Vol.:(0123456789) 1 3 Journal of Anesthesia https://doi.org/10.1007/s00540-017-2429-9 ORIGINAL ARTICLE Anatomical basis for simultaneous block of greater and third occipital nerves, with an ultrasound‑guided technique Ken Kariya 1  · Yosuke Usui 1,2  · Naoko Higashi 3  · Tatsuo Nakamoto 4  · Hironobu Shimbori 5  · Satoshi Terada 1,6  · Hideo Takahashi 1  · Hisashi Ueta 1  · Yusuke Kitazawa 1  · Yasushi Sawanobori 1  · Yasuhisa Okuda 6  · Kenjiro Matsuno 1 Received: 26 July 2017 / Accepted: 4 November 2017 © Japanese Society of Anesthesiologists 2017 Abstract Purpose In some headache disorders, for which the greater occipital nerve block is partly effective, the third occipital nerve is also suggested to be involved. We aimed to establish a simple technique for simultaneously blocking the greater and third occipital nerves. Methods We performed a detailed examination of dorsal neck anatomy in 33 formalin-fixed cadavers, and deduced two candidate target points for blocking both the greater and third occipital nerves. These target points were tested on three Thiel- fixed cadavers. We performed ultrasound-guided dye injections into these points, examined the results by dissection, and selected the most suitable injection point. Finally, this target point was tested in three healthy volunteers. We injected 4 ml of local anesthetic and 1 ml of radiopaque material at the selected point, guided with a standard ultrasound system. Then, the pattern of local anesthetic distribution was imaged with computed tomography. Results We deduced that the most suitable injection point was the medial head of the semispinalis capitis muscle at the C1 level of the cervical vertebra. Both nerves entered this muscle, in close proximity, with little individual variation. In healthy volunteers, an anesthetic injected was confined to the muscle and induced anesthesia in the skin areas innervated by both nerves. Conclusions The medial head of the semispinalis capitis muscle is a suitable landmark for blocking the greater and third occipital nerves simultaneously, by which occipital nerve involvement in various headache disorders may be rapidly exam- ined and treated. Keywords Spinal nerves · Nerve block · Ultrasonography Introduction In pain clinics, occipital nerve blocks are often performed to alleviate headache disorders. When criteria are applied based on the official classification of headache disorders, estab- lished by the International Headache Society (ICHD-3β) [1], headaches relevant to the greater occipital nerve (GON) and/ or the third occipital nerve (TON) can be identified to be cluster headache (ICHD-3β: 3.1) [2, 3], cervicogenic head- ache (ICHD-3β: 11.2.1) [4], occipital neuralgia (ICHD-3β: 13.4) [5–7], headache attributed to craniotomy (ICHD-3β: 5.5, 5.6) [8], tension-type headache associated with peri- cranial tenderness (ICHD-3β: 2.1.1, 2.2.1, 2.3.1) [3], or headache attributed to cervical myofascial pain (ICHD-3β: A11.2.5) [9, 10]. However, symptoms are often obscure without diagnostic nerve blocks. Ken Kariya and Yosuke Usui equally contributed to this work and have to be considered as first author. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00540-017-2429-9) contains supplementary material, which is available to authorized users. * Kenjiro Matsuno kenjiro@dokkyomed.ac.jp 1 Department of Anatomy (Macro), Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu, Tochigi 321-0293, Japan 2 Mizutani Pain Clinic, Shizuoka, Japan 3 Tochigi Medical Center, Tochigi, Japan 4 Department of Anesthesiology, Kansai Medical University, Osaka, Japan 5 Yokohama Pain Clinic, Yokohama, Japan 6 Department of Anesthesiology, Koshigaya Hospital, Dokkyo Medical University, Saitama, Japan