Dr Peter Gendall. Mr Steve August. Professor Nik Bogduk. Musculoskeletal Radiologist Hamilton. Physiotherapist Dunedin
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1 Professor Nik Bogduk Professor Pain Medicine University of Newcastle Mr Steve August Physiotherapist Dunedin Dr Peter Gendall Musculoskeletal Radiologist Hamilton 8:30-10:30 WS #5: Musculoskeletal Medicine 1
2 HEADACHES OF CERVICAL ORIGIN CERVICAL HEADACHE CERVICOGENIC HEADACHE Nikolai Bogduk Emeritus Professor of Pain Medicine University of Newcastle
3 REFERRED PAIN from CERVICAL SPINE
4
5 NORMAL VOLUNTEERS
6 Cyriax J. Rheumatic headache. Brit Med J 1938; 2: Campbell DG, Parsons CM. Referred head pain and its concomitants. J Nerv Ment Dis 1944; 99: Feinstein B, Langton JBK, Jameson RM, Schiller F. Experiments on referred pain from deep somatic tissues. J Bone Joint Surg 1954; 36A: Wolff HG. Headache and Other Head Pain (ed 2). New York: Oxford University Press, 1963, Piovesan EJ, Kowacs PA, Tatsui CE, Lange MC, Ribas LC, Werneck LC. Referred pain after painful stimulation of the greater occipital nerve in humans: evidence of convergence of cervical afferences on trigeminal nuclei. Cephalalgia 2001; 21: Dwyer A, Aprill C, Bogduk N 19 Cervical zygapophysial joint pain patterns I: a study in normal volunteers. Spine 1990; 15: Dreyfuss P, Michaelsen M, Fletcher D. Atlanto-occipital and lateral atlanto-axial joint pain patterns. Spine 1994; 19:
7 Cyriax J. Rheumatic headache. Brit Med J 1938; 2: Campbell DG, Parsons CM. Referred head pain and its concomitants. J Nerv Ment Dis 1944; 99: MUSCLES Feinstein B, Langton JBK, Jameson RM, Schiller F. Experiments on referred pain from deep somatic tissues. J Bone Joint Surg 1954; 36A: Wolff HG. Headache and Other Head Pain (ed 2). New York: Oxford University Press, 1963, Piovesan EJ, Kowacs PA, Tatsui CE, Lange MC, Ribas LC, Werneck LC. Referred pain after painful stimulation of the greater occipital nerve in humans: evidence of convergence of cervical afferences on trigeminal GON nuclei. Cephalalgia 2001; 21: Dwyer A, Aprill C, Bogduk N 19 Cervical zygapophysial joint pain patterns I: a study in normal volunteers. Spine 1990; 15: C2-3 Dreyfuss P, Michaelsen M, Fletcher D. Atlanto-occipital and lateral atlanto-axial joint pain patterns. Spine 1994; 19: C1-2
8 NEUROANATOMY
9 trigeminal nerve (V) pars caudalis of spinal nucleus of V V spinal tract of V C1 C2 C3 C1 spinal nerve C2 spinal nerve C3 spinal nerve
10 SOURCES
11 SOURCES Atlanto-occipital joints
12 SOURCES Lateral atlanto-axial joints
13 SOURCES C2-3 Zygapophysial joints
14 Preliminary: hit bone AP Lateral LATERAL ATLANTO-AXIAL JOINT BLOCKS
15 Enter joint AP Lateral LATERAL ATLANTO-AXIAL JOINT BLOCKS
16 Arthrogram AP Lateral LATERAL ATLANTO-AXIAL JOINT BLOCKS
17 THIRD OCCIPITAL NERVE BLOCKS C2 C3
18 THIRD OCCIPITAL NERVE BLOCKS C2 C3
19 C3,4 medial branch blocks
20 C3,4 medial branch blocks
21 C3,4 medial branch blocks
22 C3,4 medial branch blocks
23 C1-2: 0.35 C2-3: 0.65 C2-3: 1.00 C1-2: 0.13 C2-3: 0.70 C3-4: 0.17 Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Medicine 2007; 8:
24 PREVALENCE C1-2 Unknown Might be > 16% Aprill C, Axinn MJ, Bogduk N. Occipital headaches stemming from the lateral atlanto-axial (C1-2) joint. Cephalalgia 2002; 22: C2-3 53% in headache after whiplash Lord S, Barnsley L, Wallis B, Bogduk N. Third occipital headache: a prevalence study. J Neurol Neurosurg Psychiat 1994; 57:
25
26 A PERSONAL AUDIT Thanks to Dr Jay Govind Dr Wade King Dr Ian Painter Sr Beverly Bailey
27 Probable cervicogenic headache pain starting in the neck at least three of: headache constant non-throbbing concomitant pain in the neck or shoulder aggravated by neck movement reduced range of motion of the neck onset of headache shortly after neck trauma.
28 68 Patients with probable cervicogenic headache in whom headache was the dominant symptom
29 68 1st C2-3 block
30 68 1st C2-3 block 22 neg pos 46
31 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block
32 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42
33 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%)
34 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) 26
35 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) C1-2 block
36 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) C1-2 block 5 neg pos 5
37 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) C1-2 block 5 neg pos 5 5/68 = 7% (1-13%)
38 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) C1-2 block 5 neg pos 5 5/68 = 7% (1-13%) 21
39 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) C1-2 block 5 neg pos 5 5/68 = 7% (1-13%) st C3-4 block
40 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) C1-2 block 5 neg pos 5 5/68 = 7% (1-13%) st C3-4 block neg pos 8
41 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) C1-2 block 5 neg pos 5 5/68 = 7% (1-13%) st C3-4 block neg pos 8 2nd C3-4 block
42 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) C1-2 block 5 neg pos 5 5/68 = 7% (1-13%) st C3-4 block neg pos 8 2nd C3-4 block 4 neg pos 4
43 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) C1-2 block 5 neg pos 5 5/68 = 7% (1-13%) st C3-4 block neg pos 8 2nd C3-4 block 4 neg pos 4 4/68 = 6% (0-12%)
44 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) C1-2 block 5 neg pos 5 5/68 = 7% (1-13%) st C3-4 block neg pos 8 2nd C3-4 block 4 neg pos 4 4/68 = 6% (0-12%) 17
45 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) C1-2 block 5 neg pos 5 5/68 = 7% (1-13%) st C3-4 block neg pos 8 2nd C3-4 block 4 neg pos 4 4/68 = 6% (0-12%) Other blocks
46 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) C1-2 block 5 neg pos 5 5/68 = 7% (1-13%) st C3-4 block neg pos 8 2nd C3-4 block 4 neg pos 4 4/68 = 6% (0-12%) neg Other blocks pos 4 0
47 68 1st C2-3 block 22 neg pos 46 2nd C2-3 block 4 neg pos 42 42/68 = 62% (50-74%) C1-2 block 5 neg pos 5 5/68 = 7% (1-13%) st C3-4 block neg pos 8 2nd C3-4 block 4 neg pos 4 4/68 = 6% (0-12%) neg Other blocks pos Source not found: 17/68 = 25%
48 98 Patients with probable cervicogenic headache in whom headache was an incidental, minor complaint
49 98 1st C2-3 block
50 98 1st C2-3 block 51 neg pos 47
51 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block
52 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41
53 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%)
54 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) 57
55 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) st C3-4 block
56 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) st C3-4 block neg pos 19
57 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) st C3-4 block neg pos 19 2nd C3-4 block
58 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) st C3-4 block neg pos 19 2nd C3-4 block 12 neg pos 7
59 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) st C3-4 block neg pos nd C3-4 block neg pos 7 7/98 = 7% (2-12%)
60 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) st C3-4 block neg pos nd C3-4 block neg pos 7 7/98 = 7% (2-12%) 50
61 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) st C3-4 block neg pos nd C3-4 block neg pos 7 7/98 = 7% (2-12%) st other block
62 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) st C3-4 block neg pos nd C3-4 block neg pos 7 7/98 = 7% (2-12%) st other block neg pos 32
63 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) st C3-4 block neg pos nd C3-4 block neg pos 7 7/98 = 7% (2-12%) st other block neg pos 32 2 nd other block
64 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) st C3-4 block neg pos nd C3-4 block neg pos 7 7/98 = 7% (2-12%) st other block neg pos 32 2 nd other block 14 neg pos 18
65 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) st C3-4 block neg pos nd C3-4 block neg pos 7 7/98 = 7% (2-12%) st other block neg pos 32 2 nd other block 14 neg pos 18 18/98 = 18% 10-26%)
66 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) st C3-4 block neg pos nd C3-4 block neg pos 7 7/98 = 7% (2-12%) st other block neg pos 32 2 nd other block 14 neg pos 18 18/98 = 18% 10-26%)
67 98 1st C2-3 block 51 neg pos 47 2nd C2-3 block 6 neg pos 41 42/98 = 42% (32-52%) st C3-4 block neg pos nd C3-4 block neg pos 7 7/98 = 7% (2-12%) st other block neg pos 32 2 nd other block 14 neg pos 18 18/98 = 18% 10-26%) 32 Source not found: 32/68 = 33%
68
69 TREATMENT RADIOFREQUENCY THIRD OCCIPITAL NEUROTOMY for CERVICAL HEADACHE Govind J, King W, Bailey B, Bogduk N. Radiofrequency neurotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiat 2003; 74:88-93.
70 Electrode placement: oblique pass high mid low A B C high mid low D E F
71 Electrode placement: sagittal pass high mid low A B C high mid low D E F
72 OUTCOMES
73 49 patients with Third Occipital Headache; double-block positive. Complete relief: 88% median duration: 297 days ++ Repeat in 14 Complete relief: 86% median duration: 217 days++ Govind J et al. J Neurol Neurosurg Psychiat 2003; 74:88-93.
74
75 OUTCOMES Require complete relief of headache following controlled TON blocks meticulous technique Govind J et al. J Neurol Neurosurg Psychiat 2003; 74:88-93.
76 Not influenced by litigation Govind J et al. J Neurol Neurosurg Psychiat 2003; 74:88-93.
77 Status N Success Failure Duration of Relief median days (interqurtile range) Litigation ( ) No Litigation ( ) P Govind J et al. J Neurol Neurosurg Psychiat 2003; 74:88-93.
78 CERVICAL HEADACHE other sources testable sources lateral AA joint C1-2 IA blocks C2-3 Z joint TON blocks 53% RF neurotomy 86%
79 Bogduk N, Bartsch T. Cervicogenic headache. In: Silberstein SD, Lipton RB, Dodick DW (eds) Wolff s Headache, 8th edn. Oxford University Press, New York, 2008, pp Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurology 2009; 8: Bogduk N. The neck and headaches. Neurol Clin 2014; 32:
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