Occipital neuralgia(두부 신경통)... 정리중...

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후두통, 긴장성 두통, 경추성 두통은 이러한 내용을 잘 이해하고 치료하면 

아무리 오래된 두통이라 할지라도 "두통을 진통제 없이 관리범위내"로 쉽게 만들 수 있다. 

panic bird.......

The Obliquus Capitis Inferior Myodural Bridge-Pontell_Scali-Enix.pdf

대후두직근과 myodural bridge.pdf

third occipital nerve

While under the Trapezius, the medial branch of the posterior division of the third cervical nerve gives off a branch called the third occipital nerve (also known as the least occipital nerve), which pierces the Trapezius and ends in the skin of the lower part of the back of the head. It lies medial to the greater occipital and communicates with it.

소후두 신경

The lesser occipital nerve or small occipital nerve is a cutaneous spinal nerve arising between the second and third cervical vertebrae, along with the greater occipital nerve. It innervates the scalp in the lateral area of the head posterior to the ear.

The lesser occipital nerve is one of the four cutaneous branches of the cervical plexus. It arises from the lateral branch of the ventral ramus of the second cervical nerve, sometimes also from the third; it curves around and ascends along the posterior border of the Sternocleidomastoideus.

Near the cranium it perforates the deep fascia, and is continued upward along the side of the head behind theauricula, supplying the skin and communicating with the greater occipital, the great auricular, and theposterior auricular branch of the facial.

The smaller occipital varies in size, and is sometimes duplicated.

It gives off an auricular branch, which supplies the skin of the upper and back part of the auricula, communicating with the mastoid branch of the great auricular.

This branch is occasionally derived from the greater occipital nerve.

대후두 신경

The greater occipital nerve is a spinal nerve, specifically the medial branch of the dorsal primary ramus ofcervical spinal nerve 2. This nerve arises from between the first and second cervical vertebrae, along with the lesser occipital nerve. It ascends after emerging from below the suboccipital triangle beneath the obliquus capitis inferior muscle. It then passes through the trapezius muscle and ascends to innervate the skin along the posterior part of the scalp to the vertex. It innervates the scalp at the top of the head, over the ear and over the parotid glands.

Disorder of this nerve is one of the causes of cervicogenic headaches, referred to as occipital neuralgias. A common site, and usually misdiagnosed area of entrapment for the greater occipital nerve is at the obliquus capitis inferior muscle.^[1]

Some innovations in pain management technology utilize neurostimulation to target tension headaches that originate from the occipital nerve. Most people experiencing tension headaches will notice increasing intensity with time and pain originating in the back of the head (occipital) moving to the front of the head (supraorbital), and by targeting specific parts of the brain in that pathway, migraine relief can be achieved.^[2]

후두 신경통

Occipital neuralgia, also known as C2 neuralgia, or (rarely) Arnold's neuralgia, is a medical condition characterized by chronic pain in the upper neck, back of the head and behind the eyes. These areas correspond to the locations of the lesser and greater occipital nerves. The greater occipital nerve also has an artery that supplies blood that is wrapped around it - the occipital artery - that can contribute to the neuralgia. This condition is also sometimes characterized with diminished sensation in the affected area as well.

원인

Occipital neuralgia is caused by damage to these nerves. Ways in which they can be damaged include trauma (usually concussive), physical stress on the nerve, repetitious neck contraction, flexion or extension, and as a result of medical complications (such as osteochondroma, a benign tumour of the bone). Another rare but possible cause is CSF Leaks.^[3] Yet another cause is from Radio Frequency nerve ablation. Rarely, occipital neuralgia may be a symptom of metastasis of certain cancers to the spine.^[4] There are several different areas that have potential to cause injury from compression:

1. The space between the vertebral bones of C1 and C2

2. The atlantoaxial ligament as the dorsal ramus emerges

3. The deep to superficial turn around the inferiolateral border of the obliquus capitis inferior muscle and its tight investing fascia

4. The deep side of semispinalis capitis, where initial piercing can involve entrapment in either the muscle itself or surrounding fascia

5. The superficial side of semispinalis capitis, where completion of nerve piercing muscle and its fascia again poses risk

6. The deep side of the trapezius as the nerve enters the muscle

7. The tendinous insertion of the trapezius at the superior nuchal line

8. The neurovascular intertwining of the GON and the occipital artery

증상

The symptom of this condition is chronic headache. The pain is commonly localized in the back of head and around or over the top of the head, sometimes up to the eyebrow or behind the eye. Because chronic headaches are a common symptom for numerous conditions, occipital neuralgia is often misdiagnosed at first, most commonly as tension headache or a migraine leading to treatment failure or addiction. Another symptom is the eyes being sensitive to light, especially when headaches occur.

Occipital neuralgia is characterized by severe pain that begins in the upper neck and back of the head. This pain is typically one sided, although can be on both sides if the both occipital nerves have been affected. Additionally, the pain may radiate forward toward the eye, as it follows the path of the occipital nerve(s). Individuals may notice blurred vision as the pain radiates near or behind the eye. The neuralgia pain is commonly described as sharp, shooting, zapping, an electric shock, or stabbing. The bouts of pain are rarely consistent, even within an individual. The amount of time the pain lasts typically varies each time the symptom appears, it may last a few seconds or be almost continuous.

Other symptoms of occipital neuralgia may include:

• Aching, burning, and throbbing pain that typically starts at the base of the head and radiates to the scalp
• Pain on one or both sides of the head
• Pain behind the eye
• Sensitivity to light
• Tender scalp
• Pain when moving the neck

치료

Once diagnosed, occipital neuralgia's symptoms can be treated/managed in several ways. Some less invasive treatments are as follows: acupuncture,chiropractic manipulation, occupational therapy, osteopathic manipulation,naprapathic treament, massage, yoga, physical therapy, rest, heat, anti- inflammatory medication, antidepressant medication, anti- convulsant medication, opioid and nonopioid analgesia, and migraine prophylaxis medication. Alternatives to these may include local nerve block, peripheral nerve stimulation, steroids, rhizotomy, phenol injections, antidepressants, and Occipital Cryoneurolysis.

Other less common forms of surgical neurolysis or microdecompression are also used to treat the condition when conservative measures fail.

Occipital neuralgia.pdf

 Occipital neuralgia is a form of headache that involves the posterior occiput in the greater or lesser occipital nerve distribution. Pain can be severe and debilitating, with frequent paroxysms. Occipital neuralgia can be difficult to distinguish from other types of headache and, therefore, diagnosis can be challenging. Local anesthetic block of the occipital nerves, either peripherally or more proximally at the C2 and/or C3 nerve root, may aid in diagnosis. Treatment may include medications, minimally invasive percutaneous procedures, and surgical interventions. This issue of Pain Management Rounds  presents the characteristics of occipital neuralgia and outlines available treatment options.

BACKGROUND

Headache accounts for nearly 20 million outpatient visits per year in the United States and

is one of the most common complaints brought to doctors. Nearly 95% of the population will

experience a headache at some point in their life. While the parenchyma of the brain is insensate,

the scalp, head muscles, periosteum, dura, and blood vessels are all pain-sensitive; thus,

there are many possible causes of head and face pain. Occipital neuralgia is a headache

syndrome that may be either primary or secondary.

Primary headaches have no clear structural or disease-related cause, (eg, migraine, tension,

and cluster headaches). Primary headaches constitute the etiology of >90% of head and facial

pain1 and occipital neuralgia is often confused with other primary headache syndromes, including

migraine and cluster headaches.

Secondary headaches have an underlying disease process that may include tumor, trauma,

infection, systemic disease, or hemorrhage.

ETIOLOGY

Patients with occipital neuralgia may be divided into those with structural causes and those

with idiopathic causes. Structural causes include:

• trauma to the greater and/or lesser occipital nerves

• compression of the greater and/or lesser occipital nerves or C2 and/or C3 nerve roots by

degenerative cervical spine changes

• cervical disc disease

• tumors affecting the C2 and C3 nerve roots.

The greater occipital nerve receives sensory fibers from the C2 nerve root and the lesser

occipital nerve receives fibers from the C2 and C3 nerve roots. The third occipital nerve (least

occipital nerve) stems from the medial sensory branch of the posterior division of the C3 nerve  root and travels along the greater occipital nerve. It passes

through the trapezius and splenius capitus slightly medial

to the greater occipital nerve. Clinically, the third occipital

nerve may also be involved in causing occipital neuralgia.

Cervical spine changes include spondylosis, arthritis

of the upper cervical facet joints, and thickening of the

ligaments in that area (particularly C1-4 levels).2  Some

cases of presumed occipital neuralgia may in fact be C2 or

C3 radiculopathies. Compression of the greater occipital

nerve is possible as it travels up the neck, passing through

the semispinalis and trapezius muscles. Whiplash or

hyperextension injury may lead to this scenario.3  Other

possible causes include localized infections or inflammation,

gout, diabetes, and blood vessel inflammation.4

 Although it cannot be quantified, most patients fall in the

category of “unknown cause,” when no identifiable lesion

is found.

CLINICAL FEATURES

 Occipital neuralgia symptoms include aching,

burning, and throbbing pain that is often unilateral and

continuous with intermittent, shocking, shooting pain.

The pain usually originates in the suboccipital area and

radiates to the posterior and/or lateral scalp. Occasionally,

patients report pain behind the eye on the affected side.

Pain may also be perceived over the neck, temple, and

frontal regions.5  Pressure over the occipital nerves may

amplify the pain, but there is usually no clear trigger.

Furthermore, some patients may have a positive Tinel’s

sign over the occipital nerve. Occasionally, neck movements

(eg, extension and rotation) may trigger pain. At

times, patients with occipital neuralgia may experience

symptoms similar to migraine or even autonomic changes

characteristic of cluster headaches. Associated symptoms

include posterior scalp paresthesias, photophobia, and

dizziness. Many patients with occipital neuralgia report a

cycle of pain-spasm-pain.6

DIAGNOSIS

 Thorough history-taking and a complete physical and

neurological examination are necessary in diagnosing

headache.7  A diagnosis is usually made based on the

characteristic area of the pain. In addition, finding tender

areas that exacerbate the pain aids in diagnosis. It is

important to clarify whether the cause of occipital neuralgia

is structural or idiopathic. Abnormal findings on neurologic

exam usually indicate a structural cause, in which

case, computed tomography (CT) or magnetic resonance

imaging (MRI) of the head and cervical spine may be

indicated. The work-up of occipital neuralgia should

include assessment for atlanto-axial joint instability.

Patients with a history of rheumatoid arthritis or trauma

should receive a thorough spine work-up. Diagnostic

occipital nerve blockade also aids in diagnosis.

Occipital neuralgia often is confused with migraines

and other headache syndromes (Table 1). In some cases,

occipital neuralgia is misdiagnosed as fibrocytis or

fibromyalgia, cervical spine arthritis, or cervical disc

disease.

TREATMENT OPTIONS

 If the cause is structural, then surgical treatment may

be indicated. Because the majority of patients have no

clear structural cause, their treatment is usually symptomatic.

Local nerve blocks, medications, occipital nerve

stimulator implantation, surgical decompression, or

lesioning of the C2 and/or C3 nerve roots, or even the

greater and/or lesser occipital nerves, may be considered.

Occipital neuralgia is often difficult to manage because it

can easily be mistaken for other headache syndromes.8

 Management of occipital neuralgia follows the usual

course, starting with the recommended conservative treatment,

conventional therapy, and medications such as

non-steroidal anti-inflammatory drugs (NSAIDs), neuropathic

medications (seizure medications, tricyclic antidepressants),

and possibly opioids.

Conservative treatment

 Physical therapy, massage, acupuncture, and heat are

other treatments that can be used for the treatment of

occipital neuralgia.9,10

Medications

 Medications that may help relieve pain in occipital

neuralgia include gabapentin 300-3600 mg/day, carbamazepine

400-1200 mg/day, phenytoin 300-600 mg/day,

valproic acid 500-2000 mg/day, and baclofen 40-120

mg/day. NSAIDs and opioids may also be beneficial.

NERVE BLOCKS

 Nerve blocks consisting of steroids and local anesthetics may also be considered for treatment of occipital neuralgia.11

Occipital nerve block

 Occipital nerve block is indicated for the diagnosis or treatment of occipital neuralgia. The greater occipital nerve is 2.5 to 3 cm lateral to the external occipital protuberance and medial to the occipital artery. The third occipital nerve is medial to the greater occipital nerve

and the lesser occipital nerve is about 2.5 cm lateral to the artery. 

 The greater and third occipital nerves are blocked slightly above the superior nuchal line, just medial to the occipital artery, which is easily palpated. After antiseptic preparation, a 25 gauge 11 /2  inch needle attached to a 5 ml syringe is placed just medial to the artery at the above location. For diagnostic indications, 1 ml of local anesthetic is injected. For treatment, 3-5 ml of local anesthetic  combined with steroid is injected. Anesthesia in the region of the greater occipital nerve usually occurs within  10 to 20 minutes. The most serious complication is piercing the occipital artery and bleeding. Compression of the occipital artery is usually effective in avoiding any significant problems.

C2 and/or C3 ganglion block

 C2 and/or C3 ganglion block has proven successful in treating some patients. One case report demonstrated that a patient with severe intractable occipital neuralgia  became pain-free for >2 months when given a C2 ganglion block.12  However, repeat blocks with steroids may have adverse effects. A case report published in 2001 demonstrated that a 39-year-old female who had 6 bilateral greater occipital nerve blocks over a period of 3 months developed signs of Cushing’s syndrome. Signs and symptoms were intermittent hypertension, severe muscle weakness, and fluid retention.13

BOTULINUM TOXIN

 Botulinum Toxin Type A (botox) is an accepted treatment for migraine headache and muscle spasm related pain with relief  up to 4 months.14  Botox was originally used to treat strabismus and cervical dystonia. 15  One trial demonstrated that botox helped chronic daily headache and appeared to have a

cumulative effect with subsequent injections.16

 Treatment with botox is generally well-tolerated; side

effects are minimal and include minor discomfort or

bleeding at the time of injection.17  Clinical trials have

shown that botox injections for migraine headaches

reduced the duration, length, and severity of the

headaches, as well as the intake of migraine medications.

18  Botox has been shown to be effective in the

treatment of whiplash-associated disorders that often

cause occipital neuralgia. It improved the pain and

increased the range of motion in these patients.

Because of its success in the treatment of muscle

spasms and migraines, botulinum toxin may prove to

be a reasonable treatment option for occipital neuralgia

in the future.

SURGICAL OPTIONS

 Occipital neuralgia can occasionally be treated

successfully with microvascular nerve decompression.

Surgical procedures such as epifacial electric stimulation,

dorsal cervical rhizotomy, neurolysis of the

greater occipital nerve, and radiofrequency rhizotomy

may also be considered. Selective C2 and/or

C3 dorsal rhizotomy is another option, although few

papers have been published assessing its utility.

Dubuisson followed 14 patients over a period of 33

months after partial posterior rhizotomy at C1-3. He

found that 10 of 14 patients (71%) had continuing

significant relief over that period of time.19  CT or

fluoroscopy-guided percutaneous C2 and/or C3

nerve block is also useful for confirmation of occipital

neuralgia and as a preoperative guide for dorsal

cervical rhizotomy.20

RADIOFREQUENCY THERMOCOAGULATION

 Radiofrequency thermocoagulation (RF) is

another widely used method to treat occipital

neuralgia. It has many advantages, including safety,

efficacy, a rapid recovery period, and no permanent

scarring. C2 ganglionotomy by RF lesion generator

has also been performed and resulted in cases of

significant pain relief. Pulsed radiofrequency (PRF)

is yet another technique used to treat occipital

neuralgia. In a case report, a patient was treated

with PRF and, after a 12-month follow-up, was

pain-free.21  Recently, a new surgical treatment was

reported consisting of neurolysis of the greater

occipital nerve and sectioning of the inferior oblique

muscle.22

OCCIPITAL NERVE STIMULATOR IMPLANTATION

 Surgical implantation of a subcutaneous electrode

along the C1-C3 nerve level has been shown to

significantly reduce the pain of occipital neuralgia in

patients who have failed conservative therapies.23

 In one study of 19 patients, 95% reported improvement

in their quality of life and would undergo the

procedure again.24  In another study of 13 patients,

12 reported good-to-excellent pain control at up to

6 years of follow-up.25  The benefit of this procedure

is that it is minimally invasive and there is no permanent

destruction of nerves or other vital structures.

Another advantage is that patients can first undergo a

percutaneous trial of temporary lead placement for

several days prior to permanent lead implantation.

Depending on the results of the temporary percutaneous

trial, patients may or may not undergo the

more invasive permanent lead implantation. It has

been postulated that a successful temporary percutaneous

lead trial, in combination with a successful

diagnostic occipital nerve block, may predict a highly

effective permanent occipital nerve stimulator

implantation.

CONCLUSION

 Occipital neuralgia is a headache syndrome that requires careful attention to enable proper diagnosis and treatment. Typically, there is no clear structural cause, although appropriate work-up should be considered in order to rule-out pathologic structural causes. The occipital nerve block is a valuable, simple, and safe diagnostic and therapeutic tool that should be considered early in the course of treatment.  If the pain persists despite preliminary therapies, including occipital nerve blockade with local anesthetic and steroid, then botulinum toxin or permanent implantation of a percutaneous occipital nerve stimulator should be considered before destructive C2 and/or C3 root surgical procedures are implemented.

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