Severe neuropathic pain in postherpetic neuralgia (PHN) is challenging for physicians especially in patients with altered hemostasis. Several interventional techniques have been described in the literature to treat this refractory pain. We report the successful management of PHN with thoracic erector spinae plane block in a patient on anticoagulants.

Background: Transversus abdominis plane (TAP) block is a regional anesthesia technique for postoperative analgesia. Since multiple nerves are to be blocked in a single prick, mucolytic enzyme hyaluronidase is being used to improve the spread of the local anesthetic. The present study was conducted to evaluate the effect of adding hyaluronidase as an adjuvant to local anesthetic in ultrasound (US)-guided TAP block. Materials and Methods: Eighty patients were randomly divided into two groups, Group B and Group BH. Group B patients received US-guided bilateral TAP block with 38 ml of 0.25% bupivacaine (heavy) and 2 ml of NS. Group BH patients received 38 ml of 0.25% bupivacaine (heavy) with 3000 IU hyaluronidase (2 ml) after completion of surgery under spinal anesthesia. Visual analog score (VAS) and heart rate were noted periodically. Time of demand of the first rescue analgesia and total analgesic consumption in 24 h were noted. Patient satisfaction survey was done at the end of 24 h. Results: Group BH patients had lower mean VAS scores at 6 and 8 h postoperatively as compared to Group B. The mean time of demand for the first rescue analgesia was longer in Group BH (351 ± 16 min) as compared to Group B (307 ± 13 min). The cumulative dose of rescue analgesic needed was more in Group B (370 ± 9 min) as compared to Group BH (343 ± 8 min). Patient satisfaction score was 3.3 ± 0.5 in Group BH and 2.3 ± 0.5 in Group B. All the differences were statistically significant. Conclusion: Addition of hyaluronidase improved quality of postoperative analgesia which can be due to the enzymatic action of hyaluronidase which hydrolyses the hyaluronic acid in the connective tissue and facilitates the spread of local anesthetic solution.

Greater trochanteric pain syndrome (GTPS) is a common cause of lateral hip pain, seen more commonly in females between the ages of 40 and 60 years. GTPS is presently attributed to tendinopathy of the gluteus medius and/or minimus with or without coexisting trochanteric bursitis. Conventionally, cortisone injection into the lateral hip, with the intention of injecting the bursa, was accepted treatment for this condition in cases not responding to conservative treatment. But since the etiology of GTPS is not necessarily the bursa, injecting it with steroid is not as logical. As trigger points and myofascial pain of the affected hip and thigh musculature are being implicated as sources of pain, dry needling (DN), that has shown potential in treating a variety of soft-tissue injury and neuromyofascial pain, and which requires the insertion of thin monofilament needles into sensitive loci (trigger points) in the muscles and soft tissue could be an effective option. Hereby, we present a case of a 52-year-old woman, who came to us with chronic lateral lower limb pain since 1 year. The pain was dull aching in quality, extended from the right buttock region to the lateral aspect of thigh and was specially felt on abduction of thigh while sitting in cross-legged position on the ground. The patient had tenderness along proximal lateral thigh around the greater trochanteric region. One-week course of nonsteroidal anti-inflammatory drugs had minimal effect. We decided to treat her with DN in her pain area. The patient reported more than 75% pain relief after the session.

Background/objectives: Total knee replacement surgeries being the ultimate operative modality are commonly performed for severe osteoarthritis. The challenges for the anesthesiologists are to provide optimal postoperative analgesia with minimum motor blockade, so that the patients can be ambulated early, thereby minimizing the complications of delayed ambulation. Materials and methods: We compared the efficacy of fentanyl and dexmedetomidine in improving the analgesic efficacy of bupivacaine-driven regional anesthesia adductor canal block (ACB) in 60 patients who underwent total knee replacement surgeries. We conducted a randomized study of two different drug formulations for the same procedure with random allocation using a computerized table. Results: The visual analog scale (VAS) score of the patients was less in group D. The number of steps walked and the time taken to stand from supine position was better in group D. The amount of local anesthetic requirement was less in group D. Nonsteroidal anti-inflammatory drug (NSAID) requirement was comparable in both the groups. Conclusion: In our study, we observed that VAS score is less in group D, thereby promoting early ambulation and better patient satisfaction. Hence, dexmedetomidine is a better adjuvant than fentanyl for regional anesthesia.

Cervicogenic headache is a secondary headache that occurs due to referred pain from the cervical region, perceived in the trigeminal nerve distribution. It is a rare entity which is often seen in patients following whiplash injuries belonging to the early 30s age group. The pain generators are facet joints, atlanto-occipital joint, intervertebral discs, neck muscles, and cervical nerves from various pathologies. Clinically, it is a side-locked headache worsened by abnormal neck postures and neck strain. The flexion–rotation test is positive in most cases. Diagnosis is made based on the ICHD-3 criteria. The mainstay of treatment involves physical therapy for 6 weeks along with psychological therapy and pain medications. Interventional pain therapy options include cervical epidural steroid injections, trigger point injections, selective nerve root injections, and radiofrequency thermal neurolysis.

The aim was to show the efficacy of simple ultrasound-guided trigger point injection of local anesthetic in combination with steroid for the management of postoperative abdominal cutaneous nerve entrapment syndrome (ACNES). Abdominal cutaneous nerve entrapment can be the cause of severe, undiagnosed, abdominal pain. The entrapment of the nerve can be secondary to various conditions which cause increased abdominal pressure, leading to herniation of fat or connective tissue into the fibrous ring in the rectus abdominis muscle through which the nerve passes. Due to the compression of the nerve, there is ischemia which leads to pain. The nerve can be entrapped in scar tissue causing the compromised blood flow to the nerve and hence leading to postoperative pain. None of the available radiological investigations is helpful in diagnosing the abdominal cutaneous nerve entrapment. Clinical examination looking for tender trigger point on the abdominal wall and the eliciting a positive clinical sign, i.e., Carnett's sign can lead to the possible diagnosis of this frustrating condition. We successfully managed three cases of abdominal cutaneous nerve entrapment following laparoscopic meshplasty of abdominal hernia. All these cases were injected with a mixture of local anesthetic and steroid, i.e., 1 ml of 2% lignocaine and 1 ml of 10 mg triamcinolone at each trigger point under ultrasound guidance. The patients were prescribed pregabalin for 3 months and an anti-inflammatory COX-2 inhibitor for 10 days postprocedure. All the 3 patients were pain free at 6 months following the injections. A simple approach to a very disturbing problem of managing the severe pain due to abdominal cutaneous nerve entrapment in the postoperative period is a trigger point injection of local anesthetic and steroid under ultrasound guidance. Ultrasound-guided trigger point injections using a local anesthetic and a steroid offer an almost noninvasive option to the management of a very complex problem of ACNES.

Ozone is a molecule consisting of three atoms of oxygen in a dynamically unstable structure. Ozone gas has been used in pain medicine practice for intraarticular injections, intradiscal, periforaminal or intraforaminal injections. Ozone is inherently bacteriostatic, fungicidal, and virucidal. The world is now facing one of the biggest crises known to humankind, the Coronavirus pandemic. This COVID-19 is multiplying at an unprecedented pace, affecting the population worldwide. Coronaviruses have abundant cysteine in their spike proteins that may be easily and safely exploited with ozone (or other oxidation) therapy. Cysteine residues are also abundant in viral membrane proteins and must be “conserved” for viral cell entry. Ozone has a unique ability to inactivate cysteine dependent proteins. Ozone injections in pain medicine have reported encouraging effects in pain control and functional recovery. All of these factors, coupled with the comparatively low cost of Ozone make it an attractive alternative option compared to platelet-rich plasma or steroid injections in the present COVID-19 pandemic crisis.

We describe the case of a 34-year-old female patient who had ischemia of the hand and fingers following insect bite and underwent stellate ganglion block as treatment. She was otherwise fit without any significant past history. We recommend an early recognition of such cases with prompt treatment for a better outcome.