Bone block for inflammation of the trigeminal nerve. How is the blockade carried out for trigeminal neuralgia? Peripheral blockade of the branches of the trigeminal nerve

Neuralgia is damage to the nerves in peripheral part nervous system, which is located outside the spinal cord and brain, but connects them with all organs. This problem occurs quite often and is quite treatable, especially if the damage is small. One of the most common ailments is neuralgia trigeminal nerve, responsible for the sensitivity of the oral cavity and the entire face as a whole. It is the largest nerve branch emerging from the cranium. The pain with this type of neuralgia is quite severe, so even anti-inflammatory and analgesic medications are unable to drown it out. A trigeminal nerve block can help in such a situation.

The procedure for blocking impulses emanating from the trigeminal nerve branch is performed by a neurologist in a hospital setting using special drugs. The whole process takes place under local anesthesia and neurotope drugs, ganglion blockers, corticosteroids, anticholinergics and other drugs are usually used for blockade.

Such blocking is not always carried out in order to remove painful sensations. Sometimes it is performed for diagnostic purposes before surgery due to severe damage to the nerve branch of the trigeminal nerve or one of the peripheral nodes. A procedure is performed to correctly determine the source of painful pulsation. You can check whether the location is correct by injecting an anesthetic into the area where the blockade is planned. If the discomfort disappears, the procedure will be effective.

Blocking pain is performed on a specific area that has been damaged. The central blockade includes the following nodes:

• Gasserov. It is quite difficult to block it, because this node is located in cranium. Doctors perform this procedure for diagnostic purposes before surgery or if the neuralgia is of central origin. Due to the fact that the injection will be too painful for the patient, the entire process takes place under intravenous sedation (superficial drug sleep). An injection is made through the skin of the cheek in the area of ​​the 2nd molar of the upper jaw. The needle should enter the cranial cavity through the pterygopalatine fossa, and an ultrasound machine can be used to ensure that there are no malfunctions. The painful throbbing usually goes away immediately after the drug is injected, but such an injection usually leaves an unpleasant side effect. Half of a person’s face becomes numb for 8-10 hours;
• Pterygopalatine. Blockade of innervation in this area is carried out only if the pain is localized in the 2nd and 3rd branches of the trigeminal nerve. Typically, the patient exhibits autonomic disturbances, for example, increased salivation, redness on the skin, and excessive lacrimation. Invasion (implementation) in this case is not as deep as when blocking the gasserian node, so the injection is performed without intravenous sedation. Before the procedure, the doctor asks the patient to lie on his side so that the damaged area remains on top. The injection is also given through the cheek 3 cm diagonally from auricle and the depth of needle insertion is approximately 4 cm. The pain goes away almost immediately after the injection.

Anesthetizing large nodes such as the trigeminal nerve requires precision and care on the part of the physician performing the procedure. If the execution technique is not ideal or even the slightest mistake is made, then there may be severe consequences, up to paralysis of the facial muscles.

Blocking remote branches

Neuralgia may manifest itself as a secondary form and the pain will not be so pronounced. In this case, the neurologist will only numb the pinched nerves:

• Mandibular. You can stop the painful pulsation in this area with an injection of an anesthetic drug, which will be given inside the mouth. The needle must pass through the pterygomaxillary fold, which is located between the 7th and 8th teeth on the lower jaw;
• Infraorbital. Due to its pinching, pain occurs in the area of ​​the upper lip and nose (side part). You can stop the discomfort by making an injection at the level of the canine (canine) fossa. The injection is performed through the skin in the area of ​​the nasolabial fold. The infraorbital nerve is located approximately 1 cm below the edge of the eye;
• Chin. When it is damaged, pain occurs in the chin area and discomfort radiates to the lower lip. An anesthetic injection is performed between the 4th and 5th teeth in the area of ​​the chin;
• Supraorbital. In patients with pinching of this particular nerve, throbbing pain radiates to the forehead and the base of the nose. An injection to block the nerve signal should be performed near the edge of the brow ridge on its inside. You can understand exactly where the injection should be performed by palpation. After all, the place where pain is felt most strongly is the entry point of the nerve branch.

Nerve branches are usually anesthetized quite simply and if the injection is performed correctly, no side effects occur.

You can understand the location of the branches and nodes of the trigeminal nerve based on this picture:

Medicines used to perform the procedure

Medications to perform the blockade are usually selected in a standard manner. The exception is the situation when the patient is intolerant to the composition of a certain drug. The basis of treatment is local anesthetics, which prevent the nerves from sending signals, due to which pain relief occurs in a certain area. In addition to them, neurologists use special medications designed to block impulses in the nodes of the autonomic nervous system. In addition to drugs that affect pain pulsation, drugs with anti-inflammatory, anticonvulsant and wound-healing effects are used. They serve to improve the regeneration of the damaged trigeminal nerve.

The most commonly used drugs are:

• Pachycarpine and anticholinergics. Such drugs perform the function of blocking at the level nerve ganglia. After their use, the spasm subsides and nerve conduction in the damaged areas improves. Adding them to the solution for the pain blocking procedure is also recommended if the patient has pronounced vegetative symptoms;
• Corsticosterodes. Among this group, hydrocortisone is most often used, which serves to reduce the inflammatory process in nerve tissues. Due to this effect, pain relief will last much longer, and the regeneration of damaged areas of the nerve will accelerate;
• B vitamins. They are extremely important for the normal functioning of the nervous system. When added to a blockade solution, such vitamins will help normalize the functions of damaged nerves.

In the old days, alcohol-novocaine blockades were used with particular popularity. This method is based on an injection of novocaine diluted in alcohol. The injection was carried out in the tissue that surrounds the damaged nerve, due to which it was partially destroyed and the pain stopped. This method is no longer used nowadays, since scars form in the nerve fiber due to the damage received and relapses of neuralgia are possible.

Carbamazepine for trigeminal neuralgia

A course of treatment for trigeminal neuralgia is prescribed by a neurologist after a long examination. The patient will have to undergo them to find out whether the disease manifests itself or whether it is just secondary manifestation more serious pathological process. If, after performing all the necessary examinations, which include a blood test, ultrasound, MRI, CT and x-ray, the doctor diagnoses neuralgia, then Carbamazepine can help with it. This drug is an anticonvulsant and forms the basis for the treatment of damaged nerves, regardless of their location.

In the territory Russian Federation Carbamazepine is produced by many pharmaceutical companies, so purchasing it will not be difficult. Its effect consists of 2 parts:

• Reducing the duration of pain attacks;
• Increased time between attacks.

Many people think that Carbamazepine reduces pain, but this is a misconception. This drug, like other drugs with anticonvulsant effect do not eliminate pain, but only reduce its attacks and their frequency of occurrence.

Many experts recommend this medication as a preventive measure, because it does not remove discomfort, but can warn them. If an attack does begin, the drug must be combined with anesthetics so as not to feel severe discomfort.

Carbamazepine also has other forms of release, for example, Finlepsin Retard, which is its extended-release analogue. The main active ingredient of the drug exerts its effect on nerve fibers, including the trigeminal nerve, much longer than expected due to its slow release. This form of medication is suitable for people who do not like to take medications often or are afraid of missing their next dose. A long-acting drug will have its effect constantly, which means the chances of an attack occurring will be minimal.

Often people switch from carbamazepine to its long-acting analogue in order to reduce the concentration of the drug in the body and reduce the chance of developing complications from taking the medication. After all, experts have repeatedly noted that slow-release drugs are much less likely to cause side effects.

Method of taking the medication

One tablet contains 200 mg of Carbamazepine active substance and per day you are allowed to take no more than the dosage indicated in the instructions. According to experts, if you increase the dosage of the medication even more, the positive effect will not be achieved and side effects will begin to appear instead. An overdose can be recognized by the following symptoms:

• General weakness in the body;
• Allergic manifestations (itching, urticaria, allergic rhinitis);
• Drowsiness;
• Changes in taste perception.

Carbamazepine not only prevents the impulse that causes pain from passing from the damaged nerve to the central nervous system, but also slows down useful signals. Because of this, the reaction slows down when performing a muscle contraction. This nuance should be taken into account when choosing medications for the course of treatment of trigeminal neuralgia.

The dose must be selected strictly individually to avoid side effects. Initially, you should start with a minimum amount, and then gradually increase it until the result is visible, but not higher than the permissible maximum. The neurologist usually prescribes 1 tablet (200 mg) at a time, 3 times a day, and then increases it to 2 to enhance the effect.

When the desired result is achieved, namely a decrease in the frequency and duration of painful attacks, the doctor will reduce the dosage. For preventive purposes and to maintain the effect, you should use the medication on the recommendation of a doctor.

When combining the anticonvulsant drug Carbamazepine with other drugs, the maximum dose should be reduced. This should be done by a doctor, and it is not recommended to change the dosage on your own or take any medications without the knowledge of a specialist.

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.

Trigeminal – the fifth and largest pair 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 that penetrates under hard shell. Near the top temporal bone the fibers form a 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 oral cavity. Motor fibers provide communication with masticatory muscles, giving a person the opportunity 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 facial nerve 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 pain 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 are 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 exits the brain stem, it passes close to blood vessels. This reason often causes neuralgia with 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 arise 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. 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 facial muscles and skin can cause an attack. Even a breath 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 tendinitis, 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 half of the face: reaction to cold and hot, pain of different nature. 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 (tension magnetic field more than 1.5 Tesla);
• computed angiography with contrast.

Conservative treatment of neuralgia

Perhaps conservative and surgery trigeminal nerve. Almost always, conservative treatment is first used, and if it is ineffective, it is prescribed surgery. 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. Muscle relaxants central action. These are Mydocalm, Baclofen, Sirdalud, which help 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, it happens accelerated recovery nerve.

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 strain 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.

Surgery

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 general state patient, presence accompanying pathologies, 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 placed. On this moment the operation is performed extremely rarely.
4. Dissection of the bundles that lead to the sensitive nucleus in 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 procedure). 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 – 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 burn. 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. So as 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.

Novocain block of the branches of the trigeminal nerve used to relieve intense pain due to neuritis or trigeminal neuralgia. First install pain points(Balle points), with pressure on which an attack of pain most often begins. Depending on this, the injection site is chosen. A concentrated solution of novocaine (1-2%) or a mixture of it with hydrocortisone (25-30 mg per injection) is administered.

Block of the first branch of the trigeminal nerve. To determine the location of needle insertion, divide the second finger of the left hand top edge orbits in half and, without removing the finger, place the second finger of the other hand against it inwardly, immediately above the eyebrow. Here you can palpate the supraorbital foramen, or supraorbital canal. Above it, 1-1.5 ml of a 2% novocaine solution is injected intradermally with a thin needle and then, introducing an additional 2-3 ml, infiltrate subcutaneous tissue and tissue down to the bone around this hole.

After contact with bone, the needle can be immersed into the depth of the canal no more than 5-6 mm. When blocking with hydrocortisone, it is also administered after preliminary intradermal anesthesia with a solution of novocaine.

Block of the second branch of the trigeminal nerve in the area of ​​the infraorbital foramen. The middle of the lower edge of the orbit is determined. In this case, it is better to place the second finger of the hand on top so that the pulp nail phalanx rested on the edge of the eye socket. Stepping 1.5-2 cm downwards from this place, a solution of novocaine is injected intradermally and then the underlying tissues are infiltrated towards the infraorbital foramen and around it, right up to the bone. Inject 3-4 ml of 2% novocaine solution. In this case, as with blockade of the first branch, a thick and short needle is used. The most correct direction of the needle is slightly upward and outward, so that its pavilion is almost close to the wing of the nose. Do not press the needle hard on the bone and do not advance the needle after contact with it by more than 0.5 cm.
Summing up solution novocaine to the inferior orbital nerve at the inferior orbital foramen can also be performed according to the method of V.F. Voino-Yasenetsky (1946).

Block of the third branch of the trigeminal nerve at the angle of the lower jaw. The patient lies on his back, with a cushion under his shoulder blades. The head is thrown back and turned in the opposite direction. After intradermal anesthesia, a thin needle 5-10 cm long is inserted at the lower edge of the lower jaw, 2 cm anteriorly from the angle of the jaw. The needle should slide along the inner surface of the jaw parallel to its ascending branch. At a depth of 3-4 cm, the end of the needle approaches the area where the mandibular nerve enters the thickness of the jaw through the mandibular foramen. 5-6 ml of a 2% novocaine solution is injected here.

Mental nerve block performed on the lower jaw at the exit of this nerve through the mental foramen. In order to locate this foramen, it is useful to consider that the supraorbital, infraorbital and mental foramina are on the same vertical line. It is not difficult to determine the mental foramen, given that it is located under the alveolar septum between the first and second premolars or under the alveolus of the second premolar, and it is located exactly in the middle of the distance between the alveolar edge and the lower edge of the jaw. The needle can be inserted both through the skin and through the mucous membrane of the vestibule of the mouth.

Besides the introduction novocaine and hydrocortisone; for trigeminal neuralgia, perineural administration of vitamin B12 is used. A significant improvement in the condition of patients comes from supraorbital injections of this vitamin (in doses of 1000-5000 mcg per injection) into the region of the first branch of the trigeminal nerve, regardless of which branch the attack of pain begins from. Extension of pain-free intervals is also achieved by general influences that complement the antalgic effect of the blockade, as mentioned above.

Some forms trigeminalgia etiologically closely related to diseases of the paranasal sinuses. Therefore, for neuralgia of the pterygopalatine ganglion (Slader's neuralgia), lubrication of the posterior parts of the nasal cavity with a 2% solution of cocaine and instillation of a 3% solution of ephedrine into the nose (3 drops 3 times a day) are additionally prescribed.

Educational video on the anatomy of the trigeminal nerve and its branches

If you have problems watching, download the video from the page

08.01.2009, 17:17

08.01.2009, 21:44

conduct:

15.01.2009, 12:46

Computer research of the brain in in this case not indicative. MRI from 2000 is outdated. Necessary
conduct:
1. A thorough neurological examination to identify possible conditions of prolapse,
2.MRI of the brain without and with IV contrast with an emphasis on the cerebellopontine angle on the left to clarify the cause of pain and hyposthesia.
3. With pronounced pain syndrome You can try gabapeptin.
But first it is necessary to conduct neuroimaging (MRI) to exclude a tumor cerebellopontine angle(there are slow-growing tumors, and you won’t see anything on a CT scan)!

Dear doctor, thank you very much for the consultation! I will have an MRI at the end of January.
Upon receipt of the result, please allow me to contact you again.

(When examining the brain, the median structures are not displaced.
the ventricular system is not dilated. The subarachnoid spaces are slightly expanded. There is a local expansion of the perivascular spaces in the thalamic region. In the projection of the cerebellopontine angles of the lesions pathological change signal intensity is not detected. There is asymmetry in the lumen of the vertebral arteries.
Conclusion: MRI signs additional education the projection of the cerebellopontine angles was not detected. Asymmetry of the lumen of the vertebral arteries).

The results of the study are available on CD/
Please, please give me advice.
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State of the trigeminal nerve after blockade
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Hello, dear doctor!
My name is Natalia, I am 53 years old. Please, help me with at least something.
Since 2000, I have been suffering from trigeminal neuralgia on the left. MRI of the brain dated August 28, 2000 revealed only mild symmetrical hydrocele of the lateral ventricles. The pain started from the 2nd branch, then the 1st and 3rd branches became involved. She was treated on an outpatient basis and several times in the hospital. Finlepsin, amitriptyline, diclofenac, antihistamines, elenium, IRT. Pain syndrome soon after each course of treatment
resumed. In February 2001, I was given an alcohol-novocaine blockade in the gas serov node. For some time the pain subsided, but gradually after about 2 years it began to appear occasionally and a strong burning sensation appeared in all branches and in the tongue. Feeling of constantly running waves along the nerve, twitching and burning in the tongue. There are areas of numbness: cheekbone, lips on the left side. The mouth opens very poorly, about two fingers wide. Diagnostic paracentesis of the ear and puncture of the maxillary cavity did not reveal any pathology. Computer study of the brain from 04/11/2007.
no neoplasms were detected. Currently I am not taking any treatment, and my condition is getting worse.
Please help me with any advice medicines or treatment methods that are acceptable in my case. But I can’t stand the alcohol-novocaine blockade anymore.

Message from IVR
Computer research of the brain is not indicative in this case. MRI from 2000 is outdated. It is necessary to carry out:
1. A thorough neurological examination to identify possible conditions of prolapse,
2.MRI of the brain without and with IV contrast with an emphasis on the cerebellopontine angle on the left to clarify the cause of pain and hyposthesia.
3. For severe pain, you can try gabapeptin.
But first, it is necessary to conduct neuroimaging (MRI) to exclude a tumor of the cerebellopontine angle (there are slow-growing tumors, and you will not see anything on a CT scan)!

31.01.2009, 21:46

Hello, dear doctor!
My name is Natalia, I am 53 years old. Please, help me with at least something.
Since 2000, I have been suffering from trigeminal neuralgia on the left. MRI of the brain dated August 28, 2000 revealed only mild symmetrical hydrocele of the lateral ventricles. The pain started from the 2nd branch, then the 1st and 3rd branches became involved. She was treated on an outpatient basis and several times in the hospital. Finlepsin, amitriptyline, diclofenac, antihistamines, elenium, IRT. Pain syndrome soon after each course of treatment
resumed. In February 2001, I was given an alcohol-novocaine blockade in the gas serov node. For some time the pain subsided, but gradually after about 2 years it began to appear occasionally and a strong burning sensation appeared in all branches and in the tongue. Feeling of constantly running waves along the nerve, twitching and burning in the tongue. There are areas of numbness: the cheekbone, lips on the left side. The mouth opens very poorly, about two fingers wide. Diagnostic paracentesis of the ear and puncture of the maxillary cavity did not reveal any pathology. Computer study of the brain from 04/11/2007.
no neoplasms were detected. Currently I am not taking any treatment, and my condition is getting worse.
Please help me with advice on whether there are any medications or treatment methods that are acceptable in my case. But I can’t stand the alcohol-novocaine blockade anymore.
Dear Natalia!
While they haven’t answered you, I can advise you. Significant changes According to the MRI description you provided, no.
Alcoholization (alcohol-novocaine blockade) of the trigeminal nerve is not currently used. There are two approaches to the treatment of trigeminal neuralgia - conservative and, if ineffective, surgical.
Let's focus on the first one.
The drug of choice (with which treatment is started) is carbamazepine (Finlepsin) - a reasonable dose of up to 600 mg per day (up to 3 tablets per day - 1 three times), you need to start with half a tablet and add half every 3 days. When a good analgesic effect is achieved, you remain at the achieved dose. If the effect is insufficient, it is advisable to add the drug Lyrica (pregabalin), you should start with 75 mg at night, adding a capsule (75 mg) every 3-5 days - a reasonable dose - up to 300-450 mg per day (150 mg capsules can be used) , Lyrica may initially cause dizziness, drowsiness, and staggering, but this goes away over time and with a gradual increase in dose, these phenomena are minimal.

01.02.2009, 03:24

Dear Natacha. The picture you describe allows us to doubt the diagnosis of typical primary trigeminal neuralgia. Your age, the absence of a clear attack-like course of the disease, damage to 3 branches at once, zones of numbness, the presence of tongue twitching, resistance to carbamazepine, and especially the presence of a possible motor deficit with difficulty opening the mouth, a slight expansion of the ventricular system in the MRI 2000 inventory - all this allows me to with a high degree of probability will doubt the primacy of neuralgia, which means that you need to look for the reason, which is a very difficult task, especially on the Internet.
To do this, you need at least neurological examination data. You can't do without it.

Have you had a differential diagnosis of this neuralgia / multiple sclerosis, sarcoidosis.../?
Tell us all your complaints and clearly describe the pain, at the beginning of the disease and today. Please also provide the data of all your examinations, such as blood tests, lung x-rays, if available, etc. Don't forget about two MRIs /2000 and 2009/.
In any case, I think an in-person consultation with a meticulous examination is necessary. We can only guide the search, which is also a lot, but it will never replace a full clinical examination.

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 performed under intravenous sedation. The needle is inserted through the cheek code at the level of the second molar, goes around 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 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 is 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 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.