Peripheral Nerve Blocks: A Color Atlas, 3rd Edition

65. Occipital Blocks

A. C2 Selective Nerve Block

Nashaat N. Rizk

Patient Position: Supine.

Indications: Postherpetic neuralgia and headaches secondary to greater occipital neuralgia.

Needle Size: 25-gauge, 88-mm Quincke needle.

Medication/Volume: 1 to 2 mL of 0.5% bupivacaine plus 40 mg of Depo-Medrol (Pharmacia Canada, Inc., Hamilton, Ontario, Canada).

Anatomic Landmarks: The posterior arch of C1 and C2 vertebrae.

Approach and Technique: The cervical region is prepared and draped using sterile techniques. Using fluoroscopy, the lateral view identifies the posterior arch of C1 vertebra (the atlas) and a dome shape between C1 and C2 dorsally. The needle is placed parallel to the x-ray beam and advanced slowly. After the position of the needle is confirmed by a lateral view, 1 to 2 mL of water-soluble contrast media such as Isovue-200 (Bracco Diagnostics, Princeton, NJ) is injected. This injection should not be associated with any intravascular runoff or epidural or subarachnoid propagation. The local anesthetic mixture is slowly injected. An anteroposterior view (Fig. 65-1) is taken and the needle is advanced to the midfacet line between the C1 and C2 vertebrae. Figure 65-2 presents an oblique view.


Figure 65-1. C2 selective nerve block; anteroposterior view.

Figure 65-2. An oblique view.


1.   A working intravenous line and standard monitoring is essential.

2.   Appropriate resuscitation equipment is essential.

3.   Continuous monitoring equipment is essential to all procedures.

4.   Do not allow patients to walk back to their rooms. They should be transported on a stretcher and monitored for 45 to 60 minutes afterward.

B. Greater and Lesser Occipital Nerve Block

Nashaat N. Rizk

Cheryl D. Bernstein

Patient Position: Sitting, with neck flexed slightly forward.

Indications: Diagnostic or therapeutic block for the diagnosis and treatment of occipital headache, occipital neuralgia, pain in the distribution of the greater and lesser occipital nerves, and postherpetic neuralgia.

Needle Size: 25-gauge, 38-mm needle bent 60° to 90° at the hub.

Medication/Volume: 2 to 3 mL of 0.5% bupivacaine for each block, with or without 20 to 40 mg of a long-acting steroid.

Anatomic Landmarks: (Fig. 65-3A). The lesser occipital nerve arises from the ventral rami of the third cervical nerve and innervates the lateral portion of the posterior scalp and pinna of the ear. The nerve is blocked in the region of the mastoid process (Fig. 65-3B). The greater occipital nerve arises from the dorsal rami of the second cervical nerve and supplies the posterior medial aspect of the scalp to the vertex of the head. The nerve is blocked at the level of the superior nuchal ridge (Fig. 65-3C).

Figure 65-3. Anatomic landmarks for greater and lesser occipital nerve block.

Approach and Technique: After sterile preparation of the region, the needle is introduced perpendicular to the periosteum and advanced superiorly after making contact with bone. After negative aspiration, the local anesthetic mixture is injected in a fan distribution while withdrawing the needle.

Complications: Bleeding, infection, and subarachnoid injection through the foramen magnum.

Suggested Readings

Murphy TM. Somatic blockade of head and neck. In: Cousins MJ, Bridenbaugh PO, eds. Neural blockade in clinical anesthesia and management of pain, 3rd ed. Philadelphia: Lippincott-Raven, 1998.

Romanoff M. Somatic nerve blocks of the head and neck. In: Raj PP, ed. Practical management of pain, 3rd ed. Philadelphia: Mosby, 2000.

Waldman SD. Greater and lesser occipital nerve block. Atlas of interventional pain management. Philadelphia: WB Saunders Co, 1998.