Note: Becuase of the potential risks involved, injections should be performed only by those experienced with the procedure, or under direct supervision of those who have extensive experience with the procedure. More than one method to perform the injections may exist. The following are suggested injections as described in literature and various textbooks. The information contained herein is abridged; please refer to authoritative literature for more detailed information.

Supraorbital/trochlear nerve: Indications: migraine headaches and neuropathy. The terminal divisions of the ophthalmic branch of the trigeminal nerve are the supraorbital and supratrochlear nerve, which supply skin and conjunctiva sensation. Technique: perpendicular to the orbital rim above the eyebrow, the supraorbital foramen is palpated and then a needle is inserted toward the foramen without entering it so as to avoid nerve injury. 2-3 ml of local anesthetic is injected. Concerns include hematoma, supraorbital artery laceration.

Maxillary nerve: Indications: trigeminal neuralgia, neuropathic pain, atypical facial pain. The maxillary nerve provides sensation to the face. It exits the foramen rotundum and traverses the superior pterygopalatine fossa. It enters the floor of the orbit at the inferior infraorbital fissure. Technique: palpate the mandibular notch and enter the pterygoid plate. The needle is redirected 45° to the eye until paresthesia is obtained. Concerns include CSF injection, orbital injection, hemorrhage, and hematoma.

Trigeminal nerve: Indications: trigeminal neuralgia. The trigeminal nerve is composed of the ophthalmic, maxillary and mandibular divisions, which provide sensation to the face, cornea, and motor control for mastication. Technique: inject the Gasserian ganglion at Meckel’s cave; start 1 cm lateral to the mouth in the midpupillary line, with a 22-gauge 3.5 inch needle. Local anesthetic or neurolytic agent is injected in 1/4 ml increments until desired analgesic effect is achieved.
Concerns include technically challenging nature of the procedure, pain, possible CSF injection.

Glossopharyngeal nerve: Indications: Atypical face pain, neuralgia, pharyngeal cancer, refractory hiccups. It is the 9th cranial nerve with both sensory and motor components. It exits the jugular foramen between the internal carotid artery and inferior jugular vein. It provides sensation to the posterior 1/3rd of the tongue, tonsils, pharynx and auditory canal. Technique: There are two injection techniques using a 25-guage 2 inch needle. With the external technique, the needle is inserted at the midpoint of mastoid and the angle of the mandible. With the internal technique the needle is inserted at a right angle to the skin, at a depth of 2-3 cm until the styloid process is contacted and then walked off posteriorly. Concerns for injection include intravascular injection, which could result in seizures or dysphagia.

Occiptial nerve: Indications: tension headaches, whiplash injuries, occipital neuralgia. It is a branch of the posterior ramus of the second cervical nerve and
supplies the posterior scalp. Technique: palpate the superior nuchal line, midway between the external occipital protuberance and the mastoid process. Locate the nerve by palpating the occipital artery and insert the needle just lateral. The needle is advanced to bone or paresthesia then retracted 1-2 mm. If negative for blood on aspiration, 2-3 ml of local anesthetic is injected along with steroid. Concerns include post-injection ecchymosis and hematoma as well as inadvertent placement of the needle into the foramen magnum and subarachnoid administration of local anesthetic.

Suprascapular nerve: Indications: shoulder pain secondary to OA, rotator cuff lesions, adhesive capsulitis or shoulder arthroscopy. Technique: 22-gauge 1½ inch needle is inserted 1-2 cm superior to the midpoint of the spine of the scapula towards the suprascapular notch until paresthesias are noted. 5-10 ml of anesthetic are injected. Concerns for injection include pneumothorax, infection, intravascular injection, seizure, muscle atrophy.

Brachial plexus: Indications: surgery of the shoulder or arm, shoulder dislocation or extremity level. The root level is at the intrascalenes, trunk level is supraclavicular, cord level is infraclavicular, branch level is at the axillary artery. Technique: at the interscalene groove at approximately C6 at the cricoid cartilage and posterior border of the sternocleidomastoid, a 25-gauge 1½ inch needle is advanced at a 45 degree angle until paresthesia to shoulder, arm occurs. Inject approximately 20 ml of local anesthetic. There are other techniques for brachial plexus injection including infraclavicular and axillary approaches. Concern is for possible vascular injection, thrombus, hematoma.

Intercostal nerve: Indications:

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