Nerve Block: Occipital: Difference between revisions
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===Background=== | ===Background=== | ||
[[File:Gray800.png|thumb|Posterior primary divisions of the upper three cervical nerves. (Great occipital nerve labeled at center top.)]] | |||
[[File:Gray790.png|thumb|Lateral view (greater occipital nerve posterior)]] | |||
*Therapeutic and diagnostic for occipital neuralgia | *Therapeutic and diagnostic for occipital neuralgia | ||
*Nerve is between ~8-18 mm deep<ref>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.</ref> | *Nerve is between ~8-18 mm deep<ref>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.</ref> | ||
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==Indications== | ==Indications== | ||
*Suspected or confirmed occipital neuralgia | *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 <ref>https://www.nuemblog.com/blog/occipital-nerve-block</ref> | |||
==Contraindications== | ==Contraindications== | ||
* | *Infection overlying injection site | ||
==Equipment Needed== | ==Equipment Needed== | ||
*PPE | *PPE | ||
*Syringe and 27-30ga needle | |||
*Betadine or chlorhexidine | |||
*Local anesthetic | *Local anesthetic | ||
* | **40mg of methylprednisolone or triamcinolone may be mixed with the local anesthetic<ref name="Brock">Brock G. The occasional greater occipital nerve block. Can J Rural Med. 2014 Fall;19(4):152-5.</ref>, but efficacy has not been proven. | ||
==Procedure== | |||
*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). | |||
**May be palpated 1.5-2.5 cm inferior to occipital protuberance and ~1.5-2 cm lateral to midline<ref name="Dach">Dach F, Éckeli ÁL, 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.</ref> | |||
**Alternatively, may be ultrasound guided - look for occipital artery in medial third of the line from occipital tubercle to mastoid process<ref name="Palamar">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.</ref> | |||
***GON will be located medial to artery. | |||
*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<ref>Inan LE, Inan N, Karadaş Ö, 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</ref> | |||
**If using ultrasound, insert needle at 45 degrees to skin and advance toward nerve under direct ultrasound guidance | |||
*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)<ref name="Brock" /> | |||
*Repeat on contralateral side, if indicated. | |||
{{Maximum doses of anesthetic agents}} | {{Maximum doses of anesthetic agents}} | ||
==Complications== | ==Complications== | ||
''Complications are rare due to superficial location and lack of major surrounding structures.<ref name="Brock" />'' | |||
*Damage to surrounding structures | *Damage to surrounding structures | ||
*Bleeding | |||
*Infection | |||
==Follow-up== | ==Follow-up== | ||
*Follow up with appropriate specialist for the indication for nerve block. | |||
==See Also== | ==See Also== | ||
*[[Nerve Blocks (Main)]] | *[[Nerve Blocks (Main)]] | ||
*[[ | *[[Local Anesthetic Systemic Toxicity (LAST)]] | ||
*[[Headache]] | |||
*[[Migraine_headache|Migraine]] | |||
==External Links== | |||
===Videos=== | |||
{{#widget:YouTube|id=6Dj5zYbvLxo}} | |||
==References== | ==References== | ||
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[[Category:Procedures]] | [[Category:Procedures]] | ||
[[Category:Neurology]] | |||
Latest revision as of 14:50, 29 June 2021
Background
- Therapeutic and diagnostic for occipital neuralgia
- Nerve is between ~8-18 mm deep[1]
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 [2]
Contraindications
- Infection overlying injection site
Equipment Needed
- PPE
- Syringe and 27-30ga needle
- Betadine or chlorhexidine
- Local anesthetic
- 40mg of methylprednisolone or triamcinolone may be mixed with the local anesthetic[3], but efficacy has not been proven.
Procedure
- 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).
- 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]
- If using ultrasound, insert needle at 45 degrees to skin and advance toward nerve under direct ultrasound guidance
- 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)[3]
- Repeat on contralateral side, if indicated.
Maximum Doses of Anesthetic Agents
| Agent | Without Epinephrine | With Epinephrine | 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.[3]
- Damage to surrounding structures
- Bleeding
- Infection
Follow-up
- Follow up with appropriate specialist for the indication for nerve block.
See Also
External Links
Videos
{{#widget:YouTube|id=6Dj5zYbvLxo}}
References
- ↑ 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.
- ↑ https://www.nuemblog.com/blog/occipital-nerve-block
- ↑ 3.0 3.1 3.2 Brock G. The occasional greater occipital nerve block. Can J Rural Med. 2014 Fall;19(4):152-5.
- ↑ Dach F, Éckeli ÁL, 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.
- ↑ 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.
- ↑ Inan LE, Inan N, Karadaş Ö, 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