Trigeminal Neuralgia: Sphenopalatine Ganglion Block Treatment

I recently saw a physician who came in to learn how to do nasal catheter treatment blocks of the Sphenopalatine Ganglion. He had a history of decompression surgery followed by 18 months of very severe pain and never achieved complete relief.

I brought him in and administered an SPG Block with lidocaine and it relieved his trigeminal Neuralgia Symptoms. I talked to him later and he had repeated the block and again achieved pain relief.

The first description of the SPG Block was in 1908 for Sluders Neuralgia. Today it is assumed his patient was either cluster headaches, TMJ disorder or Trigeminal Neuralgia.

I decided a search of Spenopalatine Ganglion Blocks for treating Trigeminal neuralgia would be worthwhile and found 10 abstracts on PubMed.

The newest study was from the polish neurological scociety and was limited to patients who had failed pharmocologic interventions. The Blocks were done by the Supra-Zygomatic Approach that I teach for injections. The Full PubMed abstract is below.

The second article was published in Pain Physician. 2013 Nov-Dec;16(6):E769-78.
“A novel revision to the classical transnasal topical sphenopalatine ganglion block for the treatment of headache and facial pain.” It describes the use of the TX360 device for SPG Blocks. There is an ongoing study that will finish in 2017.

There are three devices that are all similar that deposit anesthetic over the area of the sphenopalatine ganglion via a nasal catheter and the patients stays supine for 30 minutes. All three have similar effects. I sometimes use a sphenocath device but I prefer the “old -Fashioned” cotton tipped nasal catheters. They work very similar to the devices but provide a continual feed of anesthetic via capillary action, do not require lying supine and most important patients can learn how to self administer the block with the nasal catheter. I do one patient who self administers with the Sphenocath device as well.

Another PubMed abstract (below) also from Pain Pract. 2012 Jun;12(5):399-412.
The pterygopalatine ganglion and its role in various pain syndromes: from anatomy to clinical practice.
discusses utilization of SPG Blocks for multiple pain conditions and found that “various pain syndromes including headaches, trigeminal and sphenopalatine neuralgia, atypical facial pain, muscle pain, vasomotor rhinitis, eye disorders, and herpes infection. Clinical trials have shown that these pain disorders can be managed effectively with sphenopalatine ganglion blockade (SPGB).”

There is another study from Pain Pract. 2010 Jul-Aug;10(4):370-4. looking at
“Pulsed radiofrequency V2 treatment and intranasal sphenopalatine ganglion block: a combination therapy for atypical trigeminal neuralgia” While it discusses radiofrequency lesions in addition to SPG Blocks and Methadone. I would always prefer to sty less invasive which is why I find self administered blocks to be so successful, the patients uses them as needed..

Still another article discusses the use of a 8% lidocaine spray (abstract below) Br J Anaesth. 2006 Oct;97(4):559-63. Epub 2006 Aug 1.
Intranasal lidocaine 8% spray for second-division trigeminal neuralgia. The reults were less impressive but the lidocaoine is not directed ove the area of the sphenopalatine ganglion. I would always rather use directed catheters or injection over a nasal spray. A nasal spray can make catheter insertion more comfortable.

This article in Headache. 1999 Jan;39(1):42-4.
Sphenopalatine ganglion block for treatment of sinus arrest in postherpetic neuralgia. Dealt specifically with post herpetic trigeminal neuralgia in a patient with underlying systemic lupus erythematosus. She had bradycardias that resolved with the SPG Blocks.

This study was a clinical case report of TGN relief. Nebr Med J. 1996 Sep;81(9):306-9.
Sphenopalatine ganglion block relieves symptoms of trigeminal neuralgia: a case report.
Manahan AP1, Malesker MA, Malone PM.

“A 56 year old, white female with a diagnosis of trigeminal neuralgia, unresponsive to medical therapy, received a sphenopalatine ganglion block using bupivacaine 0.5%. A total of ten treatments were given. The patient remained pain free as of 30 months after initial treatment. This treatment appears to be effective and deserves further study.”

This article in Cranio Journal is one of my favorites, showing success with management of temporomandibular joint (TMJ) pain, cluster headaches, tic douloureux, dysmenorrhea, trigeminal neuralgia, bronchospasm and chronic hiccup.
Cranio. 1995 Jul;13(3):177-81.
Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain.
Peterson JN1, Schames J, Schames M, King E.

Additional Information on Sphenopalatine Ganglion Blocks and Trigeminal Neruralgia:

Trigeminal Neuralgia: First Line Approach with SPG Blocks Can Be Safe and Effective

The sphenopalatine ganglion (SPG) block is a safe, easy method for the control of acute or chronic pain in any pain management office. It takes only a few moments to implement, and the patient can be safely taught to effectively perform this pain control procedure at home with good expectations and results. Indications for the SPG blocks include pain of musculoskeletal origin, vascular origin and neurogenic origin. It has been used effectively in the management of temporomandibular joint (TMJ) pain, cluster headaches, tic douloureux, dysmenorrhea, trigeminal neuralgia, bronchospasm and chronic hiccup.

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ABSTRACTS BELOW:
Neurol Neurochir Pol. 2015;49(6):389-94.
The effectiveness of neurolytic block of sphenopalatine ganglion using zygomatic approach for the management of trigeminal neuropathy.
Malec-Milewska M1, Horosz B2, Kosson D2, Sekowska A2, Kucia H2.

This study was performed to present the outcomes of trigeminal neuropathy management with the application of neurolytic block of sphenopalatine ganglion. This type of procedure is used in cases where pain is not well controlled with medical treatment. Twenty patients were treated with sphenopalatine ganglion neurolysis after their response to pharmacological management was not satisfactory. Significant pain relief was experienced by all but one patient and they were able to reduce or stop their pain medication. The time of pain relief was between a few months and 9 years during the study period. Number of procedures implemented varied as some of the patients have been under the care of our Pain Clinic for as long as 18 years, satisfied with this type of management and willing to have the procedure repeated if necessary. It appears that neurolytic block of sphenopalatine ganglion is effective enough and may be an option worth further consideration in battling the pain associated with trigeminal neuropathy.

Pain Physician. 2013 Nov-Dec;16(6):E769-78.
A novel revision to the classical transnasal topical sphenopalatine ganglion block for the treatment of headache and facial pain.
Candido KD1, Massey ST, Sauer R, Darabad RR, Knezevic NN.
Author information
Abstract
BACKGROUND:
The sphenopalatine ganglion (SPG) is located with some degree of variability near the tail or posterior aspect of the middle nasal turbinate. The SPG has been implicated as a strategic target in the treatment of various headache and facial pain conditions, some of which are featured in this manuscript. Interventions for blocking the SPG range from minimally to highly invasive procedures often associated with great cost and unfavorable risk profiles.
OBJECTIVE:
The purpose of this pilot study was to present a novel, FDA-cleared medication delivery device, the Tx360® nasal applicator, incorporating a transnasal needleless topical approach for SPG blocks. This study features the technical aspects of this new device and presents some limited clinical experience observed in a small series of head and face pain cases.
STUDY DESIGN:
Case series.
SETTINGS:
Pain management center, part of teaching-community hospital, major metropolitan city, United States.
METHODS:
After Institutional Review Board (IRB) approval, the technical aspects of this technique were examined on 3 patients presenting with various head and face pain conditions including trigeminal neuralgia (TN), chronic migraine headache (CM), and post-herpetic neuralgia (PHN). The subsequent response to treatment and quality of life was quantified using the following tools: the 11-point Numeric Rating Scale (NRS), Modified Brief Pain Inventory – short form (MBPI-sf), Patient Global Impression of Change (PGIC), and patient satisfaction surveys. The Tx360® nasal applicator was used to deliver 0.5 mL of ropivacaine 0.5% and 2 mg of dexamethasone for SPG block. Post-procedural assessments were repeated at 15 and 30 minutes, and on days one, 7, 14, and 21 with a final assessment at 28 days post-treatment. All patients were followed for one year. Individual patients received up to 10 SPG blocks, as clinically indicated, after the initial 28 days.
RESULTS:
Three women, ages 43, 18, and 15, presented with a variety of headache and face pain disorders including TN, CM, and PHN. All patients reported significant pain relief within the first 15 minutes post-treatment. A high degree of pain relief was sustained throughout the 28 day follow-up period for 2 of the 3 study participants. All 3 patients reported a high degree of satisfaction with this procedure. One patient developed minimal bleeding from the nose immediately post-treatment which resolved spontaneously in less than 5 minutes. Longer term follow-up (up to one year) demonstrated that additional SPG blocks over time provided a higher degree and longer lasting pain relief.
LIMITATIONS:
Controlled double blind studies with a higher number of patients are needed to prove efficacy of this minimally invasive technique for SPG block.
CONCLUSION:
SPG block with the Tx360® is a rapid, safe, easy, and reliable technique to accurately deliver topical transnasal analgesics to the area of mucosa associated with the SPG. This intervention can be delivered in as little as 10 seconds with the novice provider developing proficiency very quickly. Further investigation is certainly warranted related to technique efficacy, especially studies comparing efficacy of Tx360 and standard cotton swab techniques.

Pain Pract. 2012 Jun;12(5):399-412. doi: 10.1111/j.1533-2500.2011.00507.x. Epub 2011 Sep 29.
The pterygopalatine ganglion and its role in various pain syndromes: from anatomy to clinical practice.
Piagkou M1, Demesticha T, Troupis T, Vlasis K, Skandalakis P, Makri A, Mazarakis A, Lappas D, Piagkos G, Johnson EO.
Author information
Erratum in
Pain Pract. 2012 Nov;12(8):673.
Abstract
The postsynaptic fibers of the pterygopalatine or sphenopalatine ganglion (PPG or SPG) supply the lacrimal and nasal glands. The PPG appears to play an important role in various pain syndromes including headaches, trigeminal and sphenopalatine neuralgia, atypical facial pain, muscle pain, vasomotor rhinitis, eye disorders, and herpes infection. Clinical trials have shown that these pain disorders can be managed effectively with sphenopalatine ganglion blockade (SPGB). In addition, regional anesthesia of the distribution area of the SPG sensory fibers for nasal and dental surgery can be provided by SPGB via a transnasal, transoral, or lateral infratemporal approach. To arouse the interest of the modern-day clinicians in the use of the SPGB, the advantages, disadvantages, and modifications of the available methods for blockade are discussed.▪

Br J Anaesth. 2006 Oct;97(4):559-63. Epub 2006 Aug 1.
Intranasal lidocaine 8% spray for second-division trigeminal neuralgia.
Kanai A1, Suzuki A, Kobayashi M, Hoka S.

BACKGROUND:
Trigeminal nerve block has been widely used for trigeminal neuralgia. This may induce paraesthesia. The second division of the trigeminal nerve passes through the sphenopalatine ganglion, which is located posterior to the middle turbinate and is covered by a mucous membrane. We examined the effectiveness of intranasal lidocaine 8% spray on paroxysmal pain in second-division trigeminal neuralgia.
METHODS:
Twenty-five patients with second-division trigeminal neuralgia were randomized to receive two sprays (0.2 ml) of either lidocaine 8% or saline placebo in the affected nostril using a metered-dose spray. After a 7 day period, patients were crossed over to receive the alternative treatment. The paroxysmal pain triggered by touching or moving face was assessed with a 10 cm visual analogue scale (VAS) before and 15 min after treatment. Patients used a descriptive scale to grade pain outcome, and were asked to note whether the pain returned and how long after therapy it recurred.
RESULTS:
Intranasal lidocaine 8% spray significantly decreased VAS [baseline: 8.0 (2.0) cm, 15 min postspray: 1.5 (1.9) cm, mean (SD)], whereas the placebo spray did not [7.9 (2.0) cm, 7.6 (2.0) cm]. Moreover, pain was described as moderate or better by 23 patients of the lidocaine spray and 1 of the placebo group. The effect of treatment persisted for 4.3 h (range 0.5-24 h).
CONCLUSIONS:
Intranasal lidocaine 8% administered by a metered-dose spray produced prompt but temporary analgesia without serious adverse reactions in patients with second-division trigeminal neuralgia.

Headache. 1999 Jan;39(1):42-4.
Sphenopalatine ganglion block for treatment of sinus arrest in postherpetic neuralgia.
Saberski L1, Ahmad M, Wiske P.

A 64-year-old woman presented with bradycardia from sinus pauses during exacerbations of postherpetic trigeminal distribution neuralgia. She had underlying systemic lupus erythematosus. Sphenopalatine ganglion blockade was employed to treat her pain. The episodes of bradycardia resolved with successful alleviation of pain. This report emphasizes that a sphenopalatine ganglion blockade can be employed in the treatment and prevention of sinus arrest associated with postherpetic trigeminal distribution neuralgia.