Lesser Occipital Nerve Research Articles

Modified post-auricular incision for preserving lesser occipital nerve and great auricular nerve in post-auricular incision in ear surgery

Modified post-auricular incision for preserving lesser occipital nerve and great auricular nerve in post-auricular incision in ear surgery

Operative Complications of Microvascular Decompression for Hemifacial Spasm: Experience of 1548 Cases.

Although microvascular decompression (MVD) surgery is considered the gold standard treatment for hemifacial spasm, there are some MVD-related complications. We retrospectively reviewed 1548 patients with hemifacial spasm who underwent retromastoid suboccipital craniectomy with MVD from January 2009 to June 2013. All patients were followed for >2 years. Excellent and good results were 92.5% and 4.2%, respectively. Postoperative complications were recorded in 16.09% (n= 249). There was no MVD-related mortality. After MVD surgery, the most frequent complications were occipital sensory disturbance (7.3%), facial nerve palsy (9.7%), and hearing impairment (3.5%). Other complications were as follows: cerebrospinal fluid leakage (n= 24), poor healing wound (n= 14), lower cranial nerve palsy (n=12), wound infection (n= 4), and hemorrhage (n= 2). MVD operation is a safe treatment for hemifacial spasm. Facial nerve palsy is the most common MVD-related complication; preservation of the lesser occipital nerve during MVD surgery can decrease the rate of occipital sensory disturbance. Permanent or serious complications are comparatively rare in MVD surgery.

Temple and Postauricular Dissection in Face and Neck Lift Surgery.

Periauricular paresthesia may afflict patients for a significant amount of time after facelift surgery. When performing face and neck lift surgery, temple and posterior auricular flap dissection is undertaken directly over the auriculotemporal, great auricular, and lesser occipital nerve territory, leading to potential damage to the nerve. The auriculotemporal nerve remains under the thin outer superficial fascia just below the subfollicular level in the prehelical area. To prevent damage to the auriculotemporal nerve and to protect the temporal hair follicle, the dissection plane should be kept just above the thin fascia covering the auriculotemporal nerve. Around the McKinney point, the adipose tissue covering the deep fascia is apt to be elevated from the deep fascia due to its denser fascial relationship with the skin, which leaves the great auricular nerve open to exposure. In order to prevent damage to the posterior branches of the great auricular nerve, the skin flap at the posterior auricular sulcus should be elevated above the auricularis posterior muscle. Fixating the superficial muscular aponeurotic system flap deeper and higher to the tympano-parotid fascia is recommended in order to avoid compromising the lobular branch of the great auricular nerve. The lesser occipital nerve (C2, C3) travels superficially at a proximal and variable level that makes it vulnerable to compromise in the mastoid dissection. Leaving the adipose tissue at the level of the deep fascia puts the branches of the great auricular nerve and lesser occipital nerve at less risk, and has been confirmed not to compromise either tissue perfusion or hair follicles.

Regional Anesthesia to the Scalp for Craniotomy: Innovation With Innervation.

Background Effective management and pain prevention is of great importance to avoid postoperative complications such as hypertension, agitation, and vomiting. All these adverse events may lead to elevation in intracranial pressure and, in turn, unfavorable outcome and prolonged hospital stay. Development of multiple methods of analgesia may contribute to the alleviation of problems due to pain. We tested the effectiveness of bilateral maxillary block with greater and lesser occipital nerve block for providing analgesia to the scalp. Materials and methods This study was undertaken in 40 patients scheduled for craniotomy. Before skin incision, patients were assigned randomly to receive either bilateral maxillary (group M) or scalp block (group S). Data on intraoperative hemodynamics, postoperative analgesia, and sedation were collected and analyzed for statistical significance. Results The primary outcome was the visual analog pain score. It was similar between the 2 groups at 1, 2, and 4 hours after extubation. At 12 hours, the maxillary block group had better analgesia (mean visual analog score: 3.4 cm for group M and 4.1 cm for group S with P-value of 0.0002) and sedation scores. Intraoperatively, there was no difference in the heart rate, blood pressure, and the anesthetic requirements between both the groups. Three patients in group S required fentanyl supplementation in the intraoperative period. There were no adverse events noted in the perioperative period among both the groups. Conclusions Maxillary block along with greater and lesser occipital nerve block is an effective alternative to scalp block for craniotomy and has longer duration of analgesia.

Patterns of Use of Peripheral Nerve Blocks and Trigger Point Injections for Pediatric Headache: Results of a Survey of the American Headache Society Pediatric and Adolescent Section

To describe current patterns of use of nerve blocks and trigger point injections for treatment of pediatric headache. Peripheral nerve blocks are often used to treat headaches in adults and children, but the available studies and practice data from adult headache specialists have shown wide variability in diagnostic indications, sites injected, and medication(s) used. The purpose of this study was to describe current practice patterns in the use of nerve blocks and trigger point injections for pediatric headache disorders. A survey was created in REDCap, and sent via email to the 82 members of the Pediatric and Adolescent Section of the American Headache Society in June 2015. The survey queried about current practice and use of nerve blocks, as well as respondents' opinions regarding gaps in the evidence for use of nerve blocks in this patient population. Forty-one complete, five incomplete, and three duplicate responses were submitted (response rate complete 50%). About 78% of the respondents identified their primary specialty as Child Neurology, and 51% were certified in headache medicine. Twenty-six (63%) respondents perform nerve blocks themselves, and seven (17%) refer patients to another provider for nerve blocks. Chronic migraine with status migrainosus was the most common indication for nerve blocks (82%), though occipital neuralgia (79%), status migrainosus (73%), chronic migraine without flare (70%), post-traumatic headache (70%), and new daily persistent headache (67%) were also common indications. The most commonly selected clinically meaningful response for status migrainosus was ≥50% reduction in severity, while for chronic migraine this was a ≥50% decrease in frequency at 4 weeks. Respondents inject the following locations: 100% inject the greater occipital nerve, 69% lesser occipital nerve, 50% supraorbital, 46% trigger point injections, 42% auriculotemporal, and 34% supratrochlear. All respondents used local anesthetic, while 12 (46%) also use corticosteroid (8 bupivacaine only, 4 each lidocaine + bupivacaine, lidocaine + corticosteroid, bupivacaine + corticosteroid, lidocaine + bupivacaine + corticosteroid, and 2 lidocaine only). Despite limited evidence, nerve blocks are commonly used by pediatric headache specialists. There is considerable variability among clinicians as to injection site(s) and medication selection, indicating a substantial gap in the literature to guide practice, and supporting the need for further research in this area.

Modified skin incision for avoiding the lesser occipital nerve and occipital artery during retrosigmoid craniotomy: potential applications for enhancing operative working distance and angles while minimizing the risk of postoperative neuralgias and intraoperative hemorrhage

Chronic postoperative neuralgias and headache following retrosigmoid craniotomy can be uncomfortable for the patient. We aimed to better elucidate the regional nerve anatomy in an effort to minimize this postoperative complication. Ten adult cadaveric heads (20 sides) were dissected to observe the relationship between the lesser occipital nerve and a traditional linear versus modified U incision during retrosigmoid craniotomy. Additionally, the relationship between these incisions and the occipital artery were observed. The lesser occipital nerve was found to have two types of course. Type I nerves (60%) remained close to the posterior border of the sternocleidomastoid muscle and some crossed anteriorly over the sternocleidomastoid muscle near the mastoid process. Type II nerves (40%) left the posterior border of the sternocleidomastoid muscle and swung medially (up to 4.5cm posterior to the posterior border of the sternocleidomastoid muscle) as they ascended over the occiput. The lesser occipital nerve was near a midpoint of a line between the external occipital protuberance and mastoid process in all specimens with the type II nerve configuration. Based on our findings, the inverted U incision would be less likely to injure the type II nerves but would necessarily cross over type I nerves, especially more cranially on the nerve at the apex of the incision. As the more traditional linear incision would most likely transect the type I nerves and more so near their trunk, the U incision may be the overall better choice in avoiding neural and occipital artery injury during retrosigmoid approaches.

Variations of the accessory nerve: anatomical study including previously undocumented findings-expanding our misunderstanding of this nerve

Introduction: The anatomy of the accessory nerve has been well described but continued new clinical and anatomical findings exemplify our lack of a full understanding of the course of this nerve. Therefore, this study aimed to expand on our knowledge of the course of the 11th cranial nerve via anatomical dissections.Methods: Fifty-six cadavers (112 sides) underwent dissection of the accessory nerve from its cranial and spinal origins to its emergence into the posterior cervical triangle. Immunohistochemistry was performed when appropriate.Results: Our findings included two cases (1.8%) where the nerve was duplicated, one intracranially and one extracranially. One accessory nerve (0.9%) was found to enter its own dural compartment within the jugular foramen. The majority of sides (80%) were found to have a cranial root of the accessory nerve. Thirty-one sides (28%) had connections to cervical dorsal roots medially and three sides (2.7%) laterally. Medial connections were most common with the C1 nerve. Medial components of these dorsal root connections were all sensory in nature. However, lateral components were motor on two sides (1.8%). Nerves traveled anterior to the internal jugular vein on 88% of sides. One (0.9%) left side nerve joined an interneural anastomosis between the dorsal rootlets. Macroganglia were found on the spinal part of the intracranial nerve on 13% of sides. The lesser occipital nerve arose directly from the accessory nerve on two sides (1.8%) and communicated with the accessory nerve on 5.4% of sides. One side (0.9%) was found to communicate with the facial nerve with both nerves innervating the sternocleidomastoid muscle.Conclusions: Additional anatomical knowledge of the variants of the accessory nerve may benefit patient care when this nerve is pathologically involved.

Anatomic and Compression Topography of the Lesser Occipital Nerve.

Background:The surgical treatment of occipital headaches focuses on the greater, lesser, and third occipital nerves. The lesser occipital nerve (LON) is usually transected with relatively limited available information regarding the compression topography thereof and how such knowledge may impact surgical treatment.Methods:Eight fresh frozen cadavers were dissected focusing on the LON in relation to 3 clinically relevant compression zones. The x axis was a line drawn through the occipital protuberance (OP) and the y axis, the posterior midline (PM). In addition, a prospectively collected cohort of 36 patients who underwent decompression of the LON is presented with their clinical results, including migraine headache index scores.Results:The LON was found in compression zone 1, with a mean of 7.8 cm caudal to the OP and 6.3 cm lateral to the PM. The LON was found at the midpoint of compression zone 2, with an average of 5.5 cm caudal to the OP and 6.2 cm lateral to the PM. At compression zone 3, the medial-most LON branch was located approximately 1 cm caudal to the OP and 5.35 cm lateral to the PM, whereas the lateral-most branch was identified 1 cm caudal to the OP and 6.5 cm lateral to the PM. Of the 36 decompression patients analyzed, only 5 (14%) required neurectomy as the remainder achieved statistically significant improvements in migraine headache index scores postoperatively.Conclusion:The knowledge of LON anatomy can aid in nerve dissection and preservation, thereby leading to successful outcomes without requiring neurectomy.

A rare case of bifurcated lesser occipital nerve in the posterior triangle of the neck

The origin of the lesser occipital nerve (LON) may vary, but variations in its pattern are rare. We report here a case of LON, bifurcated into superior and inferior roots in the posterior triangle of the neck. Bifurcation of the LON formed about 1.5 cm above the nerve point of the neck, near the posterior border of the sternocleidomastoid muscle. Both roots ascended obliquely upwards, and later united to form a single trunk in the upper part of the posterior triangle of the neck. It then entered the scalp where its distribution was normal. Since the cutaneous nerves of the cervical plexus are anesthetized for pain relief, as with cervicogenic headache, exceptional morphological variations of these nerves should be taken into consideration before any anesthetic procedures are performed in this region.

Neuralgias of the Head: Occipital Neuralgia.

Occipital neuralgia is defined by the International Headache Society as paroxysmal shooting or stabbing pain in the dermatomes of the greater or lesser occipital nerve. Various treatment methods exist, from medical treatment to open surgical procedures. Local injection with corticosteroid can improve symptoms, though generally only temporarily. More invasive procedures can be considered for cases that do not respond adequately to medical therapies or repeated injections. Radiofrequency lesioning of the greater occipital nerve can relieve symptoms, but there is a tendency for the pain to recur during follow-up. There also remains a substantial group of intractable patients that do not benefit from local injections and conventional procedures. Moreover, treatment of occipital neuralgia is sometimes challenging. More invasive procedures, such as C2 gangliotomy, C2 ganglionectomy, C2 to C3 rhizotomy, C2 to C3 root decompression, neurectomy, and neurolysis with or without sectioning of the inferior oblique muscle, are now rarely performed for medically refractory patients. Recently, a few reports have described positive results following peripheral nerve stimulation of the greater or lesser occipital nerve. Although this procedure is less invasive, the significance of the results is hampered by the small sample size and the lack of long-term data. Clinicians should always remember that destructive procedures carry grave risks: once an anatomic structure is destroyed, it cannot be easily recovered, if at all, and with any destructive procedure there is always the risk of the development of painful neuroma or causalgia, conditions that may be even harder to control than the original complaint.

Regional Anesthesia to Scalp for Craniotomy: Innovation With Innervation.

Effective management and pain prevention is of great importance to avoid postoperative complications such as hypertension, agitation, and vomiting. All these adverse events may lead to elevation in intracranial pressure and, in turn, unfavorable outcome and prolonged hospital stay. Development of multiple methods of analgesia may contribute to the alleviation of problems due to pain. We tested the effectiveness of bilateral maxillary block with greater and lesser occipital nerve block for providing analgesia to the scalp. This study was undertaken in 40 patients scheduled for craniotomy. Before skin incision, patients were assigned randomly to receive either bilateral maxillary (group M) or scalp block (group S). Data on intraoperative hemodynamics, postoperative analgesia, and sedation were collected and analyzed for statistical significance. The primary outcome was the visual analog pain score. It was similar between the 2 groups at 1, 2, and 4 hours after extubation. At 12 hours, the maxillary block group had better analgesia (mean visual analog score: 3.4 cm for group M and 4.1 cm for group S with P-value of 0.0002) and sedation scores. Intraoperatively, there was no difference in the heart rate, blood pressure, and the anesthetic requirements between both the groups. Three patients in group S required fentanyl supplementation in the intraoperative period. There were no adverse events noted in the perioperative period among both the groups. Maxillary block along with greater and lesser occipital nerve block is an effective alternative to scalp block for craniotomy and has longer duration of analgesia.

Clinical significance of lesser occipital nerve preservation during micro-vascular decompression for hemi-facial spasm

Micro-vascular decompression (MVD) is a useful surgical technique in treating hemi-facial spasm (HFS). However, sensory disturbance and headache are the common postoperative complications. This study seeked to estimate whether lesser occipital nerve (LON) preservation was conducive to reducing the incidence of adverse events. We retrospectively compared the operation time and postoperative complications between 28 HFS patients who underwent MVD with LON preservation from January 2011 to December 2012 (LON preservation group) and 12 HFS patients who underwent MVD without preserving LON in 2010 (control group). Compared with the control group, patients in the LON preservation group showed increased operation time but reduced incidences of sensory disturbances around occipitalis (P = 0.017) and posterior auricular (P = 0.002). However, there were no significant differences in other postoperative complications such as headache (P = 0.414), incision infection (P = 0.527) or cerebrospinal fluid leakage (P = 0.527). For HFS patients who attempted to receive MVD, LON preservation could reduce the incidence of sensory disturbance around the operative region, despite causing extend operation time.

Case Report of Post Concussion Syndrome with persistent Headache treated with Functional Neurology

Event Abstract Back to Event Case Report of Post Concussion Syndrome with persistent Headache treated with Functional Neurology Brad Ralston1* 1 Chiropractic neurology, United States The following is a case report of a 17-year-old female with a history of postconcussion syndrome and a constant headache every day for four years. INTERVAL HISTORY: 17-year-old patient had a constant suboccipital headache that was both of the tension and migrainous variety, typically over the right orbital area at a consistent 6/10 on the analog pain scale. She had jaw pain, nausea, light sensitivity, depression. She had seen numerous specialists, was treated with injections, infusions, Botox. She is currently taking valproic acid ,tizanidine and she was taking baclofen as needed. All of her concussions were basketball related. METHODS: The patient was examined with the Functional Neurological Exam, VNG, and dynamic posturography. She was found to have convergence spasm with a right esophoria, and a left corectasia. She had a right ptosis and a right facial paresis. She had dysmetric movements on the left with piano playing and finger-to-nose movements. She had myospasm in the sub occipital muscles and greater and lesser occipital nerve areas. VNG showed gait instability to the right and up, hypometric pursuits to the left, poor optokinetic gain to the left . VNG showed a slight left beating nystagmus with eyes occluded. She had a pathological OTR with a left tilt and a right hyperopia. Her VOR was decreased to the right. She had poor heel-toe walking, poor double tasking. She had palpable tenderness around the TMJ joint bilaterally. She had cervical myospasm, more on the right side than left side. INTERVENTION: The patient was treated with a combination of vestibular, ocular motor, physical, and chiropractic rehab modalities. She was treated with light laser to the suboccipital area, divergence exercises, tilt table exercises, gaze stability exercises, SSEP at V3, suboccipital massage and nerve tracing was performed to the trigeminal vesicular areas, the greater and lesser occipital nerves with a prolo-therapy gel applied. The patient was treated regularly for a prescribed period of time. The patient was also recommended to eat a high protein diet and to supplement with iron for iron deficiency. RESULTS: At the end of the treatment, this patient no longer has a headache of any kind. She is symptom free of headaches. She is within healthy ranges with objective testing on dynamic posturography. She shows no convergence excess. She has normal gain in pursuit and optokinetic activity. She has stable gaze to the left, right, and up. Her saccades are within normal limits. She was released with home exercises to continue to do daily and instructed to follow up if symptoms return. Keywords: Post Concussion, Headache, Neurorehabilitation, Functional Neurology, light sensitivity, Convergence, Ocular Conference: International Symposium on Clinical Neuroscience: TBI and Neurodegeneration, Orlando, Florida, United States, 10 Dec - 14 Dec, 2015. Presentation Type: Poster Presentation Topic: Case Reports for Poster Presentation Citation: Ralston B (2015). Case Report of Post Concussion Syndrome with persistent Headache treated with Functional Neurology. Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience: TBI and Neurodegeneration. doi: 10.3389/conf.fneur.2015.58.00065 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 24 Oct 2015; Published Online: 02 Nov 2015. * Correspondence: Dr. Brad Ralston, Chiropractic neurology, Indianapolis, IN, 46260, United States, drralston@chironeuroindy.com Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Brad Ralston Google Brad Ralston Google Scholar Brad Ralston PubMed Brad Ralston Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Shoulder arthroscopy and complications: Can we afford to relax?

Shoulder arthroscopy and complications: Can we afford to relax?

Occipital neuralgia after hair transplantation and its treatment.

While undergoing full thickness tissue harvest from the posterior scalp, a 72-year-old man experienced immediate severe pain in the right occiput and was unable to complete the procedure. The pain was constant “sharp” and “shocking” with numbness in the distribution of the lesser occipital nerve, exacerbated by physical activity, and local anesthetic blocks provided temporary complete relief. After numerous treatments over several years, including oral analgesics, botulinum toxin injections, and acupuncture, proved ineffective, pulsed radiofrequency neuromodulation provided greater than 80% relief for 5 months.

Pulsed Radiofrequency for Occipital Neuralgia

Background: The clinical application of pulsed radiofrequency (PRF) by interventional pain physicians for a variety of chronic pain syndromes, including occipital neuralgia, is growing. As a minimally invasive percutaneous technique with none to minimal neurodestruction and a favorable side effect profile, use of PRF as an interventional neuromodulatory chronic pain treatment is appealing. Occipital neuralgia, also known as Arnold’s neuralgia, is defined by the International Headache Society as a paroxysmal, shooting or stabbing pain in the greater, lesser, and/or third occipital nerve distributions. Pain intensity is often severe and debilitating, with an associated negative impact upon quality of life and function. Most cases of occipital neuralgia are idiopathic, with no clearly identifiable structural etiology. Treatment of occipital neuralgia poses inherent challenges as no criterion standard exists. Initially, conservative treatment options such as physical therapy and pharmacotherapy are routinely trialed. When occipital neuralgia is refractory to conservative measures, a number of interventional treatment options exist, including: local occipital nerve anesthetic and corticosteroid infiltration, botulinum toxin A injection, occipital nerve subcutaneous neurostimulation, and occipital nerve PRF. Of these, PRF has garnered significant interest as a potentially superior, safe, non-invasive treatment with long-term efficacy. Objective: The objective of this article is to provide a concise review of occipital neuralgia; and a concise, yet thorough, evidence-based review of the current literature concerning the use of PRF for occipital neuralgia. Study Design: Review of published medical literature up through April 2013. Setting: The Center for Pain Medicine and Regional Anesthesia, the University of Iowa Hospitals and Clinics. Results: A total of 3 clinical studies and one case report investigating the use of PRF for knee occipital neuralgia have been published worldwide. Statistically significant improvements in pain, quality of life, and adjuvant pain medication usage have been demonstrated. Limitations: Lack of randomized control trials, small study sample sizes, an absence of diagnostic block imaging guidance, and the use of outcome measures that are inherently subjective, limiting objectivity and introducing an unquantifiable degree of bias. Conclusion: Clinical studies to date examining the efficacy of PRF as a treatment for occipital neuralgia have yielded promising results, demonstrating sustained improvement in pain, quality of life, and adjuvant pain medication usage. Despite these encouraging clinical studies, conclusive evidence in support of PRF as an interventional treatment option for occipital neuralgia awaits to be seen. Key words: Occipital neuralgia, pulsed radiofrequency, PRF, greater occipital nerve, lesser occipital nerve, chronic pain, interventional pain management

Sensory complications in patients after scalp mass excision and its anatomical considerations.

ObjectiveTo evaluate the incidence of postsurgical sensory complications in patients with scalp masses and classify the locations of them from a surgical standpoint according to anatomical considerations.MethodsA total of 121 patients who underwent surgery for scalp mass were included in this study. The authors reviewed medical records and preoperative radiologic images. We investigated the complications related to sensory changes after procedure. Enrolled patients have been divided into three groups. Group A included patients with tumors above the superior nuchal line (SNL), Group B with tumors within the trapezius muscle area and patients who had tumors on the lateral trapezius muscle area were assigned to Group C. We compared the incidence related to postoperative sensory complications and summarized their additional treatments for these with clinical outcome.ResultsThere were 12 patients (10%) with sensory complications related on the mass excision site (Group A: 1 patient, Group B: 2 patients, Group C: 9 patients). Six patients were affected with lesser occipital nerve (LON), 2 patients on greater occipital nerve (GON) and 4 patients on GON and LON. Over 6 months after surgery, two of the twelve patients with sensory complications did not have complete recovered pain in spite of proper medications and local chemical neurolysis with 1.0% lidocaine and dexamethasone.ConclusionOccipital neuropathy should be considered as a complication related excision of scalp mass. The sensory complications are more frequent in Group C because of the anatomical characteristics of the occipital nerves and there were no statistical difference for other variables.

An Anatomical Study of the Lesser Occipital Nerve and Its Potential Compression Points

This study maps the course of the lesser occipital nerve and its potential compression sites in the posterior scalp. Twenty sides of 10 fresh cadaveric heads were dissected. Two fixed anatomical landmarks were used: the y axis was the vertical midline in the posterior scalp through the midline of the cervical spine. The x axis was a horizontal line drawn between the most anterosuperior points of the external auditory meatus. A topographic map of the lesser occipital nerve and its potential compression points was created. The lesser occipital nerve emerged from the posterior border of the sternocleidomastoid muscle at an average of 6.4 ± 1.4 cm lateral to the y axis and 7.5 ± 0.9 cm caudal to the x axis. Branches of the occipital artery were found to interact with the lesser occipital nerve in 11 of the 20 hemiheads (55 percent). The mean location of the artery-nerve interaction was 5.1 ± 0.9 cm lateral to the y axis and 2 ± 1.45 cm caudal to the x axis. Two patterns of artery-nerve interaction were seen: a single site of artery crossing over the nerve in nine of 20 hemiheads (45 percent) and a helical intertwining relationship in two of 20 of hemiheads (10 percent). A fascial band was identified to compress the lesser occipital nerve in four of 20 hemiheads (20 percent). This anatomical study traced the lesser occipital nerve as it courses through the posterior scalp and mapped its potential decompression sites.

Noninvasive Pulsed Radio Frequency Energy in the Treatment of Occipital Neuralgia with Chronic, Debilitating Headache: A Report of Four Cases

To examine the effects of noninvasive pulsed radio frequency energy (PRFE) on recurrent migraine headache associated with occipital neuralgia. Four patients who were receiving long-term treatment with repeated greater and lesser occipital nerve blocks (GLONBs) to control recurrent migraine resistant to other treatment underwent treatment with noninvasive PRFE at home as a substitute for GLONB treatment. PRFE was administered by the patient at home for 30 minutes twice daily through an applicator pad placed directly over the occiput and upper cervical spine. Three of four patients reported a decrease in frequency, severity, or both of nonprostrating and prostrating migraines compared with their baseline symptoms; one reported no change from baseline. Comparing PRFE results with those obtained after nerve blocks, three of four patients reported decreases in nonprostrating migraines, while two reported a decrease in prostrating migraines. One patient reported an increase in prostrating migraine frequency. Variable degrees of increased productivity, decreased opioid and nonopioid analgesic use, and decreased visits to urgent care clinics were noted. In two patients who had combined PRFE and GLONB, marked improvement was noted in all symptoms. Improvement in frequency of headaches was noted, especially when PRFE was combined with GLONB. Further study is warranted.

Expert Consensus Recommendations for the Performance of Peripheral Nerve Blocks for Headaches – A Narrative Review

To describe a standardized methodology for the performance of peripheral nerve blocks (PNBs) in the treatment of headache disorders. PNBs have long been employed in the management of headache disorders, but a wide variety of techniques are utilized in literature reports and clinical practice. The American Headache Society Special Interest Section for PNBs and other Interventional Procedures convened meetings during 2010-2011 featuring formal discussions and agreements about the procedural details for occipital and trigeminal PNBs. A subcommittee then generated a narrative review detailing the methodology. PNB indications may include select primary headache disorders, secondary headache disorders, and cranial neuralgias. Special procedural considerations may be necessary in certain patient populations, including pregnancy, the elderly, anesthetic allergy, prior vasovagal attacks, an open skull defect, antiplatelet/anticoagulant use, and cosmetic concerns. PNBs described include greater occipital, lesser occipital, supratrochlear, supraorbital, and auriculotemporal injections. Technical success of the PNB should result in cutaneous anesthesia. Targeted clinical outcomes depend on the indication, and include relief of an acute headache attack, terminating a headache cycle, and transitioning out of a medication-overuse pattern. Reinjection frequency is variable, depending on the indications and agents used, and the addition of corticosteroids may be most appropriate when treating cluster headache. These recommendations from the American Headache Society Special Interest Section for PNBs and other Interventional Procedures members for PNB methodology in headache disorder treatment are derived from the available literature and expert consensus. With the exception of cluster headache, there is a paucity of evidence, and further research may result in the revision of these recommendations to improve the outcome and safety of these interventions.