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   Table of Contents - Current issue
January-April 2022
Volume 36 | Issue 1
Page Nos. 1-67

Online since Monday, April 25, 2022

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Emerging noninvasive therapies in pain management Highly accessed article p. 1
Hammad Usmani, Tariq Mansoor, Nazia Tauheed
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Quest ignited for newer analgesics p. 3
Pallavi Ahluwalia, Bhavna Gupta
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Immersive virtual reality in pain management of burn injury – A review p. 5
Fahud Khurram, Aftab Hussain, Bala Subramaniyam, Hammad Usmani
Burns are one of the most severe forms of trauma to skin and tissue which results due to contact with hot substances (liquid or solid), radiation, radioactivity, electricity, friction, or contact with chemicals. Every year, nine million people are injured due to fire, heat, and hot substances worldwide, out of which 120,632 die (1.34%). In India, with a population of over 1.3 billion, the registered annual burn admissions are 7,00, 000–8,00, 000. This review is to identify studies on virtual reality (VR) therapy in the management of burn patients in terms of their pain, anxiety, and stress during treatment and rehabilitation, in the context of the scientific world of literature. Literatures from web-based scientific databases, PubMed, Cochrane, MEDLINE, and Clarivate, National Science Library, were searched to identify the studies conducted on the use of VR in the management of pain related to burns and their dressings. Randomized controlled trials and case series were included in this review. All these studies were organized and tabulated according to the methodology and type of interventions done. Few of the studies were also analyzed to present the highlighted current trends in VR and pain management. A brief overview of the observations at this center with the use of VR technology and its role in alleviating pain during the procedures for burn management has also been included. VR is a nonpharmacological complementary strategy with proven benefits in the management of burn patients. The findings of this literature review and analysis demonstrate that the use of VR in burn patients significantly reduces pain during treatment and rehabilitation and averts its consequences. VR can be easily used in the hospital setting and offers a safe, nonpharmacologic adjunctive therapy in the management of burn patients.
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Postamputation pain: A narrative review p. 10
Samridhi Nanda, Debesh Bhoi, Virender Kumar Mohan
Postamputation phenomenon is commonly encountered in more than 80% of amputees. Due to the increasing burden of trauma and associated amputations, disability due to postamputation pain becomes rampant. In this review, we aim to describe the history, epidemiology, types and mechanisms of postamputation phenomenon, factors affecting its development, and the currently available treatment modalities – both pharmacological and nonpharmacological.
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Newer techniques for the ultrasonographic evaluation of the elbow structures: Distal biceps tendon, lateral ulnar collateral ligament and radial nerve p. 18
Kanchan Sharma, Gautam Das, Chinmoy Roy, Debjyoti Dutta, Shalina Chandran, Syeda Shaista Naz, Smruti Rekha Hota, Sarvesh Basavarajaiah
Context: Ultrasound is an excellent modality for the evaluation of the soft tissue structures as well as articular pathologies of the elbow joint. Higher resolution transducers along with the superficial location of the elbow structures make them amenable for easy visualisation However, the long learning curve and the operator dependency can limit its use. Aims: The aim of this article is to describe and demonstrate novel techniques to image distal biceps tendon, lateral ulnar collateral ligament and radial nerve at elbow joint with ease. Design: Technical advancement. Methods: The elbow joint ultrasound examination was performed on ten asymptomatic volunteers, 20–40 years old, using a linear probe of 3–13 MHz frequency. The scanning was started from the anterior elbow, the distal biceps tendon was visualised first with anterior to the medial approach followed by the lateral ulnar collateral ligament with one finger technique and radial nerve with first bone technique respectively. Conclusion: We consider our techniques as an easy approach to identify the distal biceps tendon, lateral ulnar collateral ligament and radial nerve.
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Ultrasonographic evaluation of painful joints in rheumatoid arthritis: Comparison with conventional radiography p. 22
Sadaf Sultana, Mehtab Ahmad, Ibne Ahmad, Hammad Usmani, Mohammad Arif
Context: High-frequency ultrasound (US) of painful rheumatoid joints allows an increasingly refined analysis of the extent of joint involvement and disease activity. Aims: The aim of this study was to establish the role of the US in the evaluation of painful hand joints in patients with rheumatoid arthritis (RA) and its comparison with Conventional Radiography (CR) changes. Settings and Design: Cross-sectional study. Subjects and Methods: Patients diagnosed with RA were assessed by a thorough clinical examination and relevant laboratory investigations. After X-ray imaging, grayscale, and power Doppler US examination of the wrist, metacarpophalangeal, and proximal interphalangeal joints of both hands were performed using a high-frequency linear transducer. Statistical Analysis Used: SPSS version 20.0 (a statistical package for the social sciences) was used to collect, tabulate, and analyze all data. The results were presented as mean standard deviation or percentage. Differences in categorical data were compared using the Chi-square test and Fisher's exact test. A P < 0.05 was considered statistically significant. Results: Thirty-two of the 51 individuals studied had radiographic abnormalities, whereas 44 had abnormal findings in the US. The US can detect erosions in 37 patients, including all 15 of those who had radiographically visible erosions. A statistically significant difference was noted between the findings of radiography compared with US findings (P < 0.001). Conclusions: US is more sensitive than CR for the detection of erosion and can complement the CR in the evaluation of these patients.
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Utility of ultrasound-guided erector spinae plane block in patients presenting to the emergency department with rib fractures p. 27
Madhu Srinivasarangan, Bellipady Shyam Prasad Shetty, Akkamahadevi Patil, Abhijith Sivasankar
Context: Alleviating significant pain and enhancing lung function in patients with multiple rib fractures presents a formidable challenge to all emergency physicians (EPs). Conventional pharmacological measures and traditional thoracic regional analgesia techniques are not always feasible or safe in the emergency department (ED). Therefore, an effective, feasible, and safe method for providing analgesia in such patients will be extremely advantageous to all patients and EPs alike. Here, we describe the utility of a regional block technique that can be applied in patients suffering from multiple rib fractures in the ED. Aims: The aims of this study were as follows: (1) to determine the effectiveness of an ultrasound-guided erector spinae plane block (ESPB) in ameliorating pain and improving lung function in patients presenting to the ED with multiple rib fractures and (2) to assess the safety and the feasibility of the ESPB in the ED. Setting and Design: This was a retrospective observational clinical study conducted in the ED of a tertiary care hospital over a period of 12 months. Subjects and Methods: Data regarding all patients with rib fractures who had undergone an ESPB in the ED were extracted from the ED procedure register, and the inpatient case sheets were obtained from the medical records department for review and analysis. The data included, but were not limited to, the Numerical Rating Scale (NRS) for pain and respiratory parameters, i.e., respiratory rate and peak expiratory flow rate (PEFR) at 30 min post procedure and subsequently after every top-up dose up to a period of 48 h. Statistical Analysis: Descriptive statistics such as mean, standard deviation, frequency, and percentage were used. Inferential statistics such as repeated-measures ANOVA were done using SPSS software version 22 (IBM). Results: The mean NRS was significantly reduced by >50% at 30 min and by 72% over a 48-h period (P < 0.001). Meaningful improvements in the respiratory parameters were also observed during the same period with significant increments in the PEFR values (49% increase [P < 0.001]) as well as a decrease of 36% in the respiratory rate (P < 0.001). The mean time for performing the procedure was 16.27 min, and no adverse events were observed as a consequence of the block. Conclusion: The study demonstrates the efficacy of USG-guided ESPB in ameliorating pain as well as improving lung function for multiple rib fracture patients. This procedure can be performed in a short time making it suitable for application in the ED. No adverse events as a consequence of the ESPB were noted.
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Postoperative analgesic efficacy of quadratus lumborum block in patients undergoing laparoscopic cholecystectomy: A retrospective study p. 33
Sunita Kulhari, Chetna Shamshery, Suruchi Ambasta, Anil Agarwal, Rajneesh Kumar Singh, Monalisa Srivastava
Background: Patients undergoing laparoscopic cholecystectomy (LC) often complain of pain in the postoperative period despite intravenous analgesic administration. Systemic analgesia is also associated with side effects such as postoperative nausea and vomiting, thus adding to patient's discomfort. Posterior quadratus lumborum (QL) block has been studied to provide adequate analgesia in this set of patients. We retrospectively studied the efficacy of posterior QL block in LC patients and assessed them for chronic pain. Methods: Records of patients meeting inclusion criteria were taken. Standard multimodal analgesia as per the institute protocol was performed in all patients. Posterior QL block was performed under ultrasound guidance in test group, while control group received parenteral analgesia alone. Measurements: Static and dynamic Numeric Rating Scale (NRS) were measured at different time intervals during the first 24 postoperative h and time to rescue analgesia was noted. Assessment of chronic pain was done at the same time for all the patients. Side effect profile of both the groups was compared. Results: Static and dynamic pain scores were compared between block and control groups at immediate postoperative time period, 3 h, 12 h, and 24 h and statistically significant difference was noted with lower scores in test group as compared to control group at all four time points (P < 0.05). None of the patients in test group suffered chronic pain, while 33.3% patients in control group had chronic pain. Conclusion: Posterior QL block is an effective analgesia option for LC patients with less incidence of side effects. It should be performed more frequently as it is effective in reducing acute and probably chronic pain too in LC patients.
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A comparative study of ultrasound-guided serratus anterior plane block with pectoral nerve block type II in breast surgeries p. 37
Syed Hussain Amir, Kulsum Sheikh, Qazi Ehsan Ali, Obaid Ahmed Siddiqui, SM Arman
Background: The use of ultrasonography (USG) to identify fascial layers has led to the development of several newer interfascial techniques for analgesia of the chest and abdominal wall. Two such modalities are the Pectoral nerve block (PEC) and Serratus Anterior Plane (SAP) block. Objective: To compare the duration and quality of analgesia provided by ultrasound-guided SAP block with PEC block II in patients undergoing breast surgeries after induction of general anesthesia. Design: Randomized, double-blinded, prospective study. Methods: Sixty female patients were divided into two groups of 30 each. Patients in Group P received USG guided PEC II block, whereas patients in Group S received USG-guided SAP block after induction. Outcome Measure: The primary objective was to compare the duration of pain relief, whereas the secondary objectives were to compare the degree of pain relief, postoperative analgesic requirement within 24 h after the completion of the surgery, patient satisfaction score and complications if any. Results: The mean time of the first dose of analgesic given was 826 ± 405.24 min. in Group P and 1280 ± 264.29 min. in Group S (P < 0.001). The mean numeric rating scale score at rest at 6 h, on movement at 2 h and 6 h and satisfaction scores in Group P were significantly more than Group S. Conclusion: Ultrasound-guided SAP block provides better postoperative analgesia both in quality and duration over PEC II block.
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Exploring the efficacy of ultrasound-guided lumbar erector spinae plane block for perioperative analgesia in percutaneous nephrolithotomy: Report of two cases p. 43
Samarjit Dey, Omer Mohammed Mujahid, Suresh Nagalikar, Prateek Arora
Erector spinae plane block (ESPB) is used to a great extent for perioperative analgesia. The ease of administering it, safety and the perioperative analgesia achieved make it a good addition to anesthetic plans. The reduction in opioid usage with the usage of regional analgesia techniques may aid in enhanced recovery; in addition, regional analgesia with this block provides excellent analgesia and better postoperative outcome as seen here in two cases who underwent percutaneous nephrolithotomy (PCNL). Single-shot ESPB was performed in two cases undergoing PCNL. We achieved stable hemodynamics throughout the procedure and a mean NRS of 1.8 for a duration of 18 h postsurgery in both cases, with faster mobilization and early discharge of the patients.
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Effect of intramuscular electrical stimulation of articularis genu muscle with mirror therapy on anterior knee pain in a patient with knee osteoarthritis p. 46
Sarik Chaudhary, Manoj Kumar Sharma
Knee osteoarthritis (OA) is a degenerative condition that can develop in people who have quadriceps muscle weakness. Knee OA is more likely to develop in people who have weak quadriceps muscles, which extend the knee. Dysfunction of articularis genu muscle (AGM) is thought to be a cause of anterior knee pain in patients having OA of the knee joint. Herein, we report a case of anterior knee pain caused due to the dysfunction of AGM in a 41-year male who was initially treated with physical therapy, and it failed to ease the patient's problems completely. Intramuscular electrical stimulation (IMES) along with mirror therapy relieved his symptoms with no recurrence till 2 months of follow-up. IMES of the AGM combined with mirror therapy can be a viable therapeutic option for muscle reeducation and anterior knee pain.
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Cooled radiofrequency ablation of cervical medial branches for treatment of facetogenic pain p. 49
Nithya Dinesh, Rajat Gupta, Deep Divanshu Lall, Ashu Kumar Jain
In cervical spine, the anatomical course of medial branch in significantly different and thermal radiofrequency ablation (RFA) of the cervical median branch though proven effective is technically challenging. Cooled RFA (CRFA) is a newer revolutionary technique that creates a larger spherical lesion and thus compensates for the anatomical variability of the medial branches in the cervical spine. Our case report is aimed to discuss the technique of CRFA for the treatment of cervical facetogenic pain. Right C2–C5 medial branch CRFA was done under fluoroscopic guidance under monitored anesthesia care using 17G with 75 mm length and 2 mm active tip cooled radiofrequency cannula. After 8 weeks of follow-up, the patient reported 80% pain relief.
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Intraoperative ultrasound-guided serratus anterior plane catheter for postoperative analgesia after breast surgery in a morbidly obese patient p. 53
Annie Sheeba John, T Sivashanmugam, Afreen Nahar, John Paul
Inter-fascial plane blocks play a great role as part of the multimodal analgesic regimen for breast surgery. Fascial plane blocks are effective for immediate analgesia, but their use for prolonged postoperative analgesia is not yet explored. We present a hybrid technique of successful placement of intraoperative ultrasound-guided deep serratus anterior plane (SAP) catheter for continuous postoperative analgesia in a morbidly obese patient undergoing breast surgery. A sexagenarian morbidly obese female patient with left carcinoma breast was posted for modified radical mastectomy. The deep serratus anterior fascial plane was more than 9 cms deep and was poorly visualized. Hence, intraoperative catheter was placed under ultrasound guidance and used effectively for 5 days. The static and dynamic pain scores were <4 at all-time points with local anesthetics and nonopioid systemic analgesics. We observed that intraoperative ultrasound-guided SAP catheter can be effectively used for continuous postoperative analgesia in morbidly obese patients undergoing breast surgery.
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Continuous intrathecal infusion for refractory pain management in an oncologic patient in intensive care p. 56
Alessio Cittadini, Andrea Sica, Daniele Bellantonio, Emanuele Russo, Vanni Agnoletti
Adult patients in the intensive care unit (ICU) often experience pain resulting from acute and chronic illness, as well as from standard positioning and maneuverers in the ICU. In recent years, the need for effective pain control in intensive care has emerged strongly. Partial or ineffective control is associated with multiple complications, such as agitation, delirium, inability to adapt to mechanical ventilation, increased length of stay, and post-traumatic stress disorder. Recent guidelines and studies suggest multimodal strategies for effective pain control, also re-evaluating the use of locoregional anesthesiological techniques. Oncological pain in critically ill patients represents a particular challenge for medical staff, being closely linked to the concept of palliative care. We present a case of refractory pain and agitation in an oncologic patient following an emergency exploratory laparotomy. Through the use of an intrathecal catheter, we provided effective analgesia to control pain and agitation, allowing weaning from mechanical ventilation before, and once the terminal state of the tumor was established, providing palliative care to ensure dignity and satisfaction of the patient.
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Complex regional pain syndrome associated with henoch-schonlein purpura: A rare occurrence p. 59
Sanjay Kumar, Sandeep Khuba, Shikha Awal, Sujeet Gautam, Anil Agarwal
Introduction: Henochschonlein purpura (HSP) is an acute, systemic, immune complex-mediated, leukocytoclastic vasculitis, most commonly affecting children. It is a small-vessel vasculitis which is characterized by a tetrad of palpable purpura (without thrombocytopenia), abdominal pain, arthritis, and renal impairment. Although most commonly affecting the skin, joints, gastrointestinal tract, and kidneys, other organs may also be affected. Association of HSP with complex regional pain syndrome (CRPS) has not been reported in the literature. In the present case report, we are describing the successful management of CRPS of the upper limb in a diagnosed case of HSP. Case Presentation: A 14-year-old female patient, who was a diagnosed case of HSP, presented with features characteristic of CRPS in the right hand and forearm, based on the Budapest Diagnostic Criteria. Bone scintigraphy showed increased tracer uptake in joints of the right hand, also suggestive of CRPS. The pain was severe visual analog scale-90/100 and not controlled with conservative management. Patient was administered a series of 3 stellate ganglion minimally invasive pain and spine interventions (MIPSI) over the course of 2 weeks, which led to the resolution of her symptoms. Conclusion: HSP is a small-vessel vasculitis and may lead to peripheral nerve vasculitis. As reported in other cases, small-vessel vasculitis has led to the development of CRPS and thus may influence the development of CRPS in patients with HSP. CRPS as a complication of HSP has not been reported in the literature to date. Thus in a patient with HSP, CRPS could present as a rare complication and early intervention with the MIPSI of the affected region may lead to resolution of symptoms.
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Persistent cutaneous fluid leakage from epidural puncture site: A diagnostic challenge p. 63
Sarfaraz Ahmad, Ajeet Kumar, Shagufta Naaz, Abhyuday Kumar
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Management of spasticity in cerebral palsy children with early intervention and functional physical therapy p. 65
Nusrat Jahan, Amir Ateeq
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