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Feasibility Study on MR-Guided High-Intensity Focused Ultrasound Ablation of Sciatic Nerve in a Swine Model: Preliminary Results. - Cardiovascular and interventional radiology
Spastic patients often seek neurolysis, the permanent destruction of the sciatic nerve, for better pain management. MRI-guided high-intensity focused ultrasound (MRgHIFU) may serve as a noninvasive alternative to the prevailing, more intrusive techniques. This in vivo acute study is aimed at performing sciatic nerve neurolysis using a clinical MRgHIFU system.The HIFU ablation of sciatic nerves was performed in swine (nÂ =Â 5) using a HIFU system integrated with a 3 T MRI scanner. Acute lesions were confirmed using T1-weighted contrast-enhanced (CE) MRI and histopathology using hematoxylin and eosin staining. The animals were euthanized immediately following post-ablation imaging.Reddening and mild thickening of the nerve and pallor of the adjacent muscle were seen in all animals. The HIFU-treated sections of the nerves displayed nuclear pyknosis of Schwann cells, vascular hyperemia, perineural edema, hyalinization of the collagenous stroma of the nerve, myelin sheet swelling, and loss of axons. Ablations were visible on CE MRI. Non-perfused volume of the lesions (5.8-64.6Â cc) linearly correlated with estimated lethal thermal dose volume (4.7-34.2Â cc). Skin burn adjacent to the largest ablated zone was observed in the first animal. Bilateral treatment time ranged from 55 to 138Â min, and preparation time required 2Â h on average.The acute pilot study in swine demonstrated the feasibility of a noninvasive neurolysis of the sciatic nerve using a clinical MRgHIFU system. Results revealed that acute HIFU nerve lesions were detectable on CE MRI, gross pathology, and histology.
Managing Intrathecal Drug Delivery (ITDD) in Cancer Patients. - Current pain and headache reports
Pain is a commonly reported symptom in cancer patients. Patients with cancer pain often fail conservative medical management or have significant side effects to systemic medications. The implantation of an intrathecal drug delivery (ITDD) system may be the most effective treatment option for these patients and can improve their quality of life. This article aims to discuss the choice of intrathecal medications for patients suffering from intractable cancer pain, the management of ITDD throughout a patient's disease course, and the management of complications related to the ITDD system and intrathecal medications.
Neurolytic transversus abdominal plane block with alcohol for long-term malignancy related pain control. - Pain physician
There have been several case reports in the literature of neurolytic transversus abdominis plane (TAP) blocks being used for malignant abdominal wall pain. However, most used phenol as a neurolytic agent. We found only a single case report by Sakamoto using alcohol for TAP neurolysis. Unfortunately this patient passed away only 5 days after performance of the block. We attempt to extend upon the existing literature by describing neurolytic TAP blockade outcomes using alcohol on 3 cancer patients with metastatic disease to the abdominal wall. Two of our 3 patients had colorectal cancer invading the abdominal musculature. The third patient had a metastatic neuroendocrine nodule in the left rectus muscle. In our case series, all 3 patients had sustained and significant (greater than 50%) relief of abdominal wall pain after performing TAP neurolysis using alcohol. Ultrasound guidance was used for all blocks. The concentration of alcohol used varied from 33% to 77% between patients. Duration of relief lasted between 17 days and 6 months. Opioid use either decreased or remained relatively stable for prolonged periods of time after neurolysis. Other than one patient with transient post-procedure pain related to alcohol injection, there were no significant complications. Addition of a depo steroid for diagnostic TAP blockade prior to neurolysis did not appear to extend or provide additional analgesia. Based on our observations, TAP neurolysis using alcohol also offers a feasible option for long-term control of malignant abdominal wall pain. Further investigation is needed to determine if alcohol offers any significant advantage compared with phenol.
A retrospective review and treatment paradigm of interventional therapies for patients suffering from intractable thoracic chest wall pain in the oncologic population. - Pain medicine (Malden, Mass.)
Tumors invading the chest wall and pleura are often incurable, and treatment is targeted toward palliation of symptoms and control of pain. When patients develop tolerance or side effects to systemic opioid therapy, interventional techniques can better optimize a patient's pain. We performed a retrospective review of 146 patients from April 2004 to January 2014 who underwent diagnostic and therapeutic procedures for pain relief. Using four patients as a paradigm for neurolytic approaches to pain relief, we present a therapeutic algorithm for treating patients with intractable thoracic chest wall pain in the oncologic population.For each patient, we describe the use of intercostal/paravertebral nerve blocks and neurolysis, pulsed radiofrequency ablation (PRFA) of the thoracic nerve roots, or intrathecal pump placement to successfully treat the patient's chest wall pain. Analysis of 146 patient charts is also performed to assess effectiveness of therapy.Seventy-nine percent of patients undergoing an intercostal nerve diagnostic blockade (with local anesthetic and steroid) stated that they had improved pain relief with 22% having prolonged pain relief (average of 21.5 days). Only 32% of successful diagnostic blockade patients elected to proceed to neurolysis, with a 62% success rate. Seven patients elected to proceed to intrathecal drug delivery.Intercostal nerve diagnostic blockade with local anesthetic and steroid may lead to prolonged pain relief in this population. Furthermore, depending on tumor location, we have developed a paradigm for the treatment of thoracic chest wall pain in the oncologic population.Wiley Periodicals, Inc.
Pain in cancer survivors. - Journal of clinical oncology : official journal of the American Society of Clinical Oncology
Pain is a common problem in cancer survivors, especially in the first few years after treatment. In the longer term, approximately 5% to 10% of survivors have chronic severe pain that interferes with functioning. The prevalence is much higher in certain subpopulations, such as breast cancer survivors. All cancer treatment modalities have the potential to cause pain. Currently, the approach to managing pain in cancer survivors is similar to that for chronic cancer-related pain, pharmacotherapy being the principal treatment modality. Although it may be appropriate to continue strong opioids in survivors with moderate to severe pain, most pain problems in cancer survivors will not require them. Moreover, because more than 40% of cancer survivors now live longer than 10 years, there is growing concern about the long-term adverse effects of opioids and the risks of misuse, abuse, and overdose in the nonpatient population. As with chronic nonmalignant pain, multimodal interventions that incorporate nonpharmacologic therapies should be part of the treatment strategy for pain in cancer survivors, prescribed with the aim of restoring functionality, not just providing comfort. For patients with complex pain issues, multidisciplinary programs should be used, if available. New or worsening pain in a cancer survivor must be evaluated to determine whether the cause is recurrent disease or a second malignancy. This article focuses on patients with a history of cancer who are beyond the acute diagnosis and treatment phase and on common treatment-related pain etiologies. The benefits and harms of the various pharmacologic and nonpharmacologic options for pain management in this setting are reviewed.Â© 2014 by American Society of Clinical Oncology.
Transcutaneous electrical nerve stimulation for treatment of sarcoma cancer pain. - Pain management
SUMMARYÂ Pain is often the initial presenting symptom with sarcomas. Upon resection of a sarcoma, most patients experience a resolution of their pain. However, in those patients with continued pain, treatment often requires multiple medications with moderate benefit.The authors present eight patients who suffer from continued sarcoma-related pain following resection of their initial cancer.For each patient, we describe the use of transcutaneous electrical nerve stimulation (TENS) for the treatment of sarcoma-related pain. Each patient was brought to the pain clinic for an initial four-lead trial of TENS lasting 30 min to determine the TENS setting that provided greatest pain relief. Patients were educated about the application and use of their TENS unit, which they self-utilized at home. Patients' pain response was monitored prior to the initial TENS trial and after 2 months of TENS use.Seven out of eight patients had a qualitative or quantitative reduction in their sarcoma-related pain. Three out of the seven patients demonstrated clinically significant (>30%) pain relief, while the other four patients demonstrated increased physical functionality and pain relief, during movement and rest. No patients experienced any adverse effects; however, TENS was stopped in one patient who had a beneficial response to TENS as that patient was found to have recurrent, widespread metastases of her sarcoma.Initial results indicate that TENS provides an easy-to-use, inexpensive therapeutic tool that can be used an adjunct in the treatment of sarcoma-related cancer pain. Future studies consisting of a large, randomized trial will be necessary to validate the efficacy of TENS in this patient population.
The use of combined spinal-epidural technique to compare intrathecal ziconotide and epidural opioids for trialing intrathecal drug delivery. - Pain management
SUMMARYÂ Choosing the initial medications for intrathecal delivery is often confusing and not standardized. We describe a novel way for using a combined spinal-epidural technique to compare two first-line medications for intrathecal delivery; ziconotide and morphine (or hydromorphone). Five patients with intractable chronic or cancer pain were elected to have an intrathecal drug delivery system implanted for pain management. Each patient was given a 3-day inpatient trial with the combined spinal-epidural technique. The Visual Analog Scale, Numerical Rating Scale, short-term McGill questionnaire and opioid consumption were monitored daily. The results were used to develop a paradigm to describe how ziconotide can be used in practice.
Considerations for evaluating the use of intrathecal drug delivery in the oncologic patient. - Current pain and headache reports
While the majority of cancer pain patients are successfully managed with conservative medical management, some patients may suffer from intractable pain or intolerable side effects. The implantation of an intrathecal drug delivery system offers many advantages to improve both analgesia and side effect profile. Practitioners may decide to proceed toward implantation after appropriate patient selection, and, when applicable, a suitable trial for the device. Once implantation is completed, multiple medication combinations may be used to optimize the therapeutic benefit of the device. We describe a stepwise paradigm to implement an intrathecal drug delivery program in the cancer pain population.
Novel use of noninvasive high-intensity focused ultrasonography for intercostal nerve neurolysis in a swine model. - Regional anesthesia and pain medicine
High-intensity focused ultrasound (HIFU) is a noninvasive thermal ablation technique. High-intensity focused ultrasound has been used in small-animal models to lesion neural tissue selectively. This study aimed to evaluate the efficacy of HIFU in a large-animal model for ablation of nerves similar in size to human nerves.Twelve acute magnetic resonance-guided HIFU ablation lesions were created in intercostal nerves in a swine model. In a second pig, as a control, 4 radiofrequency ablation and 4 alcohol lesions were performed on intercostal nerves under ultrasound guidance. Preprocedural and postprocedural magnetic resonance imaging was then performed to evaluate radiologically the lesion size created by HIFU. Animals were euthanized 1 hour postprocedure, and necropsy was performed to collect tissue samples for histopathologic analysis.On gross and histological examination of the intercostal nerve, acute HIFU nerve lesions showed evidence of well-demarcated, acute, focally extensive thermal necrosis. Four intercostal nerves ablated with HIFU were sent for histopathologic analysis, with 2 of 4 lesions showing pathologic damage to the intercostal nerve. Similar results were shown with radiofrequency ablation technique, whereas the intercostal nerves appeared histologically intact with alcohol ablation.High-intensity focused ultrasound may be used as a noninvasive neurolytic technique in swine. High-intensity focused ultrasound may have potential as a neuroablation technique for patients with chronic and cancer pain.
Complementary therapies and integrative medicine in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. - Chest
Physicians are often asked about complementary therapies by patients with cancer, and data show that the interest in and use of these therapies among patients with cancer is common. Therefore, it is important to assess the current evidence base on the benefits and risks of complementary therapies (modalities not historically used in modern Western medicine).A systematic literature review was carried out and recommendations were made according to the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines development methodology.A large number of randomized controlled trials, systematic reviews, and meta-analyses, as well as a number of prospective cohort studies, met the predetermined inclusion criteria. These trials addressed many different issues pertaining to patients with lung cancer, such as symptoms of anxiety, mood disturbance, pain, quality of life, and treatment-related side effects. The available data cover a variety of interventions, including acupuncture, nutrition, mind-body therapies, exercise, and massage. The body of evidence supports a series of recommendations. An evidenced-based approach to modern cancer care should integrate complementary therapies with standard cancer therapies such as surgery, radiation, chemotherapy, and best supportive care measures.Several complementary therapy modalities can be helpful in improving the overall care of patients with lung cancer.
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