Orgasmic headache responsive to greater occipital nerve blockade

We present a male with headache related to sexual activity. An injection of steroid and local anesthetic combination was applied to the greater occipital nerve of the symptomatic site. The orgasmic headache stopped after the procedure.     

The first 5 minutes after greater occipital nerve block

We performed greater occipital nerve blocks on 24 migraineurs with unilateral migraine and trigeminal nerve distribution allodynia. Using a visual analog scale for migraine pain, brush allodynia in the trigeminal nerve distribution and photophobia were reduced 64%, 75%, and 67%, respectively, after 5 minutes. Allodynia improved faster than headache. The results of this study suggest that greater occipital nerve blocks initiate an inhibitory process that shuts down several symptom generators.     

Low-frequency short-time nociceptive stimulation of the greater occipital nerve does not modulate the trigeminal system

Occipital stimulation in a small group of refractory chronic migraine and cluster headache patients has been suggested as a novel therapeutic approach with promising results. In an earlier study we have shown that a drug-induced block of the greater occipital nerve (GON) inhibits the nociceptive blink reflex (nBR). Now, we sought to examine the effects of low-frequency (3 Hz) short-time nociceptive stimulation of the GON on the trigeminal system. We recorded the nBR responses before and after stimulation in 34 healthy subjects. Selectivity of GON stimulation was confirmed by eliciting somatosensory evoked potentials of the GON upon stimulation. In contrast to an anaesthetic block of the occipital nerve, no significant changes of the R2-latencies and R2-response areas of the nBR can be elicited following GON stimulation. Various modes of electrical stimulation exist with differences in frequency, stimulus intensity, duration of stimulation and pulse width. One explanation for a missing modulatory effect in our study is the relatively short duration of the stimulation.     

The effects of greater occipital nerve block and trigger point injection on brush allodynia and pain in migraine

OBJECTIVE: To evaluate the effect of GONB, with or without trigger point injection (TPI), on dynamic mechanical (brush) allodynia (BA) and on head pain in migraine. Background.-Patients with migraine often have cutaneous allodynia that is related to sensitization of central pain neurons. Greater occipital nerve block (GONB) is an effective treatment for migraine headache; however, its effect on cutaneous allodynia in migraine is unknown. METHODS: We studied patients with migraine and BA who were treated with GONB with or without TPI. Demographic data, migraine history, and headache features were documented. Allodynia was evaluated using a structured questionnaire and by applying a 4 x 4-inch gauze pad to skin areas in the trigeminal and cervical dermatomes. Degree of allodynia (the allodynia score) was measured on a 100-mm visual analog scale (VAS) before treatment and 10 and 20 minutes thereafter. Headache levels were assessed using an 11-point verbal scale. Allodynia scores, as well as headache levels, before and after treatment were compared. RESULTS: Nineteen patients were studied. Mean age was 43.6+/-11.8 years. Twenty minutes after treatment, headache was reduced in 17 patients (89.5%) and did not change in 2 (10.5%). The average headache level was 6.53 before treatment and 3.47, 20 minutes after it. The average allodynia score decreased after 20 minutes in all patients. Average allodynia score per site was reduced by 18.69 mm and 13.74 mm in the trigeminal and cervical areas, respectively. There was a positive correlation between allodynia index, obtained through the questionnaire, and allodynia score, obtained by examination. CONCLUSION: GONB, with or without TPI, reduced both head pain and brush allodynia in this migraine patient group.     

Transient side shift of cluster headache attacks after unilateral greater occipital nerve injection

Attacks of cluster headache (CH) are usually side-locked in most, but not all, patients. In a few patients, the side may alternate between or, rarely, within cluster episodes. We observed seven cases in whom the side of CH attacks temporarily shifted immediately or shortly after unilateral injection of the greater occipital nerve (GON) with corticosteroids. In five patients with previously side-locked CH attacks and in two patients with previously side-alternating CH attacks, a side shift for several weeks occurred immediately (N = 6) or shortly (N = 1) after GON injection. We concluded that unilateral GON injections might cause a transient side shift of CH attacks through inhibition of the ipsilateral hypothalamic attack generator causing relative overactivity of the contralateral side. The potential benefit of bilateral GON injection in patients who experienced a side shift after unilateral injection should be formally investigated.     

枕大神经卡压综合征的解剖学研究

目的 为枕大神经卡压综合征的诊断、治疗提供解剖学依据.方法 用放大10倍的解剖显微镜在30具成人尸体(60侧)上观察枕大神经的行径、分段、分布、易卡压的部位及与枕血管的毗邻关系.用游标卡尺测量枕大神经易卡压部位与枕外隆凸、乳突尖、上项线等相关结构的距离,并标出易卡压部位的体表投影.结果 皮下段与浅筋膜连接紧密,较易形成卡压,枕大神经最易卡压部位在其浅出部位,且有枕血管伴行.此部位枕大神经在枕动脉的内侧、枕外隆凸外(27.60±5.20)mm、上项线下方(18.46±5.12)mm处,其体表投影为枕外隆凸与乳突尖连线的中上1/3交点部位.结论 闭合性手术治疗枕大神经综合征的最佳进针(刀)部位在枕外隆凸与乳突尖连线的中上1/3交点下方的稍内侧;术中不但要分离、松解枕大神经主干的卡压,同时也要分离、松解其皮下分支的卡压.     

Reduction of calcitonin gene-related peptide in jugular blood following electrical stimulation of rat greater occipital nerve

Although it is known that pain in the forehead may be induced by neck abnormalities, the actual neck-head connections responsible for development of pain in trigeminal areas are poorly understood. Vasoactive neuropeptides released from sensory fibres, such as substance P (SP) and calcitonin gene-related peptide (CGRP), have been considered as important elements in headache pathophysiology. The levels of CGRP-like immunoreactivity (LI) were measured bilaterally in the jugular blood (52 rats) and intraocular aspirates (66 rats) following electrical stimulation of the left greater occipital nerve, and in the jugular blood of 13 control animals. One-third of the stimulated rats had varying combinations of conjunctival injection, tearing, diminished eye aperture and miosis or mydriasis on the stimulated side. The other two-thirds exhibited no ocular signs. Significantly lower levels of CGRP-LI were present in the jugular blood on the stimulated side in comparison with control rats. There was comparatively lower CGRP-LI on the non-stimulated side as well, but to a lesser extent. Significant differences between the stimulated and the non-stimulated side were present, particularly in the tearing/diminished eye cleft group. It is proposed that stimulation of the rat GON inhibits the trigeminal system (reduction of CGRP-LI) and possibly activates parasympathetic fibres (ocular changes).     

Subcutaneous lipoma compressing the common peroneal nerve and causing palsy: Sonographic diagnosis

The compression of peripheral nerves by benign fatty tumors has rarely been reported in the literature. We present the case of a patient who had a subcutaneous lipoma in the region of the knee that caused common peroneal nerve palsy and appeared to compress the nerve on sonography. The surgical removal of subcutaneous lipoma allowed complete recovery. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound 2010     

肩胛舌骨肌及其伴行神经超声表现

目的 观察肩胛舌骨肌(OM)及其伴行神经超声表现。方法 前瞻性纳入60名健康成年人共120侧肩颈部,以超声扫查双侧OM及其伴行周围神经,观察其超声表现。结果 超声声像图显示OM中间腱多位于胸锁乳突肌(SCM)中、后区深处,83侧显著型表现为强回声带,37侧非显著型表现为低回声细带,周围均见强回声腱膜。OM周围存在较多呈低回声的神经,包括颈袢、迷走神经、膈神经、臂丛、胸长神经(LTN)及肩胛上神经(SSN)。颈袢神经表现为颈总动脉及颈内静脉表面的细条状低回声带,其中71侧位于OM上腹的外下方或深处,23侧位于SCM与颈内静脉之间,26侧超声未能识别。多数(102/120,85.00%) OM下腹深处可见SSN及LTN,SSN表现为条状低回声带,OM下腹与SSN平行走行并穿过肩胛上切迹。结论 OM中间腱超声形态多为显著型,其伴行神经包括位于OM深处的颈袢、迷走神经、膈神经、臂丛、SSN及LTN,超声表现各异。     

Sonography of Common Peripheral Nerve Disorders With Clinical Correlation

Sonography is now considered an effective method to evaluate peripheral nerves. Low cost, high resolution, the ability to image an entire limb in a short time, and dynamic assessment are several of the positive attributes of sonography. This article will review the normal appearance of peripheral nerves as shown with sonography. In addition, the most common applications for sonography of the peripheral nerves will be reviewed, which include entrapment neuropathies, intraneural ganglion cyst, nerve trauma, and peripheral nerve sheath tumors. Clinical information related to nerve disorders is also included, as it provides valuable information that can be obtained during sonographic examinations, increasing diagnostic accuracy.     

Ultrasonography of the Sural Nerve: Normal and Pathologic Appearances

Ultrasonography (US) of peripheral nerves has gained wide popularity because of the increased definition of modern high‐frequency electronic transducers, as well as the well‐known advantages of US, which include easy availability, low cost, and the possibility of realizing a dynamic examination. Traditionally, US has been deployed to assess the major nerves of the limbs. More recently, US has also been used to assess the normal appearance and pathologic changes of smaller subcutaneous nerves. The sural nerve is a small sensory nerve in the subcutaneous tissues of the calf that can be affected by a variety of disorders. This pictorial essay illustrates the normal anatomy of the sural nerve, the technique for its examination by US, as well as the US appearance of its main pathologic changes.     

Sonography of the normal ulnar nerve at Guyon's canal and of the common peroneal nerve dorsal to the fibular head

PURPOSE: This study was conducted to evaluate the ability of sonography to visualize the ulnar nerve at Guyon's canal and the common peroneal nerve dorsal to the fibular head and to test for correlations between nerve measurements and subject characteristics. METHODS: We used a 5-12-MHz linear-array transducer in sonographic evaluation of 15 healthy adult volunteers. We evaluated the correlations between nerve diameters and surface areas and subject body mass index and height. We also tested for differences between nerve measurements in women and men and between nerve measurements from the left and right sides of the body. RESULTS: Both nerves were visualized in all subjects. Subject height correlated significantly with the anteroposterior diameter of the right ulnar nerve. Body mass index correlated significantly with the surface area of both ulnar nerves, with the anteroposterior diameter of both ulnar nerves, with the transverse diameter of the left ulnar nerve, and with the transverse diameter of the right common peroneal nerve. There was a statistically significant difference in anteroposterior diameter of the left ulnar and left common peroneal nerves between women and men. There were no significant differences between left- and right-side measurements for the combined data from the entire group of subjects. CONCLUSIONS: A 5-12-MHz linear-array transducer readily allows for visualization of the ulnar nerve at Guyon's canal and the common peroneal nerve dorsal to the fibular head.     

Referred pain after painful stimulation of the greater occipital nerve in humans: evidence of convergence of cervical afferences on trigeminal nuclei

Cranial sensory innervation is supplied mainly by the trigeminal nerves and by the first cervical nerves. Excitatory and inhibitory interactions among those nerve roots may occur in a mechanism called nociceptive convergence, leading to loss of somato-sensory spatial specificity. Three volunteers in an experimental trial had sterile water injected over their greater occipital nerve on one side of the neck. Pain intensity was evaluated 10, 30 and 120 s after the injection. Two of the patients reported intense pain. Trigeminal autonomic features, suggestive of parasympathetic activation, were seen associated with trigeminally distributed pain. These data add to and reinforce previous evidence of convergence of cervical afferents on the trigeminal sensory circuit.     

Sonography of the Pronator Teres: Normal and Pathologic Appearances

The pronator teres muscle is rarely examined during a routine sonographic examination of the elbow joint. Nevertheless, it can be affected by a variety of conditions, including trauma and tumors, and can be implicated in compression of the median nerve. This pictorial essay first illustrates the anatomy and biomechanics of the pronator teres. Then we present the sonographic technique for examination, normal sonographic appearance, and anatomic variations of the pronator teres and adjacent structures as well as sonography of their main disorders. Normal and pathologic sonographic appearances are correlated with magnetic resonance imaging and radiographic results.     

Sonographic diagnosis of anatomical variations associated with carpal tunnel syndrome

Bifid median nerve is an anatomic variation that occurs in about 18% of patients with symptoms suggestive of carpal tunnel syndrome and in about 15% of symptom‐free subjects. Reversed palmaris longus is a rare anatomic muscular variation. The simultaneous presence of a bifid median nerve and a reversed palmaris longus has been very rarely described, usually during surgical exploration or in cadavers. We present two cases where ultrasound showed the presence of both abnormalities, allowing a correct diagnosis and influencing the treatment plan. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound 42 :371–374, 2014