Occipital Block

Published on 06/02/2015 by admin

Filed under Anesthesiology

Last modified 22/04/2025

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19 Occipital Block

Perspective

Occipital nerve block is most frequently used in the diagnosis and treatment of occipital neuralgia. It is also useful when combined with other head and neck blocks to provide scalp anesthesia when infiltration alone will not suffice.

Patient Selection

Most candidates for occipital nerve block will be experiencing symptoms consistent with occipital neuralgia. These patients are often at the end of a long and frustrating medical evaluation and thus may need a detailed explanation of what to expect during the block.

Pharmacologic Choice

This block requires only 3 to 5 mL of local anesthetic, so virtually any local anesthetic can be used.

Placement

Anatomy

The greater occipital nerve arises from the dorsal rami of the second cervical nerve and travels deep to the cervical musculature until it becomes subcutaneous slightly inferior to the superior nuchal line. It emerges on this line in association with the occipital artery, which is the most useful landmark for locating the greater occipital nerve (Fig. 19-1).

Figure 19-1. Occipital nerve block: anatomy and technique.

Position

The most effective patient position for the greater occipital block is the sitting position, with the chin flexed on the chest. A short, 25-gauge needle is inserted through the skin at the level of the superior nuchal line to develop a “wall” of local anesthetic surrounding the posterior occipital artery. The artery is commonly found approximately one third of the distance between the external occipital protuberance and the mastoid process on the superior nuchal line. Injection of 3 to 5 mL of local anesthetic in this area will produce satisfactory anesthesia.

Potential Problems

The superficial nature of this block should make complications infrequent. However, it is important to ask the patient whether he or she has undergone any posterior cranial surgery because total spinal anesthesia has occurred after occipital nerve block in patients who have had such surgery.

Pearls

To make this block effective for pain diagnosis and therapy, the anesthesiologist must make the expectations for the block clear to the patient before performing the block. Often patients reach the anesthesiologist only after a long and arduous trial of alternative pain therapies; thus, it is as important for the anesthesiologist to handle the psychosocial implications of the procedure as it is to discuss the technical features.

When a diagnostic block is planned, it is important to keep the dose of local anesthetic small to minimize confusion with relief of myofascial pain. Similarly, relief of ipsilateral retro-orbital or temporal pain after an occipital block does not rule out the possibility of occipital neuralgia as the cause of the pain syndrome because pain relief is produced outside the typical sensory distribution of the occipital nerve. In some of these cases, owing to brain stem and spinal cord interneuronal connections between the trigeminal nucleus and the second cervical spinal nerve, retro-orbital pain is frequently relieved with a greater occipital nerve block.

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