Lateral Pterygoid Muscle and Maxillary Artery Are Key Anatomical Landmarks for Ultrasound-guided Trigeminal Nerve Block

Background: Patients presenting with facial pain often have ineffective pain relief with medical therapy. Cases refractory to medical management are frequently treated with surgical or minimally invasive procedures with variable success rates. We report on the use of ultrasound-guided trigeminal nerve block via the pterygopalatine fossa in patients following refractory medical and surgical treatment. Objective: To present the immediate and long-term efficacy of ultrasound-guided injections of local anesthetic and steroids in the pterygopalatine fossa in patients with unilateral facial pain that failed pharmacological and surgical interventions. Setting: Academic pain management center. Design: Prospective case series. Methods: Fifteen patients were treated with ultrasound-guided trigeminal nerve block with local anesthetic and steroids placed into the pterygopalatine fossa. Results: All patients achieved complete sensory analgesia to pin prick in the distribution of the V2 branch of the trigeminal nerve and 80% (12 out of 15) achieved complete sensory analgesia in V1, V2, V3 distribution within 15 minutes of the injection. All patients reported pain relief within 5 minutes of the injection. The majority of patients maintained pain relief throughout the 15 month study period. No patients experienced symptoms of local anesthetic toxicity or onset of new neurological sequelae. Limitations: Prospective case series. Conclusion: We conclude that the use of ultrasound guidance for injectate delivery in the pterygopalatine fossa is a simple, free of radiation or magnetization, safe, and effective percutaneous procedure that provides sustained pain relief in trigeminal neuralgia or atypical facial pain patients who have failed previous medical interventions. Key words: Trigeminal nerve, ultrasound-guided, atypical facial pain, trigeminal neuralgia, tic douloureux.

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A prospective, randomized comparison of ultrasonographic visualization of proximal intercostal block vs paravertebral block

BMC Anesthesiology ◽

10.1186/s12871-020-0929-x ◽

2020 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Kamen Vlassakov ◽

Avery Vafai ◽

David Ende ◽

Megan E. Patton ◽

Sonia Kapoor ◽

...

Keyword(s):

Postoperative Pain ◽

Nerve Block ◽

Opioid Consumption ◽

Paravertebral Block ◽

Anatomical Landmarks ◽

Ultrasound Guided ◽

Paravertebral Space ◽

Pain Scores ◽

Performance Times ◽

Intercostal Block

Abstract Background Thoracic paravertebral blockade is an accepted anesthetic and analgesic technique for breast surgery. However, real-time ultrasound visualization of landmarks in the paravertebral space remains challenging. We aimed to compare ultrasound-image quality, performance times, and clinical outcomes between the traditional parasagittal ultrasound-guided paravertebral block and a modified approach, the ultrasound-guided proximal intercostal block. Methods Women with breast cancer undergoing mastectomy (n = 20) were randomized to receive either paravertebral (n = 26) or proximal intercostal blocks (n = 32) under ultrasound-guidance with 2.5 mg/kg ropivacaine prior to surgery. Block ultrasound images before and after needle placement, and anesthetic injection videoclips were saved, and these images and vidoes independently rated by separate novice and expert reviewers for quality of visualization of bony elements, pleura, relevant ligament/membrane, needle, and injectate spread. Block performance times, postoperative pain scores, and opioid consumption were also recorded. Results Composite visualization scores were superior for proximal intercostal compared to paravertebral nerve block, as rated by both expert (p = 0.008) and novice (p = 0.01) reviewers. Notably, both expert and novice rated pleural visualization superior for proximal intercostal nerve block, and expert additionally rated bony landmark and injectate spread visualization as superior for proximal intercostal block. Block performance times, needle depth, opioid consumption and postoperative pain scores were similar between groups. Conclusions Proximal intercostal block yielded superior visualization of key anatomical landmarks, possibly offering technical advantages over traditional paravertebral nerve block. Trial registration ClinicalTrials.gov, NCT02911168. Registred on the 22nd of September 2016.

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Technical considerations for approaches to the ultrasound-guided maxillary nerve block via the pterygopalatine fossa: a literature review

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2019-100569 ◽

2020 ◽

Vol 45 (4) ◽

pp. 301-305 ◽

Cited By ~ 3

Author(s):

Ariana Anugerah ◽

Kim Nguyen ◽

Antoun Nader

Keyword(s):

Nerve Block ◽

Trigeminal Nerve ◽

Case Series ◽

Pterygopalatine Fossa ◽

Ultrasound Guided ◽

Maxillary Nerve ◽

Pubmed Database ◽

Ideal Approach ◽

Maxillary Nerve Block ◽

The Ideal

Background and objectivesBlockade of the trigeminal nerve and its branches is an effective diagnostic tool and potential treatment of facial pain. Ultrasound-guided injections in the pterygopalatine fossa (PPF) to block the trigeminal nerve divisions and sphenopalatine ganglion have been described but a consensus has yet to be reached over the ideal approach. We sought to delineate and compare the various approaches to the ultrasound-guided trigeminal divisions blockade via the PPF.MethodsThe literature search was performed by searching the National Library of Medicine’s PubMed database, the Cochrane Database of Systematic Reviews and Google Scholar within the date range of January 2009–March 2019 for keywords targeted toward “trigeminal nerve,” “maxillary nerve,” or “pterygopalatine fossa,” “ultrasound,” and “nerve block,” using an English language restriction. Six papers were included in the final review: one prospective double-blinded randomized controlled trial, one prospective descriptive study, one case series, two case reports, and one cadaveric study.ResultsThere are three main approaches to the ultrasound-guided trigeminal nerve branches blockade via the PPF: anterior infrazygomatic in-plane, posterior infrazygomatic in-plane, and suprazygomatic out-of-plane approaches. Each showed injectate spread to the PPF in cadaver, adult and pediatric patients, respectively.1–5 Injectate used varied from 3 to 5 mL to 0.15 mL/kg.ConclusionsThese studies demonstrated that the PPF is a readily accessible target for the ultrasound-guided maxillary nerve block via three main approaches.2 The ideal approach is yet to be determined and must be further explored.

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