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   Table of Contents - Current issue
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May-August 2018
Volume 32 | Issue 2
Page Nos. 57-122

Online since Friday, August 31, 2018

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EDITORIAL  

At the opioid crossroad for chronic non cancer pain p. 57
Sweta Salgaonkar
DOI:10.4103/ijpn.ijpn_34_18  
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REVIEW ARTICLE Top

Rami communicans fibers in discogenic low back pain: The controversies p. 60
Gautam Das, Chinmoy Roy
DOI:10.4103/ijpn.ijpn_48_18  
Intervertebral disc innervation and mechanism of discogenic low back pain is a subject of debate. There is no controversy regarding innervation of anterior and lateral annuli. Nociception from this part is carried by sympathetic pathway. Sinuvertebral nerves innervate posterior annulus, but there are controversies about nociceptive pathway from posterior annulus. It can be mixed somatic and sympathetic or can be completely sympathetic pathway through rami communicans fibers. Local anesthetic block of rami communicans fibers with or without steroid gives very good results in discogenic low back pain. But radio frequency ablation of rami communicans fibers do not give consistent result. This article has tried to find the literature about disc innervation, role of rami communicans nerves in transmission of discogenic back pain, and role of rami communicans nerve block in management of discogenic back pain.
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ORIGINAL ARTICLES Top

Randomized study to compare the effect of pregabalin with fixed-drug combination of pregabalin and methylcobalamin in the patients of postherpetic neuralgia p. 63
Asmita Jha, Karjigi Siddalingappa, Kallappa Herakal, Karan Malhotra
DOI:10.4103/ijpn.ijpn_10_18  
Aim: To know the effect of adding methylcobalamin to pregabalin in patients of postherpetic neuralgia (PHN) and also to compare the side effects of pregabalin alone and fixed-drug combination (FDC) of pregabalin and methylcobalamin. Materials and Methods: This was a multicenter randomized 10-month prospective study. A total of 90 patients with PHN (age and sex matched) were included. Baseline pain intensity was measured on a 10-point visual analog scale (VAS) score. Patients were randomized into two groups. Group A patients received pregabalin (75 mg) 12th hourly, whereas Group B patients were given FDC of pregabalin (75 mg) along with methylcobalamin (750 μg) 12th hourly. Thereafter, patients were assessed for the pain score at 4, 8, and 12 weeks after initiation of the treatment. The frequency and severity of adverse events were assessed. Results: Before starting medication, the average VAS score of Group A and Group B was 6.86 and 6.97, respectively. Post-medication average VAS score of Group A and Group B was found out to be 2.95 and 3.11, respectively. A significant reduction in VAS scores of both the groups was observed when compared to their respective baseline VAS scores (P < 0.001). But post-medication VAS scores of both the groups were not statistically significant (P = 0.58). Side effects such as dizziness and somnolence were observed in both the groups. This was also found out to be not statistically significant when side effects of both the groups were compared (P = 0.52). Conclusion: The result of our study shows minimal statistical difference between pregabalin alone and the FDC of pregabalin with methylcobalamin for the treatment of PHN. Patients showed improvement in pain with minimal side effects such as somnolence and dizziness in both the groups.
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Ultrasonography-guided articular branch of femoral nerve and anterior obturator nerve block for perioperative pain in hip surgery p. 68
Lisa Prakash, Adnanali Sarkar, Geetanjali Akhade
DOI:10.4103/ijpn.ijpn_44_18  
Background: We present a novel block of the articular branch of the femoral nerve (ABFN) and anterior obturator (AO) nerve for perioperative analgesia during various hip surgeries. Materials and Methods: In this prospective audit, 30 patients underwent hip surgeries such as hemiarthroplasty, percutaneous femoral nailing, and dynamic hip screwing performed by the same surgeon under subarachnoid block (SAB) that was performed by the same anesthesiologist using 10–15 mg of bupivacaine 0.5% (heavy). Pain management after hip surgery used to be provided by using epidural analgesia or intravenous (IV) analgesia. During this study, we performed ultrasonography (USG)-guided block to ABFN and AO with injection ropivacaine (0.2%) 35 mL (20 + 15 mL) with 8 mg dexamethasone just before spinal anesthesia in operation theatre. Pain scores were compared using Numeric Pain Rating Scale at pre-procedure, followed by 0, 4, 8, and 12 h after the block and the requirement of first dose of IV analgesics. Results: Pain scores were significantly lower in these patients in the first 12 h of the surgery along with less requirement of IV analgesics. The onset of blocks start within 3–5 min, and patients were more comfortable in sitting position while performing SAB. Discussion: Blocking ABFN and AO nerve provides superior analgesia during perioperative period in hip surgeries and decreases the requirements of IV analgesics and provides effective analgesia in patients while performing SAB in sitting position.
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2–4 mm diameter hypo/depigmented dermal spots: ? Objective sign of somatic origin pain p. 72
Kritika Doshi
DOI:10.4103/ijpn.ijpn_69_17  
It is known that somatic nerves are affected by pathological changes occurring in the corresponding intervertebral discs. However, there is as yet no serological test or biomarker to diagnose disc pathology. A recurring observation in patients reporting to the Pain Clinic was the presence of discrete, 2-4 mm in diameter, hypo/de-pigmented spots on the skin. Is there a probable explanation to the occurrence and location of these hypo/depigmented spots? When co-related to the MRI of the spine, these spots (KD Spots) were frequently seen to lie in the dermatome corresponding to the degenerated intervertebral disc. Based on the experimental and clinical reports in scientific literature and the observation of the author a hypothesis to explain the presence of the hypo/depigmented spots in relation to degenerated intervertebral discs is proposed.
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Assessment and correlation of perceived harmfulness with psychological variables in patients with chronic shoulder pain p. 76
Ajit S Dabholkar, Ishita K Shah, Tejashree Ajit Dabholkar
DOI:10.4103/ijpn.ijpn_5_18  
Background: Chronic pain can provoke emotional reactions, such as fear or even terror, depending on what we believe about the pain signals. Chronic pain can be difficult to treat, affecting the patients psychologically causing fear avoidance in them. Patients with chronic condition often suffer catastrophizing pain and perceived harmfulness. Thus, assessing perceived harmfulness in chronic shoulder pain is utmost important. Methods: Patients (N = 48) with chronic shoulder pain (duration more than 3 months) were enrolled for the study. They were administered Photograph series of daily activities-upper extremity (PHODA-UE-110), Tampa scale of kinesiophobia (TSK-11), Pain catastrophizing scale (PCS-4), Shoulder pain and disability index (SPADI). Their responses were statistically analyzed using Pearson's co-efficient. Results: The mean scores of the outcome studied were, PHODA-UE scores were 42 ± 8.43, 95% CI [40.41, 45.32], TSK scores were 28.77 ± 3.70, 95% CI [27.69, 29.84], PCS scores were 8.39 ± 2.54, 95% CI [7.65, 9.13], SPADI (Pain) scores were 81 ± 9.5, 95% CI [78.22, 13.32] and SPADI (Disability) scores were 79 ± 13.32, 95% CI [75.12, 82.87]. Following correlations were found to be significant: PHODA-UE with TSK (r = −0.32, p = 0.02, 95% CI [−0.56, −0.04]), PHODA-UE with PCS (r = −0.49, p = <0.0003, 95% CI [−0.68, 0.24]), TSK with SPADI (Disability) (r = −0.41, p = 0.003, 95% CI [−0.62, 0.15]) and TSK with PCS (r = +0.40, p = 0.004, 95% CI [0.13, 0.61]). Conclusions: The present study reveals that the patients evaluated demonstrated low perceived harmfulness in spite of the chronic pain. Correlations between perceived harmfulness and psychological variables showed weak correlations.
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Prevalence of chronic pain based on primary health center data from a city in central India p. 81
Archana N Deshpande
DOI:10.4103/ijpn.ijpn_32_18  
Aims: To determine the prevalence of chronic pain based on primary health centre data from a city in central India. Materials and Methods: A cross sectional study was carried out in 1674 patients who attended a Primary Health Centre(PHC) over a period of two months. Information regarding name, age, gender, occupation, chief complaints and its duration was obtained. Prevalence of chronic pain (pain more than 3 months) was analyzed with respect to age, gender and site of pain. Results: Out of 1674 patients, there were 496 patients with pain resulting into a prevalence of 29.63%. The prevalence of chronic pain amongst these patients was 19.23%. It was predominant in females and age group of 21-60 years. Prevalence of chronic back pain was highest ((24.84%), followed by body pain (22.98%), Knee (16.77%), Chest (13.97%), Upper limb (10.87%). Other pains had prevalence of less than 10%. Conclusion: Almost one third of the patients visiting PHC have pain as the chief complaint. Majority of them had chronic pains. Females report pain much more commonly than males. Surprisingly young and middle aged report chronic pain more than elderly. Further studies about the type of pain and its treatment are required to gain more insight into this health problem.
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Efficacy of dexmedetomidine as an adjuvant to ropivacaine in femoral nerve block for acute pain relief in patients with fracture of femoral shaft and neck p. 86
Hemant Kumar, Archana Tripathi, Mukesh Somvanshi
DOI:10.4103/ijpn.ijpn_15_18  
Background: The patients admitted to the emergency department with the fracture of femoral shaft and neck have severe pain, and these patients require adequate analgesia to allow radiological, orthopedic, and other procedures to be performed. Femoral nerve block (FNB) has proved to be effective in providing satisfactory analgesia. Dexmedetomidine has analgesic and sedative property when used as an adjuvant in regional anesthesia. The aim of this study was to evaluate the efficacy of dexmedetomidine added to ropivacaine in FNB with regard to onset, duration, efficacy of analgesia, and patient acceptance. Materials and Methods: Sixty patients of American Society of Anesthesiologists grade I and II of either sex, aged 18–60 years, who presented with the fracture of femoral shaft and neck in the emergency department were randomly divided into two groups of 30 patients each: group D (n = 30): patients were administered 15 mL ropivacaine (0.5%) plus dexmedetomidine 1 μg/kg body weight (total volume, 16 mL) and group R (n = 30): patients were administered 15 mL ropivacaine (0.5%) plus 1 mL saline. Results: The onset of analgesia was much earlier in group D (3.77 ± 0.84 min) than that in group R (4.6 ± 1.1 min). The mean duration of analgesia was prolonged in group D (744.33 ± 179.6 min) than that in group R (263 ± 67 min). The fall in visual analog scale score was significantly higher in group D in comparison to group R. The patient acceptance after 24 h of the procedure was better in group D. Conclusion: We concluded that the addition of dexmedetomidine to ropivacaine in FNB provides early onset of analgesia, prolongs the duration of analgesia, improves the quality of analgesia, and has better patient acceptance.
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Comparison of intrathecal morphine and fentanyl in addition to ropivacaine for perioperative analgesia in lower segment caesarean section p. 91
Anupama Gupta, Rama Chatterji, Harphool Choudhary, Chandra S Chatterji
DOI:10.4103/ijpn.ijpn_14_18  
Aim: To compare the analgesic efficacy of intrathecal morphine and fentanyl as an adjuvant to isobaric ropivacaine in patients undergoing lower segment caesarean section under spinal anesthesia. Materials and Methods: A total of 120 parturients aged between 20 and 35 years of age, belonging to American Society of Anaesthesiologist (ASA) physical status I and II, were randomized into two groups: Group M received 15 mg of 0.75% isobaric ropivacaine (2 mL) and 100 μg of morphine (1 mL) intrathecally; and Group F received 15 mg of 0.75% isobaric ropivacaine (2 mL) and 25 μg of fentanyl (0.5 mL) and 0.5 mL of normal saline intrathecally. The primary outcome was the duration of postoperative analgesia. Block characteristics, hemodynamic variables, demand for rescue analgesia, and adverse effects were also assessed. Results: The demographic profiles and block characteristics were comparable in all groups. The mean duration of analgesia in Group M and Group F was 996.03 ± 25.3 and 203.88 ± 25.20 min, respectively; the difference between the groups was highly significant (P < 0.0001). Lesser visual analog scale pain scores were observed in Group M after the fourth postoperative hour and continued till 24 h (P < 0.05 at time interval of 4, 6, 8, 12, and 24 h). Conclusion: The addition of intrathecal morphine to isobaric ropivacaine resulted in a longer duration of postoperative analgesia as compared to intrathecal fentanyl in parturients undergoing caesarean section under spinal anesthesia.
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Comparative efficacy and safety of intravenous tramadol and nalbuphine for pain relief in postoperative patients p. 96
K Sai Durga Krishna Kiran, Varsha Vyas, Surekha Patil
DOI:10.4103/ijpn.ijpn_40_18  
Aim: To compare the efficacy and safety of single-dose intravenous nalbuphine versus intravenous tramadol for postoperative analgesia. Materials and Methods: In this prospective randomized study, adults with the American Society of Anesthesiologists physical status class I and II undergoing elective surgeries performed under general anesthesia, resulting in mild-to-moderate pain (n = 60), received either intravenous nalbuphine (10 mg) or tramadol (100 mg). Visual analog scale scores for pain, sedation, and nausea and vomiting were monitored for 4 h and compared between the two groups. Statistical Analysis: The mean scores within the groups were analyzed by paired t-test, whereas between the groups by unpaired t-test. The median scores were analyzed by using Mann–Whitney U test. P value <0.05 was considered statistically significant. Results: Reduction in pain after drug administration was statistically significant at all-time points as compared to before administration in both groups (P < 0.5). Pain reduction after 5 min (P = 0.01) and 30 min (P = 0.03) was significantly better with tramadol, whereas after 4 h, it was better with nalbuphine (P < 0.05). Incidence of nausea and vomiting in tramadol and nalbuphine groups was 23.3% and 40%, respectively. No statistically significant difference was observed in sedation, nausea, and vomiting scores between two groups at any time point (P > 0.05). Conclusion: Intravenous nalbuphine and tramadol both provided effective pain relief in patients with postoperative pain. Tramadol resulted in early pain relief but higher incidence of nausea and vomiting.
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Sublingual buprenorphine versus intravenous morphine as a premedicant and postoperative analgesic in laparoscopic appendectomy under general anesthesia—A randomized control trial p. 102
Bhavani Vaidiyanathan, Sangeeta Dhanger, I Joseph Raajesh
DOI:10.4103/ijpn.ijpn_13_18  
Background: Minimally invasive surgery aims to minimize trauma, cause rapid mobilization, and thus achieve a satisfactory therapeutic result. But the challenging fact with the laparoscopic surgery is its hemodynamic changes because of pneumoperitoneum and the complex visceral pain in the postoperative period. Aim: To find a safe, reliable, and highly effective drug as a premedicant in laparoscopic appendectomies under general anesthesia. Materials and Methods: A total of 110 patients undergoing laparoscopic appendectomies were randomized into two groups: group M (morphine) and group B (buprenorphine) with 55 patients in each group. Group B patients received 0.4 μg of buprenorphine tablet sublingually 1 h before surgery and group M patients received 0.1 mg/kg of intravenous morphine 10 min before anesthesia induction. Intraoperative hemodynamics, postoperative pain score, rescue analgesic requirement, and complications were recorded. Results: Intraoperative vitals that is heart rate and mean arterial pressure were significantly stable in group B compared to group M. Only 11 % patients in group B required dexmedetomidine infusion compared to 37% in group M, to control intraoperative hypertension. Visual analog scale (VAS) values in group B at 2nd (1.30 ± 0.46), 4th (1.31 ± 0.54), and 6th hour (1.33 ± 0.63) were significantly less than group M at 2nd (4.56 ± 0.65), 4th (5.68 ± 0.72), and 6th h (4.45 ± 1.15). Duration of analgesia in postoperative period in group B (260.0 ± 28.52 min) was significantly longer than group M (124.10 ± 20.832 min). Conclusion: Sublingual buprenorphine premedication is an alternative to intravenous injection of morphine with perioperative hemodynamic stability and better postoperative analgesia.
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CASE REPORTS Top

Avascular necrosis of femur treated with combination therapy of pulsed radio frequency of articular branches of femoral and obturator nerve with autologous intra-articular platelet-rich plasma therapy: A case report p. 108
Kailash Kothari, Khushali Tilvawala, Amruta Tilwe
DOI:10.4103/ijpn.ijpn_52_18  
We report a case of a 53-year-old man with early stage (stage II) avascular necrosis (AVN) of the femoral head treated with pulsed radio frequency (pRF) of articular branches of femoral and obturator nerves with autologous platelet-rich plasma (PRP) intra-articular injection. Autologous PRP was injected into the diseased hip under fluoroscopy guidance. The patient was followed up at 1, 4, and 12 weeks after treatment, together with visual analog scale (VAS) Walking Index, Harris Hip Score, and Range of Motion (ROM) assessments. The patient's severe hip pain considerably improved during subsequent follow-up at 1, 4, and 12 weeks after treatment, with significant improvement in VAS pain scores, Harris Hip Score, and ROM. This case represents the first evidence of complete resolution of symptoms of stage II AVN of the hip, following a combination treatment with pRF with PRP having a synergistic beneficial effect.
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Radio-frequency ablation of trigeminal ganglion for refractory pain of bilateral trigeminal neuralgia in a patient with multiple sclerosis p. 113
Preeti P Doshi, Namita H Parikh
DOI:10.4103/ijpn.ijpn_42_18  
Trigeminal neuralgia (TN) is one of the most excruciating variety of craniofacial neuralgias with 12% prevalence in general population. It can be either primary (idiopathic, 90% cases) or secondary (due to pathology such as tumor, multiple sclerosis [MS], and arteriovenous malformation, 10% of cases). TN has a 20 times higher risk of prevalence in patients with MS with an average incidence of 2%. Bilateral TN is significantly more common in patients with MS (18%) when compared to the normal population (5%). Pharmacotherapy is the first line and mainstay of management, but a small percentage of patients continue to have unremitting pain requiring other management modalities such as minimally invasive percutaneous techniques, microvascular decompression, or stereotactic radiosurgery. There is, however, no consensus at present regarding its selection for an individual patient. This case report highlights successful application of radio-frequency ablation in a patient with MS who had bilateral presentation with different timings.
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Percutaneous endoscopic interlaminar lumbar discectomy for high-grade inferiorly migrated L5-S1 disc: A case report with technical review p. 116
Manish Raj, Hyeun S Kim, Kailash Kothari, Anurag Agarwal, Santosh Tripathi, Shobhit Bharadwaj
DOI:10.4103/ijpn.ijpn_25_18  
L5-S1 disc has always been a difficult disc to target by rigid endoscope because of anatomical limitations. In this study, we have described the technique to overcome difficulty faced during endoscopic disc decompression of high-grade inferior migrated disc at L5-S1. We performed percutaneous endoscopic inter-laminar lumbar discectomy (PEILD) for removal of high grade inferiorly migrated disc and preserved the functional structures. After institutional review board approval, details of the patient with high-grade inferior migration at L5-S1 disc were reviewed. The patient was operated by a single specialist with use of the percutaneous endoscopic inter-laminar technique for high-grade inferior migrated extruded disc. Description of our technique & result is the focus of this study. The average VAS score was reduced from 9 pre-operatively to 3 post-operatively & to 1-2 within 2 weeks. Post-operative plantar flexion of foot improved from 2 to 4 immediately and up to 5 within 2 weeks. Ankle jerk reflex improved from 1+ to 2+. The pain severity score on BPI reduced from 9 to 3 postoperatively. Post-operative MRI showed that the high grade inferiorly ruptured disc had been successfully removed. We obtained excellent results in treating inferior extruded disc at L5-S1 using endoscopic inter-laminar approach. Inter-laminar endoscopic discectomy can be used as a safe yet minimally invasive technique for the treatment of lumbar radiculopathy in the setting of a high grade inferior migrated lumbar disc herniation.
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