Atlas of Interventional Pain Management E-Book

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Arranged by anatomic region, Atlas of Interventional Pain Management provides pain medicine specialists in practice and in training with the most up-to-date and practical guide to over 160 interventional pain management techniques. High-quality photographs, procedural videos, and 19 brand-new chapters combine to offer the detailed guidance you need to implement safe, effective treatments and achieve the best possible outcomes in Pain Medicine.

  • Maximize your success rate and reduce complications with CPT codes for each procedure, as well as indications, relevant anatomy, technique, side effects and complications, and clinical pearls.
  • Integrate interventional techniques into your practice with lavish, detailed illustrations that highlight the key steps in each procedure.
  • View line drawings paired with CT, MR and/or radiographic images to illustrate relevant points in the text.
  • Stay current on the latest injection techniques with 19 brand-new chapters including: Brachial Plexus Block - Infraclavicular Approach; Transverse Abdominis Plane Block; Anterior Cutaneous Nerve Block; Lumbar Grey Ramus Communicans Block; Lumbar Grey Ramus Communicans Block - Radiofrequency Lesioning; and more.
  • Expand the breadth of procedures you perform by focusing on the "how" rather than the "why" of various pain-relieving techniques.
  • Increase needle-placement precision and find the exact location to deliver the nerve block with significantly expanded fluoroscopy- and ultrasound-guided content.
  • Visualize proper needle placement with help from an increased number of high-quality photographs.
  • Understand how techniques are performed by watching procedural videos that cover Cervical Translaminar Epidural Block; Cervical Paravertebral Medical Branch Block; Percutaneous Facet Fusion; Lumbar Transforaminal Epidural Clock; and more.
  • Consult this title on your favorite e-reader, conduct rapid searches, and adjust font sizes for optimal readability.

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Published by
Published 30 September 2014
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EAN13 9780323321969
Language English
Document size 102 MB

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Atlas of Interventional
Pain Management
FOURTH EDITION
Steven D. Waldman, MD, JD
Clinical Professor of Anesthesiology, Clinical Professor of Medical Humanities and
Bioethics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
Kansas City, MissouriTable of Contents
Cover image
Title page
Copyright
Dedication
Preface
Video Contents
Section I: Head
Chapter 1: Atlanto-occipital Block Technique
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 2: Atlantoaxial Block Technique
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 3: Sphenopalatine Ganglion Block: Transnasal ApproachAbstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 4: Sphenopalatine Ganglion Block: Greater Palatine Foramen Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 5: Sphenopalatine Ganglion Block: Lateral Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 6: Sphenopalatine Ganglion Block: Radiofrequency Lesioning
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 7: Greater and Lesser Occipital Nerve Block
Abstract
Indications
Clinically Relevant Anatomy
TechniqueSide Effects and Complications
Chapter 8: Greater and Lesser Occipital Nerve Block: Radiofrequency Lesioning
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 9: Gasserian Ganglion Block
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 10: Gasserian Ganglion Block: Radiofrequency Lesioning
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 11: Gasserian Ganglion Block: Balloon Compression Technique
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 12: Trigeminal Nerve Block: Coronoid Approach
AbstractIndications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 13: Selective Maxillary Nerve Block: Coronoid Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 14: Selective Mandibular Nerve Block: Coronoid Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 15: Supraorbital Nerve Block
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 16: Supratrochlear Nerve Block
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and ComplicationsChapter 17: Infraorbital Nerve Block: Extraoral Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 18: Infraorbital Nerve Block: Intraoral Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 19: Mental Nerve Block: Extraoral Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Chapter 20: Mental Nerve Block: Intraoral Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 21: Inferior Alveolar Nerve Block
Abstract
Indications
Clinically Relevant Anatomy
TechniqueSide Effects and Complications
Chapter 22: Auriculotemporal Nerve Block
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 23: Greater Auricular Nerve Block
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Section II: Neck
Chapter 24: Glossopharyngeal Nerve Block: Extraoral Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 25: Glossopharyngeal Nerve Block: Intraoral Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and ComplicationsChapter 26: Glossopharyngeal Nerve Block: Radiofrequency Lesioning
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 27: Vagus Nerve Block
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 28: Spinal Accessory Nerve Block
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 29: Phrenic Nerve Block
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 30: Facial Nerve Block
Indications
Clinically Relevant Anatomy
TechniqueSide Effects and Complications
Chapter 31: Superficial Cervical Plexus Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 32: Deep Cervical Plexus Block
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 33: Superior Laryngeal Nerve Block
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 34: Recurrent Laryngeal Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 35: Stellate Ganglion Block: Anterior Approach
Abstract
Indications
Clinically Relevant AnatomyTechnique
Side Effects and Complications
Chapter 36: Stellate Ganglion Block: Posterior Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 37: Stellate Ganglion Block: Vertebral Body Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 38: Stellate Ganglion Block: Radiofrequency Lesioning
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 39: Third Occipital Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 40: Third Occipital Nerve Block: Radiofrequency Lesioning
IndicationsClinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 41: Cervical Facet Block: Medial Branch Technique
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 42: Cervical Facet Neurolysis: Radiofrequency Lesioning of the Cervical
Medial Branch
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 43: Cervical Facet Block: Intra-articular Technique
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 44: Cervical Epidural Block: Translaminar Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 45: Cervical Epidural Block: Transforaminal ApproachAbstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 46: Lysis of Cervical Epidural Adhesions: Racz Technique
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 47: Cervical Selective Nerve Root Block
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Section III: Shoulder and Upper Extremity
Chapter 48: Brachial Plexus Block: Interscalene Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 49: Brachial Plexus Block: Supraclavicular Approach
Indications
Clinically Relevant Anatomy
TechniqueSide Effects and Complications
Chapter 50: Brachial Plexus Block: Infraclavicular Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 51: Brachial Plexus Block: Axillary Approach
Abstract
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 52: Suprascapular Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 53: Radial Nerve Block at the Humerus
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 54: Medial Cutaneous and Intercostobrachial Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and ComplicationsChapter 55: Radial Nerve Block at the Elbow
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 56: Median Nerve Block at the Elbow
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 57: Ulnar Nerve Block at the Elbow
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 58: Radial Nerve Block at the Wrist
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 59: Median Nerve Block at the Wrist
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 60: Ulnar Nerve Block at the Wrist
IndicationsClinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 61: Metacarpal and Digital Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 62: Intravenous Regional Anesthesia
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Section IV: Thorax and Chest Wall
Chapter 63: Thoracic Epidural Nerve Block: Midline Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 64: Thoracic Epidural Nerve Block: Paramedian Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 65: Thoracic Epidural Nerve Block: Transforaminal Approach
IndicationsClinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 66: Thoracic Paravertebral Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 67: Thoracic Facet Block: Medial Branch Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 68: Thoracic Facet Block: Radiofrequency Lesioning of the Medial Branch of
the Primary Posterior Rami
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 69: Thoracic Facet Block: Intra-articular Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 70: Thoracic Sympathetic Ganglion Block
Indications
Clinically Relevant Anatomy
TechniqueSide Effects and Complications
Chapter 71: Intercostal Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 72: Intercostal Nerve Block: Radiofrequency Lesioning
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 73: Interpleural Nerve Block: Percutaneous Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 74: Interpleural Nerve Block: Tunneled Catheter Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Section V: Abdomen and Abdominal Wall
Chapter 75: Splanchnic Nerve Block: Classic Two-Needle Technique
Indications
Clinically Relevant Anatomy
TechniqueSide Effects and Complications
Chapter 76: Splanchnic Nerve Block: Single-Needle Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 77: Celiac Plexus Block: Classic Two-Needle Retrocrural Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 78: Celiac Plexus Block: Single-Needle Retrocrural Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 79: Celiac Plexus Block: Two-Needle Transcrural Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 80: Celiac Plexus Block: Single-Needle Periaortic Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 81: Celiac Plexus Block: Single-Needle Transaortic TechniqueIndications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 82: Celiac Plexus Block: Single-Needle Lateral Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 83: Celiac Plexus Block: Single-Needle Anterior Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 84: Transversus Abdominis Plane Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 85: Anterior Cutaneous Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 86: Ilioinguinal Nerve Block
Indications
Clinically Relevant AnatomyTechnique
Side Effects and Complications
Chapter 87: Iliohypogastric Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 88: Genitofemoral Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Section VI: Back and Pelvis
Chapter 89: Lumbar Sympathetic Ganglion Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 90: Lumbar Sympathetic Ganglion Block: Radiofrequency Lesioning
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 91: Lumbar Paravertebral Nerve Block
Indications
Clinically Relevant AnatomyTechnique
Side Effects and Complications
Chapter 92: Lumbar Facet Block: Medial Branch Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 93: Lumbar Facet Block: Radiofrequency Lesioning of the Medial Branch of
the Primary Posterior Rami
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 94: Lumbar Facet Block: Intra-articular Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 95: Lumbar Gray Ramus Communicans Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 96: Lumbar Gray Ramus Communicans Block: Radiofrequency Lesioning
Indications
Clinically Relevant Anatomy
Technique
Side Effects and ComplicationsChapter 97: Lumbar Epidural Nerve Block: Interlaminar Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 98: Lumbar Epidural Nerve Block: Transforaminal Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 99: Lumbar Selective Spinal Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 100: Lumbar Subarachnoid Nerve Block: Midline Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 101: Lumbar Subarachnoid Nerve Block: Paramedian Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 102: Lumbar Subarachnoid Nerve Block: Lumbosacral Approach of Taylor
IndicationsClinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 103: Lumbar Myelography
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 104: Superior Cluneal Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 105: Caudal Epidural Nerve Block: Prone Position
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 106: Caudal Epidural Nerve Block: Lateral Position
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 107: Lysis of Epidural Adhesions: Racz Technique
Indications
Clinically Relevant Anatomy
TechniqueSide Effects and Complications
Chapter 108: Sacral Nerve Block: Transsacral Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 109: Sacroiliac Lateral Branch Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 110: Sacroiliac Lateral Branch Radiofrequency Lesioning
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 111: Hypogastric Plexus Block: Single-Needle Medial Paraspinous Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 112: Hypogastric Plexus Block: Classic Two-Needle Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 113: Hypogastric Plexus Block: Single-Needle Transdiskal TechniqueIndications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 114: Hypogastric Plexus Block: Single-Needle Anterior Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 115: Ganglion of Walther (Impar) Block: Prone Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 116: Ganglion of Walther (Impar) Block: Transcoccygeal Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 117: Pudendal Nerve Block: Transvaginal Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 118: Pudendal Nerve Block: Transperineal Approach
Indications
Clinically Relevant AnatomyTechnique
Side Effects and Complications
Chapter 119: Sacroiliac Joint Injection
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 120: Sacroiliac Joint: Radiofrequency Lesioning
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Section VII: Lower Extremity
Chapter 121: Lumbar Plexus Nerve Block: Winnie 3-in-1 Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 122: Lumbar Plexus Nerve Block: Fascia Iliaca Compartment Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 123: Lumbar Plexus Nerve Block: Psoas Compartment Technique
Indications
Clinically Relevant AnatomyTechnique
Side Effects and Complications
Chapter 124: Femoral Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 125: Lateral Femoral Cutaneous Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 126: Obturator Nerve Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 127: Sciatic Nerve Block: Anterior Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 128: Sciatic Nerve Block: Posterior Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and ComplicationsChapter 129: Sciatic Nerve Block: Lithotomy Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 130: Piriformis Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 131: Sciatic Nerve Block at the Femur: Lateral Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 132: Tibial Nerve Block at the Knee: Posterior Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 133: Tibial Nerve Block at the Knee: Lateral Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 134: Tibial Nerve Block at the Ankle
IndicationsClinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 135: Saphenous Nerve Block at the Knee
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 136: Saphenous Nerve Block at the Ankle
Indications
Clinically Relevant Anatomy
Technique
Ultrasound-Guided Technique
Side Effects and Complications
Chapter 137: Common Peroneal Nerve Block at the Knee: Posterior Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 138: Common Peroneal Nerve Block at the Knee: Lateral Approach
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 139: Deep Peroneal Nerve Block at the Ankle
Indications
Clinically Relevant AnatomyTechnique
Side Effects and Complications
Chapter 140: Superficial Peroneal Nerve Block at the Ankle
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 141: Sural Nerve Block at the Ankle
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 142: Metatarsal and Digital Nerve Block of the Foot
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Section VIII: Advanced Interventional Pain Management Techniques
Chapter 143: Cervical Subarachnoid Neurolytic Block
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 144: Lumbar Subarachnoid Neurolytic Block
Indications
Clinically Relevant AnatomyTechnique
Side Effects and Complications
Chapter 145: Implantation of Subcutaneously Tunneled One-Piece Epidural Catheters
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 146: Implantation of Subcutaneously Tunneled Two-Piece Epidural Catheters
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 147: Neuradenolysis of the Pituitary: Needle-Through-Needle Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 148: Cervical Diskography
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 149: Thoracic Diskography
Indications
Clinically Relevant Anatomy
Technique
Side Effects and ComplicationsChapter 150: Lumbar Diskography
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 151: Epiduroscopy
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 152: Intradiskal Electrothermal Annuloplasty
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 153: Percutaneous Intradiskal Nucleoplasty
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 154: Biacuplasty
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 155: Percutaneous Diskectomy: Automated Technique
IndicationsClinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 156: Percutaneous Diskectomy: Laser-Assisted Technique
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 157: Percutaneous Laser-Assisted Annuloplasty
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 158: Percutaneous Vertebroplasty
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 159: Percutaneous Balloon Kyphoplasty
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 160: Percutaneous Sacroplasty
Indications
Clinically Relevant Anatomy
TechniqueSide Effects and Complications
Chapter 161: Cervical Spinal Cord Stimulation: Stage I Trial Stimulation
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 162: Lumbar Spinal Cord Stimulation: Stage I Trial Stimulation
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 163: Spinal Cord Stimulation: Stage II Pulse Generator Implantation
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 164: Peripheral Nerve Stimulation—Occipital Nerves
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 165: Implantation of Totally Implantable Reservoirs and Injection Ports
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 166: Implantation of Totally Implantable Infusion PumpsIndications
Clinically Relevant Anatomy
Technique
Side Effects and Complications (Fig. 166-13)
Chapter 167: Percutaneous Posterior Facet Joint Spinal Fusion
Indications
Clinically Relevant Anatomy
Technique
Side Effects and Complications
IndexC o p y r i g h t
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ATLAS OF INTERVENTIONAL PAIN MANAGEMENT, FOURTH EDITION ISBN:
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This book is dedicated to Dr. Steven Barag……….dear friend, mentor, philosopher,
clinician, teacher, comedian, and the only guy I know who can wear an ascot and
actually pull it off!
Steve#2
Fall 2014Preface
Milepost 25
—Mission Drift…..Course Correction……AKA…….Girls You Gotta Know When It's
Time to Turn the Page—
st1 Interventional Pain Management Meeting in Nice, France,
1992. Left to right, Steven D. Waldman, MD, Ronald Melzack,
PhD, and Alon Winnie, MD.
Since it is often said that pain is as old as man, it would seem that the meeting of a
couple of hundred physicians with an interest in using invasive techniques to treat
pain is hardly worth mentioning. However, it was at this meeting in Nice, France,
organized by Alon Winnie and me, that a new subspecialty of pain medicine was
born: interventional pain management. This specialty devoted its e. orts to the use
of neural blockade, implantable technologies, and neurodestructive procedures to
treat pain. This is not to say that before this meeting, physicians were not using
invasive techniques to treat pain, but rather that this was the 0rst time many of
those physicians got together in an organized fashion and began to de0ne the
subspecialty that we now refer to as interventional pain management.
As I noted in the Preface to the third edition of Atlas of Interventional Pain
Management, I came up with the term interventional pain management as a way to
signal to potential attendees that this meeting would be about invasive procedures
rather than about pills, hypnosis, biofeedback, and behavioral modalities, all of
which were de rigueur at the time. Truth be told, at the meeting some suggested that
“invasive pain management” would be a better name for our new subspecialty.

Fortunately or not, depending on how you look at it, that name did not stick, so here
were are today.
To put this ancient history in the proper context, it is useful to look at where the
specialty of pain management was back in those dark ages—before the advent of
cell phones, personal computers, and Viagra—a time when most of the discussion
surrounding pain treatment centered on tricyclic antidepressants, major
tranquilizers, anticonvulsants, biofeedback, and behavior modification.
Wait, you say! There was no specialty of pain management at that time, at least
insofar as organized mainstream medicine was concerned! Twenty-0ve years ago
there were no organized training programs for pain management (with the
exception of a few uno9 cial and uncerti0ed training programs that were run by a
rather eccentric group of anesthesiologists including Raj, Racz, Winnie, and myself),
let alone any real fellowships. At that time, a very few of us devoted our practices
solely to pain management. For most, pain management was a sideline, and for
others it was an unwelcome interruption to their day; practitioners would grudgingly
do a nerve block or two in the recovery room after spending a day giving anesthesia
in the operating room. You might ask, what about the physical medicine and
rehabilitation (PM & R) doctors and neurologists? They did not arrive on the pain
management scene until much later.
The 0rst “o9 cial” examinations in pain management were not held until 1993. I
remember Bying to Chicago along with about 250 other “grandfathered”
anesthesiologists to sit for a 3-hour written examination that was made up primarily
of questions written by those of us who were taking the examination. It is hard to
believe that although we wrote most of our own questions, the pass rate for this
examination was only about 80%! Those of us who passed were awarded the dubious
distinction of having quali0ed for a Certi cate of Added Quali cation in Pain
Management by the American Board of Anesthesiology. To be honest, no one was
clear on what that really meant or whether it was even worth listing on one's
curriculum vitae.
Fast forward to 2015 and you will 0nd that our specialty has come up in the
world. Pain Medicine (its name had been changed from Pain Management in 2002)
is now recognized by the American Board of Medical Specialties as a specialty
worthy of its own full subspecialty board certi0cation, a board certi0cation that can
be reached only after completing a 4-year residency in anesthesiology, physical
medicine and rehabilitation, neurology, and so forth; completing a 1- to 2-year
fellowship in pain medicine; and then passing a rigorous written examination. We
have traveled quite a distance in 25 years, but these years have not been without
growing pains, some good and some not so good.
As the body of knowledge of interventional pain management began to become
codi0ed by the publishing of the 0rst books in our specialty, such as Raj's Practical
Management of Pain and my textbooks Interventional Pain Management and the Atlas of
Interventional Pain Management Techniques, organized fellowships in pain
management began appearing. These training programs grew in both scope and
stature; as a result, a critical mass of quali0ed interventional pain management
specialists became available to care for the patient in pain. Interventional pain
management procedures became the gold standard for pain treatment. As with most
good things, some interventional pain management specialists, myself included,
adopted the mantra that if a little was good, more was better. To borrow a term from
Alan Greenspan, there was a “frothy, irrational exuberance” insofar as interventional
pain management procedures were concerned. Many interventional pain
management specialists bragged that “there was no place in the body that they
couldn't put a needle!” Fortunately, as the specialty evolved, so did its practitioners,
and with the help of new professional organizations such as the Society For Pain
Practice Management, the American Society of Regional Anesthesia, and later the
American Society of Interventional Pain Physicians under the tireless leadership of
Lax Manchicanti, interventional pain specialists began to promulgate guidelines for
best practices for our specialty and to the benefit of our patients.
However, there was trouble in paradise. As the result of a paper based on only 38
patients published by Portenoy and Foley, many interventional pain management
specialists (along with the rest of the medical community) were told that opioids—
speci0cally Oxycontin and the like—were the panacea we were all looking for when
treating the patient in pain. Interventional pain management specialists were
admonished: “How dare you stick a needle in a patient su. ering from back pain.”
Portenoy and Foley concluded that “opioid maintenance therapy can be a safe, salutary
and more humane alternative to the options of surgery or no treatment in those patients
with intractable non-malignant pain and no history of drug abuse.” After all, we were
told, pain was the fth vital sign and the medical community was roundly chastised
that it was being grossly undertreated. Many in our specialty drank the “opioid for
non-malignant pain Kool Aid” and eschewed the time-proven bene0cial procedures of
interventional pain management, choosing instead to reach for the prescription pad.
For a time, a feeling of guilt pervaded our specialty, especially whenever one of us
picked up a needle or scalpel, and a Dark Ages of sort descended on interventional
pain management. These guilt-ridden dark years dragged on as a relentless
campaign gathered momentum, a campaign organized and funded by
pharmaceutical companies to promote the use of opioids for chronic nonmalignant
pain. Physicians were told that “opioids were a gift from nature,” and the few
holdouts who refused to yield to this viewpoint were accused of su. ering from
opiophobia. Even the State Federation of Medical Boards and the Joint Commission
yielded to this stealth program organized and 0nanced by “big pharma” to sell
opioids and jumped on the bandwagon. It seems that our specialty was at risk for
obsolescence. It was indeed a dark time. To quote Thomas Paine, “A long habit of not
thinking a thing wrong gives it a super cial appearance of being right.” Although many
knew in their hearts that the use of opioids as a 0rst-line treatment for chronic
nonmalignant pain was wrong, few spoke up. This silence on the part of organized
medicine, and our specialty in particular, led to a public health disaster that could
only be likened to the Black Plague of the Middle Ages, a pandemic that ultimately
harmed millions of people!
Fortunately, good triumphed over evil. As the deaths and ruined lives resulting
from the inappropriate use of opioids mounted, a few voices within our specialty
began to speak out against opioids, and once again interventional pain management
specialists are putting away their prescription pads and turning to interventional
procedures to treat their patients.
Helping fuel this renewed enthusiasm for interventional pain management
modalities has been the arrival of a totally unrelated development: the use of
ultrasound guidance. Just as improvements in needle technology and implantable
devices helped fuel the early growth of our specialty, huge improvements in
ultrasound technology, both in terms of image resolution and ease of use, have made
performing many interventional pain management procedures easier and safer for
both the pain management specialist and the patient. Although time and experience
will help de0ne exactly where ultrasound 0ts within the practice of interventional
pain management, I believe that most will agree that this imaging modality has been
a great asset for our specialty.
About this fourth edition of Atlas of Interventional Pain Management, a little
information is in order. In its 0rst three editions, the Atlas of Interventional Pain
Management has enjoyed enormous success, becoming the largest selling pain
management text currently in print. The various editions have been translated into
more than 15 languages and have been a mainstay of education for a generation of
interventional pain management physicians. My colleagues at Elsevier and I are
very proud of these facts and have endeavored to make this fourth edition the best
one yet. I have added 18 new chapters and more than 200 new full-color 0gures, and
have greatly expanded information on the use of ultrasound guidance. The addition
of over 100 how-to-do-it sections on ultrasound-guided interventional pain
management techniques that are richly illustrated with full-color photographs
showing transducer placement, patient positioning, and clearly marked ultrasound
images should make this fourth edition of Atlas of Interventional Pain Management
better than ever.
As always, I hope you enjoy reading and using this text as much as I enjoyed
writing it!
Steven D. Waldman, MD, JD
Fall 2014Video Contents
1. Cervical Translaminar Epidural Block
2. Cervical Paravertebral Medial Branch Block
3. Percutaneous Facet Fusion
4. Lumbar Transforaminal Epidural Block
5. Caudal Epidural Block
6. Percutaneous Lumbar Diskectomy
7. Radiofrequency Lesioning of the Lumbar Medial Branches
8. Spinal Cord Stimulation Trial
9. Cervical Lysis of Adhesions Racz Procedure
10. VertebroplastyS E C T I O N I
Head
OUTLINE
Chapter 1: Atlanto-occipital Block Technique
Chapter 2: Atlantoaxial Block Technique
Chapter 7: Greater and Lesser Occipital Nerve Block
Chapter 9: Gasserian Ganglion Block
Chapter 15: Supraorbital Nerve Block
Chapter 16: Supratrochlear Nerve Block
Chapter 21: Inferior Alveolar Nerve Block
Chapter 22: Auriculotemporal Nerve Block
Chapter 23: Greater Auricular Nerve Block

C H A P T E R 1
Atlanto-occipital Block Technique
Abstract
The atlanto-occipital joint is di erent from the functional units of the lower cervical spine in
that the joint is not a true facet joint because it lacks posterior articulations characteristic of a
true zygapophyseal joint. The atlanto-occipital joint is susceptible to arthritic changes and
trauma secondary to acceleration-deceleration injuries. Atlanto-occipital block is useful in the
diagnosis and treatment of painful conditions involving trauma or in ammation of the
atlanto-occipital joint. These problems manifest clinically as neck pain, preauricular pain,
and/or suboccipital headache pain and occasionally as suboccipital pain that radiates into the
temporomandibular joint region.
Key Words
atlanto-occipital joint
atlanto-occipital nerve block
cervical spine
headache
neck pain
osteoarthritis
temporomandibular joint ultrasound-guided atlanto-occipital nerve block
zygapophyseal joint
CPT-2015 Code
First Joint 64490
Second Joint 64491
Third and Any Additional Joint 64492
Neurolytic First Level (Two Nerves) 64633
Relative Value Units
First Joint 12
Second Joint 12
Each Additional Joint 12
Neurolytic First Level (Two Nerves) 30







Indications
Atlanto-occipital block is useful in the diagnosis and treatment of painful conditions involving
trauma or in ammation of the atlanto-occipital joint. These problems manifest clinically as neck
pain, preauricular pain, and/or suboccipital headache pain and occasionally as suboccipital pain
that radiates into the temporomandibular joint region. The patient may note an increase in pain
when the joint is placed at extreme ranges of motion and may also experience associated nausea,
di4 culty concentrating, and sleep disturbance due to an inability to 5nd a comfortable position
when supine.
Clinically Relevant Anatomy
The atlanto-occipital joint is dissimilar to the functional units of the lower cervical spine. The joint
is not a true facet joint because it lacks posterior articulations characteristic of a true
zygapophyseal joint. The atlanto-occipital joint allows the head to nod forward and backward
with an isolated range of motion of about 35 degrees. This joint is located anterior to the
posterolateral columns of the spinal cord. Neither the atlas nor the axis has an intervertebral
foramen to accommodate the 5rst or second cervical nerves. These nerves are primarily sensory
and, after leaving the spinal canal, travel through muscle and soft tissue laterally and then
superiorly to contribute fibers to the greater and lesser occipital nerves.
The atlanto-occipital joint is susceptible to arthritic changes and trauma secondary to
acceleration-deceleration injuries. Such damage to the joint results in pain secondary to synovial
joint inflammation and adhesions.
The atlanto-occipital joint is di erent from the functional units of the lower cervical spine in
that the joint is not a true facet joint because it lacks posterior articulations characteristic of a true
zygapophyseal joint. The atlanto-occipital joint is susceptible to arthritic changes and trauma
secondary to acceleration-deceleration injuries. Atlanto-occipital block is useful in the diagnosis
and treatment of painful conditions involving trauma or in ammation of the atlanto-occipital
joint. These problems manifest clinically as neck pain, preauricular pain, and/or suboccipital
headache pain and occasionally as suboccipital pain that radiates into the temporomandibular
joint region.
Technique
Fluoroscopically Guided Technique
Atlanto-occipital block is usually done under uoroscopic guidance because of the proximity of
the joint to the spinal cord and vertebral artery, although some pain management specialists have
gained su4 cient familiarity with the procedure to perform it safely without uoroscopy. The
patient is placed in a prone position. Pillows are placed under the chest to allow moderate exion
of the cervical spine without discomfort to the patient. The forehead is allowed to rest on a folded
blanket.
If uoroscopy is used, the beam is rotated in a sagittal plane from an anterior to a posterior
position, which allows identi5cation and visualization of the foramen magnum. Just lateral to the
foramen magnum is the atlanto-occipital joint. A total of 5mL of contrast medium suitable for
intrathecal use is drawn up in a sterile 12-mL syringe. Then 3mL of preservative-free local
anesthetic is drawn up in a separate 5-mL sterile syringe. When the pain being treated is thought
to be secondary to an in ammatory process, a total of 40mg of depot-steroid is added to the local
anesthetic with the first block, and 20 mg of depot-steroid is added with subsequent blocks.


After preparation of the skin with antiseptic solution, a skin wheal of local anesthetic is raised
at the site of needle insertion. An 18-gauge, 1-inch needle is inserted at the site to serve as an
introducer. The uoroscopy beam is aimed directly through the introducer needle, which appears
as a small point on the uoroscopy screen. The introducer needle is then repositioned under
uoroscopic guidance until this small point is visualized over the posterolateral aspect of the
atlanto-occipital joint (Figs. 1-1 and 1-2). This lateral placement avoids trauma to the vertebral
artery, which lies medial to the joint at this level.
FIGURE 1-1 Anatomy of the atlanto-occipital joint.FIGURE 1-2 Fluoroscopic view of the needle over the posterolateral aspect
of the atlanto-occipital joint.
A 25-gauge, -inch styletted spinal needle is then inserted through the 18-gauge introducer.
If bony contact is made, the spinal needle is withdrawn and the introducer needle is repositioned
over the lateral aspect of the joint. The 25-gauge spinal needle is then readvanced until a pop is
felt, indicating placement within the atlanto-occipital joint. It is essential then to con5rm that the
needle is actually in the joint, which is anterior to the posterolateral aspect of the spinal cord (Fig.
1-3). This is accomplished by rotating the C-arm to the horizontal plane and con5rming needle
placement within the joint. If intra-articular placement cannot be con5rmed, the needle should be
withdrawn.





FIGURE 1-3 Lateral view of the placement of the needle into the
atlantooccipital joint.
After con5rmation of needle placement within the atlanto-occipital joint, the stylet is removed
from the 25-gauge spinal needle, and the hub is observed for blood or cerebrospinal uid. If
neither is present, gentle aspiration of the needle is carried out, and if no blood or cerebrospinal
uid is seen, 1mL of contrast medium is slowly injected under uoroscopy. An arthrogram of the
normal atlanto-occipital joint reveals a bilateral concavity representing the intact joint capsule.
However, if the joint has been traumatized, it is not unusual to see contrast medium ow freely
from the torn joint capsule into the cervical epidural space. If the contrast medium is seen to
rapidly enter the venous plexus rather than outline the joint, the needle is almost always not
within the joint space. If this occurs, the needle should be repositioned into the joint before
injection. If the contrast medium remains within the joint or if it outlines the joint and a small
amount leaks into the epidural space, 1 to 1.5mL of the local anesthetic and steroid is slowly
injected through the spinal needle.
Ultrasound-Guided Technique
The patient is placed in a prone position. Pillows are placed under the chest to allow moderate
exion of the cervical spine without discomfort to the patient. The forehead is allowed to rest on a
folded blanket. After preparation of the skin overlying the injection site with antiseptic solution, a
high-frequency linear ultrasound transducer is placed slightly o the midline in a transverse
position (Fig. 1-4). The vertebral artery is then identi5ed as it passes through the transverse
vertebral foramen. Color Doppler imaging may assist in identi5cation (Fig. 1-5). After the arteryis identi5ed, it is traced cranially under real-time ultrasound imaging until the artery is seen to
turn medially in front of the atlanto-occipital joint (Fig. 1-6). The atlanto-occipital joint is
identi5ed, and at a point just lateral to the angle of the turn of the vertebral artery, a 22-gauge,
-inch spinal needle is carefully advanced under real-time ultrasound guidance into the
atlanto-occipital joint (Fig. 1-7).
FIGURE 1-4 The patient is placed in a prone position with the cervical spine
slightly flexed and the forehead placed on a folded towel. A high-frequency
linear ultrasound transducer is placed slightly off the midline in a transverse
position.FIGURE 1-5 Color Doppler image of the vertebral artery demonstrating how
it turns medially in front of the atlanto-occipital joint.
FIGURE 1-6 The vertebral artery passes cranially through the transverse
vertebral foramen. It turns medially toward the midline. The atlanto-occipital
joint lies just in front of the turning vertebral artery.FIGURE 1-7 Ultrasound image demonstrating the relationship of the
vertebral artery (VA) to the atlanto-occipital (AO) joint.
Side Effects and Complications
The proximity to the brain stem and spinal cord makes it imperative that this procedure be
carried out only by those well versed in the regional anatomy and experienced in performing
interventional pain management techniques. Fluoroscopic guidance is recommended for most
practitioners because neural trauma is a possibility even in the most experienced hands. The
proximity to the vertebral artery, combined with the vascular nature of this anatomic region,
makes the potential for intravascular injection high. Even small amounts of local anesthetic
injected into the vertebral arteries will result in seizures. Given the proximity of the brain and
brain stem, ataxia after atlanto-occipital block due to vascular uptake of local anesthetic is not an
uncommon occurrence.
Clinical Pearls
Atlanto-occipital block is often combined with atlantoaxial block when treating pain in the
previously mentioned areas. Although neither joint is a true facet joint in the anatomic sense of
the word, the block is analogous to the facet joint block technique used commonly by pain
practitioners and may be viewed as such. Many pain management specialists believe that these
techniques are currently underused in the treatment of so-called postwhiplash cervicalgia and
cervicogenic headaches. These specialists believe that both techniques should be considered
when cervical epidural nerve blocks and occipital nerve blocks fail to provide palliation of
these headache and neck pain syndromes.
Any patient being considered for atlanto-occipital nerve block should undergo magnetic
resonance imaging (MRI) of the head to rule out unsuspected intracranial and brain stem
disease (Fig. 1-8). Furthermore, MRI of the cervical spine should be considered to rule out
congenital abnormalities such as Arnold-Chiari malformations or posterior fossa tumors that
may be the hidden cause of the patient's headache symptoms.FIGURE 1-8 A, Sagittal T1-weighted (T1W) magnetic resonance (MR)
image of an adult patient with Arnold-Chiari type II deformity. The posterior
fossa is small with a widened foramen magnum. There is inferior
displacement of the cerebellum and medulla with elongation of the pons and
fourth ventricle (black arrow). The brain stem is kinked as it passes over the
back of the odontoid. There is an enlarged massa intermedia (solid white
arrow) and beaking of the tectum (dashed white arrow). B, Axial T2W MR
image showing the small posterior fossa with beaking of the tectum (dashed
black arrow). (From Waldman SD, Campbell RSD: Arnold-Chiari
malformation type II. In Imaging of Pain. Philadelphia, Saunders, 2011, pp
29-30, Fig 9.1, A and B.)
It should be noted that in some patients, the course of the vertebral artery covers the entire
atlanto-occipital joint, which makes needle placement impossible. In such patients, a trial of
occipital nerve stimulation may be a reasonable consideration.
C H A P T E R 2
Atlantoaxial Block Technique
Abstract
The atlantoaxial joint is di erent from the functional units of the lower cervical spine in that
the joint is not a true facet joint because it lacks posterior articulations characteristic of a true
zygapophyseal joint. The atlantoaxial joint is susceptible to arthritic changes and trauma
secondary to acceleration-deceleration injuries. Atlantoaxial block is useful in the diagnosis
and treatment of painful conditions involving trauma or in ammation of the atlantoaxial
joint. Furthermore, there is no true disk or intervertebral foramen between atlas and axis. The
atlantoaxial joint allows the greatest degree of motion of all the joints of the neck: it not only
allows the head to ex and extend about 10 degrees but also allows more than 60 degrees of
rotation in the horizontal plane. The integrity and stability of the atlantoaxial joint are
almost entirely ligamentous in nature.
Key Words
atlantoaxial joint
atlantoaxial nerve block
cervical spine
headache
neck pain
osteoarthritis
rheumatoid arthritis
temporomandibular joint ultrasound-guided atlantoaxial nerve block
zygapophyseal joint
CPT-2015 Code
First Joint 64490
Second Joint 64491
Third and Additional Joints 64492
Neurolytic First Level (Two Nerves) 64633
Relative Value Units
First Joint 12
Second Joint 12
Each Additional Joint 12
Neurolytic First Level (Two Nerves) 30
Indications
Atlantoaxial block is useful in the diagnosis and treatment of painful conditions involving trauma
or in ammation of the atlantoaxial joint. These problems may manifest clinically as neck pain or
suboccipital headache pain and occasionally as suboccipital pain that radiates into the
temporomandibular joint region and is worsened with rotation of the joint. The patient may note
an increase in pain when the joint is placed at extreme ranges of motion and may also experience
associated nausea, di4 culty concentrating, and sleep disturbance due to an inability to 5nd a
comfortable position when supine.
Clinically Relevant Anatomy
The atlantoaxial joint is dissimilar to the functional units of the lower cervical spine. The joint is
not a true facet joint because it lacks posterior articulations characteristic of a true zygapophyseal
joint. Furthermore, there is no true disk or intervertebral foramen between atlas and axis. The
atlantoaxial joint allows the greatest degree of motion of all the joints of the neck: it not only
allows the head to ex and extend about 10 degrees but also allows more than 60 degrees of
rotation in the horizontal plane. The integrity and stability of the atlantoaxial joint are almost
entirely ligamentous in nature. Even minor injury of the ligaments due to trauma can result in
joint dysfunction and pain. Severe disruption of the ligaments has the same e ect as a fracture of
the odontoid process and can result in paralysis and death.
This joint is located lateral to the posterolateral columns of the spinal cord (Fig. 2-1). Neither
the atlas nor the axis has an intervertebral foramen to accommodate the 5rst or second cervical
nerves. These nerves are primarily sensory, and after leaving the spinal canal, they travel through
muscle and soft tissue laterally and then superiorly to contribute 5bers to the greater and lesser
occipital nerves. The vertebral artery is lateral to the joint compared with the medial position of
the artery relative to the atlanto-occipital joint.FIGURE 2-1 Anatomy of the atlantoaxial joint.
The atlantoaxial joint is susceptible to arthritic changes and trauma secondary to
accelerationdeceleration injuries. Such damage to the joint results in pain secondary to synovial joint
in ammation and adhesions. Rheumatoid arthritis may result in gradual erosion of the odontoid
process that may present initially as occipital headaches. This erosion leads to instability of the
atlantoaxial joint and ultimately may result in increased susceptibility to dislocation, paralysis,
and death following seemingly minor trauma. In addition to rheumatoid arthritis, there are a
number of other diseases associated with instability of the atlantoaxial joint, including Down's
syndrome, osteogenesis imperfecta, von Recklinghausen's disease, congenital scoliosis, Larsen's
syndrome, Morquio's syndrome, Kniest's dysplasia, congenital spondyloepiphyseal dysplasia, and
metatropic dysplasia.
Technique
Fluoroscopically Guided Technique
Atlantoaxial block is usually done under uoroscopic guidance because of the proximity to the
spinal cord and vertebral artery, although some pain management specialists have gained
su4 cient familiarity with the procedure to perform it safely without uoroscopy. The patient is
placed in a prone position. Pillows are placed under the chest to allow the cervical spine to be
moderately exed without discomfort to the patient. The forehead is allowed to rest on a folded
blanket.
If uoroscopy is used, the beam is rotated in a sagittal plane from an anterior to a posterior
position, which allows identi5cation and visualization of the foramen magnum and atlas. Just
lateral and inferior to the atlas and to the foramen magnum is the atlantoaxial joint (see Fig. 2-1).
A total of 5mL of contrast medium suitable for intrathecal use is drawn up in a sterile 12-mL
syringe. Then 3mL of preservative-free local anesthetic is drawn up in a separate 5-mL sterile
syringe. When the pain being treated is thought to be secondary to an in ammatory process, a
total of 40mg of depot-steroid is added to the local anesthetic with the 5rst block, and 20mg ofdepot-steroid is added with subsequent blocks.
After preparation of the skin with antiseptic solution, a skin wheal of local anesthetic is raised
at the site of needle insertion. An 18-gauge, 1-inch needle is placed at the insertion site to serve as
an introducer. The uoroscopy beam is aimed directly through the introducer needle, which
appears as a small point on the uoroscopy screen. The introducer needle is then repositioned
under uoroscopic guidance until this small point is visualized over the posterolateral aspect of
the atlantoaxial joint (see Fig. 2-1). This lateral placement avoids trauma to the spinal cord, which
lies medial to the joint at this level. It should be remembered that the vertebral artery is lateral to
the atlantoaxial joint, and care must be taken to avoid arterial trauma or inadvertent
intraarterial injection.
A 25-gauge, -inch styletted spinal needle is then inserted through the 18-gauge introducer.
If bony contact is made, the spinal needle is withdrawn, and the introducer needle is repositioned
over the lateral aspect of the joint. The 25-gauge spinal needle is then readvanced until a pop is
felt, indicating placement within the atlantoaxial joint (Fig. 2-2). It is essential then to con5rm
that the needle is actually in the joint, which is anterior to the posterolateral aspect of the spinal
cord. This is accomplished by rotating the C-arm to the horizontal plane and con5rming needle
placement within the joint (Figs. 2-3 and 2-4). If intra-articular placement cannot be con5rmed,
the needle should be withdrawn.
FIGURE 2-2 Anteroposterior fluoroscopic view of the right lateral atlantoaxial
joint with the needle tip on bone at the initial target point for an intra-articular
block. (From King W, Borowczyk JM: Zygapophysial joint pain: procedures for
diagnosis and treatment. In Lennard TA, Walkowski SA, Singla AK, et  al,
editors: Pain Procedures in Clinical Practice, 3rd ed. Philadelphia, Saunders,
2011, p 378, Fig 36-35.)FIGURE 2-3 Lateral view of the clinically relevant anatomy and proper
needle placement for atlantoaxial block.FIGURE 2-4 Lateral fluoroscopic view of the right lateral atlantoaxial joint
with the needle tip on bone at the initial target point for an intra-articular block.
(From King W, Borowczyk JM: Zygapophysial joint pain: procedures for
diagnosis and treatment. In Lennard TA, Walkowski SA, Singla AK, et  al,
editors: Pain Procedures in Clinical Practice, 3rd ed. Philadelphia, Saunders,
2011, p 378, Fig 36-36.)
After con5rmation of needle placement within the atlantoaxial joint, the stylet is removed from
the 25-gauge spinal needle, and the hub is observed for blood or cerebrospinal uid. If neither is
present, gentle aspiration of the needle is carried out, and if no blood or cerebrospinal uid is
seen, 1mL of contrast medium is slowly injected under uoroscopy. An arthrogram of the normal
atlantoaxial joint reveals a bilateral concavity representing the intact joint capsule (Figs. 2-5 and
2-6). However, if the joint has been traumatized, it is not unusual to see contrast medium ow
freely from the torn joint capsule into the cervical epidural space. If the contrast medium is seen
to rapidly enter the venous plexus rather than outline the joint, the needle is almost always not
within the joint space. If this occurs, the needle should be repositioned into the joint before
injection. If the contrast medium remains within the joint or if it outlines the joint and a small
amount leaks into the epidural space, 1 to 1.5mL of the local anesthetic and steroid is slowly
injected through the spinal needle.FIGURE 2-5 Anteroposterior fluoroscopic view of a right lateral atlantoaxial
arthrogram recorded to confirm correct placement of the needle tip for an
intra-articular block. (From King W, Borowczyk JM: Zygapophysial joint pain:
procedures for diagnosis and treatment. In Lennard TA, Walkowski SA, Singla
AK, et  al, editors: Pain Procedures in Clinical Practice, 3rd ed. Philadelphia,
Saunders, 2011, p 379, Fig 36-38.)FIGURE 2-6 Lateral fluoroscopic view of a right lateral atlantoaxial
arthrogram recorded to confirm correct placement of the needle tip for an
intra-articular block. (From King W, Borowczyk JM: Zygapophysial joint pain:
procedures for diagnosis and treatment. In Lennard TA, Walkowski SA, Singla
AK, et  al, editors: Pain Procedures in Clinical Practice, 3rd ed. Philadelphia,
Saunders, 2011, p 379, Fig 36-37.)
Ultrasound-Guided Technique
The patient is placed in a prone position. Pillows are placed under the chest to allow moderate
exion of the cervical spine without discomfort to the patient. The forehead is allowed to rest on a
folded blanket. After preparation of the skin overlying the injection site with antiseptic solution, a
high-frequency linear ultrasound transducer is placed in the transverse orientation at the level of
the occiput (Fig. 2-7). The ultrasound transducer is then slowly moved in a caudad direction to
identify the C1 and C2 vertebral bodies. The C2 vertebral body has a clearly visible bi5d spinous
process, whereas the spinous process on the C1 vertebral body is poorly seen because it is a
vestigial structure (Fig. 2-8). After the C2 vertebra has been properly identi5ed, the ultrasound
transducer is slowly moved laterally until the vertebral artery is seen. Color Doppler may aid in
the identi5cation of the vertebral artery (Fig. 2-9). Lying between the exiting C2 nerve root and
the vertebral artery is the atlantoaxial joint (Fig. 2-10). After the relative positions of the
vertebral artery laterally, the C2 nerve root medially, and the atlantoaxial joint are identi5ed, a
22-gauge, -inch styletted spinal needle is then advanced into the atlantoaxial joint using an
out-of-plane approach under real-time ultrasonography.FIGURE 2-7 Proper transverse placement of the high-frequency linear
ultrasound transducer at the level of the occiput.FIGURE 2-8 Transverse ultrasound image demonstrating the bifid nature of
the C2 spinous process.
FIGURE 2-9 Color Doppler image of the vertebral artery (VA).FIGURE 2-10 Lying between the exiting C2 nerve root and the vertebral
artery is the atlantoaxial joint.
Side Effects and Complications
The proximity to the brain stem and spinal cord makes it imperative that this procedure be carried
out only by those well versed in the regional anatomy and experienced in performing
interventional pain management techniques. Fluoroscopic guidance is recommended for most
practitioners because neural trauma is a possibility even in the most experienced hands. The
proximity to the vertebral artery, combined with the vascular nature of this anatomic region,
makes the potential for intravascular injection high. Even small amounts of local anesthetic
injected into the vertebral arteries will result in seizures. Given the proximity of the brain and
brain stem, ataxia after atlantoaxial block due to vascular uptake of local anesthetic is not an
uncommon occurrence. Many patients also complain of a transient increase in headache and
cervicalgia after injection of the joint.
Clinical Pearls
Atlantoaxial block is often combined with atlanto-occipital block when treating pain in the
previously mentioned areas. Although neither joint is a true facet joint in the anatomic sense of
the word, the block is analogous to the facet joint block technique used commonly by pain
practitioners and may be viewed as such. Many pain management specialists believe that these
techniques are currently underused in the treatment of so-called postwhiplash cervicalgia and
cervicogenic headaches. These specialists believe that both techniques should be considered
when cervical epidural nerve blocks and occipital nerve blocks fail to provide palliation of
these headache and neck pain syndromes.Any patient being considered for atlantoaxial nerve block should undergo magnetic
resonance imaging (MRI) of the head to rule out unsuspected intracranial and brain stem
disease (Fig. E2-1). Furthermore, cervical spine radiography and computerized tomography of
the cervical spine should be considered to rule out congenital abnormalities such as
ArnoldChiari malformations that may be the hidden cause of the patient's headache symptoms as well
as to identify erosion of the odontoid process in patients with rheumatoid arthritis (see Figs.
E2-1 and 2-11).
FIGURE 2-11 Abnormalities of the cervical spine: odontoid process
erosions. Lateral conventional tomogram reveals severe destruction of the
odontoid process (arrows), which has been reduced to an irregular, pointed
protuberance. (From Resnick D, Kransdorf MJ: Bone and Joint Imaging, 3rd
ed. Philadelphia, Saunders, 2004, p 244.)FIGURE E2-1 Position of the dens in a normal patient (A), in a rheumatoid
patient (B), and in a nonrheumatoid patient with basilar invagination and
platybasia (C). A, Postmyelography computed tomogram with sagittal
reformation demonstrates normal relationship of the dens with respect to
the foramen magnum, brain stem, and anterior arch of C1. A normal
atlantoaxial distance (AADI) is seen (arrow). B, T1-weighted sagittal
magnetic resonance (MR) study of the cervical spine in a rheumatoid
patient reveals erosion and pannus formation at the atlantoaxial joint
resulting in increased AADI (arrow), posterior subluxation of the dens, and
brain stem compression. C, Sagittal MR study of the brain in a
nonrheumatoid patient shows normal AADI, but basilar invagination and
platybasia have resulted in vertical subluxation of the dens and brain stem
compression. The line drawn from the hard palate to the posterior lip of the
foramen magnum is Chamberlain's line (dotted line); basilar invagination is
defined as extension of the odontoid tip 5  mm or more above this line. Also
notice the fusion of the C2 and C3 vertebrae. The small, linear, dark line at
the mid-C2 level is the subdental synchondrosis (arrow). (From Chi TL,
Mirsky DM, Bello JA, et  al: Airway imaging: principles and practical guide. In
Habberg C, editor: Benumof and Hagberg's Airway Management, 3rd ed.
Philadelphia, Saunders, 2013, p 32, Fig 2-12.)C H A P T E R 3
Sphenopalatine Ganglion Block
Transnasal Approach
Abstract
The sphenopalatine ganglion (pterygopalatine, nasal, or Meckel's ganglion) is located in the
pterygopalatine fossa, posterior to the middle nasal turbinate. Sphenopalatine ganglion
block may be used in the treatment of acute migraine headache, acute cluster headache, and
a variety of facial neuralgias including Sluder's, Vail's, and Gardner's syndromes. This
technique is also useful in the treatment of status migrainosus and chronic cluster headache.
The sphenopalatine ganglion can be blocked by topical application of local anesthetic or by
injection.
Key Words
cluster headache
Gardner's syndrome
Meckel's ganglion
migraine headache
pterygopalatine ganglion
sphenopalatine ganglion
sphenopalatine ganglion nerve block
Vail's syndrome
CPT-2015 Code
Local Anesthetic 64999
Neurolytic 64999
Relative Value Units
Local Anesthetic 8
Neurolytic 20
Indications
Sphenopalatine ganglion block may be used in the treatment of acute migraine headache, acute
cluster headache, and a variety of facial neuralgias including Sluder's, Vail's, and Gardner'ssyndromes. This technique is also useful in the treatment of status migrainosus and chronic
cluster headache. There is anecdotal evidence that sphenopalatine ganglion block may also be
useful in the palliation of pain secondary to acute herpes zoster of the trigeminal nerve.
Neurodestructive procedures of the sphenopalatine ganglion using neurolytic agents,
radiofrequency lesioning, or freezing may be indicated for the palliation of cancer pain and
rarely for headache and facial pain syndromes that fail to respond to conservative management.
Recent experience with electrical stimulation of the sphenopalatine ganglion has shown
promising early results.
Clinically Relevant Anatomy
The sphenopalatine ganglion (pterygopalatine, nasal, or Meckel's ganglion) is located in the
pterygopalatine fossa, posterior to the middle nasal turbinate (Figs. 3-1, 3-2, and 3-3). It is
covered by a 1- to 1.5-mm layer of connective tissue and mucous membrane. This 5-mm
triangular structure sends major branches to the gasserian ganglion, trigeminal nerves, carotid
plexus, facial nerve, and superior cervical ganglion (see Fig. 3-2, Fig. 3-4). The sphenopalatine
ganglion can be blocked by topical application of local anesthetic or by injection.FIGURE 3-1 The sphenopalatine ganglion (pterygopalatine, nasal, or
Meckel's ganglion) is located in the pterygopalatine fossa, posterior to the
middle nasal turbinate. (From Barral JP, Croibier A: Maxillary nerve. In
Manual Therapy for the Cranial Nerves. Edinburgh, Churchill Livingstone,
2009, pp 129-138.)FIGURE 3-2 Anatomy of the sphenopalatine (pterygopalatine) ganglion.
Note that the sphenopalatine structure sends major branches to the
gasserian ganglion, trigeminal nerves, carotid plexus, facial nerve, and
superior cervical ganglion. (From Barral JP, Croibier A: Maxillary nerve. In
Manual Therapy for the Cranial Nerves. Edinburgh, Churchill Livingstone,
2009, pp 129-138.)FIGURE 3-3 Axial computed tomographic cuts through the region of the
sphenopalatine ganglion. The right side of each image was not dissected.
The left side of each image was dissected and a radiopaque marker placed
in the pterygopalatine fossa to indicate the position of the sphenopalatine
ganglion (arrows). (From De Salles AAF, Gorgulho A, Golish SR, et  al:
Technical and anatomical aspects of novalis stereotactic radiosurgery
sphenopalatine ganglionectomy. Int J Radiat Oncol Biol Phys 66[4
suppl]:S53-S57, 2006.)
FIGURE 3-4 View of the pterygopalatine fossa through Meckel's cave.
Notice the upper retraction instrument lifting the second division of the
trigeminal nerve to expose the sphenopalatine ganglion (tip of lower
instrument). (From De Salles AAF, Gorgulho A, Golish SR, et  al: Technical
and anatomical aspects of novalis stereotactic radiosurgery sphenopalatine
ganglionectomy. Int J Radiat Oncol Biol Phys 66[4 suppl]:S53-S57, 2006.)
TechniqueSphenopalatine ganglion block through the transnasal approach is accomplished by the
application of suitable local anesthetic to the mucous membrane overlying the ganglion. The
patient is placed in the supine position, and the anterior nares are inspected for polyps, tumors,
and foreign bodies. Three milliliters of either 2% viscous lidocaine or 10% cocaine is drawn up in
a 5-mL sterile syringe. The tip of the patient's nose is then drawn upward as if to place a
nasogastric tube, and 0.5mL of local anesthetic is injected into each nostril. The patient is asked
to sni9 vigorously to draw the local anesthetic posteriorly, which serves the double function of
lubricating the nasal mucosa and providing topical anesthesia.
Two -inch cotton-tipped applicators are soaked in the local anesthetic chosen, and one
applicator is advanced along the superior border of the middle turbinate of each nostril until the
tip comes into contact with the mucosa overlying the sphenopalatine ganglion (Fig. 3-5). Then
1mL of local anesthetic is instilled over each cotton-tipped applicator. The applicator acts as a
tampon that allows the local anesthetic to remain in contact with the mucosa overlying the
ganglion. The applicators are removed after 20 minutes. If anatomic considerations such as the
presence of polyps preclude the use of cotton-tipped applicators, transnasal endoscopically
guided insertion of a 22-gauge, -inch needle may be considered (Fig. 3-6). The patient's
blood pressure, pulse, and respirations are monitored for untoward side effects.FIGURE 3-5 Two -inch cotton-tipped applicators are soaked in the local
anesthetic chosen, and one applicator is advanced along the superior border
of the middle turbinate of each nostril until the tip comes into contact with the
mucosa overlying the sphenopalatine ganglion.;
;
FIGURE 3-6 Under control of an endoscope (4  mm, 0 degrees), a long
20gauge needle is passed between the middle turbinate (MT) and inferior
turbinate (IT) and inserted into the mucosa just behind and over the middle
turbinate tail, seeking the sphenopalatine foramen. N.Ph, Nasopharynx.
(From Ali AR, Sakr SA, Rahman ASMA: Bilateral sphenopalatine ganglion
block as adjuvant to general anaesthesia during endoscopic trans-nasal
resection of pituitary adenoma. Egypt J Anaesth 26[4]:273-280, 2010.)
Side Effects and Complications
Because of the highly vascular nature of the nasal mucosa, epistaxis is the major complication of
this technique. This vascularity can lead to signi cant systemic absorption of local anesthetic
with resultant local anesthetic toxicity, especially when cocaine is used.
Patients occasionally may experience signi cant orthostatic hypotension after sphenopalatine
ganglion block. This can be a problem because postblock monitoring may be lax due to the
benign-appearing nature of the technique. For this reason, patients who undergo sphenopalatine
ganglion block should be monitored closely for orthostatic hypotension and initially allowed to
ambulate only with assistance.
Clinical Pearls
Clinical experience has shown that sphenopalatine ganglion block with local anesthetic is
useful in aborting the acute attack of migraine or cluster headache. The simplicity of the
transnasal approach lends itself to use at the bedside, in the emergency room, or in the pain
clinic. Although cocaine is probably a superior topical anesthetic for use with this technique,
the various political issues surrounding the use of controlled substances make another local
anesthetic such as viscous lidocaine a more logical choice.
For the acute headache su9erer, this technique can be combined with the inhalation of
100% oxygen via mask through the mouth while the cotton-tipped applicators are in place.
Experience has shown that this technique aborts about 80% of cluster headaches.
Sphenopalatine ganglion block should be carried out on a daily basis with the endpoint ofcomplete pain relief. This usually occurs within five block procedures.C H A P T E R 4
Sphenopalatine Ganglion Block
Greater Palatine Foramen Approach
Abstract
The sphenopalatine ganglion (pterygopalatine, nasal, or Meckel's ganglion) is located in the
pterygopalatine fossa, posterior to the middle nasal turbinate. Sphenopalatine ganglion
block may be used in the treatment of acute migraine headache, acute cluster headache, and
a variety of facial neuralgias including Sluder's, Vail's, and Gardner's syndromes. This
technique is also useful in the treatment of status migrainosus and chronic cluster headache.
The sphenopalatine ganglion can be blocked by topical application of local anesthetic or by
injection. The greater palatine foramen approach to sphenopalatine ganglion block is useful
in patients who have an alteration of the nasal anatomy secondary to trauma or malignancy
that would preclude use of the transnasal approach.
Key Words
cluster headache
Gardner's syndrome
greater palatine foramen
Meckel's ganglion
migraine headache
neurolytic sphenopalatine ganglion block
pterygopalatine ganglion
sphenopalatine ganglion
sphenopalatine ganglion nerve block
Vail's syndrome
CPT-2015 Code
Local Anesthetic 64999
Neurolytic 64999
Relative Value Units
Local Anesthetic 8
Neurolytic 20Indications
Sphenopalatine ganglion block may be used in the treatment of acute migraine headache, acute
cluster headache, and a variety of facial neuralgias including Sluder's, Vail's, and Gardner's
syndromes. This technique is also useful in the treatment of status migrainosus and chronic
cluster headache. There is anecdotal evidence that sphenopalatine ganglion block may also be
useful in the palliation of pain secondary to acute herpes zoster of the trigeminal nerve. The
greater palatine foramen approach to sphenopalatine ganglion block is useful in patients who
have an alteration of the nasal anatomy secondary to trauma or malignancy that would preclude
use of the transnasal approach.
Neurodestructive procedures of the sphenopalatine ganglion using neurolytic agents,
radiofrequency lesioning, or freezing may be indicated for the palliation of cancer pain and
rarely for headache and facial pain syndromes that fail to respond to conservative management.
Recent experience with electrical stimulation of the sphenopalatine ganglion has shown
promising early results.
Clinically Relevant Anatomy
The sphenopalatine ganglion (pterygopalatine, nasal, or Meckel's ganglion) is located in the
pterygopalatine fossa, posterior to the middle nasal turbinate. It is covered by a 1- to 1.5-mm
layer of connective tissue and mucous membrane. This 5-mm triangular structure sends major
branches to the gasserian ganglion, trigeminal nerves, carotid plexus, facial nerve, and superior
cervical ganglion. The sphenopalatine ganglion can be blocked by topical application of local
anesthetic via the transnasal approach or by injection via the lateral approach or injection
through the greater palatine foramen. The greater palatine foramen is crescent shaped and
allows for passage of the greater palatine nerve and the descending palatine vessels (Figs. 4-1
and 4-2).FIGURE 4-1 Ventral view of the hard palate. GPF, Greater palatine
foramen; IF, incisive foramen; LPF, lesser palatine foramina; M1, M2, first
and second molars; MSL, middle sagittal line; MSS, middle sagittal suture;
PNS, posterior nasal spine. (From Piagkou M, Xanthos T, Anagnostopoulou
S, et  al: Anatomical variation and morphology in the position of the palatine
foramina in adult human skulls from Greece. J Craniomaxillofac Surg
40[7]:e206-e210, 2012.)
FIGURE 4-2 Greater palatine foramen (GPF) and its content (greater
palatine artery, vein, and nerve). M1, M2, M3, first, second, and third
molars. (From Piagkou M, Xanthos T, Anagnostopoulou S, et  al: Anatomical
variation and morphology in the position of the palatine foramina in adult
human skulls from Greece. J Craniomaxillofac Surg 40[7]:e206-e210,
2012.)
Technique7
Sphenopalatine ganglion block via the greater palatine foramen approach is accomplished by the
injection of local anesthetic onto the ganglion. The patient is placed in the supine position with
the cervical spine extended over a foam wedge. The greater palatine foramen is identi ed just
medial to the gum line of the third molar on the posterior portion of the hard palate. A 25-gauge,
2-inch needle is advanced about 2.5cm through the foramen in a superior and slightly posterior
trajectory (Fig. 4-3). Use of an angled dental needle may facilitate needle placement into the
greater palatine foramen, especially in patients who are unable to fully open their mouths (Figs.
4-4 and 4-5). The maxillary nerve is just superior to the ganglion, and if the needle is advanced
too deep, a paresthesia may be elicited. After careful, gentle aspiration, 2mL of local anesthetic
is slowly injected.
FIGURE 4-3 Placement of a needle into the greater palatine foramen.
(From McDonald RE, Avery DR, Dean JA, et  al: Local anesthesia and pain
control for the child and adolescent. In Dean JA, Avery DR, McDonald RE,
editors: McDonald and Avery's Dentistry for the Child and Adolescent, 9th
ed. St Louis, Mosby, 2011, pp 241-252.)FIGURE 4-4 Proper needle placement for sphenopalatine ganglion block
using the greater palatine foramen approach.7
7
FIGURE 4-5 Lateral fluoroscopic view of the tip of an angled dental needle
placed through the greater palatine foramen.
Side Effects and Complications
Because of the highly vascular nature of this anatomic region, signi cant systemic absorption of
local anesthetic with resultant local anesthetic toxicity is a distinct possibility. This approach to
sphenopalatine ganglion block should be avoided in patients who have intraoral infections,
including herpes zoster (Fig. 4-6). Patients occasionally may experience signi cant orthostatic
hypotension after sphenopalatine ganglion block. Therefore, patients who undergo
sphenopalatine ganglion block should be monitored closely for orthostatic hypotension and
initially allowed to ambulate only with assistance.=
FIGURE 4-6 Recurrent intraoral herpes lesions are a contraindication to
sphenopalatine ganglion block via the greater palatine foramen. (From Scully
C: Herpesvirus infections. In Oral and Maxillofacial Medicine, 3rd ed. New
York, Churchill Livingstone, 2013, pp 277-285.)
Clinical Pearls
Clinical experience has shown that sphenopalatine ganglion block with local anesthetic is
useful in aborting the acute attack of migraine or cluster headache. The simplicity of the
transnasal approach lends itself to use at the bedside, in the emergency room, or in the pain
clinic. Although cocaine is probably a superior topical anesthetic for use with this technique,
the various political issues surrounding the use of controlled substances make another local
anesthetic such as viscous lidocaine a more logical choice.
If previous trauma or tumor precludes the use of the transnasal approach to sphenopalatine
ganglion block, injection via the greater palatine foramen represents a good alternative.
Because of the proximity of the sphenopalatine ganglion to the maxillary nerve, care must be
taken to avoid inadvertent neurolysis of the maxillary nerve when performing
neurodestructive procedures on the sphenopalatine ganglion. Because the sphenopalatine
ganglion can be localized more accurately by stimulation, radiofrequency lesioning via the
lateral approach probably represents the safest option if destruction of the sphenopalatine
ganglion is desired.
For the acute headache su erer, this technique can be combined with the inhalation of
100% oxygen via mask after the injection of local anesthetic. Experience has shown that this
technique aborts about 80% of cluster headaches. Sphenopalatine ganglion block should be
carried out on a daily basis with the endpoint of complete pain relief. This usually occurs
within five block procedures.C H A P T E R 5
Sphenopalatine Ganglion Block
Lateral Approach
Abstract
The sphenopalatine ganglion (pterygopalatine, nasal, or Meckel's ganglion) is located in the
pterygopalatine fossa, posterior to the middle nasal turbinate. Sphenopalatine ganglion
block may be used in the treatment of acute migraine headache, acute cluster headache, and
a variety of facial neuralgias including Sluder's, Vail's, and Gardner's syndromes. This
technique is also useful in the treatment of status migrainosus and chronic cluster headache.
The sphenopalatine ganglion can be blocked by topical application of local anesthetic or by
injection. The greater palatine foramen approach to sphenopalatine ganglion block is useful
in patients who have an alteration of the nasal anatomy secondary to trauma or malignancy
that would preclude use of the transnasal approach.
Key Words
cluster headache
coronoid notch
Gardner's syndrome
maxillary nerve
Meckel's ganglion
migraine headache
neurolytic sphenopalatine ganglion block
pterygopalatine fossa
pterygopalatine ganglion
sphenopalatine ganglion
sphenopalatine ganglion nerve block
Vail's syndrome
CPT-2015 Code
Local Anesthetic 64999
Neurolytic 64999
Relative Value UnitsLocal Anesthetic 8
Neurolytic 20
Indications
Sphenopalatine ganglion block may be used in the treatment of acute migraine headache, acute
cluster headache, and a variety of facial neuralgias including Sluder's, Vail's, and Gardner's
syndromes. The technique is also useful in the treatment of status migrainosus and chronic cluster
headache. There is anecdotal evidence that sphenopalatine ganglion block may also be useful in
the palliation of pain secondary to acute herpes zoster of the trigeminal nerve.
The lateral approach to sphenopalatine ganglion block is useful in patients who have an
alteration of the nasal anatomy secondary to trauma or malignancy that would preclude use of
the transnasal approach. It is also the preferred route for neurodestructive procedures of the
sphenopalatine ganglion. Neurodestruction of the sphenopalatine ganglion may be performed
with neurolytic agents, radiofrequency lesioning, or freezing and is indicated for the palliation of
cancer pain and rarely for headache and facial pain syndromes that fail to respond to
conservative management. Recent experience with electrical stimulation of the sphenopalatine
ganglion has shown promising early results.
Clinically Relevant Anatomy
The sphenopalatine ganglion (pterygopalatine, nasal, or Meckel's ganglion) is located in the
pterygopalatine fossa, posterior to the middle nasal turbinate. It is covered by a 1- to 1.5-mm
layer of connective tissue and mucous membrane. This 5-mm triangular structure sends major
branches to the gasserian ganglion, trigeminal nerves, carotid plexus, facial nerve, and superior
cervical ganglion (Fig. 5-1). The sphenopalatine ganglion can be blocked by topical application
of local anesthetic via the transnasal approach, by injection via the pterygopalatine fossa or
through the greater palatine foramen, or by lateral placement of a needle via the coronoid notch.7
FIGURE 5-1 Anatomy of the sphenopalatine (pterygopalatine) ganglion.
Note that the sphenopalatine (pterygopalatine) structure sends major
branches to the gasserian ganglion, trigeminal nerves, carotid plexus, facial
nerve, and superior cervical ganglion. (From Barral JP, Croibier A: Maxillary
nerve. In Manual Therapy for the Cranial Nerves, Edinburgh, Churchill
Livingstone, 2009, pp 129-138.)
Technique
Landmark and Fluoroscopically Guided Technique
Sphenopalatine ganglion block via the lateral approach is accomplished by the injection of
local anesthetic onto the ganglion via a needle placed through the coronoid notch. The patient is
placed in the supine position with the cervical spine in the neutral position. The coronoid notch
is identi ed by asking the patient to open and close the mouth several times and palpating the
area just anterior and slightly inferior to the acoustic auditory meatus (Fig. 5-2). After the notch
is identified, the patient is asked to hold the mouth open in the neutral position.7
7
FIGURE 5-2 The coronoid notch is identified by asking the patient to open
and close the mouth several times and palpating the area just anterior and
slightly inferior to the acoustic auditory meatus.
A total of 2mL of local anesthetic is drawn up in a 3-mL sterile syringe. Some pain
management specialists empirically add a small amount of depot-steroid preparation to the local
anesthetic. After the skin overlying the coronoid notch is prepared with antiseptic solution, a
22gauge, -inch styletted needle is inserted just below the zygomatic arch directly in the middle
of the coronoid notch. The needle is advanced about 1.5 to 2 inches in a plane perpendicular to
the skull until the lateral pterygoid plate is encountered. At this point, the needle is withdrawn
slightly and redirected slightly superior and anterior, with the goal of placing the needle just
above the lower aspect of the lateral pterygoid plate so that it can enter the pterygopalatine
fossa below the maxillary nerve and in close proximity to the sphenopalatine ganglion (Fig. 5-3).
If this procedure is performed under fluoroscopy, the needle tip is visualized just under the lateral
nasal mucosa, and its position can be con rmed by injecting 0.5mL of contrast medium ( Fig.
54). Additional con rmation of needle position can be obtained by needle stimulation at 50Hz. If
the needle is in the correct position, the patient experiences a buzzing sensation just behind the
nose with no stimulation into the distribution of other areas innervated by the maxillary nerve.FIGURE 5-3 Proper needle placement for sphenopalatine ganglion block
using the lateral approach.7
7
7
7
7
7
FIGURE 5-4 Anteroposterior fluoroscopic image showing the tip of the
needle with spread of the contrast agent along the lateral wall of the nasal
cavity in proximity to the sphenopalatine ganglion. (From Narouze S:
Complications of head and neck procedures. Tech Reg Anesth Pain Manag
11[3]:171-177, 2007.)
After correct needle placement is con rmed, careful aspiration is carried out, and 2mL of
solution is injected in incremental doses. During the injection procedure, the patient must be
observed carefully for signs of local anesthetic toxicity. Because of the proximity of the maxillary
nerve, the patient also may experience partial blockade of the maxillary nerve.
Ultrasound-Guided Technique
The coronoid notch is identi ed as described in the previous section (see Fig. 5-2) and the skin
overlying the notch is then prepared with antiseptic solution. A linear transducer is then placed
in the transverse plane directly over the mandibular notch. The masseter muscle is easily
identi ed by following its origin on the zygomatic arch (Fig. 5-5). Just below and deep to the
masseter muscle is the pterygopalatine fossa. The ultrasound transducer is moved slightly craniad
and caudad until the maxillary nerve is clearly identi ed within the pterygopalatine fossa. After
the maxillary nerve is identi ed, a 22-gauge, 10-cm straight styletted radiofrequency needle with
a 2-mm active tip is inserted at a point just below the zygomatic arch in the middle of the
coronoid notch using an out-of-plane approach. The needle is advanced under real-time
ultrasound guidance until the tip rests just below the previously identi ed maxillary nerve. If a
paresthesia in the distribution of the maxillary nerve is elicited, the needle should be withdrawn
and redirected in a slightly superior and anterior trajectory allowing the needle tip to pass just
above the inferior aspect of the lateral pterygoid plate to permit entry into the pterygopalatine
fossa just below the maxillary nerve and in proximity to the sphenopalatine ganglion (Fig. 5-6).7
When the operator is satis ed with the position of the needle tip, stimulation of the needle at 50
Hz should be carried out. If the patient experiences a stimulation pattern involving the gingiva,
incisors, canine, and premolar teeth on the ipsilateral side, then the needle tip is too close to the
maxillary nerve and must be repositioned caudally and medially. If the patient reports a buzzing
sensation within his or her nose, without any stimulation of the ipsilateral gingiva and/or teeth,
the needle tip is in satisfactory position and, after careful aspiration, the solution may be
carefully injected.
FIGURE 5-5 Proper transducer position for sphenopalatine ganglion block
via the lateral pterygoid approach.7
7
FIGURE 5-6 Transverse ultrasound image of the sphenopalatine ganglion.
N , Nerve.
Side Effects and Complications
Because of the highly vascular nature of the pterygopalatine fossa, signi cant facial hematoma
may occur after sphenopalatine ganglion block via the lateral approach. This vascularity means
that the pain management specialist should use small, incremental doses of local anesthetic to
avoid local anesthetic toxicity.
Patients occasionally may experience signi cant orthostatic hypotension after sphenopalatine
ganglion block. Therefore, patients who undergo sphenopalatine ganglion block should be
monitored closely for orthostatic hypotension and initially allowed to ambulate only with
assistance.
Clinical Pearls
Clinical experience has shown that sphenopalatine ganglion block with local anesthetic is
useful in aborting the acute attack of migraine or cluster headache. The simplicity of the
transnasal approach lends itself to use at the bedside, in the emergency room, or in the pain
clinic. Although cocaine is probably a superior topical anesthetic for use with this technique,
the various political issues surrounding the use of controlled substances make another local
anesthetic such as viscous lidocaine a more logical choice.
If previous trauma or tumor precludes the use of the transnasal approach to sphenopalatine
ganglion block, injection of local anesthetic via the greater palatine foramen or the lateral
approach represents a good alternative. Because of the proximity of the sphenopalatine
ganglion to the maxillary nerve, care must be taken to avoid inadvertent neurolysis of the
maxillary nerve when performing neurodestructive procedures on the sphenopalatine
ganglion. Because of the ability to more accurately localize the sphenopalatine ganglion by@
stimulation, radiofrequency lesioning via the lateral approach represents probably the safest
option if destruction of the sphenopalatine ganglion is desired.
For the acute headache su erer, this technique can be combined with the inhalation of
100% oxygen via mask after the injection of local anesthetic. Experience has shown that this
technique aborts about 80% of cluster headaches. Sphenopalatine ganglion block should be
carried out on a daily basis with the endpoint of complete pain relief. This usually occurs
within five to eight block procedures.C H A P T E R 6
Sphenopalatine Ganglion Block
Radiofrequency Lesioning
Abstract
The sphenopalatine ganglion (pterygopalatine, nasal, or Meckel's ganglion) is located in the
pterygopalatine fossa, posterior to the middle nasal turbinate. Sphenopalatine ganglion
block may be used in the treatment of acute migraine headache, acute cluster headache, and
a variety of facial neuralgias including Sluder's, Vail's, and Gardner's syndromes. This
technique is also useful in the treatment of status migrainosus and chronic cluster headache.
The sphenopalatine ganglion can be blocked by topical application of local anesthetic or by
injection. The greater palatine foramen approach to sphenopalatine ganglion block is useful
in patients who have an alteration of the nasal anatomy secondary to trauma or malignancy
that would preclude use of the transnasal approach.
Key Words
cluster headache
coronoid notch
Gardner's syndrome
maxillary nerve
Meckel's ganglion
migraine headache
neurolytic sphenopalatine ganglion block
pterygopalatine fossa
pterygopalatine ganglion
radiofrequency destruction of the sphenopalatine ganglion
sphenopalatine ganglion
sphenopalatine ganglion nerve block
Vail's syndrome
CPT-2015 Code
Neurolytic 64640
Relative Value Unit
Neurolytic 20Indications
Radiofrequency lesioning of the sphenopalatine ganglion block may be used in the treatment of
chronic cluster headache, cancer pain, and a variety of facial neuralgias including Sluder's, Vail's,
and Gardner's syndromes that have failed to respond to more conservative treatments. The
lateral approach to sphenopalatine ganglion block is used to place the radiofrequency needle,
although the transnasal and greater palatine foramen approach can be used in patients who
have an alteration of the nasal anatomy secondary to trauma or malignancy that would preclude
use of the lateral approach. Neurodestructive procedures of the sphenopalatine ganglion using
the lateral approach may be performed with neurolytic agents, freezing, or radiofrequency
lesioning. Radiofrequency lesioning has the added advantage of allowing the use of a stimulating
needle, which facilitates correct needle placement.
Clinically Relevant Anatomy
The sphenopalatine ganglion (pterygopalatine, nasal, or Meckel's ganglion) is located in the
pterygopalatine fossa, posterior to the middle nasal turbinate (Fig. 6-1). It is covered by a 1- to
1.5-mm layer of connective tissue and mucous membrane. This 5-mm triangular structure sends
major branches to the gasserian ganglion, trigeminal nerves, carotid plexus, facial nerve, and
superior cervical ganglion. The sphenopalatine ganglion can be blocked by topical application of
local anesthetic via the transnasal approach, by injection via the pterygopalatine fossa or
through the greater palatine foramen, or by lateral placement of a needle via the coronoid notch.
FIGURE 6-1 Anatomy of the sphenopalatine ganglion within the
pterygopalatine fossa. (From Narouze S: Complications of head and neck
procedures. Tech Reg Anesth Pain Manag 11[3]:171-177, 2007.)
TechniqueRadiofrequency lesioning of the sphenopalatine ganglion block is accomplished by placing a
radiofrequency needle in proximity to the sphenopalatine ganglion using the lateral approach
via an introducer needle. The patient is placed in the supine position with the cervical spine in
the neutral position. A -inch cotton-tipped applicator is soaked in contrast medium and
placed between the middle and inferior turbinates to serve as a radiopaque marker (Figs. 6-2 and
6-3).
FIGURE 6-2 Anteroposterior fluoroscopic image demonstrating the
placement of a -inch cotton-tipped applicator that has been soaked in
contrast medium and placed between the middle and inferior turbinates to
serve as a radiopaque marker.7
FIGURE 6-3 Lateral fluoroscopic image demonstrating the placement of a
-inch cotton-tipped applicator that has been soaked in contrast medium
and placed between the middle and inferior turbinates to serve as a
radiopaque marker.
A total of 2mL of local anesthetic is drawn up in a 3-mL sterile syringe. After the skin lateral
to the angle of the mouth is prepared with antiseptic solution, a 22-gauge, 10-cm insulated blunt
curved needle with a 5- to 10-mm active tip is inserted through an introducer needle placed
through the previously anesthetized area. The needle is advanced toward the tip of the
cottontipped applicator, which rests on the mucosa just over the sphenopalatine ganglion at the level
of the middle turbinate. The trajectory of the needle should be toward the posterior clinoid. The
needle is slowly advanced under 6uoroscopic guidance into the pterygopalatine fossa below the
maxillary nerve and in close proximity to the sphenopalatine ganglion (Fig. 6-4). The needle tip
ultimately is visualized just under the lateral nasal mucosa, and its position can be con rmed by
injecting 0.5 mL of contrast medium.7
7
7
7
7
<
<
FIGURE 6-4 Lateral fluoroscopic image demonstrating placement of the
stimulating needle in the pterygopalatine fossa in proximity to the
sphenopalatine ganglion.
Sensory stimulation is then applied to the needle at 0.5V at a frequency of 50Hz. If the needle
is in the correct position, the patient experiences a buzzing sensation just behind the nose with
no stimulation into the distribution of other areas innervated by the maxillary nerve, which is
often perceived by the patient as a buzzing sensation in the upper teeth (see “Side E ects and
Complications” for pitfalls in needle placement). After correct needle placement is con rmed,
pulsed radiofrequency lesioning is performed for 90 seconds at 44°C. Often a second lesion and
sometimes a third lesion is necessary to provide long-lasting relief.
Side Effects and Complications
Because of the highly vascular nature of the pterygopalatine fossa, signi cant facial hematoma
may occur after radiofrequency lesioning of the sphenopalatine ganglion. Owing to the
proximity of other nerves, misplacement of the radiofrequency needle can result in damage to
the a ected nerve with permanent neurologic de cit. Stimulation before lesioning can help
detect needle misplacement by identi cation of speci c stimulation patterns (Table 6-1). The
stimulation associated with proper placement of the needle is felt at the root of the nose. If the
needle is malpositioned in proximity to the maxillary division of the nerve, the stimulation is
experienced in the upper teeth. Should this occur, the needle should be positioned more caudad.
If the needle is malpositioned near the greater and lesser palatine nerves, the stimulation is
experienced in the hard palate. Should this occur, the needle should be redirected more medially
and posteriorly.7
TABLE 6-1
Identification of Specific Stimulation Patterns
Needle Position Stimulation Pattern Corrective Maneuver
Needle in proper position Stimulation at base None
of nose
Needle in proximity to maxillary nerve Stimulation in upper Redirect needle more
teeth caudad
Needle in proximity to greater and lesser Stimulation in hard Redirect needle more
palatine nerves palate posteriorly
Patients occasionally may experience signi cant orthostatic hypotension or bradycardia during
stimulation of the sphenopalatine ganglion. This phenomenon is thought to be analogous to the
oculocardiac re6ex and can be prevented with atropine. Patients who undergo stimulation of the
sphenopalatine ganglion should be monitored closely for orthostatic hypotension and
bradycardia and initially allowed to ambulate only with assistance.
Clinical Pearls
Clinical experience has shown that sphenopalatine ganglion block with local anesthetic is
useful in aborting the acute attack of migraine or cluster headache. The simplicity of the
transnasal approach lends itself to use at the bedside, in the emergency room, or in the pain
clinic. Although cocaine is probably a superior topical anesthetic for use with this technique,
the various political issues surrounding the use of controlled substances make another local
anesthetic such as viscous lidocaine a more logical choice.
If previous trauma or tumor precludes the use of the transnasal approach to sphenopalatine
ganglion block, injection of local anesthetic via the greater palatine foramen or the lateral
approach represents a good alternative. Because of the proximity of the sphenopalatine
ganglion to the maxillary nerve, care must be taken to avoid inadvertent neurolysis of the
maxillary nerve when performing neurodestructive procedures on the sphenopalatine
ganglion. Because of the ability to more accurately localize the sphenopalatine ganglion by
stimulation, radiofrequency lesioning via the lateral approach represents probably the safest
option if destruction of the sphenopalatine ganglion is desired.

C H A P T E R 7
Greater and Lesser Occipital Nerve
Block
Abstract
The greater occipital nerve arises from bers of the dorsal primary ramus of the second
cervical nerve and to a lesser extent from bers of the third cervical nerve. It supplies the
medial portion of the posterior scalp as far anterior as the vertex. The lesser occipital nerve
arises from the ventral primary rami of the second and third cervical nerves. The lesser
occipital nerve passes superiorly along the posterior border of the sternocleidomastoid
muscle, dividing into cutaneous branches that innervate the lateral portion of the posterior
scalp and the cranial surface of the pinna of the ear. Occipital nerve block is useful in the
diagnosis and treatment of occipital neuralgia. This technique is also useful in providing
surgical anesthesia in the distribution of the greater and lesser occipital nerves for lesion
removal and laceration repair.
Key Words
greater occipital nerve
headache
lesser occipital nerve
occipital nerve block
occipital neuralgia
ultrasound-guided occipital nerve block
CPT-2015 Code
Unilateral 64405
Bilateral 64405-50
Neurolytic 64640
Relative Value Units
Unilateral 8
Bilateral 12
Neurolytic 20
Indications

Occipital nerve block is useful in the diagnosis and treatment of occipital neuralgia. This
technique is also useful in providing surgical anesthesia in the distribution of the greater and
lesser occipital nerves for lesion removal and laceration repair. This simple technique may also be
used to supplement general anesthesia for neurosurgical procedures involving the occipital region.
Clinically Relevant Anatomy
The greater occipital nerve arises from bers of the dorsal primary ramus of the second cervical
nerve and to a lesser extent from bers of the third cervical nerve. The greater occipital nerve
pierces the fascia just below the superior nuchal ridge along with the occipital artery. It supplies
the medial portion of the posterior scalp as far anterior as the vertex (Fig. 7-1).
FIGURE 7-1 Anatomy of the occipital nerve. a . , Artery; n . , nerve.
The lesser occipital nerve arises from the ventral primary rami of the second and third cervical
nerves. The lesser occipital nerve passes superiorly along the posterior border of the
sternocleidomastoid muscle, dividing into cutaneous branches that innervate the lateral portion of
the posterior scalp and the cranial surface of the pinna of the ear (see Fig. 7-1).
Technique
Landmark and Fluoroscopically Guided Technique
The patient is placed in a sitting position with the cervical spine 2exed and the forehead on a
padded bedside table (Fig. 7-2). A total of 8mL of local anesthetic is drawn up in a 12-mL sterilesyringe. When occipital neuralgia or other painful conditions involving the greater and lesser
occipital nerves are being treated, a total of 80mg of depot-steroid is added to the local anesthetic
with the first block, and 40 mg of depot-steroid is added with subsequent blocks.
FIGURE 7-2 For the greater and lesser occipital nerve block procedure, the
patient is placed in a sitting position with the cervical spine flexed and the
forehead on a padded bedside table. n . , Nerve.
The occipital artery is then palpated at the level of the superior nuchal ridge. After preparation
of the skin with antiseptic solution, a 22-gauge, -inch needle is inserted just medial to the
artery and is advanced perpendicularly until the needle approaches the periosteum of the
underlying occipital bone (Fig. 7-3). A paresthesia may be elicited, and the patient should be
warned of such. The needle is then redirected superiorly, and after gentle aspiration, 5mL of
solution is injected in a fanlike distribution, with care taken to avoid the foramen magnum, which
is located medially (Fig. 7-4; see also Fig. 7-3).FIGURE 7-3 Needle position and trajectory for greater and lesser occipital
nerve block. a . , Artery; m . , muscle n . , nerve; S u p . , superior.
FIGURE 7-4 Needle tip in proximity to the greater occipital nerve.
The lesser occipital nerve and a number of super cial branches of the greater occipital nerve
are then blocked by directing the needle laterally and slightly inferiorly. After gentle aspiration,
an additional 3 to 4 mL of solution is injected (Fig. 7-5; see also Fig. 7-3).
:



FIGURE 7-5 Needle tip in proximity to the lesser occipital nerve.
Ultrasound-Guided Technique
For ultrasound-guided blockade of the greater and lesser occipital nerves, the patient is placed in
a sitting position with the cervical spine 2exed and the forehead on a padded bedside table. A
total of 8mL of local anesthetic is drawn up in a 12-mL sterile syringe. When occipital neuralgia
or other painful conditions involving the greater and lesser occipital nerves are being treated, a
total of 80mg of depot-steroid is added to the local anesthetic with the rst block, and 40mg of
depot-steroid is added with subsequent blocks. The nuchal ridge is identi ed by palpation and
then the occipital artery is located by palpation. A high-frequency linear ultrasound transducer is
then placed in the transverse position at the nuchal ridge at the point at which the pulsation of
the occipital artery was identi ed (Fig. 7-6). Color Doppler imaging may be used if there is
di culty in locating the occipital artery (Fig. 7-7). The occipital nerve will be in close proximity
to the artery and will appear on the sonogram as a hypoechoic ovoid structure that does not
compress when pressure is applied with the overlying ultrasound transducer (see Fig. 7-7). After
the nerve is clearly identi ed, a -inch spinal needle is inserted at the medial border of the
ultrasound transducer using an in-plane approach and is advanced toward the occipital nerve
until the needle tip impinges on the periosteum of the occipital bone. The patient may experience
a paresthesia in the distribution of the greater occipital nerve and should be warned of such before
the needle is advanced. When the needle tip is in proximity to the greater occipital nerve, after
careful aspiration, 4mL of the solution is injected in a fanlike manner. The needle is removed and
pressure is placed on the injection site to avoid hematoma formation. The greater occipital nerve
can also be blocked at the point where it passes between the obliquus capitis inferior and
semispinalis capitis muscles.

FIGURE 7-6 Proper transverse position of the high-frequency linear
ultrasound transducer over the point of palpation of the occipital artery.
FIGURE 7-7 Transverse ultrasound scan demonstrating the ovoid greater
occipital nerve and the occipital artery.
The lesser occipital nerve and a number of super cial branches of the greater occipital nerve
are then blocked by directing the needle laterally and slightly inferiorly. After gentle aspiration,
an additional 3 to 4 mL of solution is injected (see Figs. 7-3 and 7-5)
Side Effects and Complications
The scalp is highly vascular, and this, coupled with the fact that both nerves are in close proximity
to arteries, means that the pain specialist should carefully calculate the total milligram dose of
local anesthetic that may be given safely, especially if bilateral nerve blocks are being performed.
This vascularity and the proximity to the arterial supply give rise to an increased incidence of
postblock ecchymosis and hematoma formation. These complications can be decreased if manual
pressure is applied to the area of the block immediately after injection. Despite the vascularity of
this anatomic region, this technique can be performed safely in patients receiving anticoagulants
by using a 25- or 27-gauge needle, albeit with increased risk of hematoma, if the clinical situation
indicates a favorable risk-to-bene t ratio. Application of cold packs for 20-minute periods after
the block also decreases the amount of postprocedure pain and bleeding the patient may
experience.
As mentioned earlier, care must be taken to avoid inadvertent needle placement into the=
foramen magnum because the subarachnoid administration of local anesthetic in this region
results in an immediate total spinal anesthesia.
Clinical Pearls
The most common reason that greater and lesser occipital nerve block fails to relieve
headache pain is that the headache syndrome being treated has been misdiagnosed as occipital
neuralgia. In the author's experience, occipital neuralgia is an infrequent cause of headaches
and rarely occurs in the absence of trauma to the greater and lesser occipital nerves. More
often, the patient with headaches involving the occipital region is, in fact, su ering from
tension-type headaches. Tension-type headaches do not respond to occipital nerve blocks but
are amenable to treatment with antidepressant compounds such as amitriptyline in conjunction
with cervical steroid epidural nerve blocks. Therefore, the pain management specialist should
reconsider the diagnosis of occipital neuralgia in patients whose symptoms are consistent with
occipital neuralgia but who fail to show a response to greater and lesser occipital nerve blocks.
Any patient with headaches severe enough to require neural blockade as part of the
treatment plan should undergo magnetic resonance imaging of the head to rule out
unsuspected intracranial disease, which may mimic the clinical symptoms of occipital neuralgia
(Fig. 7-8). Furthermore, cervical spine radiography should be considered to rule out congenital
abnormalities such as Arnold-Chiari malformations that may be the hidden cause of the
patient's occipital headaches.
FIGURE 7-8 Positron emission tomography/magnetic resonance images
of an occipital tumor in a patient with occipital headaches. (From Kops ER,
Herzog H: Errors in MR-based attenuation correction for brain imaging with
PET/MR scanners. Nucl Instrum Methods Phys Res A 702:104-107,
2013.)

C H A P T E R 8
Greater and Lesser Occipital
Nerve Block
Radiofrequency Lesioning
Abstract
The greater occipital nerve arises from bers of the dorsal primary ramus of the
second cervical nerve and to a lesser extent from bers of the third cervical
nerve. It supplies the medial portion of the posterior scalp as far anterior as the
vertex. The lesser occipital nerve arises from the ventral primary rami of the
second and third cervical nerves. The lesser occipital nerve passes superiorly
along the posterior border of the sternocleidomastoid muscle, dividing into
cutaneous branches that innervate the lateral portion of the posterior scalp and
the cranial surface of the pinna of the ear. Radiofrequency lesioning of the
occipital nerve block is useful in select patients who have experienced short-term
relief with occipital nerve blocks performed using local anesthetic or steroid and
have failed to respond to other conservative therapies.
Key Words
greater occipital nerve
headache
lesser occipital nerve
occipital nerve block
occipital neuralgia
radiofrequency-destruction occipital nerve block
radiofrequency lesioning of the occipital nerves
CPT-2015 Code
Neurolytic 64640
Neurolytic-Bilateral 64640-50

Relative Value Units
Neurolytic 20
Indications
Radiofrequency lesioning of the occipital nerve block is useful in select patients who
have experienced short-term relief with occipital nerve blocks performed using local
anesthetic or steroid and have failed to respond to other conservative therapies.
Clinically Relevant Anatomy
The greater occipital nerve arises from bers of the dorsal primary ramus of the
second cervical nerve and to a lesser extent from bers of the third cervical nerve.
The greater occipital nerve pierces the fascia just below the superior nuchal ridge
along with the occipital artery. It supplies the medial portion of the posterior scalp
as far anterior as the vertex (Fig. 8-1).FIGURE 8-1 Anatomy of the greater and lesser occipital
nerves. a . , Artery; n . , nerve.
The lesser occipital nerve arises from the ventral primary rami of the second and
third cervical nerves. The lesser occipital nerve passes superiorly along the posterior
border of the sternocleidomastoid muscle, dividing into cutaneous branches that
innervate the lateral portion of the posterior scalp and the cranial surface of the
pinna of the ear (see Fig. 8-1).
Technique
The patient is placed in a sitting position with the cervical spine 0exed and the
forehead on a padded bedside table. A total of 4mL of local anesthetic is drawn up
in a 12-mL sterile syringe. The occipital artery is then palpated at the level of the
superior nuchal ridge. After preparation of the skin with antiseptic solution, a
22gauge, 10-cm insulated blunt curved needle with a 5- to 10-mm active tip is inserted
through an introducer needle just medial to the artery and is advanced
perpendicularly until the needle approaches the periosteum of the underlying


occipital bone (Fig. 8-2). A paresthesia may be elicited, and the patient should be
warned of such. After the needle is in satisfactory position, sensory stimulation to
con rm correct needle position is carried out at a frequency of 50Hz. An amplitude
of no more than 0.5 V should be required. The patient should experience stimulation
in the distribution of the greater occipital nerve. Then 2mL of 1% lidocaine is
injected to provide analgesia. After adequate analgesia has been obtained, lesioning
is performed using two to three 120-second cycles of pulsed radiofrequency waves at
42°C.
FIGURE 8-2 Needle tip in proximity to the greater occipital
nerve.
The lesser occipital nerve and a number of super cial branches of the greater
occipital nerve are then lesioned by redirecting the needle laterally and slightly
inferiorly (Fig. 8-3). Sensory stimulation to con rm correct needle position is again
carried out with a frequency of 50Hz. An amplitude of no more than 0.5V should be
required. The patient should experience stimulation in the distribution of the lesser
occipital nerve. Then 2mL of 1% lidocaine is injected to provide analgesia. After
adequate analgesia has been obtained, lesioning is performed using two to three
120second cycles of pulsed radiofrequency waves at 42°C.FIGURE 8-3 Needle tip in proximity to the lesser occipital
nerve.
Side Effects and Complications
The vascularity and the proximity to the arterial supply in this region give rise to an
increased incidence of postblock ecchymosis and hematoma formation. These
complications can be decreased if manual pressure is applied to the area of the block
immediately after the procedure. Application of cold packs for 20-minute periods
after the block also decreases the amount of postprocedure pain and bleeding the
patient may experience.
As mentioned earlier, care must be taken to avoid inadvertent needle placement
into the foramen magnum because the subarachnoid administration of local
anesthetic in this region results in an immediate total spinal anesthesia.
Clinical Pearls
The most common reason that greater and lesser occipital nerve block fails to
relieve headache pain is that the headache syndrome being treated has been
misdiagnosed as occipital neuralgia. In my experience, occipital neuralgia is an
infrequent cause of headaches and rarely occurs in the absence of trauma to the
greater and lesser occipital nerves. More often, the patient with headaches<
involving the occipital region is in fact su ering from tension-type headaches.
Tension-type headaches do not respond to occipital nerve blocks but are amenable
to treatment with antidepressant compounds such as amitriptyline in conjunction
with cervical steroid epidural nerve blocks. Therefore, the pain management
specialist should reconsider the diagnosis of occipital neuralgia in patients whose
symptoms are consistent with occipital neuralgia but who fail to respond to
greater and lesser occipital nerve blocks.
As with all neurodestructive procedures, the pain management specialist should
be sure that the patient fully understands that the numbness experienced after the
block may be permanent and that there is no guarantee that the procedure will
relieve the patient's pain. Any patient with headaches severe enough to require
neural blockade as part of the treatment plan should undergo magnetic resonance
imaging of the head to rule out unsuspected intracranial disease, which may
mimic the clinical symptoms of occipital neuralgia.C H A P T E R 9
Gasserian Ganglion Block
Abstract
The gasserian ganglion is canoe shaped, with the three sensory divisions—the ophthalmic
(V1), the maxillary (V2), and the mandibular (V3)—exiting the anterior convex aspect of the
ganglion. A small motor root joins the mandibular division as it exits the cranial cavity
through the foramen ovale. Gasserian ganglion block may be used as a part of the diagnostic
evaluation of facial pain when the pain management specialist is trying to determine whether
a patient's pain is somatic or sympathetic in origin. In addition to being used in anatomic
di( erential neural blockade, gasserian ganglion block may be used in a prognostic manner
before neurodestruction of the gasserian ganglion. Gasserian ganglion block also may be used
in the acute setting to provide palliation in acute pain emergencies, including trigeminal
neuralgia and cancer pain, during the wait for pharmacologic and antiblastic agents to
become e( ective. Neurodestructive procedures of the gasserian ganglion using neurolytic
agents, radiofrequency lesioning, balloon compression, or freezing may be indicated for
palliation of cancer pain, including pain associated with invasive tumors of the orbit,
maxillary sinus, and mandible.
Key Words
balloon compression
gasserian ganglion
gasserian ganglion block
mandibular nerve
maxillary nerve
ophthalmic division
retrogasserian glycerol
trigeminal nerve
trigeminal neuralgia
CPT-2015 Code
Unilateral 64400
Neurolytic 64605
61790 (with radiographic guidance)
Relative Value UnitsUnilateral 15
Neurolytic 30
Indications
Gasserian ganglion block may be used as a part of the diagnostic evaluation of facial pain when
the pain management specialist is trying to determine whether a patient's pain is somatic or
sympathetic in origin. In addition to being used in anatomic di( erential neural blockade,
gasserian ganglion block may be used in a prognostic manner before neurodestruction of the
gasserian ganglion. Gasserian ganglion block also may be used in the acute setting to provide
palliation in acute pain emergencies, including trigeminal neuralgia and cancer pain, during the
wait for pharmacologic and antiblastic agents to become effective.
Neurodestructive procedures of the gasserian ganglion using neurolytic agents, radiofrequency
lesioning, balloon compression, or freezing may be indicated for palliation of cancer pain,
including pain associated with invasive tumors of the orbit, maxillary sinus, and mandible.
Destructive techniques also may be useful in the management of trigeminal neuralgia in patients
for whom pharmacologic treatment, as well as nerve blocks with local anesthetic and steroid, has
been ine( ective and who are not considered candidates for more de6nitive neurosurgical
procedures, including microvascular decompression (Jannetta's procedure). Destruction of the
gasserian ganglion has also been used in the management of intractable cluster headache and
ocular pain secondary to persistent glaucoma.
Clinically Relevant Anatomy
The gasserian ganglion is formed from two roots that exit the ventral surface of the brain stem at
the midpontine level. These roots pass in a forward and lateral direction in the posterior cranial
fossa across the border of the petrous bone. They then enter a recess called Meckel's cave, which is
formed by an invagination of the surrounding dura mater into the middle cranial fossa (Fig. 9-1).
The dural pouch that lies just behind the ganglion is called the trigeminal cistern and contains
cerebrospinal fluid (CSF).FIGURE 9-1 Dissection demonstrating the anatomy about Meckel's cave.
The gasserian ganglion is well defined with the three major sensory branches
clearly dissected. Cranial nerves II, III, IV, V1, V2, and V3 are marked. D R ,
Dural ring; M M A , middle meningeal artery; P C A , posterior cerebral artery; P R ,
proximal ring; S C - C A , supraclinoid carotid artery. (From Post KD, Meyer SA:
Other schwannomas of cranial nerves. In Kaye AH, Laws ER Jr, editors: Brain
Tumors, 3rd ed. Edinburgh, Saunders, 2012, pp 570-587.)
The gasserian ganglion is canoe shaped, with the three sensory divisions—the ophthalmic (V1),
the maxillary (V2), and the mandibular (V3)—exiting the anterior convex aspect of the ganglion
(Fig. 9-2). A small motor root joins the mandibular division as it exits the cranial cavity through
the foramen ovale.FIGURE 9-2 Anatomy of the gasserian ganglion and the divisions of the
trigeminal nerve. I n f . , Inferior; n . , nerve.
Technique
Landmark Technique
The patient is placed in the supine position with the cervical spine extended over a rolled towel.
About 2.5cm lateral to the corner of the mouth, the skin is prepared with antiseptic solution, and
sterile drapes are placed (Fig. 9-3). The skin and subcutaneous tissues are then anesthetized with
1% lidocaine with epinephrine.FIGURE 9-3 For gasserian ganglion block, the needle is inserted 2.5  cm
lateral to the corner of the mouth.
A 20-gauge, 13-cm styletted needle is advanced through the anesthetized area, traveling
perpendicular to the pupil of the eye (when the eye is looking straight ahead). The trajectory of
the needle is cephalad toward the acoustic auditory meatus. The needle is advanced until contact
is made with the base of the skull (Fig. 9-4). The needle is withdrawn slightly and is “walked”
posteriorly into the foramen ovale (Fig. 9-5). Paresthesia of the mandibular nerve will probably
be elicited as the needle enters the foramen ovale, and the patient should be warned of such.FIGURE 9-4 A 20-gauge, 13-cm styletted needle is advanced through the
anesthetized area, traveling perpendicular to the pupil of the eye (when the
eye is looking straight ahead). The trajectory of the needle is cephalad toward
the acoustic auditory meatus. The needle is advanced until contact is made
with the base of the skull.@
@
FIGURE 9-5 After the needle makes contact with the base of the skull, the
needle is withdrawn slightly and is “walked” posteriorly into the foramen ovale.
Paresthesia of the mandibular nerve will probably be elicited as the needle
enters the foramen ovale, and the patient should be warned of such.
Fluoroscopically Guided Technique
When gasserian ganglion block is performed under uoroscopic guidance, the foramen ovale is
identi6ed on submental and oblique views (Fig. 9-6). The needle is then advanced under
uoroscopic guidance as described previously toward the foramen ovale. If the base of the skull is
encountered, the needle is redirected into the foramen ovale (Figs. 9-7 and 9-8).FIGURE 9-6 Foramen ovale.
FIGURE 9-7 Anteroposterior view of needle through the foramen ovale.@
FIGURE 9-8 Lateral view of needle through the foramen ovale.
After the needle enters the foramen ovale, the needle stylet is removed. A free ow of CSF is
usually observed. If no CSF is observed, the needle tip is probably anterior to the trigeminal
cistern but still may be within Meckel's cave. Needle position can be confirmed by injecting 0.1-mL
increments of preservative-free 1% lidocaine and observing the clinical response. Alternatively,
0.1 to 0.4mL of contrast medium suitable for central nervous system use may be administered
under fluoroscopic guidance before injection of the neurolytic substance (Fig. 9-9). Sterile glycerol,
6.5% phenol in glycerin, and absolute alcohol all have been successfully used for neurolysis of the
gasserian ganglion. The neurolytic agent should be administered in 0.1-mL increments, with time
allotted between additional increments to allow for observation of the clinical response. If
hyperbaric neurolytic solutions such as glycerol or phenol in glycerin are used, the patient should
be moved to the sitting position with the chin on the chest before injection (Fig. 9-10). This
ensures that the solution is placed primarily around the maxillary and mandibular divisions and
avoids the ophthalmic division. The patient should be left in the supine position if absolute alcohol
is used. This same approach to the gasserian ganglion may be used to place radiofrequency
needles, cryoprobes, compression balloons, and stimulating electrodes (Fig. 9-11).FIGURE 9-9 Contrast medium outlining Meckel's cave. (From Waldman SD:
Interventional Pain Management, 2nd ed. Philadelphia, Saunders, 2001, p
320.)FIGURE 9-10 If hyperbaric neurolytic solutions such as glycerol or phenol in
glycerin are used when performing gasserian ganglion block, the patient
should be moved to the sitting position with the chin on the chest before
injection. This ensures that the solution is placed primarily around the
maxillary and mandibular divisions and avoids the ophthalmic division.FIGURE 9-11 Patient with severe neuropathic pain in the territory of the
inferior alveolar nerve (trigeminal V3) after dental surgery. First, a high
cervical lead (Medtronic Resume) was applied for stimulation of the trigeminal
spinal nucleus and tract at the C1-C2 level, and in addition, a deep brain
stimulation (DBS) lead (Medtronic model 3389) shown here was used as a
trial electrode for the retrogasserian rootlet. (From Van Buyten JP, Linderoth
B: Invasive neurostimulation in facial pain and headache syndromes. Eur J
Pain Suppl 5[2]:409-421, 2011.)
Side Effects and Complications
Because of the highly vascular nature of the pterygopalatine space, as well as its proximity to the
middle meningeal artery, signi6cant hematoma of the face and subscleral hematoma of the eye
are common sequelae to gasserian ganglion block. The ganglion lies within the central nervous
system, and small amounts of local anesthetic injected into the CSF may lead to total spinal
anesthesia. For this reason, it is imperative that small, incremental doses of local anesthetic be
injected, with time allowed after each dose to observe the effect of prior doses.
Because of the potential for anesthesia of the ophthalmic division with its attendant corneal
anesthesia, corneal sensation should be tested with a cotton wisp after gasserian ganglion block
with either local anesthetic or neurolytic solution. If corneal anesthesia is present, sterile
ophthalmic ointment should be used and the a( ected eye patched to avoid damage to the
anesthetic cornea. This precaution must be continued for the duration of corneal anesthesia.
Ophthalmologic consultation is advisable should persistent corneal anesthesia occur.
Postprocedure dysesthesia, including anesthesia dolorosa, occurs in about 6% of patients who
undergo neurodestructive procedures of the gasserian ganglion. These dysesthesias can range from
mild pulling or burning sensations to severe postprocedure pain called anesthesia dolorosa. These
postprocedure symptoms are thought to be due to incomplete destruction of the ganglion.
Sloughing of skin in the area of anesthesia also may occur.
In addition to disturbances of sensation, blockade or destruction of the gasserian ganglion may
result in abnormal motor function, including weakness of the muscles of mastication and facial
asymmetry. Horner's syndrome also may occur as a result of block of the parasympathetic
trigeminal fibers. The patient should be warned that all these complications may occur.
Clinical PearlsGasserian ganglion block with local anesthetic represents an excellent stopgap measure for
patients su( ering the uncontrolled pain of trigeminal neuralgia and cancer pain while waiting
for pharmacologic and antiblastic treatments to take e( ect. This block has more side e( ects
and complications than the usual nerve block modalities used by the pain management
specialist and thus should be reserved for those special situations in which the pain is truly out
of control.
An interesting side e( ect of gasserian ganglion block is the activation of herpes labialis and,
occasionally, of herpes zoster after the procedure (Fig. 9-12). This occurs in about 10% of
patients who undergo procedures on the gasserian ganglion, and patients should be forewarned
of this possibility.
FIGURE 9-12 Herpes labialis can occur following gasserian ganglion block.
(From Sapp JP, Eversole LR, Wysocki GP: Oral infections. In
Contemporary Oral and Maxillofacial Pathology, 2nd ed. St Louis, Mosby,
2004, pp 207-251.)
As mentioned previously, bleeding complications are not uncommon, and given the dramatic
and highly visible nature of a facial and subscleral hematoma, all patients undergoing
gasserian ganglion block should be warned to expect this side e( ect to prevent undue anxiety
should bleeding complications occur. Infection, although rare, remains an ever-present
possibility, especially in the immunocompromised patient. Early detection of infection is crucial
to avoid potentially life-threatening sequelae.
The pain management specialist should be particularly careful to identify and treat
postprocedure corneal anesthesia. Failure to do so can often result in loss of vision. If persistent
corneal anesthesia occurs, immediate ophthalmologic consultation should be obtained to
manage any eye-related problems. As with all patients su( ering from pain subserved by the
trigeminal nerve and its branches, the clinician must be careful to identify the cause of the pain
to avoid clinical disasters (Fig. 9-13).FIGURE 9-13 A, Gadolinium-enhanced sagittal magnetic resonance image
(MRI) of a dumbbell-shaped tumor showing areas of decreased attenuation
representing either necrosis or cystic degeneration. B,
Gadoliniumenhanced axial MRI of a dumbbell-shaped tumor with extension through
Meckel's cave and some erosion of the posterior clinoid. C,
Gadoliniumenhanced coronal MRI of the relatively homogenously enhancing mass with
cystic components. D, Intraoperative photograph demonstrating a right
trigeminal schwannoma in the middle cranial fossa. E, Intraoperative
photograph demonstrating a preserved mandibular division of the trigeminal
nerve after resection of the schwannoma seen in D. (From Post KD, Meyer
SA: Other schwannomas of cranial nerves. In Kaye AH, Laws ER Jr,
editors: Brain Tumors, 3rd ed. Edinburgh, Saunders, 2012, pp 570-587.)C H A P T E R 1 0
Gasserian Ganglion Block
Radiofrequency Lesioning
Abstract
The gasserian ganglion is canoe shaped, with the three sensory divisions—the ophthalmic
(V1), the maxillary (V2), and the mandibular (V3)—exiting the anterior convex aspect of the
ganglion. A small motor root joins the mandibular division as it exits the cranial cavity
through the foramen ovale. Gasserian ganglion block may be used as a part of the diagnostic
evaluation of facial pain when the pain management specialist is trying to determine
whether a patient's pain is somatic or sympathetic in origin. In addition to being used in
anatomic di( erential neural blockade, gasserian ganglion block may be used in a prognostic
manner before neurodestruction of the gasserian ganglion. Gasserian ganglion block also
may be used in the acute setting to provide palliation in acute pain emergencies, including
trigeminal neuralgia and cancer pain, during the wait for pharmacologic and antiblastic
agents to become e( ective. Neurodestructive procedures of the gasserian ganglion using
neurolytic agents, radiofrequency lesioning, balloon compression, or freezing may be
indicated for palliation of cancer pain, including pain associated with invasive tumors of the
orbit, maxillary sinus, and mandible.
Key Words
balloon compression
gasserian ganglion
gasserian ganglion block
mandibular nerve
maxillary nerve
ophthalmic division
radiofrequency destruction of the gasserian ganglion
radiofrequency lesioning of the gasserian ganglion
retrogasserian glycerol
trigeminal nerve
trigeminal neuralgia
CPT-2015 Code
Neurolytic 64610 (with radiographic guidance)Relative Value Units
Neurolytic 30
Indications
Neurodestructive procedures of the gasserian ganglion using neurolytic agents, radiofrequency
lesioning, balloon compression, or freezing may be indicated for palliation of cancer pain,
including pain associated with invasive tumors of the orbit, maxillary sinus, and mandible (Fig.
10-1). Destructive techniques also may be useful in the management of trigeminal neuralgia in
patients for whom pharmacologic treatment, as well as nerve blocks with local anesthetic and
steroid, has been ine( ective and who are not considered candidates for more de4nitive
neurosurgical procedures, including microvascular decompression (Jannetta's procedure).
Destruction of the gasserian ganglion has also been used in the management of intractable
cluster headache and ocular pain secondary to persistent glaucoma. In recent years,
radiofrequency lesioning has supplanted the use of neurolytic agents as the preferred method of
destruction of the gasserian ganglion if the patient is not a suitable candidate for more de4nitive
neurosurgical treatment.FIGURE 10-1 Osteosarcoma originating from the lateral orbital wall (greater
wing of the sphenoid) and temporal bone with extension into the temporal
fossa in a 12-year-old girl with bilateral retinoblastoma in typical locations.
(From Rodjan F, de Graaf P, Brisse HJ, et  al: Second cranio-facial
malignancies in hereditary retinoblastoma survivors previously treated with
radiation therapy: clinic and radiologic characteristics and survival outcomes.
Eur J Cancer 49[8]:1939-1947, 2013.)
Clinically Relevant Anatomy
The gasserian ganglion is formed from two roots that exit the ventral surface of the brain stem at
the midpontine level. These roots pass in a forward and lateral direction in the posterior cranial
fossa across the border of the petrous bone. They then enter a recess called Meckel's cave, which is
formed by an invagination of the surrounding dura mater into the middle cranial fossa. The dural
pouch that lies just behind the ganglion is called the trigeminal cistern and contains cerebrospinal
fluid (CSF).
The gasserian ganglion is canoe shaped, with the three sensory divisions—the ophthalmic (V1),
the maxillary (V2), and the mandibular (V3)—exiting the anterior convex aspect of the ganglion
(Fig. 10-2). A small motor root joins the mandibular division as it exits the cranial cavity via the
foramen ovale.<
:
FIGURE 10-2 Anatomy of the gasserian ganglion and trigeminal nerves.
I n f . , Inferior; n . , nerve.
Technique
The patient is placed in the supine position with the cervical spine extended over a rolled towel.
About 2.5cm lateral to the corner of the mouth, the skin is prepared with antiseptic solution and
sterile drapes are placed. The skin and subcutaneous tissues are then anesthetized with 1%
lidocaine with epinephrine.
A 22-gauge, 15-cm insulated blunt curved needle with a 5- to 10-mm active tip is inserted
through an introducer needle placed through the previously anesthetized area traveling
perpendicular to the pupil of the eye (when the eye is looking straight ahead). The trajectory of
the needle is cephalad toward the acoustic auditory meatus. The foramen ovale is identi4ed on
submental and oblique views (Fig. 10-3). The needle is then advanced under uoroscopic
guidance as described previously toward the foramen ovale (Figs. 10-4 and 10-5). If the base of
the skull is encountered, the needle is redirected into the foramen ovale (Figs. 10-6 and 10-7). If
di culty is encountered in placing the needle through the foramen ovale into Meckel's cave,
submental and oblique views may be bene4cial (Figs. 10-8 and 10-9). Paresthesia of the
mandibular nerve probably will be elicited as the needle enters the foramen ovale, and the
patient should be warned of such.FIGURE 10-3 Foramen ovale.
FIGURE 10-4 Anteroposterior view of needle tip approaching the foramen
ovale.FIGURE 10-5 Lateral view of needle approaching the foramen ovale.
FIGURE 10-6 Anteroposterior view of needle through the foramen ovale.FIGURE 10-7 Lateral view of needle through the foramen ovale.
FIGURE 10-8 Submental view of needle through the foramen ovale.FIGURE 10-9 Needle properly placed in the foramen ovale.
Con4rmation that the needle is properly placed can be obtained by needle stimulation at 2Hz
with 0.5 to 1.5 V, which should produce motor stimulation of the ipsilateral muscles of the lower
mandible. If no motor response is observed, the needle should be repositioned more medially. If
the needle is in proximity to the 4rst or second divisions of the gasserian ganglion, no motor
response should be observed. A mild paresthesia in the division that is to be lesioned should then
be elicited by stimulating at 50 to 100Hz with 0.1 to 0.5 V. If higher voltages are required to
stimulate a paresthesia, the needle should be repositioned. Careful aspiration for blood and CSF
should then be carried out and the needle repositioned until blood is not present. If no CSF or
blood is present, 0.25 to 0.5mL of 0.2% ropivacaine is then injected, and the patient is
monitored closely for inadvertent intravascular or subarachnoid injection. After 60 seconds,
radiofrequency lesioning is carried out at 60°C for 90 seconds. Care should be taken to verify that
the lesion has not produced corneal anesthesia.
Side Effects and Complications
Because of the highly vascular nature of the pterygopalatine space as well as its proximity to the
middle meningeal artery, signi4cant hematoma of the face and subscleral hematoma of the eye
are common sequelae to gasserian ganglion block. The ganglion lies within the central nervous
system, and small amounts of local anesthetic injected into the CSF may lead to total spinal
anesthesia. For this reason, it is imperative that small doses of local anesthetic be injected, with
time allowed after each dose to observe the effect of prior doses.
Because of the potential for anesthesia of the ophthalmic division with its attendant corneal
anesthesia, corneal sensation should be tested with a cotton wisp after lesioning of the gasserian
ganglion. If corneal anesthesia is present, sterile ophthalmic ointment should be used and thea( ected eye patched to avoid damage to the cornea. This precaution must be continued for the
duration of corneal anesthesia. Ophthalmologic consultation is advisable should persistent
corneal anesthesia occur.
Postprocedure dysesthesia, including anesthesia dolorosa, occurs in about 6% of patients who
undergo neurodestructive procedures of the gasserian ganglion. These dysesthesias can range
from mild pulling or burning sensations to severe postprocedure pain called anesthesia dolorosa.
These postprocedure symptoms are thought to be due to incomplete destruction of the ganglion.
Sloughing of skin in the area of anesthesia also may occur.
In addition to disturbances of sensation, blockade or destruction of the gasserian ganglion may
result in abnormal motor function, including weakness of the muscles of mastication and facial
asymmetry. Horner's syndrome also may occur as a result of block of the parasympathetic
trigeminal fibers. The patient should be warned that all these complications may occur.
Clinical Pearls
Gasserian ganglion block with local anesthetic represents an excellent stopgap measure for
patients su( ering the uncontrolled pain of trigeminal neuralgia and cancer pain while
waiting for pharmacologic and antiblastic treatments to take e( ect. This block has more side
e( ects and complications than the usual nerve block modalities used by the pain management
specialist and thus should be reserved for those special situations in which the pain is truly out
of control.
An interesting side effect of gasserian ganglion block is the activation of herpes labialis and,
occasionally, of herpes zoster after the procedure. This occurs in about 10% of patients who
undergo procedures on the gasserian ganglion, and patients should be forewarned of this
possibility.
As mentioned previously, bleeding complications are not uncommon, and given the
dramatic and highly visible nature of a facial and subscleral hematoma, all patients
undergoing gasserian ganglion block should be warned to expect this side e( ect to prevent
undue anxiety should bleeding complications occur. Infection, although rare, remains an
everpresent possibility, especially in the immunocompromised patient. Early detection of infection
is crucial to avoid potentially life-threatening sequelae.
The pain management specialist should be particularly careful to identify and treat
postprocedure corneal anesthesia. Failure to do so can often result in loss of vision. If
persistent corneal anesthesia occurs, immediate ophthalmologic consultation should be
obtained to manage any eye-related problems.C H A P T E R 1 1
Gasserian Ganglion Block
Balloon Compression Technique
Abstract
The gasserian ganglion is canoe shaped, with the three sensory divisions—the ophthalmic
(V1), the maxillary (V2), and the mandibular (V3)—exiting the anterior convex aspect of the
ganglion. A small motor root joins the mandibular division as it exits the cranial cavity
through the foramen ovale. Gasserian ganglion block may be used as a part of the diagnostic
evaluation of facial pain when the pain management specialist is trying to determine
whether a patient's pain is somatic or sympathetic in origin. In addition to being used in
anatomic di( erential neural blockade, gasserian ganglion block may be used in a prognostic
manner before neurodestruction of the gasserian ganglion. Gasserian ganglion block also
may be used in the acute setting to provide palliation in acute pain emergencies, including
trigeminal neuralgia and cancer pain, during the wait for pharmacologic and antiblastic
agents to take e( ect. Neurodestructive procedures of the gasserian ganglion using neurolytic
agents, radiofrequency lesions, balloon compression, or freezing may be indicated for
palliation of cancer pain, including pain associated with invasive tumors of the orbit,
maxillary sinus, and mandible.
Key Words
balloon compression
gasserian ganglion
gasserian ganglion block
mandibular nerve
maxillary nerve
ophthalmic division
radiofrequency destruction of the gasserian ganglion
radiofrequency lesioning of the gasserian ganglion
retrogasserian glycerol
trigeminal nerve
trigeminal neuralgia
CPT-2015 Code
Neurolytic 64610 (with radiographic guidance)Relative Value Units
Neurolytic 35
Indications
Neurodestructive procedures of the gasserian ganglion using neurolytic agents, radiofrequency
lesioning, balloon compression, or freezing may be indicated for palliation of cancer pain,
including pain associated with invasive tumors of the orbit, maxillary sinus, and mandible.
Destructive techniques also may be useful in the management of trigeminal neuralgia in patients
for whom pharmacologic treatment, as well as nerve blocks with local anesthetic and steroid, has
been ine( ective and who are not considered candidates for more de3nitive neurosurgical
procedures, including microvascular decompression (Jannetta's procedure). Destruction of the
gasserian ganglion has also been used in the management of intractable cluster headache and
ocular pain secondary to persistent glaucoma. Balloon compression of the gasserian ganglion is a
reasonable choice if the patient is not a suitable candidate for more de3nitive neurosurgical
treatment. This technique has the added advantage of being performed completely under general
anesthesia, which makes it ideal for the patient who is unwilling or unable to cooperate with the
other percutaneous neurodestructive procedures on the gasserian ganglion, which require patient
participation.
Clinically Relevant Anatomy
The gasserian ganglion is formed from two roots that exit the ventral surface of the brain stem at
the midpontine level. These roots pass in a forward and lateral direction in the posterior cranial
fossa across the border of the petrous bone. They then enter a recess called Meckel's cave, which is
formed by an invagination of the surrounding dura mater into the middle cranial fossa. The dural
pouch that lies just behind the ganglion is called the trigeminal cistern and contains cerebrospinal
fluid (CSF).
The gasserian ganglion is canoe shaped, with the three sensory divisions—the ophthalmic (V1),
the maxillary (V2), and the mandibular (V3)—exiting the anterior convex aspect of the ganglion
(Fig. 11-1). A small motor root joins the mandibular division as it exits the cranial cavity through
the foramen ovale.=
=
=
=
FIGURE 11-1 Anatomy of the gasserian ganglion and trigeminal nerves.
Inf., Inferior; n., nerve.
Technique
The patient is placed in the supine position with the cervical spine extended over a rolled towel.
About 2.5cm lateral to the corner of the mouth, the skin is prepared with antiseptic solution, and
sterile drapes are placed. The skin and subcutaneous tissues are then anesthetized with 1%
lidocaine with epinephrine.
An 18-gauge styletted spinal needle is used as an introducer needle and is placed through the
previously anesthetized area traveling perpendicular to the pupil of the eye (when the eye is
looking straight ahead). The trajectory of the needle is cephalad toward the acoustic auditory
meatus. The foramen ovale is then identi3ed on submental and oblique views (Fig. 11-2). A
22gauge sterile K-wire is then placed through the spinal needle and advanced carefully to the
foramen ovale. Proper placement of the K-wire just inside the foramen ovale is con3rmed with
uoroscopy. An outer cannula is then passed over the K-wire into Meckel's cave. After
satisfactory placement of the outer cannula is con3rmed with uoroscopy, a 4-mm Fogarty
catheter is placed through the cannula carefully into Meckel's cave. After satisfactory placement
of the Fogarty catheter is con3rmed with uoroscopy, the balloon is in ated with 0.7mL of
contrast medium for a period of 2 minutes. A pear-shaped image should be observed conforming
to the internal bony constraints of Meckel's cave. A failure to observe this pear shape means that
the patient has a capacious Meckel's cave and a larger Fogarty catheter will be required (Figs.
11-3, 11-4, and 11-5). If the gasserian ganglion is not completely compressed because the=
Fogarty catheter is of inadequate size, then little or no pain relief will result. Occasionally, two
balloons are required to completely 3ll Meckel's cave and fully compress the gasserian ganglion.
After a 2-minute compression period, the Fogarty balloon catheter is de ated and, along with the
introducer cannula, is removed. The patient is then observed for postoperative bleeding.
FIGURE 11-2 Foramen ovale.FIGURE 11-3 Left to right: Different-sized outer cannulas with Nos. 3, 4, 5,
and 6 inflated Fogarty balloons. (From Goerss SJ, Atkinson JLD, Kallmes
DF: Variable size percutaneous balloon compression of the gasserian
ganglion for trigeminal neuralgia. Surg Neurol 71[3]:388-390, 2009.)
FIGURE 11-4 A, A No. 4 Fogarty balloon maximally inflated for 2 minutes
failed to produce any facial hypesthesia in this patient, with early recurrence
of pain 9 months later. B, Repeat balloon compression using a No. 5 Fogarty
balloon for 1 minute resulted in perioral hypesthesia and no pain recurrence
in 5 years. (From Goerss SJ, Atkinson JLD, Kallmes DF: Variable size
percutaneous balloon compression of the gasserian ganglion for trigeminal
neuralgia. Surg Neurol 71[3]:388-390, 2009.)FIGURE 11-5 A and B, Balloon compression in a patient with multiple
sclerosis for whom previous radiofrequency and glycerol tests had failed
(note tantalum powder behind balloon) and for whom all balloon compression
procedures over a few months also had failed. A, The balloon depicted is a
No. 6 Fogarty balloon that was held in place for 4 minutes. Note the lack of a
pear-shaped configuration owing primarily to the large dimensions of
Meckel's cave. There was no facial hypesthesia, and the patient's pain
continued unabated. B, Two No. 4 Fogarty balloons were passed through
separate cannulas. Both were inflated and held in place for 2 minutes, which
resulted in perioral hypesthesia and excellent pain relief without medications.
(From Goerss SJ, Atkinson JLD, Kallmes DF: Variable size percutaneous
balloon compression of the gasserian ganglion for trigeminal neuralgia. Surg
Neurol 71[3]:388-390, 2009.)
Side Effects and Complications
Because of the highly vascular nature of the pterygopalatine space, as well as its proximity to the
middle meningeal artery, signi3cant hematoma of the face and subscleral hematoma of the eye
are common sequelae to gasserian ganglion block. The ganglion lies within the central nervoussystem, and small amounts of local anesthetic injected into the CSF may lead to total spinal
anesthesia. For this reason, it is imperative that small doses of local anesthetic be injected, with
time allowed after each dose to observe the effect of prior doses.
Because of the potential for anesthesia of the ophthalmic division with its attendant corneal
anesthesia, corneal sensation should be tested with a cotton wisp after lesioning of the gasserian
ganglion. If corneal anesthesia is present, sterile ophthalmic ointment should be used and the
a( ected eye patched to avoid damage to the cornea. This precaution must be continued for the
duration of corneal anesthesia. Ophthalmologic consultation is advisable should persistent
corneal anesthesia occur.
Postprocedure dysesthesia, including anesthesia dolorosa, occurs in about 6% of patients who
undergo neurodestructive procedures of the gasserian ganglion. These dysesthesias can range
from mild pulling or burning sensations to severe postprocedure pain called anesthesia dolorosa.
These postprocedure symptoms are thought to be due to incomplete destruction of the ganglion.
Sloughing of skin in the area of anesthesia also may occur.
In addition to disturbances of sensation, blockade or destruction of the gasserian ganglion may
result in abnormal motor function, including weakness of the muscles of mastication and facial
asymmetry. Horner's syndrome also may occur as a result of block of the parasympathetic
trigeminal 3bers. If the balloon is inadvertently placed too high and medial to Meckel's cave,
abducens palsy may result. The patient should be warned that all of these complications may
occur.
Clinical Pearls
Gasserian ganglion block with local anesthetic represents an excellent stopgap measure for
patients su( ering the uncontrolled pain of trigeminal neuralgia and cancer pain while
waiting for pharmacologic and antiblastic treatments to take e( ect. This block has more side
e( ects and complications than the usual nerve block modalities used by the pain management
specialist and thus should be reserved for those special situations in which the pain is truly out
of control.
An interesting side effect of gasserian ganglion block is the activation of herpes labialis and,
occasionally, of herpes zoster after the procedure. This occurs in about 10% of patients who
undergo procedures on the gasserian ganglion, and patients should be forewarned of this
possibility.
As mentioned previously, bleeding complications are not uncommon, and given the
dramatic and highly visible nature of a facial and subscleral hematoma, all patients
undergoing gasserian ganglion block should be warned to expect this side e( ect to prevent
undue anxiety should bleeding complications occur. Infection, although rare, remains an
everpresent possibility, especially in the immunocompromised patient. Early detection of infection
is crucial to avoid potentially life-threatening sequelae.
The pain management specialist should be particularly careful to identify and treat
postprocedure corneal anesthesia. Failure to do so can often result in loss of vision. If
persistent corneal anesthesia occurs, immediate ophthalmologic consultation should be
obtained to manage any eye-related problems.C H A P T E R 1 2
Trigeminal Nerve Block
Coronoid Approach
Abstract
Trigeminal nerve block through the coronoid approach is used to block the maxillary and
mandibular divisions of the trigeminal nerve. The maxillary division (V2) of the trigeminal
nerve is a pure sensory nerve (Fig. 12-1). It exits the middle cranial fossa via the foramen
rotundum and crosses the pterygopalatine fossa where it is amenable to blockade by
trigeminal nerve block via the coronoid approach. The mandibular division (V3) is composed
of a large sensory root and a smaller motor root. Both leave the middle cranial fossa
together via the foramen ovale and join to form the mandibular nerve. The smaller motor
branch provides innervation to the masseter, external pterygoid, and temporalis muscles.
The technique of trigeminal nerve block via the coronoid approach can be used to perform
diagnostic, prognostic, and therapeutic neural blockade of the maxillary and mandibular
divisions of the trigeminal nerve.
Key Words
cancer pain
mandibular nerve
maxillary nerve
pterygopalatine fossa
trigeminal nerve
trigeminal nerve block
trigeminal neuralgia
CPT-2015 Code
Unilateral 64400
Neurolytic 64605
64610 (with radiographic guidance)
Relative Value Units
Unilateral 10
Neurolytic 20Indications
Trigeminal nerve block through the coronoid approach is a simple and safe way to block the
maxillary and mandibular divisions of the trigeminal nerve. This technique may be used as a part
of the diagnostic evaluation of facial pain when the pain management specialist is trying to
determine whether a patient's pain is somatic or sympathetic in origin. In addition to permitting
anatomic di1erential neural blockade, trigeminal nerve block via the coronoid approach allows
selective blockade of the maxillary and mandibular divisions, so the technique can also be used in
a prognostic manner before neurodestruction of these nerves.
Trigeminal nerve block through the coronoid approach also may be used in the acute setting to
provide palliation in acute pain emergencies, including trigeminal neuralgia, facial trauma, and
cancer pain, during the wait for pharmacologic and antiblastic agents to take e1ect. Trigeminal
nerve block with local anesthetic may be used as a treatment for trismus and as an aid to awake
intubation. Trigeminal nerve block with local anesthetic and steroid through the coronoid
approach is also useful as a 2rst-line treatment for the breakthrough pain of trigeminal neuralgia
that has previously been controlled with medications. This technique can be used in the
treatment of pain associated with acute herpes zoster and postherpetic neuralgia in the
distribution of the trigeminal nerve. Atypical facial pain syndromes, including
temporomandibular joint dysfunction, also may be amenable to treatment using this technique.
Neurodestructive procedures of the maxillary and mandibular nerves using neurolytic agents,
radiofrequency lesioning, or freezing may be carried out via the coronoid approach to the
trigeminal nerve. These neurodestructive techniques are useful in the palliation of cancer pain,
including pain secondary to invasive tumors of the maxillary sinus and mandible.
Clinically Relevant Anatomy
The maxillary division (V2) of the trigeminal nerve is a pure sensory nerve (see Fig. 12-1). It
exits the middle cranial fossa via the foramen rotundum and crosses the pterygopalatine fossa
(Fig. 12-2). Passing through the inferior orbital 2ssure, it enters the orbit, emerging on the face
via the infraorbital foramen. The maxillary nerve can be selectively blocked by placing a needle
just above the anterior margin of the lateral pterygoid plate.FIGURE 12-1 The divisions of the trigeminal nerve.FIGURE 12-2 T1-weighted image through the left face medial to the
mandible, demonstrating the maxillary sinus (M), orbital surface of the
maxilla (open white arrow), medial aspect of the pterygopalatine fossa (white
arrowhead), retroantral fat pad (solid white arrow), lateral pterygoid muscle
fibers coursing to the proximal mandible (L), marrow in the maxilla (solid
white arrow 1) and mandible (solid white arrow 2), sublingual space (top
black arrow), geniohyoid muscle (G), and hyoid bone (bottom black arrow).
(From Stark DD, Bradley WG: Magnetic Resonance Imaging, 3rd ed. St
Louis, Mosby, 1999, p 1747.)
The maxillary nerve provides sensory innervation for the dura of the middle cranial fossa, the
temporal and lateral zygomatic region, and the mucosa of the maxillary sinus. The nerve also
provides sensory innervation for the upper molars, premolars, incisors, canines, and associated
oral gingiva as well as the mucous membranes of the cheek. The nasal cavity, lower eyelid, skin
of the side of the nose, and upper lip are also subserved by the maxillary nerve.
The mandibular division (V3) is composed of a large sensory root and a smaller motor root.
Both leave the middle cranial fossa together via the foramen ovale and join to form the
mandibular nerve. Branches of the mandibular nerve provide sensory innervation to portions of
the dura mater and the mucosal lining of the mastoid sinus. Sensory innervation to the skin
overlying the muscles of mastication, the tragus and helix of the ear, the posterior
temporomandibular joint, the chin, and the dorsal aspect of the anterior two thirds of the tongue
and associated mucosa of the oral cavity is also provided by the mandibular nerve (see Fig.
121). The smaller motor branch provides innervation to the masseter, external pterygoid, and
temporalis muscles.
Technique
Landmark and Fluoroscopically Guided Technique
The patient is placed in the supine position with the cervical spine in the neutral position. The
coronoid notch is identi2ed by asking the patient to open and close the mouth several times and
palpating the area just anterior and slightly inferior to the acoustic auditory meatus. After the
notch is identified, the patient is asked to hold his or her mouth in neutral position.
A total of 7mL of local anesthetic is drawn up in a 12-mL sterile syringe. When the treatment
is for trigeminal neuralgia, atypical facial pain, or other painful conditions involving the
maxillary and mandibular nerve, a total of 80mg of depot-steroid is added to the local anestheticwith the first block, and 40 mg of depot-steroid is added with subsequent blocks.
After the skin overlying the coronoid notch is prepared with antiseptic solution, a 22-gauge,
-inch styletted needle is inserted just below the zygomatic arch directly in the middle of the
coronoid notch (Fig. 12-3). The needle is advanced about to 2 inches in a plane
perpendicular to the skull until the lateral pterygoid plate is encountered (Fig. 12-4). At this
point, if blockade of both the maxillary and mandibular nerves is desired, the needle is
withdrawn slightly. After careful aspiration, 7 to 8mL of solution is injected in incremental
doses. The needle is removed and pressure is placed on the injection site to avoid ecchymosis.
FIGURE 12-3 Relationship of the coronoid notch and the lateral pterygoid
plate (star).;
FIGURE 12-4 For trigeminal nerve block using the coronoid approach, the
needle is advanced through the coronoid notch into the pterygopalatine
fossa.
Fluoroscopic guidance may be used if the clinician has di culty in identifying the coronoid
notch (Fig. 12-5). During the injection procedure, the patient must be observed carefully for signs
of local anesthetic toxicity. The coronoid approach to blockade of the trigeminal nerve may be
used to place radiofrequency needles, cryoprobes, and stimulating electrodes.FIGURE 12-5 Fluoroscopic image demonstrating proper needle placement
for trigeminal nerve block using the coronoid approach.
Ultrasound-Guided Technique
The coronoid notch is identi2ed as described in the previous section. After the coronoid notch is
identi2ed, a high-frequency linear ultrasound transducer is placed in a transverse position over
the coronoid notch and a sonogram is taken (Fig. 12-6). The coronoid notch provides an acoustic
window into the pterygopalatine fossa and allows easy identi2cation of the maxillary nerve (Fig.
12-7). The temporomandibular joint should be identi2ed in the posterior aspect of the sonogram
by locating the ball-shaped mandibular condyle and the mandibular neck. Under real-time
ultrasound guidance, a 22-gauge, -inch needle is inserted just below the zygomatic arch
directly in the middle of the coronoid notch using an out-of-plane approach. The needle is
advanced until it impinges on the lateral pterygoid plate. The tip of the needle is then withdrawn
slightly out of the periosteum of the lateral pterygoid plate. After careful aspiration, 7 to 8mL of
local anesthetic and 40 to 80mg of depot-steroid are injected in incremental doses. The needle is
removed and pressure is placed on the injection sight to avoid ecchymosis.FIGURE 12-6 Proper placement of a high-frequency liner ultrasound
electrode over the coronoid notch.FIGURE 12-7 Transverse ultrasound image demonstrating the maxillary
nerve and surrounding structures seen via the acoustic window provided by
the coronoid notch.
Side Effects and Complications
Because of the highly vascular nature of the pterygopalatine fossa, signi2cant facial hematoma
may occur after trigeminal nerve block via the coronoid approach. This vascularity means that
the pain specialist should use small, incremental doses of local anesthetic to avoid local
anesthetic toxicity.
Postprocedure dysesthesia, including anesthesia dolorosa, may occur in a small number of
patients who undergo neurodestructive procedures of the branches of the trigeminal nerve. These
dysesthesias can range from mild pulling or burning sensations to severe postprocedure pain
called anesthesia dolorosa. These postprocedure symptoms are thought to be due to incomplete
destruction of the neural structures. Sloughing of skin in the area of anesthesia also may occur.
In addition to disturbances of sensation, blockade or destruction of the branches of the
trigeminal nerve may result in abnormal motor function, including weakness of the muscles of
mastication and secondary facial asymmetry due to muscle weakness or loss of proprioception.
The patient should be warned that all of these complications may occur.
Clinical Pearls
Trigeminal nerve block via the coronoid approach with local anesthetic and steroid
represents an excellent stopgap measure for patients su1ering from the uncontrolled pain of
trigeminal neuralgia and cancer pain while waiting for pharmacologic treatments to take
e1ect. The major side e1ects of this block are related to the vascular nature of thepterygopalatine fossa, and care must be taken to avoid local anesthetic toxicity. Despite this
vascularity, this technique can be performed safely in patients receiving anticoagulatants by
using a 25- or 27-gauge needle, albeit with increased risk of facial hematoma, if the clinical
situation indicates a favorable risk-to-benefit ratio.
Because repeated needle punctures with daily or every-other-day blocks may result in small
punctate facial scars, patients should be warned of this possibility. Infection, although rare,
remains an ever-present possibility, especially in the immunocompromised patient. Early
detection of infection is crucial to avoid potentially life-threatening sequelae.C H A P T E R 1 3
Selective Maxillary Nerve Block
Coronoid Approach
Abstract
Trigeminal nerve block through the coronoid approach is used to block the maxillary and
mandibular divisions of the trigeminal nerve. The maxillary division (V2) of the trigeminal
nerve is a pure sensory nerve (see Fig. 13-2). It exits the middle cranial fossa via the
foramen rotundum and crosses the pterygopalatine fossa where it is amenable to blockade
via trigeminal nerve block via the coronoid approach. The mandibular division (V3) is
composed of a large sensory root and smaller motor root. Both leave the middle cranial fossa
together via the foramen ovale and join to form the mandibular nerve. The smaller motor
branch provides innervation to the masseter, external pterygoid, and temporalis muscles.
The technique of trigeminal nerve block via the coronoid approach can be used to perform
diagnostic, prognostic, and therapeutic neural blockade of the maxillary and mandibular
divisions of the trigeminal nerve. This approach allows selective blockade of the maxillary
and mandibular divisions, so the technique can also be applied in a prognostic manner
before neurodestruction of these nerves.
Procedures for neurodestruction of the maxillary and mandibular nerves by neurolytic
agents, radiofrequency lesions, or freezing may be carried out using selective maxillary and
mandibular nerve block techniques.
Key Words
cancer pain
mandibular nerve
mandibular nerve block
maxillary nerve
maxillary nerve block
pterygopalatine fossa
trigeminal nerve
trigeminal nerve block
trigeminal neuralgia
CPT-2015 CodeUnilateral 64400
Neurolytic 64605
64610 (with radiographic guidance)
Relative Value Units
Unilateral 10
Neurolytic 20
Indications
Trigeminal nerve block via the coronoid approach is a simple and safe way to block the
maxillary and mandibular divisions of the trigeminal nerve. This technique may be used as a part
of the diagnostic evaluation of facial pain when the pain management specialist is trying to
determine whether a patient's pain is somatic or sympathetic in origin. In addition to permitting
anatomic di3erential neural blockade, trigeminal nerve block via the coronoid approach allows
selective blockade of the maxillary and mandibular divisions, so the technique can also be used in
a prognostic manner before neurodestruction of these nerves.
Procedures for neurodestruction of the maxillary and mandibular nerves by neurolytic agents,
radiofrequency lesioning, or freezing may be carried out using selective maxillary and
mandibular nerve block techniques. These neurodestructive techniques are useful in the palliation
of cancer pain, including pain secondary to invasive tumors of the maxillary sinus and mandible.
Clinically Relevant Anatomy
The maxillary division (V2) of the trigeminal nerve is a pure sensory nerve. It exits the middle
cranial fossa via the foramen rotundum and crosses the pterygopalatine fossa (Fig. 13-1). Passing
through the inferior orbital 4ssure, it enters the orbit, emerging on the face via the infraorbital
foramen. The maxillary nerve can be selectively blocked by placing a needle just above the
anterior margin of the lateral pterygoid plate.FIGURE 13-1 Anatomy of the gasserian ganglion and the trigeminal nerve.
I n f . , Inferior; n . , nerve.
The maxillary nerve provides sensory innervation for the dura of the middle cranial fossa, the
temporal and lateral zygomatic region, and the mucosa of the maxillary sinus. The nerve also
provides sensory innervation for the upper molars, premolars, incisors, canines, and associated
oral gingiva as well as the mucous membranes of the cheek (Fig. 13-2). The nasal cavity, lower
eyelid, skin of the side of the nose, and upper lip are also subserved by the maxillary nerve.FIGURE 13-2 Divisions of the trigeminal nerve.
The mandibular division (V3) is composed of a large sensory root and a smaller motor root.
Both leave the middle cranial fossa together via the foramen ovale and join to form the
mandibular nerve. Branches of the mandibular nerve provide sensory innervation to portions of
the dura mater and the mucosal lining of the mastoid sinus. Sensory innervation to the skin
overlying the muscles of mastication, the tragus and helix of the ear, the posterior
temporomandibular joint, the chin, and the dorsal aspect of the anterior two thirds of the tongue
and associated mucosa of the oral cavity is also provided by the mandibular nerve (see Fig.
132). The smaller motor branch provides innervation to the masseter, external pterygoid, and
temporalis muscles.
Technique
Landmark and Fluoroscopically Guided Technique
The patient is placed in the supine position with the cervical spine in the neutral position. The
coronoid notch is identi4ed by asking the patient to open and close the mouth several times and
palpating the area just anterior and slightly inferior to the acoustic auditory meatus. After the
notch is identified, the patient is asked to hold his or her mouth in neutral position.
A total of 7mL of local anesthetic is drawn up in a 12-mL sterile syringe. When the treatment
is for trigeminal neuralgia, atypical facial pain, or other painful conditions involving the
maxillary and mandibular nerve, a total of 80mg of depot-steroid is added to the local anesthetic
with the first block, and 40 mg of depot-steroid is added with subsequent blocks.After the skin overlying the coronoid notch is prepared with antiseptic solution, a 22-gauge,
-inch styletted needle is inserted just below the zygomatic arch directly in the middle of the
coronoid notch. The needle is advanced about to 2 inches in a plane perpendicular to the
skull until the lateral pterygoid plate is encountered (Fig. 13-3). For selective blockade of the
maxillary nerve, the styletted needle is withdrawn after it comes in contact with the lateral
pterygoid plate and is redirected anteriorly and slightly superiorly so that it will slip past the
anterior margin of the lateral pterygoid plate (Figs. 13-4 and 13-5). A paresthesia in the
distribution of the maxillary nerve is usually elicited about 1cm deeper than the point at which
the lateral pterygoid plate was encountered, and the patient should be warned of such. After
careful aspiration, 3 to 5mL of solution is injected in incremental doses. During the injection
procedure, the patient must be observed carefully for signs of local anesthetic toxicity. The
technique for selective maxillary nerve block via the coronoid approach may be used to place
radiofrequency needles, cryoprobes, or stimulating electrodes (Fig. 13-6).
FIGURE 13-3 Needle placed through the coronoid notch with tip resting
against the lateral pterygoid plate.FIGURE 13-4 For selective blockade of the maxillary nerve, the styletted
needle is withdrawn after it comes in contact with the lateral pterygoid plate
and is redirected anteriorly and slightly superiorly so that it will slip past the
anterior margin of the lateral pterygoid plate.FIGURE 13-5 Needle in position in front of the anterior margin of the lateral
pterygoid plate.
FIGURE 13-6 Anteroposterior and lateral radiographs demonstrating
neurostimulation of peripheral branches of the maxillary division of the
trigeminal nerve to treat post-traumatic maxillary neuralgia. (From Van
Buyten JP, Linderoth B: Invasive neurostimulation in facial pain and
headache syndromes. Eur J Pain Suppl 5[2]:409-421, 2011.)
Ultrasound-Guided TechniqueThe coronoid notch is identi4ed as described in the previous section. After the coronoid notch is
identi4ed, a high-frequency linear ultrasound transducer is placed in a transverse position over
the coronoid notch and a sonogram is taken (Fig. 13-7). The coronoid notch provides an acoustic
window into the pterygopalatine fossa and allows easy identi4cation of the maxillary nerve (Fig.
13-8). The temporomandibular joint should be identi4ed in the posterior aspect of the sonogram
by locating the ball-shaped mandibular condyle and the mandibular neck. Under real-time
ultrasound guidance, a 22-gauge, -inch needle is inserted just below the zygomatic arch
directly in the middle of the coronoid notch using an out-of-plane approach. The needle is
advanced until it impinges on the lateral pterygoid plate. The tip of the needle is then withdrawn
slightly out of the periosteum of the lateral pterygoid plate and redirected toward the pupil of
the eye until it slips past the anterosuperior margin of the lateral pterygoid plate into the
pterygopalatine 4ssure and in proximity to the maxillary nerve. A paresthesia may be elicited,
and the patient should be warned of such. After careful aspiration, 4 to 5mL of local anesthetic
and 40 to 80mg of depot-steroid are injected in incremental doses. During the injection
procedure, the patient must be observed carefully for signs of local anesthetic toxicity. Because of
the proximity of the sphenopalatine ganglion, the patient may also experience partial blockade
of this structure. The needle is removed and pressure is placed on the injection site to avoid
ecchymosis.
FIGURE 13-7 Proper transverse location of the high-frequency linear
ultrasound transducer for needle placement via the coronoid notch to block
the maxillary nerve.FIGURE 13-8 Ultrasound image through the acoustic window provided by
the coronoid notch demonstrating the maxillary nerve. Note the proximity of
the sphenopalatine ganglion. n , Nerve.
Side Effects and Complications
Because of the highly vascular nature of the pterygopalatine fossa, signi4cant facial hematoma
may occur after trigeminal nerve block via the coronoid approach. This vascularity means that
the pain specialist should use small, incremental doses of local anesthetic to avoid local
anesthetic toxicity.
Postprocedure dysesthesia, including anesthesia dolorosa, may occur in a small number of
patients who undergo neurodestructive procedures of the branches of the trigeminal nerve. These
dysesthesias can range from mild pulling or burning sensations to severe postprocedure pain
called anesthesia dolorosa. These postprocedure symptoms are thought to be due to incomplete
destruction of the neural structures. Sloughing of skin in the area of anesthesia also may occur.
In addition to disturbances of sensation, blockade or destruction of the branches of the
trigeminal nerve may result in abnormal motor function, including weakness of the muscles of
mastication and secondary facial asymmetry due to muscle weakness or loss of proprioception.
The patient should be warned that all of these complications may occur.
Clinical Pearls
Trigeminal nerve block via the coronoid approach with local anesthetic and steroid
represents an excellent stopgap measure for patients su3ering from the uncontrolled pain of
trigeminal neuralgia, acute herpes zoster, and cancer pain while waiting for pharmacologic
treatments to take e3ect. The major side e3ects of this block are related to the vascular nature
of the pterygopalatine fossa, and care must be taken to avoid local anesthetic toxicity. Despite
this vascularity, this technique can be performed safely in patients receiving anticoagulant
therapy by using a 25- or 27-gauge needle, albeit at increased risk of facial hematoma, should
the clinical situation indicate a favorable risk-to-benefit ratio.Because repeated needle punctures with daily or every-other-day blocks may result in small
punctate facial scars, patients should be warned of this possibility. Infection, although rare,
remains an ever-present possibility, especially in the immunocompromised patient. Early
detection of infection is crucial to avoid potentially life-threatening sequelae.C H A P T E R 1 4
Selective Mandibular Nerve Block
Coronoid Approach
Abstract
Trigeminal nerve block through the coronoid approach is used to block the maxillary and
mandibular divisions of the trigeminal nerve. The maxillary division (V2) of the trigeminal
nerve is a pure sensory nerve (see Fig. 14-2). It exits the middle cranial fossa via the
foramen rotundum and crosses the pterygopalatine fossa where it is amenable to blockade
via trigeminal nerve block via the coronoid approach. The mandibular division (V3) is
composed of a large sensory root and smaller motor root. Both leave the middle cranial fossa
together via the foramen ovale and join to form the mandibular nerve. The smaller motor
branch provides innervation to the masseter, external pterygoid, and temporalis muscles.
The technique of trigeminal nerve block via the coronoid approach can be used to perform
diagnostic, prognostic, and therapeutic neural blockade of the maxillary and mandibular
divisions of the trigeminal nerve. This approach allows selective blockade of the maxillary
and mandibular divisions, so the technique can also be used in a prognostic manner before
neurodestruction of these nerves.
Procedures for neurodestruction of the maxillary and mandibular nerves by neurolytic
agents, radiofrequency lesioning, or freezing may be carried out using selective maxillary
and mandibular nerve block techniques.
Key Words
cancer pain
mandibular nerve
mandibular nerve block
maxillary nerve
maxillary nerve block
pterygopalatine fossa
trigeminal nerve
trigeminal nerve block
trigeminal neuralgia
CPT-2015 CodeUnilateral 64400
Neurolytic 64605
64610 (with radiographic guidance)
Relative Value Units
Unilateral 10
Neurolytic 20
Indications
Trigeminal nerve block via the coronoid approach is a simple and safe way to block the
maxillary and mandibular divisions of the trigeminal nerve. This technique may be used as a part
of the diagnostic evaluation of facial pain when the pain management specialist is trying to
determine whether a patient's pain is somatic or sympathetic in origin. In addition to permitting
anatomic di3erential neural blockade, trigeminal nerve block via the coronoid approach allows
selective blockade of the maxillary and mandibular divisions, so the technique can also be used in
a prognostic manner before neurodestruction of these nerves.
Procedures for neurodestruction of the maxillary and mandibular nerves by neurolytic agents,
radiofrequency lesioning, or freezing may be carried out using selective maxillary and
mandibular nerve block techniques. These neurodestructive techniques are useful in the palliation
of cancer pain, including pain secondary to invasive tumors of the maxillary sinus and mandible.
Clinically Relevant Anatomy
The maxillary division (V2) of the trigeminal nerve is a pure sensory nerve. It exits the middle
cranial fossa via the foramen rotundum and crosses the pterygopalatine fossa (Fig. 14-1).
Passing through the inferior orbital 4ssure, it enters the orbit, emerging on the face via the
infraorbital foramen. The maxillary nerve can be selectively blocked by placing a needle just
above the anterior margin of the lateral pterygoid plate.FIGURE 14-1 Anatomy of the gasserian ganglion and trigeminal nerve. I n f . ,
Inferior; n . , nerve.
The maxillary nerve provides sensory innervation for the dura of the middle cranial fossa, the
temporal and lateral zygomatic region, and the mucosa of the maxillary sinus. The nerve also
provides sensory innervation for the upper molars, premolars, incisors, canines, and associated
oral gingiva as well as the mucous membranes of the cheek (Fig. 14-2). The nasal cavity, lower
eyelid, skin of the side of the nose, and upper lip are also subserved by the maxillary nerve.FIGURE 14-2 Divisions of the trigeminal nerve.
The mandibular division (V3) is composed of a large sensory root and a smaller motor root.
Both leave the middle cranial fossa together via the foramen ovale and join to form the
mandibular nerve. Branches of the mandibular nerve provide sensory innervation to portions of
the dura mater and the mucosal lining of the mastoid sinus. Sensory innervation to the skin
overlying the muscles of mastication, the tragus and helix of the ear, the posterior
temporomandibular joint, the chin, and the dorsal aspect of the anterior two thirds of the tongue
and associated mucosa of the oral cavity is also provided by the mandibular nerve (see Fig.
142). The smaller motor branch provides innervation to the masseter, external pterygoid, and
temporalis muscles.
Technique
Landmark and Fluoroscopically Guided Technique
The patient is placed in the supine position with the cervical spine in the neutral position. The
coronoid notch is identi4ed by asking the patient to open and close the mouth several times and
palpating the area just anterior and slightly inferior to the acoustic auditory meatus. After the
notch is identified, the patient is asked to hold his or her mouth in neutral position.
After the skin overlying the coronoid notch is prepared with antiseptic solution, a 22-gauge,
-inch styletted needle is inserted just below the zygomatic arch directly in the middle of the
coronoid notch. The needle is advanced about to 2 inches in a plane perpendicular to theskull until the lateral pterygoid plate is encountered (Fig. 14-3). For selective blockade of the
mandibular nerve, the styletted needle is withdrawn after it comes in contact with the lateral
pterygoid plate and is redirected posteriorly and slightly inferiorly so that it will slip past the
inferior margin of the lateral pterygoid plate (Figs. 14-4 and 14-5). A paresthesia in the
distribution of the mandibular nerve is usually elicited about 1cm deeper than the point at which
the lateral pterygoid plate was encountered, and the patient should be warned of such. After
careful aspiration, 3 to 5mL of solution is injected in incremental doses. During the injection
procedure, the patient must be observed carefully for signs of local anesthetic toxicity. The
technique for selective mandibular nerve block via the coronoid approach may be used to place
radiofrequency needles, cryoprobes, and stimulating electrodes.
FIGURE 14-3 Needle placed through the coronoid notch with tip resting
against the lateral pterygoid plate.FIGURE 14-4 For selective blockade of the mandibular nerve, the styletted
needle is withdrawn after it comes in contact with the lateral pterygoid plate
and is redirected posteriorly and slightly inferiorly so that it will slip past the
inferior margin of the lateral pterygoid plate.
FIGURE 14-5 Needle tip placed beyond the inferior margin of the lateral
pterygoid plate.
Ultrasound-Guided TechniqueThe coronoid notch is identi4ed as described in the previous section. After the coronoid notch is
identi4ed, a high-frequency linear ultrasound transducer is placed in a transverse position over
the coronoid notch and a sonogram is taken (Fig. 14-6). The coronoid notch provides an acoustic
window into the pterygopalatine fossa and allows easy identi4cation of the maxillary nerve (Fig.
14-7). The temporomandibular joint should be identi4ed in the posterior aspect of the sonogram
by locating the ball-shaped mandibular condyle and the mandibular neck. Under real-time
ultrasound guidance, a 22-gauge, -inch needle is inserted just below the zygomatic arch
directly in the middle of the coronoid notch using an out-of-plane approach. The needle is
advanced until it impinges on the lateral pterygoid plate. The tip of the needle is then withdrawn
slightly out of the periosteum of the lateral pterygoid plate and redirected toward the pupil of
the eye until it slips past the anterosuperior margin of the lateral pterygoid plate into the
pterygopalatine 4ssure and in proximity to the maxillary nerve. A paresthesia may be elicited,
and the patient should be warned of such. After careful aspiration, 4 to 5mL of local anesthetic
and 40 to 80mg of depot-steroid are injected in incremental doses. During the injection
procedure, the patient must be observed carefully for signs of local anesthetic toxicity. Because of
the proximity of the sphenopalatine ganglion, the patient may also experience partial blockade
of this structure. The needle is removed and pressure is placed on the injection site to avoid
ecchymosis.
FIGURE 14-6 Proper transverse location of the high-frequency linear
ultrasound transducer for needle placement via the coronoid notch to block
the mandibular nerve.FIGURE 14-7 Ultrasound image through the acoustic window provided by
the coronoid notch demonstrating the mandibular nerve. Note the proximity
of the sphenopalatine ganglion.
Side Effects and Complications
Because of the highly vascular nature of the pterygopalatine fossa, signi4cant facial hematoma
may occur after trigeminal nerve block via the coronoid approach. This vascularity means that
the pain specialist should use small, incremental doses of local anesthetic to avoid local
anesthetic toxicity.
Postprocedure dysesthesia, including anesthesia dolorosa, may occur in a small number of
patients who undergo neurodestructive procedures of the branches of the trigeminal nerve. These
dysesthesias can range from mild pulling or burning sensations to severe postprocedure pain
called anesthesia dolorosa. These postprocedure symptoms are thought to be due to incomplete
destruction of the neural structures. Sloughing of skin in the area of anesthesia also may occur.
In addition to disturbances of sensation, blockade or destruction of the branches of the
trigeminal nerve may result in abnormal motor function, including weakness of the muscles of
mastication and secondary facial asymmetry due to muscle weakness or loss of proprioception.
The patient should be warned that all of these complications may occur.
Clinical Pearls
Trigeminal nerve block via the coronoid approach with local anesthetic and steroid
represents an excellent stopgap measure for patients su3ering from the uncontrolled pain of
trigeminal neuralgia, acute herpes zoster, and cancer pain while waiting for pharmacologic
treatments to take e3ect (Fig. 14-8). The major side e3ects of this block are related to the
vascular nature of the pterygopalatine fossa, and care must be taken to avoid local anesthetic
toxicity. Despite this vascularity, this technique can be performed safely in patients receiving
anticoagulant therapy by using a 25- or 27-gauge needle, albeit at increased risk of facial
hematoma, should the clinical situation indicate a favorable risk-to-benefit ratio.FIGURE 14-8 Acute herpes zoster (shingles) involving the mandibular
branch of the trigeminal nerve. (From Sapp JP, Eversole LR, Wysocki GP:
Oral infections. In Contemporary Oral and Maxillofacial Pathology, 2nd ed.
St Louis, Mosby, 2004, pp 207-251.)
Because repeated needle punctures with daily or every-other-day blocks may result in small
punctate facial scars, patients should be warned of this possibility. Infection, although rare,
remains an ever-present possibility, especially in the immunocompromised patient. Early
detection of infection is crucial to avoid potentially life-threatening sequelae.



C H A P T E R 1 5
Supraorbital Nerve Block
Abstract
The supraorbital nerve arises from bers of the frontal nerve, which is the largest branch of
the ophthalmic nerve. The frontal nerve enters the orbit via the superior orbital ssure and
passes anteriorly beneath the periosteum of the roof of the orbit. The frontal nerve gives o
a larger lateral branch, the supraorbital nerve, and a smaller medial branch, the
supratrochlear nerve. Both exit the orbit anteriorly. The supraorbital nerve sends bers all
the way to the vertex of the scalp and provides sensory innervation to the forehead, upper
eyelid, and anterior scalp. Supraorbital nerve block is useful in the diagnosis and treatment
of painful conditions in areas subserved by the supraorbital nerve, including supraorbital
neuralgia and pain secondary to acute herpes zoster. Supraorbital nerve block can be used in
a diagnostic, prognostic, and therapeutic manner.
Key Words
acute herpes zoster
supraorbital nerve
supraorbital nerve block
supratrochlear nerve
supratrochlear nerve block
trigeminal nerve
trigeminal nerve ophthalmic division
CPT-2015 Code
Unilateral 64400
Bilateral 64400-50
Neurolytic 64600
Relative Value Units
Unilateral 5
Bilateral 10
Neurolytic 20
Indications



Supraorbital nerve block is useful in the diagnosis and treatment of painful conditions in areas
subserved by the supraorbital nerve, including supraorbital neuralgia and pain secondary to
acute herpes zoster (Fig. 15-1). This technique is also useful in providing surgical anesthesia in
the distribution of the supraorbital nerve for lesion removal and laceration repair.
FIGURE 15-1 Ophthalmic herpes zoster vesicles and crusting of the top
and side of the nose in herpes zoster (positive Hutchinson's sign) implies
involvement of the nasociliary branch of the trigeminal nerve and eye
involvement. (From Buttaravoli P: Herpes zoster [shingles]. In Minor
Emergencies, 2nd ed. Philadelphia, Mosby, 2007, pp 709-714.)
Clinically Relevant Anatomy
The supraorbital nerve arises from bers of the frontal nerve, which is the largest branch of the
ophthalmic nerve. The frontal nerve enters the orbit via the superior orbital ssure and passes
anteriorly beneath the periosteum of the roof of the orbit (Fig. 15-2). The frontal nerve gives o
a larger lateral branch, the supraorbital nerve, and a smaller medial branch, the supratrochlear
nerve. Both exit the orbit anteriorly. The supraorbital nerve sends bers all the way to the vertex
of the scalp and provides sensory innervation to the forehead, upper eyelid, and anterior scalp
(Fig. 15-3).FIGURE 15-2 Peripheral branches of the trigeminal nerve.



FIGURE 15-3 Sensory division of the supraorbital nerve.
Technique
Landmark and Fluoroscopically Guided Technique
The patient is placed in the supine position. A total of 3mL of local anesthetic is drawn up in a
10-mL sterile syringe. When the treatment is for supraorbital neuralgia, acute herpes zoster,
postherpetic neuralgia, or other painful conditions involving the supraorbital nerve, a total of
80mg of depot-steroid is added to the local anesthetic with the rst block, and 40mg of
depotsteroid is added with subsequent blocks.
The supraorbital foramen on the a ected side is then identi ed by palpation. The skin
overlying the foramen is prepared with antiseptic solution, with care being taken to avoid
spillage into the eye. A 25-gauge, -inch needle is inserted at the level of the supraorbital
foramen and is advanced medially about 15 degrees o the perpendicular to avoid entering the
foramen. The needle is advanced until it approaches the periosteum of the underlying bone (Figs.
15-4 and 15-5). A paresthesia may be elicited, and the patient should be warned of such. The
needle should not enter the supraorbital foramen, and should this occur, the needle should be
withdrawn and redirected slightly more medially. Fluoroscopy may be used if there is di4 culty
identifying the supraorbital foramen (Fig. 15-6).FIGURE 15-4 For supraorbital nerve block, a 25-gauge, -inch needle is
inserted at the level of the supraorbital foramen and is advanced medially
about 15 degrees off the perpendicular to avoid entering the foramen. n . ,
Nerve.
FIGURE 15-5 Technique of supraorbital nerve block. (From Massry GG:
Ptosis repair for the cosmetic surgeon. Facial Plast Surg Clin North Am
13[4]:533-539, 2005.)




FIGURE 15-6 Fluoroscopic image demonstrating the needle tip in proximity
to the supraorbital nerve.
Because of the loose alveolar tissue of the eyelid, a gauze sponge should be used to apply
gentle pressure on the upper eyelid and supraorbital tissues before injection of solution to
prevent the injectate from dissecting inferiorly into these tissues. This pressure should be
maintained after the procedure to avoid periorbital hematoma and ecchymosis. After gentle
aspiration, 3mL of solution is injected in a fanlike distribution. If blockade of the supratrochlear
nerve is also desired, the needle is then redirected medially, and after careful aspiration, an
additional 3 mL of solution is injected in a fanlike manner.
Ultrasound-Guided Technique
The patient is placed in the supine position. A total of 3mL of local anesthetic is drawn up in a
10-mL sterile syringe. When the treatment is for supraorbital neuralgia, acute herpes zoster,
postherpetic neuralgia, or other painful conditions involving the supraorbital nerve, a total of
80mg of depot-steroid is added to the local anesthetic with the rst block, and 40mg of
depotsteroid is added with subsequent blocks.
The supraorbital foramen on the a ected side is then identi ed by palpation. The skin
overlying the foramen is prepared with antiseptic solution, with care being taken to avoid
spillage into the eye. A high-frequency linear ultrasound transducer is placed in the transverse
position over the previously identi ed foramen and a sonogram is taken. The supraorbital
foramen will be easily identi ed as a discontinuity of the hyperechoic supraorbital ridge (Fig.
157). Color Doppler imaging may also be used to identify the supraorbital artery, which exits the
supraorbital foramen along with the supraorbital nerve (Fig. 15-8).

FIGURE 15-7 On an ultrasound image, the supraorbital foramen is easily
identified as a discontinuity of the hyperechoic supraorbital ridge.
FIGURE 15-8 Color Doppler imaging may also be used to identify the
supraorbital artery, which exits the supraorbital foramen along with the
supraorbital nerve.
Once the supraorbital foramen containing the supraorbital nerve and artery has been
identi ed, a 25-gauge, -inch needle is inserted at the inferior margin of the ultrasound
transducer and advanced medially about 15 degrees o the perpendicular toward the
supraorbital foramen using an out-of-plane approach. The needle is advanced under continuous
ultrasound guidance until it is in proximity to the supraorbital nerve as it exits the supraorbital
foramen. A paresthesia may be elicited, and the patient should be warned of such. The needle
should not enter the supraorbital foramen, and should this occur, the needle should be withdrawn
and redirected slightly more medially.
Because of the loose alveolar tissue of the eyelid, a gauze sponge should be used to apply
gentle pressure on the upper eyelid and supraorbital tissues before injection of solution to
prevent the injectate from dissecting inferiorly into these tissues (Fig. 15-9). This pressure should
be maintained after the procedure to avoid periorbital hematoma and ecchymosis.
FIGURE 15-9 Proper position of the ultrasound transducer for supraorbital
nerve block. Because of the loose alveolar tissue of the eyelid, a gauze
sponge should be used to apply gentle pressure on the upper eyelid and
supraorbital tissues before injection of solution to prevent the injectate from
dissecting inferiorly into these tissues.
After gentle aspiration, 3mL of solution is injected in a fanlike distribution. If blockade of the
supratrochlear nerve is also desired, the needle is then redirected medially, and after careful
aspiration, an additional 3 mL of solution is injected in a fanlike manner.
Side Effects and Complications
The forehead and scalp are highly vascular, and the pain specialist should carefully calculate the
total milligram dose of local anesthetic that may be given safely, especially if bilateral nerve
blocks are being performed. This vascularity gives rise to an increased incidence of postblock
ecchymosis and hematoma formation. Despite the vascularity of this anatomic region, this
technique can be performed safely in patients receiving anticoagulant therapy by using a 25- or
27-gauge needle, albeit at increased risk of hematoma, if the clinical situation indicates a
favorable risk-to-bene t ratio. These complications can be decreased if manual pressure is
applied to the area of the block immediately after injection. Application of cold packs for
20minute periods after the block also decreases the amount of postprocedure pain and bleeding the
patient may experience.
Clinical Pearls
Supraorbital nerve block is especially useful in the palliation of pain secondary to acute
herpes zoster involving the ophthalmic division and its branches. In this setting, the pain
management specialist also has to block the supratrochlear nerve. The addition of tepid
aluminum acetate soaks helps dry weeping lesions and makes the patient more comfortable.
Care should be taken to avoid spillage of the aluminum acetate solution into the eye.



C H A P T E R 1 6
Supratrochlear Nerve Block
Abstract
The supratrochlear nerve arises from bers of the frontal nerve, which is the largest branch
of the ophthalmic nerve. The frontal nerve enters the orbit via the superior orbital ssure
and passes anteriorly beneath the periosteum of the roof of the orbit. The frontal nerve gives
o a larger lateral branch, the supraorbital nerve, and a smaller medial branch, the
supratrochlear nerve. Both exit the orbit anteriorly. The supraorbital nerve sends bers all
the way to the vertex of the scalp and provides sensory innervation to the forehead, upper
eyelid, and anterior scalp. Supraorbital nerve block is useful in the diagnosis and treatment
of painful conditions in areas subserved by the supraorbital nerve, including supraorbital
neuralgia and pain secondary to acute herpes zoster. Supraorbital nerve block can be used in
a diagnostic, prognostic, and therapeutic manner.
Key Words
acute herpes zoster
supraorbital nerve
supraorbital nerve block
supratrochlear nerve
supratrochlear nerve block
trigeminal nerve
trigeminal nerve ophthalmic division
CPT-2015 Code
Unilateral 64400
Bilateral 64400-50
Neurolytic 64600
Relative Value Units
Unilateral 5
Bilateral 10
Neurolytic 20
Indications



Supratrochlear nerve block is useful in the diagnosis and treatment of painful conditions in areas
subserved by the supratrochlear nerve, including supratrochlear neuralgia and pain secondary to
herpes zoster. This technique is also useful in providing surgical anesthesia in the distribution of
the supratrochlear nerve for lesion removal and laceration repair.
Clinically Relevant Anatomy
The supratrochlear nerve arises from bers of the frontal nerve, which is the largest branch of
the ophthalmic nerve. The frontal nerve enters the orbit via the superior orbital ssure and
passes anteriorly beneath the periosteum of the roof of the orbit. The frontal nerve gives o a
larger lateral branch, the supraorbital nerve, and a smaller medial branch, the supratrochlear
nerve (Fig. 16-1). Both exit the orbit anteriorly. The supratrochlear nerve sends bers to provide
sensory innervation to the inferomedial section of the forehead, the bridge of the nose, and the
medial portion of the upper eyelid (Fig. 16-2).
FIGURE 16-1 Peripheral branches of the trigeminal nerve.
FIGURE 16-2 Sensory distribution of the supratrochlear nerve.
Technique
Landmark and Fluoroscopically Guided Technique
The patient is placed in the supine position. A total of 3mL of local anesthetic is drawn up in a
10-mL sterile syringe. When the treatment is for supratrochlear neuralgia, acute herpes zoster,
postherpetic neuralgia, or other painful conditions involving the supratrochlear nerve, a total of
80mg of depot-steroid is added to the local anesthetic with the rst block, and 40mg of
depotsteroid is added with subsequent blocks.
The supraorbital ridge on the affected side is then identified by palpation. The skin at the point
where the bridge of the nose abuts the supraorbital ridge is prepared with antiseptic solution,
with care being taken to avoid spillage into the eye. The patient's head should be stabilized to
avoid inadvertent trauma to the eye. A 25-gauge, -inch needle is inserted just lateral to the
junction of the bridge of the nose and the supraorbital ridge and is advanced medially into the
subcutaneous tissue (Figs. 16-3 and 16-4). A paresthesia may be elicited, and the patient should
be warned of such. Because of the loose alveolar tissue of the eyelid, a gauze sponge should be
used to apply gentle pressure on the upper eyelid and supratrochlear tissues before injection of
solution to prevent the injectate from dissecting inferiorly into these tissues. This pressure should
be maintained after the procedure to avoid periorbital hematoma and ecchymosis. After gentle
aspiration, 3 mL of solution is injected in a fanlike distribution.FIGURE 16-3 Technique for supratrochlear nerve block. n . , Nerve.
FIGURE 16-4 The patient's head should be stabilized to avoid inadvertent
trauma to the eye.
Side Effects and Complications
The forehead and scalp are highly vascular, and the pain specialist should carefully calculate the
total milligram dose of local anesthetic that may be given safely, especially if bilateral nerve
blocks are being performed. This vascularity gives rise to an increased incidence of postblock
ecchymosis and hematoma formation. Despite the vascularity of this anatomic region, this
technique can be performed safely in patients receiving anticoagulant therapy by using a 25- or
27-gauge needle, albeit at increased risk of hematoma, if the clinical situation indicates a
favorable risk-to-bene t ratio. These complications can be decreased if manual pressure is
applied to the area of the block immediately after injection. Application of cold packs for
20minute periods after the block also decreases the amount of postprocedure pain and bleeding the
patient may experience.
Clinical Pearls
Supratrochlear nerve block is especially useful in the palliation of pain secondary to acute
herpes zoster involving the ophthalmic division and its branches. In this setting, the pain
management specialist also has to block the supraorbital nerve. The addition of tepid
aluminum acetate soaks helps dry weeping lesions and makes the patient more comfortable.
Care should be taken to avoid spillage of the aluminum acetate solution into the eye. Recent
clinical experience suggests that stimulation of the supratrochlear nerve may be useful in the
treatment of intractable pain syndromes subserved by the supratrochlear nerve (Fig. 16-5).
FIGURE 16-5 Subcutaneous lead placement for supratrochlear and
supraorbital nerve stimulation in a patient with post–eye enucleation pain
syndrome. (From de Leon-Casasola OA: Spinal cord and peripheral nerve
stimulation techniques for neuropathic pain. J Pain Symptom Manage 38[2
suppl]:S28-S38, 2009.)


C H A P T E R 1 7
Infraorbital Nerve Block
Extraoral Approach
Abstract
The infraorbital nerve arises from bers of the maxillary nerve. The infraorbital nerve enters
the orbit via the inferior orbital ssure and passes along the oor of the orbit in the
infraorbital groove. The nerve exits the orbit via the infraorbital foramen and provides
cutaneous branches that innervate the lower eyelid, lateral naris, and upper lip. The
superior alveolar branch of the infraorbital nerves provides sensory innervation to the upper
incisor, canine, and associated gingiva.
Infraorbital nerve block can be used in a diagnostic, prognostic, and therapeutic manner.
Key Words
acute herpes zoster
infraorbital nerve
infraorbital nerve block
superior alveolar nerve
trigeminal nerve
trigeminal nerve maxillary division
CPT-2015 Code
Unilateral 64400
Bilateral 64400-50
Neurolytic 64600
Relative Value Units
Unilateral 5
Bilateral 10
Neurolytic 20
Indications
Infraorbital nerve block is useful in the diagnosis and treatment of painful conditions in areas
subserved by the infraorbital nerve, including infraorbital neuralgia and pain secondary to


herpes zoster. This technique is also useful in providing surgical anesthesia in the distribution of
the infraorbital nerve for lesion removal and laceration repair (Fig. E17-1).
FIGURE E17-1 Basal cell carcinoma involving the nares. (From Crawford
KM, Kobayashi T: Nevoid basal cell carcinoma syndrome or multiple
hereditary infundibulocystic basal cell carcinoma syndrome? J Am Acad
Dermatol 51[6]:989-995, 2004.)
Clinically Relevant Anatomy
The infraorbital nerve arises from bers of the maxillary nerve. The infraorbital nerve enters the
orbit via the inferior orbital ssure and passes along the oor of the orbit in the infraorbital
groove (Fig. 17-1). The nerve exits the orbit via the infraorbital foramen and provides cutaneous
branches that innervate the lower eyelid, lateral naris, and upper lip (Fig. 17-2). The superior
alveolar branch of the infraorbital nerves provides sensory innervation to the upper incisor,
canine, and associated gingiva.FIGURE 17-1 Peripheral branches of the trigeminal nerve.

FIGURE 17-2 Sensory distribution of the infraorbital nerve.
Technique
Landmark and Fluoroscopically Guided Technique
The patient is placed in the supine position. A total of 3mL of local anesthetic is drawn up in a
10-mL sterile syringe. When the treatment is for infraorbital neuralgia, facial trauma, or other
painful conditions involving the infraorbital nerve, a total of 80mg of depot-steroid is added to
the local anesthetic with the rst block, and 40mg of depot-steroid is added with subsequent
blocks.
The infraorbital notch on the a6ected side is then identi ed by palpation. The skin overlying
the notch is prepared with antiseptic solution, with care taken to avoid spillage into the eye. A
25-gauge, -inch needle is inserted at the level of the infraorbital notch and is advanced
medially about 15 degrees o6 the perpendicular to avoid entering the foramen. The needle is
advanced until it approaches the periosteum of the underlying bone (Figs. 17-3 and 17-4). A
paresthesia may be elicited, and the patient should be warned of such. The needle should not
enter the infraorbital foramen, and should this occur, the needle should be withdrawn and
redirected slightly more medially. Because of the loose alveolar tissue of the eyelid, a gauze
sponge should be used to apply gentle pressure on the lower eyelid and infraorbital tissues before
injection of solution to prevent the injectate from dissecting upward into these tissues. This
pressure should be maintained after the procedure to avoid periorbital hematoma and
ecchymosis. After gentle aspiration, 3 mL of solution is injected in a fanlike distribution.FIGURE 17-3 Technique of infraorbital nerve block using the extraoral
approach. n . , Nerve.



FIGURE 17-4 Fluoroscopic image demonstrating the needle tip in proximity
to the infraorbital nerve.
Ultrasound-Guided Technique
The patient is placed in the supine position. A total of 3mL of local anesthetic is drawn up in a
10-mL sterile syringe. When the treatment is for infraorbital neuralgia, acute herpes zoster,
postherpetic neuralgia, or other painful conditions involving the infraorbital nerve, a total of
80mg of depot-steroid is added to the local anesthetic with the rst block, and 40mg of
depotsteroid is added with subsequent blocks.
The infraorbital foramen on the a6ected side is then identi ed by palpation. The skin
overlying the foramen is prepared with antiseptic solution, with care being taken to avoid
spillage into the eye. A high-frequency linear ultrasound transducer is placed in the transverse
position over the previously identi ed notch and a sonogram is taken (Fig. 17-5). The
infraorbital foramen will be easily identi ed as a discontinuity of the hyperechoic infraorbital
ridge. Color Doppler imaging may also be used to identify the infraorbital artery, which exits the
infraorbital foramen along with the infraorbital nerve (Fig. 17-6).
FIGURE 17-5 Proper transverse placement of the high-frequency linear
ultrasound transducer over the infraorbital ridge.
FIGURE 17-6 Ultrasound image demonstrating the infraorbital foramen,
nerve, and artery.
Once the infraorbital foramen containing the infraorbital nerve and artery have been
identi ed, a 25-gauge, -inch needle is inserted at the inferior margin of the ultrasound
transducer and advanced medially about 15 degrees o6 the perpendicular toward the infraorbital
foramen using an out-of-plane approach. The needle is advanced under continuous ultrasound
guidance until it is in proximity to the infraorbital nerve as it exits the infraorbital foramen. A
paresthesia may be elicited, and the patient should be warned of such. The needle should not
enter the infraorbital foramen, and should this occur, the needle should be withdrawn and
redirected slightly more medially.
Because of the loose alveolar tissue of the eyelid, a gauze sponge should be used to apply
gentle pressure on the upper eyelid and infraorbital tissues before injection of solution to prevent
the injectate from dissecting inferiorly into these tissues. This pressure should be maintained after
the procedure to avoid periorbital hematoma and ecchymosis.
After gentle aspiration, 3 mL of solution is injected in a fanlike distribution.
Side Effects and Complications
The face is highly vascular, and the pain specialist should carefully calculate the total milligram
dose of local anesthetic that may be given safely, especially if bilateral nerve blocks are being
performed. This vascularity gives rise to an increased incidence of postblock ecchymosis and
hematoma formation. Despite the vascularity of this anatomic region, this technique can safely
be performed in patients receiving anticoagulant therapy by using a 25- or 27-gauge needle,
albeit at increased risk of hematoma, if the clinical situation indicates a favorable risk-to-bene t
ratio. These complications can be decreased if manual pressure is applied to the area of the block
immediately after injection. Application of cold packs for 20-minute periods after the block also
decreases the amount of postprocedure pain and bleeding the patient may experience. The pain
management specialist should avoid inserting the needle directly into the infraorbital foramen
because the nerve may be damaged as solution is injected into the bony canal, which results in a
compression neuropathy.
Clinical Pearls
Infraorbital nerve block is useful in the palliation of pain secondary to facial trauma and
neuropathic pain involving the infraorbital nerve. In the pediatric population and in patients
requiring repair of facial lacerations, the intraoral approach to blockade of the infraorbital
nerve should be considered. Because repeated needle punctures with daily or every-other-day
blocks may result in small punctate facial scars, patients should be warned of this possibility.
Infection, although rare, remains an ever-present possibility, especially in the
immunocompromised patient. Early detection of infection is crucial to avoid potentially
lifethreatening sequelae. Recent clinical experience suggests that stimulation of the
supratrochlear nerve may be useful in the treatment of intractable pain syndromes in areas
subserved by the supratrochlear nerve (Fig. 17-7).FIGURE 17-7 Subcutaneous lead placement for infraorbital nerve
stimulation in a patient with pain after excision of a basal cell carcinoma of
the face. (From de Leon-Casasola OA: Spinal cord and peripheral nerve
stimulation techniques for neuropathic pain. J Pain Symptom Manage 38[2
suppl]:S28-S38, 2009.)


C H A P T E R 1 8
Infraorbital Nerve Block
Intraoral Approach
Abstract
The infraorbital nerve arises from bers of the maxillary nerve. The infraorbital nerve enters
the orbit via the inferior orbital ssure and passes along the oor of the orbit in the
infraorbital groove. The nerve exits the orbit via the infraorbital foramen and provides
cutaneous branches that innervate the lower eyelid, lateral naris, and upper lip. The
superior alveolar branch of the infraorbital nerves provides sensory innervation to the upper
incisor, canine, and associated gingiva.
Infraorbital nerve block can be used in a diagnostic, prognostic, and therapeutic manner.
Key Words
acute herpes zoster
infraorbital nerve
infraorbital nerve block
superior alveolar nerve
trigeminal nerve
trigeminal nerve maxillary division
CPT-2015 Code
Unilateral 64400
Bilateral 64400-5
Neurolytic 64600
Relative Value Units
Unilateral 5
Bilateral 10
Neurolytic 20
Indications
Infraorbital nerve block is useful in the diagnosis and treatment of painful conditions in areas
subserved by the infraorbital nerve, including infraorbital neuralgia and pain secondary to



herpes zoster. The intraoral approach to infraorbital nerve block is especially useful in providing
surgical anesthesia in the distribution of the infraorbital nerve for lesion removal and laceration
repair when a cosmetic result is desired, because this approach avoids distortion of the facial
anatomy from local anesthetic in ltration at the surgical site. This approach also provides an
alternative needle path in patients in whom cutaneous lesions preclude the use of the extraoral
approach to infraorbital nerve block (Fig. 18-1). The intraoral approach is also useful in the
pediatric population.
FIGURE 18-1 The intraoral approach to infraorbital nerve block provides an
alternative needle path in patients in whom cutaneous lesions preclude the
use of the extraoral approach to infraorbital nerve block. (From Pelissier P,
Bodin F, Kadoch V, et  al: Six cas de carcinomes annexiels de la face avec
reconstruction. Ann Chir Plast Esthet 58[2]:103-108, 2013.)
Clinically Relevant Anatomy
The infraorbital nerve arises from bers of the maxillary nerve. The infraorbital nerve enters the
orbit via the inferior orbital ssure and passes along the oor of the orbit in the infraorbital
groove (Fig. 18-2). The nerve exits the orbit via the infraorbital foramen and provides cutaneous
branches that innervate the lower eyelid, lateral naris, and upper lip (Fig. 18-3). The superior
alveolar branch of the infraorbital nerve provides sensory innervation to the upper incisor,
canine, and associated gingiva.FIGURE 18-2 Peripheral branches of the trigeminal nerve.

FIGURE 18-3 Sensory distribution of the infraorbital nerve.
Technique
Landmark and Fluoroscopically Guided Technique
The patient is placed in the supine position. A total of 3mL of local anesthetic is drawn up in a
10-mL sterile syringe. When the treatment is for infraorbital neuralgia, facial trauma, or other
painful conditions involving the infraorbital nerve, a total of 80mg of depot-steroid is added to
the local anesthetic with the rst block, and 40mg of depot-steroid is added with subsequent
blocks.
The infraorbital foramen on the a4ected side is then identi ed by palpation. The upper lip is
pulled backward, and a cotton ball soaked in 10% cocaine solution or 2% viscous lidocaine is
placed in the alveolar sulcus, just inferior to the infraorbital foramen (Fig. 18-4). After adequate
topical anesthesia of the mucosa is obtained, a 25-gauge, -inch needle is advanced through
the anesthetized mucosa toward the infraorbital foramen (Fig. 18-5). A paresthesia may be
elicited, and the patient should be warned of such. Because of the loose alveolar tissue of the
eyelid, a gauze sponge should be used to apply gentle pressure on the lower eyelid and
infraorbital tissues before injection of solution to prevent the injectate from dissecting upward
into these tissues. This pressure should be maintained after the procedure to avoid periorbital
hematoma and ecchymosis. After gentle aspiration, 3mL of solution is injected in a fanlike
distribution.FIGURE 18-4 To provide topical anesthesia of the mucosa overlying the
superior alveolar sulcus, the upper lip is pulled backward, and a cotton ball
soaked in 10% cocaine solution or 2% viscous lidocaine is placed in the
superior alveolar sulcus, just inferior to the infraorbital foramen.
FIGURE 18-5 Proper needle trajectory through the previously anesthetized
mucosa to perform infraorbital nerve block via the intraoral approach. n . ,
Nerve.



Ultrasound-Guided Technique
The patient is placed in the supine position. A total of 3mL of local anesthetic is drawn up in a
10-mL sterile syringe. When the treatment is for infraorbital neuralgia, facial trauma, or other
painful conditions involving the infraorbital nerve, a total of 80mg of depot-steroid is added to
the local anesthetic with the rst block, and 40mg of depot-steroid is added with subsequent
blocks.
The infraorbital foramen on the a4ected side is then identi ed by palpation. The upper lip is
pulled backward, and a cotton ball soaked in 10% cocaine solution or 2% viscous lidocaine is
placed in the alveolar sulcus, just inferior to the infraorbital foramen (see Fig. 18-4). A
highfrequency linear ultrasound transducer is placed in the transverse position over the previously
identi ed notch and a sonogram is taken (Fig. 18-6). The infraorbital foramen will be easily
identi ed as a discontinuity of the hyperechoic infraorbital ridge. Color Doppler imaging may
also be used to identify the infraorbital artery, which exits the infraorbital foramen along with
the infraorbital nerve (Fig. 18-7). After adequate topical anesthesia of the mucosa is obtained, a
25-gauge, -inch needle is advanced through the anesthetized mucosa toward the infraorbital
foramen (see Fig. 18-5). A paresthesia may be elicited, and the patient should be warned of such.
Because of the loose alveolar tissue of the eyelid, a gauze sponge should be used to apply gentle
pressure on the lower eyelid and infraorbital tissues before injection of solution to prevent the
injectate from dissecting upward into these tissues. This pressure should be maintained after the
procedure to avoid periorbital hematoma and ecchymosis. After gentle aspiration, 3mL of
solution is injected in a fanlike distribution.
FIGURE 18-6 Proper transverse placement of the high-frequency linear
ultrasound transducer for the intraoral approach to infraorbital nerve block.
FIGURE 18-7 Ultrasound image demonstrating the infraorbital foramen,
nerve, and artery.
Side Effects and Complications
The face is highly vascular, and the pain specialist should carefully calculate the total milligram
dose of local anesthetic that may be given safely, especially if bilateral nerve blocks are being
performed. This vascularity gives rise to an increased incidence of postblock ecchymosis and
hematoma formation. Despite the vascularity of this anatomic region, this technique can be
performed safely in patients receiving anticoagulant therapy by using a 25- or 27-gauge needle,
albeit at increased risk of hematoma, if the clinical situation indicates a favorable risk-to-bene t
ratio. These complications can be decreased if manual pressure is applied to the area of the block
immediately after injection. Application of cold packs for 20-minute periods after the block also
decreases the amount of postprocedure pain and bleeding the patient may experience.
Clinical Pearls
Infraorbital nerve block is useful in the palliation of pain secondary to facial trauma and
neuropathic pain involving the infraorbital nerve. In the pediatric population and in patients
requiring repair of facial lacerations, the intraoral approach to blockade of the infraorbital
nerve should be considered. When the intraoral approach is used with children, the child's
mother or father can actually place the anesthetic-soaked cotton ball in the alveolar sulcus
under the pain management specialist's direction.
C H A P T E R 1 9
Mental Nerve Block
Extraoral Approach
Abstract
The mental nerve arises from bers of the mandibular nerve. The mental nerve exits the
mandible via the mental foramen at the level of the second premolar, where it makes a
sharp turn superiorly. The nerve provides cutaneous branches that innervate the lower lip,
chin, and corresponding oral mucosa. Mental nerve block is useful in the diagnosis and
treatment of painful conditions in areas subserved by the mental nerve, including mental
neuralgia, facial trauma, and pain secondary to herpes zoster. This technique is also useful
in providing surgical anesthesia in the distribution of the mental nerve for lesion removal
and laceration repair. Mental nerve block can be used in a diagnostic, prognostic, and
therapeutic manner.
Key Words
acute herpes zoster
mental nerve
mental neuralgia
mental nerve block
trigeminal nerve
trigeminal nerve mandibular division
CPT-2015 Code
Unilateral 64400
Bilateral 64400-50
Neurolytic 64600
Relative Value Units
Unilateral 5
Bilateral 10
Neurolytic 20
Indications
Mental nerve block is useful in the diagnosis and treatment of painful conditions in areas
subserved by the mental nerve, including mental neuralgia, facial trauma, and pain secondary to
herpes zoster. This technique is also useful in providing surgical anesthesia in the distribution of
the mental nerve for lesion removal and laceration repair.
Clinically Relevant Anatomy
The mental nerve arises from bers of the mandibular nerve. The mental nerve exits the
mandible via the mental foramen at the level of the second premolar, where it makes a sharp
turn superiorly (Fig. 19-1). The nerve provides cutaneous branches that innervate the lower lip,
chin, and corresponding oral mucosa (Fig. 19-2).
FIGURE 19-1 Peripheral branches of the trigeminal nerve.
FIGURE 19-2 Sensory distribution of the mental nerve.
Technique
Landmark and Fluoroscopically Guided Technique
The patient is placed in the supine position. A total of 3mL of local anesthetic is drawn up in a
10-mL sterile syringe. When the treatment is for mental neuralgia, facial trauma, or other painful
conditions involving the mental nerve, a total of 80mg of depot-steroid is added to the local
anesthetic with the first block, and 40 mg of depot-steroid is added with subsequent blocks.
The mental foramen on the a5ected side is then identi ed by palpation. The skin overlying the
foramen is prepared with antiseptic solution. A 25-gauge, -inch needle is inserted at the
level of the mental foramen and is advanced medially about 15 degrees o5 the perpendicular to
avoid entering the foramen. The needle is advanced until it approaches the periosteum of the
underlying bone (Fig. 19-3). A paresthesia may be elicited, and the patient should be warned of
such. The needle should not enter the mental foramen, and should this occur, the needle should
be withdrawn and redirected slightly more medially. After gentle aspiration, 3mL of solution is
injected in a fanlike distribution. Fluoroscopy can be used to aid in needle placement in patients
in whom the anatomic landmarks are difficult to identify (Fig. 19-4).FIGURE 19-3 Proper needle trajectory for mental nerve block via the
extraoral approach.


FIGURE 19-4 Fluoroscopic image demonstrating the needle tip in proximity
to the mental nerve.
The face is highly vascular, and the pain specialist should carefully calculate the total
milligram dose of local anesthetic that may be given safely, especially if bilateral nerve blocks
are being performed. This vascularity gives rise to an increased incidence of postblock
ecchymosis and hematoma formation. Despite the vascularity of this anatomic region, this
technique can be performed safely in patients receiving anticoagulant therapy by using a 25- or
27-gauge needle, albeit at increased risk of hematoma, if the clinical situation indicates a
favorable risk-to-bene t ratio. These complications can be decreased if manual pressure is
applied to the area of the block immediately after injection. Application of cold packs for
20minute periods after the block also decreases the amount of postprocedure pain and bleeding the
patient may experience.
The pain management specialist should avoid inserting the needle directly into the mental
foramen because the nerve may be damaged as solution is injected into the bony canal, which
results in a compression neuropathy.
Ultrasound-Guided Technique
The patient is placed in the supine position. A total of 3mL of local anesthetic is drawn up in a
10-mL sterile syringe. When the treatment is for mental neuralgia, facial trauma, or other painful
conditions involving the mental nerve, a total of 80mg of depot-steroid is added to the local
anesthetic with the first block, and 40 mg of depot-steroid is added with subsequent blocks.
The mental foramen on the a5ected side is then identi ed by palpation. The skin overlying the
foramen is prepared with antiseptic solution. A high-frequency linear ultrasound transducer is
placed in the transverse position over the previously identi ed foramen and a sonogram is taken
(Fig. 19-5). The ultrasound transducer is moved from a caudad to cephalad trajectory until the

mental foramen is identi ed as a discontinuity of the mandible. Color Doppler imaging may also
be used to identify the mental artery, which exits the mental foramen along with the mental
nerve (Fig. 19-6).
FIGURE 19-5 Transverse ultrasound image demonstrating the mental
foramen, which appears as a discontinuity of the mandible.
FIGURE 19-6 Color Doppler may aid in identification of the mental artery as
it exits the mental foramen.
Once the mental foramen containing the mental nerve and artery have been identi ed, a
25gauge, -inch needle is inserted at the inferior margin of the ultrasound transducer and
advanced medially about 15 degrees o5 the perpendicular toward the mental foramen using anout-of-plane approach. The needle is advanced under continuous ultrasound guidance until it is
in proximity to the mental nerve as it exits the mental foramen. A paresthesia may be elicited,
and the patient should be warned of such. The needle should not enter the mental foramen, and
should this occur, the needle should be withdrawn and redirected slightly more medially. After
gentle aspiration, 3mL of solution is injected in a fanlike distri bution. The pain management
specialist should avoid inserting the needle directly into the mental foramen because the nerve
may be damaged as solution is injected into the bony canal, which results in a compression
neuropathy.
Clinical Pearls
Mental nerve block is useful in the palliation of pain secondary to facial trauma and
neuropathic pain involving the mental nerve. In the pediatric population and in patients
requiring repair of facial lacerations, the intraoral approach to blockade of the mental nerve
should be considered.
Because repeated needle punctures with daily or every-other-day blocks may result in small
punctate facial scars, patients should be warned of this possibility. Infection, although rare,
remains an ever-present possibility, especially in the immunocompromised patient. Early
detection of infection is crucial to avoid potentially life-threatening sequelae.
The pain specialist should carefully examine the patient before performing mental nerve
block to identify preexisting neural compromise because the mental nerve is especially
vulnerable to blunt trauma and mandibular fractures owing to the acute angle at which it
exits the mental foramen (Fig. 19-7). This preblock assessment helps identify subtle neurologic
changes that might subsequently be erroneously attributed to the block.
FIGURE 19-7 The mental nerve is especially susceptible to trauma due
to the acute angle at which it exits the mental foramen. This
threedimensional computerized tomographic image shows a mandibular fracture
involving the mental foramen. (From Benech A, Nicolotti M, Brucoli M,
et  al: Intraoral extra-mucosal fixation of fractures in the atrophic
edentulous mandible. Int J Oral Maxillofac Surg 42[4]:460-463, 2013.)
C H A P T E R 2 0
Mental Nerve Block
Intraoral Approach
Abstract
The mental nerve arises from bers of the mandibular nerve. The mental nerve exits the
mandible via the mental foramen at the level of the second premolar, where it makes a
sharp turn superiorly. The nerve provides cutaneous branches that innervate the lower lip,
chin, and corresponding oral mucosa. Mental nerve block is useful in the diagnosis and
treatment of painful conditions in areas subserved by the mental nerve, including mental
neuralgia, facial trauma, and pain secondary to herpes zoster. This technique is also useful
in providing surgical anesthesia in the distribution of the mental nerve for lesion removal
and laceration repair. Mental nerve block can be used in a diagnostic, prognostic, and
therapeutic manner.
Key Words
acute herpes zoster
mental nerve
mental neuralgia
mental nerve block
trigeminal nerve
trigeminal nerve mandibular division
Cpt-2015 Code
Unilateral 64400
Bilateral 64400-50
Neurolytic 64600
Relative Value Units
Unilateral 5
Bilateral 10
Neurolytic 20
Indications
Mental nerve block is useful in the diagnosis and treatment of painful conditions in areas
subserved by the mental nerve, including mental neuralgia, facial trauma, and pain secondary to
herpes zoster.
The intraoral approach to mental nerve block is especially useful in providing surgical
anesthesia in the distribution of the mental nerve for lesion removal and laceration repair when
a cosmetic result is desired, because this approach avoids distortion of the facial anatomy from
local anesthetic infiltration at the surgical site (Fig. 20-1).
FIGURE 20-1 The intraoral approach to mental nerve block is especially
useful in providing surgical anesthesia in the distribution of the mental nerve
for lesion removal and laceration repair when a cosmetic result is desired,
because this approach avoids distortion of the facial anatomy from local
anesthetic infiltration at the surgical site and the need to place the needle
through a lesion, such as the advanced basal cell carcinoma shown here.
(From Bhatnagar A: Nonmelanoma skin cancer treated with electronic
brachytherapy: results at 1 year. Brachytherapy 12[2]:134-140, 2013.)
Clinically Relevant Anatomy
The mental nerve arises from bers of the mandibular nerve. The mental nerve exits the
mandible via the mental foramen at the level of the second premolar, where it makes a sharp
turn superiorly (Fig. 20-2). The nerve provides cutaneous branches that innervate the lower lip,
chin, and corresponding oral mucosa (Fig. 20-3).FIGURE 20-2 The mental nerve exits the mandible via the mental foramen
at the level of the second premolar, where it makes a sharp turn superiorly.
FIGURE 20-3 Sensory distribution of the mental nerve.
Technique
Landmark and Fluoroscopically Guided Technique
The patient is placed in the supine position. A total of 3mL of local anesthetic is drawn up in a
10-mL sterile syringe. When the treatment is for mental neuralgia, facial trauma, or other painful
conditions involving the mental nerve, a total of 80mg of depot-steroid is added to the local
anesthetic with the first block, and 40 mg of depot-steroid is added with subsequent blocks.
The mental notch on the a4ected side is then identi ed by palpation. The lower lip is pulled
downward, and a cotton ball soaked in 10% cocaine solution or 2% viscous lidocaine is placed in
the alveolar sulcus, just above the mental foramen (Fig. 20-4). After adequate topical anesthesia
of the mucosa is obtained, a 25-gauge, -inch needle is advanced through the anesthetized
mucosa toward the mental foramen (Fig. 20-5). A paresthesia may be elicited, and the patient
should be warned of such. After gentle aspiration, 3mL of solution is injected in a fanlike
distribution.FIGURE 20-4 To anesthetize the mucosa overlying the inferior alveolar
sulcus, the lower lip is pulled downward, and a cotton ball soaked in 10%
cocaine solution or 2% viscous lidocaine is placed into the alveolar sulcus,
just above the mental foramen.


FIGURE 20-5 Proper needle trajectory for mental nerve block via the
intraoral approach.
Ultrasound-Guided Technique
The patient is placed in the supine position. A total of 3mL of local anesthetic is drawn up in a
10-mL sterile syringe. When the treatment is for mental neuralgia, facial trauma, or other painful
conditions involving the mental nerve, a total of 80mg of depot-steroid is added to the local
anesthetic with the first block, and 40 mg of depot-steroid is added with subsequent blocks.
The mental foramen on the a4ected side is then identi ed by palpation. The lower lip is
retracted and a cotton ball soaked in 10% cocaine solution or 2% viscous lidocaine is placed in
the alveolar sulcus, just above the mental foramen (see Fig. 20-4). A high-frequency linear
ultrasound transducer is placed in the transverse position over the previously identi ed mental
foramen and a sonogram is taken (Figs. 20-6 and 20-7). The mental foramen will be easily
identi ed as a discontinuity of the hyperechoic mandible. Color Doppler imaging may also be
used to identify the mental artery, which exits the mental foramen along with the mental nerve.
After adequate topical anesthesia of the mucosa is obtained, a 25-gauge, -inch needle is
advanced through the anesthetized mucosa toward the mental foramen (see Fig. 20-5). A
paresthesia may be elicited, and the patient should be warned of such. After gentle aspiration,
3 mL of solution is injected in a fanlike distribution.
FIGURE 20-6 A high-frequency linear ultrasound transducer is placed in the
transverse position over the previously identified mental foramen and a
25gauge, -inch needle is advanced through the anesthetized mucosa
toward the mental foramen.
FIGURE 20-7 Transverse ultrasound image demonstrating the mental
foramen, which appears as a discontinuity of mandible.
Side Effects and Complications
The face is highly vascular, and the pain specialist should carefully calculate the total milligram
dosage of local anesthetic that may be given safely, especially if bilateral nerve blocks are being
performed. This vascularity gives rise to an increased incidence of postblock ecchymosis and
hematoma formation. Despite the vascularity of this anatomic region, this technique can be
performed safely in patients receiving anticoagulant therapy by using a 25- or 27-gauge needle,
albeit at increased risk of hematoma, if the clinical situation indicates a favorable risk-to-bene t
ratio. These complications can be decreased if manual pressure is applied to the area of the block
immediately after injection. Application of cold packs for 20-minute periods after the block alsodecreases the amount of postprocedure pain and bleeding the patient may experience.
Clinical Pearls
Mental nerve block is useful in the palliation of pain secondary to facial trauma and
neuropathic pain involving the mental nerve. In the pediatric population and in patients
requiring repair of facial lacerations, the intraoral approach to blockade of the mental nerve
should be considered. When the intraoral approach is used in children, the child's mother or
father can actually place the anesthetic-soaked cotton ball in the alveolar sulcus under the
pain management specialist's direction.
The pain management specialist should carefully examine the patient before performing
mental nerve block to identify preexisting neural compromise because the mental nerve is
especially vulnerable to blunt trauma owing to the acute angle at which it exits the mental
foramen. This preblock assessment helps identify subtle neurologic changes that might
subsequently be erroneously attributed to the block.
C H A P T E R 2 1
Inferior Alveolar Nerve Block
Abstract
The inferior alveolar nerve arises from bers of the mandibular nerve. The inferior alveolar
nerve passes inferiorly to enter the mandibular canal (Fig. 21-1). The nerve travels forward
through the body of the mandible, providing sensory innervation to the molars and
premolars as well as their associated gingiva. As the inferior alveolar nerve approaches the
mental foramen, it divides into two branches. The incisor branch provides sensory
innervation to the canines and incisors. The mental branch passes through the mental
foramen to provide sensory innervation to the lower lip and corresponding gingival surface.
Key Words
acute herpes zoster
inferior alveolar nerve
inferior alveolar nerve block
mandibular division of the trigeminal nerve
mandibular nerve
post-traumatic neuralgia
trigeminal nerve
CPT-2015 Code
Unilateral 64400
Bilateral 64400-50
Neurolytic 64600
Relative Value Units
Unilateral 5
Bilateral 10
Neurolytic 20
Indications
Inferior alveolar nerve block is useful in the diagnosis and treatment of painful conditions in
areas subserved by the inferior alveolar nerve, including post-traumatic neuralgias and pain
secondary to intraoral malignancies. Inferior alveolar nerve block is especially useful in
providing surgical anesthesia in the distribution of the inferior alveolar nerve for lesion removal,
dental surgery, and laceration repair.
Clinically Relevant Anatomy
The inferior alveolar nerve arises from bers of the mandibular nerve. The inferior alveolar
nerve passes inferiorly to enter the mandibular canal (Fig. 21-1). The nerve travels forward
through the body of the mandible, providing sensory innervation to the molars and premolars as
well as their associated gingiva. As the inferior alveolar nerve approaches the mental foramen, it
divides into two branches. The incisor branch provides sensory innervation to the canines and
incisors. The mental branch passes through the mental foramen to provide sensory innervation to
the lower lip and corresponding gingival surface. The lingual and buccal nerves lie just medial to
the inferior alveolar nerve and are subject to trauma during inferior alveolar nerve block (Fig.
21-2).
FIGURE 21-1 Anatomy of the inferior alveolar branch of the mandibular
nerve. (From Waldman SD: Atlas of Pain Management Injection Techniques,
3rd ed. Philadelphia, Saunders, 2013.)/


FIGURE 21-2 Anatomy of the mandibular nerve and its relationship to the
lingual and buccal nerves. (From Waldman SD: Atlas of Pain Management
Injection Techniques, 3rd ed. Philadelphia, Saunders, 2013.)
Technique
Landmark and Fluoroscopically Guided Technique
The patient is placed in a supine position with the mouth wide open. A total of 5mL of local
anesthetic is drawn up in a 10-mL sterile syringe. When the treatment is for neuralgias involving
the inferior alveolar nerve, facial trauma, or other painful or in ammatory conditions a0ecting
the inferior alveolar nerve, a total of 80mg of depot-steroid is added to the local anesthetic with
the rst block, and 40mg of depot-steroid is added with subsequent blocks. Neurolytic blocks
using small amounts of 6.5% aqueous phenol can be performed for intractable pain secondary to
malignancy.
The anterior margin of the mandible just above the last molar on the a0ected side is identi ed
by palpation (Fig. 21-3). Topical anesthesia of the gingiva overlying this area is then obtained
with either 10% cocaine solution or 2% viscous lidocaine applied with a -inch cotton-tipped
applicator. The patient is then asked to slightly close his or her mouth to relax the pterygoid
muscles. After adequate topical anesthesia of the mucosa is obtained, a 25-gauge, 2-inch needle isadvanced submucosally through the anesthetized area along the inner surface of the mandible
(Figs. 21-4 and 21-5). A paresthesia may be elicited, and the patient should be warned of such.
Three to 5mL of solution is injected as the needle is slowly advanced. Fluoroscopy can be used in
patients in whom identification of anatomic landmarks is difficult (Fig. 21-6).
FIGURE 21-3 The anterior margin of the mandible just above the last molar
on the affected side is identified by palpation. (From Waldman SD: Atlas of
Pain Management Injection Techniques, 3rd ed. Philadelphia, Saunders,
2013.)FIGURE 21-4 Proper needle trajectory for inferior alveolar nerve block. I n f . ,
Inferior; n . , nerve.