Posts tagged #nerve block

Hand Nerve Blocks

**Written by:** Aldo Gonzalez, MD (NUEM ‘23) **Edited by:** Jason Chodakowski, MD (NUEM '20)
**Expert Commentary by**: Mike Macias, MD

Hand Nerve Blocks

Nerve blocks are the use of anesthetics to anesthetize an area by injecting directly around the nerve that innervates a certain area. It is useful when there is a large area to provide anesthesia, the area might get distorted by local infiltration and make it difficult to close the tissue, or the distribution of the area to be anesthetized is well-suited to a nerve block.

Indications

Nerve blocks of the median, ulnar, radial, and digital nerves are useful for injuries of the hand including fractures, lacerations, and burns.

Contraindication

Overlying infection
Previous allergic reaction to anesthetic

Anesthetics

Landmark versus Ultrasound guidance

Ultrasound guidance is preferred given the ability to visualize the desired nerve and proper instillation of the anesthetic around the nerve. On ultrasound nerves are circular or triangular hyperechoic structures with hypoechoic structures within. Often described as having a “honeycomb” appearance as seen in the image of the median nerve below.

Materials

Ultrasound with Linear Transducer
Probe Cover
Sterile Ultrasound Gel
Anesthetic
10 cc syringe
18 gauge needle (to draw medication)
25-27 gauge needle at least 1.5 in in length
Antiseptic Solution (ex. Chlorhexidine)
Towel

Positioning

The patient can be either supine or seated with their arm slightly abducted and rested on a flat surface. Their elbow can be flexed with the wrist supinated and in slight extension. A rolled towel can be used for patient comfort and help in maintaining slight extension.

Figure 1: Nerves, arteries, and muscles of the human forearm

Radial Nerve Block

The superficial radial nerve travels between the flexor carpi radialis and the radial artery on anterior (volar) and lateral (radial) aspect of the forearm. Near the wrist the radial nerve splits into the medial and lateral branch of the superficial radial nerve. The block of this nerve should be performed at the mid-forearm to distal third of the forearm before the nerve splits. The nerve may be difficult to see at the distal forearm so instead it can be found proximally and followed distally. A lateral (radial) approach of the forearm provides the most direct route to the nerve.

Ulnar Nerve Block

At the distal forearm the ulnar nerve runs on the medial (ulnar) and anterior (volar) aspect of the forearm between the flexor carpi ulnaris tendon and the ulnar artery. The ulnar nerve lies in very close proximity to the ulnar artery in the distal forearm and increases the risk of accidental intravascular injection. It is safer to identify the ulnar nerve distally and the follow the artery and nerve proximally. Around the proximal third of the forearm the ulnar artery dives deeper and separates from the ulnar nerve. This provides a safer target. A medial (ulnar) approach of the forearm provides the most direct route to the nerve.

Median Nerve Block

At the mid to distal forearm the median nerve runs in the middle of the anterior (volar) aspect of the forearm between the flexor digitorum superficialis and flexor digitorum profundus muscles/tendons. Near the wrist the nerve can be difficult to appreciate due to all the tendons of the anterior compartment of the arm. The nerve can be best appreciated at the mid-forearm. A lateral (radial) or medial (ulnar) approach can be used for in-plane technique or a mid-line approach using out-of-plane technique. Be mindful to avoid accidentally puncturing the radial or ulnar artery If using an in-plane technique with a lateral or medial approach.

Figure 5: Demonstration of a median nerve block using a median (ulnar) approach with in-plane ultrasound technique on a patient’s right hand. Median nerve (yellow line) and ultrasound probe location (blue line).

Figure 6: Demonstration of a median nerve block using a lateral (radial) approach with in-plane ultrasound technique on a patient’s right hand. Median nerve (yellow line) and ultrasound probe location (blue line).

Steps for Ultrasound-Guided Nerve Block

Document a neurological exam prior starting the procedure
Select the nerve or nerves best suited to achieve best anesthesia for the injury
Use the linear transducer to visualize the nerve prior beginning the procedure
Plan an approach and select the best site
Draw up anesthetic in the 10 cc syringe with an 18 G needle
Replace 18 G needle with 25-27 G needle
Use antiseptic solution to prepare the skin
Dawn sterile gloves
Cover transducer in sterile cover
Use ultrasound to visualize the nerve and confirm approach
Insert the needle into the skin
Advance the needle using in-plane or out-of-plane technique
Come close to the nerve but do not puncture the nerve
Draw back to confirm not with-in a vessel
Deliver 5mL of anesthetic
The nerve will become enveloped in hypoechoic anesthetic and peel away from the fascia of nearby muscles
Withdraw the needle.
Wait 3-5 minutes until patient is fully anesthetized

References

Drake, R., Vogl, A. W., & Mitchell, A. W. (2015). Gray's Anatomy for Students (3rd ed.): Elsevier.
Farag, E., Mounir-Soliman, L., & Brown, D. L. (2017). Brown’s Atlas of Regional Anesthesia (5th ed.): Elsevier.
Gray, H. (2000). Gray's Anatomy of the Human Body. 20th edition. Retrieved from https://www.bartleby.com/107/
Harmon, D., Barrett, J., Loughnane, F., Finucane, B. T., & Shorten, G. (2010). Peripheral Nerve Blocks and Peri-Operative Pain Relief (2nd ed.): Elsevier.
Pester, J. M., & Varacallo, M. (2019). Ulnar Nerve Block Techniques. In StatPearls [Internet]: StatPearls Publishing.
Roberts, J. R., Custalow, C. B., & Thomsen, T. W. (2019). Roberts and Hedges' clinical procedures in emergency medicine and acute care (7th ed.): Elsevier.
Waldman, S. D. (2016). Atlas of Pain Management Injection Techniques E-Book (4th ed.): Elsevier.
Waldman, S. D. (2021). Atlas of Interventional Pain Management E-Book (5th ed.): Elsevier.

Expert Commentary

Thank you Drs. Gonzalez and Chodakowski for the excellent post on forearm nerve blocks! This is an important skill that definitely improves the care of our patients, especially since hand injuries are such a common emergency department presentation. This is especially true for injuries that are difficult to anesthetize using traditional local injection such as dog bites, burns, abscesses, large lacerations, and fractures of the hand. I’d like to dive a little deeper into a few aspects of forearm nerve blocks:

Ultrasound guidance

I think that the days of a landmark based approach to the majority of nerve blocks are gone with the widespread availability of ultrasound and its superiority with respect to block success and reduced complications. So if you have it, use it!

Which nerve to block?

Once you have made the commitment to block one forearm nerve, it doesn’t require much additional time or effort to block a second or even a third! Often, hand injuries will span several nerve distributions so make sure you are providing adequate anesthesia. Here is a quick way to think of it:

Major hand injury (ie burn, multiple hand fractures): Triple block
Injury to radial aspect of hand or digits 1-4: Radial + median nerve block
Injury to ulnar aspect of hand or 5th digit (ie Boxer’s fracture): Ulnar nerve block

It is important to remember that forearm nerve blocks do not provide anesthesia to the volar forearm or wrist and therefore will not be adequate for distal radius fracture reduction. In this case, an above the elbow Radial nerve block should be performed.

Which local anesthetic should I use?

It’s always important to consider what the goals of your local anesthetic are when determining which one to use. If you are performing a quick procedure, the shorter the better such as lidocaine. If you are providing prolonged pain management such as with a burn, bupivicaine is a better choice. I tend to prefer lidocaine + epinephrine (duration of acton 2-2.5 hours) for most of my hand injuries. Why? In a busy emergency department managing many patients at a time, the initial block and the procedure you plan on performing (ie lac repair, fracture reduction, etc) do not always happen simultaneously (ie patient may still need x-ray, irrigation, ring removal, etc). Using lidocaine + epinephrine will allow you to provide immediate pain relief for your patient but give you time to do other tasks before the patient is ready for the procedure

Positioning

As with any procedure, the set up is extremely important. You nicely described positioning earlier but I just want to highlight a couple additional points. Make sure your patient is comfortable and your ultrasound screen is in-line with your procedure. You don’t want to be turning your head away from your block to look at the screen. For the median and radial nerve block, the patient’s arm should be supinated and resting on a hard flat surface. Both nerves can then be approached using an in-plane technique from the radial aspect of the arm. The ulnar nerve can be cumbersome to get to with this same patient positioning so I recommend abducting the shoulder to about 90 degrees and placing the arm on a Mayo stand next to the patient. This will allow an in-plane approach from the ulnar aspect of the arm. I have also found this positioning technique helpful for the ulnar nerve block.

Procedural Tips

I wanted to end with a couple of important procedural pearls I have learned during my experience with performing these blocks:

Perform a pre-block exam! Always make sure to perform and document a full neurological exam of the hand before you block any nerve. This is important because you want to make sure you know if any sensory or motor changes are present before your perform the block otherwise if a neurological deficit is noted after, it makes it difficult to tell if the block caused the new symptom (you can always wait until the anesthetic wears off but it may be awhile if you used bupivicaine).

Follow the arteries! Sometimes it can be tricky to find the ulnar and radial nerves. The easiest method is to always start distally at the wrist. Both the radial and ulnar nerves run with their paired artery so if you start here and slide proximally, you should see the nerve split away from the artery around the mid forearm. Block them here!
Target the fascial plane! The key to an effective forearm nerve block is “bathing” the nerve in anesthetic. You will want to see spread of the anesthetic around the nerve in a crescent shape, full circumferential spread is not needed. Since these nerves run in the fascial plane the goal is to get your needle tip into this plane to deposit anesthetic. There is never a need to actually touch the nerve so avoid this by aiming for the fascia and not the nerve.
Protect the hand! After you perform a forearm nerve block be sure to communicate with nursing, consultants, and the patient regarding what block was performed and how long the effects will last. If a long acting agent was used such as bupivicaine, the hand should be splinted or arm placed in a sling and instructions provided to patient regarding care at home if they are being discharged.

Thank you again for providing this excellent piece on forearm nerve blocks. I cannot stress enough how essential I think these blocks are to the toolkit of the modern emergency physician. I promise you once you add these to your practice your patient’s will thank you!

Michael Macias, MD

Global Ultrasound Director, Emergent Medical Associates

Clinical Ultrasound Director, SoCal MEC Residency Programs

How To Cite This Post:

[Peer-Reviewed, Web Publication] Gonzalez, A. Chodakowski, J. (2021, Nov 29). Hand Nerve Blocks. [NUEM Blog. Expert Commentary by Macias, M]. Retrieved from http://www.nuemblog.com/blog/hand-nerve-blocks

Oral Nerve Blocks

Written by: Vytas Karalius, MD, MPH (PGY-2) Edited by: Andrew Cunningham, MD (NUEM ‘19) Expert commentary by: Jeffery Hill, MD, MEd — **Written by:** Vytas Karalius, MD, MPH (PGY-2) **Edited by:** Andrew Cunningham, MD (NUEM ‘19) **Expert commentary by**: Jeffery Hill, MD, MEd

Nerve Blocks of the Head & Neck Part III:

Oral Nerve Blocks

“I can’t feel my face when I’m with you…. but I love it.” – The Weeknd

About this series…

This article is part of a series of articles on the nerve blocks of the head and neck. For more information on other types of useful nerve blocks, please refer to the links below:

Nerve Blocks of the Head & Neck Part I: Facial Nerve Blocks

Nerve Blocks of the Head & Neck Part II: The Occipital Nerve Block

Oral Nerve Blocks

What are the advantages to oral nerve blocks?

Regional nerve blocks can be used in the ED for their ease, efficacy and efficiency in providing anesthesia for common procedures and complaints.

Facial nerve blocks are particularly useful and have several advantages:

Better anesthesia: Provides comparable, sometimes even better, anesthesia
Less needle pokes: Provides complete anesthesia without multiple needle pokes, making them great for the difficult patient, and results in a happier patient and safer procedure
Less pain medications: Decreases opiate and other oral analgesic use

The Set-Up

In addition to the materials you might need for the rest of the procedure, you will need the following items for the nerve block:

Anesthetic (see below)
5mL or 10mL syringe
Blunt fill or 18 gauge needle
25-27 gauge needle
Gauze
Long cotton tipped applicators and/or cotton pledgets
Personal protective equipment – gloves and eye protection are a must
Bite block if necessary
Appropriate, dedicated lighting such as an overhead lamp

Choices of Anesthetic

For oral nerve blocks, use bupivacaine with epinephrine when available. Oral/dental pain can be immensely painful and compromise a patient’s quality of life. The longer you can provide pain relief until they receive definitive care, the better off they will be.

Table 1: Commonly used local anesthetics. Courtesy of our NUEM Clinical Pharmacologist, Dr. Kelsea Caruso, PharmD.Table adapted from Pharmacology and Physiology for Anesthesia, Chapter 17, 291-308. — **Table 1:** Commonly used local anesthetics. *Courtesy of our NUEM Clinical Pharmacologist, Dr. Kelsea Caruso, PharmD.*
Table adapted from Pharmacology and Physiology for Anesthesia, Chapter 17, 291-308.

General Considerations to Reduce Pain Include:

Using buffered anesthetic
Avoiding cold/refrigerated anesthetic – allow time to warm up to room temperature
Decreasing the rate with which you infiltrate (you’re not pushing adenosine)

Special Considerations for pediatrics:

Depending on your resources, distraction with iPads, child-life specialists, etc. can help improve your success as well.
Hide the needle from view while preparing for the procedure.
Do not forget that the parent can also help with positioning and de-escalating the patient’s anxiety.

Special Considerations for Oral Blocks:

Topical lidocaine should be used prior to nerve block – this will greatly increase the patients’ comfort, their ability to remain still, and ultimately, your success.
Method 1: Ask them to swish viscous lidocaine around in their mouth for about 30 seconds, or as long as they can tolerate it.
Method 2: Soak and generously coat 1-2 cotton tipped applicators (Q-tips) or cotton pledgets with viscous or regular lidocaine and place them in the buccal mucosa at your intended target for 1-5 minutes.

The Anatomy

Figure 1: The area of distribution of areas innervated by different nerves of the maxilla and mandible. — **Figure 1:** The area of distribution of areas innervated by different nerves of the maxilla and mandible.

Superior Alveolar Nerve Blocks

Step 1: Apply topical anesthetic as discussed earlier to make entry with the needle more comfortable.

Step 2: Retract the lip. Insert your needle through the mucobuccal fold at the at the area locations depicted in Figure 2, Figure 3 and Figure 4.

Step 3: With the bevel facing the maxilla, inject 1-3mL of anesthetic.

Figure 2: For the posterior superior alveolar nerve, enter just posterior to the root of the second molar. [1] — **Figure 2:** For the posterior superior alveolar nerve, enter just posterior to the root of the second molar. [1]

Figure 3: For the middle superior alveolar nerve, enter between the first molar and second premolar. [1] — **Figure 3:** For the middle superior alveolar nerve, enter between the first molar and second premolar. [1]

Figure 4: For the anterior superior alveolar nerve, enter just above the canine tooth. [1] — **Figure 4:** For the anterior superior alveolar nerve, enter just above the canine tooth. [1]

Inferior Alveolar Nerve Block

Step 1: Apply topical anesthetic as discussed earlier to make entry with the needle more comfortable.

Step 2: Retract the lip/cheek and with the same hand, palpate the coronoid notch with your thumb.

Step 3: With your syringe, enter at an angle in which you are approaching from the contralateral incisor.

Step 4: Insert the needle about 1-2cm posterior to your thumb.

Step 5: Inject 1-3mL of local anesthetic.

Figure 5: The approach and anatomy of the alveolar nerve block. [1] — **Figure 5:** The approach and anatomy of the alveolar nerve block. [1]

Mental Nerve Block & Infraorbital Nerve Block

Mental nerve and infraorbital nerve blocks can also be used to supply anesthesia to the mouth and oral cavity.
- These can be found in Part I of our series of Nerve Blocks of the Head and Neck: [insert link].
The infraorbital block can be very useful in conjunction with a superior alveolar block for patients with extensive facial pain stemming from their dental complaints.
Please note: the mental nerve block does not supply anesthesia to the teeth – only the lips, skin and buccal tissue. For anesthesia to the bottom teeth, an inferior alveolar nerve block is recommended (Figure 1).

Expert Commentary

Thank you for this concise review of a necessary and practical skill for any Emergency Medicine provider. As you point out performing oral blocks not only can facilitate laceration repair/abscess drainage but they can also immediately relieve a patient’s pain from acute or chronic pulpitis or a developing peri-apical abscess.

Here are a couple of additional tips/points of reinforcement:

Patient positioning and lighting is key to identifying landmarks - When you are the recipient of these blocks in a dentist office you will note that they have you lying nearly completely and that they have exceptionally bright overhead lights. Trying to perform these blocks with the patient sitting upright is a literal pain in the back and not having a bright light sources means you are going mostly be feel. So, for all these patients, I recommend lying them back in the bed with the HOB at approximately 20 degrees. And, I recommend either a headlamp, swinging over an overhead light (if available), or bringing in a portable light source.

Superior Alveolar Nerve Blocks can be tough - I often find that those that are first learning dental blocks shy away from the superior alveolar nerve blocks. I, personally find them to be a bit more difficult than the inferior alveolar nerve blocks and, consequently, also find that my success rate is not as good as with inferior alveolar nerve blocks. However, when they do work, they are every bit as effective in helping your patient feel better in a dramatic way. And since you will always be better at the procedure you have done 50 times than the procedure you have done once or twice, I heartily encourage offering this to patient’s with upper dental pain. Over time I have found greater success with the procedure by ensuring that I am placing my needle and instilling my anesthetic about 1 mm above the junction of the buccal and gingival mucosa. If you try to instill into the gingival mucosa, it tends to be quite a painful injection and somewhat less effective as a block.

Talk it up, but Don’t Sell it as a Cure All - I offer dental blocks to nearly all of my patients that present with dental pain. I think it is a highly effective way to immediately take care of the patient’s pain. When you are talking to your patient’s about the procedure, let them now that they could have up to 8 hours of pain relief but that every patient is different in the way they metabolize the anesthetic and the blocks themselves will have variable effectiveness (how close did you get to the nerve, how much did you still, etc). I also let them know that there is a chance you might miss your mark and the block won’t be effective which would either necessitate a second attempt or an alternative approach to controlling their pain.

Jeffery Hill, MD, MEd

Assistant Professor of Emergency Medicine

Assistant Residency Program Director

University of Cincinnati Health

References

Ailes D, Waseem M. Regional Anesthesia (Nerve Blocks). In: Ganti L. (eds) Atlas of Emergency Medicine Procedures. Springer, New York, NY. 2016.

Cepeda MS, Tzortzopoulou A, Thackrey M, Hudcova J, Arora Gandhi P, Schumann R. Adjusting the pH of lidocaine for reducing pain on injection. Cochrane Database Syst Rev. 2010 Dec 8;(12).

Hollander JE, Camacho, M. Assessment and management of facial lacerations. Stack AM, Wolfson AB, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on March 20, 2019.)

Hsu DC. Clinical use of topical anesthetics in children. Stack AM, Wiley JF, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on March 20, 2019.)

Jeng CL, Rosenblatt MA. Overview of peripheral nerve blocks. Maniker R, Crowley M, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on March 20, 2019.)

Spangler RM, Abraham MK. Regional Anesthesia of the Head and Neck. In: Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. Elsevier Inc, Philedelphia, PA. 2019: Chapter 30, 545-559.

Suzuki S, Koköfer A, Gerner G. Local Anesthetics. In Hemmings HC & Egan TD, eds. Pharmacology and physiology for anesthesia: foundations and clinical application, 1st ed. Saunders, Philedelphia, PA. 2013: 291-308.

All images were obtained from:

[1] Spangler RM, Abraham MK. Regional Anesthesia of the Head and Neck. In: Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. Elsevier Inc, Philedelphia, PA. 2019: Chapter 30, 545-559.

How to Cite This Post

[Peer-Reviewed, Web Publication] Karalius V, Cunningham, A. (2020, Jan 20). Oral Nerve Blocks. [NUEM Blog. Expert Commentary by Friedman, B]. Retrieved from http://www.nuemblog.com/blog/oralnerveblock

Occipital Nerve Block

Written by: Andrew Rogers, MD (PGY-2) Edited by: Aaron Quarles, MD (NUEM ‘19) Expert commentary by: Ben Friedman, MD

Nerve Blocks of the Head & Neck Part II:

The Occipital Nerve Block

About this series…

This article is part of a series of articles on the nerve blocks of the head and neck. For more information on other types of useful nerve blocks, please refer to the links below:

Nerve Blocks of the Head & Neck Part I: Facial Nerve Blocks

Nerve Blocks of the Head & Neck Part III: Oral Nerve Blocks

Introduction/Overview

An occipital nerve block is a peripheral nerve block performed on the greater and lesser occipital nerves to help treat headache. Occipital nerve block (ONB) has been used in the treatment of cervicogenic headache, cluster headache, and occipital neuralgia, with demonstrated efficacy in improving pain and reducing headache frequency (1-3). By definition, occipital neuralgia will respond to ONB, and failure of symptoms to resolve should raise into question of the original diagnosis (2, 3).

Occipital nerve block may also be efficacious in the treatment of migraine. In a retrospective cohort study of 562 patients who received at least one greater occipital nerve block (GONB) for the treatment of migraine, 82% had >30% reduction in numeric pain scale from baseline with 58% having a >50% improvement (4). Recently, a small, randomized, sham-controlled trial of GONB performed in the Emergency Department for migraine refractory to metoclopramide therapy demonstrated greater short-term headache relief (5). GONB may be particularly useful in migraine patients with evidence of occipital nerve irritation or tenderness.

Indications

Occipital neuralgia
Cluster headache
Cervicogenic headache
Migraine, particularly with occipital nerve irritation or tenderness

Contraindications

Medication allergy
Infection overlying site of injection
Skull defect

Anatomy

Key anatomy points of review:

The occipital nerve originates from C2-C3 nerve roots
The GON perforates the fascia just underneath the superior nuchal ridge
The GON lies just medial to the occipital artery

Figure 1: Greater Occipital Nerve Anatomy (6) — **Figure 1:** Greater Occipital Nerve Anatomy (6)

What to Inject

Typically, a local anesthetic such as lidocaine (1-2%) or bupivacaine (0.5%) (or a combination of the two) is injected.. Lidocaine has a quicker onset, while bupivacaine has a longer lasting effect. Total volume injected is 2-4cc per nerve block.

A steroid such as such as betamethasone (2-4mg) or triamcinolone (10-20mg) may be added to the local anesthetic (3). For the Emergency Physician, one should consider how the addition of a steroid may complicate or impact a patient’s follow up with their primary neurologist or primary care physician. Additionally, one study failed to show a significant difference in headache relief for transformed migraines treated with or without triamcinolone in addition to local anesthetic (7).

The Procedure:

Identify the location of the GONB via one of 3 methods:
1. Palpate the occipital artery pulse about 2cm lateral to the occipital protuberance. The greater occipital nerve is just medial to the occipital artery

Alternatively

Palpate the occipital protuberance and the mastoid process (on side of interest). Measure 1/3 the distance between the two points starting from the occipital protuberance. Stay just superior to the superior nuchal line to remain over the cranium. (Figure 2)

Alternatively

Identify the point of maximal tenderness in the general region as defined above that may elicit paresthesia in the occipital nerve distribution when palpated

Clean the site of injection with an alcohol swab or similar cleaning solution.
Using a 23-25G needle, insert the needle at a 90-degree angle toward the occiput until a bony endpoint is obtained. Aspirate to avoid intravascular injection and to prevent injection into CSF. Inject 1cc at the GON, 1cc medial to the nerve, and 1cc lateral to the nerve.
The procedure can be performed bilaterally.

Figure 2: Representative schematic to aid in locating the greater occipital nerve, using method 1(b) as described above.

Key Points:

The greater occipital nerve block can used in the treatment of refractory migraine, cluster headache, occipital neuralgia, or cervicogenic headache
If palpation of the GON reproduces headache pain or irritation, it may be a good target for GONB
A GONB can be performed bilaterally if needed
Use local anesthetics such as lidocaine and/or bupivacaine
Aspirate while inserting the needle to avoid intravascular injection and to avoid being in CSF
Inject in a fanning technique just medial to the occipital artery pulse, one third of the distance from the occipital protuberance to the mastoid process, or at the site of maximal tenderness in the region

Expert Commentary

This well-written and informative review of the greater occipital nerve block (GONB) will help clinicians choose appropriate patients for this procedure and perform it with a high likelihood of success. In my experience, the GONB is easy to learn and easy to utilize clinically because it is a “forgiving” nerve block—patients often seen to respond even if the local anesthetic is not delivered precisely. As Dr. Rogers notes, using a “fan” technique maximizes the chances of success. While corticosteroids are efficacious for migraine, the most common type of headache seen in the ED, I prefer to deliver the corticosteroids separately from the GONB as either an intravenous or intramuscular injection. That way, I am not limited by volume and can administer more local anesthetic. And while a 23 or 25 gauge needle can certainly get the job done, my patients seem to appreciate it more when I use a 27 gauge needle. Finally, while not evidence-based, I think about using the GONB for any type of headache that is refractory to first or second line treatment—I’ve had success using it in a wide variety of atypical headaches (just don’t forget to rule out badness!)

Benjamin W. Friedman, M.D.

Professor

Department of Emergency Medicine

Montefiore Medical Center

How to Cite this Post

[Peer-Reviewed, Web Publication] Rogers A, Quarles A. (2020, Jan 13). Occipital Nerve Block. [NUEM Blog. Expert Commentary by Friedman, B]. Retrieved from http://www.nuemblog.com/blog/occipitalnerveblocl

References:

Sources

“Occipital Nerve Blocks: When and What to Inject?” Tobin, Joshua; Flitman, Stephen. Headache. 2009. Nov-Dec, 49 (10):1521-33
“Occipital Neuralgia.” Garza, Ivan. UpToDate. 25 August, 2017. Accessed 28 January 2019.
“Greater Occipital Nerve Block.” Ward, John. Seminars in Neurology. 2003; 23(1): 059-062. Accessed 28 January 2019.
“Greater Occipital Nerve Block for Acute Treatment of Migraine Headache: A Large Retrospective Cohort Study.” Allen et al. Journal of the American Board of Family Medicine. Vol 31, Issue 2. March/April 2018. P 211-218.
“A Randomized, Sham‐Controlled Trial of Bilateral Greater Occipital Nerve Blocks With Bupivacaine for Acute Migraine Patients Refractory to Standard Emergency Department Treatment With Metoclopramide.” Friedman, Benjamin, et. Al. Headache. October 2018. Vol58, Issue 9. Pp1427-1434.
“Greater Occipital Nerve.” Volker, Joseph. Earthslab.com. 8 August, 2018.
“Greater Occipital Nerve Block Using Local Anaesthetics Alone or with Triamcinolone for Transformed migraine: a radomised comparative study.” Ashkenazi A, et al. Journal of Neurology, Neurosurgery, and Psychiatry. 2008 April; 79(4):415-7

The Best Agent For Digital Nerve Blocks

Explore the evidence behind previously held beliefs regarding local anesthetic use in digital nerve blocks.