Background and Objectives: We evaluated the effect of adding dexamethasone to ropivacaine for supraclavicular brachial blockade. The primary endpoints were the onset and total duration of sensory and motor block, quality of analgesia, and duration of analgesia. Materials and Methods: Eighty patients of age group 20-50 years, scheduled for various elective orthopedic surgeries on forearm and around the elbow under supraclavicular brachial block were divided into two equal groups in a randomized, double-blinded fashion. In group R (n = 40), 30 ml (150 mg) of 0.5% ropivacaine + 2 ml saline; and in group RD (n = 40), 30 ml (150 mg) of 0.5% ropivacaine + 2 ml dexamethasone (8 mg) were given. Motor and sensory block onset times, block durations, quality of intraoperative analgesia, and duration of analgesia were recorded. Results: Demographic data and surgical characteristics were similar in both groups. The sensory and motor block onset time was earlier in group RD as compared to group R (P < 0.05). Sensory and motor blockade durations were longer in group RD than in group R (P < 0.001). Duration of analgesia was longer in group RD than in group R (P < 0.001). The 24 h Visual Analogue Scale (VAS) was more in group R as compared to group RD. The quality of anesthesia was excellent in both the groups. Mean arterial blood pressure levels in groups at 5, 10, 15, 30, 45, 60, 90, 120, and 150 min were statistically insignificant between the two groups (P > 0.05). The mean pulse rate at different time intervals was statistically insignificant between the groups (P > 0.05). Conclusions: Dexamethasone added to ropivacaine for supraclavicular brachial plexus block prolongs the duration of the block and the duration of postoperative analgesia.

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Pain assessment remains a challenge to medical professionals and received much attention over the past decade. Effective management of pain remains an important indicator of the quality of care provided to patients. Pain scales are useful for clinically assessing how intensely patients are feeling pain and for monitoring the effectiveness of treatments at different points in time. A number of questionnaires have been developed to assess chronic pain. They are mainly used as research tools to assess the effect of a treatment in a clinical trial but may be used in specialist pain clinics. This review comprises the basic information of pain intensity scales and questionnaires. Various pain assessment tools are summarized. Pain assessment and management protocols are also highlighted.

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Background: Nalbuphine is a synthetic opioid with mixed agonist-antagonist action, when added as adjuvant to intrathecal bupivacaine acts on kappa receptors in the dorsal horn of the spinal cord producing analgesia. Aim: To evaluate the onset of sensory block, hemodynamic changes, duration and quality of analgesia, and adverse effects of different doses of nalbuphine with bupivacaine for spinal anesthesia. Materials and Methods: Randomized double blind study done on 100 patients undergoing lower abdominal and lower limb orthopedic surgeries under subarachnoid block. Patients were randomly allocated to four groups receiving either intrathecal 15 mg of bupivacaine + 0.5 mL normal saline alone or 15 mg of bupivacaine with either of nalbuphine 0.8, 1.6, and 2.5 mg + 0.5 mL normal saline. Results: The mean visual analogue scale score in group A is 4.08 ± 0.5 and in groups B, C, and D are 3.4 ± 0.4, 3.5 ± 0.5, and 3.5 ± 0.5, respectively. The duration of analgesia in group A is 190.4 ± 20.0 and in groups B, C, and D were 322.4 ± 31.1, 319 ± 39.8 and 317.8 ± 47.5. The quality of analgesia was good in 72%-76% and excellent in 16%-28% in groups B, C, and D and poor 28% to satisfactory 72% in group A. Conclusion: Addition of 0.8 mg of nalbuphine to 0.5% bupivacaine for subarachnoid block provides excellent analgesia with longer duration of action compared with 1.6 and 2.4 mg of nalbuphine.

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Preemptive analgesia, initiated before the surgical procedure to prevent pain in the early postoperative period has the potential to be more effective than a similar analgesic treatment initiated after surgery. This article aims to review all the recent published evidences that assess the efficacy of this enigmatic concept. Materials and Methods: We reviewed original research articles, case-reports, meta-analyses, randomized control trials (RCTs), and reviews based on pain physiology for preemptive analgesia from Medline, Medscape, and PubMed from 1993 to 2013. A broad free-text search in English was undertaken with major keywords "Preemptive analgesia," "postoperative pain," "preoperative," and "preincisional". Results: Review of publications showed that intravenous (IV) nonsteroidal anti-inflammatory drugs (NSAIDs) are quite effective when used alone, as well as with low dose iv ketamine, preemptively to provide adequate postoperative analgesia. However, ketamine has a doubtful role as a standalone agent. Preemptive administration of LA at the incision site reduces postoperative pain, but achieves an analgesic effect similar to that of postincisional anesthetic infiltration as does intraperitoneal administration. Preemptive epidural analgesia has proved its efficacy in controlling perioperative immune function and pain in comparison to parenteral opioids. Gamma-amino butyric acid (GABA) analogues like gabapentin and pregabalin have great potential as preemptive analgesic with the added advantage of its anxiolytic effect. Conclusion: Multimodal approaches that address multiple sites along the pain pathway is necessary to treat pain adequately. However, we need to find an answer to the question of how to obtain the maximal clinical benefits with the use of preemptive analgesia.

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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.

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Background: Epidural adjuvants enhance the quality and duration of surgical anesthesia. The present study was aimed to compare the hemodynamic, sedative, and analgesia potentiating effects of dexmedetomidine versus fentanyl with epidural 0.5% levobupivacaine for vaginal hysterectomy. Patients and Methods: Sixty consented females of ASA physical status I and II aged 35-65 years weighing 55-75 kg, were double blindly randomized into two treatment groups. Patients received epidural 0.5% levobupivacaine 15 ml either with of 25 μg dexmedetomidine (Group LD) or 50 μg fentanyl (Group LF) and the total volume of study solution was kept 16 ml. Onset of analgesia at T10, sensory and motor block levels and duration of analgesia were observed. Intra-operatively, they were assessed for sedation, hemodynamic changes, respiratory efficiency, and side effects. The data obtained, was compiled systematically and analyzed statistically using Chi-square test and ANOVA. Value of P < 0.05 is considered significant. Result: The demographic profile was comparable between groups. The onset of sensory analgesia at T10 (7.25 ± 2.3 versus 9.27 ± 2.79 min) and time to achieve complete motor blockade (19.27 ± 4.7 versus 22.78 ± 5.57 min) was significantly earlier in patients of LD Group. The intraoperative hemodynamic changes were comparable between groups. Ramsey Sedation score was better in LD group with statistically significance. Postoperative analgesia was significantly prolonged in LD Group. Incidence of nausea, vomiting, and pruritus was high in LF group. Conclusion: Dexmedetomidine was better than fentanyl as an epidural adjuvant for providing early onset of sensory analgesia, adequate sedation with no respiratory depression and prolonged postoperative analgesia.

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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.

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Background: Transversus abdominis plane (TAP) block is a regional anesthesia technique whose efficacy has been proven for postoperative pain relief after cesarean section (CS). Dexamethasone, a glucocorticoid, is now emerging as a new adjunct to local anesthetics for prolonging the duration of action and has been studied in different brachial plexus blocks. The primary outcome was to study the effect of dexamethasone as additive to ropivacaine on the duration of TAP block as assessed by time to first analgesic (TFA) . The secondary outcome was total postoperative analgesic consumption, postoperative nausea and vomiting, and patient satisfaction. Method: This RCT was conducted on seventy American Society of Anesthesiology Grade I and II patients undergoing CS under subarachnoid block. Patients were randomly allocated to two groups comprising 35 patients each. Patients in Group I received ultrasound-guided bilateral TAP block at the end of surgery using 40 ml ropivacaine 0.2% and 2 ml saline, and patients in Group II received the block using 40 ml ropivacaine 0.2% and 2 ml (8 mg) dexamethasone. Result: TFA was significantly longer in Group II (5.92 ± 1.02 vs. 3.11 ± 0.82 h, P = 0). Group II also had decreased tramadol requirement postoperatively (100.00 ± 0.00 vs. 140.00 ± 50.26 mg, P = 0.046). The incidence of nausea and vomiting was also lower (82.86% vs. 97.14%, P = 0.02318). The patient satisfaction with regard to pain relief was more (57.14% vs. 25.71%, P = 0.038). Conclusion: Addition of dexamethasone to ropivacaine in TAP block prolonged the duration of the block. There was no complication seen with TAP block in any of the patients.

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The effective management of pancreatic cancer pain continues to be a major challenge for patients and clinicians. Up to 80% of patients with advanced pancreatic cancer present with the symptoms of severe pain. One of the most important goals in their management is achieving the highest quality of life throughout the course of disease with effective palliation of pain. Majority of the current data supports the use Neurolytic celiac plexus block (NCPB) and has been shown to be more effective in reducing pain compared with standard pharmacotherapy. NCPBs have led to decreased opioid requirements and related side effects, thus preventing deterioration in quality of life. In this article, we discuss the treatment of pancreatic cancer pain and the advances in techniques of performing NCPB. We also analyzed the incidence of complications and the quality of pain relief with the use of NCPB. NCPB is effective, has a low incidence of complications, and should be used more often in patients with pancreatic cancer pain.

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Objectives: Moringa oleifera is a highly valued plant distributed in many countries of the tropic and subtropics. Moringa oleifera leaves are a potential source of phytochemical ingredients claimed to have analgesic property. Pain is an unpleasant sensation, which in many cases represents the only symptom for the diagnosis of several diseases. Therefore analgesic drugs lacking the side effect as alternative to nonsteroidal anti-inflammatory drugs (NSAIDs) and opiates are in demand by the society. The present study is undertaken to evaluate the analgesic activity of Moringa oleifera using acetic acid induced writhing test and Eddy's hot plate test. Materials and Methods: It is a randomized control study. The present study was done using two experimental models. The albino mice were divided into six groups, each group consisting of 6 mice. A total of 36 mice were used in each of the two experimental models. Group I: Control (normal saline given orally at 2 ml/kg body weight); Group II: Standard (diclofenac 10 mg/kg i.p/ morphine 1 mg/kg i.p); Group III, IV, V, VI (ethanolic extract of Moringa oleifera (EMO) 50, 100, 200, 400 mg/kg, respectively). The EMO leaves were administered at 50, 100, 200, 400 mg/kg doses orally 1 hour before the experiments. For peripheral analgesic effect, acetic acid induced writhing test was used. The central analgesic effect was screened using Eddy's hot plate method. The standard drug used in acetic acid induced writhing test was diclofenac and in Eddy's hot plate test was morphine. Results: The EMO leaf showed significant (P < 0.01) analgesic activity at 100, 200, 400 mg/kg in the acetic acid induced writhing test showing 32.21%, 59.71% and 78.61% inhibition of writhes, respectively in comparison with the control. In the Eddy's hot plate test EMO at 400 mg/kg showed significant (P < 0.01) analgesic activity from 15 min to 90 min with a mean rank ranging from 28.92 to 26.00, second mean rank following morphine in comparison with control. In both the tests, EMO showed significant (P < 0.01) analgesic activity in a dose-dependent manner. Conclusion: The ethanolic leaf extract of Moringa oleifera exhibited analgesic activity in both models showing its both central and peripheral analgesic actions.

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Background: Brachial plexus block is a reliable, regional anesthetic technique for upper arm surgeries. Opioid agonist-antagonists are also used as adjuvant to enhance the analgesia of bupivacaine. The present study was aimed to assess the analgesic efficacy and safety of nalbuphine as an adjuvant to 0.5% bupivacaine for brachial plexus block. Patients and Methods: Sixty adult patients of American Society of Anesthesiologists physical status I and II of both genders were randomized into two groups of thirty patients each to receive either 20 mL of 0.5% bupivacaine with 1 mL of normal saline (Group 1) or 20 mL of 0.5% bupivacaine with 1 mL of nalbuphine 10 mg (Group 2) for brachial plexus block under ultrasound guidance. Patients were observed for onset and duration of sensory and motor block with duration of pain relief as primary end points while occurrence of any adverse effect due to technique or nalbuphine was noted as secondary outcome. Results: The ultrasound guided the visualization of the nerves, needle, and spread of local anesthetic at brachial plexus block site. Nalbuphine did not affect the onset time of block but enhanced the duration of sensory and motor block. The duration of postoperative analgesia was 481.53 ± 42.45 min in Group 2 and 341.31 ± 21.42 min in Group 1, with statistically highly significant difference (P < 0.001). There were no hemodynamic variations and no complication of technique or adverse effects due to nalbuphine occurred. Conclusion: Nalbuphine 10 mg has significantly extended the duration of analgesia of brachial plexus block with no adverse effects.

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Diclofenac and aceclofenac are nonsteroidal antiinflammatory drugs (NSAIDs). Diclofenac is advocated for the treatment of painful and inflammatory rheumatic and certain nonrheumatic conditions such as rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, tendinitis, and bursitis, and in other inflammatory or painful conditions such as strains and sprains, dysmenorrhea, back pain, sciatica, and postoperative pain. Aceclofenac provides symptomatic relief in a variety of painful conditions such as joint inflammation, and reduces pain intensity and the duration of morning stiffness in the patients with rheumatoid arthritis, improves spinal mobility in the patients with ankylosing spondylitis. Gastrointestinal (GI) problems are the most frequent effects, which are caused by diclofenac and include dyspepsia and abdominal pain. Aceclofenac also has similar adverse effect but they are mild compared to diclofenac. We have reviewed 9 prospective studies that compared efficacy and safety of diclofenac with those of aceclofenac, 5 studies on osteoarthritis patients, 1 study on rheumatoid arthritis patients, 1 study on overall musculoskeletal disorders, 1 study on lower back pain, and 1 study on postextraction dental pain. Western Ontario and McMaster (WOMAC) universities scores, visual analogue scale (VAS), the Ritchie index, Lequesne OA severity index (OSI) were used in assessing the pain intensity and measuring the efficacy of the drug that proved beneficial in assessing the pain intensity and measuring the efficacy of both the drugs. All the studies came to the conclusion that aceclofenac is a better choice of drug in managing pain in case of all the above conditions with better efficacy and tolerability, patients experienced more number of adverse events (AEs) with diclofenac when compared with aceclofenac.

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Background: Chronic knee osteoarthritis (OA) is one of the most common diseases of advanced age. Available therapies have insufficient evidence and adverse effects. Hyaluronic acid (HA) injection reduces knee pain in certain patients only for short duration. Radiofrequency (RF) neurotomy of genicular nerve branches has been tried recently. Comparison of these two modalities is lacking. The aim of this study was to compare pain relief and daily activities by visual analog scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores between intra-articular HA injection and RF neurotomy of genicular nerves. Materials and Methods: Patients were treated with intra-articular HA injection and RF neurotomy of genicular nerves 12 in each group (n = 12). Pain relief and day-to-day activity were compared. Results: There was statistically significant difference and lower VAS and WOMAC scores in the RF group compared to HA group after treatment. Conclusion: As compared to intra-articular HA injection, RF neurotomy of genicular nerves appears to be a promising and more effective therapeutic procedure for patients with chronic knee OA.

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Objective: A prospective, randomized, double-blind study was conducted to compare the efficacy of Ropivacaine 0.125% and Bupivacaine 0.125%, both with Fentanyl 2 microgm/ml, in labor epidural analgesia and their effect on duration and course of labor. Background: Ropivacaine was introduced as S-enantiomer. In various human and animal studies, it was found to be less cardiotoxic and has high sensory:motor differential blocking property. Both these characteristics are beneficial for labor epidural analgesia. Materials and Methods: Sixty pregnant women of ASA grade I and II, who were primigravida or multigravida, with singleton vertex presentation in established labor were randomly selected and divided into two groups of 30 each. Group R patients received Ropivacaine 0.125% with Fentanyl 2 μg/ml and group B patients received Bupivacaine 0.125% with Fentanyl 2 μg/ml as intermittent bolus doses epidurally. After taking consent from them, epidural catheter was placed in L2-3/3-4 space, followed by administration of study drugs given as top-up doses intermittently. Maternal heart rate, systolic blood pressure (SBP), Visual Analogue Scale (VAS) score, fetal heart rate (FHR), Bromage score, level of sensory analgesia, APGAR score at 1 and 5 min, and duration of labor were recorded. Results: The groups were similar in demographic attributes and obstetric variables. Ropivacaine showed no difference in the mean VAS scores and the quality of analgesia, as compared to Bupivacaine. At 20 min, all the patients in both groups were absolutely pain free with the VAS score of 0. No patient in group R developed motor block, whereas five patients in group B developed grade 2 (mild) motor block. APGAR scores were comparable in both the groups. Conclusion: We conclude that Ropivacaine is equipotent, produces less motor block, has no adverse effect on the course and duration of labor, and can be used safely.

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Background: Spinal anesthesia is still the most commonly used technique for lower abdominal surgeries as it is very economical and easy to administer. Its main disadvantage remains the short duration of action. Hence, different additives have been used. Nalbuphine is an agonist-antagonist opioid that binds to μ-receptors, as well as to κ-and δ-receptors. The aim of this randomized, double-blind study was to evaluate the potentiating effect of intrathecal nalbuphine with bupivacaine for postoperative analgesia in three different doses. Materials and Methods: A total of 100 patients were randomized into four groups. Group A: Patients received 15 mg of 0.5% hyperbaric bupivacaine, group B: Patients received 15 mg of 0.5% hyperbaric bupivacaine plus 0.8 mg of nalbuphine, group C: Patients received 15 mg of hyperbaric bupivacaine plus 1.6 mg of nalbuphine, and group D: Patient received 15 mg of hyperbaric bupivacaine plus 2.4 mg of nalbuphine intrathecally. Results: The onset of sensory and motor block and duration of motor block were comparable in all groups. Two-segment regression was statistically significant when group A was compared to groups B, C, and D. The total durations of analgesia were 133.8 + 28.3 min, 199.8 + 25.9 min, and 166.8 + 27.8 min in groups B, C, and D, respectively. Conclusion: Our study showed that the combination of intrathecal bupivacaine with nalbuphine significantly prolonged postoperative analgesia as compared to the control group, and a 1.6 mg dose of nalbuphine administered intrathecally showed the best results among all other study groups.

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Post herpetic neuralgia (PHN) is a chronic neuropathic pain in the region of the herpes zoster (HZ) rash, persisting after the cutaneous lesions have healed. Despite numerous treatment advances, many patients remain refractory to the current therapies and continue to have pain, physical and psychological distress. In this review, we will discuss the current strategies for prevention and management of this disease, as also the insight into the future probabilities.

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The sensation of pain is an indication that something is wrong somewhere in the body. Pain and inflammation may be linked by cyclooxygenase (COX) enzymes most especially COX ₂ , which help in the synthesis of prostaglandins (PGs) precisely PGE2 and PGF2a, found in high concentration at the inflammatory site. The released PGs either stimulate pain receptor or sensitized pain receptors to the action of other pain producing substances such as histamine, 5-hydroxytryptamine (5HT), bradykinin which initiate and cause the nerve cells to send electrical pain impulse to the brain. In the present review, an attempt is made to unveil the treatment approach adopted in the management of pain and inflammation as well as animal models used in evaluating herbal plants with analgesic and anti-inflammatory properties. The choice of the use of herbal medicine have been encouraged due to it availability, affordability, accessibility, and little or no side effect associated with it. However, the question remains can herbal therapy serves as an alternative to available conventional drugs. Different treatment options in the management of pain and inflammation have been highlighted.

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Introduction: Postoperative pain management of high quality is important and in majority of post surgical cases pain is not treated adequately. We have evaluated the efficacy and safety of pregabalin and gabapentine as preemptive analgesic for post operative pain management in patients undergoing lower abdominal and lower limb surgery under spinal anesthesia. Materials and Methods: In a randomized double blind study, 90 patients were divided into three groups. Group G received tab gabapentin 900 mg, Group P received tab pregabalin 300 mg and Group C received placebo tablet orally 1 hour prior to surgery. All patients underwent surgery under spinal anesthesia using 0.5% Bupivacaine. Assessment of postoperative pain was made with visual Analogue Scale (VAS) score at 1, 2, 4, 6, 8, 12, 18, and 24 hours post operatively. Injection tramadol 100 mg was given as rescue analgesic intramuscularly when VAS score was > 7 in all the groups. Time to first rescue analgesics and number of rescue analgesics received were noted in all groups. The occurrences of side effects were noted in all groups. Results: The tramadol as rescue analgesia consumption was less in pregabalin and gabapentin groups compared to control and was statistically significant (P < 0.001). Initial VAS scores were lower in pregabalin (3.2 ± 0.4) and gabapentin (3.63 ± 0.32) groups compared to control (6.60 ± 0.77) and was statistically significant (P < 0.001). Time to first rescue analgesia was significantly longer for pregabalin (24.6 hours) followed by gabapentin (20.76 hours) and control (4.93 hours) groups. Conclusion: Pregabalin 300 mg single dose given 1 hour prior to surgery is superior to 900 mg gabapentin and placebo in attenuating post operative in patients undergoing lower abdominal and lower limb surgery. Both drugs are better than placebo.

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Introduction: Lumbar disc prolapse is most common between 30 and 50 years of age and is associated with severe disability and pain. It commonly occurs at L4/5 and L5/S1. Transforaminal endoscopic discectomy is an emerging technique for treatment of degenerative disc disease. Literature has shown clinical outcomes, comparable to classical open and micro lumbar discectomy. Central disc herniations in lumbar spine pose technical challenge for transforaminal endoscopic decompression due to its location. Existing techniques to access central herniations and ventral epidural space have trajectory related challenges due to the proximity of the retroperitoneal space and abdominal organs and technically difficult for the less experienced surgeon. Materials and Methods: Thirty patients – 19 males and 11 females – with central, multifocal, central-paracentral disc herniations in the lumbar spine operated in 2015 and 2016 were considered in this study. All patients underwent selective endoscopic discectomy under monitored care anesthesia and local anesthesia with modification of the classical technique, medialization of annulotomy, undercutting the nonarticular part of superior articular process (foraminotomy) and use of articulating and long jaw instruments either alone or in combination. Results: In all the thirty patients, we were able to achieve adequate decompression with neurological recovery. All patients improved in their neurological status. Postoperatively, visual analog scale dropped from 7.8 to 1.8 and ODI dropped from 73.46% to 32. 90% of the patients reported excellent and good results. One patient had recurrent herniation and was treated with transforaminal surgery. One patient had persistent back pain and reported poor outcome. Three patients underwent medial branch block for facet joint pain followed by medial branch rhizotomy and reported excellent and good results. Conclusion: Transforaminal endoscopic spine surgery with modifications as described above to reach the dorsal part of the disc in the midline and to access ventral epidural space is safe and effective.

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Current evidence-based practice guidelines for the management of nonacute persistent and recurring musculoskeletal-related pain have emphasized the use of holistic multidisciplinary approaches including nonpharmacological therapies. Kinesiology taping is a simple, economical, easy-to-apply, nondrug therapeutic technique that is used by health-care professionals for managing and rehabilitating musculoskeletal injuries. High-quality research on kinesiology taping is limited, although recent evidence suggests that kinesiology taping may have a small effect in mitigating pain and may be associated with mild cutaneous side effects. We present a review of the principles of kinesiology taping and an evaluation of research on its efficacy to catalyze discussion among clinicians about the merits of kinesiology taping as an adjunct for pain management.

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One of the most important cause of postoperative morbidity is insufficiently treated pain. Patient undergoing spinal surgery often suffer from severe preoperative pain and may require large doses of analgesic drugs including opioids. Longer-lasting, preoperative or chronic pain of greater intensity, patients with 'failed back syndrome' have been identified to cause problems towards control of postoperative pain. Because neurologic examination to detect spinal cord complications requiring immediate intervention are based upon patient cooperation and awareness, different modalities for postoperative pain treatment and a choice of drugs from various classes of analgesics may be effective in these circumstances. Overall, moderate to severe postoperative pain has been correlated with an increased risk for the development of persistent, chronic pain states. These problems may be prevented by successful management of postoperative pain. Acute postoperative pain management is a dynamic process. A detailed preoperative assessment should be done at the beginning and the most appropriate pain management should be provided by utilizing the newer drugs and techniques after estimation of risk-benefit status for each patient.

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Avascular osteonecrosis (AVN) of the femoral head is one of the most common skeletal complications of kidney transplantation. Patients with hip joint avascular necrosis usually undergo joint arthroplasty. However, if a patient is unfit for surgery due to some comorbidities, hip joint articular branches denervation can be done to control pain and improve functional life. There is a large variation in the contribution as well in the position of the articular branches to hip joint by obturator, femoral, and sciatic nerves. Several authors have proposed percutaneous radio frequency denervation of the hip joint to eliminate pain.In our case, the patient was having an intractable hip joint pain which was not responding to conservative drug therapy as well physiotherapy. In our patient, hip arthroplasty was contraindicated because of the high risk of infection and anticoagulants. After diagnostic block, the pain in his groin and hip disappeared immediately. The patient noted a decrease in pain (Visual Analog Scale, VAS 9-10 to 1-2) and an improvement in the ability to walk. Then we performed percutaneous radio frequency ablation of the articular branches of the obturator nerve and the femoral nerve. Nerve blocks were performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. Because optimal coagulation requires electrodes to lie parallel to the nerves, a perpendicular approach probably produced only a minimal lesion. A perpendicular approach is likely to puncture femoral vessels. Vessel puncture can be avoided if an oblique pass is used. The patient had improved ability to ambulate and the patient can carry out his daily routine activites at home without much pain and can sleep comfortably. There were no complications like motor deficit, neuritis, bleeding, or infection. Our case report gives few impressions. First, it shows that if radio contrast agent (omnipaque dye) use is restricted or contraindicated, a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve and articular branch of femoral nerve. Second, it confirms the radiological anatomy of articular branches of hip joint. Third, oblique approach is safe and gives optimum lesion.

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Background: Ropivacaine is a newer local anesthetic, proven to have a better safety margin than bupivacaine and lignocaine. While maintaining this advantage and improving the intraoperative quality of anesthesia, the use of analgesic adjuvants has been proven to be valuable. Aim: To compare the efficacy of clonidine and fentanyl as adjuvants to intrathecal isobaric ropivacaine for major lower limb surgeries. Settings and Designs: Randomized double-blind control trial. Materials and Methods: Seventy patients were randomly divided in two groups. Ropivacaine-Clonidine group (RC) received 60 mcg of clonidine with 15 mg of 0.5% isobaric ropivacaine, Ropivacaine Fentanyl group (RF) received 25 mcg of fentanyl with 15 mg of 0.5% isobaric ropivacaine intrathecally. The onset and duration of sensory-motor block were recorded. The total analgesia time, sedation score, hemodynamic parameters, and side-effects were noted. Statistical Analysis: SPSS statistical package was used for statistical analysis. Paired and unpaired t-test, analysis of variance and chi-square test were used for statistical calculation. Result: The duration of sensory block in RC (329.42 ± 33.86), RF (226 ± 46.98), and motor block in RC (248.51 ± 55), RF (212.60 ± 43.52) out lasted the duration of surgery (125.61 + 64.46). In clonidine group, there was significant prolongation of sensory block (P < 0.001), motor block (P < 0.01) and the total analgesia time (P < 0.001). Hypotension and bradycardia occurred in 8.6% patients in clonidine group, whereas pruritus was experienced by 8.6% patients in fentanyl group. Conclusion: Ropivacaine when combined with clonidine or fentanyl provided adequate subarachnoid block for major surgeries, wherein clonidine has advantage over fentanyl as it increased the duration of subarachnoid block and prolonged the postoperative analgesia.

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Pain causes a reflex withdrawal from any stimuli that can cause actual or potential tissue damage. It is frequently an early symptom of a disease process and is often the impetus for a patient to seek medical treatment. In many disorders where pain appears late, patients are at risk of developing complications without getting noticed. 'Congenital insensitivity to pain' is a rare disorder. Traumatic injury and self-mutilation is an almost consistent feature in this disorder. Injuries most frequently involve the oral and paraoral structures such as teeth, lips, tongue, and also ears, eyes, nose, and fingers. Oral manifestations may be the presenting complaint. Thus, it is important for the clinicians to be familiar with the condition. The present article provides a brief review of the condition and its insinuation in dentistry.

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Until recently, perioperative pain management in neurosurgical patients has been inconsistently recognized and inadequately treated. An increased awareness of pain management in general along with advances in the understanding of pain modulation and pathophysiology, has led to improved practice and perioperative care of patients following craniotomy. Otherwise, severe postoperative pain impairs the quality of recovery and causes emotional distress with the possibility of inducing chronic pain and lasting functional deficits. The greatest challenge in managing neurosurgical patients is the need to assess the neurological function while providing superior analgesia with minimal side effects. To achieve this goal, a multimodal approach to analgesia, using various drugs and techniques, is advocated. There still remains a need, however, to conduct further randomized, controlled trials, to determine the best combination of drugs or techniques for treating perioperative pain in this patient population. Improved awareness, assessment, and treatment of pain result in better care and overall patient outcome.

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