C H A P T E R

Somatic Blocks of
6 the Head and Neck
SERDAR ERDINE, GABOR B. RACZ, AND CARL E. NOE
BLOCK AND Hakanson in 1981,8 and periorly by the inferior C
NEUROLYSIS OF percutaneous balloon surface of the temporal A
TRIGEMINAL compression by Mullan lobe of the brain, and T
and Lichtor in 1978 and posteriorly by the brain I
GANGLION O
published in 1983.9 stem. The ganglion is
AND N
shaped like a crescent
BRANCHES moon. The convex side is S
A aimed an- terolaterally. It
H N Approaches to the
is bounded medially by the
I A trigeminal ganglion by
internal carotid artery and
S T various methods aim to
trochlear and optic nerves.
T O relieve the pain
The posterior border of
O M transmitted through the
R the ganglion includes the
Y trigeminal nerve. In the
Y dura of Meckel’s cave and
past, trigeminal ganglion
The ganglion lies within cere- brospinal fluid
block has been extensively
Trigeminal neuralgia was the cranium in an area (CSF). Anteriorly, the
used in the treatment of
treated for the first time called Meckel’s cave or ganglion gives off three
trigeminal neuralgia or tic
by alco- hol injection into Meckel’s cavity, close to the branches intracranially:
douloureux. With the
the nerve by Pitres in apex of the pe- trous part ophthalmic, maxillary, and
introduction of
1902.1 He was followed of the temporal bone mandibular.
thermogan- gliolysis, the
by other authors who gave (Figure 6-1A). Medially, Sensation of the oral
trigeminal ganglion
this technique a great deal the trigeminal ganglion is mucosa, anterior and
block is rarely used,
of publicity. By 1905, bounded by the cavernous middle cra- nial fossa,
except for intraoperative
Schlosser2 had reported 68 sinus, su- tooth pulp, surrounding
or postoperative pain. In
cases of severe trigeminal gingiva, and periodontal
addition
neuralgia successfully membrane is innervated
treated by alco- hol nerve by the trigeminal nerve. 77
block. According to Proprio- ceptive
Cushing,3 the information from the
percutaneous muscles of mastication
transforamen ovale and extraoccular muscles
approach to the trigeminal also terminates in the
(gasserian) ganglion using trigeminal gan- glion. The
absolute alcohol was first trigeminal ganglion is
described by Hartel in named after a Viennese
1912.4 anatomist, Johann
In the early 1930s, Laurentius Gasser (Figure
Kirschner5 began to 6-1B). The two medial
use radiofre- (ophthalmic and maxillary)
quency neurolysis. Using are sensory, whereas the
diathermy, it produced lateral most mandibular
high- current lesions of the branch is partly motor.
trigeminal ganglion for The trigeminal ganglion is
relief of trigeminal somatotropically located.
neuralgia, being the first The oph- thalmic branch
report in medical lit- is located dorsally, the
erature to use maxillary branch is
radiofrequency for the intermediate, and the
treatment of chronic mandibular branch is
intractable pain. located ven- trally. These
Putnam and nerves and their branches
Hamptom,6 who provide the cutane- ous
reported 18 cases of and dermatomal
trigeminal neuralgia and innervation of the head
four cases of carcinoma and face as shown in
of the mouth, Figure 6-2.
recommended x-ray Trigeminal ganglion
control during the links with the autonomic
procedure, using 0.5 mil nervous system via the
of 5% phenol, and were ciliary, sphenopalatine,
the first to publish the use otic and submaxil- lary
of phenol as a neurolytic ganglia, and
agent for the treatment of communicates with the
this condition. oculomotor, facial, and
In the evolution of the glossopharyngeal nerves.10
treatment, radiofrequency
(RF) lesioning for this
ganglion was described I
by Sweet and Wepsic in N
1965,7 retrogasserian D
glycerol injection by I
Somatic Blocks 78
 Supratrochlear nerve Meckel’s cavity (cisterna trigemina)
Somatic Blocks 79
Supraorbital nerve

Ophthalmic nerve
Maxillary Trigeminal ganglion
nerve
Infraorbital
nerve

Auriculotemporal
nerve

Mandibular
nerve

B Dura
Mental nerve

A
FIGURE 6–1
(A) The figure shows the location of the trigeminal ganglion in the middle cranial fossa and the course of its three branches: (1) oph-
thalmic, (2) maxillary, and (3) mandibular. (B) The relationship of the trigeminal ganglion in Meckel’s cavity. CSF, cerebrospinal
fluid.

to idiopathic trigeminal neuralgia, secondary neuralgic Balloon Compression

pain due to facial pain resulting from terminal cancer or
■ 25-gauge needle (for skin infiltration)
multiple sclerosis may also be treated with these ap-
■ 5-ml syringe (for local anesthetic solution)
proaches. These techniques are to be used only when
■ 2-ml syringe (for iohexol [Omnipaque] injection)
conventional medical treatment is inadequate or causes
■ 14-gauge, 10-cm needle (for initial insertion prior
undesirable side effects. Table 6-1 enumerates the indica-
to Fogarty catheter)
tions and contraindications.
■ Fogarty catheter (4-French)

EQUIPMENT
DRUGS
Trigeminal Block
Block
■ 25-gauge needle (for skin infiltration)
■ 1% lidocaine for infiltration
■ 5-ml syringe (for local anesthetic solution)
■ 0.25% bupivacaine or 0.2% ropivacaine
■ 22-gauge, B-bevel, 8- to 10-cm needle (for injec-
■ Methylprednisolone, optional
tion of local anesthetic for a block)
Balloon Compression
Radiofrequency Lesioning
■ 1% lidocaine for infiltration
■ RF thermocoagulation (RFTC) lesion generator
■ Iohexol
and cables
■ 25-gauge needle (for skin infiltration)
Neurolytic Block
■ 5-ml syringe (for local anesthetic solution)
■ 16-gauge intravenous catheter (for introducing the ■ Alcohol 97%–1-ml vial or
RF needle) ■ Phenol in saline or glycerin 6%–1 ml or
■ RF needles, 10 cm in length; 2-mm or 5-mm RF ■ Phenol in iohexol 6 to 10%–1 ml
tip (depending on the branch to be lesioned) ■ Glycerol 40 to 50%–1 ml
 Supraorbital
nerve

Supratrochlear
nerve
 Lacrimal
nerve Auriculotemporal
nerve
Infraorbital Zygomaticotemporal
nerve nerve FIGURE 6–2
This drawing illustrates the innervation of the skin and
Nasociliary
the face by the peripheral branches of the trigeminal
nerve
nerve.
Infraorbital
nerve Zygomaticofacial
nerve

Buccal nerve

Mental nerve

TRIGEMINAL GANGLION BLOCK PROCEDURE (3) needle should be directed toward the pupil when seen
from the front of the face (Figure 6-4A). Cannula insertion
Preparation of Patient
should be performed following the bisector (45°C) of the
Comfort should be provided to the patient during percuta- sagittal plane, which passes through the pupil and the
neous procedures. The patient should be alert enough frontal-mentonian plane.
to respond to the testing, for example, with electrical
stimulation. Generally, intravenous fentanyl (average dose Position of Patient
0.1–0.16 mg), midazolam (average dose 3.0–5.5 mg), and
methohexital (average dose 51.4 mg) are used. In a study The patient is supine on the table with the head in an ex-
comparing several regimens it was concluded that high-dose tended position. The C-arm is placed at the head of the
fentanyl and midazolam together with droperidol improved table for posteroanterior (PA), lateral, and submental views.
the comfort of the patient during the prodecure.11 The direction of the needle is toward the pupil when one
looks from the front and midpoint of the zygomatic arch
Technique of Needle Insertion
when one looks from the side.

The procedure should be performed under fluoroscopic

X-Ray Technique
control. Landmarks follow: (1) entry point is 2 to 3 cm
lateral to the commissura labialis (angle of the mouth) 1. Oblique projection. Lateral inclination of
(Figure 6-3); (2) needle should be directed 3 cm anterior to approximately 30 degrees toward the side of the
the external auditory meatus when seen from the side lesion, with caudal inclination of approximately
(Figure 6-4B); and 30 degrees. The mentonian arch must be seen
and, in the upper-internal quadrant to it, the
foramen ovale.
2. Lateral projection. Performed when the cannula
TABLE 6–1 Use of Trigeminal Ganglion
Nerve Block has already been inserted into the foramen ovale.
Its usefulness is to calculate the insertion of the
Indications Contraindications cannula into the bony tunnel of the foramen
Trigeminal neuralgia Local infection ovale. The tip of the cannula must not exceed
Cluster headaches Sepsis 2 mm in distance from the plane of clivus.
Intractable ocular pain Coagulopathy
Cancer pain Increased intracranial pressure A finger may be placed inside the mouth. This helps
Surgical anesthesia Major psychopathology guide the needle and prevents penetration of the oral
 Then the C-arm is moved slightly lateral and oblique
submentally to see the foramen ovale (Figure 6-7). In many
patients, it is possible to see the foramen ovale. When the
foramen ovale is seen, the needle is directed toward the
foramen through the entrance point (Figure 6-8). Note
anatomically, the mandibular nerve is on the lateral part of
the foramen ovale, whereas the maxillary and ophthalmic
divisions are more medial.
When the needle enters the foramen ovale, the fluoro-
scope is turned laterally (Figure 6-9). The lateral image
should reveal that the needle is directed toward the direct
angle produced by the clivus and the petrous ridge of the
temporal bone (Figures 6-10 to 6-12). The lateral view is
important to verify the depth of the needle inside Meckel’s
cave. The aspiration test is mandatory. A 0.5-ml iohexol
solution helps determine that the needle has not penetrated
FIGURE 6–3
the dura.
The needle entry point is 3 cm lateral to the angle of the mouth.

Diagnostic
Block
mucosa (Figure 6-5). There is a definite risk of meningitis
if the needle enters the mucosa. For confirming that the pain generator is the trigeminal
The direction of the needle should be verified under ganglion, after negative aspirations, up to 1 ml of local
fluoroscopy in submental, lateral, and PA views (Figure 6-6). anesthetic (lidocaine, bupivacaine, or ropivacaine) is in-
To obtain the submental view, the C-arm of the jected. The patient should have pain relief if the pain
fluoroscopy is first placed in the PA direction. In this generator is present. The physician should monitor that
view, the orbital line, the petrous ridge may be visualized the solution has not entered the cranial CSF. The brain
through the orbits. The target site in this dimension is a stem function should be evaluated to determine if the lo-
point approximately cal anesthetic solution has not reached it. Brain stem
9 mm to 1 cm medial to the lateral rim of the internal audi- function is affected if the patient complains of bilateral
tory meatus. This usually coincides with the medial extent headache or fourth or sixth nerve palsy, or if pupillary
of a dip that occurs in the petrous ridge. changes occur.

Trigeminal
ganglion

Foramen
ovale

A B
FIGURE 6–4
(A) The drawing shows the needle penetration toward the pupil in the anterior view. (B) This illustration shows the
needle direction 3 cm anterior to the external auditory meatus on the zygoma.
 alcohol have been used commonly in the past but are not
recommended currently.
Three neurolytic agents used in neurolysis are alcohol,
phenol, or glycerol.
1. Alcohol is the most spreadable solution and
hence should be used with caution. A maximum
of 1 ml alcohol is used in divided doses watching
for signs of bilateral spread.
2. Phenol is a viscous solution. Consequently, it
will spread less and have more contact time
with the target tissues. The most commonly
used neurolytic agent is 6% phenol in
glycerol. Recently some clinicians are using
6–10% phenol in contrast (Omnipaque)
instead.
3. Glycerol may be directly injected like other neuro-
lytic agents, or the retrogasserian glycerol injection
technique may be used as described below.

Technique for Glycerol Injection

After correct needle placement on the trigeminal ganglion,
FIGURE 6–5 the patient is kept in a supine position. The needle should
To prevent the needle from penetrating the cheek and the oral cavity, pierce the foramen ovale just anterior to its geometric
one can put a finger in the mouth, as the needle is advanced toward the center to place the needle into the trigeminal cistern. The
fora- men ovale.
needle is advanced until free flow of the CSF is observed.
The patient is then placed in the semi-sitting position, and
the neck is flexed. Contrast solution, iohexol 0.1 to 0.5 ml,
NEUROLYSIS OF TRIGEMINAL GANGLION is injected at this position in the cistern.
Failure of visualization or diffusion of the dye indi-
The amount of the neurolytic solution should not exceed cates a wrong placement of the needle and the needle
1 ml given in smaller aliquots. Otherwise, it may spread to should be repositioned. When the cistern is visualized, the
the brain stem and cause severe complications. Phenol and contrast material is drawn back by free flow. The flow of
 Rotation to get FIGURE 6–6
a submental view
The fluoroscopic position to obtain the submental
view of foramen ovale.
 FIGURE 6–9
The lateral C-arm placement for viewing the lateral view of the base of
the skull.
FIGURE 6–7
The submental view of the face with the needle in the foramen ovale.
Note the “tunnel view” of the hub of the needle. The arrow indicates the
rim of the foramen ovale. Complications
Complications of retrogasserian glycerol injection are par-
esthesia, dysesthesia, anesthesia dolorosa, corneal hypoes-
thesia or anesthesia, diminished corneal reflex, keratitis,
and masticatory weakness.

Orbit
TECHNIQUE OF TRIGEMINAL GANGLION
STIMULATION AND RADIOFREQUENCY LESIONING
Maxilla Stimulation
Coronoid
process
A test stimulation is mandatory before radiofrequency
Foramen lesioning. Apart from other techniques like glycerol, neu-
ovale rolytic solution injection, or balloon compression, the le-
sion is more precise with radiofrequency lesioning and
should be limited to the affected nerve. Thus, during the
sensorial stimulation the patient should be awake enough
to respond to the test with sensorial stimulation for proper
localization of the tip of the electrode.
Spine The mandibular nerve has some motor fibers. If the
nerve is stimulated at 2 Hz with 0.1 to 1.5 V, the muscle
contraction of the lower mandible is observed. This is also
a way of verifying that the needle is passed through the
FIGURE 6–8 foramen ovale and is on the retrogasserian rootlets. If the
When the submental view is obtained, the foramen ovale is seen to ap- first and second divisions are affected, there should be no
pear medial to the medial edge of the mandible. Depending on the lateral
rotation of the C-arm, the foramen ovale visualization can move more motor response.
medially toward the maxilla. The second step is to seek for paresthesia in the
proper localization. A stimulation at 50 to 100 Hz is given
with 0.1 to 0.5 V. If the needle is properly located, there
will be a tingling-like sensation or electric-like paresthe-
the dye is slower than the CSF itself. The same amount of sias in the innervation of that branch in the face. If this
glycerol is injected in the cistern. The patient is kept at the sensation is obtained after 0.5-V stimulation, then the
same semi-sitting position for the next 2 hours. needle should be redirected to get the same response at a
During this injection, severe headache or dysesthesia lower voltage. However, it should be kept in mind that
may occur, and the patient should be warned about this there might be residual sensorial deficits from previous
result prior to the injection. Some patients may get benefit lesioning.
immediately, whereas some patients may experience relief When the electrode is adjusted for localization, it
within the next 2 weeks. should also be remembered that the gasserian ganglion
 Pituitary Anterior
forsa clinoid
Clivus process
A

Petrous part of
Sphenoid
temporal bone Orbit
sinus
External
auditory canal

Foramen
ovale
Base of the skull

Mandible

FIGURE 6–10
FIGURE 6–11
Lateral view radiographic imaging showing the anterior clinoid process
(A), posterior clinoid process (B), clivus (C), temporal bone (D), and line A line drawn perpendicularly (D–E) through where the intersection of
drawn from the point clivus meets the temporal ridge perpendicularly the clivus and petrous part of the temporal bone meet identifies the fora-
towards the base of the skull (D) to (E). At the base of the skull, this locates men ovale at the base of the skull.
the foramen ovale.

Lesioning
Several types of electrodes may be used for lesioning,
such as cordotomy-type electrodes and trigeminal elec-
trodes with the Tew needle and the Racz-Finch curved-
blunt needle. In order to prevent inadvertent puncture of
vessels in the region, it is preferable to use the curved
blunt needle. If the needle is properly placed and stimu-
lated, the patient is then ready for lesioning (Figures 6-13
to 6-16).

Stimulation Parameters
Voltage is 0–1 volts, and sensory, 50 Hz. Paresthesia be-
tween 0.2 and 0.5 V must be noted in the painful zone.
Motor is 2 Hz. Motor contraction of the masseter muscle
FIGURE 6–12
is sought with 0.7–1 V. If no motor contraction happens,
Another lateral view (see Figure 6-10) of the cranium. (A) Clivus.
(B) Petrous part of the temporal bone. (C) Foramen ovale with needle
the tip of the needle is positioned in the I or II branch of
entering it. V cranial nerve.

Lesion Parameters
and its retrogasserian rootlets lie on a plane running from
a superomedial to inferolateral direction. If there is a mo- First lesion: 60 seconds at 65°C. When the lesion is in-
tor response, it means that the needle is too lateral, and for duced, check the bilateral corneal reflex and pain sensitivity
a better response, it should be more medial. in the neuralgic and contralateral zones. Second lesion:
After stimulation is completed, the physician should 60 seconds at 70°C. Proceed in a similar manner. Third
again rule out if the needle is in a vessel or not. If blood is lesion: 60 seconds at 72–75°C. Proceed in a similar manner.
aspirated, the needle position should be adjusted. If blood A fourth lesion may be assessed at 75°C if pain involves
is still aspirated, the procedure should be terminated and two branches of the V cranial nerve.
a second attempt should be made another day. Impedance The patient can either be sedated by midazolam and
monitoring is not essential for trigeminal ganglion lesion- fentanyl or 0.5 ml of 0.25% bupivacaine, or 0.2% ropi-
ing, but if used, it should be 150 to 350 O for rootlets vacaine may be injected. One should wait at least
bathing in the CSF and 1000 O if it is in a non-neural 30 seconds prior to RF lesioning. RF lesioning is done at
tissue. 60°C for 60 seconds. If the patient cannot tolerate the
 For the first division lesioning, corneal reflex should be
preserved at each lesion, and lesioning should begin at lesser
degrees than 60°C to preserve the corneal reflex. After the
lesioning is completed, the needle is removed. The patient
is instructed to watch for swelling of the face and to put ice
on the face to reduce any swelling that may occur.

Patient Follow-Up
Immediate and later follow-up of the patient are impor-
tant. Some authors prefer to do the lesioning on an outpa-
tient basis, and some hospitalize the patient for a day. In
some patients there is immediate pain relief, but the next
day or within the first week the pain may return. In such
patients, lesioning may be repeated. The patient should be
monitored for an additional month to determine if side
FIGURE 6–13
effects appear.
Radiofrequency needle entering the facial skin without a catheter. Note
the draping of the patient with the area of entry exposed and an O2 can-
nula in place for trigeminal ganglion radiofrequency.
PERCUTANEOUS TRIGEMINAL GANGLION
BALLOON COMPRESSION

The percutaneous trigeminal ganglion balloon compression

procedure is performed under light general anesthesia. The
position of the patient is the same as it is with RF lesioning.
The needle is introduced, as described earlier, through the
foramen ovale. A 4-French Fogarty catheter is advanced
through the needle into Meckel’s cavity. The balloon of
the catheter is inflated by injecting contrast solution. The
shape of the balloon inside the cavity in the lateral
position re- sembles a pear (Figure 6-17). The inflated
balloon is left there for 60 seconds or more, although
there is no agree- ment on the duration.
The procedure should be done with vital sign moni-
toring because bradycardia and hypertension may be
observed.

FIGURE 6–14
The alternative technique of introducing the curved-blunt Racz-Finch
radiofrequency needle is shown in this drawing. Initially, an angiocathe-
ter is introduced at the entry site toward the foramen ovale. Following
that, the RF needle is inserted through the angiocatheter.

lesioning, stop and wait another 30 seconds, and try

again or add another 0.5 ml of local anesthetic prior to
RF lesioning.
If more than one branch of the trigeminal nerve is af-
fected, several lesions by repositioning of the needle should
be performed. After each repositioning, the stimulation FIGURE 6-15
test should be repeated to seek paresthesia at the desired Submental view with a fluoroscope. Note the curved-blunt Racz-Finch
site. radiofrequency needle entering the foramen ovale in its lateral aspect.
 Orbit

Coronoid Maxilla
process

Foramen
ovale

Spine

FIGURE 6-16
This drawing of the submental view of the face illustrates the relationship
of the foramen ovale and the needle entry at the medial border of the FIGURE 6-17
mandible and maxilla. The needle entry is shown in the lateral aspect of
The lateral view of the balloon during trigeminal ganglion neurolysis.
the foramen ovale.
sion and highest for RF lesioning. This is not a desirable
Complications condition, but in some patients, because of the intolerable
pain, it may be preferred.12
Significant masseter weakness is a common complication,
especially in the initial period. This weakness generally dis- Motor Deficit
appears within the first 3 months. Hypoesthesia, dysesthesia,
anesthesia dolorosa, balloon failure, and hematoma on the Motor deficit occurs during the lesioning of the third
cheek may also be observed (Table 6-2). branch, the mandibular nerve. The incidence is the high-
est, 66%, with balloon compression. For RF rhizotomy it
is 24%, and for glycerol injection it is 1.7%. The motor
COMPLICATIONS deficit improves within 1 year.

Percutaneous interventions of the trigeminal ganglion are Carotid Artery Puncture

not free of complications. In selected series, Taha and
Carotid artery puncture occurs when the radiographic
Tew12 compared the results and complications of percuta-
landmarks are not employed and the needle is too inferior
neous techniques. The total number of patients was 6205
and medial. Blind technique is not recommended.
for RF rhizotomy, 1217 for glycerol rhizotomy, and 759
for balloon compression. Facial numbness occurred in Retrobulbar Hematoma and Hematoma in Cheek
98% of the patients after RF rhizotomy, in 72% after bal-
loon compression, and in 60% after glycerol injection. If the needle is advanced to the retrobulbar space, retro-
Taha and Tew found that anesthesia dolorosa occurred bulbar hematoma may develop. This is a dramatic
in complication to the patient, although it is relieved by
1.5%, 1.8%, and 0.1%, respectively.12 Anesthesia dolorosa
TABLE 6–2 Complications of Trigeminal Ganglion Block or
occurred at a rate of 0.3% to 4% in RF lesioning.13–15 For
Neurolysis
glycerol injection, anesthesia dolorosa occurs in 0–2% of
cases.16–20 For balloon compression, ipsilateral masticatory Annoying dysesthesia and anesthesia dolorosa, loss of corneal reflex
weakness, hypoesthesia, dysesthesia, and anesthesia dolo- Neurolytic keratitis
Visual loss
rosa may occur in 3–5% of cases.21–23
Retrobulbar hematoma
Hematoma in the cheek
Loss of Corneal Reflex Significant motor root deficit
The overall incidence of corneal reflex loss and neurolytic Carotid puncture
Meningitis
keratitis is 0.6–1.8%, depending on the technique used. Cor-
Inadvertent intracranial placement of electrode resulting in intracranial hemorrhaging,
neal anesthesia was the highest for RF rhizotomy with 7%; penetration through wrong foramen causing defects in other cranial nerves
it was less for glycerol with 3.7% and balloon compression
with 1.5% occurrence rates. It is lowest for balloon compres-
conservative methods L neurolysis of adjacent should be replaced, and if
without any sequelae. cranial nerves could bleeding continues, the
The eyeball is pushed P occur. proce- dure should be
from the retrobulbar E If slight liquorrhage stopped.
space and exophthalmus A occurs during the During repeated
develops. Compression R procedure, it should be lesioning, the aspiration
over the eye stops the L considered to be a test should be repeated
bleeding, and the swelling S consequence of the and impedance should be
subsides during the ganglion puncture, with monitored to verify the
following days. He- With edentulous patients, the risk of CSF fistula position of the needle
matoma in the cheek the needle’s point of being minimal. before each RFTC
may develop if the introduc- tion sometimes Irritation of the dura application. If the needle
needle passes through a needs to be a little more may cause persistent is in the nerve, the
vessel while it is posterior than for the headache, and in some impedance is generally
introduced. Compression patients with a full set of patients, nausea and between 300 and 450 O.
over the cheek by cold teeth; the needle will vomiting lasting for days The endpoint is
pack after the needle is strike the foramen ovale at may also be observed. If reached when the desired
withdrawn may be too acute an angle. This blood is aspirated, the division of the trigeminal
helpful. may be pre- vented if the needle nerve has become slightly
procedure is done under analgesic but not
I fluoroscopy. anesthetic. Usually at
n Because this is an about 70°C, analgesia
f uncomfortable procedure, occurs and further
e some form of intravenous coagulations are made at
c sedation given immediately
t the same temperature
before the procedure often until some analgesia is
i
o
affords satisfactory produced in the required
n analgesia for the pro- division. At this stage, the
cedure without obtunding time for each coagulation
One of the main concerns the patient’s ability to
is infection and the can be increased or
cooperate and provide decreased; however, if the
incidence of infection. In necessary feedback. The
the series by Sweet, there temperature is increased
patient must be con- with- out first trying extra
were 24 cases of scious between each time, anesthesia will
meningitis in 7000 cases.
coagulation application so suddenly develop.
One of these patients
that sen- sory testing of Analgesia produced by
died.24 the face can take place. this method tends to
Ocular motor paralysis and
The placement of the increase over the first 2
cavernous sinus fistula25 is
needle should be hours.
a pos-
confirmed by the lateral Sequential throbbing
sibility. An intracranial
view. In case of deep of the cannula may
hemorrhage26 has been
needle placement, one can occasion- ally be
reported to be fatal.
enter the brain stem and observed during the early
Misplacement of needles
cause hemorrhage. seconds of the lesion.
into incorrect skull base
The aspiration test is This is due to the fact that
foramina can lead to
mandatory because the in conventional RF,
vascular damage and
poste- rior part of the current is emitted every
secondary hyper- tension
trigeminal ganglion is 0.66 seconds, but every 20
that, in turn, can lead to
surrounded by an milliseconds in pulsatile
bleeding.27 The most com-
invagination of cranial RF.
mon problem from
dura mater containing To prevent hematoma
neurodestructive
CSF in Meckel’s cavity. in the cheek, ice
procedures is altered
Inadvertent injection of compression after the
sensation or numbness that
therapeutic agents into needle is withdrawn
has been reported to range
this cul-de-sac can spread should be done in every
from
6 to 26% of patients to other intracranial struc- in- stance. Hemifacial
undergoing RF-type tures, producing profound numbness that develops
procedures. and rapid loss of after chemical neurolysis
consciousness and or extensive RF
collapse. This is lesioning, especially if
C obviously an eminently three branches of the
L reversible situation when trigeminal nerve are
I local anesthetic agents are involved, is a distress- ing
N used, but in the event that experience for patients.
I such a catastrophe Weakness of the
C occurred with neurolytic homolateral masseter
A agents, inadvertent muscle may occur during
the postoperative period.
Because of the
subsequent analgesia of
the conjunc- tiva, the eye
must be protected from
chronic inflammatory
processes that would go
undetected because of the
altered sensation.
Therefore, it is usually
necessary to approximate
the upper and lower
eyelids surgically to reduce
the area of conjunctiva
exposed to dust and
other environmental
sources of contamination.
Protective spectacles with
side shields can also help
reduce the introduction
of foreign bodies into the
numb eye.
Another difficulty
with long-term hemifacial
analgesia is saliva dribbling
from the anesthetized half
of the mouth; this can
sometimes be alleviated by
an antisialagogue such as
diphenhydramine, 25 mg
tid.

E
F
F
I
C
A
C
Y

The three most popular

techniques are RF
rhizotomy, retrogasserian
glycerol injection, and
percutaneous com-
pression of the gasserian
ganglion. All the
techniques have several
advantages and several
disadvantages. The
advantages of RF
lesioning are a high pain
relief rate, a low relapse
rate, and a high degree of
effectiveness.
There is a light
sensory deficit after
retrogasserian glyc- erol
injection. Shorter duration
of pain relief, higher recur-
rence rates, and
development of fibrosis at
the foramen ovale are the
main disadvantages. Slight
sensory deficit and
moderate rate of In several series, this q In conclusion, the
recurrence may be the result varied. u initial success rate with
e
advantages of gasserian Retrogasserian glycerol s
all three approaches is
ganglion compression. injection is also an effective similar—91–93%. The
However, it cannot be con- method, but the initial Apfelbaum compared 20 long-term success rate for
nected to a single branch, pain relief and duration of years of data on 702 RFL and MVD are also
and the gauge of the needle pain relief are less than RF patients who had equal (81%), while glyc-
enter- ing the foramen lesioning. It may easily be microvascular erol has a 64% success
ovale is larger than the applied when RF facili- decompression (MVD), rate, indicating more
ones used in other ties are absent. Partial percutaneous neurolytic frequent re- currences.
percutaneous methods, sensorial loss may also procedures (PTN), Complications with MVD
which may damage the develop with this radiofrequency lesioning could be serious or even
nerve. technique. Fibrosis may (RFL), or glycerol.28 life threatening (1%), such
develop at the entrance of MVD initially produced as cerebellar hemorrhage
T fo- ramen ovale, enhancing 91% excel- lent results, or edema. A number of
e further injections. 6% good results, and transient cranial nerve
c Percutaneous balloon failed in 3%. On long- deficits were also seen
h compression causes mild term follow-up, 66% were
n with a 2% chance of
sen- sory loss in most excellent and 15% good permanent ipsilateral
i
cases. However, it is not for an hearing loss. These
c
a possible to re- strict 81% success rate. PTN complications were not
l compression to a single using RFL initially seen with PTN, but
division. It is not used as produced 87% excellent meningitis and
S commonly as other results, 6% good, and intracerebral hemorrhage
u techniques. failed in 7%, while oc- curred in rare cases.
c All these techniques glycerol produced 83%
c
Being destructive, PTN
are less morbid and more excellent and 9% good procedures intentionally
e
cost effective than open results with 8% failures. reduced fifth nerve
s
s surgical techniques. Thus, both achieved 92– function. RFL was asso-
However, each technique 93% initial success. In ciated with annoying
The technical success rate long-term follow-up, RFL
must be applied in dysesthesia in 22%,
varies between 97.4 and had 71% excellent and
precise indications and in anesthesia dolo- rosa in
100% 10% good for an 81%
well-equipped centers 2%, and corneal anesthesia
for RF lesioning at the success rate. Glycerol had
with experienced in 1.2% of the patients.
initial phase. The success 52% excellent and 12%
personnel. Glycerol produced only
rate is
Pulsed RF is not good results for a 64% 2–4% annoying
94% for glycerol and 99%
useful in the treatment of long-term success rate. dysesthesia and
for balloon compression.
V cranial nerve neuralgia The average time for 0.3% anesthesia dolorosa.
In another study,
and could only be recurrence with either Both procedures are
technical failure for
indicated in posther- procedure was effective ways to treat
glycerol was reported to
petic V par neuralgia, 1 trigeminal neuralgia.28
be as high as 15%.14,19 8
together with other MVD is recom- mended
However, there is no –
pharmacological therapies for younger, better-risk
general agreement on 1
these results. and in the painful sequelae patients, and PTN for
of “anesthesia dolo- rosa” 9
patients who are
P in the V cranial nerve medically infirm or older
a territory by conventional m (over age 65).
i RF, with variable results. o
n n
C t C
R o h O
e m s N
c p . C
u a L
r r U
r i S
e s I
n o
O
c n
N
e
o Procedures involving the
Evaluating pain recurrence
f
is not easy because of the trigeminal ganglion and
het- erogeneity of the its branches are
T
follow-up reported. The e
occasionally carried out
highest rate of recurrence c to facilitate acute facial
is 54% for glycerol h pain relief during
rhizotomy, with a mean n surgery. However, much
fol- low-up of 4 years.15 i more frequently the
indications are chronic, the coronoid process of
debilitating painful the mandible and infe- rior
conditions. Clearly, the to the zygomatic arch.
use of fluoroscopy and The more commonly used
additional training led to lat- eral approach
better outcome and described by Levy and
reduction of poten- tially Baudoin31 in 1906 is
devastating complications. described and preferred by
All three percutaneous the authors.
techniques may be used
to block the trigeminal
nerve in the treatment of A
neuralgic pain of the N
face. There are A
advantages and T
O
disadvantages of each of
M
the techniques.
Y

M The maxillary nerve is the

second division of the
A
trigemi- nal nerve and is
X also known as the V2
I division of the tri-
L geminal ganglion. The
L maxillary nerve is a purely
A sensory nerve that begins
at the gasserian ganglion
R
and travels anteriorly and
Y inferiorly along the
cavernous sinus through
N the foramen rotundum
E 32
(Figure 6-18). It extends
R to the
V
E

B
L
O
C
K

H
I
S
T
O
R
Y

There are four different

approaches to the
maxillary nerve. Of these
approaches, an oral
approach is commonly
used by dentists. An
orbital approach
described originally by
Rudolph Matas involves
inserting a needle through
the or- bital cavity and
exiting the infraorbital
fissure.29 Schlosser30 in
1907 described an
anterolateral approach
with skin entry anterior to
 Maxillary nerve The 10 branches of the maxillary nerve supply sensa-
tion to the dura, upper jaw, teeth, gums, hard and soft
palates, and cheek, as well as carry parasympathetic fibers.
The maxillary artery and five terminal branches are also
Trigeminal
contained within the pterygopalatine fossa. Also within
ganglion this space are emissary veins from the orbit.
The main part of the maxillary nerve, which consti-
tutes the second division of the trigeminal nerve, can be
anesthetized in the pterygopalatine fossa. Its branches can
Mandibular be anesthetized at the posterior and lateral borders of the
nerve maxilla, and its terminal branch can be anesthetized as it
emerges through the infraorbital foramen on the front of
the face 1 cm below the orbital margin in the same vertical
plane as the pupil (Figure 6-19).

INDICATIONS

The maxillary nerve block is usually performed for re-

gional analgesia of the upper jaw and can be used for acute
intraoperative pain during maxillofacial surgery. It can also
be used for surgical procedures on the teeth of the upper
FIGURE 6–18 jaw. It provides excellent postoperative pain relief for such
Maxillary nerve anatomy. surgical maneuvers, and it is also used to treat chronic
pain, most frequently for diagnostic and therapeutic blocks
involving painful tumors of the maxillary antrum that are
unresponsive to more conventional methods.
superior aspect of the pterygopalatine fossa along the in-
ferior portion of the orbit in the infraorbital fissure and
exits through the infraorbital foramen in the face. CONTRAINDICATIONS
The nerve innervates the maxillary sinus, as well as the
anterior teeth of the upper jaw via the anterior and middle ■ Absolute
superior alveolar nerves. The branch that leaves the infraor- ■ Local infection
bital foramen innervates the skin of the face, the underlying ■ Coagulopathies
mucosa from the lower eyelid to the upper lip. While the ■ Relative
nerve is at the pterygopalatine fossa, it is connected to the ■ Altered anatomy
pterygopalatine ganglion, through which it gives the
branches to the nasal cavity, pharynx, and palate. The
zygomatic branch supplies the lateral portion of the face and EQUIPMENT
posterior superior alveolar branch supplies the upper molar Nerve Block
region.
The branches of the maxillary nerve are divided into ■ 25-gauge, 3/4-inch needle
four regional groups: (1) the intracranial group, including ■ 22-gauge, 3-1/4-inch spinal needle
the middle meningeal nerve, which innervates the dura ma- ■ 3-ml syringe
ter of the medial cranial fossa; (2) the pterygopalatine ■ 5-ml syringe
group including zygomatic nerve, which provides sensory ■ IV T-piece extension
innerva- tion to the temporal and lateral zygomatic region,
and sphenopalatine branches to innervate the mucosa of Neurolytic Block/Pulsed Radiofrequency
the maxillary sinus, upper gums, upper molars, and mucous ■ 16-gauge, 1-1/2-inch angiocatheter
membranes of the cheek; (3) the infraorbital canal group, ■ 10-cm curved radiofrequency thermocoagulation
comprising the anterosuperior alveolar branch innervating needle (RFK) with 5-mm active tip
the incisors and canines, the anterior wall of the maxillary
antrum, the floor of the nasal cavity, and the middle
superior branch, supplying the premolars; and (4) the DRUGS
infraorbital facial group, consisting of the inferior
palpebral branch, which innervates the conjunctiva and the Local Anesthetic Block
skin of the lower eyelid, the external nasal branch, which ■ 1.5% lidocaine for skin infiltration
supplies the side of the nose, and the superior labial branch, ■ 2% lidocaine
which supplies the skin of the upper lip and part of oral
mucosa.
A B
FIGURE 6–19
The patient is supine with the C-arm positioned for the AP view (A) and lateral view (B).
 ■ 0.5% Landmarks are notch, which should be
bupivacaine/ropivacai assessed as close to the middle of A
ne follows: the zygoma. The needle p
■ Steroids (optional) is advanced until it p
1. Midpoint of the r
encounters the lateral
zygomatic arch o
N pterygoid plate (4–5 cm).
e of the temporal a
The needle is then c
u bone
withdrawn and redirected h
r 2. Condyle of the
o mandibular head anteriorly and superiorly
Three technique
l 3. at about a 45-degree
variations when
y Coro angle toward the upper
performing intraoral
t noid root of the nose (Figure
i maxillary block follow:
proce 6-20). The needle is
c again advanced with the 1. A retractor or
s ss of
the pterygopalatine fossa left index finger
■ 6% phenol with or mand until a paresthesia is retracts the
without contrast ible obtained. It is important cheek at the
agent 4. Mandibular to obtain a paresthesia, angle of the
■ 40–50% glycerol notch otherwise the block will mouth upward
with or without between the have a high rate of failure and backwards
contrast agent condyle and (Figure 6-21). until the first
coronoid Three to 5 ml of local upper molar
process anesthetic is injected, tooth is seen.
P
R although some authors The needle is
E advocate the use of as introduced
E much as 10 ml. Neu- through the
P x
A rolytic procedures can be mucosa over the
t
R r
done with 6% phenol or tooth and
A a abso- lute alcohol. A advanced
T o maximum volume of 1–1.5 backward,
I r ml delivered in
O a 0.1-ml
N l divide
d
A doses
O
p is
F p
recom
r
P o mende
A a d.
T c Pulsed radiofrequency.
I h Placement of the
E The mandibular notch is radiofrequency (RF) needle
N identified, which is most is the same as described
T easily done by having the previously (Figure 6-22).
patient open and close Confirmation of proper
For preoperative needle placement is with
the mouth. A
medication, use the sensory stimulation (50 Hz,
22-gauge, 3-1/4-inch
standard recommen- 0.3–0.6 V) and motor
needle is then placed
dations for conscious stimulation (2 Hz,
perpendicu- lar to the
sedation by the American 0.6–-1.2 V) . Once
skin at the posterior and
Society of satisfactory placement is
inferior aspects of the
Anesthesiologists. obtained, pulsed
radiofrequency for 120–-
180 seconds at 42°C for
P two cycles is performed. A
R local anesthetic does not
O
need to be injected prior to
C
removal of the needle.
E
D I
U n
R t
E r
a
The patient is placed o
supine with the head r
straight a
(Figure 6-19). l
 Maxillary nerve Maxillary nerve

FIGURE 6–20
Maxillary nerve block in the lateral view.
Initial needle direction (1) and redirec-
tion (2) after it encounters the pterygoid
Lateral pterygoid plate plate are shown. Inset shows detailed
(anterior margin) 2 anatomy. (From Raj PP, editor:
Practical Management of Pain, 3rd ed.
1 Lateral St. Louis, Mosby, 2000, figure 41-8, p.
pterygoid 586, with permission.)
plate

inward, and upward, making a 40-degree angle the needle is directed upward and backward, and the en-
with the sagittal plane of the skull passing trance to the foramen is felt. The needle should not be in-
tangential to the maxillary tuberosity. When troduced more than 1 cm and only a small amount of
the contact with the bone is lost at a depth of glycerol, 0.2–0.3 ml, may be given to the area. If a larger
3–4 cm from the point of entrance, the needle volume is used, there is the risk of compression
is then advanced 0.5 cm more and 2 ml of neuropathy. Pulsed RF may also be applied.
1% lidocaine is injected.
2. Pterygomaxillary approach: The needle is intro- Complications
duced from the back of the upper molar tooth,
directed upward and inward, almost perpendic- In the extraoral approach, it is essential that the needle
ularly to the tooth. The needle passes laterally be introduced in a horizontal fashion, and it certainly
to the angle formed by the tuberosity of the should not enter the pterygomaxillary fissure in a cephalad
maxilla and the pterygoid process at a depth of direction or advance too deeply, because anesthetic injec-
3.5–4 cm and reaches the sphenomaxillary fossa; tions here are rapidly spread to the posterior aspect of the
2 ml of 1% lidocaine is injected after aspiration orbit and the optic nerve, producing temporary blindness
test. with reversible agents or, more seriously, permanent blind-
3. Posterior palatinal approach: The same technique ness with neurolytic agents. Because of the exceedingly
by the pterygomaxillary route is employed through vascular nature of the compartment in which the maxillary
the posterior palatinal foramen into the canal until nerve lies (the pterygomaxillary fissure is a veritable net-
the needle tip reaches the sphenomaxillary fossa, work of small vessels), intravascular injection is quite
and 2 ml of 1% lidocaine is administered. possible, and meticulous aspiration tests are essential. He-
matoma may develop. If the direction of the needle is too
backwards, penetration to the pharnyx is possible. If this
Infraorbital Block
happens, air can be aspirated in the syringe.
The infraorbital nerve is the terminal branch of the maxil- Toxic reaction to local anesthetics may also develop.
lary nerve. In some cases with trigeminal neuralgia, in Inadvertent puncture of the dura is possible if the
spite of radiofrequency lesioning or other percutaneous needle is advanced too deep. During aspiration CSF may
techniques of the gasserian ganglion, the pain in the area come. In such cases, the block should immediately be
of innervation of the infraorbital nerve continues and in- ceased.
fraorbital block may be useful at that instance. Careful aspiration can help prevent vascular and
The infraorbital foramen is situated 0.5–1 cm below subarachnoid injection. The close proximity of the orbit
the lower margin of the orbit, at the uppermost part of the to this nerve makes it likely to be involved in a complica-
canina fossa. The infraorbital canal is directed 45 degrees tion. Orbital swelling, anesthesia of the orbital tissues,
backward and upward and 20–25 degrees outward and var- ophthalmoplegia, loss of visual acuity, or diplopia can
ies from 1 to 1.5 cm in length. occur if the local anesthetic or neurolytic solution enters
The needle is introduced through a point on the cheek the infraorbital fissure. Damage to vascular structures
0.5–1 cm lateral to the midportion of the ala of the nose. As can cause hemorrhage into the orbit, and blindness can
soon as there is contact with maxilla, below the foramen, occur.
 Maxillary nerve

Trigeminal
ganglion

Mandibular
notch

Mandibular
nerve

FIGURE 6–21
A patient with the needle on the maxillary nerve entering through the
mandibular notch.
CLINICAL PEARLS

Because the maxillary nerve injection site is quite vascular, A

Orbit
hematoma formation is common. An intravascular injec- B
tion can also occur despite negative aspiration if the maxil-
lary or mandibular artery or vein is injured during the
performance of the block. Aspiration of air usually indi- Maxillary
cates that the needle has been placed too far posteriorly sinus
and the pharynx has been entered. If this occurs, it is pru-
dent to change the needle before proceeding.
Seeking paresthesia is important for the precise local-
B
ization of the needle. However, when the tip of the needle FIGURE 6–22
contacts with the lateral pterygoid lamina, the patient per- (A) The needle is in the pterygopalatine fossa (arrow in A–P view). (B)
ceives this as a paresthesia. The paresthesia should be felt Confirmation of the needle in the lateral view. Arrow (A) shows the base
in the whole area; where the nerve innervates, the pain of of the skull. Arrow (B) shows the needle in pterygopalative.
the periosteum is more localized.
ANATOMY
EFFICACY The mandibular nerve is the third largest nerve. It is the
On an individual patient basis, maxillary nerve block has only mixed division of the trigeminal ganglion, being
been helpful in managing upper and midfacial pain, but no formed by the union of a large sensory root and a small
reliable data can be found for efficacy and prolonged relief. motor root (Figure 6-23). The sensory fibers arise from the
anterolateral portion of the gasserian ganglion, whereas the
motor fibers are the same motor nerve mentioned in con-
MANDIBULAR NERVE BLOCK nection with the trigeminal ganglion, which arises from the
pons and passes beneath the gasserian ganglion to reach the
HISTORY foramen ovale, through which, together with the sensory
root, it leaves the cranial cavity. Within or immediately
There is no specific history on who first described the outside the foramen ovale, the two roots fuse into a single
mandibular nerve block. It followed soon after the first trunk. The formed nerve traverses anteriorly and inferiorly
description of the trigeminal ganglion block was de- deep in the infratemporal fossa just anterior to the middle
scribed. meningeal artery; lateral to the otic ganglion and internal
 Maxillary nerve
Trigeminal nerve

Trigeminal
ganglion

Mandibular
nerve

Inferior
alveolar
nerve

Lingual
nerve
FIGURE 6–23
The drawing shows the anatomic location of the trigeminal ganglion and
its mandibular and maxillary branches (lateral view).

FIGURE 6–24
This line drawing shows the course of lingual and inferior alveolar
nerve.
pterygoid muscle; and medial to the external pterygoid, the
masseter and the temporal muscles, and the ramus of the
mandible.
Soon after it is formed, the mandibular nerve gives off The terminal branch of the inferior alveolar nerve is
two small branches: the nervus spinosus, which enters the the mental nerve, which exits the mandible via the mental
cranial cavity with the middle meningeal artery to supply foramen and provides sensory innervation to the chin and
the dura, and the nerve to the internal pterygoid muscle. It to the skin and mucous membrane of the lower lip.
then divides into a small anterior and large posterior trunk.
The small anterior trunk, which is composed mostly of INDICATIONS
motor fibers, then promptly divides into the masseteric,
the anterior and posterior deep temporal, and the external The mandibular nerve block is excellent for intraoperative
pterygoid nerves that supply the muscles of mastication or postoperative pain control after surgical reduction of a
and also give off a small sensory branch, the buccinator, fractured mandible. It is also useful for chronic pain states,
which supplies the mucous membrane and skin over this such as carcinoma of the tongue, lower jaw, or floor of the
muscle. The large posterior trunk, on the other hand, is mouth.
composed mostly of sensory fibers. After a short course it
also divides into the auriculotemporal, the lingual, and
inferior alveolar nerves. The auriculotemporal nerve arises CONTRAINDICATIONS
from the posterior aspect of this trunk and immediately
■ Absolute
runs posterolaterally beneath the external pterygoid mus-
■ Local infection
cle to reach the medial side of the neck of the mandible,
■ Coagulopathies
where it turns sharply cephalad to ascend between the
■ Relative
anterior border of the auricle and the condyle of the man-
■ Distorted anatomy
dible under cover of the parotid gland, finally reaching the
subcutaneous tissue overlying the zygomatic arch, where it
divides into the anterior auricular, the external meatal, ar- EQUIPMENT
ticular, parotid, and superficial temporal branches. The
Local Nerve Block
lingual and inferior alveolar nerves proceed in an inferolat-
eral direction to reach the medial side of the ramus of the ■ 22-gauge, 3-1/2-inch spinal needle
mandible and to be distributed to the anterior two thirds ■ 25-gauge, 3/4-inch infiltration needle
of the tongue and inferior jaw, respectively (Figure 6-24). ■ 3-ml syringe
 ■ 5-ml syringe
■ IV T-piece extension

Pulsed Radiofrequency
■ 10-cm Racz-Finch radiofrequency thermocoagula-
tion needle (RTK)
■ 5-cm RFTC needle may be acceptable
■ 16-gauge, 1-1/4-inch angiocatheter

DRUGS
Local Nerve Block
■ 1.5% lidocaine for skin infiltration FIGURE 6–25
■ 0.5% bupivacaine/ropivacaine The position of the patient and C-arm for an external approach to a
■ 2% lidocaine mandibular nerve block (lateral view).
■ Steroids (optional)
■ Iohexol (Omnipaque 240) contrast medium
Maxillary nerve Trigeminal ganglion
Neurolytics
■ 6% phenol
■ Absolute alcohol
■ 50% glycerol

Mandibular
PREPROCEDURE PREPARATION nerve Mandibular
notch
Physical Examination
Examine for anatomic anomalies and local infections that
may interfere with performance of the block. Also confirm
that the jaw can be opened and closed.

Preoperative Medication
For preoperative medication, use the standard recommen-
dations for conscious sedation by the American Society of
Anesthesiologists.

PROCEDURE
FIGURE 6–26
Position of Patient
Point of needle entry in the mandibular notch for extraoral mandibular
The patient is placed supine on the table. The C-arm is nerve block.
initially placed in an anteroposterior and lateral position to
locate needle entry (Figure 6-25).
of the lower lip, lower jaw, or ipsilateral tongue or ear is
Extraoral Approach obtained (Figure 6-28).
The approach for blocking this nerve is identical to that For best results, paresthesia should be elicited before
for blocking the maxillary nerve, that is, the needle is 2 to 4 ml of anesthetic solution is injected.
introduced through the mandibular notch of the mandi-
ble, and advanced through the infratemporal fossa, with Intraoral Approach
the lateral pterygoid plate serving as a bony endpoint The cheek is retracted by the index finger or retractor
(Figures 6-26, 6-27). However, in this instance, the nee- until the second upper molar tooth is seen. A 5-inch
dle is walked backward off the lateral pterygoid plate, needle is inserted into the mucous reflection above mu-
maintaining the same depth as the plate until paresthesia cosa on the tooth, directed backward, upward, and inward
 Maxillary sinus

Needles on:

Mandibular nerve

Lateral pterygoid plate

Maxillary nerve

FIGURE 6–27
Transverse section of the head and face at the level of the mandibular
notch showing needle placement on the mandibular nerve, on the lateral
pterygoid plate, and on the maxillary nerve. After the pterygoid plate is
touched, the needle is slightly withdrawn and pushed posterior until it
slips off the pterygoid plate.

FIGURE 6–28
The technique for the extraoral block of the mandibular nerve is essen-
toward the infratemporal plate. The direction of the tially the same as that for the maxillary block, except that the needle is
needle from lateral view should be toward the midpoint of directed upward and posteriorly; thus, the mandibular nerve is contacted
the zygomatic arch and from the frontal view toward the as it exits from the foramen ovale. (From Raj PP, editor: Textbook of
Re- gional Anesthesia. Philadelphia, Churchill Livingstone, 2002, figure
outer canthus. 20-17, p. 338, with permission.)
At a depth of 4–5 cm, the needle will contact the in-
fratemporal plate, and at that area paresthesia should be
sought. When the patient feels paresthesia, 2 ml of 1% COMPLICATIONS
lidocaine is injected slowly.
Mandibular nerve block, a relatively straightforward
Mental Nerve Block block, is associated with a high degree of success. How-
ever, there is always the risk of complications. As the
In some cases in spite of blocking the gasserian ganglion,
needle is walked posteriorly off the lateral pterygoid
the peripheric branches of the trigeminal nerve are blocked.
plate, it comes to lie on the superior constrictor muscle
The mental nerve is one of them. Also, in some cases with
of the pharynx, which is attached to the border of the
trigeminal neuralgia, only the mental nerve is affected and
lateral pterygoid plate. If the needle is advanced deeper
mental nerve block may be adequate.
at this stage, it can enter the pharynx. If the tip of the
Mental block by extraoral route (by Labat). A line is
needle enters the pharynx, air bubbles will be seen dur-
drawn from the two lower bicuspid teeth perpendicular
ing aspiration.
to the lower margin of the mandible. The distance be-
A very close posterolateral relation of the mandibular
tween the gingival margin of mandible and lower margin
nerve at this site is the middle meningeal artery, which
of the mandible is bisected. Through this bisecting point
enters the cranial cavity through the spinous foramen,
a line is drawn parallel to the lower margin of the man-
thus making meticulous aspiration tests necessary.
dible. These two lines cross each other at right angles and
Hemorrhage in the cheek often occurs during and fol-
their intersection marks the position of the mental fora-
lowing the block by the anterolateral extraoral route. He-
men. The quadrant in which the second bicuspid lies is
matoma of the face and subscleral hematoma of the eye
bisected and a point is taken on the bisector. A 5-cm
may occur.
needle is introduced until it contacts the bone 1.5 cm
from the point of intersection of the lines. The needle is
then inclined slightly inward and passed through the fo- CLINICAL PEARLS
ramen. In some cases the foramen can also be palpated.
The needle should not be introduced too deep in the It should never be necessary to advance the needle more
foramen and the solution should be given in very few than 5.5 cm beyond the skin in the extraoral technique. If
amounts in order to prevent compression over the nerve, paresthesia is not obtained at this depth, the needle should
which may cause neuropathy. Glycerol, 0.2–0.3 ml, may be be withdrawn and the landmarks reconsidered before it is
injected or pulsed. RF may be applied (Figure 6-29). reintroduced.
 H mediated by the the parotid gland (Figure
I glossopharyngeal nerve. 6-30A).39
S Intracranial sec- tion of The glossopharyngeal
T the glossopharyngeal nerve exits the jugular
O nerve was first performed fora- men near the vagus
R by Adson in 1925 and and accessory nerves and
Y was subsequently refined the internal jugular vein.40
by Dandy. The All three nerves lie in the
The early use of
intracranial approach to groove between the
Mental nerve glossopharyngeal nerve
section of the internal jugular vein
block in pain management
glossopharyn- geal nerve and internal carotid
centered around two
appeared to yield better artery (Figure 6-30B).
applications: (1) the
M
results for both A significant
treatment of
e glossopharyngeal neuralgia landmark for
glossopharyngeal
n and cancer pain but was a glossopharyngeal nerve
t neuralgia, and (2) the pal-
much riskier procedure.36 block is the styloid
a liation of pain secondary to
l Recently, interest in process of the temporal
head and neck
extracranial de- struction bone. This structure is the
malignancies. In the late
f of the glossopharyngeal calcification of the
1950s, the clinical use of
o nerve by glycerol or by cephalad end of the sty-
r the glossopharyngeal creation of a lohyoid ligament.
a nerve block as an adjunct radiofrequency lesion has Although usually easy to
m to awake endotracheal
e been renewed.37 identify, when ossification
intubation was
n is limited, it may be
documented.
difficult to locate with the
Weisenburg first A
described pain in the exploring needle.
N
distribution of the A
F glossopharyngeal nerve in T I
I
a patient with a cerebello- O N
G
U pontine angle tumor in M D
R 1910.33 In 1921, Harris Y I
E reported the first C
idiopathic case and coined The glossopharyngeal
A
6 nerve is the ninth cranial
–
the term glossopharyn- geal T
2 neuralgia.34 He suggested nerve. It contains both I
9 that blockade of the motor and sensory O
Injection technique for mental glosso- pharyngeal nerve fibers.38 The motor fi- N
nerve block. (From Waldman
might be useful in bers innervate the S
SD: Atlas of Interventional Pain
Management, 2nd ed. palliating this painful stylopharyngeus muscle.
Philadelphia, Saunders, 2003, p. condition. The sensory portion of Indications for
54, with permission.) Early attempts at the nerve innervates the glossopharyngeal nerve
permanent treatment of posterior third of the block are summa- rized in
glossopha- ryngeal tongue, the palatine tonsil, Table 6-3. In addition to
neuralgia and cancer pain and the mucous application for surgical
in the distribution of the membranes of the mouth anesthesia,
E and pharynx. Special glossopharyngeal nerve
F glossopharyngeal nerve
consisted principally of visceral afferent sensory block with local anes-
F
extra- cranial surgical fibers transmit thetics can be used as a
I
section or alcohol information from the taste diagnostic tool when
C
neurolysis of the glosso- buds of the posterior third performing differential
A
pharyngeal nerve.35 These of the tongue. neural blockade in the
C
approaches met with Information from the ca- evaluation of head and
Y
limited success in the rotid sinus and body, facial pain.41
No efficacy studies are treatment of which help control the Glossopharyngeal nerve
available. The efficacy is glossopharyngeal blood pres- sure, pulse, block is used to help
deter- mined by the neuralgia, but were useful and respiration, are differentiate geniculate
patient’s successful pain in some patients suffering carried via the carotid ganglion neuralgia from
relief after the nerve from cancer pain sinus nerve, a branch of glosso- pharyngeal
block. the glossopharyngeal neuralgia. If destruction
nerve.38 of glossopharyngeal nerve
Parasympathetic fibers is being considered, this
GLOSSOPHA pass via the technique is useful as an
glossopharyngeal nerve to indicator of the extent of
RYNGEAL the otic ganglion. motor and sensory
NERVE Postganglionic fibers from impairment that the
BLOCK the ganglion carry patient will likely
secretory information to experience.42
Glossopharyngeal nerve
block with local anesthetic
may be used to palliate
acute pain emergencies,
including glossopharyngeal
neu- ralgia and cancer
pain until pharmacologic,
surgical, and
Glossopharyngeal nerve

Internal
jugular vein

Vagus nerve
Internal
carotial artery

A B
FIGURE 6–30
(A) The anatomy of the glossopharyngeal nerve as it exits the jugular foramen. Note the close relationship of the vagus nerve. (B) This
is an anatomical dissection of the region where the glossopharyngeal nerve is traversing below the jugular foramen close to vagus, acces-
sory nerves and internal carotid artery, and internal jugular vein. (Courtesy of U. Pai, MD.)
antiblastic methods take indications are EQUIPMENT A
effect.43 This technique compelling, blockade of d
Local Nerve Block j
is also useful for atypical the glossopharyngeal
u
facial pain in the nerve using a 25-gauge ■ 25-gauge, 3/4-inch n
distribution of the needle may be carried out needle for infiltration c
glossopharyngeal nerve44 in the presence of ■ 22-gauge, 1- t
and as an adjunct for coagulopathy, al- beit 1/2-inch needle
awake en- dotracheal with increased risk of for injection at t
intubation.45 ecchymosis and the site o
Destruction of the hematoma formation. ■ 3-ml syringe
glossopharyngeal nerve ■ IV T-piece a
is indi- cated in the extension w
palliation of cancer pain, a
k
including invasive tumors Pulsed Radiofrequency e
of the posterior tongue,
hypopharynx, and ton- ■ 16-gauge, 1-1/4-
inch catheter i
sils.38 This technique is n
■ 5-cm
useful in the management t
radiofrequency
of the pain of u
thermocoagulation
glossopharyngeal b
neuralgia for those (RFTC) needle a
patients who have failed with 5-mm active- t
to respond to medical tip Racz-Finch i
Kit Needle o
management or who are n
not candidates for surgical Neurolytic Block or
microvascular de- Neurodestructive Procedure
compression.46 Cancer pain (palliation)
TABLE 6–3 Indications for
Management of glossopharyngeal
Glossopharyngeal Nerve neuralgia
C Block
O Local Anesthetic Block
N Surgical anesthesia
T Differential neural blockade
R Prognostic nerve block prior to
A neurodestructive procedures
I A
N c
u
D
t
I e
C
A
p
T a
I i
O n
N
S e
m
Contraindications to the e
blockade of the r
glossopharyngeal nerve g
are summarized in Table e
n
6-4. Local infection and
c
sepsis are absolute i
contraindications to all e
procedures. Coagulopathy s
is a strong
contraindication to (
glossopha- ryngeal nerve p
block, but owing to the a
desperate nature of many l
l
patients’ suffering from i
invasive head and face a
ma- lignancies, ethical and t
humanitarian i
considerations dictate its o
n
use, despite the risk of
)
bleeding.
When clinical
TABLE 6-4 Contraindications i D For preoperative
to Glossopharyngeal Nerve c U medication, use the
Block a
l
R standard recommen-
L
E dations for conscious
o a sedation by the American
c n P Society of
a o R Anesthesiologists.
l m
a
E
l P
i y A P
n R R
f A
e O
T C
c
D I E
t
i
R O D
o U N U
n G R
S P
h E
S y
L P
e
o s
p o
c i
s s
a c
i i
l a
s t
l
i
N o
C E
e n
o x
r
a a
v o
g m
e f
u i
l
B n
o P
l a
p a
o t
a t
c i
t i
k o
h e
n
y n
■ 1.5% lidocaine for
S It is customary to obtain a t
i skin infiltration
full history and physical
g ■ 0.5%
n exami- nation. The a
ropivacaine/bupivacai
i
ne mixture physical examination n
fi should include an assess- d
c ■ 2% lidocaine
a ■ Steroids (optional)
ment of the ability to
n move the neck and P
■ Iohexol
t inspection for normal h
(Omnipaque 240) y
landmarks at the site of
b s
the needle insertion. i
e N
h e c
a u P i
v r a
i r
o e n
o
l o
r The patient is placed in
a y p
s the supine position. The
l e
i r land- marks are (1)
a s a ipsilateral mastoid
b t process; (2) angle of the
■ 6% phenol in
n i mandible, anteriorly; and
o glycerin/iohexol v (3) feel the styloid process
r ■ Absolute alcohol e
m of the temporal bone, in
(97%)
a the middle between the
l M two landmarks. An
i e
t imaginary line is
P d
i i visualized or drawn
R
e
c running from the mastoid
s E
a process to the angle of the
A P
n R
t mandible.47 The fluo-
a i roscope should be placed
O o
t in an oblique position
o C n
m E and di- rected toward the
area of the mandible and at this midpoint location fluoroscopic image was Impedance was
the mastoid process in a plane perpendicular obtained. The styloid approximately 220 ohms
(Figure 6-31). The styloid to the skin. The styloid process, mastoid, and but dropped to
process should lie just process should be angle of the mandibular 113–140 ohms following
below the midpoint of this encountered within ra- mus were visible. An instillation of 3 cc of a
line. 3 cm. After contact is intracutaneous skin wheal 1:1:1 mixture of lidocaine
made, the needle is with 1% lidocaine was 2%, ropivacaine 0.2%, and
E withdrawn and walked raised at a point 4 mg dexamethasone.
x off the styloid process overlying the distal tip of Pulsed radiofrequency
t posteriorly. As soon as the styloid process. A 16- lesioning was per- formed
r bony contact is lost and gauge angiocatheter was for three cycles of 120
a placed about 1.5 cm seconds at a constant tem-
careful aspiration reveals
o
no blood or CSF, 7 ml of through the skin, aiming perature of 42°C. The
r
a 0.5% preservative-free for the styloid pro- cess. rate was 2 Hz, and the
l lidocaine combined with An anteroposterior view pulse width was 20
80 mg of confirmed that the tip of milliseconds. The
A methylprednisolone is the needle was at the patient was monitored
p injected in incremental level of the mandibular for
p doses. ramus. A 1 hour postprocedure,
r 20-gauge blunt curved andvital signs
Subsequently, daily
o radiofrequency needle remained stable.
a nerve blocks are
c performed in the same (RFK),
h manner, but 40 mg of 10 cm in length, 10-mm
methylprednisolone are active tip is advanced
The skin is prepared through the angiocatheter
substituted for the first
with antiseptic solution. until bony contact with
80-mg dose. This
After a local infiltration the styloid process is
approach may also be used
with a 25-gauge needle, made. The needle is then
for breakthrough pain in
a 22-gauge, walked off posteriorly
patients who previ- ously
1.5-inch needle attached experienced adequate pain and advanced another 1–
to a 3–5-ml syringe is 1.5 cm (Figure 6-34).
control with oral medica-
advanced Intermittent dual rotation
tions (Figures 6-32 and 6-
33).46 C-arm fluoroscopy was
used during needle
advancement. Aspiration
P with a 1-cc syringe was
u
l
negative for blood and
s CSF. One to 2 milliliters
e of Omnipaque
d 240 mg/dl, iodinated,
nonionic contrast
R demonstrated lo- cal
a filling, inferior spread,
d and absence of vascular
i
runoff on a lateral view
o
f (Figure 6-34). A line
r drawing of this
e fluoroscopic projection is
q displayed (Figure 6-35).
u Sen- sory stimulation up
e
to 1 volt at 50 Hz
n
c reproduced concor- dant
y pain at the base of the
tongue, pharynx, and
Informed consent and tonsils. Motor stimulation
intravenous access were up to 2.5 volts at 2 Hz
obtained. The patient reproduced lo- cal
was placed supine on the muscular contractions.
fluoroscopy table. Oxygen Contractions of the
was administered by nasal muscles innervated by
cannula, and vital signs the phrenic and spinal
were monitored accessory nerves were
noninvasively. The right absent. The patient
mastoid, lateral neck, and remained
mandible were prepped hemodynamically stable
and draped in a sterile without any bradycardic
fashion. A lateral or hypotensive episodes.
 FIGURE 6–33
The lateral radiographic view shows the tip of the needle on the styloid
process (arrow). This position ensures that the needle tip is close to the
FIGURE 6–31 glossopharyngeal nerve.
The C-arm is turned obliquely toward the mandible to visualize the sty-
loid process to create a lateral radiographic image.

acetaminophen 500 mg, sodium valproate, and nonsteroi-

EFFICACY dal anti-inflammatory drugs. An outside physician started
the patient on OxyContin 20 mg bid. The patient still had
The patient’s pain intensity reduced to 0/10, and this pain
no relief. A repeat glossopharyngeal pulsed radiofre-
relief persisted for 8-1/2 months. Thereafter, her pain
quency was performed, but this offered minimal relief for
recurred and gabapentin 200 mg/day was started. This
the first 2 weeks. Remarkably, there was a gradual im-
was not helpful and she went to the emergency room for
provement in pain and by the 6th week the patient was
intravenous analgesics on two occasions. Several analge-
pain free. The patient was weaned off of all analgesics
sics were prescribed: zonisamide, hydrocodone 5 mg with
except gabapentin, and this pain relief lasted for 6 months.
Pulsed radiofrequency lesioning was repeated, and the
patient reported complete pain relief at 8 months. How-
ever, she had a syncopal episode during this period and
required a pacemaker. In total, pulsed mode RF lesioning
of the glossopharyngeal nerve was performed three times
over a 24-month period.
Treatments for glossopharyngeal neuralgia can be di-
vided into surgical versus nonsurgical. Several classes of
drugs are used empirically with anecdotal success: carbam-
azepine, phenytoin, diazepam, amitriptyline, phenobarbi-
tal, ketamine, and baclofen.49,50 Nonetheless, intolerable
side effects and difficulty with oral intake impede patient
compliance. Surgical methods include peripheral neurec-
tomy, rhizotomy, styloidectomy, microvascular decompres-
sion (MVD), and motor cortex stimulation.49,51,52 Initially
introduced by Jannetta,53,54 MVD has been refined from a
technical standpoint to reduce complication rates.52 MVD
continues to demonstrate the most successful and repro-
ducible long-term outcomes.52,53 Peripheral neurectomy
and surgical rhizotomy have poorer outcomes and higher
rates of recurrent pain and morbidity.55 Several authors
suggest that MVD alone should be performed for glosso-
FIGURE 6–32 pharyngeal neuralgia,53,55,56 but these series were limited to
The site of entry for a glossopharyngeal nerve block is between the mas- patients with primary glossopharyngeal neuralgia. MVD is
toid process and the angle of the mandible. not applicable to secondary glossopharyngeal neuralgia.
 primary and secondary glossopharyngeal neuralgia.58–60
Percutaneous thermocoagulation of peripheral nerves,
however, carries the risks of neuritis, deafferentation pain,
Right styloid and neurovascular injury.61 Percutaneous thermocoagula-
process tion of the glossopharyngeal nerve, in particular, carries the
Needle posterior
to right styloid
hazard of damage to the vagus nerve.58 Vagal nerve damage
process or stimulation can cause severe hemodynamic problems,
such as syncope, asystole, or bradycardia.49 Due to these
concerns and the success of MVD, glossopharyngeal nerve
RF has not gained widespread acceptance.52,53,55 MVD is a
Right mandible
Left styloid surgical procedure requiring a craniectomy53 that has a 5%
process risk of mortality in the most experienced centers.39 These
figures are sobering, since untreated primary glossopharyn-
geal neuralgia is typically a nonterminal illness.
Arias58 modified the RF technique by using low-
FIGURE 6–34
temperature lesioning. This avoids iatrogenic injury to the
vagus nerve.58 Pulsed RF is a newer, nondestructive neural
Lateral fluoroscopic image displaying needle tip posterior to right styloid
process. (From Shah RV, Racz GB: Case conference: pulsed mode radio- lesioning method that provides relief of experimental and
frequency lesioning to treat chronic post-tonsillectomy pain. Pain Pract clinical neuropathic pain.62,63 Short pulses of radiofre-
3:233, 2003, with permission.) quency energy, delivered at a constant temperature, pro-
duce central and peripheral neuromodulatory effects.62
The precise mechanisms of pain relief are unknown but
Styloidectomy is recommended as a treatment for may involve alterations in the expression of genes such as
chronic post-tonsillectomy pain in the otolaryngology lit- c-fos.64
erature.51 The role of styloidectomy, in the absence of Temperatures in pulsed RF, unlike conventional RF,
peristyloid pathology or an elongated styloid process, is typically do not exceed 42°C. Temperatures below 45°C
unclear.57 Styloidectomy, moreover, is not a benign proce- do not irreversibly harm neural tissues.64,65 The risks of
dure. We are aware of one death due to iatrogenic vascular neuritis, deafferentation pain, and neuroma formation are
injury following styloidectomy. This case is undergoing minimal with pulsed RF. Furthermore, even if identical
litigation and is not reportable. temperatures are used, pulsed RF demonstrates better ef-
Percutaneous radiofrequency thermocoagulation of ficacy than conventional RF.64 This implies that the elec-
the glossopharyngeal nerve has been successful in treating trical field rather than the heat lesion may be responsible

Trigeminal
Styloid process
ganglion
Vagus n.
Mandibular n. Jugular
foramen 2
Lingual n.

1
FIGURE 6–35
Inferior Drawing detailing relevant anatomic
alveolar n. structures, initial needle position con-
Styloid process
tacting styloid process (1), and final
Glossopharyngeal n. position at glossopharyngeal nerve (2).
2 (Adapted from Shah RV, Racz GB:
Case conference: pulsed mode radio-
Stylohyoid frequency lesioning to treat chronic
ligament post-tonsillectomy pain. Pain
Pract
Internal 3:233, 2003, with permission.)
jugular v. 1
External
carotid a.

Internal carotid a.

Glossopharyngeal
nerve
for the clinical effect of O to vagal nerve block is block results in
RF.66 Pulsed RF may M also observed in some weakness of the tongue
provide long-term pain P patients.38 Inadvertent and trapezius muscle. 68
relief, reduce analgesic L block of the hypoglossal A small percentage of
consumption, and provide I and spi- nal accessory patients who undergo
patient satisfaction.66 C nerves during chemical neurolysis or
Even when the pain A glossopharyngeal nerve neurodestructive
recurs, the procedure is T procedures of the glosso-
easily repeatable. I pharyngeal nerve
Technically, there are O experience postprocedure
several percutaneous N dysesthesias in the area of
S the nerve.69 These
methods to target the
glossopharyngeal nerve. Inadvertent puncture of symptoms range from a
An intraoral approach is either vessel during mildly uncomfortable
often used for preemptive glossopha- ryngeal nerve burning or pulling
analgesia,67 but this block can result in sensation to severe pain.
method caries the risk of intravascular injection or Such severe
infection and iatrogenic hematoma formation. postprocedure pain is
injury to several Even small amounts of called anes- thesia dolorosa.
neurovascular structures, local anesthetic injected Anesthesia dolorosa can
including internal carotid into the carotid artery at be worse than the
artery, vagus nerve, this site can produce patient’s original pain and
brainstem, vertebral artery, profound local anesthetic is often harder to treat.
and upper cervical spinal Slough- ing of skin and
toxicity.36
nerves. Two extraoral subcutaneous tissue has
Because extraoral
approaches can be been associated with
blocks of the
performed with anesthesia dolorosa.
glossopharyngeal nerve
fluoroscopic guidance. The glossopharyngeal
can readily spread to
One approach, similar to nerve is susceptible to
the vagus and accessory
that used for trigeminal trauma from needle,
nerves, neurolytic blocks
ganglion blockade, uses hematoma, or
often produce analgesia
Hartel’s pro- jection.58 compression during
of the hemilarynx and/or
Instead of aiming for the injection procedures. Such
trapezius muscle, and
foramen ovale, the op- complications, although
sternocleido- mastoid
erator aims for the usually transi- tory, can be
paralysis on the ipsilateral
medial part of the jugular quite upsetting for the
side. Both these com-
foramen. This approach, patient.
plications may be well
however, can cause severe Even though risk of
tolerated by patients with
damage to the vital infection is uncommon, it
terminal cancer pain.
neurovascular structures is ever present, especially
The major
mentioned earlier. The in patients with cancer
complications associated
tech- nique of Shah and who are
with glossopha- ryngeal
Racz can be safely immunocompromised.44
nerve block are related to
performed, especially Early detection of
trauma to the internal
when curved blunt infection is crucial to
jugular vein and carotid
needles, contrast avoid potentially life-
artery.38 Hematoma
fluoroscopy, prepro- threatening sequelae.
formation and
cedure motor and sensory intravascular injection of
electrical stimulation, local anesthetic with sub- C
hemody- namic sequent toxicity are L
monitoring, and pulsed significant problems for I
mode RF are used. These the patient. Blockade of N
technical refinements may the motor portion of the I
dispel concerns about this glossopharyngeal nerve C
pro- cedure’s safety and can result in dysphagia A
permit its gradual re- secondary to weakness of L
introduction as a the stylopharyngeus
treatment for muscle.43 If the vagus P
glossopharyngeal nerve is inad- vertently E
neuralgia. Larger studies blocked, as it often is A
are needed to further during glossopharyngeal R
substantiate claims of nerve block, dysphonia L
safety and efficacy. secondary to paralysis of S
the ip- silateral vocal
cord may occur. Reflex Patients with pharyngeal
tachycardia sec- ondary cancer will often have
C
undergone radical neck
dissection and the
sternocleidomastoid The term occipital
muscle will have been neuralgia was first used in
removed. This makes 1821, when Beruta y
identification of the Lentijo and Ramos made
styloid process much reference to an oc-
easier, since this particular cipital neuralgic
bony landmark is now syndrome.70 The
almost subcutaneous, technique of occipital
allowing this block to be
performed easily.
Because of the
proximity of the large
vascular conduits of the
internal carotid artery and
the internal jugular vein,
the risks of intravascular
injection are always
significant, demanding
meticulous aspiration tests.
With the temporary and
perhaps permanent
analgesia produced by this
block, a degree of
incoordination of
swallowing, with the
accompa- nying potential
risk of aspiration, must be
appreciate d by patients
and attendants alike. With
numbness of half of the
pharynx and the larynx,
ingestion and swallowing
are often severely
compromised.

E
F
F
I
C
A
C
Y

No data are available to

establish the efficacy of the
block. Pain relief by the
patient is a good
indication of success and
purely anecdotal.

GREATER AND
LESSER
OCCIPITAL
NERVE
BLOCKS

H
I
S
T
O
R
Y
nerve block seems to be first described by Bonica in
1953.71

ANATOMY
The greater occipital nerve gets fibers from the dorsal
primary ramus of the second cervical nerve and to a lesser Greater
extent from the third cervical nerve. The lesser occipital occipital nerve
nerve arises from the ventral primary rami of the second
Lesser
and third cervical nerves (Figure 6-36). occipital
The greater occipital nerve ascends in the posterior nerve
neck over the dorsal surface of the rectus capitis posterior
major muscle, at the midpoint of this muscle; turns dor-
sally to pierce the semispinalis capitis; and then runs a Sternocleidomastoid
short distance rostrolaterally, lying deep to the trapezius. muscle
The nerve becomes superficial below the superior nuchal
line, along with the occipital artery.
It supplies the medial portion of the posterior scalp
as far anterior as the vertex. The lesser occipital nerve
passes superiorly along the posterior border of the sterno-
cleidomastoid muscle, innervating the lateral portion of FIGURE 6–36
the posterior scalp and the cranial surface of the pinna of Anatomy and technique of injection of the greater occipital nerve.
(A) The third occipital nerve, which is not shown, is usually located me-
the ear.72–74 dial to the greater occipital nerve. The lesser occipital nerve (B) can be
blocked at a point 2.5 cm lateral to the site of the injection for greater
occipital nerve block.
INDICATIONS

■ Diagnosis of occipital neuralgia DRUGS

■ Management of occipital neuralgia
■ Treatment of cancer pain in region ■ 1.5% lidocaine for skin infiltration
■ Headache associated with muscular tension or ■ 2% lidocaine for nerve block
spasm ■ Steroids (optional)
■ Cervigonenic headache
■ Anesthesia of posterior part of the scalp Neurolysis
■ 2 ml 6% phenol in glycerine or in Omnipaque
CONTRAINDICATIONS
PROCEDURE
■ Local infections
■ Coagulopathies With the patient seated and the head flexed slightly for-
■ Metastasis in region ward, both the greater and lesser occipital nerves can be
■ Significant behavioral abnormalities blocked. Alternatively, the patient can lie prone with the
head hyperflexed on a pillow.
There are three landmarks for locating the greater
EQUIPMENT
occipital nerve: (1) the occipital artery, (2) the mastoid
Local Anesthetic Nerve Block process, and (3) the greater occipital protuberance. An
imaginary line is passed through these landmarks, and
■ 22-gauge, 1-1/2-inch needle
the occipital artery is generally found at a point ap-
■ 5 ml syringe
proximately one-third the distance from the occipital
protuberance on the superior nuchal line. The lesser
Radiofrequency Lesioning occipital nerve is found at a two-thirds distance from
■ 25-gauge, 3/4-inch needle the occipital protuberance on the superior nuchal line
■ 16-mm or 14-mm catheter (Figure 6-37).
■ 3 ml syringe The artery is palpated and a short (1–1/2-inch),
■ 5-cm radiofrequency thermocoagulation needle 25-gauge needle is inserted through the skin at the level of
with 5-mm active tip the superior nuchal line. The nerve is often medial to the
artery at this level. However, the anatomy varies and it
may also be lateral to the artery.
The needle is advanced until a paresthesia or bone is
encountered and then withdrawn 2 mm. Local anesthetic
solution of 2–5 ml is injected after negative aspiration.
Injection site for
A paresthesia is not necessary for a successful block. If greater occipital nerve
the artery is not identified, the medication is injected in a Injection site for
fan-like fashion (medially and laterally) and 5 ml of local lesser occipital
anesthetic is injected. nerve
The lesser occipital nerve is blocked by introducing X
X
the needle medial to the origin of the sternocleidomas-
toid muscle at the mastoid process. The needle is aimed
in a cephalad and medial direction until it contacts the
skull. The needle is withdrawn 2 mm and aspirated, after
which approximately 3 ml of local anesthetic should be
injected. To prolong effectivity, 80 mg of depot steroids
may be added.

Neurolytic Block
The needle is advanced until a paresthesia is encoun-
tered. It will be better to seek for paresthesia with a FIGURE 6–37
stimulator. When the paresthesia is met, 1 ml 6% phenol Anatomic landmarks for skin entry points of the greater occipital nerve
(A) and lesser occipital nerve (B).
in glycerine or Omnipaque is slowly injected after nega-
tive aspiration.
CLINICAL PEARLS

Pulsed Radiofrequency The principal role of occipital nerve block is for the diag-
nosis of occipital neuralgia. If a diagnostic block is planned,
A 5-cm radiofrequency needle with 5-mm active tip is the dose should be limited to 1–2 ml to minimize confusion
advanced to make contact, through a previously intro-
duced catheter, with the bone in the close vicinity of the
Lesser occipital nerve
nerve. Sensorial stimulation with a frequency of 50 Hz is
the next step. The stimulation should be felt below
0.5 V. When the patient feels the paresthesia, 1 ml of
2% lidocaine is injected. Ten minutes later, pulsed RF
at
42°C for two or three cycles of 120 seconds is performed
(Figure 6-38).

COMPLICATIONS

1. Due to the high vascularity of the scalp, Greater

occipital
ecchymosis or hematoma formation can nerve
occur. This is usually transient.
2. Although very rare, intravascular injection of
the local anesthetic can occur. A small volume
(1–2 ml) of local anesthetic has the capability
of developing CNS toxicity.
3. Nerve injury due to the direct trauma from
the needle or compression of nerves with large
volume of local anesthetic can occur.
4. If the needle is introduced too deeply when trying
Pulse
to achieve paresthesia, inadvertent placement of radiofrequency
the needle into the foramen magnum can occur. Sternocleidomastoid Trapezius muscle needles
Administration of local anesthetics in this muscle
situation can result in total spinal block and FIGURE 6–38
respiratory depression. Technique of pulsed radiofrequency.
with relief of myofascial of the authors, where one From the clinical
pain when larger volumes In 1980, a 76-year-old injection gave 13 years of experience of many users,
are in- jected. Failure to woman complaining of pain relief from 1982 to a pattern of problems has
obtain successful block can severe occipital neuralgic 1995, at which point the become evident. The
be due to an anatomic type pain was evaluated. severe pains re- turned injection technique
variation. Upon examination there and repeat injection coming from just below
The vascularity and was tenderness at the C1- needed to be carried the nuchal line through
the proximity to the arterial C2 occipital area. out. The analgesic effect the facial layers is clearly a
supply give rise to an Following review of lasted the rest of her life. very safe technique;
increased incidence of literature and anatomy, the however, if the tip of a
postblock ecchymosis and entrapment of the greater sharp needle enters the
hematoma formation. oc- cipital nerve in the greater occipital nerve,
These complications can suboccipital compartment retro- grade longitudinal
be de- creased if manual was assumed. Ten spread may give rise to a
pressure is applied to the milliliters of local “locked-in phenomenon”
area of the block anesthetic and steroid where the patient stops
immediately after the mixtures were injected breathing and stares with
injection. Application of from just below the nuchal dilated pupils. Airway
cold packs for 20-minute line bilaterally, through the ventilation must be
periods after the block deep fascia trapezius and initiated. One of the
will also de- crease the semispinalis muscle layers patients had this
amount of postprocedure into the suboccipital occurrence; after approxi-
pain and bleeding. compartment. The pain mately 30 minutes of
Strict care must be relief was very rapid and ventilation, the patient
taken to avoid inadvertent lasted 3 years, the rest of made a full and uneventful
needle placement into the her life. The needle used recovery. A similar event
foramen magnum, as the was occurred in the practice
subarachnoid 1/2-inch, 22-gauge B bevel. of one of the trainees
administration of local The technique of the after 6–8 years of practice
anesthetic in this region procedure, virtually and many procedures with
will result in an immediate unchanged, was repeated similar good outcomes.
total spinal block. several thousand times in Intra- neural injection–
numerous cases in related problems have
subsequent years.
been reported.76
E In a 1994 presentation
Eight additional cases
F in Perth, Australia,
have been reported in the
F Umberto Rossi, in a medicolegal literature,
I patient with the same
C where the worst
condition, dissected down complication was
A to the C1-C2 lamina to
C permanent brain damage
cut the inferior oblique because of absence of
Y muscle with prompt relief ventilator support. Several
of the pain on recovery. cases of infarction of the
No good data are
He noted the greater brain stem were reported
available to evaluate the
occipital nerve to be in which glossopharyngeal
efficacy of the block.
flattened. He also nerve impairment and
Success is anecdotal.
observed that while the swallowing difficulty were
pain would stop, these the consequences as
patients would de- velop predicted by Seelander.76
SUBO
similar pain on the During the last 6-8 years,
CCIPI opposite side.
TAL the technique changed to
The suboccipital the use of fluoroscopy
COMP compartmental injection and a bullet-tipped, side-
ARTM technique from the ported stealth needle
ENT beginning has been a (Epimed International)
DEC bilateral injection. In and in- jection of contrast
OMP 2004, similar to verify a lack of
RESS neurosurgical intraneural spread prior to
ION observations were made the large-volume
where the sectioning of injection.
H the inferior oblique Lessons learned are
I muscle was that it is a bilateral
S recommended. 75 disease and repeat
T The longest follow-up injections are safe and
O observation following the effective. Younger
R injection technique has patients need to be trained
Y been of the mother of one in physical therapy
exercises and relax- ation 3
9
technique (Figures 6-39
Moving backwards loosens
and 6-40). inferior oblique muscle; greater
Cadaver studies occipital nerve entrapment
confirm the suboccipital lessens.
compart- ment and the
spread of the injected
contrast along the greater
occipital nerve (Figures 6-
41 and 6-42).

A
N
A
T
O
M
Y

The suboccipital triangle,

not to be confused with
the oc- cipital triangle, is
bounded by rectus
capitus posterior major
muscle laterally and
above. The muscle
originates on the spinous
process of the axis and
inserts on the lateral

Mo
ng
bac
ward
s
loos
ens
infe
or
obliq
ue
mus
cle;
grea
ter
occi
pital
ner
e
ent
apm
ent
less
ens

F
I
G
U
R
E

6
–
 aspect of the inferior nuchal line of the occiput. It rotates
the skull ipsilaterally.
The obliquus capitus superior muscle is the lateral,
upper border. It originates from the transverse process of
the atlas and inserts on the occipital bone between the
superior and inferior nuchal lines lateral to the semispina-
Forward movement
lis capitus. The obliquus capitus superior pulls the head
tightens inferior backward to the ipsilateral side.
oblique muscle - The obliquus capitus inferior is the lateral boundary
more entrapment of
greater occipital nerve
below, and it originates from the spinous process of the
axis and inserts on the transverse process of the atlas. It
rotates the atlas and occiput. The roof of the space is a
FIGURE 6–40
tough layer of connective tissue beneath the semispinalis
Forward movement tightens inferior oblique muscle. More entrapment
of greater occipital nerve. capitus, and the floor is the occipito-atlantal membrane
and posterior arch of the atlas.
The posterior branch of the first occipital nerve, the
suboccipital nerve, exits posteriorly between the occiput
and the posterior arch of the atlas. It supplies
the muscles bounding the suboccipital triangle and com-
municates with the greater and lesser occipital nerves.
Entrapment can occur at the obliquus capitus inferior
(inferior oblique) or semi-spinalis or trapezius (Figures
6-43 and 6-44).

Stealth needle with bullet

tip and side port - for
suboccipital compartment
injection—10 ml

The three entrapments

FIGURE 6–41 1) Trapezius
Stealth needle placement in a cadaver is shown on the right side, while 2) Semispinalis
conventional approach is shown on the left side. (contrast and anesthetic)
3) Inferior oblique

FIGURE 6–43
Lateral view suboccipital entrapment.

Greater Trapezius muscle

occipital nerve (entrapment)

Semispinalis
muscle
(entrapment)

Inferior
oblique muscle
(entrapment)
FIGURE 6–42
Methylene blue injected bilaterally shows suboccipital compartment FIGURE 6–44
spread on right. Occipital nerves are retracted. Posterior view suboccipital entrapment.
I ■ 0.2% ropivacaine – The suboccipital
4
N 5 compartment opens and
D S injectate spreads in the
I T t perineural space of greater
C E e occipital nerve (Figures 6-
A a
C l 46 and 6-47).
T H t
I N h
O I
N Q n
S U e
e
E d
■ Diagnostic
l
therapeutic The patient is positioned e
■ Suboccipital in the prone position
tenderness with the neck in flexion. p
dorsolateral C1-C2 The nuchal line is l
area a
palpated. Skin entry is c
■ Occipital frontal made 1/2 inch e
headache paramedial. Aim and m
e
advance the stealth needle n
through fascial layers t
C
(Figure 6-45). .
O
On the lateral
N
T fluoroscopic view, the
R direction should be
A toward the arch of C1.
I Inject contrast, which
N should spread around
D needle tip and not within
I the nerve. Ten milliliters
C of 0.2% ropivacaine and
A 20 mg of depomedrol are FIGURE 6–46
T used for the block. Anteroposterior view with
I contrast.
O
N
S

■ Infection
■ Previous local
surgery unless Injected
contrast is used volume opens
up the
ent
compa
E filling
Q
U The three
entrapme
I
nts
P 1)
M Trapezius
E 2)
Semispin
N alis
T (cont
and
■ Stealth needle anesthetic
)
■ Fluoroscopy 3) In
■ Small-bore tubing oblique
■ Syringe

D FIGURE 6–47
R F Lateral view with contrast.
I
U G
G U
S R
E
■ Corticosteroid
■ Omnipaque 240 6
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