From P. Raj. Textbook of Regional Anesthesia

a. Pterygopalatine fossab. Sella turcicac. Maxillary sinusd. Ramus of mandiblee. Hard palatef. Base of skull

Trigeminal NerveTrigeminal Nerve

Trigeminal Nerve Trigeminal Nerve Submental ViewSubmental View

Submental Oblique View

Sella Turcica

Foramen ovale

Clivus

Supraorbital NerveSupraorbital Nerve

Supraorbital Supraorbital NeuralgiaNeuralgia

Confused with migraine, cluster headaches, frontal sinusitis

May be caused by trauma (windshield, punch to face) and may not present for many years

Triggered by fluid retention (perimenstrual)

Injured by poor fitting glasses

Entrapped by frowning, squinting

May need to treat supratrochlear as well

Supraorbital Exam and Supraorbital Exam and InjectionInjection

Infraorbital NerveInfraorbital Nerve

Infraorbital InjectionInfraorbital Injection

Mandibular NerveMandibular Nerve

Largest of the 3 trigeminal branches V3

Made up of 2 roots A large sensory root from the

inferior edge of the trigeminal ganglion

Small motor nerve

Supplies the myohyoid and digastric muscles, anterior 2/3rds of the tongue

Maxillary/Mandibular Nerve Block

Maxillary Nerve Block

Inferior Alveolar NerveInferior Alveolar Nerve

Mental NerveMental Nerve

Mental InjectionMental Injection

Auriculotemporal Nerve Auriculotemporal Nerve (ATN)(ATN)

Auriculotemporal Auriculotemporal NeuralgiaNeuralgia

Temple headache, menstrual migraines, referred to retro-orbital region

Unilateral or bilateral

Misdiagnosed as TMJ

4 am headache 2° to bruxism

Auriculotemporal Auriculotemporal InjectionInjection

Facial NerveFacial Nerve

7th cranial nerve Primarily motor but some

sensory fibers Petrous temporal bone ->

the internal auditory meatus -> stylomastoid foramen, Through the parotid gland Five major branches.

Though it passes through the parotid gland, it does not innervate the gland.

The facial nerve forms the geniculate ganglion prior to entering the facial canal.

StylomastoidForamen

Styloid Process

JugularForamen

1 cm

Facial NeuralgiaFacial Neuralgia

Most common is zygomatic entrapment by coronoid notch

Mimics ATN or infraorbital neuralgia

Worse in am after dentures have been out all night

Posterior Auricular Posterior Auricular NeuralgiaNeuralgia

Causes ear pain and parietal headache

Triggered by flexion/extension injuries (esp if head turned at impact) or blows to the head

Pain pattern similar to SCM (see TP section)

Posterior Auricular Posterior Auricular InjectionInjection

Occipital NerveOccipital Nerve

Lesser Occipital NerveLesser Occipital Nerve

Dorsal ramus of C2 and sometimes C3

Curves around and ascends across the posterior border of the SCM Considered part

of the superficial cervical plexus

33rdrd Occipital Nerve Occipital Nerve

Dorsal ramus of C3

Pierces the trapezius medial to the occipital nerve

Innervates the lower back of the head

Occipital NervesOccipital Nerves

Greater Occipital Greater Occipital InjectionInjection

Classically taught large volume injection at nuchal ridge

Greater Occipital Greater Occipital InjectionInjection

Classically taught large volume injection at nuchal ridge

But the entrapment is at the base of the skull

Stealth NeedleStealth Needle

Glossopharyngeal Glossopharyngeal NerveNerve

Glossopharyngeal Glossopharyngeal Nerve Nerve

Anatomy Exists the skull through the jugular foramen

located posterior to the tip of the mastoid process

The nerve then passes anteriorly between the internal jugular vein and internal carotid artery, coursing medial to the styloid process and lateral to the vagus and spinal accessory nerves

Supplies sensation to the posterior one-third of the tongue, the palatine tonsils and the pharyngeal wall

Glossopharyngeal Glossopharyngeal InjectionInjection

StyloidProcess

Spinal Accessory NerveSpinal Accessory Nerve

Sphenopalatine Sphenopalatine GanglionGanglion

Migraine headaches, cluster headaches, atypical face pain

Migraines are associated with increased parasympathetic tone

Nasal pledget vs injections

PterygomaxillaryFissure

MiddleTurbinate

Stellate GanglionStellate Ganglion

Atlanto-Occipital and Atlanto-Occipital and Atlanto- Axial (AO and AA) Atlanto- Axial (AO and AA)

JointsJoints

Vertebral ArteryVertebral Artery

Variations of the Vertebral Variations of the Vertebral ArteryArtery

Aprill C, Axinn MJ, Bogduk N: Occipital headaches stemming from the lateral atlanto-axial (C1-2) joint. Cephalalgia 22:15-22, 2002

Cervical Facet Joints

Cervical FacetsCervical Facets

Medial Branch Blocks

Cervical Epidural

Cervical DiscogramCervical Discogram

TMJTMJ

Trigger Point InjectionsTrigger Point Injections

Masseter MuscleMasseter Muscle

Temporalis MuscleTemporalis Muscle

Trapezius MuscleTrapezius Muscle

Trapezius Pain PatternTrapezius Pain Pattern

Tension headache

Can cause intractable occipital and retro-orbital headaches

Caused by chronic stress, postural, flexion/extension injuries

Sternocleitomastoid Sternocleitomastoid MuscleMuscle

SCM Pain PatternSCM Pain Pattern

Botulism ToxinBotulism Toxin

Two types of clinically effective toxins Botulism A (Botox) Botulism B (Myobloc)

Work by blocking Ach release (muscle paralysis)

Prevents entrapment supraorbital, occipital, ATN

Restorative Injection Restorative Injection TherapyTherapy

Originally called “prolotherapy”or “sclerotherapy”

Use of proliferant to promote ligament strengthening

Tries to restore structural integrity

CryoneuroablationCryoneuroablation

Used to treat nerve pathologies (occipital, ATN, supraorbital)

Kills nerve but leaves myelin sheath intact (no neuroma formation)

Radiofrequency LesionRadiofrequency Lesion

Used for facets and enesthopathies (such as ISL)

Creates a thermal lesion which kills the nerves and potentially shrinks the tissues

Pulsed RF

Occipital StimulatorOccipital Stimulator

Similar to spinal cord stimulation

Exchanges pain for tingling

Subq generator or antenna

Primarily for occipital pain, but described for supraorbital pain (PHN) and trigeminal neuralgia

Occipital StimulationOccipital Stimulation

If you would test the If you would test the skill of a young skill of a young

physician, give him a physician, give him a patient with a patient with a

headache to treat.headache to treat.William Sunderman, MDUniversity of Michigan1935