Korean J Pain.  2018 Apr;31(2):80-86. 10.3344/kjp.2018.31.2.80.

Efficacy of bilateral greater occipital nerve block in postdural puncture headache: a narrative review

• Nair AS
• Kodisharapu PK
• Anne P
• Saifuddin
• Asiel C
• Rayani BK

• KMID: 2410829
• DOI: http://doi.org/10.3344/kjp.2018.31.2.80

Abstract

The Epidural blood patch is considered the gold standard for managing postdural puncture headache when supportive measures fail. However, it is a procedure which can lead to another inadvertent dural puncture. Other potential adverse events that could occur during a blood patch are meningitis, neurological deficits, and unconsciousness. The bilateral greater occipital nerve block has been used for treating chronic headaches in patients with PDPH with a single injection. This minimally invasive, simple procedure can be considered for patients early, along with other supportive treatment, and an epidural blood patch can be avoided.

Keyword

Epidural blood patch; Greater occipital nerve; Nerve block; Pain management; Postdural puncture headache; Ultrasound

MeSH Terms

Blood Patch, Epidural
Headache Disorders
Humans
Meningitis
Nerve Block*
Pain Management
Post-Dural Puncture Headache*
Punctures
Ultrasonography
Unconsciousness

Figure

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  Fig. 1 The origin of greater occipital nerve and its course along the occipital region (Modified from http://www.kidport.com/RefLib/Science/HumanBody/SkeletalSystem/Skull.htm). The figure has been edited and labelled at appropriate places.

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  Fig. 2 Relevant landmark for locating the needle entry using a landmark technique. The same point could be marked prior to performing an ultrasound scan also (Modified from http://resizeandsave.online/openphoto.php? img=http://images.fineartamerica.com/images-medium-large-5/anatomy-of-human-skull-rear-view-leonello-calvetti.jpg). The figure has been labelled at appropriate places.

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  Fig. 3 The probe placement while performing a greater occipital nerve block. The entry of needle in plane, with the needle entering from lateral to medial direction (Consent have been obtained from the patient to display the shaved skull with appropriate labelling for academic purpose).

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  Fig. 4 Ultrasonographic view of relevant anatomy i.e. greater occipital artery, semispinalis muscle, obliquus capitis inferior muscle and greater occipital nerve medial to arterial pulsations.

Reference

1. Evans RW, Armon C, Frohman EM, Goodin DS. Assessment: prevention of post-lumbar puncture headaches: report of the therapeutics and technology assessment subcommittee of the american academy of neurology. Neurology. 2000; 55:909–914. PMID: 11061243.

2. Oedit R, van Kooten F, Bakker SL, Dippel DW. Efficacy of the epidural blood patch for the treatment of post lumbar puncture headache BLOPP: a randomised, observer-blind, controlled clinical trial [ISRCTN 71598245]. BMC Neurol. 2005; 5:12. PMID: 15998467.

3. Arevalo-Rodriguez I, Ciapponi A, Roqué i Figuls M, Muñoz L, Bonfill Cosp X. Posture and fluids for preventing post-dural puncture headache. Cochrane Database Syst Rev. 2016; 3:CD009199. PMID: 26950232.

4. Boonmak P, Boonmak S. Epidural blood patching for preventing and treating post-dural puncture headache. Cochrane Database Syst Rev. 2010; CD001791. PMID: 20091522.

5. Desai MJ, Dave AP, Martin MB. Delayed radicular pain following two large volume epidural blood patches for postlumbar puncture headache: a case report. Pain Physician. 2010; 13:257–262. PMID: 20495590.

6. Nair AS, Rayani BK. Sphenopalatine ganglion block for relieving postdural puncture headache: technique and mechanism of action of block with a narrative review of efficacy. Korean J Pain. 2017; 30:93–97. PMID: 28416992.

7. Mojica J, Mo B, Ng A. Sphenopalatine ganglion block in the management of chronic headaches. Curr Pain Headache Rep. 2017; 21:27. PMID: 28432602.

8. Cho JC, Haun DW, Kettner NW, Scali F, Clark TB. Sonography of the normal greater occipital nerve and obliquus capitis inferior muscle. J Clin Ultrasound. 2010; 38:299–304. PMID: 20544865.

9. Natsis K, Baraliakos X, Appell HJ, Tsikaras P, Gigis I, Koebke J. The course of the greater occipital nerve in the suboccipital region: a proposal for setting landmarks for local anesthesia in patients with occipital neuralgia. Clin Anat. 2006; 19:332–336. PMID: 16258972.

10. Loukas M, El-Sedfy A, Tubbs RS, Louis RG Jr, Wartmann CH, Curry B, et al. Identification of greater occipital nerve landmarks for the treatment of occipital neuralgia. Folia Morphol (Warsz). 2006; 65:337–342. PMID: 17171613.

11. Güvençer M, Akyer P, Sayhan S, Tetik S. The importance of the greater occipital nerve in the occipital and the suboccipital region for nerve blockade and surgical approaches: an anatomic study on cadavers. Clin Neurol Neurosurg. 2011; 113:289–294. PMID: 21208741.

12. Ducic I, Moriarty M, Al-Attar A. Anatomical variations of the occipital nerves: implications for the treatment of chronic headaches. Plast Reconstr Surg. 2009; 123:859–863. PMID: 19319048.

13. Naja ZM, El-Rajab M, Al-Tannir MA, Ziade FM, Tawfik OM. Repetitive occipital nerve blockade for cervicogenic headache: expanded case report of 47 adults. Pain Pract. 2006; 6:278–284. PMID: 17129309.

14. Naja Z, Al-Tannir M, El-Rajab M, Ziade F, Baraka A. Nerve stimulator-guided occipital nerve blockade for postdural puncture headache. Pain Pract. 2009; 9:51–58. PMID: 19019052.

15. Eom KS, Kim TY. Greater occipital nerve block by using transcranial Doppler ultrasonography. Pain Physician. 2010; 13:395–396. PMID: 20648209.

16. Walker KJ, McGrattan K, Aas-Eng K, Smith AF. Ultrasound guidance for peripheral nerve blockade. Cochrane Database Syst Rev. 2009; CD006459. PMID: 19821368.

17. Greher M, Moriggl B, Curatolo M, Kirchmair L, Eichenberger U. 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; 104:637–642. PMID: 20299347.

18. Zipfel J, Kastler A, Tatu L, Behr J, Kechidi R, Kastler B. Ultrasound-guided intermediate site greater occipital nerve infiltration: a technical feasibility study. Pain Physician. 2016; 19:E1027–E1034. PMID: 27676673.

19. Binici O, Kuyrukluyıldız U, Şahin M, Alagöl A, Yılmaz İ. Ultrasound-guided bilateral greater occipital nerve block for mass excision. Turk J Anaesthesiol Reanim. 2015; 43:437–439. PMID: 27366544.

20. Shim JH, Ko SY, Bang MR, Jeon WJ, Cho SY, Yeom JH, et al. Ultrasound-guided greater occipital nerve block for patients with occipital headache and short term follow up. Korean J Anesthesiol. 2011; 61:50–54. PMID: 21860751.

21. Ashkenazi A, Levin M. Greater occipital nerve block for migraine and other headaches: is it useful? Curr Pain Headache Rep. 2007; 11:231–235. PMID: 17504651.

22. Selekler MH. Greater occipital nerve blockade: trigeminicervical system and clinical applications in primary headaches. Agri. 2008; 20:6–13.

23. Blumenfeld A, Ashkenazi A, Napchan U, Bender SD, Klein BC, Berliner R, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches: a narrative review. Headache. 2013; 53:437–446. PMID: 23406160.

24. Levin M. Nerve blocks in the treatment of headache. Neurotherapeutics. 2010; 7:197–203. PMID: 20430319.

25. Matute E, Bonilla S, Gironés A, Planas A. Bilateral greater occipital nerve block for post-dural puncture headache. Anaesthesia. 2008; 63:557–558. PMID: 18412667.

26. Uyar Türkyilmaz E, Camgöz Eryilmaz N, Aydin Güzey N, Moraloğlu Ö. Bilateral greater occipital nerve block for treatment of post-dural puncture headache after caesarean operations. Braz J Anesthesiol. 2016; 66:445–450. PMID: 27591456.

27. Niraj G, Kelkar A, Girotra V. Greater occipital nerve block for postdural puncture headache (PDPH): a prospective audit of a modified guideline for the management of PDPH and review of the literature. J Clin Anesth. 2014; 26:539–544. PMID: 25441250.

28. Akin Takmaz S, Unal Kantekin C, Kaymak C, Başar H. Treatment of post-dural puncture headache with bilateral greater occipital nerve block. Headache. 2010; 50:869–872. PMID: 20353435.

29. Naja ZM, El-Rajab M, Al-Tannir MA, Ziade FM, Tawfik OM. Occipital nerve blockade for cervicogenic headache: a double-blind randomized controlled clinical trial. Pain Pract. 2006; 6:89–95. PMID: 17309715.

30. Akyol F, Binici O, Kuyrukluyildiz U, Karabakan G. Ultrasound-guided bilateral greater occipital nerve block for the treatment of post-dural puncture headache. Pak J Med Sci. 2015; 31:111–115. PMID: 25878625.

31. Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater occipital nerve injection in primary headache syndromes--prolonged effects from a single injection. Pain. 2006; 122:126–129. PMID: 16527404.

32. Strauss L, Loder E, Rizzoli P. Transient facial nerve palsy after occipital nerve block: a case report. Headache. 2014; 54:1651–1655. PMID: 24913733.