Summary

In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures.

Chapters

Introduction to the Pain Exam Podcast and Topic Overview

Dr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease.

Upcoming Conferences and Educational Opportunities

Dr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities.

Overview of Postherpetic Neuralgia

Dr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life.

Treatment Options Overview

Dr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics.

Phases of Herpes Zoster and Definitions

Dr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash.

Incidence and Risk Factors

Dr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia.

Impact on Quality of Life

Dr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia.

Literature Review and Pathophysiology

Dr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia.

Central Sensitization and Nerve Damage

Dr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome.

Different Phenotypes and Classification

Dr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration.

Deafferentation Phenotype

Dr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial.

Diagnosis and Physical Examination

Dr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients.

Sensory Testing and Assessment

Dr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons.

Prevention Through Vaccination

Dr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions.

Treatment Objectives

Dr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation.

Antiviral Medications

Dr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised.

Benefits of Antiviral Therapy

Dr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible.

Corticosteroids and Opioids

Dr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction.

Methadone and Antidepressants

Dr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction.

Antiepileptics and Pharmacological Treatment Summary

Dr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011.

Topical Agents

Dr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group.

Intracutaneous Injections

Dr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study.

Summary of Local Anesthetics

Dr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy.

Interventional Treatments: Epidural and Paravertebral Injections

Dr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster.

Comparative Studies on Injection Approaches

Dr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster.

Timing of Interventions and Continuous Epidural Blockade

Dr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality.

Interventions for Postherpetic Neuralgia

Dr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence.

Summary of Epidural and Paravertebral Injections

Dr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy.

Pulsed Radiofrequency (PRF) Evidence

Dr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy.

PRF Studies for Acute Herpes Zoster

Dr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group.

PRF for Trigeminal Neuralgia

Dr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group.

PRF Compared to Other Interventions

Dr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate.

Summary of PRF and Final Recommendations

Dr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature.

Sympathetic Blocks and Conclusion

Dr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia.

Personal Clinical Approach and Closing

Dr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast.

Q&A

No Q&A session in this lecture

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Highlights

David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care.  As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.

Awards

New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025

Schneps Media: 2015, 2016, 2017, 2019, 2020

Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025

Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023

Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology.  He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County’s Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures.  He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!

Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy  and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques. 

Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators.

He is currently treating patients in his great neck and Brooklyn office.  For an appointment go to AABPpain.com or call

Brooklyn     718 436 7246

Reference

Adriaansen, E. J., Jacobs, J. G., Vernooij, L. M., van Wijck, A. J., Cohen, S. P., Huygen, F. J., & Rijsdijk, M. (2025). 8. Herpes zoster and post herpetic neuralgia. Pain Practice, 25(1), e13423.

Summary

In this Pain Exam Podcast episode, Dr. David Rosenblum discusses a journal club article on low volume neurolytic retrocrural celiac plexus blocks for visceral cancer pain. The study reviewed 507 patients with severe malignancy-related abdominal pain, with data retained for 455 patients at the 5-month mark. Dr. Rosenblum explains that the procedure involves injecting 3-5ml of 6% aqueous phenol at the T12-L1 level under fluoroscopic guidance, with an average procedure time of 16.3 minutes. The study found significant pain relief lasting up to six months, reduced opioid consumption, and improved quality of life for patients with primary abdominal cancer or metastatic disease. Dr. Rosenblum shares his personal experience with celiac plexus blocks, including the trans-aortic approach he trained on, and mentions his interest in ultrasound-guided approaches. He also announces upcoming teaching engagements at ASPN, Pain Week, and other conferences, as well as CME ultrasound courses available through nrappain.org. Additionally, he mentions a new community page on the website where users can share board preparation information, though he emphasizes that remembered board questions should not be posted as he is a board question writer himself.

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Highlights

Introduction and Upcoming Events

Dr. David Rosenblum introduces the Pain Exam Podcast and shares information about upcoming events. He mentions teaching ultrasound at ASPN in July, attending Pain Week in September, and participating in the Latin American Pain Society conference. Dr. Rosenblum also promotes his CME ultrasound courses available at nrappain.org and mentions he's considering organizing another regenerative medicine course in fall or winter. He offers private training for those wanting more intensive ultrasound instruction.

Board Prep Community Announcement

Dr. Rosenblum announces a new community page on the nrappain.org website for board preparation. He explains that registered users can access free information and keywords relevant to board exams. He emphasizes that users should not post remembered questions as this would be inappropriate, noting that he himself is a board question writer for various pain boards. Dr. Rosenblum mentions that a post about phenol in this community inspired today's podcast topic.

Journal Article Overview on Celiac Plexus Block

Dr. Rosenblum introduces a journal article on low volume neurolytic retrocrural celiac plexus block for visceral cancer pain, a retrospective review of 507 patients with severe malignancy-related abdominal pain. He explains that the study assessed pain relief provided by this procedure, its duration, reduction in daily opioid consumption, and quality of life improvements. The patients received neurolytic blocks without previous diagnostic blocks due to multiple comorbidities, which Dr. Rosenblum acknowledges is sometimes necessary with very sick patients despite the typical preference for diagnostic blocks before neurolysis.

Dr. Rosenblum's Personal Experience with Celiac Plexus Blocks

Dr. Rosenblum shares his personal training experience with trans-aortic celiac plexus blocks, where a needle is inserted through the aorta after confirming no plaques or aneurysms are present. He describes it as a safe and effective procedure despite sounding intimidating. He mentions he's only performed a handful of these procedures and doesn't do many now as an outpatient pain doctor.

Study Methods and Results

Dr. Rosenblum details the study methods, noting that of 507 patients studied, data for 455 was retained at the end of the review. Patients were evaluated before and after the neurolytic retrocrural celiac plexus block under fluoroscopic guidance. Assessment included procedure duration, pain scores (0-10 scale), daily opioid consumption, and quality of life improvement. Follow-up was completed six months after the procedure, showing improved pain scores, reduced opioid consumption, and better quality of life throughout the study period. Some pain returned during months 4-6 due to disease progression and the anticipated duration of the neurolytic agent. The study noted a 6.7% initial vascular contrast uptake during the procedure while using digital subtraction angiography with fluoroscopy.

Study Limitations and Conclusions

Dr. Rosenblum discusses the study's limitations, including the need for a larger sample size and a prospective trial with a control group, though he acknowledges this is unrealistic given the patient population. He mentions that a proven quality of life questionnaire would be beneficial, and that comparing alcohol, phenol, and RF thermocoagulation would be interesting to evaluate duration effects and side effects. The study concluded that low volume neurolytic retrocrural celiac plexus block with phenol is safe, providing up to six months of pain relief for abdominal pain due to primary malignancy or metastatic spread.

Detailed Procedure Technique

Dr. Rosenblum explains the detailed procedure technique used in the study. The retrocrural celiac plexus was targeted at L1 level with aim towards T12. Anterior and posterior radiographic imaging aligning the spinous process of T12-L1 junction was used with 15-20 degree oblique rotation. Local anesthetic (1% lidocaine with sodium bicarbonate) was infiltrated along the injection path. A 22 or 25 gauge 3.5-7 inch curved spinal needle was used depending on patient body habitus. Dr. Rosenblum notes he typically uses a 6-inch Chiba needle or 25 gauge spinal needle for such procedures.

Procedure Execution and Monitoring

Dr. Rosenblum continues describing the procedure, noting that the needle was advanced to the anterior border of T12-L1 under multiple imaging views. Contrast dye studies verified spread and location, with digital subtraction angiography used to check for intravascular uptake. A test dose of 1ml of 0.5% bupivacaine with epinephrine per site was administered, which Dr. Rosenblum finds interesting as he typically doesn't mix bupivacaine with epinephrine. After confirming no vascular uptake, 3-5ml of 6% aqueous phenol was injected in 1ml aliquots while communicating with the patient. The average procedure time was 16.3 minutes with minimal or no sedation. Patients remained prone for 30 minutes afterward to avoid neuroforaminal spread, as phenol is heavier and more viscous than alcohol.

Post-Procedure Care and Study Evaluation

Dr. Rosenblum explains that patients were monitored in recovery for one hour for adverse events and their ability to eat and void easily. They were discharged once hospital post-anesthetic criteria were met and received a follow-up call 24 hours later. Dr. Rosenblum praises the study and notes that the procedure looks similar to a lumbar sympathetic plexus block, which is also a sympathetic block.

Ultrasound Considerations and Alternative Approaches

Dr. Rosenblum shares his interest in ultrasound-guided celiac plexus blocks but acknowledges concerns about bowel perforation. He mentions a conversation with an interventional radiology colleague who suggested a transhepatic approach. Dr. Rosenblum recalls scanning a very thin patient where the aorta was easily visible and close to the anterior abdominal wall, making the celiac plexus potentially accessible if bowel perforation, liver bleeding, or gallbladder perforation could be avoided. He shares an experience with a patient suffering from severe pancreatitis pain who received temporary relief from a paravertebral thoracic nerve block at T8-T10, noting that paravertebral blocks provide some sympathetic spread.

Conclusion and Community Resource Reminder

Dr. Rosenblum concludes by recommending the article, noting its well-written analysis and graphs showing morphine consumption dropping over months following the procedure. He suggests neurolytic procedures are underutilized because they sound intimidating. He again encourages listeners to check out the community he created with separate chat rooms for regenerative medicine, regional anesthesia, and pain boards, where users can share keywords but not specific board questions. Dr. Rosenblum reminds listeners about upcoming courses and his website resources, mentions an upcoming PRP lecture, and asks for five-star reviews if listeners enjoy the podcast. The episode ends with a standard medical disclaimer.

Reference

https://www.painphysicianjournal.com/current/pdf?article=NTQwOA%3D%3D&journal=113

Summary

Dr. David Rosenblum delivered a comprehensive lecture on gender differences in opiate effects and prescribing practices. He discussed several key studies examining how opiates affect males and females differently, both in animal models and humans. Dr. Rosenblum shared findings showing that morphine has stronger analgesic effects in males, while females experience longer-lasting effects. He also addressed racial disparities in opiate prescribing, noting that white patients are more likely to receive opiates. From his personal clinical experience in Brooklyn, Dr. Rosenblum observed that certain populations tend to be at higher risk for opiate abuse. The lecture covered gender-specific risk factors for opiate misuse, with women tending toward emotional/psychological factors and men showing more behavioral issues.

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Chapters

Introduction and Upcoming Conferences

Dr. Rosenblum introduced himself as the host of the Pain Exam Podcast and announced several upcoming conferences including ASPN in July, PainWeek in September, and other events where he will be teaching ultrasound and regenerative medicine.

Board Preparation and Opiate Topics

Dr. Rosenblum discussed his role in board preparation through painxam.com and nreppain.org. He emphasized that opiates are a frequently tested topic across different board examinations (FIP, ABPM, ABIP, ABA).

Gender Differences in Opiate Effects - Animal Studies

Dr. Rosenblum presented research showing that in animal studies, morphine exhibited stronger analgesic effects in males, while females showed longer-lasting effects and could tolerate higher doses. He noted that physical dependence was more severe in male rats during spontaneous withdrawal.

Racial and Gender Disparities in Opiate Prescribing

Dr. Rosenblum discussed a 2025 study revealing racial disparities in opiate prescribing, with white patients more likely to receive opiates. He shared his personal clinical experience in Brooklyn, noting that young white males were often higher-risk for abuse.

Gender-Specific Risk Factors for Opiate Misuse

Dr. Rosenblum detailed how women tend to show emotional and psychological risk factors for opiate misuse, while men demonstrate more behavioral risk factors. Women were more likely to report distress and past trauma, while men showed higher rates of criminal behavior and substance abuse history.

References

Djurendic-Brenesel, Maja, et al. "Gender-related differences in the pharmacokinetics of opiates." Forensic science international 194.1-3 (2010): 28-33.

Cicero, Theodore J., Shawn C. Aylward, and Edward R. Meyer. "Gender differences in the intravenous self-administration of mu opiate agonists." Pharmacology Biochemistry and Behavior 74.3 (2003): 541-549.

Podcast Show Notes: Peripheral Vascular Disease in PainManagement

Episode Highlights:
- Host: Dr. David Rosenblum
- Podcast: Pain Exam Podcast
- Focus: Peripheral Arterial Disease (PAD) in Pain Management

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Key Topics Covered:
1. Peripheral Arterial Disease (PAD) Overview
- Definition: Arterial sclerosis condition developing over long term
- WHO Definition: Exercise-related pain or ankle-brachial index (ABI) < 0.9
- Prevalence:
  * 3-4% in 60-65 year olds
  * Increases to 15-20% in 85-90 year olds
  * Up to 50% of patients may progress to symptomatic stages

2. Diagnostic Considerations
Diagnostic Tests:
- Ankle Brachial Index (ABI)
- Ultrasound
- CT Angiography
- Physical examination
- Pulse volume recordings
- Transcutaneous oximetry

ABI Interpretation:
- 1.0-1.4: Normal
- 0.9-1.0: Acceptable
- 0.8-0.9: Some arterial disease
- 0.5-0.8: Moderate arterial disease
- < 0.5: Severe arterial disease

3. Pain Characteristics
Types of Pain:
- Intermittent claudication
- Chronic limb ischemia
- Nociceptive pain
- Neuropathic pain
- Mixed pain syndrome

4. Pain Management Strategies
Pharmacological Approaches:
- Mild Pain: Paracetamol, NSAIDs
- Neuropathic Pain: Lidocaine patches, gabapentin, duloxetine
- Severe Pain: Morphine, fentanyl, ketamine

Non-Pharmacological Interventions:
- Music therapy
- Aromatherapy
- Psychotherapy
- Massage
- Acupuncture
- TENS
- Intermittent pneumatic compression

Upcoming Conferences Mentioned:
- ASPN
- ASIPP
- Pain Week
- Latin American Pain Society

Additional Resources:
- Pain Exam newsletter: painexam.com
- Virtual pain fellowship at nrappain.org

Disclaimer: Always consult with a healthcare professional for personalized medical advice.

Reference

Garba Rimamskep Shamaki, Favour Markson, Demilade Soji-Ayoade, Chibuike Charles Agwuegbo, Michael Olaseni Bamgbose, Bob-Manuel Tamunoinemi,
Peripheral Artery Disease: A Comprehensive Updated Review,
Current Problems in Cardiology, Volume 47, Issue 11, 2022,101082,

Maier, J.A.; Andrés, V.; Castiglioni, S.; Giudici, A.; Lau, E.S.; Nemcsik, J.; Seta, F.; Zaninotto, P.; Catalano, M.; Hamburg, N.M. Aging and Vascular Disease: A Multidisciplinary Overview. J. Clin. Med. 2023, 12, 5512. https://doi.org/10.3390/jcm12175512

Maier, J.A.; Andrés, V.; Castiglioni, S.; Giudici, A.; Lau, E.S.; Nemcsik, J.; Seta, F.; Zaninotto, P.; Catalano, M.; Hamburg, N.M. Aging and Vascular Disease: A Multidisciplinary Overview. J. Clin. Med. 2023, 12, 5512. https://doi.org/10.3390/jcm12175512  

Dr. Rosenblum Reviews Questions from my previous lecture, he gave at the trigeminal academy in Indonesia.

Dr. Rosenblum explores techniques for rich plasma injection and preparation. He discusses centrifuge settings with plasma volume and concentration as well as the addition of hyaluronic acid to platelet rich plasma.

Dr. Rosenb;um also received multiple comments on the recent video that he filmed on performing a cervical selective nerve root block under ultrasound. 

For more informatin go to NRAPpain.org

Disclaimer: This Podcast,video, website and any content from NRAP Academy   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.

Episode Summary: In this episode of NRAP's PainExam Podcast, host David Rosenblum, MD, interviews Dr. Thomas Strouse about his extensive experience with Scrambler Therapy and the evidence supporting its use in treating chronic pain.

 

They delve into the intricacies of this innovative therapy, discussing treatment protocols, patient responses, and the overall effectiveness of Scrambler Therapy for various pain conditions. 

 

Key Topics Discussed: - Overview of Scrambler Therapy and its analgesic response. - The importance of adjusting treatment intensity based on patient feedback. - Sensations experienced by patients during therapy (from burning to tapping). - Safety considerations for patients with pacemakers during treatment. - Insights into the effectiveness of Scrambler Therapy for conditions such as discogenic back pain and peripheral neuropathy. - Discussion on treatment costs for patients and providers. - Experiences with patients who have experienced pain recurrence after treatment. - The role of booster sessions in maintaining pain relief. -

 

Challenges faced by failed back surgery patients and the potential benefits of Scrambler Therapy. Resources Mentioned: -

 

Contact information for Stefan Erickson at  stefan@mail.scramblertherapy.com to integrate Scrambler therapy into your practice.

 

Links to additional resources and research on Scrambler Therapy. Info] Additional Information: - For more information about upcoming webinars, including the next session on cervical ultrasound, visit  www.NRAPpain.org

 

Thank you for tuning in to NRAP's PainExam Podcast! We hope you find the insights shared in this episode valuable in your journey toward understanding and managing chronic pain.

 

NY based anesthesiologist, David Rosenblum, MD, is one of the first interventional pain physicians in the country to integrate ultrasound guidance into his pain practice. Since 2007, he has been an international leader in the treatment of chronic pain. He has helped countless of patients suffering from back, neck, knee, shoulder, hip joint pain and has been at the forefront of regenerative pain medicine, minimally invasive pain therapies and medical education. Patients can schedule a consultation by going to www.AABPpain.com or calling: Brooklyn Office 718 436 7246

 

Creators Biography: David Rosenblum, MD, currently treats patients in Garden City and Brooklyn. He serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care. As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn , NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.

 

 Dr. Rosenblum has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County’s Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is working closely with the American Society of Interventional Pain Physicians (ASIPP), Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, and various state societies, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures. He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!

 

Doctor Rosenblum is a co-founder of the International Pain Academy and created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques. Office based Pain Physicians, Physiatrists, Emergency Room Physicians, Anesthesiologists, Neurologists and Orthopedics who treat pain, utilize Neuromodulation and use PRP, Bone Marrow Aspirate or any other Biologics will benefit from this course. #longislandpaindoctor #interventionalpain #paindoctor #scrambler #scramblertherapy

Host: David Rosenblum, MD Guest: Phillip Kim, MD Date: January 24, 2025 Time: 6:30 AM

Episode Summary: In this episode of the PainExam Podcast, Dr. David Rosenblum engages with Dr. Phillip Kim to discuss the Federation Pain Care Access, a newly formed organization advocating for improved access to interventional pain treatments. The episode delves into the challenges posed by restrictive insurance coverage policies and the collaborative efforts needed to address these issues effectively.

Key Discussion Points: -Introduction to Federation Pain Care Access: A new entity focused on advocating for emergent and standard care in interventional pain treatments, aiming to enhance access through advocacy and legislative solutions. - Impact of Restrictive Policies: Dr. Kim highlights how insurance carriers like Evicor, AIM, and Optum impose restrictive coverage policies that harm patients and practitioners, particularly amid the ongoing opioid epidemic.

AIM, Optum and Evicore are not insurance carriers. these are separate entities which oversee utilization management and prior auth requests for insurance carriers (HMO, TPA's etc) e g. BCBS plans, UHS etc.

Prior Authorization Challenges: Discussion on the AMA 2022 Prior Authorization Physician Survey, which indicates significant negative impacts on patient care due to prior authorization processes. - Case Studies: Dr. Kim shares specific cases where patients faced harm due to denied claims, including issues related to medical cannabis and necessary medical equipment.

- Collaboration with Medical Societies: The Federation works alongside various pain societies and stakeholders to address common concerns and push for better coverage policies. - Future Goals Plans for meetings with CMS and Medicare Administrative Contractors (MACs) regarding specific treatments like SI joint radiofrequency ablation, aiming to improve coverage and access.

Fundraising and Outreach: The Federation seeks to grow its membership and funding through outreach to allied health professionals and patient care groups while launching a media campaign to raise awareness of patient struggles

 Legal and Advocacy Efforts: Emphasis on the need for legal considerations in advocacy efforts and the importance of public support in achieving the Federation's goals. - The No Pain Act: Discussion on recent legislation aimed at expanding access to non-opioid treatments and alternatives for chronic pain management. Guest Bio: Phillip Kim, MD is a leading advocate for pain care access and a founding member of the Federation Pain Care Access. He brings extensive experience in managing chronic pain patients and navigating healthcare policies. Resources

 Federation Pain Care Access Website: 

https://www.painfed.org

# board Listeners are encouraged to support the Federation Pain Care Access by visiting their website to learn more about their initiatives and consider contributing to help advance their mission.

Join Dr. Rosenblum and Dr. Kim in this vital conversation about the ongoing efforts to improve pain care access and the importance of collaboration in overcoming the challenges faced by patients and healthcare providers.

Long island based anesthesiologist, David Rosenblum, MD, is one of the first interventional pain physicians in the country to integrate ultrasound guidance into his pain practice. Since 2007, he has been an international leader in the treatment of chronic pain. He has helped countless of patients suffering from back, neck, knee, shoulder, hip joint pain and has been at the forefront of regenerative pain medicine, minimally invasive pain therapies and medical education.

 Patients can schedule a consultation by going to

 www.AABPpain.com or calling: Brooklyn Office 718 436 7246

Garden City Office 516 482 7246

Unlock new, well-reimbursed services: Spravato, a needle-mover for pain practices. Discover how Spravato, an FDA-approved esketamine treatment for depression, can drive significant financial reimbursement for your practice while improving patient outcomes. Join me as I meet with Yakov Kagan, CEO and co-founder of Big Leap Health, as he highlights the clinical efficacy of Spravato, its comparison to ketamine, and its financial impact. Learn key considerations for launching—whether independently or via an MSO—and actionable steps to get started, from staff training to billing essentials. Yakov will also share insights into future developments like monotherapy developments, helping your practice stay ahead in this rapidly evolving field.

For more information and to integrate Spravato into your Pain Practice go to https://www.bigleaphealth.com

Host David Rosenblum, MD Long island based anesthesiologist, David Rosenblum, MD, is one of the first interventional pain physicians in the country to integrate ultrasound guidance into his pain practice. Since 2007, he has been an international leader in the treatment of chronic pain. He has helped countless of patients suffering from back, neck, knee, shoulder, hip joint pain and has been at the forefront of regenerative pain medicine, minimally invasive pain therapies and medical education.

Patients can schedule a consultation by going to www.AABPpain.com or calling:

Brooklyn Office 718 436 7246

Garden City Office 516 482 7246

NRAP Academy also offers:

• Board Review
• Anesthesiology
• Pain Management
• Physical Medicine and Rehabilitation
• Regenerative Medicine Training 
• Live Workshops
• Online Training
• The Virtual Pain Fellowship (online training program with discount to live workshops)

Regional Anesthesia & Pain Ultrasound Course

Private Training Available

Email Info@NRAPpain.org

**Disclaimer:** The information presented in this podcast is for educational purposes only and should not be considered medical advice. Always consult a healthcare professional for medical concerns.

Episode Title: Ketamine for Cancer and Pain Management - Journal Club

Host: David Rosenblum, MD

Upcoming Free Webinars:
1. Exploring Innovative Mental Health Treatments which are well reimbursed
   Discussing Spravato, Transmagnetic Stimulation, and Ketamine Infusion, sponsored by Big Leap Health. Register!

2. Understanding Scrambler Therapy
   Learn about this revolutionary approach to pain management. Register!

3. Cervical Ultrasound: Anatomy and Interventional Pain Targets
   Sponsored by Clarius, this session will explore advanced imaging techniques. Register!

Sign up for the webinars and check out our full calendar of events.

Join us for this insightful episode as we explore the potential of ketamine in transforming pain management practices!

Summary

In today's episode, we delve into the emerging role of ketamine in managing cancer and chronic pain. Our discussion is anchored around a comprehensive review article titled "Ketamine Use for Cancer and Chronic Pain Management," published in Frontiers in Pharmacology on February 1, 2021. This review, authored by Clayton Culp, Hee Kee Kim, and Salahadin Abdi, explores ketamine's potential as an analgesic in chronic pain conditions, particularly cancer-related neuropathic pain.

Key Points from the Review Article:
- Mechanism of Action: Ketamine functions as an N-methyl-D-aspartate receptor antagonist, providing analgesic effects at sub-anesthetic doses. Its ability to counteract central nervous system sensitization makes it effective in opioid-induced hyperalgesia.
- Clinical Efficacy: Recent studies highlight ketamine's potential to reduce pain scores and opioid consumption, offering a promising alternative for patients with refractory pain.
- Safety Profile: At lower doses used for analgesia, ketamine's safety and adverse event profile are significantly improved compared to its use as an anesthetic.
- Pharmacogenomics and Interactions: The article discusses how genetic variations can affect ketamine metabolism and highlights potential drug interactions that clinicians should be aware of.

Reference

Culp, Clayton, Hee Kee Kim, and Salahadin Abdi. "Ketamine use for cancer and chronic pain management." Frontiers in Pharmacology 11 (2021): 599721.

Episode Title: Evidence-Based Regenerative Pain Medicine with Guilherme Ferreira Dos Santos, MD CIPS

Host: David Rosenblum  
Guest: Guilherme Ferreira Dos Santos, MD CIPS

Episode Overview:
In this insightful episode of the PainExam Podcast, Dr. David Rosenblum sits down with Dr. Guilherme Ferreira Dos Santos, a distinguished expert in pain medicine who is well known for his research, educational endeavors and expertise in Regenerative Pain Medicine and Ultrasound-Guided interventions. Together, they delve into the evolving landscape of regenerative pain medicine, focusing on evidence-based practices and the standardization of Platelet-Rich Plasma (PRP) quality. 

Key Topics Discussed: 

- Evidence-Based Regenerative Pain Medicine: An exploration of current research and practices that inform effective pain management strategies.

- PRP Quality and Standardization: Discussion on the importance of PRP quality in treatment outcomes and the need for standardized protocols.

- Ultrasound-Guided Spine Interventions: Insights into the benefits and techniques of ultrasound guidance in performing spinal interventions, including a conversation on avoiding cervical epidurals.

- Access to Pain Care: A comparative analysis of the differences in access to pain care across Portugal, Spain, the USA, and Canada, highlighting challenges and opportunities in each region.

- Pain Expo Dubai: An overview of the upcoming Pain Expo in Dubai, where both Dr. Rosenblum and Dr. Ferreira Dos Santos will be presenting, sharing their expertise with a global audience.

Guest Biography:  
Dr. Guilherme Ferreira Dos Santos is an Interventional Pain Medicine Specialist and Clinical Scientist with a career spanning Portugal, the United States, Canada, and Spain. He began his journey at the University of Lisbon, earning his Medical Degree in 2014, followed by a five-year residency program in Physical Medicine and Rehabilitation, which he completed in 2020. His fascination with Interventional Pain Medicine led him to the Department of Pain Medicine at Mayo Clinic, where he served as an Invited Clinical Research Scholar in 2018 and 2021 under the mentorship of Dr. Mark Friedrich Hurdle. At Mayo Clinic, he contributed to refining ultrasound-guided techniques for chronic spinal pain.

Dr. Ferreira dos Santos further advanced his expertise with a Clinical Fellowship in Chronic Pain Medicine at the University of Toronto in 2022, training under esteemed mentors such as Dr. Anuj Bhatia, Dr. Paul Tumber, and Dr. Philip Peng. In this role, he was instrumental in advancing education on ultrasound-guided techniques nationally and internationally, which deepened his clinical skills and passion for mentorship.

Currently based in Barcelona, Dr. Ferreira Dos Santos serves as the Senior Specialist and Responsible Clinical Lead for the Education and Training Excellence Center in Pain Medicine at Hospital Clínic de Barcelona. He is also the Director of the Clinical Fellowship Program in Interventional Pain Medicine. Throughout his career, he has lectured at international conferences in over 25 countries and authored more than 35 peer-reviewed Q1 articles. His contributions have earned him several accolades, including the 2018 Grant for Young Clinical Researcher of the Year in Pain Medicine from the Grünenthal Foundation, the 2020 Gofeld Academic Scholarship Award, and the 2022 Nikolai Bogduk Young Investigator Grant. His journey across four countries has shaped his approach to clinical care, research, and mentorship, fueling his mission to improve pain management globally.

 Listen to the Episode:  
Tune in to gain valuable insights from Dr. Ferreira Dos Santos and learn more about the future of pain medicine. Available on all major podcast platforms.

 Links and Resources: 
- NRAP Academy
- Follow Dr. David Rosenblum on X and LinkedIn
- Follow Dr. Guilherme Ferreira Dos Santos on LinkedIn

 Join the Conversation: 
We encourage our listeners to reach out with their thoughts and questions! Use the hashtag #PainExamPodcast on social media to engage with us.

S ubscribe and Review: 
If you enjoyed this episode, please subscribe and leave a review on your favorite podcast platform. Your feedback helps us improve and reach more listeners!

 Next Episode Preview:   
Stay tuned for our next episode, where we will continue to explore the latest advancements in pain management and treatment options.

 Painexam Podcast Episode Show Notes 

 Episode Title:  Exploring Naturopathy in Pain Medicine with Dr. Sarah Trahan

 Host: David Rosenblum, MD  
David Rosenblum is a dedicated pain management specialist with extensive experience in treating chronic pain conditions. He is passionate about integrating various approaches to improve patient outcomes and enhance quality of life. His expertise and commitment to patient-centered care make him a trusted voice in the field of pain medicine. His NY Practice is located in Brooklyn and Garden City and through his international educaitonal platform he has attracted physicians and pateints from all over the world to seek out consultation on the latest breakthroughs in interventional pain management. 

 Guest: Dr. Sarah Trahan  
Dr. Sarah Trahan is a licensed naturopathic physician with a focus on holistic approaches to pain management and regenerative therapies. With a background in both conventional and alternative medicine, Dr. Trahan is committed to empowering patients through education and personalized treatment plans that address the root causes of pain.

 Episode Summary: 
In this episode, David Rosenblum, MD, interviews Dr. Sarah Trahan to explore the role of naturopathy in pain medicine and the potential of regenerative therapies. Dr. Trahan shares her insights on how naturopathic principles can complement traditional pain management approaches, offering a comprehensive view of patient care.

 Key Discussion Points: 

-  ntroduction to Naturopathy: 
  Dr. Trahan explains the philosophy of naturopathic medicine and its emphasis on treating the whole person rather than just symptoms.

-  The Role of Naturopathy in Pain Management: 
  The conversation delves into how naturopathy can be integrated into pain management strategies, including dietary changes, lifestyle modifications, and natural supplements.

- Regenerative Therapies: 
  Dr. Trahan discusses the latest advancements in regenerative therapies, focusing on how these approaches can be applied in the context of pain management without delving into stem cell treatments.

- Patient-Centered Care: 
  Emphasizing the importance of a collaborative approach, Dr. Trahan shares strategies for working with patients to develop tailored treatment plans that align with their individual needs and preferences.

- Success Stories  
  Dr. Trahan recounts some of her most impactful approaches and  success stories, illustrating the benefits of combining naturopathic and conventional approaches to pain relief.

- NRAP Academy Online Courses and Workshops:   
  Dr. Trahan highlights the educational opportunities available through the NRAP Academy, which offers online courses and workshops aimed at healthcare professionals interested in enhancing their understanding of naturopathic principles in pain management. Private ultrasound training is also available for those seeking hands-on experience. For more information, visit NRAPpain.org

 Resources  

Pain Management CME Workshop Calendar  

Pain Medicine CME Board Prep and Online Courses  

Tune in to this insightful conversation to learn more about how naturopathy and regenerative therapies can play a vital role in managing pain and improving patient outcomes.

Stay connected with Painexam for more episodes on pain management and treatment innovations. Don't forget to subscribe and leave a review!

 
For questions or feedback, reach out to us at info@nrappain.org

---

This episode promises to provide valuable insights for healthcare professionals and patients alike, highlighting the importance of a holistic approach to pain management.

Exploring the Efficacy of Autologous Platelet Leukocyte Rich Plasma Injections in Chronic Low Back Pain & Understanding Degenerative Lumbar Spinal Stenosis

 Host David Rosenblum, MD

 Episode Date: October 25, 2024

In this episode, Dr. David Rosenblum discusses two significant studies related to chronic low back pain and degenerative lumbar conditions. The first study focuses on the use of autologous platelet leukocyte rich plasma (PLRP) injections for treating atrophied lumbar multifidus muscles, while the second study investigates the correlation between muscle atrophy and the severity of degenerative lumbar spinal stenosis (DLSS).

 Featured Article 1: 
- Effect of Autologous Platelet Leukocyte Rich Plasma Injections on Atrophied Lumbar Multifidus Muscle in Low Back Pain Patients with Monosegmental Degenerative Disc Disease
- **Authors:** Mohamed Hussein, Tamer Hussein
 

 Key Points Discussed 
1. Background:  Correlation between lumbar multifidus muscle dysfunction and chronic low back pain.
2.  Study Overview: 115 patients treated with weekly PLRP injections for six weeks, followed for 24 months.
3.  Outcome Measures:  Significant improvements in NRS and ODI scores, with high patient satisfaction.
4. Conclusions: PLRP injections into the atrophied multifidus muscle are safe and effective for managing chronic low back pain.

 Featured Article 2: 
-   Degenerative Lumbar Spinal Stenosis
 Authors:*  Gen Xia, Xueru Li, Yanbing Shang, Bin Fu, Feng Jiang, Huan Liu, Yongdong Qiao

 Key Points Discussed 
1. Background:  DLSS is a common condition in older adults, often leading to muscle atrophy and disability.
2. Study Overview: A retrospective analysis involving 232 patients to investigate the correlation between muscle atrophy and spinal stenosis severity.
3.  Results: 
   - Significant differences in the ratio of fat-free multifidus muscle cross-sectional area between stenotic and non-stenotic segments.
   - A strong positive correlation was found between multifidus atrophy and the severity of spinal stenosis.
   - The atrophy was more pronounced on symptomatic sides of the spine compared to contralateral sides.
4.  Conclusions:  The findings suggest that more severe spinal stenosis is associated with greater muscle atrophy, emphasizing the importance of addressing muscle health in DLSS patients.

 Discussion: 
Dr. Rosenblum provides insights into how these studies inform clinical practices for treating chronic low back pain and managing degenerative conditions. He emphasizes the need for comprehensive treatment strategies that consider both muscle health and spinal integrity which may be achieved via peripheral nerve stimulation of the medial branch nerve and multifidus muscle or PRP injection in to the multifidus muscle.

 Closing Remarks: 
Listeners are encouraged to stay informed about innovative treatment options and the importance of muscle assessment in managing spinal disorders.

**Follow Us:**
- Subscribe to the Painexam Podcast for more episodes discussing the latest in pain management research and treatments.
- Connect with us on social media [insert social media links].

NRAP Academy also offers:

• Board Review
• Anesthesiology
• Pain Management
• Physical Medicine and Rehabilitation
• Regenerative Medicine Training 
• Live Workshops
• Online Training
• The Virtual Pain Fellowship (online training program with discount to live workshops)

Regional Anesthesia & Pain Ultrasound Course

Private Training Available

Email Info@NRAPpain.org

**Disclaimer:** The information presented in this podcast is for educational purposes only and should not be considered medical advice. Always consult a healthcare professional for medical concerns.

References

Xia, G., Li, X., Shang, Y. et al. Correlation between severity of spinal stenosis and multifidus atrophy in degenerative lumbar spinal stenosis. BMC Musculoskelet Disord 22, 536 (2021). https://doi.org/10.1186/s12891-021-04411-5

Hussein M, Hussein T. Effect of autologous platelet leukocyte rich plasma injections on atrophied lumbar multifidus muscle in low back pain patients with monosegmental degenerative disc disease. SICOT J. 2016 Mar 22;2:12. doi: 10.1051/sicotj/2016002. PMID: 27163101; PMCID: PMC4849261.

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.

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

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.

 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?

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 esteemed 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.

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 Anesthesia Board Prep Click Here!

References

https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2023.1293358/full

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.

Dr. Rosenblum reviews information he found regarding the various types of peptides that private practices are useing for healht and wellness. 

Upcoming Pain Management Conferences

Upcoming Workshops and Events

For  up to date Calendar, Click Here!

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/