[SPEAKER_00]: Hello and welcome back to Accrex.
[SPEAKER_00]: I'm Jeville Faulk and I am thrilled to have a fabulous guest on the show today for really important in high yield talk and not only is he a wonderful guest but he's a former resident and current colleague and how fun is that?
[SPEAKER_00]: I have with me Dr. Eric Wing.
[SPEAKER_00]: Eric is an associate clinical professor at Johns Hopkins in the Division of Pain Medicine.
[SPEAKER_00]: He previously served as a program director of the Pain Medicine Fellowship and currently holds appointed committee positions with both the American Society of Anasthesiologists and the American Society of Regional Anasthesia and Pain Medicine.
[SPEAKER_00]: This clinical and research interest focus on spine pain and neuropathic pain and he practices in both anesthesiology and interventional pain management.
[SPEAKER_00]: Now we're going to talk about some very highly tested autonomic blocks and this is
[SPEAKER_00]: Anyone who has taken oral boards knows that these things come up all the time.
[SPEAKER_00]: You may not be a pain doctor, you may never do these blocks, but you need to know them at the very least for your exams.
[SPEAKER_00]: And we're going to go over those.
[SPEAKER_00]: Those ones that come up a lot on tests, so that you know what you need to know.
[SPEAKER_00]: Not to be a trained pain medicine doctor.
[SPEAKER_00]: You obviously have to do a fellowship for that.
[SPEAKER_00]: But so you at least know a little bit about these things and can get the questions right on exams.
[SPEAKER_00]: So I'm excited to have Eric here to help us with that.
[SPEAKER_00]: Eric, welcome to the show.
[SPEAKER_01]: Thank you so much, it's really my pleasure.
[SPEAKER_00]: Well, let's start by telling us a little about you.
[SPEAKER_00]: So I mentioned you were resin here, and we were thrilled to have you stay on faculty when you finished your residency.
[SPEAKER_00]: Tell me a little bit about how you decided to pursue a career in pain medicine.
[SPEAKER_01]: I think all of us, when we decided to go into the healthcare field, we all wanted to relieve suffering in some way through a different specialties or different skillsets.
[SPEAKER_01]: This is what I think all of us want to do deep down inside in some way.
[SPEAKER_01]: And I think before we all start clinical training, everyone knows that suffering is more than just physical aspects.
[SPEAKER_01]: There's also the
[SPEAKER_01]: spiritual, mental, emotional, and social components as well, and I think hospitals to their credits recognize this because there are services that they offer for each of these components.
[SPEAKER_01]: But I think, ironically, as we all progress in our training and our expertise, our view often becomes inadvertently very reductionist and becomes to be only about the physiology, the
[SPEAKER_01]: and we kind of lose sight of the bigger picture of what is leading to a person's overall suffering.
[SPEAKER_01]: And I think the structure of the health care system of 15 to 20 minutes per patient certainly does that help.
[SPEAKER_01]: And I feel that pain medicine as it field is very unique and meaningful.
[SPEAKER_01]: because even though the specific diagnoses or a particular individual are, of course, directly pain-related, a truly great treatment plan will also involve other components of the patients overall suffering, such as having people from physical therapy, waiting in, or psychiatry, or psychology.
[SPEAKER_01]: perhaps even social services.
[SPEAKER_01]: You really have the opportunity to have a multi-disciplinary plan for a patient and address all these different facets of suffering.
[SPEAKER_01]: And also perhaps unique among most anesthesia specialties because you get to know the patients over a long period of time.
[SPEAKER_01]: You can have a very individualized plan and try to tailor these options in the best way that you believe would be helpful because you've gotten to know that person.
[SPEAKER_00]: Yeah, fabulous.
[SPEAKER_00]: I love that and I think that that's a real draw for a lot of people into this specialty.
[SPEAKER_00]: Let's talk about some of the background for the autonomic blocks that we're going to talk about.
[SPEAKER_00]: So how are autonomic blocks relevant to relieving pain?
[SPEAKER_01]: So, after it nourishes from the viscera, travel alongside and eventually converge along the sympathetic ganglia and the plexuses of the sympathetic chain.
[SPEAKER_01]: So, the inculming go and they join together at some point along their path.
[SPEAKER_01]: And so, therefore, if you block those ganglia or the plexuses, it does two things.
[SPEAKER_01]: Number one, interrupts this perception or the transmission of pain from the viscera.
[SPEAKER_01]: And number two, the sympathy text to me, from blocking the sympathetic ganglia or plexus, leads to direct and indirect energies like effects.
[SPEAKER_01]: So because of that, these blocks are used for number one, visceral pan conditions, and number two, for sympatheticly maintained pain.
[SPEAKER_01]: One example would be a certain subtypes of CRPS.
[SPEAKER_00]: All right, so when we talk about visceral pain, we're talking about, for example, cancer pain, in the abdomen or pelvis or wherever the cancer is.
[SPEAKER_00]: And then as you said, there's the sympathy maintained pain like CRPS, which is obviously not from cancer, but from something else that we call CRPS.
[SPEAKER_00]: OK, so that's what these blocks are for.
[SPEAKER_00]: And what is the rest stop analogy?
[SPEAKER_01]: So the rest stop analogy is something I came up with.
[SPEAKER_01]: If you imagine the sympathetic chain, you have two chains, one on both sides of the body.
[SPEAKER_01]: So it's a bilateral system.
[SPEAKER_01]: It goes all the way from head to tail basically, but along the spine.
[SPEAKER_01]: And you can imagine each plexus or a ganglia is being the rest stop that the nerves and the meaty area have to rest at or plug into before the signals then eventually reach the spinal cord.
[SPEAKER_01]: So if you were to block one of these rest stops, then if you can imagine traffic being around the rest stop and all the cars had to go through that rest stop first, then you can really cause a big traffic jam.
[SPEAKER_01]: If you block that particular rest stop in immediate area.
[SPEAKER_01]: And now if you do something like a neural license in that you cause really big damage to the road going
[SPEAKER_00]: And it is analogy to traffic jam, the traffic are the signals, right?
[SPEAKER_00]: The pain signals that are traveling along those hybrids.
[SPEAKER_01]: That's great.
[SPEAKER_00]: Great.
[SPEAKER_00]: And so you mentioned that, so this is going through the sympathetic chain, the sympathetic ganglia.
[SPEAKER_00]: So are all of these blocks that we're going to talk about sympathetic in nature?
[SPEAKER_01]: So, a great question.
[SPEAKER_01]: So, the vast majority of the ganglia that we'll be talking about today are sympathetic ganglia.
[SPEAKER_01]: But, the one exception is the sphealopalantine ganglia, which is also sometimes on the board exams.
[SPEAKER_01]: And that one is unique because the sphealopalantine ganglia is a parasitic ganglia.
[SPEAKER_01]: So therefore, the title of the talk, or our discussion today, is autonomic blocks, but
[SPEAKER_00]: Great, okay, so we'll get to that.
[SPEAKER_00]: Let's start with the Stelee gangley in block.
[SPEAKER_00]: This is something that for sure comes up on tests.
[SPEAKER_00]: So tell us a little bit about that.
[SPEAKER_00]: What are the indications for the Stelee gangley in block?
[SPEAKER_01]: Yeah, so for all the blocks in general, I'm going to try to hone down on three particular topics that must precede your based questions or ask about indications and atomic key points and complications.
[SPEAKER_01]: So, to start things off with these still a ganglamp block, the classic indication is
[SPEAKER_01]: CRPS, or complex visual of pain syndrome, want to be upper extremities.
[SPEAKER_01]: But sometimes in the boards and also in real life, some other indications that you might see might be VT storm, or in other words, be factory ventricular tachyridmios, PTSD, phantom limb pain, or COVID-related enos via.
[SPEAKER_01]: Sometimes,
[SPEAKER_01]: the silly gangland block is also used for be factory paying from baskler insufficient sea or hyper hydros as well.
[SPEAKER_01]: But again the classic indication is CRPS of the upper extremity.
[SPEAKER_01]: Great.
[SPEAKER_00]: So, yeah, absolutely, I mean, I think this is really key.
[SPEAKER_00]: This comes up all the time, CRPS itself is highly tested and, of course, the treatment for it, in this case, this block.
[SPEAKER_00]: So, great, that's the indication you're probably going to see, and then you mentioned some other ones.
[SPEAKER_00]: The COVID related, and I was always really interesting one, and I wonder as questions from the COVID time get worked into the test, and we're going to start seeing that more.
[SPEAKER_00]: That's really interesting.
[SPEAKER_00]: Okay.
[SPEAKER_00]: Now, you were going to start by telling us a little bit about the anatomy that may come up.
[SPEAKER_00]: How do you want to reach know about the anatomy?
[SPEAKER_01]: Yes, so one of the most tested items about this delicate game to unlock is where the block is actually placed, which is specifically at the C6 tubical, or the epinome that is often on the exams as the chest and necked tubical, so it's a French epinome, and the importance
[SPEAKER_01]: Typical is that the retrieval artery is actually shielded by the transistors process at that level and that when you perform the procedure if the needle is usually blocked by that bone, so it's a level of safety to prevent the needle from getting into the retrieval artery.
[SPEAKER_01]: So that's why that an atomic point is often tested.
[SPEAKER_00]: Okay, so the stealth, gangly itself is C7 to T1, but you're going in at C6 because it's a little safer.
[SPEAKER_01]: That's correct.
[SPEAKER_01]: The state of Gailigan is a fusion of two smaller processes along C7 to T1, but because of the table artery, many practitioners do the injection at C6.
[SPEAKER_01]: So it's close by, but not actually close enough to get into the table artery or at least the exit goal.
[SPEAKER_00]: Okay, great.
[SPEAKER_00]: So speaking of getting into the table artery, something we don't want to do, that's obviously one of the complications if you get the get it wrong.
[SPEAKER_01]: Yes, so this is another key point that's tested on exams, is that if you do inadvertently entered a table artery, even a small volume of local anesthetic, and I might mean as small as 0.2 milliliters, something really might need, because of how close the table artery is to these cerebral circulation, you can cause a seizure, and the examiner is up to test this, because if a patient on a stem has a seizure after a stale, ganglion block,
[SPEAKER_01]: The knee-jerk reaction might be to think, oh, maybe the patients having local anesthetic systemic toxicity, or last, so that then you might, in your mind, go down the treatment algorithm, the last algorithm, by Azra, and start thinking about intro lipid, on the exam, for example.
[SPEAKER_01]: However, in this context, the important thing is to recognize that the seizures are self-limited, and separate and distinct from last.
[SPEAKER_01]: Patients can get it last from the still again,
[SPEAKER_01]: but in the context of the exam, they're probably testing you to know that a small volume of local can cause a seizure and the treatment to management is to treat a seizure, number one by giving in benzodiazepine, and number two supporting the airway of the patient becomes ethnic, which again should be temporary, but you might have to do positive pressure ventilation, they optimize
[SPEAKER_01]: We see this very different from going down the treatment algorithm of using intralipid and the last algorithm.
[SPEAKER_00]: Yeah, great.
[SPEAKER_00]: That's really important.
[SPEAKER_00]: Okay.
[SPEAKER_00]: So that's a big one to know what other complications should be be aware of.
[SPEAKER_01]: So other complications that could occur are laryngeal and they're a or frenic nerve blockade.
[SPEAKER_01]: Just because those nerves run pretty close to the still a ganglion.
[SPEAKER_01]: And if you were to block them bilaterally and you were to have
[SPEAKER_01]: by lateral ginger nerve or for neck nerve blockade, and this can really cause issues of breathing.
[SPEAKER_01]: So bilateral blocks are contraindicated, and you can also enter the esophagus or epidural space or interethical space with the stilogangolin block, just because you're working in the neck.
[SPEAKER_01]: So just other potential side effects complications to be aware of.
[SPEAKER_00]: Great.
[SPEAKER_00]: Okay.
[SPEAKER_00]: Other things we should know about this block?
[SPEAKER_01]: So the hordor syndrome is something that occurs with aesthetic ganglion because, again, you are doing a sympathetic block.
[SPEAKER_01]: The still a ganglion is a sympathetic ganglion.
[SPEAKER_01]: So if you were to block it, you caused a sympathetic tentomy, therefore, the hordor syndrome.
[SPEAKER_01]: So, it's not really a complication actually in this particular context, it's something that is expected.
[SPEAKER_01]: So, you have the classic Toses and Hydrosis and Myosis that occurs with the Horde syndrome.
[SPEAKER_01]: And you would also recognize that the Epsilateral Upper Extremity, the temperature of a go-up.
[SPEAKER_01]: This is because we knew cause the sympathetic blockade.
[SPEAKER_01]: You
[SPEAKER_01]: caused basal dilation as a consequence, and the increased blood flow makes the arm warmer.
[SPEAKER_01]: This is also why one of the secondary indications I mentioned earlier were regarding pain from basal insufficient C. Sometimes, you are intentionally causing this increased basal dilation to treat pain from its skin.
[SPEAKER_00]: Great.
[SPEAKER_00]: All right.
[SPEAKER_00]: That was really great.
[SPEAKER_00]: Hi, you know, let's move to another often tested block to celiac flexus block.
[SPEAKER_00]: And let's go through those same things.
[SPEAKER_00]: What are the indications for celiac flexus block?
[SPEAKER_01]: The most common indication is abdominal cancer associated pain.
[SPEAKER_01]: And among that category, most commonly from pink-rated cancer.
[SPEAKER_00]: Yeah, so that is where I've seen it the most is a question about pancreatic cancer pain, though as you say it could be other pain in the abdomen from different cancers, but I do think the most likely way this will come up is pancreatic cancer.
[SPEAKER_00]: All right, and so what is the anatomy we need to know for this one?
[SPEAKER_01]: The anatomical considerations can help you to distinguish this block.
[SPEAKER_01]: They see that click as a block from some of the other blocks.
[SPEAKER_01]: We'll talk about a little bit later, and let's talk today.
[SPEAKER_01]: But they T5 to T12, visceral afference, all eventually plugged into the C-like plexus.
[SPEAKER_01]: So therefore, not just the pancreas, but the visceral from the GI tract, all the way from the stomach through the transverse colon,
[SPEAKER_01]: If you have cancer pain from any of these structures within that distribution, these could all benefit from a CDAC places block.
[SPEAKER_01]: And from the T5 to T9, those nerves, converging to what's called the greater splink beginner.
[SPEAKER_01]: The T10 and T11, there's plugging to the lesser splink beginner.
[SPEAKER_01]: And the T12 nerve is also called the lesser.
[SPEAKER_01]: split-minute nerve as they all approach the C-deck plexus and the C-deck plexus itself that ganglondic self is at T12 to L1 and even though we oftentimes think of it as a midline structure because it is technically there is a left in the right C-deck plexus ganglion but there is just an intermess together in front of the A-order.
[SPEAKER_00]: okay yeah and man in front of the aorta should scare anybody right so that is obviously going to be related to the potential adverse effects so what do we think of in terms of effects that will come from this and that verse effects that we want to try to avoid.
[SPEAKER_01]: So the two most common effects that we see on exams are number one, orthostatic hypotension and number two, diarrhea.
[SPEAKER_01]: And these two occur because, again, you cause a sympathetic blockade.
[SPEAKER_01]: So the parasympathetic function is in overdrive.
[SPEAKER_01]: So because of that, you have base of dilation.
[SPEAKER_01]: So that leads to a plain thing base of dilation, in this case, leading to orthostatic hypotension,
[SPEAKER_01]: and with the person pathetic driving in a full gear, you have Daria from the Geometility being increased as well.
[SPEAKER_01]: And among these two, the exam might also ask, put just the most common, and between these two, orthostatic hypertension is even more common.
[SPEAKER_00]: Okay, so that's the most common, and that's exactly right.
[SPEAKER_00]: Those kind of questions, which of the following is the most common complication of what would you expect, what you most expect to see is going to be the orthostatic hypotension.
[SPEAKER_00]: Okay, so those really aren't adverse effects because they are expected effects orthostatic hypotension and diarrhea kind of means you did the block correctly, just kind of like the change of temperature you mentioned with the
[SPEAKER_00]: prior block we just got this deli gangly in block.
[SPEAKER_00]: So we would expect to see those.
[SPEAKER_00]: What about adverse effects that we don't want to see if we do it right?
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[SPEAKER_01]: Okay, and now we're back with Eric Wang.
[SPEAKER_01]: Yes, and also as a brief addition about the Orvisitic hypotension, sometimes the XAMO asks what is the best treatment and it sounds really simple, but it's as IV fluid preloading.
[SPEAKER_01]: So you just preload the patient 500 to 500 milliliters to liter before the block, and that should help at least immediately mitigate the hypotension.
[SPEAKER_01]: Great.
[SPEAKER_00]: This sounds like we could think of this much like doing a spinal for a C section, right?
[SPEAKER_00]: Where we would expect the vasodilation from that spinal, this imperfection from that spinal to cause hypotension.
[SPEAKER_00]: So doing subfluid loading, maybe even stuck in that setting, they'll probably not, this one starting some phenylephrine or norepinephrine, but basically knowing this is going to come in then pre-treat.
[SPEAKER_01]: I think that's a great convention, yes.
[SPEAKER_00]: Great.
[SPEAKER_00]: Okay.
[SPEAKER_00]: So how about unexpected or not unexpected, but adverse effects that we want to try to avoid.
[SPEAKER_01]: So some of these include the most severe one, the most dangerous one would be Peripleja from the artery of a dampuped vasospasmine from the needle itself, or even having anacrosis, usually in context of doing a neuralicis, in which you have the injected spreading outside of the plexus.
[SPEAKER_01]: and getting on to the artery of edamific bits or one of its smaller branches, and because those feeding to the anterior spinal cord, you can have unfortunately periplegia from this.
[SPEAKER_01]: So this is something that the exam might test as well.
[SPEAKER_01]: other complications might be much apparent to Neil Hemitoma if you enter the kidneys, for example, or other structures along the way to the C.I.
[SPEAKER_01]: Plexus or pneumothorax.
[SPEAKER_01]: And that is more common as a risk if you try to deal with what's called a
[SPEAKER_01]: Splitting nerve block which is a little bit more granular.
[SPEAKER_01]: I don't know what they're gonna test us on the exam But with that block you are high you often times approach the target from but thoracic cavity So the lungs are enclosure proximity great and then the what you mentioned Let's review of course the artery of a damn quiz right the famous artery the high most highly tested vessel of the body Right, so just remind us there.
[SPEAKER_00]: What is that?
[SPEAKER_01]: Stay with us will be right back
[SPEAKER_00]: All right, and we're back talking about the artery of a damcoist.
[SPEAKER_01]: So, that's one of the major branches in the aorta that supplies the anti-responding cord.
[SPEAKER_01]: So, therefore, if you have a fatal spasm or if you outright damings that artery, if you impede basketball flow to the anti-responding cord, then you can have a schema and therefore, a neurologic deficit, and particularly the lower extremities, therefore, a paraplegia.
[SPEAKER_01]: Great.
[SPEAKER_00]: Yeah, so that is highly tested just in general and then in this context as well.
[SPEAKER_00]: Okay, other things we should know about the see their clicks this block.
[SPEAKER_01]: Sometimes you'll see terms such as anti-choral or retrochoral.
[SPEAKER_01]: The cruel in those words, we first did a diaphragmatic cure.
[SPEAKER_01]: So you can do the injection by placing needle in front or anterior to the diaphragm or posterior to the diaphragm.
[SPEAKER_01]: And I think that's something that you'll see on the stems, but I doubt they'll actually test
[SPEAKER_01]: which technique is better as a side note in real life does that great evidence that one is better than the other.
[SPEAKER_01]: I think the most important thing is you as a practitioner of your pain physician, which approach that you can do more safely, that's the best one I'd take.
[SPEAKER_00]: Great.
[SPEAKER_00]: Alright, let's move on.
[SPEAKER_00]: Let's talk about a Lumbar Sympathetic Block.
[SPEAKER_00]: What are the indications for this one?
[SPEAKER_01]: The classification for the non-barsomenetic block is CRPS of the lower extremity.
[SPEAKER_01]: So, just as we talked about, the stillaging beyond block is classically for CRPS of one of the arms, the non-barsomenetic block is often times used for CRPS of one of the legs.
[SPEAKER_00]: Great, okay, so CRPS of the lower extremities, you're going to think of a non-barsomenetic block.
[SPEAKER_00]: What's the anatomy here we want to know?
[SPEAKER_01]: The key name and anatomical points are that the plexus runs along from L2 to L4 and we usually target the plexus at L3 along the antrolateral surface of the L3 vertebra body.
[SPEAKER_01]: So if you see a question stem and they mention some kind of sympathetic block along L2 to the L4 or L3 then you know that they're talking about the lumbar sympathetic block.
[SPEAKER_00]: Great.
[SPEAKER_00]: Okay, and then that should be easier remember your goal is L2L4 and you're going right in the middle of L3 that's your target.
[SPEAKER_00]: All right, so what are the complications that we want to know about for this one?
[SPEAKER_01]: The most tested complication is actually genital femoral neurologia, which might sound surprising, but we need to do this injection.
[SPEAKER_01]: The needle has to traverse through the so-as muscle.
[SPEAKER_01]: And along the way, you might either damage or come really near to the genital femoral nerve as it crosses through the so-as muscle.
[SPEAKER_01]: So how this usually represents on boards or in real life is that you do a limb-barcipathetic block.
[SPEAKER_01]: And then afterward, a patient says that they have this dye or growing pain that has a burning or numbness kind of sensation, that should clue you in into general primordial deralgia.
[SPEAKER_00]: Okay, that sounds like something we really want to avoid.
[SPEAKER_00]: It sounds miserable.
[SPEAKER_00]: Anything we can do if it does happen?
[SPEAKER_01]: I think the main thing is to try to offer the patient's supportive care and to tell them that almost always the nerve itself is not constructed or seriously injured, but it might have been partially anesthetized by the block simply because of the proximity to
[SPEAKER_01]: the lumbar specific plexus, so usually if the patient can continue moving their hips moving their thighs, just doing normal activities, if it's safe, perhaps seeing physical therapy, applying local anesthetic topical creams, usually within a couple weeks, the symptoms should subside, and if they don't, definitely they should follow up with their pain physician to see whether there's something else that might be contributing to the symptoms, not getting better.
[SPEAKER_00]: Okay, great.
[SPEAKER_00]: Other complications we need to know about for the Lumbar Subathetic Block.
[SPEAKER_01]: High-potention is also something that could occur again, similarly with the other sympathetic blocks because some degree of raise a dilation with this block, but usually you don't really see as much of a distinct drop and blood pressure as you do with the CDAC Plexus block.
[SPEAKER_01]: So on the exam, they might say high-potention is one of the answers on a particular question, but if the question is asking about complications,
[SPEAKER_01]: I think hypotension is going to be the red herring, and the answer is really going to be about the genital primoral neurology.
[SPEAKER_00]: Okay, fabulous, and then how do we know if we were successful?
[SPEAKER_00]: Is it the same as the upper extremity where we're looking for a temperature change?
[SPEAKER_01]: Yes, absolutely.
[SPEAKER_01]: So if you do the block correctly and you do induce this impact, it's
[SPEAKER_01]: lateral lower extremities should increase in temperature.
[SPEAKER_01]: Again, secondary to the base of dilation that occurs with a sympathetic block and a temperature increase of at least one to two degrees indicates a successful block and the higher the better usually sometimes as much as even seven to eight degrees Celsius of an increase would be a great mark of a successful block.
[SPEAKER_00]: Okay, and if I remember correctly from way back when I was a resident at a simple sit watching me to be done, you put like a, almost like a sticker type thermometer on the limb.
[SPEAKER_00]: Is that right?
[SPEAKER_00]: And then it changes color when the temperature changes, is that how you do it?
[SPEAKER_01]: So yes.
[SPEAKER_01]: So there are thermometers that work that way.
[SPEAKER_01]: You can also even use something very similar to what they use in the pack you.
[SPEAKER_01]: You just do a skin temperature.
[SPEAKER_01]: You do one on both legs, both lower extremities.
[SPEAKER_01]: Before the block, you'd be core that temperature is on both sides.
[SPEAKER_01]: And then you'd be core that temperature is again after the block.
[SPEAKER_01]: And you could use the same type of thermometer for the arms of the upper extremities for the still looking in the block as well.
[SPEAKER_00]: Okay, great.
[SPEAKER_00]: All right.
[SPEAKER_00]: Let's talk about the superior hypogastric plexus block.
[SPEAKER_00]: This one also comes up on tests.
[SPEAKER_00]: What is this one for?
[SPEAKER_01]: And so this one is for visceral lower domino or pelvic pain.
[SPEAKER_00]: And so lower down even then we talked about for the celiac plexus block.
[SPEAKER_01]: Absolutely.
[SPEAKER_01]: So, if you recall from a little bit earlier, the anatomical considerations about the C-dact plexus, it receives innovation from about at 8.5 to 10.12.
[SPEAKER_01]: So therefore, the innovation runs through the transfers colon.
[SPEAKER_01]: So, anything distilled to that in the GI system, such as the remainder of the colon, and also the pelvic viscera, those organs, if you have, for example, cancer associated pain.
[SPEAKER_01]: the superior hypogasic block.
[SPEAKER_01]: Flexus block is going to be more representative of that coverage.
[SPEAKER_00]: Okay, great.
[SPEAKER_00]: So what anatomy are we talking about here?
[SPEAKER_00]: You said this is going to be more distal.
[SPEAKER_00]: So this is like L5S1.
[SPEAKER_01]: Absolutely, yes, L5 to S1, and specifically it receives the afferent of an innovation from the rectum and the pelvic booster that we taught to Bell.
[SPEAKER_01]: So the bladder, the uterus, and the prostate, think about organs in that low of the body.
[SPEAKER_00]: OK, so lower end of the body, you mentioned some key ones, prostate cancer, uterine cancer, probably cervical cancer, I would imagine, and bladder cancer.
[SPEAKER_00]: OK, so cancer pain from the pelvis or even the distal colon.
[SPEAKER_00]: OK, and so then we're going to do this block and what are the potential complications.
[SPEAKER_01]: The main complication that might show up on boards is aliac vessel injury, because you're targeting the plexus at about L5 to S1, so you're below where the aortic bifurcation is.
[SPEAKER_01]: So if you do have some vessel that you're inadvertently entering from the block, then that vessel is going to be one of the aliac vessels, whether it's the alic artery or the aliac vein.
[SPEAKER_01]: So that might be something that the boards might ask you about.
[SPEAKER_01]: And the answer is not going to be the error.
[SPEAKER_01]: It's going to be one of the aliac vessels.
[SPEAKER_01]: Another complication might be a discidus.
[SPEAKER_01]: You can't perform this procedure by going through the disc of L5 to S1.
[SPEAKER_01]: And you can entrain small bacterium or other pathogens if you were to do this technique.
[SPEAKER_01]: And you can cause a discidus.
[SPEAKER_01]: The advantage of the technique, if you're wondering why one may do this at all, is because if you go to the disc,
[SPEAKER_01]: So, for some practitioners, they might find it to be safer and easier and faster to go through that route.
[SPEAKER_01]: But that's just one publication to be aware of.
[SPEAKER_00]: Okay, and now you said, this is distilled to the A-ordic bivardation, so you can't hit the A-orda.
[SPEAKER_00]: And in fact, if they gave you, and the A-ordic puncture as a complication, it would not be this block that had been done.
[SPEAKER_01]: That's correct.
[SPEAKER_01]: Now, in real life, I like to say anything can happen, but in board world, I think they're going to be looking for the alien vessels here.
[SPEAKER_00]: Okay, great.
[SPEAKER_00]: Yeah, I guess anybody could be off enough that they would hit something really unusual.
[SPEAKER_00]: Okay, now here's one that I am not familiar with, but tell us about the gangly and in-par block.
[SPEAKER_01]: Yeah, so we used a bit of a highway analogy earlier.
[SPEAKER_01]: So this would be the end of the road, the end of the sympathetic chain.
[SPEAKER_01]: So you have the bilateral sympathetic chains in the body and they all end at one point, which is the Gang the In part.
[SPEAKER_01]: So this is the only unpaired ganglia in the body, actually.
[SPEAKER_01]: And it's blocked for most commonly for a coxigenia.
[SPEAKER_01]: It's the most common and classic indication.
[SPEAKER_01]: But also just like we talked about or the superior hypogastic plexus block when we're targeting visceral pain from the lower abdomen.
[SPEAKER_01]: This is for pain that's from even more just even more distal structures, like the distal rectum.
[SPEAKER_01]: Almost right at the level of the aim is that's how external we're talking about.
[SPEAKER_01]: other structures that might benefit from this block or the urethra, the bulba, the perennium.
[SPEAKER_01]: So think about pain that's really as close to the exterior of the body as you can think of.
[SPEAKER_01]: If you're considering between a superior hypogastic-puts block versus a gingling in part block.
[SPEAKER_00]: Okay, great.
[SPEAKER_00]: And so this is as you said.
[SPEAKER_00]: This is Thompair Gangwin, the terminus, the farthest down, the sympathetic chain, where exactly is it located in terms of anatomy.
[SPEAKER_01]: So, it's so far down, it's actually right in front of the S5-Coxix junction.
[SPEAKER_01]: So, you perform this procedure by actually just going through a ligament and a cartilage and the joint that connects the S5 to the caxix.
[SPEAKER_01]: So, the main complication that is actually if you were to go to anterior, then you might enter the rectum inadvertently.
[SPEAKER_00]: Okay, because this is posterior to the rectum.
[SPEAKER_01]: That's correct.
[SPEAKER_01]: It's between the epoxics and the retin.
[SPEAKER_01]: Okay, so you just can't go too far or you might hit the rectum.
[SPEAKER_01]: Okay, correct.
[SPEAKER_00]: All right.
[SPEAKER_00]: Now, you mentioned up front the spino-palleting gangli and block as a, the only one we were going to talk about that is parasympathetic.
[SPEAKER_00]: So, let's talk about that.
[SPEAKER_00]: What are the indications for a spino-palleting gangli and block?
[SPEAKER_01]: The classic indications are cluster headaches and also migraines.
[SPEAKER_01]: But in recent years, there's been more of interest using it for posterior puncture headache as well.
[SPEAKER_01]: Simply because the classic treatment has been epidural blood patches, but these feel a parenting ganglomb block, I think most people would agree is much more straightforward to perform and perhaps one was the easier to perform.
[SPEAKER_01]: than the epidural book patch.
[SPEAKER_01]: So that's something that people have been using it for in recent years as well.
[SPEAKER_00]: OK, great.
[SPEAKER_00]: So you have to be aware of that potential use that could come up, but the more classic our cluster headaches and migraines.
[SPEAKER_00]: And how about trigeminal neurologist?
[SPEAKER_00]: Are you used for that?
[SPEAKER_01]: It might because it does connect to the trigeminal autonomic ganglion as well, but I just have you seen it as much with that indication, and I wouldn't expect it to be one of the answer choices on the boys at this time.
[SPEAKER_00]: Okay, and what's the theory of how it helps post-architentially helps post-architogenic?
[SPEAKER_01]: The headache in posterior puncture headache is believed to be a contributed by compensatory intracranial phase of dilation that occurs when you have the leak and the C is a pressure from the puncture.
[SPEAKER_01]: So if you were to block the parasiped headache outflow, then you would cause cerebral
[SPEAKER_00]: And do we know if it actually works or is this just kind of maybe maybe not?
[SPEAKER_01]: So even though I think those of us with love it to work and I think many of us have seen it actually work in cases and it dorsely, the 2024 multi-society posterior puncture headache, clinical practice guideline actually looked at this, and unfortunately they haven't found the speed ofality and gain the block to have great evidence for efficacy at the
[SPEAKER_01]: So, at end of the day, the epidural blood patch is still the gold standard interventional option for posterior puncture headache.
[SPEAKER_01]: Of the ill, perhaps if there is more literature down online, maybe the speed of penalty gave you and block can be further supported.
[SPEAKER_00]: Okay, so we'll keep an eye out for that.
[SPEAKER_00]: What's the anatomy of this one?
[SPEAKER_01]: The sputopalatin ganglion is the largest extracranial perspicinity ganglion, and it's located in the terapalatin falsa.
[SPEAKER_01]: So the term's periological palatin falsa, that might be on the stem as well.
[SPEAKER_01]: And again, this is the largest perspicinity ganglion extracranially.
[SPEAKER_01]: OK, and how do we get at it?
[SPEAKER_01]: So, how you perform this block is actually a quest through forward.
[SPEAKER_01]: You use a cognitive applicator, such as a acute to up essentially, and you soak it in local anesthetic, and you just advance it along.
[SPEAKER_01]: The four of them, those as far back as you can safely do so to the posterior, there's a free individual wall.
[SPEAKER_01]: Usually, we talk about the middle terminate, for example, if you can meet that far and you just let it rest there for a couple of minutes.
[SPEAKER_01]: and the local anesthetic on the cotton, but then the soak through the mucosa and they don't reach the gangly on the eventually.
[SPEAKER_01]: Sometimes people do this block by using a spray or some kind of atomizer, that might work as well, but at end of the day you're relying on that mucosa diffusion to reach the gangly on.
[SPEAKER_01]: You're not actually using a needle and injecting the gangly directly.
[SPEAKER_00]: Okay, and what are the complications to keep in mind?
[SPEAKER_01]: Because you are introducing something into the nose, epistaxis is the most common convocation although this is usually self-limited and doesn't require intervention apart from those holding the nose, apply a pressure, maybe apply a aspirin, but I doubt the boards were good to get to that level of granularity.
[SPEAKER_01]: You might also have numbness along the crinion nerve v2 distribution or the maxilla.
[SPEAKER_01]: And that's because the maxillary nerve actually is one of the nerves that is connected to this ganglion.
[SPEAKER_01]: So if you have numbness along the top of your maxilla along your cheekbone, that could be a complication of this block as well.
[SPEAKER_00]: Okay.
[SPEAKER_00]: Great.
[SPEAKER_00]: Let's touch briefly upon the neural license.
[SPEAKER_00]: You mentioned up front that you can do a block or you can do an actual neural license and that's going to give you a longer acting effect.
[SPEAKER_00]: So, tell us what agents do you use for a neural license?
[SPEAKER_01]: Yeah.
[SPEAKER_01]: So, a clinical practice, the most common agents are alcohol and phenol.
[SPEAKER_01]: And I'll talk about the key points for both of these super and abort exams.
[SPEAKER_01]: Great.
[SPEAKER_01]: So for alcohol, usually we use a concentration of 50 to 100% or maybe 99% and the key points are that it causes immediate burning pain on injection, so you have to proceed that injection with the local anesthetic block.
[SPEAKER_01]: So in practice, you actually give a local first, give it a couple minutes, make sure that the patient does have to pain your lead and then you follow that local anesthetic block with the
[SPEAKER_01]: And another important point is that alcohol precipitates if you directly mix it with iodinated contrast.
[SPEAKER_01]: So you can't put it in the same syringe, you have to inject it sequentially, not simultaneously.
[SPEAKER_01]: A third point is that alcohol is relatively hyperbaric, and the fourth point is that this is the most commonly used in your litigated agents.
[SPEAKER_01]: We use a far more impractice, and I imagine for the boards as well, compared to phenol, because alcohol is commercially manufactured.
[SPEAKER_01]: So it's ready off the shelf, whereas phenol, which we talk about in the second, you have to compound that.
[SPEAKER_00]: Okay.
[SPEAKER_00]: All right.
[SPEAKER_00]: So those are the key things to build that alcohol.
[SPEAKER_01]: So for phenol, you can think of these points.
[SPEAKER_01]: It's sort of being opposites compared to alcohol.
[SPEAKER_01]: So just like we talked about, how alcohol causes a severe burning sensation on administration, phenol is less painful because it contains some intrinsic local anesthetic properties.
[SPEAKER_01]: And also, if this is alcohol, would precipitate if you mix it with contrast, phenol does not precipitate with our genetic contrast.
[SPEAKER_01]: So it's actually okay to mix it with the contrast.
[SPEAKER_01]: And the advantage actually, is you can inject it and look at the spread and real time on a ferroscopy, because you can mix it simultaneously.
[SPEAKER_01]: And just as alcohol is hypobaric, phenol is often suspended in glycerin, and that mixture is hyperbaric.
[SPEAKER_01]: And lastly, we mention alcohol is most commonly used for your license, and phenol is not.
[SPEAKER_01]: It's less commonly used because you have to compound it.
[SPEAKER_01]: But the advantage if one word is as then why you spinole it all is because you can oftentimes use smaller volumes.
[SPEAKER_01]: So you can perhaps directly decrease the risk of the spread getting onto other structures that you don't want it to get to.
[SPEAKER_00]: And then I have to ask, you know, I remember learning initially that, oh, yeah, you know, if a block works, then you might do a neurologic injection.
[SPEAKER_00]: It seems like that should be permanent, but it's not, right?
[SPEAKER_00]: It's just longer acting, but it is that because you're not actually completely destroying the nerve, you're just kind of stunning it for a while and then it grows back or heels as that would happen.
[SPEAKER_01]: I think that's one major reason, so whenever you do these injections, we oftentimes do these under fluoroscopy.
[SPEAKER_01]: Sometimes under CT, but most commonly through the fluoroscopy, and you can't actually see the nerve.
[SPEAKER_01]: You see the building landmarks, and you know where the nerve lives.
[SPEAKER_01]: But it's really difficult to tell what you've gotten every single strand of that nerve or plexus.
[SPEAKER_01]: So any remainder is still there.
[SPEAKER_01]: The body is going to try to repair it.
[SPEAKER_01]: And it might take a long time, sometimes the body never gets there.
[SPEAKER_01]: But oftentimes some degree of mean for repair does happen.
[SPEAKER_01]: And you have sensations, pain sensations, namely, return.
[SPEAKER_01]: Okay.
[SPEAKER_00]: Fabulous.
[SPEAKER_00]: All right.
[SPEAKER_00]: Well, Eric, this has been fabulous.
[SPEAKER_00]: Let's move to the portion of our show where we make random recommendations.
[SPEAKER_00]: What would you recommend the audience check out for fun?
[SPEAKER_01]: So we started off the talk talking about Paymentists and then its relevance to Suffering.
[SPEAKER_01]: And even though this may not be a fun read per se, I think it's a very meaningful read.
[SPEAKER_01]: And my recommendation would be the book when breath becomes air by Paul Colonity.
[SPEAKER_01]: I think one of the main themes of the book is the importance of finding meaning
[SPEAKER_01]: the myths of suffering, not just afterward or before, but even in middle suffering, even when the oftentimes wonder why and how you can still have meaning even if the why itself is elusive and not to spoil the book, but the book is written by 36 year old neurosurgery resident who is diagnosed with stage four,
[SPEAKER_01]: And the book at the end was also a co-written by Dr. Lucie Planetti, who turns out was one of the keynote speakers that our NSC's Yology meeting last year.
[SPEAKER_01]: So it's a great book, really recommended.
[SPEAKER_00]: fully agree super well written and very, very meaningful.
[SPEAKER_00]: I'm going to balance that with a totally fun recommendation.
[SPEAKER_00]: So I'm sure I've shouted this out before, but it's been a while.
[SPEAKER_00]: And I really enjoyed the podcast Conan O'Brien needs a friend.
[SPEAKER_00]: It's Conan O'Brien from, you know, the old late night show.
[SPEAKER_00]: He's got this podcast he's now had for years.
[SPEAKER_00]: It is.
[SPEAKER_00]: absolutely hilarious.
[SPEAKER_00]: And if you want some of the funniest episodes, check out I think the three now that he's done with Kevin Neilen as the guest.
[SPEAKER_00]: They are just laugh out loud hilarious.
[SPEAKER_00]: You don't have to know much of anything about Conan or Kevin, but just their repartei back and forth, making fun of each other is so funny.
[SPEAKER_00]: Highly highly recommend.
[SPEAKER_00]: Check out Conan or Ryan needs a friend interviews with Kevin Neilen.
[SPEAKER_00]: Alright Eric, been such a pleasure.
[SPEAKER_00]: This was super high yield.
[SPEAKER_00]: Thanks so much for coming on the show.
[SPEAKER_01]: Thank you so much.
[SPEAKER_01]: It's really my pleasure.
[SPEAKER_00]: All right, hopefully you got as much out of that as I did.
[SPEAKER_00]: That was really fantastic.
[SPEAKER_00]: Let us know what you thought.
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[SPEAKER_00]: All right, that is it for today.
[SPEAKER_00]: For the ACRAG podcast, I'm Jed Wolpa.
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