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