Table 4.
Studies evaluating pain referral patterns for atlanto–occipital and atlanto–axial injections
| Author, year | Patients | Design | Results | Comments |
|---|---|---|---|---|
| Busch and Wilson, 1989 [168] | 25 pts with head and neck pain of which 2 pts received LA and steroid AO and AA joints injections | Case series/ retrospective | Pain relief in both cases ranged from 3 weeks to 4 months (one patient received serial injections). AA and AO joints may be a source of occipital headache refractory to conservative therapy | 25 pts treated but only 2 cases described |
| Aprill et al 2002 [5] | 34 pts with a history of occipital or SO pain, tenderness over C1 and decreased ROM of AA joint treated with AA IA injection of LA and steroid | Prospective observational | 21 of 34 (62%) pts experienced complete relief (≤1/10 on VAS) for 2 hours following the injection | No control group, no sham injection or other joints examined |
| Narouze et al 2007 [62] | 32 pts with clinical exam consistent with AA-mediated pain treated with AA IA injection of LA and steroid | Retrospective study | 15 of 32 (46.8%) pts obtained complete pain relief (NRS pain score=0), 26/32 (81.2%) pts with ≥50% pain relief | No control or comparison groups or other joints examined |
| Lee et al 2015 [165] | 24 pts with headache and/or SO pain, SO tenderness, and limited range of lateral bending with rotation at the AO joint, treated with AO IA injection of LA. Responders received IA LA and steroid injection | Prospective observational | 20 of 24 (83%) pts had ≥50% pain relief for 30 min following the injection. 18 of 20 (90%) pts had a 2-point or greater reduction in pain score | No control or sham groups, 2 month follow-up. 14 of 14 pts with headache had ≥50% relief. 15 of 20 pts with posterior neck pain had ≥50% relief. 13 of 17 pts with shoulder/arm pain had ≥50% relief |
| Dreyfuss et al 1994 [50] | 5 asymptomatic volunteers (no history of headache or neck pain) received one AO and one AA provocative injection with contrast | Prospective observational | AO injections provoked variable referred pain from the level of the C5 spinal segment through the vertex of the head. AA injections were more consistent, producing pain only in the SO region | Provoked pain described as dull, deep ache, or heavy pressure |
| Cooper et al 2007 [49] | 5 pts with neck or SO headache treated with AA injection of LA (one patient had bilateral injections) | Prospective observational | Responders had 100% pain relief or complete relief in a definable portion of the patient’s area of pain. 5 out of 134 (3.7%) total pts with positive cervical diagnostic blocks had C1–2 as a source | AA injections relieved pain in the neck up to the vertex of the head, occasionally in the region of the ear and orbit |
| Fukui et al 1996 [51] | 10 pts with neck pain were treated with AO and 10 pts with neck pain were treated with AA IA injections with LA and steroid | Prospective observational | AO and AA injections produced pain in the posterior occiput and posterolateral cervical spine (areas over the mastoid process) | Pain relief was not reported, although LA and steroid was used in the provocative injection |
| Ehni and Benner, 1984 [56] | 7 pts with SO pain, tenderness and pain during rotation were treated with AA IA injection of LA and steroid | Case series | AA injections produced immediate relief | No details provided regarding injection technique. No quantification of pain relief was provided |
AA, atlanto–axial (C1–C2) joint; AO, atlanto–occipital (C0–C1) joint; IA, intra-articular; LA, local anesthetic; MBB, medial branch blocks; NRS, numerical rating scale; pts, patients; ROM, range of motion; SO, suboccipital.