Introduction

Occipital nerve blocks are routinely performed for the treatment of various headache disorders. Occipital neuralgia commonly presents as sharp, shooting, unilateral pain that lasts for a few seconds to hours. When conventional medications no longer work for recurring attacks, using minimally invasive methods such as occipital nerve blocks can become a viable option to relieve pain. Occipital nerve blocks offer several advantages. They can be performed in the outpatient setting, do not require sedation or significant pre-procedural planning, and generally carry a low risk of complications. The targeted nerves, the greater occipital and lesser occipital nerve, can be reached using anatomical landmarks or, in rare cases, using imaging such as fluoroscopy and ultrasound. Here we present a case of an occipital nerve block procedure inadvertently leading to the discovery of a high-grade neoplasm.

Materials and Methods

• Our patient is a 78-year-old female who presented to the pain clinic for chief complaint of headache for 2 years. The pain was moderate to severe intensity, originated from the left > right occipital region and would radiate superiorly and anteriorly. It was sharp/shooting/stabbing in quality and would typically manifest within a few hours after waking.

• She was diagnosed with occipital neuralgia by an outside provider and had undergone two left occipital nerve blocks, with significant but temporary relief.

• The patient was evaluated by neurology at our institution, who concurred with the diagnosis of left > right occipital neuralgia and was referred to the pain clinic for bilateral occipital nerve blocks.

• Occipital nerve block with 10% lidocaine under fluoroscopic guidance was planned. Using standard protocol, a 25-gauge, 1.5-inch needle was advanced approximately 0.50 inches on the left, but no contact was made with the occipital bone. The thickness of the scalp was re-evaluated by palpation over the targeted area and was normal.

• A lateral X-ray was taken to assess the distance between the needle tip and the periosteum and demonstrated an abnormal appearance of the occipital bone suspicious for a lytic lesion. Due to this finding, the procedure was aborted.