Atlas of Pain Management Injection Techniques E-Book

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Master every essential pain management injection technique used today with Atlas of Pain Management Injection Techniques, 3rd Edition. With expert tips from leading authority Steven D. Waldman, MD, JD and abundant step-by-step color illustrations, you’ll see how to evaluate the causes of pain, identify the most promising injection approach, locate the injection site with precision, and deliver the relief your patients crave. From the head and neck to the foot and ankle - and everywhere between - this best-selling pain management reference equips you to perform a complete range of clinical injection techniques with greater confidence!

  • Consult this title on your favorite e-reader with intuitive search tools and adjustable font sizes. Elsevier eBooks provide instant portable access to your entire library, no matter what device you're using or where you're located.
  • Perform each technique like an expert and avoid complications with clinical pearls in each chapter.
  • Diagnose pain syndromes effectively with updated coverage encompassing the latest identification guidelines and definitions.
  • See exactly how to proceed and fully understand the nuances of each technique thanks to hundreds of illustrations - many in full color, many new to this edition - demonstrating relevant anatomy, insertion sites, and more.

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Published 30 August 2012
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EAN13 9781455728145
Language English
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Atlas of Pain Management
Injection Techniques
Third Edition
Steven D. Waldman, MD, JD
Clinical Professor of Anesthesiology, Professor of Medical
Humanities and Bioethics, University of Missouri–Kansas City
School of Medicine, Kansas City, Missouri
S a u n d e r sTable of Contents
Cover image
Title page
Copyright
Dedication
Preface
Acknowledgments
Section 1: Head and Neck
Chapter 1: Temporomandibular Joint Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 2: Supraorbital Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 3: Trochlear Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 4: Buccal Fold Injection for Incisors and Canine Teeth
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 5: Buccal Fold Injection Technique for Upper Premolar Teeth
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and ComplicationsChapter 6: Buccal Fold Injection for Upper Molar Teeth
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 7: Incisive Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 8: Inferior Alveolar Nerve Block for Lower Premolar Teeth
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 9: Inferior Alveolar Nerve Block for Lower Molar Teeth
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 10: Styloid Process Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 11: Stylohyoid Ligament Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 12: Nasociliary Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 13: Auriculotemporal Nerve BlockIndications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 14: Omohyoid Muscle Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 15: Trigeminal Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 16: Injection Technique for Trapezius Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 17: Injection Technique for Cervical Strain
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 18: Injection Technique for Sternocleidomastoid Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 19: Occipital Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 20: Injection Technique for Splenius Cervicis Syndrome
Indications and Clinical ConsiderationsClinically Relevant Anatomy
Technique
Side Effects and Complications
Section 2: Shoulder
Chapter 21: Intraarticular Injection of the Shoulder Joint
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 22: Acromioclavicular Joint Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 23: Supraspinatus Tendon Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 24: Infraspinatus Tendon Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 25: Subscapularis Tendon Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 26: Injection Technique for Deltoid Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 27: Injection Technique for Pectoralis Major Syndrome
Indications and Clinical ConsiderationsClinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 28: Injection Technique for Pectoralis Major Tear Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Differential Diagnosis
Side Effects and Complications
Chapter 29: Injection Technique for Teres Major Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 30: Bicipital Tendon Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 31: Injection Technique for Subacromial Impingement
Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 32: Injection Technique for Os Acromiale Pain Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 33: Injection Technique for Biceps Brachii Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 34: Injection Technique for Triceps Brachii SyndromeIndications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 35: Injection Technique for Rotator Cuff Tear
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 36: Injection Technique for Quadrilateral Space Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 37: Subdeltoid Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 38: Subcoracoid Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 39: Injection Technique for Frozen Shoulder Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 40: Injection Technique for Scapulocostal Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Section 3: Elbow and Forearm
Chapter 41: Intraarticular Injection of the Elbow JointIndications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 42: Injection Technique for Anconeus Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 43: Injection Technique for Anconeus Epitrochlearis
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 44: Ulnar Nerve Block at the Elbow
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 45: Injection Technique for Driver’s Elbow
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 46: Injection Technique for Os Supertrochleare Related Elbow
Pain
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 47: Lateral Epicondyle Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 48: Radial Nerve Block at the HumerusIndications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 49: Medial Epicondyle Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 50: Triceps Tendon Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 51: Olecranon Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 52: Cubital Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 53: Injection Technique for Supinator Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 54: Injection Technique for Extensor Carpi Ulnaris Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 55: Injection Technique for Extensor Carpi Radialis Longus
SyndromeIndications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 56: Injection Technique for Flexor Carpi Ulnaris Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 57: Injection Technique for Flexor Carpi Radialis Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 58: Median Nerve Block at the Elbow
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 59: Median Nerve Block below Elbow
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 60: Lateral Antebrachial Cutaneous Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Section 4: Wrist and Hand
Chapter 61: Intraarticular Injection of the Wrist Joint
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 62: Intraarticular Injection of the Radioulnar JointIndications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 63: Flexor Carpi Radialis Tendon Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 64: Flexor Carpi Ulnaris Tendon Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 65: Radial Nerve Block at the Wrist
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 66: Injection Technique for de Quervain Tenosynovitis
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 67: Injection Technique for Intersection Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 68: Intraarticular Injection of the Carpometacarpal Joint of the
Thumb
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 69: Intraarticular Injection of the Carpometacarpal JointIndications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 70: Flexor Pollicis Longus Tendon Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 71: Flexor Digitorum Superficialis Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 72: Digital Nerve Block of the Thumb
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 73: Sesamoid Joint Injection of the Hand
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 74: Intraarticular Injection of the Metacarpophalangeal Joints
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 75: Intraarticular Injection of the Interphalangeal Joints
Indications and Clinical Syndromes
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 76: Injection Technique for Carpal Tunnel Syndrome
Indications and Clinical ConsiderationsClinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 77: Ulnar Nerve Block at the Wrist
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 78: Carpal Boss Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 79: Injection Technique for Secretan Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 80: Injection Technique for Os Centrale Carpi
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 81: Injection Technique for Ganglion Cysts of the Wrist and
Hand
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 82: Dupuytren Contracture Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 83: Digital Nerve Block of the Finger
Indications and Clinical ConsiderationsClinically Relevant Anatomy
Technique
Side Effects and Complications
Section 5: Chest Wall, Trunk, Back, and Abdomen
Chapter 84: Injection Technique for Sternoclavicular Joint Pain
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 85: Long Thoracic Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 86: Suprascapular Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 87: Costosternal Joint Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 88: Costovertebral Joint Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 89: Costosternal Joint Injection Technique for Tietze Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 90: Manubriosternal Joint Injection
Indications and Clinical ConsiderationsClinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 91: Injection Technique for Sternalis Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 92: Xiphisternal Joint Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 93: Injection Technique for Slipping Rib Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 94: Anterior Cutaneous Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 95: Injection Technique for Lumbar Myofascial PainSyndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Section 6: Hip and Pelvis
Chapter 96: Intraarticular Injection of the Hip Joint
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 97: Adductor Tendon Injection
Indications and Clinical ConsiderationsClinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 98: Ischial Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 99: Gluteal Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 100: Psoas Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 101: Iliopectineal Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 102: Trochanteric Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 103: Injection Technique for Thigh Splints
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 104: Injection Technique for Snapping Hip Syndrome
Indications and Clinical Considerations
Clinically Relevant AnatomyTechnique
Side Effects and Complications
Chapter 105: Intraarticular Injection of the Sacroiliac Joint
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 106: Injection Technique for Gluteus Maximus Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 107: Injection Technique for Gluteus Medius Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 108: Injection Technique for Levator Ani Pain Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 109: Obturator Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 110: Lateral Femoral Cutaneous Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 111: Sciatic Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
TechniqueSide Effects and Complications
Chapter 112: Injection Technique for Osteitis Pubis Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 113: Ilioinguinal Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 114: Genitofemoral Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 115: Sacrococcygeal Joint Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Section 7: Knee and Lower Extremity
Chapter 116: Intraarticular Injection of the Knee Joint
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 117: Superior Tibiofibular Joint Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 118: Injection Technique for Semimembranosus Insertion
Syndrome
Indications and Clinical Considerations
Clinically Relevant AnatomyTechnique
Side Effects and Complications
Chapter 119: Coronary Ligament Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 120: Medial Collateral Ligament Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 121: Injection Technique for Quadriceps Expansion Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 122: Quadriceps Tendon Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 123: Suprapatellar Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 124: Prepatellar Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 125: Superficial Infrapatellar Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
TechniqueSide Effects and Complications
Chapter 126: Deep Infrapatellar Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 127: Pes Anserinus Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 128: Iliotibial Band Bursa Injection
Indications and Clinical Syndromes
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 129: Medial Collateral Ligament Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 130: Iliotibial Band Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 131: Hamstring Tendon Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 132: Injection Technique for Baker Cyst
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and ComplicationsChapter 133: Fabella Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 134: Fascia Lata Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 135: Saphenous Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Section 8: Ankle and Foot
Chapter 136: Intraarticular Injection of the Ankle Joint
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 137: Intraarticular Injection of the Subtalar Joint
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 138: Intraarticular Injection of the Midtarsal Joints
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 139: Intraarticular Injection of the Toe Joints
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and ComplicationsChapter 140: Deltoid Ligament Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 141: Anterior Talofibular Ligament Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 142: Deep Peroneal Nerve Block
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 143: Tibial Nerve Block at theAnkle
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 144: Achilles Tendon Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 145: Achilles Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 146: Fibulocalcaneal Ligament Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 147: Peroneal Tendon InjectionIndications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 148: Plantar Fasciitis Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 149: Injection Technique for Calcaneal Spurs
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 150: Superficial Extensor Tendon Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 151: Posterior Tibialis Tendon Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 152: Injection Technique for Bunion Pain Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 153: Injection Technique for Bunionette Pain Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 154: Injection Technique for Mallet Toe Pain Syndrome
Indications and Clinical ConsiderationsClinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 155: Injection Technique for Hammer Toe Pain Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 156: Injection Technique for Morton Neuroma Syndrome
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 157: Intermetatarsal Bursa Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 158: Sesamoid Bone Injection of the Foot
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Chapter 159: Metatarsal Liagament Injection
Indications and Clinical Considerations
Clinically Relevant Anatomy
Technique
Side Effects and Complications
Index>
>
Copyright
1600 John F. Kennedy Blvd.
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ATLAS OF PAIN MANAGEMENT INJECTION TECHNIQUES ISBN:
978-14377-3793-6
Copyright © 2013, 2007, 2000 by Saunders, an imprint of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or
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copyright by the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this eld are constantly changing. As new research
and experience broaden our understanding, changes in research methods,
professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identi ed, readers are
advised to check the most current information provided (i) on procedures featured
or (ii) by the manufacturer of each product to be administered, to verify the
recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine
dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the author assumes
any liability for any injury and/or damage to persons or property as a matter of
products liability, negligence or otherwise, or from any use or operation of any
methods, products, instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Waldman, Steven D.
Atlas of pain management injection techniques / Steven D. Waldman. — 3rd
ed.
p. ; cm.
Includes bibliographical references and index. ISBN 978-1-4377-3793-6 (hardcover : alk. paper)
I. Title.
[DNLM: 1. Pain—drug therapy—Atlases. 2. Injections—methods—Atlases. WL
17]
615’.6—dc23 2012012534
Content Strategist: Pamela Hetherington
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Senior Project Manager: Claire Kramer
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Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1D e d i c a t i o n
To E. Grey Dimond, MD
Clinician, Educator, Visionary, Mentor, and Friend





Preface
One hundred twenty-seven years have passed since Carl Koller rst used
cocaine to perform an eye operation without pain. Although Koller’s landmark
discovery forever changed how surgery is performed and he unwittingly created a
cottage industry in regional anesthesia drugs, needles, and, of course, regional
anesthesia textbooks, a careful analysis of the ensuing 127 years reveals that most
of the advances in regional anesthesia drugs have centered around the
development of safer local anesthetics and improved needles. The landmark texts
by Pitkin, DeJong, Moore, and others helped make the use of regional anesthesia
drugs accessible to the general practitioner. These early books standardized
techniques, needle sizes and lengths, and, perhaps most important, the dosages of
local anesthetics for the common techniques. Lofgren’s discovery of lidocaine in
1943 moved regional anesthesia drugs into the operating room and obstetric suite,
as well as into doctors’ and dentists’ o0 ces. Much safer than ester local anesthetics
such as procaine, the most widely used local anesthetic up to that time, lidocaine’s
larger therapeutic window was much more forgiving of clinical missteps when
nerve blocks were performed, and lidocaine has been the mainstay of regional
anesthesia drugs ever since.
In the 1980s, pain medicine came into its own as practitioners tested and
applied the simple hypothesis that the cause of pain must be diagnosed rst to
ensure a successful treatment. Along with the birth of this new subspecialty came a
new set of “bibles” by Raj and by Cousins and Bridenbaugh and the rst edition of
Atlas of Pain Management Injection Techniques, which was first published in 2000.
I think that the eld of pain management is entering a new and exciting era,
now that ultrasound guidance has become increasingly utilized when regional
anesthesia drugs are administered. Only time will tell whether ultrasound guidance
is a true “moment” or merely a passing fancy that will go the way of nesacaine and
succinylcholine drips, but my clinical impression is that ultrasound guidance
represents an important advance in regional anesthesia and pain management that
I think will stand the test of time. In addition to presenting the fundamentals of
ultrasound guidance in the how-to-do-it format that has made previous editions of
this book so popular, I have included many new color gures and ultrasound,
9uoroscopic, and magnetic resonance images, along with new full-color, clinically
relevant anatomic drawings to make the techniques described even more accessible
to my readers. With the able assistance of Sabina Borza, Content Development
Specialist, we have added clear, concise captions to every gure and strived to
improve the layout of the book to make it even more readable than previous
editions.
I sincerely hope that you will enjoy using this book as much as I enjoyed
writing it.
Steven D. Waldman, MD, JD
2012A c k n o w l e d g m e n t s
I would like to thank my editor, Pamela Hetherington, for her wisdom, hard
work, and patience and Sabina Borza, who worked tirelessly to improve the content
and layout of this book.
SDWSection 1
Head and NeckChapter 1
Temporomandibular Joint Injection
Indications and Clinical Considerations
Injection of the temporomandibular joint is indicated as an important component
in the management of temporomandibular joint dysfunction, in the palliation of
pain secondary to internal derangement of the joint, and in the treatment of pain
secondary to arthritis of the joint. Temporomandibular joint dysfunction (also
known as myofascial pain dysfunction of the muscles of mastication) is characterized
by pain in the joint itself that radiates into the mandible, ear, neck, and tonsillar
pillars. Headache often accompanies the pain of temporomandibular joint
dysfunction and is clinically indistinguishable from tension-type headache. Stress is
often the precipitating or exacerbating factor in the development of
temporomandibular joint dysfunction. Dental malocclusion may also play a role in
the evolution of temporomandibular joint dysfunction. Internal derangement and
arthritis of the temporomandibular joint may manifest as clicking or grating when
the joint is opened and closed (Figure 1-1). If the condition is not treated, the
patient may experience increasing pain in the just-mentioned areas and limitation
of jaw movement and opening. Recently the injection of autologous blood into the
temporomandibular joint has gained popularity in the treatment of recurrent
temporomandibular joint hypermobility dislocation (Figure 1-2). This injection
technique is also useful in the injection of other substances into the
temporomandibular joint such as hyaluronic acid derivatives and tenoxicam.Figure 1-1 Osteoarthritis compared in a specimen radiograph (A) and
photograph (B) of a sagittally sectioned specimen. The joint space is narrow and
the disk is dislocated anteriorly, with thinning and fraying of the meniscal (m)
posterior attachment or bilaminar zone. The condylar head cortex is thickened, with
small osteophytes (arrows). The mandibular fossa is sclerotic and remodeled, and
only a shallow concavity is seen where the articular eminence once was.
(From Resnick D: Diagnosis of bone and joint disorders, ed 4, Philadelphia, 2002,
Saunders.)+
+
+
Figure 1-2 Injection of autologous blood into the temporomandibular joint.
(From Daif ET: Autologous blood injection as a new treatment modality for chronic
recurrent temporomandibular joint dislocation, Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 109:31-36, 2010.)
Clinically Relevant Anatomy
The temporomandibular joint is a true joint that is divided into an upper and a
lower synovial cavity by a brous articular disk. Internal derangement of this disk
may result in pain and temporomandibular joint dysfunction, but extracapsular
causes of temporomandibular joint pain are much more common. The joint space
between the mandibular condyle and the glenoid fossa of the zygoma may be
injected with small amounts of local anesthetic and corticosteroid. The
temporomandibular joint is innervated by branches of the mandibular nerve. The
muscles involved in temporomandibular joint dysfunction often include the
temporalis, masseter, and external pterygoid and internal pterygoid and may
include the trapezius and sternocleidomastoid. Trigger points may be identi ed
when these muscles are palpated.
Technique
The patient is placed in the supine position with the cervical spine in the neutral
position. The temporomandibular joint is identi ed by asking the patient to open
and close his or her mouth several times and by palpating the area just anterior
and slightly inferior to the acoustic auditory meatus. After the joint has been
identified, the patient is asked to hold his or her mouth in a neutral position.
A total of 0.5 mL of local anesthetic is drawn up in a 3-mL sterile syringe.
When temporomandibular joint dysfunction, internal derangement of the
temporomandibular joint, arthritis pain of the temporomandibular joint, or other+
+
8
+
painful conditions involving the temporomandibular joint are treated, a total of 20
mg of depot corticosteroid is added to the local anesthetic with the rst block, and
10 mg of depot corticosteroid is added to the local anesthetic with subsequent
blocks.
After the skin overlying the temporomandibular joint has been prepared with
antiseptic solution, a 25-gauge, 1-inch styletted needle is inserted just below the
zygomatic arch directly in the middle of the joint space. The needle is advanced ½
to ¾ inch in a plane perpendicular to the skull until a “pop” is felt that indicates
the joint space has been entered (Figure 1-3). After careful aspiration, 1 mL of
solution is slowly injected. Injection of the joint may be repeated at 5- to 7-day
intervals if the symptoms persist.
Figure 1-3 Needle placement into the temporomandibular joint is simpli ed by
having the patient open and close the mouth to facilitate identification of the joint.
Side Effects and Complications
This anatomic region is highly vascular. This vascularity and proximity to major
blood vessels also give rise to an increased incidence of postblock ecchymosis and
hematoma formation, and the patient should be warned of such. In spite of the
vascularity of this anatomic region, this technique can be performed safely in the
presence of anticoagulation by using a 25- or 27-gauge needle, albeit at increased
risk of hematoma, if the clinical situation dictates 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 will also decrease the amount of postprocedure pain and
bleeding the patient may experience.
Additional side e ects that occur with su9 cient frequency include inadvertent
block of the facial nerve with associated facial weakness. When this occurs,
protection of the cornea with sterile ophthalmic lubricant and patching is
mandatory.+
Clinical Pearls
Pain from temporomandibular joint dysfunction requires careful evaluation to
design an appropriate treatment plan. Infection and in; ammatory causes
including collagen vascular diseases rst must be ruled out. When
temporomandibular joint pain occurs in older patients, the pain must be
distinguished from the jaw claudication associated with temporal arteritis. Stress
and anxiety often accompany temporomandibular joint dysfunction; these factors
must be addressed and treated. The myofascial pain component of
temporomandibular joint dysfunction is best treated with tricyclic antidepressant
compounds such as amitriptyline. Dental malocclusion and nighttime bruxism
should be treated with an acrylic bite appliance. Narcotic analgesics and
benzodiazepines should be avoided in patients with temporomandibular joint
dysfunction.
Suggested Readings
Daif E.T. Autologous blood injection as a new treatment modality for chronic
recurrent temporomandibular joint dislocation. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2010;109:31–36.
Mountziaris P.M., Kramer P.R., Mikos A.G. Emerging intra-articular drug delivery
systems for the temporomandibular joint. Methods. 2009;47:134–140.
Sidebottom A.J. Current thinking in temporomandibular joint management. Br J Oral
Maxillofac Surg. 2009;47:91–94.
Waldman S.D. Temporomandibular joint dysfunction. In: Pain review. Philadelphia:
Saunders–Elsevier; 2009.
Waldman S.D. Temporomandibular joint injection. In: Pain review. Philadelphia:
Saunders–Elsevier; 2009.
$



Chapter 2
Supraorbital Nerve Block
Indications and Clinical Considerations
Supraorbital nerve block is useful in the diagnosis and treatment of swimmer’s
headache and supraorbital neuralgia. Swimmer’s headache is the result of
compression of the supraorbital nerves by swimming goggles that t poorly or are
worn too tightly, exerting pressure on the supraorbital nerves as they exit the
supraorbital foramen. Repetitive microtrauma from wearing swim goggles may also
cause swimmer’s headache. The pain of swimmer’s headache is characterized as
persistent pain in the supraorbital region and forehead with occasional sudden,
shocklike paresthesias in the distribution of the supraorbital nerves. Sinus headache
involving the frontal sinuses, which is much more common than swimmer’s
headache, occasionally mimics the pain of swimmer’s headache. Occasionally, a
patient with swimmer’s headache will complain that the hair on the front of the
head “hurts.”
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.
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 (Figure 2-1).$

$

Figure 2-1 Swimmer’s headache is characterized by persistent pain in the
supraorbital region with associated intermittent shocklike paresthesias.
Technique
The patient is placed in a supine position. A total of 3 mL of local anesthetic is
drawn up in a 10-mL sterile syringe. When swimmer’s headache is treated with
supraorbital nerve block, a total of 80 mg of depot corticosteroid is added to the
local anesthetic with the rst block, and 40 mg of depot corticosteroid is added
with subsequent blocks.
The supraorbital notch on the a ected side is then identi ed by palpation. The
skin overlying the notch is prepared with antiseptic solution, with care being taken
to avoid spillage into the eye. A 25-gauge, 1½-inch needle is inserted at the level of
the supraorbital notch and is advanced medially approximately 15 degrees o the
perpendicular to avoid entering the foramen. The needle is advanced until it
approaches the periosteum of the underlying bone (Figure 2-2). A paresthesia may
be elicited, and the patient should be warned of such. The needle should not enter
the supraorbital foramen; should this occur, the needle should be withdrawn and
redirected slightly more medially.
Figure 2-2 When the needle is placed for supraorbital nerve block, care should be
taken to avoid advancing the needle into the supraorbital foramen.
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, 3 mL of solution is injected in a fanlike distribution. If
blockade of the supratrochlear nerve is also desired, the needle is then redirected
medially; 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 safely given,
especially if bilateral nerve blocks are being performed. This vascularity gives rise
to an increased incidence of postblock ecchymosis and hematoma formation. In
spite of the vascularity of this anatomic region, this technique can be safely
performed in the presence of anticoagulation by using a 25- or 27-gauge needle,
albeit at increased risk of hematoma, if the clinical situation dictates 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
Supraorbital nerve block is especially useful in the diagnosis and palliation of pain

secondary to swimmer’s headache and supraorbital neuralgia. The rst step in the
management of the unusual cause of headache is the correct tting of swim
goggles that do not compress the supraorbital nerves. Coexistent frontal sinusitis
should be ruled out in patients who do not respond rapidly to a change in swim
goggles and a series of the just-described nerve blocks.
Any patient with headaches severe enough to require neural blockade as part
of the treatment plan should undergo computed tomography (CT) or magnetic
resonance imaging (MRI) of the head to rule out unsuspected intracranial
pathology.
Suggested Readings
Levin M. Nerve blocks in the treatment of headache. Neurotherapeutics. 2010;7:197–
203.
O’Brien J.C., Jr. Swimmer’s headache, or supraorbital neuralgia. Proc (Bayl Univ Med
Cent). 2004;17:418–419.
Pareja J.A., Caminero A.B. Supraorbital neuralgia. Curr Pain Headache Rep.
2006;10:302–305.
Sharma R.R., Pawar S.J., Lad S.D., et al. Frontal intraosseous cryptic hemangioma
presenting with supraorbital neuralgia. Clin Neurol Neurosur. 1999;101:215–219.
Sjaastad O., Stolt-Nielsen A., Pareja J.A., et al. Supraorbital neuralgia. On the
clinical manifestations and a possible therapeutic approach. Headache.
1999;39:204–212.$
$
&

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Chapter 3
Trochlear Nerve Block
Indications and Clinical Considerations
Trochlear injection is useful in the diagnosis and treatment of primary trochlear
headache. As with most headache syndromes, the exact cause of the pain of
primary trochlear headache is unknown, and whether the trochlear nerve plays a
role in pathogenesis of this uncommon source of head and face pain is the subject
of ongoing debate.
In patients with primary trochlear headache the presenting symptom is
unilateral periorbital pain radiating from the trochlear area with associated
headache. The pain of primary trochlear headache is exacerbated by supraduction
of the a ected eye, although no limitation of range of motion of the superior
oblique should be noted. The pain of this uncommon headache syndrome is often
worse at night, and whereas initially the pain is characterized by remissions and
exacerbations, without treatment it can become chronic. As the name implies,
primary trochlear headache is a diagnosis of exclusion because it occurs in the
absence of primary orbital, retro-orbital, or ocular pathology.
Often confused with acute ocular diseases such as glaucoma or herpes zoster of
the rst division of the trigeminal nerve or Charlin syndrome, pathology of the
orbit and the retro-orbital region must be ruled out before the diagnosis of primary
trochlear headache can be made. In ammatory and autoimmune conditions
involving the trochlear nerve anywhere along its path such as multiple sclerosis,
cranial neuritis, and Tolosa-Hunt syndrome, as well as compromise of the trochlear
nerve by tumor, abscess, or vascular abnormality must be carefully sought before
the diagnosis of primary trochlear can be considered (Figures 3-1 and 3-2). The
diagnosis of primary trochlear headache is then con rmed by injection of the
trochlear region with local anesthetic and antiin ammatory steroid. Primary
trochlear headache will uniformly respond to this injection.$
Figure 3-1 Axial, T1-weighted, contrast-enhanced image demonstrates soft tissue
in the left cavernous sinus, which has enhanced markedly. The enhancement
extends along the free edge of the tentorium cerebelli. Imaging is nonspeci c, but
after exclusion of other conditions this patient was diagnosed with Tolosa-Hunt
syndrome.
(From Tang Y, Booth T, Steward M, et al: The imaging of conditions affecting the
cavernous sinus, Clin Radiol 65:937-945, 2010.)$
$

$
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Figure 3-2 Axial T1-weighted image with gadolinium and fat saturation. This
55year-old man had painful ophthalmoplegia (III, IV, VI, and VI) and slight proptosis
of the right eye. Magnetic resonance imaging shows an enhancing ill-de ned
process in the right orbital apex. Cavernous sinus not involved (Tolosa-Hunt
syndrome).
(From Ferreira T, Verbist B, van Buchem M, et al: Imaging the ocular motor nerves, Eur J
Radiol 74:314-322, 2010.)
Clinically Relevant Anatomy
The trochlear nerve (cranial nerve IV) is composed of somatic general e erent
motor bers. It innervates the superior oblique extraocular muscle of the
contralateral orbit (Figure 3-3). Contraction of the superior oblique extraocular
muscle intorts (rotates inward), depresses, and abducts the globe. The superior
oblique extraocular muscle works in concert with the five other extraocular muscles
to allow the eye to perform its essential functions of tracking and xation on
objects.
Figure 3-3 Trochlear nerve (IV) in the orbit.
(From Drake RL, Vogl W, Mitchell AWM: Gray’s anatomy for students, ed 2,
Philadelphia, 2010, Churchill Livingstone.)
The bers of the trochlear nerve originate from the trochlear nucleus, which is
just ventral to the cerebral aqueduct in the tegmentum of the midbrain at the level
of the inferior colliculus. As the trochlear nerve leaves the trochlear nucleus, it
travels dorsally, wrapping itself around the cerebral aqueduct to then decussate in
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the superior medullary velum. The decussated bers of the trochlear nerve then
exit the dorsal surface of the brainstem just below the contralateral inferior
colliculus, where they then curve around the brainstem, leaving the subarachnoid
space along with the oculomotor nerve (cranial nerve III) between the superior
cerebellar and posterior cerebral arteries. The trochlear nerve then enters the
cavernous sinus and runs anteriorly along the lateral wall of the sinus with the
oculomotor nerve (cranial nerve III), trigeminal nerve (cranial nerve V), and
abducens nerve (cranial nerve VI).
After exiting the cavernous sinus, the trochlear nerve enters the orbit via the
superior orbital ssure. Unlike the oculomotor nerve, the trochlear nerve does not
pass through the tendinous ring of the extraocular muscles but passes just above
the ring. The trochlear nerve then crosses medially along the roof of the orbit above
the levator palpebrae and superior rectus muscles to innervate the superior oblique
muscle (see Figure 3-3).
Disorders of the trochlear nerve can be caused by central lesions that a ect the
trochlear nucleus such as stroke or space-occupying lesions such as tumor, abscess,
or aneurysm. Increased intracranial pressure from subdural hematoma, sagittal
sinus thrombosis, or abscess can compromise the nucleus and/or the e erent bers
of the trochlear nerve as they exit the brainstem and travel toward the orbit, with
resultant abnormal nerve function. Traction on the trochlear nerve from loss of
cerebrospinal uid has also been implicated in cranial nerve IV palsy. Small vessel
disease from diabetes or vasculitis associated with temporal arteritis may cause
ischemia and even infarction of the trochlear nerve with resultant pathologic
symptoms.
In almost all disorders of the trochlear nerve, symptoms will take the form of a
palsy of the superior oblique muscle, most commonly manifesting as an inability to
look inward and downward. Often the patient will report di6 culty in walking
down stairs owing to the inability to depress the a ected eye or eyes. On physical
examination the clinician may note extorsion (outward rotation) of the a ected eye
as a result of the unopposed action of the inferior oblique muscle (Figure 3-4, A). In
an e ort to compensate, the patient may deviate his or her face forward and
downward with the chin rotated toward the a ected side to look downward (Figure
3-4, B). However, it should be remembered that isolated trochlear nerve palsy is
the least common of the ocular motor palsies, and its presence should be viewed as
an ominous warning sign.$
$
Figure 3-4 A, The unopposed action of the inferior oblique muscle in the presence
of trochlear nerve palsy results in extorsion of the globe and associated weak
downward gaze. B, To compensate for the unopposed action of the inferior oblique
muscle in the presence of trochlear palsy, the patient deviates his face forward and
downward with the chin rotated toward the affected side.
Technique
The patient is placed in a supine position. A total of 2 mL of local anesthetic is
drawn up in a 10-mL sterile syringe. When primary trochlear headache is treated
with trochlear region block, a total of 80 mg of depot corticosteroid is added to the
local anesthetic with the rst block, and 40 mg of depot corticosteroid is added
with subsequent blocks.
For trochlear region block to be performed, the medial canthus is identi ed
and a line is drawn superiorly to a point just below the eyebrow. The skin at the
midpoint of this line is prepared with antiseptic solution, with care being taken to
avoid spillage into the eye. A 25-gauge, 1½-inch needle is inserted at this point and
advanced until the tip of the needle makes contact with the bony surface of the
orbit. After careful gentle aspiration, the contents of the syringe are slowly injected
as the needle is slowly directed superiorly and inferiorly (Figure 3-5). 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. When trochlear region block is used to treat the pain and
symptoms associated with primary trochlear headache, 8 to 10 daily nerve blocks
with local anesthetic may be required. If daily blocks are being performed, as a
general rule the total dose of depot corticosteroids included in these blocks should
not exceed 360 to 400 mg.$
$
Figure 3-5 For trochlear block to be performed, the medial canthus is identi ed,
and a line is drawn superiorly to a point just below the eyebrow.
Side Effects and Complications
The major complication of this procedure is inadvertent injury to the eye. Failure to
maintain bony contact while advancing the needle will greatly increase the risk of
the devastating complication. The practitioner should also remember that this area
is highly vascular and the potential for intravascular injection of local anesthetic
with its attendant risks remains an ever-present possibility. This vascularity gives
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. Application of cold packs for 20-minute
periods after the block also decreases the amount of postprocedure pain and
bleeding.
Clinical Pearls
Trochlear nerve block is especially useful in the diagnosis and palliation of pain
secondary to primary trochlear headache. The rst step in the care of patients
thought to have this unusual cause of headache is ruling out more common types
of headache that may mimic primary trochlear headache. Any patient with
headaches bad enough to require neural blockade as part of the treatment plan
should undergo computed tomography (CT) or magnetic resonance imaging (MRI)
of the head to rule out unsuspected intracranial pathologic conditions.
Suggested Readings
Becker M., Kohler R., Vargas M.I., et al. Pathology of the trigeminal nerve.
Neuroimaging Clin N Am. 2008;18:283–307.
Ferreira T., Verbist B., van Buchem M., et al. Imaging the ocular motor nerves. Eur J
Radiol. 2010;74:314–322.
Lin C.M., Hseu I.H. Isolated trochlear nerve palsy associated with carotid-cavernous
sinus fistula. Int J Gerontol. 2009;3:129–132.
Rait J. Ocular causes of headache. In: Selvaratnam P., Niere K., Zuluaga M.
Headache, orofacial pain and bruxism. New York: Churchill Livingstone; 2009:127–138.
Waldman S.D. The trochlear nerve—cranial nerve IV. In: Pain review. Philadelphia:
Saunders–Elsevier; 2009.
Yangüela J., Sánchez-del-Rio M., Bueno A., et al. Primary trochlear headache: a new
cephalgia generated and modulated on the trochlear region. Am J Ophthalmol.
2004;138:703.
Yangüela J., Sánchez-del-Rio M., Bueno A., et al. Primary trochlear headache: a new
cephalgia generated and modulated on the trochlear region. Neurology.
2004;62:1134–1140.
Chapter 4
Buccal Fold Injection for Incisors and Canine
Teeth
Indications and Clinical Considerations
The buccal fold injection technique is useful in the diagnosis and treatment of pain
involving the incisors or canine teeth of the upper jaw. This technique can provide
much-needed emergency relief of dental pain while the patient is waiting for
de nitive dental treatment. It can also serve as a useful diagnostic maneuver when
the clinician is trying to localize the nidus of pain that the patient perceives as
dental in origin.
Dental pain is the result of irritation or in ammation of the nerves of the pulp
and/or root of the tooth. Common causes of irritation or in ammation responsible
for dental pain include infection, decay with resultant nerve exposure, gingival
disease, plaque at or below the gum line, bruxism, injury, tumor, and tooth
extractions (Figure 4-1). Less common causes include chemotherapy-induced
odontalgia and barodontalgia. Pain involving the incisors or canine teeth may also
be referred from other anatomic areas. Such referred pain may be indicative of
temporomandibular joint dysfunction, sinus disease, abnormalities of the
trigeminal nerve and its branches, and coronary artery stenosis.
Figure 4-1 Intruded primary incisor. A, Day of injury. B, Radiograph on day of
injury. C, Three weeks postinjury. D, Five months postinjury.
(From McTigue DJ: Managing injuries to the primary dentition, Dent Clin North Am


53:627-638, 2009.)
Dental pain may range from a dull ache to severe, unremitting pain. Its onset
may be insidious or acute. Dental pain is often worse when the a/ ected tooth or
teeth are exposed to hot or cold temperatures as well as when direct pressure is
applied to the tooth or teeth when chewing. Tapping on the a/ ected tooth or teeth
may elicit an acute exacerbation of the pain. If signi cant in ammation or
infection is present, rubor and color may be present, as well as swelling. Gingival
bleeding or purulent drainage may also be present. It should be remembered that
on occasion a severely compromised tooth that is causing a patient signi cant pain
may appear completely normal.
Clinically Relevant Anatomy
The incisor and canine and surrounding periosteum and buccal and gingival tissue
are innervated by the superior alveolar nerve, which is a branch of the inferior
alveolar nerve just before it exits from the infraorbital canal below the orbit (Figure
4-2). Fibers of the ipsilateral superior alveolar nerve may cross the midline and
may anastomose with bers of the contralateral nerve, although medial spread of
injected local anesthetics may be limited by the attachments of the labial frenulum
at the midline. The periosteum and bone that surround and support the root of the
tooth are relatively thin and readily allow di/ usion of local anesthetics injected in
this region (Figure 4-3).
Figure 4-2 The relationship of the superior alveolar nerve to the incisor and
canine.Figure 4-3 Lateral view of the canine demonstrating relationship of the
supporting structures and apical region.
Technique
The patient is placed in a supine position. A total of 1 to 2 mL of local anesthetic is
drawn up in a 3-mL sterile syringe. The lip overlying the a/ ected tooth is retracted,
and a small amount of topical anesthetic such as viscous lidocaine or EMLA cream
is applied to the alveolar sulcus with a cotton-tipped applicator. After topical
anesthesia has been achieved, a 25-gauge, 1½-inch needle is inserted through the
previously anesthetized area and advanced axially and slightly medially toward the
apex of the a/ ected tooth. When the needle tip impinges on bone, it is withdrawn
slightly out of the periosteum, and after gentle aspiration the local anesthetic is
slowly injected around the apex target area. The anesthetic will rapidly di/ use and
anesthetize the pulp of the a/ ected tooth (Figure 4-4). It should be remembered
that the root of the canine tooth is longer than the root of the incisor and the apical
portion of the root is often slightly more distally oriented.
Figure 4-4 Proper needle placement with needle tip in good position. Green area
indicates the initial flow of local anesthetic.
Side Effects and Complications
In general, the use of nerve blocks in dentistry has enjoyed an amazing track record
of utility and safety. Most side e/ ects and complications are related to inadvertent
intravascular injection, the use of local anesthetics containing epinephrine, and
vasovagal syncope. Occasional hematoma and ecchymosis formation after dental
nerve block is encountered, especially in patients taking anticoagulants or
antiplatelet drugs. Pitfalls in needle placement include decreased di/ usion of local
anesthetic resulting from placement that is too super cial or positioning of the
needle tip between the relatively impermeable fascia and labial muscle. Excessive
pain from overly rapid injection of local anesthetic should also be avoided. The
clinician is reminded that severe dental abscess can be life-threatening, and
emergency incision and drainage combined with aggressive antibiotic therapy may
be required to avoid disaster. Referred pain as well as pain from tumor should
always be considered when evaluating a patient with dental pain.
Clinical Pearls
Traumatic or nontraumatic dental pain is an increasingly frequent reason for
adult and pediatric patients to visit urgent care and emergency room facilities.
Often, urgent care or emergency room physicians have little or no training in the
treatment of painful dental conditions. The use of dental nerve blocks with
longacting local anesthetics can provide excellent palliation of pain while the patient
waits to obtain emergent dental care.
Suggested Readings
Abt E. Topical anesthetics are more effective in diminishing pain from needle stick
insertion alone compared to reducing pain from insertion with anestheticinjection. J Evid Based Dent Pract. 2010;10:160–161.
Kato T., Lavigne G.J. Sleep bruxism: a sleep-related movement disorder. Sleep Med
Clin. 2010;5:9–35.
McTigue D.J. Managing injuries to the primary dentition. Dent Clin North Am.
2009;53:627–638.
van Wijk A.J., Hoogstraten J. Anxiety and pain during dental injections. J Dent.
2009;37:700–704.
Zadik Y. Barodontalgia: what have we learned in the past decade? Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2010;109:e65–e69.
Zadik Y., Vainstein V., Heling I., et al. Cytotoxic chemotherapy-induced odontalgia:
a differential diagnosis for dental pain. J Endod. 2010;36:1588–1592.





Chapter 5
Buccal Fold Injection Technique for Upper
Premolar Teeth
Indications and Clinical Considerations
The buccal fold injection technique is useful in the diagnosis and treatment of pain
involving the premolar teeth of the upper jaw. This technique can provide
muchneeded emergency relief of dental pain while the patient is waiting for de nitive
dental treatment. It can also serve as a useful diagnostic maneuver when the
clinician is trying to localize the nidus of pain that the patient perceives as dental
in origin.
Dental pain is the result of irritation or in ammation of the nerves of the pulp
and/or root of the tooth. Common causes of irritation or in ammation responsible
for dental pain include infection, decay with resultant nerve exposure, gingival
disease, plaque at or below the gum line, bruxism, injury, tumor, and tooth
extraction. Less common causes include chemotherapy-induced odontalgia and
barodontalgia. Pain involving the incisors or canine teeth may also be referred from
other anatomic areas. Such referred pain may be indicative of temporomandibular
joint dysfunction, sinus disease, abnormalities of the trigeminal nerve and its
branches, and coronary artery stenosis.
Dental pain may range from a dull ache to severe, unremitting pain. Its onset
may be insidious or acute. Dental pain is often worse when the a( ected tooth or
teeth are exposed to hot or cold temperatures as well as when direct pressure is
applied to the tooth or teeth when chewing. Tapping on the a( ected tooth or teeth
may elicit an acute exacerbation of the pain. If signi cant in ammation or
infection is present, rubor and color may be present, as well as swelling. Gingival
bleeding or purulent drainage may also be present. It should be remembered that
on occasion a severely compromised tooth that is causing a patient signi cant pain
may appear completely normal.
Clinically Relevant Anatomy
The upper premolar is innervated by the superior dental plexus, which is composed
of convergent bers from the superior, posterior, and anterior alveolar nerves
(Figure 5-1). In some patients the premolars are innervated from bers from the
middle superior alveolar nerve. The periosteum and bone that surround and
support the root of the tooth are relatively thin and readily allow di( usion of local
anesthetics injected in this region (Figure 5-2). The adjacent palate is innervated by
the greater palatine nerve and occasionally bers of the nasopalatine nerve (Figure
5-3). Supplemental blockade of these nerves will often be required to completely
relieve upper premolar pain.Figure 5-1 Innervation of the upper premolars.
Figure 5-2 Spread of local anesthetic with blockade of upper premolar. Green
indicates spread of local anesthetic.Figure 5-3 Anatomy of the greater palatine nerve.
Technique
The patient is placed in a supine position. A total of 1 to 2 mL of local anesthetic is
drawn up in a 3-mL sterile syringe. The lip overlying the a( ected tooth is retracted,
and a small amount of topical anesthetic such as viscous lidocaine or EMLA cream
is applied to the alveolar sulcus with a cotton-tipped applicator. After topical
anesthesia has been achieved, a 25-gauge, 1½-inch needle is inserted through the
previously anesthetized area and advanced axially toward the apex of the a( ected
tooth (Figure 5-4). If the needle tip impinges on bone, it is withdrawn slightly out
of the periosteum, and after gentle aspiration the local anesthetic is slowly injected
around the apex target area. The anesthetic will rapidly di( use and anesthetize the
pulp of the a( ected tooth. Supplemental block of the greater palatine nerve is
carried out by placing the needle at right angles to the mucosa at a point
approximately half the height of the affected premolar (Figure 5-5).Figure 5-4 Needle placement for block of the upper premolars.
Figure 5-5 Needle placement for greater palatine nerve block.
Side Effects and Complications
In general, the use of nerve blocks in dentistry has enjoyed an amazing track record
of utility and safety. Most side e( ects and complications are related to inadvertent
intravascular injection, the use of local anesthetics containing epinephrine, and
vasovagal syncope. Occasional hematoma and ecchymosis formation after dental
nerve block is encountered, especially in patients taking anticoagulants or
antiplatelet drugs. Pitfalls in needle placement include decreased di( usion of local
anesthetic as a result of placement that is too super cial placement or positioning
of the needle tip between the relatively impermeable fascia and labial muscle.
Excessive pain caused by overly rapid injection of local anesthetic should also be
avoided. The clinician is reminded that severe dental abscess can be
lifethreatening, and emergency incision and drainage combined with aggressive
antibiotic therapy may be required to avoid disaster. Referred pain as well as pain
from tumor should always be considered when evaluating a patient with dental
pain.
Clinical Pearls
Traumatic or nontraumatic dental pain is an increasingly frequent reason for
adult and pediatric patients to visit urgent care and emergency room facilities.
Often, urgent care or emergency room physicians have little or no training in the
treatment of painful dental conditions. The use of dental nerve blocks with
longacting local anesthetics can provide excellent palliation of pain while the patient
waits to obtain emergent dental care.
Suggested Readings
Abt E. Topical anesthetics are more effective in diminishing pain from needle stick
insertion alone compared to reducing pain from insertion with anesthetic
injection. J Evid Based Dent Pract. 2010;10:160–161.
Kato T., Lavigne G.J. Sleep bruxism: a sleep-related movement disorder. Sleep Med
Clin. 2010;5:9–35.
McTigue D.J. Managing injuries to the primary dentition. Dent Clin North Am.
2009;53:627–638.
van Wijk A.J., Hoogstraten J. Anxiety and pain during dental injections. J Dent.
2009;37:700–704.
Zadik Y. Barodontalgia: what have we learned in the past decade? Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2010;109:e65–e69.
Zadik Y., Vainstein V., Heling I., et al. Cytotoxic chemotherapy-induced odontalgia:
a differential diagnosis for dental pain. J Endod. 2010;36:1588–1592.


Chapter 6
Buccal Fold Injection for Upper Molar Teeth
Indications and Clinical Considerations
The buccal fold injection technique is useful in the diagnosis and treatment of pain
involving the molars of the upper jaw. This technique can provide much-needed
emergency relief of dental pain while the patient is waiting for de nitive dental
treatment. It can also serve as a useful diagnostic maneuver when the clinician is
trying to localize the nidus of pain that the patient perceives as dental in origin.
Dental pain is the result of irritation or in ammation of the nerves of the pulp
and/or root of the tooth. Common causes of irritation or in ammation responsible
for dental pain include infection, decay with resultant nerve exposure, gingival
disease, plaque at or below the gum line, bruxism, injury, tumor, and tooth
extraction. Less common causes include chemotherapy-induced odontalgia and
barodontalgia. Pain involving the incisors or canine teeth may also be referred from
other anatomic areas. Such referred pain may be indicative of temporomandibular
joint dysfunction, sinus disease, abnormalities of the trigeminal nerve and its
branches, and coronary artery stenosis.
Dental pain may range from a dull ache to severe, unremitting pain. Its onset
may be insidious or acute. Dental pain is often worse when the a( ected tooth or
teeth are exposed to hot or cold temperatures as well as when direct pressure is
applied to the tooth or teeth when chewing. Tapping on the a( ected tooth or teeth
may elicit an acute exacerbation of the pain. If signi cant in ammation or
infection is present, rubor and color may be present, as well as swelling. Gingival
bleeding or purulent drainage may also be present. It should be remembered that
on occasion a severely compromised tooth that is causing a patient signi cant pain
may appear completely normal.
Clinically Relevant Anatomy
The upper molars and surrounding periosteum and buccal and gingival tissue are
innervated by the superior alveolar nerve, which branches from the infraorbital
nerve before it enters the orbital cavity. These branches travel downward along the
maxillary tuberosity to provide innervation for the upper molars and the buccal
gingiva and associated periosteum. The gingiva, mucosa, and periosteum of the
adjacent palate are innervated by the greater palatine nerve (Figure 6-1). The
greater palatine nerve passes from the pterygopalatine fossa via the pterygopalatine
canal through the pterygopalatine foramen (see Figure 5-3). In some patients an
anatomic variation occurs, and the upper molars are innervated primarily by the
middle alveolar nerves. This variation has little clinical import insofar as the
success of this block is concerned. The palate adjacent to the molars is innervated
by the greater palatine nerve and in some patients by small anastomosing branches
of the nasopalatine nerve (see Figure 5-3). The periosteum and bone that surround
and support the roots of the molars are relatively thin and readily allow di( usion oflocal anesthetics injected in this region. For satisfactory anesthesia to be provided
to the upper molars, three separate injections are usually required: (1) the buccal
fold injection, (2) the tuberosity injection, and (3) the supplemental greater
palatine nerve injection. Each injection is described in the following sections.
Figure 6-1 Innervation of the upper molars.
Technique
Buccal Fold Injection
The patient is placed in a supine position. If the more distal molars are to be
blocked, it is important not to have the patient open the mouth too widely, or the
coronoid process of the mandible will move ventrally and block the injection site. A
total of 4 mL of local anesthetic is drawn up in a 5-mL sterile syringe. The lip
overlying the a( ected tooth is retracted, and a small amount of topical anesthetic
such as viscous lidocaine or EMLA cream is applied to the alveolar sulcus with a
cotton-tipped applicator. After topical anesthesia has been achieved, a 25-gauge,
1½-inch needle is inserted through the previously anesthetized area and advanced
axially and slightly posteriorly toward the apex of the a( ected tooth. When the
needle tip impinges on bone, it is withdrawn slightly out of the periosteum, and
after gentle aspiration 1 to 2 mL of local anesthetic is slowly injected around the
apex target area; the anesthetic will rapidly di( use and anesthetize the pulp of the
a( ected tooth (Figures 6-2 and 6-3). It should be noted that unlike the previously
described buccal fold injection techniques for the incisors, canines, and premolars,
this technique yields relatively little anesthesia of the adjacent lip (Figure 6-4).Figure 6-2 Buccal fold injection for the upper molars.
Figure 6-3 Needle trajectory for buccal fold injection for the upper molars.
Figure 6-4 Spread of anesthesia after buccal fold injection for the upper molars.
Note the relative lack of lip anesthesia.
Tuberosity Injection
The lip overlying the a( ected tooth is retracted, and the infrazygomatic crest is
palpated with the gloved index nger, which also gently retracts the corner of the
mouth posteriorly. A 25-gauge, 1½-inch needle is inserted slightly distal to the
second molar and; while it is kept close to the maxillary tuberosity, it is advanced
in a superior and posterior trajectory (Figure 6-5). After gentle aspiration, an
additional 2 mL of local anesthetic is slowly injected around the apex target area;
the anesthetic will rapidly di( use and anesthetize the pulp of the a( ected tooth
(Figure 6-6). This injection will augment the anesthesia of the second and third
molars (Figure 6-7).Figure 6-5 Tuberosity injection for the upper molars.
Figure 6-6 Needle trajectory for tuberosity injection for the upper molars.

Figure 6-7 Spread of anesthesia after tuberosity injection for the upper molars.
Supplemental Greater Palatine Nerve Injection
Most patients with signi cant molar pain or those undergoing major procedures on
the molars (e.g., root canals, extractions) will require supplementation of the
anesthesia, obtained with upper molar dental block with injection of the bers of
the greater palatine nerve. This technique is carried out through injection of 0.1 to
0.2 mL of local anesthetic at right angles to the a( ected tooth at a point
approximately one half of the tooth height (Figures 6-8 and 6-9).
Figure 6-8 Injection of the greater palatine nerve for anesthesia of the upper
molars.
Figure 6-9 Spread of anesthesia after greater palatine nerve injection for the
upper molars.
Side Effects and Complications
In general, the use of nerve blocks in dentistry has enjoyed an amazing track record
of utility and safety. Most side e( ects and complications are related to inadvertent
intravascular injection, the use of local anesthetics containing epinephrine, and
vasovagal syncope. Occasional hematoma and ecchymosis formation after dental
nerve block is encountered, especially in patients taking anticoagulants or
antiplatelet drugs. Pitfalls in needle placement include decreased di( usion of local
anesthetic as a result of placement that is too super cial placement or positioning
of the needle tip between the relatively impermeable fascia and labial muscle.
Excessive pain caused by overly rapid injection of local anesthetic should also be
avoided. The clinician is reminded that severe dental abscess can be
lifethreatening, and emergency incision and drainage combined with aggressive
antibiotic therapy may be required to avoid disaster. Referred pain as well as pain
from tumor should always be considered when evaluating a patient with dental
pain.
Clinical Pearls
Traumatic or nontraumatic dental pain is an increasingly frequent reason for
adult and pediatric patients to visit urgent care and emergency room facilities.
Often, urgent care or emergency room physicians have little or no training in the
treatment of painful dental conditions. The use of dental nerve blocks with
longacting local anesthetics can provide excellent palliation of pain while the patient
waits to obtain emergent dental care.Suggested Reading
Abt E. Topical anesthetics are more effective in diminishing pain from needle stick
insertion alone compared to reducing pain from insertion with anesthetic
injection. J Evid Based Dent Pract. 2010;10:160–161.
Kato T., Lavigne G.J. Sleep bruxism: a sleep-related movement disorder. Sleep Med
Clin. 2010;5:9–35.
McTigue D.J. Managing injuries to the primary dentition. Dent Clin North Am.
2009;53:627–638.
Mylonas A.I., Tzerbos F.H., Mihalaki M., et al. Cerebral abscess of odontogenic
origin. J Craniomaxillofac Surg. 2007;35:63–67.
van Wijk A.J., Hoogstraten J. Anxiety and pain during dental injections. J Dent.
2009;37:700–704.
Zadik Y. Barodontalgia: what have we learned in the past decade? Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2010;109:e65–e69.
Zadik Y., Vainstein V., Heling I., et al. Cytotoxic chemotherapy-induced odontalgia:
a differential diagnosis for dental pain. J Endod. 2010;36:1588–1592.



Chapter 7
Incisive Nerve Block
Indications and Clinical Considerations
This injection technique is useful in the diagnosis and treatment of pain involving
the incisors or canine teeth of the lower jaw. This technique can provide
muchneeded emergency relief of dental pain while the patient is waiting for de nitive
dental treatment. It can also serve as a useful diagnostic maneuver when the
clinician is trying to localize the nidus of pain that the patient perceives as dental
in origin.
Dental pain is the result of irritation or in ammation of the nerves of the pulp
and/or root of the tooth. Common causes of irritation or in ammation responsible
for dental pain include infection, decay with resultant nerve exposure, gingival
disease, plaque at or below the gum line, bruxism, injury, tumor, and tooth
extraction (Figure 7-1). Less common causes include chemotherapy-induced
odontalgia and barodontalgia. Pain involving the incisors or canine teeth may also
be referred from other anatomic areas. Such referred pain may be indicative of
temporomandibular joint dysfunction, sinus disease, abnormalities of the
trigeminal nerve and its branches, and coronary artery stenosis.
Figure 7-1 Right lower gingival carcinoma in a 45-year-old man with
histopathologically con rmed alveolar bone invasion (A, arrow) . A, Cropped
panoramic image. B to D, Cone-beam computed tomography (CT) images (B,
horizontal; C, parallel; D, cross section). Cone-beam CT images reveal alveolar



bone destruction of the right mandible (B, C, and D, arrow), whereas corresponding
bone destruction cannot be seen on panoramic image.
(From Momin MA, Okochi K, Watanabe H, et al: Diagnostic accuracy of cone-beam CT
in the assessment of mandibular invasion of lower gingival carcinoma: comparison with
conventional panoramic radiography, Eur J Radiol 72:75-81, 2009.)
Dental pain may range from a dull ache to severe, unremitting pain. Its onset
may be insidious or acute. Dental pain is often worse when the a1ected tooth or
teeth are exposed to hot or cold temperatures as well as when direct pressure is
applied to the tooth or teeth when chewing. Tapping on the a1ected tooth or teeth
may elicit an acute exacerbation of the pain. If signi cant in ammation or
infection is present, rubor and color may be present, as well as swelling. Gingival
bleeding or purulent drainage may also be present. It should be remembered that
on occasion a severely compromised tooth that is causing a patient signi cant pain
may appear completely normal.
Clinically Relevant Anatomy
The lower incisors and canine teeth are innervated by a branch of the incisive
nerve, which is a distal branch of the inferior dental nerve. In most patients the
nerve is covered by a thin layer of osseous lamina that allows easy di1usion of local
anesthetic (Figure 7-2). Occasionally the bone is too thick to allow rapid di1usion
of local anesthetic, and a mental or mandibular nerve block will be required. It
should be noted that bers of the contralateral incisive nerve may cross the midline
and confuse the clinical picture. The buccal soft issues in this region are innervated
by branches of the mental nerve, whereas the lingual gingiva and associated
periosteum are innervated by branches of the sublingual nerve (Figure 7-3).
Supplemental blockade of the mental and sublingual nerves may be required to
provide complete anesthesia for the lower incisors and canine teeth.
Figure 7-2 The incisive nerve provides innervations to the lower incisors and
canines.Figure 7-3 The relationship of the lingual nerve to the lower incisors and canines.
Technique
The patient is placed in a supine position. A total of 1 to 2 mL of local anesthetic is
drawn up in a 3-mL sterile syringe. The lip overlying the a1ected tooth is retracted,
and a small amount of topical anesthetic such as viscous lidocaine or EMLA cream
is applied to the buccal fold with a cotton-tipped applicator. After topical
anesthesia has been achieved, a 25-gauge, 1½-inch needle is inserted through the
previously anesthetized area and advanced toward the apex of the a1ected tooth.
When the needle tip impinges on bone, it is withdrawn slightly out of the
periosteum, and after gentle aspiration the local anesthetic is slowly injected
around the apex target area; the anesthetic will rapidly di1use and anesthetize the
pulp of the a1ected tooth (Figure 7-4). To perform the supplemental lingual nerve
block, the needle is advanced just under the attached gingiva; after careful
aspiration, 1.0 mL of local anesthetic is slowly injected (Figure 7-5).Figure 7-4 Buccal fold injection for the lower incisors and canine teeth.
Figure 7-5 Lingual nerve block for lower incisor and canine tooth dental pain.
Side Effects and Complications
In general, the use of nerve blocks in dentistry has enjoyed an amazing track record
of utility and safety. Most side e1ects and complications are related to inadvertent
intravascular injection, the use of local anesthetics containing epinephrine, and
vasovagal syncope. Occasional hematoma and ecchymosis formation after dental
nerve block is encountered, especially in patients taking anticoagulants or
antiplatelet drugs. Pitfalls in needle placement include decreased di1usion of local
anesthetic from placement that is too super cial or positioning of the needle tip
between the relatively impermeable fascia and labial muscle. Excessive pain from
overly rapid injection of local anesthetic should also be avoided. The clinician is
reminded that severe dental abscess can be life-threatening, and emergent incision
and drainage combined with aggressive antibiotic therapy may be required to
avoid disaster. Referred pain as well as pain from tumor should always be
considered when evaluating a patient with dental pain.
Clinical Pearls
Traumatic or nontraumatic dental pain is an increasingly frequent reason for
adult and pediatric patients to visit urgent care and emergency room facilities.
Often, urgent care or emergency room physicians have little or no training in the
treatment of painful dental conditions. The use of dental nerve blocks with
longacting local anesthetics can provide excellent palliation of pain while the patient
waits to obtain emergent dental care.
Suggested Readings
Abt E. Topical anesthetics are more effective in diminishing pain from needle stick
insertion alone compared to reducing pain from insertion with anesthetic
injection. J Evid Based Dent Pract. 2010;10:160–161.
Kato T., Lavigne G.J. Sleep bruxism: a sleep-related movement disorder. Sleep Med
Clin. 2010;5:9–35.
McTigue D.J. Managing injuries to the primary dentition. Dent Clin North Am.
2009;53:627–638.
van Wijk A.J., Hoogstraten J. Anxiety and pain during dental injections. J Dent.
2009;37:700–704.
Zadik Y. Barodontalgia: what have we learned in the past decade? Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2010;109:e65–e69.
Zadik Y., Vainstein V., Heling I., et al. Cytotoxic chemotherapy-induced odontalgia:
a differential diagnosis for dental pain. J Endod. 2010;36:1588–1592.

!
!
!

Chapter 8
Inferior Alveolar Nerve Block for Lower Premolar
Teeth
Indications and Clinical Considerations
The inferior alveolar nerve block is useful in the diagnosis and treatment of pain
involving the premolars of the lower jaw. This technique can provide much-needed
emergency relief of dental pain while the patient is waiting for de nitive dental
treatment. It can also serve as a useful diagnostic maneuver when the clinician is
trying to localize the nidus of pain that the patient perceives as dental in origin.
Dental pain is the result of irritation or in ammation of the nerves of the pulp
and/or root of the tooth. Common causes of irritation or in ammation responsible
for dental pain include infection, decay with resultant nerve exposure, gingival
disease, plaque at or below the gum line, bruxism, injury, tumor, or tooth
extraction. Less common causes include chemotherapy-induced odontalgia and
barodontalgia. Pain involving the incisors or canine teeth may also be referred from
other anatomic areas. Such referred pain may be indicative of temporomandibular
joint dysfunction, sinus disease, abnormalities of the trigeminal nerve and its
branches, and coronary artery stenosis.
Dental pain may range from a dull ache to severe, unremitting pain. Its onset
may be insidious or acute. Dental pain is often worse when the a) ected tooth or
teeth are exposed to hot or cold temperatures as well as when direct pressure is
applied to the tooth or teeth when chewing. Tapping on the a) ected tooth or teeth
may elicit an acute exacerbation of the pain. If signi cant in ammation or
infection is present, rubor and color may be present, as well as swelling. Gingival
bleeding or purulent drainage may also be present. It should be remembered that
on occasion a severely compromised tooth that is causing a patient signi cant pain
may appear completely normal.
Clinically Relevant Anatomy
The lower premolars are innervated primarily by the inferior alveolar nerve (Figure
8-1). Fibers of the buccal nerve innervate the buccal gingiva; the lingual gingiva is
innervated by the sublingual nerve. Because of the thicker mandibular bone which
supports the premolars, di) usion of local anesthetic with the buccal fold block is
limited, and mental or mandibular nerve block is required. The mental foramen
lies just inferior to and between the lower premolars (Figure 8-2).
Figure 8-1 The lower premolars are innervated primarily by branches of the
inferior alveolar nerve. Note the dense mandibular bone surrounding the premolars
as well as the relationship of the mental foramen to the premolars.
Figure 8-2 The relationship of the mental nerve to the premolars.
Technique
The patient is placed in a supine position. A total of 1 to 2 mL of local anesthetic is
drawn up in a 3-mL sterile syringe. The mental foramen is identi ed, and the lower
lip overlying the lower premolars is retracted. A small amount of topical anesthetic
such as viscous lidocaine or EMLA cream is then applied to the alveolar sulcus just
superior to the mental foramen with a cotton-tipped applicator. After topical
anesthesia has been achieved, a 25-gauge, 1½-inch needle is inserted through the
previously anesthetized area and advanced toward the mental foramen (Figure
83). Care should be taken to avoid inserting the needle directly into the mental
foramen to avoid inadvertent injection into the blood vessels or damage to the
mental nerve. When the needle tip impinges on bone, it is withdrawn slightly out of
the periosteum, and after gentle aspiration the local anesthetic is slowly injected
around the apex target area; the anesthetic will rapidly di) use and anesthetize the
pulp of the affected tooth (Figure 8-4). Some spillover of local anesthetic may result
in blockade of some bers of the buccal nerve, resulting in large areas of anesthesia
of the buccal soft tissues. Supplemental blockade of the lingual nerve is often
required to provide complete anesthesia of the premolars. To block the lingual
nerves, simply place the needle just beneath the surface of the lingual mucosa
adjacent to the a) ect premolar. After careful aspiration, 0.5 mL of local anesthetic
per premolar is injected (Figures 8-5 and 8-6).
Figure 8-3 Mental nerve block for lower premolar dental pain.Figure 8-4 Area of anesthesia after mental nerve block.
Figure 8-5 Relationship of the lingual nerve to the lower premolars.
Figure 8-6 Lingual nerve block for the premolars.
Side Effects and Complications
In general, the use of nerve blocks in dentistry has enjoyed an amazing track record
of utility and safety. Most side e) ects and complications are related to inadvertent
intravascular injection, the use of local anesthetics containing epinephrine, and
vasovagal syncope. Occasional hematoma and ecchymosis formation after dental
nerve block is encountered, especially in patients taking anticoagulants or
antiplatelet drugs. Pitfalls in needle placement include decreased di) usion of local
anesthetic because placement is too super cial or positioning of the needle tip
between the relatively impermeable fascia and labial muscle. Excessive pain caused
by overly rapid injection of local anesthetic should also be avoided. The clinician is
reminded that severe dental abscess can be life-threatening, and emergency
incision and drainage combined with aggressive antibiotic therapy may be required
to avoid disaster. Referred pain as well as pain from tumor should always be
considered when evaluating a patient with dental pain.
Clinical Pearls
Traumatic or nontraumatic dental pain is an increasingly frequent reason for
adult and pediatric patients to visit urgent care and emergency room facilities.
Often, urgent care or emergency room physicians have little or no training in the
treatment of painful dental conditions. The use of dental nerve blocks with
longacting local anesthetics can provide excellent palliation of pain while the patient
waits to obtain emergent dental care.
Suggested Readings
Abt E. Topical anesthetics are more effective in diminishing pain from needle stick
insertion alone compared to reducing pain from insertion with anesthetic
injection. J Evid Based Dent Pract. 2010;10:160–161.
Kato T., Lavigne G.J. Sleep bruxism: a sleep-related movement disorder. Sleep Med
Clin. 2010;5:9–35.
McTigue D.J. Managing injuries to the primary dentition. Dent Clin North Am.
2009;53:627–638.
van Wijk A.J., Hoogstraten J. Anxiety and pain during dental injections. J Dent.
2009;37:700–704.
Zadik Y. Barodontalgia: what have we learned in the past decade? Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2010;109:e65–e69.
Zadik Y., Vainstein V., Heling I., et al. Cytotoxic chemotherapy-induced odontalgia:
a differential diagnosis for dental pain. J Endod. 2010;36:1588–1592.

!
!
!

Chapter 9
Inferior Alveolar Nerve Block for Lower Molar
Teeth
Indications and Clinical Considerations
The inferior alveolar nerve block is useful in the diagnosis and treatment of pain
involving the molars of the lower jaw. This technique can provide much-needed
emergency relief of dental pain while the patient is waiting for de nitive dental
treatment. It can also serve as a useful diagnostic maneuver when the clinician is
trying to localize the nidus of pain that the patient perceives as dental in origin.
Dental pain is the result of irritation or in ammation of the nerves of the pulp
and/or root of the tooth. Common causes of irritation or in ammation responsible
for dental pain include infection, decay with resultant nerve exposure, gingival
disease, plaque at or below the gum line, bruxism, injury, tumor, or tooth
extraction. Less common causes include chemotherapy-induced odontalgia and
barodontalgia. Pain involving the incisors or canine teeth may also be referred from
other anatomic areas. Such referred pain may be indicative of temporomandibular
joint dysfunction, sinus disease, abnormalities of the trigeminal nerve and its
branches, and coronary artery stenosis.
Dental pain may range from a dull ache to severe, unremitting pain. Its onset
may be insidious or acute. Dental pain is often worse when the a) ected tooth or
teeth are exposed to hot or cold temperatures as well as when direct pressure is
applied to the tooth or teeth when chewing. Tapping on the a) ected tooth or teeth
may elicit an acute exacerbation of the pain. If signi cant in ammation or
infection is present, rubor and color may be present, as well as swelling. Gingival
bleeding or purulent drainage may also be present. It should be remembered that
on occasion a severely compromised tooth that is causing a patient signi cant pain
may appear completely normal.
Clinically Relevant Anatomy
The lower molars are innervated primarily by the mandibular (inferior alveolar)
nerve (Figure 9-1). Because of the thicker mandibular bone which supports the
premolars, di) usion of local anesthetic with buccal fold block is limited, and
blockade of the mandibular nerve before it enters the mandibular canal is required
(Figure 9-2), The lingual gingiva in the region of the lower molars is innervated by
the lingual nerve (see Figure 9-2). Terminal branches of the buccal nerve pass
through the buccinator muscles and provide innervations for the buccal mucosa in
the region of the lower molars (see Figure 9-2). For satisfactory anesthesia to be
provided to the lower molars, both the mandibular and lingual nerves need to be
blocked, as well as the buccal nerve (Figure 9-3).Figure 9-1 Anatomy of the mandibular nerve and lower molars.

Figure 9-2 Anatomy of the mandibular nerve and its relationship to the lingual
and buccal nerves.
Figure 9-3 Relationship of the mandibular lingual and buccal nerves.
Technique
Both the mandibular and lingual nerves can be blocked with one needle stick and
minor repositioning of the needle. For the mandibular and lingual nerves to be
blocked, the patient is placed in a supine position and a total of 3 mL of local
anesthetic is drawn up in a 3-mL sterile syringe. The patient is then asked to open
his or her mouth widely, and the coronoid notch is palpated with the index nger
of the left hand (Figure 9-4). The syringe with an attached 25-gauge, 1½-inch
needle is then directed from between the contralateral premolars toward an area
approximately 1 cm above the level of the occlusal surface of the molars to be
blocked just in front of the palpating index nger (Figure 9-5). The patient is then
asked to slightly close his or her mouth to decrease tension of the pterygoid
muscles. With the decrease of tension on the tightly stretched pterygoid muscles,
the lateral margin of the pterygoid muscle relaxes, allowing the displaced nerve to
return to its proper anatomic position.
Figure 9-4 Palpating the coronoid notch.
Figure 9-5 Injection site for mandibular nerve block lies at the level of the nger
palpating the coronoid notch, which is approximately 1 cm above the occlusal
surfaces of the lower molars.
The needle is now advanced dorsally approximately 1.5 to 2.0 cm along the
medial aspect of the mandibular ramus, with the trajectory of needle advancement
horizontal to the occlusal plane of the molars (Figure 9-6). When the needle
impinges onto the middle portion of the mandibular ramus, it is withdrawn
slightly, and after careful aspiration 1.5 mL of local anesthetic is injected. Theneedle is then withdrawn into the soft tissue and the trajectory is redirected
medially and ventrally toward the mandibular crest to block the lingual nerve
(Figure 9-7). The buccal nerve is then blocked by inserting the needle just above
the buccal fold at the third molar and advancing it toward the ipsilateral
mandibular ramus (Figure 9-8). After careful aspiration, 0.5 mL of additional local
anesthetic is then slowly injected.
Figure 9-6 Advancement of the needle for mandibular nerve block with the
needle shaft in contact with the mandibular ramus and the trajectory in the
horizontal plane of the occlusal surfaces of the molars being blocked.
Figure 9-7 Needle trajectory for lingual nerve block for lower molar dental pain.
Figure 9-8 Needle trajectory for buccal nerve injection for lower molar dental
pain.
Side Effects and Complications
In general, the use of nerve blocks in dentistry has enjoyed an amazing track record
of utility and safety. Most side e) ects and complications are related to inadvertent
intravascular injection, the use of local anesthetics containing epinephrine, and
vasovagal syncope. Occasional hematoma and ecchymosis formation after dental
nerve block is encountered, especially in patients taking anticoagulants or
antiplatelet drugs. Pitfalls in needle placement include decreased di) usion of local
anesthetic caused by placement that is too super cial or positioning of the needle
tip between the relatively impermeable fascia and labial muscle. Excessive pain
from overly rapid injection of local anesthetic should also be avoided. The clinician
is reminded that severe dental abscess can be life-threatening, and emergency
incision and drainage combined with aggressive antibiotic therapy may be required
to avoid disaster. Referred pain as well as pain from tumor should always be
considered when evaluating a patient with dental pain.
Clinical Pearls
Traumatic or nontraumatic dental pain is an increasingly frequent reason for
adult and pediatric patients to visit urgent care and emergency room facilities.
Often, urgent care or emergency room physicians have little or no training in the
treatment of painful dental conditions. The use of dental nerve blocks with
longacting local anesthetics can provide excellent palliation of pain while the patient
waits to obtain emergency dental care.Suggested Readings
Abt E. Topical anesthetics are more effective in diminishing pain from needle stick
insertion alone compared to reducing pain from insertion with anesthetic
injection. J Evid Based Dent Pract. 2010;10:160–161.
Kato T., Lavigne G.J. Sleep bruxism: a sleep-related movement disorder. Sleep Med
Clin. 2010;5:9–35.
McTigue D.J. Managing injuries to the primary dentition. Dent Clin North Am.
2009;53:627–638.
Mylonas A.I., Tzerbos F.H., Mihalaki M., et al. Cerebral abscess of odontogenic
origin. J Craniomaxillofac Surg. 2007;35:63–67.
van Wijk A.J., Hoogstraten J. Anxiety and pain during dental injections. J Dent.
2009;37:700–704.
Zadik Y. Barodontalgia: what have we learned in the past decade? Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2010;109:e65–e69.
Zadik Y., Vainstein V., Heling I., et al. Cytotoxic chemotherapy-induced odontalgia:
a differential diagnosis for dental pain. J Endod. 2010;36:1588–1592.

Chapter 10
Styloid Process Injection
Indications and Clinical Considerations
Eagle syndrome (also known as stylohyoid syndrome) is caused by pressure on the
internal carotid artery and surrounding structures including branches of the
glossopharyngeal nerve by an abnormally elongated styloid process or a calci ed
stylohyoid ligament (Figure 10-1). The pain of Eagle syndrome is sharp and
stabbing and occurs with movement of the mandible or with turning of the neck.
The pain starts below the angle of the mandible and radiates into the tonsillar
fossa, the temporomandibular joint, and the base of the tongue. A trigger point
may be present in the tonsillar fossa. Injection of the attachment of the stylohyoid
ligament to the styloid process with local anesthetic and corticosteroid serves as
both a diagnostic and a therapeutic maneuver. Rarely, the elongated styloid
process or calci ed stylohyoid ligament may actually cause vascular occlusion
(Figure 10-2).

Figure 10-1 Ossi cation of the stylohyoid ligament (Eagle syndrome). Note the
large ossi ed structure (arrows), which represents an elongated styloid process or
ossified stylohyoid ligament or both.
(From Resnick D: Diagnosis of bone and joint disorders, ed 4, Philadelphia, 2002,
Saunders.)
Figure 10-2 A, Axial computed tomography angiography (CTA) with right
sigmoid sinus occlusion (black arrow) and dye present in the left sigmoid sinus (white
arrow). B, Computed tomography (CT) venogram con rming the left internal
jugular vein compressed between the styloid process (black arrow) and lateral mass
of C1 (white arrow). C, Three-dimensional CTA demonstrating the left internal
jugular vein compressed between the styloid process (black arrow) and lateral mass
of C1 (white arrow). D, Left internal jugular vein, both compressed between the
styloid and C1 lateral mass. E, Sagittal view of subsequent CTA demonstrating
compression of the right internal jugular vein but some early recanalization.
(From Callahan B, Kang J, Dudekula A, et al: New Eagle’s syndrome variant complicating
management of intracranial pressure after traumatic brain injury, Inj Extra 41:41-44,
2010.)



Clinically Relevant Anatomy
The styloid process extends in a caudal and ventral direction from the temporal
bone from its origin just below the auditory meatus. The stylohyoid ligament’s
cephalad attachment is to the styloid process, and its caudal attachment is to the
hyoid bone. In Eagle syndrome the styloid process is abnormally elongated, either
alone or in combination with calci cation of the stylohyoid ligament. The
elongated process or calci ed ligament impinges on the internal carotid artery and
branches of the glossopharyngeal nerve (Figure 10-3). The glossopharyngeal nerve
exits from the jugular foramen in proximity to the vagus and accessory nerves and
the internal jugular vein and passes just inferior to the styloid process (see Figure
10-3). All three nerves lie in the groove between the internal jugular vein and the
internal carotid artery.
Figure 10-3 In patients with Eagle syndrome, the abnormally elongated styloid
process impinges on the internal carotid artery and glossopharyngeal nerve.
The key landmark for injection when treating Eagle syndrome is the styloid
process of the temporal bone. This osseous process represents the calci cation of
the cephalad end of the stylohyoid ligament. Although the styloid process is usually
easy to identify, if ossi cation is limited it may be di2 cult to locate with the
exploring needle.
Technique
Technique
The patient is placed in the supine position. An imaginary line that runs from the
mastoid process to the angle of the mandible (Figure 10-4) is visualized. The
styloid process should lie just below the midpoint of this line. The skin is prepared
with antiseptic solution. A 22-gauge, 1½-inch needle attached to a 10-mL syringe is
advanced at this midpoint location in a plane perpendicular to the skin. The styloid
process should be encountered within 10 cm. After contact has been made, the
needle is withdrawn slightly out of the periosteum or substance of the calci ed
ligament. After careful aspiration reveals no blood or cerebrospinal 5uid, 5 mL of
0.5% preservative-free lidocaine combined with 80 mg of methylprednisolone is
injected in incremental doses. Subsequent daily nerve blocks are carried out in a
similar manner, substituting 40 mg of methylprednisolone for the initial 80-mg
dose.
Figure 10-4 For proper needle placement when Eagle syndrome is treated, an
imaginary line is drawn from the mastoid process to the angle of the mandible to
facilitate locating the styloid process.
Side Effects and Complications
The major complications associated with this injection technique are related to
trauma to the internal jugular vein and carotid artery. Hematoma formation andintravascular injection of local anesthetic with subsequent toxicity are not
uncommon complications. Inadvertent blockade of the motor portion of the
glossopharyngeal nerve can result in dysphagia secondary to weakness of the
stylopharyngeus muscle. If the vagus nerve is inadvertently blocked, dysphonia
secondary to paralysis of the ipsilateral vocal cord may occur. A re5ex tachycardia
secondary to vagal nerve block is also observed in some patients. Inadvertent block
of the hypoglossal and spinal accessory nerves during glossopharyngeal nerve block
will result in weakness of the tongue and trapezius muscle.
Clinical Pearls
This injection technique for Eagle syndrome is a simple technique that can produce
dramatic relief for patients reporting the just-described types of pain. The
proximity of the styloid process to major vasculature makes the presence of
postblock hematoma and ecchymosis a distinct possibility. Although these
complications are usually transitory, their dramatic appearance can be quite
upsetting to the patient; therefore the patient should be warned of this possibility
before the procedure. The vascularity of this region also increases the incidence of
inadvertent intravascular injection. Even small amounts of local anesthetic
injected into the carotid artery at this level will result in local anesthetic toxicity
and seizures. Incremental administration while carefully monitoring the patient
for signs of local anesthetic toxicity helps avoid this complication.
Glossopharyngeal neuralgia can be distinguished from Eagle syndrome in that
the pain of glossopharyngeal neuralgia is characterized by paroxysms of shocklike
pain as in trigeminal neuralgia, rather than the sharp, shooting pain on
movement that is associated with Eagle syndrome. Because glossopharyngeal
neuralgia may be associated with serious cardiac bradyarrhythmias and syncope,
the clinician must distinguish between the two syndromes.
The clinician should always evaluate the patient with pain in this anatomic
region for occult malignancy. Tumors of the larynx, hypopharynx, and anterior
triangle of the neck may manifest as clinical symptoms identical to hyoid
syndrome. Given the low incidence of Eagle syndrome relative to pain secondary
to malignancy in this anatomic region, Eagle syndrome must be considered a
diagnosis of exclusion.
Suggested Readings
Andrade M.G., Marchionni A.M., Rebello I.C., et al. Three-dimensional identification
of vascular compression in Eagle’s syndrome using computed tomography: case
report. J Oral Maxillofac Surg. 2008;66:169–176.
Callahan B., Kang J., Dudekula A., et al. New Eagle’s syndrome variant complicating
management of intracranial pressure after traumatic brain injury. Inj Extra.
2010;41:41–44.
Lee S., Hillel A. Three-dimensional computed tomography imaging of eagle’s
syndrome. Am J Otolaryngol. 2004;25:109.
Mendelsohn A.H., Berke G.S., Chhetri D.K. Heterogeneity in the clinical presentation
of Eagle’s syndrome. Otolaryngol Head Neck Surg. 2006;134:389–393.
Olusesi A.D. More on heterogeneity of clinical presentation of Eagle’s syndrome.
Otolaryngol Head Neck Surg. 2006;135:488.


Chapter 11
Stylohyoid Ligament Injection
Indications and Clinical Considerations
Hyoid syndrome is caused by calci cation and in ammation of the attachment of
the stylohyoid ligament to the hyoid bone. Tendinitis of the other muscular
attachments to the hyoid bone also may contribute to this painful condition. Hyoid
syndrome also may be seen in conjunction with Eagle syndrome or as a sequela of
traumatic injuries of the hyoid (Figure 11-1). The pain of hyoid syndrome is sharp
and stabbing and occurs with movement of the mandible, turning of the neck, or
swallowing. The pain starts below the angle of the mandible and radiates into the
anterolateral neck. The pain of hyoid syndrome often is referred to the ipsilateral
ear. Some patients also may report a foreign body sensation in the pharynx.
Injection of the attachment of the stylohyoid ligament to the greater cornu of hyoid
bone with local anesthetic and corticosteroid will serve as both a diagnostic and a
therapeutic maneuver.
Figure 11-1 Bilateral hyoid bone fracture with disarticulation of the greater horns
from the body, thyroid cartilage injury, mandibular symphyseal fracture, and left
condyle fracture.
(From Badiali G, Pasquini E, Piccin O, Marchetti C: Injury risk related to the helmet strap:
mandible and hyoid bone fractures with a hyoepiglottic ligament lesion, Inj Extra
41:8991, 2010.)
Clinically Relevant Anatomy
The styloid process extends in a caudal and ventral direction from the temporal
bone from its origin just below the auditory meatus. The stylohyoid ligament’s
cephalad attachment is to the styloid process, and its caudal attachment is to the
hyoid bone. In hyoid syndrome, the stylohyoid ligament becomes calci ed at its
caudal attachment to the hyoid bone (Figure 11-2). Tendinitis of the other
muscular attachments to the hyoid bone may also occur, contributing to the pain
symptomatology.




Figure 11-2 Hyoid syndrome is usually caused by calci cation of the stylohyoid
ligament at its caudal attachment to the hyoid bone.
The key landmark for injection when treating hyoid syndrome is the cornu of
the hyoid bone at a point between the mandible and the larynx. This osseous
process is more easily identi ed if the greater cornu of the hyoid on the opposite
side is steadied. Given the relationship of the great vessels of the neck to the greater
cornu of the hyoid, care must be taken when placing needles in this anatomic area.
Technique
The patient is placed in the supine position. The angle of the mandible on the
a- ected side is then identi ed. The greater cornu of the hyoid bone should lie
approximately 1 inch inferior to the angle of the mandible. Gentle pressure at the
same point on the contralateral side of the neck will steady the hyoid bone and
make identification of the greater cornu and subsequent injection easier (Figure
113). The skin is prepared with antiseptic solution. A 22-gauge, 1½-inch needle
attached to a 10-mL syringe is advanced at the point 1 inch inferior to the angle of
the mandible in a plane perpendicular to the skin. The greater cornu of the hyoid
bone should be encountered within 2.5 to 3 cm (see Figure 11-2). After contact has
been made, the needle is withdrawn slightly out of the periosteum or substance of
the calci ed ligament. After careful aspiration reveals no blood or cerebrospinal
uid, 5 mL of 0.5% preservative-free lidocaine combined with 80 mg of
methylprednisolone is injected in incremental doses. Subsequent daily nerve blocks
are carried out in a similar manner, substituting 110 mg of methylprednisolone for
the initial 80-mg dose.

Figure 11-3 The hyoid bone can be stabilized by placing gentle pressure on the
contralateral side of the hyoid bone, which will facilitate injection of the calci ed
ligamentous attachment.
Side Effects and Complications
This anatomic region is highly vascular, and because of the proximity of major
vessels, the pain specialist should carefully observe the patient for signs of local
anesthetic toxicity during injection. This vascularity and proximity to major blood
vessels also give rise to an increased incidence of postblock ecchymosis and
hematoma formation; the patient should be warned of such. In spite of the
vascularity of this anatomic region, this technique can be safely performed in the
presence of anticoagulation by using a 25- or 27-gauge needle, albeit at increased
risk of hematoma, if the clinical situation dictates 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 will decrease the amount of postprocedure pain and
bleeding the patient may experience.
Because of the proximity to the spinal column, it also is possible to
inadvertently inject the local anesthetic solution into the epidural, subdural, or
subarachnoid space. At this level, even small amounts of local anesthetic placed
into the subarachnoid space may result in total spinal anesthesia. If needle
placement is too inferior, pneumothorax is possible because the dome of the lung
lies at the level of the C7-T1 interspace.
Additional side e- ects associated with the injection of local anesthetic and
corticosteroid in the treatment of hyoid syndrome include inadvertent block of therecurrent laryngeal nerve with associated hoarseness and dysphagia and the
sensation that there is a lump in the throat when swallowing. Horner syndrome
occurs when the superior cervical sympathetic ganglion is inadvertently blocked
during this technique. The patient should be warned of the possibility of these
complications before injection of local anesthetic and corticosteroid in the region of
the greater cornua of the hyoid bone.
Clinical Pearls
This injection technique for hyoid syndrome is a simple one that can produce
dramatic relief for patients experiencing the just-described types of pain. The
proximity of the greater cornu of the hyoid bone to major vasculature makes
postblock hematoma and ecchymosis a distinct possibility. Although these
complications are usually transitory, their dramatic appearance can be quite
upsetting to the patient; therefore the patient should be warned of such a
possibility before the procedure. The vascularity of this region also increases the
incidence of inadvertent intravascular injection. Even small amounts of local
anesthetic injected into the carotid artery at this level will result in local anesthetic
toxicity and seizures. Incremental administration while carefully monitoring the
patient for signs of local anesthetic toxicity will help avoid this complication.
Glossopharyngeal neuralgia can be distinguished from hyoid syndrome in that
the pain of glossopharyngeal neuralgia is characterized by paroxysms of shocklike
pain as in trigeminal neuralgia, rather than the sharp, shooting pain that occurs
on movement associated with hyoid syndrome. Because glossopharyngeal
neuralgia may be associated with serious cardiac bradyarrhythmias and syncope,
the clinician must distinguish the two syndromes.
The clinician should always evaluate the patient with pain in this anatomic
region for occult malignancy. Tumors of the larynx, hypopharynx, and anterior
triangle of the neck may cause clinical symptoms identical to those of hyoid
syndrome. Given the low incidence of hyoid syndrome relative to pain secondary
to malignancy in this anatomic region, hyoid syndrome must be considered a
diagnosis of exclusion.
Suggested Readings
Badiali G., Pasquini E., Piccin O., Marchetti C. Injury risk related to the helmet strap:
mandible and hyoid bone fractures with a hyoepiglottic ligament lesion. Inj Extra.
2010;41:89–91.
Ernest E.A., 3rd., Salter E.G. Hyoid bone syndrome: a degenerative injury of the
middle pharyngeal constrictor muscle with photomicroscopic evidence of insertion
tendinosis. J Prosthet Dent. 1991;66:78–83.
Nir D., Hefer T., Joachims H.Z. Hyoid bone syndrome and its treatment with
nonsteroidal anti-inflammatory drugs. Am J Otolaryngol. 1998;19:296–300.
Rubin M.M., Sanfilippo R.J. Osteomyelitis of the hyoid caused by Torulopsis glabrata
in a patient with acquired immunodeficiency syndrome. J Oral Maxillofac Surg.
1990;48:1217–1219.
Waldman S.D. Hyoid syndrome. Waldman S.D., ed. Atlas of uncommon pain
syndromes, ed 2, Philadelphia: Saunders, 2008."
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Chapter 12
Nasociliary Nerve Block
Indications and Clinical Considerations
Nasociliary nerve block is useful in the diagnosis and treatment of Charlin
syndrome, which is also known as nasociliary neuralgia. Although as with most
headache syndromes the exact cause of the pain of Charlin syndrome is unknown,
the pathogenesis of this uncommon source of head and face pain is thought to be
dysfunction of the nasociliary ganglion in a manner analogous to the dysfunction of
the sphenopalatine ganglion that is thought to be the source of cluster headache.
The presenting symptom of patients with Charlin syndrome is severe paroxysms of
ocular or retro-orbital pain that radiates into the ipsilateral forehead, nose, and
maxillary region. This pain is associated with voluminous ipsilateral rhinorrhea and
congestion of the nasal mucosa as well as signi cant in ammation of the a ected
eye. The pain of Charlin syndrome has a rapid onset to peak, with attacks lasting
45 to 60 minutes. In some patients these attacks can be triggered by sensory
stimulation of the a ected areas. Although in many ways similar to cluster
headache (e.g., the retro-orbital location of pain, profuse unilateral rhinorrhea, the
rapid onset to peak, and the short duration of attacks), there are many
dissimilarities. Unlike in cluster headache, alcohol does not seem to trigger attacks
of Charlin syndrome, and the seasonal and chronobiologic patterns so characteristic
of cluster headache appear to be absent (Table 12-1). Furthermore, blockade of the
sphenopalatine ganglion, which is so e ective in the treatment of cluster headache,
is of little value in the treatment of Charlin syndrome, whereas patients with
Charlin syndrome uniformly respond to daily nasociliary nerve blocks with local
anesthetic, as described later.
TABLE 12-1 Comparison of Cluster Headache and Charlin Syndrome
Cluster Charlin
Headache Syndrome
Ocular and retro-orbital location Yes Yes
Unilateral Yes Yes
Rapid onset to peak Yes Yes
Severe intensity Yes Yes
Attacks occur in paroxysms Yes Yes
Duration of attacks is short Yes Yes
Pain free between attacks Yes YesSignificant rhinorrhea during attacks Yes Yes
Alcohol triggers attacks Yes No
Tactile trigger areas No Yes
Seasonal pattern of attacks Yes No
Chronobiologic pattern of attacks Yes Yes
Significant eye inflammation No Yes
Responds to sphenopalatine ganglion Yes No
block
Responds to nasociliary block No Yes
Clinically Relevant Anatomy
The rst division of the trigeminal nerve is the ophthalmic nerve, which provides
sensory innervation to the cornea, iris, ciliary body, conjunctiva, and associated
lacrimal gland. Branches of the ophthalmic nerve provide sensory innervation to
the skin of the eyelid, forehead, and nose, as well as providing sensory innervation
to portions of the nasal mucosa. The ophthalmic nerve arises from the superior
portion of the gasserian ganglion and passes forward along the lateral wall of the
cavernous sinus. Just before entering the orbit via the superior orbital ssure, the
ophthalmic nerve divides into the lacrimal, frontal, and nasociliary branches
(Figure 12-1). The nasociliary branch enters the orbit between the two heads of the
rectus lateralis muscle and between the superior or inferior rami of the oculomotor
nerve. The nasociliary nerve then passes across the ipsilateral optic nerve to the
medial wall of the orbital cavity to pass through the anterior ethmoidal foramen to
cross the lateral margin of the cribriform plate of the ethmoid bone into the nasal
cavity, where the internal nasal branch provides sensory innervation to the anterior
nasal septum and lateral wall of the nasal cavity. The external nasal branch of the
nasociliary nerve provides sensory innervation to the skin of the ala and apex of the
nose.