Any discussion about evidence-based medicine (EBM) is bound to reveal both negative and positive reactions. Evidencebased practice with respect to interventional pain management specialty is reviewed here, and the most common appraisals and criticisms described. A few potential solutions to the most common negative reactions are being described with a highlight on future areas anticipating further input of efforts.
DOI: 10.5005/jp-journals-10046-0116 |
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Kotekar N, Matche P, H K, Gaddam N. Intra-articular Injection of Platelet-rich Plasma vs. Local Anesthetic with Steroid to Treat Knee Osteoarthritis: A Prospective Randomized Controlled Study. J Recent Adv Pain 2018; 4 (3):91-95.
Introduction: Osteoarthritis (OA) of the knee is a prevailing, chronic degenerative condition that generates a high expense. Alternative and adjuvant therapies are currently being foraged to improve the physical function and quality of life of affected patients. Intraarticular (IA) corticosteroid injection provides a short-term reduction in OA knee pain. Platelet-rich plasma (PRP) is now an emerging modality for OA knee, but there is still a lack of clinical evidence.
Aim: To evaluate the clinical effectiveness of knee IA injection of corticosteroid + local anesthetic (LA) with that of autologous PRP using standard scoring systems. To assess the degree of pain relief, improvement in range of motion of the knee joint and incidence of adverse effects.
Materials and methods: Sixty-four patients selected according to the inclusion criteria were treated with two IA injections given 4 weeks. All patients were divided into two groups–group P and S. Thirty two patients in group P were treated with PRP and 32-patients in group S with LA + Steroid. All patients were prospectively evaluated at the pain clinic and 3 and 6 months after the treatment for the following parameters: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, index of severity for knee osteoarthritis (ISK) score by Lequesne et al., visual analog score (VAS) score and range of motion of knee. Adverse events were also chronicled.
Results: There was an improvement in both the groups at 3 months, but there was no statistically significant difference between the ISK scores, MWI scores, and ROM whereas VAS score in group S was significantly lower than group P (p value = 0.03). At 6 months follow-up, the mean VAS score, the ISK scores, MWI scores and ROM in the group P were significantly lower than group S (p value = 0.0001; 0.0001; 0.003; 0.001). No significant complications related to injection were observed during the treatment and follow-up.
Conclusion: Improvement in the knee function was better with PRP than steroid group at short term follow-up. PRP is safe and more effective than steroids in alleviating pain in symptomatic OA knee.
Subhra D Mistry,
Post-injection pain, Platelet-rich plasma injection, Osteoarthritis of the knee
DOI: 10.5005/jp-journals-10046-0117 |
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Das G, Bhattacharya D, Mistry SD, Das S. Comparative Study of Post-injection Pain in Superolateral vs. Inferolateral Approach in Platelet-rich Plasma Injection for Osteoarthritis of Knee: A Retrospective Study. J Recent Adv Pain 2018; 4 (3):96-99.
Background: Injection site pain is not uncommon after interventional procedures particularly after platelet-rich plasma (PRP) injection. This retrospective study aims to find out the incidence of post-injection pain after injection and any relation of post-injection pain with injection site in PRP injection for osteoarthritis of the knee.
Methods: Patients of osteoarthritis of the knee who received PRP injection were grouped into two. Group A received PRP injection at the superolateral approach and group B received PRP injection at the inferolateral approach. Pre-procedure pain score on verbal rating score and post-procedure injection pain were compared in both the group and post-procedure injection pain were compared between the two groups.
Results: The sample size was calculated accepting alpha error as 0.05 and power of study 80%. The inferolateral approach was thought to be more painful because of narrowing of injection space and mean pain score was presumed as 6/10 ± 1 on the verbal rating scale (VRS). The superolateral approach was considered as less painful and anticipated pain score on VRS was 5/10. The calculated sample size was 16 in each group. However, in our study sample size were 35 in group A and in group B, it was 34. Demographic profiles were compared using students t-test and Chi-square test and the two groups were found similar in age and sex ratio. Pain score of two groups was compared using the Mann–Whitney U test and was found comparable (6.31 ± 1.1 in group A and 5.76 ± 1.46 in group B). Post-injection pain at 7 days was compared between groups and was also found similar (4.62 ± 1.7 in group A and 4.74 ± 1.4 in group B) without any statistically significant difference between two groups. Pre-procedure pain (6.04 ± 1.31) in both groups compared with post-injection pain (4.68 ±1.55) of both groups and were found less than pre-injection pain and was found statistically significant (p < 0.00001).
Discussion: Post-injection pain after 7 days after PRP injection were found to be less than pre-procedure injection and there is no relation pain with the injection site.
Chronic pain, Depression, Elderly patients, Pain and activities of daily living, Pain assessment, Pain prevalence
DOI: 10.5005/jp-journals-10046-0118 |
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Kotekar N, Matche P, Manjunath D, Pereira P. Assessment of Prevalence and Characteristics of Pain and Its Association with Quality of Life in Elderly. J Recent Adv Pain 2018; 4 (3):100-104.
Background: Last century has witnessed great advancement in the medical field which has resulted in a significant increase in mean survival age. Elderly population present with increased incidence certain pain syndromes increases. Despite this pain is often underreported in elderly patients due to incorrect belief that pain is a normal process of aging. Pain is a serious concern especially in the later years of life, however, very little is known about its incidence in elderly patients. This is due to a lack of systematic epidemiological surveys considering pain as a physiological problem in the elderly.
The aim of this study is to determine the prevalence of pain in the geriatric population, to assess the characteristics of pain and to study its association with depression and functional mobility.
Methods: This was a prospective study, in which a questionnaire concerning pain and multidimensional assessment tools for depression and functional mobility was administered to 200 patients above 65 years of age visiting the Geriatric Clinic of Department of Medicine.
Results: Prevalence of pain was found to be 69.5%, i.e., 139 patients experienced pain out of 200. Amongst the patients who suffered from pain, 79% of the patients complained of the musculoskeletal type of pain, the majority of it being knee joint pain followed by low back pain, 12% suffered from neuropathic pain and 9% suffered from a mixed type of pain. The intensity of pain was measured using a visual analog scale (VAS) score. 21% of the patients had mild pain, 65% had moderate pain and 14 % had severe pain. It was found that 13% of patients experienced pain for less than 1 year, 21% had pain between 1and 2 years, 38% experienced pain for 2–3 years and 28% of them had pain for more than 3 years. Our study showed a positive correlation between depression and duration of pain, i.e., an increase in the duration of pain increases depression scores. We found a negative correlation between functional mobility and duration of pain, i.e., as the duration of pain increases, the functional mobility decreases.
Conclusion: Assessment and treatment of prolonged and persistent pain in the elderly is challenging. As the patient’s age, the prevalence of pain increases. The consequences of chronic pain in the elderly include impaired activities of daily living (ADLs) and ambulation, depression all of which result in poor quality of life.
Spontaneous cerebrospinal fluid (CSF) leakage is recognized as a cause of headache due to decreased intracranial pressure. Spontaneous intractable headache was developed in a 43-yearold man and in a 26-year-old female which was diagnosed on computed tomography (CT). Myelography imaging with a generous CSF leak was identified at C6 in a male patient and right side L4-5 level and left side D12-L1 level in the female patient. Successful treatment was performed by fluoroscopyguided epidural blood patch at the leakage site. Image-guided precise placement of the blood patch is safe and recommended which gives dramatic relief of symptoms.
Aim: The aim of this report is to stress upon Bertolotti syndrome being a common cause of back pain in young adults and possible futility of interventional pain management in such cases.
Background: Bertolotti’s syndrome is characterized by unilateral or bilateral enlargement of the transverse process of the most caudal lumbar vertebra which may articulate or fuse with the sacrum or ilium. The syndrome affects 4 to 21% some reports stating incidence to be as high as 30% of the population. Diagnosis is not difficult if clinical suspicion is high, but mimics other common causes of low back pain. Treatment by interventional pain management may not be very effective as the problem is structural.
Case report: A 32-year-old soldier with low back pain, not relieved with medication was diagnosed with right-sided sacroiliitis. X-ray showed fusion of the transverse process of the 5th lumbar vertebra with the iliac crest. A fluoroscopy-guided sacroiliac joint injection along with the injection of the pseudoarthrosis was performed with no relief. An MRI scan was done which revealed degenerative disc at L4-L5 level. Caudal epidural steroid injection was done, however, the patient failed to obtain relief. He was then referred to a spine surgeon who has advised him surgery.
Conclusion: We conclude that Bertolotti’s syndrome could be an important cause of intractable back pain in young adults. Being a structural anomaly, usually, surgical intervention is needed.
Clinical implication: Patients with Bertolloti syndrome should be taken up for interventional pain management, after explaining guarded prognosis due to it being a structural anomaly.
Aim: To diagnose and aid the treatment of a patient with an unknown cause of epigastric pain.
Background: Harjola first described median arcuate ligament syndrome (aka celiac artery compression syndrome) in 1963. Typically it occurs in young patients (20–40 years age group) and is more common in lean women, presents with epigastric pain and weight loss.
Case description: An 18-year-old male visited the emergency room with a complaint of recurrent episodes of abdominal pain. There was no past or any medical history of any previous illness. On physical examination, the patient was afebrile and had pallor. All the vitals were within normal limits. The abdominal examination did not reveal any significant abnormality. Laboratory investigations (Hb, GBP, TLC) were within normal limits.
Conclusion: Median arcuate ligament syndrome is a rare clinical entity which can be found in normal asymptomatic people. In a few cases, however, celiac axis compression can cause symptoms which can be relieved with laparoscopic surgical decompression.
Clinical significance: The median arcuate ligament syndrome as an entity must be kept in mind when no other cause of abdominal pain is zeroed on even after all the clinical examinations and investigations.
Background: Piriformis syndrome is a neuromuscular disorder where there is compression of the sciatic nerve by the piriformis muscle. It may present with buttock pain with or without radiation in the distribution of the ipsilateral sciatic nerve. There are no standardized diagnostic criteria for its diagnosis, but the diagnostic block is helpful for its confirmation. However, injection into the piriformis muscle is not devoid of complications including muscle weakness and numbness.
Case description: A 60-year-old male patient presented with right buttock pain radiating along the posterior aspect of the thigh and leg up to the great toe over the dorsum of the foot. Right SLR, FAIR, Pace tests were positive, and piriformis tenderness was present. Provisional diagnosis was made as right-sided piriformis syndrome, and diagnostic piriformis block was done under fluoroscopic guidance. But the patient developed numbness and motor weakness of the right lower limb with modified Bromage scale score 4/6 immediately after the procedure, and the score was 5/6 even after 3 hours of the procedure.
Conclusion: One should be cautious in a post-procedure period of piriformis injection as the prolonged neurological deficit may occur following the piriformis injection.