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   Table of Contents - Current issue
Coverpage
May-August 2019
Volume 33 | Issue 2
Page Nos. 51-117

Online since Wednesday, August 7, 2019

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EDITORIAL  

ISSP coding system uniform nomenclature for interventional pain procedures p. 51
Pankaj N Surange
DOI:10.4103/ijpn.ijpn_50_19  
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REVIEW ARTICLES Top

Outline for setting up acute postoperative pain service for Indian Hospital p. 54
Rashid M Khan, Aziz Haris, Abdullah Al-Jadidi, Naresh Kaul
DOI:10.4103/ijpn.ijpn_36_19  
Majority of Indian hospitals still lack the provision of acute postoperative pain relief service. In other parts of the world, field of acute pain management strategy has witnessed a surge in its implementation. Today, acute pain has begun to be recognized not merely as a distressing symptom but also as a precursor of chronic, debilitating pain. This development warrants that we in India address this issue on an urgent basis through the use of analgesic/narcotic combination via parenteral/oral/rectal route as well as by performing regional blocks, to meet the interpatient variability and available facility. In this review article, we have provided the organization and function of acute pain service (APS) program that can be adapted to a wide spectrum of Indian hospitals. We have outlined the role of APS team including the use of easily available analgesic/narcotic drug combinations for various categories of Indian hospitals dealing with different grades of surgical conditions, including those hospitals that are not sufficient in resources and funding. This article has also tabulated possible regional block techniques with their indications for treating acute postoperative pain in combination with parenteral/oral/rectal analgesics/narcotics in the more developed Indian hospitals. Staffing and equipment requirements have also been outlined.
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Trigeminal autonomic cephalalgias: The impersonators p. 62
Agrah Jose, R Sesha Prasad, Anuradha Pai
DOI:10.4103/ijpn.ijpn_2_19  
Orofacial pain disorders are highly prevalent and debilitating conditions involving the head, face, and neck. Headache is the most common complaint reported to dental and medical practitioners, which manifests as a myriad of neuro-ophthalmologic symptoms, including orbital pain, disturbances of vision, aura, photophobia, lacrimation, conjunctival injection, ptosis, and other manifestations. The differential diagnosis is extensive and includes both primary and secondary headache disorders. The similarity in clinical presentation and diagnostic features is a challenge to the clinicians because of two facts: (a) the orofacial region is complex and (b) pain can arise from many sources. The term “trigeminal autonomic cephalalgias (TACs)” includes a group of headache disorders characterized by moderate-to-severe, short-lived head pain in the trigeminal distribution, with accompanying unilateral cranial parasympathetic autonomic features, such as lacrimation, rhinorrhea, conjunctival injection, eyelid edema, and ptosis. TACs include cluster headache (CH), paroxysmal hemicrania (PH), short-lasting unilateral neuralgiform headache attacks, and hemicrania continua. They are grouped on the basis of their shared clinical features of unilateral headache of varying durations and ipsilateral cranial autonomic symptoms. TACs are rare with the prevalence rate of <1%. The peculiarity of these conditions is their similar clinical presentation and overlapping features. A sound knowledge of TACs is essential for proper diagnosis. Moreover, multidisciplinary approaches for the management of these conditions are strongly recommended. Hence, the aim of this article is to provide an overview of trigeminal autonomic cephalalgias.
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ORIGINAL ARTICLES Top

A study to assess the improvement in physical function and spinal pain after a 3-month supervised rehabilitation program in patients with axial spondyloarthritis p. 67
Arupratan Ghosh, Pankaj Kumar Mandal
DOI:10.4103/ijpn.ijpn_64_18  
Context: Axial spondyloarthritis (Ax-spA) is a disease for which there is hardly any treatment ensuring permanent cure. Hence, rehabilitation is the mainstay of management for improving the quality of life and sustaining socioeconomic productivity. A randomized controlled trial was done to assess the improvement in physical function and reduction in spinal pain after a supervised rehabilitation program (SRP). Aims: This study aims to assess the effect on physical function and spinal pain in patients with Ax-spA after a 3-month SRP. Settings and Design: A concurrent parallel randomized controlled trial was done at the Department of Physical Medicine and Rehabilitation, R. G. Kar Medical College, Kolkata, during June 2014 to July 2015 after approval from the institutional ethics committee. Subjects and Methods: A total of 63 participants (53 male, 10 female) with Ax-spA, aged 18–45 years, were randomly allocated into two groups. Participants of intervention group had undergone SRP and control group were put on home exercise program for 3 months. Physical function was measured by Bath Ankylosing Spondylitis Functional Index (BASFI) and spinal pain was measured by numerical rating score (NRS) at baseline and after 3 months. Statistical Analysis Used: The data were collected and compiled in Microsoft Office Excel 7 and analyzed with SPSS version 20. Results: After 3 months, BASFI improved significantly in both groups, whereas intergroup analysis showed a significant improvement (P < 0.001) in the intervention group compared to the control group. Spinal pain measured with NRS improved significantly in both groups, whereas intergroup analysis showed a significant improvement (P < 0.001) in the intervention group. Conclusions: Physical function and spinal pain improved significantly after SRP in patients with Ax-spA.
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Targeting the therapeutic need in musculoskeletal inflammatory pain with thiocolchicoside and aceclofenac sustained-release combination therapy p. 71
Manish N Maladkar, Chitra M Tekchandani, Ashok S Yadav
DOI:10.4103/ijpn.ijpn_23_19  
Context: Musculoskeletal pain is usually associated with inflammation and muscular spasm which further contributes to the elevation of pain. Traditionally, nonsteroidal anti-inflammatory drugs (NSAIDs) are employed in the treatment of pain. Literature review reveals that the benefits were more significant in terms of overall symptom reduction, when the patients suffering from musculoskeletal pain were administered the combination of a NSAID & a muscle relaxant. Aims: The present study was undertaken with the aim to assess the efficacy and safety of fixed-dose sustained-release combination of aceclofenac and thiocolchicoside in patients with acute inflammatory conditions associated with muscle spasm. Settings and Design: A multicenter, prospective, open-label, noncomparative clinical study was carried out in 442 patients with clinical diagnosis of inflammation associated with spasm. Subjects and Methods: fixed-dose combination of aceclofenac (200 mg) and thiocolchicoside (8 mg)-sustained-release capsules was orally administered once daily for 2 weeks. Results: The treatment led to significant pain reduction from the baseline noted with visual analog score at the 1st week itself. After 2 weeks of treatment, the mean pain score declined by 90%, joint tenderness improved in 90% of the patients, and the mean joint mobility scores were near normal in most of the patients. Furthermore, at the end of the treatment, nearly all of the patients were symptom free. No serious adverse events were reported. Conclusions: The current study confirms that fixed-dose combination of aceclofenac and thiocolchicoside in sustained-release form is effective and well tolerated in the treatment of patients with acute musculoskeletal inflammatory conditions.
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Effects of 0.5% heavy bupivacaine at room versus body temperature on shivering and analgesia after spinal anesthesia in patients undergoing cesarean section p. 77
Khoula Mohammed Saif Al-Mandhari, Amal Ali Mubarak Al-Shukaili, Basman Younis, Shobha Lad, Rashid M Khan, Naresh Kaul
DOI:10.4103/ijpn.ijpn_42_19  
Background: Shivering is an undesirable, unpleasant experience after spinal anesthesia. Injecting cold bupivacaine has been incriminated as a contributory factor. Aims and Objective: In this prospective study we evaluated the efficacy of warming the heavy bupivacaine to body temperature for prevention of shivering and if it influences analgesic quality of spinal anesthesia. Materials and Methods: In this double blind, randomized controlled study, 100 patients aged 20-35 years of American Society of Anesthesiologist physical status I and II undergoing elective or emergency Caesarean sections were included and allocated to either Room temperature group (RT Group, n= 50), or Body temperature group (BT group, n = 50). A standard spinal anesthetic of 2ml of 0.5 % heavy bupivacaine plus 20 microgram of fentanyl was administered using 25G pencil point spinal needle in the sitting position. Besides the incidence and intensity of shivering and effect on intraoperative analgesia, effect on hemodynamics, nausea, vomiting, blood loss, pruritis and Apgar scores were recorded. Data was analyzed using SPSS (The Statistical Package for Social Sciences) version 22.0 software (International Business Machines Corporation, Armonk, New York, USA). P < 0.05 was considered significant. Results: The patients were comparable in terms of demographic variables. Shivering was present in 31 (62%) and 7 (14%) patients respectively in RT and BT Groups, which was statistically significant (P = 0.0001). Intensity of shivering ≥3 was observed in 15 (30%) patients of RT group and 5 (10%) patient in BT group. We did not note any difference in the analgesic status intraoperatively nor any difference in the duration of analgesia. Surprisingly, the incidence of pruritis was significantly reduced in the BT group as compared to RT group (P = 0.037). Conclusions: Warming the heavy bupivacaine to body temperature is effective in preventing shivering and reducing pruritis secondary to spinal anesthesia without affecting analgesia.
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Comparison between epidural ropivacaine and ropivacaine–clonidine combination for infraumbilical surgeries: A randomized clinical study p. 81
Neeraj Kumar, Omprakash Sanjeev, Abhyuday Kumar, Sashi Kant, Vinod Kumar Verma, Ajit Kumar Gupta
DOI:10.4103/ijpn.ijpn_28_19  
Introduction: Lower abdominal and lower limb surgeries may be performed under local, regional (spinal or epidural) or general anaesthesia, but neuraxial blockade is preferred mode of anaesthesia. Major advantage of epidural anaesthesia over spinal anaesthesia is the ability to titrate the extent and duration of anaesthesia. Aims and Objective: The primary outcome of the study was to measure the duration of sensory analgesia. The secondary outcomes were onset of sensory block, onset of motor block, highest level of sensory block, degree of motor block, duration of motor block, and quality of sensory blockage as measured by visual analog scale. Material and Methods: After getting institutional ethical clearance from our institute and proper written consent from each patient a total of 80 patients who underwent infraumbilical surgeries. A total of 80 patients who underwent infraumbilical surgeries were included randomly into two clinical study groups comprising 40 patients in each study group. Epidural anaesthesia was administered with 20ml of Ropivacaine 0.75% (GROUP-R) and 20 ml of epidural Ropivacaine 0.75% and Clonidine 75mcg combination (GROUP-RC). Statistical Analysis: Statistical comparison was made by comparison between groups by applying chi-square test to a contingency table for categorical data and two sample t–test and independent t-test for numerical data. Result: A total of 102 patients were assessed for eligibility, of which 16 patients did not meet the inclusion criteria and 6 patients were excluded during the study period. The groups was comparable with regard to demographic data and incidences of side effects except for the higher incidence of dry mouth in patients of RC group. Onset of analgesia was much shorter in RC group with prolonged duration of analgesia. The incidence of bradycardia and hypotension was more in RC group as compared to R group which was statistically significant. Conclusion: The addition of 75mcg clonidine to isobaric epidural ropivacaine results in longer, complete and effective analgesia with similar block properties and helped to reduce the effective dose of ropivacaine when compared with plain ropivacaine for infraumbilical surgery
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Comparison of 0.125% levobupivacaine with dexmedetomidine and 0.25% levobupivacaine in ultrasonography-guided pediatric caudal block: A prospective, randomized, double-blinded study p. 86
Farah Nasreen, Atif Khalid, Hassan Rashid
DOI:10.4103/ijpn.ijpn_38_19  
Background: Caudal anesthesia is a safe and reliable technique for infraumbilical surgeries in pediatric patients. Addition of dexmedetomidine to local anesthetic (LA) in caudal block prolongs the duration of block, but the effect on reducing the concentration of LA drug has not been extensively evaluated. This study was, therefore, designed to evaluate the efficacy of addition of dexmedetomidine to lower concentration of levobupivacaine required for ultrasonography (USG)-guided caudal block. Methods: A total number of 60 children with American Society of Anesthesiologists Grade I and II, aged 2–8 years from both sexes, and undergoing infraumbilical surgeries were recruited in a prospective, double-blinded, randomized controlled study over a duration of 1 year. The study children were allocated into groups A and B (n = 30 each) via computer-generated randomization. Group A children received caudal 0.25% levobupivacaine 0.75 ml/kg with 1 ml of normal saline and Group B children received 0.125% levobupivacaine 0.75 ml/kg with 1 μg/kg dexmedetomidine in 1 ml of normal saline after induction and the insertion of I-gel. Heart rates, blood pressure, and SpO2were monitored perioperatively. Postoperative hemodynamic monitoring; face, legs, activity, cry, and consolability (FLACC) pain score up to 24 h; time to first rescue analgesia; and emergence delirium using Watcha scale and Ramsay sedation score were recorded. Rescue analgesia was administered when FLACC pain score was >4. Any adverse events were noted and documented. Results: The study groups were comparable in terms of demographic characteristics and nature/duration of surgery. The mean FLACC pain scale in Group B was significantly lower compared to Group A. The mean duration of analgesia was statistically prolonged in Group B (P < 0.05) as compared to Group A (1299 ± 145 min in Group B vs. 348 ± 36 min in Group A). Emergence delirium as measured by Watcha scale was significantly lower in Group B (P < 0.05). Perioperative hemodynamic parameters were stable in the two groups, and no clinically significant adverse effects were noted. Conclusion: Addition of 1 μg/kg of dexmedetomidine decreases the effective concentration of levobupivacaine required for USG-guided caudal block, extends the duration of analgesia, and lowers the incidence of emergence delirium among pediatric patients undergoing infraumbilical surgery.
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Retrospective analysis of regional anesthesia techniques employed for postoperative pain management in pediatric patients undergoing pyeloplasty p. 94
Deepak Dwivedi, Sadhan Sawhney, Saurabh Sud, Puja Dudeja, Shankar Raman, Santosh Dey
DOI:10.4103/ijpn.ijpn_27_19  
Context: Pediatric pain management is always a challenge for the anesthesiologist as surgery and pain inflicted at a young age has a bearing on the response to pain in the future. Aims: The aim of the study was to compare the different regional anesthesia techniques adopted for the postoperative pain relief in children aged between 6 months and 6 years who underwent open pyeloplasty. Settings and Design: It was a retrospective study. Materials and Methods: Children were divided into three groups: caudal group (n = 18), epidural group (n = 23), and transversus abdominis plane (TAP) group (n = 32) based on the regional anesthesia technique used. The primary outcome measured was total duration of postoperative analgesia. The secondary outcomes measured were median Face, Legs, Activity, Cry, Consolability (FLACC) score, intraoperative and postoperative heart rate, and mean arterial pressure along with incidence of any complication. Statistical Analysis Used: One-way ANOVA and Kruskal–Wallis test were applied for comparison between the three groups. Results: Postoperative analgesia duration in minutes was highest in the epidural group (1117.3 ± 112.2), followed by TAP group (1070.0 ± 109.3) and caudal group (261.5 ± 18.2). Median FLACC pain scores achieved at 12 and 24 h were least in the epidural group, followed by the TAP and caudal groups. Conclusions: Epidural analgesia is best suited in terms of the duration as well as the quality of postoperative analgesia is concerned, but surgeon-assisted TAP block looks promising and a feasible option with comparable postoperative analgesia quality and duration.
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CASE SERIES Top

Role of pulsed radiofrequency neuromodulation adjacent to lumbar dorsal root ganglion in bone metastatic cancer pain p. 100
Bablesh Mahawar, Vivek Mahawar, Ravi Shanker Sharma
DOI:10.4103/ijpn.ijpn_10_19  
Metastatic bone pain is among the most commonly reported pain conditions in cancer patients. Conventional therapy for metastatic bone pain is multidisciplinary, for example, radiotherapy, systemic treatment, and supportive care, which sometimes does not give adequate pain relief. Pulsed radiofrequency (PRF) neuromodulation of dorsal root ganglion (DRG) is a minimally invasive and an effective alternative procedure in treating symptomatic bone metastases in regard to pain reduction, safety, and quality of life. Although cervical DRG PRF has some evidence in pain relief, there is paucity in the literature evaluating the efficacy of lumbar DRG PRF for metastatic bone pain.
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CASE REPORTS Top

Role of ultrasound guided continuos sciatic nerve blocks in a complicated case of vasopressor induced lower limb ischemic pain p. 103
Uma Pradeepa Lakkaraju, Ram Mohan Gurram
DOI:10.4103/ijpn.ijpn_68_18  
Acute limb ischemia (ALI) is defined as any sudden decrease in limb perfusion causing a potential threat to limb viability. We are presenting a case of vasopressor-induced ALI involving both the lower limbs in a patient with altered coagulation, thrombocytopenia, and severe cardiovascular dysfunction. It is challenging to provide pain relief to a very sick hemodynamically unstable patient. A continuous peripheral nerve block of the lower limb has been shown to provide multiple benefits. In this patient, we successfully placed ultrasound-guided bilateral sciatic nerve catheters for continuous pain relief up to 2 weeks, with no major complications during or after the procedure. This case highlights that continuous peripheral nerve catheters provide good analgesia in ALI and have a positive effect on microcirculation, hence to be more frequently used.
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Continuous erector spinae plane block in a patient with multiple comorbidities undergoing modified radical mastectomy p. 106
Rakesh Kumar, Rashmi Syal, Manoj Kamal, Ravi Shankar Sharma
DOI:10.4103/ijpn.ijpn_3_19  
Anesthesia in patients with multiple comorbidities is always challenging for anesthesiologists. Moderate-to-severe pain is common after modified radical mastectomy. Good perioperative analgesia in such surgeries enhances recovery, leads to early ambulation, prevents any cardiac event, and decreases chances of chronic pain.
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Pulsed radiofrequency lesioning at multiple trigger points around the scar for management of chronic persistent postsurgical neuropathic pain following total abdominal hysterectomy and laparotomy p. 109
Anand Kumar Chopra, Megha Bajaj, Ashok Kumar Saxena, Hazel Talwar, Nitika Yadav, Geetanjali T Chilkoti
DOI:10.4103/ijpn.ijpn_22_19  
Chronic persistent postsurgical pain (CPPP) is a common complication following surgery. If a pain persists for >3 months following surgery and cannot be explained by any other causes, then it is labeled as CPPP. The mechanism is not fully understood. A 35-year-old female presented with chronic persistent postsurgical neuropathic pain following total abdominal hysterectomy and gynecological laparotomy. Multimodal integrated approach for the management of pain was adopted. After having no relief with oral pregabalin therapy, the patient was then planned for pulsed radiofrequency (PRF) lesioning at multiple trigger points along the scar. The patient was followed up to 6 months after the second PRF procedure. After 2 months following the PRF procedure, the Numerical Rating Scale score improved from 9/10 to 2/10.
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LETTERS TO THE EDITOR Top

Comprehensive systematic pain assessment form: Patient's Visiting Pain Clinic p. 112
Neha Kathor, Azka Zuberi, Namrata Gupta, Ajit Kumar
DOI:10.4103/ijpn.ijpn_32_19  
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The use of smart phones to decrease analgesic requirements in children with chronic renal failure p. 117
Divya Jain, Komal Gandhi, Sumit Kumar, Deepesh Benjamin Kenwar
DOI:10.4103/ijpn.ijpn_43_19  
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