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.

Trigeminal neuralgia (TN) is defined as sudden, usually unilateral, severe, brief, stabbing, and recurrent pain in the distribution of one or more branches of the fifth cranial nerve. The pain is generally abrupt, severe, and can pose a significant impact on the quality of life. The etiology of TN is not always clear, and therefore, treatment can be challenging and multimodal. Pharmacotherapy is generally the first-line treatment though unsuccessful in over a third of patients requiring minimally invasive modality. We report the case of a young patient with refractory and debilitating TN with failed four sessions of radiofrequency ablation (RFA) in addition to the regular use of oral medications. Our treatment included simultaneous RFA and phenol injection with complete symptomatic resolution within fortnight after intervention. In conclusion, the treatment of TN poses a clinical challenge. Although RFA or phenol injections are recognized invasive treatment modalities, we have proven that simultaneous use of both therapies at the same time is safe and effective treatment option for refractory TN with failed previous multi-modal therapy.

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.

Cervical radicular pain is often due to a combination of factors including intervertebral disc prolapse or herniation, narrowing of the intervertebral foramen, osteoarthritis of facet joints, and spondylolisthesis. Cervical Epidural with local anesthetics along with steroids is used for evaluation and management of radicular pain in patients with pathology that exists at multiple vertebral levels. Medial branch block is given for facet joint arthropathy both for diagnostic and therapeutic purposes. Therefore, the aim of performing this procedure was to provide an interlaminar epidural steroid injection at C7-T1 vertebral level along with a diagnostic right medial branch block under fluoroscopic guidance to 86 years old hypertensive female, with complaints of pain in the neck lower portion, upper part of back and shoulder on the right side, radiating down the arm up to medial two fingers and thumb for 2 years. An interlaminar epidural steroid injection was planned on the right side at the C7-T1 vertebral level under C-arm guidance. A diagnostic right medial branch block was also planned to be given on the same day at 2 levels C5/C6 and C6/C7 facet joint each using 2 mg dexamethasone (0.5 ml) and 1.5 ml of 1% lignocaine. A repeat epidural injection was given using a combination of 1 ml of steroid dexamethasone (4 mg) and 3 ml of 1% lignocaine along with facet medial branch block injection at the same levels using 0.5% bupivacaine 1.5 ml and 2 mg dexamethasone (0.5 ml) on her follow-up visit after 6 weeks. Following the block patient on her first visit, she had considerable pain relief with a visual analog scale (VAS) of 3. She was prescribed gabapentin, methyl-cobalamine and clonazepam. After 6 weeks, the patient had VAS score of 6. She looked comfortable and her paresthesia had grossly improved. At the end of the procedure, patient had good pain relief with no deficit. She was advised to continue gabapentin. On her third follow-up after 3 months, the patient presented with >70% relief in her initial pain with a VAS of <3 and minimal paresthesia along the distribution of the ulnar nerve and hence required no intervention. Cervical epidural steroid injections under fluoroscopy guidance are being used for the conservative management of neck pain or cervical radiculopathy. Facet joint injections and medial branch blocks aim to diagnose and treat the pain arising from facet joints in the spine. It is also important to prescribe drugs to manage the neuropathic component of the pain.

Spinal accessory nerve entrapment is difficult to diagnose due to its overlapping clinical features with other common diseases and nerve entrapments. It severely affects the life of an individual as normal neuronal physiology of the nerve is important for proper functioning and stability of the shoulder girdle. The patient develops symptoms like pain over the shoulder and neck, drooping of the shoulder, and weakness of overhead abduction of the arm. Ultrasound-guided block of this nerve has been described in the literature, but hydro-dissection using ultrasound as treatment has not been described yet. We have reported a case of spinal accessory nerve entrapment following sebaceous cyst excision in the posterior neck which was diagnosed clinically and confirmed using ultrasound-guided block and managed simultaneously by hydro-dissection. A case of 56 years female who underwent sebaceous cyst excision in the posterior triangle of the neck on the right side in May 2016. After 6 weeks of surgery, the patient developed pain in the right shoulder and gradually developed weakness in the overhead abduction of the arm. She went from one hospital to another for her pain relief but her pain remained undiagnosed and untreated. She came to Daradia Pain Hospital with complaint of pain in her right shoulder.