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Background: Supplementation of spinal anaesthesia with sedatives or anxiolytics has emerged as a standard protocol to alleviate patients' anxiety and to produce amnesia during the surgical procedure. Thus, judicious use of sedation can make surgeries under spinal anaesthesia more comfortable and acceptable for the elderly patient, the surgeon, and the anaesthesiologist. However, over-sedation may jeopardise the safety of the patient. Appropriate sedation helps reduce physiological stress, which leads to a better result. Therefore, monitoring the depth of sedation becomes essential. The Ramsay sedation scale (RSS) and bispectral index (BIS) both are used widely to assess the depth of sedation., Objectives: The primary objective of the study was to assess and correlate the depth of sedation between the BIS and RSS in elderly patients using midazolam and propofol under spinal anaesthesia. The secondary objectives were to observe any difference in the commencement of sedation between the two groups and to observe haemodynamic changes between the two groups., Methods: A total of 60 elderly patients undergoing urological procedures under spinal anaesthesia were randomly assigned to receive either midazolam (Group A, n=30) or propofol (Group B, n=30) for sedation. In Group A, patients were given an initial bolus of midazolam 0.03 mg/kg and a maintenance incremental bolus of 0.01 mg/kg up to a maximum of 2.5 mg in 10-minute intervals. Group B used propofol with an initial bolus dose of 0.5 mg/kg over two minutes and a maintenance bolus of 10-20 mg as required for the maintenance of sedation depth. Sedation was titrated to achieve a BIS score of 70-80 and an RSS score of 3-4. Heart rate, non-invasive systolic, diastolic, mean arterial blood pressure, oxygen saturation (SPO2), and the correlation coefficient between the BIS and RSS were measured at 0 (baseline), 5, 10, 20, 30, 40, 50, and 60 minutes of interval., Results: The correlation coefficient between the BIS and RSS scores in Group A at various time intervals indicate a strong correlation coefficient of -0.76 at five minutes, -0.64 at 20 minutes, -0.78 at 30 minutes, -0.56 at 40 minutes, and -0.39 at 50 minutes. In Group B, the correlation coefficient between the BIS and RSS scores at various time intervals indicate a strong correlation coefficient of -0.75 at five minutes, -0.76 at 20 minutes,-0.64 at 30 minutes, -0.89 at 40 minutes, and -0.46 at 50 minutes of interval. We also observed that the BIS drops to a lower level in patients receiving propofol (Group B) with a significant difference depicting early onset of sedation with propofol. In Group B, HR and MAP were significantly less than those of Group A. There was no significant difference in terms of mean age, sex, and body weight in the patients of both groups., Conclusion: The BIS and RSS scores indicate a strong correlation with a magnitude of 70%-80%, but more in Group B (propofol) than Group A (midazolam). Therefore, the characteristics of each sedative drug can influence the level of sedation during spinal anaesthesia. Clinicians should use a combination of BIS values and other objective sedative methods to determine the degree of sedation, rather than relying exclusively on BIS values., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Sachdeva et al.)

Study Design: Prospective cohort study., Purpose: Inflammatory cytokines produced at the site of disc herniation are considered as pain generators in patients with lumbar disc disease. Whether a high-sensitivity C-reactive protein (hs-CRP) assay can be used in order to predict the quantum of inflammation surrounding nerve roots is a matter of investigation. This study aimed to evaluate the association of hs-CRP level and functional outcomes measured by the Modified Oswestry Low Back Pain Disability Questionnaire (MODY) before and after epidural steroid injection (ESI) in patients with lumbar disc disease., Overview of Literature: Although many studies examining the role of hs-CRP levels and lumbar pain have been published previously, the results are equivocal, and there is no clear consensus regarding which patients will benefit from an ESI., Methods: This was a prospective study, with 77 patients in the study group and 23 participants in the control group. Baseline hs-CRP levels were obtained for both groups. Study group patients received a single ESI and were subjected to detailed pre- and postprocedure evaluation using MODY scores. For this group, hs-CRP levels were measured at 1 and 2 months after injection., Results: Out of 77 patients, 52 had acute and 25 had chronic low back pain. Thirty-six patients with acute pain obtained significant improvement, while 16 had an insignificant response to the ESI. None of the chronic cases had a significant response. The mean baseline hs-CRP (mg/L) among the study group (29.83±10.43) was significantly higher than for the controls (10.26±2.783). The baseline hs-CRP among acute cases, where post ESI MODY score at 2 months had significant reduction, was 32.19±5.126, and those with insignificant reduction was 18.13±7.949 (p<0.001)., Conclusions: Baseline hs-CRP levels can be used to prognosticate the outcome following ESI in patients with acute lumbar disc disease, with radicular pain refractory to physiotherapy and analgesics.

Purpose: To compare the effects of three modalities of pain management i.e. SSNB (suprascapular nerve block) with NIR (non invasive rehabilitation), IAI (intra articular injection) with NIR and, NIR alone in idiopathic frozen shoulder patients., Methods: A double blinded randomized clinical trial was conducted. 60 cases of idiopathic frozen shoulder were selected and randomly divided into three treatment groups; group 1: NIR, group 2: NIR + SSNB, group 3: NIR +IAI. Range of motion, pain score and disability (SPADI: shoulder pain and disability index) score were evaluated pre-treatment and at 12 weeks follow up., Results: All three groups were homogenous and comparable regarding their age, sex ratio, pretreatment pain score, disability score and range of motion. There was significant improvement ( p  < 0.05) post treatment in all three groups with respect to pain score, disability score and range of motion. SSNB with NIR group patients demonstrated better improvement in all parameters examined, which was statistically significant in pain score, disability score and internal rotation but was statistically equivalent for total range of motion and external rotation as compared to shoulder injection group., Conclusion: SSNB in combination with non invasive rehabilitation is an effective and safe mode of treatment for idiopathic frozen shoulder. Present study also proves that SSNB with NIR is a more effective mode of treatment for idiopathic frozen shoulder as compared to NIR alone or in combination with IAI.Level of evidence: Level 1., Competing Interests: Conflict of interestThe authors declare that they have no conflict of interest., (© Indian Orthopaedics Association 2020.)

Background: Intra-articular injections of platelet-rich plasma to treat symptoms of knee osteoarthritis have been successfully used in young patients. However in most of these studies the control and test knees were present in different patients thus incorporating a large amount of bias in the results. Therefore, the present study was designed in which patients with bilateral osteoarthritis knee were included and platelet-rich plasma was administered in one knee and normal saline in another knee of same patient., Methods: 20 patients aged 30-65 years with bilateral osteoarthritis knees (ASA class I and II) of either gender were included in the study. Patients were randomized to receive platelet-rich plasma and normal saline in one of the two knees. The primary outcome was VAS and WOMAC score at 6months after procedure. The secondary outcome included changes in joint stiffness, physical function, any adverse effects noted during the course of study., Results: The baseline VAS score in platelet-rich plasma knee was 8.4 ± 0.88 which improved significantly to 4.85 ± 2.48 (p < 0.001) at 6months as compared to normal saline knee (p = 0.017). The WOMAC pain score also improved from baseline (14.5 ± 1.3) to over 6month 7.00 ± 4.24 (p < 0.001) in platelet-rich plasma knee while in the normal saline knee, no significant change occurred from baseline to six months (10.2 ± 1.2 to 10.05 ± 1.23). There was also significant decrease in stiffness and improvement of physical activity in the platelet-rich plasma knee as compared to normal saline knee., Conclusion: The present study showed significant decrease in pain and stiffness and improvement of physical functions of knee joint with intra-articular platelet-rich plasma injection as compared to normal saline., (Copyright © 2019 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Background and Aims: The accuracy of age-, length- and weight-based formulae to predict optimal size of uncuffed tracheal tubes (TTs) in children varies widely. We determined the accuracy of age, length and weight in predicting the size of TT in Indian children, and derived and validated a formula using the best predictor., Methods: In the derivation phase, 100 children aged 1-8 years undergoing general anaesthesia and tracheal intubation with an uncuffed tube were prospectively studied. The correct size of the TT used was confirmed using the leak test. A bootstrap resampling procedure was used to estimate the accuracy of the predictors (age, weight, or length alone; length and age; length and weight; and length, weight and age). The best predictor was used to derive a formula (Paediatric Tube Size Predictor, PTSP) to calculate the size of TT. The accuracy of PTSP was tested in 150 children of the same age group in the validation phase., Results: Length (L (in meters), R 2 = 0.61) was the best single predictor of the size of TT and was used to derive the PTSP as internal diameter = 3L + 2.5. In the validation phase, the PTSP predicted the size of TT correctly in 75% of children. Re-intubation was associated with a higher incidence of respiratory morbidity than one-time tracheal intubation., Conclusion: Length of the child predicts the size of an uncuffed TT better than age and weight. The PTSP formula based on length correctly predicts the size of uncuffed TT in 75% of children., Competing Interests: There are no conflicts of interest.

Background and Objectives: Inadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound-guided adductor canal block with ropivacaine alone and ropivacaine with clonidine., Methods: A prospective randomized double blinded study was conducted including sixty-three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S - control group received adductor canal block with 30mL saline, Group R - ropivacaine group received adductor canal block with 30mL of 0.375% ropivacaine and Group RC - clonidine group received adductor canal block with 30mL of 0.375% ropivacaine with clonidine 1μg.kg -1 . The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting., Results: The mean pain free periods were 20min, 384.76min and 558.09min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p < 0.001). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement., Conclusion: Addition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement, and rescue analgesic requirement, did not differ., (Copyright © 2018. Publicado por Elsevier Editora Ltda.)

Background: The management of glossopharyngeal neuralgia due to oropharyngeal carcinoma is particularly difficult because of rich innervations of the area, erosive nature of neoplasm and dynamic pain evoked by the functional movements like swallowing and chewing. Few case reports have shown the efficacy of pulsed radiofrequency (PRF) treatment in primary and secondary glossopharyngeal neuralgia in non-cancer patients. However, the efficacy of PRF ablation of the glossopharyngeal nerve in oral cancer patients is not known., Objectives: This study was conducted to evaluate the efficacy and safety of PRF ablation of the glossopharyngeal nerve for the management of oropharyngeal cancer pain involving the base of the tongue, tonsillar fossa, and oropharynx., Study Design: Prospective interventional clinical trial., Setting: Tertiary care hospital and medical education and research institute., Methods: A total of 25 adult patients suffering from oropharyngeal carcinoma, complaining of severe pain in the area mainly supplied by glossopharyngeal nerve, were included. The patients underwent fluoroscopy-guided PRF ablation of the glossopharyngeal nerve of the affected site 3 times at 42°C temperature for 120 seconds with 22-gauge, 10 cm long, 5 mm active tip radiofrequency needle. They were followed up for one year for pain relief, nausea-vomiting and sleep disturbances. The treatment was considered effective if there was 50% reduction in pain score at 2 weeks., Results: There was significant reduction in the overall pain score including site specific pain, odynophagia and ear pain after radiofrequency ablation (P < 0.0001) in all the patients. This was associated with decreased opioid consumption (P < 0.001), lesser nausea/vomiting, and improved sleep. The treatment was effective in 23 out of 25 patients (92%) for more than 3 months. No major complication was observed in any patient. The average duration of effective pain relief was 5 to 9 months., Limitations: Patients having bilateral glossopharyngeal neuralgia or an advanced stage of oral cancer with large lymph nodes at the angle of mandible were not included. This study was a single-center observational clinical trial and further multi-center, randomized, controlled trails are needed to obtain higher level of evidence., Conclusion: Our results showed that PRF ablation can be used effectively and safely for the treatment of glossopharyngeal neuralgia secondary to oropharyngeal carcinoma., Key Words: Glossopharyngeal neuralgia, ear pain, odynophagia, oral cancer pain, pulsed radiofrequency ablation, side effects.

Background: Epidural steroids injections (ESI) are frequently used to treat lumbar radicular pain. Although different volume have been used for interlaminar ESI in adults, there is no controlled trial comparing the effect of different volumes on pain relief for the same dose of steroid ., Objective: To compare the effect of increase in volume of epidural drug on pain relief in lumbar ESI., Study Design: Randomized double blind trial SETTING: Pain OR of a tertiary care centre METHODS: Sixty patients were randomly allocated to 1 of 3 groups: Group A (4 mL), Group B (6 mL), and Group C (8 mL). Pain was evaluated using visual analog scale (VAS) and improvement in disability using modified Oswestry Disability Questionnaire scores (MODQS) at 2, 4, 8, 12, and 24 weeks. Patients having less than 50% pain relief from baseline received an additional epidural injection of the same volume with a maximum of 3 injections at least 15 days apart. The primary objective of the study was incidence of patients attaining more than 50% pain relief at 6 months. Secondary outcome included MODQS and pattern of spread of iodinated contrast on fluoroscopy., Results: At the end of 6 months, there was no significant difference in the effective pain relief between the 3 groups (Group A-16/22 (72.7%), Group B-15/20 (75%), Group C-13/18 (72.2%); P = 0.98, chi- square test). All groups demonstrated a significant reduction in mean VAS scores. There was no significant intergroup difference in VAS sores and MODQS at all the time intervals. The pattern of contrast spread did not differ between the 3 groups., Limitation: Not a placebo controlled trial., Conclusions: An increase in volume of the injectate from 4 mL to 8 mL did not increase the efficacy of interlaminar ESI., Key Words: Epidural steroid, volume, low back pain, interlaminar.

Background: Despite widespread use of steroids to treat sacroiliac joint (SIJ) pain, their duration of pain reduction is short. Platelet-rich plasma (PRP) can potentially enhance tissue healing and may have a longer-lasting effect on pain., Objectives: To assess the efficacy and safety of PRP compared with methylprednisolone in ultrasound-guided SIJ injection for low back pain., Study Design: Prospective randomized open blinded end point (PROBE) study., Methods: Forty patients with chronic low back pain diagnosed with SIJ pathology were randomly allocated into 2 groups. Group S received 1.5 mL of methylprednisolone (40 mg/mL) and 1.5 mL of 2% lidocaine with 0.5 mL of saline, while Group P received 3 mL of leukocyte-free PRP with 0.5 mL of calcium chloride into ultrasound-guided SIJ injection. Visual analog scale (VAS) scores, Modified Oswestry Disability Questionnaire (MODQ) scores, Short Form (SF-12) Health Survey scores, and complications (if any) were evaluated at 2 weeks, 4 weeks, 6 weeks, and 3 months., Results: Intensity of pain was significantly lower in Group P at 6 weeks (median [interquartile range (IQR)] = 1 [1 to 1] vs. 3.5 [2 to 5]; P = 0.0004) and 3 months (Median [IQR] = 1 [1 to 3] vs. 5 [3 to 5]; P = 0.0002) as compared to Group S. The efficacy of steroid injection was reduced to only 25% at 3 months in Group S, while it was 90% in Group P. A strong association was observed in patients receiving PRP and showing a reduction of VAS ≥ 50% from baseline when other factors were controlled. The MODQ and SF-12 scores were improved initially for up to 4 weeks but deteriorated further at 3 months in Group S, while both the scores improved gradually for up to 3 months in Group P., Conclusion: The intra-articular PRP injection is an effective treatment modality in low back pain involving SIJ., (© 2016 World Institute of Pain.)

Background: Early recovery from anesthesia and avoidance of analgesics with respiratory depressant properties are vital for maintenance of extubated airway in cervical spine surgeries. The current study investigated the role of dexmedetomidine as an anesthetic sparing agent and as a sole postoperative analgesic in these cases., Materials and Methods: Sixty adult patients undergoing cervical spine surgeries were randomized into 2 groups. Group D received intravenous dexmedetomidine infusion 0.5 μg/kg/h throughout the surgery after a loading dose of 1 μg/kg over 10 minutes. Postoperatively, dexmedetomidine infusion was continued at 0.2 μg/kg/h for 24 hours. Group C received a volume-matched bolus and infusion of 0.9% saline. Intraoperative anesthetic requirement, time to recovery, and discharge were recorded. Patients were observed for rescue analgesic requirements for 24 hours after surgery. Hemodynamic stability, sedation scores, and pain scores were assessed for 48 hours after surgery., Results: There was significant reduction in intraoperative anesthetic requirement in group D (P<0.001). Although sedation scores and recovery criteria were comparable, pain scores were significantly lower in group D compared with group C for first 24 hours postoperatively at all corresponding times. The mean pain-free period after surgery was significantly longer in group D (1460.67±517.16 min) with significantly less rescue analgesic requirement during 24-hour postoperative period (P=0.018) compared with group C (98.17±81.20 min). Hemodynamic parameters were maintained within clinically normal range during study period., Conclusions: Dexmedetomidine lowered the anesthetic requirement with clinically permissible hemodynamic variations without undue prolongation of recovery time. Postoperative dexmedetomidine infusion provided effective analgesia without excessive sedation in patients undergoing cervical spine surgeries.

Introduction: In spite of three decades of neuroimaging, we are unable to find consistent and coherent anatomical or pathophysiological basis for autism as changes are subtle and there are no studies from India., Aim: To study the regional cerebral glucose metabolism in children with autism using positron emission tomography (PET) scan and to study the behavior and cognitive functioning among them., Materials and Methods: Ten subjects (8-19 years) meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for autism were evaluated on Childhood Autism Rating Scale (CARS), trail making test (TMT) A and B, Wisconsin card sorting test, Raven's progressive matrices, and PET scan. A control group of 15 matched subjects without any brain pathology or neurological disorder was similarly studied., Results: Four out of the ten patients with autism had abnormal PET scan findings, and in contrast, none of the patients in the control group had abnormal PET scan. Of the four patients with abnormality in the PET scan, two patients had findings suggestive of hypometabolism in cerebellum bilaterally; one patient showed bilateral hypometabolism in anterior temporal cortices and cerebellum, and the fourth patient had hypermetabolism in the bilateral frontal cortices and medial occipital cortices. Subjects with autism performed poorly on neuropsychological testing. Patients with abnormal PET scan findings had significantly higher scores on the "body use" domain of CARS indicating more stereotypy., Conclusion: Findings of this study support the view of altered brain functioning in subjects with autism., Competing Interests: There are no conflicts of interest.

Background: No randomized controlled trial demonstrates the efficacy of erythromycin or metoclopramide in patients with traumatic brain injury (TBI). This study was conducted to determine the efficacy of metoclopramide and erythromycin for improving gastric aspirate volume (GAV) in patients with TBI., Materials and Methods: Patients with Glasgow coma score more than 5 admitted to trauma Intensive Care Unit within 72 h of head injury were assessed for eligibility. 115 patients were prospectively randomized to receive metoclopramide, erythromycin, or placebo eighth hourly. Gastric feeding intolerance was defined as GAV more than 150 ml with abdominal symptoms. Two consecutive high GAV was defined as feeding failure. Feeding failure was treated by increasing the frequency of dose to 6 hourly in metoclopramide and erythromycin group. Combination therapy with both drugs was given as rescue in the placebo group., Results: Incidence of high GAV was as high as 60.5% in placebo group. Use of erythromycin was associated with a decrease in the incidence of feeding intolerance to 28.9% (P = 0.006). Although feed intolerance decreased to 43.6% in metoclopramide group, values did not reach statistical significance. The proportion of patients not having high GAV at different days were significantly higher in erythromycin group (P = 0.027, log-rank test). There was no difference in the proportion of patients not having feeding failure in three groups with increasing number of days., Conclusion: There was a significant decrease in the incidence of high GAV with the use of erythromycin when compared to metoclopramide and placebo.

Background: High doses of opioids are frequently used to treat postoperative pain after spine surgery. This leads to opioid-related side effects like nausea, vomiting, respiratory depression, etc. The current study is an attempt to find a safe analgesic adjuvant, which will afford opioid sparing property., Method: Sixty-six patients undergoing spine surgery were randomized into 1 of the 3 groups-group K (ketamine bolus 0.25 mg/kg followed by infusion of 0.25 mg/kg/h with midazolam bolus 10 μg/kg and infusion of 10 μg/kg/h mixed in the same infusion pump), group D (dexmedetomidine bolus 0.5 μg/kg followed by 0.3 μg/kg/h infusion), and group C (normal saline). Study drugs were started in the postoperative period and continued for 24 hours. Pain-free period, pain scores, rescue analgesic (morphine) requirements, and side effects were noted for 48 hours postoperatively., Result: Mean pain-free periods in the ketamine group (860 min) and the dexmedetomidine group (580 min) were longer than in the saline group (265 min) (P<0.002) during the observation period of 48 hours. There was a significant decrease in the rescue analgesic requirement in both ketamine and dexmedetomidine group (P<0.05) (cumulative morphine requirement at 24 h-group C 15.64±9.31 mg, group D 6.89±5.88 mg, group K 2.45±2.06 mg; at 48 h-group C 21.09±12.88 mg, group D 7.98±7.72 mg, group K 2.59±1.97 mg). Hemodynamics were maintained within normal range in all the groups. Patients in ketamine and dexmedetomidine groups were sedated, but none required assistance for maintaining airway patency. Few patients in the ketamine group had nausea, dizziness, and diplopia, but the difference was insignificant in comparison with other groups (P>0.05)., Conclusions: Infusion of low-dose ketamine and dexmedetomidine both provide good postoperative analgesia with minimal side effects. Both of the tested analgesic regimes can be used safely and effectively for postoperative pain relief in patients after spine surgery.

Background and Aims: A high percentage of patients undergoing arthroscopic repairs on day care basis complain of inadequate postoperative pain relief. Clonidine was evaluated for the best route as an adjuvant in regional anesthesia in anterior cruciate ligament (ACL) repair to prolong analgesia., Material and Methods: A prospective randomized double-blinded study was planned in a tertiary care hospital in North India in which 85 American Society of Anesthesiologists I and II patients undergoing ACL repair were enrolled. All groups received 0.5% hyperbaric bupivacaine intrathecally as in control group C. Group IT received intrathecal 1 μg/kg of clonidine along with hyperbaric bupivacaine, group IA received 0.25% bupivacaine and 1 μg/kg clonidine intra-articularly, and group NB received 0.25% bupivacaine and 1 μg/kg clonidine in femoro-sciatic nerve block (FSNB). Postoperative pain free interval and block characteristics were the primary outcomes studied., Results: Pain-free duration was 546.90 (±93.66) min in group NB (P < 0.001) in comparison to 234.90 (±20.99), 367.80 (±47.40) and 172.20 (±54.82) min in groups IA, IT and C, respectively. Sensory block and motor blockade in NB were 474.90 (±43.80) and 267.40 (±34.59) min, respectively, and were significantly prolonged (P > 0.001) in comparison to other groups. The mean rescue analgesic requirement and cumulative frequency of rescue analgesia were least in group NB, followed by groups IT, IA and C., Conclusion: Clonidine is safe and effective adjuvant with bupivacaine in prolonging analgesia through various routes employed for post knee surgery pain. The maximum prolongation of analgesia is achieved through FSNB with a risk of prolonging postanesthesia care unit stay.

Detailed knowledge of variations of the infraorbital foramen (IOF) and the establishment of a constant reference point for needle insertion are important for safe and successful regional block and for avoiding iatrogenic injury to the nerve during surgery in the midfacial region. Infraorbital foramina from 133 sides of 67 dry intact adult skulls of undetermined gender were examined for variations in shape, number, location in relation to bony landmarks, and relationship to the maxillary teeth. The angles of needle insertion in the sagittal and Frankfurt planes were determined. The infraorbital foramina were located at an average distance of 6.33 ± 1.39 mm below the infraorbital margin, 25.69 ± 2.37 mm from the median plane, 15.19 ± 1.70 mm from the lateral margin of the piriform aperture, and 28.41 ± 2.82 mm above the maxillary alveolar border. The average angles of needle insertion through the IOF with the sagittal and Frankfurt planes were 21.14° ± 10.10° and 31.79° ± 7.68°, respectively. Multiple foramina were found in 21% of the hemi-skulls. The foramen was less than 2 mm in size in 23.31% of the hemi-skulls. The position of the IOF with respect to the maxillary teeth varied from the interval between the canine and first premolar to the first molar, but in half of the specimens it lay in line with the second maxillary premolar tooth. The observations made in this study should be useful for planning infraorbital nerve block or surgery around the IOF., (© 2015 Wiley Periodicals, Inc.)

Study Design: Prospective randomized pilot study., Objective: Evaluation of the efficacy of epidural perineural injection of autologous conditioned serum (ACS) versus methylprednisone (MPS) in unilateral cervical radiculopathy patients., Summary of Background Data: Cervical radiculopathy is often treated by nonoperative and operative means. Guided injections of steroids have been used previously. We used ACS, an orthobiologic derived from patients' own blood in patients of unilateral cervical radiculopathy., Methods: Forty patients were equally allocated into ACS and MPS groups and were injected with 2.5 to 3 mL of ACS or MPS, respectively, under image guidance into the perineural area of the affected nerve root. They were followed up for 6 months with visual analogue scale for pain, neck pain disability scale in Hindi language, neck disability index, and Short Form of Health Survey-12 (SF-12)., Results: Patients who had received injections of ACS and MPS both had improvements in the scores of the evaluation tools. The improvement in the ACS patients was gradual and sustained during the entire study period whereas that in the MPS group had some deterioration over time. No major complications were noted among the 2 groups. Minor complications were noted in both the groups., Conclusion: ACS can be considered an equally good or better modality of nonoperative management in patients of unilateral cervical radiculopathy as MPS. The safety profile is good and the improvement seen is sustained over time. Thus, it may be offered to affected patients before offering them surgery., Level of Evidence: 2.

Background: Epidural injections (EI) are the most commonly performed minimally invasive intervention to manage chronic low back pain (CLBP) with lumbosacral radicular pain (LRP). Local anesthetic (LA) and/or steroids are frequently used injectates for EI and are reported with variable effectiveness. The majority of earlier studies have used either caudal, transforaminal (TF), or undefined interlaminar approaches for EI. The parasaggital interlaminar (PIL) approach route is reported to have good ventral epidural spread and comparable effectiveness to the TF route. However, there is a lack of head-to-head comparative effectiveness research of LA with or without steroid for managing CLBP with LRP using a PIL approach., Objective: To compare the effectiveness of EI of LA alone and LA with steroid using a PIL approach for managing CLBP with LRP., Study Design: Randomized, double blind, active control one year follow-up study., Setting: Interventional pain management clinic in a tertiary care center in India., Methods: Sixty-nine patients were randomized to receive fluoroscopic guided EI of either 8 mL of 0.5% lidocaine (group L, n = 34) or 6 mL of 0.5% lidocaine mixed with 80 mg (2 mL) of methylprednisolone acetate (group LS, n = 35). Patients were evaluated for pain intensity using 0 - 10 numerical rating scale (NRS) and functional disability using Modified Oswestry Disability Questionnaire (MODQ) at baseline; and 2 weeks, one, 2, 3, 6, 9, and 12 months after injection. Patients with inefficacy with the initial injection or response deterioration received an additional injection of the same injectate and dose. Patients were evaluated for achieving effective pain relief (EPR, i.e., ≥ 50% from baseline), overall NRS and MODQ, number of injections, and presence of ventral and perineural spread over one year follow-up. Primary outcome was proportion of patients achieving EPR at 3 months., Results: A significantly higher proportion of patients achieved EPR at 3 months in group LS [30 (86%, 90% CI 73% - 93%)] as compared to group L [17 (50%, 90% CI 36% - 64%)] (P = 0.02). Similar results were obtained at 6, 9, and 12 months, respectively. The probability of achieving EPR was significantly higher in group LS at various time-points during the one year follow-up as compared to group L (P = 0.01) A significant reduction in NRS and improvement in MODQ were observed at all time-points post-intervention compared to baseline (P < 0.001) in both groups. NRS and MODQ scores were significantly lower in group LS as compared to group L at all time intervals post baseline. On average patients in group L received 2.0 (0.85) and group LS received 1.7 (0.71) injections annually (P = 0.07). Ventral epidural spread was comparable in both groups (97%). No major complications were encountered in either group; however, intravascular spread of contrast was noted during 2 injections (one in each group) requiring relocation., Limitations: A single center study, lack of documentation of adjuvant therapies like individual analgesic medication, and lack of placebo group., Conclusions: Using a PIL approach and the addition of steroid to LA for EI may provide superior effectiveness in terms of extent and duration of pain relief for managing CLBP with unilateral LRP, even though, local anesthetic alone also was effective., Trial Registration: CTRI/2014/04/004572

Aims: To compare the efficacy, complications, cost analysis and hospital stay between two methods of drainage of the kidney: double J (DJ) stent versus nephrostomy tube following open pyeloplasty for ureteropelvic junction obstruction hydronephrosis., Patients and Methods: This was a prospective randomized study of 20 patients in each group over 14 months. Pre and post-operative (3 months) function and drainage were assessed by ethylenedicysteine scan and intravenous urogram., Results: Both groups showed similar good improvement in function and drainage. Nephrostomy group had significantly longer hospital stay (P < 0.001) but incurred less cost. Complications with nephrostomy included tube breakage (n = 1) and urine leak after tube removal (n = 2). DJ stents were associated with stent migration (n = 4), increased frequency of micturition (n = 9), dysuria (n = 4) and urinary tract infection (n = 1)., Conclusion: Both methods of drainage did not interfere with improvement after pyeloplasty. Minor complications were more with DJ stent (P = 0.0003). Although overall cost of treatment was more with stents, they reduced length of hospital stay. Optimal length of stent is essential to reduce complications secondary to migration and bladder irritation.

Introduction: Aim of sedation during pediatric urodynamic studies (UDS) is a calm and cooperative child while not affecting measurements. We compared the effectiveness of midazolam to low-dose ketamine infusion for sedation and their impact on urodynamics., Materials and Methods: ASA-I children undergoing UDS were randomly assigned to group K (ketamine) loading dose (0.25 mg·kg(-1)) followed by infusion of 10-20 μg·kg(-1) ·min(-1) or group M (midazolam) loading dose of (0.02 mg·kg(-1)) followed by 1-2 μg·kg(-1) ·min(-1). The sedation scores and reactivity to catheterization were monitored by Children Hospital of Wisconsin Sedation Scale and Frankl Behavior Rating Scale, respectively. The UDS included two-channel filling cystometry in supine position followed by a free uroflowmetry in sitting position. The UDS was performed and interpreted in accordance with good urodynamic practice guidelines of International Continence Society (2002)., Results: A total of 34 children were enrolled. Group K children (n = 17) attained sedation earlier 6.80 (±3.36) min vs. 9.40 (±2.82) min; (P = 0.03) than group M (n = 17) and also recovered earlier 11.60 (±3.13) min vs. 19.67 (±5.49) min (P = 0.01). Reactivity scores during urinary and rectal catheterization were lower in group K (P = 0.03 and 0.01), respectively. Historical UDS data of 21 participants were available for comparison with effect of medication. None of the study drugs affected UDS parameters significantly., Conclusions: Midazolam or low-dose ketamine provide satisfactory sedation during pediatric UDS without impacting urodynamic values., (© 2012 Blackwell Publishing Ltd.)

This randomised, double-blind study was designed to compare the duration of analgesia and adverse effects following intrathecal administration of dexmedetomidine or clonidine, both with bupivacaine, in trauma patients. Ninety adult trauma patients of American Society of Anesthesiologists physical status I-II, scheduled for lower limb surgery under subarachnoid block, were randomly allocated to one of three groups. All groups received hyperbaric bupivacaine 0.5% 3 ml, to which was added saline 0.5 ml (Group B): clonidine 50 µg (Group C) or dexmedetomidine 5 µg (Group D). The onset and duration of sensory and motor blockade, severity of postoperative pain, time to first rescue analgesia and total analgesic requirement for 24 hours were noted. There was no significant difference in the onset time of the block but the duration of sensory and motor blockade was prolonged in Groups C and D, compared with Group B. The time to analgesia was significantly prolonged in Group D (824±244 minutes) compared with Group C (678±178 minutes; P=0.01), the latter being longer than Group B (406±119 minutes; P=0.0001). Postoperative pain scores were lower in Groups C and D compared with group b. The requirement for rescue analgesia during the first 24 postoperative hours was significantly less in Groups C and D as compared to Group B (P=0.0001), but comparable between Groups C and D (P=0.203). In conclusion, dexmedetomidine 5 µg added to intrathecal bupivacaine 15 mg produces longer postoperative analgesia than clonidine 50 µg among trauma patients undergoing lower limb surgery.

Background: This was a prospective observational study carried out to objectively assess the effect of shunt surgery on intestinal morphology and function in patients with extrahepatic portal vein obstruction (EHPVO) and correlate it with growth improvement., Patients and Methods: Twenty patients who were operated upon for EHPVO were divided into two groups for the purpose of analysis depending on the outcome of surgery: group A--patients who underwent successful shunt surgery (n=14) and group B--patients who underwent splenectomy with devascularization (n=1) and those with thrombosed shunts (n=5). The patient groups were created on the basis of the type and outcome of the surgery and not prospective stratification. Growth parameters, endoscopy findings, duodenal histology, brush border enzyme activity, urinary D-xylose levels, fecal steatocrit, fecal α-1 antitrypsin, serum growth hormone and insulin-like growth factor-1 levels, and quality-of-life scores were assessed before surgery and at a mean of 24.9 weeks after surgery., Results: There was no significant difference between the preoperative and postoperative duodenal histology. Preoperative brush border lactase activity was significantly lower than normal and did not change significantly after surgery. EHPVO did not affect intestinal absorption or permeability. Shunt surgery resulted in significantly improved z scores for height after surgery as well as quality of life. There was no significant growth hormone resistance., Conclusion: Our patients did not have any significant malabsorption or abnormality in small intestinal structure and function when compared with established normal levels. There was no significant change in the above parameters after shunt surgery, although an improvement in growth was observed. Thus, factors other than enteropathy or other lesser known enteral factors seem to be responsible for the growth retardation observed in EHPVO and its subsequent improvement after shunt surgery.

Background and Purpose: Optical internal urethrotomy is the most commonly performed procedure for the management of anterior urethral stricture. This study was performed to compare the safety and efficacy of spongiosum block along with intraurethral lignocaine with intraurethral lignocaine alone for optical internal urethrotomy., Patients and Methods: Fifty patients with anterior urethral stricture were prospectively randomized to undergo optical internal urethrotomy under spongiosum block along with intraurethral lignocaine (group 1=25 patients) and intraurethral lignocaine only (group 2=25 patients). The procedure-related pain was noted using the visual analogue scale. Postprocedure evaluation was performed by uroflowmetry and urethral calibration. Retrograde urethrography and micturating cystourethrography were performed as needed., Results: Optical internal urethrotomy was successfully completed in all patients. The mean visual analogue score for pain in group 1 (1.5 ± 1.4) was significantly lower than the score in group 2 (2.7 ± 1.8) (P=0.006). At 6 months follow-up, recurrent strictures developed in three patients in group 1 and five patients in group 2., Conclusions: Spongiosum block with intraurethral lignocaine has a better anesthetic effect than intraurethral lignocaine alone for performing optical internal urethrotomy. Spongiosum block with intraurethral lignocaine is a viable alternative for regional and general anesthesia in the management of anterior urethral stricture with optical internal urethrotomy.

Purpose: The caudal epidural space is a popular site for analgesia in pediatrics. High variation in blind needle placement is common during caudal epidurals, increasing the risk of intravascular and intrathecal spread. Knowledge of safe distances and angles for accessing the caudal epidural space in premature infants can improve the safety of caudal epidural blocks., Methods: Thirty-nine fetuses with crown-heel length between 33 and 50 cm, corresponding to gestational age of 7-9 months, were included. The dorsal surface of the sacrum from the fourth lumbar vertebra to the tip of the coccyx was dissected, following which measurements were taken on dorsal surface and midsagittal sections. The angle of depression of the needle was measured using a goniometer following the two-step method of needle insertion., Results: Right and left sacral cornua were palpable in 23 of 39 fetuses (58.97%). Termination of dural sac was at S2 in most of the fetuses (53.84%), whereas the apex of the sacral hiatus was at S3 in most (58.97%). The distance from the apex of the hiatus to the termination of dura ranged from 3 to 13 mm; the anteroposterior distance of the canal at the apex of the hiatus ranged from 1.72 to 4.38 mm. All sacral parameters correlated with crown-heel length except inter-cornual distance, depth of canal at hiatus, and height of sacral hiatus., Conclusion: Distances and angles for accessing the caudal epidural space in fetuses do not provide all parameters for safe performance of caudal epidural blocks in premature and low birth weight infants because the apex of the sacral hiatus and the termination of the dura show wide variation in location.

Anatomical variations of the brachial plexus may be important in regional anesthesia and upper limb procedures. A fused single cord of the brachial plexus, although considered rare, was discovered in 4 Indian male cadavers during the dissection of 90 brachial plexuses. All 4 cases demonstrated deviation from the usual pattern starting at the division of trunks continuing to the formation of cords. The location of these single cords was lateral to the axillary artery instead of the typical perivascular relationship. A fused single cord of brachial plexus might be more common than previously thought. The impact on the performance or success of blockade remains unknown.

The role of regional anesthetic techniques such as cervical epidural and inter-scalene brachial plexus blockade (ISB) in rehabilitated stroke patients remains uncertain. We present a case of rehabilitated stroke patient with reactive airway disease, which was managed using cervical epidural anesthesia for an above the elbow amputation. We further discuss the implications of the performance of cervical epidural anesthesia in post stroke patients.

Patients with congenital Long QT are known to have normal QT interval in symptom-free period and in the early years of life. Precipitating factors like surgical stress, interactions with anesthetic agents prolonging QT interval, and electrolyte imbalances can manifest with life threatening arrhythmias in congenital or acquired Long QT syndrome. We report a case of concealed LQTS manifesting under anesthesia and its subsequent perioperative course., (© 2011 Blackwell Publishing Ltd.)

Background: Advances in perinatal care and increased use of diagnostic and interventional procedures on foetal airway demand a clear understanding of their normal anatomy and development. This study is aimed at determining the normal dimensions of larynx, cricoid cartilage and epiglottis and their correlation to age and crown rump length (CRL)., Method: After approval from institutional ethics committee and written parental informed consent, laryngeal measurements were taken from 79 foetuses of varying CRL from 30 to 299 mm. The entire larynx from the tip of epiglottis to lowest extension of thyroid gland was isolated and preserved. In small foetuses (30-165 mm) the measurements were taken under a dissecting microscope. In foetuses above the CRL of 165 mm, the measurements were taken with help of Vernier Calliper., Results: Foetuses were analysed for dimensions based on CRL. The length of the larynx significantly increased in comparison to CRL (P < 0.001). Similar measurements were observed for transverse diameter, anteroposterior diameter and inter-cartilaginous distance of larynx, the anterior height of arch and posterior height of lamina of cricoid cartilage and the length and breadth of epiglottis. The internal anteroposterior and transverse diameter of cricoid cartilage showed no correlation with CRL., Conclusion: All the measured parameters of larynx, epiglottis and cricoid cartilage showed positive correlation with the CRL except the internal diameters of cricoid.

Background: Propofol is a popular agent for providing procedural sedation in pediatric population during lumbar puncture and spinal anesthesia. Adjuvants like clonidine and fentanyl are administered intrathecally to prolong the duration of spinal anesthesia and to provide postoperative analgesia. We studied the propofol requirement after intrathecal administration of clonidine or fentanyl in infants undergoing lower abdominal surgeries., Methods: Sixty-five ASA I infants undergoing elective lower abdominal surgery under spinal anesthesia were assigned into four groups in this prospective randomized double-blinded study. Group B received bupivacaine based on body weight (<5 kg = 0.5 mg kg(-1); 5-10 kg = 0.4 mg kg(-1)). Group BC received 1 microg kg(-1) of clonidine with bupivacaine, group BF received 1 microg kg(-1) of fentanyl with bupivacaine, and patients in group BCF received 1 microg kg(-1) each of clonidine and fentanyl with bupivacaine. A bolus of 2-3 mg kg(-1) of propofol bolus was administered for lumbar puncture. Sedation was assessed using a six-point sedation score (0-5) and a five-point reactivity score (0-4) which was based on a behavioral score. After achieving a sedation and reactivity score of 3-4, the patients were placed lateral in knee chest position and lumbar puncture performed and test drug administered. Further intraoperative sedation was maintained with an infusion of 25-50 microg kg(-1) min(-1) of propofol infusion., Results: The mean +/- SD infusion requirement of propofol decreased from 35.5 +/- 4.5 in group B to 33.4 +/- 5.4 microg kg(-1) min(-1) in group BF and further decreased to 16.7 +/- 6.2 microg kg(-1) min(-1) and 14.8 +/- 4.9 microg kg(-1) min(-1) in group BC and BCF, respectively. There were no statistically significant differences between BC and BCF groups. The mean sedation and reactivity scores were higher in groups BC and BCF when compared to groups B and BF., Conclusion: Our study show that the requirement of propofol sedation reduces with intrathecal adjuvants. The reduction was significant with the addition of clonidine and clonidine-fentanyl combination as opposed to bupivacaine alone or with fentanyl. There was no significant difference in propofol infusion requirement with the use of bupivacaine alone or with fentanyl.

Objectives: This study was designed to compare the efficacy and safety of propofol vs propofol-ketamine combination for sedation during pediatric spinal anesthesia., Methods: Forty children, aged 3-8 undergoing spinal anesthesia for lower abdominal surgeries were included. Participants were randomly assigned into two groups. Group 1 received propofol bolus of 2 mg.kg(-1) followed by an infusion of 4 mg.kg(-1).h(-1). Group 2 received a combination of 1.6 mg.kg(-1) propofol and 0.4 mg.kg(-1) ketamine followed by an infusion of 3.2 mg.kg(-1).h(-1) and 0.8 mg.kg(-1).h(-1), respectively. The infusion rate was titrated to keep the child sedated at University of Michigan Sedation Score of 3. The heart rate, blood pressure, respiratory rate and oxygen saturation were recorded every 5 min. The episodes of spontaneous body movements and requirement of supplemental sedation were recorded. The postoperative recovery was assessed by modified Aldrette score., Results: Seventeen patients in group 1 and four patients in group 2 (P < 0.001) required extra boluses of study drug to prevent movements during lumbar puncture. Four patients experienced respiratory depression and three airway obstruction in group 1 when compared to one patient each in group 2 (P < 0.05). The recovery time was similar in both groups. None of the patient had postoperative nausea/vomiting or psychomimetic reactions., Conclusions: Propofol-ketamine combination provided better quality of sedation with lesser complications than propofol alone and thus can be a good option for sedation during spinal anesthesia in children.

Background: Neostigmine is cholinomimetic and is used for postoperative analgesia. Its urodynamics effects on voiding function have not been elucidated., Materials and Methods: Adult patients without bothersome voiding symptoms planned for rigid cystoscopy under local anesthesia were enrolled. They underwent multichannel urodynamics (filling cystometry and pressure-flow study) before and 30 min after lumbar epidural administration of Neostigmine (2 microg/kg)., Results: Indications for cystoscopy were check examination for follow up of carcinoma urinary bladder (n = 3), staging for carcinoma cervix (5), and removal of ureteral stent (4). Patients' mean age was 51.9 +/- 11.7 years and international Prostatic symptom score 2.34 +/- 3.41. A trend of decreased maximum cystometric capacity (MCC) was observed after Neostigmine (413.50 +/- 142.45 ml vs. 357.00 +/- 145.62 ml; P = 0.056) without any change in end-filling pressure. Five patients developed detrusor overactivity (DO) and one had increase in its amplitude (P = 0.031). Four patients developed rhythmic rectal contractions and one had increase in its amplitude (P = 0.219). There was no difference in any of the voiding parameters. Mean Visual Analog Pain Score (VAS scale 0-10) during cystoscopy for this group was significantly lower than that in a similar group of patients who did not receive Neostigmine prior to rigid cystoscopy (1.16 +/- 0.94 vs. 4.57 +/- 1.45; P = 0.0001). The drug was well tolerated in majority of the patients., Conclusion: Epidural Neostigmine is effective in providing analgesia during diagnostic rigid cystoscopy. It leads to development of DO and decrease in bladder capacity without any effect on voiding function. These findings may help clinicians to use it for transurethral procedure-related pain relief without apprehension of voiding difficulty., ((c) 2009 Wiley-Liss, Inc.)

Infective endocarditis is uncommon during pregnancy. The difficulty in diagnosing infective endocarditis during pregnancy, may increase the likelihood of development of complications like a mycotic aneurysm of the descending thoracic aorta. We describe a case of mycotic aneurysm in the postpartum period, as sequel to delayed diagnosis; who developed pulmonary edema during its repair.