1. 1
Ultrasound-guided pain blocks
Greater Occipital Nerve, Third Occipital
Nerve and Cervical Plexus
9th A l I t ti l S i f Ult d f9th Annual International Symposium of Ultrasound for
Regional Anaesthesia and Pain Medicine
ISURA, Toronto, Canada, June 22-25, 2012
Urs Eichenberger MD, PhD
Department of Anaesthesiology, Intensive Care and Pain
Medicine, St. Anna Clinic, Lucerne and University of Bern,
Switzerland
Greater occipital nerve (GON) block
1 = obliquus capitis
inferior muscle
1
1
Standard “blind”
approach of GON
block
New approach: more
centrally where it is
1 Obliquus capitis inferior muscle
2 Greater occipital nerve (GON)
usually not divided and
can be seen better by
ultrasound
Greher M et al., Br J Anaesth 2010
Our new approach:
more centrally where
1 Obliquus capitis inferior muscle
2 Greater occipital nerve (GON)
it is usually not
divided and can be
seen better by
ultrasound
Greher M et al., Br J Anaesth 2010
1
Nerve supply (TON) and
background C2/3 joint pain
> Pain after whiplash injury is
common and in up to 50% of cases
cervical facet joints are the reason
Lord et al, Spine 1996
> The only reliable diagnostic is the
diagnostic block of the nerves
innervating the joint (medial
branches)
Barnsley et al., Pain 1993
Siegenthaler et al., Anesth Analg 2010
> After two times positive diagnostic
block - there is an evidence based
and effective therapy: RF ablation
of the nerves
Lord et al., NEJM 1996
TON innervates the joint
C 2/3 and a small skin area
Diagnostic nerve block (TON) for
cervical zygapophysial joint pain C2/3
> Easy and fast by fluoroscopy
> 2 positive diagnostic blocks
— VAS reduction > 90%
— Duration lidocaine < bupivacainep
> Radiofrequency ablation gives
same result in about 70% of cases
up to 1 year
> Question: nerve (TON) visible by
ultrasound?

2. 2
Why ultrasound?
Are there any advantages?
> Visualisation of neighboured vulnerable
structures
=> Target: needle guidance without touching
these structures
> Spread of local anaesthetic visible
=> Correction of needle tip position if needed
> Reduction in radiation exposure
3rd occipital nerve (TON) block
Volunteer study, ultrasound guidance
> Our first study in Bern in the
field of ultrasound guided
pain therapy 2003.
> 10 volunteers on both sides.
Eichenberger et al., Anesthesiology 2006
> We could visualize the
nerve in all volunteers,
position the needle
(fluoroscopic control) and
block the nerve accurately
(skin test after saline and
LA injection)
Third occipital nerve (TON)
30
35
40
45
50
nts
Good
Visibility of TON in patients
Data of 50 pain patients admitted for cervical blocks
0
5
10
15
20
25
30
C2-3 C3 C4 C5 C6 C7
No.Patie
Good
Difficult
Impossible
Siegenthaler et al, RAPM 2011
D1 D2
C2/3
C3/4
TON
mbC3
*
*
bony target bony target
Relation TON to bony
target points
Siegenthaler et al, RAPM 2011
My practical approach for TON block
using ultrasound
> If nerve can be seen, 0.5 - 1 ml of LA to the nerve under
sight
> Longitudinal transducer position (to see the nerve)
> I prefer the short axis approach (superficial target)
> Needle from anterior to posterior> Needle from anterior to posterior
> If positive first block: second block using 0.5 ml of LA and
fluoroscopy as control
> Radiofrequency-ablation of the nerve: always fluoroscopy
as control, needle position under US (legal reasons)

3. 3
Potential of ultrasound for novel
radiofrequency neurotomy technique?
> Scan nerve and its
course in relation to
articulation
> RF probe under> RF probe under
ultrasound guidance
close to nerve
> Only one ore two lesions
> Same results?
> 15 patients
> Time needed for RF-
ablation: 35 min
> Pain reduction ≥ 80%:
— 13 patients after 6
months
6 ti t ft 12
Novel radiofrequency neurotomy technique
— 6 patients after12
months
> Median duration until
pain was 50% of initial
pain: 44 weeks
Results comparable with
traditional method but
procedure much faster Siegenthaler et al. Pain Med 2011
Anatomy plexus cervicalis: skin innervation Ultrasound images of cervical nerve roots
Ultrasound images of cervical nerve roots