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   Table of Contents - Current issue
Coverpage
September-December 2020
Volume 34 | Issue 3
Page Nos. 145-220

Online since Monday, December 28, 2020

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EDITORIALS  

Ultrasound tour of the anterior neck for the interventional pain physician p. 145
Nan Xiang, Vinita Singh
DOI:10.4103/ijpn.ijpn_150_20  
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Need for online registration of the clinical trials on humans by authors! p. 148
Rakesh Garg, Kanika Rustagi, Hammad Usmani
DOI:10.4103/ijpn.ijpn_53_20  
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REVIEW ARTICLES Top

Role of ultrasound in chronic pain management Highly accessed article p. 151
Rajendra Kumar Sahoo, Philip W H. Peng
DOI:10.4103/ijpn.ijpn_133_20  
Ultrasound application in interventional pain medicine has made tremendous growth in recent years. Ultrasound not only avoids radiation exposure but also allows real-time visualization of the drug delivery and avoids damage to the surrounding structures. It also ensures accurate delivery of medication; thus improves efficacy and outcome. Furthermore, ultrasound is a valuable tool for pain physicians in confirming the diagnosis of many musculoskeletal pain conditions and entrapment neuropathies in the clinic. Its role in various aspects of chronic pain like spinal pain, musculoskeletal pain and nerve-related pain are discussed below.
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A comprehensive review of complications following ultrasound-guided blocks: “Continue D'avancer” p. 160
Suman Choudhary, Ashok Kumar Saxena, Megha Bajaj, Anwesha Banerjee
DOI:10.4103/ijpn.ijpn_134_20  
The use of ultrasound-guided (USG) technique for regional blocks is a well- established method in regional anaesthesia with the added advantage of providing real-time images of the plexus and nerves and surrounding structures, while significantly minimizing complications. Even if the evidence is in favour of USG guided blocks suggesting that the complications and frequency of complications are significantly lower, this review article is all about few complications that have been published so far in the scientific literature. The complications encountered following USG guided blocks has been categorised into two broad headings: technical and non-technical (neurological, haematological, miscellaneous) in this article.
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ORIGINAL ARTICLES Top

Ultrasound in pain and musculoskeletal interventions: A nation-wide survey of practicing pain physicians p. 164
Rajendra Kumar Sahoo, Pratibha Matche, Sanjay Khanna, Sunita Lawange, Pankaj Surange, Gautam Das
DOI:10.4103/ijpn.ijpn_60_20  
Background: Conventionally, fluoroscopy has been used by Pain Physicians to perform minimally invasive pain and spine interventions. In recent times, the use of ultrasound (US) in interventional pain management (IPM) has increased significantly. However, there is no Indian data with regard to US use for IPM. Hence, the musculoskeletal (MSK) pain special interest group (SIG) of the Indian Society for Study of Pain (ISSP) decided to conduct a survey among Indian Pain Physicians to get an insight into various aspects of US in IPM. Materials and Methods: The MSK Pain SIG of ISSP developed the questionnaire, and the same was sent to ISSP members with an active E-mail ID. The questionnaire was mainly about US availability at the workplace, training received for US-guided IPM, barriers to US use, and suggestions to improve widespread US use. Results: The response rate was only 15% (176 out of 1160 physicians responded). The majority (69.3%) of the respondents used both US and fluoroscopy and the US machine was available in 76.1% pain clinics. Over three-fourth reported that they have received training for US-guided IPM. Only half of the participants expressed that they received US training during pain fellowships. Barriers for US use included lack of formal teaching/training of US, availability of US machine, and preconception and prenatal diagnostic techniques (PCPNDT) act. The future strategy includes taking measures for US availability for pain physicians, mandatory US training during fellowships and regular workshops. Conclusion: This first-of-its-kind survey provides many valuable insights on US availability, barriers, and future suggestions. ISSP can consider joint collaboration with other organizations on dilution of existing law and take measures to improve US training and its widespread use.
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Pain physicians' perspectives on chronic pain management during COVID-19 pandemic: An online survey p. 171
Samarjit Dey, Shovan Kumar Rath, Pankaj Surange, Rajendra Sahoo, Gaurav Sharma, Priyanka Dev
DOI:10.4103/ijpn.ijpn_143_20  
Background: The ongoing COVID-19 pandemic has affected the current health care to the core. As a result, there is a shift of focus on health care to control the pandemic. The chronic pain patients, though at risk, are also the sufferers. The aim of this online survey was to evaluate the perspective of the pain physicians on chronic pain management during COVID-19 pandemic in India. Methods: The survey was conducted under the aegis of Indian society for study of pain. The questionnaire in the form of Google Forms was filled by pain physicians online after webinar. Results: In this survey, majority of the pain physicians (71.12%) reported that they are practicing pain even during COVID pandemic but with precautions. Around 65.77% of the pain physicians were using telemedicine for consultation. A prior COVID test for interventional procedures was opted by 85.56% of pain physicians. Total 89.30% feel that personal protective equipment is necessary for doing pain interventions. Meanwhile, during the pandemic, 97.32% of the pain physicians are attending webinars to keep themselves updated. Conclusion: This survey of pain physicians' perspectives on impact of COVID-19 shows that chronic pain practice was greatly affected. Although webinars are a modality to keep the pain physicians updated, telemedicine has taken its stride forward to prove its major role during this pandemic for consultation. The personal protection is the new must-have among pain physicians in clinics and hospitals during and after pandemic.
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Ultrasound-guided transmuscular quadratus lumborum block for anterior iliac crest bone graft promotes early ambulation in patients undergoing cervical corpectomy and fusion p. 175
Rahul Pillai, Bijesh Ravindran Nair, Prasad Kanna Prabhakar, Georgene Singh, Karen Ruby Lionel, Ranjith K Moorthy, Melvin Joy, Ramamani Mariappan
DOI:10.4103/ijpn.ijpn_88_20  
Context: The iliac crest (IC) is widely used as an autograft for bony fusion in spine surgeries. The pain after IC harvesting is severe enough to delay ambulation and thus hospital discharge. Aim: This study aimed to determine the effect of a transmuscular quadratus lumborum block (QLB) on postoperative ambulation in patients undergoing anterior IC bone graft harvesting. Settings and Design: This was a retrospective study of patients who underwent cervical corpectomy and fusion with anterior IC bone graft over a period of 3 years. Materials and Methods: Group A was patients who received QLB for anterior IC bone graft harvest site pain, and those who did not receive QLB were Group B. The primary outcome was the time taken for ambulation, and the secondary outcomes compared were the pain scores, hemodynamics, and the duration of hospital stay. Results: A total of 34 patients were studied, of which 17 patients received QLB (Group A) and the rest 17 did not receive QLB (Group B). The demographics, preoperative and intraoperative variables, and the pain score were comparable between the groups. The patients in the QLB group ambulated early as compared to Group B (1.5 ± 0.7 vs. 2.4 ± 0.9 days = 0.002). Further, the duration of postoperative hospitalization was shorter in the former as compared to the latter (3.8 ± 1.6 vs. 5.1 ± 2.1 days; P = 0.054). There were no complications related to the QLB. Conclusion: The administration of QLB resulted in earlier postoperative ambulation in patients undergoing cervical corpectomy with AIC bone graft. Although the length of hospitalization was shorter in the QLB group, it was not statistically significant.
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The effectiveness of piriformis injection under fluoroscopy and nerve stimulator guidance with local anaesthetic and steroid for management of piriformis syndrome among manual workers in Eastern India: A prospective interventional study p. 183
Debasish Jatua, Biplab Sarkar, Gargi Nandi, Baibhav Bhandari, Prasanta Ray Karmakar, Subrata Goswami, Sagar May Basu
DOI:10.4103/ijpn.ijpn_76_20  
Background: Piriformis syndrome (PS) is a neuromuscular disorder characterized by compression or irritation of sciatic nerve by the piriformis muscle causing pain, tingling, and numbness in the buttocks and sometimes along the distribution of the sciatic nerve descending down to the leg. Pharmacotherapy and physical-therapy remain the first line of management. Local anesthetic (LA) with steroid injection in piriformis muscle is given if conservative management fails. Nerve stimulator, electromyography, radiological imaging, and various other methods have been used to increase the reliability of injections. In the present study, the efficacy of combined fluoroscopy and nerve stimulator guided piriformis injection with LA and steroid for the management of PS has been re-validated among the manual workers of Eastern India. Subjects and Methods: With ethical permission and informed consent from 35 patients of PS fulfilling the inclusion and exclusion criteria were given piriformis injection with 5 mL of 0.25% bupivacaine and 20 mg methyl prednisolone under guidance of a combination of fluoroscopy and nerve stimulator. Thirty-one patients completed the study. Pain in Numeric Rating Scale and Disability by Ronald Morris Disability Questionnaire were recorded for all patients before the procedure, 1 h, 1 week, 3 weeks, and 12 weeks after the procedure and were statistically analyzed. Results: Pain score and back disability score decreased significantly (P < 0.05) after the injection, and the effect was also sustained up to 12 weeks. Conclusions: Injection of LA along with steroid in piriformis muscle under fluoroscopy and nerve stimulator guidance, followed by physiotherapy, is an effective treatment for PS among manual workers.
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Evaluation of magnesium sulfate as an adjuvant to bupivacaine for postoperative analgesia in ultrasound-guided transversus abdominis plane block in patients scheduled for lower segment caesarean section under subarachnoid block – A prospective, randomized, double-blind study p. 189
Mayuresh Umalkar, Nandini Londhe
DOI:10.4103/ijpn.ijpn_104_20  
Background and Aims: Various adjuvants such as magnesium sulfate (MgSO4), dexamethasone, and clonidine have been used in transversus abdominis plane (TAP) block to prolong the duration analgesia. MgSO4 is N-methyl D-aspartate receptor antagonist (NMDA) and presence of NMDA receptors in skin and muscle can prolong the duration of postoperative analgesia. We aimed to evaluate the effects of MgSO4 as an adjuvant to bupivacaine in ultrasound-guided (USG) TAP block for prolongation of duration of postoperative analgesia. Materials and Methods: Sixty pregnant patients of the American Society of Anesthesiologists physical Status I and II between age group of 18–35 years, scheduled for elective cesarean section under subarachnoid block were allocated randomly into two groups:- Group BM (bupivacaine + MgSO4) and Group B (bupivacaine + Normal saline). All patients received USG bilateral TAP block after caesarean section using either 25 ml of 0.25% bupivacaine and 0.3 ml (75 mg) of 25% injection MgSO4 or 25 ml of 0.25% Bupivacaine and 0.3 ml of normal saline on each side. All patients were evaluated for dynamic pain at 0, 30 min, 1, 2, 4, 6, 12, and 24 h, for postoperative analgesia and adverse effects. The normally and nonnormally distributed data were analyzed using unpaired t-test and Mann–Whitney U-test, respectively. P < 0.05 was considered statistically significant. Results: Duration of analgesia in Group BM (12.3 h. ±0.83666 h) and Group B (12.0333 h. ±1.24522 h) were comparable (P = 0.3348). The average pain scores at different time points did not differ significantly between the two groups (P > 0.05). Conclusion: MgSO4 as an adjuvant to bupivacaine in USG TAP block does not prolong duration of postoperative analgesia.
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Comparison of clonidine and fentanyl as adjuvant in femoro-sciatic nerve block for postoperative analgesia – A prospective randomized controlled trial p. 193
Usha Kumari Chaudhary, Nidhi Panda, Neerja Bharti, Neeru Sahni, Komal Gandhi, Yatinder K Batra, Mandeep Singh Dhillon
DOI:10.4103/ijpn.ijpn_35_20  
Introduction: Arthroscopic anterior cruciate ligament reconstruction (ACLR) is associated with moderate-to-severe postoperative pain which may delay hospital discharge as well as physiotherapy resulting in poor outcome. The aim of our study was to compare the effect of clonidine or fentanyl as adjuvant to bupivacaine in femoro-sciatic nerve block (FSNB) on the duration of pain-free period and requirement of rescue analgesic postoperatively. Materials and Methods: Sixty adult patients undergoing ACLR of the knee joint received subarachnoid block as anesthesia for surgery and FSNB for postoperative analgesia. Patients in Group C (control group) received 40 ml of 0.25% isobaric bupivacaine (20 ml in femoral and sciatic block each), whereas Group F (fentanyl group) received fentanyl (1 μg/kg) and Group CL (clonidine group) received clonidine (1 μg/kg) with 40 ml of 0.25% isobaric bupivacaine. The duration of pain-free period, rescue analgesic consumption, postoperative pain score, sedation levels and adverse effects were monitored along with hemodynamic parameters for 24 h postoperatively. Results: The patients in the clonidine group had longer pain-free period (10.06 ± 3.62 h) as compared to the fentanyl group (7.94 ± 3.62 h) and control group (4.59 ± 1.20 h) (P < 0.001). Postoperative pain scores were higher in the control group at the 4th, 8th, and 12th h and comparable between the fentanyl and clonidine groups. The total amount of rescue analgesic requirement was less in the clonidine group (71.25 ± 16.77 mg) than the fentanyl group (86.25 ± 36.71 mg) and control group (161.20 ± 50.34 mg) (P < 0.001). No clinically significant adverse effects were observed in any group. Conclusion: Clonidine as an adjuvant to bupivacaine in FSNB provides better postoperative analgesia compared to fentanyl by significantly prolonging the pain-free period and decreasing rescue analgesic requirement in postoperative period without any untoward side effect.
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CASE SERIES Top

Ultrasound-guided transversus abdominis plane block in high-risk infants, better option than opioids: A series of five cases p. 199
Farah Nasreen, Atif Khalid, Divyashree S Mallur
DOI:10.4103/ijpn.ijpn_73_20  
Perioperative analgesia poses specific problems, especially when it comes to neonates and infants. The use of opioid in neonates is usually associated with the risk of delayed extubation and postoperative mechanical ventilation. Regional analgesia including epidural and caudal may be technically challenging or has limitations in a certain group of patients. Ultrasound (US)-guided transversus abdominis plane block (TAP) is gaining popularity as a new technique of regional anesthesia applicable to infants and children. Precise drug administration is a major concern with TAP blocks in pediatric patients, especially infants and neonates. The application of US has enhanced the accuracy of local anesthetic deposition and hence the efficacy of analgesia in TAP block. We, hereby, report a series of five high-risk infants and neonates posted for abdominal surgeries wherein an ultrasonography-guided TAP resulted in satisfactory perioperative analgesia obviating the need of systemic opioids.
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Efficacy of ultrasound guided bilateral single shot erector spinae plane block for post-operative analgesia in patients undergoing lumbar spine surgery p. 202
Neha Kanojia, Amarnath Reddy Basvanapalli, Vamsikrishna Chagalakonda, Balaraja Sekhar
DOI:10.4103/ijpn.ijpn_72_19  
Severe postoperative pain following the lumbar spine surgery is a cause of significant morbidity, increased analgesic usage, and delayed discharge. With the present case series of 15 patients, we want to explore the efficacy of preincisional single-shot bilateral ultrasound-guided erector spinae plane block at L2 vertebrae level for postoperative analgesia in patients undergoing lumbar spine surgeries.
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CASE REPORTS Top

Superficial peroneal nerve entrapment: The eyes do not see what the mind does not know p. 206
Ashok Jadon, Swastika Chakraborty, Neelam Sinha, Bhupendra Singh
DOI:10.4103/ijpn.ijpn_101_20  
Entrapment of the superficial peroneal nerve (SPN) is common, but it can remain unrecognized. Due to variable topography of the nerve, the symptoms may vary from pain, tingling, and numbness to weakness in the foot. Therefore, anatomical knowledge is essential for early diagnosis and successful management. We report two cases of SPN entrapment where treatment was delayed due to incorrect diagnosis or inadequate treatment strategy. Both the patients were managed successfully by ultrasound-guided hydrodissection around the SPN and injection of a local anesthetic mixed with corticosteroids. The case reports highlight the importance of ultrasound in the correct diagnosis and early intervention to avoid unnecessary suffering and sequelae of delayed treatment.
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Ultrasound-guided continuous transmuscular quadratus lumborum block as a sole anesthetic technique for inguinal hernia repair in a high-risk patient p. 209
Virender Kumar Mohan, Shikha Jain
DOI:10.4103/ijpn.ijpn_17_20  
Quadratus lumborum (QL) block has been described as a postoperative analgesic technique by Blanco following superficial abdominal surgeries but has not been used as a sole anesthetic technique. This ipsilateral block with an indwelling catheter inserted for continuous QL block provided the pain-free course. It decreased opioid use both during intra and postoperative periods with a sensory block of T8–L1, thus avoiding complications related to general and neuraxial anesthesia in patients with low cardiac reserve. We report a high-risk case undergoing inguinal mesh hernioplasty under continuous QL block.
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Greater occipital nerve block- A case report of a patient of Occipital neuralgia using proximal approach under USG guidance p. 212
Vikas Tyagi, Dhruv Bibra, GP Dureja
DOI:10.4103/ijpn.ijpn_10_20  
Occipital neuralgia is a neuropathic pain disorder with distinctive diagnostic and therapeutic challenges. Many pain physicians and neurologists consider this to be a nonexistent condition which merely represents a variant of cervicogenic headache emanating from C1 to C4 nerve roots. Repetitive microtrauma from a hyperextended neck (painting ceilings or working with computers for long hours with a high focal point) may result in the development of this condition. Failure of conservative management necessitates greater occipital nerve (GON) block in the treatment of occipital neuralgia. Conventionally, GON has been blocked at superior nuchal line through a landmark-guided technique using occipital artery pulsations as guidance or using ultrasound as done in classical distal technique at the same site. Another less frequently used technique under ultrasound is the one where the nerve is blocked at a proximal site. We describe here a case report where we chose proximal technique done under ultrasound, superficial to the obliquus capitis inferior muscle (OCIM), which has a higher success rate and allows for a more precise blockade of the nerve before it branches out as in distal technique.
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LETTERS TO THE EDITOR Top

Aberrant artery within the brachial plexus: Doppler ultrasound as a savior p. 215
Kirthiha Govindaraj, Ramya Ravi, Stalin Vinayagam, Rajasekar Ramadurai
DOI:10.4103/ijpn.ijpn_83_20  
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Role of telerehabilitation in musculoskeletal conditions during COVID-19 pandemic Highly accessed article p. 217
Amir Ateeq, Nusrat Jahan, Md Farhan Alam, Fatima Khanum
DOI:10.4103/ijpn.ijpn_136_20  
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Quick Entonox/nitrous oxide: Oxygen to ease spinal anesthesia in obstetrics p. 219
Reena R Kadni, Pooja G Roa
DOI:10.4103/ijpn.ijpn_119_20  
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