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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Patients who are diagnosed clinically as Coccygodynia often do not get satisfactory relief. The clinical diagnosis is based on various hypotheses that have been proposed to explain the pain of coccydynia - including coccygeal spicules, pain from the pericoccygeal soft tissues, pelvic floor muscle spasm, referred pain from lumbar pathology, arachnoiditis of the lower sacral nerve roots, local posttraumatic lesions, somatization, etc. The diagnosis is difficult and the pathophysiology is poorly understood. Till recently, use of dynamic X-rays and MRI imaging was not considered to diagnose this condition. The author would like to report three patients who presented to the pain clinic with refractory coccygeal pain and underwent dynamic coccyx X-rays and MRI as part of their evaluation. All these patients had positive findings on MRI. These patients were treated satisfactorily as a result of the added diagnostic value of MRI.

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Background: Laparoscopic cholecystectomy is associated with postoperative pain due operative ports site and residual intraperitoneal gas CO ₂ . Preemptive analgesia is one of the promising strategies of postoperative pain relief. The present study is undertaken to compare the efficacy of preemptive intravenous paracetamol versus ketorolac for post operative analgesia after laparoscopic cholecystectomy. Method: Ninety adult consented patients 18-58 yr of age, of either sex, of ASA grade I/II were randomized into two equal groups of 45 patients each. Patients of group I received infusion of paracetamol 1 g and group II received infusion of ketorolac 30 mg, 30 minutes before the induction of general anaesthesia. Postoperative pain was evaluated by standard 10 cm linear visual analogue scale at different time intervals. When VAS was more than 3 rescue analgesic 50 mg tramadol intravenously stat was given. Intraoperative hemodynamic and any side effects were also recorded for statistical analysis. Results: Demographic profile and hemodynamic parameters i.e intraoperative heart rate and mean arterial blood pressure were comparable in both the groups. Post operative VAS scores were persistently higher in paracetamol group with statistically significant difference (P value < 0.05). All 45 patients in paracetamol group and 8 patients in ketorolac group required rescue analgesic within 6 hrs of study time. Total tramadol consumption was much higher (2250 mg) in paracetamol group as compared to 400 mg in ketorolac group. Conclusion: Preemptive use of ketorolac exerted superior postoperative analgesia after laparoscopic cholecystectomy in comparison to paracetamol without any significant side effect.

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Radiofrequency ablation is a safe and minimally invasive procedure that has been found effective for the treatment of various chronic pain conditions. Hereby, we report a case of severe pelvic pain due to advanced carcinoma cervix refractory to oral medications that was managed successfully by radiofrequency ablation of the superior hypogastric plexus under fluoroscopy. Her pain relieved markedly immediately after the procedure with significant reduction in opioid consumption. The effect was sustained during her follow-up period with improved quality of life.

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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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Celiac plexus block (CPB) for chronic upper abdominal pain, particularly cancer pain, can be given in both supine and prone positions, using anterior and posterior approaches, respectively. Both approaches suffer from their own demerits. In ultrasonography (USG)-guided anterior approach, the needle has to pass through the liver, intestine, stomach, pancreas, and vessels, exposing the patient to the risk of infection, hemorrhage, and fistula formation. Moreover, in the presence of ascites and large lymph nodes, retroperitoneal area cannot be visualized clearly using USG. In the posterior approach, the patient lies prone with a pillow underneath the abdomen to alleviate lumbar lordosis, and the block is given under fluoroscopic or computed tomography (CT) guidance. Terminally ill patients have difficulty in tolerating prone position because of pain and discomfort due to abdominal distension. To the best of my knowledge, no position other than the supine, prone and rarely lateral, have been described for giving CPB in patients. We present three cases with carcinoma head of pancreas, where CPB was given under fluoroscopic guidance. As all three patients could not tolerate the prone position because of pain and ascites, we modified the position to a knee-chest position [Figure 1]. The patients found the position comfortable to maintain, and they were cooperative during the block. We encountered no problems in imaging the vertebral bodies in anteroposterior (AP) and lateral view. No pillow was required, as the lumbar lordosis was already abolished in this position. In each patient, bilateral block was given using 15-20 mL of 50% alcohol in 0.25% bupivacaine, on either side using a 15-cm Chiba needle. Subsequent follow-up showed successful blockade in all three patients. The use of a modified knee-chest position has not been described earlier for this procedure, but may be a suitable, convenient, and comfortable alternative for terminally ill patients who are unable to lie prone.

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Background: Preemptive analgesia involves the introduction of an analgesic regimen before the onset of noxious stimuli, with the goal of preventing sensitization of the nervous system to subsequent stimuli that could amplify pain. Aims: To compare the efficacy of pregabalin and gabapentin as preemptive analgesics in surgery below the umbilicus under spinal anesthesia. Materials and Methods: This study was conducted in a time span of 1 year in a tertiary care hospital of eastern India after obtaining institutional ethical clearance and informed consent of the subjects. Sixty-two patients were randomly allocated to two groups using an online randomizer. Group G (n = 31) received single dose of gabapentin 1,200 mg and Group P (n = 31) received a single dose of pregabalin 300 mg. the parameters were studied for comparing the quality of intraoperative and postoperative analgesia and sedation and complications. Results: In the 24 h of postoperative period, the mean visual analogue scale (VAS) scores at rest of Group P was always significantly lower than those of Group G. In Group G (gabapentin group) rescue analgesic was given after 9.41 ± 1.84 h while in Group P (pregabalin group), rescue analgesic was required after 15.38 ± 3.52 h. In Group G subsequent rescue analgesic was required in only three cases while in Group P, subsequent rescue analgesic was required in only two cases. In the pregabalin group, the incidence of somnolence and dizziness was significantly less than the other group. Conclusion: Single oral dose of pregabalin (300 mg) given preoperatively provides better postoperative pain control and decreases postoperative rescue analgesic consumption compared to a single dose of gabapentin (1,200 mg).

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Introduction: Complex regional pain syndrome (CRPS) is a chronic painful and disabling condition, often triggered by a minor injury. It is characterized by sensory disturbances, vasomotor and sudomotor dysfunction, motor abnormalities and maladaptive neuroplasticity. An integrated multimodal multidisciplinary treatment approach is recommended. Other than pharmacological and interventional management the use of visual illusion created by mirror has also been reported. It is a neuro-rehabilitation technique designed to re-modulate cortical mechanism of pain. Aim: To assess the effectiveness of mirror visual feedback (MVF) and establish it as a therapeutic measure in CRPS. Materials and Method: Ten patients of CRPS had been treated with Motor Imagery through MVF method for 2 weeks, where reflection of unaffected side seems to visually superimpose on the felt location of the affected one. The pre-post data of this study were collected prior and at the end of 2 weeks of treatment. Data Analysis: Done using a paired "t" test. Results: Results shows significant improvement (P < 0.05) in resting and movement pain and swelling. Conclusion: The study can be considered as an important document for establishing MVF as a treatment of choice for the patients with CRPS.

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Fibrous dysplasia (FD) is a skeletal developmental disorder of the unknown etiology, uncertain pathogenesis, and diverse histopathology with one-fourth involving head and neck. The aim of this article is to report a rare case of craniofacial FD of the maxillary sinus as an etiology of trigeminal neuralgia treated with radiofrequency lesioning.

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Introduction: Lumbar facet joint pain accounts for 5-15% of the cases of chronic, axial low back pain. Most commonly, facetogenic pain is the result of repetitive stress and/or cumulative low level trauma, leading to inflammation and stretching of the joint capsule. Patients and Methods: In this descriptive study 76 patients who were diagnosed, after a diagnostic block, as having lumbar facet joint pain were evaluated by their age, sex, and body mass index (BMI). Data were collected according to a checklist and entered to SPSS version 16. Results: The mean age of the participants was 48.53 years; the participants included 44 women and 32 men. Lumbar facet joint pain was more frequent in the age range of 40-55 years. With respect to BMI, lumbar facet joint pain was most frequently seen in patients with BMI of 24.5-29.5 kg/m ² (40.8%). Conclusion: Based on our findings, the chances of developing lumbar facet joint pain is more in women who are between 40 years and 55 years of age and whose BMI is 24.5-29.5 kg/m ² .

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Aims and Objectives: The objective of this study was to investigate the prevalence of stress and depression within temporomandibular disorder (TMD) patient subgroups with chronic facial pain (cfp) and healthy controls and to assess possible relationships among the different subgroups. It also evaluated the correlation among pain, stress, and depression scores. Materials and Methods: A total number of 120 patients, 60 cases and 60 controls aged 20-40 years were included in the study. The study group after clinical examination was assigned into subgroups depending on the Research Diagnostic Criteria for TMD (RDC/TMD). Age- and sex-matched patients with no complaints of TMD formed the control group. Both the groups were administered the Beck's inventory of depression (BDI) and stress symptom rating scale (SSRS) questionnaires. Pain intensity was measured by the visual analogue scale. All the scores were statistically analyzed. Results: Depression and stress scores were seen more in the myofascial pain group. Depression was prevalent in 53.3% and stress in 60% of the study group. Positive correlation was seen among pain scores, depression, and stress scores (P < .001). Conclusion: The findings are consistent with previous research indicating a link among depression, stress, and TMD. Screening for such symptoms should be an integral part of the evaluation for effective cognitive behavioural therapy.

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Introduction: Frozen shoulder is a painful and disabling condition in patients in 40-70 years age group , affecting 2-5% of general population. Aim of the study was to assess pain relief and functional improvement after supracapular nerve block with or without pregabalin, in patients with diagnosed case of frozen shoulder who failed to respond to medical treatment for 3 months. Material and methods: 100 patients with unilateral frozen shoulder was divided into two equal groups (n = 50) in a randomized double blind protocol. Group A (n = 50) received three doses of suprascapular nerve block and oral pregabalin 75 mg at bed time daily while Group B (n = 50) received suprascapular nerve block and oral placebo tablets in a similar way. Suprascapular nerve block was given with Inj depot methyl prednisolone acetate 1 ml (40 mg) + 9 ml 0.25% inj bupivacine for three successive weeks with ultrasound. Patients were followed up at 4 ^th , 6 ^th and 12 ^th week after injection. Visual Analogue Scale (VAS) was used to assess intensity of pain and range of movement estimated using goniometer in terms of abduction, external rotation and internal rotation in sitting position. Results: Results showed Group-A patients had almost complete pain relief and significant improvement in the range of movement at the end of 12 ^th week compared to Group B (P < 0.05). Conclusion: Combination therapy of suprascapular nerve block and oral pregabalin 75 mg is better for patients with frozen shoulder compare to suprascapular nerve block only.

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Introduction: Intra-articular (IA) local anesthetics are often used for the management and prevention of pain after arthroscopic knee surgery. Clonidine prolongs the duration of local anesthetics. In this study, analgesic effect of intra-articular administration of levobupivacaine and clonidine was compared with ropivacaine and clonidine in knee joint arthroscopic surgery under spinal anesthesia. Method: 88 patients, aged between 15 to 55 years, ASA I and II undergoing knee arthroscopy under spinal anesthesia were assigned into two equal groups (n = 44) in a randomized double blind protocol. Patients in Group L received 10 ml of 0.50% levobupivacaine and 1 mcg/kg clonidine and Group R received 10 ml of 0.75% ropivacaine and 1 mcg/kg of clonidine through intra-articular route at the end of the procedure. In the post-operative period, pain intensity was assessed by VAS (Visual Analogue Scale) Score recorded at 1 ^st , 5 ^th , 8 ^th , 12 ^th , 18 ^th post-operative hours. Duration of analgesia, total rescue analgesic dose in first 18 hours and any side effects were also recorded. Result: Group L experienced significantly longer duration of effective postoperative analgesia and lesser rescue analgesic compared to group R. Group R had higher mean VAS score at 5 ^th and 12 ^th post-operative hours (P < 0.05). No side effects were observed among the groups. Conclusion: Intra-articular administration of levobupivacaine and clonidine give better post-operative pain relief by increasing duration of analgesia, and decreasing need of rescue analgesic compared to intra-articular ropivacaine and clonidine.

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Introduction: Central post stroke pain is a variety of neuropathic pain that occurs after stroke as a result of dysfunction of either spino-thalamic tract or thalamo-cortical sensory pathway. Hyperirritability in surviving cells along the affected pain pathways found with changes in inhibitory pathways, spinal and cortical reorganization and central sensitization. Aim: Clinical features like character of pain and other sensory features with neuroimaging findings of central post stroke pain for a part of Indian population were analyzed in this study. Materials and Method including analysis: 120 numbers of patients, who developed new onset pain symptoms after stroke, attending outpatient and inpatient department of a neurology department during a whole year were examined with history including extensive sensory symptoms analysis; sensory examinations including assessment of pain score and other neurological examinations were done and rechecked by neurologists. All were investigated by neuroimaging with either MRI or CT scan or both. Neuro imaging was interpreted by experienced neuroradiologist and corroborated by neurologists and pain physician. Results: 45% of the lesions were in Thalamus when 75% of the lesions were detected as infarction. 57.5% symptoms started within 3 months. Ataxia found with 60%, increased threshold to warm and cold were seen in 40% of patients, burning sensation was seen in 40% followed by numbness with 20%, dysesthesia found with 60%, reduced sensation to temperature changes found with 40% patients. Conclusion: CPSP patients may presents with various sensory symptoms beside pain. Distribution of sensory symptoms may be with any part of the body as well as over one half of the body. Most common trigger factor was mechanical; while thalamic lesions found in 45%, extra thalamic lesions werefound with 55% of patients.

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