Letters to Editor
anaphylaxis etc. Most of these conditions can be managed barring a few exceptions like this. The presence of multiple cervical abscesses (vertebral or epidural) during pre-operative examination should prompt the anesthesiologist to anticipate high risk of such complication and devise a prior strategy in consultation with the surgeons to avoid any serious mishap. Anirban Hom Choudhuri, Mritunjay Kumar Department of Anesthesiology and Intensive Care, GB Pant Hospital, New Delhi, India Address for correspondence: Dr. Anirban Hom Choudhuri, 12/203, East End Apartments, Mayur Vihar Phase 1 (extn), New Delhi - 110 096, India. E-mail: [email protected]
References 1. 2.
3.
4.
5.
Kahn JL, Bourjat P. The peripharyngeal space. Anatomy and normal imaging. J Radiol 1996;77:87-9. Ozlugedik S, Ibrahim Acar H, Apaydin N, Firat Esmer A, Tekdemir I, Elhan A, et al. Retropharyngeal space and lymph nodes: An anatomical guide for surgical dissection. Acta Otolaryngol 2005;125:1111-5. Parker GD, Harnsberger HR. Radiologic evaluation of the normal and diseased posterior cervical space. AJR Am J Roentgenol 1991;157:161-5. Wurtz R, Quader Z, Simon D, Langer B. Cervical tuberculous vertebral osteomyelitis: Case report and discussion of the literature. Clin Infect Dis 1993;16:806-8. Turgut M. Multifocal extensive spinal tuberculosis (Pott’s disease) involving cervical, thoracic and lumbar vertebrae. Br J Neurosurg 2001;15:142-6. Access this article online Quick Response Code:
Website: www.joacp.org
Second degree burns (involving the dermis) are usually associated with moderate to severe pain in the acute phase. Second degree burns during the healing phase may be complicated by hypertrophic scars (HS). Pain associated with post burn HS is caused by small fiber damage rather than large ner ve entrapments. [1] Third degree burns involving the muscles may lead post burn contractures leading to nerve entrapments. Chronic post burn may lead to peripheral and central sensitization thereby causing allodynia. Burn cases are usually associated with thermal allodynia. A wide variety of treatments are available to treat HS associated pruritus, pain, movement restriction and cosmetic disfigurement. These include intralesional corticosteroids, topical treatments, cryotherapy, surgery, radiation, silicone gel dressing and laser therapy.[2] Patient being discussed is a 25-year-old male patient who had suffered extensive burn injury due to explosion of a domestic liquefied petroleum gas cylinder [Figure 1]. The burn had occurred approximately 18 months back. The medical records of primary care revealed that the burn was 35% and grade 2. The recovery care had been performed at a local district hospital. The later part of recovery was complicated by development of HS with associated burning pain. Patient presented to us with severe burning pain in the HS. The pain was worse particularly in the summers and relatively better in the winters. Application of menthol talc decreased the symptoms for some time. Due to the severe thermal (warm) and dynamic mechanical (brush) allodynia the patient was unable to wear clothes over the affected part. The chronic pain had rendered the patient jobless, highly irritable, sleepless and depressed. The DN4 score at presentation was 5/10
DOI: 10.4103/0970-9185.125720
An effective pharmacological management of postburn hypertrophic scar pain Sir, The pain associated with burn injuries is intense, unremitting, chronic and often debilitating.
Figure 1: Patient with extensive post burn hypertrophic scar
Journal of Anaesthesiology Clinical Pharmacology | January-March 2014 | Vol 30 | Issue 1
111
Letters to Editor
and pain on the visual analog scale (VAS) varied between 30 and 70/100. Physical examination revealed extensive HS over the burnt area. The sensations over the affected area were normal without any static mechanical allodynia (allodynia to touch and pressure). The scar was too extensive to consider any local therapy (e.g., steroid infiltration within the scar). The cosmetic deformity was not an issue for the patient so a decision to start systemic therapy with tablet pregabalin and amitriptyline was made. Pregabalin was advised 75 mg in the night for 3 days and then twice a day thereafter. Amitriptyline was advised in the dose of 10 mg in the night for 1 week followed by 25 mg thereafter. Patient was kept on a fortnightly follow-up. Patient showed a significant improvement in symptoms within 5 days with progressive improvement in symptoms as the treatment proceeded. At 3 months since the start of treatment patient has shown progressive improvement and is now pursuing his occupation and has started socializing with friends. His sleep has normalized and he is much less irritable. While on medicines the DN4 score was 0/10 and VAS was 10/100. Neuropathic pain has always been a difficult to treat in comparison with the nociceptive pain. Diabetic neuropathy and neuropathic pain associated with it has been the basis of treatment of the neuropathic pain in other disorders. We propose that systemic medical therapy using standard anti-neuropathic medications may be effective in treating pain in HS. Pregabalin by binding to the α2δ subunit of the voltage-dependent calcium channel in the central nervous system decreases the release of neurotransmitters including glutamate, noradrenaline, substance P and calcitonin generelated peptide.[3] Amitriptyline inhibit sodium channels and L-type calcium channels, inhibits serotonin-norepinephrine reuptake by blocking the serotonin transporter and the norepinephrine transporter leading to elevation of the synaptic concentrations of these neurotransmitters, thus an enhancement of neurotransmission in the descending pain modulating pathway.[4] Although pharmacotherapy is essential for management of HS pain, the role of psychotherapy in the form of a variety of cognitive-behavioral therapies including distraction, imagery, biofeedback or hypnotic analgesia provided by trained staff cannot be underemphasized. 112
Anuj Jain, Anil Agarwal, Chetna Shamshery Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India Address for correspondence: Dr. Anuj Jain, Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: [email protected]
References 1.
2.
3.
4.
Isoardo G, Stella M, Cocito D, Risso D, Migliaretti G, Cauda F, et al. Neuropathic pain in post-burn hypertrophic scars: A psychophysical and neurophysiological study. Muscle Nerve 2012;45:883-90. Kawecki M, Bernad-Wiśniewska T, Sakiel S, Nowak M, Andriessen A. Laser in the treatment of hypertrophic burn scars. Int Wound J 2008;5:87-9. Micheva KD, Taylor CP, Smith SJ. Pregabalin reduces the release of synaptic vesicles from cultured hippocampal neurons. Mol Pharmacol 2006;70:467-76. Gillman PK. Tricyclic antidepressant pharmacology and therapeutic drug interactions updated. Br J Pharmacol 2007;151:737-48. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.125721
Transient compressive lumbar radiculopathy following post-epidural blood patch Sir, Post-dural-puncture-headache is a common complication seen after an intentional or an accidental breach of the dura mater at the spinal level. Epidural blood patch (EBP) is a commonly utilized interventional modality for treating difficultto-intractable headache after a dural puncture. However, in comparison with the reports about the success rates of EBP, the complications and concerns related to EBP as an intervention itself have been rarely reported.[1] We hereby present a case wherein, our patient was re-admitted to the emergency room due to radicular pains after a successful EBP. A 20-year-old female patient presented to the emergency room with the chief complaint of intermittent and shooting low back pain, radiating bilaterally to buttocks and knees. Four days prior, she had undergone a continuous labor epidural
Journal of Anaesthesiology Clinical Pharmacology | January-March 2014 | Vol 30 | Issue 1
Copyright of Journal of Anaesthesiology Clinical Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
anaphylaxis etc. Most of these conditions can be managed barring a few exceptions like this. The presence of multiple cervical abscesses (vertebral or epidural) during pre-operative examination should prompt the anesthesiologist to anticipate high risk of such complication and devise a prior strategy in consultation with the surgeons to avoid any serious mishap. Anirban Hom Choudhuri, Mritunjay Kumar Department of Anesthesiology and Intensive Care, GB Pant Hospital, New Delhi, India Address for correspondence: Dr. Anirban Hom Choudhuri, 12/203, East End Apartments, Mayur Vihar Phase 1 (extn), New Delhi - 110 096, India. E-mail: [email protected]
References 1. 2.
3.
4.
5.
Kahn JL, Bourjat P. The peripharyngeal space. Anatomy and normal imaging. J Radiol 1996;77:87-9. Ozlugedik S, Ibrahim Acar H, Apaydin N, Firat Esmer A, Tekdemir I, Elhan A, et al. Retropharyngeal space and lymph nodes: An anatomical guide for surgical dissection. Acta Otolaryngol 2005;125:1111-5. Parker GD, Harnsberger HR. Radiologic evaluation of the normal and diseased posterior cervical space. AJR Am J Roentgenol 1991;157:161-5. Wurtz R, Quader Z, Simon D, Langer B. Cervical tuberculous vertebral osteomyelitis: Case report and discussion of the literature. Clin Infect Dis 1993;16:806-8. Turgut M. Multifocal extensive spinal tuberculosis (Pott’s disease) involving cervical, thoracic and lumbar vertebrae. Br J Neurosurg 2001;15:142-6. Access this article online Quick Response Code:
Website: www.joacp.org
Second degree burns (involving the dermis) are usually associated with moderate to severe pain in the acute phase. Second degree burns during the healing phase may be complicated by hypertrophic scars (HS). Pain associated with post burn HS is caused by small fiber damage rather than large ner ve entrapments. [1] Third degree burns involving the muscles may lead post burn contractures leading to nerve entrapments. Chronic post burn may lead to peripheral and central sensitization thereby causing allodynia. Burn cases are usually associated with thermal allodynia. A wide variety of treatments are available to treat HS associated pruritus, pain, movement restriction and cosmetic disfigurement. These include intralesional corticosteroids, topical treatments, cryotherapy, surgery, radiation, silicone gel dressing and laser therapy.[2] Patient being discussed is a 25-year-old male patient who had suffered extensive burn injury due to explosion of a domestic liquefied petroleum gas cylinder [Figure 1]. The burn had occurred approximately 18 months back. The medical records of primary care revealed that the burn was 35% and grade 2. The recovery care had been performed at a local district hospital. The later part of recovery was complicated by development of HS with associated burning pain. Patient presented to us with severe burning pain in the HS. The pain was worse particularly in the summers and relatively better in the winters. Application of menthol talc decreased the symptoms for some time. Due to the severe thermal (warm) and dynamic mechanical (brush) allodynia the patient was unable to wear clothes over the affected part. The chronic pain had rendered the patient jobless, highly irritable, sleepless and depressed. The DN4 score at presentation was 5/10
DOI: 10.4103/0970-9185.125720
An effective pharmacological management of postburn hypertrophic scar pain Sir, The pain associated with burn injuries is intense, unremitting, chronic and often debilitating.
Figure 1: Patient with extensive post burn hypertrophic scar
Journal of Anaesthesiology Clinical Pharmacology | January-March 2014 | Vol 30 | Issue 1
111
Letters to Editor
and pain on the visual analog scale (VAS) varied between 30 and 70/100. Physical examination revealed extensive HS over the burnt area. The sensations over the affected area were normal without any static mechanical allodynia (allodynia to touch and pressure). The scar was too extensive to consider any local therapy (e.g., steroid infiltration within the scar). The cosmetic deformity was not an issue for the patient so a decision to start systemic therapy with tablet pregabalin and amitriptyline was made. Pregabalin was advised 75 mg in the night for 3 days and then twice a day thereafter. Amitriptyline was advised in the dose of 10 mg in the night for 1 week followed by 25 mg thereafter. Patient was kept on a fortnightly follow-up. Patient showed a significant improvement in symptoms within 5 days with progressive improvement in symptoms as the treatment proceeded. At 3 months since the start of treatment patient has shown progressive improvement and is now pursuing his occupation and has started socializing with friends. His sleep has normalized and he is much less irritable. While on medicines the DN4 score was 0/10 and VAS was 10/100. Neuropathic pain has always been a difficult to treat in comparison with the nociceptive pain. Diabetic neuropathy and neuropathic pain associated with it has been the basis of treatment of the neuropathic pain in other disorders. We propose that systemic medical therapy using standard anti-neuropathic medications may be effective in treating pain in HS. Pregabalin by binding to the α2δ subunit of the voltage-dependent calcium channel in the central nervous system decreases the release of neurotransmitters including glutamate, noradrenaline, substance P and calcitonin generelated peptide.[3] Amitriptyline inhibit sodium channels and L-type calcium channels, inhibits serotonin-norepinephrine reuptake by blocking the serotonin transporter and the norepinephrine transporter leading to elevation of the synaptic concentrations of these neurotransmitters, thus an enhancement of neurotransmission in the descending pain modulating pathway.[4] Although pharmacotherapy is essential for management of HS pain, the role of psychotherapy in the form of a variety of cognitive-behavioral therapies including distraction, imagery, biofeedback or hypnotic analgesia provided by trained staff cannot be underemphasized. 112
Anuj Jain, Anil Agarwal, Chetna Shamshery Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India Address for correspondence: Dr. Anuj Jain, Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: [email protected]
References 1.
2.
3.
4.
Isoardo G, Stella M, Cocito D, Risso D, Migliaretti G, Cauda F, et al. Neuropathic pain in post-burn hypertrophic scars: A psychophysical and neurophysiological study. Muscle Nerve 2012;45:883-90. Kawecki M, Bernad-Wiśniewska T, Sakiel S, Nowak M, Andriessen A. Laser in the treatment of hypertrophic burn scars. Int Wound J 2008;5:87-9. Micheva KD, Taylor CP, Smith SJ. Pregabalin reduces the release of synaptic vesicles from cultured hippocampal neurons. Mol Pharmacol 2006;70:467-76. Gillman PK. Tricyclic antidepressant pharmacology and therapeutic drug interactions updated. Br J Pharmacol 2007;151:737-48. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.125721
Transient compressive lumbar radiculopathy following post-epidural blood patch Sir, Post-dural-puncture-headache is a common complication seen after an intentional or an accidental breach of the dura mater at the spinal level. Epidural blood patch (EBP) is a commonly utilized interventional modality for treating difficultto-intractable headache after a dural puncture. However, in comparison with the reports about the success rates of EBP, the complications and concerns related to EBP as an intervention itself have been rarely reported.[1] We hereby present a case wherein, our patient was re-admitted to the emergency room due to radicular pains after a successful EBP. A 20-year-old female patient presented to the emergency room with the chief complaint of intermittent and shooting low back pain, radiating bilaterally to buttocks and knees. Four days prior, she had undergone a continuous labor epidural
Journal of Anaesthesiology Clinical Pharmacology | January-March 2014 | Vol 30 | Issue 1
Copyright of Journal of Anaesthesiology Clinical Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
