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.     

Convergence of afferents from superior sagittal sinus and tooth pulp on cells in the thalamus of the cat

We have previously shown convergence of craniovascular and tooth pulp afferents in the cervical spinal cord of cats. This study looked for similar convergence in the thalamus. Fifty-four thalamic cells with input from tooth pulp, superior sagittal sinus, or both, were identified. Twenty-nine cells with tooth pulp and superior sagittal sinus input were located in the ventrobasal complex or the intralaminar nuclei. Most of these 29 cells were also excited by cooling the contralateral tooth pulp, and 21 had receptive fields on the contralateral face or forelimb. Twenty cells excited by stimulation of superior sagittal sinus, and not tooth pulp, were found in several nuclei. The 5 cells excited by stimulation of tooth pulp, but not sagittal sinus, were restricted to the ventrobasal complex. The data confirm convergence from sagittal sinus, tooth pulp, and skin in the thalamus of anaesthetized cats.     

刺激大鼠上矢状窦区硬脑膜对中脑导水管周围灰质c-fos蛋白表达的影响

目的 :采用电刺激刺激大鼠上矢状窦区 (superiorsagittalsinus ,SSS)硬脑膜 ,观察中脑导水管周围灰质 (PAG)c fos蛋白的表达 ,以探讨PAG在血管源性头痛 (如偏头痛 )涉及的伤害觉信息的传递中的作用。方法 :以雄性SD大鼠为实验对象 ,在手术暴露其上矢状窦后电刺激SSS区硬脑膜 ,应用免疫组织化学染色技术 ,观察中脑导水管周围灰质c fos蛋白 (Fos)表达的变化。结果 :Fos免疫反应阳性神经元主要位于中脑导水管周围灰质的腹外侧区 ,阳性细胞数头侧至尾侧逐渐增多。空白对照组、假手术对照组、刺激组每张切片的Fos阳性神经元数分别为 7.2± 4 .2、13.6± 4 .3、76 .0± 12 .3。结论 :PAG可能参与血管源性头痛 (如偏头痛 )的痛觉中枢调控。     

Response to occipital nerve block is not useful in predicting efficacy of occipital nerve stimulation

Occipital nerve stimulation (ONS) may be effective for the treatment of headaches that are recalcitrant to medical therapy. The objective of this study was to determine if response to occipital nerve block (ONB) predicts response to ONS in patients with chronic, medically intractable headaches. We evaluated 15 patients who underwent placement of occipital nerve stimulators for the treatment of chronic headaches. Data were collected regarding analgesic response to ONB and to ONS. Nine of 15 patients were ONS responders (> or =50% reduction in headache frequency or severity). Thirteen patients had ONB prior to stimulator implantation. Ten of 13 who had ONB had significant relief of head pain lasting at least 24 h, and three were ONB non-responders. Of the three ONB non-responders, two were ONS responders. Of the two patients who did not have ONB prior to ONS, one was an ONS responder and one was an ONS non-responder. In conclusion, analgesic response to ONB may not be predictive of the therapeutic effect from ONS in patients with medically refractory chronic headaches.     

Activation of the trigeminovascular system by mechanical distension of the superior sagittal sinus in the cat

Distension of dural sinuses in man produces migraine-like pain. In eight alpha-chloralose anaesthetized cats mechanical distension of the superior sagittal sinus with a small intraluminal device was used to activate single units in the dorsolateral C2 spinal cord. Units in this region have been shown to respond to electrical stimulation of the superior sagittal sinus in the cat model. Linked responses to mechanical dilatation could only be obtained with very rapid stretching stimuli or high amplitudes of distension of the vessel. Lower thresholds for transduction of distension in the vessel wall may depend on transferral to the dura or biochemical or neural pre-sensitization of the superior sagittal sinus. These data are consistent with the view that migraine is not primarily a vascular disorder but requires at least humoral or neural facilitation.     

Immunoreactivity of NOS, CGRP, PACAP, SP and VIP in the trigeminal nucleus caudalis and in the cervical spinal cord C1 and C2 of the cat

Abstract The aim of the present study was to map the presence of neurotransmitters and nitric oxid synthase (NOS) in the trigeminal nucleus caudalis and cervical spinal cord of cat. Immunocytochemistry was used to map the presence of neuronal NOS, calcitonin gene-related peptide (CGRP), pituitary adenylate cyclase activating peptide (PACAP), substance P (SP) and vasoactive intestinal peptide (VIP). The superior sagittal sinus (SSS) was stimulated electrically for 2h (0.3 Hz, 0.25 ms duration, 120 V) to examine if this would lead to depletion of the neurotransmitters. Numerous SP- and CGRP-positive nerve fibers (but no cells) were found in the trigeminal nucleus caudalis (TNC) and in Rexed lamina I and II° of the dorsal horn at C1/C2 level of the spinal cord. Moderate amounts of PACAP- and NOS-positive nerve fibers were also seen in these areas while there were only few VIP-positive fibers. There was no observable difference in the amount of immunoreactivity of NOS or the neuropeptides between stimulated and control cats. The stimulation resulted in marked c-fos immunoreactivity in the same regions of the TNC. The bipolar trigeminal neurons project to the TNC and C1/C2 areas with fibers containing neuropeptides and NOS. Stimulation of the SSS for 2 h was not sufficient to cause noticeable depletion.     

颈部脊髓损伤对患者双下肢神经传导功能的影响

目的:观察颈部脊髓损伤(SCI)后双下肢周围神经传导功能的变化,并比较完全性颈部SCI和不完全性颈部SCI之间的差异。方法:分别检测20例完全性颈部SCI患者、20例不完全性颈部SCI患者以及20例正常成年男性的胫神经、腓总神经、腓肠神经、隐神经的神经传导潜伏期、波幅和传导速度。结果:(1)运动神经:完全性损伤组和不完全性损伤组的末端运动神经潜伏期(DML)延长、运动神经传导速度(MCV)降低,与正常组比较有显著性差异(P0.05),但其异常率都低于10%;完全性损伤组和不完全性损伤组的复合肌肉动作电位(CAMP)降低,与正常组比较有显著性差异(P0.05),其异常率都高于20%,且完全性损伤组CAMP异常率高于不完全性损伤组(P0.05)。(2)感觉神经:完全性损伤组和不完全性损伤组的感觉神经动作电位(SNAP)波幅降低、感觉神经传导速度(SNCV)降低,与正常组比较有显著性差异(P0.05),但其异常率为0。结论:颈部SCI患者双下肢运动神经存在轴索变性,完全性损伤比不完全性损伤更重,感觉神经无明显异常。     

Stenting for acute cerebral venous sinus thrombosis in the superior sagittal sinus

Endovascular treatment for superior sagittal sinus (SSS) thrombosis is not always successful because of difficult access and long thrombus lesions. We report the first two cases of patients with acute cerebral venous sinus thrombosis at the SSS that was not recanalized by anticoagulation, mechanical thrombectomy, or thrombolysis, but was successfully treated by stent placement. Case 1 was a 37-year-old woman with bilateral subdural hematomas. Digital subtraction angiography showed obstruction of the sinus from the SSS to the right transverse sinus. Recanalization was achieved by selective thrombolysis using urokinase followed by balloon angioplasty, but re-occlusion occurred on the next day of treatment. Repeated endovascular treatment including balloon angioplasty, thrombus aspiration and thrombolysis using recombinant tissue plasminogen activator failed to achieve recanalization. We thus placed intracranial stents in the SSS, which did achieve recanalization. Case 2 was a 69-year-old woman with a small infarction in the left parietal lobe. Digital subtraction angiography showed sinus obliteration from the SSS to the bilateral transverse sinuses. Recanalization was not achieved by balloon angioplasty, thrombus aspiration and selective thrombolysis. We thus placed intracranial stents in the SSS, which did achieve recanalization. Postoperative course was uneventful in both cases and venous sinus patency was confirmed by venography >1.5 years after treatment. When conventional endovascular strategies have been unsuccessful, placement of intracranial stents, which can easily gain access to the distal part of the SSS as compared with carotid stents, may be a useful treatment option for the acute sinus thrombosis in this region.     

Occipital nerve stimulation for headache: mechanisms and efficacy

Headache disorders are common problems in medicine and it is this commonness that often provides an air of the simple or obvious. Patients expect doctors understand headache; indeed doctors expect they may understand headache, and in turn since simple treatments exist and can be purchased from a supermarket, the very concept of the difficult headache problem has a pejorative connotation. A decade ago none of the authors were using device-based therapies to any substantial extent, and now hardly a week goes by when we will not see a patient who has considerable potential to benefit from such approaches. Here we cover the most promising of the device-based approaches, neurostimulation therapy using occipital nerve stimulation. Far from proven and with much work to be done, this is an exciting potential development for patients and doctors. Other device-based therapies, such as deep brain stimulation for cluster headache and patent foramen ovale closure, are covered elsewhere.     

Greater occipital nerve blockade in migraine, tension-type headache and cervicogenic headache

The blockade of the greater occipital nerve (GON) has been used in the treatment of migraine without aura (MWOA), tension-type headache (TTH) and cervicogenic headache (CH). There have been only a few reports about the effectiveness of the GON blockade in patients with MWOA and TTH and it has not yet been clarified whether or not it is a diagnostic tool for CH. In this study, we therefore investigated the diagnostic value of GON blockade in patients with CH, MWOA and TTH. Sixty patients who were affected by TTH, MWOA and CH participated in the study. They were divided into three main groups, each of which consisted of 20 patients with TTH, MWOA and CH respectively. Each group was then divided into two sub-groups with 10 patients, ten of whom were injected with 1 ml 2% prilocaine, and the other ten with 1 ml physiological saline (PS). Our results showed that GON blockade reduced pain in the orbitofrontal (OF) and orbitonuchal (ON) areas in patients with CH. In MWOA and TTH patients, GON blockade reduced pain only in the ON area. In the light of these findings, we may conclude that GON blockade is a diagnostic tool if it is effective in the ON and OF areas. Received: 31 January 2002, Accepted in revised form: 2 July 2002 Correspondence to B. Karakurum     

颈脊髓损伤患者的呼吸道管理

探讨颈脊髓损伤患者呼吸道管理的方法,为提高临床疗效提供有效的保证。对我科2008年6月至2010年10月收治的38例颈脊髓损伤患者的呼吸道管理进行回顾性分析。38例颈脊髓损伤患者进行呼吸道管理后,呼吸功能完全恢复35例,3例发生急性呼吸衰竭死亡。颈脊髓损伤患者的呼吸道管理是颈椎骨折手术成功的关键性因素,合理可靠的呼吸道管理,为患者术后顺利恢复提供了有效的保障。     

Treatment of chronic cluster headache with burst and tonic occipital nerve stimulation: A case series

Objectives and Background

Chronic cluster headache (CCH) is a rare but severely debilitating primary headache condition. A growing amount of evidence suggests that occipital nerve stimulation (ONS) can offer effective treatment in patients with severe CCH for whom conventional medical therapy does not have a sufficient effect. The paresthesia evoked by conventional (tonic) stimulation can be bothersome and may thus limit therapy. Burst ONS produces paresthesia-free stimulation, but the amount of evidence on the efficacy of burst ONS as a treatment for intractable CCH is scarce.

Methods

In this case series, we report 15 patients with CCH treated with ONS at Aarhus University Hospital, Denmark, from 2013 to 2020. Nine of these received burst stimulation either as primary treatment or as a supplement to tonic stimulation. The results were assessed in terms of the frequency of headache attacks per week and their intensity on the Numeric Rating Scale, as well as the Patient Global Impression of Change (PGIC) with ONS treatment.

Results

At a median (range) follow-up of 38 (16–96) months, 12 of the 15 patients (80%) reported a reduction in attack frequency of ≥50% (a reduction from a median of 35 to 1 attack/week, p < 0.001). Seven of these patients were treated with burst ONS. A significant reduction was also seen in maximum pain intensity. Overall, 10 patients stated a clinically important improvement in their headache condition following ONS treatment, rated on the PGIC scale. A total of 16 adverse events (nine of which were in the same patient) were registered.

Conclusion

Occipital nerve stimulation significantly reduced the number of weekly headache attacks and their intensity. Burst ONS seems to function well alone or as a supplement to conventional tonic ONS as a preventive treatment for CCH; however, larger prospective studies are needed to determine whether the effect can be confirmed and whether the efficacy of the two stimulation paradigms is even.     

正常人颈髓扩散张量成像的定量分析

目的 定量分析健康人扩散张量成像(DTI)的部分参数值.方法 使用SE-EPI序列对22名健康志愿者行DTI扫描.在矢状位上分别测量不同节段颈髓各项参数值(ADC、FA、RA)以及本征值(λ1、λ2、λ3);在横轴位同一颈髓节段(C3水平)不同部位分别测量各项参数值.结果 矢状位测得颈髓C3水平FA值及RA值较其余部位高(P<0.05);横轴位测得颈髓前索FA及RA值较其余部位低而其ADC值较其余部位高(P<0.05).结论 使用SE-EPI序列行颈髓扩散张量成像的检查能够获得比较满意的图像;DTI可以定量测量颈髓的各项参数值.     

颈椎椎弓根螺钉内固定治疗无骨折脱位型颈脊髓损伤

目的探讨颈椎椎弓根螺钉内固定治疗无骨折脱位型颈脊髓损伤的临床疗效。方法将2011年1月至2013年5月于治疗的76例无骨折脱位型颈脊髓损伤患者按照治疗方法分为两组,治疗组38例,采用颈椎椎弓根螺钉内固定治疗;对组组38例,应用大剂量的甲强龙激素治疗。治疗后比较两组疗效、JOA神经功能评分以及并发症。结果治疗后,治疗组的总有效率为97.37%,高于对照组的81.58%,差异具有显著性(P0.05);治疗组于治疗3个月后、治疗6个月后以及治疗12个月后的JOA神经功能评分均明显高于对照组,差异均具有显著性(P0.01);治疗组的并发症发生率也明显低于对照组,差异具有显著性(P0.05)。结论颈椎椎弓根螺钉内固定治疗无骨折脱位型颈脊髓损伤的临床疗效显著,值得临床推广应用。     

下颈椎骨折脱位伴颈髓损伤患者的预见性护理

目的 探讨下颈椎骨折伴颈髓损伤患者的预见性护理要点.方法 在11例下颈椎骨折脱位伴颈髓损伤患者预见性护理中,加强病人及家属的心理护理术前做好相关准备同时加强并发症的预防,术后密切监测生命体征及病情变化,做好基础护理同时重视并发症的预防,加强康复训练.结果 通过各项预见性护理,11例下颈椎骨折脱位伴颈髓损伤患者中,有1例术后发生颈部血肿及时清除恢复顺利,1例肺部感染经综合治疗痊愈,1例低钠血症积极治疗后恢复正常.余无其他并发症发生.结论 良好有效的预见性护理能提高病人及家属的依从性及满意度,降低并发症及残障率,提高治愈率,促进病人康复.     

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.     

大鼠腰、颈段脊髓神经元间联系的c-fos基因研究

目的：应用c-fos基因研究腰段和颈段脊髓神经元之间的联系。方法：成年雄性SD大鼠20只，钳夹左侧坐骨经神，灌注取材后行c-fos免疫组化染色。结果：在腰段L4-6脊髓中，钳夹诱发的c-fos基因表达均在钳夹同侧脊髓灰质内，脊髓灰质前角神经元和后角神经元中的c-fos基因表达明显增多，对照侧右侧脊髓中的神经元c-fos基因未见明显表达。在颈段C5-8脊髓中．双侧脊髓灰质前角中可见c-fos基因表达明显增多．双侧脊髓灰质后角中未见明显c-fos基因表达。结论：颈段脊髓和腰段脊髓神经元之间存在着神经纤维联系。     

Cervical spinal cord neurons receiving sensory input from the cranial vasculature

The superior sagittal sinus, middle meningeal artery or superficial temporal artery was stimulated electrically in anaesthetized cats. Field potential recordings were used to locate areas of maximum responses in the upper cervical cord, which were then further examined for responsive single units. Short latency units responded to stimulation of the superior sagittal sinus with a mean latency of 11.9 ms. Some units also responded at longer latencies in the 200-250 ms range. Spontaneous discharge rates of some units in a dorsolateral area of the cervical cord were accelerated by iontophoretic application of glutamic or homocysteic acid to these same units. Evoked action potentials were commonly multiphasic. Dorsolateral area units commonly received convergent input from two vessels and often had receptive fields on the face and limbs. Spontaneously active cells which respond to electrical stimulation were accelerated by the local application of bradykinin to the sinus and responses of dorsolateral area units could be reversibly blocked by local application of lignocaine to the sinus. It was concluded that the dorsolateral area is a relay area for the perception of pain from cranial vessels.