In December 2019, an outbreak of COVID-19 occurred in Wuhan, China, which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The infection became pandemic within next few weeks. The literature regarding interventional pain practice with respect to COVID-19 is scarce. But pathological and structural features of SARS-CoV-2 and SARS-CoV resemble each other and hence long-term sequelae, with respect to chronic pain, similar to severe acute respiratory syndrome (SARS) can be expected with COVID-19. Also, on literature search, we could not find any recommendations or guidelines for interventional pain practice. However, American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anesthesia and Pain Therapy (ESRA) have jointly put forth the recommendations for neuroaxial and peripheral nerve blocks for current pandemic situation. We are of opinion that with certain modifications these recommendations can be extrapolated for practice of interventional pain management. We propose the recommendations for interventional pain practice for current pandemic situation of COVID-19.

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.

Introduction: The primary objective of the present study was to assess the safety and efficacy of platelet-rich plasma (PRP) injections for management of adhesive capsulitis and compare the clinical outcome with injection of corticosteroid. Materials and methods: A total of 120 patients were randomized into PRP (group I) or steroid (group II) group. Patients were assigned to receive a single injection of 1% lidocaine with either methylprednisolone (steroid) or PRP. All patients were assessed at 1, 3, and 6 months after the index procedure. The shoulder pain and disability index (SPADI) was used to evaluate the clinical results. Data were analyzed with a paired t test. The level of significance was considered as p < 0.05. Results: The efficiency of PRP injection was better and sustained than steroid. In PRP group, mean pain scale, mean disability, and total SPADI scores were almost linearly improved, while the scores increased to a higher level at the final follow-up visit compared with that post 1 and 3 months in the steroid group (p < 0.05). No major adverse complications were noted. Conclusion: In the current randomized, single-center, prospective preliminary study, results indicate that treating adhesive capsulitis with PRP injections is safe and has the potential to reduce pain and improve the functional outcome. The PRP injection had a more prolonged efficiency than steroid injections. Clinical significance: The PRP injections are safe and valuable therapeutic modality to alleviate the symptoms in subjects with adhesive capsulitis of shoulder.

Among the techniques of epidural steroid injections, transforaminal injection allows for a concentrated application of steroids around the inflamed neural structure. The transforaminal injection technique can be performed via the subpedicular or Kambin's approach. The purpose of this article is to identify key features of anatomy of the lumbar neural foramen and to describe techniques of transforaminal epidural injection.

Platelet-rich plasma (PRP), prepared from autologous blood, is commonly used in various pathologies like hip and knee osteoarthritis, rotator cuff pathology, epicondylitis, tendinitis, fracture healing and back pain, for tissue regeneration, wound healing, scar revision, skin rejuvenating effects, and also in treatment of alopecia. It is one of the important products, which is nowadays being used by pain physicians aggressively. But, the preparation protocols vary and there are many factors that influence the composition of PRP. The aim of this review is to find the details of PRP and the standard preparation protocol, if any.

Aim: This article aims to review the currently available evidence on the ganglion impar block (GIB) and neurolysis for management of chronic pain of malignant or nonmalignant etiology. Introduction: Ganglion impar (GI) represents the fused termination of bilateral thoracolumbar sympathetic chains. It is a retroperitoneal structure, lying behind the rectum and ventral to the sacrococcygeal junction (SCJ) or coccyx. Ganglion impar provides sympathetic and nociceptive innervation to the perineum, coccyx, anus and distal urethra, rectum, vagina, and vulva. In this review, the indications, approaches, effectiveness and, complications of GIB are discussed based on the data from the current literature. Results: We screened 18 full-text studies based on our search. Out of them, 2 were randomized controlled trials (1 each on GIB for chronic intractable coccydynia and phantom rectum pain), 15 were observational (prospective or retrospective) studies, and 1 was anatomic cadaveric study. These studies included were from 2004 to till date. Our review results inferred that (1) GIB appears to be a safe and effective technique for management of pain in patients with chronic coccydynia, chronic perineal and pelvic pain, not responding to the conservative measures; (2) both anatomic location of GI and technical feasibility favor the transcoccygeal approach (Co1–Co2) as the most suitable approach followed by the transsacrococcygeal approach. Conclusion: Ganglion impar block improves pain and the quality of life in patients suffering from chronic intractable coccydynia, chronic perineal and pelvic pain of both malignant and nonmalignant etiology.

Frozen shoulder, also known as adhesive capsulitis of the shoulder joint, is a very common and well-known entity in the field of pain medicine. The shoulder joint, being one of the most important and complex joint in the human body, gives much flexibility while compromising stability. But when flexibility is reduced, it causes much trouble and discomfort. Frozen shoulder is known for years but its definition, pathology, and treatment are yet to be standardized. In this article, there will be recapitulation of the anatomy, pathogenesis of frozen shoulder, and its correlation with clinical features in different stages, plus diagnosis of adhesive capsulitis on clinical examination as well as using advanced imaging techniques, will be discussed. The current available treatment modalities for frozen shoulder are also enumerated. Although newer imaging studies like arthrography, magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and ultrasound aid the diagnosis of frozen shoulder, clinical examination with exclusion of other pathology remains the mainstay and the most cost-effective way of diagnosis. The commonest treatment modality still being physiotherapy with some interventions; operative management is done only in very selected cases as the last option. Interventions like hydrodilatation of joint capsule and intraarticular platelet-rich plasma (PRP) have a very good role in management along with physiotherapy. It is recommended that ultrasound should be used routinely for the interventions in frozen shoulder.

Objective: The purpose of this article is to understand the principles of cooled radiofrequency ablation (C-RFA) and the description of the procedure of hip CRFA. Cooled radiofrequency ablation uses a constant flow of ambient water circulated through the electrode via a peristaltic pump to maintain a lower tissue temperature by creating a heat sink, but still allowing neurolysis to occur. Cooled radiofrequency ablation lesions are spherical and project several millimeters beyond the electrode tip as compared to thermal-radiofrequency ablation (T-RFA), thereby increasing the probability of successful denervation of the target nerve. Cooled radiofrequency ablation is a preferred technique for ablation of articular branches of the hip joint. Chronic pain in the hip occurs mainly due to osteoarthritis along with other causes like rheumatoid arthritis, osteonecrosis, chronic infectious coxarthrosis, posttraumatic pain, and persistent postoperative pain following total hip arthroplasty (THA).

Background: Chronic musculoskeletal disease is one of the causes of a patient seeking help from a doctor due to the inhibition of daily activity, and hip pain is one of them.¹ Not everyone who is a candidate for an operation will choose this option.^1,2 Prolotherapy is becoming a widespread form of pain management associated with chronic tendonitis and joint degenerative arthritis. Prolotherapy then becomes an affordable cost treatment option and can be a consideration for patients who are contraindicated for surgery.^4,5 Case description: A 63-year-old female arrived complaining of right hip pain for 10 months. She began feeling the pain after motorcycle collision with the right hip crashing into the street. The pain would come and go but had been especially troubling after 2 months of accident. She noticed decreased strength and inability to abduct her right hip. The problem progressed until she could not walk without pain. The patient underwent four dextrose prolotherapy treatments at 3-week intervals. Conclusion: Prolotherapy may be an additional method and even a solution with a good prognosis for the treatment of hip chronic musculoskeletal pain. The dramatic loss of pain for the patient after a series of prolotherapy injection, and radiological parameters showed improvement, is the reason why hip prolotherapy is considered indispensable for people suffering with chronic hip pain.^1–3

Background: Myofascial pain is one of the common clinical findings in patients who present with musculoskeletal pain. The main symptom of chronic myofascial pain is ongoing or longer lasting muscle pain in areas such as the low back, neck, shoulders, and chest. You might feel the pain or the pain may get worse when you press on a trigger point. The muscle may be swollen or hard and you may hear it called a “taut band” in the muscle. Sometimes it may associate with interspinous ligaments or other systems. Case description: A 65-year-old female patient came with complaint of severe axial and left-sided chest and back pain since 2 years, which was mixed in character and of aching, burning, stabbing type, with numeric rating scale (NRS) of 8/10 and the score on pain detect tool was 18. On examination the patient had normal skin and had no scar or redness of the overlying skin. On palpation, the patient had tenderness over midline at T3-4 vertebral level and also had myofascial trigger point over left trapezius. The pain aggravated on flexion of the neck. Systemic examination was normal. Based on these findings, our provisional diagnosis was interspinous ligament sprain with myofascial trigger point. Subsequently trigger point injection of left trapezius with 1 mL lignocaine hydrochloride 2% along with injection of platelet-rich plasma 0.5 mL for T3-4 interspinous sprain was administered. Interventional procedure was done after withholding the anticoagulants (tab aspirin 75 mg and clopidogrel 75 mg) for 7 days. On follow-up visit after 1 month, the patient reported excellent pain relief with an NRS score of 1 to 2. Conclusion: Trigger point over back can cause burning numbness and tingling if it entraps a nerve and can lead to pain that emulates like pain due to cardiac problems. So a proper clinical examination must be done for every chest pain. As every chest pain is not originated from the heart, it may be myofascial in origin.

A 62-year-old man presented with chronic pain with an exacerbation for the last 15 days. His left index finger was surgically amputated and the pain was around the base of his index finger which was referred to forearm and other fingers too. A couple of years ago, he sustained an injury to the left index finger and started having pain once the wound was healed. Subsequently exploration was done to relive pain which did not reduce and for some unknown reason the finger was amputated surgically later. Although the symptoms and signs were mimicking complex regional pain syndrome (CRPS), the other possible causes for the pain such as nerve entrapment and neuromas on the course of the nerve were considered. The surgical exploration was done at the stump and multiple neuromas were found. The neuromas were removed and the wound was closed by carefully burying the nerve endings. Patient had a complete pain relief at the second postoperative day and he had been followed for the next couple of weeks.