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   2017| January-April  | Volume 31 | Issue 1  
    Online since May 5, 2017

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Role of platelet-rich plasma: The current trend and evidence
Kailash Kothari
January-April 2017, 31(1):1-6
Platelets contain many important growth factors, which helps in healing. These lead researchers to inject high concentration of Platelets in plasma (platelet-rich plasma [PRP]) at injury site. There is a variety of PRP preparations produced by the different commercial equipment. The concentration of platelets should be more than 5 times the normal in PRP. PRP can be used for long list of conditions, for example, orthopedic, neurology, musculoskeletal, cardiology, dermatology, and plastic surgery. The research on PRP is still in infancy, and there is no consensus on platelet concentration, amount of PRP, which is the best technology in preparing PRP. There are many animal studies, which are showing encouraging results, but human studies are lacking. PRP is very promising treatment option which is nonsurgical. We need to wait for more concrete evidence to emerge to define its exact clinical role.
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Strength-duration curve: A measure for assessing pain in trapezius spasm
Shivani Chowdhury Salian, Gauri Namdeo Tulsankar
January-April 2017, 31(1):41-49
Objective: To ascertain the normative values of Strength-duration curve parameters for motor and sensory nerves of trapezius muscle in asymptomatic subjects and compare them with subjects suffering from chronic bilateral trapezius spasm. Methods: A multi-centric cross-sectional study was conducted to compare the Strength-duration curve parameters derived from normal healthy group of subjects (n = 100) and with subjects presenting with bilateral trapezius spasm (n = 100). The subjects were recruited after explaining the procedure in the language best understood by them and a written consent was procured before starting the research. Results: Level of significance was set at P value < 0.05. Rheobase values were found to be lower, whereas, chronaxie, rise time and pulse ratio were increased for both sensory and motor nerve in subjects with trapezius spasm as compared to normal healthy subjects. Discussion: Strength-duration curve parameters can be an important addition to the objective measurement tools of pain assessment and prognosis in musculoskeletal painful conditions. Conclusion: SDC can be effectively used an objective measure of assessment of pain in patients suffering from trapezius spasm. Clinical Implications: On the same lines further studies can be conducted and applied in various neuromuscular conditions.
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Percutaneous endoscopic interlaminar lumbar discectomy for superiorly sequestrated disc L5–S1: A case report with technical review
Manish Raj, Hyeun Sung Kim, Kailash Kothari, Anurag Agarwal, Kifayat Maqsood
January-April 2017, 31(1):68-72
L5-S1 disc has always been a difficult disc to target by rigid endoscope because of anatominal limitations .These limitation severely hampers transforaminal approach for superiorly migrated disc at L5-S1. We performed percutaneous endoscopic interlaminar lumbar decompression (PEILD) for removal of superiorly migrated sequestrated disc and preserved the functional structures. Through this approach nerve root and dural sleeve were exposed and adequate removal of migrated disc was done, which was also confirmed by immediate post operative MRI. The clinical outcome was evaluated using visual analogue scale (VAS) score and brief pain inventory (BPI) . We obtained excellent results in treating superiorly sequestrated disc at L5-S1 using endoscopic interlaminar angled approach.
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Dexmedetomidine in supraclavicular block: Effects on quality of block and analgesia
Vivek S Palsule, Avani P Shah, Hitendra H Kanzariya
January-April 2017, 31(1):28-34
Context and Objectives: Upper limb surgeries are most commonly performed under brachial plexus block (BPB). A variety of adjuvants have been used to enhance the effect of local anesthetics in peripheral nerve block. We evaluated the effect of dexmedetomidine as an adjuvant to 0.25% bupivacaine in supraclavicular block (SCB) in terms of onset and duration of sensory and motor block, analgesia, and quality of block. Subjects and Methods: Sixty American Society of Anesthesiologists physical status I and II patients undergoing upper limb surgery, in which SCB was used, were enrolled. Patients were assigned to one of the following groups alternatively: Group C received BPB with bupivacaine 0.25% (34 ml) + normal saline 1 ml. Group D received BPB with bupivacaine 0.25% (34 ml) + dexmedetomidine 1 μg/kg. Onset and duration of sensory and motor block, duration of analgesia, sedation score, and hemodynamic parameters were studied in both the groups. Results: There were no significant differences in patient and surgery characteristics between two groups. In Group D, shorter time to onset of sensory block (09.8 vs. 15.3 min, P = 0.006) and longer duration (691.3 vs. 395.6 min, P = 0.006) was observed. Onset time to achieve motor block (11.8 vs. 17.3 min, P = 0.009) was also short and duration was longer (637 vs. 367.6 min, P< 0.001) in Group D. Duration of analgesia (735.6 vs. 423.6 min, P< 0.001) was higher as compared to control group. Conclusions: Adding dexmedetomidine to bupivacaine during supraclavicular BPB shortens sensory and motor block onset time, increases the sensory and motor block duration, and prolongs the duration of postoperative analgesia without any significant side effect.
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Radiofrequency ablation of sphenopalatine ganglion for head and neck cancer pain management
Priti R Sanghavi, Dipak D Patel, Geeta M Joshi
January-April 2017, 31(1):13-17
Introduction: Pain in advanced head and neck cancer is intractable and many a times difficult to manage with pharmacological agents. Sphenopalatine ganglion (SPG) block provides excellent pain relief in patients who are suffering from various types of orofacial pain. Role of radiofrequency ablation (RFA) of SPG is described for orofacial cancer pain. Aim: The aim of the study was to observe efficacy and duration of pain relief by RFA of SPG in advanced head and neck cancer patients. Materials and Methods: Thirty-three patients suffering from advanced head and neck cancer were enrolled in this study between September 2013 and February 2016. All patients underwent RFA of SPG, under fluoroscopy guidance following a successful diagnostic block of SPG with local anesthetic. Pain was assessed before the procedure, immediately after the procedure, and during each follow-up visit. Follow-up visits were weekly for 4 weeks and then monthly till the end of life. Patients were continued on oral morphine, but the dose was reduced to one-third of total dose and was adjusted according to patients' requirement during each follow-up. Duration of analgesia, morphine requirements, and incidence of complications were noted. Results: There were 32 males and one female. Mean age of patients was 43.24 ± 13.52 (mean ± standard deviation [SD]), ranging from 19 to 58 years. Three patients did not undergo RFA due to cheek hematoma formation during the procedure. Visual analog score was reduced from 8.43 ± 1.10 (preprocedure) to 1.36 ± 1.61 (postprocedure) (mean ± SD). Mean duration of analgesia was 17.55 ± 26.12 (mean ± SD) weeks. Mean reduction in the dose of morphine was from 124.65 ± 46.78 to 40.00 ± 18.05 mg (mean ± SD) immediately after the procedure. One patient was followed up for 30 months. Sixteen patients died within 3 months and had good pain relief. None of the patients had any serious complications. Conclusion: RFA of SPG is a good adjuvant method of pain management in head and neck cancer patients. It gives significant pain relief and reduces morphine requirement. It is safe and it can be carried out as day-care procedure.
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Newer anticoagulants and their impact on interventional pain procedures
Babita Ghai, Nitin Ahuja
January-April 2017, 31(1):9-12
Heparins and coumarins have been ruling the anticoagulant class for the past 60 years, but the trend in the drug discovery, prominence of target-based approach, and high-throughput screening has brought newer molecules in the forefront. Newer oral anticoagulants (NOACs) with different therapeutic challenges have largely come up in the past 5 years and overcome the limitations of traditional anticoagulants. The debate for specific guidelines for their use has been on for years. Interventional pain physicians admonished that available guidelines for regional anesthesia in patients receiving anticoagulants were insufficient as pain procedures covered a far broader gamut reflecting diverse goals. Hence, experts from different groups and committees got together and summed up guidelines and stratified interventional pain procedures based separately on patient- and procedure-specific factors. Here, in this review, we discuss the NOACs and their impact on interventional pain procedures.
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Epigenetics, pain, and analgesia
Krishnan Sivaraman, Palanisamy Vijayanand
January-April 2017, 31(1):7-8
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Effect of anaerobic bout using wingate cycle ergometer on pressure pain threshold in normal individuals
Ajit Dabholkar, Aditya Andhansare, Tejashree Ajit Dabholkar
January-April 2017, 31(1):55-58
Introduction: Published studies reveal that incremental graded and short term anaerobic exercise lead to an increase in beta-endorphin levels, the extent correlating with the lactate concentration. Beta- endorphin can be released into the circulation from the pituitary gland or can project into areas of the brain through nerve fibers. Exercise of sufficient intensity and duration has been demonstrated to increase circulating Beta-endorphin levels. Thus, our study investigates the effect of anaerobic activity on pressure pain threshold (PPT) in normal individuals. Materials and Methods: Normal individuals (N = 30) between the age group of 20-30 years were recruited for this study. The subjects performed an anaerobic bout on Monark Wingate cycle egometer. A pre and post assessment of PPT was evaluated. Data Analysis: Graphpad Instat 3 software program was used for statistical analysis. A paired't' test was done to analyse the level of statistical significance between the pre and post PPT. Results: Study revealed that post anaerobic bout there was statistical significant difference between pre and post PPT in quadriceps, Mean 14.41,95% CI[12.95,15.87], Mean 16.73,95% CI[15.06,18.40] & (P value 0.0411) and gastrocnemius,Mean 13.56, 95% CI[12.18,14.93], Mean 15.55,95% CI[13.94,17.16] & (P value <0.0001). Conclusion: The study emphasizes the influence of pain modulation after an anaerobic bout.
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Correlation of physical factors with musculoskeletal pain among physiotherapists
Vidhi Rajen Kalyani, Surendra Kiran Wani, Savita Rairikar, Ashok Shyam, Parag Sancheti
January-April 2017, 31(1):50-54
Introduction: The etiology of musculoskeletal work related disorders remains largely unclear, pain being the predominant complaint. The prevalence of neck pain, shoulder pain, upper and lower back pain increases drastically during professional practice in Physiotherapy. This study evaluated the prevalence of musculoskeletal pain. Also, the study determined the role of modifiable risk factors for physiotherapists (physical activity, psychological status and quantity and quality of sleep) for pain. Method: The study population includes 60 physiotherapists with atleast work experience of 1 year and work duration of 6 hours per day. Outcome measures used were Nordic Musculoskeletal Questionnaire as a screening tool, Orebro Musculoskeletal Pain Questionnaire, The Short Questionnaire to Assess Health-Enhancing Physical Activity (SQUASH), University of Cambridge sleep questionnaire and Internet Mental Health Quality of Life (IMHQOL) scale. Results: Comparatively, pain was more concentrated at spinal regions than peripheral locations among physiotherapists. Surprisingly, many physiotherapists reported multiple sites of musculoskeletal pains. Conclusion: A weak correlation was established between physical activity and musculoskeletal pain among physiotherapists.
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Retrospective analysis of clinical efficacy of protocol-based management of postdural puncture headache in patients undergoing cesarean section under spinal anesthesia
Zainab Salim Said Al Amri, Abdullah Al-Jadidi, Rashid Manzoor Khan, Naresh Kaul
January-April 2017, 31(1):18-22
Despite advances in needle size and design, postdural puncture headache (PDPH) still remains a significant cause of morbidity in parturients receiving spinal anesthesia. Several treatment options have been suggested to treat PDPH ranging from bed rest, rehydration, and analgesics to epidural blood patch. At our institution, we adhere to a strict protocol for managing PDPH wherein adrenocorticotrophic hormone (ACTH) is one of the treatment steps in cases of unrelieved PDPH. We carried out a 1-year retrospective analysis to note the efficacy of ACTH in managing PDPH in patients undergoing spinal anesthesia for cesarean section. All patients with PDPH were followed up for at least 2 months after being discharged from the hospital to note recurrence, if any. Data revealed that a total of 614 patients received spinal anesthesia during this period using a 25- or 26-G Quincke needle with the patient in the sitting position using a midline approach. Totally 31 patients developed PDPH and all patients reported their headache spontaneously. As per protocol, if the PDPH did not resolve or lessen in intensity with bed rest and simple analgesics (paracetamol, diclofenac or tramadol alone, or in combination) over the first 24 h, two injections of ACTH (1.5 μg/kg in 500 ml saline intravenous over 30 min) were administered 12 h apart. No further injections of ACTH were administered. If any treatment modality demonstrated relief or attenuation in PDPH, the patient was observed for the next 2 days. If there was no further improvement, next step of the protocol using epidural blood patch was adopted. Of these 614 patients, 31 developed PDPH giving an incidence of 5.04%. The first line of conservative treatment with bed rests and simple analgesics was successful in relieving or alleviating PDPH in 20 patients (64.5%) within 24 h. About 11 patients (35.5%) went on to receive ACTH as the second conservative line of management. In 10 of these 11 patients (90.9%), PDPH either resolved or showed significant relief between 12 and 48 h after the last ACTH injection. No further treatment was required in them. In 1 out of 11 (9.1%) patients who received ACTH, PDPH remained unresolved and the patient went on to receive epidural blood patch for alleviation of her symptoms. Epidural blood patch resulted in 90% relief of her PDPH. In conclusion, initial conservative line of treatment using analgesic combination resolved PDPH in 64.5% of patients while ACTH had a 90.9% of efficacy when administered 24–48 h after the onset of PDPH.
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Pectoral nerve block: A novel modality for managing chronic chest wall pain
Varsha Shrikant Kurhade, Nivedita D Page
January-April 2017, 31(1):73-74
A 54-year-old male presented with chronic left-sided chest wall pain. Diagnosed as myofascial pain after ruling out other causes, he had little or no relief with the conventional treatment consisting of oral nonsteroidal anti-inflammatory drugs and muscle relaxants. An ultrasound-guided pectoral nerve block (PECSB) supplemented with intramuscular stimulation (IMS) was performed, with IMS being repeated after a week. Near total pain relief was achieved, which was sustained for up to 90 days, the period for which the patient has been followed up. We conclude that PECSBs are safe, easy to perform and effective for chronic chest wall pain.
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Low-dose intravenous alpha-2 agonists as adjuvants to spinal levobupivacaine: A randomized study
Pranav Jetley, Mamta Khandelwal, Usha Bafna, Gaurav Sharma, Shweta Jain, Debojyoti Dutta
January-April 2017, 31(1):35-40
Background: Alpha-2 agonists have been used with spinal anesthesia for anxiolysis, analgesia, and hypnosis and for postoperative pain relief. These beneficial effects may, however, be offset by their propensity to prolong the duration of motor block and adversely affect hemodynamics when used in higher doses. This study compares the effects of low-dose premedication with intravenous (IV) dexmedetomidine and IV clonidine with placebo, on spinal blockade duration, analgesia, and sedation with intrathecal levobupivacaine. Materials and Methods: In this prospective, randomized, double-blinded, placebo-controlled study, ninety American Society of Anesthesiologists Status I and II patients were randomly allocated into three groups: Group A (control) received 10 ml normal saline IV, Group B received IV dexmedetomidine 0.6 μg/kg, and Group C received IV clonidine 1.2 μg/kg over 10 min, before spinal anesthesia with 0.5% levobupivacaine. Hemodynamics, total duration of analgesia, onset and duration of sensory and motor block, visual analog scale score, and sedation score were assessed. Complications, if any, were noted. Results: The level of sensory block achieved was higher with dexmedetomidine (T4.2 ± 0.8) and clonidine (T4.4 ± 0.7) as compared to control (T5.1 ± 0.7; P< 0.001). Time to two segment regression was greater with dexmedetomidine (146.5 ± 12.5 min) and clonidine (138.9 ± 17.4 min) compared to control (90.1 ± 9.4; P< 0.001). Dexmedetomidine maximally prolonged the duration to first patient request for analgesia (245.2 ± 26.8 min), followed by clonidine (175.3 ± 20.1 min, P< 0.001) and control (121.3 ± 16.1 min, P< 0.001). The duration of motor block was similar in all three groups. Incidence of bradycardia was significantly greater with both dexmedetomidine and clonidine compared to saline (P < 0.05). Conclusion: Premedication with low-dose IV dexmedetomidine and clonidine prolonged sensory blockade and analgesic duration and provided suitable sedation, without prolonging motor blockade.
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Postoperative pain relief using intrathecal morphine for lumbar spine decompression and instrumentation surgery: A comparative study of two different doses
Priyanka Dhir, Sharwan Mittal, Umesh K Valecha, Jasbir S Khanuja
January-April 2017, 31(1):23-27
Background and Aims: Patients undergoing lumbar spine instrumentation surgery suffer severe postoperative pain which is difficult to treat by conventional multimodal analgesic methods. We aimed to compare the analgesic effect of two different doses of intrathecal morphine (ITM) 0.2 mg and 0.3 mg in patients undergoing lumbar spine decompression and instrumentation surgery. Design: This was a randomized, prospective, double-blinded study. Materials and Methods: After approval from the Institutional Ethics Committee, forty American Society of Anesthesiologists 1 and 2 patients of either sex aged 18 years or older undergoing lumbar spine surgery were randomly assigned to receive ITM either 0.2 mg (Group A, n = 20) or 0.3 mg (Group B, n = 20) in 2 ml saline before general anesthesia. A morphine intravenous patient-controlled analgesia (PCA) device was used for rescue analgesia in the postoperative period. Assessment parameters included hemodynamics, sedation score, pain using numeric rating scale (NRS), total consumption of PCA morphine recorded for 24 h, and patient's satisfaction score. The data were analyzed using Chi-square test for categorical variables and Student's t-test for quantitative variables. Results: NRS score was significantly low in Group B at 4, 8, 12, and 24 h as compared to Group A (P < 0.05). Group B also had decreased requirement for rescue analgesia (P = 0.001) with higher patient satisfaction. There was no significant difference between the two groups in other studied parameters. Conclusions: 0.3 mg ITM provided superior analgesia postoperatively in terms of NRS score and higher patient satisfaction compared to 0.2 mg with no significant difference in the incidence of side effects.
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Pain-relevant anxiety affects desire for pain relief, but not pain perception
Adriana Banozic, Ivana Beljan
January-April 2017, 31(1):59-64
Background: Pain context plays a significant role in the perception of pain. Despite recent interest in vicarious learning and anxiety in pain modulation, there have been no attempts to explore pain modulation by specific environmental cues. Aims: Therefore, the present study evaluated pain responses in the condition that was attributed as either anxiety relevant (AR) or anxiety irrelevant. Materials and Methods: Participants were exposed to both conditions through social observational learning. Pain perception was assessed by means of a visual analog scale ranging from 0 = no pain to 10 = maximum imaginable pain. State anxiety, empathy, expectancy, and desire for pain relief were also measured at both neutral and emotionally inducing conditions. Results: No effect of relevancy of anxiety for the pain context on any of the pain-related constructs was found. However, participants in the AR condition reported an increased desire for pain relief. Maximizing similarities between observed and experienced pain context did not enhance observational learning effects in the emotionally inducing condition regardless of its relevance, but significant changes were found in comparison to the affectively neutral group. Conclusions: These results could have potentially significant clinical implications suggesting that even though observing painful procedures does not increase pain it could affect medication usage.
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Safe perioperative opioid taper in cancer patients needs meticulous multimodal management
Anjum Khan Joad, Manisha Hemrajani, Pratima Agarwal, Shikha Jain, Vinita Jain
January-April 2017, 31(1):65-67
Opioid therapy plays a vital role in chronic pain management of advanced cancer patients. Some patients require discontinuation of opioids when an intervention appropriately controls the pain. Safe discontinuation of opioids poses a challenge among lack of evidence-based standardized taper protocol. We report a patient with a soft tissue sarcoma in whom opioid was tapered in the background of acute postoperative pain.
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