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   Table of Contents - Current issue
Coverpage
September-December 2019
Volume 33 | Issue 3
Page Nos. 119-175

Online since Thursday, December 5, 2019

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EDITORIAL  

Pain management in neurocritical care: Challenges and the road ahead Highly accessed article p. 119
Obaid Ahmad Siddiqui
DOI:10.4103/ijpn.ijpn_89_19  
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REVIEW ARTICLES Top

Persistent postarthroplasty knee pain p. 121
Rajesh Gupta
DOI:10.4103/ijpn.ijpn_56_19  
Knee arthroplasty is done to relieve pain. The procedure itself can cause long lasting pain which can significantly decrease the quality of life and mobility. The factors leading to pe rsistent pain relate to patient and surgery and the management of pain before and after the surgery. The management of persistent arthroplasty pain is multidisciplinary and involves conservative and interventional pain medicine.
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Platelet-Rich Plasma for Degenerative Knee Joints: What is the Evidence? p. 126
Kanchan Sharma, Gautam Das, B Sarvesh, Amit Agarwal
DOI:10.4103/ijpn.ijpn_57_19  
Platelet-rich plasma (PRP) has been gaining popularity for degenerative joints because of its success and ease of performing procedure; however, there is a lack of standardized protocols for PRP preparation and clinical applications. Various studies have reported inconsistency and variations in their results. Evidence are inconclusive for its usage in knee osteoarthritis. We conducted a search in the English language literature using keywords such as “Platelet-rich plasma,” “knee joint,” “osteoarthritis,” “techniques,” “growth factors,” or “complications” in PubMed, Embase, and Google Scholar databases. Obtained articles were scrutinized and relevant content was included. This article has reviewed various studies regarding the definition, preparation, concentrates, and clinical application of PRP with respect to degenerative knee joint.
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ORIGINAL ARTICLES Top

Risk factors analysis for development of chronic postsurgical pain after modified radical mastectomy: A single-centered, prospective, observational study p. 131
Vidya Bhagat, Sweta Salgaonkar, Priti Devalkar, Jayshree Gite
DOI:10.4103/ijpn.ijpn_46_19  
Background: The “chronic post-surgical pain” (CPSP) is defined as pain of at least 2 months duration which has developed after a surgical procedure when other causes such as disease recurrence or preexisting pain syndromes are ruled out. The incidence of CPSP is found maximum after amputation surgeries (50%–85%), followed by thoracotomy (30%–50%) and mastectomy. The aim of our study is to analyze the risk factors such as preoperative pain, anxiety, and specific surgical techniques for development of CPSP after modified radical mastectomy (MRM). Materials and Methods: A total of thirty patients undergoing MRM satisfying inclusion criteria were enrolled out, of which one patient died during the study period of 1 year. Preoperative pain evaluation was done with Visual Analog Scale, and for measuring preoperative anxiety, Hamilton Anxiety Rating Scale was used. Medical and surgical records were studied for evaluation of some postoperative parameters. Appropriate statistical tests were used to evaluate the relationship of different risk factors for development of CPSP. Results: Incidence proportion of CPSP in our study was approximately 24%. All the risk factors we analyzed, i.e. preoperative pain and anxiety, surgical techniques like preservation of intercostobrachialis nerve, type of surgical incision, and duration of surgery were found to be statistically insignificant for development of CPSP. Conclusion: In conclusion, one should be very cautious to identify women who are at risk of developing CPSP or who have already developed CPSP. Establishing a prediction model based on known risk factors to identify susceptible patients and applying protective measures are important steps toward preventive, personalized health care.
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Percutaneous balloon compression of Gasserian ganglion for idiopathic trigeminal neuralgia p. 136
Shivani Rastogi, Anurag Agarwal, Manjari Bansal, Hitesh Patel, Deepak Malviya, Arvind Singh
DOI:10.4103/ijpn.ijpn_55_19  
Objective: The aim of this study was to evaluate the outcome and complication in patients with idiopathic trigeminal neuralgia (TN) posted for percutaneous balloon compression (PBC). Materials and Methods: The study included twenty patients of idiopathic TN presented in the outpatient department of pain clinic posted for PBC from the years 2016 to 2018. All patients were followed up for 6 months after the balloon compression of Gasserian ganglion. Out of the twenty patients, 40% were female and 60% were male. The mean age was 55.4 years (range: 37–70 years). These patients were on antineuropathic (carbamazepine, baclofen, and gabapentin) drugs with inadequate pain relief and 13 patients also had undergone radiofrequency ablation. PBC of Gasserian ganglion was planned by the technique described by Mullan and Lichtor in all patients. Visual Analog Score (VAS) and Barrow Neurological Intensity (BNI) score were compared pre and post procedure. Intraoperative and postoperative complications and side effects were analyzed retrospectively. Results: Eighteen out of twenty patients (90%) had excellent results with improvement in the VAS and BNI scores, which was statistically significant. The difference between the mean change in VAS and BNI scores for single nerve and multiple nerve roots was not statistically significant. Nearly 85% (17) of the patients had initial facial numbness, which improved in about 3 months. Only 10% of the patients had residual facial numbness, which was mild in nature and not bothersome to the patients. Masseter muscle weakness was present in seven (35%) patients. No patient reported corneal anesthesia or any other complications. Intraoperatively, four patients (20%) experienced moderate-to-severe bradycardia during entry to the foramen ovale and on inflation of the Fogarty balloon, which responded to injection atropine 0.6 mg intravenously stat. Conclusion: Hereby, we state that PBC is an effective and safe method with marked improvement in pain scores and improvement in quality of life of patients of idiopathic TN.
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Comparison of analgesic efficacy of dexamethasone versus tramadol as adjuvant to ropivacaine for oblique subcostal transversus abdominis plane block in open cholecystectomy p. 141
Shashi Kiran, Renu Bala, Kuldeep Kumar
DOI:10.4103/ijpn.ijpn_62_19  
Background: “Oblique subcostal” transversus abdominis plane (TAP) block is a combination of rectus abdominis and TAP block which is currently used in a wide variety of abdominal procedures. Dexamethasone and tramadol are both used as adjuvants in several blocks for improving efficacy and prolonging analgesia. The present study was intended to compare both these drugs along with ropivacaine in ultrasound-guided subcostal TAP block following open cholecystectomy. Materials and Methods: The present prospective, randomized, and double-blind study was conducted in 60 adult patients of either sex undergoing open cholecystectomy. The patients were randomized into two groups; Group D (n = 30) and Group T (n = 30). Former received 18 ml of 0.75% ropivacaine with 2 ml (8 mg) of dexamethasone whereas latter received 18 ml of 0.75% ropivacaine with 2 ml (25 mg/ml) of tramadol through right-sided ultrasound-guided oblique subcostal TAP block after the induction of general anesthesia following standard protocol. Postoperative pain at rest and knee flexion as per visual analog scale (VAS) score, time for first and second rescue analgesia, total tramadol consumption in 24 h, sedation and nausea score, and quality of healing at discharge were noted. Results: Requirement for first and second rescue analgesia was similar in two groups but overall 24 h tramadol consumption was less in Group D. VAS score was similar in two groups except at 4 and 24 h. None of the patients were sedated, but nausea score was less in Group D. The quality of wound healing was good in both groups. Conclusion: The addition of 8 mg dexamethasone or 50 mg tramadol as adjuvants to ropivacaine is effective and safe drugs to administer in TAP block for postoperative analgesia following open cholecystectomy.
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Pain relief following arthroscopy: A comparative study of intra-articular bupivacaine, neostigmine, and clonidine p. 147
Varun Gupta, MC Rajesh, Schiller Jos, EK Ramdas
DOI:10.4103/ijpn.ijpn_66_18  
Background and Aims: Quality pain relief after arthroscopic knee surgery is not only a challenge but also a necessity for adequate postoperative rehabilitation after anterior cruciate ligament (ACL) repair. In the past, different agents were tried for pain relief by parenteral and intra-articular routes with varying results. The aim of the present study is to compare the analgesic effects of intra-articularly instilled bupivacaine, clonidine, and neostigmine in the postoperative period after ACL repair. Methods: This was a double-blind study on three groups of patients, wherein bupivacaine, clonidine, or neostigmine was instilled intra-articularly at the end of knee arthroscopic ACL repair and the postprocedure pain relief was assessed. All patients received subarachnoid block with the same volume (17.5 mg) of 0.5% bupivacaine heavy. Postoperative pain was assessed with the visual analog scale (VAS), and rescue analgesics were prescribed for a more than tolerable pain. Pain score was observed at definite intervals and rescue doses were charted in crosstabs. Efficiency of the three drugs in question was tested with Bonferroni technique. Results: VAS scores at 2 h, 6 h, and 12 h were lowest with bupivacaine followed by clonidine and neostigmine. The requirement of rescue analgesics was also in the same order. Conclusion: On the basis of this study, we conclude that intra-articularly instilled bupivacaine provides superior and long-lasting analgesia than clonidine and neostigmine.
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Randomized trial comparing the incidence of unintended sciatic nerve block following ultrasound-guided pudendal nerve block with two different volumes of ropivacaine for hemorrhoidectomy: A pilot study p. 151
Krishnagopal Vinod, Pranjali Kurhekar, Krishnakumar Sharanya
DOI:10.4103/ijpn.ijpn_60_19  
Aim: To compare the incidence of unintended sciatic nerve block following pudendal nerve block in the interligamentous plane with two different volumes of ropivacaine for post hemorrhoidectomy pain. Materials and Methods: 30 patients undergoing hemorrhoidectomy were enrolled for the study and randomly divided into two groups. Prior to the block a scout scan was performed and the pudendal artery, nerve and the sciatic nerve were identified in the interligamentous plane. All the patients received bilateral pudendal nerve block under ultrasound guidance with 5ml of 0.25% ropivacaine in group 1 and 10 ml in group 2. The spread of local anaesthetic to the ipsilateral sciatic nerve was noted under ultrasound imaging. The time of first rescue analgesia (FRA) and total analgesic requirement(TAR) were noted in both groups. The overall patient satisfaction was assessed with a three point scale.The unintended motor and sensory block of the sciatic nerve was noted. Results: The right pudendal artery was visualized in all cases where but left pudendal artery was not visualized in 1 case. The right & left pudendal nerve was visualized in 40% & 46.7% of cases in group I and 40% in both sides of group 2. The incidence of spread of drug towards the right and left sciatic nerve was more in group II (73.3% & 66.6%) than group I (40% & 33.3%). Statistically significant difference was not noted in the time for FRA (P value 0.684) & TAR (P value 0.579). There was no clinically significant sciatic nerve block. Conclusion: We conclude that less volume of local anaesthetic can achieve effective pudendal nerve block minimizing the spread to ipsilateral sciatic nerve.
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Comparative study of morphine or dexmedetomidine as intrathecal adjuvants to 0.5% hyperbaric bupivacaine in infraumbilical surgeries p. 156
Mamta Khandelwal, Harshita Rao, Pradeep Kumar, Usha Bafna, Sonali Beniwal
DOI:10.4103/ijpn.ijpn_31_19  
Background: Morphine and Dexmedetomidine have been used with subarachnoid block for postoperative pain relief, sedation and analgesia. In higher doses, it may produce adverse effect on haemodynamics. Aim and Objective: This study compares the block characteristics and side effects effects of morphine and intrathecal Dexmedetomidine, given with intrathecal bupivacaine. Materials and Methods: A prospective, randomised, double-blinded study was conducted in department of anaesthesiology at a tertiary referral hospital. Eighty patients with American Society of Anaesthesiologists Status I and II were randomly allocated to receive either dexmedetomidine (5 μg) or Morphine (200 mcg) with or 0.5% hyperbaric bupivacaine. Results: Time to first dose of rescue analgesia was significantly more with dexmedetomidine (386.75102.27 min) as compared to Morphine (232.5045.45 min). Duration of motor block was also significantly longer with dexmedetomidine (192.3836.50) than Morphine (155.488.66). There was no significant difference between the two groups in relation to onset of sensory or motor block, time to reach maximum level of sensory block, and the time for two segment regression. Conclusion: Intrathecal dexmedetomidine as compared to Morphine as an adjuvant to intrathecal bupivacaine prolonged the time to first rescue analgesia, without any significant adverse effect.
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CASE REPORTS Top

Atypical presentation with malignant transformation in neurofibromatosis Type 1 and strategies for managing neuropathic pain p. 161
Deepti Ahuja, Rakesh Garg
DOI:10.4103/ijpn.ijpn_26_19  
Pain is considered as a vital parameter for any patient management. Type I neurofibromatosis (NF-1) is an autosomal dominant neurocutaneous disorder caused by loss-of-function mutations in the NF-1 gene. The presence of severe pain is an atypical feature of NF-1, and the possibility of malignant transformation with the development of a malignant peripheral nerve sheath tumor (MPNST) should be considered in such situation. These tumors are universally foreshadowed by the onset of severe pain. The present treatment options that can be used in the management of these patients have not been well described in the available literature. We report a case of NF-1 with atypical pain, its malignant transformation, and its management. This case report is unique as it attempts to correlate the mechanism and target therapeutic options in the management of pain in patients of NF with MPNST. We conclude by emphasizing that various available options for management of pain should be employed after understanding the pathophysiology behind the occurrence of pain in a clinical setting. Treatment of malignancy and management of pain should be done simultaneously.
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Lumbar sympathetic block for pain relief and healing of chronic vascular ulcer on lower limb in patient with antiphospholipid syndrome and immune thrombocytopenic purpura p. 164
Awisul-Islah Ghazali, Narwani Hussin
DOI:10.4103/ijpn.ijpn_33_19  
Lower extremity ulcer is an infrequent but disabling complication of long-standing connective tissue disease such as antiphospholipid syndrome (APS). We reported a case of a 51-year-old female suffering from APS and immune thrombocytopenic purpura who was referred to our pain clinic with a history of 1-year chronic pain on the dorsal part of the bilateral foot. She also had a poor healing vascular ulcer on her right leg. Drug therapy managed to control her bilateral foot pain, but her chronic ulcer pain was not resolved, resulting in her decision to finally quit being a teacher. She even underwent 24 sessions of hyperbaric oxygen therapy but with unsatisfactory outcome. Later, a trial of lumbar sympathetic block was offered to her. Surprisingly, she responded very well. The chronic ulcer healed completely after her second session, and she was no longer dependent on any pain killer.
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Single-needle celiac plexus block for pain management in a case of liver hemangioma p. 168
Kalpana Kulkarni
DOI:10.4103/ijpn.ijpn_63_19  
Pain is the most common reason for presentation of a patient to a physician suffering from upper abdominal pathologies such as pancreatitis, benign tumors, or malignancies of liver/gall bladder/stomach/colon. Inflammation, scarring, and increased pancreatic duct pressure or malignant invasion of celiac plexus are the major causes of pain. A comprehensive evaluation of the patient for pain, associated pathological problem, and to find out any surgical indication is necessary. We present a 55-year-old female patient diagnosed of liver hemangioma with right upper abdominal pain. Treatment options of embolization under radiological guidance and/or surgical resection–enucleation were not acceptable and affordable to the patient. The patient was then referred for upper right intra-abdominal pain management. Following informed consent and vital monitoring inside the operation theater, the patient was given prone position. Under aseptic precautions and fluoroscopy guidance, diagnostic celiac plexus block was given on the right side with 5 ml of 2% lignocaine with adrenaline + 20 ml of 0.25% bupivacaine + fentanyl 25 μg at the level of L1 body of vertebra, which resulted in 80% of relief in pain for 18 h. Later, this was followed by neurolytic block using 15 ml of 8% phenol after injection of 10 ml of 0.25% bupivacaine to confirm the effective pain relief. Numerical Rating Scale score decreased from 7 to 2 at 1 week. Seventy-five percent of pain relief was present at the 6th month of follow-up. There was significant improvement in quality of life and sleep. Single-needle technique of celiac plexus block is a useful method for the control of chronic upper abdominal pain due to liver pathology.
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LETTERS TO THE EDITOR Top

Narcotic prescription for terminally ill patient by proxy: Do we justify? p. 172
Abhijit S Nair, Srinivasa Shyam Prasad Mantha, Krishna Kishore Kotthapalli, Basanth Kumar Rayani
DOI:10.4103/ijpn.ijpn_59_19  
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Cannabis derivatives in chronic pain: Is it legitimate? p. 174
Abhijit S Nair, Sandeep Diwan
DOI:10.4103/ijpn.ijpn_45_19  
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