|Year : 2013 | Volume
| Issue : 2 | Page : 103-107
Lateral atlanto-axial joint block for cervical headache
Shantanu P Mallick
Interventional Pain Physician, Dr. D. Y. Patil Hospital and Research Center, Nerul, Navi Mumbai, Maharashtra, India
|Date of Web Publication||4-Oct-2013|
Shantanu P Mallick
B-702, Chawla Plaza, PLST No 14 and 15, Sector-11, CBD Belapur, Navi Mumbai - 400 614, Maharashtra
Source of Support: None, Conflict of Interest: None
The patient is a 32-year-old car mechanic, having chronic headache for three years affecting the left upper lateral part of the neck, suboccipital region, and scalp (VAS: 8/10), having a history of whiplash injury from a car accident three years ago, with a deep cut injury on the scalp. He was complaining of neck stiffness and pain during all neck movements and a burning pain in the entire left side of the neck and scalp. He was treated, using conservative methods, by Orthopedists, Neurologists, as well as Psychiatrists, and all investigations including computed tomography (CT) of the brain, X-ray cervical spine, and all related blood reports were within normal limits. He was sent to the Pain Clinic for further assessment. Suspecting sympathetic mediated pain on the left side and upper cervical facet pain, he was given a diagnostic Stellate Ganglion Block, a Third Occipital Nerve block, and a fourth cervical medial branch block (MBB), which gave him good relief; by this the visual analog scale (VAS) score reduced to 3/10. Yet, he was complaining of pain on a focal area on the left upper cervical spine corresponding to the C1-2 joint with lateral rotation on the left side. Subsequently it was decided that a diagnostic Atlanto-axial joint block under fluoroscopy would be carried out. This gave him very good relief from the cervicogenic headache.
Keywords: Atlanto-axial joint, cervicogenic headache, intra-articular atlanto-axial joint injection
|How to cite this article:|
Mallick SP. Lateral atlanto-axial joint block for cervical headache. Indian J Pain 2013;27:103-7
| Introduction|| |
To every clinician, one of the most difficult problems is to diagnose head and neck pain. It has been proved several times in the last 30 years, that different diseases and injuries of the cervical spine cause neck pain and cervicogenic headaches, which also include the suboccipital muscles, C1-C2 nerve, C2-3 intervertebral disc, upper cervical ligaments, and the upper three synovial joints. ,, As there is no disc between the atlanto-occipital (AO) and the atlanto-axial (AA) level, the facet joints and numerous ligaments provide the only stability between the two bones, which are thought to possess the articular nociceptors and sensory afferents necessary to mediate the pain and facet syndrome.  It has been clearly documented that an intra-articular injection or denervation of the AA and AO joints under fluoroscopy with Local Anesthetics (LA) and steroid can give excellent pain relief in different pathological conditions. ,
| Case Report|| |
A 32-year-old old car mechanic suffering from chronic cervicogenic headache for three years, affecting the left upper lateral part of the neck, suboccipital region, and scalp, with a pain intensity of 8/10 (VAS) presented for treatment. He had a history of a car accident three ago, with a deep cut injury on the scalp. He complained of severe neck stiffness and pain during all neck movements and a burning pain on the entire left side of the neck and scalp. In spite of all conservative treatments by Orthopedists, Neurologists, as well as Psychiatrists, and all investigations including a CT of the brain, X-ray cervical spine, and all related blood reports being within normal limits, his complaints had not subsided. He was then sent to the Pain Clinic for further assessment.
Initially he was given diagnostic Stellate Ganglion Block and third occipital nerve (TON) and fourth cervical MBB, which gave him good relief and by which the VAS reduced to 3/10.
Even following this, he was complaining of pain on a focal area on the left suboccipital zone corresponding to the left C1-2 joint, with lateral rotation on the same side. Then it was decided to go for the diagnostic atlanto-axial joint block under fluoroscopy, which gave him good relief from the cervicogenic headache.
Excluding all red flags (Vascular, Inflammatory, Neoplastic, Degenerative, Infectious, Connective tissue disorders, Autoimmune disorders, Trauma, Endocrinopathies (VINDICATE-mnemonic), taking proper informed consent (risks, bleeding, total spinal, nerve injury, no pain relief), keeping proper resuscitation measures with monitor, antibiotics, and antiemetic prophylaxis, the patient was lying prone with a pillow below his chest and a support below the forehead in such a way that he could open his mouth comfortably to show the atlanto-axial joint.
First, in the PA view [Figure 1], after seeing the joint clearly by keeping the fluoroscopic C-arm in a slight caudal tilt, divide the joint into three quadrants; the entry point will be on the lateral one-third of the joint [Figure 2]. The entry point may come at the lower part of the hairy-scalp, but no shaving is required, mainly for males. Locally anesthetize the entry point, a 25 g 10 cm LP needle is inserted in a tunnel view and a pop will be felt after piercing the thick capsule of the joint, which is also confirmed by the lateral view [Figure 3]. Then a small amount (not more than 0.3 ml) of radio-opaque contrast is injected into the joint under continuous fluoroscopy, to see the spread into the joint or inadvertent vascular or intrathecal entry. In the AP view [Figure 4], the transverse spread across the joint as well as the medial and lateral joint capsule is filled. This also is confirmed by the lateral view [Figure 5] and a small amount (<1 ml) of mixed solution of LA + steroid is injected into the joint.
Post procedure, the patient was monitored for 30 minutes. There was no complaint of ataxia or any other unwanted complication. The patient was comfortable and the pain reduced with lateral rotation of the neck. He was discharged after one hour. On the follow-up, after two weeks, he was quiet comfortable.
| Discussion|| |
Atlanto-axial is the joint of 'negative expression,' because that is the motion that allows the head to make a lateral rotation. On the contrary Atlanto-occipital is a joint of 'Yes,' nodding, where the movement is forward and backward bending. On account of the close proximity of the vital structures, this block should be restricted not only to patients who really need it, but also to experienced hands.
From the beginning of the 1980s, it was believed that there was an involvement of the cervical facet joint in neck pain and cervicogenic pain [Figure 6]. Bogduk described the C2 spinal nerve block, which was the main supply for this joint.  Ehni and Benner described the AA periarticular block for arthritic pain. McCormick had given the first intra-articular block in the late 1980s. 
Atlanto-axial joint anatomy itself also provides a lot of information in the treatment of headaches, dizziness, and severe neck pain. The spinal cord, perhaps the most sensitive tissue in the body, passes down through the Atlas More Details and Axis, carrying vital information to and from the body. On account of this intimate relationship in the Atlanto-axial joint anatomy, subluxations of the Atlas have a profoundly negative effect on the body.
As there is no disc between the AO and the AA level, the facet joints and numerous ligaments provide the only stability between the two bones, which are thought to possess the articular nociceptors and sensory afferents necessary to mediate the pain and facet syndrome. There are two atlanto-axial joints: Median and lateral:  The median atlanto-axial joint is sometimes considered a double joint:  One between the posterior surface of the anterior arch of the Atlas and the front of the odontoid process and one between the anterior surface of the Transverse Ligament of the Atlas (TLA) and the back of the odontoid process. The position of the dens is maintained by the transverse ligaments of the Axis. Another pair of alar ligaments attach the dens to the occipital condyle of the rear skull and Atlas, preventing over-rotation within the atlanto-axial joint. The alar ligaments are stretched during flexion and relax on extension of the head. Usually a bursa intervenes between the dens and the transverse ligament, protecting the TLA from erosion, with continuous lateral rotation. ,
Two lateral atlanto-axial joints complement the median atlanto-axial joint. On each of these, the inferior articulate facet of the Atlas pivots on the superior articulate facet of the Axis. The concave shape of the Atlas perfectly cups the convex Axis, and loose, capsular ligaments allow the back and forth gliding during rotation of the Atlas (arthrodial or gliding joint). Additionally, the lateral atlanto-axial joints help to transfer the weight of the skull from the atlanto-occipital joint.
Both the atlanto-occipital and lateral atlanto-axial joints are morphologically equivalent to the uncovertebral joints of the lower cervical vertebrae. ,,
The obliquus capitis inferior, splenius capitis, and rectus capitis, posterior major muscles of one side of the body, work in tandem with the sternocleidomastoid of the other side, to control motion of the atlanto-axial joint. That is why a spasm in these muscles can also create symptoms of cervicogenic headache. Along with the alar ligaments, these muscles also prevent over-rotation of the joint. ,
The vertebral artery is lying lateral to the C1-C2 joint, which is protected from the sharp osseous surface of the lateral joint by a pericapsular soft tissue. In old age, with severe degenerative changes, its course may vary. Neck pain may be associated with vertebrobasilar artery insufficiency, with or without head turning, which creates symptoms like headache, lightheadedness, dizziness, vertigo, facial numbness, nausea, vomiting, blurred vision, diplopia, dysphagia, gait abnormality, and tongue symptoms. 
The articular cartilage is quiet thick, 1.4 to 3.2 mm, and accommodates large, intra-articular menisci emerging from the flaccid roomy joint capsule. Sometimes degeneration of this menisci causes sharp local catching pain. ,
The lateral atlanto-axial joint was shown to be extensively supplied by the articular branches of the C2 nerve elements (dorsal ganglion, spinal nerve, and ventral ramus). That is why a local anesthetic injection at the C2 nerve could be of benefit in the relief of occipital pain due to cervical trauma or degenerative disease involving the lateral atlanto-axial joint. 
The AA joint has a wide range of motion on all articulation in the neck, which does not happen at other vertebral levels. Rotation around the axis through the dens is limited to 40-45 degrees to each side, but it allows only 5-10 degrees of flexion or extension. The most interesting point is, during rightward rotation, the inferior articular surface of C1 translates posterior on the right articular surface of C2. Then on the articular surface of left side C1vertebra translates anterior and slight caudal on articular surface of C2 vertebra due to convex-convex relationship of the joint. ,
The pain pattern is different from other cervical facet pain. It is a focal pain around the joint area during lateral rotation of the neck on the same side. 
The following complications may occur during this block: 
On account of its proximity to the brain stem and importance in stabilization, fracture or injury at this level can be catastrophic. The common trauma and pathologies include: ,
- Penetration into the subarachnoid space
- Injury to the nerve roots
- Injury to the spinal cord
- Total spinal
- Inadvertent vertebral injection of non-particulate steroids or LA
- Drug reactions
In spite of having problems in this area, the patient may be relatively asymptomatic because of the Steele Rule of thirds.
- Fracture of the dens
- Rupture of the transverse ligament of the Atlas
- Down syndrome exhibits laxity or agenesis of the ligament.
- Rupture of the alar ligaments
- Compression of the C2 spinal ganglion, with severe lateral rotation in the hyperextended state, which may cause prolonged severe headaches and excruciating cervico-occipital pain.
- Death by judicial hanging may be due to a rupture of the transverse ligament of the Atlas or fracture of the dens of the Axis. As a result, the Atlas is dislocated from the Axis and compresses the spinal cord with a fatal outcome.
Approximately one-third of the Atlas ring is occupied by the dens, one-third by the spinal cord, and the remaining third by the free fluid space and tissues surrounding the cord: Steele Rule of Thirds. 
This is the reason why some patients with anterior displacement of the Atlas may be relatively asymptomatic until a large degree of movement (greater than one-third of the diameter of the atlas ring) occurs.
The extent and duration of pain relief may vary from a few weeks to several months according to the inflammation and co-existing factors. It has been reported that long-term pain relief is achieved in patients with cervicogenic headaches after pulsed radiofrequency application into the lateral atlanto-axial (C1-2) joint. 
Post-procedure, the patient may feel ataxia for some time. If no other complication occurs, the patient can be discharged after one hour. If there is no pain relief we should search for other causes. If pain relief exists we should monitor the patient for a specific period. 
Although the block technique is mostly preferred in a prone position and PA view, some institutes also prefer to do using the lateral approach [Figure 7]. During this technique, the patient is kept in a lateral position and the needle entry point is at the anterior one-third of the joint. 
| Conclusion|| |
The lateral atlanto-axial joint is one of the most important structures involved in the pathogenesis of an occipital headache. Several studies have demonstrated that injection of this joint with local anesthetic can alleviate occipital headaches and for long-term relief even Intra-articular Pulse Radiofrequency or C2 nerve root block can be tried. Although the atlanto-axial joint intra-articular injection or C2 denervation is an OPD procedure, selecting patients and the skill and experience of the interventionist have to be kept in mind.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]