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TRIGEMINAL NEURALGIA MIGRAINES
CERVICAL PAIN
MASTER CLASS 2013
MACRO-ANATOMY
“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
HOW TO TREAT?
“Regional neuropathic pain syndrome”
of the
Trigeminal, Facial and Cervical nerves
TRIGEMINAL NERVES
FACIAL NERVE
POSTERIOR SUPRACLAVICULAR NERVE
OCCIPITAL NERVES
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”
Gray’s Anatomy
of the Facial
nerve and branches
FACIAL-TRIGEMINAL ANASTOMOSIS
Spalteholz Anatomy Trigeminal
Facial Cervical nerves
Hebb’s postulate
(1949): “nerves that fire
together, wire together”
Encyclopedia Anatomica: Right Facial nerve Hilton’s law (1863):
”The joints and muscles acting on them and the overlying skin share a nerve supply”
CERVICAL PLEXUS LAST’S ANATOMY
Superficial nerves neck Last’s Anatomy
The Greater Auricular nerve (C2-3) anastomosing with
the Facial nerve (VII) provides it’s perineurium with Nervi Nervorun (sensocrine innervation)
The Greater Auricular nerve (C2-3) anastomosing with the Facial nerve (VII) provides it’s perineurium with Nervi
Nervorum (sensocrine innervation)
“Punctus Nervosum” on the posterior supraclavicular nerve
is a prime headache “Trigger Point”
Ophtalmic nerve (V1)
Maxillary nerve (V2)
Mandibular nerve (V3)
Trigeminal Nerve Paired cranial nerve with three major branches:
Facial Nerve and Artery Last’s Anatomy
Trigeminal Nerve Divisions I, II & III Last’s Anatomy, ninth Edition, McMinn
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.
STEP THREE Locate and palpate gently for the tender spots along the five major Facial and/or Cervical nerve branches
“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)
Trigeminal Neuralgia Patients Treated
with Neural Proloterapy
Ferrara, Italy 2011
Dr Steven Cavallino
The Italian Twelve
7/12 were actual Trigeminal Neuralgias (V2-V3)
Only 1/7 also showed pain in opthalmic branch
(V1)
The Italian Twelve
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
All 12
patients
showed an
immediate
pain relief
following
initial NPT
treatment
The Italian Twelve
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
Christchurch Thirteen
From August 2011
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”
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.
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