PainExam Podcast

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**PainExam Podcast**

David Rosenblum, MD, creator of PainExam.com and Director of Pain Management at New York Based, AABP Pain Management discusses Pain Board Review and issues relevant to pain physicians.

Marketing, practice management and Board Prep are discussed. For more information and CME Credit’s go to PainExam.com

Also, be sure to check out Dr. Rosenblum’s children’s book: Welwyn Ardsley and the Cosmic Ninjas: Preparing your child and yourself for anesthesia and surgery.

Available at Amazon.com and www.MyKidsSurgery.com

Latest Episodes:

New Guidelines for Corticosteroid Injections in Chronic Pain Management Jul 31, 2024

Show notes

Podcast Show Note Summary:

Episode Title: "New Guidelines for Corticosteroid Injections in Chronic Pain Management"

This podcast is a discussion about the recent review article

Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the International Pain and Spine Intervention Society, and the North American Spine Society

In this episode, we dive into the recently published guidelines on the use of corticosteroid injections for managing chronic pain, developed by the American Society of Regional Anesthesia and Pain Medicine, along with several other prominent pain societies. These guidelines address the safety and efficacy of corticosteroid injections for sympathetic and peripheral nerve blocks, as well as trigger point injections.

Key Discussion Points:

Background and Need for Guidelines:
- Overview of potential adverse events from corticosteroid injections, such as increased blood glucose levels, decreased bone mineral density, and suppression of the hypothalamic–pituitary axis.
- Importance of using lower doses of corticosteroids, which studies have found to be just as effective as higher doses.
Development of the Guidelines:
- The guidelines were approved by multiple pain societies and structured into three categories: sympathetic and peripheral nerve blocks, joint injections, and neuraxial injections.
- Extensive literature review and consensus-building through a modified Delphi process.
Key Recommendations:
- The addition of corticosteroids to local anesthetics is recommended for certain nerve blocks, such as the greater occipital nerve block for cluster headaches and ilioinguinal/iliohypogastric nerve blocks for post-herniorrhaphy pain.
- Corticosteroid addition is not recommended for sympathetic nerve blocks, greater occipital nerve blocks for migraines, and pudendal nerve blocks for pudendal neuralgia.
- Imaging guidance (ultrasound or fluoroscopy) improves the safety and accuracy of certain procedures.
Efficacy and Safety:
- Detailed analysis of various studies on the effectiveness of corticosteroid injections for different types of chronic pain.
- Discussion on the minimal benefit of corticosteroids in trigger point injections and the potential risks associated with their use.
Clinical Implications:
- How these guidelines can assist clinicians in making informed decisions regarding corticosteroid use in chronic pain management.
- Emphasis on the need for personalized treatment plans based on individual patient characteristics and clinical data.
Future Directions:
- Identification of gaps in the current research and the need for well-designed studies to further assess the benefits and risks of corticosteroid injections.

Join us as we explore these comprehensive guidelines and their potential impact on improving chronic pain management practices.

Resources:

Link to the full guidelines: Journal Online

Other Announcements from NRAP Academy:

PainExam App is ready for iphone
- Pain Management Board Prep migrated to NRAPpain.org
AnesthesiaExam Board Prep migrated to NRAPpain.org
PMRExam Board Prep migrated to NRAPpain.org

Live Workshop Calendar Ultrasound Interventional Pain Course Registration For Anesthesia Board Prep Click Here!

References https://rapm.bmj.com/content/rapm/early/2024/07/16/rapm-2024-105593.full.pdf

Disclaimer

Disclaimer: This Podcast, website and any content from NRAP Academy (NRAPpain.org) otherwise known as Qbazaar.com, LLC is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user's own risk. Professionals should conduct their own fact finding, research, and due diligence to come to their own conclusions for treating patients. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.

Trigeminal Nerve Block for Cancer: Ultrasound and Flouro Approaches Jul 19, 2024

Show notes

PainExam Show Notes: Mandibular Division of the Trigeminal Nerve Block with Dr. David Rosenblum

VIsit the NRAP Academy for the PainExam Board Prep!

Introduction

Host: Dr. David Rosenblum
Topic: Mandibular Division of the Trigeminal Nerve Block for Cancer Pain Management
Techniques: Ultrasound and Fluoroscopic Guidance

Overview

Purpose: Alleviate chronic facial pain, specifically in cancer patients suffering from trigeminal neuralgia or other related conditions.
Focus: Detailed discussion on the anatomy, clinical presentation, and procedural techniques for effective nerve block.

Anatomy of the Mandibular Nerve

Origin: Mandibular nerve is a branch of the trigeminal nerve (cranial nerve V).
Pathway: Exits the middle cranial fossa through the foramen ovale and descends between the lateral and medial pterygoid muscles.
Sensory Innervation:
- Anterior two-thirds of the tongue
- Teeth and mucosa of the mandible
- Skin of the chin and lower lip
- Skin over the mandible (excluding the mandibular angle)
- Tragus and anterior part of the ear
- Posterior part of the temporalis muscle up to the scalp

Ultrasound-Guided Technique

Patient Positioning:
- Patient lies on their side with the affected side facing upward.
Transducer Selection:
- Curvilinear transducer preferred for deeper structures.
Transducer Placement:
- Place distal and parallel to the zygomatic arch to bridge the coronoid and condylar processes.
Anatomical Landmarks:
- Identify the lateral pterygoid muscle and plate.
- Use power Doppler to locate the sphenoid palatine artery.
Needle Trajectory:
- Introduce the needle using an out-of-plane approach to target the pterygopalatine fossa (anterior to the lateral pterygoid plate).
- For the mandibular nerve block, target the area posterior to the lateral pterygoid plate between the medial and lateral pterygoid muscles.
Electrostimulation (Optional):
- Utilize a 22G, 10 cm insulated short beveled needle connected to a peripheral nerve simulator.
- Position confirmed by motor response from the temporalis and masseter muscles.

Fluoroscopic-Guided Technique

Patient Positioning:
- Similar to ultrasound guidance, patient lies on their side with the affected side facing upward.
C-arm Positioning:
- Position the C-arm to visualize the foramen ovale.
Needle Insertion:
- Insert the needle under fluoroscopic guidance towards the foramen ovale.
Contrast Injection:
- Confirm needle placement with contrast injection.
Anesthetic Administration:
- Administer local anesthetic and/or neurolytic agents.

Clinical Symptoms and Diagnosis

Symptoms:
- Unilateral sharp, stabbing, or burning pain in the mandibular nerve distribution.
- Pain triggered by activities such as eating, talking, washing the face, or cleaning the teeth.
Diagnostic Imaging:
- MRI or CT scans to identify causes like vascular compression, mass lesions, or fractures.

Complications and Considerations

Potential Complications:
- Bleeding, hematoma, infection, and hypersensitivity reaction to the injectate.
- Serious complications from neurolytic agents like permanent sensory deficit and tissue necrosis.
Alternative Treatments:
- PNS? Radiofrequency or cryoablation for recalcitrant cases.

Conclusion

Efficacy: Ultrasound and fluoroscopic guidance provide precise targeting of the affected nerves, minimizing collateral damage.
Safety: Routine use of power Doppler imaging to avoid injury to surrounding vessels.
Recommendation: Consider these techniques for patients unresponsive to oral medications or unsuitable for surgery.

These show notes provide a comprehensive overview of the discussion, highlighting key points on the anatomy, technique, and clinical considerations for mandibular nerve blocks in cancer patients.

Other Announcements from NRAP Academy:

PainExam App is ready for iphone
- Pain Management Board Prep migrated to NRAPpain.org
AnesthesiaExam Board Prep migrated to NRAPpain.org
PMRExam Board Prep migrated to NRAPpain.org

Live Workshop Calendar Ultrasound Interventional Pain Course Registration For Anesthesia Board Prep Click Here!

References

Nicholas A Telischak, Jeremy J Heit, Lucas W Campos, Omar A Choudhri, Huy M Do, Xiang Qian, Fluoroscopic C-Arm and CT-Guided Selective Radiofrequency Ablation for Trigeminal and Glossopharyngeal Facial Pain Syndromes, Pain Medicine, Volume 19, Issue 1, January 2018, Pages 130–141, https://doi.org/10.1093/pm/pnx088

Allam, Abdallah El-Sayed, et al. "Ultrasound‐Guided Intervention for Treatment of Trigeminal Neuralgia: An Updated Review of Anatomy and Techniques." Pain Research and Management 2018.1 (2018): 5480728.

isclaimer

Intraosseous PRP vs Intraarticular, ESW vs PRP, Conspiracy Theory and more! Jun 27, 2024

Show notes

Dr. Rosenblum addresses 2 Studies on this Pain Management Journal Club Podcast

Article 1:

The Treatment of Bone Marrow Lesions Associated with Advanced Knee Osteoarthritis: Comparing Intraosseous and Intraarticular Injections with Bone Marrow Concentrate and Platelet Products

Article 2:

Autologous US-guided PRP injection versus US-guided focal extracorporeal shock wave therapy for chronic lateral epicondylitis: Aminimum of 2-year follow-up retrospective comparative study

Editorial:

Dr. Rosenblum poses some important questions:

Why are regenerative therapies not covered? Why is CMS limiting trigger point injections and not paying for certain peripheral nerve blocks? Who is making the decision? Do lobbying groups or big pharma have a role?

Other Announcements from NRAP Academy:

PainExam App is ready for iphone
- Pain Management Board Prep migrated to NRAPpain.org
AnesthesiaExam Board Prep migrated to NRAPpain.org
PMRExam Board Prep migrated to NRAPpain.org

Live Workshop Calendar Ultrasound Interventional Pain Course Registration For Anesthesia Board Prep Click Here!

References

Alessio-Mazzola M, Repetto I, Biti B, Trentini R, Formica M, Felli L. Autologous US-guided PRP injection versus US-guided focal extracorporeal shock wave therapy for chronic lateral epicondylitis: A minimum of 2-year follow-up retrospective comparative study. Journal of Orthopaedic Surgery. 2018;26(1).

Centeno, Christopher, et al. "The treatment of bone marrow lesions associated with advanced knee osteoarthritis: comparing intraosseous and intraarticular injections with bone marrow concentrate and platelet products." Pain Physician24.3 (2021): E279.

Exosomes, 2 Year Pain Fellowship, Research and more with Christopher Robinson, MD PhD Jun 04, 2024

Show notes

Join us on this episode of the PainExam Podcast where rising star, Christopher Robinson, MD PhD discusses his upcoming paper on exosomes featuring some of the largest names in pain managment. Dr. Rosenblum also alludes to degenerative disc disease being a partially infectious podcast.

Other topics discussed on this podcast:

The Anesthesiology Job Market

Pain Management Fellowship

Duration of Pain Management Fellowships

Should Pain Management be an Independent Residency?

Other Announcements from NRAP Academy:

PainExam App almost ready
- Pain Management Board Prep migrated to NRAPpain.org
AnesthesiaExam Board Prep migrated to NRAPpain.org
PMRExam Board Prep migrated to NRAPpain.org

Live Workshop Calendar Ultrasound Interventional Pain Course Registration For Anesthesia Board Prep Click Here!

Is Degenerative Disc Disease an Infectious Disease? The role of L-PRP. Journal Club May 20, 2024

Show notes

Journal Club: Treating Degenerative Disc Disease with Leukocyte Rich PRP

Dr. Rosenblum discusses an article written by Dr. Gregory Lutz describing Leukocyte RIch PRP's role in treating Degenerative Disc Disease and the theory that there is an infectious disease component to disc injury.

Dr. Lutz describes multiple articles, as well as anectodal experience in which bacterial infectious was demonstrated in pathological discs, and PRP was successful in alleviating symptoms, modic changes and improved clinical as well as radiographic appearance.

Other Announcements from NRAP Academy:

PainExam App almost ready
- Pain Management Board Prep migrated to NRAPpain.org
AnesthesiaExam Board Prep migrated to NRAPpain.org
PMRExam Board Prep migrated to NRAPpain.org

Live Workshop Calendar Ultrasound Interventional Pain Course Registration For Anesthesia Board Prep Click Here!

References

Lutz, Gregory E. "Intradiscal Leukocyte Rich Platelet Rich Plasma for Degenerative Disc Disease." Physical Medicine and Rehabilitation Clinics of North America 34.1 (2023): 117-133.https://www.binasss.sa.cr/bibliotecas/bhm/feb23/61.pdf

Iliopsoas Dry Needling for Acute Lumbar Radiculits and CMS' Trigger Point Policy! May 02, 2024

Show notes

Dr. Rosenblum reviews an article by Dr. Reuben Ingber regarding the use of iliopsoas trigger point dry needling and therapeutic stretching in the treatement of 6 consecutive patients wiht acute lumbar radiculitis and foot drop. Other Announcements from NRAP Academy:

PainExam App almost ready
- Pain Management Board Prep migrated to NRAPpain.org
AnesthesiaExam Board Prep migrated to NRAPpain.org
PMRExam Board Prep migrated to NRAPpain.org

Live Workshop Calendar Ultrasound Interventional Pain Course Registration For Anesthesia Board Prep Click Here!

References

Reuben S. Ingber, Iliopsoas trigger point dry needling and therapeutic stretching in the treatment of a series of six consecutive patients presenting with acute lumbar radiculitis and foot drop, Journal of Bodywork and Movement Therapies, Volume 36, 2023, Pages 1-4, ISSN 1360-8592,

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57702#:~:text=No%20more%20than%203%20Trigger,group%20are%20not%20billed%20separately.

CMS National Coverage Policy

Chronic Pain after Shoulder Joint Replacement: RFA Revisited Apr 17, 2024

Show notes

Dr. Rosenblum describes a patient with chronic shoulder pain who failed shoulder replacement, steroid injections, nerve blocks, cryotherapy, and peripheral nerve stimulation of the axillary and suprascapular nerve block. In this podcast, he discusses his perfomance of Shoulder Radiofrequency Ablation targeting the articular branches of the suprascapular nerve, axillary nerve, nerve to subscapularis and lateral pectoral nerve. Reference: https://www.asra.com/news-publications/asra-newsletter/newsletter-item/asra-news/2020/11/01/how-i-do-it-shoulder-articular-nerve-blockade-and-radiofrequency-ablation Other Announcements from NRAP Academy:

PainExam App almost ready
- Pain Management Board Prep migrated to NRAPpain.org
AnesthesiaExam Board Prep migrated to NRAPpain.org
PMRExam Board Prep migrated to NRAPpain.org

Live Workshop Calendar Ultrasound Interventional Pain Course Registration For Anesthesia Board Prep Click Here!

Pain Docs Lobby for more Oversight of Independent Review Organizations Apr 03, 2024

Show notes

Advocating for Transparency and Oversight in Pain Management

Introduction:

Welcome back to Painexam, where we delve into the latest advancements and challenges in pain management.
Today's episode highlights a significant advocacy effort made by leading Interventional Pain Physicians and industry experts.

Summary of Lobbying Effort:

On March 20, 2024, a group of widely known and respected pain physicians and industry leaders, including Drs. Sean Li, Peter Staats, Mehul J. Desai, David Reece, Hemant Kalia, and David Rosenblum, alongside industry figures Mark Stultz, Christopher Conrad, and Cecelia Ruble, visited Capitol Hill to advocate for greater oversight and transparency in independent review organizations.
Despite their busy schedules, they recognized the critical need to address the 0% turnover rate in appeals for denied treatments, which disproportionately affects patients seeking alternatives to surgery and opioid medication.

Importance of Transparency:

The issue extends beyond pain management, impacting patients across various medical fields.
While opioid therapy may seem economically favorable initially, the long-term consequences, including delayed care and medication side effects, often outweigh the costs.
The group emphasized the importance of an unbiased review for accessible, cutting-edge treatments to improve patient outcomes and reduce overall healthcare expenses.

Purpose of the Lobbying Effort: Contrary to pushing any specific company agenda, the initiative aims to highlight the challenges patients and physicians encounter in securing optimal treatment outcomes.

For Board Prep, Ultrasound Training and more, visit:

Dr. David Rosenblum, a pioneer in interventional pain medicine, particularly in ultrasound-

guided procedures and regenerative pain medicine, underscores the necessity of addressing these issues for the benefit of countless patients suffering from chronic pain.

Conclusion and Actionable Steps:

To schedule a consultation with Dr. Rosenblum, patients can visit www.AABPpain.com or contact the Brooklyn Office at 718-436-7246 or the Garden City Office at 516-482-7246.
Stay tuned for more updates on advancements and advocacy efforts in pain management.

Outro:

Thank you for joining us on this episode of Painexam. Be sure to subscribe for future discussions on navigating the complexities of pain management.

Interventional Psych and Pain? The Stellate Ganglion, Scope of Practice, Ketamine & Magnesium and more! Mar 13, 2024

Show notes

Dr. Rosenbum discusses Interventional Psychiatry, the role of Stellate Ganglion Blocks in PTSD, Ketamine Infusions for Depression, and the role of Magnesium as a co-factor in ketamine infusions. Other Announcements from NRAP Academy:

PainExam App almost ready
- Pain Management Board Prep migrated to NRAPpain.org
AnesthesiaExam Board Prep migrated to NRAPpain.org
PMRExam Board Prep migrated to NRAPpain.org

Live Workshop Calendar Ultrasound Interventional Pain Course Registration For Anesthesia Board Prep Click Here! References https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2023.1293358/full References Górska N, Cubała WJ, Słupski J, Wiglusz MS, Gałuszko-Węgielnik M, Kawka M, Grzegorzewska A. Magnesium in Ketamine Administration in Treatment-Resistant Depression. Pharmaceuticals (Basel). 2021 May 3;14(5):430. doi: 10.3390/ph14050430. PMID: 34063604; PMCID: PMC8147622. https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2021.513068/full https://www.sutterhealth.org/services/behavioral-health/interventional-psychiatry Hanling SR, Hickey A, Lesnik I, et al Stellate Ganglion Block for the Treatment of Posttraumatic Stress Disorder: A Randomized, Double-Blind, Controlled Trial Regional Anesthesia & Pain Medicine 2016;41:494-500. https://www.psychiatrist.com/jcp/oral-ketamine-for-depression/

Rudy Malayil, MD WVSIPP President, Stellate Ganglion for Hot Flashes and more! Feb 28, 2024

Show notes

Dr. Rosenblum interviews West Viriginia Society of Interventional Pain Physician's President Rudy Malayil, MD and discusses the upcoming WVSIPP meeting in April 2024 as well as Dr. Rosenblum's upcoming ultrasound course.

Rudy Mathew Malayil, M.D., completed his internship in General Surgery at New York Presbyterian/Cornell Hospital in New York City, followed by residency training in Physical Medicine and Rehabilitation at New York University Medical School. Dr. Malayil further completed a Pain Medicine Fellowship at the Albert Einstein School of Medicine at the Beth Israel Medical Center Campus in New York City.

After training he went settled in West Virginia and eventually became the president of West Virginia Society of Interventional Pain Physicians and started private practice Pain Management 360.

https://pain360.org https://www.malayilmd.com Ultrasound Interventional Pain Course Registration For Pain Management Board Prep Go to: References https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2023.1293358/full

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