Previously we have discussed the use of propofol for migraine headache (part 1, part 2). In this post, we’ll look at another headache treatment that can be added to your armamentarium, the paraspinous cervical block.
There are many standard cocktails for headache management in the ED, but unfortunately, many of these require an IV, fluids, and multiple medications. This requires a significant amount of nursing time and often ties up a precious bed in the ED. What if we could perform an injection at the bedside and send the patient home 10-15 minutes later? Wouldn’t that be awesome?
The majority of literature on the paraspinous cervical block has been published by Larry Mellick, an Emergency Physician in Georgia, and his twin brother, Gary Mellick. According to them, this can be used for all types of headache, from tension type/migraine headaches, to orofacial/dental pain, to meningitis. The meningitis part is self-report by Larry, not anything that has been studied.
Tim McCormick and Stuart Swadron have previously written on the subject over at EPMonthly, please read their short article now and then come back here. It will only take about a minute, I promise.
So how do I perform this?
It’s actually very easy. The steps are listed here, and below are videos from Larry Mellick and Al Sacchetti on how to perform the technique.
1)Landmark the C7 spinous process, which is usually the most prominent one.
2)Mark a point 1 inch lateral to the spinous process on each side, basically in the belly of the trapezius muscle overlying the transverse process.
3)Clean the area with alcohol swab.
4)Raise a wheal using lidocaine.
5)With patient in a sitting position and head held upright, insert a 25 gauge, 1.5 inch needle angled parallel to the floor. The needle should be nearly buried. Aspirate before injecting to ensure you are not in a vessel (more on this below) and slowly inject 1.5 cc of bupivacaine.
6)Remove needle and dress wound.
Are there any risks of this procedure?
I think most people worry about the potential harms of this procedure, particularly the many vascular and nerve structures in the neck. Rightly so, you should know the relevant anatomy before performing a procedure.
Looking at Netter’s Atlas of Human Anatomy, you can see that this area is pretty much all muscle, with the trapezius, levator scapula, splenius capitis and splenius cervicis all in that area. If you do hit a vascular structure, it will usually be a vertebral vein, but rarely could be a vertebral artery. However, this is unlikely because it is deeper and protected by the foramen transversarium. If you are injecting over the transverse process, that will further protect you from hitting a vascular structure.
Here are a few videos of this being performed by Drs. Mellick and Sacchetti.
Larry Mellick performing block (7:33)
Al Sacchetti video (3:25)
Mellick LB, McIlrath ST, Mellick GA. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006 Oct;46(9):1441-49.