Chetna Shamshery

Bertolotti syndrome: a diagnostic and management dilemma for pain physicians.

Background Bertolottis syndrome (BS), a form of lumbago in lumbosacral transitional vertebrae, is an important cause of low back pain in young patients. The purpose of this study was to assess the etiology of low back pain and the efficacy of treatment offered to patients with BS. Methods All patients of BS Castellvi type1a during a period of 6 months were enrolled in the study. The patients underwent interventional pain procedures for diagnosis and pain relief. Response to the therapy was assessed based on VAS and ODI scores. A 50% decrease in VAS score or a VAS score less than 3 would be considered adequate pain relief. Results All 20 patients diagnosed with BS during the 6-month observation period had scoliosis. Common causes of back pain were the ipsilateral L5-S1 facet joint, neoarticulation, the SI joint, and disc degeneration. Responses to various interventions for pain relief were different and inconsistent from patient to patient. In particular, responses to interventions for neoarticular pain were generally poor. Conclusions Pain in patients with BS does not usually respond to interventional pain treatment. A very dynamic treatment approach must be pursued while managing BS patients, and the treatment plan must be individualized at various stages in order to obtain satisfactory pain relief.

Double blind randomized control trial to evaluate the efficacy of ketoprofen patch to attenuate pain during venous cannulation

Background Venipuncture pain is an uncomfortable suffering to the patient. It creates anxiety, fear and dissatisfaction. The ketoprofen transdermal patch is a proven treatment for musculoskeletal and arthritic pain. We planned this study to evaluate the efficacy of the ketoprofen patch to reduce venipuncture pain. Methods Two hundred adult patients, aged 18–60 years, of either sex, ASA grade I or II, were enrolled. Presuming that therapy would decrease venipuncture pain by 30%, a power calculation with α = 0.05 and β = 0.80 required enrollment of at least 24 patients into each group. However, 100 patients in each group were recruited. Group I (Control) received a placebo patch; Group II (Ketoprofen) received a 20 mg ketoprofen patch. A selected vein on the dorsum of the patients non-dominant hand was cannulated with 18 g intravenous cannula 1 h after the application of the respective patch. Assessment of pain was done by a 10 cm visual analogue scale (VAS) of 0–10, where 0 depicts “no pain” and 10 is “the worst imaginable pain”. The venipuncture site was assessed for the presence of skin erythema, swelling and rashes at 12 h, 24 h and at the time of decannulation. Results Incidence of pain was 100% (94/94) in the control group as compared to 93% (85/91) in the ketoprofen group. The severity of the venipuncture pain was 6 (2) and 2 (2) for control and ketoprofen groups respectively (P < 0.05). Conclusions Application of a ketoprofen patch at the proposed site of venipuncture one hour before the attempt is effective and safe for attenuating venipuncture pain.

Vasopressin infusion during combine spinal epidural anesthesia for cesarean section in a patient with severe mitral stenosis with pulmonary hypertension

Abstract Presence of mitral stenosis deteriorates the already compromised cardiac status of a pregnant female. Decision between regional and general anesthesia can be crucial in such cases. Our patient a 20-year-old, and primigravida scheduled for emergency cesarean section due to acute fetal distress was a diagnosed case of severe mitral stenosis and pulmonary hypertension (48 mmHg). During antenatal she was on anticoagulants and was monitored regularly. In the operation theater she was monitored for heart rate, invasive blood pressure, central venous pressure, SpO2 and urine output. We gave combined spinal epidural anesthesia (CSEA) at L3–4, using 7.5 mg 0.5% bupivacaine with 8% dextrose. Immediately after CSEA a continuous vasopressin infusion at 2–4 units/h was started, which took care of hypotension and pulmonary hypertension and it was stopped at the end of the surgery. The patient was stable hemodynamically intra and postoperatively. A baby of 2.2 kg was delivered with an APGAR score 7, 8, 9.

Prevention of hypotension induced by combined spinal epidural anesthesia using continuous infusion of vasopressin: A randomized trial

Background: Central neuraxial blockade (CNB) is an established technique of providing anesthesia for surgeries of the lower limb and abdomen. Hypotension is the most common side effect of CNB. It was hypothesized that by supplementing the initial burst of vasopressin following hypovolemia, hypotension following combined spinal epidural anesthesia (CSEA) could be avoided. Materials and Methods: A total of 122 patients undergoing lower limb and abdomen surgeries were included in the study, with 61 patients randomized into two groups - I and II. Patients in Group I received infusion of normal saline as soon as CSEA was applied. When systolic blood pressure (SBP) decreased to <90 mmHg, they received a 6 mg bolus of mephentermine to counteract hypotension. Patients in Group II received a continuous infusion of vasopressin as soon as CSEA was applied. If despite maximum dose of vasopressin, SBP dropped to < 90 mmHg, then intravenous mephentermine was administered to counteract hypotension. Hemodynamic parameters and side effects were noted. Results: Level of block attained in both groups was comparable in terms of dermatomal height. The mean SBP and mean arterial pressure values of Group I were significantly lower than in Group II in the initial 14 min. Diastolic BP was also significantly lower in Group I. Heart rate was found to be lower in Group II, especially after 30 min (P < 0.05). Conclusion: Maintaining plasma levels of the physiological burst of vasopressin helps to avoid hypotension following neuraxial blockade. Continuous infusion of vasopressin at 1–3 U/h can prevent hypotension following neuraxial blockade.

An unusual cause of unilateral facial injuries caused by horseshoe headrest during prone positional craniovertebral junction surgery.

Pressure injuries are an accepted complication of prone positioning during the neurosurgical procedures. Horseshoe headrest are intended to reduce the incidence and severity of such injuries by allowing limited areas of contact between the skin of dependent areas of contact and the supporting surfaces. We report a case where a patient positioned prone over a horseshoe headrest developed inadvertent unilateral facial pressure injuries following a 6-h long craniovertebral junction (CVJ) surgery. We attempt to highlight this complication, analyze its causation, and briefly review the existing literature related to similar reported injuries.

Post orbit exenteration cases: a "red flag" for airway management.

• Patients of orbital exenteration surgeries are at risk of developing orbito nasal fistulas.

Comparative Evaluation of Retrocrural versus Transaortic Neurolytic Celiac Plexus Block for Pain Relief in Patients with Upper Abdominal Malignancy: A Retrospective Observational Study.

Aim: To compare retrocrural versus transaortic techniques for neurolytic celiac plexus block (NCPB) in patients suffering from upper abdominal malignancy. Methods: In this retrospective observational study between October 2013 and April 2015, 64 patients with inoperable upper abdominal malignancy received fluoroscopy-guided percutaneous NCPB in our institute. Their case files were reviewed and the patients were divided into two groups depending on the technique used to perform NCPB: retrocrural (Group R; n = 36) versus transaortic (Group T; n = 28). The primary outcome measure was pain as assessed with a numeric rating scale (NRS) from 0 to 10; the secondary outcome measures were morphine consumption per day (M), quality of life (QOL) as assessed by comparing the percent of positive responses in each group, and complications if any. These were noted and analyzed prior to intervention and then on day 1, weeks 1, 2, 3, and months 1, 2, 3, 6 following NCPB. Results: Patients in Group R had significantly reduced NRS pain scores at week 1, 2, 3, month 1 and 2 as compared to Group T (P < 0.05). Morphine consumption also reduced significantly in Group R at day 1, week 1, 2, and 3 (P < 0.05). QOL was found to be comparable between the groups, and no major complications were noted. Conclusion: Retrocrural NCPB provides superior pain relief along with a reduction in morphine consumption as compared to transaortic NCPB in patients with pain due to upper abdominal malignancy.

Fluoroscope-guided celiac plexus block in a pregnant patient: a case report

A 28-weeks gestation pregnant patient with chronic pacreatitis and severe abdominal pain leading to impaired nutrition is presented. After detailed consideration of the case, fluoroscopic-guided celiac plexus neurolysis was performed. The block was performed using the transaortic approach as it reduces radiation exposure.