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   Table of Contents - Current issue
Coverpage
May-August 2021
Volume 35 | Issue 2
Page Nos. 93-182

Online since Tuesday, August 31, 2021

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EDITORIALS  

Chronic pain: It is time to act…. p. 93
Megha Pruthi, Gaurav Chanana
DOI:10.4103/ijpn.ijpn_56_20  
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Biomarkers of chronic pain: A tool for diagnosis and evaluation of management – Where do we stand? p. 95
Shamila Fatima, Nazia Tauheed
DOI:10.4103/ijpn.ijpn_55_21  
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REVIEW ARTICLES Top

Medical cannabis in chronic pain management – Where are we now? p. 97
Shamim Haider, Wan Jane Liew
DOI:10.4103/ijpn.ijpn_1_21  
Chronic pain is a debilitating condition that afflicts a significant number of people throughout the world. The mechanisms of chronic pain remain to be fully understood, and treatment for chronic pain has remained a challenge for pain practitioners. Cannabis and cannabis-based medicine (CBM) have emerged over the last two decades as potential treatment options for an array of medical issues, of which chronic pain is one of them. Clinical trials thus far seem to suggest that medical cannabis may have some clinical effect in reducing pain severity in chronic noncancer pain as an adjunct to standard treatment, but inherent weaknesses in the available evidence mean that the verdict for medical cannabis has yet to be set in stone. The issue of medical cannabis is further complicated by the connection of cannabis with neuropsychiatric side effects and substance misuse. Much work needs to be done by both clinicians and government bodies to translate the benefits of medical cannabis in the laboratory into positive patient outcomes at the bedside in a safe manner.
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Efficacy of radiofrequency lesioning for chronic spinal pain: A systematic review p. 105
Sujeet Gautam, Pratibha Singh, Vineetha G Gopal, Anil Agarwal, Sanjay Kumar, Sandeep Khuba, Chetna Shamshery
DOI:10.4103/ijpn.ijpn_165_20  
Introduction: Facet joint pain, discogenic pain, sacroiliac joint (SIJ) pain, and radicular pain are chronic spinal pain conditions, where radiofrequency (RF) lesioning has been used so far with variable results. It is always desired to choose a therapeutic option based on its current evidence. The present systematic review has focused on the efficacy of RF lesioning for chronic spinal pain conditions. Methods: A literature search was done in PubMed from the year 1966 onward. The basic idea of the literature search was to find out studies focusing on RF lesioning for chronic spinal pain. The randomized controlled trials and observational studies focusing on RF lesioning for chronic spinal pain of more than 3 months duration have been included in this review. Results: A total of 286 studies have been identified after literature search and assessed for inclusion in this review. Forty-two of these studies meeting the inclusion criteria have been included for the formulation of evidence; 26 of these studies were of high quality, 14 were of moderate quality, and 2 were of low quality as per Cochrane review criteria score. The level of evidence for RF lesioning of conditions giving rise to nonradicular pain is Level I for continuous RF lesioning of lumbar facet medial branch, for both short- and long-term effectiveness; level II evidence for continuous RF lesioning of cervical facet medial branch, continuous RF or cooled RF lesioning of SIJ and bipolar cooled RF in intradiscal biacuplasty for discogenic pain, for both short- and long-term effectiveness; level III evidence for continuous RF lesioning of thoracic facet medial branch. For radicular pain management, there is Level II evidence for dorsal root ganglion (DRG) pulsed RF lesioning, for both short- and long-term effectiveness. Conclusion: The evidence for RF lesioning of chronic spinal pain is summarized as follows:
  1. Nonradicular pain.
    1. Cervical facet joint pain: Level II evidence for continuous RF lesioning of cervical facet medial branch.
    2. Thoracic facet joint pain: Level III evidence for continuous RF lesioning of thoracic facet medial branch.
    3. Lumbar facet joint pain: Level I evidence for continuous RF lesioning of lumbar facet medial branch.
    4. Sacro-iliac joint pain: Level II for continuous RF or cooled RF lesioning of SIJ.
    5. Discogenic pain: Level II evidence for bipolar cooled RF in intradiscal biacuplasty for discogenic pain.
  2. Radicular Pain: Level II evidence for DRG pulsed RF lesioning for the management of radicular pain.
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Spiritual knowledge and practices to conquer chronic pain: A systematic review p. 123
Sweta Viraj Salgaonkar, Yashashri Shetty, Vishal Singh
DOI:10.4103/ijpn.ijpn_114_20  
Understanding of pain as multidimensional experience has improved quality of life of many sufferings from chronic pain. Addressing spiritual dimension in chronic pain patients can improve outcome. The purpose of the present study was to systematically review literature from 1994 to 2018 using PubMed search engine to correlate between spirituality and pain management. The review included 25 randomized controlled trials (RCT). Positive correlation with spiritual healing was proved in 7 RCTs that included patients of idiopathic chronic pain syndromes. Patients with cancer pain, showed improvement in quality of life, visual analog scores with various spiritual techniques in 4 out of 6 RCTs. Pray meditation was recommended as one of management techniques for reducing pain after cesarean surgery in 1 RCT. Migraine medication usage decreased in spiritual meditation group improving the pain tolerance with significant improvements in anxiety, depression, and reduction in muscle tension in 3 RCTs. A study of cognitive behavioral therapy of 8 weeks, done in fibromyalgia patients recommended second generation mindfulness as a therapy to control their symptomatology in 1 RCT. In 2 RCTs involving students, the cold pressor task and the length of cold immersion seemed to be longer in those receiving spiritual intervention. One RCT, involving hospitalized patients concluded that spiritual healing was effective in promoting a state of muscle relaxation, reducing anxiety and depression, and raising the perceptions of wellness in patients. In a RCT involving chronically ill patients, encouraging spiritual coping was associated with better psychosocial and health outcome. Three RCTS involving patients of rheumatoid arthritis, neurofibromatosis, and chronic pain states not responding to conventional therapy did not show any significant correlation with spiritual intervention. Pain physicians can use better understanding of spiritual knowledge with non-pharmacotherapy techniques.
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ORIGINAL ARTICLES Top

Clinician's perspective on neuropathic pain and use of Lidocaine 5% patch with hydrogel technology in postherpetic neuralgia p. 135
Kailash Kothari, Shirazahmed A Munshi, Manish Raj, Prakash Rajendra Deshmukh, Manjiri Neelesh Ranade, Venkatesh Nevagi
DOI:10.4103/ijpn.ijpn_13_21  
Background: Neuropathic pain (NP) is a condition that affects the quality of life (QoL) of many patients. It is often difficult to treat effectively due to the complexity of this disorder. This study was aimed to assess clinician's perspectives on NP, particularly for postherpetic neuralgia (PHN), posttraumatic neuralgia (PTN), and painful diabetic neuropathy (PDN). Further, the study aimed to evaluate the safety and efficacy of lidocaine 5% patch with hydrogel technology in PHN. Materials and Methods: These two aspects were assessed through two prospective survey-based questionnaire studies that were conducted from January 2018 to December 2018 with clinicians from relevant specialties across India. Data were collected from clinicians' inputs based on their clinical practice and statistically analyzed. Results: More than half of the clinicians reported prolonged duration of NP in PHN, PTN, and PDN conditions. After applying lidocaine 5% patch with hydrogel technology, around 83.58% of clinicians opined that patients experienced a cooling and soothing effect due to the presence of a hydrogel layer in the patch. A significant reduction in pain score was reported by 76.11% of clinicians and 79.1% of them agreed that there was pain relief during the intermittent patch-free period also. The majority of the doctors (74.6%) reported an absence of any side effects. Conclusion: Study findings revealed that topical application of lidocaine 5% patch with hydrogel technology is safe and effective in PHN.
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Evaluation of effectiveness of dry needling in the treatment of chronic low back pain: A retrospective analysis p. 141
Archana Niteen Deshpande, Suneeta Ashok Lawange
DOI:10.4103/ijpn.ijpn_91_20  
Aim: The aim of the study was to analyze the effectiveness of dry needling (DN) in the management of chronic low back pain (LBP). Materials and Methods: Forty patients with chronic LBP (CLBP) (already treated with analgesics and physiotherapy by other clinicians) with myofascial trigger points were given five sessions of DN for 20 min each on every 3rd day. The effect on pain intensity, range of motion (ROM), and disability was observed with the help of numerical rating score (NRS), ROM score, and Owestry Disability Index respectively at 1, 4, and 12 weeks interval. Results: The NRS decreased from a mean of 7.39 to 3.68 at the end of 4 weeks and then 2.32 by 12 weeks showing a significant relief in the pain intensity. The ROM improved from the mean of 4.95 to 2.38 at 4 weeks and to 1.34 by 12 weeks. The mean Oswestry disability index was 38.95 before the treatment and significantly reduced to 17.70 after 12 weeks. The use of paracetamol and hot fomentation was very minimal in the majority of patients. Conclusion: DN is an effective intervention for the management of chronic LBP with myofascial component up to 12 weeks, irrespective of age or gender after the red flags ruled out.
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Comparative study of positive predictive value of diagnostic single versus dual median branch block for radiofrequency neurotomy in lumbar facet joint syndrome p. 146
Baibhav Bhandari, Subrata Ray, Subrata Goswami
DOI:10.4103/ijpn.ijpn_160_20  
Background: Almost 60%–85% of people suffer from low back pain once in their lifetime. Due to a large number of pain generators, many a times lower back pain pose as enigma. Many clinical trials have shown validity of median branch block (MBB) in the management of chronic low back pain arising from facet joint pathology. Single blocks result in 27%–63% false positives, whereas double controlled blocks significantly decrease the false positives and increases the sensitivity to 54% and specificity to 88%. The aim of our study was to determine positive predictive value of diagnostic single and dual MBB for radiofrequency (RF) neurotomy in patients with facet joint arthropathy in Indian population. Subjects and Methods: Thirty patients allocated into two groups (n = 15), Group S - Single diagnostic MBB and Group D - Dual diagnostic MBB. Numerical Rating Score (NRS) and Roland Morris Disability Questionnaire (RMDQ) were recorded in all patients in both the groups at multiple times. Pre and postprocedure NRS and RMDQ score in both the groups were statistically compared. Results: NRS in Group D was lower as compared to Group S 1 month after neurotomy (P = 0.034). RMDQ in Group D 1 month after RF neurotomy was lower as compared to Group S (P = 0.045). The positive predictive value in Group S with single MBB is 66.6%, whereas the positive predictive value in Group D with dual MBB is 86.6% at the end of 1 month post-RF ablation. Conclusions: Single MBB injection for diagnosis of facet joint syndrome yields many false positives results and the positive predictive value for the same is lower as compared to Dual MBB.
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Functional outcome of percutaneous spine endoscopic intervention in lumbar disc herniation- A retrospective analysis p. 150
Anurag Agarwal, Shivani Rastogi, Deepak Malviya, Swagat Mahapatra, Virendra Kumar, Manoj Tripathi, Kavya Sindhu
DOI:10.4103/ijpn.ijpn_78_20  
Introduction: Low back pain is one of the most common musculoskeletal problems among developed and developing nations. The prolapsed intervertebral disc (PIVD) is the most common pathology associated with treatable low back pain. The management protocol for PIVD has evolved from conservative treatment to surgical and finally to minimally invasive pain and spine interventions. Aims and Objectives: The aim of study was to evaluate the functional efficacy and patient satisfaction in PIVD patients with minimally invasive percutaneous endoscopic disc decompression (PEDD). Materials and Methods: All data was obtained from pain medicine OT records of tertiary hospital regarding epidemiological data, VAS score for pain, ODI score for functional outcome and Modified Macnab's criteria for patient satisfaction(Pre-op, 1 week, 1 month, 3 months and 1 year) were tabulated and statistically analyzed using SPSS version 21. Results: There were 30 male and 26 female patients in our series with the mean age of the 42.09±10.57 years. The VAS score showed statistically significant improvement 3 months (P=0.034) and at 1 year (P=0.012) postoperative. The modified ODI score showed statistically significant improvement during 3 months (P= 0.015) and 1-year score (P=0.008). The modified MACNAB scores (P= 0.001) showed significant improvement in patient satisfaction. One patient had a recurrence and opted for conventional surgical management. Few patients had transient side effects (dysesthesia-7, mild weakness-1) which improved with conservative measures. Conclusion: We conclude that percutaneous endoscopic disc decompression for single-level lumbar disc herniation is a safe, effective and low-cost definitive treatment modality with minimal complications.
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Correlation of endogenous pain modulation function with physical activity in elders having chronic pain p. 157
Alifiya S Sirohiwala, Gloria Alva, Shaswat Verma
DOI:10.4103/ijpn.ijpn_113_20  
Context: Chronic pain is a major predicament of the elderly population and lacks appropriate treatment. In normal healthy individuals, physical activity (PA) shows an effect on endogenous pain modulation (EPM) function by producing central opioids and producing exercise-induced analgesia. Aims: This study aimed to determine a correlation between EPM function and PA of the elderly having chronic pain. Methodology: This was a cross-sectional study of 45 elderly individuals who were between 60 and 80 years of age, suffering from chronic pain. The EPM function was tested using conditioned pain modulation test and PA levels were obtained using Yale Physical Activity Survey (YPAS). In addition, we collected demographic details, duration of pain, and site of pain from the study population. Descriptive statistics was depicted in terms of frequency. Categorical variables were indicated as the mean and standard error of mean. The Spearman's rank correlation (r) test was used to find the correlation between conditioned pain modulation (CPM) and YPAS score. Results: A positive moderate correlation was found between EPM function and PA of elderly having chronic pain (r = 0.05; P = 0.0002). Analysis of EPM function based on the gender of the study population showed that both females (22.54 ± 23.92) and males (6.24 ± 29.19) had similar EPM function values. YPAS score was found as a significant predictor of CPM (P = 0.0003). Conclusion: There is a positive moderate correlation between EPM function and PA levels of elderly having chronic pain.
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CASE REPORTS Top

Humeroplasty for pain control in multiple myeloma p. 162
Ricardo Plancarte, Dhanalakshmi Koyyalagunta, Sudhir Diwan, Karla Mota, B Carolina Hernández-Porras
DOI:10.4103/ijpn.ijpn_10_21  
Pathological fractures in patients with primary skeletal cancer or metastases are associated with significant morbidity and poor prognosis. We present three cases of patients with osseous pain despite having received radiotherapy and multimodal analgesic management. Humeroplasty was offered to treat pain and decrease the risk of fracture. We report three patients with osseous pain secondary to osteolytic tumoral activity in the humerus and a Mirels score >7. Humeroplasty was performed under sedation and under fluoroscopy guidance. The three patients reported a decrease in pain most significantly with incidental pain and improved mobility. There were no fractures noted and no other complications. Percutaneous humeroplasty could be an option in multiple myeloma patients with impending humeral fractures, especially when the osteolytic lesion is localized in the humeral head. The procedure provided good pain relief to the patient. However, more studies should be conducted to asses efficacy and complications.
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A case report on efficacy of platelet-rich plasma therapy in avoiding surgical intervention for trapeziometacarpal joint osteoarthritis p. 166
Minal Chandra, Sudheer Dara, Karthika Keethidi Reddy, Rachna Varma
DOI:10.4103/ijpn.ijpn_139_20  
Osteoarthritis of the first carpometacarpal joint also called as trapeziometacarpal joint is the most common of all five carpometacarpal joints to undergo degeneration. The patient suffers with chronic pain, tenderness, stiffness of joint, and sometimes, even deformity can be seen in long-standing cases. Due to limited treatment options, patients have to suffer with side effects of pain killers or may have to undergo surgical intervention, but intra-articular joint injections and platelet-rich plasma therapy have been proven efficacious in providing good pain relief.
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Painful traumatic neuroma formed in chronic osteomyelitis surgical scar treated by pulsed radiofrequency ablation p. 169
Rachna Varma, Gauri Varma, Sudheer Dara, Minal Chandra
DOI:10.4103/ijpn.ijpn_33_20  
Traumatic neuromas are sometimes formed in the surgical scars. Peripheral nerve injuries lead to complex clinical presentation. They are benign tumors which are formed by critical nerve tissue interaction and are extremely painful. They are formed by intraneural or extraneural scar formation affecting the nerve-gliding plane. Their main clinical presentation is neuropathic pain. This condition is also termed as “painful scar neuropathy.” There have been different approaches to treatment depending on the type of lesion whether it is perineural, endoneurial, or combined and type of pain due to traction or trauma, rest pain, and severity. Varying degrees of therapeutic success has been described in literature using different techniques. There is no consensus on the best therapeutic approach to treat neuropathic pain due to scar tethering. Patient counseling about the condition and the need for multiple interventions, if needed, is essential. Here, we report a case of a 16-year-old female with traumatic neuroma of superficial peroneal nerve formed in the surgical scar of chronic osteomyelitis presenting with severe pain and paresthesia treated by pulsed radio frequency (PRF). PRF is a novel therapeutic method to treat many conditions in pain medicine as it offers treatment without motor deficits and deafferentation syndrome.
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Conventional radiofrequency ablation of the articular sensory branches of the obturator and femoral nerves under fluoroscopic guidance for chronic hip joint pain in a case of ankylosing spondylitis p. 173
Anshul Taran, Biplab Sarkar, Gargi Nandi, Subrata Goswami
DOI:10.4103/ijpn.ijpn_94_19  
Chronic hip pain is often a debilitating problem, especially ankylosing spondylitis (AS), and few patients with the problem are not good surgical candidates. Hence, other conservative approaches should be used. We report the case of a 37-year-old male, a known case of AS, who presented with severe hip pain along with other joint involvements. The hip joint pain was managed with radiofrequency (RF) ablation of the articular sensory branches of the hip joint after initially tested with positive diagnostic block. This case emphasizes the role of RF ablation as a safe alternative to hip replacement.
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Ultrasound-guided radiofrequency ablation in a patient with resistant intercostal neuralgia secondary to chronic osteomyelitis of anterior end of ribs p. 176
Natasha Kale, Sheetal Shah, Hemant Mehta
DOI:10.4103/ijpn.ijpn_22_20  
Intercostal neuralgia is a complex painful disorder characterized by intense, sharp shooting, or burning pain, along the distribution of intercostal nerve. It is difficult to treat condition in which pharmacological modalities of treatment often fail. We report a case of a 56-year-old female with postoperative sternal wound infection, following coronary artery bypass grafting, involving the left costochondral junction and left anterior ends of 7th, 8th, and 9th ribs. She presented with severe excruciating pain over left T7, T8, and T9 dermatomes for 3 months. Conservative management failed to provide significant improvement in pain relief. Hence, intercostal nerve block was performed and it provided good pain relief for 3 weeks. It was then followed by radiofrequency ablation (RFA) that provided good symptomatic pain relief at 9-month follow-up. Thus, ultrasound-guided RFA can be effectively and safely used in patients suffering from resistant intercostal neuralgia for providing quick and long-term pain relief.
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LETTERS TO THE EDITOR Top

Newer horizons for the pericapsular nerve group block p. 179
Priyanka Pavithran
DOI:10.4103/ijpn.ijpn_56_21  
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Flank pain from postherpetic neuralgia and role of erector spinae plane block p. 181
Rajendra Kumar Sahoo, Ashok Jadon, Ganesh C Satapathy, Lingaraj Sahu
DOI:10.4103/ijpn.ijpn_57_21  
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