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The PMRExam Podcast

PMR Board Prep instructor and PMRExam's creator, David Rosenblum, MD discusses issues relevant to Physiatrists and Pain Physicians. Dr. Rosenblum's Physical Medicine and Rehabilitation Podcast, The PMRExam Podcast, features, interviews, board prep and practice management issues relevant to rehab physicians. For more information on Physiatry board prep and CME credits, go to PMRExam.com
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Now displaying: 2024
Jul 19, 2024

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

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

  1. Patient Positioning:
    • Patient lies on their side with the affected side facing upward.
  2. Transducer Selection:
    • Curvilinear transducer preferred for deeper structures.
  3. Transducer Placement:
    • Place distal and parallel to the zygomatic arch to bridge the coronoid and condylar processes.
  4. Anatomical Landmarks:
    • Identify the lateral pterygoid muscle and plate.
    • Use power Doppler to locate the sphenoid palatine artery.
  5. 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.
  6. 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

  1. Patient Positioning:
    • Similar to ultrasound guidance, patient lies on their side with the affected side facing upward.
  2. C-arm Positioning:
    • Position the C-arm to visualize the foramen ovale.
  3. Needle Insertion:
    • Insert the needle under fluoroscopic guidance towards the foramen ovale.
  4. Contrast Injection:
    • Confirm needle placement with contrast injection.
  5. 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
  •  
  • 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.

 

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.

Jun 27, 2024

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
  •  
  • AnesthesiaExam Board Prep migrated to NRAPpain.org
  • PMRExam Board Prep migrated to NRAPpain.org
 

 

 

 
 
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.

Jun 4, 2024

 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:
 
Live Workshop Calendar

 

 

 
Ultrasound Interventional Pain Course Registration 
 
 
For Anesthesia Board Prep Click Here!
May 20, 2024

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:
 
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

May 2, 2024
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:
 
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

Apr 17, 2024
 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:
 
Live Workshop Calendar
Ultrasound Interventional Pain Course Registration 
 
 
For Anesthesia Board Prep Click Here!
Apr 3, 2024

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.
Feb 28, 2024

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.

 
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
Feb 8, 2024

In this episode, Garden City (long island) based Pain Physician, Dr. David Rosenblum explores Peripheral Nerve Stimulation, Biologics and Ablations for hip pain.

He reviews a case report of a 67-year-old female with a history of a mechanical fall causing injury to her lumbar spine and pelvis resulting in hip and pelvic pain is presented. The patient had hypertrophic non-union of the right iliac wing fracture and displacement of the pubic symphysis and right sacroiliac joint. Medications were not effectively managing her pain, so she sought treatment at a pain management clinic.

The patient underwent diagnostic obturator and femoral articular nerve branch injections, as well as a middle cluneal nerve steroid injection, all guided by fluoroscopy and ultrasound. She experienced improvement in her pain following these procedures. Subsequently, she had a peripheral nerve stimulator (PNS) trial and underwent implantation of leads targeting the right middle cluneal nerve and right obturator and femoral articular nerve branches.

The patient reported significant relief in both the posterior and anterior distribution of her pain. Her activities of daily living improved, and she was able to sleep without pain after the PNS implantation. The successful use of combined fluoroscopy and ultrasound in targeting the specific nerves and replicating the patient's pain distribution before permanent PNS implantation is highlighted in this case.

Additionally, the show notes mention an events calendar located at this link: https://www.nrappain.org/pages/ultrasound-course-calendar.

Upcoming Course schedule for NRAP Academy includes the following events:

  1. Ultrasound Guided Pain & Regional Anesthesia Course in New York City on February 10, 2024. This course will cover nerve blocks, joint injections, and more. Attendees will have the opportunity to scan live models after the didactic session.

  2. MSK Pain & Regional Anesthesia Course in Miami, Florida on February 18, 2024. This course will focus on ultrasound-guided nerve blocks and MSK (musculoskeletal) pain management.

  3. Ultrasound Guided Pain Course in Key West, Florida on February 23, 2024. This 4 CME (Continuing Medical Education) course will cover ultrasound-guided nerve blocks, MSK, PRP (platelet-rich plasma), BMAC (bone marrow aspirate concentrate) targets, and regional anesthesia.

  4. Regional Anesthesia and US Guided Pain Management Course in New York City on March 9, 2024. This course will provide training in ultrasound-guided interventional pain management and regional anesthesia.

  5. Ultrasound Guided IPM (Interventional Pain Management) Course in West Virginia on April 14, 2024. This course is part of the Appalachian Regional Spine and Pain Meeting and will be conducted by NRAP Academy. It will focus on interventional pain management using ultrasound guidance.

  6. Regenerative Pain Medicine Course in New York City on May 4, 2024. This course will cover PRP (platelet-rich plasma) and other regenerative pain medicine techniques.

In addition to the live training, attendees will receive bonus material including access to the On Demand Ultrasound Guided MSK Interventional Pain Management Course, a course workbook and certificate, post-course guidance and discounts, and the opportunity to join the mailing list for calendar updates.

Please note that these course details are subject to change, so it's recommended to visit the NRAP Academy website for the most up-to-date information.

Reference

Fu E, Elsharkawy H
#35977 Peripheral nerve stimulation implant for chronic post-traumatic hip and pelvic pain
Jan 24, 2024

Painexam Podcast Show Notes: Journal Club on "Ventricular Infusion and Nanoprobes Identify Cerebrospinal Fluid and Glymphatic Circulation in Human Nerves"

Special Thanks to Robert Stall, MD

Introduction:

  • Welcome to another episode of the Painexam Podcast! In today's journal club edition, we delve into a fascinating study by Dr. Joel E. Pessa on cerebrospinal fluid (CSF) circulation in human nerves.

Background:

  • The study addresses the growing evidence of CSF circulation in human nerves and its implications in various conditions encountered by plastic surgeons.
  • Conditions such as nerve transection, stretch injuries, and peripheral neuropathy may be related to dysregulation of the CSF system.

Methods:

  • Dr. Pessa and his team developed the ventricular infusion technique using buffered saline in 2017.
  • The technique was applied to eight fresh cadavers before dissecting the median nerve.
  • Fluorescent imaging and nanoprobe injections were combined with ventricular infusion in selected specimens.

Results:

  • The eight cadaver specimens (six female, two male) aged 46–97 underwent successful ventricular infusion.
  • Ventricular cannulation was performed successfully using specific coordinates.
  • Results suggest that CSF flows in neural sheaths, including pia meninges, epineurial channels, perineurium, and myelin sheaths (neurolemma).

Conclusions:

  • Ventricular infusion and nanoprobes effectively identify CSF flow in neural sheaths of human nerves.
  • CSF flow in nerves is described as an open circulatory system occurring via channels, intracellular flow, and cell-to-cell transport associated with glial cells.
  • Neural sheaths, including neurolemma, may play a role in glucose and solute transport to axons.
  • The techniques showcased in this study can be utilized in anatomic dissection and live animal models and have been extended to the central nervous system to identify direct ventricle-to-pia meninges CSF pathways.

Significance:

  • This study opens new avenues for understanding the intricate mechanisms of CSF circulation in neural tissues.
  • Plastic surgeons and researchers can benefit from these techniques in studying and addressing conditions related to CSF dysregulation in nerves.
  • The findings have implications not only for nerve-related conditions but also for broader applications in the central nervous system.

Closing:

  • Thank you for joining us on this insightful journey through Dr. Joel E. Pessa's study. Stay tuned for more engaging discussions on pain management and neurology in future Painexam Podcast episodes!

Reference

Pessa JE. Ventricular Infusion and Nanoprobes Identify Cerebrospinal Fluid and Glymphatic Circulation in Human Nerves. Plast Reconstr Surg Glob Open. 2022 Feb 17;10(2):e4126. doi: 10.1097/GOX.0000000000004126. PMID: 35198353; PMCID: PMC8856590.

Jan 10, 2024

 

Exploring the Role of Ultrasound in Headache Evaluation and Treatment

A Journal Club based on Dr. Andrea Trescott's article: 

 Ultrasound for evaluation and treatment of headaches. Anaesth Pain & Intensive Care 2017;21(2):241-253.

Click Here to Claim CME for reflecting on content presented in this journal club.

David Rosenblum, MD

Accepting New Patients

Patients Interested in scheduling a consultation with Dr. David Rosenblum can call 

516 482 7246 (Garden City) or 718 436 7246 (Brooklyn)

In this Podcast, Dr. Rosenblum discusses patient's in his practice who responsed to ultrasound guided nerve blocks in the treatment of headaches.  He discusses the use of ultrasound injections as opposed to medication to manage the pain and references Dr. Trescott's comprehensive article on the various nerves and clinical presentations of headaches related to terminal nerve entrapment or irritation. 

Dr. Rosenblum discusses

  • Supraorbital Neuralgia
  • Auriculotemproal Nerve
  • Anatomy
  • Clinical presentation
  • Interventional Pain Therapies

Summary of Dr. Trescott's Article and Key Points:

  • Headaches, affecting 28 million people in the US, pose a significant burden on society in terms of medical costs and lost labor. They are complex neurologic disorders with diverse origins and causes.
  • Headaches are often viewed as the primary pathology, but they are fundamentally a symptom. Understanding them is an evolving science, and their patterns can be recognized for effective diagnosis and treatment.
  • In 2003, Pareja et al proposed the term "epicrania" for headaches triggered by extracranial causes, suggesting a link between intracranial components and extracranial nerves.

Peripheral Triggers and Plastic Surgery:

  • Plastic surgeons noted relief of migraines through corrugator muscle resection and botulinum toxin injection, indicating peripheral headache triggers.
  • Severe migraines post-head or neck injury may have an extracranial origin, suggesting peripheral nerve irritation. Traditional migraine medications may offer modest relief.
  • Primary treatment involves inhibiting nerve irritation through interventional pain techniques, turning off the pain origin and associated migraine centers.

Ultrasound Advantages:

  • Evaluation and injection of nerves have traditionally used landmarks and fluoroscopic images, but ultrasound offers unique advantages.
  • Nerves often travel with arteries, potentially contributing to "throbbing" pain. Ultrasound provides a more precise and dynamic visualization of these structures.

Exploring Extracranial Causes:

  • The International Classification of Headache Disorders (ICHD) categorizes headaches as primary or secondary. While valuable, it broadly defines peripheral nerve contributions as "Other Terminal Branch Neuralgias."
  • The study of extracranial peripheral nerve entrapments and dysfunction reveals overlap between ICHD-defined headaches and potential nerve entrapments causing these pain patterns.
  • Collaboration with disciplines like pain management enriches the understanding and treatment options for headaches.

Conclusion:

  • Headaches, often seen as isolated intracranial phenomena, may have extracranial triggers. Understanding and treating these triggers, especially through ultrasound-guided techniques, present a promising avenue in headache management.

NRAP Academy also offers:

 

Private Ultrasound Training Available

Email Info@NRAPpain.org

Reference:

  • Trescot A. Ultrasound for evaluation and treatment of headaches. Anaesth Pain & Intensive Care 2017;21(2):241-253.

Publication Details:

  • Received: 15 Aug 2015, Reviewed: 2 Jun 2016, Accepted: 28 Jun 2016.

This podcast explores the dynamic relationship between intracranial and extracranial factors in headaches, shedding light on potential breakthroughs in their evaluation and treatment.

  #interventionalpain #painboards #painfellowship #painexam  #regionalanesthesia #ultrasoundguidedpain #ultrasoundpain #ultrasoundmsk   #paincme #paincmecourse

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