- Pediatric Neurosurgery, Children's Hospital, Birmingham, AL, USA
- Department of Anatomic Sciences, St. George's University, Grenada
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
Aaron A. Cohen-Gadol
3Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
DOI:10.4103/2152-7806.143743Copyright: © 2014 Tubbs RS. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Tubbs RS, Watanabe K, Loukas M, Cohen-Gadol AA. The Intramuscular Course of the Greater Occipital Nerve: Novel Findings with Potential Implications for Operative Interventions and Occipital Neuralgia. Surg Neurol Int 31-Oct-2014;5:155
How to cite this URL: Tubbs RS, Watanabe K, Loukas M, Cohen-Gadol AA. The Intramuscular Course of the Greater Occipital Nerve: Novel Findings with Potential Implications for Operative Interventions and Occipital Neuralgia. Surg Neurol Int 31-Oct-2014;5:155. Available from: http://sni.wpengine.com/surgicalint_articles/the-intramuscular-course-of-the-greater-occipital-nerve-novel-findings-with-potential-implications-for-operative-interventions-and-occipital-neuralgia/
Background:A better understanding of the etiologies of occipital neuralgia would help the clinician treat patients with this debilitating condition. Since few studies have examined the muscular course of the greater occipital nerve (GON), this study was performed.
Methods:Thirty adult cadaveric sides underwent dissection of the posterior occiput with special attention to the intramuscular course of the GON. Nerves were typed based on their muscular course.
Results:The GON traveled through the trapezius (type I; n = 5, 16.7%) or its aponeurosis (type II; n = 15, 83.3%) to become subcutaneous. Variations in the subtrapezius muscular course were found in 10 (33%) sides. In two (6.7%) sides, the GON traveled through the lower edge of the inferior capitis oblique muscle (subtype a). On five (16.7%) sides, the GON coursed through a tendinous band of the semispinalis capitis, not through its muscular fibers (subtype b). On three (10%) sides the GON bypassed the semispinalis capitis muscle to travel between its most medial fibers and the nuchal ligament (subtype c). For subtypes, eight were type II courses (through the aponeurosis of the trapezius), and two were type I courses (through the trapezius muscle). The authors identified two type IIa courses, four type IIb courses, and two type IIc courses. Type I courses included one type Ib and one type Ic courses.
Conclusions:Variations in the muscular course of the GON were common. Future studies correlating these findings with the anatomy in patients with occipital neuralgia may elucidate nerve courses vulnerable to nerve compression. This enhanced classification scheme describes the morphology in this region and allows more specific communications about GON variations.
In 2004, the International Headache Society[
Most commonly associated with occipital neuralgia is the greater occipital nerve (GON). The GON originates from the medial branch of the dorsal ramus of spinal nerve C2. After coursing backwards between the first and second vertebrae, the GON ascends between the inferior capitis oblique and the semispinalis capitismuscles.[
Most anatomic studies have focused on the subcutaneous course of the GON and its relationship to surrounding bony landmarks. As there is a lack of studies focused on the intramuscular course and relation of this nerve, the current study was undertaken with the hope of better understanding the anatomy of the nerve and potentially adding to our knowledge of its musculofibrous relationships in patients with occipital neuralgia. Additionally, since occipital neuralgia may occur after surgery of the upper cervical spine or posterior skull,[
While placed in the prone position, 15 adult formalin fixed cadavers (30 sides) underwent dissection of the bilateral posterior occiput with special attention to the intramuscular course of the GON. Ten specimens were male and five were female, with an average age at death of 72 years (range 44–90 years). No specimen was found to have had prior surgery or gross injury to the areas dissected. After removing the skin, we identified the nerves above the EOP and followed them deeply through succeeding muscle layers while documenting the exact relationship and point of emergence through these layers. Each nerve was followed deep to the inferior border of the suboccipital triangle. Nerves were typed based on their muscular course.
A GON was identified in all specimens. In general, the GON wrapped around the lower edge of the inferior capitis oblique muscle and ascended deep to the semispinalis muscle to pierce this muscle more superiorly near its attachment onto the occiput. At this point, the nerve traveled through the trapezius (type I; n = 5, 16.7%) or its aponeurosis (type II; n = 15, 83.3%) to become subcutaneous inferolateral to the EOP [
Schematic drawing of the GON in the occipital region. Note that the various muscular relationships with the GON, including an exit through the aponeurosis of the trapezius (right sides and type I GON), exit through the muscle of the trapezius (left sides and type II GON), exit through the tendinous intersection-left image/right side (type IIIa), and exit medial to the semispinalis capitis muscle-right image/right side (type III). Also, note that on the left figure, the GON pierces the inferior oblique muscle before ascending through the overlying muscles
In 1991, Bovim et al.[
Janis et al.[
Topographically, Mosser et al.[
Variations in the muscular course of the GON were often seen in our study. Future studies aimed at correlating these anatomic findings with the anatomy found in patients with occipital neuralgia may elucidate potential nerve courses that are more prone to nerve compression. Furthermore, the classification scheme described herein better describes the morphology in this region and will allow for more specific communication of variations of the muscular course of the GON.
The authors thank the individuals who generously donated their bodies to scientific research so that this cadaveric study could be conducted.
The authors declare no conflict of interest. No funding was received for this study.
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