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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: July, 2024
Jul 31, 2024

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

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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. Clinical Implications:

    • https://form.jotform.com/240446610837052How 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.
  6. 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.

Wisipp annual meeting

Resources:

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 
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.

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.

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