Abstract
Purpose
In some headache disorders, for which the greater occipital nerve block is partly effective, the third occipital nerve is also suggested to be involved. We aimed to establish a simple technique for simultaneously blocking the greater and third occipital nerves.
Methods
We performed a detailed examination of dorsal neck anatomy in 33 formalin-fixed cadavers, and deduced two candidate target points for blocking both the greater and third occipital nerves. These target points were tested on three Thiel-fixed cadavers. We performed ultrasound-guided dye injections into these points, examined the results by dissection, and selected the most suitable injection point. Finally, this target point was tested in three healthy volunteers. We injected 4 ml of local anesthetic and 1 ml of radiopaque material at the selected point, guided with a standard ultrasound system. Then, the pattern of local anesthetic distribution was imaged with computed tomography.
Results
We deduced that the most suitable injection point was the medial head of the semispinalis capitis muscle at the C1 level of the cervical vertebra. Both nerves entered this muscle, in close proximity, with little individual variation. In healthy volunteers, an anesthetic injected was confined to the muscle and induced anesthesia in the skin areas innervated by both nerves.
Conclusions
The medial head of the semispinalis capitis muscle is a suitable landmark for blocking the greater and third occipital nerves simultaneously, by which occipital nerve involvement in various headache disorders may be rapidly examined and treated.
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References
Headache Classification Committee of the International Headache S. The international classification of headache disorders, 3rd edition (beta version). Cephalalgia. 2013;33:629–808.
Blumenfeld A, Ashkenazi A, Napchan U, Bender SD, Klein BC, Berliner R, Ailani J, Schim J, Friedman DI, Charleston LT, Young WB, Robertson CE, Dodick DW, Silberstein SD, Robbins MS. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches—a narrative review. Headache. 2013;53:437–46.
Tobin J, Flitman S. Occipital nerve blocks: when and what to inject? Headache. 2009;49:1521–33.
Biondi DM. Cervicogenic headache: a review of diagnostic and treatment strategies. J Am Osteopath Assoc. 2005;105:16S–22S.
Cesmebasi A, Muhleman MA, Hulsberg P, Gielecki J, Matusz P, Tubbs RS, Loukas M. Occipital neuralgia: anatomic considerations. Clin Anat. 2015;28:101–8.
Eichenberger U, Greher M, Kapral S, Marhofer P, Wiest R, Remonda L, Bogduk N, Curatolo M. Sonographic visualization and ultrasound-guided block of the third occipital nerve: prospective for a new method to diagnose C2–C3 zygapophysial joint pain. Anesthesiology. 2006;104:303–8.
Greher M, Moriggl B, Curatolo M, Kirchmair L, Eichenberger U. Sonographic visualization and ultrasound-guided blockade of the greater occipital nerve: a comparison of two selective techniques confirmed by anatomical dissection. Br J Anaesth. 2010;104:637–42.
Tubbs RS, Mortazavi MM, Loukas M, D’Antoni AV, Shoja MM, Chern JJ, Cohen-Gadol AA. Anatomical study of the third occipital nerve and its potential role in occipital headache/neck pain following midline dissections of the craniocervical junction. J Neurosurg Spine. 2011;15:71–5.
Dash KS, Janis JE, Guyuron B. The lesser and third occipital nerves and migraine headaches. Plast Reconstr Surg. 2005;115:1752–8.
Robbins MS, Kuruvilla D, Blumenfeld A, Charleston LT, Sorrell M, Robertson CE, Grosberg BM, Bender SD, Napchan U, Ashkenazi A, Peripheral Nerve B, Other Interventional Procedures Special Interest Section of the American Headache S. Trigger point injections for headache disorders: expert consensus methodology and narrative review. Headache. 2014;54:1441–59.
Busch V, Jakob W, Juergens T, Schulte-Mattler W, Kaube H, May A. Functional connectivity between trigeminal and occipital nerves revealed by occipital nerve blockade and nociceptive blink reflexes. Cephalalgia. 2005;26:50–5.
Baron EM. Spinal cords and spinal nerves: gross anatomy. In: Sandring S, editor. Gray’s anatomy. 41st ed. Philadelphia: Elsevier; 2016. p. 768.
Arai T, Ishikawa K, Saito T, Hashimoto Y, Asai T, Okuda Y. Distance from the external occipital protuberance to the occipital artery for occipital nerve block. J Anesth. 2013;27:801–2.
Okuda Y, Ishikawa K, Usui Y, Nagao M, Ikeda T, Kitajima T. Use of an ultrasound Doppler flowmeter for occipital nerve block. Reg Anesth Pain Med. 2002;27:444–5.
Natsis K, Baraliakos X, Appell HJ, Tsikaras P, Gigis I, Koebke J. The course of the greater occipital nerve in the suboccipital region: a proposal for setting landmarks for local anesthesia in patients with occipital neuralgia. Clin Anat. 2006;19:332–6.
Finlayson RJ, Etheridge JP, Vieira L, Gupta G, Tran DQ. A randomized comparison between ultrasound- and fluoroscopy-guided third occipital nerve block. Reg Anesth Pain Med. 2013;38:212–7.
Usui Y, Kobayashi T, Kakinuma H, Watanabe K, Kitajima T, Matsuno K. An anatomical basis for blocking of the deep cervical plexus and cervical sympathetic tract using an ultrasound-guided technique. Anesth Analg. 2010;110:964–8.
Hayashi S, Homma H, Naito M, Oda J, Nishiyama T, Kawamoto A, Kawata S, Sato N, Fukuhara T, Taguchi H, Mashiko K, Azuhata T, Ito M, Kawai K, Suzuki T, Nishizawa Y, Araki J, Matsuno N, Shirai T, Qu N, Hatayama N, Hirai S, Fukui H, Ohseto K, Yukioka T, Itoh M. Saturated salt solution method: a useful cadaver embalming for surgical skills training. Medicine (Baltimore). 2014;93:e196.
Gray AT. Ultrasound-guided regional anesthesia: current state of the art. Anesthesiology. 2006;104:368–73.
Mayoux-Benhamou MA, Revel M, Vallee C. Selective electromyography of dorsal neck muscles in humans. Exp Brain Res. 1997;113:353–60.
Fowler IM, Tucker AA, Weimerskirch BP, Moran TJ, Mendez RJ. A randomized comparison of the efficacy of 2 techniques for piriformis muscle injection: ultrasound-guided versus nerve stimulator with fluoroscopic guidance. Reg Anesth Pain Med. 2014;39:126–32.
Zink W, Graf BM. Local anesthetic myotoxicity. Reg Anesth Pain Med. 2004;29:333–40.
Usui Y, Kobayashi T, Kakinuma H, Watanabe K, Kitajima T, Matsuno K. In response “ultrasound-guided deep or intermediate cervical plexus block: the target should be the posterior cervical space”. Anesth Analg. 2010;111:1565.
Acknowledgements
The authors thank Drs. Akihito Mizutani and Kaori Shirakawa for their critical reading of the manuscript and valuable discussions and Prof. Koichi Hirata for critical comments on classification of headache disorders relevant to occipital nerves. We also thank Mr. Hideo Sakurai for help arrangement of all cadaver studies. This work was supported in part by an official donation from Mr. Jin Sasanuma (no conflict of interest).
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Ken Kariya has no conflict of interest. Yosuke Usui has no conflict of interest. Naoko Higashi has no conflict of interest. Tatsuo Nakamoto has no conflict of interest. Hironobu Shimbori has no conflict of interest. Satoshi Terada has no conflict of interest. Hideo Takahashi has no conflict of interest. Hisashi Ueta has no conflict of interest. Yusuke Kitazawa has no conflict of interest. Yasushi Sawanobori has no conflict of interest. Yasuhisa Okuda has no conflict of interest. Kenjiro Matsuno has no conflict of interest.
Electronic supplementary material
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540_2017_2429_MOESM1_ESM.tif
Supplementary material 1 Online Resource 1 Gross image of an ultrasound-guided dye injection into the dorsal surface of the OCI (obliquus capitis inferior muscle) in a Thiel-fixed cadaver. (A) Schematic drawing indicates the orientation of the fascia-like septum (white lattice) that covers the greater occipital nerve (GON, yellow) and the dorsal surface of the OCI (brown); (left) dorsal view, (right) sagittal view. Injected dye (green) is shown beneath the fascia-like septum. (B, C) Serial photographs of a dissected cadaver (left) and the same photographs with labels (right). SSC, semispinalis capitis muscle. (B) The fascia-like septum (white) covers the GON (yellow) and the dorsal surface of the OCI (brown). The third occipital nerve (TON, light green) was located outside of this septum, in a compartment separate from the GON. (C) Dye was restricted to the compartment that holds the GON (yellow) (TIFF 14454 kb)
540_2017_2429_MOESM2_ESM.tif
Supplementary material 2 Online Resource 2 Gross image of an ultrasound-guided dye injection into the medial head of the SSC (semispinalis capitis muscle) in a Thiel-fixed cadaver. (A) Schematic drawing shows the greater occipital nerve (GON, yellow) and the third occipital nerve (TON, light green) piercing the medial head of the SSC (latticed purple). (Left) dorsal view, (right) sagittal view. Injected dye (green) is shown in the medial head. (B) The tendinous septum (pink) is readily seen between the medial (latticed purple) and lateral (purple) heads of the SSC. The middle and cranial parts of the SSC are cut transversely to show the tendinous septum and the fascia-like septum (light brown). (C) At the medial head (latticed purple) of the SSC, both the GON and TON are surrounded by the dye (green). In this case, the TON divided into two branches within the SSC (TIFF 14782 kb)
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Kariya, K., Usui, Y., Higashi, N. et al. Anatomical basis for simultaneous block of greater and third occipital nerves, with an ultrasound-guided technique. J Anesth 32, 483–492 (2018). https://doi.org/10.1007/s00540-017-2429-9
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DOI: https://doi.org/10.1007/s00540-017-2429-9