Overview

Low paraspinal cervical injections are thought to work through the dorsal root fibers of the cervical spine by downregulating the trigeminocervical complex efferent output to the higher cortical levels.^1-7 Figure 1

Indications

Headache

Migraine

Orofacial Pain

Trigeminal Neuralgia

Contraindications

Fever

Traumatic Headache

Suspicion for SAH

Meningismus or suspicion of meningitis

Altered Mental Status

Focal Neuro Deficits

Procedure & Administration

With the patient in a seated position, locate the prominent spinous process of C7.

Mark 1 inch lateral to the spinous process on both sides, being sure to stay over the belly of the trapezius muscle overlying the transverse process.

Clean the area with an alcohol swab/chlorhexidine.

Fill a 3-cc syringe with 0.5% bupivacaine.

Using a 1.5-in 23- or 25-gauge needle, inject at your marked location 2 to 3 cm deep, making sure your needle entry is parallel to the floor.

Aspirate to confirm you are not in a vessel. Then inject 1.5 mL of bupivacaine.

Repeat this process at the other marked site.

Withdraw the needle. Then compress and massage the injection site to both stop bleeding and help diffuse the local anesthetic into the tissue.

Dress each site.

Complications

Local site irritation

Muscle soreness at site

Discharge Procedure

Patient should be instructed they may have soreness at the injection site.

Where to Learn More

Paraspinous Block for Headache in ED - Video

References

1. Mellick GA, Mellick LB. Lower cervical injections for headache relief. Letter. Headache. 2001 Nov–Dec;41(10):992–4.
2. Mellick GA, Mellick LB. Regional head and face pain relief following lower cervical intramuscular anesthetic injection. Headache. 2003 Nov–Dec;43(10):1109–11.
3. Noseida R, Burstein R. Migraine pathophysiology: anatomy of the trigeminovascular pathway and associated neurological symptoms, CSD, sensitization and modulation of pain. Pain. 2013 Dec;154 Suppl 1.
4. Mellick GA, Mellick LB. Lower cervical intramuscular bupivacaine injections – another treatment option for headaches. Business Briefing: Emergency Medicine Review. 2005; 39–42.
5. 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):1441–9.
6. Hipskind J. Paraspinous cervical nerve block for primary headache. Emerg Med. 2017 April; 49(4):162–5.
7. Bond C. 2014. Paraspinous cervical block for headache.