trigeminal neuralgia migraines cervical pain · 2013. 11. 8. · along the trigeminal nerve...
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TRIGEMINAL NEURALGIA MIGRAINES
CERVICAL PAIN
MASTER CLASS 2013
MACRO-ANATOMY
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“Neuralgias of the head”
Facial Neuralgias
Trigeminal Neuralgia
Atypical Trigeminal Neuralgia
Atypical Facial Pain
Anesthesia Dolorosa
Cluster headaches
Tension headaches
Sinus headaches
Migraine headaches with or
without aura
Cephalgia
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HOW TO TREAT?
“Regional neuropathic pain syndrome”
of the
Trigeminal, Facial and Cervical nerves
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TRIGEMINAL NERVES
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FACIAL NERVE
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POSTERIOR SUPRACLAVICULAR NERVE
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OCCIPITAL NERVES
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Encyclopedia Anatomica 1771
Nerves involved in “Trigeminal Neuralgia,
headaches, sinusitis and migraines”
John Marshall (1883):
”Neuralgia is most likely where the nerves leave
the bony or fibrous framework or around
bones”
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Gray’s Anatomy
of the Facial
nerve and branches
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FACIAL-TRIGEMINAL ANASTOMOSIS
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Spalteholz Anatomy Trigeminal
Facial Cervical nerves
Hebb’s postulate
(1949): “nerves that fire
together, wire together”
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Encyclopedia Anatomica: Right Facial nerve Hilton’s law (1863):
”The joints and muscles acting on them and the overlying skin share a nerve supply”
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CERVICAL PLEXUS LAST’S ANATOMY
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Superficial nerves neck Last’s Anatomy
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The Greater Auricular nerve (C2-3) anastomosing with
the Facial nerve (VII) provides it’s perineurium with Nervi Nervorun (sensocrine innervation)
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The Greater Auricular nerve (C2-3) anastomosing with the Facial nerve (VII) provides it’s perineurium with Nervi
Nervorum (sensocrine innervation)
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“Punctus Nervosum” on the posterior supraclavicular nerve
is a prime headache “Trigger Point”
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Ophtalmic nerve (V1)
Maxillary nerve (V2)
Mandibular nerve (V3)
Trigeminal Nerve Paired cranial nerve with three major branches:
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Facial Nerve and Artery Last’s Anatomy
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Trigeminal Nerve Divisions I, II & III Last’s Anatomy, ninth Edition, McMinn
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STEP ONE: Palpate and mark the pain sites on the three (3) Trigeminal foramen V1,V2,V3. Then inject 0,5 ml of DW5 with a 30G ½ inch needle
STEP TWO Mark all the tender spots along the trigeminal nerve branches. Inject these tender sites using 0.5 ml of D5W. If completely pain-free, pathology is caused by a pure Trigeminal Nerve involvement. If not completely pain-free, consider a mix Facial ,Trigeminal and Cervical Neuralgia and proceed to Step Three.
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STEP THREE Locate and palpate gently for the tender spots along the five major Facial and/or Cervical nerve branches
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“Differential Diagnosis”
of Craniofacial Pain
Primary and secondary headache disorders
Ophthalmologic
Ear, nose, and throat
Sinus disorders
Teeth and jaw (TMJ)
Oral cavity and salivary glands
Craniocervical
Neoplasia (intra/extra-cranial)
Psychogenic (DSM-IVR)
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Trigeminal Neuralgia Patients Treated
with Neural Proloterapy
Ferrara, Italy 2011
Dr Steven Cavallino
The Italian Twelve
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7/12 were actual Trigeminal Neuralgias (V2-V3)
Only 1/7 also showed pain in opthalmic branch
(V1)
The Italian Twelve
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Neural Prolotherapy Injection Sites
in Facial Neuralgia
Red ………Trigeminal Nerve Injection Sites (V1,V2, V3)
Yellow ……Temporal Nerve Injection Sites
Blue ………Facial Nerve Injection Sites
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All 12
patients
showed an
immediate
pain relief
following
initial NPT
treatment
The Italian Twelve
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Patients returned weekly for a total of 3 NPT treatments
9 /12 patients (75%) showed less pain and decreased
frequency after first treatment with NPT ( DW5)
The pain scale was 3/10 after one week and was 1/10 after the
second week
The remaining 3 patients (25%) that were still 6/10 after one
treatment needed more attention and treatment. After 3
treatments they were 1/10.
The Italian Twelve
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Christchurch Thirteen
From August 2011
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Christchurch Thirteen
• All thirteen had an immediate and complete resolution of their pain
• Two patients with an ‘isolated’ Trigeminal neuralgia. One patient with a 30 year Hx of TN after dental work did not want to continue after two treatments, “too difficult”. One patient, age 72, with a 9 year Hx of TN of the Maxillary branch after chiropractic manipulation, had lasting relief after two treatments but was diagnosed with disseminated Ca breast and hasn’t returned.
• One 9 year old girl with a 18 month Hx of chronic frontal and parietal headaches following ‘headers’ in a game of football, had instant relief, but this didn’t last. She fractured her Tibia during the treatment period and was in a great deal of associated pain and disability. BMI very high.
• Six patients with ‘stinking headaches’ resolved with one treatment.
• Four mixed TN, Facial, Cervical neuralgia’s responded instantly. One female patient age 48 with a 20 year Hx of ‘TN’ has come back every month and is without medication. One female patient age 42 with a 30 year Hx of ‘TN’ returned after 4 months of no headaches and requested a ‘top-up’, “just in case”. One female patient age 45 with a’ lifelong Hx’ of TN has been back 3 times since August and is no longer on any medication. One female patient, age 36, had instant relief but did not return. “too painful”
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Christchurch three with ‘sinus pain’
• One male patient, age 48, had three previous sinus operations, but still with pain and ‘snorting and sniffing’. Wife C/O his snoring. Has had two Rx’s and reports no more ‘sinus pain’, ‘wife happy’ and not ‘sniffing’ anymore. Treatment of all TN branches and some Facial branches
• One male patient, age 36 with 2 previous sinus operations, but still with ‘sinus pain’ responded with one treatment of TN I and II.
• One female patient with a Hx of 3 previous operations was lost to follow up. TN 1 and II were treated.