Occipital Nerve Block (for occipital neuralgia)

19 Aug

First, what is occipital neuralgia?

Diagnostic criteria:

1. Paroxysmal stabbing pain in the distribution of one of the occipital nerves (greater/lesser/third)

2. Tenderness over the affected nerve

3. Pain is eased by block of the nerve

 

-Other qualities of occipital neuralgia: Sharp, stabbing, or electric-like pain, pain starting at the neck and shooting toward the top of the head, usually unilateral although can be bilateral, may have decreased sensation in this distribution, dysesthesia (eg- it hurts when hair is touched)

 

Nerve Block Technique:

There are several different injection techniques.  All seem to be effective.  For each, a 25 or 27 G needle is typically used.   First some anatomy then 3 of the techniques:

occ1 

1. Proximal injection:

-Inject 2-4 cc of anesthetic ~3 cm below and 1.5 cm lateral to the inion (occipital protuberance). This is in to the muscle where the greater occipital nerve first exits.  This also anesthetizes the paraspinal muscles as well, which acts as a sort of trigger point injection too.

 occ2

2. Distal injection (I’ve seen this or a variation of it the most):

-Inject ~2 cc of anesthetic over the occipital ridge 1/3 of the distance from the inion to the mastoid process.  Be aware that the occipital artery runs right along the nerve here.  You may palpate the occipital artery to help guide then inject medial and lateral to the nerve and over the nerve.

 

3. Inject where it hurts:

-Locally infiltrate 2-3 cc of anesthetic at the area of maximum occipital scalp tenderness. This anesthetized region may or may not encompass the greater occipital nerve.  

 

Which anesthetic do I use?

-Short- or long-acting local anesthetics can be used. The two most common are lidocaine and bupivacaine.

-Many people mix the local anesthetic with an injectable steroid.  40-80 mg methylprednisolone, 10-20 mg of triamcinolone, and 2-4 mg betamethasone are common choices. 

 

Submitted by H. Groth.

 

ReferencesYoung, William B. “Blocking the Greater Occipital Nerve: Utility in Headache Management”. Current Pain and Headache Reports  July 2010.; Tobin J et al. “Occipital nerve blocks: when and what to inject?” Headache. 2009 Nov-Dec; 49(10): 1521-33.; Shah et al. Essential Emergency Procedures; Up-To-Date

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