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   Table of Contents - Current issue
Coverpage
September-December 2017
Volume 31 | Issue 3
Page Nos. 143-205

Online since Thursday, January 18, 2018

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EDITORIAL  

Diagnostic pain procedures in managing chronic pain: Relevance in today's time! p. 143
Kailash Kothari, Khushali Tilvawala
DOI:10.4103/ijpn.ijpn_81_17  
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ORIGNAL ARTICLES Top

The comparative study of two techniques of lumbar plexus block by anterior and posterior approach for lower limb surgery p. 146
Milon Vasant Mitragotri, Pushpa Ishwarlal Agrawal, Vaishnavi V Kulkarni, Nilambree S Adke, Dharmesh Arvind Ladhad
DOI:10.4103/0970-5333.223663  
Background: Lower extremity peripheral nerve blocks (PNBs) have been traditionally less employed compared to other forms of regional anesthesia. The advent of peripheral nerve stimulator and ultrasonography, complications associated with neuraxial anesthesia, and improved rehabilitation with PNBs has led to renewed interest in lower limb blocks. Lumbar plexus block can be given by anterior (Winnie's “3 in 1” block) and posterior (psoas compartment block) approaches. Subjects and Methods: In this randomized, observer-blinded study, we compared these techniques in two groups of patients (Group A [n = 30] and Group P [n = 30]) undergoing lower limb surgeries using nerve locator. They were supplemented with sciatic nerve block by Labat's approach. The primary objective was to compare the onset of sensory and motor blockade. Secondary objectives included the duration of sensory and motor blockade, sparing of nerves and complications if any. The onset of sensory analgesia was assessed by visual analog scale <3 and motor blockage by modified Bromage scale. For data analysis, t-test and Chi-square test were applied. Results: In Group A, onset of sensory block was 4.816 ± 0.932 min, and in Group P, 17.167 ± 2.364 min. In Group A, the onset of motor action was 7.833 ± 1.227 min, and in Group P, 22.8 ± 4.42 min. The duration of motor block was 5.6 ± 1.07 h in group A and 5.88 ± 0.90 h in Group P. The duration of sensory block was found to be 8.18 ± 1.32 h in Group A and 8.18 ± 0.88 h in Group P. Conclusion: Winnie's 3-in-1 block is associated with rapid onset of sensory and motor block but is associated with sparing of lateral femoral cutaneous nerve and obturator nerve causing inadequate analgesia and tourniquet pain needing additional block or sedation compared to psoas compartment block which provides denser block.
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Awareness, attitude, and knowledge about “pain clinics” among general practitioners in Nagpur City p. 152
Archana N Deshpande, Anukriti V Sahni
DOI:10.4103/ijpn.ijpn_66_17  
Aims: The number of patients with chronic pain is increasing every year, and effective management of it is one of the prime concerns of doctors across the world. But this demands appropriate awareness, knowledge, and attitude regarding pain and specialized clinics where pain can be dealt with, using the most effective approaches. The latter vividly points at “Pain Clinics,” which form the basis of our study. Considering the Indian scenario, patients prefer visiting either their family physicians or general practitioners (GPs) to be alleviated of their pain, as they essentially believe in the suggestions of these doctors. Materials and Methods: A survey of 170 GPs was conducted in Nagpur, India, to know about their knowledge, awareness, and attitude toward pain clinics through a structured questionnaire. Results: About 72% of the GPs had awareness about pain clinics, but only 32% actually referred patients to pain clinics. Sixty percent of the GPs referred patients to other specialists, mostly orthopedic surgeons. Forty percent of the GPs were aware of few techniques of pain relief; however, 65% answered negatively about techniques at pain clinics. GPs showed interest in knowing more about such clinics (88.2%). Conclusions: Majority of the GPs in Nagpur are aware of the pain clinics but are reluctant to refer patients to pain clinics. This may be due to limited knowledge about pain physicians and procedures performed at pain clinics and their efficacy and safety.
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Physical risk factors for low back pain among young sedentary individuals - A prospective study Highly accessed article p. 157
Saddam Husen Meman, Veena Pais, Bhuvanesh Sukhlal Kalal
DOI:10.4103/ijpn.ijpn_50_17  
Aims: To find the relationship of several physical risk factors on the occurrence of low back pain (LBP) over a period of 6 months among young sedentary individuals. Settings and Design: Yenepoya University, Mangaluru, India; prospective cohort design. Methods and Material: In this study, total number of 187 students of Yenepoya University, aged 18 to 30 years, with the international physical activity questionnaire (IPAQ) score of less than 600 metabolic equivalent (MET) minutes /week were recruited through convenience sampling. Participants were assessed for body mass index (BMI), hamstring and iliopsoas muscle tightness, abdominal and back muscle strength and endurance, and trunk range of motion (ROM) at baseline. All measurements were taken by using standardized procedures. Statistical Analysis Used: Frequency distribution, Karl Pearson's correlation test by SPSS. Results: The Logistic regression analysis showed that there was a significant positive correlation between low back pain and trunk flexion ROM with odds ratio of 1.671 (P < 0.001), LBP and trunk extension ROM with odds ratio of 1.602 (P < 0.001), LBP and abdominal endurance with odds ratio of 1.602 (P < 0.001), LBP and BMI of overweight with odds ratio of 1.534 (P < 0.001), LBP and BMI of obese with odds ratio of 1.429 (P < 0.001). Conclusions: The study shows that there is a statistically significant correlation between trunk flexion and extension ROM, abdominal muscle endurance and BMI of obese & overweight category with low back pain, among young sedentary individuals.
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Efficacy of motor imagery through mirror visual feedback therapy in complex regional pain syndrome: A comparative study Highly accessed article p. 164
Biplab Sarkar, Subrata Goswami, Debapriya Mukherjee, Sagarmay Basu
DOI:10.4103/ijpn.ijpn_51_17  
Background: Complex regional pain syndrome (CRPS) is characterized by disabling pain, swelling, vasomotor instability, sudomotor abnormality, and impairment of motor function. An integrated multimodal multidisciplinary treatment approach is recommended to treat CRPS including pharmacological treatment, interventional therapy, and physiotherapeutic management. As imaging studies indicate that CRPS is associated with manifestation of changes in brain, mirror visual feedback (MVF) therapy may also have effect in neuromodulation and cortical reorganization. Aims and Objectives: The aim and objective of this study are to compare the effectiveness of MVF therapy with other conventional treatment. Subjects and Methods: A total 30 patients were selected and randomly allocated into three groups. Group C was treated with pharmacological management with contrast bath, Group E was additionally treated with exercises, and Group M was additionally treated with MVF therapy. Prognosis of the patients was documented on the basis of pain at rest, on movement, and swelling. Statistical Analysis Used: Two-way (3 × 4) ANOVA test. Results: Patients with CRPS were benefited by pharmacological therapy, physical exercises, and mirror therapy as pain in rest and on movement improved over time. However, patients, additionally treated with mirror therapy, improved to a greater extent when compared to the other groups. Conclusion: MVF therapy has been established as a low-cost treatment technique for CRPS along with other conventional treatments.
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An audit to study pain after laparoscopic cholecystectomy with the use of nonopioid analgesics p. 170
Sourangshu Sarkar, Amit Rastogi, Rudrashish Haldar, Ashok Kumar, Surendra Singh
DOI:10.4103/ijpn.ijpn_52_17  
Back ground: An Audit to study pain after laparoscopic cholecystectomy with the use of non-opioid analgesics. Patient and Methods: Hundred and nine patients were enrolled in this study that underwent elective laparoscopic cholecystectomy. Aged between 20 – 55 years, patients of either gender were enrolled in this prospective observational study. Seven patients were excluded from the study because of the conversion of laparoscopic procedure to open cholecystectomy and two patients were lost to follow-up. These patients were instructed and taught how to use the Numerical Pain Rating Scale (NPRS) for assessment of pain at rest, during deep breath and on movement. Pain score at rest, deep breath and movement including (Mild, Moderate and Severe pain), dynamic pain, breakthrough episodes of pain and time to discharge post surgery were recorded. Results: We found that none of the patients had severe pain at rest at any time interval. Only 1 patient had severe pain with deep breath at 2 hours and 2 patients had severe pain with deep breath at 6 hours after surgery. 2 patients had severe pain with movement at 2 hours and 6 patients had severe pain with movement at 6 hours after surgery. The dynamic pain was present in 12% patients (12) at 2 hours after surgery, which progressively declined to 4% (4) at 12 hours post surgery. The total number of breakthrough episodes was higher in patients having dynamic-pain at 2 hours. Conclusion: Maximum pain scores were found at 6 hours. Patients having higher dynamic pain score values at 2 hours have frequent breakthrough episodes (p value < 0.05) so an optimal analgesic control is warranted in such subset of patients. The time to discharge of patients was positively correlated to the pain scores of postoperative day 1.
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Evaluation of two different dosages of local anesthetic solution used for ultrasound-guided femoral nerve block for pain relief and positioning for central neuraxial block in patients of fracture neck of the femur p. 175
Abhijit A Karmarkar, Vidhu Bhatnagar, Deepak Dwivedi, Arnab Das
DOI:10.4103/ijpn.ijpn_57_17  
Introduction: Surgical management of the fracture femur is preferred so as to prevent complications associated with prolonged immobilization. Central neuraxial blockade (CNB) is an attractive option for these patients, and an optimal positioning of the patient is a definite requirement. Owing to the pain associated with movement of the fractured limb, it becomes difficult for the patients to give suitable positioning. Femoral nerve block (FNB) features as a rescue analgesia so as to provide adequate analgesia for facilitation of satisfactory positioning. Aim: This study aims to compare analgesic effect of two different dosages of local anesthetic (LA) solution administered for ultrasonography (USG)-guided FNB given to facilitate optimal positioning for conduct of CNB. Materials and Methods: After taking permission from the institutional review board, eighty patients were enrolled in the study to find out the efficacy of dosage of LA solution for FNB in providing pain relief caused by movement of fractured limb during conduct of regional anesthesia. Informed consent was taken. All patients were given USG-guided FNB. Patients were randomized using a computer-generated random number table, into two groups of forty patients each. Group A patients received USG-guided 12 ml of LA solution containing 10 ml lignocaine solution without preservative (2%) plus 2 ml normal saline (NS), while Group B patients received USG-guided 15 ml of LA solution containing 13 ml lignocaine solution without preservative (2%) plus 2 ml NS for positioning before combined spinal epidural. Results: A total of eighty patients, divided randomly into two groups, were enrolled in the study. Demographics (age, sex, weight, and American Society of Anesthesiologists grades) were similar in both groups. No statistical significance was found in the numeric rating scale scores at baseline, zero minutes, 5, and 15 min in both the groups. Conclusion: USG-guided FNB with 12 ml of LA solution was as effective as 15 ml of LA solution for achieving adequate pain relief so as to give optimal positioning for CNB in patients of fracture neck of femur.
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Comparison between single-level and multi-level unilateral thoracic paravertebral block in patients undergoing modified radical mastectomy p. 180
Sanjay Kalani, C V Prashanth Kumar, Suresh Chandra Dulara
DOI:10.4103/ijpn.ijpn_43_17  
Background: General anesthesia (GA) is the conventional norm whenever major breast surgeries are thought of. However, in recent years, thoracic paravertebral block (TPVB) has emerged as a potential alternative to GA. Previously, studies have compared analgesic efficacy between TPVB administered before GA and GA alone. Aims and Objectives: we aimed to compare analgesic efficacy and safety between multi-level TPVB (MPVB) and single-level TPVB (SPVB) in modified radical mastectomy (MRM). Main objective was to assess the duration of postoperative analgesia provided by MPVB and SPVB. Materials and Methods: In this prospective, randomized, double-blind study, we compared MPVB (Group M) with SPVB (Group S) using 0.3 ml/kg of 0.5% bupivacaine with 0.5 μg/kg dexmedetomidine in 60 American Society of Anesthesiologists I and II female patients who were posted for MRM. Patients were randomly allotted into Group M (n = 30) or S (n = 30). Results: Mean time to primary rescue analgesia (RA) administration was significantly longer in Group M than Group S (736.90 min vs. 581.57 min, P < 0.001). Frequency of primary RA (Group M 1.17 vs. Group S 1.87, P < 0.001) and primary RA consumption (Group M 101.17 mg vs. Group S 166.20 mg, P < 0.001) in the first 24 h of the postoperative period was significantly less in Group M than Group S. Postoperative nausea and vomiting occurred in 3.34% (n = 1) and 6.67% (n = 2) of Group M and Group S, respectively. Conclusion: Multi-level technique of administering TPVB is a better choice for providing stand-alone intraoperative anesthesia and postoperative analgesia in patients undergoing MRM.
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CASE REPORTS Top

Use of sequential diagnostic pain blocks in a patient of posttraumatic complex regional pain syndrome-not otherwise specified complicated by myofascial trigger points and thoracolumbar pain syndrome p. 186
Kailash Kothari, Khushali Tilvawala, Parth Shah, Ankur Garg
DOI:10.4103/ijpn.ijpn_79_17  
We are presenting a case of posttraumatic lower limb Complex regional pain syndrome – Not otherwise specified (CRPS – NOS). As it was not treated in acute phase, the pain became chronic and got complicated by myofascial and thoracolumbar pain syndrome. This case posed us a diagnostic challenge. We used sequential diagnostic pain blocks to identify the pain generators and successfully treat the patient. We used diagnostic blocks step by step to identify and treat pain generators – T12,L1 and L2 Facet joints, Lumbar sympathetic block for CRPS NOS and Trigger point injection with dry needling for myofascial pain syndrome. This case highlights the facet that additional pain generators unrelated to original pain may complicate the presentation. Identifying these pain generators requires out of box thinking and high index of suspicion.
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An atypical case of postsurgical complex regional pain syndrome in a patient having nonhealing varicose venous ulcer treated by lumbar sympathectomy p. 191
Kailash Kothari, Ankur Garg, Sakthi Vignesh, Brinda Patel, Khushali Tilvawala
DOI:10.4103/ijpn.ijpn_80_17  
Complex regional pain syndrome (CRPS) of the lower limb is a relatively uncommon entity as compared to CRPS of the upper extremity. Literature search has revealed only 2 retrospective case series and a single case report of lower extremity CRPS type I from 1975 to 2014 on Pubmed, isolated cases of CRPS type I of lower extremity have also been reported following knee surgeries and arthroscopies. This report presents a case of lower limb CRPS type I, following surgery for varicose vein ulcer. Pain was not relieved with medications. Diagnostic lumbar sympathectomy was done and patient had tremendous relief of pain following that, proving sympathetic mediated pain of the involved limb.
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Pneumocephalus after epidural injection: A rare complication of a common procedure p. 194
Sohail Sachdeva, Sadhana Sanwatsarkar, Meghna Maheshwari, Priyank Singh
DOI:10.4103/ijpn.ijpn_75_17  
Our patient with prolapsed intervertebral disc at L3–L4 was given lumbar epidural steroid injection using loss of resistance to air technique with 3 ml of air. After 5–6 h, she developed severe frontal and temporal headache with few episodes of nonprojectile vomiting, followed by disorientation and agitation. An urgent magnetic resonance imaging was done which revealed pneumocephalus.
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A case report of cervical myelopathy after neck manipulation in a patient with cervical spondylosis and radiculopathy: Cause and effect or natural progression? p. 197
Gaurav Chauhan, Murali Patri, Cheryl J Mordis, Vivek Loomba
DOI:10.4103/ijpn.ijpn_60_17  
A 47-year-old female, with cervical spondylosis and radiculopathy, presented with clinical features of cervical myelopathy after outpatient physical therapy. An emergent neurological surgery was scheduled after radiological evidence of cord compression. The symptoms subsided after surgery. Conservative management modalities should be practiced keeping in mind the potential of cervical spondylosis to progress to catastrophic complications such as myelopathy. It may be difficult to accurately implicate neck manipulation in the onset of the cervical myelopathy as it may be clinically silent or coexist with radiculopathy. It is vital to adequately counsel the patient, about this phenomenon to avoid legal ramifications.
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Successful use of botulinum toxin a in intractable, severe muscle spasms in spinal cord injury: A case report p. 201
Madhuri A Lokapur, Gautam D Modak, Kalpana V Kelkar, Vinaya R Kulkarni
DOI:10.4103/ijpn.ijpn_35_17  
Botulinum toxin is a protein produced by Clostridium botulinum, which inhibits muscle contraction by transiently blocking the release of acetylcholine at the neuromuscular junction. At a neuromuscular junction, the toxin inactivates some of the fusion proteins, such as SNAP-25, syntaxin, or synaptobrevin, which are essential for cellular function. This process involves the temporary inhibition of presynaptic acetylcholine release; consequently, its effects are restricted to motor neurons that depend on the cholinergic transmission (muscular plate, gland innervating cells). Injections of botulinum toxin A have been shown to be useful in the treatment of etiologically diverse types of muscle spasms. Ultrasonography (USG) has been used as a guide for confirming muscle fasciculations and also is an effective tool for confirming precise needle positioning and correct drug placement. We describe a case of a 25-year-old man with meningomyelocele and paraparesis with painful muscle spasms in bilateral thighs treated by USG-guided botulinum toxin injection.
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LETTER TO THE EDITOR Top

Nalbuphine relieves esophageal spasmodic pain: A report of three cases p. 204
Md Rabiul Alam, S M Mizanur Rahman, Kh Iqbal Karim, Mozibul Haque
DOI:10.4103/ijpn.ijpn_62_17  
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