Podcast Summary

This episode of the Pain Exam Podcast, hosted by Dr. David Rosenblum, discusses an interesting article about Ketorolac injections for musculoskeletal conditions. The podcast covers:

• Ketorolac is an NSAID that provides analgesic and anti-inflammatory effects through inhibition of prostaglandin synthesis

• Multiple studies comparing Ketorolac injections to corticosteroids and hyaluronic acid for various conditions

• Research shows Ketorolac injections are equally effective as corticosteroids for subacromial conditions, adhesive capsulitis, carpal-metacarpal joint issues, and hip/knee osteoarthritis

• Ketorolac may be a safer alternative to steroids for certain patients, though it has its own contraindications for those with renal, gastrointestinal, or cardiovascular disease

• Dr. Rosenblum considers the potential of using Ketorolac injections directly at pain sites rather than intramuscularly

Upcoming Courses and Conferences

• Ultrasound courses in New York and Costa Rica (check unwrappedpain.org)

• Private ultrasound sessions available

• Dr. Rosenblum will be speaking at Pain Week about ultrasound in pain practice and PRP

• Presenting at a primary care conference in London

• Teaching ultrasound at ISPN

• LAPSES conference in Chile (Dr. Rosenblum won't attend this year)

Ketorolac Injections: An Effective Alternative for Musculoskeletal Pain Management

Musculoskeletal conditions such as bursitis, adhesive capsulitis, and osteoarthritis affect millions and often require injectable therapies to reduce pain and inflammation. Traditionally, corticosteroid injections have been the mainstay treatment. However, concerns over side effects like tendon rupture, cartilage damage, and systemic hyperglycemia have prompted exploration of alternatives. A recent narrative review by Kiel et al. (2024) highlights ketorolac—a parenteral nonsteroidal anti-inflammatory drug (NSAID)—as a promising substitute for corticosteroids in musculoskeletal injections.

Warning: OFF Label use of Ketorolac discussed. Please consult your physician.

See full article  for details.

Subacromial Ketorolac Injections for Shoulder Pain

Subacromial bursitis and impingement syndrome are common causes of shoulder pain and disability. Several randomized controlled trials have shown that subacromial ketorolac injections provide pain relief and functional improvement comparable to corticosteroids:

• Goyal et al. demonstrated significant reductions in pain scores after subacromial injection of 60 mg ketorolac versus 40 mg methylprednisolone, with no difference in outcomes between groups.
• Taheri et al. found similar short-term pain relief at 1 and 3 months with either ketorolac or corticosteroid subacromial injections.
• Kim et al. reported equivalent clinical improvement in rotator cuff syndrome patients receiving ketorolac or triamcinolone injections.
• Min et al. noted ketorolac led to better forward flexion and patient satisfaction at 4 weeks compared to corticosteroids.

These studies support ketorolac as an effective agent for subacromial injection, offering an alternative for patients where corticosteroid use is limited.

Intra-articular Ketorolac Injections for Adhesive Capsulitis and Osteoarthritis

Adhesive capsulitis (frozen shoulder) and osteoarthritis of the hip, knee, and carpometacarpal joint are often treated with intra-articular corticosteroids. Ketorolac injections have shown comparable efficacy in these conditions:

• Akhtar et al. found intra-articular ketorolac significantly reduced shoulder pain at 4 weeks in adhesive capsulitis compared to hyaluronic acid.
• Ahn et al. reported similar pain relief between intra-articular ketorolac and corticosteroid injections in adhesive capsulitis, with ketorolac providing superior shoulder mobility at 3 and 6 months.
• Koh et al. showed that adding ketorolac to hyaluronic acid injections in carpometacarpal osteoarthritis resulted in faster onset of pain relief compared to hyaluronic acid alone.
• Park et al. observed equivalent functional improvements with intra-articular ketorolac or corticosteroids in hip osteoarthritis.
• Jurgensmeier et al. demonstrated similar symptom improvement at 1 and 3 months post-injection for ketorolac and triamcinolone in hip and knee osteoarthritis.
• Xu et al. and Bellamy et al. confirmed ketorolac’s comparable pain relief and functional benefits to corticosteroids for knee osteoarthritis, with ketorolac being more cost-effective.
• Lee et al. noted quicker pain reduction with intra-articular ketorolac combined with hyaluronic acid versus hyaluronic acid alone in knee osteoarthritis.

aSafety and Pharmacologic Considerations

Ketorolac’s anti-inflammatory action stems from cyclooxygenase inhibition, reducing prostaglandin synthesis. Its half-life is approximately 5.2–5.6 hours, and it is metabolized in the liver. Unlike corticosteroids, ketorolac avoids systemic hyperglycemia and cartilage damage risks. Animal and in vitro studies suggest ketorolac may protect cartilage by inhibiting inflammatory cytokines.

While gastrointestinal, renal, and cardiovascular risks associated with NSAIDs remain considerations, localized intra-articular and subacromial ketorolac injections may limit systemic exposure and adverse effects. Mild, transient post-injection pain has been reported but resolves without intervention.

Conclusion

Ketorolac injections, administered intra-articularly or subacromially, are a safe, effective, and economical alternative to corticosteroids for managing common musculoskeletal conditions. Their comparable efficacy in reducing pain and improving function, combined with a more favorable side effect profile, makes ketorolac an appealing option for clinicians and patients alike. Further research is warranted to fully elucidate long-term safety and optimal dosing strategies.

FAQS

Ketorolac Injections for Musculoskeletal Conditions: Frequently Asked Questions

Musculoskeletal pain from conditions like bursitis, adhesive capsulitis, and osteoarthritis often requires injectable treatments. Ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is emerging as a promising alternative to corticosteroids. Below are common questions and answers based on a recent narrative review by Kiel et al. (2024).

1. What is ketorolac and how does it work?

Ketorolac is a parenteral NSAID that reduces pain and inflammation by inhibiting cyclooxygenase enzymes, which decreases prostaglandin synthesis. It can be administered orally, intramuscularly, intravenously, or by injection directly into joints or around bursae.

2. How effective is ketorolac for musculoskeletal conditions?

Studies show ketorolac injections provide significant pain relief and functional improvement comparable to corticosteroids in conditions like:

• Subacromial bursitis and shoulder impingement (subacromial injections)
• Adhesive capsulitis (frozen shoulder) (intra-articular injections)
• Osteoarthritis of the hip, knee, and thumb carpometacarpal joint (intra-articular injections)

3. What evidence supports subacromial ketorolac injections?

Randomized controlled trials found:

• Goyal et al. and Taheri et al. reported similar pain reduction and functional outcomes between ketorolac and corticosteroids for subacromial injections.
• Kim et al. and Min et al. observed comparable or better patient satisfaction and shoulder mobility with ketorolac versus corticosteroids.

4. How does intra-articular ketorolac compare to corticosteroids for adhesive capsulitis?

• Akhtar et al. showed ketorolac reduced shoulder pain more than hyaluronic acid.
• Ahn et al. found ketorolac and corticosteroids equally effective for pain relief, with ketorolac providing better shoulder mobility at 3 and 6 months.

5. What about ketorolac for osteoarthritis?

• Ketorolac combined with hyaluronic acid provided faster pain relief than hyaluronic acid alone in thumb carpometacarpal joint osteoarthritis (Koh et al.).
• Intra-articular ketorolac had similar efficacy to corticosteroids in hip (Park et al., Jurgensmeier et al.) and knee osteoarthritis (Bellamy et al., Xu et al.).
• Ketorolac injections were more cost-effective compared to corticosteroids (Bellamy et al.).

6. Are ketorolac injections safe?

Ketorolac's side effects are similar to other NSAIDs, mainly involving gastrointestinal, renal, and cardiovascular risks. However, localized intra-articular and subacromial injections may reduce systemic exposure. Animal studies suggest ketorolac does not harm cartilage and may protect against inflammatory damage. Mild, transient local pain post-injection is possible but usually resolves without treatment.

7. What are the limitations of ketorolac use?

Ketorolac is not suitable for patients with:

• Renal impairment
• Gastrointestinal ulcers or bleeding risk
• Cardiovascular disease or hypertension
• NSAID hypersensitivity, especially in asthma or chronic urticaria patients

Clinicians should assess individual risks before choosing ketorolac injections.

8. How does ketorolac’s pharmacokinetics affect its use?

Ketorolac has a plasma half-life of about 5.2 to 5.6 hours and is metabolized in the liver. Pharmacokinetics for subcutaneous or intra-articular administration are less defined but systemic absorption occurs. Its relatively short half-life supports repeated dosing if needed.

9. Why consider ketorolac over corticosteroids?

Ketorolac avoids corticosteroid-associated risks such as tendon rupture, cartilage damage, and steroid-induced hyperglycemia. It is also more cost-effective, making it a favorable option for patients and healthcare systems.

10. What further research is needed?

More large-scale, long-term studies are needed to fully understand ketorolac’s intra-articular effects, optimal dosing, and safety profile compared to corticosteroids and other treatments.

Summary: Ketorolac injections, whether intra-articular or subacromial, offer a safe, effective, and economical alternative to corticosteroids for managing various musculoskeletal conditions. This makes ketorolac an important option in pain management and inflammation control.

 

 

Reference:

Kiel J, Applewhite AI, Bertasi TGO, Bertasi RAO, Seemann LL, Costa LMC, Helmi H, Pujalte GGA. Ketorolac Injections for Musculoskeletal Conditions: A Narrative Review. Clinical Medicine & Research. 2024;22(1):19-27. DOI: https://doi.org/10.3121/cmr.2024.1847

Disclaimer: This Podcast, website and any content from NRAP Academy (PMRexam.com) 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.

 

 

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

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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

PRP in the Epidural Space for Radiculopathy

Brooklyn Based Pain Physician, David Rosenblum, MD known for his work publishing and teaching Regenerative Pain Medicine and Ultrasound Guided Pain Procedures hosts this podcast covering the latest and most advanced concepts in Pain Medicine.

Summary

Dr. David Rosenblum delivered a comprehensive lecture covering several key topics in pain management. He discussed his upcoming speaking engagements at PainWeek, ASPN and great upcoming meetings like the Latin American Pain Society, and other conferences. Dr. Rosenblum shared his extensive experience with PRP (Platelet-Rich Plasma) epidural injections, reviewing multiple research studies that support their efficacy. He highlighted three significant studies: a randomized control trial comparing PRP epidural injections to traditional treatments, a CT-guided epidural PRP study, and a 2025 meta-analysis comparing PRP to steroids. Dr. Rosenblum emphasized that PRP treatments are showing comparable or better results than traditional steroid injections, with potentially fewer required treatments and longer-lasting relief. He noted that while PRP is currently not covered by insurance, it represents a growing trend in 'natural' treatment approaches that patients increasingly prefer.

Chapters Introduction and Upcoming Events

Dr. Rosenblum announced his upcoming lectures at Pain Week focusing on ultrasound and regenerative medicine, followed by presentations at the Latin American Pain Society in Chile and the New York, New Jersey Pain Conference. He mentioned the SoMeDocs online pain conference accessible through nrappain.org, and upcoming ultrasound training sessions in New York City.

PRP Epidural Research Review

Dr. Rosenblum discussed a randomized control trial involving 30 patients receiving transforaminal epidural injections. The study showed that PRP patients demonstrated significant improvements in leg pain scores at 6, 12, and 24 weeks. He noted that while the study didn't use contrast, he personally prefers using contrast diluted with saline for better visualization.

CT-Guided Epidural Study Analysis

Dr. Rosenblum reviewed a study comparing CT-guided epidural PRP versus steroid injections, questioning the necessity of CT guidance. The study included 60 patients and showed similar results between PRP and steroid groups at six weeks, though he criticized the short follow-up period, noting that PRP typically takes months to show full effects.

Meta-Analysis Discussion

Dr. Rosenblum presented a 2025 meta-analysis comparing PRP to steroids in epidural injections. The analysis included 310 patients across five RCTs, demonstrating comparable efficacy between PRP and steroid injections without increased adverse events. He emphasized that his clinical experience shows patients typically require fewer PRP injections compared to steroid treatments.

 

 

 

 

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References

Wongjarupong, Asarn, et al. "“Platelet-Rich Plasma” epidural injection an emerging strategy in lumbar disc herniation: a Randomized Controlled Trial." BMC Musculoskeletal Disorders 24.1 (2023): 335.

Bise, Sylvain, et al. "Comparison of interlaminar CT-guided epidural platelet-rich plasma versus steroid injection in patients with lumbar radicular pain." European radiology 30 (2020): 3152-3160.

Muthu S, Viswanathan VK, Gangadaran P. Is platelet-rich plasma better than steroids as epidural drug of choice in lumbar disc disease with radiculopathy? Meta-analysis of randomized controlled trials. Exp Biol Med (Maywood). 2025 Feb 4;250:10390. doi: 10.3389/ebm.2025.10390. PMID: 39968415; PMCID: PMC11832311.

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.

  Kosten, Thomas R., Bruce J. Rounsaville, and Herbert D. Kleber. "Ethnic and gender differences among opiate addicts." International Journal of the Addictions 20.8 (1985): 1143-1162.  

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.

Jamison, Robert N., et al. "Gender differences in risk factors for aberrant prescription opioid use." The Journal of Pain 11.4 (2010): 312-320.

 

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  

Summary

At some point this medication may show its face on the pain boards.  Whether or not Suzetrigine will appear on the pain boards, all of us need to know about this new class of analgesic.

Brought to you by NRAP Academy, home of the PainExam Board Prep

Here, Dr. David Rosenblum delivered a comprehensive lecture about a new pain medication called Journavx (Suzetrigine). He discussed its mechanism of action as a NAV 1.8 receptor inhibitor, its clinical applications, contraindications, and dosing guidelines. Dr. Rosenblum emphasized that this non-opioid medication represents a new class of pain management drugs with no addiction potential. He also shared information about upcoming educational events, including ultrasound courses and various pain management conferences. The lecture included detailed information about drug interactions, safety considerations, and clinical trial results comparing Journavx to placebo and hydrocodone-acetaminophen combinations. Key findings from clinical trials showed that Jornavix achieved pain relief in 119 minutes compared to 480 minutes for placebo in abdominoplasty trials, and 240 minutes versus 480 minutes in bunionectomy trials. The recommended dosing is 50mg tablets twice daily, with an initial loading dose of 100mg. While the drug showed promising results for moderate to severe acute pain management, it did not demonstrate superiority over hydrocodone in clinical trials. Important contraindications include CYP3A inhibitors, and special considerations are needed for patients with hepatic impairment or those taking hormonal contraceptives. The medication should be taken on an empty stomach, either one hour before or two hours after food, and patients should avoid grapefruit juice while on this medication.

For more infomation....

Chapters Introduction and Upcoming Events

Dr. Rosenblum announced several upcoming events, including an ultrasound course in New York City on May 17th, 2025. He mentioned offering ultrasound and IV training for healthcare professionals, particularly nurses, ICUs, PAs, and hospital doctors. He also highlighted upcoming conferences including ASPN, Pain Week, Latin American Pain Society, New York, New Jersey Pain Congress, ASIPP, and EPA.

Introduction to Journavx (Suzetrigine)

Dr. Rosenblum introduced Suzetrigine (Journavx), a new 50mg tablet medication. He emphasized that this discussion was not sponsored by any pharmaceutical company but rather focused on educating about a new class of pain medication. He noted its potential importance as a future board examination topic.

Mechanism of Action

Dr. Rosenblum explained that Jornavx works by inhibiting the NAV 1.8 receptor. He detailed how the drug blocks sodium ions from entering pain-sensing neurons, disrupting action potential initiation and propagation. He emphasized that the drug is highly selective, binding over 31,000 times more selectively to NAV 1.8 than other NAV subtypes.

Contraindications and Drug Interactions

Dr. Rosenblum outlined various contraindications, particularly focusing on CYP3A inhibitors and inducers. He listed specific medications in each category and emphasized the importance of careful monitoring when prescribing Journavx alongside these medications.

Clinical Trial Results and Dosing Guidelines

Dr. Rosenblum presented clinical trial results showing Journavx's effectiveness in treating moderate to severe acute pain. He detailed the dosing guidelines: 50mg tablets twice daily, with an initial loading dose of 100mg. He emphasized the importance of taking the medication on an empty stomach and avoiding grapefruit juice.

Q&A

No Q&A session in this lecture

Summary

The video covers a conversation between Dr. David Rosenblum and Dr. Hamed Sadeghipour, discussing board preparation experiences and the current state of pain management practice. Dr. Rosenblum begins by announcing upcoming events, including a May 17th ultrasound course in New York City and his lectures at various conferences. He also mentions shadowing opportunities at his office. Dr. Sadeghipour shares his board preparation experience, discussing three main resources he used: Huntoon book (800 questions), Board Vitals (700 questions), and Pain Exam. He achieved notably high scores using these resources. Regarding his current practice, Dr. Sadeghipour describes working both in academic anesthesia (40-50% time) and private pain practice, managing four offices with four nurse practitioners.   The discussion then shifts to the changing landscape of pain management, with both doctors noting concerning trends: increasing focus on surgery center procedures over office-based ones due to reimbursement differences, the challenge of maintaining competency in advanced procedures, and competition from non-specialists entering the field. They also discuss the future of the specialty, suggesting it's moving toward becoming a hybrid of neurosurgery and orthopedic surgery with traditional pain management procedures.

 

For pain medicine Board Prep go to NRAPpain.org

For ultraound training go to NRAP Academy

Highlights Introduction and Upcoming Events

Dr. Rosenblum introduces the podcast and announces several upcoming events, including an ultrasound course in New York City on May 17th, appearances at ASPN and Pain Week conferences, and opportunities for shadowing at his practice.

Board Preparation Experience Discussion

Dr. Sadeghipour details his board preparation strategy using three main resources: Huntoon book (800 questions), Board Vitals (700 questions), and Pain Exam(700 questions videos, lectures, ultrasound training, regenerative medicine training and more). He explains the strengths and limitations of each resource and mentions achieving exceptionally high scores.

Current Practice Structure

Dr. Sadeghipour describes his dual practice model: 

Evolution of Pain Management Practice

Both doctors discuss the shifting landscape of pain management, noting increased focus on surgery center procedures, reimbursement challenges, and competition from non-specialists. They address concerns about fellowship training adequacy and the financial pressures affecting new practitioners.

Future of Pain Management Specialty

The discussion concludes with perspectives on the specialty's future, suggesting it's evolving toward a combination of minimally invasive spine surgery and traditional pain management, with concerns about maintaining specialty integrity and the need for stronger regulatory oversight.

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  [email protected] 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