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   Table of Contents - Current issue
Coverpage
May-August 2020
Volume 34 | Issue 2
Page Nos. 61-144

Online since Thursday, August 6, 2020

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EDITORIALS  

Pain practice during the COVID-19 pandemic: Transitioning to a new normal p. 61
Samarjit Dey, Hammad Usmani, Aftab Hussain
DOI:10.4103/ijpn.ijpn_89_20  
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COVID-19 will shift chronic pain management towards genetics Highly accessed article p. 62
Helen Gharaei
DOI:10.4103/ijpn.ijpn_59_20  
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ISSP consent form for minimally invasive pain and spine interventions p. 65
Pankaj N Surange, Swati Bhat
DOI:10.4103/ijpn.ijpn_52_20  
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REVIEW ARTICLES Top

Indian society for study of pain position statement for pain medicine practice during the COVID pandemic Highly accessed article p. 71
Sidharth Verma, Pankaj Surange, Kailash Kothari, Naveen Malhotra, Babita Ghai, Ashu Jain, Gaurav Sharma, GN Goyal, Swaty Bhat, Shovan Rath, Hitesh Patel
DOI:10.4103/ijpn.ijpn_62_20  
The COVID pandemic due to the severe acute respiratory syndrome-coronavirus-2, also known as SARS-CoV-2 (COVID-19), has affected humans across the globe. This document on pain practice reflects the current position statement of the Indian Society for Study of Pain.
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Unique challenges and opportunities faced by pain physicians during COVID-19 crisis p. 85
Babita Ghai, Sidharth Verma
DOI:10.4103/ijpn.ijpn_75_20  
The COVID pandemic has affected pain practice throughout the world. It has now become amply clear that the pandemic is here to stay for long. Pain physicians have a very important role to play in the pandemic and that is taking care of the chronic pain patients to avoid complications. This responsibility falls in the essential service category and cannot be shrugged off the shoulders by practitioners of pain medicine. Initially, various associations, societies, and organizations came up with various guidelines recommending management options following a conservative approach. However, the stance has changed almost on a real-time basis, and the current approach is to decide management on a case-to-case basis. This unique scenario has put up a lot of challenges ahead for the budding superspecialty of pain medicine. However, it also offers some opportunities which can pave the way for a bright future for the pain physicians and more importantly for their patients.
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ORIGINAL ARTICLES Top

High-viscosity bone cement for vertebral compression fractures: A prospective study on intravertebral diffusion of bone cement p. 89
Meiyong Wang, Qunhua Jin
DOI:10.4103/ijpn.ijpn_26_20  
Objective: Bone cement leakage causes severe complication following percutaneous vertebroplasty. This study probed the diffusion and leakage status of bone cement injected within diverged time duration, to find the optimal injection time for bone cement. Methods: A total of 70 patients with osteoporotic vertebral compression fractures with a symptom of low back pain who underwent treatment at hospital were enrolled in this study. Patients were randomized into three groups: <180 s, 180–300, and >300 s of injection time duration from the beginning to the completion of the injection. The scenarios of vertebral bone cement leakage and diffusion were inspected using postoperative computed tomography. Results: The diffusion coefficient was higher in Group A than in Group B, whereas it was higher in Group B than in Group C, but without statistical significance among the three groups. The leakage rate was without statistical significance among the three groups. The injection time of bone cement was negatively correlated with the diffusion coefficient, at the correlation coefficient of −0.253. Conclusions: The diffusion coefficient of high-viscosity bone cement is likely negatively correlated with the injection time, and the leakage rate of high-viscosity bone cement probably does not reduce with the prolongation of injection time.
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Comparative analysis of fluoroscopic-guided and ultrasound-guided sacroiliac joint injection in patient with clinical sacroiliitis p. 94
Chetna Shamshery, Vijayakumar Vissnu Kumar, Anil Agarwal, Rajashree Madubashi, Aakanksha Aggarwal
DOI:10.4103/ijpn.ijpn_27_20  
Background: The complex anatomy of sacroiliac joint (SIJ) mandates an imaging modality to perform the diagnostic or therapeutic joint injection. Methods: Thirty-eight patients with sacroiliitis were randomly allocated into two groups, and were given SIJ injection using either fluroscopy (FL) or ultrasound (USG) as a guide to intervene. The assessment of pain by numerical rating scale (NRS), psychological and quality of life assessment by Depression Anxiety Stress Scale (DASS) and Oswestry Disability Index (ODI), respectively, learning curve evaluation by the number of attempts, time taken and subjective ease of performing the procedure were evaluated. Results: Decreased numerical rating score (NRS) of pain from preprocedure mean value of 7.39 ± 0.20–0.94 ± 0.15 in the FL grp and 7.22 ± 0.21 to 2.78 ± 0.32 in the USG group at 4 weeks was significant and comparable (P < 0.001). The improvement in DASS from 40.78 ± 1.96–22.78 ± 0.49 (P < 0.001) in FL grp and 41.33 ± 1.62–25.22 ± 0.73 (P < 0.001) in USG group were significant and comparable after 12 weeks' follow-up. ODI decreased from 45.44 ± 0.99–20.78 ± 0.84 (P < 0.001) and 46.33 ± 0.98–24.11 ± 0.95 (P < 0.001) in FL and USG grp after 12 weeks. Fluoroscopic procedure took 1–3 attempts compared to 2–4 for USG. The average time taken to perform fluoroscopic intervention was 6.89 ± 0.23 min as compared to 9.32 ± 0.87 min by USG. Conclusion: USG and FL both are effective tools to intervene the SIJ but USG requires greater skill.
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Comparison of clinical efficacy between dexamethasone and triamcinolone for transforaminal epidural steroid injections in the management of low back pain p. 101
Dinesh Kumar Sahu, Ajinkya Kale, Atul Sharma, Reena Parampill
DOI:10.4103/ijpn.ijpn_35_19  
The objective of this study was to compare the clinical efficacy of transforaminal epidural injection of dexamethasone and triamcinolone in the management of chronic low back pain with or without radiculopathy due to herniated intervertebral disc. It was a prospective, randomized, single-blind study, conducted in eighty patients of either sex suffering from low back pain of more than 3 months duration due to herniated intervertebral disc. The patients were allocated into two groups to receive either injection dexamethasone 8 mg or injection triamcinolone acetonide 40 mg as 2 ml solution through transforaminal epidural route. Each patient underwent unilateral lumbar transforaminal epidural steroid injections (TFESIs) at one level only depending on predominant involvement of nerve root on magnetic resonance imaging computed tomography of the spine and consistent with a clinical presentation of patients. Patients in both the groups were assessed prior to epidural injection and at the 2nd, 6th, and 12th weeks following epidural injection for the intensity of pain using a numerical rating scale of 0–10 and requirement of analgesics on weekly basis. Any adverse event following epidural injection was also noted during the follow-up period of the study. Improvement in pain score was significantly better with transforaminal epidural injection of triamcinolone acetonide compared to dexamethasone, in patients with chronic low back pain due to herniated intervertebral disc. No major adverse event was reported during the follow-up period in patients of either group.
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Study of effectiveness of lateral wedge insole on medial compartment of osteoarthritis of knee treated with viscosupplementation p. 106
Vinay Kanaujia, Ajay Gupta, Deepak Kumar Sharma, Shipra Verma, Raj Kumar Yadav
DOI:10.4103/ijpn.ijpn_48_20  
Context: Knee Osteoarthritis (OA) is a common disorder affecting the elderly population in the Asia-Pacific region. The goals of OA treatment include alleviation of pain and improvement of functional status. There is lack of consensuses regarding the management of knee OA. Aims: The main aim of this study is to evaluate any synergistic effect of adding lateral wedge insoles to viscosupplementation. Settings and Design: This is a randomized interventional study in which total 60 patients were selected from a tertiary care center and divided in two equal groups using computerized block randomization. Methods and Material: Group A got only VS while Group B got VS with LWI. Assessment was done at baseline and then after 2nd, 4th and 12thweeks after the intervention by using Visual Analogue Scale (VAS) for pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for function and Health Assessment Questionnaire (HAQ) for quality of life. Statistical Analysis Used: The data were entered in MS EXCEL spreadsheet and analysed by using Statistical Package for Social Sciences (SPSS) version 21.0. Results: In this study all the patients in both group showed statistically significant improvement in VAS, WOMAC and HAQ on all three follow-ups over the baseline assessment (P value < 0.0005). On inter-group comparison, statistically significant better results were noticed in the WOMAC scores of group B at 2nd week and 4th week (P value <0.0005) on follow up over group A. The statistically better result in group B on WOMAC was not seen at the 12 week follow up. Conclusions: Viscosupplementation has significant role in OA knee management. Intra articular Hyaluronic acid injection improves significantly the pain, function and quality of life of moderate grade OA Knee patients. Addition of Lateral wedge insole in the treatment gave initial relief in stiffness and function but not on subjective pain felt or on quality of life. Also, in long-term, it had no added advantage over viscosupplementation.
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Continuous epidural versus continuous adductor canal block for postoperative pain management in total knee arthroplasty p. 112
RK Singh, GV Krishna Prasad
DOI:10.4103/ijpn.ijpn_76_19  
Background: The aim of the study was to compare the study of continuous epidural and continuous adductor canal block for postoperative pain management in total knee arthroplasty (TKA). Materials and Methods: A total of 150 cases were recruited with 75 cases in each group; patients participated in the study were divided into the adductor canal block (ACB) group and continued epidural group. All the patients received the standardized anesthesia and analgesia on hospitalization. Outcome evaluations included the visual analog scale (VAS) scores during activity and at rest, range of motion, quadriceps strength, complication occurrence, total opioid consumption and sleep disruptions caused by pain, postoperative hospital stay, and postoperative nausea and vomiting (PONV) before discharge in all groups. Results: The lateral VAS scores of the knee were lower in the continuous epidural group at rest and during activity as compared with the ACB group. However, the overall knee VAS score, complication occurrence, total opioid consumption and sleep disruptions caused by pain, and PONV were similar between ACB and epidural groups. The urinary retention in patients receiving continuous epidural was common compared to no retention in the adductor group, early mobilization in the adductor group, and no muscle weakness in the ACB group. Conclusion: The ACB does not relieve the lateral knee pain at an early stage but offers comparable analgesic effect and enhanced effectiveness of the early rehabilitation compared to an epidural in patients who underwent TKA.
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Effect of intravenous versus intrathecal dexmedetomidine on the characteristic of spinal anesthesia in patients undergoing infra umbilical surgeries p. 118
Pradeep Kumar, Usha Bafna, Mamta Khandelwal, Rama Chatterji
DOI:10.4103/ijpn.ijpn_88_19  
Background: Dexmedetomidine have been used as an adjuvant to local anaesthetic in subarachnoid block and as intravenous medication for postoperative pain relief and sedation. In higher doses, it may produce adverse effect on haemodynamic. Aim: This study compares the effects of low-dose intravenous (IV) dexmedetomidine or Intrathecal dexmedetomidine with hyperbaric bupivacaine on spinal characteristic, total duration of analgesia, and sedation. Objective: the primary objective of our study evaluate the total duration of analgesia and a secondary objective was to assess and compare the onset time and duration of sensory block, changes in hemodynamic parameter and side effect. Materials and Methods: In this prospective, randomised, double-blinded study, 240 American Society of Anaesthesiologist Status I and II patients were randomly allocated into two groups: Group IV: Patients received dexmedetomidine 0.5 μg/kg body weight diluted up to 10 ml with normal saline intravenously by infusion pump and 3 ml of 0.5% hyperbaric bupivacaine diluted in 0.5 ml of normal saline intrathecally.Group IT: Patients received 10 ml of normal saline intravenously by infusion pump and 3 ml of 0.5% hyperbaric bupivacaine with 0.5 ml (5 μgm) of dexmedetomidine intrathecally. Onset and duration of sensory and motor block, first request for analgesia, hemodynamic, VAS score, and sedation score were assessed. Results: Time to two segment regression was more in group IT (127.7 ± 16.69 min) as compared to group IV (116 ± 16.2 min). Total duration of analgesia was also prolonged in group IT (274.68 ± 58.21 min) than group IV (211.37 ± 32.87 min)(P < 0.001). Conclusion: IT dexmedetomidine as compared to IV dexmedetomidine as an adjuvant to intrathecal bupivacaine prolonged the time to first request for analgesia, without any significant adverse effect.
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A comparative study of supraclavicular block, interscalene block, and combination of supraclavicular with interscalene block using 0.5% ropivacaine and dexmedetomidine as adjuvant by nerve stimulation technique in upper limb surgery p. 124
Balwinder Kaur Rekhi, Tripat Kaur Bindra, Rajandeep Khera, Mandeep Kaur
DOI:10.4103/ijpn.ijpn_3_20  
Background: Anesthesia for upper limb surgeries may include general anesthesia, regional anesthesia, or combination of both. Compared with general anesthesia, brachial plexus regional anesthesia technique is preferred for upper limb surgeries. Aims and Objectives: A comparative study of supraclavicular block, interscalene block, and combination of supraclavicular and low interscalene blocks using 0.5% ropivacaine and dexmedetomidine as adjuvant by nerve stimulation technique in upper limb surgery in terms of the onset of sensory and motor block and duration of sensory and motor block. Materials and Methods: The patients in supraclavicular block group (n = 20) were given supraclavicular block, in interscalene block (IRD) group (n = 20) were given low interscalene block, and in combination of supraclavicular and interscalene block (ISRD) group (n = 20) were given combination of supraclavicular block and low interscalene block using nerve stimulator by injecting 30 ml 0.5% ropivacaine and 50 μg dexmedetomidine in each group. Results: The results showed that there was no statistically significant difference seen in demographic and hemodynamic parameters. Combined supraclavicular block and low interscalene block had statistically better outcomes than supraclavicular block and low interscalene block individually. Conclusion: The onset of sensory and motor block in combined supraclavicular and interscalene blocks as significantly faster with prolonged duration of sensory and motor block followed by low interscalene block and supraclavicular block, respectively. There were no significant complications encountered during the procedure.
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CASE SERIES Top

“Abdominal pain” in COVID-19 patients: A conundrum for the pain physician p. 128
Ashok Kumar Saxena, Suman Choudhary, Diksha Gaur
DOI:10.4103/ijpn.ijpn_63_20  
In the current scenario of Corona-19 pandemic, absolute awareness among all health – care workers is necessary. History taking and analyzing the symptoms obviously remains the cornerstone for the detection of COVID-19. However,physician must suspect COVID-19 in patients presenting with the chief complaint of gastrointestinal symptoms such as abdominal pain,diarrhea, and vomiting with or without respiratory complaints. This case series conveys an important message about changing our approach in the initial assessment and management of patients with acute abdominal pain or acute on chronic abdominal pain.
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CASE REPORTS Top

Cauda equina syndrome in a postoperative patient of total hip replacement surgery: Possible exacerbation due to extreme intraoperative manipulation p. 131
Omer Mohammed Mujahid, Samarjit Dey, Javaid Iqbal, Tuhin Mistry, Jitendra Kalbande, Monica Khetarpal
DOI:10.4103/ijpn.ijpn_43_20  
Cauda equina syndrome (CES) is a rare but devastating complication, which warrants an urgent or emergency decompressive surgery. To diagnose it early and also, a timely intervention can halt neurological sequelae. More common causes for CES include chronic disc diseases, spinal injury, and fractures. However, there are less common causes such as spinal manipulation, tuberculosis, and spinal tumors. Here, we report a rare cause of CES precipitated by extreme manipulation of the spine during total hip replacement surgery done under neuraxial blockade. This condition was diagnosed by the acute pain service team at an early stage and successfully treated with emergency decompressive surgery to avert any further neurological complications.
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Ultrasound-guided erector spinae plane block – A novel analgesic technique for low back pain p. 134
Preeti Soni, Virender Kumar Mohan
DOI:10.4103/ijpn.ijpn_5_20  
We describe the successful use of a novel interfacial plane block and the ultrasound-guided erector spinae plane (ESP) block in two cases with severe chronic low back pain. Both of our patients have received conservative treatment (medicines and exercise therapy) for long and have also undergone invasive treatment modalities for their low backache. Ultrasound-guided ESP block provided better analgesia due to greater dermatomal coverage as well as reduced risk of complications as compared to a lumbar epidural that had previously been employed in both patients. The ESP block anesthetizes the dorsal rami of spinal nerves that innervate the paraspinal muscles and bony vertebra, and it offers a simple and safe technique to treat chronic low backache.
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Stellate ganglion intervention for pain associated with morphea p. 138
Ravi Shankar Sharma, Manoj Kamal, Bharat Paliwal, Pradeep Bhatia, Suyashi
DOI:10.4103/ijpn.ijpn_58_20  
Morphea is an autoimmune connective tissue disease of unrevealed etiology. It is associated with skin changes in the form of thickening along with deposition of excess of collagen in the affected lesion. Pain associated with morphea is usually a rare finding and is refractory to conventional analgesics. Hence, here we discuss a case of morphea with debilitating pain, that was successfully managed with stellate ganglion block.
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LETTERS TO THE EDITOR Top

Telemedicine pain clinic facilities in the era of COVID-19 p. 141
Pratibha Singh, Sujeet Gautam, Anil Agarwal
DOI:10.4103/ijpn.ijpn_71_20  
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Headache in COVID-19: An observation p. 142
Won Sriwijitalai, Viroj Wiwanitkit
DOI:10.4103/ijpn.ijpn_37_20  
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Severe acute respiratory syndrome coronavirus 2: Concerns for palliative care physicians p. 143
Prashant Sirohiya, Brajesh Kumar Ratre
DOI:10.4103/ijpn.ijpn_72_20  
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