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Greater Occipital Nerve Injection
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Greater Occipital Nerve Injection | |
---|---|
Indication | Occipital Neuralgia |
Syringe | 3mL |
Needle | 27-30G |
Steroid | optional 4mg dexamethasone'"`UNIQ--ref-00000001-QINU`"' |
Local | 1-3mL of anaesthetic |
Volume | 1-3mL |
Background
- Therapeutic and diagnostic for occipital neuralgia
- Usually performed by targeting the tender points that approximate the affected branches of the C2 nerve, either the greater or lesser occipital nerve.
- The greater occipital nerve is 2cm inferior and lateral to the external occipital protuberance, and is between ~8-18 mm deep[2]. It can also be identified at one third of the distance from the external occipital protuberance to the mastoid process.
- The lesser occipital nerve is 5cm lateral to the external occipital protuberance.
Indications
- Suspected or confirmed occipital neuralgia
- Migraine refractory to conservative treatment
- Post-lumbar puncture headache refractory to conservative treatment
- Cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness [3]
Contraindications
- Infection overlying injection site
Procedure
Ultrasound Guided
- In-plane technique
- Prone, side-lying, or seated position with the head slightly flexed.
- Stand contralateral to the injection site, in line with the transducer and with the ultrasound screen on the opposite side
- Using a high-frequency linear array transducer, localize the C2 spinous process which is bifid. The C1 spinous process is not bifid.
- Slide the probe laterally (away from yourself) towards the ipsilateral lamina of C2.
- Rotate the lateral part of the transducer cephalad until the transverse process of C1 is visualized (around 20โ30 degrees).
- Identify the muscular tissue planes and the greater occipital nerve
- Colour doppler can be used to identify the occipital artery which lies just medial to the greater occipital nerve
- Insert the needle in-plane from medial to lateral and advance until the needle tip is close to the nerve.
See Palamar et al for a review on technique[4].
Non-ultrasound Guided
- Patient in position of comfort allowing access to posterior head and neck. (laying prone or sitting with head down in arms)
- Identify Greater Occipital Nerve (GON), which may be palpated 1.5-2.5 cm inferior to occipital protuberance and ~1.5-2 cm lateral to midline[5]
- Cleanse skin with betadine or chlorhexidine and allow to dry
- Insert needle over nerve at 90 degrees to skin until hit bone, then withdraw slightly[6]
- Aspirate to ensure not in vessel.
- Inject ~1-3 mL of local anesthetic. (may inject small amount medial and lateral to nerve to ensure adequate block)[1]
- Repeat on contralateral side, if indicated.
Maximum Doses of Anesthetic Agents
Agent | Without Adrenaline | With Adrenaline | Duration | Notes |
Lidocaine | 5 mg/kg (max 300mg) | 7 mg/kg (max 500mg) | 30-90 min |
|
Mepivicaine | 7 mg/kg | 8 mg/kg | ||
Bupivicaine | 2.5 mg/kg (max 175mg) | 3 mg/kg (max 225mg) | 6-8 hr |
|
Ropivacaine | 3 mg/kg | |||
Prilocaine | 6 mg/kg | |||
Tetracaine | 1 mg/kg | 1.5 mg/kg | 3hrs (10hrs with epi) | |
Procaine | 7 mg/kg | 10 mg/kg | 30min (90min with epi) |
Complications
Complications are rare due to superficial location and lack of major surrounding structures.[1]
- Damage to surrounding structures
- Bleeding
- Infection
- Repeated blocks with steroid may result in transient dizziness or elevated blood pressure, and the patient may rarely become cushingoid.
Aftercare
- The procedure may be repeated if pain recurs
References
- โ 1.0 1.1 1.2 Brock G. The occasional greater occipital nerve block. Can J Rural Med. 2014 Fall;19(4):152-5.
- โ M. Greher, B. Moriggl, M. Curatolo, L. Kirchmair and U. Eichenberger. 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 (5): 637-642.
- โ https://www.nuemblog.com/blog/occipital-nerve-block
- โ Palamar D, Uluduz D, Saip S, et al. Ultrasound-guided greater occipital nerve block: an efficient technique in chronic refractory migraine without aura? Pain Physician. 2015 Mar-Apr;18(2):153-62.
- โ Dach F, รckeli รL, Ferreira Kdos S, Speciali JG. Nerve block for the treatment of headaches and cranial neuralgias - a practical approach. Headache. 2015 Feb;55 Suppl 1:59-71.
- โ Inan LE, Inan N, Karadaล ร, et al. Greater occipital nerve blockade for the treatment of chronic migraine: a randomized, multicenter, double-blind, and placebo-controlled study. Acta Neurol Scand. 2015 Mar 13. doi: 10.1111/ane.12393