Gasserian ganglion block technique?

[Ligament]

Hi All,

Can you please recommend a good reference (journal or book) for a good gasserian ganglion block technique? Also share any pearls you may have if you would. Thanks!

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[CB1Antagonist]

A handy reference Re: fluoroscopic imaging for gasserian blocks/RF is
J Neurosurg. 1994 Jan;80(1):156-9. Email me if you need the paper. The file is too big to upload.

Heres how I have done them. Supine position, towel roll underneath the shoulders to extend the neck, creating a "sniffing" position, face looking straight up.

Take a straight AP with the C-arm, then caudad tilt approx 55 degrees with ipsilateral oblique of 10-15 degrees. The foramen ovale will show up adjacent to the ramus of the mandible.

Needle entry site is 2.5 cm lateral to the oral canthus. Gunbarrel, aiming for the inferolateral corner of the foramen. Hit bone, walk off and switch to a lateral projection before advancing further. Tip: align the dental shadows to superimpose each other for a true lateral.

 

[Mister Mxyzptlk]

After you've done a few of these you will realize the best technique is to refer the patient elsewhere.

 

[Ligament]

Hey thanks, I've done a few of these but wondered if there were any pearls out there. Seems to be the best pearl is "Son, dont stick the needle in the brain." I think that sage advice has helped me a lot.

I did one this week that really helped a patient with trigeminal neuralgia.

This is a procedure I would only do in an OR or ASC at a minimum with anesthesia at the ready. Well, actually, maybe I'll just have a pain CRNA do it for me....

In my state only a couple pain docs will do this injection. The majority get sent to neurosurgeons, and I can understand why. Is this the case for the rest of you on here?

 

[BeefyRedEye]

I have a few of these patients - I wanted to resurrect this topic. Would any of you do this procedure in the office, under minimal sedation, and just doing a pulsed RF without first doing a diagnostic local anestheic block? My rationale for doing it this way is I avoid any potential complications in an office setting if the local gets circulated in the CSF (loss of concious etc). It is incredibly hard for me to get surgicenter time to do a case like this. I am an anesthesiologist and I have full resuscitation equipement in my office including all airway.

My rationale for pulsed RF is that I want to avoid any potential complications for anesthesia dolorosa. Has anyone had this happen? Any experience with pulsed RF of the Trigeminal Ganglion? I have read the Way paper and am comfortable with the fluoroscopy technique.

 

[lobelsteve]

THe attached article is comprehensive and well written.
I do local blocks in the office setting with sedation.
I do pulsed RF for this in the office with sedation.
I'm too chicken to burn it or ETOH/GLyc the area owing to the whole eyeball exploding/falling out/drying up and blowing away complication thingy. No matter how rare, I'll defer that part to the University.

I do 5 per year, mostly TN due to MS. The usual suspects.

 

[BeefyRedEye]

Isn't injecting local anesthestic potentially into the brain much more potentially dangerous in an office setting than doing a RF burn?

Dr. Way just mentions burning it. What would some of the other practitioners do in an office setting?

1. Positive local anesthetic response then burn?
2. Positive pulsed RF response then burn?
3. Go straight to burn?

Anyone have any complications from the RF lesioning?

 

[lobelsteve]

See what Raj says. I'll say he knows more than I do.
He is Yoda.

http://www.box.net/shared/gqu93qnndk

 

[BeefyRedEye]

Thanks for sharing. That is an excellent article and an excellent presentation. After reading I think I am going to go straight ahead to RF lesioning. The 95%pain relief success rate is amazing.

Anyone doing these sphenopalatine ganglion blocks? It seems not too difficult to perform - anyone have some good fluoro images?

Steven do you have the videos that were included with that Raj presentation?

 

[lobelsteve]

Thanks for sharing. That is an excellent article and an excellent presentation. After reading I think I am going to go straight ahead to RF lesioning. The 95%pain relief success rate is amazing.

Anyone doing these sphenopalatine ganglion blocks? It seems not too difficult to perform - anyone have some good fluoro images?

Steven do you have the videos that were included with that Raj presentation?

SPG: 100% transnasal with sterile applicator and no needle.

As far as video- I can see if I still have the CD at my office.

 

[painfre]

I did once sphenopalatine(my attedning called Trigeminal block) ganglion block once for Atypical facial pain with my attending during my fellowship . Its done in lateral view once mandibular process were aligned, go in the center of mandibular notch in tunnel vision and hit the bone and slightly with draw the needle and inject the local. It appeared easy to me at that time. I donot know if I dare to do it now when I am alone. The pt was not even sedated

 

[SleepIsGood]

I did once sphenopalatine(my attedning called Trigeminal block) ganglion block once for Atypical facial pain with my attending during my fellowship . Its done in lateral view once mandibular process were aligned, go in the center of mandibular notch in tunnel vision and hit the bone and slightly with draw the needle and inject the local. It appeared easy to me at that time. I donot know if I dare to do it now when I am alone. The pt was not even sedated

I think you only get V2 and V3 this way

 

[Ligament]

SPG blocks are quite easy. Although I don't perform a lot of them (very few people do a "lot" of facial blocks). The most important thing in my opinion is to minimize vascular uptake as this is a VERY vascular area...

 

[lovebailey2001]

Hi E'body! does anybody practices glycerol gasserian gangliolysis out there! if yes, how do you make glycerol anhydrous?

 

[BeefyRedEye]

Can someone go over the technique for lateral transnasal sphenopalatine ganglion block under fluoro? Pictures? I have been referred some refractory cluster headaches that I think would benefit from this -

 

[lobelsteve]

Can someone go over the technique for lateral transnasal sphenopalatine ganglion block under fluoro? Pictures? I have been referred some refractory cluster headaches that I think would benefit from this -

Why do this when you can get the same results using a sterile applicator?

 

[oreosandsake]

Why do this when you can get the same results using a sterile applicator?

was unsuccessfully looking for an article comparing efficacy rates between lateral v intranasal.

anyone?

also, how long are you all finding the intranasal blocks to last for? do you add steroid to your anesthetic?

thanks

 

[lobelsteve]

was unsuccessfully looking for an article comparing efficacy rates between lateral v intranasal.

anyone?

also, how long are you all finding the intranasal blocks to last for? do you add steroid to your anesthetic?

thanks

As little as 24 hrs and as long as 6 months. Some folks need to cycle broken, others have chronic daily pain. We do 2-3 in office and then train those that need a weekly procedure to do it at home. I can give them supplies to get started and then order from pharmacy on Rx.

Just follow the video.

[YOUTUBE]http://www.youtube.com/watch?v=rHy_UH57uIk[/YOUTUBE]

 

[oreosandsake]

Thanks for the video. who's the James Bond look-a-like? 😉