Pain

Pain management in the eyes of a surgeon: A reality check in combating the epidemic of persistent post operative pain Tariq Mansoor Indian Journal of Pain 2019 33(1):1-2

Consensus on evidence and experience: Future road map for framing guidelines Gautam Das, Pankaj Surange, Debjyoti Dutta, Jeshnu Prakash Tople, Suspa Das Indian Journal of Pain 2019 33(1):3-6 The approach to management of any patient is justified when based on evidence rather than experiences. However, there may be a class of patients for whom experience-based approach shows much better results. This article is an analysis of evidence-based guidelines versus experience-based approach. Although the protocols and guidelines deduced from evidence-based medicine appear infallible, the essential loopholes in standardization of this approach include turning a blind eye to the facts that publications may be company sponsored, with secondary gains intended, unfit for all socioeconomic strata, with a flaw in the review process itself, and many more. It would not be an overstatement that the experience of clinicians may be seriously ignored when adhering to evidence-based guidelines alone. A thorough knowledge of the subject based on the evidence, clinical experience, and clinical acumen together plays a vital role in prescribing the treatment to an individual. While framing the clinical practice guidelines, the role of an experienced clinician also needs to be highlighted. A proposed road map to formulation of the Indian Pain Practice guidelines should be such that an equal emphasis is given to expert opinion as well study-based evidence-based medicine. Among several other aspects, it is also emphasized that practitioners with more than 7 years of experience with dedicated pain practice will be sought for and considered as experts.

Role of interventional treatment in acute pain of herpes zoster and prevention of postherpetic neuralgia Shubhangi Mishra, Adil Rasul, Hammad Usmani Indian Journal of Pain 2019 33(1):7-10 Acute pain associated with herpes zoster (HZ) is the most debilitating symptom, which if not treated in early phase may lead to postherpetic neuralgia (PHN), a potentially crippling disorder with prolonged intractable chronic pain. The socioeconomic consequences secondary to prolonged severe pain include decreased socialization, depression, fatigue, restricted daily activities, and poor quality of life. HZ and PHN impose a significant economic burden in the form of direct inpatient care and loss of productivity. Early interventional treatments attenuate central sensitization by interrupting the transmission of nociceptive afferent impulses to the central nervous system and minimize nerve damage by improving blood flow to the nervous tissue in addition to the local anti-inflammatory action of corticosteroids. Interventions treatment options have been increasingly used as a part of multimodal approach in the management of acute pain of HZ in addition to pharmacological agent. This article reviews the various interventional treatment options which have used in the recent years for the management of acute pain of HZ and subsequent prevention of PHN.

Combination of critical care pain observation tool and face, legs, activity, cry, consolability scale in assessment of postoperative pain severity in postanesthesia care unit: A prospective cross-sectional analytical study Debanjali Ray, Sudesna Gupta, Subrata Ray Indian Journal of Pain 2019 33(1):11-14 Context: Effective post-operative pain assessment is mandatory to exclude overdose of analgesics and avoid adverse effects. Patients in PACU have impaired ability to communicate making pain assessment challenging. This study aims to establish agreement between two pain scales, CPOT (Criticalcare Pain Observation Tool) and FLACC (Face, Legs, Activity, Cry, Consolability) and to find out specificity of combination of scales. Methods: Taking sample size of 50 patients of either sex, aged 18-80 years, ASA-PS I-III, undergoing elective surgeries were chosen, study period being June-September 2017. Adequately reversed, extubated patients not receiving sedatives, analgesics and local anaesthetics within 15 minutes before end of operation were included while patients with ASA-PS more than III or on ventilator were excluded. Assessment was done upto 2 hours at 30 minutes interval using CPOT tool and FLACC scale simultaneously by two observers, both being blinded about study. Results: Combination of two scales show high odds ratio (41%) and kappa coefficient (0.78) suggesting excellent agreement. Specificity of combination of scales is very high (95.2%) than individual test. Conclusion: CPOT and FLACC scale together has excellent agreement and their combination are more specific to assess the severity of post-operative pain than when used individually.

Clinical efficacy of oral gabapentin versus clonidine for preemptive analgesia in knee arthroplasty under epidural anesthesia with 0.75% Ropivacaine – A comparative study Ivesh Singh, Kumkum Gupta, Salony Agarwal, Manoranjan Kumar Bansal, Abdul Samad, Pavitra Kalra Indian Journal of Pain 2019 33(1):15-19 Background: The preemptive analgesia for knee arthroscopic repair may reduce the postoperative pain without affecting the mobility of patients. The present study was designed to compare the clinical efficacy of oral gabapentin with clonidine as preemptive analgesic to epidural ropivacaine (0.75%) for knee arthroscopic repair, done under epidural anesthesia. Patients and Methods: Sixty adult patients of both genders of the American Society of Anesthesiologists physical status I and II aged 20–58 years, scheduled for knee arthroscopic repair under epidural anesthesia, were randomized into two groups of 30 patients each. Patients of Group RG were given oral gabapentin 300 mg, and patients of Group RC received oral clonidine 100 μg, 90 min before surgery with sip of water. All patients received epidural anesthesia with 15 ml of 0.75% ropivacaine. Groups were compared for onset and duration of sensory and motor blockade and postoperative analgesia as primary end points. Intraoperative hemodynamic changes, sedation score, or any side effects were evaluated as secondary end points. Results: The onset of complete sensory block to T10 (15.4 ± 4.7 vs. 17.5 ± 3.8 min) and time to achieve complete motor block (23.7 ± 3.3 vs. 26.9 ± 1.4 min) was earlier in patients of Group RC. Postoperative analgesia was prolonged in patients of Group RG (248.17 ± 19.6 vs. 217.36 ± 12.3 min). Intraoperative hemodynamic changes showed no significant difference. There was an increased incidence of nausea and vomiting in clonidine group. Conclusion: Oral gabapentin proved to be better as preemptive adjuvant for providing postoperative analgesia and good sedation during knee arthroscopic repair.

Noninvasive neuromodulation of supraorbital and occipital nerves as an adjunct to management of chronic headache: A pilot study Nazia Tauheed, Aftab Hussain, Hira Afzal, Lubna Zafar, Hammad Usmani Indian Journal of Pain 2019 33(1):20-24 Background: Chronic daily headache (CDH) results in significant distress and a substantial impact on the quality of life. Due to its nature of refractoriness to conservative management, exploring other modalities seems worthwhile. Invasive nerve stimulation, though promising, has seen complication rates in plenty. The goal of the present study was to assess the efficacy of noninvasive neuromodulation of supraorbital and occipital nerves (SON and ON) using hybrid pulsed radiofrequency device (Stimpod NMS460) in patients of CDH. Methods: Thirty patients suffering from CDH were enrolled in this randomized double-blind sham-controlled trial and randomly allocated to two groups of 15 patients each. SON and ON stimulations were given using the device Stimpod NMS460 thrice a week for 3 weeks. Follow-up visits were scheduled at 6 and 12 weeks of therapy. Pain relief was measured using numerical rating scale score. The overall change in quality of life (measured by Short Form-12 Health Survey) and associated complications were also noted. Results: Successful stimulation (50% or greater decrease in pain intensity) was seen in 66.67% patients; inadequate response in 33.3% in the intervention group. The 50% responder rate in sham control group was 13.3%; remaining 86.6% showed an inadequate response. This response remained sustained up to 12 weeks of follow-up. Similar changes were observed in the quality of life of patients. No adverse effect was documented during the study period. Conclusion: Noninvasive neuromodulation may serve as a safer and cost-effective treatment option in CDH refractory to conservative management.

A Comparative study of intra-articular injection of steroid versus prolotherapy for pain relief in patients of osteoarthritis knee Sarita Singh, Shashank Kumar, Hemlata , Ajay Chaudhary, Anita Malik Indian Journal of Pain 2019 33(1):25-30 Background: Osteoarthritis (OA) is a major source of disability owing to pain and loss of function. Intra-articular (IA) injection is the last nonoperative modality that can be used. We compared the efficacy of IA steroids and prolotherapy for relieving pain in patients of knee OA. Materials and Methods: We conducted a randomized, double-blind comparative study on 56 patients of OA knee assigned into two groups: steroid and prolotherapy group. Injections were given at 0, 1, and 2 months. During 6-month follow-up, patients were evaluated for pain relief by visual analog scale (VAS) score, quality of life (QOL) score, and requirement of rescue analgesic. Results: At baseline, mean VAS score of prolotherapy group (6.71 ± 0.94) and steroid group (6.36 ± 0.99) were comparable (P = 0.166). After 6 months, mean VAS score in prolotherapy group was 4.07 ± 1.44 as compared to 3.14 ± 0.89 in steroid group, and difference was statistically significant (P = 0.009). Furthermore, at baseline, QOL score of prolotherapy group (81.75 ± 4.69) and steroid group (79.29 ± 3.89) were comparable. After 6 months, it was found to be 70.43 ± 4.97 in prolotherapy group and 67.36 ± 2.74 in steroid group, the difference being highly significant (P = 0.007). Number of patients requiring rescue analgesia (P = 0.280) and the mean number of doses of rescue analgesic consumed (P = 0.538), both were slightly higher in prolotherapy group. Conclusion: Intra-articular steroid was better than prolotherapy in relieving pain of OA knee.

Dexmedetomidine with 0.375% bupivacaine for prolongation of postoperative analgesia in supraclavicular brachial plexus block Jaya Lalwani, Rashmi Naik Bhuaarya, Nasir Ali, Pratibha Jain Shah Indian Journal of Pain 2019 33(1):31-34 Background: Regional anesthesia is the recommended technique for upper-limb surgeries with better postoperative profile. Various agents have been used as adjuvants to prolong the duration of action and improve the efficacy of local anesthetic agents, α2-agonists being the most recent ones. We evaluated the effect of dexmedetomidine with bupivacaine for prolongation of the duration of analgesia in supraclavicular brachial plexus block. Materials and Methods: After Institutional Ethics and Scientific Committee approval and written informed consent, this prospective, observational study was carried out on 64 ASA Grade I and II patients of either sex, aged 18–60 years who underwent upper-limb surgery under brachial plexus block. Patients received either bupivacaine or bupivacaine with dexmedetomidine and were randomly divided into two groups. The primary outcome was duration of analgesia, and the secondary outcome was onset and duration of sensory and motor blockade, Ramsay sedation score, and side effects, if any observed at scheduled intervals. Results: Duration of analgesia in Group B was 391.46 ± 30.66 min and in Group BD was 810 ± 39.52 min (P < 0.0001), onset of sensory block in Group B was 7.9 ± 1.33 min and in Group BD was 5.65 ± 0.68 min (P < 0.0001), onset of motor block in Group B was 15.65 ± 1.66 min and in Group BD was 8.93 ± 0.788 min (P < 0.0001), duration of sensory block in Group B was 236.43 ± 17.52 min and in Group BD was 479.68 ± 40.50 min (P < 0.0001), duration of motor block in Group B was 206.09 ± 24.26 min and in Group BD was 447.81 ± 41.88 min, and slightly higher Ramsay sedation score was seen in Group BD as compared to Group B. The side effects were found to be insignificant and incidental. Only two cases of bradycardia(6.25%) and one case(3.12%) of hypotension were noticed in group BD. Conclusion: Addition of dexmedetomidine to bupivacaine was associated with prolonged analgesia, prolonged sensory and motor blockades with mild sedation.

To compare the efficacy of preemptive oral pregabalin versus oral pregabalin with intravenous ketamine as premedication on early postoperative pain Shivi , Shashank Bhardwaj Indian Journal of Pain 2019 33(1):35-38 Background and Objectives: Using opioid alone for postoperative pain relief is usually inadequate, and higher doses can cause a multitude of complications. A drug, which has anxiolytic property without the adverse effects of traditional analgesics mentioned, may be an attractive choice for postoperative analgesia. This study was done to compare analgesic efficacy of different nonopioid drugs on early postoperative pain and thus opioid-sparing effect. Materials and Methods: It was a randomized controlled trial. Sixty patients scheduled to undergo elective abdominal surgery under general anesthesia were assessed in the study. Primary Objective: The primary objective of this study was to observe the effect of preemptive pregabalin and pregabalin with intravenous (IV) ketamine on Cumulative analgesic requirement postoperatively. Secondary Objective: The secondary objective of this study was to observe the effect of preemptive pregabalin and pregabalin with IV ketamine on (1) analgesia and (2) adverse effects. Patients were randomly divided into two groups each containing 30 patients. Group P received 150 mg of oral pregabalin, 2 h before induction of anesthesia. Group PK received 150 mg of oral pregabalin, 2 h before induction of anesthesia, and injection ketamine 0.15 mg/kg intravenously just before induction of anesthesia. Heart rate and mean blood pressure (MBP) were observed and recorded at different time intervals during surgery. Heart rate, MBP, time to first analgesic demand, visual analog scale (VAS) score, total postoperative analgesic requirement, sedation score, and side effects were recorded in postoperative period. Results: In Group P, the mean total analgesia requirement in postoperative period was 44.47 ± 5.06 mg, whereas in Group PK, it was 41.8 ± 2.34 mg (P = 0.006). VAS score and time to first analgesic demand were insignificantly higher in Group P. No statistically significant difference was found in side effect profile among the two groups. Conclusion: From our study, it could be concluded that a combination of oral pregabalin and IV ketamine when administered preoperatively can decrease opioid consumption while providing good pain control.

Increased neuropathic pain following cervical epidural steroid injection Nana Morkane, Manoj Shinde, Kailash Kothari, Vishal Gunjal Indian Journal of Pain 2019 33(1):39-41 To draw attention to an uncommon complication that could arise from routinely performed procedure in pain practice like cervical epidural steroid injection. We report a case of 47-year-old female whose neuropathic pain was increased after cervical epidural steroid injection. Cervical epidural injection with methylprednisolone and lignocaine produced transient paresthesia during injection followed by a dull ache with pronounced allodynia in fingers. Next day, the patient reported severe pain in left forearm and hand with burning and sensitivity to light touch and swelling of the dorsum of the hand. On examination, there was marked allodynia, warmth, erythema, and swelling of the left hand. Sensory examination showed decreased sensation to pinprick. Patient was prescribed a tapering dose of oral steroids, pregabalin, and analgesic-muscle relaxant combination. Symptoms gradually resolved on weekly follow-ups for 4 weeks and no further intervention was needed. Increased neuropathic pain after cervical epidural steroid injection may result from either a direct nerve root irritation caused by the steroid solution or nerve root injury. Direct nerve root irritation by steroid injection is most probable cause in midline approach.