Sphenopalatine Ganglion Block: Cluster Headache, Migraine and Burning Mouth Syndrome

If the femoral head is involved, we can perform radiofrequency ablation of the hip joint, ablating the articular nerves supplying the joint — it's a very rewarding procedure. But if the pain is arising from the bone itself or visceral involvement, the best approach is opioid analgesics rather than high-dose NSAIDs, which will damage the kidneys. Primary management is opioid-based — morphine or tramadol with paracetamol and a neuropathic agent — and where there is a specific anatomical target, we address that interventionally as well.

According to international Spine Society guidelines, any pain coming from the spine where the primary problem is pain alone does not require surgery. The indications for surgery are disability — foot drop, motor or sensory deficit — or more than moderate to severe canal stenosis on MRI, where pain intervention can buy time but can't treat the disease. If a patient comes to me with a neurological deficit, I immediately refer to the spine surgeon and don't proceed with intervention. If pain is the only presenting symptom, we treat it — there's a very clear demarcation.

If you use opioids for chronic low back pain, knee pain or musculoskeletal pain, yes, they are habit-forming. But for cancer pain, and for pain like sickle cell disease — which we manage on the same lines as cancer pain — they are never habit-forming. Visceral pain is mediated by the sympathetic nervous system and doesn't respond to conventional NSAIDs, so it needs neuropathic agents and opioids in combination; back pain, knee pain and shoulder pain are peripheral musculoskeletal or neuropathic pain and don't carry the same opioid receptor expression, which is why the risk profile is so different between the two.

The nerve cannot truly regenerate in the clinical sense. When there is nerve injury, the patient can go into complex regional pain syndrome Type II. Nerve regeneration takes a very long time and the results are poor — if you believe you can treat a patient through nerve regeneration, in present-day practice that is a myth.

For nerve blocks we use ropivacaine. For steroids, we primarily use dexamethasone in spinal procedures. For joint injections, we usually use Kenacort (triamcinolone).

It sits deep in the pterygopalatine fossa at the base of the skull. Blocking or ablating it treats cluster headache that has not responded to medical management, migraine, and atypical facial pain, particularly burning mouth syndrome.

A condition in which patients feel a persistent burning sensation on the tongue and in the mouth, which can be severe and disabling.

Yes. A 27-year-old patient from Oman with severe bilateral burning mouth syndrome was treated in a single sitting, with needles placed on both sides of the face under fluoroscopic guidance over about an hour, and was completely well afterward.