Download Mitra Yari MD HEAD AND NECK BLOCK

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‫بسم اهلل‬
Head and neck block
 For diagnosis and therapy
 Informed consent
 Absolute contraindications :patient refusal ,local
infection ,sepsis
 Relative contraindications :coagulopathy ,facial
trauma ,neurologic deficit
 Allergy to medication
Trigeminal ganglion block
 Indication :tic doulorex , secondary trigeminal
neuralgia from injury , cancer pain ,chronic
interactable cluster headache ,idiopathic facial pain.
Trigeminal ganglion
 In middle cranial fossa (meckel cavity)
 Superior :temporal lobe
 medial :cavernous sinus ,optic and trochlear nerve
 Posterior :brain stem
 Divitions :ophthalmic ,maxillary ,mandibular
Trigeminal ganglion block
 Supine position ,light sedation ,eye exposed draps
 C arm (pulse or continuous fluroscopy) , view foramen
oval ,insert glove finger to the mouth ,2-3 cm lateral to
the corner of the mouth .
 External landmarks :above external auditory meatus
medially toward toward the pupil ,advance 1-2 cm
increments until bone touch ,obtain lat image to check
,after negative aspiration ,0.5-1 cm contrast filling of
meckel cavity.
 In CSF leak ,stop procedure . In small CSF leak 0.250.5 at a time up to 1-2 ml.
Trigeminal ganglion neurolysis
 After successful diagnostic block
 Heavier sedation
Trigeminal nerve branches
 Ophthalmic :supraorbital ,supratrochlear ,nasociliary
(forehead and nose)
 Maxillary :infraorbital ,superior alveolar ,palatine
,zygomatic (sensation from maxilla ,nasal cavity ,palate
,nasopharynx ,meninges of anterior and middle cranial
 Mandibular :buccal ,lingual ,inferior alveolar
,auriculotemporal (sensation of buccal region ,side of the
head and scalp ,lower jaw ,anterior 2/3 of the tongue) (
motor :masseter ,temporal ,pterygoid) (interface with
autonomic nervous system in otic ,ciliary ,submaxillary
Maxillary nerve block
 Fluroscopy only in neurolytic plan or in nonpalpable
 Indication :surgery of the upper jaw ,chronic pain of
maxillary divitions of the trigeminal nerve.
Maxillary block
 Supine position
 22 guage 8-10 cm needle
 Bellow zygma anterior to temporomandibular joint in
horizontal plane until lateral pterygoid plate touched in 45 cm, redirect ant sup through the pterygomaxillary
fissure0.25-0.5 cm ,paresthesia in upper jaw and teeth ,3-5
ml LA
 In fluroscopy 0.5-1 ml contrast for R/O intravascular
 Neurolysis with 6% or absolute alcohole
 Before removal 0.5 ml saline pushed.
Mandibular nerve block
 Until lateral pterygoid plate is similar to maxillary
then redirect caudal and posterior 0.1-0.25 until
paresthesia in lower jaw ,lip ,tongue or ear.
If paresthesia not elicited in 5.5 cm ,withdrawn needle
and redirected .
2-3 ml LA
In fluroscopy 0.5-1 ml contrast for R/O intravascular or
intratechal injection
1 ml 6% phenol or absolute alcohol
Occipital nerve
 Occipital headache (occipital neuralgia).irritation of
GON and or LON and pain relief after LA injection.
 Causes :trauma ,compression of C2 and C3by
degenerative cervical spine changes , cervical disc
disease , myofascial pain , reffered pain from
trigeminal and tumors of C2 or C3 nerve root
 Treatment of structural lesion is surgery , conservative
pain management (physical therapy ,NSAID ,massage
,muscle relaxant ,TCA ,anticonvalsants .
most patients treated with botolinium ,medication
and LA block .
 Greater occipital nerve arises from dorsal ramus of the
C2 and C3
 Lesser occipital nerve arises from ventral ramus of C2
and C3
Occipital nerve block technique
 Sitting position
 GON is medial to occipital artery ,one third the distance
between occipital protuberance and mastoid process.
For GON advance 1.5 inch needle medial to artery until
bone contact ,slightly withdrawn ,after negative aspiration
, inject 3-5 ml LA ,fan-like not recommended.
For diagnostic block 1-1.5 ml LA be used for distinguish
neuralgia from myofascial pain.
Complication is bleeding
LON is in two third the distance between occipital
protuberance and mastoid process.
occipital neuralgia
 Traditional GON blocking is based on superficial
entrapment of GON ,but fails for deeper in
suboccipital tiangle
 Other treatments :C2 gangliectomy ,C2,C3 rhizotomy ,
nerve stimulator and radiofrequency ,sectioning of
inferior oblique muscle ,
 Surgery has better outcome and greater mortality and
 Suboccip0ital compartment injection advised without
complications associated with surgery.
Suboccipital compartment
 Triangle anatomy :posterior(rectus capitis posterior)
inferior(oblique capitis inferiois)
superior(oblique capitis superioris)
Components :GON ,suboccipital nerve ,vertebral artery.
The most common site of entrapment is the inferior
oblique muscle in triangle ,and in outside is trapezius.
Suboccipital compartment
 Position :prone
 Needle insertion : 2-3 cm lateral to occipital
protuberance toward the arch of C1.
 After 2-3 cm advance ,a lateral view is obtained.
 Check lat view with contrast media.
 5-10 ml LA (0.2% ropivacain )and steroid (20 m5
Depo-medrol)is injected
Glossopharyngeal nerve block
 GN is a mixed nerve
 Sensation of post. 1/3 of the tongue ,middle ear
,palatine tonsil ,mucus membrane of the mouth
pharynx , carotid sinus and carotid bodies
 Connection between GN and vagus result reflex
bradycardia and asystol.
Glossopharyngeal nerve block
 Indication :Glossopharyngeal neuralgia ,surgical
anesthesia ,depress gag reflex for awake intubation
,diagnostic block prior to neurolysis.
LA for block and LA with steroid for treatment.
Glossopharyngeal block technique
 Extraoral :with fluroscopy ,supine position ,slight lat.
Rotation of neck ,1.5 inch needle insert midway between
angle of the mandibule and mastoid process ,advance
toward styloid process ,at 3 cm bony contact ,slightly
withdrawn and walked off the styloid process in an anterior
direction ,0.5-1 ml contrast then 2-3 ml LA (0.2%
ropivacain and 4 mg dexamethason )
 Intraoral :used in anatomic distortion (tumor ,surgery)
,supine position ,tongue retracted ,insert 22-25 guage
needle slight distal bend ,inferior portion of the tonsillar
pillar ,no more than 0.5 cm ,after negative aspiration ,2-3
LA (0.2% ropivacain and 4 mg dexamethason )
Complications of glossopharyngeal
nerve block
 Extraoral :blockade of CN X ,XI ,XII ,vessel trauma
,internal carotid artery and internal jugular vein
injection (convulsion and cardiovascular collapse)
 Intraoral :vessel trauma ,neurotoxicity ,(less than
extraoral) , blockade of CN X ,XI ,XII ,
blockade of the vagus can lead to bradycardia ,asystole
,reflex tachycardia ,syncope ,dysphonia.
Cervical plexus block
 Anatomy:deep to the internal jugular vein and
underneat the SCM.
Anterior divitions of C1-C4
Divisions are superficial and deep cervical plexus
Indication :surgical anesthesia ,analgesia .
superficial cervical plexus : C2 innervate skin of the
post. Scalp and mastoid . C3innervate lteral of the
deep cervical plexus :SCM C2-C4
terapezius C2-C3
levator scapula C3-C4
Cervical plexus block
 Indication : CPB is a safe alternative to GA for
operation of anterior posterior portion of the neck
,upper shoulder and posterior scalp.
Superficial neck procedure ,thyroglossal and branchial
cysts surgery ,thyroidectomy ,lymph node disection
,carotid endartrectomy ,neuralgia.
superficial cervical plexus
 Only sensory
 Contains 4 nerve lesser occipital ,greater ouricular
,transverse cervical ,supraclavicular
 Used for :postoperative pain ,reduce nausea and
vomiting in tympano-mastoid surgery ,superficial
procedure such as plastic.
deep cervical plexus
 Sensory and motor
 Prvide anesthesia and analgesia of the superficial and
the deep muscles within the anterior and lateral neck
up to the upper shoulder region.
 Nerve root anesthetized.
 Thyroidectomy , tracheostomy , laceration repair
,awake carotid endarterectomy ,interactable hiccups.
superficial cervical plexus block
 Supine position ,head turned away ,draw a line
between mastoid process and chassaignac of the C6
over the SCM.
 Insert a 22-25 guage, 4-5 cm needle midpoit of the line
behind the posterior border of the SCM
subcutaneously 2- 3 cm , inject 3-5 ml ,and 3-5 ml each
Deep cervical plexus block
 Supine position ,head turned away ,draw a line between
mastoid process and chassaignac of the C6 over the SCM.
Identify transverse process of C2 ,C3 ,C4 ,C6 ,Cricoid
cartilage is in level of C6 ,Thyroid notch is in level of C4
Intertransverse distance is typicaly 2 cm
Insert 1.5 inch 22 guage needle medial caudal direction to
avoid vertebral artery ,spinal ,epidural injection until
transverse process contact.(1.5-2 cm)
If paresthesia is seen ,redirect posterior(spinal nerves),after
bony contact ,withdrawn ,aspirate ,inject 3-5 ml LA
Never go deeper than 3 cm or cephalad
Deep cervical plexus block choice
of local anesthetic
 Based on duration of block and length of surgery
 Shorter procedure 2% lidocain or mepivacain(4h)
 Longer procedure ropivacain or bupivacain (8h) , Total
dose 0.4-0.5 mg/kg , 30 ml
 Epinephrine with lidocain and bupivacain
 Don’t use Clonidin with lidocain (potentiate toxicity)
Complications of cervical plexus
 Infection
 Hematoma
 Temporary diaphragmatic paresis in deep C.P.B (don’t
perform bilateral)(don’t perform in chronic respiratory
disease patients)
 Local anesthetic toxicity (CNS and cardiac)
 Intravascular injection