Hydrodissection of the cervical plexus and auricular temporal nerve

In this video, we are going to see a hydrodissection procedure of the cervical plexus (which is responsible for the muscles that move the neck, head, and upper torso as well as providing the sensation of touch in parts of the occiput (base of the skull), neck, and shoulder) and the auricular temporal nerve (provides sensation to the jaw. ear, and side of the head).

What is Nerve Release and Regeneration Injection Therapy?

Hydrodissection is a procedure where fluid is injected around a nerve. Specifically, the fluid is injected into the nerve sheath. The hydrodissection procedure has the potential to release a nerve from impingement or entrapments or release a plexus (nerve “station”) that is getting pulled, tugged, stretched, or compressed. When regenerative solutions are injected such as Platelet-rich plasma or bone marrow aspirate stem cells, hydrodissection has the potential to regenerate the nerves.

An explanation of the Plexuses

Below we see a schematic drawing of the deep cervical plexus and superficial cervical plexus. (A) Four superficial branches of the cervical plexus are depicted using yellow color and deep branches of the cervical plexus (ansa cervicalis) are depicted using green color.

The cervical plexus anastromosizes (fuse or connect) with several cranial nerves and the sympathetic trunk. The image to the right shows the superficial cervical plexus emerging behind the posterior border of the SCM (sternocleidomastoid) muscle and innervates the head neck and shoulder areas.

Symptoms can come from compression of the cervical plexus where the nerves meet.

Lesser occipital nerve problems cause pain in the scalp on the side of the head behind the ear.
Greater auricular nerve problems cause pain in the ear lobe and the rear mandible at the jab bone’s angle.
Transverse cervical nerve problems cause pain in the front of the neck
Supraclavicular nerve problems cause pain in the clavicle, anteromedial (front, middle) shoulder, and the chest area near the shoulder.

In the green, we see the superior and inferior roots of the ansa cervicalis. As you see these “green nerves” form a loop and hence the Latin name ansa cervicalis meaning the handle of the neck. From the ansa cervicalis comes the nerves of the sternohyoid, sternothyroid, and superior and inferior bellies of the omohyoid muscles. “All of the muscles supplied by branches of the ansa cervicalis, along with the thyrohyoid, are infrahyoid muscles, and therefore serve to depress the hyoid bone. This function is necessary for proper speech and swallowing.”(1)

Other nerves have neural connections with cranial nerves through the cervical plexus, ansa cervicalis, and trigeminocervical nucleus (TCN) in the upper cervical cord, such as the hypoglossal nerve (CN XII). Upper cervical instability and the neural connections between the ansa cervicalis and the hypoglossal nerve also explain conditions such as burning mouth syndrome, hypoglossal nerve palsy, and neck-tongue syndrome, the latter condition is assumed with neck pain and tongue numbness following quick rotations of the neck

In this article, our focus is on when the nerves are compressed and the symptoms they cause. In many patients we see upper cervical instability, that is wandering, loose cervical vertebrae as the culprit of nerve compression. In our practice, we offer Cervical spine Prolotherapy injections to stimulate the cervical ligaments to tighten and thicken to resolve cervical spine instability and thereby alleviate and many times eliminate symptoms suffered by the patient. Sometimes however the ligament is very damaged and will take time to heal. The resulting cervical spine instability will cause excessive and destructive movements of the bones and can cause significant compression and stretch on the plexus and the nerves described above.

The patient case described in the video

In our patient Edwin’s case, he was having pain in the jaw. In the image above you see the sensory innervation of the head and neck and the greater auricular nerve which is right by the temporomandibular joint or TMJ. Compression of this nerve can cause problems with sensation in this region and give a lot of pain basically in the TMJ region. Edwin is going to get hydrodissection of this nerve and this nerve plexuses specifically for pain relief.

Edwin’s description of his pain: “In 2020 I came in for Prolotherapy injections for widespread pain in my neck, upper back, and shoulder area. I continued the treatments because it was working. During this time I also noticed that I was having pain in my jaw. Dr. Hauser recommended hydrodissection. I questioned him on how a shot that he was suggesting in the neck area would help my jaw pain and muscle contractions. Dr. Hauser went through the steps to explain nerve compression. I had the treatment it lasted for over a year and now I am back to get another.

Summary

Pain and symptoms caused by the cervical nerves can come from neck instability, an excessive stretch of the cervical ligaments, neurogenic inflammation, and/or nerve entrapment. When peripheral nerve entrapment plays a significant role in the symptoms, Hydrodissection or Nerve Release and Regeneration Injection Therapy (NRRIT) can provide significant and sometimes immediate relief.

An August 2020 paper published in the Journal of Pain Research (2) and cited in the video wrote: “The technique of high-resolution ultrasound (US)-guided hydrodissection (HD) of peripheral nerves has recently drawn the attention of the medical profession, especially in the fields of pain and musculoskeletal medicine. Randomized controlled trials published in high-impact journals have suggested that this technique can safely and effectively treat carpal tunnel syndrome, the most extensively studied clinical condition treated by ultrasound-guided HD of peripheral nerves. Other clinical studies have also used this technique to treat neuropathic pain related to deep nervous structures or the neuraxial spine.”

References

1 Waxenbaum JA, Reddy V, Bordoni B. Anatomy, Head and Neck, Cervical Nerves. StatPearls [Internet]. 2022 Jan. [Google Scholar]
2 Lam KH, Hung CY, Chiang YP, Onishi K, Su DC, Clark TB, Reeves KD. Ultrasound-guided nerve hydrodissection for pain management: rationale, methods, current literature, and theoretical mechanisms. Journal of pain research. 2020;13:1957. [Google Scholar]