Background and Aims A young woman in great distress presented with a decade plus history of bilateral nociceptive and nociplastic orofacial pain, with a significant TMJ component. Her case was complicated further by PTSD and fibromyalgia. Conservative treatments including oral medications, physical therapy, oral splints and psychological interventions had been trialed, as well as botox injections and TMJ arthrocentesis. At this time, she was being managed with a combination of medications including high dose opioids. None of these treatments had given sustained pain relief or improved quality of life.

Methods We decided upon an interventional management plan combining somatic and sympathetic nerve blockade. Targeting the worst affected side first, we performed stellate ganglion and superficial cervical plexus blocks along with dedicated auriculotemporal, posterior auricular and occipital nerve blocks. After success on one side, we performed mirror image blocks on the opposite side after a three month interval.

Results Pain relief was almost immediate following the blocks and was sustained for a number of months, along with a reduction in anxiety and distress. The success of the blocks allowed us to successfully wean the opioids with patient consent, and facilitated better engagement with the wider bio-psycho-social treatment offered by the multidisciplinary team, which has ultimately resulted in a significant improvement in function and quality of life.

Conclusions While interventions are not always the answer in chronic pain, with careful patient selection and in skilled hands, they can be a very useful adjunct to the struggling patient, while avoiding the potential complications of long term medications.