2026-07-09 | Mesotherapy With Lidocaine and Ketamine in Complex Regional Pain Syndrome Type 1: A Randomized Double-Blind Trial.

Complex regional pain syndrome type 1 (CRPS1) is a disabling pain syndrome whose treatment remains challenging. Mesotherapy is a therapeutic method involving the injection of low doses of active substances through the skin. No studies assessed mesotherapy in CRPS1 patients. The aim of this study was to evaluate the efficacy on pain relief of ketamine and lidocaine mixtures versus lidocaine alone administered by mesotherapy. This three-arm, randomized, double-blind trial compared mesotherapy with lidocaine 20 mg alone or mixed with ketamine at a dose of 20 mg or 40 mg, in addition to standard treatment. The primary outcome was the difference in pain between inclusion and D56 after four mesotherapy sessions, assessed by a visual analog scale (VAS). Thirty-one patients were randomized to receive lidocaine 20 mg (n = 10), lidocaine 20 mg + ketamine 20 mg (n = 11), or lidocaine 20 mg + ketamine 40 mg (n = 10). The mean difference in VAS score between inclusion and D56 was -25.60 (95% CI: -42.81, -8.39) in the lidocaine 20 mg group, -10.13 (95% CI: -26.24, 5.99) in the lidocaine 20 mg + ketamine 20 mg group, and -19.06 (95% CI: -36.11, -2.02) in the lidocaine 20 mg + ketamine 40 mg group. There was no statistically significant difference in change of VAS score between the 3 groups (p = 0.36). No infectious or severe adverse events occurred. This study did not demonstrate the superiority of mesotherapy with ketamine and lidocaine mixtures compared to lidocaine alone in relieving pain for CRPS1 patients. Lidocaine alone or mixed with ketamine can be administered safely with a rigorous mesotherapy procedure. The study was registered with ClinicalTrials.gov, number NCT04650074, and EudraCT, number 2020-005557-24.

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2026-06-26 | Pectoralis Minor Tenotomy with Occasional Secondary Neurolysis Significantly Reduces Self-Reported Pain and Headaches Across Heterogenous Chronic Pain Disorders of the Upper Limb.

Background and Objectives: Many patients suffer from chronic pain of the shoulder, neck, upper back, and/or arm. They may be diagnosed with fibromyalgia, complex regional pain syndrome, myofascial pain, thoracic outlet, subacromial pain, cervical radiculopathy, cervicogenic headaches, post-mastectomy pain, and/or occupational shoulder disorder. The pectoralis minor (PM) is the only muscle of the scapula controlled by the lower trunk of the brachial plexus. In the Human Disharmony Loop (HDL), this neurologic asymmetry produces persistent protraction of the scapula. Protraction deforms the scapula's connections, generating headaches and neck stiffness, upper back tightness, shoulder weakness, and hand numbness. We hypothesize patients with the above who meet HDL diagnostic criteria will benefit from PM tenotomy with brachial plexus neurolysis (PM+ICN). Materials and Methods: Patients diagnosed with the above disorders who also met HDL criteria of medial coracoid tenderness and scapula protraction on exam underwent PM+ICN, with secondary neurolysis after 3 months if needed. Clinical neuropathy was diagnosed via the scratch-collapse test. Outcomes included self-reported Visual Analogue Score pain scores, active shoulder abduction range of motion (ROM), prevalence of occipital headaches. Results: N = 318 patients were included. Average age was 51; 68.0% were female. Following treatment, average pain decreased from 7.3/10 to 2.1/10 (p < 0.001), average shoulder ROM increased from 96 to 170 degrees (p < 0.001), and occipital headaches decreased from 76.7% to 1.6% (p < 0.001). Scapular protraction normalized from 98.8% static to 92.5% none (p < 0.001). Overall, 17% required subsequent neurolysis, chiefly of the axillary, radial, and ulnar nerves. The pain reductions were statistically indistinguishable across all diagnoses (p = 0.709, I2 = 0.02%). Average follow-up was 22 months. Conclusions: PM+ICN significantly reduced self-reported pain and headaches in select intractable patients. The PM pathologizing the scapula may constitute a shared anatomic mechanism that contributes to chronic pain across heterogenous disorders of the upper limb.

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2026-06-24 | Too Complex to Treat? Equity in Access to Inpatient Pediatric Pain Rehabilitation.

An adolescent with complex regional pain syndrome, functional neurological symptoms, and significant psychosocial complexity was hospitalized for severe decline. Despite meaningful progress through a structured, multidisciplinary inpatient approach, she was repeatedly denied admission to pediatric inpatient pain rehabilitation programs across the United States-often based on process requirements such as caregiver engagement, outpatient intake completion, and medical or psychiatric complexity. These denials delayed access to intensive, coordinated care previously shown to benefit her. This case illustrates how the intersection of medical and psychosocial complexity can operate as an unspoken exclusion criterion in pediatric pain rehabilitation, disproportionately affecting vulnerable youth. Policies and eligibility checklists intended to optimize outcomes may inadvertently reinforce inequities when applied without attention to context. We argue that readiness should not be defined solely by patient or family characteristics but by the health system's capacity to respond to complexity with flexibility and equity. We propose system-level strategies to promote equitable access: requiring clinician-to-clinician dialogue before denials are issued, creating formal appeal pathways to reconsider complex cases, clarifying and publishing admission criteria, and designing inclusive rehabilitation tracks. Rather than asking whether patients are ready for our programs, we must ask whether our programs are prepared to meet our patients.

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