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   Table of Contents - Current issue
May-August 2022
Volume 36 | Issue 2
Page Nos. 69-115

Online since Thursday, August 25, 2022

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From the desk of new editor-in-chief p. 69
Samarjit Dey
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Ideal pain-free hospital – A step forward p. 70
Pradeep Jain, Naresh Dua, Jayashree Sood, Chand Sahai, Priya Yadav, Arti Sharma
Pain is the most common and distressing symptom which a patient fears when admitted to the hospital for medical or surgical reasons. Well-managed pain relief improves the quality of life, lessens complications, shortens hospital stay, and decreases health-care expenses. Inadequate control of pain has consequences that go beyond suffering: Insomnia, mood swings, decreased gut motility, reduced mobility, increased risk of deep-vein thrombosis, and respiratory and cardiac morbidity to name a few. The harsh reality is that postoperative pain is inadequately addressed worldwide, and many patients both inpatients and outpatients go home where they cannot manage their pain effectively. This is not necessarily the result of the absence of effective pain relief measures but is the outcome of inappropriate management for postoperative pain relief. The ideal pain-free hospital (PFH) is achievable by putting together a multidisciplinary team of pain physicians, pain nurses, physiotherapists, and other medical professionals. Education of the patient through counseling and printed handouts with information about postoperative pain and the techniques to manage it reduces anxiety. The PFH team is founded on the tenets of thorough preoperative assessment, better-educated pain-relieving staff along all the updated facilities. The pain education incorporates all teaching gadgets for medical and paramedical staff. Round-the-clock super-specialist pain relief services along with the preplanning of proper pain management, upgraded minimally invasive and daycare surgeries make the patient pain-free up to the maximum extent.
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Pulsed radiofrequency treatment of the dorsal root ganglion in patients with chronic neuropathic pain: A narrative review p. 75
Sarah Waicus, Nishaant Bhambra
Background: Chronic neuropathic pain (CNP) is a complex condition that has profound impacts on quality of life. Pulsed radiofrequency (PRF) on the dorsal root ganglia (DRGs) is a novel treatment that has shown clinical efficacy in pain relief, however, its mechanism remains unknown. Objectives: The objective of this review is to synthesize the literature on inflammatory markers and clinical pain outcomes in CNP patients treated with PRF. Study Design: A narrative review was conducted. Setting: Eligibility criteria included human trials on adults diagnosed with CNP. Monopolar and bipolar PRF treatments on the DRG were included. Methods: Four peer reviewed electronic databases (Medline, EMBASE, PubMed, and Cochrane) were systematically searched for studies on PRF on the DRG to treat CNP. The primary outcome measures included pain scores and cerebrospinal fluid samples taken pre- and posttreatment measuring inflammatory markers. Results: Thirty-three articles were identified in the database searches. Titles, abstracts, and full-text articles were evaluated, and eight articles met the inclusion criteria. The study designs included five randomized-controlled trials and three quasi-experimental studies. Patients: There were 311 patients pooled with an age range of 35–76 years. Types of CNP included chronic radicular pain, postmastectomy pain syndrome, chronic lumbosacral pain, and postherpetic neuralgia. Intervention: Treatments in included studies included monopolar and bipolar PRF stimulation ranging from 120 s at 2 Hz to 360 s with 5 Hz pulses. Measurement: The main findings revealed that PRF treatment provided significant pain relief (P < 0.05), with the greatest pain reduction at 3 months. Pro-inflammatory markers were found to decrease, whereas anti-inflammatory markers increased post-PRF intervention. Limitations: There were differing PRF procedure standards, and it is uncertain whether a higher frequency or duration is correlated with better outcomes. Studies had small sample sizes increasing the margin of error. Longer duration randomized-controlled trials are needed to understand the optimal therapeutic duration using PRF.
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A prospective study to determine the effect of Vitamin D levels on musculoskeletal pain, anxiety, and depressions in patients with type II diabetes p. 84
Raunak Kumar, Nonica Laisram, Neelima Jain
Objectives: The primary objective was to investigate the correlation of musculoskeletal pain (MSP) intensity with Vitamin D status and glycemic control in patients of type II diabetes mellitus. The secondary objective was to monitor the anxiety and depression levels with Vitamin D supplementation. Methods: A prospective observational cohort study was conducted over a period of 18 months where 100 patients of type II diabetes mellitus with MSP were screened for Vitamin D status and glycemic levels in terms of HbA1c, anxiety, and depression. MSP was assessed by Visual Analog Scale (VAS) score. The patients who were found with Vitamin D levels (<30 ug/dL) were supplemented with Vitamin D and followed at 3 monthly intervals for 6 months for determining the change in MSP, anxiety, and depression scores. Results: After adjusting for the duration of diabetes, HbA1c, and statin therapy, there was no significant correlation between VAS score and Vitamin D (r = −0.133, P = 0.195). After 6 months of Vitamin D supplementation, all cases attained optimal Vitamin D levels of mean (standard deviation [SD]) of 32.5 (4.1) ng/ml as compared to mean (SD) of 23.4 (2.5) ng/ml at baseline (P < 0.0001). Concurrently, there was a significant reduction in the median (range) VAS scores from 6 (2–10) to 4 (0–8), anxiety levels from 11 (7.75–18) to 10 (7–17), and depression levels from 10 (7–15) to 9 (6–14) (P < 0.0001), respectively. Conclusion: There was no significant independent correlation of MSP intensity with Vitamin D levels or glycemic control. However, the supplementation of Vitamin D significantly alleviated MSP in patients with diabetes, with a significant reduction in anxiety and depression among them.
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Ultrasonography-guided hydrodissection using platelet-rich plasma or corticosteroid in adhesive capsulitis of the shoulder: A comparative study p. 90
Iqra Mehak, Aftab Hussain, Hammad Usmani, Syed Hussain Amir
Background: Adhesive capsulitis is a condition that presents with pain and progressive limitation of both active and passive shoulder movements. It can be primary or secondary, the latter includes causes such as rotator cuff tear, cardiovascular disease, and diabetes mellitus. The American Shoulder and Elbow Surgeons defines that adhesive capsulitis is a condition of uncertain ethology characterized by a significant restriction of both active and passive shoulder motions that occur in the absence of known intrinsic shoulder disorder. Commonly described as: Stage 1 – Freezing stage, with pain and stiffness lasting around 9 months. Stage 2 – Frozen stage, with persistent stiffness lasting 4–12 months. Stage 3 – Thawing stage, with spontaneous recovery lasting 12–42 months. Ultrasonography (USG)-guided hydrodissection is used for adhesive capsulitis of the shoulder due to its cost-effectiveness and acceptance among patients. As adhesive capsulitis is postulated as an i nflammatory and fibrotic disease, easy treatment with intra-articular corticosteroids (CSs) injection may reduce synovitis, limit the development of capsular fibrosis, and alter the natural history of disease. CS injections are effective for shorter duration, but newer agents such as platelet-rich plasma (PRP) are more effective with no serious side effects. Materials and Methods: In this study, 40 patients were taken of adhesive capsulitis of the shoulder and were divided randomly into two groups. One group received injection PRP and the other group received injection CS. The outcome was recorded. Results: There was a statistically significant reduction in numeric rating scale pain scores in both the groups over a time period of 6 weeks, but the PRP injection was observed to be better in reducing the pain scores when compared to the CS injection after the 6th week (P = 0.037). Initially, the CS injection performed better in the 1st week due to anti-inflammatory action. By the 3rd week, both the injections showed a similar effect. However, at the end of the study period (6 weeks), there was a better reduction in the Shoulder Pain and Disability Index (SPADI) pain scores (P = 0.0057) and SPADI disability scores (P = 0.029) of the group PRP. Conclusion: We concluded that USG-guided hydrodissection with PRP is more effective therapy than CS in terms of reduction of pain and improvement in shoulder function in the treatment of adhesive capsulitis of shoulder.
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Radiofrequency to the rescue in a case of pancoast tumor p. 95
Prateek Arora, Abhishek Bharadwaj
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A technical report of postmastectomy axillary web syndrome symptom management using ultrasound-guided trigger point injections p. 97
Mohammad H Bawany, Rachna Subramony, Joel Castellanos, Jessica Oswald
Axillary web syndrome (AWS) is a painful and difficult-to-manage complication of breast surgery with axillary lymph node dissection. Patients may believe that symptoms, including the presence of palpable axillary cords and reduced shoulder mobility, are a normal part of postoperative recovery. Both physician and patient education regarding this quality-of-life impairing condition is needed. In this report, we describe treating AWS using ultrasound-guided trigger point injections to avoid inadvertent damage to the neighboring lung, nerve, lymph nodes, and/or vasculature. There is limited information on their utility in treating AWS. At 4-month follow-up, our patient reported 70% improvement in her pain and discontinuation of her opioid medications, along with increased functionality. Ultrasound played a critical role in enhancing procedure accuracy and safety in zones that contain important nerve and vascular tissue and decreasing the risk of iatrogenic injury. While ultrasound was used historically for diagnostic purposes, we show why its use for interventions is on the rise.
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Celiac plexus chemical neurolysis for refractory pain associated with superior mesenteric artery syndrome p. 100
Ravi Shankar Sharma, Ajit Kumar, Girish Kumar Singh, Sonal Goyal, Suyashi Sharma
Superior mesenteric artery (SMA) syndrome is caused by the compression of a part of the intestine between the aorta and SMA. It may lead to severe epigastric pain that is even refractory to conservative and surgical forms of therapy. Celiac plexus chemical neurolysis has been used in the past for debilitating pain associated with upper gastrointestinal malignancies and chronic pancreatitis. However, to date, this intervention has never been described in the literature for managing pain in SMA syndrome patients. Here, we describe the case of SMA syndrome whose pain was successfully managed with celiac plexus chemical neurolysis.
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Ultrasound guided rectus sheath and transverse abdominis blocks for robotic urological surgeries – A case series p. 103
Divya Rani, Shipra Aggarwal, Arushi Gupta, Pratibha Mudgal
Background: Robotic surgeries have improved perioperative outcomes. We have combined ultrasound (USG) guided bilateral rectus sheath (RS) block along with transverse abdominis plane (TAP) block to assess perioperative opioid requirement, visual analog scale (VAS) score, and modified Post Anesthetic Discharge Scoring System (PADSS) criteria for robotic urological surgeries. Ultrasound (USG)-guided blocks were given bilaterally after induction of general anesthesia. Methods: A total of ten patients scheduled for robotic urological surgeries were administered 30 ml of 0.25% bupivacaine (2.5 mg kg-1) with 0.75 mcg kg-1 of clonidine (10 ml of drug was given for TAP block and 5 ml of drug for RS block on each side) after negative aspiration. Results: Supplemental opioid was not required perioperatively, and 9 out of 10 patients were pain free (VAS score <3) for at least 6 h. Ten patients had a modified PADSS score ≥10 after 6 h of surgery. Conclusion: USG combined TAP and RS blocks is a promising technique with low learning curve, excellent analgesia, reduced opioid consumption, and higher PADSS score in the perioperative period.
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Role of erector spinae plane block in end-of-life care for a patient with advanced abdominal malignancy p. 108
Naina Kumar, Sunny Malik, Shraddha Malik, Vibhu Ranjan Sahni, Saurabh Joshi
Celiac plexus block (CPB) is the most commonly used intervention in patients suffering from pain related to upper abdominal malignancies. Placing a CPB requires a patient to be placed in a prone position on the operating room table which becomes difficult in many patients with advanced disease and therefore makes it more challenging for the interventional pain physician, simultaneously risky for the patient. In such cases, a more superficial minimally invasive intervention is desirable. The erector spinae plane block (ESPB) is one such intervention that has been used in a large variety of settings and can be used in the abovementioned cases. So far, no reports have emphasized the role of this field block for chronic cancer pain relief in a patient with advanced and progressive malignancy nearing the end of life. We present such a case with end-stage carcinoma gallbladder, in which ESPB was used effectively for providing pain relief during her final days.
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Ultrasound-guided multiple injection costotransverse block in a patient with postradiation therapy recurrent dermatofibrosarcoma protuberans: A technical glitch p. 111
Debesh Bhoi, Raunak Parida
Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive soft-tissue tumor with a high recurrence rate, often requiring multiple surgeries with multiple sessions of radiotherapy that alters the anatomy and makes regional anesthesia challenging in these patients. The multiple injection costotransverse block (MICB) is a type of “paravertebral by proxy” block in which the drug is injected within the thoracic intertransverse tissue complex with spread to the paravertebral space without any epidural spread. Unlike the traditional approach to paravertebral block, which involves piercing the superior costotransverse ligament, the MICB has a shallower needle trajectory making needle visualization easier and the more superficial needle tip location reduces the chances of a pleural puncture and subcostal vessel injury. We present the case of a 51-year-old male with recurrent DFSP in the anterior axillary fold who was posted for tumor debulking. As the sonoanatomy was altered due to multiple previous surgeries and radiotherapy, we chose to perform an ultrasound-guided MICB.
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Block: Component of a multimodal approach to taming the stress response in pheochromocytoma resection p. 114
Bhavna Hooda, Shalendra Singh, Deepak Dwivedi, Rahul Goyal
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