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Lack of efficacy during treatment of groin pain: case report A 61-year-old woman exhibited lack of efficacy during treatment with gabapentin, methocarbamol, duloxetine, tizanidine, hydrocodone and fentanyl for groin pain [routes not stated]. The woman, who had depression and anxiety, sustained a fall resulting in a non-displaced, left pubic ramus fracture. Orthopedic surgery recommended conservative management comprising oral unspecified medications, physical therapy and rest. She was referred to Pain Management Service due to progressive refractory right groin pain. Evaluation revealed pain in the right groin that radiated along the medial aspect of the thigh above the knee. She described pain as shooting, sharp and electric and was associated with muscle spasms in the medial thigh. The pain exacerbated by prolonged sitting or walking and was partially relieved by lying in the supine position. Physical examination showed severe tenderness over the right upper medial thigh with associated allodynia and hyperalgesia. An ultrasound guided obturator nerve block provided 100% pain relief for 24 hours. She was started on gabapentin 600mg three times a day, methocarbamol 500mg two times a day as needed, duloxetine 60 mg/day, tizanidine 4mg at bedtime and hydrocodone 5mg three times a day for pain management. However, these medications did not provide pain relief (lack of efficacy). The pain affected her activities of daily living. Therefore, she stopped working. Psychotherapy including cognitive behavioral therapy was started. Visual Analogue Scale (VAS) pain scores were continuously between 8/10–10/10 along with insomnia secondary to pain. She required a rolling walker. Two years after the initial fracture, a tonic, dual-lead spinal cord stimulator trial was performed with resulted in pain reduction from 8/10 to 3/10. A permanent device was implanted shortly thereafter, which resulted in pain score of 2/10 or 70% relief at the first post-operative clinic evaluation. The woman reported improvements in sleep and function. Eight months later, the pain started to increase in intensity and two months later she reported pain scores of 9/10. The painful area remained covered by paresthesia. Deactivation of the spinal cord stimulator lead to pain scores of 10+/10. Cryoablation of the obturator nerve failed to provide relief. Her medication regimen was intensified that comprised of gabapentin 1200mg three times a day, tizanidine 4mg three times a day, duloxetine 60mg/day and fentanyl patch 50µg. Subsequently, burst stimulation was given to the pre-existing implanted battery. However, these therapies failed to provide relief in pain or functional improvement (lack of efficacy). Repeated attempts of physical therapy exacerbated her pain and her mobility reduced further. Her Pain/Disability Index (PDI) was at 49. Due to focal, but refractory nature of the pain, she was given dorsal root ganglion (DRG) stimulation (five years following the initial fracture), which led to 90% pain relief. Then, the permanent device was implanted