There are many different types of pain blocks for different disorders. The best pain block for an individual patient will depend on their specific problem.
The Sphenopalatine Ganglion (SPG) Block meets the criteria of high effectiveness and safety and it can be used for a wide variety of problems. It has an impressive 100 year plus history of safety. It can treat a wide variety of pain disorders and is extremely effective for Cluster Headaches, Sinus Pain and Sinus Headaches. It has been shown to be very effective for a wide variety eye, ear, and facial pains including trigeminal neuralgia, CRPS, Lumbago, Asthma and TMJ disorders.
A 1930 article in the Annals of Internal Medicine (JAMA) Hiram Byrd reported on the incredible safety record of transnasal SPG blocks in a report detailing 10,000 blocks in over 2000 patients to the Sphenopalatine Ganglion.
Elsewhere in this site there are a multitude of blog posts detailing success of SPG Blocks for pain. They are also effective for about a third of new essential hypertension patients, vasomotor rhinitis, treat anxiety and depression and all of this is possible utilizing lidocaine as the medication.
I will discuss the risks and benefits of other nerve blocks used for pain after I make the case for Sphenopalatine Ganglion Blocks being the ideal first block to be utilized in most chronic pain patients.
Greenfield Sluder MD originally described the trans-nasal approach to the sphenopalatine ganglion, an easy and minimally invasive technique. He originally used a 10% cocaine solution on a cotton-tipped applicator but excellent results are also attained with lidocaine.
There are currently three FDA approved devices used by neurologists to treat migraines and cluster headaches with sphenopalatine ganglion blocks. The Sphenocath and the Allevio are very similar and the TX 360 has a similar function but is designed specifically to be used for bilateral directed blocks. All three are essentially “squirt guns” designed to accurately dispense anesthetic to the nasal mucos overlying the very thin bony wall of the pterygopalatine fossa over the sphenopalatine ganglion also called the pterygopalatine ganglion. It is dispensed and ideally the patient stays supine for 10-20 minutes allowing anesthetic to cross to the ganglion.
There are also multiple approaches for injection into the ganglion, including several that use guided imaging which greatly increases both time and costs of the procedure. The intra-oral injection through the Greater Palatine Foramen is relatively easy for oral surgeons and general dentists who have learned the anatomy. In fact, denists probably do more nerve blocks than any other specialy on a routine basis. The ganglion is often anesthetized by accident during some dental procedures. The Suprazygomatic is also relatively easy for trained dentists and oral surgeons, ENT’s and neurosurgeons. It is actually easier to preform then a mandibular block used by dentists regularly in general practice. These injections techniques, especially the Suprazygomatic approach give very rapid relief.
The best approach for blocking the Sphenopalatine ganglion for most patients is self-administered sphenopalatine ganglion blocks with cotton-tipped nasal catheters (CTNC). Nasal passages with deviated septums and large turbinates can be difficult to navigate in some patients. In these cases nasal lidocaine sprays or drops allow self administration but results are far less impressive. I often utilize oxymetazoline spray to shrink the nasal membranes followed by lidocaine to make the procedure of self-administration of cotton-tipped catheters easier and more comfortable. The beauty to these catheters is they provide continuous delivery of lidocaine by capillary action. This keeps the anesthetic solution in contact with mucosal tissues for long periods of time, even several hours. The lidocaine has a natural anti-inflammatory effect. This cannot be duplicated with any other nasal approaches.
The most important factor of self administered blocks with cotton-tipped nasal catheters (CTNC) is that thpain at the patient is in control of application frequency, timing and duration of application. I typically start patients with twice daily application with CTNC until the pain or symptoms are well controlled and the reduce to once daily, the 2-3 times /week. Patients can use on an as needed basis when pain occurs or do it prophylactically to eliminate. There are enormous advantages to patients controlling their pain relief.
Costs of different techniques vary considerably. The FDA approved devices cost about $75.00 for a single use device and physicians typically charge about $750.00 per application and a series of ten blocks, every two weeks is typical course of treatment. This is approximately $7500.00 per 10 block treatment regimen. Injections are slightly less expensive depending on the method. Both of these have additional expense of interferences in quality of life related to visits to physician offices and emergency departments. Patients in pain must live with their pain until they can be seen and this creates disturbances in normal life routines.
Self administration allows the patient to skip the visits to physician offices. The nasal lidocaine sprays and drops are usually far less effective than other techniques. I do teach some patients to self-administer SPG blocks with the Sphenocath device. It is expensive $75.00 but when used for self administration on a single patient it can be reused over and over again. The TX 360 is also expensive ($75.00) but easy to utilize for self-administration but it is STRICTLY a single use device. All of these methods give a short-term exposure to anesthetic and ideally patients remain supine for 20 minutes interfering with daily activities.
Contrast this to self-administration with a cotton-tipped nasal catheters that can be placed in a minute ofr two similar to nasal spray or drops but due to continual feed does not require supine positioning. Patients can read, watch TV, work on computers, clean house while the lidocaine is continually released to the mucosa overlying the ganglion. Effectiveness of blocks performed with CTNCs is extremely high rivaling injections of the ganglion.
The sphenopalatine ganglion block has an almost universal ability to block pain throughout the body in many patients. This is well illustrated by an article “Sphenopalatine Phenomena” published in 1930 by Hiram Byrd MD in the Annals of Internal Medicine (JAMA) which looked at 10,000 blocks in 2000 patients with minimal negative side effects and high efficacy for a wide variety of problems. Dr Sluder wrote two books about the procedure, the second Nasal Neurology was a major medical textbook. . Unfortunately, the Sphenopalatine Block was in danger of being “Forgotten Medicine” when a poly-pharmaceutical approach to problems began in the mid 20th century. SPG blocks may have disappeared until a popular book was published in 1986 by Albert Gerber described the remarkable practice of Dr Milton Reder a New York City Otolaryngologist who only utilized Sphenopalatine Ganglion Blocks to treat a wide swath of chronic pain issues. He treated senators, representatives, kings and many famous or well known personalities.
I became aware of the book when a patient brought it into my office and asked me to find someone who did the procedure in Chicago. I was fascinated by the book that i read cover to cover in a single day but Icould find no one in the Chicago metropolitan area who did the procedure. It turned out that an excellent TMJ expert I knew professionally and as a friend, Dr Jack Haden knew the procedure and I travelled to Kansas City to learn his technique using a cotton tipped applicator. I have been doing the procedure ever since. Several years later I was introduced to the cotton-tipped nasal catheter and made the change due to better efficacy.
The Sphenopalatine Ganglion is the largest parasympathetic ganglion of the head and has somatosensory fibers, sympathetic and parasympathetic fibers that run through it including some from the superior sympathetic chain in the neck. Another autonomic block I will cover later is the stellate ganglion which can also be extremely effective but is far more complicated and carries greater risks. Notably, new research shows it may provide a one shot cure for PTSD making it very valuable to the military / veteran physicians and a study is currently underway.
Occipital, Greater Occipital and Lesser Occipital nerve blocks are also commonly utilized for headaches of all types but especially occipital headaches. Both are very safe and can be effective. The Greater Occipital Nerve Block is by far the safest of the two and is usually effective for occipital headaches and migraines. Cervicalgia or neck pain associated with occipital headaches will usually respond better to an occipital nerve block. I will usually begin with Greater and Lesser Occipital Blocks and if there is not resolution move lower down to occipital area. There is a common medical practice to inject a steroid with the anesthetic when doing occipital nerve blocks. I have always done them with anesthetic and no steroid. There are no compelling studies showing greater efficacy with steroids over just anesthetic. Some studies have found statistically equivilant results between anesthetic with/ or without steroids.
A procedure I teach patients which seems to improve efficacy of occipital blocks is systematic twisting of scalp hair over the area of the nerve. With chronic headache pain there is frequently tightening and shortening of the scalp muscles and decrease in blood flow. Small bundles of hair are picked up then twisted and held for 30 seconds and then the direction of the twist is reversed. This loosens the tight muscles that often press on the occipital nerves.
The Stellate Ganglion Block and other Sympathetic nerve blocks in the neck carry a significantly higher risk and are usually done by neurosurgeons though many physicians and anesthesiologists are comfortable with the procedure. Patients may be put out with an IV medication and guided imagery is often utilized.
Stellate Ganglion Blocks may be done if Sphenopalatine Ganglion Blocks are only partially effective. Due to safety of SPG Blocks they are often the first line of treatment. Stellate Ganglion Blocks are currently under study by the US military as a one shot technique for treating PTSD. This was originally seen serendipitously in soilders and verterans being treated for CRPS or Chronic Regional Pain Syndrome.
A stellate ganglion blocks sympathetic nerves that go to the arms, and the sympathetic nerves that go to the face. Many of those sympathetic nerves pass thru the Sphenopalatine Ganglion and can be more easily blocked with SPG Block. They may reduce pain, swelling, color and sweating changes in the upper extremity and may improve mobility in patients with Reflex Sympathetic Dystrophy (RSD), Sympathetic Maintained Pain, Complex Regional Pain Syndrome and Herpes Zoster (shingles) involving an arm or the head and face.
Selective cervical nerve root blocks and facet injections can be extremely helpful for various pain syndromes. These also carry high risk and are often painful. I suggest anesthesiologist, neurosurgeon or pain specialist be utilized for these blocks. These are frequently done with guided imaging.
I will often see patient who have widespread pain of indeterminate origin who come in for SPG Blocks and the bulk of the pain disappears but often a specific pain from single nerve root becomes easily identifiable when most of the pain has been eliminated. A case of “you cannot see the forest for the trees”.
A Gasserian Ganglion Block is a much more invasive technique and carries greater risks. It is usually done by neurosurgeons or interventional radiologists. The Gasserian ganglion or more commonly the trigeminal (nerve) ganglion is important in the treatment of some types of facial pain relieved by blocking the Gasserian ganglion. The Gasserian ganglion is found in Meckel’s cave inside the skull (middle cranial fossa) next to the brainstem and has three nerve divisions known as the trigeminal nerves. These are often thought of as the Dentist’s nerve because they go to all of the dental and jaw structures. There are three divisions, the maxillary branch (the Sphenopalatine Ganglion is attached to that division in the Pterygopalatine fossa) which goes to all the maxillary (upper teeth) and sinuses and nasal mucosa, the mandibular division that goes to the lower jaws, tongue and lips. Dentists routinely use block and infiltration anesthesia on all of these structures,. The last division is the ophthalmic division which goes to eyes, cornea, eyelids, nose, sinus and frontal areas.
More focused blocks of the Trigeminal nerve include those done at the Supraorbital Foramen ,the Supratrochlear Nerve (together represent frontal nerve) Infraorbital foramen, the mental foramen, and the iferior Alveloar nerve or mandibular /block.
The Gasserian Ganglion Block is done for severe Herpes Zoster, Trigeminal Neuralgia and other severe head and facial pain syndromes. Blocking of potions of the Trigeminal nerve can be done to evaluate effects prior to doing a Gasserian Ganglion Block. Due to the invasive nature and the risk of adverse events I recommend the Sphenopalatine Ganglion Blocks should always be tried prior to a Gasserian Ganglion Block.
The Auricular Temporal Nerve is a branch of the mandibular division of the Trigeminal nerve. A block to this area will give numbness to the ear, the temporomandibular joint and to the tesor tympani area. It is relatively safe and easy but may cause temporary eyelid drooping.
The rest of this post was lost…….to be continued