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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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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Background: Surgical intervention is associated with postoperative pain, nausea and vomiting. Paravertebral blockade (PVB) has been advocated as a useful technique for analgesia after breast surgery. Aims and Objectives: The aim is to study the efficacy of PVB and associated complications against intramuscular diclofenac sodium 0.75mg. Materials and Methods: Fifty patients of ASA grade I and II were randomized to receive either PVB (group A) or intramuscular diclofenac sodium (group B); there were 25 patients in each group. Group A patients received PVB with catheter at T3 and T6 levels with 0.3ml/kg 0.25% bupivacaine, whereas group B patients received intramuscular diclofenac sodium preoperatively. All patients were observed for quality and duration of analgesia, incidence of nausea and vomiting, hemodynamic stability, and complication. Results: The patients given PVB experienced lower visual analog score (VAS) at rest (P < 0.001) and longer duration of analgesia (P < 0.001) on movement (P < 0.0001) for 1 to 12 h in postoperative period as compared to group B. In group A, fewer patients required rescue analgesia and experienced less postoperative nausea and vomiting as compared to group B. Conclusion: PVB provides better pain control and decreased nausea and vomiting after modified radical mastectomy.

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Background: It is now well-established that chronic pain and depression are interrelated but the exact reasons for this association remain unclear. Although, in the majority, chronic pain is the source of depression; in a few, chronic pain is a manifestation of depression. The objective of this survey was to study the pattern of socio-demographic characteristics of persons with depression and chronic pain carried out by online survey. Materials and Methods: Two-hundred and ten psychiatrist from all over India were selected randomly from those who were registered with the Indian Psychiatry Society. Online survey was conducted with these psychiatrists. Survey questionnaire included 16 questions on depression with chronic pain. Results: One hundred and fourteen psychiatrist responded on online survey. The data was compiled and analyzed. The results showed that 201 patients/week visit psychiatric clinics.47% psychiatrist say 15-30% present with chronic pain, 35% say depression with chronic pain is present in 20-40% patients. Eighty-four percent psychiatrist say pain and depression are related to each other. Forty-one say 25-50% patients of chronic pain have depression. Conclusion: The results of this survey showed that chronic pain and depression co-exist commonly.

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Background: The fascia iliaca compartment block and three in one block (two single injections, anterior approach procedures) was compared simultaneously to block the femoral, obturator, genitofemoral and lateral femoral cutaneous (LFC) nerves in patients undergoing lower limb orthopedic surgeries. Study Design: Prospective randomized single-blinded study. Materials and Methods: Sixty patients of ASA I, II and III scheduled for hip and femur shaft surgery under spinal anesthesia were included in the study. On completion of the surgery, patients were randomly divided into two groups, Group I and Group II each consisting of 30 patients. Group I received fascia iliaca compartment block and Group II received three in one block. Patients of both the groups received 35-40 ml of 0.25% bupivacaine. Sensory blockade of femoral nerve, obturator nerve, LFC nerve and genitofemoral nerve, and motor blockade of femoral and obturator nerves were observed by weakness in knee extension and thigh adduction. Duration of analgesia, number of doses of rescue analgesics required in 24 hours, visual analog scale (VAS) scores at rest and during physiotherapy were also noted. Results: Sensory blockade of femoral, obturator and genitofemoral nerves, and motor blockade of femoral and obturator nerves did not differ between the two groups; however, sensory blockade of LFC nerve was significantly higher in Group I. VAS at 12 hours after surgery during movement of 3.43 ± 2.36 in Group I and 4.57 ± 0.15 in Group II were statistically significant (P value = 0.03) but the duration of analgesia between Group I and Group II was not statistically significant (P > 0.05). Conclusion: Fascia iliaca compartment block may represent an attractive alternative to three in one block for treatment of pain at rest and during physiotherapy.

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Introduction: Bone marrow aspirate concentrate (BMAC) has been demonstrated to induce unfathomable healing activity in various forms of arthritis. On the other hand, viscosupplementation is widely used as one of the modalities to palliate the symptoms of knee osteoarthritis (OA). To the best of our knowledge, no research involving a comparison of the two interventions has been done. We evaluated and critically analyzed the comparative efficacy of an intra-articular injection of BMAC or sodium hyaluronate injection (Halonix; Cadila) in terms of pain relief or functional improvement using validated scoring instruments. Materials and Methods: Fifty patients of either sex, aged more than 18 years with grade 0 and grade 1 primary knee OA were randomized to receive intra-articular injection of either the mononuclear marrow concentrate or Halonix, and they were followed for 6 months. The patients treated received single injection either of mononuclear marrow concentrate or Halonix during the course of study. An independent, blinded evaluator assessed the patient with the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and the visual analog pain scale. Results: Both the cohorts treated with mononuclear marrow concentrate and with Halonix showed improvements from the baseline parameters at the end of 1-month follow-up. Group treated with BMAC showed significant difference (p<0.05) with respect to WOMAC, or visual analog scale results at the end of 6 months of follow-up. Men demonstrated significant improvement (p<0.05) in both the groups. Conclusion: Statistical significant differences were detected between patients treated with intra-articular injections of monocular marrow concentrate and those treated with the Halonix with respect to pain relief or function at 6 months of follow-up. Clinical Relevance: Direct delivery of bone marrow mononuclear concentrate to radiographic symptomatic grade 0 and grade 1 knee OA has the clinical potential to improve functional activity/ functional aspect of knee OA, providing a cost-effective approach for grade 0 and grade 1 knee OA.

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Aim: The aim of this study was to evaluate and compare the Pain Perception and Procedural Tolerance (PPPT) by the pediatric patients, while experiencing 'Computer Controlled Local Anesthetic Technique' (CCLAD, Wand) and 'Conventional local anesthetic technique'. Material and Methods: Fifteen subjects, of age 8-10 years requiring local anesthesia on both sides of the dental arch for the purpose of extraction were selected for this study. In this cross-over design study, randomization was done to allocate the type of local anesthetic technique to be used first, children who received CCLAD (Wand) during 'First Anesthetic Exposure' (FAE) visit subsequently received 'Conventional anesthetic technique' during 'Second Anesthetic Exposure' (SAE) visit and vice versa. Behavior assessment using 'Frankel's Behavior Rating Scale' (FBRS) and anxiety assessment using 'Faces Version of Modified Child's Dental Anxiety Scale' (MCDAS _f ) were done prior to the anesthetic exposure. 'Wong Baker's Facial Pain Scale' (WBFPS) was used to assess the child's pain perception to each of the two techniques, immediately after the injection. Various physiological parameters like 'Heart Rate'(HR), 'Respiratory Rate'(RR), and 'Oxygen Saturation' were measured during pre-operative phase, LA-phase, post LA-phase, Extraction phase and post Extraction phase, during FAE and SAE. Results: Paired t-test revealed a very highly significant (P = 0.001) difference between CCLAD (Wand) and conventional during SAE. Non-significant difference was observed when physiological parameters were compared at various intervals between the two anesthetic techniques. Conclusion: CCLAD (Wand) provides lesser pain perception as compared to conventional local anesthetic technique.

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Context: Chronic pain, depression and poor sleep quality are the most prevalent cause of human suffering, often co-occurring in a mutually reinforcing relationship. However, the prevalence and the risk factors for development of depression and poor sleep quality in Indian patients suffering from chronic pain remains elusive. Aims: The purpose of the present study was to study the prevalence and severity of depression, self-reported sleep disturbance and their co-relation with various pain descriptors such as intensity and duration of pain in 471 Indian patients suffering from chronic pain (more than 3 months). Materials and Methods: The patients were assessed for depression and sleep disturbance by using preformed questionnaires. Depression was evaluated by 'Patient Health Questionnaire 9 (PHQ-9) depression scale', a self-administered version of mental disorder assessing tool PRIME-MD. Self-reported descriptors like 'waking up refreshed', 'waking up fatigued', 'can't find a comfortable position' and 'toss and turn frequently' were used to assess sleep quality and classify patients into those with good (waking up refreshed) or poor (waking up fatigued, cannot find a comfortable position and toss and turn frequently) sleep quality. Results: We found a high prevalence (87.6%) of depression among Indian patients suffering from chronic pain. Moderate-severe depression was found in 31.2% of patients and 68.8% of patients reportedly having poor sleep quality. Females outnumbered males in terms of suffering from chronic pain, moderate-severe depression and poor sleep quality with a female:male of 1:0.514, 1:0.43 and 1:0.6, respectively. Patients suffering from moderate-severe depression and poor sleep quality reported greater perceived intensity of pain, P = 0.005 and 0.012, respectively. Conclusion: Depression and pain frequently co-exist and evaluation and treatment of both are of paramount importance for optimal treatment. Female sex, intensity of pain and poor sleep quality act as risk factors for development of depression in Indian patients suffering from chronic pain.

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Although there is an increased awareness of and treatment of acute pain in infants and children, the lack of awareness on various chronic and persistent pains in children often leads to physicians/pediatricians pursuing an endless search for the underlying etiology of the discomfort. Continued lab investigations are undertaken for the sake of "completeness" to search for a biological explanation for the pain. The author would like to present this case report where there was no obvious cause for the pain found on investigations. The child was treated for neuropathic pain with complete recovery. Though complex regional pain syndrome (CRPS) was suspected, the difficulty in establishing a diagnosis, convincing caregivers and compliance to pharmacotherapy are the major challenges in the pediatric pain patients.

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The complex regional pain syndrome (CRPS) I is a neurogenic pain syndrome that is characterized by pain, vasomotor and dystrophic changes and often motor impairments. The etiology of the condition resides in multiple theories, and diagnosis can be difficult and therapy focuses on pain management and restoration of physical function. The conservative treatment includes both non-pharmacological and pharmacological methods, and invasive therapy is centered on sympathetic and somatic blocks. We report a case of CRPS type-I in a 15-year-old young boy following repeated trauma to right elbow, which was successfully managed by a stellate ganglion block and continuous interscalene brachial plexus block and function restored to its full extent.

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Background: Trigger finger is a common problem encountered in rheumatologic practice that causes a triggering or locking that may produce an uncomfortable sensation. There are various methods of treatment ranging from conservative management to surgical release. Aim: To determine effectiveness of corticosteroid injection and percutaneous release in terms of symptomatic relief, patient satisfaction and complications. Materials and Methods: At this prospective study, 50 patients who presented with trigger finger Grade 2 and 3 were randomized into 2 groups. One group received corticosteroid injection and in the other group, percutaneous release was done. These patients were then assessed weekly over a period of 6 weeks and their progress noted. Results: Thirty cases (60%) were females and 20 (40%) were males. The age of patients at this study was 40-65 years (mean: 48). Twenty-three (46%) were manual workers, 17 (34%) were semi-professionals and 10 (20%) were housewives. Most of the patients had involvement of dominant hand (62%); non-dominant hand was involved in 38% of the cases. The most common presenting symptom was pain with triggering. In both groups, significant improvement in pain and triggering occurs in the first 2 weeks but there was improvement in pain and triggering in the corticosteroid group after 2 weeks. In terms of swelling of the digits, no difference was noted during the course of the treatment in the two groups. The corticosteroid group of patients had a complication rate of 6% while the percutaneous group had 18% complication rate. A total of 12 patients had recurrence (recurrence rate: 24%); 5 (41.6%) cases in the first or corticosteroid group and 7 (58.3%) cases in the surgery group. Conclusion: The group of patients treated with corticosteroid had better relief from pain and triggering and had a lower complication rate. Recurrence was equal in both the groups.

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