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
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