Supratrochlear Research Articles

Delayed Superior Orbital Fissure Syndrome After Reconstruction of Blowout Fracture

The superior orbital fissure syndrome (SOFS) has been known to be a condition caused by impairment of the nerves that cross the superior orbital fissure. Traumatic SOFS is an uncommon complication which occurs usually within 48 hours after a facial injury. A 25-year-old male sustained facial trauma following an altercation. Clinical findings on presentation included swelling, ecchymosis, hyphema, subretinal hemorrhage, and mild extraocular movement limitation upon lateral gaze on his right eyelids. Facial computed tomography scan confirmed fractures of the medial walls of the right orbit and herniation of orbital soft tissue without the incarceration of medial rectus muscle. Ten days after the trauma, the operation was performed. On postoperative day 16, the patient showed ptosis of the right upper eyelid with a fixed pupil, and there was a hypoesthesia over the distribution of the right supraorbital and supratrochlear nerves. The authors diagnosed as a delayed SOFS and prescribed 4 mg of methylprednisolone q.i.d. for 30 days. After steroid therapy, extraocular movement limitations improved progressively. After 8 months, movement was completely restored. The authors experienced delayed SOFS on posttrauma day 27, and it was treated by steroid therapy. Surgical intervention is required when there is an evident etiology such as underlying hematoma or plate migration. If the reason is not clear like our case, steroid therapy can be considered as one of the options. Particularly, the authors should give special attention to the patient who has congenitally narrow superior orbital fissure, like Fujiwara et al suggested.

Efficacy and Safety of a Lidocaine and Ropivacaine Mixture for Scalp Nerve Block and Local Infiltration Anesthesia in Patients Undergoing Awake Craniotomy.

Mixtures of various local anesthetics, such as lidocaine and ropivacaine, have been widely used. However, their efficacy and safety for scalp nerve blocks and local infiltration during awake craniotomy have not been fully elucidated. We prospectively investigated 53 patients who underwent awake craniotomy. Scalp block was performed for the blockade of the supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, greater occipital, and lesser occipital nerves with a mixture containing equal volumes of 2% lidocaine and 0.75% ropivacaine, including 5 μg/mL of epinephrine. Infiltration anesthesia was applied at the site of skin incision using the same mixture. The study outcomes included changes in heart rate and blood pressure after head pinning and skin incision, and incidence of severe pain on emergence from anesthesia. Total doses and plasma concentrations of lidocaine and ropivacaine were measured at different time points after performing the block. The heart rate and blood pressure after head pinning were marginally, but significantly, increased when compared with baseline values. There were no significant differences in heart rate and blood pressure before and after the skin incision. Nineteen percent of the patients (10/53) complained of incisional pain at emergence from anesthesia. The highest observed blood concentrations of lidocaine and ropivacaine were 1.9±0.9 and 1.1±0.4 μg/mL, respectively. No acute anesthetic toxicity symptom was observed. Scalp block with a mixture of lidocaine and ropivacaine seems to provide effective and safe anesthetic management in patients undergoing awake craniotomy.

Effect of pre-incisional anterior scalp block on intraoperative opioid consumption in adult patients undergoing elective craniotomy to remove tumor: study protocol for a randomized double-blind trial

Background: Scalp block is a selective nerve block technique to inhibit the afferent input from nerves that innervate the scalp, including supratrochlear, supraorbital, zygomaticofacial, and zygomaticotemporal nerves for the anterior scalp. The greater and lesser occipital nerves innervate the posterior scalp. Methods/Design: This study is a prospective, randomized, double-blind, placebo-controlled trial, which will be performed to examine the benefits of a pre-incisional anterior scalp block with 0.5% bupivacaine in adult patients who are scheduled for supratentorial craniotomy to remove tumor. Primary outcome will be the difference of intraoperative fentanyl consumption between patients who receive anterior scalp block with 0.5% bupivacaine and those who receive normal saline solution administration. Secondary outcomes will be the hemodynamic changes from preoperative baseline at a skull pin insertion and the time from the end of surgery to successful extubation. Discussion: Skull pin insertion is known as the strongest stimulus prior to craniotomy. The results from previous studies are inconclusive regarding the advantage of scalp block as a pre-emptive analgesic technique. This study will fill this knowledge gap, and examine whether this technique is worth performing as a standard technique. Trial registration: ClinicalTrials.gov identifier: NCT02057367; registered in February 2014. Ethics: This study protocol was approved by the Ethics Committee of Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Thailand (approval number: ANE-2556-01510) and will be performed in accordance with the Declaration of Helsinki. Informed consent: Written informed consent will be obtained from participants prior to inclusion in this study.

Ophthalmic branch radiofrequency thermocoagulation for atypical trigeminal neuralgia:a case report.

BackgroundTrigeminal neuralgia is an intense neuralgia involving facial areas supplied by trigeminal nerve. The pain is characterized by sudden onset, short persistence, sharp or lancinating. Trigeminal neuralgia commonly affects frontal areas, infraorbital or paranasal areas, mandibular areas and teeth. While Trigeminal neuralgia affecting merely the upper eyelid is rare. Here we report a case of atypical Trigeminal neuralgia confined to the upper eyelid. The patient was pain free during the follow-up period of 6 months after unusual ophthalmic branch radiofrequency thermocoagulation.Case presentationA 55-year-old female patient was diagnosed as primary trigeminal neuralgia involving the right upper eyelid. As the pain could not be controlled by drug therapy, peripheral nerve branch radiofrequency thermocoagulation was recommended. A combination of infratrochlear, supratrochlear and lacrimal radiofrequency thermocoagulation was implemented in this case. The point where the bridge of the nose abuts the supraorbital ridge and the point slightly above the lateral canthus along outer border of the orbit were selected respectively as the puncture sites. After positive diagnostic test, radiofrequency thermocoagulation of the above-mentioned nerve branches was performed respectively. The patient was pain free immediately after the treatment and during the follow-up period of 6 months.DiscussionTrigeminal neuralgia is a common severe and chronic facial neuralgia which requires accurate diagnosis and effective therapy. With typical clinical symptoms, normal neurological signs, normal CT and MRI findings, the patient was diagnosed as classic trigeminal neuralgia. As the patient was drug resistant, some invasive treatments were considered. Peripheral branch neurolysis was chosen for its minimal invasiveness, convenience, low risk and not affecting further invasive treatments. According to the anatomic data and the diagnostic test results, infratrochlear, supratrochlear and lacrimal nerve were responsible, therefore, an unusual combination of infratrochlear, supratrochlear, and lacrimal radiofrequency thermocoagulation was implemented for this patient.ConclusionsRadiofrequency thermocoagulation is an effective treatment option for trigeminal neuralgia. Peripheral branch radiofrequency thermocoagulation for trigeminal neuralgia should be considered preferentially due to its minimal invasiveness and convenience. Furthermore, as the sensory innervation of the upper eyelid is complex, the knowledge of peripheral distribution of trigeminal nerve is essential.

New players in the preventive treatment of migraine.

Migraine is a common, chronic disorder of the brain causing much disability, as well as personal, familial and societal impact. Several oral preventive agents are available in different countries for the prevention of migraine, but none have performed better than 50 % improvement in 50 % of patients in a clinical trial. Additionally, each has various possible adverse events making their tolerability less than optimal. Recently, three monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) ligand (LY2951742, ALD403 and TEV-48125) and one targeting the CGRP receptor (AMG 334) have completed phase 2 trials, and the results have been reported. These early results show them all to be somewhat more effective than placebo, with no serious adverse events. Three have been studied for episodic migraine, and only TEV-48125 has been studied for both high frequency episodic and chronic migraine. Moreover, preliminary data suggests that neurostimulation is effective in migraine treatment, including stimulation of the sphenopalatine ganglion, transcutaneous supraorbital and supratrochlear nerve, and transcutaneous vagus nerve. In this article, these innovative therapies will be reviewed.

Combined pre-expansion of forehead and facial region for repairing tissue defects after removal of lesions in nose and facial area

Objective To investigate the treatment methods of tissue defects in nose and lower eyelid area. Methods Based on the impaired area, combined pre-expansion of forehead and facial region was adopted. The volume of soft tissue expander was determined. 150-170 ml expander was implanted between frontalis muscle and periosteum of forehead, while at the facial region, and the volume of expander should be determined by the normal skin area as large as possible. The excision of impaired tissue was performed after sufficient expansion, and then skin flap or transposition skin flap were advanced at the facial region. At forehead, ortho-position skin flap based on supratrochlear vessels was designed for repairing the nose and palpebra inferior region. Three weeks later division of the ortho-position skin flap was carried out. With the flattened pedicle, the rest part of impaired area was replaced. Results Six cases were performed with this method. For all the cases, the survival rate of flap was 100%. Esthetic appearance and satisfying color-match were achieved, without appearance of lower eyelid ectropion. Conclusions Combined pre-expansion of forehead and facial region is an ideal method in treatment of the defects in nose and lower eyelid area. Key words: Facial region; Soft tissue expansion technique; Flap

Topographic Relationship between the Supratrochlear Nerve and Corrugator Supercilii Muscle--Can This Anatomical Knowledge Improve the Response to Botulinum Toxin Injections in Chronic Migraine?

Chronic migraine has been related to the entrapment of the supratrochlear nerve within the corrugator supercilii muscle. Recently, research has shown that people who have undergone botulinum neurotoxin A injection in frontal regions reported disappearance or alleviation of their migraines. There have been numerous anatomical studies conducted on Caucasians revealing possible anatomical problems leading to migraine; on the other hand, relatively few anatomical studies have been conducted on Asians. Thus, the aim of the present study was to determine the topographic relationship between the supratrochlear nerve and corrugator supercilii muscle in the forehead that may be the cause of migraine. Fifty-eight hemifaces from Korean and Thai cadavers were used for this study. The supratrochlear nerve entered the corrugator supercilii muscle in every case. Type I, in which the supratrochlear nerve emerged separately from the supraorbital nerve at the medial one-third portion of the orbit, was observed in 69% (40/58) of cases. Type II, in which the supratrochlear nerve emerged from the orbit at the same location as the supraorbital nerve, was observed in 31% (18/58) of cases.

Supratrochlear and Supraorbital Nerve Stimulation for Chronic Headache: a Review.

Chronic daily headache accounts for a significant socioeconomic burden due to decreased productivity, work absenteeism, multiple office and ER visits, and hospital admissions for pain control. Associated comorbidities add to this cost. Current traditional medical therapies may fail to provide adequate relief leading to the search for and use of other therapeutic modalities such as innovative medical devices. It is in this setting of the urgent demand for better pain control and to assimilate chronic headache sufferers back into society that a variety of neuromodulatory approaches have been emerging. This review aims to familiarize the reader with current literature regarding supraorbital and supratrochlear nerve stimulation for chronic headache, point out the advantages of this approach, address unanswered questions about this subject, and highlight future directions.

Novel High-Frequency Peripheral Nerve Stimulator Treatment of Refractory Postherpetic Neuralgia: A Brief Technical Note.

The study aims to describe an ultrasound (US)-guided peripheral nerve stimulation implant technique and describe the effect of high-frequency peripheral nerve stimulation on refractory postherpetic neuralgia. Following a cadaver pilot trial using US and confirmatory fluoroscopic guidance, a 52-year-old man with refractory left supraorbital neuralgia underwent combined US and fluoroscopic-guided supraorbital peripheral nerve stimulator trial. The patient was subsequently implanted with a percutaneous lead over the left supraorbital and supratrochlear nerve utilizing a high-frequency stimulation paradigm. At 9 months follow-up, the pain intensity had declined from a weekly average of 8/10 to 1/10 on the pain visual analog scale (VAS). After implant, both nerve conduction and blink reflex studies were performed, which demonstrated herpetic nerve damage and frequency-specific peripheral nerve stimulation effects. The patient preferred analgesia in the supraorbital nerve distribution accomplished with high-frequency paresthesia-free stimulation (HFS) at an amplitude of 6.2 mA, a frequency of 100-1200 Hz, and a pulse width of 130 μsec, to paresthesia-mediated pain relief associated with low-frequency stimulation. We report the implant of a supraorbital peripheral nerve stimulating electrode that utilizes a high-frequency program resulting in sustained suppression of intractable postherpetic neuralgia.

Corneal neurotization from the supratrochlear nerve with sural nerve grafts: a minimally invasive approach.

Corneal anesthesia is a debilitating condition which can ultimately lead to blindness from repetitive corneal injury and scarring. We have developed a minimally invasive technique for corneal re-innervation that we have used with excellent results in ten eyes. This article and accompanying video describes the relevant anatomy and demonstrates the technique in detail.

Occipital Nerve Blockage in Cervicogenic Headache: A case Report and Brief Review of Literature

Head and neck pains are frequently encountered complaints in physical therapy outpatient clinics. In most clinics worldwide, nerve blockage technique is successfully used together with pharmacological treatments. Trigger point blockage, occipital nerve blockage, trigeminal nerve blockage, and C2-3 spinal nerve blockage are all effective in the treatment of all types of headaches. Peripheral nerve blockages have long been used in the treatment of headaches. Peripheral nerve blockages may include the major and minor occipital, supraorbital, supratrochlear, trigeminal, auriculotemporal and glossopharyngeal nerves. Additionally there is no significant consensus on peripheral nerve blockage techniques applied to primary or secondary headaches. Occipital nerve blockage is an easy, reliable, practical method such other peripheral nerve blockages. Here, we present a 64-year old male with head and neck pain diagnosed as cervical spondylosis and treated with occipital nerve and trigger point blockage.

Peripheral nerve blocks in the treatment of migraine in pregnancy.

To describe the use of peripheral nerve blocks in a case series of pregnant women with migraine. A retrospective chart review of all pregnant patients treated with peripheral nerve blocks for migraine over a 5-year period was performed. Injections targeted greater occipital, auriculotemporal, supraorbital, and supratrochlear nerves using local anesthetics. Peripheral nerve blocks were performed 27 times in 13 pregnant women either in a single (n=6) or multiple (n=7) injection series. Mean patient age was 28 years and gestational age was 23.5 weeks, and all women had migraine, including 38.5% who had chronic migraine. Peripheral nerve blocks were performed for status migrainosus (51.8%) or short-term prophylaxis of frequent headache attacks (48.1%). Before peripheral nerve blocks were performed, oral medications failed for all patients and intravenous medications failed for most. In patients with status migrainosus, average pain reduction was 4.0 (±2.6 standard deviation) (P<.001) immediately postprocedure and 4.0 (±4.4 standard deviation) (P=.007) 24 hours postprocedure in comparison to preprocedure pain. For patients receiving peripheral nerve blocks for short-term prophylaxis, immediate mean pain score reduction was 3.0 (±2.1 standard deviation). No patients had any serious immediate, procedurally related adverse events, and the two patients who had no acute pain reduction ultimately developed preeclampsia and had postpartum headache resolution. Peripheral nerve blocks for treatment-refractory migraine may be an effective therapeutic option in pregnancy.

A functional periorbital subunit allograft: Vascular, anatomic, and technical considerations for future subunit facial transplantation

Injury to the face can result in the loss of critical specialized structures (the eyelids, lips, ears and nose). Vascularized composite allotransplantation (VCA) allows the surgeon to replace exactly what has been lost. The success of the clinical face transplants suggests the possibility of transplanting specialized units of the face. In this study we explore the neurovascular anatomy and technical specifics for harvest of a functional composite eyelid subunit flap. 12 fresh cadaver heads were studied, each yielding two flaps (N=24). The facial (FA) and superficial temporal arteries (STA) were cannulated and injected with a gelatin/acrylic dye mixture. 6 cadaver heads were evaluated via high-resolution three-dimensional CT scans with contrast. The dye injected into the STA uniformly stained the tissue of the eyelid/periorbital subunit. Injection into the FA resulted in staining of the skin and soft tissues in the medial canthal region and superior eyelid skin in 66% of specimens. CT scan studies confirm our findings with injection into the STA resulting in contrast infiltration of the palpebral arterial arcades in all cases. Injection of the FA resulted in contrast infiltration of the palpebral arterial arcades in 2 of 3 cases. Based this study, a periorbital flap can be based on the STA. Motor innervation of the flap is via the zygomatic and buccal branches of the facial nerve with sensory innervation via the infraorbital, supraorbital and supratrochlear nerves. FA could be used, but its ability to perfuse the entire flap was inconsistent.

Supraorbital and Supratrochlear Stimulation for Trigeminal Autonomic Cephalalgias

Trigeminal autonomic cephalalgias (TAC) is a rare primary headache disorder with challenging and limited treatment options for those unfortunate patients with severe and refractory pain. This article will review the conventional pharmacologic treatments as well as the new neuromodulation techniques designed to offer alternative and less invasive treatments. These techniques have evolved from the treatment of migraine headache, a much more common headache syndrome, and expanded towards application in patients with TAC. Specifically, the article will discuss the targeting of the supratrochlear and supraorbital nerves, both terminal branches of the trigeminal nerve.

Treatment Strategy for Post-Traumatic Supraorbital and Supratrochlear Neuroma

Trauma to the supraorbital ridge is common and long-term sequalae of injury to the supraorbital and supratrochlea nerves is under-appreciated. Blunt trauma from motor vehicle accidents, sports injury, cosmetic surgery, and craniofacial surgery all represent potential sources of injury to these nerves, which are at risk as they traverse a path from intra-orbital to subcutaneous through a bony notch/foramen at the supraorbital ridge. Pain related to these nerves causes migraine headaches, dysesthesias in the forehead, and disability related to medication for chronic pain. A series of 5 patients are presented who represent post-traumatic pain related to these two nerves. Treatment strategies are reviewed. A new operative approach is described in which the proximal end of the supraorbital and the supratrochlear nerves are left within the orbit. Long-term follow-up documents no complications with regard to extraocular muscles and range of motion of the orbit, and significant relief of pain.

Supratrochlear and Supraorbital Nerves

This article elucidates the anatomical details of the course and territory of the supraorbital (SO) and supratrochlear (ST) nerves. Possible applications of the SO and ST nerves for sensory nerve transfer are also examined. The dissection of 3 fresh cadaver heads (6 hemifaces) was performed. In each hemiface, the ST and SO nerves were identified. The following data were recorded: 1) number of branches, 2) skin boundaries, 3) communicative branches, and 4) branch length. The feasibility of specific nerve-transfer procedures was also examined. In 4 hemifaces the SO nerve exited from the SO notch and in 2 hemifaces from the SO foramen. The position was lateral to the midline, with a mean distance of 1.93 cm. In all dissections, a maximum of 4 SO branches (range 2-4) were identified. The ST nerve exited the orbital rim medial to the SO nerve, and lateral to the midline with a mean distance of 0.866 cm. The mean distance between the SO and ST nerves at the level of the SO rim was 1.06 cm. In 5 of 6 hemifaces, several sub-branches emerged from the main trunk of the ST nerve. In 1 hemiface the ST nerve was divided in 2 main branches. The data presented in the current study are in agreement with previous anatomical studies. Both ST and SO nerves can be used as sensory nerve donors in the head and neck area for numerous expanding applications.

Sihler staining study of anastomosis between the facial and trigeminal nerves in the ocular area and its clinical implications

The trigeminal nerve (CN V) supplies mostly sensory innervation to the face, and the facial nerve (CN VII) conveys primarily motor fibers. The aim of this study was to elucidate their distributions and anastomoses. Fourteen specimens of hemisectioned faces were gathered from human cadavers and stained with Sihler staining. The temporal (Tbr), zygomatic (Zbr), and buccal (Bbr) branches of CN VII formed trigeminofacial anastomoses in the ocular area. Communications were observed between the supraorbital nerve and the Tbr (85.7%), the infraorbital nerve and the Bbr (100%) and Zbr (28.6%), and the zygomaticofacial nerve and the Zbr (41.7%). Anastomoses were formed between the supratrochlear nerve and the Tbr (57.1%) and Bbr (50%), and the infratrochlear nerve and the Bbr (85.7%). Motor and sensory axons to the face contribute to trigeminofacial anastomoses, which may play key roles in subtle movements of muscles of facial expression.

English

Introduction The lower end of the humerus has two large fossae, the olecrenon fossa and the coronoid fossa, sepa rated by a thin bony plate that rarely bears an opening known as supratrochlear foramen. Supra trochlear fracture of humerus is very common in the paediatric age group, and it can alter the line of fracture as well as management. Due to its clinical relevance, its presence cannot be ignored. This report discusses a case of a supra trochlear foramen. Case report During routine osteology demonstra tion, we encountered the humerus with supratrochlear foramen. Morpho metric analysis was done and compared with the previous litera tures.

Anatomy of the Supratrochlear Nerve

Migraine headaches have been linked to compression, irritation, or entrapment of peripheral nerves in the head and neck at muscular, fascial, and vascular sites. The frontal region is a trigger for many patients' symptoms, and the possibility for compression of the supratrochlear nerve by the corrugator muscle has been indirectly implied. To further delineate their relationship, a fresh tissue anatomical study was designed. Dissection of the brow region was undertaken in 25 fresh cadaveric heads. The corrugator muscle was identified on both sides, and its relationship with the supratrochlear nerve was investigated. The supratrochlear nerve was found in all 50 hemifaces. Three potential points of compression were uncovered in this investigation: the nerve entrance into the brow through the frontal notch or foramen, the entrance of the nerve into the corrugator muscle, and the exit of the nerve from the corrugator muscle. The nerve generally bifurcates within the retro-orbicularis oculi fat pad, and these branches enter into one of four relationships with the corrugator muscle: both branches enter the muscle, one branch enters the muscle and one remains deep, both branches remain deep, and the branches further branch into ever smaller filaments that cannot be identified cranially. Some patients are nonresponders to migraine decompression techniques that address the supraorbital nerve. The supratrochlear nerve may be compressed in these patients. A standard corrugator resection that comes more medially within 1.8 cm of the midline may be beneficial. The morphology of the frontal notch/foramen must be examined and addressed if necessary.

Reply

Background:This study was designed to compare the efficacy of the transpalpebral versus endoscopic approach to decompression of the supraorbital and supratrochlear nerves in patients with frontal migraine headaches.Methods:The medical charts of 253 patients who underwent surgery for frontal migraine