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First described in 1821 by Beruto y Lentijo and Ramos, occipital neuralgia is a common and some-times debilitating disorder characterized by recurrent

occipital headaches.27 The symptoms of occipital neuralgia include paroxysmal burning pain in the occipital region that sometimes radiates to the forehead and may follow surgery of the occiput or nuchal regions.18,20,23,34 Hyperalgesia, dys-esthesia, and paroxysmal vertigo have also been associ-

ated with this condition, a syndrome similar to migraine headaches.2,23 Occipital neuralgia has been referred to by many names, including Arnold neuralgia, syndrome sym-patique, cervicale posterieur, migraine cervicale, occipital neuritis, cervicogenic headache, and spinally transformed migraine.3,7,13,19,30

Occipital neuralgia can be conservatively managed in several ways, including nonsteroidal analgesics, opioids, neuromodulators, transcutaneous electrical nerve stimula-tion, and external orthosis.1,25 While pharmacotherapy and

Anatomical study of the third occipital nerve and its potential role in occipital headache/neck pain following midline dissections of the craniocervical junction

Laboratory investigation

R. Shane TubbS, M.S., P.a.-C., Ph.D.,1 MaRTin M. MoRTazavi, M.D.,1 MaRioS LoukaS, M.D., Ph.D.,2 anThony v. D’anToni, Ph.D.,3 MohaMMaDaLi M. Shoja, M.D.,4 joShua j. CheRn, M.D., Ph.D.,1 anD aaRon a. Cohen-GaDoL, M.D., M.SC.4

1Pediatric Neurosurgery, Children’s Hospital, Birmingham, Alabama; 2Department of Anatomical Sciences, St. George’s University, Grenada, West Indies; 3New York College of Podiatric Medicine, New York, New York; and 4Goodman Campbell Brain and Spine, and Department of Neurological Surgery, Indiana University, Indianapolis, Indiana

Object. Occipital neuralgia can be a debilitating disease and may occur following operative procedures near the occipital and nuchal regions. One nerve of this region, the third occipital nerve (TON), has received only scant atten-tion, and its potential contribution to occipital neuralgia has not been appreciated. Therefore, in the present study the authors aimed to detail the anatomy of this nerve and its relationships to midline surgical approaches of the occiput and posterior neck.

Methods. Fifteen adult cadavers (30 sides) underwent dissection of the upper cervical and occipital regions. Special attention was given to identifying the course of the TON and its relationship to the soft tissues and other nerves of this region. Once identified superficially, the TON was followed deeply through the nuchal musculature to its origin in the dorsal ramus of C-3. Measurements were made of the length and diameter of the TON. Additionally, the distance from the external occipital protuberance was measured in each specimen. Following dissection of the TON, self-retaining retractors were placed in the midline and opened in standard fashion while observing for excess tension on the TON.

Results. Articular branches were noted arising from the deep surface of the nerve in 63.3% of sides. The authors found that the TON was, on average, 3 mm lateral to the external occipital protuberance, and small branches were found to cross the midline and communicate with the contralateral TON inferior to the external occipital protuberance in 66.7% of sides. The TON trunk became subcutaneous at a mean of 5 cm inferior to the external occipital protuber-ance. In all specimens, the cutaneous main trunk of the TON was intimately related to the nuchal ligament. Insertion of self-retaining retractors in the midline placed significant tension on the TON in all specimens, both superficially and more deeply at its adjacent facet joint.

Conclusions. Although damage to the TON may often be unavoidable in midline approaches to the craniocervi-cal region, appreciation of its presence and knowledge of its position and relationships may be useful to the neurosur-geon who operates in this region and may assist in decreasing postoperative morbidity. (DOI: 10.3171/2011.3.SPINE10854)

key WoRDS      •      anatomy      •      craniocervical anatomy      •      pain syndromes

Abbreviation used in this paper: TON = third occipital nerve.

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noninvasive procedures can help manage the symptoms of mild occipital neuralgia, refractory pain usually warrants surgery. The procedures used to treat occipital neuralgia include neurolysis and decompression, neurectomy, rhi-zotomy and ganglionotomy, C1–2 fusion, radiofrequency ablation, and peripheral nerve stimulation.2,4,12,20,21,24–26,33

Several causes of occipital neuralgia have been im-plicated, including trauma, fibrositis, myositis, fracture of the atlas, and compression of the C-2 nerve root, C1–2 ar-throsis syndrome, atlantoaxial lateral mass osteoarthritis, cervical cord tumor, Chiari malformation, neurosyphilis, and surgery.1,7–9,28,29,32

Third Occipital NerveOf the nerves potentially contributing to occipi-

tal neuralgia, the TON is by far the least referenced, and the symptoms of TON neuralgia commonly mimic those of greater occipital nerve neuralgia (Fig. 1 left). Furthermore, many textbooks of anatomy fail to men-tion this structure, which is readily visible on sonography and MR imaging.16 The third cervical dorsal ramus has a complex branching pattern, which starts at the articular pillar of the C-3 vertebra.31 The nerve then divides into lateral and medial branches, the latter of which ramifies into deep and superficial divisions. The superficial me-dial branch, referred to as the third occipital nerve, travels around the dorsolateral surface of the C2–3 facet joint,

which it innervates. Interestingly, at levels below C2–3, each joint is innervated by 2 branches of the dorsal rami, but the C2–3 joint is innervated solely by the TON.15 The TON then supplies the semispinalis capitis muscle and travels deeply along the muscle before sending a com-municating branch to the greater occipital nerve. After exiting overlying muscles, the nerve becomes cutaneous and supplies a small area of skin just below the superior nuchal line.31,36

The C2–3 Facet JointPerhaps the most heavily implicated area in TON

neuralgia results from the nerve’s innervation of the C2–3 facet joint, which is a less familiar potential source of headache.5 While the atlantooccipital and atlantoaxial joints lie ventral to the emerging spinal nerves, the C2–3 facet joints are positioned behind the intervertebral joints at the level of the intervertebral disc.6 This biomechani-cal vulnerability, compared with the other upper cervi-cal synovial joints, has been documented in the literature concerning TON entrapment.6,14,35 For example, Trevor-Jones35 reported on 3 patients in whom the TON was en-trapped by osteophytes, and, following decompression, all patients had resolution of their preoperative headaches. An epidemiological analysis by Lord et al.22 revealed that a combination of headache and tenderness over the C2–3 facet joint yields a positive likelihood ratio of 2:1 for TON neuralgia.

Fig. 1. Schematic drawings. Left: The nerves of the posterior craniocervical region. Note the deep and superficial course of the TON. Right: Note the tension observed on the TON following the use of a self-retaining retractor. Also note that the superficial fascia that is pierced by the TON acts as a pulley, thus placing additional tension on the deeper components of the TON, including its facet branches.

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As occipital neuralgia can be a debilitating disease and result from operative procedures near the occiput and nuchal regions, a thorough understanding of the anatomy of the nerves supplying this region is important. Moreover, of craniotomies, subtemporal and suboccipi-tal approaches are associated with the most postoperative pain.11 Some authors have posited that such chronic pain may be due to scar tissue enveloping the occipital nerves and that, with movement, these nerves no longer have the capacity to move tension free.11 Therefore, the aim of the present study was to further elucidate the anatomy, course, and relationships of the TON to better understand its relationship to midline approaches to the posterior cra-niocervical region.

MethodsFifteen adult cadavers (30 sides) underwent dissec-

tion of the upper cervical and occipital regions. In the cadavers in the prone position, we removed the skin and superficial fasciae with special attention to identifying the course of the TON and its relationship to the soft tissues and other nerves of this region. Once identified superficially, the TON was followed deeply through the nuchal musculature (for example, the splenius and semi-spinalis capitis muscles) and to its origin from the dorsal ramus of C-3. Its relationships to these deeper muscles and the adjacent facet joint were documented. Nine speci-mens were female and 6 were male with an age range at death of 42–85 years (mean 71 years). Ten specimens were formalin fixed and 5 specimens were not embalmed. Measurements were made of the length and diameter of the TON. Additionally, the distance from the external oc-cipital protuberance was measured in each specimen. All measurements were made twice and the average taken. Following dissection of the TON, self-retaining retrac-tors were placed in the midline and opened in standard fashion while observing for excess tension on the TON. Statistical analysis comparing sides and sexes was per-

formed using Statistica for Windows. The significance level was set at p < 0.05.

ResultsIn all specimens, the TON arose from the dorsal ra-

mus of the third spinal nerve and traveled posteriorly, where it divided into a medial and a lateral branch (Fig. 2). Articular branches were noted arising from the deep surface of the nerve as it crossed the facet joint in 63.3% of sides. At the level of the C-2 spinous process, the TON turned dorsally and pierced the semispinalis capitis, sple-nius capitis, and trapezius muscles. We found that the TON was, on average, 3 mm (range 1.8–12 mm) lateral to the external occipital protuberance, and small branches were found to cross the midline and communicate with the con-tralateral TON inferior to the external occipital protuber-ance in the majority (66.7%) of sides. The mean diameter of the main TON trunk was 1.5 mm (range 1–2.2 mm). This trunk became subcutaneous at a mean of 5 cm (range 3.4–8 cm) inferior to the external occipital protuberance. The TON was found to often send fine communicating branches (range 0–5, mean 2.5) to the terminal branches of the greater occipital nerve. In all specimens, the cutane-ous main trunk of the TON was intimately related to the nuchal ligament. Placement of self-retaining retractors in the midline created significant tension on the soft tissues surrounding the TON in all specimens, both superficially and more deeply at the adjacent facet joint with the turn of the nerve through the superficial fascia acting as a pulley (Fig. 1 right). No statistical difference was noted for mea-surements of the TON between sides or sexes.

DiscussionAnatomical Findings

Based on our cadaveric findings, in a midline dis-section through the nuchal ligament one will encounter

Fig. 2. Left: Cadaveric dissection noting the superficial course of the TON. Right: Deeper dissection of a cadaveric speci-men demonstrating the relationship of the TON to surrounding structures such as the laterally placed greater occipital nerve, vertebral artery, and muscles of the suboccipital triangle.

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and potentially injure the TON in the majority of patients. Additionally, placement of self-retaining retractors in the midline may place significant tension on the TON. The small branches found to cross the midline and commu-nicate with the contralateral TON inferior to the exter-nal occipital protuberance would be difficult to avoid in midline surgical procedures. However, based on our findings, knowledge that the main TON trunk becomes subcutaneous at a mean of 5 cm inferior to the external occipital protuberance may allow early identification and minimize its damage. Finally, for potential surgical de-compression of the TON, the surgeon should consider our observation of the nerve’s upward turn at the C-2 spinous process, the muscle layers that it traverses, and its rela-tion to its adjacent facet joint. Other theories have been suggested that account for the pain distribution of TON headaches. Dash and colleagues10 have also suggested that the TON could be constricted peripherally by its musculotendinous investment.

Clinical Features of TON CompressionAlthough restricted neck movements and facet ten-

derness are cited as putative diagnostic signs of TON neu-ralgia, the only true diagnostic feature of TON headache is a positive response to TON blocks.6 Lord et al.22 stated that the prevalence of TON-related headaches among pa-tients in whom headache is the predominant complaint after whiplash was as high as 53%. This suggests that TON neuralgia is the most common cause of headache in patients who experienced whiplash.22 Although there exists no standard treatment for TON neuralgia, Lord et al.,22 Govind et al.,17 and Bogduk and Marsland6 listed several therapies including intraarticular injections of ste-roids, percutaneous radiofrequency neurotomy, and cryo-coagulation. However, Bogduk and Marsland found that open neurectomy achieved the most enduring responses.

ConclusionsAlthough damage to the TON may often be unavoid-

able in midline approaches to the craniocervical region, appreciation of its presence and knowledge of the TON’s position and its relationships may be useful to the neuro-surgeon who operates in this region and may assist in de-creasing postoperative morbidity. Based on our anatomi-cal study, we found that midline retraction in this region will place tension on the TON both superficially at its cu-taneous branches and deeper near its facet branches. This tension, with subsequent injury to the TON, could be one reason for postcraniotomy headaches—either from local cutaneous nerve irritation/compression or cervicogenic from traction on the deeper facet branches of this nerve. Maneuvers such as intermittently releasing the retractors may minimize long periods of tension on the TON.

Disclosure

The authors report no conflict of interest concerning the mate-rials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Tubbs. Acquisition of

data: Tubbs, Mortazavi, Chern. Analysis and interpretation of data: all authors. Drafting the article: all authors. Critically revising the article: all authors. Approved the final version of the paper on behalf of all authors: Cohen-Gadol. Study supervision: Tubbs.

References

1. Anthony M: Headache and the greater occipital nerve. Clin Neurol Neurosurg 94:297–301, 1992

2. Ashkenazi A, Levin M: Three common neuralgias. How to manage trigeminal, occipital, and postherpetic pain. Postgrad Med 116:16–18, 21–24, 31–32, 2004

3. Austad ED: Relevance of the lesser occipital nerve in facial rejuvenation surgery. Plast Reconstr Surg 105:2600–2603, 2000

4. Blume HG: Radiofrequency denaturation in occipital pain: a new approach in 114 cases. Adv Pain Res Ther 7:691–698, 1976

5. Bogduk N: The clinical anatomy of the cervical dorsal rami. Spine (Phila Pa 1976) 7:319–330, 1982

6. Bogduk N, Marsland A: On the concept of third occipital headache. J Neurol Neurosurg Psychiatry 49:775–780, 1986

7. Bovim G, Bonamico L, Fredriksen TA, Lindboe CF, Stolt-Nielsen A, Sjaastad O: Topographic variations in the periph-eral course of the greater occipital nerve. Autopsy study with clinical correlations. Spine (Phila Pa 1976) 16:475–478, 1991

8. Brown CR: Occipital neuralgia: symptoms, diagnosis, and treatment. Pract Periodontics Aesthet Dent 8:587–588, 1996

9. Clavel M, Clavel P: Occipital neuralgia secondary to exuber-ant callus formation. Case report. J Neurosurg 85:1170–1171, 1996

10. Dash KS, Janis JE, Guyuron B: The lesser and third occipi-tal nerves and migraine headaches. Plast  Reconstr  Surg 115:1752–1760, 2005

11. de Gray LC, Matta BF: Acute and chronic pain following cra-niotomy: a review. Anaesthesia 60:693–704, 2005

12. Dubuisson D: Treatment of occipital neuralgia by partial pos-terior rhizotomy at C1-3. J Neurosurg 82:581–586, 1995

13. Ducic I, Hartmann EC, Larson EE: Indications and outcomes for surgical treatment of patients with chronic migraine head-aches caused by occipital neuralgia. Plast  Reconstr  Surg 123:1453–1461, 2009

14. Ehni G, Benner B: Occipital neuralgia and the C1-2 arthrosis syndrome. J Neurosurg 61:961–965, 1984

15. Eichenberger U, Greher M, Kapral S, Marhofer P, Wiest R, Remonda L, et al: Sonographic visualization and ultrasound-guided block of the third occipital nerve: prospective for a new method to diagnose C2-C3 zygapophysial joint pain. Anesthesiology 104:303–308, 2006

16. Galiano K, Obwegeser AA, Bodner G, Schatzer R, Schocke M, Gruber H: Ultrasound is not the only technique to visual-ize third occipital nerve blockade. Anesthesiology 105:858, 2006

17. Govind J, King W, Bailey B, Bogduk N: Radiofrequency neu-rotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiatry 74:88–93, 2003

18. Graff-Radford SB, Jaeger B, Reeves JL: Myofascial pain may present clinically as occipital neuralgia. Neurosurgery 19: 610–613, 1986

19. Hecht JS: Occipital nerve blocks in postconcussive headaches: a retrospective review and report of ten patients. J  Head Trauma Rehabil 19:58–71, 2004

20. Horowitz MB, Yonas H: Occipital neuralgia treated by intradu-ral dorsal nerve root sectioning. Cephalalgia 13:307, 354–360, 1993

21. Joseph B, Kumar B: Gallie’s fusion for atlantoaxial arthrosis with occipital neuralgia. Spine (Phila Pa 1976) 19:454–455, 1994

22. Lord SM, Barnsley L, Wallis BJ, Bogduk N: Third occipital

J Neurosurg: Spine / Volume 15 / July 2011

Third occipital nerve

75

nerve headache: a prevalence study. J  Neurol  Neurosurg Psychiatry 57:1187–1190, 1994

23. Loukas M, El-Sedfy A, Tubbs RS, Louis RG Jr, Wartmann CH, Curry B, et al: Identification of greater occipital nerve landmarks for the treatment of occipital neuralgia. Folia Morphol (Warsz) 65:337–342, 2006

24. Lozano AM: Treatment of occipital neuralgia, in Gildenberg PL, Tasker RR (eds): Textbook of Stereotactic and Functional Neurosurgery. New York: McGraw-Hill, 1972, pp 9–33

25. Oh MY, Ortega J, Bellotte JB, Whiting DM, Aló K: Peripheral nerve stimulation for the treatment of occipital neuralgia and transformed migraine using a C1–2–3 subcutaneous paddle style electrode: a technical report. Neuromodulation 7:103–112, 2004

26. Onofrio BM, Campa HK: Evaluation of rhizotomy. Review of 12 years’ experience. J Neurosurg 36:751–755, 1972

27. Perelson HN: Occipital nerve tenderness; a sign of headache. South Med J 40:653–656, 1947

28. Poletti CE: Third cervical nerve root and ganglion compres-sion: clinical syndrome, surgical anatomy, and pathological findings. Neurosurgery 39:941–949, 1996

29. Poletti CE, Sweet WH: Entrapment of the C2 root and gan-glion by the alanto-epistrophic ligament: clinical syndrome and surgical anatomy. Neurosurgery 27:228–291, 1990

30. Slavin KV, Colpan ME, Munawar N, Wess C, Nersesyan H: Trigeminal and occipital peripheral nerve stimulation for cra-niofacial pain: a single-institution experience and review of the literature. Neurosurg Focus 21(6):E5, 2006

31. Standring S: Neck, in Standring S (ed): Gray’s Anatomy: The 

Anatomical Basis of Clinical Practice, ed 40. Philadelphia: Churchill Livingstone/Elsevier, 2008, p 435–466

32. Star MJ, Curd JG, Thorne RP: Atlantoaxial lateral mass os-teoarthritis. A frequently overlooked cause of severe occipito-cervical pain. Spine (Phila Pa 1976) 17 (6 Suppl):S71–S76, 1992

33. Stechison MT, Mullin BB: Surgical treatment of greater oc-cipital neuralgia: an appraisal of strategies. Acta Neurochir (Wien) 131:236–240, 1994

34. Sulfaro MA, Gobetti JP: Occipital neuralgia manifesting as orofacial pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 80:751–755, 1995

35. Trevor-Jones R: Osteo-arthritis of the paravertebral joints of the second and third cervical vertebrae as a cause of occipital headaches. S Afr Med J 38:392–394, 1964

36. Tubbs RS, Salter EG, Wellons JC, Blount JP, Oakes WJ: Landmarks for the identification of the cutaneous nerves of the occiput and nuchal regions. Clin Anat 20:235–258, 2007

Manuscript submitted December 3, 2010.Accepted March 23, 2011.Please include this information when citing this paper: pub-

lished online April 15, 2011; DOI: 10.3171/2011.3.SPINE10854.Address correspondence to: Aaron A. Cohen-Gadol, M.D., M.Sc.,

Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, 1801 North Senate Boulevard, Suite 610, Indianapolis, Indiana 46202. email: acohenmd@gmail.com.