EFFECTIVENESS OF LUMBAR SYMPATHETIC BLOCK IN PATIENTS OF CHRONIC LEG PAIN PRESENTED TO PAIN CLINIC AT A TERTIARY GOVERNMENT HOSPITAL OVER PAST TWO-YEARS: A RETROSPECTIVE AND OBSERVATIONAL STUDY.

Background:Lumbar sympathetic block is used in inoperable peripheral vascular disease. The block acts as a vasodilator by decreasing sympathetic tone and improves tissue oxygenation and helps in ulcer healing. No guidelines exist till date for its use in patients with chronic leg pain and ulcers. The management of patients with unreconstructable distal disease with rest pain has always been difficult. Lumbar sympathetic block helps to abolish this rest pain. Aims and Objectives: 1. To study the effectiveness of lumbar sympathetic block 2. To study the ideal level for needle insertion for 100% success rate. 3. To follow up the patients for 1 week, 4 weeks and 12 weeks for relief of symptoms. 4. To study the safety of the block and note the complications. Materials and Methods: After approval of ethical committee, this retrospective study was conducted from Pain Clinic Records over the past two years. Total number of patients studied were 30 over past 2 years. Data Collection: Demographic Data and VAS score was recorded Preblock walking distance was recorded. CT guided lumbar sympathetic block was given. Results and Conclusion: Lumbar sympathetic block was very useful, safe and effective method to decrease the rest pain in patients presented to pain OPD of our hospital. Follow up for 3 months showed healing of ulcers in some of these patients.

Early and eighteen month clinical outcomes of first UK case of percutaneous deep vein arterialisation (pDVA) to treat “no option” chronic limb-threatening ischemia using the LimFlow system

Background Chronic limb-threatening ischaemia (CLTI) in cases where there are no further standard treatment options for limb salvage represents the most advanced stage of peripheral arterial disease. For these “no-option” CLTI patients, an experimental treatment of foot vein arterialisation (FVA) was first described in 1912, however, it was never widely adopted as outcomes varied significantly most likely due to the complexity of the surgical intervention and lack of standardisation. In recent years there have been significant developments in performing FVA fully percutaneously and standardising the procedure with the introduction of specific indications for patient selection, a dedicated set of devices and structured follow up. This case represents the first UK use of the dedicated LimFlow System as a standardised procedure to perform percutaneous deep vein arterialisation (pDVA) in a “no option” CLTI patient according to the latest treatment recommendations in the literature, with outcomes out to 18 months post-procedure. Case presentation We present the case of a 78 year old male diabetic patient with a history of contralateral below knee amputation who presented with ischaemic rest pain and dry gangrene involving his left heel and first and second toes. Following review by the lower limb multi-disciplinary team at our institution, the patient was deemed to have no surgical or endovascular treatment options, apart from major amputation, as there was no suitable target for either angioplasty or bypass. He was therefore referred as a candidate for percutaneous deep vein arterialisation (pDVA) with the LimFlow System (LimFlow SA, France). After screening of the patient according to the indications for use, the pDVA procedure was successfully performed resulting in complete resolution of ischaemic rest pain immediately following the procedure, and adequate revascularisation of the foot. Following the index procedure, the subject went on to have minor amputation of the first, second and third toes 2 months post initial procedure with further secondary angioplasty procedures to optimise the flow throughout the arterialised circuit up to 4 months after the initial procedure. He underwent elective completion transmetatarsal amputation at 13 months post index procedure. The surgical wounds post minor amputation and the heel wound showed continued healing, especially after secondary optimisation of the pDVA outflow, with tissue epithelialisation by 6 months and complete healing by 18 months after the index procedure. Conclusions This case report demonstrates the clinical outcomes of a technically-successful standardised pDVA procedure with the LimFlow system including both limb salvage and wound healing at 18 months. It also highlights the importance of close clinical and radiological surveillance post-index procedure and the requirement for re-interventions to optimise wound healing.

Effect of Ḥijāma (wet cupping), Dalk (massage) & Bukhūr (medicated steam) in amelioration of Waja al-Zahr (non-specific low back pain) – an open prospective clinical trial

Objectives Low back pain is the most widespread musculoskeletal ailment and a common cause of disability worldwide. Conventional medicine typically treats low back pain with a combination of physical therapy; activity modification and rest; pain-relieving and anti-inflammatory medications which are associated with huge socioeconomic implications and adverse drug reactions. In contrast Ḥijāma, Dalk and Bukhūr are ancient medical techniques recommended in the management of musculoskeletal disorders with little or no adverse effects. To evaluate the safety and effectiveness of Ḥijāma bi’l Shart (wet cupping), followed by Dalk (Massage) with Roghan Dafli and Bukhūr (medicated steam) with Tukhm Soya (Anethum graveolens Linn) in patients of Waja al-Zahr (Non-specific Low back pain). Methods Patients of either gender in the age group of 18–50 years with low back pain persisting for four weeks or more as chief complaint were recruited in the trial. The study was GCP compliant. The duration of the protocol therapy carried out was 14 days. Results Ninty two patients of NSLBP were screened, of which 34 who fulfilled the inclusion criteria and were willing to participate in the study were recruited. Three participants were lost to follow-ups due to personal reasons and 31 patients completed the trial during the study period. Overall therapeutic response observed in this study was 97% while 3% of the patients did not respond to intervention. Conclusions The study findings imply that there is a credible evidence to ensure that the regimens intervened are safe and effective in ameliorating the symptoms of Waja al-Zahr.

A Never Described Variant of the Cervical Rib Causing Arterial Thoracic Outlet Syndrome: World's First Case

Cervical ribs, also known as Eve's ribs, are rare and found in 1% of population. They are more common in females and more common on right side. They are asymptomatic in 90% of cases. Cervical rib fused with transverse process of sixth vertebra is rarer. We present a case of dry gangrene of lateral three fingers with right radial and subclavian artery thrombosis with rest pain, due to right cervical rib fused with transverse process of sixth vertebra. After development of line of demarcation of the dry gangrene, patient was operated for excision of cervical rib and sixth cervical vertebral transverse process followed by Ray's amputation of right second finger. Postoperative course was uneventful. Patient was discharged with oral anticoagulation and a healthy wound in right hand.

Outcome after total knee arthroplasty with or without patellar resurfacing

<p><strong>Background: </strong>Patellar resurfacing in total knee arthroplasty has had its defenders and detractors. There seems to be a great difference in patellar resurfacing between countries and patellar resurfacing is still controversial. Some surgeons resurface the patella routinely, others not at all, and a third group prefers selective resurfacing. Therefore, in this prospective and randomised study, we compared the outcome after total knee arthroplasty with or without patellar resurfacing.</p><p><strong>Methods: </strong>In this study 50 cases (100 knees) were selected and each case was followed up for 2 years. In each case, one knee was operated by TKA with patellar resurfacing and the other by TKA with patellar non-resurfacing. Patients were followed-up for a period of 2 years and clinical and functional outcome of both knees was measured and compared by the help of knee society score (KSS) and VAS score.</p><p><strong>Results: </strong>There was statistically significant difference between the patellar resurfacing and non-resurfacing group with regard to knee society score, pain score and visual analogue score (VAS), with the patellar resurfacing having better scores. There was no significant difference in the functional scores between the 2 groups. Range of motion was complication rate was comparable in both the groups. However, there was no case of reoperation nor was there any complication related to the patellar implant. </p><p><strong>Conclusions:</strong> Patellar resurfacing in TKA leads to less post-operative persisting knee pain, and also leads to better outcome in terms of walking without pain, using stairs without pain and rest pain as compared to TKA without patellar resurfacing.</p>

Early and Eighteen Month Clinical Outcomes of First UK Case of Percutaneous Deep Vein Arterialisation (pDVA) to Treat “No Option” Chronic Limb-Threatening Ischemia Using the Limflow System

Background: Chronic limb-threatening ischaemia (CLTI) in cases where there are no further standard treatment options for limb salvage represents the most advanced stage of peripheral arterial disease. This case represents the first UK use of the LimFlow System to perform percutaneous deep vein arterialisation (pDVA) in a “no option” CLTI patient, with outcomes out to 18 months post-procedure.Case Presentation: We present the case of a 78 year old male diabetic patient with a history of contralateral below knee amputation who presented with ischaemic rest pain and dry gangrene involving his left heel and first and second toes. Following review by the lower limb multi-disciplinary team at our institution, the patient was deemed to have no surgical or endovascular treatment options, apart from major amputation, as there was no viable target for angioplasty or bypass. He was therefore referred as a candidate for percutaneous deep vein arterialisation (pDVA) with the LimFlow System (LimFlow SA, France). After screening of the patient according to the indications for use, the pDVA procedure was successfully performed resulting in complete resolution of ischaemic rest pain immediately following the procedure, and adequate revascularisation of the foot. The subject went on to have minor amputation of the first, second and third toes 2 months post initial procedure with further secondary angioplasty procedures to optimise the flow throughout the arterialised circuit up to 4 months after the initial procedure. He underwent elective completion transmetatarsal amputation at 13 months post index procedure. The surgical wounds post minor amputation and the heel wound showed continued healing progress, especially after secondary optimisation of the pDVA outflow, with tissue epithelialisation by 6 months and complete healing by 18 months post index procedure.Conclusions: This case report demonstrates the clinical outcomes of a technically-successful LimFlow pDVA including both limb salvage and wound healing at 18 months.

Systematic review of inframalleolar endovascular interventions and rates of limb salvage, wound healing, restenosis, rest pain, reintervention and complications

Objectives Peripheral artery disease is estimated to affect 237 million individuals worldwide. Critical limb ischaemia, also known as chronic limb threatening ischaemia is a consequence of the progression of peripheral artery disease which occurs in ∼21% of patients over a five-year period. The aim of this systematic review is to assess the use of additional below-the-ankle angioplasty in comparison to the use of above-the-ankle angioplasty alone, and the subsequent rates of amputation, wound healing, restenosis, rest pain, reintervention and complications. Methods This systematic review was undertaken in accordance with PRISMA guidelines following a registered protocol (CRD42019154893). Online databases were searched using a search strategy of 20 keywords. Included articles reported the outcome for inframalleolar (pedal artery, pedal arch, plantar arteries) angioplasty with additional proximal angioplasty in comparison to proximal angioplasty alone. GRADE assessment was applied to assess the quality of the evidence. Results After screening 1089 articles, 10 articles met the inclusion criteria. Comparative performance assessment of below-the-ankle with above-the-ankle versus above-the-ankle angioplasty alone was undertaken in 3 articles, with the remaining 7 articles reporting outcomes of below-the-ankle with above-the-ankle angioplasty with no distinct comparator group. Significant decrease in major lower limb amputation at the last follow-up in the below-the-ankle group when compared with the above-the-ankle angioplasty alone group was observed in a single study (3.45% vs. 14.9%, p < 0.05). Improved wound healing rate at follow-up in the below-the-ankle group versus above-the-ankle angioplasty alone group was also reported in a single study (59.3% vs. 38.1%, p < 0.05). Subsequent rate of amputation after below-the-ankle angioplasty has been estimated as 23.5%. Conclusion To date, there is a lack of studies assessing inframalleolar interventions and their use in improving limb salvage, wound healing and symptomatology. Prospective RCTs should be undertaken with adequate participant numbers to be sufficiently powered and report clinically important end-points.

Outcomes of Anticoagulant Therapy with Low-Molecular-Weight Heparin (LMWH) and Warfarin for Thromboangiitis Obliterans (TAO)

Background: Thromboangiitis obliterans (TAO) is a chronic, non-atherosclerotic, progressive inflammatory vascular disease affecting the small- and medium-size arteries and veins of the extremities. Objective: To evaluate whether long-term anticoagulation with low-molecular-weight heparin (LMWH) and warfarin is beneficial for treating the inflammation and symptoms associated with TAO. Methods: Patients with TAO who underwent anticoagulation as the mainstay of treatment were included in this prospective study. Rest pain relief and healing of trophic lesions (as the primary and secondary endpoint) were investigated at day 14 and after 6 months of follow-up. High sensitivity C-reactive protein (hsCRP), monocyte count, and ankle-brachial index (ABI) were recorded and the difference compared before and after 2-week anticoagulation. The Chi-square test was used to compare the difference between anticoagulant and aspirin groups (based on the literature). Results: From 2014 to 2019, 18 patients were included. Only 1 patient with wet gangrene received endo-therapy for a failing stent at the start of treatment. After ~14 days, 12 of 13 (92%) patients showed complete ulcer healing and 17 of 18 (94%) patients showed complete relief from rest pain. Monocyte-counts and hsCRP levels decreased significantly (p<0.001) after a 2-week period of anticoagulation with LMWH. The mean follow-up was 2.6 years (range 0.5-5 years). At 6 months, all patients showed relief of rest pain and complete healing of trophic lesions. All endpoints were significantly improved compared with the aspirin group (p<0.01), and no rest pain or ulcer/gangrene recurred during follow-up. Conclusion: Anticoagulant therapy may alleviate the inflammation and symptoms of TAO.