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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 MedicineISURA, Toronto, Canada, June 22-25, 2012

Urs Eichenberger MD, PhDDepartment of Anaesthesiology, Intensive Care and PainMedicine, St. Anna Clinic, Lucerne and University of Bern, Switzerland

Greater occipital nerve (GON) block

1 = obliquus capitis inferior muscle

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Standard “blind” approach of GON block

New approach: more centrally where it is

1 Obliquus capitis inferior muscle2 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 muscle2 Greater occipital nerve (GON)

it is usually not divided and can be seen better by ultrasound

Greher M et al., Br J Anaesth 2010

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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 1993Siegenthaler 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?

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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)

3035404550

nts

Good

Visibility of TON in patientsData of 50 pain patients admitted for cervical blocks

05

1015202530

C2-3 C3 C4 C5 C6 C7

No.

Pat

ie Good

Difficult

Impossible

Siegenthaler et al, RAPM 2011

D1 D2

C2/3C3/4TON

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)

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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 months6 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