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Managing Migraine During Pregnancy and Lactation – Neurology Advisor

Managing Migraine During Pregnancy and Lactation Share this content: Print A particular challenge in this population is the effective management of migraine during pregnancy and lactation, while minimizing the risk for harm to the fetus.
Migraine patterns in women are closely linked to various reproductive stages. During puberty, migraine prevalence becomes more pronounced in females compared with males, and remains so throughout the remaining life span. An estimated 40% of women experience migraine during the reproductive life cycle, and one-fourth of reproductive-aged women suffer from migraines. 1 Up to 70% of female migraine patients report changes in headache frequency or severity during menstruation, hormonal contraceptive use, pregnancy, and menopause. 1
A particular challenge in this population is the effective management of migraine during pregnancy and lactation while minimizing the risk for harm to the fetus. For many women with migraine, the frequency, intensity, and duration of headaches improve during pregnancy. Some research has shown similar effects with lactation, although findings have been mixed overall. 2
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In a recent paper published in Current Pain and Headache Reports, 2 Simy K. Parikh, MD, from the Jefferson Headache Center at Thomas Jefferson University in Philadelphia, Pennsylvania, reviewed evidence pertaining to preventive and abortive therapies for migraine during pregnancy and lactation. 2 Her findings are highlighted here.
Preventive treatment during pregnancy Among nutraceutical options, findings suggest that riboflavin (400 mg/day) and coenzyme Q10 (100 mg 3×/day) may be effective in preventing migraine if initiated 3 months before pregnancy. Anticonvulsants, including valproic acid and topiramate, should generally be avoided because of demonstrated risks for cognitive and motor impairment and for congenital birth defects, respectively. Among beta blockers, atenolol has been linked to low birth weight when used during the first trimester. The use of other beta blockers warrants close fetal monitoring for issues such as bradycardia and intrauterine growth retardation. Tricyclic antidepressants are associated with cardiac and craniofacial malformations, whereas serotonin-norepinephrine reuptake inhibitors have not been linked to these outcomes. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be avoided during pregnancy. Use of these agents in the second and third trimesters may lead to pulmonary, renal, and skull malformations. Evidence for use in the first trimester is inconclusive.
Abortive treatment during pregnancy As prostaglandin synthetase inhibitors, nonsteroidal anti-inflammatory drugs increase the “risk for premature closure of the ductus arteriosus during use in the third trimester and are therefore contraindicated during that time,” whereas a recent study reported no adverse effects with the use of ibuprofen during the first trimester. 2 Findings indicate that metoclopramide is safe for use in pregnancy, including during the first trimester. No significant adverse outcomes were noted in a prospective observational cohort study of 432 pregnant women taking triptans. 3 As sumatriptan has the most supporting evidence, this is the recommended option among the triptans.
Preventive treatment during lactation Topiramate is likely safe for use during breastfeeding, whereas valproic acid should be avoided. Propranolol is the preferred beta blocker for use during lactation because of its low maternal plasma levels With maternal use of tricyclic antidepressants, as “active metabolites are secreted into breast milk in small amounts[, infants] should be monitored for sedation, poor feeding, and anticholinergic side effects.” 2 Although angiotensin-converting enzyme inhibitors and angiotensin receptor blockers do not generally transfer to human breast milk in significant amounts, there have been concerns about renal toxicity when used in premature infants.
Abortive treatment during lactation Ibuprofen is the preferred nonsteroidal anti-inflammatory drug, based on studies showing very low levels of the drug in breast milk, even with frequent doses. Naproxen has been linked to drowsiness and vomiting in infants. Aspirin should be avoided because of the associated risk for Reye’s syndrome. Sumatriptan and eletriptan have low concentrations in breast milk.
“It is important for clinicians to think critically about pharmacologic options, as medications misattributed as teratogens or as a lactation risk could lead to poor treatment of episodic migraine in pregnancy, while use of true teratogens could lead to unnecessary exposure,” Dr Parikh concluded. 2
To get a better idea of current treatment trends in this population, Neurology Advisor conducted a roundtable discussion with several experts across neurology and headache medicine, as well as women’s health: Teshamae Monteith, MD, a neurologist at the University of Miami Health System n Florida, and a member of the American Academy of Neurology; Huma Sheikh, MD, assistant clinical professor of neurology at Mount Sinai Beth Israel, New York City; and Paru S. David, MD, FACP, NCMP, assistant professor of medicine in the Division of Women’s Health-Internal Medicine at Mayo Clinic, Phoenix, Arizona. Related Articles Migraine With Aura Increases Risk for Carotid Thickening in Middle-Aged Women
Neurology Advisor: What are some of the challenges of treating migraine in patients who are pregnant or lactating?
Dr Monteith: The majority of patients with migraine without aura actually improve during pregnancy, but some may worsen, especially if they have to be taken off their migraine-preventive treatments. The biggest challenges are the lack of safe and effective treatments for pregnant patients.
Dr Sheikh: The main challenge is providing effective relief that is not harmful to the developing fetus. Trials usually exclude pregnant women; therefore, there is little information about which therapies are safe to use in pregnancy. Most of the evidence is based on observational trials. There are few treatments that have a level A rating for women who are pregnant or breastfeeding.
The other challenge is making sure that a headache is a primary headache caused by migraine or tension-type headache and not a symptom of another more dangerous disease, as pregnancy can increase the risk for certain disorders, including clots and stroke.
Dr David: Very little research has examined which medications are safe to use for migraine treatment during pregnancy and lactation in humans. Most medications have safety labeling based on animal studies, but many medications require a risk/benefit analysis because fetus or infant risk cannot be ruled out. Many clinicians who take care of pregnant or lactating women who also have migraine headache may not feel comfortable in deciding which medications are safe, either because they are not experts in migraine (obstetricians) and are unfamiliar with many of the migraine medications or because they are not experts in female hormones and their effects on migraine throughout the reproductive years of a woman (neurologists).
Acetaminophen has been thought to be safe in pregnancy, but some recent research has questioned this, so now the recommendation by the US Food and Drug Administration is that a risk/benefit analysis needs to be performed. It does appear to be safe in lactation. Nonsteroidal anti-inflammatory drugs were felt to be safe in the first and second trimesters, and unsafe in the third trimester, but recent studies have shown possible harm in the first trimester, so now the recommendation is to do a risk/benefit analysis.
Neurology Advisor: What appear to be the best treatment options for these patients?
Dr Monteith: Metoclopramide and acetaminophen can be used safely. More recent large observational studies suggest sumatriptan is safe during pregnancy, and little drug gets excreted in breast milk.
Nonpharmacological treatments such as aerobic exercise, cognitive behavioral therapy, biofeedback, acupuncture, and relaxation techniques may be effective for migraine prevention. Increasing evidence suggests nerve blocks may be effective and are safe during pregnancy.
Dr Sheikh: The first line of treatment should be ways to avoid known headache triggers, including poor sleep or stress. Stretching exercises and mild yoga tailored specifically for pregnant women can be helpful in preventing migraine attacks. Other approaches such as a warm compress or resting, especially sleeping, can be helpful and a way to avoid taking medications. Complementary methods such as relaxing breathing exercises or mindfulness can also provide great relief and are more likely to be effective if they are used as a daily practice or as a preventive.
In general, most medications should be avoided if possible. However, if needed, a large registry now shows that triptans are safe to use in women who are pregnant, although it is still important for physicians to consider other alternatives and whether triptans are safe in each situation.
Dr David: Healthy lifestyle changes such as regular meals, adequate sleep, stress management, trigger avoidance, exercise, and smoking cessation may reduce the frequency of migraine attacks during pregnancy. Biofeedback and relaxation are safe and beneficial for pregnant and nursing women.
Neurology Advisor: What are additional recommendations for clinicians?
Dr Monteith: Clinicians should emphasize lifestyle modifications including good sleep, stress management, and regular meals. Pregnancy planning should include a plan for migraines. Good communication between obstetrics/gynecology and neurology early on may lead to the best success.
Dr Sheikh: Most headaches during pregnancy will be primary headaches, but they can still be disabling. It is important to discuss the possible worsening of headaches before getting pregnant to set up strategies to help alleviate possible anxieties. It is important to work on healthy lifestyle techniques that are very effective at preventing headaches.
Always look for red flags in women with worsening headaches, so that a dangerous secondary headache is not missed. Thankfully, for most women, their migraine attacks improve during the second and third trimester, most likely as a result of stable hormone levels, but they can worsen again during the postpartum period. [ Editor’s note: A prospective study published in 2003 reported that up to 83% of female migraineurs experienced a reduction in migraine frequency during the second trimester. 2 ]
Neurology Advisor: What should be the focus of future research in this area?
Dr Monteith: Studies are needed to determine the safety of exposure to calcitonin gene-related peptide monoclonal antibodies for migraine prevention during pregnancy. In addition, evidence-based guidelines are needed.
Dr David: Exploring nonpharmacologic ways to manage migraine headache could be helpful because to date, no randomized controlled studies looking at the effects of migraine medications have been conducted on pregnant or lactating women, or likely will be, for ethical reasons.
References

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I suffered severe daily migraines since April, 2010. I was treated with almost every FDA approved prophylactic without any success. The only triptan that worked to stop the headaches was relpax. I would get several headaches a day. The triggers are horns honking, sirens, jarring, light, expressed anger, anger expressed at me, sugar, strong odors, among others.
In January 2014, I woke up with a seized neck on left side, and pain on left side of head piercing through my left eyeball. I could not move my neck or eyeball to the left without triggering piercing pain. This continued for close to 2 years.
I changed doctors to headache center at University of California medical Center (UCSF), where I was eventually treated for hemacrainia continua with indomethacin. It worked well. But not as a prophylactic.
I spent 3 years at UCSF headache center and went for second opinion with Dr. Robert Cowan at Stanford headache center. Dr. Cowan told me I had new daily persistent headaches superimposed over hemacrania continua. Dr. Cowan told me to continue with indomethacin up to 300 mg per day, and use an herbal supplement called Boswellia when the indomethacin did not provide enough relief.
I continued on that protocol for a several months. I went to Rite Aid pharmacy one day, and saw a topical get called stopain migraine (that is exact spelling). The cost was approximately $10. When I get the eye pain, I immediately put a small dab of the stopain on my left cheek and over my eyebrow, and on the left side of my eye. The eye pain goes away almost immediately.
My left eye starts tearing for a couple of minutes. I clear it up with a tissue.
I was able to lower my dosage of indomethacin to 50 mg at night before going to bed. I now take indomethacin approximately 1 time every 2 to 3 weeks. I do not take relpax anymore.
I take just boswellia during the day if the headaches become numerous. The stopain migraine will last about a year for a bottle. You can get it on Amazon.
My biggest fear is that the company that manufactures it will go out of business, so I stocked up with several bottles.
I urge anyone with hemacrania to get stopain migraine. The cost is very little and the potential benefit is great. Boswellia also works well. Neither is a prophylactic.
The stopain migraine also works on migraine headaches. The instructions say to rub it in occipital area at base of back of scull. I find it works better if you dab it around the headache area.

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I’m actually in the same boat as you . Except for my anxiety I have Xanax which I hate Bc it slows my digestive system down as is plus pregnancy . Since I got pregnant , I’ve had horrible morning sickness , horrible headaches (can’t take Tylenol without it hurting my stomach) I don’t eat much Bc I’m nauseous so I do smoke marijuana. I have smoked it in the early weeks with the last 2 pregnancies and this one as well. My babies are fine but beings my stomach can’t handle breaking down any medicine without it tearing my stomach or physically hurting me , then I’d rather smoke . I have digestion issues tho. I don’t have a medical marijuana license Bc it’s just becoming legal and able to let the people in my state who have certain diseases take it .
I only smoke maybe 2 times a week right now and I can’t immediately stop my anxiety medicine Bc it will literally kill me and the baby. I have to prolong the weening process which sucks but my little smoke helps so much. I was at 160lbs and I’m now down to 137lbs in just 2 weeks . That’s from throwing up and having a migraine 24/7 I can’t get rid of unless I smoke. TMI (too much information) – I suffer from constipation (not going for a week or so) , I bleed everytime I go , I have issues down their so what I put in my stomach really goes hand and hand . Hence why I can’t take Tylenol and why I’ve had a migraine for 4 days with no relief even when I did cave and take Tylenol New Year’s Eve.
I’ll probably get a lot from this post but I’m tryong to have a healthy body, mind , and baby.

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Journal of Pain

EDITORIAL
Percutaneous vertebroplasty: Current controversy p. 123 Kailash Kothari
DOI :10.4103/ijpn.ijpn_67_18 [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta REVIEW ARTICLES
Full-endoscopic lumbar discectomy for high canal compromised disc at upper lumbar level: A technical review p. 125 Manish Raj, Kailash Kothari, Anurag Agarwal, Hyeun Sung Kim, Pankaj Surange, Kapil Tyagi, Prashant Punia, Palea Ovideu
DOI :10.4103/ijpn.ijpn_51_18 Objective: In this study, we have described the technique to overcome difficulty faced during trans-foraminal endoscopic discectomy for the treatment of lumbar radiculopathy in patients who have herniated discs at the upper lumbar level & thoracolumbar junction. Method: After institutional review board approval, A retrospective analysis of 27 patients operated between March 2013- September 2017, by a single specialist for disc herniation at upper lumbar levels D12-L1, L1-2, L2-3 with or without high canal compromise by outside in technique (using rigid endoscope, sequential reamers) along with detailed description of our technique is the focus of this study. Results: Out of 27 patients there were 11 cases for L1-2 & 16 cases of L2-3 disc herniation respectively. There were 21 cases of broad-based, high canal compromised disc herniation with significant neurological deficit & only 6 cases were of focal herniation type. The average preoperative VAS score of 8.5 (range 6-10) reduced to 4 (range 2-7) immediate postoperatively & it further reduced to 2 (range 0-4) at one month follow up. The average preoperative ODI score of 65 (range 28- 88) reduced to 27 (range 12-40) immediate postoperatively & it further reduced to 10 (range 3- 18) at one month follow up. Post-operative MRI showed that the ruptured disc had been successfully removed. Conclusion: An anatomically modified surgical technique promote a more successful outcome after percutaneous endoscopic discectomy for upper lumbar disc herniation. Foraminotomy is recommended for all intra-canalicular herniation. Transforaminal endoscopic discectomy and foraminotomy can be used as a safe yet minimally invasive technique for the treatment of lumbar radiculopathy in the setting of an upper lumbar disc herniation. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Pharmacological management of neuropathic pain in India: A consensus statement from Indian experts p. 132 Ashok Kumar Saxena, Parmanand Jain, Gur Prasad Dureja, Anil Venkitachalam, Subrata Goswami, Hammad Usmani, Shardul Kothari, Dipit Sahu, Baljit Singh, Vandana Trivedi, Gaurav Sharma, Sanjay Kamble, Amit Qamra, Salman Motlekar, Rishi Jain
DOI :10.4103/ijpn.ijpn_47_18 Neuropathic pain (NeP) constitutes a major pain-related disorder, which is often underdiagnosed and undertreated. Adverse physical, psychological, and economic consequences associated with NeP lead to poor quality of life. Burden of NeP in developing countries like India is colossal. Various international guidelines provide effective approaches to diagnose and manage NeP. However, differences in the genetic makeup of Indian population can result in subtle differences in clinical response, considering their low body weight, drug metabolism ability, and pain perception. Similarly, treatment-related adverse effects may also vary. Practice of Indian physicians may also differ for choice of drugs based on their availability and affordability. In the absence of country-specific guidelines, this document could serve as a guiding tool for health-care providers, ensuring uniformity in the treatment of NeP. Thus, applicability of all recommendations from any of these guidelines in Indian setting demands careful evaluation. Clinical experience of Indian physicians suggests that there are lot many challenges (e.g., busy outpatient departments, nonavailability of screening questionnaires in regional languages, and availability and affordability of medications) faced by them when managing NeP. In addition, in India, there are no country-specific guidelines that would help them to address these challenges. The objective for this consensus was to develop an expert opinion guideline to harmonize the management of NeP in India. The expert panel consisted of experts from various specialties such as pain medicine, anesthesiology, diabetology, neurology, and orthopedics. The panel critically reviewed the existing literature evidence and guideline recommendations to provide India-specific consensus on the management of NeP. The final consensus document was reviewed and approved by all the experts. This expert opinion consensus will help health-care professionals as a guiding tool for effective management of NeP in India. Use of Douleur Neuropathique 4 (DN4) questionnaire for NeP screening should be routine in day-to-day clinical practice. For effective utilization of DN4 questionnaire, it should be converted to regional language. If DN4 questionnaire screening fails to identify NeP, it should not be disregarded and should not replace the sound clinical judgment from the treating physician. Diagnostic tests may be considered as a supplement to clinical judgment. Cost-effective treatment should be the initial choice. Dosing should be individualized based on efficacy and tolerability. Tricyclic antidepressants (TCAs), gabapentinoids, and serotonin-norepinephrine reuptake inhibitors (SNRIs) can be considered among initial choices. Tramadol can be considered as a second-line add-on treatment for NeP if there is partial response to the first-line agent either alone or in combination. Fixed-dose combination (FDC) of gabapentinoids such as pregabalin (75 mg) with TCA such as nortriptyline (10 mg) is synergistic and improves treatment adherence. Among other treatments, Vitamin B12 (methylcobalamin) can be used either alone or in combination for the management of NeP. Use of Vitamin D and steroids should be limited to specific NeP in individual cases. Referral to pain specialists can be considered if two drugs fail to provide relief in NeP. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta ORIGINAL ARTICLES
Is tactile acuity altered in individuals with acute mechanical neck pain? p. 145 Shobhalakshmi S Holla, Turiya Vats, Pratima Nagpal
DOI :10.4103/ijpn.ijpn_20_18 Background: Tactile acuity measured by point discrimination (TPD) refers to the precision by which we can sense touch.An increase in TPD threshold (loss of tactile acuity) is considered suggestive of disruptions to S1 cortical maps of that specific body part. In some chronically painful conditions, reduced tactile acuity is a manifestation of Central sensitization (CS).The other symptoms include hyperalgesia and allodynia due to repeated activation of spinal nociceptors. A recent study has shown that tactile acuity is affected in individuals with chronic neck pain. While there seems to be adequate evidence stating that tactile acuity is reduced in individuals with chronic pain, CS may not be limited to chronic pain states. There is a paucity of literature with respect to the tactile acuity of a person with acute neck pain. A measurement of tactile acuity of the affected body area in acute pain, may suggest the extent of the altered threshold of sensory discriminative aspect of pain experience. Objectives: To compare the two-point discrimination over C7 spinous process between the symptomatic individuals with mechanical neck pain and age matched healthy controls. Methods: 30 individuals with mechanical neck pain & 30 age matched normals were assessed for two point discrimination using mechanical calipers, The two sharp points of the caliper were vertically placed against the skin surface over C7 spinous process, commencing with 5mm, which was stretched out till the subject appreciated the two points. Values were noted down in millimeters. Results: An independent t – test showed a significant difference in the two point discrimination between the 2 groups ( P < 0.000). Conclusion: It can be concluded that individuals with acute mechanical neck pain demonstrated a change in tactile acuity. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
A comparative study of ultrasound-guided femoral nerve block versus fascia iliaca compartment block in patients with fracture femur for reducing pain associated with positioning for subarachnoid block p. 150 Neena Jain, Pooja Rawat Mathur, Veena Patodi, Saurav Singh
DOI :10.4103/ijpn.ijpn_21_18 Context: Lower extremity peripheral nerve blocks are increasingly being recommended for pain control in patients with fracture femur as it reduces pain and shortens the duration of hospital stay. Aims: To compare analgesic efficacy of ultrasound guided femoral nerve block (FNB) and fascia iliaca compartment block (FICB) in patients with fracture femur for reducing pain associated with positioning for subarachnoid block. Settings and Design: It was a prospective, randomized, double blind study. Methods and Material: Group A ( n = 25) received ultrasound guided FNB and Group B ( n = 25) received ultrasound guided FICB using 0.5% ropivacaine. Primary objective was to observe reduction in pain associated with positioning (sitting) for subarachnoid block. Statistical Analysis used: For data analysis t test, Mann Whitney test and Chi-square test were applied. Results: Visual analog scale (VAS) score for pain before giving peripheral nerve block between Group A (7.60 ± 0.57) and Group B (7.44 ± 0.50) was comparable ( P = 0.302). VAS score for pain in sitting position before giving subarachnoid block was lesser in Group A (1.88 ± 0.83) than in Group B (2.40 ± 0.57) ( P = 0.013). Mean reduction in VAS score for pain was more in Group A (5.72 ± 0.73) compared to Group B (5.04 ± 0.73) ( P = 0.002). Conclusion: Ultrasound guided FNB is more efficacious in reducing pain associated with positioning (sitting) for subarachnoid block in patients undergoing surgery for fracture femur compared to ultrasound guided FICB. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Image guided trans foraminal epidural injection: Is it a viable stopgap therapy for low backache p. 155 Samaresh Sahu, Rochan Pant, Sashank Sharma
DOI :10.4103/ijpn.ijpn_33_18 Aims: 1. Study the change in pain and function in patient with lumbosacral disc disease on MRI using visual analogue scale (VAS) and the revised Oswestry disability index (ODI) for back pain after administration of fluoroscopically guided transforaminal epidural injection. 2. Correlate the response of the patient with the spread of contrast in epidural space. Method: 100 patients with history of low back ache and imaging findings of disc herniation were enrolled based on inclusion criteria. Patients scored their pain on the VAS and functional disability on revised ODI. The patient was evaluated for distribution of pain and was administered a combination of anaesthetic and steroid after confirming the position of the tip of needle using iodinated contrast. Follow up for response to pain and improvement in disability in immediate post procedure done at 3 and 6 months. Result: 102 injections were administered for 100 patients which comprised of n =69 {67.6%} male and 33{32.4%} female and age distribution was 21-79 years. The distribution of indication was disc bulge n =29 (28.4%), extrusion n =12 (11.8%), post operative n =19 (18.6%), protrusion n =42 (41.2%). No significant difference between the VAS scores ( p =0.20) of the individual indication pre procedure. After 3 & 6 months there was statistically significant difference between the mean rank value of population indicating maximum benefit for disc bulge population and least for post operative population at three months follow up. Conclusion: There is statistically proven good results in all cases for 6 months, after which repeat injections may be tried. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Perception, knowledge, and attitudes of first-year postgraduates toward postoperative pain management: A questionnaire-based study p. 163 Pritam B Adsule, Pradnya M Bhalerao, Prakash R Dhumal
DOI :10.4103/ijpn.ijpn_31_18 Context: Inadequately controlled postoperative pain has undesirable physiological and psychological consequences. It increases postoperative morbidity, delays recovery, and hence causes a delayed return to normal daily living. Furthermore, the lack of adequate postoperative pain treatment may lead to persistent pain after surgery, which is often overlooked. Overall, inadequate pain management increases the use of health care resources and health care costs. Aim: To evaluate the knowledge and attitudes of first-year postgraduate students toward postoperative pain. Study Design: This questionnaire-based cross-sectional study was conducted on 42 first-year postgraduate students. Materials and Methods: A 20-point questionnaire was prepared based on the various aspects of postoperative pain services. The students were asked to provide their answers on a five-point Likert scale ranging from "strongly disagree" to "strongly agree." The responses were kept anonymous, and the results were expressed in terms of percentage. Results: Almost 70% of students had a good knowledge of opioids, 52% strongly felt the need for a structured pain curriculum, 76% were well aware of nonpharmacological methods of pain relief, 48% agreed on the need for a pain physician, and 52% were aware of the advantage of postoperative analgesia. Conclusion: This pilot study helped us to evaluate the current understanding of our first-year postgraduate students and further created awareness on the importance of pain relief postoperatively. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Executive function and its clinical correlates among migraineurs p. 167 Ashitha Sreedhar, Suresh M Kumar, Anjali N Shobha
DOI :10.4103/ijpn.ijpn_38_18 Background: The studies conducted in the field of migraine and its effect on various cognitive functions revealed contradicting results mainly due to the incorporation of patients from varied socioeconomic status, clinical conditions, and the methodology adopted to the study. Methods: The participants of the study consist of 130 migraineurs, selected from the outpatient department of neurology from reputed tertiary centers at Chennai, South India, and controls were picked up from the community. Patients were selected on the basis of clinical examination and screening. The instruments used are Migraine Severity Scale, Headache impact test, hospital anxiety and depression scale (HADS), Wisconsin Card Sorting Test, Trail Making Test, and Controlled Oral word Association Test. Results: The study found that migraine group to have deficits in some aspects of problem-solving and concept formation competencies in comparison with healthy individuals and also found strong and weak correlation with various clinical variables such as its severity, duration, and headache impact indicating the role of migraine on cognitive functioning. Conclusion: The condition of migraine does lead to mild-to-moderate levels of impairment in various frontal lobe-involved cognitive functions such as attention, planning, and problem-solving even in a high-profile samples having higher levels of education and occupation. The relation between the migraine and impairment in cognitive functions are further cemented by the strong correlation found between various clinical factors such as its severity, duration, and its impact. Findings from such a study will also pave new ways and means to incorporate the implementation of a holistic approach in the treatment and management of migraine, and thereby to enhance the quality of life of these patients. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Translation and validation of Marathi version of Fear-Avoidance and Belief Questionnaire in patients with chronic low back pain p. 173 Vrushali P Panhale, Reshma S Gurav, Kartiki Suradkar
DOI :10.4103/ijpn.ijpn_41_18 Background: Fear-Avoidance Beliefs Questionnaire (FABQ) is widely used to assess the fear-avoidance beliefs in patients with low back pain (LBP). However, English serves as a barrier to the population of the state where Marathi is the prime language. Hence, the FABQ needs to be translated into Marathi for the ease of its use. Materials and Methods: FABQ was successfully translated in Marathi using forward-backward translation using recommended guidelines. The final version of FABQ-Marathi version (FABQ-M) was used on 100 patients with chronic nonspecific LBP to assess its reliability and validity. Reliability was assessed by measuring the internal consistency of FABQ-M and its subscales and by checking the test-retest reliability on day 1 and day 2. For the determination of construct validity, convergent and divergent validity was assessed. The floor and ceiling effects were studied. Results: Reliability-internal consistency-Cronbach's alpha for FABQ-M was 0.860 and test–retest: correlation between FABQ-M on day 1 and day 2 were highly significant. The intraclass coefficient was 0.976. There was a high internal consistency between the FABQ-M and its subscales. On assessing convergent validity, there was moderate correlation found between FABQ-M and TSK ( r = 0.52, P = 0.00). Divergent validity showed moderate correlation between FABQ-M and NRS ( r = 0.48, P = 0.00) and between FABQ-M and RMDQ ( r = 0.59, P = 0.00). Conclusion: The translated FABQ-M proved to be acceptable. The results suggest it is a validated, an easy to comprehend, reliable, and valid instrument for the measurement of the fear and avoidance beliefs caused by back disorders in the Marathi-speaking population. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta CASE SERIES
A case series discussing the intrathecal drug delivery system to improve the quality of life in terminal cancer patients p. 179 Joanna Samantha Rodrigues, Preeti Gupta, Shalini Saksena, Manju Butani
DOI :10.4103/ijpn.ijpn_49_18 Cancer is a life changing diagnosis and chronic pain in these terminally ill patients is extremely debilitating. In the present case series, the feasibility of continuous infusion of low dose local anaesthetics and opioids through the intrathecal route has been discussed pertaining to patient selection, technique, drugs used and trouble shooting. The intrathecal catheters were connected through a subcutaneous port to an external ambulatory infusion device (CADD pump) and used on a home care basis. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta CASE REPORTS
Quadratus lumborum: One of the many significant causes of low back pain p. 184 Asha Satish Barge, Satish Mahadeo Barge
DOI :10.4103/ijpn.ijpn_53_18 Quadratus lumborum is one of the common sources of pain and that can be missed or ignored easily. Quadratus lumborum pain syndrome is a myofascial pain syndrome. The pain is due to spasm and stiffness of the muscle. Many a times, weak back muscles are compensated by quadratus lumborum leading to painful spasm. It is diffi cult to differentiate between quadratus lumborum and iliopsoas pain syndrome. Diagnostic quadratus lumborum injection helps differentiate between these two. In this report, we reported a case of quadratus lumborum pain syndrome as a primary diagnosis and iliopsoas pain syndrome as a secondary diagnosis. The diagnosis was confi rmed by fl uoroscopically guided quadratus lumborum injection. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Management of chronic postsurgical pain following cholecystectomy p. 187 Parthasarathy Srinivasan, Gobinath Jayaraman
DOI :10.4103/ijpn.ijpn_36_18 A 50-year-old female presented with severe pain at the cholecystectomy scar site of 4 months' duration. She had an open cholecystectomy done followed by continuous pain from the time of discharge. She was diagnosed as a case of chronic postsurgical pain (CPSP) syndrome. We administered right-sided erector spinae (ES) block by ultrasound guidance depositing 15 ml of 0.25% bupivacaine and 40 mg of methylprednisolone at site of incision. The visual analog score showed significant improvement from 7/10 to 2/10 for the next 2 months of follow-up. We conclude that ultrasonography-guided ES block combined with intralesional steroid is a viable treatment option in cases of CPSP. This is possibly the first case report of postcholecystectomy chronic pain managed with ES block. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Horner syndrome: A hidden benign complication of cervical epidural injection p. 190 Sudheer Dara, Minal Chandra, Rachna Varma
DOI :10.4103/ijpn.ijpn_59_18 Cervical epidural steroid injection is an intervention done for cervical prolapsed intervertebral disc. Cervical epidural steroid injection is done if a patient has not responded to medications and physical therapy. We discuss a case report of the occurrence of Horner's syndrome in the patient with cervical radiculopathy undergoing cervical interlaminar epidural steroid injection which resolved spontaneously without residual side effects. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta

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Journal of Pain

EDITORIAL
Percutaneous vertebroplasty: Current controversy p. 123 Kailash Kothari
DOI :10.4103/ijpn.ijpn_67_18 [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta REVIEW ARTICLES
Full-endoscopic lumbar discectomy for high canal compromised disc at upper lumbar level: A technical review p. 125 Manish Raj, Kailash Kothari, Anurag Agarwal, Hyeun Sung Kim, Pankaj Surange, Kapil Tyagi, Prashant Punia, Palea Ovideu
DOI :10.4103/ijpn.ijpn_51_18 Objective: In this study, we have described the technique to overcome difficulty faced during trans-foraminal endoscopic discectomy for the treatment of lumbar radiculopathy in patients who have herniated discs at the upper lumbar level & thoracolumbar junction. Method: After institutional review board approval, A retrospective analysis of 27 patients operated between March 2013- September 2017, by a single specialist for disc herniation at upper lumbar levels D12-L1, L1-2, L2-3 with or without high canal compromise by outside in technique (using rigid endoscope, sequential reamers) along with detailed description of our technique is the focus of this study. Results: Out of 27 patients there were 11 cases for L1-2 & 16 cases of L2-3 disc herniation respectively. There were 21 cases of broad-based, high canal compromised disc herniation with significant neurological deficit & only 6 cases were of focal herniation type. The average preoperative VAS score of 8.5 (range 6-10) reduced to 4 (range 2-7) immediate postoperatively & it further reduced to 2 (range 0-4) at one month follow up. The average preoperative ODI score of 65 (range 28- 88) reduced to 27 (range 12-40) immediate postoperatively & it further reduced to 10 (range 3- 18) at one month follow up. Post-operative MRI showed that the ruptured disc had been successfully removed. Conclusion: An anatomically modified surgical technique promote a more successful outcome after percutaneous endoscopic discectomy for upper lumbar disc herniation. Foraminotomy is recommended for all intra-canalicular herniation. Transforaminal endoscopic discectomy and foraminotomy can be used as a safe yet minimally invasive technique for the treatment of lumbar radiculopathy in the setting of an upper lumbar disc herniation. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Pharmacological management of neuropathic pain in India: A consensus statement from Indian experts p. 132 Ashok Kumar Saxena, Parmanand Jain, Gur Prasad Dureja, Anil Venkitachalam, Subrata Goswami, Hammad Usmani, Shardul Kothari, Dipit Sahu, Baljit Singh, Vandana Trivedi, Gaurav Sharma, Sanjay Kamble, Amit Qamra, Salman Motlekar, Rishi Jain
DOI :10.4103/ijpn.ijpn_47_18 Neuropathic pain (NeP) constitutes a major pain-related disorder, which is often underdiagnosed and undertreated. Adverse physical, psychological, and economic consequences associated with NeP lead to poor quality of life. Burden of NeP in developing countries like India is colossal. Various international guidelines provide effective approaches to diagnose and manage NeP. However, differences in the genetic makeup of Indian population can result in subtle differences in clinical response, considering their low body weight, drug metabolism ability, and pain perception. Similarly, treatment-related adverse effects may also vary. Practice of Indian physicians may also differ for choice of drugs based on their availability and affordability. In the absence of country-specific guidelines, this document could serve as a guiding tool for health-care providers, ensuring uniformity in the treatment of NeP. Thus, applicability of all recommendations from any of these guidelines in Indian setting demands careful evaluation. Clinical experience of Indian physicians suggests that there are lot many challenges (e.g., busy outpatient departments, nonavailability of screening questionnaires in regional languages, and availability and affordability of medications) faced by them when managing NeP. In addition, in India, there are no country-specific guidelines that would help them to address these challenges. The objective for this consensus was to develop an expert opinion guideline to harmonize the management of NeP in India. The expert panel consisted of experts from various specialties such as pain medicine, anesthesiology, diabetology, neurology, and orthopedics. The panel critically reviewed the existing literature evidence and guideline recommendations to provide India-specific consensus on the management of NeP. The final consensus document was reviewed and approved by all the experts. This expert opinion consensus will help health-care professionals as a guiding tool for effective management of NeP in India. Use of Douleur Neuropathique 4 (DN4) questionnaire for NeP screening should be routine in day-to-day clinical practice. For effective utilization of DN4 questionnaire, it should be converted to regional language. If DN4 questionnaire screening fails to identify NeP, it should not be disregarded and should not replace the sound clinical judgment from the treating physician. Diagnostic tests may be considered as a supplement to clinical judgment. Cost-effective treatment should be the initial choice. Dosing should be individualized based on efficacy and tolerability. Tricyclic antidepressants (TCAs), gabapentinoids, and serotonin-norepinephrine reuptake inhibitors (SNRIs) can be considered among initial choices. Tramadol can be considered as a second-line add-on treatment for NeP if there is partial response to the first-line agent either alone or in combination. Fixed-dose combination (FDC) of gabapentinoids such as pregabalin (75 mg) with TCA such as nortriptyline (10 mg) is synergistic and improves treatment adherence. Among other treatments, Vitamin B12 (methylcobalamin) can be used either alone or in combination for the management of NeP. Use of Vitamin D and steroids should be limited to specific NeP in individual cases. Referral to pain specialists can be considered if two drugs fail to provide relief in NeP. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta ORIGINAL ARTICLES
Is tactile acuity altered in individuals with acute mechanical neck pain? p. 145 Shobhalakshmi S Holla, Turiya Vats, Pratima Nagpal
DOI :10.4103/ijpn.ijpn_20_18 Background: Tactile acuity measured by point discrimination (TPD) refers to the precision by which we can sense touch.An increase in TPD threshold (loss of tactile acuity) is considered suggestive of disruptions to S1 cortical maps of that specific body part. In some chronically painful conditions, reduced tactile acuity is a manifestation of Central sensitization (CS).The other symptoms include hyperalgesia and allodynia due to repeated activation of spinal nociceptors. A recent study has shown that tactile acuity is affected in individuals with chronic neck pain. While there seems to be adequate evidence stating that tactile acuity is reduced in individuals with chronic pain, CS may not be limited to chronic pain states. There is a paucity of literature with respect to the tactile acuity of a person with acute neck pain. A measurement of tactile acuity of the affected body area in acute pain, may suggest the extent of the altered threshold of sensory discriminative aspect of pain experience. Objectives: To compare the two-point discrimination over C7 spinous process between the symptomatic individuals with mechanical neck pain and age matched healthy controls. Methods: 30 individuals with mechanical neck pain & 30 age matched normals were assessed for two point discrimination using mechanical calipers, The two sharp points of the caliper were vertically placed against the skin surface over C7 spinous process, commencing with 5mm, which was stretched out till the subject appreciated the two points. Values were noted down in millimeters. Results: An independent t – test showed a significant difference in the two point discrimination between the 2 groups ( P < 0.000). Conclusion: It can be concluded that individuals with acute mechanical neck pain demonstrated a change in tactile acuity. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
A comparative study of ultrasound-guided femoral nerve block versus fascia iliaca compartment block in patients with fracture femur for reducing pain associated with positioning for subarachnoid block p. 150 Neena Jain, Pooja Rawat Mathur, Veena Patodi, Saurav Singh
DOI :10.4103/ijpn.ijpn_21_18 Context: Lower extremity peripheral nerve blocks are increasingly being recommended for pain control in patients with fracture femur as it reduces pain and shortens the duration of hospital stay. Aims: To compare analgesic efficacy of ultrasound guided femoral nerve block (FNB) and fascia iliaca compartment block (FICB) in patients with fracture femur for reducing pain associated with positioning for subarachnoid block. Settings and Design: It was a prospective, randomized, double blind study. Methods and Material: Group A ( n = 25) received ultrasound guided FNB and Group B ( n = 25) received ultrasound guided FICB using 0.5% ropivacaine. Primary objective was to observe reduction in pain associated with positioning (sitting) for subarachnoid block. Statistical Analysis used: For data analysis t test, Mann Whitney test and Chi-square test were applied. Results: Visual analog scale (VAS) score for pain before giving peripheral nerve block between Group A (7.60 ± 0.57) and Group B (7.44 ± 0.50) was comparable ( P = 0.302). VAS score for pain in sitting position before giving subarachnoid block was lesser in Group A (1.88 ± 0.83) than in Group B (2.40 ± 0.57) ( P = 0.013). Mean reduction in VAS score for pain was more in Group A (5.72 ± 0.73) compared to Group B (5.04 ± 0.73) ( P = 0.002). Conclusion: Ultrasound guided FNB is more efficacious in reducing pain associated with positioning (sitting) for subarachnoid block in patients undergoing surgery for fracture femur compared to ultrasound guided FICB. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Image guided trans foraminal epidural injection: Is it a viable stopgap therapy for low backache p. 155 Samaresh Sahu, Rochan Pant, Sashank Sharma
DOI :10.4103/ijpn.ijpn_33_18 Aims: 1. Study the change in pain and function in patient with lumbosacral disc disease on MRI using visual analogue scale (VAS) and the revised Oswestry disability index (ODI) for back pain after administration of fluoroscopically guided transforaminal epidural injection. 2. Correlate the response of the patient with the spread of contrast in epidural space. Method: 100 patients with history of low back ache and imaging findings of disc herniation were enrolled based on inclusion criteria. Patients scored their pain on the VAS and functional disability on revised ODI. The patient was evaluated for distribution of pain and was administered a combination of anaesthetic and steroid after confirming the position of the tip of needle using iodinated contrast. Follow up for response to pain and improvement in disability in immediate post procedure done at 3 and 6 months. Result: 102 injections were administered for 100 patients which comprised of n =69 {67.6%} male and 33{32.4%} female and age distribution was 21-79 years. The distribution of indication was disc bulge n =29 (28.4%), extrusion n =12 (11.8%), post operative n =19 (18.6%), protrusion n =42 (41.2%). No significant difference between the VAS scores ( p =0.20) of the individual indication pre procedure. After 3 & 6 months there was statistically significant difference between the mean rank value of population indicating maximum benefit for disc bulge population and least for post operative population at three months follow up. Conclusion: There is statistically proven good results in all cases for 6 months, after which repeat injections may be tried. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Perception, knowledge, and attitudes of first-year postgraduates toward postoperative pain management: A questionnaire-based study p. 163 Pritam B Adsule, Pradnya M Bhalerao, Prakash R Dhumal
DOI :10.4103/ijpn.ijpn_31_18 Context: Inadequately controlled postoperative pain has undesirable physiological and psychological consequences. It increases postoperative morbidity, delays recovery, and hence causes a delayed return to normal daily living. Furthermore, the lack of adequate postoperative pain treatment may lead to persistent pain after surgery, which is often overlooked. Overall, inadequate pain management increases the use of health care resources and health care costs. Aim: To evaluate the knowledge and attitudes of first-year postgraduate students toward postoperative pain. Study Design: This questionnaire-based cross-sectional study was conducted on 42 first-year postgraduate students. Materials and Methods: A 20-point questionnaire was prepared based on the various aspects of postoperative pain services. The students were asked to provide their answers on a five-point Likert scale ranging from "strongly disagree" to "strongly agree." The responses were kept anonymous, and the results were expressed in terms of percentage. Results: Almost 70% of students had a good knowledge of opioids, 52% strongly felt the need for a structured pain curriculum, 76% were well aware of nonpharmacological methods of pain relief, 48% agreed on the need for a pain physician, and 52% were aware of the advantage of postoperative analgesia. Conclusion: This pilot study helped us to evaluate the current understanding of our first-year postgraduate students and further created awareness on the importance of pain relief postoperatively. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Executive function and its clinical correlates among migraineurs p. 167 Ashitha Sreedhar, Suresh M Kumar, Anjali N Shobha
DOI :10.4103/ijpn.ijpn_38_18 Background: The studies conducted in the field of migraine and its effect on various cognitive functions revealed contradicting results mainly due to the incorporation of patients from varied socioeconomic status, clinical conditions, and the methodology adopted to the study. Methods: The participants of the study consist of 130 migraineurs, selected from the outpatient department of neurology from reputed tertiary centers at Chennai, South India, and controls were picked up from the community. Patients were selected on the basis of clinical examination and screening. The instruments used are Migraine Severity Scale, Headache impact test, hospital anxiety and depression scale (HADS), Wisconsin Card Sorting Test, Trail Making Test, and Controlled Oral word Association Test. Results: The study found that migraine group to have deficits in some aspects of problem-solving and concept formation competencies in comparison with healthy individuals and also found strong and weak correlation with various clinical variables such as its severity, duration, and headache impact indicating the role of migraine on cognitive functioning. Conclusion: The condition of migraine does lead to mild-to-moderate levels of impairment in various frontal lobe-involved cognitive functions such as attention, planning, and problem-solving even in a high-profile samples having higher levels of education and occupation. The relation between the migraine and impairment in cognitive functions are further cemented by the strong correlation found between various clinical factors such as its severity, duration, and its impact. Findings from such a study will also pave new ways and means to incorporate the implementation of a holistic approach in the treatment and management of migraine, and thereby to enhance the quality of life of these patients. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Translation and validation of Marathi version of Fear-Avoidance and Belief Questionnaire in patients with chronic low back pain p. 173 Vrushali P Panhale, Reshma S Gurav, Kartiki Suradkar
DOI :10.4103/ijpn.ijpn_41_18 Background: Fear-Avoidance Beliefs Questionnaire (FABQ) is widely used to assess the fear-avoidance beliefs in patients with low back pain (LBP). However, English serves as a barrier to the population of the state where Marathi is the prime language. Hence, the FABQ needs to be translated into Marathi for the ease of its use. Materials and Methods: FABQ was successfully translated in Marathi using forward-backward translation using recommended guidelines. The final version of FABQ-Marathi version (FABQ-M) was used on 100 patients with chronic nonspecific LBP to assess its reliability and validity. Reliability was assessed by measuring the internal consistency of FABQ-M and its subscales and by checking the test-retest reliability on day 1 and day 2. For the determination of construct validity, convergent and divergent validity was assessed. The floor and ceiling effects were studied. Results: Reliability-internal consistency-Cronbach's alpha for FABQ-M was 0.860 and test–retest: correlation between FABQ-M on day 1 and day 2 were highly significant. The intraclass coefficient was 0.976. There was a high internal consistency between the FABQ-M and its subscales. On assessing convergent validity, there was moderate correlation found between FABQ-M and TSK ( r = 0.52, P = 0.00). Divergent validity showed moderate correlation between FABQ-M and NRS ( r = 0.48, P = 0.00) and between FABQ-M and RMDQ ( r = 0.59, P = 0.00). Conclusion: The translated FABQ-M proved to be acceptable. The results suggest it is a validated, an easy to comprehend, reliable, and valid instrument for the measurement of the fear and avoidance beliefs caused by back disorders in the Marathi-speaking population. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta CASE SERIES
A case series discussing the intrathecal drug delivery system to improve the quality of life in terminal cancer patients p. 179 Joanna Samantha Rodrigues, Preeti Gupta, Shalini Saksena, Manju Butani
DOI :10.4103/ijpn.ijpn_49_18 Cancer is a life changing diagnosis and chronic pain in these terminally ill patients is extremely debilitating. In the present case series, the feasibility of continuous infusion of low dose local anaesthetics and opioids through the intrathecal route has been discussed pertaining to patient selection, technique, drugs used and trouble shooting. The intrathecal catheters were connected through a subcutaneous port to an external ambulatory infusion device (CADD pump) and used on a home care basis. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta CASE REPORTS
Quadratus lumborum: One of the many significant causes of low back pain p. 184 Asha Satish Barge, Satish Mahadeo Barge
DOI :10.4103/ijpn.ijpn_53_18 Quadratus lumborum is one of the common sources of pain and that can be missed or ignored easily. Quadratus lumborum pain syndrome is a myofascial pain syndrome. The pain is due to spasm and stiffness of the muscle. Many a times, weak back muscles are compensated by quadratus lumborum leading to painful spasm. It is diffi cult to differentiate between quadratus lumborum and iliopsoas pain syndrome. Diagnostic quadratus lumborum injection helps differentiate between these two. In this report, we reported a case of quadratus lumborum pain syndrome as a primary diagnosis and iliopsoas pain syndrome as a secondary diagnosis. The diagnosis was confi rmed by fl uoroscopically guided quadratus lumborum injection. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Management of chronic postsurgical pain following cholecystectomy p. 187 Parthasarathy Srinivasan, Gobinath Jayaraman
DOI :10.4103/ijpn.ijpn_36_18 A 50-year-old female presented with severe pain at the cholecystectomy scar site of 4 months' duration. She had an open cholecystectomy done followed by continuous pain from the time of discharge. She was diagnosed as a case of chronic postsurgical pain (CPSP) syndrome. We administered right-sided erector spinae (ES) block by ultrasound guidance depositing 15 ml of 0.25% bupivacaine and 40 mg of methylprednisolone at site of incision. The visual analog score showed significant improvement from 7/10 to 2/10 for the next 2 months of follow-up. We conclude that ultrasonography-guided ES block combined with intralesional steroid is a viable treatment option in cases of CPSP. This is possibly the first case report of postcholecystectomy chronic pain managed with ES block. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Horner syndrome: A hidden benign complication of cervical epidural injection p. 190 Sudheer Dara, Minal Chandra, Rachna Varma
DOI :10.4103/ijpn.ijpn_59_18 Cervical epidural steroid injection is an intervention done for cervical prolapsed intervertebral disc. Cervical epidural steroid injection is done if a patient has not responded to medications and physical therapy. We discuss a case report of the occurrence of Horner's syndrome in the patient with cervical radiculopathy undergoing cervical interlaminar epidural steroid injection which resolved spontaneously without residual side effects. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta

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