The PMRExam Podcast

Exploring the Role of Ultrasound in Headache Evaluation and Treatment

A Journal Club based on Dr. Andrea Trescott's article:

Ultrasound for evaluation and treatment of headaches. Anaesth Pain & Intensive Care 2017;21(2):241-253.

Click Here to Claim CME for reflecting on content presented in this journal club.

David Rosenblum, MD

Accepting New Patients

Patients Interested in scheduling a consultation with Dr. David Rosenblum can call

516 482 7246 (Garden City) or 718 436 7246 (Brooklyn)

In this Podcast, Dr. Rosenblum discusses patient's in his practice who responsed to ultrasound guided nerve blocks in the treatment of headaches. He discusses the use of ultrasound injections as opposed to medication to manage the pain and references Dr. Trescott's comprehensive article on the various nerves and clinical presentations of headaches related to terminal nerve entrapment or irritation.

Dr. Rosenblum discusses

• Supraorbital Neuralgia
• Auriculotemproal Nerve
• Anatomy
• Clinical presentation
• Interventional Pain Therapies

Summary of Dr. Trescott's Article and Key Points:

• Headaches, affecting 28 million people in the US, pose a significant burden on society in terms of medical costs and lost labor. They are complex neurologic disorders with diverse origins and causes.
• Headaches are often viewed as the primary pathology, but they are fundamentally a symptom. Understanding them is an evolving science, and their patterns can be recognized for effective diagnosis and treatment.
• In 2003, Pareja et al proposed the term "epicrania" for headaches triggered by extracranial causes, suggesting a link between intracranial components and extracranial nerves.

Peripheral Triggers and Plastic Surgery:

• Plastic surgeons noted relief of migraines through corrugator muscle resection and botulinum toxin injection, indicating peripheral headache triggers.
• Severe migraines post-head or neck injury may have an extracranial origin, suggesting peripheral nerve irritation. Traditional migraine medications may offer modest relief.
• Primary treatment involves inhibiting nerve irritation through interventional pain techniques, turning off the pain origin and associated migraine centers.

Ultrasound Advantages:

• Evaluation and injection of nerves have traditionally used landmarks and fluoroscopic images, but ultrasound offers unique advantages.
• Nerves often travel with arteries, potentially contributing to "throbbing" pain. Ultrasound provides a more precise and dynamic visualization of these structures.

Exploring Extracranial Causes:

• The International Classification of Headache Disorders (ICHD) categorizes headaches as primary or secondary. While valuable, it broadly defines peripheral nerve contributions as "Other Terminal Branch Neuralgias."
• The study of extracranial peripheral nerve entrapments and dysfunction reveals overlap between ICHD-defined headaches and potential nerve entrapments causing these pain patterns.
• Collaboration with disciplines like pain management enriches the understanding and treatment options for headaches.

Conclusion:

• Headaches, often seen as isolated intracranial phenomena, may have extracranial triggers. Understanding and treating these triggers, especially through ultrasound-guided techniques, present a promising avenue in headache management.

NRAP Academy also offers:

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

Private Ultrasound Training Available

Email [email protected]

Reference:

• Trescot A. Ultrasound for evaluation and treatment of headaches. Anaesth Pain & Intensive Care 2017;21(2):241-253.

Publication Details:

• Received: 15 Aug 2015, Reviewed: 2 Jun 2016, Accepted: 28 Jun 2016.

This podcast explores the dynamic relationship between intracranial and extracranial factors in headaches, shedding light on potential breakthroughs in their evaluation and treatment.

#interventionalpain #painboards #painfellowship #painexam #regionalanesthesia #ultrasoundguidedpain #ultrasoundpain #ultrasoundmsk #paincme #paincmecourse

Phenol in the treatment of Hip Pain Bonus CME Available ($15 Processing Fee) The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/wo9gDI Dr. Rosenblum discusses the use of phenol injected into the pericapsular nerve group, hip joint and outcome a isolated case reports. Also discussed, phenol, its mechanism of action and a refractory case of neuralgia paresthetica. Pain from hip cancer, pain from DVT and IPACK or articular branch of the tibial nerve block discussed for knee pain. Dr. Rosenblum discusses his ultrasound training programs, the migration of the PainExam platform to the new NRAPpain.org website and offers a testimonial from a previous ultrasound course from the student who inspired this podcast. Patients interested in scheduling a consultation with Dr. Rosenblum can call 516 482 7246 or 718 436 7246 For our Live Course Calendar, Click here Board Prep for PM&R, Pain and Anesthesiology Boards

References

Monagle, John; Ee, Joanne1. Treatment of chronic hip osteoarthritic pain with intra-articular phenol. Indian Journal of Pain 27(1):p 41-43, Jan–Apr 2013. | DOI: 10.4103/0970-5333.114866 Marcio V. Pimenta, Amanda T. Nakamura, Hazem A. Ashmawi, Joaquim E. Vieira, Hermann dos Santos Fernandes, Ultrasound-guided pericapsular nerve group and obturator nerve phenol neurolysis for refractory inpatient hip cancer metastasis pain: a case report, Brazilian Journal of Anesthesiology (English Edition), 2021, Rocha Romero, A., Carvajal Valdy, G. & Lemus, A.J. Ultrasound-guided pericapsular nerve group (PENG) hip joint phenol neurolysis for palliative pain. Can J Anesth/J Can Anesth 66, 1270–1271 (2019). https://doi.org/10.1007/s12630-019-01448-y

PainExam Podcast Show Notes: Exploring Traumeel as an Alternative for Back Pain Relief

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

Board Prep and Continuing Education

Introduction:

• Today, Long Island Based Pain Physician David Rosenblum, MD delves into the latest advancements and alternative treatments for pain management.
• In today's episode, we shine a spotlight on Traumeel®, a homeopathic alternative gaining traction for its anti-inflammatory properties, with fewer reported side effects compared to corticosteroids.

Understanding Traumeel:

• Traumeel, a fixed combination of diluted plant and mineral extracts, has been available over-the-counter in Europe for over 60 years.
• Contrary to corticosteroids, Traumeel's popularity has surged due to its limited side effect profile, with reported contraindications primarily linked to allergies [9].

View Full Calendar

Scientific Insights:

• A study by Lussignoli et al. demonstrated Traumeel's efficacy in decreasing systemic interleukin-6 production and reducing edema, countering an unregulated inflammatory response [10].
• In vitro studies revealed Traumeel's inhibition of pro-inflammatory mediators (IL-1β, TNFα, IL-8) in immune cells, suggesting its potential in stabilizing the immune system [8].
• Notably, Traumeel's effectiveness seems to surpass the sum of its individual components, indicating a synergistic interaction [9-10].

Clinical Applications:

• Traumeel has shown efficacy comparable to nonsteroidal anti-inflammatory drugs (NSAIDs) in treating various inflammatory conditions.
• It is available in oral, topical, and injectable preparations, making it a versatile option for pain relief [8-9].

Research Gaps and Potential:

• Despite its established use, current research lacks information on Traumeel's efficacy in epidural injections for short-term back pain relief.
• No studies have compared Traumeel to corticosteroid injections, although the TRARO study protocol proposes a potential avenue for comparison in rotator cuff syndrome patients [11].

Pain Management Board Prep

Clinical Cases:

• Five patients seeking back pain relief opted for Traumeel injections due to either a contraindication to or a preference against steroids.
• This real-world scenario lays the groundwork for further exploration into Traumeel's efficacy in epidural injections, providing additional pain-relieving options for patients unable to tolerate corticosteroid injections.

Conclusion:

• Traumeel presents a promising alternative for pain management, particularly in cases where corticosteroids may be unsuitable, however the FDA has yet to approve it and therefore it has failed to gain traction in the US. [14]
• As we wrap up, stay tuned for future developments in the research landscape surrounding Traumeel and its potential role in enhancing pain relief options.

Disclaimer:

• Consult with a healthcare professional before considering any alternative treatments. The information provided in this podcast is for educational purposes only and does not replace medical advice.

David Rosenblum, MD President, NRAP Academy Clinical Assistant Professor Department of Anesthesiology SUNY Downstate Medical Center Director of Pain Management Maimonides Medical Center

References 1. Cassidy JD, Carroll LJ, Côté P: The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults. Spine (Phila Pa 1976). 1998, 23:1860-66. 10.1097/00007632-199809010-00012 2. Rudy TE, Weiner DK, Lieber SJ, Slaboda J, Boston JR: The impact of chronic low back pain on older adults: a comparative study of patients and controls. Pain. 2007, 131:293-301. 10.1016/j.pain.2007.01.012 3. Fyneface-Ogan S: Anatomy and Clinical Importance of the Epidural Space. Epidural Analgesia - Current Views and Approaches. IntechOpen. IntechOpen (ed): IntechOpen, Internet; 2012. 1-14. 10.5772/39091 4. Waldman SD: Complications of cervical epidural nerve blocks with steroids: a prospective study of 790 consecutive blocks. Reg Anesth. 1989, 14:149-51. 5. McGrath JM, Schaefer MP, Malkamaki DM: Incidence and characteristics of complications from epidural steroid injections. Pain Med. 2011, 12:726-31. 10.1111/j.1526-4637.2011.01077.x 6. Watters WC 3rd, Resnick DK, Eck JC, et al.: Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion. J Neurosurg Spine. 2014, 21:79-90. 10.3171/2014.4.SPINE14281 7. Understanding Potential Complications Of Epidural Steroid Injections . (2011). Accessed: October 1, 2019: https://www.practicalpainmanagement.com/treatments/interventional/injections/understanding-potentialcomplications-ep…. 8. Schneider C: Traumeel - an emerging option to nonsteroidal anti-inflammatory drugs in the management of acute musculoskeletal injuries. Int J Gen Med. 2011, 4:225-34. 10.2147/IJGM.S16709 9. Grech D, Velagala J, Dembek DJ, Tabaac B: Critical literature review of the homeopathic compound Traumeel for treatment of inflammation. Pharmacology & Pharmacy. 2018, 9:67-83. 10. Lussignoli S, Bertani S, Metelmann H, Bellavite P, Conforti A: Effect of Traumeel S®, a homeopathic formulation, on blood-induced inflammation in rats. Complement Ther Med. 1999, 7:225-30. 10.1016/S0965-2299(99)80006-5 11. Vanden Bossche L, Vanderstraeten G: A multi-center, double-blind, randomized, placebo-controlled trial protocol to assess Traumeel injection vs dexamethasone injection in rotator cuff syndrome: the TRAumeel in ROtator cuff syndrome (TRARO) study protocol. BMC Musculoskelet Disord. 2015, 16:8. 10.1186/s12891- 015-0471-z 12. Birnesser H, Oberbaum M, Klein P, Weiser M: The homeopathic preparation Traumeel® S compared with NSAIDS for symptomatic treatment of epicondylitis 13. Ehlert, Dianna, and Ariel Majjhoo. "Traumeel® Epidural Injection: A Viable Alternative to Corticosteroids-A Five-Patient Case Study." Cureus 11.11 (2019) 14. https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/medinatura-inc-596269-06112020

Dr. Rosenblum reviews the anatomy of the ilioinguinal nerve and entrapment syndromes related to the nerve and its relationship to the iliohypogastric nerve. He describes cases in which patients have a tender spot (tinel's) over the lateral iliac crest. Live Regenerative Medicine and Ultrasound Workshops

For up to date Calendar, Click Here!

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

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

References

https://assets.cureus.com/uploads/review_article/pdf/94743/20220610-32009-17da8fm.pdf https://www.bizwan.com/en/index.php?view=article&id=82:proximal-entrapments-of-the-lower-extremity&catid=86&start=1

Hydroxyapatite Deposition Disease Dr. Rosenblum discusses shoulder pain, and the pathophysiology of Hydroxyapatite Deposition Disease. He discusses personal experience with infraspinatous tendon tear, and treatments such as NSAIDs, Lidocaine patch and steroid injections of the infraspinatous tendon. Dr. Rosenblum discusses his experience with a failed suprascapular nerve block as well as evidence to support PRP injections and ethical safe care. Dr. Rosenbum also is the NRAP Academy Course director for Ultrasound, Regenerative Pain Medicine and Regional Anesthesia CME Workshops and developed online PainExam, AnesthesiaExam and PMRExam Board Reviews Pain Management Board Review Upcoming Workshops and Events NYC Regional Anesthesia and Pain Ultrasound CME Workshop Saturday, December 16, 2023 7:30 AM NYC Regional Anesthesia and Pain Ultrasound CME Workshop Saturday, January 6, 2024 7:30 AM

For up to date Calendar, Click Here!

References

1. Valerio Sansone, Emanuele Maiorano, Alessandro Galluzzo & Valerio Pascale (2018) Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment, Orthopedic Research and Reviews, 10:, 63-72, DOI: 10.2147/ORR.S138225 Seijas R, Ares O, Alvarez P, Cusco X, Garcia-Balletbo M, Cugat R. Platelet-Rich Plasma for Calcific Tendinitis of the Shoulder: A Case Report. Journal of Orthopaedic Surgery. 2012;20(1):126-130. doi:10.1177/230949901202000128 Hegazi T. Hydroxyapatite Deposition Disease: A Comprehensive Review of Pathogenesis, Radiological Findings, and Treatment Strategies. Diagnostics (Basel). 2023 Aug 15;13(16):2678. doi: 10.3390/diagnostics13162678. PMID: 37627938; PMCID: PMC10453434.

Dr. Rosenblum reviews an ASRA Newsletter article discussing the technique, relevant anatomy and more for performing Shoulder Articular Branch Radiofrequency ablation for chronic pain.

David Rosenblum, MD practices Interventional Pain Medicine in New York.

To schedule a conusultation call 718 436 7246 for Brooklyn and 516 482 7246 for Garden City locations or go to www.AABPpain.com

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

Upcoming Workshops and Events

NYC Regional Anesthesia and Pain Ultrasound CME Workshop

Saturday, October 28, 2023 8:00 AM

NRAP Academy: Regenerative Pain Medicine Course NYC

Saturday, November 11, 2023 8:00 AM

NYC Regional Anesthesia and Pain Ultrasound CME Workshop

Saturday, December 16, 2023 7:30 AM

NYC Regional Anesthesia and Pain Ultrasound CME Workshop

Saturday, January 6, 2024 7:30 AM

For up to date Calendar, Click Here!

Reference

https://www.asra.com/news-publications/asra-newsletter/newsletter-item/asra-news/2020/11/01/how-i-do-it-shoulder-articular-nerve-blockade-and-radiofrequency-ablation

Dr. Rosenblum explores Peptides, the various types, usess and applications for health and wellness.

Upcoming Pain Management Conferences

Upcoming Workshops and Events

NYC Regional Anesthesia and Pain Ultrasound CME Workshop

Saturday, October 28, 2023 8:00 AM

Charleston, SC Regional Anesthesia and Pain Ultrasound CME Workshop

Sunday, October 29, 2023 9:00 AM

NRAP Academy: Regenerative Pain Medicine Course NYC

Saturday, November 11, 2023 8:00 AM

NYC Regional Anesthesia and Pain Ultrasound CME Workshop

Saturday, December 16, 2023 7:30 AM

NYC Regional Anesthesia and Pain Ultrasound CME Workshop

Saturday, January 6, 2024 7:30 AM

For up to date Calendar, Click Here!

References

https://healthgains.com/wellness/peptide-therapy/#Selank

https://www.nature.com/articles/s41392-022-00904-4

Dr. Rosenblum discusses his concerns over:

RFA of the Genicular Nerves being a non reimbursed service when the patient already had them in the past with excellent relief.

Plus a discussion on CMS policy toward Peripheral Nerve Block reimbursement limitations and documentation!

Pain Management, Anesthesiology, PMR Board Review

Upcoming Workshops and Events

NYC Regional Anesthesia and Pain Ultrasound CME Workshop

Saturday, October 28, 2023 8:00 AM

Charleston, SC Regional Anesthesia and Pain Ultrasound CME Workshop

Sunday, October 29, 2023 9:00 AM

NRAP Academy: Regenerative Pain Medicine Course NYC

Saturday, November 11, 2023 8:00 AM

NYC Regional Anesthesia and Pain Ultrasound CME Workshop

Saturday, December 16, 2023 7:30 AM

NYC Regional Anesthesia and Pain Ultrasound CME Workshop

Saturday, January 6, 2024 7:30 AM

For up to date Calendar, Click Here!

Reference

The 2024 Physician Fee Schedule and Remote Patient Care with Rachel Trobman, CEO of Upside Health. Dr. Rosenblum and Rachel Trobman cover topics ranging from Remote Patient Care coding, acronyms, implementation, reimbursement and much more!

Upcoming Workshops and Events

ASPN Webinar: Continuing Eduction and Board Prep October 4, 2023 8PM

Maximizing Profit: Understanding the 2024 Physician Fee Schedule

Wednesday, September 20, 2023 8:00 PM

NYC Regional Anesthesia and Pain Ultrasound CME Workshop

Saturday, October 28, 2023 8:00 AM

Charleston, SC Regional Anesthesia and Pain Ultrasound CME Workshop

Sunday, October 29, 2023 9:00 AM

NRAP Academy: Regenerative Pain Medicine Course NYC

Saturday, November 11, 2023 8:00 AM

NYC Regional Anesthesia and Pain Ultrasound CME Workshop

Saturday, December 16, 2023 7:30 AM

NYC Regional Anesthesia and Pain Ultrasound CME Workshop

Saturday, January 6, 2024 7:30 AM

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

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

Upcoming Pain Management Conferences

Course Calendar

2023

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

Oct. 28 Regional Anesthesia and Interventional Pain Medicine NYC

Nov.11 Regenerative Pain Medicine Course: NYC

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

2024

Jan. 6 Regional Anesthesia and Interventional Pain Ultrasound Training NYC

For up to date Calendar, Click Here!

References

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

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

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