The PMRExam Podcast

It's the day before the pain boards, so Dr. David Rosenblum skipped the Zoom and recorded a rapid-fire, last-minute review of the high-yield keywords and "board traps" most likely to show up on the ABA Pain Medicine exam. Listen on your commute or at the gym.

High-yield topics covered

• Neonatal pain: A-delta and C fibers and ascending pathways work before birth, but descending inhibition is immature, so neonatal pain may be exaggerated or prolonged. Board trap: incomplete myelination does not mean neonates can't feel pain.
• Dorsal horn anatomy: Rexed laminae I, II and V. Lamina II is the substantia gelatinosa.
• Peripheral vs. central sensitization: the "inflammatory soup" (prostaglandins, bradykinin, H+, ATP, histamine, serotonin, cytokines, NGF) causes primary hyperalgesia. NMDA activation, wind-up and expanded receptive fields cause secondary hyperalgesia and allodynia.
• Superficial cervical plexus (C2–C4): lesser occipital, great auricular, transverse cervical and supraclavicular nerves. Blocked behind the SCM, and useful for clavicle pain.
• Eagle syndrome: an elongated styloid process irritating the glossopharyngeal nerve.
• Pain scales: NIPS, CRIES, FLACC and modified FLACC, Wong-Baker FACES, FPS-R, NRS, VAS and PROMIS-10 Global Health.
• Statistics: sensitivity and specificity don't depend on prevalence, but PPV and NPV do. Type I error is a false positive (α = 0.05) and Type II error is a false negative.
• Acetaminophen toxicity: use the Rumack-Matthew nomogram at 4 hours or later (acute single ingestion only). N-acetylcysteine is the antidote.
• Buprenorphine: a high-affinity partial mu agonist and kappa antagonist, with a ceiling effect on respiratory depression.
• Drug toxicities: carbamazepine (SIADH, SJS with HLA-B*1502, CYP3A4 induction), methotrexate (leucovorin rescue), hydroxychloroquine (retina), TNF-α inhibitors (TB reactivation), JAK inhibitors (boxed warning for MACE, thrombosis, malignancy), NSAIDs, SSRIs/SNRIs and tramadol (hyponatremia).
• Muscle relaxants: baclofen, tizanidine, cyclobenzaprine, methocarbamol, metaxalone, carisoprodol (meprobamate), chlorzoxazone, dantrolene, diazepam and botulinum toxin (cleaves SNARE proteins).

Upcoming events

Coming up: the NY/NJ Pain Congress in November and the Latin American Pain Society meeting next year. Hands-on NRAP ultrasound courses in New York are coming up in October and November. See the calendar at nrappain.org.

Taking the boards next year? Start here:

More CME, board review and ultrasound training at www.NRAPpain.org.

Patients: in pain in Brooklyn or NYC?

Dr. Rosenblum treats patients with back, neck, joint and nerve pain in Brooklyn, NY, and offers virtual second opinions. Visit RosenblumPain.com or call (718) 436-7246 to book an appointment.

For educational purposes only. Not medical advice.

Artificial intelligence is moving fast from buzzword to clinical tool — and pain medicine is no exception. In this episode, Dr. David Rosenblum breaks down how AI is already touching the field, drawing on "Artificial Intelligence and Pain Medicine: An Introduction" by Hagedorn, George, Aiyer, Schmidt, Halamka, and D'Souza (Journal of Pain Research, 2024;17:509–518).

Topics covered:

• Why AI is expected to be a genuine turning point for healthcare, not just another tech trend
• Using machine learning to optimize clinical trial design and patient selection in pain research
• Natural language processing (NLP) tools that streamline physician workflow and improve doctor-patient communication
• Deep learning approaches to analyzing patient outcomes and predicting who responds best to a given treatment
• What better disease recognition and treatment selection could look like in day-to-day pain practice
• Practical implications for cost and time savings, product development, and clinical decision-making
• Where the evidence is still early, and what physicians should watch for as AI tools move toward the bedside

Bottom line: AI won't replace clinical judgment in pain medicine, but it's already starting to augment it — from trial design to the exam room. Physicians who understand where the technology is headed will be best positioned to use it well.

Reference: Hagedorn JM, George TK, Aiyer R, Schmidt K, Halamka J, D'Souza RS. Artificial Intelligence and Pain Medicine: An Introduction. J Pain Res. 2024;17:509–518. https://pmc.ncbi.nlm.nih.gov/articles/PMC10848920/

About the Host

David Rosenblum, MD is Director of Pain Management at Maimonides Medical Center and Co-Owner/Clinic Director of AABP Integrative Pain Care and Wellness in Brooklyn, NY. Dual board-certified in Anesthesiology and Pain Medicine, he is a co-author of the ASIPP Peripheral Nerve Stimulation (PNS) guidelines and a widely recognized educator in regenerative pain medicine (PRP, BMAC, amniotic therapies). As founder of NRAP Academy, he has trained 3,500+ physicians for pain board certification since 2008, and hosts the PainExam, AnesthesiaExam, and PMRExam podcasts. He has been named a New York Magazine "Top Doctor" from 2016–2026.

Living with chronic pain? Dr. Rosenblum sees patients for interventional and regenerative pain treatment - including epidurals, nerve blocks, spinal cord & peripheral nerve stimulation, and PRP/BMAC - at his Brooklyn, NY office. Visit RosenblumPain.com for more information. or call 718 436 7246

For Physicians & APPs - Continue Your Education:

• CME Course Calendar: https://www.nrappain.org/pages/upcoming-pain-management-conferences
• Virtual Pain Fellowship: https://www.nrappain.org/bundles/Virtual-Pain-Fellowship
• PainExam Board Prep: https://www.nrappain.org/pages/pain-management-cme-courses

This episode is brought to you by NRAP Academy and PainExam - visit www.NRAPpain.org for CME in neuromodulation, regional anesthesia, and pain medicine.

Ketamine clinics have exploded worldwide, offering low-dose intravenous infusions for chronic pain patients who've run out of options. But is this practice actually backed by evidence, or has off-label use outpaced the science?

In this episode of the PainExam Podcast, Dr. David Rosenblum reviews the current literature on subanaesthetic-dose ketamine infusions (SDKIs) for chronic pain, drawing on the 2023 British Journal of Pain review by Harry M. Griffiths, "Low-dose ketamine infusions for chronic pain management: Does this qualify as evidence-based practice?"

Topics covered:

• Why conventional analgesics (opioids, anticonvulsants, antidepressants) fail in 60–70% of chronic pain patients
• How ketamine works as an NMDA receptor antagonist, and why that mechanism is likely an oversimplification
• Typical SDKI dosing (~0.35–0.5 mg/kg) versus anesthetic dosing, and why the IV route dominates the evidence base
• What the meta-analyses actually show: modest, time-limited pain reduction (mean difference around -1.83 on a 0–10 scale) with higher efficacy but more side effects at higher doses
• Key trials — Corriger et al.'s 1-year follow-up (256 patients), Orhurhu et al.'s systematic review and meta-analysis, and smaller RCTs in CRPS, fibromyalgia, and ischemic limb pain
• Common side effects (nausea, psychomimetic symptoms) versus rare but serious adverse events (hepatic, cardiac, urogenital) — and how dose and premedication with clonidine/midazolam affect risk
• Why blinding failure (up to 93% of patients correctly guessing their treatment in one trial) may be inflating reported effect sizes
• The absence of standardized protocols, guidelines, or a clear "exit strategy" for patients on long-term SDKI therapy
• What needs to happen next: larger multicenter RCTs, ketamine clinic registries, and better outcome measures beyond simple pain scores

Bottom line: SDKIs offer a promising but still under-evidenced option for refractory chronic pain — reserved for the right patient, with modest expectations and careful monitoring.

Reference: Griffiths HM. Low-dose ketamine infusions for chronic pain management: Does this qualify as evidence-based practice? Br J Pain. 2023;17(5). https://journals.sagepub.com/doi/full/10.1177/20494637231182804

Show Image

About the Host

David Rosenblum, MD is Director of Pain Management at Maimonides Medical Center and Co-Owner/Clinic Director of AABP Integrative Pain Care and Wellness in Brooklyn, NY. Dual board-certified in Anesthesiology and Pain Medicine, he is a co-author of the ASIPP Peripheral Nerve Stimulation (PNS) guidelines and a widely recognized educator in regenerative pain medicine (PRP, BMAC, amniotic therapies). As founder of NRAP Academy, he has trained 3,500+ physicians for pain board certification since 2008, and hosts the PainExam, AnesthesiaExam, and PMRExam podcasts. He has been named a New York Magazine "Top Doctor" from 2016–2026.

Living with chronic pain? Dr. Rosenblum sees patients for interventional and regenerative pain treatment — including epidurals, nerve blocks, spinal cord & peripheral nerve stimulation, and PRP/BMAC — at his Brooklyn, NY office. Visit RosenblumPain.com for more information.

For Physicians & APPs — Continue Your Education:

• CME Course Calendar: https://www.nrappain.org/pages/upcoming-pain-management-conferences
• Virtual Pain Fellowship: https://www.nrappain.org/bundles/Virtual-Pain-Fellowship
• PainExam Board Prep: https://www.nrappain.org/pages/pain-management-cme-couåçrses

This episode is brought to you by NRAP Academy and PainExam — visit www.NRAPpain.org for CME in neuromodulation, regional anesthesia, and pain medicine.

*]:pointer-events-auto R6Vx5W_threadScrollVars scroll-mb-[calc(var(--scroll-root-safe-area-inset-bottom,0px)+var(--thread-response-height))] scroll-mt-(--sticky-padding-top)" dir="auto" data-turn-id="c3881c21-13af-4075-a5be-171053d37466" data-turn-id-container="c3881c21-13af-4075-a5be-171053d37466" data-testid="conversation-turn-3" data-turn="user"> *]:pointer-events-auto R6Vx5W_threadScrollVars scroll-mb-[calc(var(--scroll-root-safe-area-inset-bottom,0px)+var(--thread-response-height))] scroll-mt-[calc(var(--header-height)+min(200px,max(70px,20svh)))]" dir="auto" data-turn-id= "request-WEB:435fda1a-0142-445e-a974-3323f9f0ded7-1" data-turn-id-container= "request-WEB:435fda1a-0142-445e-a974-3323f9f0ded7-1" data-testid= "conversation-turn-4" data-turn="assistant"> PainExam Podcast Show Notes NAD+ Supplementation in Pain and Inflammation: Hype, Hope, or Emerging Science?

Hosted by: PainExam Podcast Presented by: NRAP Academy (Neuromodulation, Regional Anesthesia & Pain) Host: David Rosenblum, MD

Episode Overview

In this episode of the PainExam Podcast, we explore the growing interest in NAD+ (Nicotinamide Adenine Dinucleotide) supplementation and its potential role in pain management, inflammation reduction, cellular recovery, and healthy aging.

NAD+ is a naturally occurring coenzyme found in every living cell and is essential for energy production, mitochondrial function, DNA repair, and cellular resilience. As NAD+ levels decline with age, chronic stress, inflammation, and disease, researchers have begun investigating whether restoring NAD+ levels may improve outcomes in chronic pain conditions and inflammatory disorders.

We review the current science, discuss potential mechanisms of action, and examine how NAD+ therapy is being integrated into regenerative medicine, wellness programs, and pain management practices.

What is NAD+?

NAD+ is a coenzyme involved in:

✅ Cellular energy production (ATP generation)

✅ Mitochondrial health

✅ DNA repair pathways

✅ Oxidative stress reduction

✅ Neuroprotection

✅ Cellular signaling

✅ Activation of longevity-associated proteins called sirtuins

Without adequate NAD+, cells become less efficient at producing energy and managing inflammation.

Why Might NAD+ Matter in Chronic Pain?

Many chronic pain conditions involve:

• Mitochondrial dysfunction
• Oxidative stress
• Neuroinflammation
• Peripheral and central sensitization
• Impaired cellular recovery

Researchers hypothesize that optimizing NAD+ levels may help address several of these pathways simultaneously.

Potential areas of interest include:

Neuropathic Pain

NAD+ may support:

• Nerve repair
• Axonal recovery
• Mitochondrial function within neurons
• Reduction of oxidative injury

Inflammatory Pain

NAD+ influences inflammatory signaling pathways and may help modulate:

• Cytokine production
• Immune cell activity
• Cellular stress responses

Fatigue and Recovery

Patients with chronic pain frequently report:

• Fatigue
• Brain fog
• Reduced exercise tolerance
• Poor recovery

Because NAD+ plays a critical role in energy metabolism, some clinicians report improvements in energy and recovery following supplementation.

Potential Mechanisms of Action 1. Improved Mitochondrial Function

Mitochondria generate ATP, the body's energy currency.

Reduced NAD+ levels are associated with:

• Cellular aging
• Impaired energy production
• Increased inflammation

Supplementation may help restore mitochondrial efficiency.

2. Activation of Sirtuins

Sirtuins are proteins involved in:

• Cellular repair
• Longevity
• Metabolic regulation
• Inflammation control

NAD+ serves as a critical substrate for sirtuin activity.

3. DNA Repair Support

NAD+ is required for enzymes known as PARPs (Poly ADP Ribose Polymerases), which participate in DNA repair processes following cellular injury.

4. Reduction of Oxidative Stress

Chronic inflammation often produces excessive reactive oxygen species (ROS).

NAD+ may help maintain cellular antioxidant defenses and reduce oxidative injury.

Routes of NAD+ Supplementation Intravenous (IV) NAD+

Most commonly marketed in wellness and recovery clinics.

Potential advantages:

• Direct systemic delivery
• Avoids gastrointestinal absorption issues
• Allows higher dosing protocols

Potential limitations:

• Cost
• Time commitment
• Variable evidence base

Oral Precursors

Rather than NAD+ itself, many supplements provide precursors such as:

• Nicotinamide Riboside (NR)
• Nicotinamide Mononucleotide (NMN)

These compounds are converted into NAD+ within the body.

What Does the Evidence Show?

Current evidence remains preliminary.

While preclinical and mechanistic studies are promising, large-scale randomized controlled trials evaluating NAD+ specifically for chronic pain are still limited.

Areas under active investigation include:

• Neuropathic pain
• Neurodegenerative disorders
• Chronic fatigue syndromes
• Recovery optimization
• Healthy aging

Patients should understand that NAD+ therapy remains an emerging treatment rather than a standard evidence-based pain intervention.

Safety Considerations

Reported side effects may include:

• Nausea
• Flushing
• Chest tightness during rapid infusions
• Headache
• Fatigue
• Lightheadedness

Most adverse effects appear infusion-rate dependent and can often be minimized through slower administration protocols.

Patients should discuss treatment with a qualified healthcare professional, especially if they have:

• Cardiovascular disease
• Active cancer
• Significant medical comorbidities

Clinical Pearls for Pain Physicians

✔ Consider NAD+ as a potential adjunct—not a replacement—for evidence-based pain care.

✔ Continue emphasizing exercise, sleep optimization, nutrition, behavioral health, and appropriate interventional therapies.

✔ Discuss realistic expectations with patients.

✔ Recognize that evidence continues to evolve.

✔ Focus on patient-centered outcomes rather than laboratory markers alone.

Key Takeaways

• NAD+ is essential for cellular energy production and repair.
• Declining NAD+ levels may contribute to aging, inflammation, and chronic disease.
• Early evidence suggests possible benefits in inflammation, recovery, fatigue, and nerve health.
• Robust pain-specific clinical trials remain limited.
• NAD+ therapy should currently be viewed as an adjunctive and investigational strategy in pain management.

Resources for Physicians Pain Medicine Board Preparation

Prepare for the ABA Pain Medicine Boards with:

🎯 Comprehensive Question Banks 🎯 Virtual Pain Fellowship 🎯 Flashcards and Mock Exams 🎯 Weekly Board Review Content

👉 Pain Management Board Prep at NRAP Academy

Hands-On Ultrasound Courses – New York

Learn:

• Peripheral nerve imaging
• Ultrasound-guided injections
• Regenerative medicine procedures
• Diagnostic musculoskeletal ultrasound
• Advanced pain intervention techniques

👉 NRAP Ultrasound Courses in New York

Ultrasound & Regenerative Medicine Training – Costa Rica

Join physicians from around the world for immersive training in:

🌴 Playa Grande, Costa Rica

☀️ Small-group hands-on instruction

🦴 Regenerative medicine applications

📡 Ultrasound-guided pain procedures

👉 Costa Rica Ultrasound Training Courses

Connect With PainExam

🌐 NRAP Academy Website

🎙️ Search PainExam Podcast on your favorite podcast platform.

📚 Explore the Virtual Pain Fellowship, Board Review Programs, Ultrasound Training, and CME opportunities.

References

1. Hudson Health. NAD+ Infusion Therapy: Full Clinical Review and Background Paper. 2023.
2. Verdin E. NAD⁺ in aging, metabolism, and neurodegeneration. Science. 2015.
3. Covarrubias AJ, Perrone R, Grozio A, Verdin E. NAD⁺ metabolism and its roles in cellular processes. Nature Reviews Molecular Cell Biology. 2021.
4. Rajman L, Chwalek K, Sinclair DA. Therapeutic potential of NAD-boosting molecules. Cell Metabolism. 2018.
5. Katsyuba E, Auwerx J. Modulating NAD⁺ metabolism for health and longevity. Nature Reviews Endocrinology. 2017.

Disclaimer: This podcast is intended for educational purposes only and should not be construed as medical advice. Always consult qualified healthcare professionals before initiating any treatment.

PainExam Podcast Show Notes Compression Fractures, Vertebroplasty, Kyphoplasty & Occipital Neuralgia for the ABA Pain Medicine Boards

In this episode of the PainExam Podcast, Dr. David Rosenblum reviews two frequently tested topics on the ABA Pain Medicine Board Examination: Occipital Neuralgia and Vertebral Compression Fractures, including the indications, techniques, complications, and evidence surrounding vertebroplasty and kyphoplasty.

Whether you are preparing for the ABA Pain Medicine Boards, ABPM, ABIPP, FIPP, or simply looking to strengthen your interventional pain knowledge, this episode covers essential board pearls, anatomy, diagnosis, imaging findings, and treatment options.

Episode Highlights Occipital Neuralgia

Topics discussed include:

• Anatomy of the greater, lesser, and third occipital nerves

• C2 dorsal ramus anatomy and clinical relevance

• Diagnostic criteria for occipital neuralgia

• Differentiating occipital neuralgia from:

  • Cervicogenic headache

  • Migraine

  • Cluster headache

  • Tension headache

• Physical examination findings

• Occipital nerve blocks

• Pulsed radiofrequency ablation

• Cryoneurolysis

• Peripheral nerve stimulation (PNS)

Board Pearl

The greater occipital nerve originates from the dorsal ramus of C2 and temporary pain relief following a diagnostic occipital nerve block strongly supports the diagnosis.

Vertebral Compression Fractures

Topics reviewed include:

• Osteoporotic vertebral compression fractures

• Thoracolumbar fracture patterns

• MRI findings

• STIR sequence interpretation

• Patient selection for vertebral augmentation

• Conservative treatment versus intervention

• Vertebroplasty technique

• Kyphoplasty technique

• Cement leakage and other complications

• Evidence supporting vertebral augmentation procedures

Board Pearl

Bone marrow edema on MRI STIR imaging is one of the most important findings suggesting an acute compression fracture.

Kyphoplasty vs Vertebroplasty Vertebroplasty

• Direct injection of PMMA cement into the vertebral body

• Stabilizes micro-motion within the fracture

• Can provide rapid pain relief

Kyphoplasty

• Balloon tamp creates a cavity before cement placement

• May partially restore vertebral body height

• May reduce risk of cement extravasation

• Often preferred in selected patients with significant vertebral collapse

Commonly Tested Complications

• Cement leakage

• Pulmonary cement embolism

• Adjacent level fractures

• Infection

• Neurologic injury (rare)

High-Yield ABA Pain Medicine Keywords

• Occipital Neuralgia

• Greater Occipital Nerve

• C2 Dorsal Ramus

• Third Occipital Nerve

• Cervicogenic Headache

• Peripheral Nerve Stimulation

• Vertebral Compression Fracture

• Kyphoplasty

• Vertebroplasty

• PMMA Cement

• STIR MRI

• Osteoporosis

• Cement Extravasation

Upcoming Educational Meetings & Conferences 2026 ASPN Annual Meeting – Miami

Learn more about the upcoming meeting hosted by the American Society of Pain and Neuroscience:

📍 ASPN Annual Conference & Miami Meeting Information

PainWeek 2026 – Las Vegas

Join thousands of pain physicians, APPs, nurses, and industry professionals at:

📍 PAINWeek Las Vegas 2026

Latin American Pain Society Meeting – Brazil

For information regarding the upcoming regional pain meeting in Brazil:

📍 Latin American Pain Federation (FEDELAT) Information

CME, Ultrasound & Board Review Resources NRAP Academy

CME Courses, Virtual Pain Fellowship, Ultrasound Workshops, Regenerative Medicine Training, and Board Review Programs:

📍 NRAP Academy Website

CME Calendar

Upcoming Ultrasound Workshops, Regenerative Medicine Courses, Board Review Programs, and Conferences:

📍 NRAP Academy CME Calendar

Virtual Pain Fellowship

Comprehensive longitudinal pain management education:

📍 Virtual Pain Fellowship Program

Pain Management Board Review

Prepare for:

• ABA Pain Medicine Boards

• ABPM

• ABIPP

• FIPP

📍 PainExam Board Review Resources

Connect With Dr. David Rosenblum Patients Seeking Care

Appointments and consultation requests:

📍 AABP Integrative Pain Care & Wellness

Physician Education

CME, Ultrasound Training, Regenerative Medicine, and Board Review:

📍 NRAP Academy

References

1. Margetis K, Patel A, Petrone B, et al. Percutaneous Vertebroplasty and Kyphoplasty. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Updated April 6, 2025. Available at: https://www.ncbi.nlm.nih.gov/books/NBK525963/

2. Daher M, Kreichati G, Kharrat K, Sebaaly A. Vertebroplasty versus Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fractures: A Meta-Analysis. World Neurosurgery. 2023;171:65-71.

3. Masala S, Fiori R, Massari F, Simonetti G. Kyphoplasty: Indications, Contraindications and Technique. Radiologia Medica. 2005;110(1-2):97-105.

4. Headache Classification Committee of the International Headache Society (IHS). International Classification of Headache Disorders (ICHD-3). Cephalalgia. 2018.

5. Bogduk N. The Clinical Anatomy of the Cervical Dorsal Rami. Spine-related anatomy and occipital nerve pain syndromes.

Subscribe to the PainExam Podcast

For weekly board review content, ultrasound-guided procedures, regenerative medicine updates, pain medicine literature reviews, and expert interviews, subscribe to the PainExam Podcast and visit:

📍 PainExam Podcast & Board Review Resources

🎓 Earn CME and advance your skills through the NRAP Academy and Virtual Pain Fellowship.

🎙️ PainExam Podcast Show Notes CRPS & Intrathecal Pain Pumps — High-Yield ABA Pain Board Review 🔥 Episode Overview

In this episode of the PainExam Podcast, David Rosenblum reviews two essential ABA Pain Medicine Board topics:

• Complex Regional Pain Syndrome (CRPS)
• Intrathecal Drug Delivery Systems (Pain Pumps)

This episode focuses on:

• High-yield board pearls
• Clinical decision-making
• Interventional treatment strategies
• Common exam pitfalls

Whether you are preparing for the:

• ABA Pain Medicine Boards
• ABPM
• ABIPP
• FIPP

—or looking to sharpen your interventional pain knowledge—this episode delivers practical and testable concepts.

🧠 Topic 1: Complex Regional Pain Syndrome (CRPS) 🔬 What is CRPS?

CRPS is a chronic neuropathic pain condition characterized by:

• Disproportionate pain
• Autonomic dysfunction
• Sensory abnormalities
• Motor and trophic changes

📋 CRPS Types CRPS Type I

• No confirmed nerve injury
• Formerly "Reflex Sympathetic Dystrophy"

CRPS Type II

• Confirmed nerve injury
• Formerly "Causalgia"

⚠️ Pathophysiology

CRPS involves:

• Peripheral sensitization
• Central sensitization
• Sympathetic dysfunction
• Neurogenic inflammation
• Cortical reorganization

🩺 High-Yield Clinical Features

• Burning pain
• Allodynia
• Hyperalgesia
• Temperature asymmetry
• Skin color changes
• Edema
• Weakness and trophic changes

📚 Budapest Criteria (BOARD FAVORITE)

Diagnosis requires:

• Continuing pain disproportionate to injury
• Symptoms in ≥3 categories
• Signs in ≥2 categories

💊 Treatment First-Line

• Physical therapy (MOST important)
• Early mobilization

Medications

• Gabapentin
• Pregabalin
• TCAs

Interventional

• Sympathetic blocks
• Spinal cord stimulation

🚨 Board Pearls

• Early treatment improves outcomes
• CRPS may spread beyond the initial site
• Immobilization worsens symptoms

💉 Topic 2: Intrathecal Drug Delivery Systems (Pain Pumps) 🔬 What Are Intrathecal Pumps?

Intrathecal pumps deliver medications directly into the CSF, allowing:

• Lower systemic doses
• Better analgesia
• Reduced systemic side effects

🎯 Indications

• Failed back surgery syndrome
• Cancer pain
• Refractory neuropathic pain
• Severe chronic pain not responsive to conservative therapy

💊 Common Intrathecal Medications Opioids

• Morphine
• Hydromorphone

Non-Opioid

• Ziconotide

Other

• Baclofen (spasticity)

⚠️ Ziconotide — HIGH-YIELD BOARD PEARL

Ziconotide:

• Blocks N-type calcium channels
• Does NOT cause respiratory depression
• Can cause psychiatric side effects

⚠️ Major Complications

• Infection
• Catheter malfunction
• Pump failure
• Withdrawal syndromes
• Catheter-tip granuloma formation

🚨 Granuloma Formation

High-dose intrathecal opioids may cause:

• Catheter-tip inflammatory masses
• Cord compression
• Neurologic deficits

📋 Trialing

Patients typically undergo:

• Bolus trial
• Continuous infusion trial

before permanent implantation.

🎯 Board Pearls

• Ziconotide = no respiratory depression
• Pump failure can cause life-threatening withdrawal
• Granulomas are associated with opioid concentration

📝 High-Yield Board Takeaways CRPS

• Budapest criteria = critical
• Early PT = first-line
• Autonomic dysfunction = hallmark

Intrathecal Pumps

• Ziconotide is highly testable
• Know granuloma risks
• Understand pump complications and withdrawal

🎓 Pain Board Prep Resources

Prepare for your ABA Pain Medicine boards with:

👉 https://painexam.com 👉 https://nrappain.org

🏆 Why Physicians Choose NRAP Academy

• Comprehensive board prep
• High-yield MCQs
• Virtual Pain Fellowship
• Ultrasound-guided pain training
• Interventional pain education

🎤 Upcoming Training

Join upcoming:

• Ultrasound-guided procedure workshops
• Regenerative medicine courses
• Pain board review sessions

📢Register today!

If you're serious about: ✅ Passing your pain boards ✅ Mastering interventional pain ✅ Improving patient outcomes

Subscribe to the PainExam Podcast and join the Virtual Pain Fellowship.

👉 https://nrappain.org 👉 https://painexam.com

Reference

https://dontforgetthebubbles.com/complex-regional-pain-syndrome/

https://www.ncbi.nlm.nih.gov/books/NBK459151/

🎙️ PainExam Podcast Show Notes Corticosteroids & Contrast Agents in Pain Management + Evidence-Based Steroid Selection 🔥 Episode Overview

In this high-yield episode of the PainExam Podcast, David Rosenblum breaks down a must-know board topic:

👉 Injectable corticosteroids vs contrast agents in interventional pain procedures

This episode goes beyond basics and dives into:

• Particulate vs non-particulate steroids
• Comparative profiles of dexamethasone, betamethasone, triamcinolone, and methylprednisolone
• Contrast agent selection and safety
• Critical complications including embolization and neurotoxicity
• A recent study comparing steroid effectiveness in transforaminal epidural injections

This is essential for physicians preparing for the ABA Pain Medicine boards and for clinicians performing spine interventions.

🧠 Core Concept

• Corticosteroids = therapeutic (reduce inflammation)
• Contrast agents = diagnostic + safety tools (confirm needle placement)

👉 Board pearl: Steroids treat pain — contrast prevents complications

💉 Corticosteroids — High-Yield Comparison 🔬 Mechanism

• Inhibit phospholipase A2
• Reduce inflammatory mediators
• Decrease nerve root irritation

⚖️ Key Steroids Compared Steroid Type Particle Profile Key Advantage Major Risk Dexamethasone Non-particulate No aggregation Safest for TFESI Possibly shorter duration Triamcinolone Particulate Large particles Longer depot effect Embolic infarction Methylprednisolone Particulate Aggregates Strong anti-inflammatory Avoid in cervical TFESI Betamethasone Mixed Depends on formulation Potent Acetate = particulate risk 🚨 Major Steroid Risks

Local:

• Tissue atrophy
• Depigmentation

Systemic:

• Hyperglycemia
• Adrenal suppression
• Immunosuppression

Catastrophic (Board Tested):

• Spinal cord infarction
• Stroke

👉 Caused by intra-arterial injection of particulate steroids

📊 Contrast Agents — High-Yield Review Common Agents

• Iohexol (Omnipaque)
• Iopamidol (Isovue)
• Iodixanol (Visipaque)

🎯 Purpose

• Confirm needle placement
• Detect intravascular injection
• Prevent intrathecal injection

⚠️ Risks

• Allergic reaction
• Anaphylaxis
• Contrast-induced nephropathy

👉 Board pearl: Shellfish allergy ≠ contrast allergy

⚠️ Critical Safety Topic: Gadolinium

Gadolinium-based contrast agents are:

❌ NOT approved for epidural or intrathecal use ❌ NOT safe substitutes for iodinated contrast in spine procedures

🚨 Intrathecal Gadolinium Risks

• Encephalopathy
• Seizures
• Respiratory distress
• Death

👉 Extremely high-yield board concept

📚 Evidence-Based Medicine Segment Study Review: Steroid Selection in TFESI

A recent study comparing:

• Dexamethasone
• Methylprednisolone
• Betamethasone

🔑 Key Findings

• Dexamethasone showed comparable or better outcomes
• No clear advantage of particulate steroids
• Similar rates of:
  • Repeat injections
  • Surgical progression

🎯 Clinical Implication

👉 Efficacy differences are smaller than previously thought 👉 Safety is driving practice change

🚨 Board-Level Takeaway

• Non-particulate steroids = safer
• Outcomes ≈ similar
• Technique matters more than steroid choice

👉 Best exam answer: dexamethasone for TFESI

🎯 Board Prep Summary

• Dexamethasone = safest for transforaminal injections
• Particulate steroids = embolic risk
• Contrast must be used before steroid injection
• Gadolinium = dangerous in neuraxial space
• Clinical outcomes often similar across steroid types

🎓 Pain Board Prep Resources

Prepare for your ABA Pain Medicine boards with:

👉 https://painexam.com 👉 https://nrappain.org

🏆 Why Physicians Choose NRAP Academy

• High-yield board review content
• Thousands of MCQs
• Virtual Pain Fellowship
• Ultrasound + regenerative training
• Real-world clinical integration

Register Today!

🎤 Upcoming Training

• Ultrasound-guided pain procedures
• Regenerative medicine courses (PRP, biologics)
• Hands-on workshops

Register Today!

📢 Call to Action

If you're serious about passing your boards and practicing safer interventional pain medicine:

✅ Subscribe to the PainExam Podcast ✅ Join the Virtual Pain Fellowship ✅ Visit https://nrappain.org

References

Calvo N, Jamil M, Feldman S, Shah A, Nauman F, Ferrara J. Neurotoxicity from intrathecal gadolinium administration: Case presentation and brief review. Neurol Clin Pract. 2020 Feb;10(1):e7-e10. doi: 10.1212/CPJ.0000000000000696. PMID: 32190427; PMCID: PMC7057078.

Moreira, Alexandra M., et al. "Comparing the effectiveness and safety of dexamethasone, methylprednisolone and betamethasone in lumbar transforaminal epidural steroid injections." Pain physician 27.5 (2024): 341.

🎙️ AnesthesiaExam Podcast & Video Show Notes Spine Pain, Facet Syndromes, and Interventional Concepts for the Anesthesia Boards 🔥 Episode Overview

In this episode of the AnesthesiaExam Podcast, David Rosenblum delivers a high-yield, board-focused review of spine pain concepts every anesthesiologist must know:

• Lumbar, cervical, and thoracic facet-mediated pain
• Key anatomy and spinal innervation patterns
• Medial branch blocks and radiofrequency ablation (RFA)
• Important clinical correlations for anesthesia and pain boards

This episode bridges the gap between anesthesiology board knowledge and real-world interventional pain practice.

🧠 Key Topics Covered 🦴 Facet-Mediated Spine Pain

• Common cause of axial back and neck pain
• Mechanical pain pattern:
  • Worse with extension
  • Improved with flexion

🔬 High-Yield Anatomy for Boards

• Dual innervation of facet joints
• L5–S1 facet → L5 dorsal ramus (classic exam question)
• C2–3 facet → third occipital nerve

💉 Diagnostic & Interventional Concepts

• Diagnosis via medial branch blocks (MBB)
• RFA for longer-term pain relief
• Understanding procedural anatomy is key for:
  • Regional anesthesia
  • Pain procedures
  • Board exams

⚡ Why This Matters for Anesthesia Boards

Even if you don't perform interventional pain procedures, these concepts are critical for:

• Spine anatomy questions
• Regional anesthesia understanding
• Pain management scenarios
• Oral boards and OSCE-style cases

🎯 Board Prep Takeaways

• Facet pain = axial, mechanical
• Dual innervation = high-yield test concept
• L5 dorsal ramus = commonly tested
• Understand difference between:
  • Radicular vs axial pain
  • Facet vs discogenic pain

🎓 Anesthesia Board Prep Resources

If you're preparing for the ABA Anesthesiology boards, start here:

👉 AnesthesiaExam Board Review Platform: https://nrappain.org

👉 Full Question Bank + Lecture Series: https://nrappain.org

👉 Pain + Anesthesia Integrated Learning: https://painexam.com

🏆 Why Anesthesiologists Choose NRAP Academy

• Comprehensive ABA anesthesiology board prep
• Integrated pain + anesthesia curriculum
• High-yield MCQs and rapid review lectures
• Ultrasound and regional anesthesia content
• Real-world clinical correlations

🎤 Live Courses & Advanced Training

Enhance your skills beyond the boards:

• Ultrasound-guided regional anesthesia courses
• Pain + regenerative medicine workshops
• Hands-on training for real clinical application

🔗 Connect & Learn More

• 🌐 NRAP Academy: https://nrappain.org
• 📚 PainExam: https://painexam.com
• 🎥 YouTube: NRAP Academy
• 🎓 Courses: Ultrasound + Regional Anesthesia

📢 Call to Action

If you're serious about passing your anesthesia boards and mastering pain + regional techniques:

✅ Subscribe to the AnesthesiaExam Podcast ✅ Join the NRAP Board Review Platform ✅ Explore advanced training courses

🎙️ PainExam Podcast Show Notes Phantom Limb Pain & Sacroiliac Joint Dysfunction — High-Yield Pain Board Review 🔥 Episode Overview

In this episode of the PainExam Podcast, David Rosenblum delivers a high-yield review of two must-know topics for the ABA Pain Medicine Board Certification exam:

• Phantom Limb Pain — mechanisms, risk factors, and advanced treatment strategies
• Sacroiliac (SI) Joint Dysfunction — diagnosis, provocative testing, and interventional management

Whether you're preparing for the ABA, ABPM, ABIPP, or FIPP boards, or looking to sharpen your clinical practice, this episode focuses on testable concepts, real-world applications, and interventional pearls.

👉 Explore full board prep and CME: PainExam.com

🧠 Topic 1: Phantom Limb Pain — Key Points

Phantom limb pain is a neuropathic pain syndrome following amputation, driven by both peripheral and central mechanisms.

High-Yield Pearls

• Caused by cortical reorganization + central sensitization
• Strongly associated with pre-amputation pain
• Distinct from:
  • Phantom sensation (non-painful)
  • Stump pain (localized)

Clinical Features

• Burning, cramping, or electric pain
• Perceived in the missing limb
• May be triggered by stress or environmental factors

Treatment Strategies

• First-line: gabapentinoids, TCAs
• Advanced: ketamine, neuromodulation
• Key non-pharmacologic therapy: mirror therapy

🚨 Board Pearl

Preemptive analgesia reduces the risk of phantom limb pain

🦴 Topic 2: Sacroiliac Joint Dysfunction — Key Points

SI joint dysfunction is a major cause of axial low back pain, accounting for up to 25% of cases.

High-Yield Pearls

• Pain is typically:
  • Unilateral
  • Buttock-dominant
  • Radiates to posterior thigh (rarely below knee)

Physical Exam

• Positive provocative tests:
  • FABER
  • Gaenslen
  • Thigh thrust
  • Compression

👉 3 or more positive tests = high diagnostic accuracy

Diagnosis

• Confirmed with image-guided intra-articular injection
• Imaging alone is NOT diagnostic

Treatment

• Physical therapy
• SI joint injections
• Lateral branch RFA
• SI joint fusion (refractory cases)

🚨 Board Pearl

Diagnostic SI joint injection is the gold standard

🎯 Board Prep Takeaways

• Always distinguish central vs peripheral mechanisms in neuropathic pain
• Know diagnostic confirmation strategies (blocks vs imaging)
• Focus on first-line vs interventional escalation pathways
• Understand procedure indications for boards

🎓 Upcoming Events & Live Training 🏆 ASPN 2026 Annual Meeting

Join Dr. Rosenblum for:

• Ultrasound-guided peripheral nerve blocks
• Spine interventions
• Regenerative medicine techniques (PRP, biologics)
• Hands-on procedural training

💉 Ultrasound-Guided Regenerative Medicine Course

Learn:

• PRP injection techniques
• Ultrasound-guided joint and nerve procedures
• Real-world workflows for integrating regenerative medicine into your practice

👉 Hosted through NRAP Academy

🎤 PainWeek 2026 Lectures

Dr. Rosenblum will be presenting on:

• Precision image-guided pain procedures
• Ultrasound integration in clinical practice
• Regenerative medicine in interventional pain
• Future directions: AI and neuromodulation

🔗 Resources

• 🌐 Pain Board Review: PainExam.com
• 🎓 Courses & CME: NRAPPain.org
• 📺 YouTube: NRAP Academy
• 🧠 Question Bank + Virtual Fellowship: Available now

📢 Call to Action

If you're preparing for the pain boards or want to elevate your clinical skillset:

✅ Subscribe to the PainExam Podcast ✅ Join our Virtual Pain Fellowship ✅ Attend a live ultrasound or regenerative medicine course

PainExam Podcast Show Notes Red Light Therapy (Photobiomodulation) for Pain Evidence, Mechanisms, and Clinical Applications

Host: Dr. David Rosenblum

Red light therapy, also known as photobiomodulation (PBM) or low-level laser therapy (LLLT), is an emerging non-invasive treatment modality increasingly used in pain medicine, rehabilitation, and regenerative medicine practices.

In this episode of the PainExam Podcast, Dr. Rosenblum reviews the mechanisms, clinical evidence, indications, and safety considerations surrounding photobiomodulation therapy for pain.

Red and near-infrared wavelengths stimulate mitochondrial activity, increase ATP production, reduce inflammatory mediators, and promote tissue healing. These physiologic effects may translate into analgesic benefits for a variety of musculoskeletal and neuropathic pain conditions.

Clinical research suggests potential benefit in temporomandibular disorders, chronic neck pain, and inflammatory oral conditions, though results vary due to differences in dosing parameters and treatment protocols.

Despite these limitations, PBM has a favorable safety profile and is increasingly being integrated into multimodal pain management strategies.

Key Topics Covered

• What is photobiomodulation therapy (PBM) • How red and near-infrared light interact with mitochondria • Mechanisms of analgesia and tissue repair • Evidence from clinical trials in TMD, neck pain, and oral inflammatory pain • The biphasic dose response (Arndt-Schulz law) • Safety profile and contraindications • How PBM may integrate with regenerative pain medicine

Mechanism of Action

Photobiomodulation works primarily through stimulation of mitochondrial chromophores, particularly cytochrome c oxidase.

This leads to:

• Increased ATP production • Modulation of inflammatory cytokines • Increased angiogenesis and tissue repair • Reduced oxidative stress

These effects may improve pain, inflammation, and healing in certain musculoskeletal conditions.

Evidence Discussed in This Episode Temporomandibular Disorders

Randomized trial demonstrating improvements in pain and mandibular function with red light therapy.

De Carvalho et al., Pain Research and Treatment (2019) https://onlinelibrary.wiley.com/doi/full/10.1155/2019/8578703

Chronic Neck Pain

Clinical trial demonstrating improvements in pain scores and pressure pain thresholds after photobiomodulation therapy.

Chen et al., Lasers in Medical Science (2022) https://link.springer.com/article/10.1007/s10103-022-03540-0

Oral Pain and Dental Inflammation

Randomized study demonstrating reduced pain and improved healing following PBM treatment.

Almeida et al., BMC Oral Health (2023) https://link.springer.com/article/10.1186/s12903-023-02784-8

Who May Benefit From Photobiomodulation?

Red light therapy may be considered as an adjunct treatment for:

• myofascial pain • cervical spine pain • temporomandibular disorder • tendinopathy • peripheral neuropathy • musculoskeletal injury recovery

Safety and Contraindications

Photobiomodulation has a very favorable safety profile.

Reported adverse effects are rare and usually mild:

• transient erythema • warmth at treatment site • headache • eye irritation without proper protection

Precautions include:

• avoiding direct retinal exposure • avoiding treatment over malignancy • avoiding application over the uterus during pregnancy • caution in photosensitive disorders

Resources For Patients Seeking Treatment

Learn more about integrative and regenerative pain treatments including PRP, ultrasound-guided injections, and advanced pain therapies:

AABP Integrative Pain Care & Wellness https://www.AABPpain.com

For Pain Physicians and Advanced Practice Providers

Training in ultrasound, interventional pain procedures, and pain board preparation:

NRAP Academy CME Education https://www.NRAPpain.org