Journal of Anesthesia

, Volume 32, Issue 4, pp 483–492 | Cite as

Anatomical basis for simultaneous block of greater and third occipital nerves, with an ultrasound-guided technique

  • Ken Kariya
  • Yosuke Usui
  • Naoko Higashi
  • Tatsuo Nakamoto
  • Hironobu Shimbori
  • Satoshi Terada
  • Hideo Takahashi
  • Hisashi Ueta
  • Yusuke Kitazawa
  • Yasushi Sawanobori
  • Yasuhisa Okuda
  • Kenjiro Matsuno
Original Article



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.


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.


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.


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.


Spinal nerves Nerve block Ultrasonography 



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).

Compliance with ethical standards

Conflict of interest

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.

Supplementary material

540_2017_2429_MOESM1_ESM.tif (14.1 mb)
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 (14.4 mb)
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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Copyright information

© Japanese Society of Anesthesiologists 2017

Authors and Affiliations

  • Ken Kariya
    • 1
  • Yosuke Usui
    • 1
    • 2
  • Naoko Higashi
    • 3
  • Tatsuo Nakamoto
    • 4
  • Hironobu Shimbori
    • 5
  • Satoshi Terada
    • 1
    • 6
  • Hideo Takahashi
    • 1
  • Hisashi Ueta
    • 1
  • Yusuke Kitazawa
    • 1
  • Yasushi Sawanobori
    • 1
  • Yasuhisa Okuda
    • 6
  • Kenjiro Matsuno
    • 1
  1. 1.Department of Anatomy (Macro)Dokkyo Medical University School of MedicineMibuJapan
  2. 2.Mizutani Pain ClinicShizuokaJapan
  3. 3.Tochigi Medical CenterTochigiJapan
  4. 4.Department of AnesthesiologyKansai Medical UniversityOsakaJapan
  5. 5.Yokohama Pain ClinicYokohamaJapan
  6. 6.Department of Anesthesiology, Koshigaya HospitalDokkyo Medical UniversitySaitamaJapan

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