Chapter 73 Head and Neck Blocks Flashcards Preview

Essentials of Pain Medicine > Chapter 73 Head and Neck Blocks > Flashcards

Flashcards in Chapter 73 Head and Neck Blocks Deck (130):

Absolute contraindications include

patient refusal,
local infection and sepsis, and increased intracranial pressure
(trigeminal ganglion block).


Relative contraindications

coagulopathy, anticoagulant therapy, history of facial trauma,
and pre-existing neurologic deficits. Allergy to medications used can be absolute or relative depending on the severity of the allergy.


The trigeminal ganglion resides in

the middle cranial fossa. It is situated in a fold of dura mater that forms
an invagination around the posterior two-thirds of the ganglion. This region is referred to as Meckel’s cavity and contains cerebrospinal fluid.


trigeminal ganglion bounded by

medially by the cavernous sinus and optic and trochlear
nerves; superiorly by the inferior surface of the temporal lobe of the brain; and posteriorly by the brain stem.


trigeminal ganglion formed by

the fusion of a series of cell bodies
that originate at the mid-pontine level of the brainstem


trigeminal ganglion divisions

ophthalmic (V1),
maxillary (V2), and mandibular (V3).


The ophthalmic
division is located

dorsally, the maxillary branch intermediate,
and the mandibular branch ventrally. The ophthalmic
division leaves the ganglion and passes into the orbit
through the superior orbital fissure.


division further divides into

the supraorbital, supratrochlear, and nasociliary nerves which innervate the forehead and the nose.


The maxillary division exits the middle cranial fossa via

rotundum, crosses the pterygopalatine fossa, and enters
the orbit through the inferior orbital fissure.


Branches of maxillary division

infraorbital, superior alveolar, palatine and
zygomatic nerves which carry sensory information from the maxilla and overlying skin, the nasal cavity, palate,
nasopharynx and meninges of the anterior and middle cranial fossa


The mandibular division exits through

foramen ovale and divides into the buccal, lingual, inferior alveolar and auriculotemporal nerves. These nerves carry sensory input from the buccal region, the side of the head and scalp, and the lower jaw including teeth, gums, anterior two-thirds of the tongue, chin, and lower lip.


The motor component of V3 innervates

the several muscles
including the masseter, temporal, and medial and lateral pterygoids.


The ganglion interfaces with the autonomic
nervous system via

the ciliary, sphenopalatine, otic, and
submaxillary ganglia. It also communicates with the oculomotor, facial, and glossopharyngeal nerves


most common indication

regional anesthesia for surgery of the upper jaw, but is also effective for acute postoperative pain control. it is indicated for the diagnosis and
treatment of chronic pain in the distribution of the maxillary division of the trigeminal nerve




Place the patient in
the supine position. Palpate the mandibular notch located below the zygoma and anterior to the temporomandibular
joint. Under sterile conditions, anesthetize the skin over the notch. Insert the block needle (usually a
22-gauge, 8–10 cm, short-bevel or a same-size curved, blunt needle) in a horizontal plane through the mandibular notch until bone (lateral pterygoid plate) is touched (typically 4–5 cm). Withdraw the needle and redirect it anteriorly and superiorly
through the pterygomaxillary fissure into the
pterygopalatine fossa. Advance the needle approximately 0.25 to 0.5 cm at which depth a paresthesia is usually
perceived in the upper lip or teeth.



Technique (Fluoroscopy)

If performed under
fluoroscopy, the needle is angled toward the superior portion of the pterygopalatine fossa, which appears as a
“V” on the lateral image. On an anteroposterior image, the needle tip should be above the level of the middle turbinate. Inject 3 to 5 ml of local anesthetic. If fluoroscopy
is used, 0.5 to 1.0 ml of contrast can be injected first to rule out intravascular placement of the needle


blocks can be done with

6% phenol or absolute alcohol. After appropriate placement of the needle, up to 1.0 to 1.5 ml of the neurolytic solution is injected in 0.1-ml aliquots. The needle should then be flushed with 0.5 ml
of saline prior to removal.


Pulsed radiofrequency lesioning

can also be performed after a successful diagnostic block. Sensory stimulation is performed at 50 Hz, 1 V. Paresthesia in the upper teeth should be perceived at less than 0.3 V. Once confirmed, two or three 120-sec pulsed radiofrequency cycles are administered at 45V




regional anesthesia for surgery of the lower jaw, but is also effective for acute postoperative pain control. it is indicated for the diagnosis and treatment of chronic pain in the distribution of the mandibular division of the trigeminal nerve



area to anesthetize or treat pain is

the lower jaw and tongue.




once the lateral pterygoid plate has been touched with the block needle, withdraw it and redirect in a slightly caudal and posterior direction until a paresthesia is produced in the lower lip, lower jaw, or ipsilateral tongue or ear. The depth should not be more than 0.1 to
0.25 cm beyond the depth at which the lateral pterygoid plate was contacted. The total distance should not exceed 5.5 cm. After proper positioning, inject 2 to 3 ml of local anesthetic, remove the needle, and apply an ice pack to the side of the


using fluoroscopy

Since this technique involves blocking the nerve as it exits the
foramen ovale, a submental, oblique view can be obtained in order to verify the position of the needle tip in relation to foramen ovale. The needle tip should be adjacent to, or overlie, the shadow of the foramen ovale. To
rule out intravascular or intrathecal injection, instill 0.5 to 1.0 ml of contrast. If negative, inject the aforementioned
volume of local anesthetic. Chemical neurolysis can be
achieved using 6% phenol, 50% glycerol, or absolute alcohol. After a successful diagnostic block and after proper
positioning of the needle, up to 1.0 ml of the neurolytic solution is injected in 0.1-ml increments. Flush the needle with 0.5 ml normal saline before removing it.



For pulse
radiofrequency lesioning

perform sensory and motor stimulation at 50 Hz, 1 V, and 2 Hz, 2 V, respectively, to
check needle position. Paresthesia should be obtained at less than 0.3 V, and masseter contraction should be apparent at less than 0.6 V. Two to three 120-sec pulsed cycles
should be carried out at 45 V.


the most common indication for trigeminal
ganglion blockade

Tic douloureux (Trigeminal neuralgia (TN))


Indications for trigeminal
ganglion blockade

Secondary trigeminal neuralgias from injury to the major divisions or the distal branches of the ganglion, in the treatment of chronic, intractable cluster
headaches. Persistent idiopathic facial pain (formerly atypical facial pain)




Place the patient on the table in the supine position with the head slightly extended. Light sedation with midazolam and fentanyl is usually required. Sterilely prepare and drape the appropriateside, leaving the eye exposed. Utilizing continuous or
pulsed fluoroscopy, locate foramen ovale by rotating the C-arm image intensifier obliquely away from the nose approximately 20 to 30 degrees, and then angle the C-arm image intensifier approximately 30 to 35 degrees in the
caudocephalad direction to bring the foramen ovale into view.




Raise a skin wheal directly over the shadow of the foramen which will be ~2 to 2.5 cm lateral to the corner of the mouth. Insert a short, 16- or 18-gauge
angiocatheter through the skin wheal and advance to the hub. Insert a gloved finger into the oral cavity to confirm that the buccal mucosa has not been breached. Re-glove
before proceeding. Insert a 20- or 22-gauge, curved, blunt
block needle through the angiocatheter and advance a few
centimeters. Obtain a fluoroscopic image to check the trajectory
of the needle. The goal is to advance the needle in a coaxial fashion toward the foramen ovale. With respect to external
landmarks, the trajectory of the needle will be in a plane
slightly superior to the external auditory meatus and medially
toward the pupil in the midline. Advance the needle in 1- to 2-cm increments until bone is touched. Obtain a lateral image to check the position of the needle. If the foramen
has not been traversed, adjust the needle tip (usually posterior) and advance through the foramen a distance of
0.5 to 1.0 cm.



After a negative aspiration for CSF or blood

inject 0.5 to 1.0 ml of nonionic, water-soluble contrast to confirm position and filling of
Meckel’s cavity. Any vascular runoff requires repositioning of the needle. If cerebrospinal fluid is obtained, the needle tip can be withdrawn until fluid is no longer appreciated



If an abundant cerebrospinal fluid leak is present

the remainder of the procedure should be halted. With a significant
leak, a high spinal block can be caused with even low volumes of local anesthetic. A small leak of cerebrospinal fluid may or may not cause a high spinal and if present, the pain
practitioner should proceed with caution.



Drug and Dosing

Inject local anesthetic
in volumes of 0.25 to 0.5 ml at a time, up to 1 to 2 ml, and observe for effect. Remove the needle and apply
an ice pack to the cheek to decrease swelling.


For conventional radiofrequency lesioning, a 3- to 5-mm active-tip needle is placed. The target depth of the needle tip depends on the division of the trigeminal nerve that needs to be lesioned

The mandibular division is rostral
and lateral; the maxillary division is intermediate; and
the ophthalmic division is mostly cephalad and medial.


Location of the needle tip on the appropriate division/s is determined by

the response to sensory and motor stimulation (50 Hz, 1 V, and 2 Hz, 2 V, respectively) of
the ganglion. Paresthesia should be perceived at less than
0.3 V, with little to no muscle contraction of the masseter
muscle at 0.6 to 1.0 V.



If no contraction is seen, then the tip of the needle is on

the ophthalmic or maxillary divisions.



Once the patient senses paresthesia in the painful area

inject 0.5 ml of 0.25% bupivacaine or 0.2% ropivacaine with steroid. Wait 30 to 60 sec and begin lesioning at 60° C for 90 sec.



For lesioning of
the ophthalmic division, assess the

corneal reflex during
and after each lesion. Lesioning is typically started at temperatures
of 55 to 65° C to preserve this reflex. One or two lesions are recommended. If the corneal reflex diminishes, lesioning should be stopped.



not a temperature-dependent technique. It is a nondestructive method of providing
long-term pain relief




After proper positioning of the
needle tip, perform two or three pulsed radiofrequency cycles for 120 sec each at 45 V. The temperature of the needle tip rarely exceeds 42° C, thus local anesthetic is not
required. If significant masseter contraction is noted during pulsing, inject 1 to 2 ml of local anesthetic to diminish
this, or hold the patient’s mouth closed with your hand while the cycles are completed.


ganglion blockade.


Chemical neurolysis has been performed with phenol and
alcohol in the past, but their use is not currently recommended. chemical neurolytic of choice is



ganglion blockade.


Once through the foramen ovale, advance the needle until
cerebrospinal fluid is observed returning through the needle. Place the patient in a semi-sitting position with the
neck flexed. Inject water-soluble, nonionic contrast solution in 0.1-ml aliquots (up to 0.5 ml) into the trigeminal cistern. Once the cistern is visualized,
draw back the contrast material by free flow. The
flow of contrast is slower than cerebrospinal fluid. Inject the same amount of glycerol into the cistern. Flush the needle with 0.5 ml of saline prior to removal. Keep the
patient in a semi-sitting position for 2 hr. During the procedure,
patients often report pain, burning, or paresthesia
in the affected division/s


in relation to procedures

complications considered for all neurolytic techniques,
radiofrequency thermal lesioning had the highest number of complications (29.2%) followed by glycerol
rhizotomy and balloon compression at 24.8% and 16.1%, respectively.



Retrobulbar hematoma (needle is advanced into the retrobulbar space)
Exophthalmus (secondary to bleeding in the retrobulbar space)
Masseter weakness (especially with lesioning of the mandibular division. The incidence is highest with balloon microcompression)
Loss of the corneal reflex, keratitis (likely to occur after radio frequency lesioning and glycerol neurolysis), ulceration, and hypesthesia are
observed in 3% to 15% of patients after a neurolytic procedure. Corneal anesthesia
was highest for radiofrequency rhizotomy at 7%, and was observed with glycerol rhizotomy and balloon compression
at 3.7% and 1.5%, respectively. Anesthesia dolorosa (deafferentation pain) occurs in up to 4% of patients with radiofrequency, followed by glycerol
where it occurs in 2% of cases.


Other complications

meningitis, dural arteriovenous fistulae, rhinorrhea, transient cranial nerve deficits, tissue sloughing, and even death


Postprocedure trigeminal nerve sensory loss

an expected occurrence after a properly performed neurolytic procedure. The incidence with radiofrequency
rhizotomy is as high as 98%, followed by balloon compression (72%) and glycerol neurolysis (60%)



The ganglion resides in the pterygopalatine fossa. The fossa
is bordered anteriorly by the maxillary sinus; posteriorly by
the medial pterygoid plate; medially by the palatine bone;
and superiorly by the sphenoid sinus.


The pterygomaxillary
fissure and pterygopalatine foramen

The pterygomaxillary
fissure allows passage of a needle into the fossa, while the
pterygopalatine foramen is located medial to the ganglion
and is just posterior to the middle turbinate. The fossa is
approximately 1 cm wide and 2 cm high and resembles a V-shaped vase on a lateral fluoroscopic image.A large venous plexus overlies the fossa.


Foramen rotundum and
the pterygoid canal

Foramen rotundum and
the pterygoid canal are located on the superolateral and
inferomedial aspect of the fossa, respectively


The maxillary artery

resides in the pterygopalatine fossa


SPHENOPALATINE GANGLION is “suspended” from the maxillary nerve by the

pterygopalatine nerves and is medial to the maxillary nerve.


Posteriorly the ganglion is connected to the

vidian nerve which is formed by the deep
petrosal (sympathetic from the upper thoracic spinal cord) and greater petrosal (parasympathetic from the superior
salivatory nucleus) nerves.


branches and forms the

superior posterior lateral nasal and
pharyngeal nerves.



the greater and lesser palatine nerves


Sensory fibers arise from the maxillary
nerve, pass through the SPHENOPALATINE GANGLION, and innervate the

upper teeth, nasal membranes, soft palate, and some parts of the pharynx. A small number of motor nerves are believed to
travel with the sensory trunks


Indications for sphenopalatine ganglion block and neurolysis

sphenopalatine neuralgia, trigeminal neuralgia, migraine headaches, cluster headaches, atypical facial pain, and cancer of the tongue and floor of the mouth


Other reported therapeutic uses of sphenopalatine ganglion block include

sinus arrest in postherpetic neuralgia, vasomotor rhinitis,
complex regional pain syndrome of the lower extremity, low back pain, and post-traumatic headache.


The intranasal SPG block

allows absorption of local anesthetic from a cotton-tipped applicator
inserted into the nare.

The location of the SPG in relation to the middle turbinate as well as the lateral nasal mucosa


anesthetic of choice in the intranasal SPG block

Four percent cocaine is the local anesthetic of choice secondary to its inherent vasoconstrictor property. If this is not available or there is a contraindication to using cocaine, 1% to 2% lidocaine or 0.25% to 0.5% bupivacaine or ropivacaine can be used instead. If these are
chosen, the practitioner can pretreat the nare/s with neosynephrine
to produce vasoconstriction.


The intranasal SPG block


Place the patient in the
supine position. Estimate the depth of insertion by externally measuring the distance from the opening of the nare to the mandibular notch. Place a mark corresponding to this depth on the shaft of the cotton-tipped applicator. Soak the applicators
in the local anesthetic for several minutes. Slowly
insert the applicator into the nare and advance in a line parallel to the zygoma with the tip angled laterally. Do not
advance the applicator in a cephalad direction. The endpoint should be the depth marked on the applicator. Place a second applicator into the nare using the same technique, except
advance it ~ 0.5 to 1.0 cm deeper and superior
to the first. If resistance is encountered at any time, slightly withdraw and redirect the applicator. The second applicator is not a necessity and the nares of some patients may not accommodate it. Leave the applicator(s) in for 30 to 45 min


Signs of a successful block of the SPG include

ipsilateral tearing, conjunctival injection, and nasal congestion. If the SPG is a pain generator or transmitter, analgesia should also
be apparent.


In the intranasal SPG block, If after 20 to 30 min there are no signs of a block or the patient has not received any pain relief

additional local anesthetic may be needed and can be trickling down the shaft of the applicator. Remove the cotton-tipped applicators after 45 min even if there are no signs of a block
or analgesia. If there are no signs of a block or analgesia, the SPG may be too deep to be blocked by this technique, or is not involved in the transmission of pain.


The infrazygomatic approach to SPG blockade


fluoroscopic guidance is highly recommended. Noninvasive monitors should be used to record vital signs. Light sedation with midazolam and fentanyl can be used, but on occasion, deeper sedation may be
necessary for radiofrequency lesioning. For pulsed radiofrequency, heavy sedation is not required.
Place the patient in the supine position. Sterilely prep and drape the appropriate side of the face. Obtain a lateral fluoroscopic image.


The infrazygomatic approach to SPG blockade


Palpate the mandibular notch and anesthetize
the skin. If the notch is not palpable, identify the
notch on a lateral fluoroscopic view. Identify the pterygopalatine
fossa (appears as a “V”) on the lateral image and
superimpose the right and left fossae. The
block can be performed with a 4.5-inch, 22-gauge, shortbevel
needle with the distal tip bent at a 30-degree angle, or with a curved, blunt, 10-cm, 20- or 22-gauge needle. Anesthetize the skin and insert a 1.25-inch, 16-gauge angiocatheter
through the skin and advance until it is just medial to the ramus of the mandible. This can be checked on an
anteroposterior (AP) image. Pass the block needle through the angiocatheter and advance it medial, anterior, and slightly cephalad. Obtain a lateral image to check the direction of the needle. Your target is the mid portion of the pterygopalatine fossa. Get an AP view and advance the needle toward the middle turbinate, stopping
when the tip is adjacent to the palatine bone. Once in the fossa, inject 0.5 to 1 ml nonionic, water soluble contrast, and observe for intravascular spread and/or intranasal placement of the needle. Once correct placement has been confirmed, inject 2 cc of local anesthetic, with or
without steroids.



After a successful diagnostic block, two therapeutic choices are available:

conventional radiofrequency lesioning (RFTC)
and pulsed electromagnetic field radiofrequency (P-EMF).





An insulated RF needle with a 3- or 5-mm active tip is
placed using the infrazygomatic approach. Once in place, sensory stimulation is performed at 50 Hz up to 1 V. If the tip of the needle is adjacent to the SPG, the patient should
perceive a paresthesia at the root of the nose at less than 0.3 V. If the paresthesia is felt in the hard palate, the needle should be redirected cephalad and medial. A paresthesia in the upper teeth indicates stimulation of the maxillary nerve
and the needle should be more caudal and medial. Motor stimulation is not necessary. After appropriate sensory stimulation, RFTC can be performed at 67 to 80° C for 90 sec
times two cycles. Before lesioning, 2 to 3 ml of local anesthetic should be injected. With P-EMF lesioning, two to four 120-sec lesions are performed at 45 V. Local anesthetic is not required for P-EMF.





bruising, bleeding, infection, damage to nerves, proptosis from retrobulbar hematoma,
dysesthesias, paresthesias, and/or numbness from RFTC. Bradycardia (“Konen” reflex) has been noted during RFTC and P-EMF, and can be prevented with pretreatment with
atropine or glycopyrolate


Occipital neuralgia

The term described an irritation of the greater occipital nerve (GON), and/or the lesser occipital nerve (LON). The International Headache Society defines occipital neuralgia as a paroxysmal jabbing pain in the distribution
of the greater or lesser occipital nerves or of the
third occipital nerve, sometimes accompanied by diminished sensation or dysesthesia in the affected area. It is
commonly associated with tenderness over the nerve concerned and the pain is often relieved with a local anesthetic block.


Recognized causes of occipital neuralgia

trauma to the greater and lesser occipital
nerves, compression of the greater and/or lesser occipital nerves or C2 and/or C3 nerve roots by degenerative
cervical spine changes, cervical disc disease, myofascial pain, referred pain from ipsilateral trigeminal distribution, and tumors involving the C2 and C3 nerve roots.


Management of occipital neuralgia

Management usually begins with conservative treatment such as physical therapy, massage, non-steroidal
anti-inflammatory drugs (NSAIDs), muscle relaxants, tricyclic antidepressants, and anticonvulsants.


When occipital
neuralgia has a structural basis then treatment is
aimed at the cause and surgery may be warranted such as
decompression or resection. Structural lesions are rare and
most patients that suffer from occipital neuralgia are usually treated with

local anesthetic blocks, botulinum toxin injections, medications, and occipital nerve stimulators.


occipital nerve block is an effective treatment for

cervicogenic headache, cluster headache, and occipital neuralgia


The cutaneous innervation of the posterior head and neck is from

the cervical spine nerves.


greater occipital nerve (GON) arises from the

dorsal ramus of the second cervical nerve and to a lesser
extent the dorsal ramus of third cervical nerve. This nerve passes between the inferior capitis oblique and semispinalis capitis muscles and ascends to pierce the semispinalis capitis and the trapezius superiorly. At this point, it travels with the occipital artery to provide cutaneous innervation to the posterior scalp as far anterior as the vertex of the skull. Medially and over the occiput, this nerve communicates
with the third occipital nerve (TON) and laterally
with the LON( lesser occipital nerve).


lesser occipital nerve LON

composed of branches from the ventral ramus of the second and third cervical nerves and ascends toward the occiput by running parallel to the posterior border of the sternocleidomastoid muscle. Near the scalp it perforates the deep fascia, and is continued
superiorly over the occiput where it supplies the skin over the posterior lateral portion of the scalp and above the ear.


third occipital nerve (TON)

The TON arises deep to the trapezius from the medial branch of the dorsal ramus of the third cervical nerve. This nerve ascends medial to the GON and is connected to it both over the occiput and as the GON rounds the inferior edge of the inferior capitis oblique.


The medial terminal
branch of the TON supplies

the skin over the rostral end of the neck and the occiput near the external occipital protuberance




The patient is placed in a sitting position with the head slightly flexed downward. At the nuchal ridge a 1.5-inch, 22- or 25-gauge, B-bevel needle is inserted in the skin at the nuchal ridge and advanced until bony contact is made. The needle is then slightly withdrawn just of the bone and after negative aspiration a total of 3 to 5 ml of local anesthetic is injected. If a diagnostic block is planned a small volume should (1–1.5 ml) be used, to avoid any confusion in distinguishing greater occipital neuralgia from
myofascial pain. The LON block is performed in a similar fashion at its location




The occipital protuberance, superior nuchal ridge, occipital artery, and mastoid process. The location of
the GON is typically medial to the occipital artery one third the distance between the occipital protuberance and the mastoid process on the nuchal ridge. The LON is often found two thirds the distance from the occipital protuberance and the mastoid process on the nuchal ridge. When
the occipital artery is palpated the GON should be located
just medial to the artery.




piercing the occipital artery and bleeding. Compression of the occipital artery is usually effective in avoiding any
significant problems.


Treatment for occipital neuralgia is theorized
on the basis of

neural entrapment within the muscle
and fascia investing the suboccipital compartment and the
posterior occiput.


The traditional approach to blocking
the greater occipital nerve has been to

infiltrate local anesthetic
with or without steroid into the subcutaneous tissue around the course of the nerve after it has penetrated the trapezius muscle. The goal of infiltration at this point along the course of the nerve is the pharmacological
blockade of nociceptive transmission. This treatment is effective when the entrapment is superficial, but fails
when the entrapment occurs deeper within the suboccipital triangle.


treatment of occipital headaches treatment options

conservative medical management, physical therapy, nerve
stimulators, C2 gangliectomy, C2–C3 rhizotomy/root
decompression, radiofrequency lesioning, and sectioning of the inferior oblique muscle. procedures such as surgical decompression of the nerves in the suboccipital compartment have proven effective for longer periods of time


The suboccipital triangle

a region of the posterior cervical
neck that has the potential for neural structures to become
entrapped at multiple locations. The triangle is composed of bony articulations, ligaments, fibro-fatty tissue and bounded by three different muscles: the rectus capitis posterior major, obliquus capitis inferioris (inferior oblique), and obliquus
capitis superioris.


The suboccipital triangle content

The contents of the triangle are the suboccipital nerve, greater occipital nerve, third occipital nerve
and the vertebral artery.


The most common site of entrapment within the suboccipita triangle is

the inferior
oblique muscle and outside the triangle, the trapezius


greater occipital nerve within the suboccipital triangle

GON begins within the suboccipital triangle
and courses downward and lateral in a posterior direction at the lower edge of the inferior oblique muscle where it
bends around the muscle and ascends in a superior and medial direction above the rectus capitis toward the head of the semispinalis muscle. Here the nerves form another bend from its upward orientation in a deep to a superficial direction as it begins to move laterally. As the nerve courses upward and lateral it moves between the dorsal aspect of the semispinalis muscle and deep to the trapezius muscle. Here the nerve may pierce the semispinalis muscle or just continue upward until it pierces the trapezius muscle and travels subcutaneously
upward toward the base of the occiput.




The patient is placed in a prone position with the neck slightly flexed. The superior nuchal ridge is palpated and the occipital protuberance is identified. Two to three centimeters
lateral to the occipital protuberance at the nuchal ridge the skin is anesthetized with 1% lidocaine. Once
anesthetized a 22-gauge, 1.5- to 3.5- inch, sharp or blunt
Stealth™ (Epimed International) needle is advanced in a
posterior-anterior direction perpendicular to the skin toward the arch of C1. Once the needle is advanced 2 to 3 cm into the tissue a lateral view is obtained. While in the lateral view, the needle is further
advanced under live fluoroscopy toward the arch of C1. As the needle is advanced you should experience two to three distinct pops as each muscle fascial layer is penetrated. Once the needle tip is positioned at posterior arch of C1, contrast material is injected in the lateral radiographic view. The contrast spread should
be limited around the muscle layers within that enclose the
suboccipital compartment and no vascular uptake must
be noted. After successful needle position is confirmed, a total of 5 to 10 ml of local anesthetic (0.2%
Ropivacaine) and steroid (20 mg Depo-Medrol) is injected




rare and patients may complain of
slight dizziness immediately after the procedure


The glossopharyngeal nerve course

originates from the cranial part of the medulla oblongata. Its rootlets form one root
and course forward and laterally until it reaches the jugular
foramen. As it exits the jugular foramen it joins with the vagus and spinal accessory nerve and passes between the
internal jugular vein (IJV) and the internal carotid artery (ICA). It continues to descend anterior to the ICA and dips medially behind the styloid process in close proximity to the vagus nerve, accessory nerve, and IJV emerging beneath the tip of the styloid and continuing to its
terminal branches


The glossopharyngeal nerve innervates

a mixed nerve containing sensory, motor, and autonomic
fibers. It provides sensation to the posterior one-third of
the tongue, middle ear, palatine tonsils, and mucous membranes of the mouth and pharynx above the vocal
cords. Additionally, it innervates the carotid sinus and the carotid bodies. The motor fibers innervate the stylopharyngeus
muscle and its autonomic functions are related to the parotid gland via the otic ganglion


The glossopharyngeal nerve lies in close relation to the

vagus and spinal accessory nerve. Specifically, they are in close approximation until they diverge at the midpoint of the styloid process. reported cases of GN
paroxysms with associated bradycardia and asystole


Lesions arising from the GN can send
afferent impulses via

the tractus solitarius to the dorsal motor nucleus of the vagal nerves result in reflex bradycardia or asystole


complications following blockade of the GP nerve.

a potential of pharyngeal and trapezius weakness due to unwanted blockade of the closely
situated nerves.


Blockade of the glossopharyngeal nerve several indications

used for the treatment of glossopharyngeal
neuralgia. The block can be done with local anesthetics as a diagnostic tool to determine if the patient truly has
glossopharyngeal neuralgia or it can be performed with the addition of steroids for therapeutic treatment. The procedure also can be used for surgical anesthesia or as an
adjunct to depress the gag reflex in an awake, endotracheal intubation. If a neurolytic procedure is considered, the
block can be used prior to neurolysis as a prognostic indicator.



Extraoral Approach


Two major landmarks must first be identified: the angle of the mandible anteriorly and the mastoid process posteriorly. The patient is placed supine and the head is turned slightly opposite the direction of the affected side. Once in correct position a lateral fluoroscopic view is obtained visualizing the angle of the mandible and the mastoid process. Once identified
and marked a line is drawn between those two points inferior to the ear and the styloid process should lie midway between both points. When the target is identified a small
skin wheal with 1% lidocaine is applied to the skin and a
22-gauge, 1.5-inch needle is advanced perpendicular toward the styloid process. Bony contact is typically obtained at 3 cm. After contact, the needle is slightly withdrawn and walked off the styloid process in an anterior direction, ~ 0.5 cm. Inject 1 ml of contrast agent under continuous fluoroscopy. After injecting the contrast then 2 to 3 ml of local anesthetic (0.2% Ropivacaine) and steroid (4 mg dexamethasone) is



Intraoral Approach


when there is an anatomic distortion externally by previous surgery or tumor. The patient is placed in a supine position with mouth wide open and the tongue is retracted
downward and medially using a tongue depressor or a laryngoscope blade. The nerve will be located at the
inferior portion of the tonsillar pillar and is accessed via
the palatoglossal fold. Once the fold is identified, a topical local anesthetic spray or pledget with 1 ml of
saline with epinephrine is applied for hemostasis. A 22-
or 25-gauge needle with a slight distal bend (25 degrees)
is advanced to a depth no more than 0.5 cm into the mucosa. After negative aspiration, 2 to 3 ml of local
anesthetic (0.2% ropivacaine) and steroid (4 mg of
dexamethasone) are injected.




The extraoral approach

lead to complications secondary to the close proximity of relation of the CN IX, CN X, CN XI,
and CN XII at the styloid process. There can be accidental puncture of the vessels leading to vessel trauma and
hematoma formation. Also inadvertent intravascular injection of the ICA or IJV may lead to seizures or even
cardiovascular collapse




The intraoral approach

With the intraoral approach there
is a potential of vessel trauma and neurotoxicity but much
less that the extraoral approach. Other complications
can occur with unwanted blockade of CN X, CN XI, and


Blockade of the vagus can lead to

bradycardia, asystole, reflex tachycardia, and syncope, as well as dysphonia secondary to ipsilateral vocal cord paralysis


Blockade of CNXI and CNII can result

in temporary weakness of the trapezius muscle and the tongue


The cervical plexus block is performed for

anesthesia and
analgesia involving the head and neck region


The cervical
plexus is formed by

the anterior divisions of the first four upper cervical nerves (C1–C4) and the lower four nerves (C5–C8) together with the first thoracic ventral ramus
(T1) form the brachial plexus.


The location of the cervical plexus lies

deep to the internal jugular vein upon the
levator scapulae, scalene muscles and underneath the sternocleidomastoid muscle.


cervical plexus is divided two separate rami each dividing into

an ascending (superficial cervical plexus) and descending (deep cervical plexus)
branch forming loops at each level with the corresponding
nerves except for the first ramus.


The first cervical ramus
(suboccipital nerve)

primarily a motor
nerve. Even though it lacks cutaneous innervation it does
have some sensory function and communicates sensory
information to deeper muscles in the suboccipital region as
the suboccipital nerve.


The C1 nerve is often not affected
by a cervical plexus block due to

its posterior and deeper


The second, third, and fourth cervical nerves
leave their respective transverse processes

anteriorly and
surface lateral to the vertebral artery. The C2 and C3 nerves continue on and emerge at the midpoint of the posterior
border of the SCM muscle and travel
toward to their destination


The C2 nerve moves upward along

the sternocleidomastoid toward the posterior and lateral part of the scalp.


C2 nerve provides cutaneous innervation
to the

posterior scalp behind the ear, the upper and posterior auricle as well as the mastoid and angle of the mandible as the lesser occipital and great auricular nerve.


The C3 nerve bifurcates into

an anterior and descending portion. The anterior branch runs in an anterior oblique
direction where it gives cutaneous innervation to the lateral neck from the chin to the sternum as the transverse
cervicalis. The descending branch continues along the SCM muscle into the posterior triangle
of the neck beneath the platysma and deep cervical fascia and joins the fourth cervical nerve. Here these
nerves provide cutaneous innervation to the upper trapezius,
shoulder and pectoral region as the supraclavicular


The deep branches of the cervical plexus divide into

medial and lateral branches. The medial branches supply the anterior and lateral neck muscles and gives rise to the phrenic nerve via the fourth cervical nerve as the main
contributor. The lateral deep branch forms communicating
branches between C1 and C2 rami to the vagus and hypoglossal nerves.


the deep cervical plexus
gives rise to several muscular branches. These branches
supply the

rectus capitus lateralis (C1), rectus capitus anterior (C1, C2), longus capitus (C1–C3), and longus colli
(C2–C4). The muscular
branches are distributed to the SCM
(C2–C4), trapezius (C2, C3), levator scapulae (C3, C4) and scalene medius (C3, C4)


deep branches of the cervical plexus lateral branches communicate with the

spinal accessory nerve and supply the deep surface of
the trapezius via the communicating branches.




a safe alternative to general anesthesia for procedures involving the anterior-lateral portion of the neck, upper shoulder, and posterior scalp. Its potential indications
are many and include superficial neck procedures, neck
dissection, thyroglossal and brachial cyst surgery, thyroidectomy,
lymph node dissection, cervical node biopsy,
carotid endarterectomy, and other head and neck neuralgias.



motor and sensory

The sensory and motor component of the cervical plexus can each be blocked separately or together. A deep cervical plexus block provides motor and sensory blockade while a superficial plexus block only blocks the sensory component of the plexus.


The blockade of the
superficial cervical plexus provides anesthesia and analgesia for

the posterior and anterior auricular scalp region, lateral and anterior neck, and the upper shoulder region


The superficial cervical plexus block is useful for

pain relief; reduce nausea and vomiting with surgeries involving the tympanic-mastoid region, and for
simple superficial procedures such as involved with plastics
or superficial biopsies involving the neck. Additionally, this block is sometimes performed for carotid endarterectomy
and thyroid surgery.


The branches blocked by the
superficial cervical plexus block include

the lesser occipital,
great auricular, transverse cervicalis and the supraclavicular
nerves. For blockade of the deeper structures and the motor components a deep cervical plexus block is


Blockade of the deep cervical plexus provides anesthesia and analgesia of the

superficial and the deeper muscles
within the anterior and lateral neck up to the upper shoulder region.


Blockade of the deep cervical plexus indications

This technique can be used for surgical
anesthesia, post operative pain relief and diagnosis and
treatment of painful conditions involving the neck, posterior
scalp, and upper shoulder region. This block is performed
for procedures such as thyroidectomy, tracheostomy, and laceration repairs under local anesthesia or any
procedure that require muscle relaxation of the neck. One of the most common indications is for awake carotid


One of the more uncommon indications is for Blockade of the deep cervical plexus

the treatment of intractable hiccups as the deep branches
innervate the muscle of the diaphragm


Superficial Cervical Plexus Block


The patient is placed
in a supine position with the head turned away from the side that is going to be blocked. Once in correct position, it is important to identify the posterior border of the SCM muscle. This can be done one of two
ways. Two landmarks must be identified; the mastoid process and Chassaignac’s tubercle at C6. A line is drawn
from the mastoid process to Chassaignac’s tubercle over the SCM muscle. The drawn line should overly the path of the superficial cervical plexus over the posterior border of the SCM muscle. The position of
needle entry will be at the midpoint of line drawn from the mastoid process to Chassaignac’s tubercle. This is the site where the branches superficial plexus appear behind the posterior boundary of the SCM muscle. A 22- or 25-gauge, 4- to 5-cm needle is inserted subcutaneously 2 to 3 cm deep at the midpoint of the posterior border of the SCM muscle and
3 to 5 ml of local anesthetic is injected. The needle is then withdrawn and redirected subcutaneously in a superior direction toward the mastoid process while injecting
3 to 5 ml of local anesthetic in a fan-like fashion. The needle is then redirected in an inferior direction subcutaneously
toward Chassaignac’s tubercle injecting 3 to 5 ml of local anesthetic in a fan-like fashion


Deep Cervical Plexus Block:



the transverse
processes of C2 to C4 will be targeted. The patient
is placed in a supine position with the head turned away
from the side that is going to be blocked. Once in correct
position, two landmarks are identified; the mastoid process
and Chassaignac’s tubercle at C6


Deep Cervical Plexus Block:


A line is drawn from the mastoid process to chassaignac’s tubercle
overlying the SCM muscle. Once the SCM
is identified then the transverse processes
of C2, C3, C4, and C6 must be identified. This is achieved by first identifying the cricoid cartilage. Once identified, a line is drawn from the inferior aspect of the cricoid to the SCM. The point where these two lines intersect at a right angle is the C6 transverse process. Next the thyroid notch and superior cornu is palpated. Once located, a line is drawn to the SCM, and the
transverse process of C4 is identified at the point where the two lines intersect. Once the C4 transverse process is located, the transverse processes of C2 and C3 can be
easily identified. This is done by taking half the distance between C4 and C6. This measurement will be the distance between the transverse processes at each level. Once the intertransverse process distances are determined it is plotted along the original line drawn from the mastoid to Chassaignac’s tubercle. Beginning at the C4 transverse
process the distance is plotted upward toward the mastoid process and it should identify the C3 transverse process. The same distance is plotted from C3 to the mastoid and
the C2 transverse process will be identified


Deep Cervical Plexus Block:


After drawing out the points of interest the neck is prepped, cleaned, and draped in sterile fashion. The block is performed by using a 22-gauge, 1.5-inch needle, the transverse processes are located by entering
the skin in a perpendicular fashion. The needle is always
directed in a medial caudal direction to avoid any unintentional
vertebral artery, epidural, subdural, or spinal injection.
The needle is advanced slowly until the transverse process is contacted, which is typically 1.5 to 2.5 cm. the needle should
be redirected slightly posteriorly as the spinal nerves are located just in front of the transverse process. When bony contact is made, withdraw the needle 1 cm and
after negative aspiration, 3 to 5 ml of local anesthetic is
injected slowly. The needle is then removed and the entire procedure is repeated at the other two transverse processes


Cervical Plexus Block:


For shorter duration procedures 2% lidocaine and mepivacaine may be desired as this may achieve blockade up to 4 hr. For longer procedures ropivacaine or
bupivacaine can be used and this may prolong the block
up to 8 hr. Higher concentrations of local anesthetic will also prevent required supplemental infiltrations from the
surgeon. Lidocaine will
have faster onset times than mepivacaine, ropivacaine and


Cervical Plexus Block:


A total amount of 0.4 or 0.5 ml/kg (30 ml) is usually considered sufficient to perform either the superficial, deep or a combination of both blocks.
Furthermore, toxicity and systemic absorption can be
decreased with the addition of epinephrine to the local anesthetics. Epinephrine will decrease systemic absorption of bupivacaine and lidocaine by 20% or more.


adjunct used with local anesthetic



complications can occur when performing a cervical plexus block

always a risk of infection, risk of hematoma, Local anesthetic toxicity, Intravascular injection (vertebral or carotid artery), Nerve injury. Temporary diaphragmatic paresis invariably will occur
with the deep cervical plexus block. The blockade of the phrenic nerve cannot be avoided with this block. For that reason this procedure should never be performed in a bilateral fashion. The superficial plexus block will not cause blockade of the phrenic nerve. a high spinal (Avoid inserting the needle to deep as there is a
possibilty of a cervical cord or intrathecal injection.)


injection of local anesthetics can lead to

central nervous
system (CNS) or cardiac side effects. The CNS effects can
vary and will most likely consist of perioral numbness, sedation, tinnitus, or even seizures. Cardiac effects can
occur but usually happen with higher blood levels of local


if you experience high resistance with injection. This may indicate that the needle has been placed into

the nerve or nerve sheath and injection of
local anesthetics may lead to nerve ischemia and permanent


The injection of local anesthetics within the dural sleeves
around the nerves can cause

some of the volume to back track into the epidural space and even the subarachnoid
space leading to a high spinal. This will present as hypotension
and loss of consciousness. Treatment will involve
airway control and cardiovascular support until the local
anesthetic is metabolized from the CNS.

Decks in Essentials of Pain Medicine Class (80):