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   Table of Contents - Current issue
May-August 2017
Volume 31 | Issue 2
Page Nos. 77-142

Online since Wednesday, September 6, 2017

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Holistic care in chronic pain p. 77
Geeta M Joshi
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A systematic approach to give bedside ultrasound-guided celiac plexus block p. 80
Ekta Dhamija, Indermohan Khandelwal, Sushma Bhatnagar, Sanjay Thulkar
Celiac plexus neurolysis (CPN) is an established modality of choice for the management of pain due to advanced upper abdominal malignancies. The procedure is usually performed under imaging guidance, traditionally, using fluoroscopy. Numerous techniques and approaches have been described in literature for conducting CPN with fluoroscopy and computed tomography guidance. Ultrasound (USG) has gained popularity recently for performing the procedure with added advantage of being radiation free, enabling real-time visualization of the needle tract, and possibility of performing CPN in bedside setting. This article describes the technique of USG-guided CPN using percutaneous anterior approach and discusses the dos and don'ts associated with it.
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Technical consideration of transforaminal endoscopic spine surgery for central herniation p. 86
Girish P Datar, Ajit Shinde, Kalyan Bommakanti
Introduction: Lumbar disc prolapse is most common between 30 and 50 years of age and is associated with severe disability and pain. It commonly occurs at L4/5 and L5/S1. Transforaminal endoscopic discectomy is an emerging technique for treatment of degenerative disc disease. Literature has shown clinical outcomes, comparable to classical open and micro lumbar discectomy. Central disc herniations in lumbar spine pose technical challenge for transforaminal endoscopic decompression due to its location. Existing techniques to access central herniations and ventral epidural space have trajectory related challenges due to the proximity of the retroperitoneal space and abdominal organs and technically difficult for the less experienced surgeon. Materials and Methods: Thirty patients – 19 males and 11 females – with central, multifocal, central-paracentral disc herniations in the lumbar spine operated in 2015 and 2016 were considered in this study. All patients underwent selective endoscopic discectomy under monitored care anesthesia and local anesthesia with modification of the classical technique, medialization of annulotomy, undercutting the nonarticular part of superior articular process (foraminotomy) and use of articulating and long jaw instruments either alone or in combination. Results: In all the thirty patients, we were able to achieve adequate decompression with neurological recovery. All patients improved in their neurological status. Postoperatively, visual analog scale dropped from 7.8 to 1.8 and ODI dropped from 73.46% to 32. 90% of the patients reported excellent and good results. One patient had recurrent herniation and was treated with transforaminal surgery. One patient had persistent back pain and reported poor outcome. Three patients underwent medial branch block for facet joint pain followed by medial branch rhizotomy and reported excellent and good results. Conclusion: Transforaminal endoscopic spine surgery with modifications as described above to reach the dorsal part of the disc in the midline and to access ventral epidural space is safe and effective.
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Clinical profile of patients with trigeminal neuralgia visiting a dental hospital: A prospective study p. 94
Arpita Rai, Ansul Kumar, Akhilesh Chandra, Venkatesh Naikmasur, Lejoy Abraham
Aims: To assess the clinical characteristics and parameters of trigeminal neuralgia (TN) in a group of South Indian population. Study Design: Records of sixty patients with TN were reviewed prospectively for patient demographics, characteristics of the pain, and treatment modalities. Results: Of the sixty patients, 55% were male and 45% were female. The peak incidence was in the age range of 55–64 years. Pain occurred equally on the right and left side of the face. The maxillary division of the trigeminal nerve was the most frequently affected (40%), followed by mandibular division (35%) and the combined maxillary and mandibular division alone (25%). The majority of patients described their attack as a shock like (78.33%) and of spontaneous onset (86.67%). Conclusion: In the present study, TN affected males more than females, and this disorder occurred most frequently in patients aged 55–64 years. Comparison of the pain characteristics between different age groups and gender is useful for the management of these patients.
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Evaluation of hypnotherapy in pain management of cancer patients: A clinical trial from India p. 100
Vikas Kumar Sharma, Pranav Pandya, Rakesh Kumar, Gaurav Gupta
Context: In the present era, cancer is one of the major growing diseases in human beings. People with cancer often experience a lot of problems ranging from psychological impairments to pain, fatigue, and sleep disorders. Pain is closely associated with all types of cancer. Cancer patients feel intense pain in the affected organ not only because of cancer but also because of the medical treatment procedure. Aim: The present study aimed at exploring the efficacy of hypnotherapy in mollifying the pain in persons with cancer. Settings and Design: This study was systematically planned through before and after control group design with matching; a quasi-experimental research design.Subjects and Methods: The present study was carried out by taking a total of 57 cancer patients as per inclusion/exclusion criteria from Jawaharlal Nehru Cancer Hospital and Research Center, Bhopal, Madhya Pradesh, through convenience sampling method. Out of these 57 participants, the experimental group consisted of thirty participants who were given intervention in the form of 15 sessions of hypnotherapy along with medical treatments. The control group consisted of another 27 participants who were administered medical treatments alone. Participants were given Numerical Rating Scale for a rating of pain in cancer patients. Statistical Analysis Used: Independent samples t-test and Eta-squared statistics were used to analyze the mean difference between experimental group and control group on pain and computing the magnitude of the effect of intervention, respectively. Results: The directional hypothesis was accepted P < 0.005 (one-tailed). Thus, mean score of pain (mean = 3.23, standard deviation [SD] = 1.36) for experimental group is statistically significant lower than posttest score (mean = 6.00, SD = 2.15) for control group. For power analysis, Cohen's d was estimated at 0.38 which indicates a large effect of the intervention on pain. Conclusions: The finding of the present study indicates that hypnotherapeutic interventions are effective in the management of pain in individuals with cancer.
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A comparative study of intravenous patient-controlled analgesia with tramadol alone and tramadol plus dexmedetomidine for major lower abdominal surgery p. 107
Neeta Abhay Kavishvar, Bhavesh H Prajapati
Background: Different techniques are used to provide postoperative pain relief to the patients. The patient-controlled analgesia (PCA) has come out as promising option. The main advantage of it is a stable plasma concentration of analgesic drug and the control of medication in patients' hand. Morphine has been used extensively for postoperative analgesia, but almost no respiratory depression makes tramadol equally popular for postoperative analgesia. Alpha-2 agonist-like dexmedetomidine can have additive analgesic effect. The above background was the base of planning this study to evaluate the effect of dexmedetomidine added to tramadol for postoperative analgesia. Materials and Methods: This prospective study was conducted in sixty female patients undergoing lower abdominal surgery. All patients were given spinal anesthesia for surgery. When effect of spinal anesthesia wear off and the patient had verbal rating score (VRS) more than three PCA was started. In Group T, all patients received tramadol 1 mg/kg followed by PCA tramadol. In Group D, all patients received tramadol 1 mg/kg and dexmedetomidine 0.5 mcg/kg followed by PCA having combination of tramadol and dexmedetomidine. VRS for pain, total consumption of tramadol, and side effects were recorded for 24 h postoperatively. Results: VRS for pain was comparable in both the groups. PCA demand and total dose of tramadol were less in group who received tramadol with dexmedetomidine. There was no significant difference in occurrence of side effects. Conclusions: The combination of dexmedetomidine with tramadol reduces the tramadol requirement for postoperative analgesia.
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Buprenorphine as an adjuvant to 0.5% ropivacaine for ultrasound-guided supraclavicular brachial plexus block: A randomized, double-blind, prospective study p. 112
Neena Jain, Arvind Khare, Shubham Khandelwal, Pooja Mathur, Maina Singh, Veena Mathur
Context: Ultrasound-guided supraclavicular brachial plexus block is ideal for upper limb surgical procedures. Buprenorphine used as an adjuvant to ropivacaine may prolong analgesia. Aims: The aim is to assess the analgesic efficacy and safety of buprenorphine added to 0.5% ropivacaine solution. Settings and Design: This prospective, double-blind, randomized study was conducted on 60 adult patients of the American Society of Anesthesiologists physical Status I and II undergoing various upper limb surgeries under ultrasound-guided supraclavicular brachial plexus block. Subjects and Methods: Patients were allocated into two groups of 30 each to receive either 30 ml 0.5% ropivacaine with 1 ml buprenorphine (0.3 mg) (Group B) or 30 ml 0.5% ropivacaine with 1 ml normal saline (Group C) for supraclavicular brachial plexus block. Onset, duration, and quality of sensory block and motor block; duration of analgesia and side effects were observed. Results: The mean duration of analgesia was significantly longer in Group B (868.2 ± 77.78 min) than in Group C (439.3 ± 51.19 min). The mean duration of motor and sensory block were significantly longer in Group B (451.8 ± 57.18 min) and (525.8 ± 50 min), respectively, than in Group C (320.5 ± 43.62 min) and (373 ± 53.78 min), respectively (P < 0.05). Conclusions: Addition of buprenorphine to ropivacaine for ultrasound-guided supraclavicular brachial plexus block prolonged the duration of sensory and motor blockade and postoperative analgesia without an increase in side effects.
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Prevalence and patterns of musculoskeletal pain among school students in Puducherry and its association with sociodemographic and contextual factors p. 119
S Parthibane, Anindo Majumdar, Vinoth K Kalidoss, Gautam Roy
Background: Limited data exist in India regarding burden of musculoskeletal pain (MSP) in school children. Objectives: The objective of this study is to determine the prevalence and patterns of MSP, to find out the association of sociodemographic and contextual factors with MSP, and to report the association of MSP-related characteristics and bag weight with school attendance. Material and Methods: It was a cross-sectional study conducted among 7th and 8th grade students of a private school in urban Puducherry. Students who could ambulate independently and stand on the weighing scale were included in this study. Previously diagnosed self-reported pathological causes of MSP were excluded from the study. A self-administered questionnaire was used for data collection. Height and weight were measured along with weight of student's backpack. Results: A total of 327 students were enrolled, majority (67%) being boys. Mean age of participants was 12.7 (standard deviation ±0.7) years. About 86% (282 out of 327) participants had experienced MSP in the preceding 2 weeks. Shoulders, neck, and knees were the parts reported to have maximum pain, i.e., in 43.6%, 39%, and 34.8% of the participants, respectively. A high proportion, i.e., 96% of the school bags weighed more than 10% of body weight. Significant association of MSP was found with participants' grade of study (P = 0.04), perception of bag weight (P = 0.01), comfort level of carrying bag (P < 0.01), and duration of carrying bag (P < 0.01). Factors such as pain affecting daily activities (P < 0.01) and number of health-care consultations (P < 0.01) were significantly associated with school attendance (P < 0.05). Conclusion: The prevalence of MSP in school children was high. Associated sociodemographic and contextual factors should be addressed urgently.
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Comparison of analgesic efficacy of levobupivacaine, levobupivacaine and clonidine, and levobupivacaine and dexmedetomidine in wound infiltration technique for abdominal surgeries: A prospective randomized controlled study p. 127
B Jyothi, Kirthiha Govindaraj, Pratishruthi , Safiya I Shaikh
Background: This study was designed to evaluate the postoperative analgesic efficacy of levobupivacaine (L) alone and its combination with clonidine (C) or dexmedetomidine (D) in wound infiltration technique for abdominal surgeries. Materials and Methods: After ethical committee approval, a double-blind randomized controlled study was conducted on 90 patients (power of study 80%), physical status American Society of Anesthesiologists Grade I and II, aged 18–60 years scheduled for abdominal surgeries over 1 year duration. A standard general anesthetic technique was used. Patients were randomly allocated into three groups, by computer-generated random number table. Patients received wound infiltration during wound closure. Group L received 29 ml of 0.25% levobupivacaine plus 1 ml 0.9% normal saline, Group LC received 29 ml of 0.25% levobupivacaine with 1 ml (3 mcg/kg) clonidine, and Group LD received 29 ml of 0.25% levobupivacaine with 1 ml (2 mcg/kg) dexmedetomidine. Postoperative rescue analgesia was provided with injection tramadol. Statistical analysis for duration of analgesia was determined by one-way analysis of variance and side effects by Chi-square test. Results: The total duration of analgesia in LD group was 23.4 h, when compared to LC group 20.9 h and L group 11.65 h (P = 0.0001) with excellent to good quality of analgesia in adjuvant group (P < 0.001) and incidence of minimal side effects such as sedation, nausea, and vomiting. Conclusion: Clonidine and dexmedetomidine were the effective adjuvants to levobupivacaine for single shot wound infiltration analgesic technique; however, dexmedetomidine was found to be superior to clonidine.
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Role of oral gabapentin as preemptive adjuvant with spinal anesthesia for postoperative pain in patients undergoing surgeries under spinal anesthesia p. 133
Roshan Lal Gogna, Deepak Dwivedi, Urvashi Tandon, Kunal Sarin, Vidhu Bhatnagar
Background and Aims: The study was undertaken to evaluate postoperative benefit in patients administered tablet gabapentin as premedication with the primary outcome determining the effect on duration of analgesia with total analgesic requirement and measurement of postoperative sedation scores as our secondary outcomes. Methods: The study was a prospective randomized observational study in sixty patients undergoing surgeries in spinal anesthesia (SA). Patients were randomly assigned into two groups. Group A (n = 30) patients received tablet gabapentin (600 mg) while Group B (n = 30) received a placebo (Vitamin B complex) orally 2 h before surgery. Postoperative pain was managed with intravenous tramadol 2 mg/kg. Postoperative monitoring and assessment included pain assessment every 2 h with Numeric Rating Scale (0–10) for 12 h and then at 24 h. Results: On comparison of intergroup data, the duration of analgesia was prolonged in Group A (288.79 ± 38.81 min) as compared to Group B (218.67 ± 37.62 min) with P (0.0001). Total opioid requirement was higher in placebo group as compared to the Group A (P = 0.025). Statistical difference in mean (standard deviation) pain score at 24 h was statistically significant (P = 0.0002). Sedation scores were significantly higher in Group A at 2 and 4 h post-SA. Conclusion: Single dose of gabapentin administered 2 h before surgery provides better pain control as compared to placebo. It prolongs the duration of analgesia, reduces the total analgesic requirement during the postoperative period.
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Gout as a consequence of bone healing: A diagnostic dilemma p. 138
Rajeev Kumar Dubey
Diagnosis of acute gout remains a diagnostic challenge if associated with trauma, and may easily be mistaken as cellulitis or septic arthritis. Gout is an inflammatory arthritis that is triggered by the deposition of sodium urate crystals within the joints and soft tissues, and is frequently associated with hyperuricemia. Hyperuricemia may arise in a wide range of clinical situations that cause overproduction or under-excretion of uric acid, or a combination of both. As uric acid is the ultimate breakdown product of purine nucleotide degradation in humans, any increase in purine production due to accelerated cell turnover may precipitate an acute attack of gout. Gout may be precipitated by conditions such a trauma, surgery, diuretic therapy, or ethanol intake. All predisposed individuals such as those with hypreuricemia, hypothyroid etc. with trauma and bone fractures should be observed for precipitation of acute gouty arthritis. Bone healing after a fracture may also lead to acute gout. Healing of a fractured bone, through multiple mechanisms, can precipitate acute gout, particularly in the presence of certain predisposing factors such as hypothyroidism, pre-existing hyperuricemia or tissue hypoxia. Acute inflammation and pain, if resistant to non-steroidal anti-inflammatory drugs, may necessitate treatment with colchicine.
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Pelvic pain: Understanding the psychological conundrum Highly accessed article p. 141
Madhur R. P. Chadha, Apurv Mahalle, Sorabh Garg
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