Nerve Block: Occipital
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.
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) |
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.
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
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
- Typically, a local anesthetic such as lidocaine (1-2%) or bupivacaine (0.5%) (or a combination of the two) is injected. Lidocaine has a quicker onset, while bupivacaine has a longer lasting effect. Total volume injected is 2-4cc per nerve block.
- Identify the location of the greater occipital nerve via one of 3 methods:
- Palpate the occipital artery pulse about 2cm lateral to the occipital protuberance. The greater occipital nerve is just medial to the occipital artery
- Alternatively, palpate the occipital protuberance and the mastoid process (on side of interest). Measure 1/3 the distance between the two points starting from the occipital protuberance. Stay just superior to the superior nuchal line to remain over the cranium.
- Alternatively, identify the point of maximal tenderness in the general region as defined above that may elicit paresthesia in the occipital nerve distribution when palpated
- Clean the site of injection. Using a 23-25G needle, insert the needle at a 90-degree angle toward the occiput until a bony endpoint is obtained. Aspirate to avoid intravascular injection and to prevent injection into CSF. Inject 1cc at the GON, 1cc medial to the nerve, and 1cc lateral to the nerve.