Pinching of the occipital nerve

Those who suffer from recurrent headache, localized in the occipital region, should be aware that this symptom is often manifested by pinching of the occipital nerve.

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Epidemiology

Separately, clinical statistics of data on occipital nerve disorders are not kept: the number of patients with prolonged primary or secondary headaches is taken into account.

According to experts of the American Osteopathic Association, the prevalence of neurological headache in the general population is 4%, and among patients suffering from strong cephalalgias, it reaches 16-17.5%.

According to the American Migraine Foundation (AMF), the occipital neuralgia is diagnosed annually in no more than three or four people for every 100,000 people.

As noted, the majority of patients are over 40 years old, and the ratio of men to women with neuralgic pains in the nape is 1: 4.

Causes of the pinching the occipital nerve

The pathological condition, called occipital  neuralgia, was first described nearly two centuries ago. Etiologically spontaneously developing intense  pain in the back of the head  may be associated with pinching of the occipital nerve.

The large occipital nerve (nervus occipitalis major), which innervates the occipital and parietal regions of the head, is formed by the dorsal branch of the second spinal cervical nerve, which extends between the cervical vertebrae C1 (atlanteus) and C2 (axis) and, bending around the inferior oblique muscle (opliquus), and oplique c1 musculus) and passing through the ligament of the musculus trapezius (ligament of the trapezius muscle), forms several branches at once. The longest of them - first appearing subcutaneously, and then moving to the back of the head - and is a large afferent (sensitive) occipital nerve.

From the fibers of the anterior branches of the cervical nerves, a small occipital nerve (nervus occipitalis minor) is formed, which provides dermal sensitivity of the lateral surfaces of the head, including the auricles, and also innervates the posterior cervical muscles. In addition, the branch of the third cervical nerve, which passes medially to the large occipital and ends in the skin of the lower part of the neck, is considered the third occipital nerve (nervus occipitalis tertius), which innervates the joint of the second vertebra of the neck and the intervertebral disc between it and the third cervical vertebra.

Noting the most likely causes of occipital nerve pinching, neurologists call:

• squeezing of nerve fibers during traumatic changes in normal anatomical structures (for example, between the muscle and the occipital bone or between the muscle layers of the upper and back of the neck);
• atlantoaxial osteoarthritis (osteoarthrosis of the cervical vertebrae C1-C2) or cervical  osteochondrosis ;
• spondylolisthesis or  cervical dislocation ;
• fibrous induration of muscle tissue in the neck or  myogeliosis of the cervical spine ;
• intramuscular formations (cyst, lipoma), for example, in the area of the deep belt muscle (musculus splenius capitis) behind the neck;
• spinal cavernous (vascular) anomalies in the form of arteriovenous malformations;
• intramedullary or epidural tumors of the spine in the cervical region.

Risk factors

The key risk factors for pinching the occipital nerve are any spinal injuries in the neck. Atlanto-axial circular rotation subluxes, as well as injuries of the so-called whip character, are particularly distinguished: when due to car accidents, sudden blows to the head or falls, the head strongly deviates forward, backward or to the side (with a sharp change in the position of the cervical vertebrae).

In addition to extreme factors, pathological changes in biomechanics supporting the stability of the cervical spine of anatomical structures are a real threat of infringement of these nerves. This refers to regional deformity of muscles due to permanent violation of posture in the so-called syndrome of proximal cross-muscle imbalance: tension of some neck muscles (with aggravation of the kyphosis of the cervical spine), shoulder girdle and anterior chest, and simultaneous weakening of the diagonally positioned muscles.

Pathogenesis

When the occipital nerve is pinched, the pathogenesis directly depends on the location and specificity of the damage. So, in osteoarthritis of the cervical vertebrae, compression of the nerve fiber can occur with an osteophyte bone growth, and in cases of their displacement, the stability of the cervical spine is broken, and the nerve can be pinched between the vertebral bodies.

In most cases, in case of arthrosis of the first two cervical vertebrae, as well as pathological changes of the zygapophyseal (cuspid) joint C2-C3, peripheral pinching of the large occipital nerve is observed in the craniovertebral junction area - the place of the spinal cord “docking” with the skull.

Specialists are aware of other points of potential compression along the large occipital nerve: near the spinous process of the first vertebra; when the nerve enters the semi-erectus or trapezius muscle; when leaving the fascia of the trapezius muscle to the line of the occipital crest - in the region of the occiput.

If, at least at one of these points, the muscle fibers are in a state of hypertonus for a long time, a compression effect on the axons of the occipital nerve passing through them occurs with increased excitation of pain receptors.

Symptoms of the pinching the occipital nerve

The result of pinching the occipital nerve, and, in fact, its effects and complications are occipital neuralgia, the symptoms of which are manifested by unilateral shooting or stabbing headaches in the neck (at the base of the skull) and the occiput.

Moreover, unlike migraine, the first signs of  neuralgic pain of  this etiology do not include the prodromal period and are not accompanied by aura.

Also, patients may experience:

• burning and throbbing pain that spreads from the neck to the scalp (back and sides);
• retro and supra-orbital pain (localized around and behind the eyeball);
• increased sensitivity to light and sound;
• skin hyperpathy (increased surface sensitivity along the pinched nerve);
• dizziness and ringing in the ears;
• nausea;
• pain in the neck and neck when turning or tilting the head.

Between attacks of shooting pain, a less acute pain of a permanent nature is also possible.

Diagnostics of the pinching the occipital nerve

The diagnosis of occipital nerves pinching is made by neurologists on the totality of anamnesis, clinical signs, palpation of the neck and the results of diagnostic blockade (local anesthetic injection).

Diagnostic injections (which, in the event of compression, lead to the relief of pain) are made into the atlantoaxial joint, the zygapophysial joints C2-3 and C3-4, nervus occipitalis major and nervus occipitalis minor, as well as the third occipital nerve.

In order to visualize the cervical spine and the surrounding occipital soft tissues and assess their condition, instrumental diagnostics is carried out using magnetic resonance imaging - positional and kinetic. Conventional radiography and CT are useful for detecting arthritis, spondylosis, vertebral dislocation and pathological bone formations of this localization.

Differential diagnosis

Since neuralgia due to pinching of the nerve can be confused with migraine (hemicrania) or a headache of a different etiology, differential diagnosis is of particular importance. The differential diagnosis includes tumors, infections (inflammation of the brain, arachnoiditis), myofascial syndrome, congenital anomalies, etc.

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Treatment of the pinching the occipital nerve

Before a visit to the doctor and examination, the patient does not know that his excruciating  occipital pain  is a consequence of pinching the nerve, so only after determining the exact diagnosis the doctor will explain what to do when pinching the occipital nerve, and prescribe appropriate symptomatic treatment.

There is a wide range of conservative (drug) drugs to reduce pain. In particular, various medications are used, including nonsteroidal anti-inflammatory drugs (NSAIDs), for example,  Ibuprofen  (Ibuprom, Ibufen, Imet, Nurofen) and other analgesics. See details -  Pills for neuralgia.

In cases of neuropathic pain, the effectiveness of such oral antiepileptic drugs as Pregabalin,  Gabapentin  (Gabalept, Meditan, Tebantin) or  Carbamazepine, which reduce the activity of nerve cells, is similar to the inhibitory neurotransmitter gamma-aminobutyric acid (GABA).

For example, Pregabalin can be prescribed to adults for 0.05-0.2 g three times a day. However, these drugs can have side effects in the form of dizziness, dry mouth, vomiting, drowsiness, tremor, as well as anorexia, urination, coordination of movements, attention, vision, consciousness and sexual functions.

In difficult cases, muscle relaxant Tolperisone (Mydocalm) is used to relax the muscles of the neck - 50 mg three times a day. Among its side effects are nausea, vomiting, hypotension, headache.

It is locally recommended to use ointment with capsaicin (Kapsikam and Nikofleks), the analgesic effect of which is due to the neutralization of the tachykinin neuropeptide of nerve endings. Analgesic cream with lidocaine Emla and 5% lidocaine ointment, as well as procaine ointment Menovazan also relieves pain without side effects.

On the recommendation of the doctor, homeopathy can be used to relieve pain, in particular, such remedies as: Aconite, Arsenicum, Belladonna, Bryonia, Colocynthis, Pulsatilla, Spigelia, Gelsemium, Glonoinum, Nux Vom. The dosage of drugs is determined by a homeopath.

An interventional treatment of pain syndrome is performed by injecting anesthetic (Lidocaine) and a steroid (Hydrocortisone) into the region of the occipital nerve. The duration of anesthetic blockade is about two weeks (in some cases longer).

Perhaps more prolonged analgesia (for several months) by introducing into the trigger zone botulinum toxin A (BoNT-A), which reduces the activity of neurons. In order to stop the flow of pain signals to the brain, pulsed radiofrequency stimulation of the occipital nerves is performed.

It is advisable to practice yoga and acupuncture sessions (acupuncture), as well as physiotherapy treatment aimed at strengthening the muscles and improving posture; read more -  Physical Therapy for Neuritis and Peripheral Nerve Neuralgia. Myofascial therapy contributes to the elimination of pain through therapeutic massage, which causes blood flow to the tissues and positively affects the muscles, tendons and ligaments.

Among the remedies that popular treatment offers, hot showers, alternating cold and hot compresses on the occipital region (relieving headaches) can be helpful. Also on the painful area, some advise to apply the composition prepared from chloroform and acetylsalicylic acid tablets (Aspirin) dissolved in it.

It should be borne in mind that treatment with herbs — ingestion of feverfew’s girlish or skullcap ordinary — does not give a quick analgesic effect. And tea with peppermint leaves just soothes the nerves.

Also read -  Treatment of neuropathic pain.

Surgery

With the ineffectiveness of all means of conservative anesthetic therapy possible surgical treatment using:

• selective radiofrequency rhizotomy (destruction) of nerve fibers;
• radiofrequency neurotomy (ablation), which consists in thermal denervation of the pinched nerve;
• cryoneuroablation;
• radiofrequency neurolysis (excision of tissues that cause compression of the occipital nerve);
• microvascular decompression (in case of infringement of the nerve fiber by blood vessels), during which during the microsurgical operation the vessels will be mixed from the site of compression.

According to experts, even after surgical treatment, almost a third of patients continue to suffer from headaches, so the advantages of the operation should always be carefully weighed according to its risks: the possibility of developing causalgia or a painful nerve tumor (neuroma).

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Prevention

What can be the prevention of occipital nerve pinching? In the prevention of injuries of the cervical vertebrae and the entire spine; correct posture; sufficient physical activity; a healthy diet containing all the necessary vitamins and micro and macro elements. In general, in a conscious attitude to their health.

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Forecast

According to neurologists, a long-term prognosis in the event of pinching a large or small occipital nerve depends not only on timely medical attention and adequate treatment, but also on the causal factors of this damage.

If the etiology of compression of the nerve fiber is due to irreversible changes in the corresponding anatomical structures, the treatment of chronic occipital neuralgia becomes lifelong.