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   Table of Contents - Current issue
January-April 2021
Volume 35 | Issue 1
Page Nos. 1-92

Online since Tuesday, April 27, 2021

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Comeuppance of adult cancer pain in contemporary modern times: The dawn of a new era of understanding Highly accessed article p. 1
Ashok Kumar Saxena, Suman Choudhary, Hammad Usmani
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Bone cancer pain p. 4
B Carolina Hernandez-Porras, Ricardo Plancarte, Juan Miguel Jimenez Andrade, Dhanalakshmi Koyyalagunta
In 2012, the International Agency for Research on Cancer reported 14.1 million new cancer cases, 8.2 million cancer deaths, and 32.6 million people living with cancer. Cancer pain not only causes significant suffering but also contributes to a decreased quality of life, functional status, and greatly increases health-care costs. The bones are a common site for metastases, especially tumors involving breast, lung, prostate, and kidneys. This can lead to significant pain, pathological fractures, compression of the spinal cord, poor quality of life, and increased mortality. Pathophysiology of cancer-induced bone pain is complex and has neuropathic and nociceptive characteristics. The aim of the treatment of bone metastases is palliating painful symptoms and preventing progression of skeletal-related events. A multimodal approach including various cancer therapies, analgesic and adjuvant agents, and interventional modalities should be used. This review focuses on the pathophysiology of bone cancer pain and pharmacological and non-pharmacological modalities that reduce bone cancer pain.
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Interventional management for cancer pain Highly accessed article p. 11
Parmanand N Jain
The WHO analgesic ladder (1986) has recommended certain oral analgesics vis-a-vis intensity of cancer pain for optimum relief as a practical doctrine, easy to implement, and taught extensively to healthcare professionals globally. However, the WHO approach despite been implemented appropriately and aggressively in the last three decades, 10%–20% of patients may not achieve acceptable pain relief. There is a refractory group of patients which is considered for interventional pain management; however, reserving this modality as a last resort is questioned by interventional protagonists. It is anticipated that the general understanding of interventional approach on cancer pain relief may not only expedite pain relief but should also consider all potential therapeutic options. Interventional physicians, mainly anesthesiologists, have a well-defined and beneficial role in the treatment of cancer pain, if patients are appropriately selected with various cancer pain syndromes. Pain physicians should successfully optimize outcomes depends on timely referral with adequate assessment and patient selection. Pain physicians have a complex role. Managing expectations of referring physicians, of patients, and family members, assuring adequacy of interventional care is not an easy task. An experienced, skilled interventionist who is well versed in not only techniques of procedure but side effects management, if any, will assume full responsibility for pre- and postintervention evaluation and follow-up care as indicated by the circumstances of each patient to be managed.
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Celiac plexus neurolysis for intractable upper abdominal malignant pain: A review article Highly accessed article p. 16
Anurag Agarwal, Shivani Rastogi, Anuj Gautam, Deepak Malviya, Sujeet Rai, Manoj Giri, Shilpi Mishra, Sandeep Yadav
Celiac plexus neurolysis (CPN) is an effective intervention of upper abdominal malignant pain. Multiple approaches have been described for performing CPN. This narrative review has been done to evaluate current literature on CPN by different approaches and to determine whether anyone approaches is better. The literature search of PubMed and Google Scholar was done and relevant literature was compiled for the review. The literature was reviewed to find the preferred technique of CPN by different investigators and differences in the outcome and/or complications and side effects. Multiple techniques of CPN such as classic retrocrural approach, antecrural approach, transaortic approach, anterior approach, and transdiscal approach have been used by different researchers. Effective pain relief and improved quality of life (QOL) have been reported to be achieved by all the approaches. Unilateral transaortic approach has been found to be associated with less morbidity owing to single needle and with a lesser volume of neurolytic agent used. The most common imaging method used by a large number of researchers is c-arm fluoroscope, though few authors have recommended computed tomography scan-guided CPN, especially in cases with distorted anatomy due to disease spread or metastasis. This review has focused only on CPN by the pain physicians. Other techniques such as endoscopic ultrasound technique by gastroenterologists and splanchnic radio-frequency ablation have not been compared. CPN is an effective technique for pain control and improved QOL in upper abdominal malignant pain. The selection of approach is largely dependent on the pain physician's choice and does not show the difference in the outcomes.
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Mobile applications for chronic pain management: An analysis of pain apps available in the app store Highly accessed article p. 24
Bhavna Gupta, Pallavi Ahluwalia
Background: There has been considerable interest in mobile and tablet technology in the field of health care. This interest has brought the area of mobile health apps, described as providing health care and health-related services through communications devices, into-sharp focus. This study aimed to assess the status of contemporary apps targeted at chronic pain assessment and management with a particular focus on patient-centered approach, criterion for pain assessment, medication assessment, targeted system, and pain management/guidance. Methodology: We searched for pain apps specific for chronic pain on the App Store for iOS devices and Google Play for Android devices. Each app store was searched using terms related to “pain,” “chronic pain,” “pain scale,” and “pain management.” Various parameters such as the name of the app, availability in operating systems (iOS or Android), download cost, creation dates, date of latest update, language, type of pathology, user rating, number of downloads, reviews, type of target population, the objective of the app and target population were explored. To explore the downloaded apps, an Excel® tool was designed for data extraction. Observations: Two hundred and fifty-four numbers of apps were identified after excluding duplicates. Forty-seven apps were included in the study that had a rating of above 4 in Google play store for further analysis. Eight out of 47 apps only did extensive pain assessment, and pain rating score was available in 14 apps. Most of the apps targeted exercise as a primary modality of management, and provided knowledge about the disease process. Few apps were based on the patients' hospital-based management and very few apps targeted yoga, integrative therapy, and trigger point as the primary modalities of management. 75% of apps targeted general pain, and only 25% were specific to an organ system. Majority of the apps were neither designed nor edited by licensed health-care providers, and there was little direct involvement by health-care professionals. Conclusion: The use of mobile devices can offer many advantages and opportunities for enhancing medical care. At present, due to the lack of evidence supporting their use, caution should be taken in the use of smartphones apps. These applications should also be assessed and regularly analyzed, and integrated with pain assessment and pain management and incorporate various integrative therapies based on available recommendations.
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Magnetic resonance imaging scan of the dimensions of normal lumbar intervertebral foramina - An observational study p. 34
Santanu P Mallick
Background: Intervertebral foramen (IVF) is an oval, round, or inverted teardrop shaped bilateral fibro osseous window throughout the entire vertebral column through which neurovascular structures pass. The lumber canal stenosis due to variations of narrowing of intervertebral foramina causes compression of exiting spinal nerve or other foraminal components, for which normal IVF dimensions must be known and understood thoroughly. Aims and Objectives: Although computed tomography scan remains very effective in the evaluation of osseous tissues, but being a fibro osseous canal, intervertebral foramina can be better evaluated by magnetic resonance imaging (MRI) scan for superior resolution. Materials and Methods: Normal morphometric database of right and left lumber IVF of 195 normal adult males (96) and females (99) from different age groups (20–69 years) has been taken to draw conclusions from the data relevant to clinical practice and future research. MRI scan in the sagittal plane gives a complete view of the fibro osseous canal, whereas horizontal imaging (axial view) does not demonstrate the entire IVF on a single image. That's why all the measurements were taken from the sagittal plane. Results: All the values are evaluated with the subjects' age, sex, weight, height, and also with the left versus right sides. The development of this normal database should further allow for more meaningful evaluation of the dimensions of the IVFs in pathologic states. Although diagnosis can be suspected from the history and physical findings, knowledge of the specific anatomy of this clinically significant area with radiological support is very important in the differential diagnosis which helps in proper management. Conclusion: Therefore, it is really convincing that, with regard to morphometry of the spine by means of MRI, the future is very promising.
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A comparative retrospective study of the efficacy of caudal epidural with manipulation versus ganglion impar block with manipulation in patients with coccydynia p. 42
Y Govardhani, G RamMohan, S Abhijith, B Savithri
Objective: The objective of the study was to compare the effectiveness of caudal epidural with manipulation and ganglion impar block with manipulation in treating patients with coccydynia. Materials and Methods: In this retrospective study, patients (n = 60) were divided into two groups of 30 each. Group C (n = 30) received caudal epidural with transrectal manipulation, whereas Group G (30) received ganglion impar block with transrectal manipulation. Preprocedural and procedural Visual Analog Scale (VAS) scores for 10 days, 1, 3, and 6 months were recorded. Preprocedural painless sitting period and postprocedure painless sitting period in two groups were recorded. Results: Preprocedural VAS score was not statistically significant between the two groups (7.76 ± 0.63 vs. 7.6 ± 0.72; P = 0.16). There was no statistically significant difference in the VAS score after 10 days of the procedure in both the groups. Significant decrease in VAS score was observed in Group G than in Group C after 1, 3, and 6 months of the follow-up. The painless sitting period was increased in Group G than in Group C after 6 months of follow-up (79.33 ± 48.4 min vs. 144.16 ± 37.87 min; P < 0.0001). Recurrence was observed in six patients in Group C. No significant complications were observed in both the groups. Conclusion: Ganglion impar block with manipulation is more effective in improving pain sensation and painless sitting period in patients with coccydynia.
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A prospective observational study to assess drug aberrant behaviours in chronic pain patients on gabapentinoids p. 46
Martyna Berwertz, Sangeeta Das, John Michael Raj
Aim: The aim is to explore whether addiction or drug aberrant behavior exists among patients being treated with pregabalin or gabapentin in our outpatient service. Methods: A self-administered questionnaire, the current opioid misuse measure (COMM) was distributed to all patients attending the outpatient service. They filled this voluntarily with maintenance of complete anonymity and confidentiality. Statistical analysis was conducted using the SPSS software. Results: A total of 52 questionnaires were received. Twenty-one patients were on gabapentin and 19 on pregabalin. Eighty percent of the patients had little or no benefit and yet an attempt to taper the doses was made only in 37.8% patients. About 56.9% patients had COMM scores above 9, the cut off value for detecting drug abuse/misuse. The COMM scores showed a positive association with the dose magnitude of gabapentin (P = 0.006) but not pregabalin. They also showed a significant positive correlation with the duration of treatment with pregabalin (P = 0.000). The Mann–Whitney U-test showed that the COMM scores were significantly higher in the pregabalin group (P = 0.022). Conclusions: Our findings suggest gabapentinoids do carry a potential risk of addiction. Pregabalin more than gabapentin may have a potential for drug aberrant behavior. We must regularly review patient's doses and duration of treatment. Large scale studies are needed to validate the findings. Setting up of national pharmacovigilance databases may be the way forward in preventing a potential drug abuse problem.
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The effectiveness of low-level laser therapy on controlling pain and discomfort during separator placement before fixation of orthodontic appliances p. 52
Sahar Abdelatif Muctar, Ali Abdelrahman Marouf, Elhadi Mohieldin Awooda
Background: Pain and discomfort are the most common sequel of orthodontic treatment both before and after separator placement. The aim of this study was to evaluate the effectiveness of low-level laser therapy (LLLT) on pain and discomfort control during separator placement before orthodontic fixed appliance placement. Materials and Methods: A single-blind, split-mouth clinical trial with a sample size of six patients (12 half mouths as cases where three positions on the buccal side of each tooth lased by the power of 1 Watt diode laser before orthodontic separator placement, while the other 12 teeth acted as control where separators were placed without laser application. Assessment of pain and discomfort was done by visual analog scale. The results of pain intensity and discomfort between the study group (EG) and the control group (CG) were compared by t-test and ANOVA, and the level of significance was set at a level at P ≤ 0.05. Results: The majority of the laser group experienced pain during chewing (85.70%) and most of them change their food habits (66.70%). In most of the lased cases (70%), pain intensity increased after 72 h, while among the control cases; it increased after 24 h (83.40%). There was a statistically significant difference in pain degree among the laser group at different time intervals (P = 0.05), while on the control group, statistically significant difference was found at baseline immediately after placement of orthodontic separator (P = 0.05). The majority of the patients' followed the instructions and did not take any medication to decrease pain intensity (66.70%). Conclusion: LLLT was effective in decreasing pain and discomfort during elastic separator placement for orthodontic patients with fixed appliances.
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A comparative study of ultrasound-guided transversus abdominis plane block with local anesthetic infiltration in inguinal hernia repair: A prospective randomized study p. 57
Syed Hussain Amir, Kumari Chitra, Qazi Ehsan Ali, Prabhash Chandra Jha, Md Shahab Saquib
Background: Transversus abdominis plane (TAP) block is a relatively newer block that provides analgesia to the parietal peritoneum, skin and muscles of the anterior abdominal wall. Aims: To determine the effectiveness of the TAP block over wound infiltration for hernia repair. Settings and Design: Randomized, double-blinded, prospective study in an academic teaching hospital. Methods: Sixty patients were divided into two groups of 30 each. In Group T, patients received ultrasound-guided TAP block for inguinal hernia repair whereas in Group I, local anesthetic infiltration at the wound site was done. Primary outcome measure was pain relief as assessed by a numeric rating scale (NRS) whereas secondary outcome measures were duration (from the time at which TAP block or local anesthetic infiltration is given to the time at which patient first requests for rescue analgesic) of post-operative analgesia, patient satisfaction score, and complications, if any. Results: Mean NRS score at 0hr for a group I was 0.88±0.74 and for group T was 0.68±0.70 with a p-value of 0.28 and the mean NRS score at 24hr for the group I was 4.47±0.66 and for group T was 4.54±0.62 with a p-value of 0.68 but at 2hr, 6hr and 12hr, the NRS was significantly more in group I (p < 0.05). Mean time of 1st analgesic request in group I was 403.73 minutes as compared to group T where it was 711.33 mins (P<0.001). The post-operative nausea and vomiting (PONV) and sedation in group I was significantly more than group T. Conclusion: Ultrasound-guided TAP block provides better postoperative analgesia both in quality and duration. TAP block reduces the opioid demand and opioid-related side effects like sedation and postoperative nausea vomiting and thus, improves overall patient satisfaction.
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Evaluation of analgesic efficacy of caudal bupivacaine with clonidine versus bupivacaine alone in pediatric laparoscopic surgery p. 62
Lakshmi Kumar, Mahesh Chandran Nair, Kalesh Divakar, Meenakshi Vijayakumar, Rekha Varghese, Sunil Rajan
Background: Caudal local anesthetics with and without additives are increasingly being used for pain management in children. The primary objective of the present study was to compare intraoperative fentanyl consumption in pediatric patients undergoing laparoscopic surgeries under general anesthesia with supplemental caudal analgesia with and without addition of clonidine. The secondary outcomes were comparison of intraoperative and postoperative hemodynamic changes, postoperative pain, and postoperative analgesic requirements. Materials and Methods: In this prospective randomized trial, 32 children aged 6 months to 6 years were recruited. Group B received 2 mg/kg bupivacaine in 1.25 ml/kg, while Group BC received 2 mg/kg bupivacaine with 1 µg/kg clonidine in 1.25 ml/kg as caudal medication after induction of general anesthesia. Chi-square test, independent sample t-test, and Mann–Whitney U-test were used as applicable. Results: Intraoperative use of fentanyl and percentage of patients who required additional fentanyl intraoperatively and postoperatively were comparable in both groups. Intraoperative heart rate (HR), systolic blood pressure (SBP), and mean arterial pressure (MAP) were comparable in both groups most of the time. HR was significantly higher in Group B at 1 h intraoperatively with significantly higher SBP at 10 min after caudal. Postoperative HR and SBP were comparable in both groups. Group B had significantly higher MAP in the immediate postoperative period. Postoperative pain as assessed by FLACC (Face, Legs, Activity, Cry, Consolability) scale was comparable between groups with the exception of it being lesser in Group B at 8 h postoperatively. Conclusion: Clonidine 1 µg/kg added to caudal bupivacaine did not improve analgesia in comparison to bupivacaine alone in children undergoing laparoscopic surgery.
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Our experience with the mid-point transverse process to pleura block in two patients undergoing modified radical mastectomy p. 68
Rashmi Syal, Swati Chhabra, Rakesh Kumar, Manoj Kamal
Thoracic paravertebral block is frequently used in the breast surgeries. Procedure-related complications lead to the development of safer approaches to make patient pain free with fewer side effects. One such approach is the “mid-point transverse process to pleura” (MTP) block. Here, we present our experience with two patients scheduled for modified radical mastectomy where ultrasound-guided MTP block was performed for analgesia.
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Balloon kyphoplasty - Boon for vertebral compression fractures in metastatic cancer patients p. 71
Shiraz A Munshi, Bhuvna Ahuja, Agam Gargia, Parth Shah
Vertebral compression fractures are common in the elderly population. Common aetiology includes, osteoporosis, metastatic disease, and trauma. Vertebral bone metastasis is not common in cases of pancreatic cancer. Here, we report how we managed a 78 year old, male patient, case of known pancreatic cancer having severe back pain (Numerical Pain score (NRS): 9), due to vertebral compression fracture over first lumbar vertebrae (L1). Percutaneous balloon kyphoplasty was performed with an injection of 5 ml bone cement at L1 level under local anaesthesia with sedation. The NRS had come down to 3 and the patient could walk. Our patient get benefited with early interventional pain management of metastatic vertebral compression fractures. Preventing the complications such as immobilization accompanied with adverse events such as musculoskeletal, respiratory, and cardiovascular systems. Providing with significant reduction of pain and leading a better quality of life.
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Pulsed radiofrequency lesioning of the lumbosacral dorsal root ganglion in a patient with lumbosacral plexopathy due to locally advanced pelvic liposarcoma p. 75
Anand Murugesan, Indumathi Daivam, Sapna Nangia, Nagarjuna Burela, Pankaj Kumar Panda, MS Raghuraman
Neoplastic lumbosacral plexopathy can be associated with pelvic malignancies where patients present with severe lumbosacral radicular pain (LSP) involving the lower extremities, leading to weakness of the affected limb. We hereby report the case of a 34-year male who presented with pain in low back radiating to left lower limb for the past 2 months. MR imaging, histopathological examination after debulking surgery confirmed it as a liposarcoma involving the anterior aspect of the left side of sacrum extending toward left neural foramina of S1-S2, left greater sciatic notch and left piriformis muscle. As the LSP was refractory to previous neuropathic medications it was planned to perform pulsed radiofrequency lesioning (PRFL) of lumbosacral Dorsal root ganglion (DRG) from L3 to S1 before further oncological management. Each DRG was treated with PRFL at 42°C for 120 s. Postprocedure, the patient had a satisfactory pain relief and underwent further oncological management.
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Epidural pump implantation in refractory pain in pancreatic carcinoma p. 79
Sunny Malik, Saurabh Joshi, Shraddha Malik, Leena Dadhwal, Samarjit Dey
Reported is a case of an epidural pump implantation done in a patient with refractory pancreatic cancer pain. The patient was earlier given celiac and splanchnic nerve block and later an epidural pump was implanted when the total oral morphine dose requirements increased to >100 mg/day that led to poor tolerance of its side effects. The patient responded very well to the epidural pump with >50% pain relief.
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Continuous adductor canal block for the management of below-knee postamputation stump pain in a diabetic patient p. 83
Samir Basak, Krishna Poddar
Limb amputation surgery is one of the oldest surgical procedures. Below-knee amputation (BKA) surgery is indicated for advanced critical limb ischemia, diabetic foot sepsis, and major trauma. The majority of unplanned readmission after lower limb amputation surgery occurs mainly due to persistent postamputation stump pain. One of the important causes of postamputation stump pain is stump site infection. A higher rate of infection is seen in diabetic patients. Postamputation stump pain management is challenging due to the presence of mixed nociceptive and neuropathic pain component. Various modalities of treatment to control the stump pain are published in different articles. However, no single technique or drug is found superior to others. Here, we report a case of severe postamputation stump pain after BKA surgery in a diabetic patient with stump site infection. The pain was successfully managed by continuous infusion of analgesics via the adductor canal perineural catheter. After the stoppage of the infusion, the patient did not report any phantom limb pain syndrome during the 6-month follow-up.
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Plexiform neurofibroma: An uncommon cause of back pain p. 87
S Sheetal, Reji Thomas, Aswathy Sasidharan, S Vijayalekshmi
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Intrathecal neurolysis is still an economical glorious art in terminal cancer patients in a developing country like India p. 89
Bablesh Mahawar, Vivek Mahawar, Ravi Shankar Sharma
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Quadratus lumborum block for postoperative analgesia – A feasible option in pediatric patients with congenital anomalies p. 91
Deepak Dwivedi, Kapil Kulkarni, Shankar Raman, Shalendra Singh
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