Intraarticular (IA) local anesthetics and opioids are often used for the management and prevention of pain after arthroscopic anterior cruciate ligament (ACL) reconstruction. In this study, analgesic efficacy of IA administration of equipotent dose of morphine and fentanyl with bupivacaine and bupivacaine alone in arthroscopic ACL reconstruction under spinal anesthesia has been compared. Forty-five patients, aged between 15 and 55 years, of American Society of Anesthesiologists (ASA) grade I and II were assigned into three equal groups (n = 15) in a randomized double-blind protocol. Group B received 20 mL of 0.25% bupivacaine and 1 mL normal saline (NS); group BF received 20 mL of 0.25% bupivacaine and 50 μg (1 mL) fentanyl; and group BM received 20 mL of 0.25% bupivacaine and 5 mg (0.5 mL) morphine and 0.5 mL NS through IA route at the end of the procedure. Postoperative analgesia was assessed by visual analogue scale (VAS) score. The VAS score in BM group was less during all the time in the postoperative period compared with the other two groups. This group also experienced longer duration of postoperative analgesia and lesser rescue analgesic. Intraarticular administration of morphine and bupivacaine is safe and provides prolonged analgesia with minimal side effects compared with bupivacaine and fentanyl and bupivacaine alone.

Introduction: Ozone disk nucleolysis is a nonsurgical percutaneous procedure for the treatment of discogenic sciatica, and published success rates of ozone disk nucleolysis vary significantly. This study assesses the outcome difference between two treatment modalities among patients with discogenic sciatica secondary to a herniated disk in Bangladesh: Intradiscal ozone injection and combination therapy with intradiscal ozone and transforaminal triamcinolone and bupivacaine injection. Materials and methods: Prospectively recruited 50 patients (group I) received intradiscal injections of an oxygen–ozone mixture and 150 patients (group II) received identical oxygen–ozone injections, followed by transforaminal triamcinolone 20 mg in 2 mL of 0.25% bupivacaine, in relevant foramen. Discography was noted for each case. All patients underwent follow-up examinations at 1-week, 1-month, and 6-month time points. Clinical outcome was evaluated by using the verbal rating scale (VRS) and modified Macnab method. Results: According to the modified Macnab method, group II showed “excellent and good” result of about 97, 90, and 88% in 1-week, 1-month and 6-month time points respectively, whereas group I showed 70, 70, and 68% at the same time point. The difference is significant in each time point. Groups I and II demonstrated similar VRS scores prior to intervention,but patients in group II had significantly better VRS pain scores at all three time points. Conclusion: A combination of transforaminal triamcinolone and local anesthetic with intradiscal ozone provides clearly superior outcomes when compared with ozone therapy alone in discogenic sciatica.

Aim: The objective of Chronic Pain Challenge project is designing and construction of a machine-learning system to calculate the dynamic changes to the chronic pain risk score of an individual based on various weighted health behaviors. Materials and methods: The visual analog scale (VAS) and Oswestry Disability Index (ODI) ratings of 218 subjects were studied for dynamic changes based on three weighted health behaviors, physical exercise, nutrition, and depression in order to predict their individual and cumulative impact on severity of chronic pain. The predictive function was used to produce confidence and prediction intervals for the calculation of new VAS and ODI scores using supervised and unsupervised machine-learning algorithms and R programing language for statistical computation. Results: This 9 months research study resulted in the development of innovative design and construction of a machinelearning program that accurately predicted the changes to standardized tests, such as VAS and ODI based on weighted values for depression score (DS), nutrition score (NS) and physical activity score (PAS). The testing of both extreme and moderate ranges of health behavior values in a variety of subjects and comparison against simple weightage confirmed the accuracy and validity of the program. Conclusion: Chronic Pain Challenge program is a valid and accurate method in predicting chronic pain risk of an individual based on the engagement in various health behaviors. The Chronic Pain Challenge program can predict and prevent progression of chronic pain and disability by global education and empowerment, thereby disrupting the current health care model with the emerging and accelerating technology. Clinical significance: The Chronic Pain Challenge program is an innovative statistical machine-learning program for chronic pain predictability based on individual's health behavior patterns.

Sacroiliac joint (SIJ) is third most common cause for low back pain. SIJ block is one of the common procedures done in pain clinic. Though this procedure is relatively complication free, it is technically difficult due to joint anatomy. With better knowledge of joint anatomy and needling skill, this block can be made easy and successful.

Epidemiological studies have found that 10.1 to 55.2% of people in various countries have chronic pain. Various medicines are prescribed, depending on whether the pain originates from tissue damage or is neuropathic. Evidence suggests that chronic pain from tissue inflammation or damage as in rheumatoid arthritis and cancer pain is best treated with opioids and anti-inflammatory drugs, while for neuropathic pain where pain is caused by a damaged or dysfunctional nervous system other drugs may be more effective. Chronic pain is a global concern affecting people from all walks of life. As the epidemic of opioid misuse continues to grow, the need for balanced, multimodal approaches to the treatment of pain syndromes has become more apparent. These include medications which, though originally designed to treat other pathologies, have demonstrated benefits in the treatment of chronic pain. This article is a review of the pharmacodynamics of various classes of antidepressants and anticonvulsants and the effects of these drugs on pain signaling and perception. Finally, recommendations for the use of such drugs in the patient with chronic pain are discussed.

Researchers from Johns Hopkins Hospital have reported that 40%-80% of chronic pain patients are misdiagnosed. The leading causes for these errors are a failure to take a thorough and comprehensive history from the patient, and ordering the wrong tests. Typical testing errors are the use of anatomical tests to detect the physiological phenomenon of chronic pain, and a failure to understand the specificity and sensitivity of medical testing commonly in use.

Chronic pain is a common problem not only in adults but also in children. Though there are ample data regarding acute pain and its management in the pediatric age group, information regarding chronic pain in the pediatric population is seriously lacking. Prevalence of chronic pain in children and adolescents varies according to the study and is between 15 and 25%. Chronic pain often interferes with the child's participation in normal physical, academic, and social activities. Caregivers of children and adolescents with chronic pain suffer a great sense of burden, which affects their emotional, social, and family functioning. The problem is also exacerbated by the additional financial burden secondary to increased physician consultation and medication use. A better understanding of pain in children is needed in order to gain insight into its etiology. Management of chronic pain in this age group requires a multidisciplinary approach as in the adult population. While chronic pain is not well understood, there is emerging evidence that young people and their parents can recover from chronic disability, dependency, and distress and return to a normal life.

Aim: The aim of this study is to investigate scrambler therapy as a modality of treatment for chronic pain. Materials and methods: Four patients with chronic drugresistant severe pain were treated with scrambler therapy, a new bioengineering-based method for treating pain, especially neuropathic pain. The effectiveness of the treatment was evaluated using numeric rating score (NRS); reduction in amount of pain medications and side effects if any were also noted. Each patient was given 10 cycles (or the number of cycles required for complete pain relief) of 30 minutes duration each, and the above parameters were noted. Three of the four patients had chronic neuropathic pain, and the fourth patient had somatic (bony) pain. All of them showed more than 80% reduction in their pain scores and reduction in the consumption of pain medications.

Most of the cervical facet arthropathy cases present with neck pain with referred pain in the head and upper extremities. Tenderness to palpation over the facet joints or paraspinal muscles, accentuation of pain with cervical extension or rotation, and the absence of any neurologic deficits are the usual findings. Radicular symptoms are seldom associated with cervical facet arthropathy. We report a case of a 23-year-old female patient presented with chief complaints of neck pain radiating to entire right upper limb with weakness and numbness of that limb. Physical examination revealed limitation of range of motion of neck, painful extension and lateral rotation of neck, tenderness over C4-5 and C5-6 facet joints, and tenderness over right trapezius muscle. Weakness and numbness over hand was also present, though electromyography and nerve conduction velocity study was normal in both upper limbs. Magnetic resonance imaging (MRI) cervical spine was suggestive of mild posterior disk osteophytes at C4-5, C5-6, and C6-7 causing grade 1 cervical canal stenosis and cervical spondylosis with degenerative disk disease. Trigger point injections were given in trapezius and scalene muscle. There was not much improvement. Considering facet arthropathy as a differential diagnosis, diagnostic median branch block at C4, C5, and C6 level was done. It was positive with more than 80% pain relief. Later on, radiofrequency (RF) ablation of C4, C5, and C6 median branch was done. Pain was reduced significantly with improvement of other symptoms like weakness and numbness.

We report a case of a 50-year-old male diagnosed with fracture tibia shaft posted for open reduction internal fixation (tibial interlocking). His comorbidities included diabetes mellitus (DM), hypertension, ischemic heart disease (IHD), and chronic obstructive pulmonary disease (COPD). The surgery was successfully completed under regional anesthesia with single injection combined sciatic femoral nerve block using peripheral nerve stimulator (PNS). Regional techniques like peripheral nerve block are preferred modalities to avoid undue complication of general anesthesia and to provide adequate postoperative analgesia. It provides good intraoperative conditions with adequate postoperative analgesia with least hemodynamic alterations in high-risk cases, especially IHD.

We report a case of a 55-year-old female diagnosed with multiple gallbladder stones posted for laparoscopic cholecystectomy. Her comorbidities included obesity, diabetes, previous spinal surgery, chronic renal dysfunction with abnormal renal profile. She was also anxious about postoperative pain. The surgery was successfully completed under general anesthesia with intraperitoneal instillation of ropivacaine which was done just before creation of pneumoperitoneum, which also provided excellent postoperative analgesia, good intraoperative conditions with least hemodynamic alterations in a high-risk case where other modalities for postoperative pain relief had their own limitations.