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POST-TRAUMATIC OCCIPITAL HEADACHE
6 General and the Controller of H.M. Stationery Office for fig. 3; and to Dr. Maynard Smith and the Ciba Foundation and Messrs. Churchill for fig. 4.
cal intervertebral space. Distressing pain in the occipital region may persist after the healing of fractures of the odontoid peg. The pain will in all cases be referred through the recurrent branches and medial branches of the posterior primary divisions of the spinal nerves which constitute the nerve-supply for all the affected structures. Pederson et al. (1956) showed that the recurrent branch of the spinal nerve, after entering the spinal canal, passes towards the
REFERENCES
Comfort, A. (1956) The Biology of Senescence. London. Jacobs, P. A., Court Brown, W. M., Doll, R. (1961) Nature, Lond., 191, 1178. Medawar, P. B. (1952) An Unsolved Problem of Biology. London. Penrose, L. S., Delhanty, J. D. A. (1961) Lancet, i, 1261. Platt, R. (1956) ibid. i, 61. (1962) Trans. Med. Soc. Lond. 1962. Sonneborn, T. (1955) Cited in Lancet, i, 656. Tanner, J. M. (1962) Growth at Adolescence. Oxford. Welford, A. T. (1962) Lancet, i, 335. —
posterior longitudinal ligament, giving filaments to the ligaments, periosteum, epidural blood-vessels, and dura mater. The posterior primary divisions pass backwards through the intertransverse connective tissue, and then they divide into
All other scientific references and sources are to be found in the Ciba Foundation " Colloquia on Ageing ". Volumes 1, 2, and 5. Published in London by Messrs. Churchill.
medial and lateral divisions. Of these, the medial descends on the posterior aspect of the transverse process to supply the interneural articulations, and then it continues downwards, * POST-TRAUMATIC OCCIPITAL HEADACHE ramifying in the muscles, lying next to the lamina,. and anastomising with the branches from other levels; finally it GEOFFREY KNIGHT follows the inferior border of the spinous processes almost to M.B. Lond., F.R.C.S. the midline to supply the interspinous ligaments. In this posiCONSULTING NEUROLOGICAL SURGEON, tion the terminal branches of the medial divisions are prone to MEDICAL OF POSTGRADUATE SCHOOL LONDON, W.12 injury as they run along the lower margin of the spinal tip where RECURRENT occipital headaches which spread to the they may be involved in chip fractures of the spinal tips or vertex and forward to the region of the eye or temple are tears of the interspinous ligaments. Experimental stimulation of these branches causes widespread muscle spasm and changes a common sequel of head injury and of whiplash injuries of the cervical spine. This pain, which is referred from in blood-pressure and respiration, indicating the presence of strains inflicted on the upper cervical joints and ligaments, pain fibres which may readily give rise to referred pain and responds well to local treatment. But, because the head- muscle spasm. Post-traumatic occipital headache from local strains is often ache commonly follows minor or major concussion, it is referred through the posterior primary division of the 2nd usually regarded as part of a post-concussional state, and cervical nerve or the great occipital nerve, which is the largest no specific treatment is adopted; in certain patients primary division in the body. Hunter and Mayfield secondary depressive features may then develop owing to posterior (1949), however, suggest that the pain results from a traumatic the worry of their continuing pain. neuritis produced by contusion of the great occipital nerve Patients with evidence of anxiety and depression who between the posterior arches of the atlas and axis, which complain of an almost constant pain in the absence of become approximated when the head is hyperextended and notable physical signs may be regarded as neurotics and rotated. From a series of dissections they have shown that referred for psychiatric treatment, or the diagnosis may rotation of the head produces a movement in which the inferior be confused with post-traumatic migraine. The syndrome atlantal facet on the side to which the head is turned slides towards the midline until it almost impinges on the arch of the is common and its frequency appears to be increasing with axis. They suggest that if unusual force were applied in this the rise in road accidents. position, or if the nerve ran an aberrant course, crush injury of Referred pain of spinal origin should be suspected when the nerve could occur at this site. On the opposite side the í chronic pain in the region of the eye or temple, with or arches of atlas and axis are in contact for a distance of 25 mm. without pain in the back of the head, follows upon an from the midline of the axis, and they could potentially com-i emerging posterior primary ramus. Within the normal i injury in which the neck has been forcibly hyperextended press the of movements the 2nd cervical nerve is not vulnerable to range in the brow or flexed (e.g., those who fall and strike but Hunter and Mayfield suggest that the essential against a wall or who slip and strike the back of the head; trauma, cause of post-traumatic occipital headache is a contusion of the v against a skirting without being rendered unconscious, or nerve produced by the application of added force to the neckI in those who are knocked against the windscreen or when it is already at the limit of its normal range in the hypersubjected to whiplash injuries in motorcar accidents, withLextended position. This explanation, which may apply in or without sustaining concussion). It should be particucertain circumstances, can only be acceptable when such a when a headache a follows very large larly suspected veryposition is in fact produced; yet we see exactly the same small injury. Hyperextension or flexion of the neck: syndrome in head injuries which have only caused a sudden sufficient to strain the cervical spinal joints or ligaments; sharp flexion of the neck, and also in cases of high cervical accompanies many blows upon the brow or occiput,, arthritis where there has been no traumatic incident. Pain felt deeply in or around the eye or in the temple is including the forward lurch and recoil of a passenger’s; very common and may lead to confusion in diagnosis. body in motorcar accidents. .
I
.
Referred pain may arise from a variety of causes: from1 interspinous ligament injury, from strains on the interneural and intervertebral joints, or from the exacerbation1 of a preceding cervical spondylosis. Cervical spondylosis, however, is so often symptomless that its presence must not be accepted as providing the undoubted cause of symptoms ; it may merely alter the mechanism of injury in such1 a way as to cause stress to fall on other joints elsewhere, usually at a higher level. Occipital pain is often seen in association with obvious disc degeneration at the 5/6 cervi-* Part of a paper on Referred Pain of Spinal Origin read to the Society of British Neurological Surgeons, at Swansea in November, 1960. -
-
.
-
Zander’s (1897) anatomical dissections have shown that filaments of the cervical nerves can be encountered in all but the central portions of the face, which Lewy (1938) has termed the pure trigeminal field. As Sherrington 1898) showed in the macaque monkey, there is a considerable overlap of the trigeminal areas by cervical segments; and there are therefore appropriate peripheral anatomical pathways by which pain from the cervical region may reach the trigeminal areas without the necessity of invoking complex mechanisms within the brain-stem, though ascending fibres from the upper cervical region dorsomedially to the spinal tract of the 5th nerve in the medulla.
(1893,
Le npass
7
Clinical Features Difficulties in diagnosis seem to arise for three reasons: because the pain is often experienced in and around the eye, because a long-lasting headache should complicate so small an injury, and because the headache appears at first to be increased by mental concentration. Usually chronic pain or discomfort appears intermittently in the suboccipital region and it may or may not be made worse by resting the back of the head on a pillow or chair. It may be increased by any form of exercise or by placing the head in certain maintained postures, such as in reversing a car, watching television or looking up at a theatre stage. In other cases continued flexion of the neck will provoke it; and, because the neck is normally bent, when one concentrates on reading or writing, the complaint is often that of a post-traumatic headache made worse by mental concentration. As the pain increases in severity it passes up to the vertex or through to the temporal region or the region around or deeply in the eye, usually on one side but sometimes on both. Cases in which the pain around the eye is the predominant feature with little pain at the back of the neck may be confusing. Some patients experience a tingling sensation in the occipital region of the scalp as the
pain increases, and occasionally vertiginous symptoms appear at the climax of the pain. Vertigo often accompanies cervical spinal lesions; in some cases a feeling of slight instability and disequilibrium is more or less always present (the patient describes this as a muzzy feeling), but it disappears rapidly after successful treatment. Physical examination usually shows no reduction in sensation in the scalp, but pressure on the greater occipital nerves or on one or both sides is unusually painful and reproduces the pain in the area of which complaint is made. In other
midline pressure over the upper interspinous ligaments will excite pain with or without associated tenderness over the nerves. This tenderness is in all cases sharply localised over a definite point, and it is commonly unilateral. These findings are unlike those in neurotics, whose wrinkled brow and over-contracting occipitofrontalis muscle may produce occipital and vertical tension headache, but in whom, if tenderness is present at all, it is ill localised and diffuse. Contralateral rotation and extension of the neck, which stretches the occipital nerve, will reproduce the pain on one side in certain cases, but by no means in all. There is a definite group of " organic neuroses " in which post-traumatic head pain of organic origin is mistakenly given a psychiatric label. Other well-known examples arise from a contusion of the supraorbital or auriculotemporal nerves or from involvement of these branches in scar tissue, but the most common are undoubtedly cases of referred occipital pain of spinal origin. Because the headache is almost always present and builds up to a throbbing pain on moderate activity, and because the patient often becomes dizzy at the climax of the pain and has no physical signs other than occipital tenderness, these patients are often diagnosed as having tension headaches or post-traumatic neurasthenia, and indeed cases
many become neurotic
owing
to
the worry of their
persistent pain. Illustrative Case-reports Case 1.-A doctor’s wife, who had had persistent pain for 3 years after a car accident, was diagnosed at a well-known hospital as having a chronic depression. She was referred to the psychiatric department where treatment with electroconvulsive
threatened when no success had resulted from with tranquillising drugs. Her pain was relieved in 3 weeks by a series of injections of local anaesthetic around the occipital nerve. The diagnosis of neurosis was thought to be supported by the fact that the patient could not sit in the theatre stalls looking up at the stage without developing increasing headache which would eventually lead to giddiness, nor could she look down from the circle in comfort for any length of time. The pain was also increased by riding in a car and by bending her head over the sink. Finally the limitations of her activities produced a secondary superimposed depression which recovered rapidly when the causative factor was removed. Case 2.-A man who had acute pain caused by striking his head in a crashing van (without being concussed) spent 6 months in a well-known psychiatric outpatient department without benefiting from psychotherapy. After long unemployment, he fell so behind with his hire-purchase agreements that he became seriously depressed and sought admission to a mental hospital as a voluntary patient, where he remained for 4 months.
therapy lengthy
was
treatment
After serious head injuries the syndrome may at first be masked by a coexistent post-concussional state, but it may remain as a cause of persistent disability after the postconcussional features themselves have resolved: Case 3.-A company director, aged 44, who was involved in car accident in 1957, sustained cerebral contusion with 2 hours’ post-traumatic amnesia, multiple superficial glass injuries of the face and nose, bruising of the chest, whiplash injury of the cervical spine, and a lumbar sprung back. After a few days’ rest he attempted to resume work, and he struggled on for 6 weeks despite the difficulty in concentrating and lack of drive which resulted from his cerebral injury. A constant dull ache developed in the occipital region, his neck felt stiff, and he had severe pain in the eyes whenever he attempted to concentrate. He became increasingly depressed, and he was regarded as having a nervous breakdown for which he was admitted to a private institution for 12 months. At the end of this his post-contusional syndrome had improved, but for 18 months more he continued to have pain and tenderness in the neck and occiput which was increased by mental concentration and by driving, and which made it difficult for him to obtain fresh employment. He complained of lapses of memory and terrible headaches whenever he concentrated or if he attempted to travel far. Examination revealed tenderness over the great occipital nerves. Treatment by massage, manipulation, and heat had no effect, and finally, some 3 years after the injury, a right occipital neurectomy was performed. The response was extremely satisfactory; not only were the constant headaches relieved but the patient was able to do more work and to travel, and this alleviated his depression. Minor confusion and depression appeared on extreme fatigue only. a
Treatment and Results In mild cases the pain subsides spontaneously within a matter of weeks. In the early stages manipulation or stretching of the cervical spine sometimes produces rapid improvement, presumably from repositioning of a displaced joint which relieves the stretch on some deeply situated ligament or joint capsule. When the pain has become chronic it will often respond to repeated injections of 2% procaine given around the great occipital nerves low down in their course on one or both sides, or into the upper interspinous ligaments if these are tender, or at both these sites. But these injections must be repeated daily for a short period. Patients who are working can be admitted to hospital over a long weekend and given a series of injections on 5 consecutive days, from Thursday to the Monday. Many successes have resulted. It may be that the injections, by abolishing pain, relax reflex muscle spasm and thus allow a displaced joint to be replaced. (One patient, after a series of injections,
8 tuined his head suddenly and felt a slight " click ", and he was immediately relieved of discomfort.) The response varies from patient to patient from complete relief to slight improvement, but success is unlikely in those with
much osteoarthritis. Some patients complain of a spell of giddiness immediately after the injection treatment: Case 4.-A crane driver, aged 35, had had intermittent typical right-sided occipital pain spreading in the distribution of the great occipital nerve to a point above the eye for 18 months after he had sustained a blow on the right side of the face from a crane hook. Some days he was free of it, but he had had to have 10 days off work on account of severe episodes. In bad phases, when the pain lasted for several days at a time, he gradually became depressed; when the pain went off it left him with a heavy " head " like a haze ", which lasted for 2-3 days. A series of injections produced complete relief of the pain, but for 2 weeks after the final injection he continued to have giddiness, which prevented him from returning to work. On recovery, however, his head felt much clearer; he no longer had the " muzzy feelings " in his head which were part of the general disequilibrium produced by abnormal cervical "
stimulation.
Complete relief of referred pain may likewise result from injections of the interspinous ligaments alone, and the effects of injections into the cervical ligaments are far more lasting than those in the lumbar region, probably because lesser strains
are
involved:
Case 5.-A van driver had been sitting in a stationary van when it was struck from behind: " My head snapped back to my shoulders, the van ran forward and struck the car ahead, and my head came back again quickly ". Thereafter increasing pain developed in his neck and shoulders, and within 11 days he had to give up work because of terrific pain in the back of the heaçi at the end of a day’s work. Incomplete relief followed a week’s bed rest in hospital. He tried to resume work but he had to give up after 3 days because jolting of the car, acceleration, or deceleration would hurt his neck. Physiotherapy gave no relief, and 3 months after the injury he was given a supporting collar which he wore night and day for the next year while working as a storekeeper. The pain in his lower neck and shoulders subsided, but he continued to have " pressure " in the back of his head, and he could drive the car only with his collar on. Physical examination revealed tenderness of the interspinous ligaments between the 3/4 cervical spines. Before settlement of his compensation claim a series of 5 injections was given into the upper interspinous ligaments; all his pain was completely relieved, he discarded his collar, and he was able to drive his car without discomfort on holiday.
described as a headache, radiating to the forehead in the distribution of the right great occipital nerve; the pain was only relieved for an hour by taking medicine. She had become very depressed over the continued pain, and she had lost weight from 111/xto 10 stones. Examination revealed tenderness over the upper interspinous ligaments and right great occipital nerve. Injections at this site produced temporary relief of pain followed by early recurrence as the anaesthetic effect wore off. Accordingly, the right occipital nerve was excised. 3 months later the patient reported occasional tingling only in the anesthetic area and occasional stiff necks. She was sleeping well and had gained 1 stone in weight.
There are definite advantages in using a vertical incision the line of the nerve so that the lateral division can be easily identified if it happens to originate at an abnormally low level. At operation the nerve is identified as it emerges from the occipital muscle and traced down through this muscle to be divided below the point of origin of the lateral branch. In one or two cases where a transverse incision has been employed the lateral division was not identified and pain persisted behind the ear until it was relieved by excision of the lateral branch at a later date. In the majority of cases the operation causes no inconvenience though a few patients complain of a feeling of soreness or tingling of the scalp at the upper margin of the ancesthetic area. This peripheral operation has been performed with success in more than twenty cases. The response is interesting in that the site of the nerve division is distal to that from which referred pain originates. Pain of a similar character which arises independently of trauma in cervical spondylosis can also be relieved by excision of the great occipital nerve and its branches, again distal to the site of the causative lesion. Perhaps, in these cases, the effect is produced by abolition of muscle spasm; but alternatively the observations may support the view that, for referred pain to be appreciated, the area of skin to which the pain is referred must receive an innervation (Weiss and Davis 1928). over
REFERENCES
Hunter, C., Mayfield, F. (1949) Amer. J. Surg. 78, 743. Lewy, F. H. (1938) Amer. J. med. Sci. 196, 564. Pedersen, H. E., Blunck, C. F. S., Gardner, E. (1956) J. Bone Jt Surg. 38, 377. Sherrington, C. S. (1893) Phil. Trans. 184, 641. (1898) ibid. 190B, 45. Weiss, S., Davis, D. (1928) Amer. J. med. Sci. 176, 517. Zander, R. (1897) Arb. anat. Inst., Wiesbaden, 9, 2. —
THE ROUTINE USE OF 132I IN THE DIAGNOSIS OF THYROID DISEASE
-
In other cases, injections cause only temporary relief for hour or two at a time, and as the anxsthetic effect wears off the pain recurs. When this positive response is obtained, pain may then be relieved by excision of the great occipital nerve on one or both sides, as required: an
Case 6.-A housewife of 53, employed as a cashier in a butcher’s shop, was struck on the vertex by a falling leg of " I felt a terrible crunch in my neck, mutton weighing 8 lb. : my glasses fell off, and I was dazed ". That night pain developed all down her neck and spread to the vertex and the region around the right eye, and this became increasingly severe in the following week. X-rays showed cervical spondylosis. For a year she was treated with drugs. Physiotherapy relieved the pain in the lower part of her neck for 1 or 2 days at a time before it recurred, but the occipital referred pain persisted unchanged. She had to lie flat in bed at night because flexion of the neck made her pain worse. Every morning she woke with a dull pain at the top of her neck, and this would increase steadily throughout the day. She could not have her hair washed by a hairdresser because hyperextension of the neck made the pain worse, nor could she look up without discomfort. The pain in the occipital region was associated with what she
J. R. HOBBS M.B., B.Sc. Lond., M.R.C.P. REGISTRAR IN CHEMICAL
PATHOLOGY *
R. I. S. BAYLISS M.A., M.D. Cantab., F.R.C.P. PHYSICIAN
N. F. MACLAGAN M.D., D.Sc. Lond., F.R.C.P. PROFESSOR OF CHEMICAL PATHOLOGY
S.W.1 DURING the past twenty years the popularity of 1311 for = the study of thyroid function has been so great that the use of other isotopes of iodine has been relatively neglected, and the diagnostic possibilities of 1321 have not received adequate attention. Although this isotope became readily available some four years ago, and a number of reports on its diagnostic value have appeared (Goolden and Mallard 1958, Halnan 1958, Halnan and Pochin 1958), recent
WESTMINSTER HOSPITAL AND MEDICAL SCHOOL, LONDON,
*
Present address:
Royal
Free
Hospital, Gray’s Inn Road, London,
W.C.1.
cal intervertebral space. Distressing pain in the occipital region may persist after the healing of fractures of the odontoid peg. The pain will in all cases be referred through the recurrent branches and medial branches of the posterior primary divisions of the spinal nerves which constitute the nerve-supply for all the affected structures. Pederson et al. (1956) showed that the recurrent branch of the spinal nerve, after entering the spinal canal, passes towards the
REFERENCES
Comfort, A. (1956) The Biology of Senescence. London. Jacobs, P. A., Court Brown, W. M., Doll, R. (1961) Nature, Lond., 191, 1178. Medawar, P. B. (1952) An Unsolved Problem of Biology. London. Penrose, L. S., Delhanty, J. D. A. (1961) Lancet, i, 1261. Platt, R. (1956) ibid. i, 61. (1962) Trans. Med. Soc. Lond. 1962. Sonneborn, T. (1955) Cited in Lancet, i, 656. Tanner, J. M. (1962) Growth at Adolescence. Oxford. Welford, A. T. (1962) Lancet, i, 335. —
posterior longitudinal ligament, giving filaments to the ligaments, periosteum, epidural blood-vessels, and dura mater. The posterior primary divisions pass backwards through the intertransverse connective tissue, and then they divide into
All other scientific references and sources are to be found in the Ciba Foundation " Colloquia on Ageing ". Volumes 1, 2, and 5. Published in London by Messrs. Churchill.
medial and lateral divisions. Of these, the medial descends on the posterior aspect of the transverse process to supply the interneural articulations, and then it continues downwards, * POST-TRAUMATIC OCCIPITAL HEADACHE ramifying in the muscles, lying next to the lamina,. and anastomising with the branches from other levels; finally it GEOFFREY KNIGHT follows the inferior border of the spinous processes almost to M.B. Lond., F.R.C.S. the midline to supply the interspinous ligaments. In this posiCONSULTING NEUROLOGICAL SURGEON, tion the terminal branches of the medial divisions are prone to MEDICAL OF POSTGRADUATE SCHOOL LONDON, W.12 injury as they run along the lower margin of the spinal tip where RECURRENT occipital headaches which spread to the they may be involved in chip fractures of the spinal tips or vertex and forward to the region of the eye or temple are tears of the interspinous ligaments. Experimental stimulation of these branches causes widespread muscle spasm and changes a common sequel of head injury and of whiplash injuries of the cervical spine. This pain, which is referred from in blood-pressure and respiration, indicating the presence of strains inflicted on the upper cervical joints and ligaments, pain fibres which may readily give rise to referred pain and responds well to local treatment. But, because the head- muscle spasm. Post-traumatic occipital headache from local strains is often ache commonly follows minor or major concussion, it is referred through the posterior primary division of the 2nd usually regarded as part of a post-concussional state, and cervical nerve or the great occipital nerve, which is the largest no specific treatment is adopted; in certain patients primary division in the body. Hunter and Mayfield secondary depressive features may then develop owing to posterior (1949), however, suggest that the pain results from a traumatic the worry of their continuing pain. neuritis produced by contusion of the great occipital nerve Patients with evidence of anxiety and depression who between the posterior arches of the atlas and axis, which complain of an almost constant pain in the absence of become approximated when the head is hyperextended and notable physical signs may be regarded as neurotics and rotated. From a series of dissections they have shown that referred for psychiatric treatment, or the diagnosis may rotation of the head produces a movement in which the inferior be confused with post-traumatic migraine. The syndrome atlantal facet on the side to which the head is turned slides towards the midline until it almost impinges on the arch of the is common and its frequency appears to be increasing with axis. They suggest that if unusual force were applied in this the rise in road accidents. position, or if the nerve ran an aberrant course, crush injury of Referred pain of spinal origin should be suspected when the nerve could occur at this site. On the opposite side the í chronic pain in the region of the eye or temple, with or arches of atlas and axis are in contact for a distance of 25 mm. without pain in the back of the head, follows upon an from the midline of the axis, and they could potentially com-i emerging posterior primary ramus. Within the normal i injury in which the neck has been forcibly hyperextended press the of movements the 2nd cervical nerve is not vulnerable to range in the brow or flexed (e.g., those who fall and strike but Hunter and Mayfield suggest that the essential against a wall or who slip and strike the back of the head; trauma, cause of post-traumatic occipital headache is a contusion of the v against a skirting without being rendered unconscious, or nerve produced by the application of added force to the neckI in those who are knocked against the windscreen or when it is already at the limit of its normal range in the hypersubjected to whiplash injuries in motorcar accidents, withLextended position. This explanation, which may apply in or without sustaining concussion). It should be particucertain circumstances, can only be acceptable when such a when a headache a follows very large larly suspected veryposition is in fact produced; yet we see exactly the same small injury. Hyperextension or flexion of the neck: syndrome in head injuries which have only caused a sudden sufficient to strain the cervical spinal joints or ligaments; sharp flexion of the neck, and also in cases of high cervical accompanies many blows upon the brow or occiput,, arthritis where there has been no traumatic incident. Pain felt deeply in or around the eye or in the temple is including the forward lurch and recoil of a passenger’s; very common and may lead to confusion in diagnosis. body in motorcar accidents. .
I
.
Referred pain may arise from a variety of causes: from1 interspinous ligament injury, from strains on the interneural and intervertebral joints, or from the exacerbation1 of a preceding cervical spondylosis. Cervical spondylosis, however, is so often symptomless that its presence must not be accepted as providing the undoubted cause of symptoms ; it may merely alter the mechanism of injury in such1 a way as to cause stress to fall on other joints elsewhere, usually at a higher level. Occipital pain is often seen in association with obvious disc degeneration at the 5/6 cervi-* Part of a paper on Referred Pain of Spinal Origin read to the Society of British Neurological Surgeons, at Swansea in November, 1960. -
-
.
-
Zander’s (1897) anatomical dissections have shown that filaments of the cervical nerves can be encountered in all but the central portions of the face, which Lewy (1938) has termed the pure trigeminal field. As Sherrington 1898) showed in the macaque monkey, there is a considerable overlap of the trigeminal areas by cervical segments; and there are therefore appropriate peripheral anatomical pathways by which pain from the cervical region may reach the trigeminal areas without the necessity of invoking complex mechanisms within the brain-stem, though ascending fibres from the upper cervical region dorsomedially to the spinal tract of the 5th nerve in the medulla.
(1893,
Le npass
7
Clinical Features Difficulties in diagnosis seem to arise for three reasons: because the pain is often experienced in and around the eye, because a long-lasting headache should complicate so small an injury, and because the headache appears at first to be increased by mental concentration. Usually chronic pain or discomfort appears intermittently in the suboccipital region and it may or may not be made worse by resting the back of the head on a pillow or chair. It may be increased by any form of exercise or by placing the head in certain maintained postures, such as in reversing a car, watching television or looking up at a theatre stage. In other cases continued flexion of the neck will provoke it; and, because the neck is normally bent, when one concentrates on reading or writing, the complaint is often that of a post-traumatic headache made worse by mental concentration. As the pain increases in severity it passes up to the vertex or through to the temporal region or the region around or deeply in the eye, usually on one side but sometimes on both. Cases in which the pain around the eye is the predominant feature with little pain at the back of the neck may be confusing. Some patients experience a tingling sensation in the occipital region of the scalp as the
pain increases, and occasionally vertiginous symptoms appear at the climax of the pain. Vertigo often accompanies cervical spinal lesions; in some cases a feeling of slight instability and disequilibrium is more or less always present (the patient describes this as a muzzy feeling), but it disappears rapidly after successful treatment. Physical examination usually shows no reduction in sensation in the scalp, but pressure on the greater occipital nerves or on one or both sides is unusually painful and reproduces the pain in the area of which complaint is made. In other
midline pressure over the upper interspinous ligaments will excite pain with or without associated tenderness over the nerves. This tenderness is in all cases sharply localised over a definite point, and it is commonly unilateral. These findings are unlike those in neurotics, whose wrinkled brow and over-contracting occipitofrontalis muscle may produce occipital and vertical tension headache, but in whom, if tenderness is present at all, it is ill localised and diffuse. Contralateral rotation and extension of the neck, which stretches the occipital nerve, will reproduce the pain on one side in certain cases, but by no means in all. There is a definite group of " organic neuroses " in which post-traumatic head pain of organic origin is mistakenly given a psychiatric label. Other well-known examples arise from a contusion of the supraorbital or auriculotemporal nerves or from involvement of these branches in scar tissue, but the most common are undoubtedly cases of referred occipital pain of spinal origin. Because the headache is almost always present and builds up to a throbbing pain on moderate activity, and because the patient often becomes dizzy at the climax of the pain and has no physical signs other than occipital tenderness, these patients are often diagnosed as having tension headaches or post-traumatic neurasthenia, and indeed cases
many become neurotic
owing
to
the worry of their
persistent pain. Illustrative Case-reports Case 1.-A doctor’s wife, who had had persistent pain for 3 years after a car accident, was diagnosed at a well-known hospital as having a chronic depression. She was referred to the psychiatric department where treatment with electroconvulsive
threatened when no success had resulted from with tranquillising drugs. Her pain was relieved in 3 weeks by a series of injections of local anaesthetic around the occipital nerve. The diagnosis of neurosis was thought to be supported by the fact that the patient could not sit in the theatre stalls looking up at the stage without developing increasing headache which would eventually lead to giddiness, nor could she look down from the circle in comfort for any length of time. The pain was also increased by riding in a car and by bending her head over the sink. Finally the limitations of her activities produced a secondary superimposed depression which recovered rapidly when the causative factor was removed. Case 2.-A man who had acute pain caused by striking his head in a crashing van (without being concussed) spent 6 months in a well-known psychiatric outpatient department without benefiting from psychotherapy. After long unemployment, he fell so behind with his hire-purchase agreements that he became seriously depressed and sought admission to a mental hospital as a voluntary patient, where he remained for 4 months.
therapy lengthy
was
treatment
After serious head injuries the syndrome may at first be masked by a coexistent post-concussional state, but it may remain as a cause of persistent disability after the postconcussional features themselves have resolved: Case 3.-A company director, aged 44, who was involved in car accident in 1957, sustained cerebral contusion with 2 hours’ post-traumatic amnesia, multiple superficial glass injuries of the face and nose, bruising of the chest, whiplash injury of the cervical spine, and a lumbar sprung back. After a few days’ rest he attempted to resume work, and he struggled on for 6 weeks despite the difficulty in concentrating and lack of drive which resulted from his cerebral injury. A constant dull ache developed in the occipital region, his neck felt stiff, and he had severe pain in the eyes whenever he attempted to concentrate. He became increasingly depressed, and he was regarded as having a nervous breakdown for which he was admitted to a private institution for 12 months. At the end of this his post-contusional syndrome had improved, but for 18 months more he continued to have pain and tenderness in the neck and occiput which was increased by mental concentration and by driving, and which made it difficult for him to obtain fresh employment. He complained of lapses of memory and terrible headaches whenever he concentrated or if he attempted to travel far. Examination revealed tenderness over the great occipital nerves. Treatment by massage, manipulation, and heat had no effect, and finally, some 3 years after the injury, a right occipital neurectomy was performed. The response was extremely satisfactory; not only were the constant headaches relieved but the patient was able to do more work and to travel, and this alleviated his depression. Minor confusion and depression appeared on extreme fatigue only. a
Treatment and Results In mild cases the pain subsides spontaneously within a matter of weeks. In the early stages manipulation or stretching of the cervical spine sometimes produces rapid improvement, presumably from repositioning of a displaced joint which relieves the stretch on some deeply situated ligament or joint capsule. When the pain has become chronic it will often respond to repeated injections of 2% procaine given around the great occipital nerves low down in their course on one or both sides, or into the upper interspinous ligaments if these are tender, or at both these sites. But these injections must be repeated daily for a short period. Patients who are working can be admitted to hospital over a long weekend and given a series of injections on 5 consecutive days, from Thursday to the Monday. Many successes have resulted. It may be that the injections, by abolishing pain, relax reflex muscle spasm and thus allow a displaced joint to be replaced. (One patient, after a series of injections,
8 tuined his head suddenly and felt a slight " click ", and he was immediately relieved of discomfort.) The response varies from patient to patient from complete relief to slight improvement, but success is unlikely in those with
much osteoarthritis. Some patients complain of a spell of giddiness immediately after the injection treatment: Case 4.-A crane driver, aged 35, had had intermittent typical right-sided occipital pain spreading in the distribution of the great occipital nerve to a point above the eye for 18 months after he had sustained a blow on the right side of the face from a crane hook. Some days he was free of it, but he had had to have 10 days off work on account of severe episodes. In bad phases, when the pain lasted for several days at a time, he gradually became depressed; when the pain went off it left him with a heavy " head " like a haze ", which lasted for 2-3 days. A series of injections produced complete relief of the pain, but for 2 weeks after the final injection he continued to have giddiness, which prevented him from returning to work. On recovery, however, his head felt much clearer; he no longer had the " muzzy feelings " in his head which were part of the general disequilibrium produced by abnormal cervical "
stimulation.
Complete relief of referred pain may likewise result from injections of the interspinous ligaments alone, and the effects of injections into the cervical ligaments are far more lasting than those in the lumbar region, probably because lesser strains
are
involved:
Case 5.-A van driver had been sitting in a stationary van when it was struck from behind: " My head snapped back to my shoulders, the van ran forward and struck the car ahead, and my head came back again quickly ". Thereafter increasing pain developed in his neck and shoulders, and within 11 days he had to give up work because of terrific pain in the back of the heaçi at the end of a day’s work. Incomplete relief followed a week’s bed rest in hospital. He tried to resume work but he had to give up after 3 days because jolting of the car, acceleration, or deceleration would hurt his neck. Physiotherapy gave no relief, and 3 months after the injury he was given a supporting collar which he wore night and day for the next year while working as a storekeeper. The pain in his lower neck and shoulders subsided, but he continued to have " pressure " in the back of his head, and he could drive the car only with his collar on. Physical examination revealed tenderness of the interspinous ligaments between the 3/4 cervical spines. Before settlement of his compensation claim a series of 5 injections was given into the upper interspinous ligaments; all his pain was completely relieved, he discarded his collar, and he was able to drive his car without discomfort on holiday.
described as a headache, radiating to the forehead in the distribution of the right great occipital nerve; the pain was only relieved for an hour by taking medicine. She had become very depressed over the continued pain, and she had lost weight from 111/xto 10 stones. Examination revealed tenderness over the upper interspinous ligaments and right great occipital nerve. Injections at this site produced temporary relief of pain followed by early recurrence as the anaesthetic effect wore off. Accordingly, the right occipital nerve was excised. 3 months later the patient reported occasional tingling only in the anesthetic area and occasional stiff necks. She was sleeping well and had gained 1 stone in weight.
There are definite advantages in using a vertical incision the line of the nerve so that the lateral division can be easily identified if it happens to originate at an abnormally low level. At operation the nerve is identified as it emerges from the occipital muscle and traced down through this muscle to be divided below the point of origin of the lateral branch. In one or two cases where a transverse incision has been employed the lateral division was not identified and pain persisted behind the ear until it was relieved by excision of the lateral branch at a later date. In the majority of cases the operation causes no inconvenience though a few patients complain of a feeling of soreness or tingling of the scalp at the upper margin of the ancesthetic area. This peripheral operation has been performed with success in more than twenty cases. The response is interesting in that the site of the nerve division is distal to that from which referred pain originates. Pain of a similar character which arises independently of trauma in cervical spondylosis can also be relieved by excision of the great occipital nerve and its branches, again distal to the site of the causative lesion. Perhaps, in these cases, the effect is produced by abolition of muscle spasm; but alternatively the observations may support the view that, for referred pain to be appreciated, the area of skin to which the pain is referred must receive an innervation (Weiss and Davis 1928). over
REFERENCES
Hunter, C., Mayfield, F. (1949) Amer. J. Surg. 78, 743. Lewy, F. H. (1938) Amer. J. med. Sci. 196, 564. Pedersen, H. E., Blunck, C. F. S., Gardner, E. (1956) J. Bone Jt Surg. 38, 377. Sherrington, C. S. (1893) Phil. Trans. 184, 641. (1898) ibid. 190B, 45. Weiss, S., Davis, D. (1928) Amer. J. med. Sci. 176, 517. Zander, R. (1897) Arb. anat. Inst., Wiesbaden, 9, 2. —
THE ROUTINE USE OF 132I IN THE DIAGNOSIS OF THYROID DISEASE
-
In other cases, injections cause only temporary relief for hour or two at a time, and as the anxsthetic effect wears off the pain recurs. When this positive response is obtained, pain may then be relieved by excision of the great occipital nerve on one or both sides, as required: an
Case 6.-A housewife of 53, employed as a cashier in a butcher’s shop, was struck on the vertex by a falling leg of " I felt a terrible crunch in my neck, mutton weighing 8 lb. : my glasses fell off, and I was dazed ". That night pain developed all down her neck and spread to the vertex and the region around the right eye, and this became increasingly severe in the following week. X-rays showed cervical spondylosis. For a year she was treated with drugs. Physiotherapy relieved the pain in the lower part of her neck for 1 or 2 days at a time before it recurred, but the occipital referred pain persisted unchanged. She had to lie flat in bed at night because flexion of the neck made her pain worse. Every morning she woke with a dull pain at the top of her neck, and this would increase steadily throughout the day. She could not have her hair washed by a hairdresser because hyperextension of the neck made the pain worse, nor could she look up without discomfort. The pain in the occipital region was associated with what she
J. R. HOBBS M.B., B.Sc. Lond., M.R.C.P. REGISTRAR IN CHEMICAL
PATHOLOGY *
R. I. S. BAYLISS M.A., M.D. Cantab., F.R.C.P. PHYSICIAN
N. F. MACLAGAN M.D., D.Sc. Lond., F.R.C.P. PROFESSOR OF CHEMICAL PATHOLOGY
S.W.1 DURING the past twenty years the popularity of 1311 for = the study of thyroid function has been so great that the use of other isotopes of iodine has been relatively neglected, and the diagnostic possibilities of 1321 have not received adequate attention. Although this isotope became readily available some four years ago, and a number of reports on its diagnostic value have appeared (Goolden and Mallard 1958, Halnan 1958, Halnan and Pochin 1958), recent
WESTMINSTER HOSPITAL AND MEDICAL SCHOOL, LONDON,
*
Present address:
Royal
Free
Hospital, Gray’s Inn Road, London,
W.C.1.