Introduction: Postdural puncture headache¹ (PDPH) is an occipitofrontal type of headache, a known complication of subarachnoid block or spinal anesthesia. There are several forms of treatments available for PDPH that includes conservative treatments such as bed rest with 15 degree head down, abdominal binders, pharmacological therapy with caffeine, paracetamol, sumatriptan, pregabalin, or nonsteroidal antiinflammatory drugs. Epidural blood patch is the gold standard when supportive treatment fails. Still PDPH remains a difficult situation for clinicians. Materials and methods: Sphenopalatine ganglion is a parasympathetic ganglion through which sympathetic nerves passes. Sphenopalatine ganglion block has been used for treatment of different types of headache including cluster headache, migraine and atypical facial pain. Transnasal sphenopalatine ganglion block (SPGB) is being used recently for the management of PDPH also. Transnasal Sphenopalatine ganglion block is a noninvasive procedure in which local anesthetic is applied locally to the mucosal surface on the posterior pharyngeal wall superior to middle turbinate under which lies the sphenopalatine ganglion. Discussion: Review of literature supports the use of SPGB in PDPH. It is becoming popular for its simplicity in use and high success rate compared to epidural blood patch.

Background: Closed reduction of the fractured and displaced nasal bones results in nasal bleeding at the site of fracture which needs judicious management. Usually general anesthesia is used with orotracheal intubation, whereas managing these cases with combined nasociliary and infraorbital blocks needs a better understanding of the surface landmark and foraminal anatomy. Materials and methods: We report a randomized study of 2 groups of 25 patients each, with fractures of the nasal bones in our institution over 12 months. Group I included 25 patients with nasal bone fracture reduction done under general anesthesia, and group II included 25 patients in whom regional block anesthesia was given. Most of the patients in the study were in the ASA grade I and II and all had obvious nasal deformity observed and recorded with a history of trauma and injury. Results: The time for full sensory loss in group A was 45 minutes and 21 minutes in group B. The procedure time of 12 minutes was the same in both the groups, while an added imaging time of 15 minutes resulted in an overall procedure time of 27 minutes. Splints were used for septal support as well as externally, which needed an extra 20 minutes for the gypsum salt or the thermoplast to settle. The time of recovery was immediate in group B, while 20 minutes of recovery was seen in group A. Most of the patients in group A commented a painless recovery, while most patients of group B commented an experience of discomfort during the procedure. Conclusion: Unilateral fractures were reduced under regional block anesthesia. Comorbidities should overweigh compliance while preferring regional anesthesia, as the risks involved in general anesthesia have been reduced to the minimum possible extent. The regional block has reduced the operative costs but the complications of the procedure are nearly equal in both types of anesthesia.

Background: Ultrasound-guided bilateral transversus abdominis plane (TAP) block provides analgesia by blocking the anterior abdominal wall afferent nerves. We evaluated the analgesic efficacy of TAP block as a component of multimodal analgesia in patients undergoing major abdominal oncosurgeries. The study design is prospective, randomized, and controlled. Materials and methods: Sixty patients of 18–65 years of age of either sex and American Society of Anesthesiology (ASA) grade I, II, or III undergoing major abdominal oncosurgeries were randomized to the TAP group (n = 30) and the control group (n = 30). All patients received standard general anesthesia. In the TAP group patients after the completion of the surgery, ultrasound-guided 18G Braun Perifix epidural catheter was placed in TAP and 50 mg bupivacaine was given bilaterally 8 hourly up to 24 hours. In the control group patients, the TAP block was not performed. Patients of both groups received patient-controlled analgesia (PCA) with intravenous morphine and IV paracetamol 1 g 8 hourly. In the postoperative anesthesia care unit (PACU), we observed all patients visual analogue scale (VAS) pain score at rest and on knee flexion, PCA morphine demands, sedation score, and nausea/vomiting score at 0, 2, 4, 6, 12, 18, and 24 hours. The primary outcome measure was to study the VAS pain score in TAP and control group patients at rest and on knee flexion up to 24 hours. The secondary outcome measure was to calculate the PCA morphine requirement in both groups with 24 hours’ time frame. Results: Patients receiving TAP block with 0.25 % bupivacaine 20 mL eight hourly had reduced postoperative VAS pain score at rest and on knee flexion compared to the control group (p < 0.05). Up to 24 hours in PACU, IV morphine requirement in the TAP group was reduced to 19 mg as compared to 32 mg in the control group which is highly significant (p < 0.001). Conclusion: Patients receiving TAP block had effective postoperative analgesia and decreased morphine requirement up to 24 hours; hence, TAP block should be considered as a major component of multimodal analgesia for pain management of major abdominal oncosurgeries. The study has been registered with www.clinicaltrials.gov ID NCT03165383.

Introduction: Osteoarthritis (OA) of the knee is a chronic degenerative condition where pain is the predominant symptom. The most important reason for replacement surgery in advanced OA of the knee is pain. But pain may persist even after total knee arthroplasty in about 20% situation. Clinicians are searching an easier alternative to knee arthroplasty. Materials and methods: Platelet-rich plasma (PRP) is a new modality of treatment which helps in regeneration and relieves pain. It has been used successfully in injured and degenerated tissues. It has been used successfully in knee OA too. Most studies indicate it as an excellent modality and superior to hyaluronic acid (HA) injection in the knee. Some studies indicate that the combination of PRP and HA is even better than PRP alone. Discussion: Inspired by recent studies on PRP, question is raised on whether PRP injection can help avoid replacement surgery? But unless more studies with PRP are conducted on advanced OA, we cannot comment on this based on the available literature.

Introduction: Shoulder pain is a common and disabling complaint. The reported annual incidence of shoulder pain in primary care is 14.7 per 1000 patients per year with a lifetime prevalence of up to 70%. The most common causes of shoulder pain are rotator cuff tendinopathy, frozen shoulder or adhesive capsulitis and acromioclavicular (AC) joint osteoarthritis. Glenohumeral joint arthritis is uncommon. Discussion: Platelet rich plasma (PRP) is plasma that contains higher than physiologic platelet content. It has been seen that these growth factors are markedly up-regulated following tendon injury and are active at multiple stages of the healing process. Platelet rich plasma is an autologous source of growth factors and has been found to be helpful for treatment of tendinopathies and osteoarthritis. Platelet rich plasma injections for shoulder joint pathologies can be done using either fluoroscopy or by ultrasound guidance. Conclusion: Fluoroscopic guided PRP injection is better than ultrasound guidance as it helps to inject PRP with a single needle prick at three sites including glenohumoral joint, supraspinatous tendon and acromioclavicular joint.

Aim: To draw attention to the uncommon consequences that can arise after standard procedures like epidural steroid injections. Background: Epidural steroid injections have become a standard treatment modality for the management of chronic lumbar radiculopathy. They have shown good efficacy in relieving low back and radicular pain, but adverse reactions have also been reported. Abnormal vaginal bleeding is one such adverse reaction which needs to be treated on priority. Case description: A 42-year-old female patient came with chronic lower back pain and left lower limb radicular pain with MRI showing left paracentral disk protrusion at L4–5, with narrowing of neural foramen and L4 nerve root indentation. She was treated with left L4–5 transforaminal epidural steroid injection under fluoroscopic guidance. She had good pain relief after the procedure, but after one week, the patient experienced unusually heavy and painful menstrual bleeding which was not her regular menstrual cycle bleeding. The bleeding continued for 7 days and stopped without any treatment. After 10 days severe bleeding started again. She was given oral hormonal pills by the gynecologist, and bleeding was controlled in 3–4 days. In the next menstrual cycle, she had abnormal heavy bleeding and the gynecologist put her on medications for a month. After this episode, her menstrual cycle was totally normal and there were no complaints of bleeding or radicular pain on subsequent monthly follow-ups for next 4 months. Conclusion: We postulate that the introduction of exogenous corticosteroids directly into the neuraxial space can initiate a negative feedback loop on the hypothalamic–pituitary–ovarian axis. This may lead to decreased levels of circulating hormones, resulting in episodes of abnormal uterine bleeding in female patients. Clinical significance: Reporting such cases will make pain physicians more aware of uncommon consequences after standard procedures and start informing women that abnormal vaginal bleeding is a potential risk following procedures with corticosteroids.

It has become problematic that the number of noncardiac chest pain (NCCP) patients is increasing among those who come to the emergency room with chest pain as a chief complaint. They tend to come to hospitals often and over many years, even after cardiac chest pain has been excluded from their diagnosis. Moreover, studies have shown that NCCP patients have a high prevalence of anxiety, depression, and disability. However, most NCCP patients are usually treated by cardiologists or primary physicians. Ordinary biomedical approaches often fail to treat NCCP. NCCP is one of the most important functional somatic syndromes from the view of medical economics. The cause of NCCP includes gastroesophageal reflux disease (most common), panic disorder, and esophageal dysmotility.

Piriformis syndrome (PS) is a condition in which the piriformis muscle causes low back pain and buttock pain. Spasm of the piriformis muscle may cause radiating pain along the course of sciatic nerve (sciatica) due to the proximity of the sciatic nerve with the piriformis muscle. Foot drop due to piriformis muscle spasm is a rare clinical presentation. We have reported a case of acute foot drop due to piriformis muscle spam managed successfully with pulsed radiofrequency (PRF) of the piriformis muscle.

Radiating low back pain along the sciatic nerve or along L5 and/or S1 dermatome is common in clinical practice. Intraspinal pathologies are the common causes for such symptoms and, hence, are primarily considered during evaluation of patient with radiating low back pain. However, one must be aware of extraspinal pathologies that can lead to radiating pain to lower extremities. This case of space occupying lesion of gluteal region highlights the need for detailed, meticulous, and unbiased evaluation even in an apparently straight forward case so that an unusual clinical finding should not get missed.

Local injection therapies, often referred to as “wet needling”, use hollow-bore needles to deliver corticosteroids, anesthetics, sclerosants, botulinum toxins, or other agents. In contrast, “dry needling” refers to the insertion of thin monofilament needles, as used in the practice of acupuncture, without the use of injectate. Dry needling is typically used to treat muscles, ligaments, tendons, subcutaneous fascia, scar tissue, peripheral nerves, and neurovascular bundles for the management of a variety of neuromusculoskeletal pain syndromes. Our case report is about a 64-year-old male patient who presented with pain along the anterolateral aspect of the left thigh which developed after undergoing a hip surgery in 2001. The pain was electric shock like, aggravated on sitting and walking. The patient was treated with drugs like baclofen and paracetamol as we had made a diagnosis of the lateral cutaneous nerve of thigh entrapment, but did not have any relief. Injection of local anesthetic and steroid provided some pain relief, but when radiofrequency ablation was done, it did not produce any results. We then thought of a diagnosis of post-scar neuralgia and dry needling was carried out and the patient reported a pain relief of 50%.

Introduction: Low back pain (LBP) is a common symptom arising from many potential anatomic sources such as nerve roots, myofascial structures, bone, joints, intervertebral discs, and organs within the abdominal cavity. It's critical to identify the LBP secondary to the other causes. The diagnosis and treatment of patients who have both hip and lumbar spine pathologies may be a challenge because overlapping symptoms may delay a correct diagnosis and appropriate treatment. Common complaints of patients who have both hip and lumbar spine pathologies include low back pain with associated buttock, groin, thigh, and, possibly, knee pain. A thorough patient history should be obtained and a complete physical examination should be performed in these patients to identify the primary source of pain. Case description: Our case report is about a 74-year-old male who presented with complaints of low back pain radiating to his right thigh. A previous MRI spine had been done revealed multiple level disc prolapse at lumbar levels along with L5-S1 anterolisthesis and he was treated for his spine complaints. On examination the hip movements were painful in all directions. We had asked for X-ray pelvis which revealed advanced osteoarthritis and avascular necrosis of right hip. The patient was then referred to orthopaedic speciality where he underwent right total hip replacement.