Regional anesthetic blocks play a significant role not only in perioperative management but also in the holistic management of chronic intractable pain including cancer pain. Pudendal neuralgia can hamper daily life functions such as sitting, standing and sexual functions thus affecting patient's quality of life. Pudendal nerve arises from ventral divisions of S2,3,4. The nerve lies medial to the internal pudendal vessels at the level of ischial spine and is accompanied by the internal pudendal artery through the lesser sciatic foramen into the pudendal (Alcock's) canal. Pudendal Nerve is 80% sensory and 20% motor. Techniques are dependable on the precise identification of important anatomic landmark structures positioned in the close proximity of the pudendal nerve. These techniques are nerve stimulator guided, Conventional C-arm fluoroscopy guided, CT guided, Ultrasound-guided and latest being ultrasound guided accompanied with Pulsed radiofrequency. Pudendal nerve block may be performed through one the approaches: Anterior/perineal or Posterior/trans gluteal. It has got important role to play in acute and chronic perineal pain which is frequently encountered after gynecologic surgery, obstetric surgery, urologic surgery and gastrointestinal surgery. Ultrasound guided pudendal nerve block has advantages such as no radiation exposure, real time needle insertion guidance with the visualization of spread of local anesthesia. It helps to visualize not only bony structures but also vascular structures, ligaments (interspinous ligament) as well as soft tissues. However, since a lot many multi-institutional trails are needed to conducted to explore the efficacy and safety of ultrasound guided blocks for chronic pelvic pain, as it happens to be highly challenging condition to manage.

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Analgesia for a parturient is an important element of care provided by an anesthesiologist as a member of the multidisciplinary team. Neuraxial anesthesia is considered the gold standard. With increasing evidence of safety and efficacy of various available techniques and equipment, including ultra-short–acting opioids, local anesthetics, newer combined spinal–epidural needles, monitors, patient-controlled infusion pumps, and point-of-care ultrasound, obstetric care has become less challenging with higher patient satisfaction rates and better safety profiles. Recent articles spanning the last few years on important related topics, including care of the parturient during COVID, newer developments, enhanced recovery after cesarean (ERAC) protocols, and patients with unique profiles, are discussed in this update on obstetric analgesia.

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Context: Central sensitization (CS) has been proposed as a common underlying pathophysiology to explain poorly understood pain-related syndromes. This is termed under central sensitivity syndromes (CSSs), for which no specific organic cause has been found. Aims: The aim of the present study was to investigate whether there is an association between the CS Inventory (CSI) score, pain-related symptoms, pain-related disability, health-related quality of life (QOL), and poorly understood pain-related syndromes and whether they differed by disease type. This study also evaluated the association between severity of CS and the associated CSSs. Methods: A total of seventy patients who attended a pain clinic (chronic pain outpatient department) were assessed randomly. CSI score, CSSs, EuroQOL-5 Dimension-5 Level, Brief Pain Inventory, and Fibromyalgia (FM) Severity Scale were assessed and compared. Statistical Analysis: Univariate correlation analysis was performed in each group to evaluate: (1) severity of CS, (2) presence/absence of CSSs, (3) pain intensity and pain interference, and (4) CSI score and FM Severity Scale. Results: CSI score has a significant association with CSSs, pain-related symptoms such as pain/discomfort, anxiety/depression, mood, and sleep. Conclusions: In our study, CS has been shown to have a significant impact on mean pain score and QOL by strongly impacting mobility, mood, and sleep. CS is the underlying root cause of various CSSs. This study concludes that CS should be evaluated as a routine in all chronic pain patients.

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Context and Aim: Evasion of activity is an elemental reaction that normally allows an injury to heal, but among patients with chronic pain, avoidance behavior is found to persist longer than it takes for the actual injury to heal. This may lead to kinesiophobia which is an irrational, weakening, and devastating fear of movement and activity stemming from the belief of fragility and susceptibility to injury. Studies have shown that older people with low back pain (LBP) demonstrate high levels of kinesiophobia with prevalence ranging up to 80%. Despite the pain and fear that they experience, advising them to avoid painful movements or activities may actually be counter-productive as it will decrease their functional independence. Hence, the aim of the present study was to assess the impact of kinesiophobia on disability and quality of life (QOL) in elderly LBP patients. Subjects and Methods: With ethical permission and informed consent from 125 elderly patients with chronic LBP fulfilling the inclusion and exclusion criteria, three scales were administered to assess kinesiophobia (Tampa Scale of Kinesiophobia), disability (Oswestry Disability Index), and QOL (WHO QoL scale). Statistical Analysis Used: Data were collected and statistically analyzed for correlation using Spearman's correlation coefficient. Results: Sixty-five percent of the study population were male of which 82% had clinically significant kinesiophobia and 45% were female of which 85% had clinically significant kinesiophobia. Kinesiophobia was found to have a moderate positive correlation with disability (r = 0.6061) and a strong negative correlation with QOL (r = −0.7598). Conclusions: Kinesiophobia has a moderate-to-severe impact on disability and QOL and should be addressed as a separate symptom and adequate intervention strategies should be incorporated so as to minimize its impact.

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Background: Facet joint (FJ)-mediated pain is one of the frequent causes of low back pain. Fluoroscopy and computed tomography guided medial branch blocks (MBBs) are accepted as standard techniques to diagnose FJ arthropathy. Ultrasound-guided (USG) MBB can be an alternative approach for the diagnostic MBB in FJ arthropathy. This study evaluates the feasibility of USG MBB in FJ arthropathy and validates by fluoroscopy. Materials and Methods: Diagnostic USG MBBs were performed in sixty patients. Two medial branches were targeted for each FJ. The needle was inserted in an in-plane technique after identifying the desired site. The needle position was confirmed by fluoroscopy. Pain scores were assessed before and after the nerve block. Results: Out of 161 needle insertions, 139 needles (86.3%) were at the radiologically defined target point as confirmed by fluoroscopy and were labeled as successful. Mean baseline, immediately before, immediately after, and at 24 h, Numeric Rating Scale (NRS) scores were 7.53 (0.93), 7.02 (0.93), 3.03 (1.75), and 2.80 (1.99), respectively (P < 0.05). The mean Modified Oswestry Disability Questionnaire scores before and 24 h after block were 48.77 (8.94) and 32.55 (11.32), respectively. Fifty-three patients had ≥60 points on the 100-point scale given by Helbig, and out of these patients, 44 patients had a ≥50% reduction in the NRS score. Conclusion: Diagnostic USG lumbar MBBs, a minimally invasive procedure without radiation exposure, can be performed with a high success rate in FJ arthropathy.

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Vulvodynia is a condition of considerable vulvar pain and discomfort to women which affects approximately 16% of women and is mostly not diagnosed. The patients are rarely treated. The patients mostly consult gynecologist and as they do not present with any local signs are treated with antibiotics and analgesics only. The cause of vulvodynia is not known, so there is no known effective treatment available. The patients' symptoms and literature suggest it be neuropathic in origin. A ganglion impar block was used in this patient which was effective in treating the patient.

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Background: Postdural puncture headache (PDPH) is a serious and debilitating complication and a major cause of postoperative morbidity occurring after spinal anesthesia (SA) or inadvertent dural puncture after epidural anesthesia. The understanding of pathophysiology of PDPH has improved over the last few decades and its occurrence is now on decrease with use of better techniques and smaller gauge needles. Over the past several years, many of the risk factors attributable to PDPH have been identified and studied extensively, but only few studies have evaluated the effect of increasing altitude on the occurrence of PDPH. As a significant proportion of population undergo surgery in such elevations, we retrospectively evaluated the effect of high altitude on the incidence of PDPH following SA. Materials and Methods: This study was conducted at a single center, retrospective observational study in the high altitude and cold climate region, for a period of 5 years. The data collected were evaluated for the occurrence of PDPH. Results: The total number of cases undergoing surgery under SA in our center was 440 over a period of 5 years. The cumulative incidence of PDPH in this cohort was 6.6%. The incidence was 7.15% and 5.56% with use of 26G and 27G Quincke needle, respectively, which is higher than that observed in the low-lying areas. Conclusions: The incidence of PDPH is higher in patients undergoing surgery under SA at high altitude.

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Perineal pain is a complex clinical condition causing significant functional impairment and frustration to the patient. The diversity of presentation and etiologies poses a challenge to the treating physician. Ganglion Impar is a solitary retroperitoneal structure in front of sacrococcygeal junction behind the rectum. It provides nociceptive and sympathetic supply to the perineal structures. Interventional pain management in the form of fluoroscopy guided Ganglion Impar block has been shown to benefit in patients with perineal pain. Here we describe a case series of Ganglion Impar block in four patients with various etiologies analysing its safety and efficacy. In this case series, four patients visiting the pain clinic in a tertiary care hospital with complaints of perineal pain of various etiologies were included. All the patients were given Ganglion Impar block under fluoroscopy guidance. NRS was assessed before the block, immediately after the block, and at time intervals of three months, six months, and one year post block. Any complications during the procedure and the follow up period were noted. All four patients had very good pain relief after block. The mean NRS value before the block was 8 ± 0.701. Ten minutes after the procedure, mean NRS value was 2.75 ± 0.95. NRS scores at three months, six months and one year follow-up intervals were 1.5 ± 1.29, 1.25 ± 1.25, and 1 ± 1.41 which is statistically significant. There were no complications. Fluoroscopy guided Ganglion Impar Block is a safe and effective intervention in the management of acute and chronic perineal pain of various etiologies providing good pain relief.

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Postherpetic neuralgia (PHN) affecting the first division of the trigeminal nerve (TrN) (V1) is a difficult to manage condition, characterized by neuropathic symptoms such as burning sensation, allodynia, and hyperalgesia that continues even after the resolution of the acute phase and decreasing the patient's quality of life. Interventional procedures such as Gasserian Ganglion continuous radiofrequency (CRF) have been performed to control pain despite the possible complications involving V1 division. We present the case of a 47-year-old male with PHN at V1 successfully treated with ultrasound-guided CRF at the supraorbital foramen. Postherpetic, neuralgia, TrN, facial pain, neuropathic pain, trigeminal ganglion, interventional ultrasonography, chronic pain, and hyperalgesia.

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Background: Pain is the primary symptom that brings patients to seek health care and is considered a global health problem. Thus, pain control is a fundamental goal in the management of the hospitalized patients. Despite the development of analgesics and advancement in pain management, the pain remains undermanaged. The untreated pain has a detrimental effect on the patient's quality of life, affects their outcomes, delays recovery, and increases the hospital stay. Nurses play a significant role in pain management as they spend a considerable portion of their time with the patients and deal with all their complaints, including pain. One of the significant obstacles to effective pain management among nurses is their limited knowledge and negative attitudes towards pain management. The primary purpose of this study was to explore nurses' knowledge, attitude, and practices toward pain management. Methods: An online survey was conducted for 224 nurses of various departments to assess their knowledge, attitude, and practices regarding pain management using a 30-item questionnaire in Google Forms. Results: Our survey shows a deficiency in knowledge related to the basics of pain, opioid use, and pain management in the elderly and pediatric age group. Conclusions: It may be prudent to consider training programs regarding opioid use and pain management as a part of continuous education and nursing undergraduate curricula.

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Background: Universal provision of safe, effective, and inexpensive analgesia for labor remains a challenge. In India, antispasmodics, especially drotaverine, are widely used as an adjunct to decrease labor pain and duration. Therefore, we aimed to determine the efficacy of sterile water block (SWB), with or without drotaverine. Materials and Methods: This study was a randomized, triple arm, controlled trial on 105 patients in active labor, assigned to receive either intramuscular drotaverine (Group D), Intradermal SWB (Group B), or drotaverine with SWB (Group DB). SWB was given in Michaelis Rhomboid, in active phase of the first stage of labor. Primary outcomes were extent of pain relief, as measured by the numeric rating scale (NRS). Other outcomes included patient's satisfaction, duration of active phase of first stage of labor, APGAR scores, incidence of instrumentation or cesarean section, and any adverse effects. Results: One hundred and five patients were randomized into three groups of 35 patients each. At 30 min postintervention, mean (± standard deviation) NRS score was 7.30 (±1.03), 4.88 (±0.68), and 5.04 (±0.75) in Group D, B, and DB, respectively; (P < 0.001). Two hours' postintervention, NRS was 7.61 ± 0.89, 6.66 ± 0.91, and 6.95 ± 0.85 in Groups D, B, and DB respectively with P < 0.01. Number of patients satisfied in Group D, B, and DB were 0, 24, and 25, respectively. The duration of active phase of 1^st stage of labor was 144.80 (±47.46), 198.88 (±92.16), and 142.50 (±50.77) minutes in Group D, B, and DB, respectively (P < 0.01). APGAR score was comparable in three groups. No adverse effect was seen on mother or fetus except burning sensation at the time of giving SWB. The occurrence of cesarean section was 8 in Group B, 8 in Group D, and 6 in Group DB. Conclusion: SWB is a safe modality for labor analgesia, causing a significant reduction in labor pain, both with and without drotaverine. Although not always effective as a sole modality, it may be effective in reducing the requirement of other analgesics when used in conjunction with other modalities for labor analgesia. Drotaverine may not significantly lower the labor pain alone or in conjunction with SWB. Yet, it significantly decreases the duration of active phase of first stage of labor (CTRI/2019/09/021125).

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We at Our Pain Clinic witnessed a rare event of recurrent bradycardia and hypotension during radiofrequency ablation of mandibular division of trigeminal nerve. A 48-year-old lady with trigeminal neuralgia in left V3 distribution was posted for V3 division rhizotomy under fluoroscopy. The patient had transient episodes of bradycardia and hypotension during the procedure. The patient had transient episodes of bradycardia and hypotension during the procedure. HR and BP were reverted to baseline with injection atropine and intravenous fluids. This response is most likely attributed to trigemino cardiac reflex, which occurs due to inadvertent stimulation of trigeminal nerve.

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