Trigeminal nerve neurosis symptoms treatment blockade. View full version

The emergence and development of such an important method of pain relief as blockade is based on experiments in alcoholization of the trigeminal nerve and partly in the Gasserian ganglion (this is the Gasseri ganglion), with Schlosser, Ostwalt, Wright, Bodin, Keller and others. These experiments served as the basis for the blockade of the trigeminal nerve and for deep injections into individual branches of n. trigeminus at the base of the skull, up to and including the gasserian ganglion. The technique for this valuable method of pain relief was developed mainly by Braun, Peuckert, Offerhaus and Hartel, but they also worked on this issue in other places: Georg Hirschel simultaneously reported several successful blocks of the branches of the trigeminal nerve at the Heidelberg Surgical Clinic.

At the beginning of the 20th century, extensive experiments in this area were published, mainly by Hartel, and he is credited with the use of local anesthesia for the gasserian ganglion. For a long time, local anesthesia, thanks to its extraordinary development, has become a special field that requires sufficient experience for its correct execution, but now this experience is even more necessary, after anesthesia of the trigeminal nerve and gasserian ganglion has been allocated to some extent to a special branch of regional anesthesia. Without dexterity and experience in this field, reliable and safe anesthesia is impossible. This certainly requires a thorough knowledge of the course of the branches and their innervation of individual areas of the head. When learning how to perform a blockade, it is hardly possible to do without a good model or skull, according to which the direction of the inserted needle and the depth to which it should penetrate are established.

How to anesthetize the trigeminal nerve?

Block of the first branch of the trigeminal nerve

The first branch of the trigeminal nerve is n. ophthalmicus is divided into three branches:

1. n. frontalis,
2. n. lacrymalis,
3. n. nasociliaris.

The blockade of these individual branches, according to the methods described by Brown and Peakert, consists of injecting a local anesthetic, in particular into the orbit along the course of these nerves, outside the muscular layer of the eyeball - bulbus oculi.

Damage to the eyeball can be easily avoided if you follow the suggested rules. For this, straight long needles are used; the use of curved varieties, as recommended by some, is unnecessary, and Brown warned against this in the early 20th century. Injection into individual nerve endings of the first branch of the trigeminal nerve is performed precisely in those places where, according to the anatomical structure of the bony cavity of the orbit, there are the best and most reliable paths for passing the needle. The tip of the latter must penetrate the orbit when driven along the bone, and this is only possible where the bony wall of the orbit is flatter and not too concave. Such places are located on the lateral and upper parts of the medial wall of the orbit; on its lower wall there is also a mostly flat bony surface, so a blockade can be carried out here too. The photo below shows the inserted needles for medial and lateral orbital injections.

The branches of n. are anesthetized by a medial injection. nasociliaris and nn. ethmoidales; lateral injection - n. frontalis and n. lacrymalis.

The injection points for these three orbital injections are depicted in the photo below.

Block of the first branch of the trigeminal nerve through lateral orbital injection

At point “a”, which lies above the most lateral corner of the eye, a lateral injection is made to anesthetize n. frontalis and n. lacrymalis.

According to Brown, a needle is inserted at this point so that its tip, once on the bone, does not come off the bone, and then the needle is inserted to a depth of 4½-5 cm to the fissura orbitalis super. Here they encounter the upper wall of the orbit, so that further advancement of the tip is impossible. Brown here injects 5 ml of a 1% solution of novocaine with adrenaline into the circumference of the fissura orbitalis superior; Hartel advises penetrating to a maximum depth of 3 cm and only then injecting local anesthetic.

With this lateral orbital injection, anesthesia occurs in the skin at the lateral canthus, at the medial canthus, on the upper eyelid, on the forehead and crown; in addition, anesthesia occurs in the conjunctiva of the lateral and medial parts of the upper eyelid and part of the conjunctiva of the lower eyelid.

Block of the first branch of the trigeminal nerve through medial orbital injection

With medial orbital injection, for pain relief nn. ethmoidales the point of injection will be point “b”. It lies, according to Brown, a finger higher above the inner corner of the eye (see photo above).

The needle is inserted here, under the control of palpation with the tip of the bone, to a depth of 4-5 cm in the horizontal direction. Brown here injects 5 ml of a 1% solution of novocaine with adrenaline, calculated on the medial and upper wall of the orbit.

According to Hartel for blockade n. ethmoidalis ant., innervating the upper and anterior part of the nasal mucosa and the skin of the tip of the nose, the needle should be inserted about 2 cm deep. This depth is not enough to reach n. ethmoidalis post., which supplies the posterior cells of the ethmoid bone and the sphenoid cavity. Since with a deeper injection in the direction of the foramen ethmoidale post, they get too close to, Hartel suggests making a medial injection of the orbit, no deeper than 3 cm, counting on the diffusion of the solution to a greater depth.

After injection into the orbit, according to Brown's experience, a rapidly passing protrusio bulbi with swelling of the upper eyelid is observed. There are no complications. Since the orbital injection is performed according to Brown along the bone wall outside the circulus tendineus and the muscular funnel of the bulbus oculi, the effect on n. opticus and on nn. ciliares were not observed. According to Credel, in connection with the injection of the orbit, the appearance of amaurosis was noted, lasting about ten minutes. It could be caused by adrenaline or the local anesthetic itself. Voino-Yasenetsky observed passing amaurosis, which occurred only a day after the operation and was caused by inflammatory edema of the orbit. This case should be considered as a consequence of local anesthesia performed for empyema of the frontal sinus.

Retrobulbar block

To anesthetize the eyeball during enucleation or exenteration, it is necessary to perform a retrobulbar blockade of the nn. ciliares and ggl. ciliare.

For this purpose, Lowenstein inserted a needle at the middle of the lateral edge of the orbit, to a depth of 4½ cm into the orbit, between the eyeball and the conjunctiva; here he turned the needle to the medial side and approached n. opticus and ganglion ciliare. Here he injected 1 ml of a 1% solution of cocaine with adrenaline. Next, he injected ½ ml of the same solution around the eyeball.

Siegrist injected retrobulbar tissue with curved needles in a circle from four injection points of the conjunctiva.

For retrobulbar blockade, Mende recommended inserting a needle behind the eyeball from two injection points, temporal and nasal, near the entry point of the optic nerve and nn. ciliares; he injected about 2 ml of a 1 or 2% solution of novocaine with adrenaline. In addition, 1 ml of the same solution was injected subconjunctivally near the insertion of the rectus muscle.

Seidel injected 1-2 ml of a 1% solution of novocaine with adrenaline subconjunctivally, around the eyeball. Then he injected 1 ml of solution retrobulbarly through the conjunctiva from four points and 1 ml of the same solution while the needle penetrated the retrobulbar tissue.

Block of the second branch of the trigeminal nerve

The second branch of the trigeminal nerve is n. maxillaris, as it passes at the base of the skull through the foramen rotundum, can be reached with an injection needle in various ways. This nerve trunk passes in a horizontal direction from the foramen rotundum into the pterygopalatine fossa, which it passes in the direction of the canalis infraorbitalis. After passing through this channel, it appears as n. infraorbitalis from the opening of the same name.

One can now enter the second branch of the trigeminal nerve at the foramen rotundum or on the intraorbital path, or, as tried before, by inserting a needle under the zygomatic arch and moving it along the posterior surface of the upper jaw into the fossa pterygopalatina.

The orbital path, according to Hartel, was first proposed by Payer, but implemented and methodically developed first. Hartel calls this path “axial puncture foramen rotundum.”

If on the skull, on the lateral part of the lower edge of the orbit, a needle is passed directly into the depth, then it enters through the fissura inferior into the canalis infraorbitalis, between the sphenoid bone and the upper jaw; at the end of this channel lies the foramen rotundum. First, the needle encounters some obstacle at the planum pterygoideum of the sphenoid bone.

If you now move the needle along this obstacle up and in the middle, then a foramen rotundum is achieved.

The distance of the foramen rotundum from the lower edge of the orbit is approximately 4-5 cm.

Since the foramen rotundum is very narrow and completely filled with n. maxillaris, the needle encounters strong resistance and the injection requires sufficient pressure. If you hit the nerve, the patient feels pain radiating along the area of ​​innervation of the second branch of the trigeminal nerve.

Intraorbital blockade of the second branch of the trigeminal nerve according to Hartel

Orbital blockade of the second branch of the trigeminal nerve in the foramen rotundum

According to Hartel, the technique of intraorbital blockade n. maxillaris in foramen rotundum is as follows:

The needle is inserted at the lower edge of the orbit, in the middle between the sutura zygomaticomaxillaris and the outer lower edge of the orbit. With the index finger of the left hand, the eyeball is pushed upward and the needle is passed between the finger and the lower wall of the orbit sagittally and horizontally in depth until, after passing through the fissura orbitalis inferior, it encounters at a depth of 4-5 cm the planum pterigoideum of the sphenoid bone. From this bone obstacle, a passage is felt deeper in the upward and inward direction until complaints of pain radiating to the n area appear. maxillaris. Having got the needle into the foramen rotundum, it is inserted into it a few millimeters more and ½ ml of a 2% solution of novocaine with adrenaline is injected at some pressure. If the injection is successful, anesthesia immediately occurs throughout the entire area innervated by the second branch of the trigeminal nerve.

The direction of the inserted needle is shown in the photo above by an arrow.

Complications

With the correct technique, damage to both the eyeball and n can be avoided. opticus, but according to Hartel, hematomas are possible. The orbital tract to the second branch of the trigeminal nerve is traversable in only 90% of skulls.

Block of the second branch of the trigeminal nerve according to Brown

Block of the second branch of the trigeminal nerve in the foramen rotundum with an injection under the zygomatic arch

Blockade n. maxillaris into the fossa pterygopalatina from an injection point lying under the zygomatic arch was first performed by Matas in 1900. Schlosser used this method for alcoholization of the trigeminal nerve for neuralgia, and Braun used this technique for local anesthesia.

According to Hartel, only in 33% of cases is it possible to penetrate the foramen rotundum with the tip of the needle in this way; in most cases, the effect of the blockade is explained by the penetration of the local anesthetic to the nerve through diffusion in the loose adipose tissue of the fossa pterygopalatina.

According to Brown, the blockade technique n. maxillaris from the lower edge of the zygomatic arch is as follows:

The needle is inserted under the lower angle of the cheekbone and moves inward and upward. It slides along the tuber maxillare and if it is too curved, then the injection point should be chosen more posteriorly. Sometimes the needle catches on the large wing of the sphenoid bone; then you need to carefully change direction. At a depth of 5-6 cm they fall into the hole on the nerve.

Brown injected 5 ml of a 1% solution of novocaine with adrenaline into this place with slight advancement and pulling of the needle. While pulling, he injected another 5 ml of the same solution behind the upper jaw to cause compression of the branches of art. maxillaris. If you hit n correctly. maxillaris, the patient again feels widespread pain in the face. If advancing the needle along the tuber maxillare presents difficulties, then under some circumstances it is necessary to make a new injection, more under the middle of the zygomatic bone, and administer a double dose of a solution of novocaine with adrenaline, that is, 10 ml of a 1% solution, so that the anesthetic can reach the nerve by diffusion.

In the photo above, the needle is inserted into the foramen rotundum from under the zygomatic arch; the arrow shows the direction.

Peculiarities

Before the injection, it is recommended, as with all blocks of the branches of the trigeminal nerve, to first navigate the skull and outline the direction of the needle. The latter is easy to fix by anesthetizing the 2nd branch of the trigeminal nerve, a line that appears to be drawn from 1 or 2 small molars of the lower jaw, obliquely through the skull to the middle of the cranial lid.

Guiding this guide line (see photo above) is often very helpful to anesthesiologists. The technique of this method of approaching the foramen rotundum is relatively simple, reliable and therefore recommended by many specialists.

Ostwalf maxillary nerve block

It is also worth mentioning the method of pain relief n. maxillaris according to Ostwalf, who inserts a needle from the side of the oral cavity behind the last molar and moves it forward along the planum infratemporale, ending up in the fossa pterygoidea.

Offerhaus maxillary nerve block

The next method of anesthetizing the maxillary nerve is according to Offerhaus. He measures with a compass the distance between the middles of both zygomatic arches and, subtracting from the resulting measurement the distance between the upper alveolar processes behind the molars, determines how far the foramen rotundum is from its puncture point. The latter is located either above or below the middle of the cheekbone.

Block of the third branch of the trigeminal nerve

The third branch of the trigeminal nerve, the area of ​​​​sensitive innervation of which has already been discussed in one of the articles on our website, enters the base of the skull through the foramen ovale.

Ostwalt mandibular nerve block

Ostwalt, in order to alcoholize the trigeminal nerve, inserted a needle bent at an angle with the mouth open behind the third upper molar through m. pterygoideus and reached the foramen ovale.

Block of the mandibular nerve according to Schltisser

Schltisser also uses for the purpose of alcoholization of the third branch n. trigeminus, another way. He inserts the needle at the anterior edge of m. masseter, pierces the cheek and reaches the oral cavity. Here he feels the needle with a finger inserted into the mouth and pushes it further to the greater wing of the sphenoid bone. The tip should now be a few millimeters from the foramen ovale. This method is especially bad because if the blockade is performed incorrectly, the mucous membrane of the mouth can be pierced.

Brown mandibular nerve block

Harris, Alexander, Offerhaus and Braun choose a transverse path to reach the foramen ovale.

According to Brown, the injection point lies under the middle of the cheekbone. The needle is advanced in an oblique direction into the skull. And here it is best to have a model of the skull near you, on which the oblique direction is fixed with another needle.

Technique

The needle is injected to proc. pterygoideus; its tip is now approximately 1 cm from the foramen ovale. The depth of the inserted needle is noted, and the latter is then pulled out to the subcutaneous tissue, turned back at a small angle and inserted again to the same depth. Then its tip is at the foramen ovale.

At the same moment, the patient feels pain spreading to the lower jaw. At this point, Brown injected 5 ml of a solution of novocaine with adrenaline. This technique used by Brown is very easy to perform and reliable, but as Hartel pointed out, variations in the base of the skull can sometimes create obstacles.

Hartel mandibular nerve block

Block of the third pair of the trigeminal nerve at the foramen ovale (the hatched arrow indicates the angle of the needle required to approach the ganglion). Blockade of the gasserian ganglion (Gasseri ganglion).

A very noteworthy method is to reach the foramen ovale from the front, developed by Hartel and recommended for blockade of the Gasseri ganglion. This method, similar to the Schltisser technique, was successfully used by the author for quite a long time. It differs from the Schltisser technique in that puncture of the oral mucosa with a needle is avoided. The cannula is passed to the tuber maxillae under the zygomatic bone along the cheek, at the height of the upper molars, between the ascending ramus of the mandible and the tuber maxillare to the planum infratemporale. Hartel used this path to pass through the foramen ovale to the gasser node.

This Hartel method, the same for blocking the third branch of the trigeminal nerve and the Gasserian ganglion, is as follows:

On the cheek, at the height of the alveolar edge of the second upper molar, a wide nodule is placed under the zygomatic arch, so that the injection point can be slightly changed if desired. Here a long thin needle, about 10 cm in length, is injected into the skin. The index finger of the left hand is inserted into the oral cavity; the right hand controls the needle. With further advancement of the latter, the tip passes between the edge of the lower jaw and the tuber maxillare. Due to the fact that the needle, with the help of a finger inserted into the mouth, goes around m. buccinator, the oral mucosa remains intact. If the needle now enters the fossa infratemporalis, then m. pterygoideus externus and the planum infratemporale is achieved.

The reached depth should be 5-6 cm. This place is easy to mark.

Peculiarities

It is best to measure the length of the needle before injection and test the distance on the skull. The direction of the needle axis is immediately established at the same time. Without knowing this direction, you cannot confidently get to the foramen ovale.

Hartel made a small movable pointer on his needle, which was fixed at any distance. This addition undoubtedly facilitates the entire blockade of the third branch of the trigeminal nerve, but it is not necessary.

It is very important to note, in addition to the depth, the direction of the inserted needle. According to Hartel, when viewed from the front, the axis extended in the imagination passes through the pupil of the eye, the same side. When viewed from the side, the needle points to the tuberculum articulare of the zygomatic arch, that is, the axis extended in the imagination passes through this point.

The arteria maxillaris interna intersects in the fossa infratemporalis. The danger of injuring it or the consequences of accidental damage are not very great. When using thin needles and skillfully injecting them directly, there are no complications with the artery. Hartel and Georg Hirschel never observed hematomas in their practice.

Before advancing the needle from the fossa infratemporalis into the foramen ovale, in order to orient itself regarding the depth of penetration, Hartel set the pointer on his needle 1.5 cm from the level of the skin at the injection site.

If desired, block n. mandibularis of the trigeminal nerve at the foramen ovale, without penetrating the bony canal to the Gasserian ganglion, there is no need to insert the needle as steeply as described above, and it must be injected under the zygomatic arch in a more horizontal direction to the protuberantia occipitalis.

In the photo above, the needle is inserted under the zygomatic arch into the foramen ovale. The axis marked with an arrow points to protuberantia occipitalis externa. This direction is easy to mark on the skull and remember. The outer injection point on the cheek is approximately 2.5 cm outward from the corner of the mouth.

Using this method, Georg Hirschel always successfully reached the third branch of the trigeminal nerve at the foramen ovale. When viewed from the front, the direction of the needle is the same as with the method given by Hartel, the tip of the needle, elongated in the imagination, points to the pupil of the same eye (photo below).

Direction of the needle when blocking the trigeminal nerve (n. mandibularis) in the foramen ovale (when viewed from the front)

With the method of inserting a needle through the foramen ovale to the ganglion Gasseri, as described above by Hartel, the direction of the imaginary axis when viewed from the side is different. The needle has a steeper stroke, as can be seen in the photo, where it is sketched in the form of an arrow passing through the foramen ovale. Above the direction leads more to the crown of the skull, while below it leads, lengthening, to the foramen mentale of the lower jaw. This change in direction depends on the anatomical structure of the bony canal for the third branch of the trigeminal nerve, which opens in a steeper direction.

To anesthetize the third branch of the trigeminal nerve, 5 ml of a 1-2% anesthetic solution is sufficient. When the needle correctly hits the nerve, the patient indicates pain spreading to the tongue and lower jaw.

There are many types of complications that arise during this procedure. They are also associated with a violation of the technique of performing manipulation and the wrong combination of drugs in the blockade mixture. It is because of this that bone blockades are currently performed by a very narrow circle of specialists, and this method of treatment is not widespread. However, doctors who use this method of treatment achieve high cure rates and allow patients to avoid the currently common surgical interventions aimed at decompressing the nerve or destroying it. Moreover, the effectiveness of such operations is currently being questioned.

Thus, complications of bone blockade are rare and are practically excluded if the rules of the procedure are followed. Carrying out a bone blockade by an experienced doctor guarantees the effectiveness and safety of the procedure. Bone blockades for neuralgia are a way to reduce pain, and often get rid of them altogether. The main thing is not to endure the pain, but to start the right treatment on time.

A. Indications. Blockade of the facial nerve is indicated for spasms of the facial muscles, as well as for herpetic lesions of the nerve. In addition, it is used in some ophthalmological operations (see Chapter 38).

B. Anatomy. The facial nerve leaves the cranial cavity through the stylomastoid foramen, where it is blocked. The facial nerve provides taste sensation to the anterior two-thirds of the tongue, as well as general sensation to the eardrum, external auditory canal, soft palate, and part of the pharynx.

The point of needle insertion is just anterior to the mastoid process, below the external auditory canal and at the level of the middle of the ramus of the mandible (see Chapter 38).

The nerve is located at a depth of 1-2 cm and is blocked by injecting 2-3 ml of local anesthetic into the area of ​​the stylomastoid foramen.

D. Complications. If the needle is inserted too deeply, there is a risk of blocking the glossopharyngeal and vagus nerves. Careful aspiration testing is necessary since the facial nerve is located in close proximity to the carotid artery and internal jugular vein.

Glossopharyngeal nerve block

A. Indications. Blockade of the glossopharyngeal nerve is indicated for pain caused by the spread of a malignant tumor to the base of the tongue, epiglottis, palatine tonsils. In addition, the blockade makes it possible to differentiate neuralgia of the glossopharyngeal nerve from trigeminal neuralgia and neuralgia caused by damage to the knee ganglion.

B. Anatomy. The glossopharyngeal nerve exits the cranial cavity through the jugular foramen medial to the styloid process and then passes in an anteromedial direction, innervating the posterior third of the tongue, muscles and mucous membrane of the pharynx. The vagus nerve and accessory nerve also leave the cranial cavity through the jugular foramen, passing next to the glossopharyngeal nerve; the carotid artery and internal jugular vein are closely adjacent to them.

B. Method of performing the blockade. A 22 G, 5 cm long needle is used and inserted just posterior to the angle of the mandible (Fig. 18-5).

Rice. 18-5. Glossopharyngeal nerve block

The nerve is located at a depth of 3-4 cm, stimulation of the nerve allows you to more accurately orient the needle. Inject 2 ml of anesthetic solution. An alternative approach is made from a point located midway between the mastoid process and the angle of the mandible, above the styloid process; the nerve is located immediately anterior to the styloid process.

D. Complications. Complications include dysphagia and vagal block, leading to ipsilateral vocal cord paralysis and tachycardia, respectively. Blockade of the accessory and hypoglossal nerves causes ipsilateral paralysis of the trapezius muscle and tongue, respectively. Performing an aspiration test helps prevent intravascular injection of anesthetic.

Occipital nerve block

A. Indications. Occipital nerve blocks are indicated for the diagnosis and treatment of occipital headaches and occipital neuralgia.

Rice. 18-6. Occipital nerve block

B. Anatomy. The greater occipital nerve is formed from the posterior rami of the cervical spinal nerves C2 and C3, while the lesser occipital nerve is formed from the anterior rami of these same nerves.

B. Method of performing the blockade. The greater occipital nerve is blocked by injecting 5 ml of anesthetic solution approximately 3 cm lateral to the occipital protuberance at the level of the superior nuchal line (Fig. 18-6). The nerve is located medial to the occipital artery, which can often be palpated. The lesser occipital nerve is blocked by injecting 2-3 ml of anesthetic further lateral along the superior nuchal line.

D. Complications. There is a negligible risk of intravascular injection.

And simple analgesics practically do not relieve it.

About the treatment method

Blockade of the gasserian or pterygopalatine ganglion of the trigeminal nerve, or its branches, in some cases may be the only treatment that helps relieve the patient of pain. In addition to the local anesthetic drug, ganglion blockers and anticholinergics, corticosteroid hormones and neurotropic agents are used when carrying out blockades.

Trigeminal nerve block can be both therapeutic and diagnostic. In the second case, it is carried out before, associated with the destruction of the peripheral nodes or one of the branches of the trigeminal nerve, to ensure that the source of pathological pain impulse is identified correctly. If the pain disappears after injecting a local anesthetic into the area where the nerve will be cut, the block will be effective.

Central blocks of the trigeminal nerve ganglia

The central ones include blockade of the Gasserian and pterygopalatine node, as well as the second and third branches in the pterygopalatine fossa:

• Gasserian ganglion block is a technically difficult procedure, since this ganglion is located inside the skull. This procedure is indicated for neuralgia of central origin, often as a diagnostic procedure before performing its percutaneous destruction. Because the injection itself can be painful, it is most often done under intravenous sedation. The needle is inserted through the cheek at the level of the second molar, goes around the upper jaw and, in the area of ​​the pterygopalatine fossa, penetrates into the cranial cavity through the foramen ovale. The position of the needle is controlled using fluoroscopy or ultrasound. The pain goes away immediately after the administration of the anesthetic; numbness of the corresponding half of the face may persist for 6-12 hours.

• Blockade of the pterygopalatine ganglion is carried out if the pain is localized in the zone of innervation of the II or III branch of the trigeminal nerve and is accompanied by autonomic disorders (redness of the skin, lacrimation or hypersalivation). This is a less invasive procedure than a semilunar ganglion block and can therefore be performed without additional anesthesia. The patient is placed on his side with the affected side up. The needle is inserted through the skin of the cheek 3 cm “anteriorly” from the tragus of the auricle, along the lower edge of the zygomatic arch to a depth of 3.5-4 cm, depending on individual anatomical features. From the same access, the doctor can selectively block the maxillary (at the round foramen) or the mandibular (at the oval) nerve.

Trigeminal nerve block

Peripheral blocks of individual branches of the trigeminal nerve

In secondary symptomatic forms of neuralgia, peripheral anesthesia of the mandibular or maxillary, mental, sub- or supraorbital nerve is often sufficient:

• The mandibular nerve can be blocked using an intraoral injection of anesthetic. The needle is inserted through the mucous membrane in the area of ​​the pterygomaxillary fold, which is located behind the third molars between the upper and lower jaw. In the same way, by slightly changing the trajectory of the needle, the doctor can block the lingual nerve in isolation;

• The infraorbital nerve, responsible for the sensitivity of the skin of the upper lip and wing of the nose, is blocked at the level of the canine fossa. The needle is inserted through the skin in the area of ​​the nasolabial fold and advances to the infraorbital foramen, which is located 1 cm below the infraorbital margin;

• A mental nerve block helps eliminate pain in the skin of the chin and lower lip. The needle is inserted through the skin at the level of the mental foramen, which is located between the roots of the first and second premolar of the mandible;

• Blockade of the supraorbital nerve, which is responsible for the sensitivity of the skin of the forehead and base of the nose, is carried out at the inner edge of the brow ridge. The exit point of the nerve is considered to be the place where, upon palpation, pain or paresthesia occurs along the branch.

Drugs for blocking the trigeminal nerve

The main group of drugs for blocking peripheral nerves are local anesthetics. They turn off the conduction of pain sensitivity, due to which the analgesic effect is achieved. In addition, specific drugs are used to block conduction in the vegetative nodes, as well as drugs that reduce the severity of symptoms of inflammation and promote the regeneration of the damaged nerve:

• Anticholinergic blockers platiphylline and pachycarpine are administered to block the conduction of autonomic signals at the level of the node. This eliminates spasm of the vascular wall and improves trophism of the nerve fiber. Adding these substances to the solution to blockade is also advisable in the presence of severe autonomic disorders during an attack;

• Corticosteroid hormones: hydrocortisone and kenalog help reduce the severity of reactive inflammation in nerve fibers and perineural tissues, thereby providing a deeper, longer-lasting and lasting analgesic effect;

• group B are introduced into the injection solution in order to normalize the function of the peripheral nerve.

Previously, alcohol-novocaine blockades were actively used, which were performed with the aim of destroying a section of the peripheral nerve, which led to the cessation of pain impulses. Currently, this procedure is being gradually abandoned due to the high probability of relapses caused by the development of scar changes in the nerve fiber.

Fortunately, few people are familiar with the pain that occurs with trigeminal neuralgia. Many doctors consider it one of the strongest a person can experience. The intensity of the pain syndrome is due to the fact that the trigeminal nerve provides sensitivity to most facial structures.

The trigeminal is the fifth and largest pair of cranial nerves. It belongs to the nerves of a mixed type, having motor and sensory fibers. Its name is due to the fact that the nerve is divided into three branches: orbital, maxillary and mandibular. They provide sensitivity to the face, soft tissues of the cranial vault, dura mater, oral and nasal mucosa, and teeth. The motor part provides nerves (innervates) some muscles of the head.

The trigeminal nerve has two motor nuclei and two sensory ones. Three of them are located in the hindbrain, and one is sensitive in the middle. The motor ones form the motor root of the entire nerve at the exit from the pons. Next to the motor fibers, they enter the medulla, forming a sensory root.

These roots form the nerve trunk, penetrating under the dura mater. Near the apex of the temporal bone, the fibers form the trigeminal ganglion, from which three branches emerge. The motor fibers do not enter the ganglion, but pass under it and connect with the mandibular branch. It turns out that the ophthalmic and maxillary branches are sensory, and the mandibular branch is mixed, since it includes both sensory and motor fibers.

Branch functions

1. Ophthalmic branch. Transmits information from the scalp, forehead, eyelids, nose (excluding nostrils), and frontal sinuses. Provides sensitivity to the conjunctiva and cornea.
2. Maxillary branch. Infraorbital, pterygopalatine and zygomatic nerves, branches of the lower eyelid and lips, sockets (posterior, anterior and middle), innervating the teeth on the upper jaw.
3. Mandibular branch. Medial pterygoid, auriculotemporal, inferior alveolar and lingual nerves. These fibers transmit information from the lower lip, teeth and gums, chin and jaw (except at a certain angle), part of the outer ear and the oral cavity. Motor fibers provide communication with the masticatory muscles, giving a person the ability to speak and eat. It should be noted that the mandibular nerve is not responsible for taste perception; this is the task of the chorda tympani or the parasympathetic root of the submandibular ganglion.

Pathologies of the trigeminal nerve are expressed in disruption of the functioning of certain motor or sensory systems. The most common type is trigeminal or trigeminal neuralgia - inflammation, compression or pinching of fibers. In other words, this is a functional pathology of the peripheral nervous system, which is characterized by attacks of pain in half of the face.

Neuralgia of the facial nerve is predominantly an “adult” disease; it is extremely rare in children.
Attacks of facial neuralgia are marked by pain, which is conventionally considered one of the most severe that a person can experience. Many patients compare it to a lightning strike. Attacks can last from a few seconds to hours. However, severe pain is more typical for cases of inflammation of the nerve, that is, for neuritis, and not for neuralgia.

Causes of trigeminal neuralgia

The most common cause is compression of the nerve itself or a peripheral node (ganglion). Most often, the nerve is compressed by the pathologically tortuous superior cerebellar artery: in the area where the nerve leaves the brain stem, it passes close to blood vessels. This reason often causes neuralgia in the case of hereditary defects of the vascular wall and the presence of an arterial aneurysm, in combination with high blood pressure. For this reason, neuralgia often occurs in pregnant women, and after childbirth the attacks go away.

Another cause of neuralgia is a defect in the myelin sheath. The condition can develop with demyelinating diseases (multiple sclerosis, acute disseminated encephalomyelitis, Devic's opticomyelitis). In this case, neuralgia is secondary, since it indicates a more severe pathology.

Sometimes compression occurs due to the development of a benign or malignant tumor of the nerve or meninges. Thus, in neurofibromatosis, fibroids grow and cause various symptoms, including neuralgia.

Neuralgia can be a consequence of brain contusion, severe concussion, or prolonged fainting. In this condition, cysts appear that can compress tissue.

Rarely, the cause of the disease is postherpetic neuralgia. Along the course of the nerve, characteristic blistering rashes appear and burning pain occurs. These symptoms indicate damage to the nervous tissue by the herpes simplex virus.

Causes of attacks with neuralgia

When a person has neuralgia, it is not necessary that the pain is constant. Seizures develop as a result of irritation of the trigeminal nerve in trigger or “trigger” areas (corners of the nose, eyes, nasolabial folds). Even with a weak impact, they generate a painful impulse.

Risk factors:

1. Shaving. An experienced doctor can determine the presence of neuralgia by the patient’s thick beard.
2. Stroking. Many patients refuse napkins, scarves and even makeup, protecting their face from unnecessary exposure.
3. Brushing teeth, chewing food. Movement of the muscles of the mouth, cheeks, and pharyngeal constrictors causes the skin to shift.
4. Taking fluids. In patients with neuralgia, this process causes the most severe pain.
5. Crying, laughing, smiling, talking and other actions that provoke movement in the structures of the head.

Any movement of the facial muscles and skin can cause an attack. Even a blow of wind or a transition from cold to heat can provoke pain.

Symptoms of neuralgia

Patients compare pain due to trigeminal nerve pathology to a lightning bolt or powerful electric shock, which can cause loss of consciousness, tearing, numbness and dilated pupils. The pain syndrome covers one half of the face, but the entirety: skin, cheeks, lips, teeth, orbits. However, the frontal branches of the nerve are rarely affected.

For this type of neuralgia, pain irradiation is not typical. Only the face is affected, with no sensation spreading to the arm, tongue or ears. It is noteworthy that neuralgia affects only one side of the face. As a rule, attacks last a few seconds, but their frequency may vary. The resting state (“light interval”) usually lasts days and weeks.

Clinical picture

1. Severe pain that has a piercing, through or shooting nature. Only one half of the face is affected.
2. Distortion of individual areas or the entire half of the face. Distortion of facial expressions.
3. Muscle twitching.
4. Hyperthermic reaction (moderate increase in temperature).
5. Chills, weakness, pain in the muscles.
6. Small rash in the affected area.

The main manifestation of the disease, of course, is severe pain. After an attack, distortions in facial expression are noted. With advanced neuralgia, changes can be permanent.

Similar symptoms can be observed with tendonitis, occipital neuralgia and Ernest's syndrome, so it is important to carry out a differential diagnosis. Temporal tendonitis causes pain in the cheeks and teeth, and discomfort in the neck.

Ernest syndrome is damage to the stylomandibular ligament, which connects the base of the skull and the lower jaw. The syndrome causes pain in the head, face and neck. With occipital neuralgia, pain is localized in the back of the head and moves to the face.

Nature of pain

1. Typical. Shooting sensations resembling electric shocks. As a rule, they occur in response to touching certain areas. Typical pain occurs in attacks.
2. Atypical. Constant pain that covers most of the face. There are no decay periods. Atypical pain due to neuralgia is more difficult to cure.

Neuralgia is a cyclical disease: periods of exacerbation alternate with subsidence. Depending on the degree and nature of the lesion, these periods have different durations. Some patients experience pain once a day, while others complain of attacks every hour. However, for everyone, the pain begins abruptly, reaching its peak within 20-25 seconds.

Toothache

The trigeminal nerve consists of three branches, two of which provide sensation to the oral area, including the teeth. All unpleasant sensations are transmitted by the branches of the trigeminal nerve to one side of the face: reaction to cold and hot, pain of different types. There are often cases when people with trigeminal neuralgia go to the dentist, mistaking the pain for a toothache. However, rarely do patients with pathologies of the dental system come to a neurologist with suspected neuralgia.

How to distinguish toothache from neuralgia:

1. When a nerve is damaged, the pain is similar to an electric shock. The attacks are mostly short, and the intervals between them are long. There is no discomfort in between.
2. Toothache, as a rule, does not begin and end suddenly.
3. The intensity of pain during neuralgia makes a person freeze, and the pupils dilate.
4. Toothache can begin at any time of the day, and neuralgia manifests itself exclusively during the day.
5. Analgesics help relieve toothache, but they are practically ineffective for neuralgia.

It is easy to distinguish toothache from inflammation or a pinched nerve. Toothache most often has a wave-like course, the patient is able to indicate the source of the impulse. There is an increase in discomfort when chewing. The doctor can take a panoramic photo of the jaw, which will reveal dental pathologies.

Odontogenic (tooth) pain occurs many times more often than manifestations of neuralgia. This is due to the fact that pathologies of the dental system are more common.

Diagnostics

With severe symptoms, making a diagnosis is not difficult. The main task of the doctor is to find the source of neuralgia. Differential diagnosis should be aimed at excluding oncology or another cause of compression. In this case, they talk about a true condition, not a symptomatic one.

Examination methods:

• High-resolution MRI (magnetic field strength greater than 1.5 Tesla);
• computed angiography with contrast.

Conservative treatment of neuralgia

Conservative and surgical treatment of the trigeminal nerve is possible. Almost always, conservative treatment is first used, and if it is ineffective, surgery is prescribed. Patients with this diagnosis are entitled to sick leave.

Drugs for treatment:

1. Anticonvulsants (anticonvulsants). They are able to eliminate congestive excitation in neurons, which is similar to a convulsive discharge in the cerebral cortex during epilepsy. For these purposes, drugs with carbamazepine (Tegretol, Finlepsin) are prescribed at 200 mg per day with the dose increasing to 1200 mg.
2. Centrally acting muscle relaxants. These are Mydocalm, Baclofen, Sirdalud, which eliminate muscle tension and spasms in neurons. Muscle relaxants relax the trigger zones.
3. Analgesics for neuropathic pain. They are used if there is burning pain caused by a herpetic infection.

Physiotherapy for trigeminal neuralgia can relieve pain by increasing tissue nutrition and blood supply to the affected area. Thanks to this, accelerated nerve recovery occurs.

Physiotherapy for neuralgia:

• UHF (ultra-high frequency therapy) improves microcirculation to prevent atrophy of the masticatory muscles;
• UVR (ultraviolet irradiation) helps relieve pain due to nerve damage;
• electrophoresis with novocaine, diphenhydramine or platyphylline relaxes the muscles, and the use of B vitamins improves the nutrition of the myelin sheath of the nerves;
• laser therapy stops the passage of impulses through the fibers, relieving pain;
• electric currents (impulsive mode) can increase remission.

It should be remembered that antibiotics are not prescribed for neuralgia, and taking conventional painkillers does not have a significant effect. If conservative treatment does not help and the intervals between attacks become shorter, surgical intervention is required.

Massage for facial neuralgia

Massage for neuralgia helps eliminate muscle tension and increase tone in atonic (weakened) muscles. In this way, it is possible to improve microcirculation and blood supply in the affected tissues and directly in the nerve.

Massage involves influencing the exit areas of nerve branches. These are the face, ears and neck, then the skin and muscles. The massage should be carried out in a sitting position, leaning your head back on the headrest and allowing the muscles to relax.

You should start with light massaging movements. It is necessary to focus on the sternocleidomastoid muscle (on the sides of the neck), then move up to the parotid areas. Here the movements should be stroking and rubbing.

The face should be massaged gently, first on the healthy side, then on the affected side. The duration of the massage is 15 minutes. The optimal number of sessions per course is 10-14.

Surgical treatment

As a rule, patients with trigeminal nerve pathology are offered surgery after 3-4 months of unsuccessful conservative treatment. Surgical intervention may involve eliminating the cause or reducing the conduction of impulses along the branches of the nerve.

Operations that eliminate the cause of neuralgia:

• removal of tumors from the brain;
• microvascular decompression (removal or displacement of vessels that have dilated and put pressure on the nerve);
• expansion of the exit of the nerve from the skull (the operation is performed on the bones of the infraorbital canal without aggressive intervention).

Operations to reduce the conductivity of pain impulses:

• radiofrequency destruction (destruction of altered nerve roots);
• rhizotomy (dissection of fibers using electrocoagulation);
• balloon compression (compression of the trigeminal ganglion with subsequent death of fibers).

The choice of method will depend on many factors, but if the operation is chosen correctly, attacks of neuralgia will stop. The doctor must take into account the general condition of the patient, the presence of concomitant pathologies, and the causes of the disease.

Surgical techniques

1. Blockade of certain sections of the nerve. A similar procedure is prescribed in the presence of severe concomitant pathologies in old age. The blockade is carried out using novocaine or alcohol, providing an effect for about a year.
2. Ganglion block. The doctor gains access to the base of the temporal bone, where the Gasserian node is located, through a puncture. Glycerol is injected into the ganglion (glycerol percutaneous rhizotomy).
3. Transection of the trigeminal nerve root. This is a traumatic method, which is considered radical in the treatment of neuralgia. To implement it, extensive access to the cranial cavity is required, so trepanation is performed and burr holes are applied. At the moment, the operation is performed extremely rarely.
4. Dissection of the bundles that lead to the sensory nucleus in the medulla oblongata. The operation is performed if the pain is localized in the projection of the Zelder zones or distributed according to the nuclear type.
5. Decompression of the Gasserian node (Janetta operation). The operation is prescribed when a nerve is compressed by a vessel. The doctor separates the vessel and the ganglion, isolating it with a muscle flap or synthetic sponge. Such an intervention relieves the patient of pain for a short period of time, without depriving him of sensitivity or destroying nerve structures.

It must be remembered that most operations for neuralgia deprive the affected side of the face of sensitivity. This causes inconvenience in the future: you can bite your cheek and not feel pain from injury or damage to the tooth. Patients who have undergone such surgery are advised to visit the dentist regularly.

Gamma knife and particle accelerator in treatment

Modern medicine offers patients with trigeminal neuralgia minimally invasive, and therefore atraumatic, neurosurgical operations. They are carried out using a particle accelerator and a gamma knife. They are relatively recently known in the CIS countries, and therefore the cost of such treatment is quite high.

The doctor directs beams of accelerated particles from ring sources to a specific area of ​​the brain. The cobalt-60 isotope emits a beam of accelerated particles, which burns out the pathogenic structure. The processing accuracy reaches 0.5 mm, and the rehabilitation period is minimal. Immediately after the operation, the patient can go home.

Traditional methods

There is an opinion that you can relieve pain from trigeminal neuralgia with the help of black radish juice. The same remedy is effective for sciatica and intercostal neuralgia. It is necessary to moisten a cotton swab with juice and gently rub it into the affected areas along the nerve.

Another effective remedy is fir oil. It not only relieves pain, but also helps restore the nerve in case of neuralgia. It is necessary to moisten a cotton wool with oil and rub along the length of the nerve. Since the oil is concentrated, do not use it vigorously, otherwise you may get burned. You can repeat the procedure 6 times a day. The course of treatment is three days.

For neuralgia, fresh geranium leaves are applied to the affected areas for several hours. Repeat twice a day.

Treatment regimen for a cold trigeminal nerve:

1. Warming your feet before bed.
2. Take vitamin B tablets and a teaspoon of beebread twice a day.
3. Apply Vietnamese “Star” to the affected areas twice a day.
4. Drink hot tea with soothing herbs (motherwort, lemon balm, chamomile) at night.
5. Sleeping in a hat with rabbit fur.

When pain affects teeth and gums, you can use chamomile infusion. Infuse a teaspoon of chamomile in a glass of boiling water for 10 minutes, then strain. You need to take the tincture into your mouth and rinse until it cools. You can repeat the procedure several times a day.

Tinctures

1. Hop cones. Pour vodka (1:4) over the raw material, leave for 14 days, shake daily. Drink 10 drops twice a day after meals. Must be diluted with water. To normalize sleep and calm the nervous system, you can stuff your pillow with hop cones.
2. Garlic oil. This product can be purchased at a pharmacy. In order not to lose essential oils, you need to make an alcohol tincture: add a teaspoon of oil to a glass of vodka and wipe the whiskey with the resulting mixture twice a day. Continue the course of treatment until the attacks disappear.
3. Marshmallow root. To prepare the medicine, you need to add 4 teaspoons of the raw material to a glass of cooled boiled water. The product is left for a day, in the evening gauze is soaked in it and applied to the affected areas. The top of the gauze is covered with cellophane and a warm scarf. You need to keep the compress for 1-2 hours, then wrap your face with a scarf overnight. Usually the pain stops after a week of treatment.
4. Duckweed. This remedy is suitable for relieving puffiness. To prepare duckweed tincture, you need to prepare it in the summer. Add a spoonful of raw materials to a glass of vodka and leave for a week in a dark place. The product is filtered several times. Take 20 drops mixed with 50 ml of water three times a day until complete recovery.