ULTRASOUND-GUIDED

PAIN MANAGEMENT
INJECTION TECHNIQUES
(HEAD)
Presenter : dr. TCT Novy, Sp.KFR, M. Kes, FIPP CIPS

DEPARTEMENT OF
FACULTY OF MEDICINE
PADJADJARAN UNIVERSITY
Dr. Hasan Sadikin Hospital, Bandung
2017
ULTRASOUND-GUIDED
ATLANTO-OCCIPITAL BLOCK
CLINICAL PERPECTIVES
• The atlanto-occipital joint is an often overlooked source of upper posterior neck pain
and suboccipital headache, susceptible to arthritis and is frequently traumatized during
acceleration/deceleration injuries.
• The pain is ill defined and dull in nature, involving the upper neck and occipital region
(picture below)
• The patient suffering from pain from the atlanto-occipital joint will frequently complain of
neck pain, occipital and suboccipital headaches, preauricular pain, and limited range of
motion.
• The patient may experience an exacerbation of pain at extremes of range of motion as
well as sleep disturbance, nausea, and difficulty in concentrating.
RELEVANT ANATOMY
• The atlanto-occipital joint serves as the
articulation between the occiput of the skull
and atlas, possesses a well-developed joint
capsule, cartilage, and synovium.
• This modified V-shaped joint has a limited
range of motion of 35 degrees and
functions to aid in the positioning of the
sense organs by allowing the head to nod
forward and backward.
• The C1 nerve root, which is also known as
the suboccipital nerve, exits between the
skull and C1 vertebra and lacks the
The vertebral artery ascends within the cervical spine via
characteristic dorsal sensory root seen with the transverse foramen and then exits the C1 transverse
other spinal nerves in most patients. foramen and turns medially to course diagonally across
• It provides motor innervation to the the posteromedial aspect of the atlanto-occipital joint to
join with the contralateral vertebral artery at the level of
suboccipital muscles and interconnects with the medulla to form the basilar artery that enters the
fibers of the C2 and C3 nerves, which may foramen magnum in the midline. This diagonal turn
explain the overlapping pain provides an excellent landmark when performing
ultrasound-guided atlanto-occipital nerve block.
symptomatology when any of these nerves
are traumatized or inflamed.
RELEVANT ANATOMY

Longitudinal ultrasound image of the atlanto-occipital

joint.

The relationship of the vertebral artery to the atlanto-

occipital joint
ULTRASOUND-GUIDED TECHNIQUES

• Prone position with the patient’s cervical spine slightly flexed and the skin prepped with
antiseptic solution.
• A high-frequency linear transducer is placed in the transverse position slightly off the
midline over the upper cervical vertebra, and the vertebral artery is identified as it passes
through the transverse foramina.
• The artery is then traced cranially by slowly moving the transducer in a cranial direction
until the vertebral artery is seen to turn medially in front of the atlanto-occipital joint.
• In most patients, a needle can be placed into the joint just lateral to the point where the
artery makes its turn.
• In an occasional patient, the vertebral artery blocks the entire extent of the joint as it courses
from lateral to medial to join the contralateral vertebral artery, rendering safe needle
placement virtually impossible.
COMPLICATIONS

• In some patients, the vertebral artery completely covers the atlanto-occipital joint as it turns
medially to join the contralateral vertebral artery to form the basilar artery, safe needle
placement is impossible.
• Even small doses of local anesthetic inadvertently injected into the vertebral or basilar artery
can result in immediate local anesthetic–induced seizures and central nervous system
toxicity.
• The particulate nature of steroids can also cause significant side effects if intra-arterial
injection occurs.
• The proximity of the exiting C2 nerve root makes the inadvertent injection of local anesthetic
into the dural sleeve with resultant total spinal anesthesia an ever-present possibility.
CLINICAL PEARLS

• Given the significant overlap and cross connections of the fibers of the C1, C2, and C3
nerves, blockade of addition neural structures including the greater and lesser occipital
nerves as well as the third occipital nerve may be required to provide the patient with
complete pain relief.
• Blockade of the atlantoaxial joint may also be beneficial, especially if the patient has also
sustained trauma to that joint.
• The ability of ultrasound imaging to identify the precise position of the vertebral artery relative
to the atlanto-occipital joint when performing atlanto-occipital nerve block suggests a
significant theoretical advantage over the use of fluoroscopic guidance that more clearly
defines the joint but does not delineate the relative position of the artery.
• Injection of small amounts of iodinated contrast media suitable for use in the central
nervous system may help identify intravascular or subdural or subarachnoid placement prior
to the injection of local anesthetic if fluoroscopy is utilized concurrently with ultrasound
guidance.
ULTRASOUND-GUIDED
ATLANTOAXIAL BLOCK
CLINICAL PERPECTIVES
• The atlantoaxial joint is an often overlooked source of upper posterior neck and
suboccipital headache pain.
• The pain following such injuries is often initially attributed to soft tissue injury such as
muscle strain and/or bruising, involving the upper neck and occipital region.
• Frequently complain of neck pain, occipital and suboccipital headaches, preauricular
pain, as well as a limited range of motion with exacerbation of pain at the extremes of
range of motion.
• Sleep disturbance is common as is nausea and difficulty in concentrating.
• The clinician should look carefully for atlantoaxial joint abnormalities and/or instability
in patients who have sustained trauma to the joint or who are suffering from the
diseases.

Trescot, A. (2017). Ultrasound for evaluation

and treatment of headaches. Anaesth Pain &
Intensive Care, 21(2), 241-253.
CLINICAL PERPECTIVES

Diseases Associated with Atlantoaxial Joint Instability :

• Rheumatoid arthritis
• Down syndrome
• Von Recklinghausen disease
• Osteogenesis imperfect
• Congenital scoliosis
• Morquio syndrome
• Larsen syndrome
• Kniest dysplasia
• Congenital spondyloepiphyseal dysplasia
• Metatropic dysplasia
RELEVANT ANATOMY
• The atlantoaxial joint serves as the articulation between the C1 and C2 vertebra.
• The joint allows lateral rotation of the skull of 72 degrees in either direction from the midline
and functions to aid in the positioning of the sense organs.
• It also allows a limited degree of flexion and extension independent of the atlanto-
occipital joint and other facet joints of the cervical spine.
• The vertebral artery ascends via the transverse foramen of the cervical spine, traveling
across the lateral one-third of the atlantoaxial joint. The artery exits the C1 transverse
foramen and turns medially to course diagonally across the posteromedial aspect of the
atlanto-occipital joint to join with the contralateral vertebral artery at the level of the medulla
to form the basilar artery. The basilar artery then ascends to enter the foramen magnum in
the midline.
• The course of the vertebral artery provides an important landmark when performing
ultrasound-guided atlantoaxial nerve block.
• The C2 nerve root exits above the C2 vertebra and provides some motor innervation to the
suboccipital muscles. The fibers of the medial branch of the C2 nerve root dorsal primary
ramus form the greater occipital nerve. Fibers from the C2 nerve root interconnect with fibers
of the C1 and C3 nerves, which may help explain the overlapping pain symptomatology when any
of these nerves are traumatized or inflamed.
RELEVANT ANATOMY

Ultrasound short-axis view showing the relationship of the

vertebral artery to the atlanto-axial joint as it ascends
through the transverse foramen.

The relationship of the vertebral artery to the atlanto-

axial joint
RELEVANT ANATOMY
Anatomy of the occipital region, modified from an image
from Bodies, The Exhibition, with permission. Note the
connection of the greater and lesser occipital nerves.
(Image: Andrea Trescot, MD)
The path of the occipital nerve. IO = inferior oblique; P1
= Part 1 of the occipital nerve; P2 = Part 2 of the
occipital nerve; P3 = Part 3 of the occipital nerve; A1 =
site of entrapment of inferior oblique; A2 = site of
entrapment by trapezius muscle. (Image: Andrea Trescot,
MD)
PHYSICAL EXAMINATION
Trescot, A. (2017). Ultrasound for evaluation and treatment of headaches. Anaesth Pain & Intensive Care, 21(2), 241-253.

• For the physical Examination of the greater occipital nerve, the patient should be positioned sitting with the neck
slightly flexed, with the examiner supporting the forehead with the non-examining hand
• With the examining hand, place the middle finger at the midline base of the head to identify the site of the foramen
magnum.
• The index finger is placed at the conjoined tendon attachment.
• The thumb will then palpate the area just lateral to the conjoined tendon, approximately 3cm inferior and 1.5cm
lateral to the occipital inion.
• If an area of paresthesia is created, reproducing the patient’s pain and symptomatology, the greater occipital
nerve is likely the source.
ULTRASOUND-GUIDED TECHNIQUES
• The patient is placed in prone position with patient’s
cervical spine slightly flexed and the skin prepped
with antiseptic solution.
• A high-frequency linear transducer is placed in the
transverse orientation in the midline at the level of the
occiput.
• The transducer is then slowly moved caudally to identify
first the C1 and then the C2 vertebral bodies. The C1
vertebral body has only a vestigial spinous process, and
the C2 vertebral body is the first cervical vertebral body
with a bifid spinous process making its identification
easier. When the C2 vertebra is identified, the
transducer is then moved laterally until the exiting C2
nerve root is identified. The transducer is then moved
slightly more laterally until the vertebral artery is
identified. Color Doppler may be used if the vertebral
artery is not readily apparent.
• The atlantoaxial joint should then be easily identified in
between the exiting C2 root and the vertebral artery.
• A 22-gauge, 3½-inch styletted spinal needle is then
advanced into the atlantoaxial joint using an out-of-
plane approach under real-time ultrasonography, while
constant attention is paid to the location of the vertebral
artery laterally and the C2 nerve root medially. A = Location of ultrasound transducer: 1 = standard occipital nerve ultrasound
site; 2 = US approach with (2A) being the initial probe placement and (2B)
being the final probe placement. B = Distal US occipital nerve and artery. C
= Proximal US of greater and third occipital nerve. (Images: Andrea Trescot,
MD – modified from Greher et al
COMPLICATIONS

• The proximity of the vertebral artery, spinal cord, exiting nerve roots, brain stem, and foramen
magnum makes complete knowledge of the relevant clinical anatomy essential to avoid
disaster.
• Even small doses of local anesthetic inadvertently injected into the vertebral or basilar artery
can result in immediate local anesthetic–induced seizures and central nervous system
toxicity.
• The particulate nature of steroids can also cause significant side effects if intra-arterial
injection occurs.
• The proximity of the exiting C2 nerve root makes the inadvertent injection of local anesthetic
into the dural sleeve an ever-present possibility.
CLINICAL PEARLS

• Given the significant overlap and cross connections of the fibers of the C1, C2, and C3
nerves, blockade of addition neural structures including the greater and lesser occipital
nerves as well as the third occipital nerve may be required to provide the patient with
complete pain relief.
• Blockade of the atlanto-occipital joint may also be beneficial, especially if the patient has
sustained trauma to the region.
• The ability of ultrasound imaging to identify the precise position of the vertebral artery relative
to the atlan-toaxial joint suggests a significant theoretical advantage over the use of
fluoroscopic guidance, which more clearly defines the joint, but does not delineate the
actual position of the artery.
• Injection of small amounts of iodinated contrast media suitable for use in the central
nervous system may help identify intravascular or subdural or subarachnoid placement
prior to the injection of local anesthetic if fluoroscopic guidance is utilized concurrently with
ultrasound guidance.
 ULTRASOUND-GUIDED
SPHENOPALATINE GANGLION BLOCK
CLINICAL PERPECTIVES
 Sphenopalatine ganglion block is useful in the
treatment of acute migraine headache, acute cluster
headache, and a variety of facial neuralgias including Indications for
Sluder, Vail, and Vidian neuralgia, as well as Gardner Sphenopalatine Ganglion Block
syndrome. • Acute migraine headache
 The technique has also been utilized in the treatment
• Acute cluster headache
of status migrainosus and chronic cluster headache.
• Chronic cluster headache
 Anecdotal evidence suggests that sphenopalatine
ganglion block may also play a role in the palliation of • Sluder neuralgia
pain secondary to acute herpes zoster involving the • Vidian neuralgia
trigeminal nerve. • Vail neuralgia
 The lateral infrazygomatic approach to sphenopalatine • Gardner syndrome
ganglion block is indicated in patients who have
• Status migrainosus
anatomic abnormalities of the nose that would
• Chronic cluster headache
preclude the use of the transnasal approach to
• Acute herpes zoster involving the trigeminal
sphenopalatine ganglion block. nerve
 Neurodestruction of the sphenopalatine ganglion may
be carried out by the injection of neurolytic agents, the
use of radiofrequency lesioning, or the use of
cryoneurolysis.
RELEVANT ANATOMY
• The sphenopalatine ganglion, which is also known as the pterygopalatine, nasal, or
Meckel ganglion, is located deep within the pterygopalatine fossa lying just posterior
to the middle turbinate beneath a thin layer of lateral nasal mucosa.
• The sphenopalatine ganglion is triangular in shape and is 5 to 6 mm in size.
• It lies just below the maxillary nerve as it traverses the pterygopalatine fossa,
appearing suspended from the maxillary nerve by its two interconnecting branches.
• It is the largest of the parasympathetic ganglion and provides innervation to the
paranasal sinuses, the lacrimal glands, and the glands associated with the mucosa of
the nasopharynx and hard palate.
• It also sends fibers to the carotid plexus, gasserian ganglion, and trigeminal nerves as
well as to the facial nerve and the superior cervical ganglion.
• The sphenopalatine ganglion can be blocked by the topical application of local
anesthetic via the transnasal approach, by intraoral injection through the greater
palatine foramen, or by the lateral infrazygomatic placement of a needle via the
coronoid notch.
RELEVANT ANATOMY

Anatomy of the sphenopalatine ganglion.

The relationship of the sphenopalatine ganglion and

maxillary nerve.
ULTRASOUND-GUIDED TECHNIQUES
• Ultrasound-guided sphenopalatine ganglion block via the lateral
infrazygomatic approach is a straightforward technique if attention
is paid to the clinically relevant anatomy.
• To perform ultrasound-guided sphenopalatine ganglion block via the
lateral infrazygomatic approach, the patient is placed in supine
position with the cervical spine in the neutral position.
• The mandibular notch provides easy access to the pterygopalatine
fossa and the sphenopalatine ganglion.
• The mandibular notch of the mandible is identified by asking the
patient to open and close his or her mouth several times while
palpating the area just anterior and slightly inferior to the acoustic
auditory meatus. Once the mandibular notch is identified, the patient
is asked to hold his or her mouth open in a relaxed.
• A linear transducer is placed in the transverse plane directly over
the mandibular notch.
ULTRASOUND-GUIDED TECHNIQUES

• Two milliliters of local anesthetic is drawn up in a 3-mL sterile

syringe.
• Twenty to forty milligrams of depot steroid preparation may be
empirically added to the local anesthetic.
• Under real-time ultrasound guidance, a 22-gauge, 10-cm
straight styletted radiofrequency needle with a 2-mm active tip
is inserted just below the zygomatic arch directly in the
middle of the mandibular notch using an out-of-plane approach.
• The needle is advanced to an area just below the maxillary
nerve.
• If a paresthesia in the distribution of the maxillary nerve is
encountered, the needle is withdrawn and redirected in a more
inferior and posterior trajectory.
• If the lateral pterygoid plate is encountered, the needle is
withdrawn slightly and redirected slightly superior and anterior.
• This will place the needle just above the lower aspect of the
lateral pterygoid plate allowing entry into the pterygopalatine
fossa just below the maxillary nerve and in close proximity to
the sphenopalatine ganglion.
ULTRASOUND-GUIDED TECHNIQUES

• When the needle is felt to be in satisfactory position, stimulation

of the needle should be carried at 50 Hz.
• If the needle is in the correct position in proximity to the
spheno-palatine ganglion, the patient will experience a
buzzing sensation inside the nose.
• If the patient reports stimulation in the upper teeth and gingiva,
the needle is too close to the maxillary nerve and must be
repositioned caudally and medially.
• If the patient reports stimulation in the roof of the mouth, it
means that the needle tip is in proximity to the greater and
lesser palatine nerves and the needle must be repositioned
caudally and posteromedially.
• If the procedure is being performed with concurrent
fluoroscopic and ultrasound guidance, when a satisfactory
Fluoroscopic image of needle traversing the stimulation pattern is obtained, 0.5 mL of contrast medium
mandibular notch and resting against the lateral suitable for use in the central nervous system can be injected
pterygoid plate. after careful aspiration to fill the pterygopalatine fossa.
• After correct needle placement is confirmed, careful aspiration
is carried out and 2 mL of solution is injected in incremental
doses.
• During the injection procedure, the patient must be observed
carefully for signs of local anesthetic toxicity.
COMPLICATIONS

• The pterygopalatine fossa is highly vascular, and the potential for trauma to the
vasculature, especially the maxillary artery, remains an ever-present possibility.
• Needle damage to the artery may result in significant facial hematoma formation, which
can be very distressing to the patient and clinician alike.
• The vascularity of the region means that the pain specialist should carefully aspirate the
needle prior to injecting any medications and should then inject small, incremental doses of
local anesthetic to avoid local anesthetic toxicity.
• Patients may occasionally experience profound bradycardia and hypotension when
undergoing sphenopalatine ganglion block via the lateral infrazygomatic approach, and
monitoring for these potentially serious side effects is mandatory. These side effects are
thought to be due to the widespread parasympathetic influence of the sphenopalatine
ganglion when it is stimulated.
• Atropine or atropine-like drugs such as glycopyrrolate and vasopressors such as ephedrine
should be readily available should bradycardia and/or hypotension occur.
• Following sphenopalatine block, the patient’s blood pressure should be monitored when
moving the patient from a supine to a sitting or standing position.
CLINICAL PEARLS

• The simplicity of the transnasal approach to sphenopalatine ganglion block lends itself to use
in the physician’s office or emergency department when treating acute migraine or cluster
headache.
• Two percent viscous lidocaine is a suitable local anesthetic for this application. When using
sphenopalatine ganglion block to treat the acute headache sufferer, the concurrent
administration of oxygen may hasten the resolution of the patient’s headache
symptomatology.
• If anatomic abnormality, trauma, or tumor makes the use of the transnasal approach to the
sphenopalatine ganglion impossible, the injection of local anesthetic and/or steroid via the
greater palatine foramen or the lateral infrazygomatic approach represents a reasonable
alternative.
• The lateral zygomatic approach to sphenopalatine block using ultrasound and/or fluoroscopic
guidance in combination with nerve stimulation is the preferred approach for neurodestructive
procedures of the sphenopalatine ganglion.