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

Regional Anesthesia & Pain Medicine 2023;48:A193.

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.

For  up to date Calendar, Click Here!

#painboards #painfellowship #abpm #aspn #abipp #Asipp

#nans #painexam #painexampodcast #regionalanesthesia #regemed #regenerativepainmedicine #jointinjections #prppain #bmac #painqbank #uspaininjections #Usjointinjections #interventionalpain

References

Dr. Rosenblum discusses posterior hip pain/buttock pain near scar after Total Hip Arthroplasty. Included in this episode:

• Patient Testimonial re: SPRINT PNS (superior gluteal and superior cluneal nerve)
• Superior Gluteal Nerve Anatomy
• Hip Innervation
• Upcoming Private and Group Ultrasound Training

Upcoming Pain Management Conferences

Course Calendar

2023

Ultrasound Guided Regional Anesthesia and Pain Medicine- Sept 15, 2023, San Juan, PR

Oct. 28 Regional Anesthesia and Interventional Pain Medicine NYC

Nov.11 Regenerative Pain Medicine Course: NYC  

Dec. 16th Regional Anesthesia and Interventional Pain Ultrasound Training NYC

2024

Jan. 6 Regional Anesthesia and Interventional Pain Ultrasound Training NYC

For  up to date Calendar, Click Here!

Board Review

References

Pierre Laumonerie and others, Sensory Innervation of the Hip Joint and Referred Pain: A Systematic Review of the Literature, Pain Medicine, Volume 22, Issue 5, May 2021, Pages 1149–1157, https://doi.org/10.1093/pm/pnab061

Pinho, A.R.; Leite, M.J.; Lixa, J.; Silva, M.R.; Vieira, P.; Nery-Monterroso, J.; Bezerra, M.C.; Alves, H.; Madeira, M.D.; Pereira, P.A. Superior Gluteal Nerve Anatomy and Its Injuries: Aiming for a More Secure Surgical Approach of the Pelvic Region. Diagnostics 2023, 13, 2314. https://doi.org/10.3390/diagnostics13142314

Lung K, Lui F. Anatomy, Abdomen and Pelvis: Superior Gluteal Nerve. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK535408/

David Rosenblum, MD Garden City and Brooklyn Pain Physician, world renown for his work on the PainExam Podcast, PainExam Pain Management Board Review and NRAP Academy’s Continuing Medical Education Programs, discusses: a case of paresthesia in the upper neck realted to C3 and C4 stenosis and considers a selective nerve root block while wondering if a deep cervical plexus block would suffice.  

Rational :

• Desire to avoid epidural due to proximity to spinal cord
• Ultrasound approach of cervial plexus may anesthetize C3 and C4 roots and may be sufficient to do with ultrasound alone
• Unfortunately, no data found to support this particular situation, however, it may be safe and effective if performed properly.   

Claim CME

The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/lubWXJ

Also discussed on this podcast:

The Superficial Cervical Plexus and applications for headache, neck pain, and clavicular fractures. 

Caution: Phrenic Nerve

Anatomy

The cervical plexus is a complex network of nerves located in the neck region, originating from the anterior rami (branches) of the cervical spinal nerves, specifically those stemming from the upper cervical segments (C1 to C4). This intricate network serves to provide sensory and motor innervation to various structures within the neck and surrounding areas.

The cervical plexus is positioned within a groove between the longus capitis and the middle scalene muscles in the neck. It is organized into different nerve loops and branches that radiate outwards to supply various regions. The cervical plexus can be divided into deep and superficial components, each with distinct functions and innervation patterns.

Cervical Plexus: The plexus involves nerve loops and branches that provide both sensory and motor functions. The superficial sensory branches originating from adjacent anterior spinal nerves (C2 to C4) are responsible for providing sensation to specific areas of the skin, particularly in the head, neck, and shoulder regions. These sensory branches include the lesser occipital nerve (C2, C3), great auricular nerve (C2, C3), transverse cervical nerve (C2, C3), and supraclavicular nerves (C3, C4). These nerves typically run posteriorly and then penetrate the prevertebral fascia before reaching the skin and superficial structures.

For Pain Management and Anesethesiology Board Review, go to

For the Virtual Pain Fellowship Experience, Go to:

Ultrasound Workshops and Courses

Ultrasound Guided Regional Anesthesia and Pain Medicine NYC- July 19, 2023

Ultrasound Guided Regional Anesthesia and Pain Medicine NYC- August 19th, 2023

Ultrasound Guided Regional Anesthesia and Pain Medicine- Sept 15, 2023, San Juan, PR

Regenerative Pain Medicine Course NYC- November 11, 2023

For  up to date Calendar, Click Here!

Refereces

Kim JS, Ko JS, Bang S, Kim H, Lee SY. Cervical plexus block. Korean J Anesthesiol. 2018 Aug;71(4):274-288. doi: 10.4097/kja.d.18.00143. Epub 2018 Jul 4. PMID: 29969890; PMCID: PMC6078883. Read more!

ISPN Dubai 2023

David Rosenblum, MD interviews Reda Tolba, MD on the PainExam Podcast

In this episode, we delve into the realm of Pain Management in the US and the Middle East. Our international pain experts discuss the upcoming ISPN (International Society for Pain and Neuroscience) meeting in Dubai this december.

Dr. Reda Tolba, MD, chairs the Pain Management Department at Cleveland Clinic Abu Dhabi. He's internationally recognized for his contributions to Pain Medicine, boasting a wealth of experience from institutions like Wake Forest University Medical Center and Ochsner Health System.

Dr. David Rosenblum, MD, is the Director of Pain Management at Maimonides Medical Center and a driving force behind pain education platforms like PainExam.com and NRAP Academy. He's a pioneer in ultrasound-guided pain procedures, having trained thousands of physicians online and in person.

Tune in to hear Dr. Tolba's journey to being named Chair of Pain at Cleveland Clinic, Abu Dhabi, and his impressive academic and clinical achievements.Dr. Rosenblum, on the other hand, is known through his contributions to safe pain management protocols, and his mission to spread knowledge through podcasts and educational events.

Patients, interested he's scheduling an appointment with Dr. Rosenblum at his Long Island or Brooklyn Locations can go to AABPpain.com or call 718 436 7246 or 516 482 7246

To learn more about their work and educational initiatives, explore NRAPpain.org and PainExam.com/events. Join us in this episode to uncover insights from these leading figures in Pain Management.

Ultrasound Guided Regional Anesthesia and Pain Medicine NYC- August 19th, 2023

Ultrasound Guided Regional Anesthesia and Pain Medicine- Sept 15, 2023, San Juan, PR

For  up to date Calendar, Click Here!

Reference

Ruth Bedson, MBBS FRCA , Anna Riccoboni, MBChB FRCA, Physiology of pregnancy: clinical anaesthetic implications, Continuing Education in Anaesthesia Critical Care & Pain, Volume 14, Issue 2, April 2014, Pages 69–72, https://doi.org/10.1093/bjaceaccp/mkt036

Neurosurgery and Regional Anesthesia

Claim CME Credit:

In this episode, we will explore the various regional anesthesia techniques used in neurosurgery, specifically focusing on blocks for head, neck, and spinal surgeries.

Segment 1: Blocks used in Head and Neck Surgeries

1. Scalp Block:

• The scalp block involves blocking six nerves that provide sensory innervation to the scalp.
• It is performed by subcutaneous infiltration of local anesthetics (such as bupivacaine, ropivacaine, or levobupivacaine) for each nerve.
• Ultrasound guidance has improved the precision of block administration.
• The main indication for a scalp block is awake craniotomy, but it is also used in other procedures like deep brain stimulation and cranioplasty surgery.
• Scalp block offers advantages such as accurate neurological evaluation, pre-emptive analgesia, and hemodynamic stability during surgery.
• It also reduces postoperative pain, the need for rescue analgesics, and pain scores in the early postoperative period.

2. Infraorbital Block (IOB):

• The infraorbital nerve block targets the infraorbital nerve, which supplies the skin and mucous membrane of the upper lip, lower eyelid, and cheek.
• The IOB can be performed using the classical landmark technique or ultrasound guidance.
• Ultrasound guidance provides real-time visualization and accurate needle placement.
• IOB combined with general anesthesia is beneficial for postoperative pain relief in procedures like endoscopic trans-nasal trans-sphenoidal (TNTS) approach for pituitary tumor excision.
• Other regional techniques like sphenopalatine ganglion block and maxillary nerve blocks have also been attempted for transsphenoidal surgeries.

3. Trigeminal Nerve Block:

• Trigeminal nerve block is used for patients unresponsive to medical management of trigeminal neuralgia.
• Traditionally performed using the paresthesia technique, ultrasound guidance allows real-time visualization and confirmation of local anesthetic spread.
• Ultrasound guidance helps locate the Gasserian ganglion and visualize the trigeminal ganglion, providing a safe and radiation-free procedure for pain relief.

Segment 2: Blocks used for Spinal Surgeries

1. Cervical Plexus Block (CPB):

• CPB is commonly used in carotid endarterectomy (CEA) and cervical spine surgery.
• Different levels of CPB can be performed depending on the depth of injection.
• Superficial CPB involves injecting local anesthetic superficially into the deep cervical fascia.
• Deep CPB requires depositing local anesthetic deep to the prevertebral fascia.
• CPB helps in monitoring cerebral blood flow during CEA and provides postoperative pain relief.
• Ultrasound guidance can be used for superficial CPB, ensuring accurate needle placement and local anesthetic spread.

2. Erector Spinae Block (ESB):

• ESB is used for pain control in spinal surgeries.
• It involves depositing local anesthetic in the plane between the erector spinae muscle and the transverse process.
• ESB provides effective postoperative analgesia and reduces opioid consumption.

Regional anesthesia techniques play a crucial role in neurosurgery, providing effective pain relief and improving patient outcomes. Blocks like scalp block, infraorbital block, trigeminal nerve block, cervical plexus block, and erector spinae block offer numerous advantages in specific procedures. Ultrasound guidance has enhanced the precision and safety of block administration. These techniques contribute to improved surgical outcomes and patient satisfaction in neurosurgical procedures.

Upcoming Courses and Workshops!

Course Calendar

Practice Management Webinar: The End of the Public Health Emergency. What’s Changed and what Opportunities Remain!

Pain Management Board Review/Refresher Course/ Ultrasound Training NYC- June 9-11, 2023

Ultrasound Guided Regional Anesthesia and Pain Medicine NYC- July 19, 2023

Ultrasound Guided Regional Anesthesia and Pain Medicine NYC- August 19th, 2023

Ultrasound Guided Regional Anesthesia and Pain Medicine- Sept 15, 2023, San Juan, PR

For  up to date Calendar, Click Here!

Introduction: Providing anesthesia for pediatric orthopedic patients poses unique challenges for anesthesiologists. The approach must consider the psychological development of the child and the prevalence of respiratory infections. Pain management, management of concomitant diseases, and risk reduction for adverse events are crucial aspects of anesthetic care. This blog post will review the perioperative concerns specific to pediatric orthopedic procedures, discuss pain control methods used, and highlight anesthetic considerations for certain surgeries.

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Select Pediatric Perioperative Concerns:

1. Upper Respiratory Tract Infections (URI): Pediatric patients presenting for orthopedic surgery with current or recent URIs pose a challenge for anesthesiologists and surgeons. Children commonly experience URIs with symptoms like a runny nose, cough, and fever. While the viral infection may reside in the nasopharynx, the lower respiratory tract remains sensitive for up to 6 weeks after URI symptoms have resolved. This increased sensitivity puts patients at risk for perioperative complications like laryngospasm, bronchospasm, and oxygen desaturation. Delaying surgery for 6 weeks after URI resolution is often impractical, as another URI is likely to occur. For elective surgery, severe symptoms and complications warrant postponing surgery, but clear nasal discharge in an otherwise healthy patient may proceed with elective surgery. Clinical decision-making becomes challenging for cases falling between these extremes. Factors such as patient age, comorbidities, prior cancellations, surgery complexity, and urgency are considered when deciding whether to postpone surgery. If elective surgery is delayed, most clinicians would wait 2 to 4 weeks after URI symptom resolution.
2. Anxiety in the Pediatric Patient: Pediatric patients undergoing orthopedic surgery often experience varying levels of anxiety and distress. Preoperative stressors can include unfamiliar environments, procedures, hunger, fear of pain, and separation from parents. Certain risk factors contribute to preoperative anxiety, such as ages 1 to 5 years, shy temperament, prior negative medical experiences, high cognitive levels, and parental anxiety. Unaddressed anxiety can lead to postoperative behavioral changes, including generalized anxiety, separation anxiety, aggression, and nighttime crying. It can also result in higher pain scores and increased pain medication requirements after surgery. Strategies to mitigate preoperative anxiety include presurgical preparation programs involving site visits, videos, books, and child-life interventions. Allowing parental presence during anesthesia induction can help alleviate separation anxiety. Pharmacologic interventions like oral midazolam can improve compliance and reduce negative behavioral changes in the short term.
3.  

Anesthetic Management for Orthopedic Procedures:

1. Anesthetic Considerations for Select Pediatric Orthopedic Surgeries: Scoliosis Surgery: Anesthetic concerns during scoliosis surgery include optimizing neuromonitoring signals, managing blood loss, preventing positioning-related injuries, and minimizing the risk of postoperative visual loss.

2. Pain Management: Pain control for pediatric orthopedic patients involves a multimodal pharmacologic approach to minimize opioid requirements. This approach includes non-opioid analgesics, local anesthetics, and regional anesthesia techniques. Regional anesthesia, such as peripheral nerve blocks and caudal anesthesia, is particularly valuable for postoperative pain control. Recent studies have confirmed the safety of regional anesthesia in the pediatric population.

Pediatric orthopedic surgeries present unique challenges for anesthesiologists. Effective management of preoperative anxiety, careful consideration of upper respiratory tract infections, and appropriate pain control strategies are essential for successful outcomes. Anesthesiologists must tailor their approach to the specific needs of pediatric patients undergoing orthopedic procedures to ensure their safety and well-being.

Reference

 Wu JP. Pediatric Anesthesia Concerns and Management for Orthopedic Procedures. Pediatr Clin North Am. 2020 Feb;67(1):71-84. doi: 10.1016/j.pcl.2019.09.006. PMID: 31779838; PMCID: PMC7172179.

Anesthesiology Board Review Newsletter

Practice Management Webinar: The End of the Public Health Emergency. What’s Changed and what Opportunities Remain!

Join digital health leader and Upside Health CEO Rachel Trobman and PainExam.com founder Dr. David Rosenblum in a conversation about the impact of the end of the public health emergency in May could have on your pain management practice. We'll specifically discuss the changes to telehealth and remote patient monitoring. The webinar will close with one of Upside Health's clients outlining the launch and successes of RTM in their practice and be available for Q&A.

Course Calendar

Regenerative Pain Medicine Course NYC- May 13

Pain Management Board Review/Refresher Course/ Ultrasound Training NYC- June 9-11, 2023

Ultrasound Guided Regional Anesthesia and Pain Medicine NYC- July 19, 2023

Ultrasound Guided Regional Anesthesia and Pain Medicine NYC- August 19th, 2023

Ultrasound Guided Regional Anesthesia and Pain Medicine- Sept 15, 2023, San Juan, PR

For  up to date Calendar, Click Here!

For Board Prep go to www.AnesthesiaExam.com

For more questions Email Rachel Trobman at Rachel@upside.health

References