radiological signs, a diagnosis of persistent idiopathic facial pain is often made. Standard management of persistent idiopathic facial pain includes pharmacotherapy and psychotherapy with variable therapeutic efficacy. Whiplash can result in persistent facial pain although its clinical presentation and management are poorly defined. This report includes 3 patients with refractory bilateral facial pain. A detailed review of history revealed whiplash before the onset of the symptoms. The authors present a novel intervention, an intermediate cervical plexus block that produced durable analgesia.

Objectives Post cholecystectomy pain syndrome can affect over a third of patients undergoing laparoscopic cholecystectomy. Acute exacerbations can result in recurrent emergency admission with excessive healthcare utilization. Standard surgical management appears to focus on visceral aetiology. Abdominal myofascial pain syndrome is a poorly recognised somatic pathology that can cause refractory pain in this cohort. It develops as a result of trigger points in the abdominal musculature. The report describes the pathophysiology and a novel interventional pathway in the management of post cholecystectomy pain secondary to abdominal myofascial pain syndrome. Methods The prospective longitudinal audit was performed at a tertiary pain medicine clinic in a university teaching hospital. Over a six-year period, adult patients with refractory abdominal pain following laparoscopic cholecystectomy were included in a structured interventional management pathway. The pathway included two interventions. Intervention I was a combination of abdominal plane blocks and epigastric port site trigger injection with steroids. Patients who failed to report durable relief (>50% pain relief at 12 weeks) were offered pulsed radiofrequency treatment to the abdominal planes (Intervention II). Outcomes included patient satisfaction, change in opioid consumption and impact on emergency visits. Results Sixty patients who failed to respond to standard management were offered the pathway. Four patients refused due to needle phobia. Fifty-six patients received Intervention I. Failure rate was 14% (8/56). Forty-eight patients (48/56, 86%) reported significant benefit at 12 weeks while 38 patients reported durable relief at 24 weeks (38/56, 68%). Nine patients received Intervention II and all (100%) reported durable relief. Emergency admissions and opioid consumption were reduced. Conclusions Abdominal myofascial pain syndrome is a poorly recognised cause of post cholecystectomy pain. The novel interventional management pathway could be an effective solution in patients who fail to benefit from standard management.