Chronic pain problem is one of the most common symptoms for which a patient visits a primary health-care practitioner in India. Pain management is a rapidly growing specialty of medicine concerned with the prevention of pain, and the evaluation, treatment, and rehabilitation of persons in pain. Pain as a specialty has grown enormously in the last decade and is being recognized at the national level by the government, medical fraternity, and community at large. The time has come for the formation of a uniform, high-quality, standardized, multidisciplinary pain education, and training framework which would include health-care providers from the grass root level to the specialized pain consultants.

Acute post-operative pain and other forms of pain are widely undertreated globally including the Indian hospitals. As a result a large proportion of patients suffer from moderate to severe forms of pain. Undertreated pain can have many negative consequences such as pulmonary complications, acute myocardial ischemic events, delayed wound healing, prolonged hospital stay, etc. In spite of this acute pain continues to be negelected. The solution to poorly managed pain is not just developing newer and sophisticated techniques. But the solution lies in developing a dedicated, round-the-clock service called as acute pain service. This concept has gained world wide acceptance in last two decades and a majority of countries are developing such pain services in the hospitals. Unfortunately in India the field of acute pain medicine is still in its infancy. A very few hospitals have full fledged Acute Pain Services. In this review article we have tried to throw light on the hurdles in developing Acute Pain Services in our country. Also we have suggested a few possible solutions.

Background: Subarachnoid block (SAB) possesses many benefits with a drawback of short duration of anesthetic action. Intrathecal opioids have been used to enhance the clinical efficiency and duration of action of local anesthetic drugs. The present study was aimed to compare the clinical efficiency of intrathecal fentanyl with nalbuphine as adjuvant to 0.5% hyperbaric bupivacaine for orthopedic surgery of lower limbs. Patients and Methods: Sixty-eight adult patients of American Society of Anesthesiologist physical status I and II of both gender aged 25-65 years were randomized into two groups of 34 each to receive either fentanyl 25 μg (Group I) or nalbuphine 2 mg (Group II) with 3.5 mL 0.5% hyperbaric bupivacaine, making intrathecal drug volume to 4 mL in each group. Sensory and motor block characteristics and time to first rescue analgesic (intravenous tramadol 100 mg) were recorded as the primary end points. Drug-related side effects of pruritus, nausea/vomiting, and respiratory depression were recorded as the secondary outcomes. Results: Both groups were comparable regarding the onset and cephalic extension of block. The time to two dermatome regressions and time for complete motor recovery were significantly prolonged in patients of Group II with statistical significant difference (P < 0.05). Duration of analgesia was also extended in patients of Group II (378.0 ± 35.72 min) as compared to Group I (234.0 ± 24.10 min) with highly significant difference (P < 0.001). No drug-related side effects were observed in either group. Conclusion: Intrathecal nalbuphine 2 mg as adjuvant to 0.5% bupivacaine was clinically more efficient than fentanyl for enhancing the postoperative analgesia.

Background: Postoperative pain is a common and distressing symptom after knee arthroscopy. This study aims at analyzing the efficacy of intra-articular dexmedetomidine for postoperative pain relief in patients undergoing arthroscopic knee procedures under unilateral spinal anesthesia. Materials and Methods: Fifty adult patients of American Society of Anaesthesiologists Class 1-2, aged 20-60 years posted for arthroscopic knee surgery were randomly divided into Groups I (control group) and II (dexmedetomidine group) with 25 patients in each group. Anesthetic technique used was unilateral spinal in all the patients. Group I was the control group and Group II the dexmedetomidine group. Group II patients received 1 μg/kg dexmedetomidine diluted to 20 ml in normal saline via intra-articular route at the end of the procedure and Group I patients received an equal volume of normal saline. Visual analog scale (VAS) score for 24 h, time to give the first dose of analgesia and total dose of analgesic required in each group was evaluated. Results: VAS scores were significantly lower in Group II, time to first analgesic requirement was significantly greater in Group II (308 ± 3.59) than in Group I (244 ± 2.92), P < 0.001 and total dose of analgesic used in Group II (36 mg ± 7.65) patients was significantly lesser compared to patients in Group I (129 mg ± 6.87), P < 0.001. Conclusion: Intra-articular dexmedetomidine is effective in providing prolonged postoperative analgesia after arthroscopic knee procedures and reduces the total dose of analgesic required postoperatively.

Introduction: Major laparotomies generally herald high pain scores postoperatively and have high intraoperative hemodynamic shifts. Traditional analgesic regimens with intravenous opioids were supplanted with the superior epidural analgesia (EA) in the mid-1980s. This was based on the perception that EA provided highly effective postoperative analgesia for patients undergoing major abdominal surgery. However, recent literature points to a high failure rate. We aimed to retrospectively audit our EA performance in terms of success and complications and take an in-depth look at factors associated with failure. Methods: We retrospectively reviewed charts and our EA forms over 6 months. Results: Our results show a low rate of mortality and neurological morbidity. However we have a high rate of failure of 37% as judged by high pain scores, use of adjuvant analgesics and also an unacceptably high rate of hypotension from epidural infusions, requiring fluid boluses, inotropes and Intensive Care Unit admission. Registrar level and senior insertion did not show any difference in failure rate. Conclusion: Level of training per se does not equate to experiential skip and prior level of experience with administration of this type of anesthesia. We can conclude that EA in our setting is safe but not effective and requires further and frequent scrutiny in terms of procedures, technical skill, education and perhaps looking at its cost-effectiveness and need for standardization.

Introduction: Chronic pain is one of the most common complaints with which patients present to the physiotherapist. Somatic symptoms, anxiety, and depression are common in this group of patients. The present study was carried out to assess the levels of somatic symptoms, anxiety, and depression in patients with chronic pain. Materials and Methods: About 200 patients (113 male and 87 females) with chronic pain were subjects of the study. They were administered the Chronic Pain Grade Questionnaire, Somatic Symptom Severity-8 scale, and the Hospital Anxiety and Depression Scale. The scores were assessed using descriptive statistics and correlation where needed. Results: Grade II or moderate pain was the commonest severity of pain reported (42 males and 34 females). Most patients reported a low prevalence of somatic symptoms (43 males and 39 females). Combined anxiety and depression levels were seen across both genders (56 males and 52 females). A positive correlation between chronic pain grade and levels of anxiety and depression as well as severity of somatic symptoms were noted across both genders (P < 0.0001). Conclusion: Levels of depression, anxiety, and somatic symptoms are common in patients with chronic pain and also are directly related to the level of intensity of pain.

Background: The level of quality of life (QOL) and disability among women with low back pain is an important health issue at global level. Objective: To find out the prevalence of low back pain and to assess the relationship of low back pain with disability and QOL among women. Materials and Methods: A community-based cross-sectional study was conducted among 250 women in age group of 30-65 years residing in field practice area of a Tertiary Care Medical Institution, Puducherry. Severity of the pain was assessed using Numerical Pain Scale. Modified Oswestry Low Back Pain Disability Questionnaire was used to measure the disability level and WHO-BREF scale to assess the QOL among women with low back pain. Results: Overall, the prevalence of low back pain was found to be 42%. The majority of women (60.9%) with low back pain experienced moderate disability. Almost 72% of women with low back pain perceived their QOL as good and overall mean QOL score was 88.41 (standard deviation = 12.9). The low back pain was influenced by the demographic variables that include age, marital status, illiteracy, total family income, type of delivery, number of children and household chores, menopausal status, and chronic illness (P < 0.05). Disability was influenced by age, education, and occupation, whereas QOL was influenced by education of the women with low back pain (P < 0.05). Conclusions: Prevalence of low back pain among women was comparatively more than other studies in India. Although moderate disability was more among those with low back pain, overall QOL was good.

Background: There is a lack of information about the prevalence of pain among school going Indian children, and therefore, this study was conducted. A cross-sectional population survey was conducted in school children from Grades III to VI. The objective was to determine the prevalence of pain, including chronic pain. The secondary objectives were to find a correlation between chronic pain with age, gender, parental history of chronic pain and past surgical history along with the various characteristics of chronic pain. Method: Seven hundred questionnaires were distributed in schools from Grades III to VI. They were answered at home by the children along with their parents. The data thus obtained were analyzed with appropriate statistical tests. The level of significance was set at P ≤ 0.05. Results: The overall prevalence of non-chronic pain was found to be 37.6% (95% confidence interval being 34.0-41.2%). The prevalence of chronic pain was 3.90% (95% confidence interval being 2.86-4.94%). There was no statistically relevant correlation between gender, age, family history of chronic pain, or past surgical history with chronic pain. Conclusion: Our study suggests that prevalence of pain in Indian school going children is common, although the prevalence of chronic pain is far less than that estimated world-wide.

Background and Aims: The use of transdermal patches to deliver drugs systemically for postoperative analgesia offers lots of pharmacological and nonpharmacological advantages over the conventional enteral and parenteral drug therapies. Aim of this study was to assess the difference in mean duration and quality of postspinal analgesia in patients underwent elective abdominal hysterectomy. Methods: Sixty patients of American Society of Anesthesiologists Grade I and II undergoing elective abdominal hysterectomy were randomized into three groups of 20 each using chit in box method (Group I control, Group II 2.5 mg fentanyl patch, and Group III 5 mg fentanyl patch). The ANOVA test and post hoc test were used for continuous data and Chi-square test was used for count data. Results: The mean difference of visual analog scale score were significantly low in Group III and Group II (P = 0.00). The mean total duration of analgesia was more in Group III and Group II (P = 0.00). The requirement of rescue analgesic dose was significantly low in Group II and no rescue analgesic needed in Group III (P = 0.00). No significant side effects were noted. Conclusions: Transdermal fentanyl patch (TFP) (50 mcg/h) provides better postoperative analgesia than TFP (25 mcg/h) and placebo patch with significant reduction of requirement of rescue analgesic dose.

Introduction: Backache and sciatic pain are routinely seen in day-to-day practice. In all urban settings with changed lifestyle, lack of exercise, bad posture, excessive use of vehicles, and disturbed nutrition; problem of discogenic backache and sciatica is on the rise. The treatment modalities vary from conservative to surgical methods, but they predominantly provide relief to leg pain and not back pain. Nerve root block acts at these inflammatory processes, by the action of the steroid and thus decreasing the chemical irritation to the nerve roots. Furthermore, there is a decrease in sensitization of dorsal horn neurons by bupivacaine. Aims and Objectives: To evaluate diagnostic and therapeutic efficacy of root block procedure. To study relief in terms of pain alleviation, activities of daily living, and straight leg raising (SLR) restriction. Materials and Methods: Retrospective study of fifty patients of sciatic radiculopathy between the ages of 20 and 60 years were evaluated under this study at Dr. D. Y. Patil Medical College and Research Centre, Pune. All the patients of different age and sex had radicular pain with or without back pain, restricted spinal mobility, positive active and passive SLR test, and other nerve tension signs. Results: Out of fifty patients selected after thorough clinical and radiological examination, 45 (90%) had enjoyed complete pain relief and 31 (62%) of which were completely symptom-free at the end of 1 year. Conclusion: Spinal nerve root block may provide lasting therapeutic benefit, allowing the patient to participate in physical therapy and early  return to routine activities saving working manpower hours.

Background: Thromboangiitis obliterans (Buerger's disease) is a nonatherosclerotic inflammatory disorder primarily involving small and medium sized vessels, mainly arteries of the extremities. As the disease progresses, it could cause gangrene and amputation of limbs, eventually leading to persistent pain and disability. Settings and Design: A prospective, randomized, single-blinded comparative study. Materials and Methods: Fifty patients of Buerger's disease planned for amputation below the knee were divided randomly into two equal groups of 25 each. Patients of both groups were advised to stop smoking. Lumbar (chemical) sympathectomy was carried out in patients of study group 1 week before amputation. The severity of postamputation stump pain was assessed using visual analog scale (VAS) and requirement of analgesics on weekly basis for 12 weeks. The incidence of phantom limb pain and overall quality of life was also evaluated using Short Form-36 (SF-36) scale. Results: VASs and requirement of analgesics were significantly less in patients who underwent lumbar sympathectomy as compared to patients of control group. The quality of life as reflected by SF-36 score was also significantly better in the study group. However, there was no significant difference in the incidence of phantom limb pain in the two groups. No major complications were reported following lumbar sympathectomy. Conclusions: Lumbar sympathectomy significantly decreases the severity of postamputation stump pain of lower limbs and thus improves the overall quality of life in patients of Buerger's disease.

Phantom limb pain which is basically neuropathic in nature resulting from functional changes in peripheral and central pain pathways subsequent to amputation, is challenging to treat. We report an interesting case of phantom limb pain during the regression phase of spinal anesthesia in a patient to be operated for revision amputation for chronic ulcer.

Cluster headache is a primary neurovascular unilateral headache associated with autonomic symptoms. The sphenopalatine ganglion plays an important role in the pathogenesis of this disorder. Although medications are the first line of treatment, percutaneous, and surgical interventions have been proposed to treat cluster headache. An attractive option is the radiofrequency ablation of the sphenopalatine ganglion for the treatment of cluster headache due to its relative safety and simplicity compared with other procedures.