Anatomical analysis of the distribution patterns of occipital cutaneous nerves and the clinical implications for pain management

Hyun-Jin Kwon,1,2 Hong-San Kim,3 Jehoon O,2 Hyo Jong Kang,4 Ji Yeon Won,4 Hun-Mu Yang,2 Shin Hyung Kim,4 You-Jin Choi2 1Division in Anatomy and Developmental Biology, Department of Oral Biology, Yonsei University College of Dentistry, Seoul, Republic of Korea; 2Department of Anatomy, Yonsei University College of Medicine, Seoul, Republic of Korea; 3Department of Anatomy, School of Medicine, Ewha Womans University, Seoul, Republic of Korea; 4Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea Purpose: Establishing the distribution patterns of occipital cutaneous nerves may help us understand their contribution to various occipital pain patterns and ensure that a proper local injection method for treatment is employed. The aim of this study was to demonstrate the detailed distribution patterns of the greater occipital nerve (GON), lesser occipital nerve (LON), and third occipital nerve (TON) using the modified Sihler’s staining technique. Methods: Ten human cadavers were manually dissected to determine the nerve distributions. Specimens from eight human cadavers were treated using the modified Sihler’s staining. Results: In all cases, distinct GON branches proceeded laterally and were intensively distributed in the superolateral area from their emerging point. Very thin twigs were observed at the middle-trisected area, which had a fan-like shape, in the middle-upper occipital region. Conclusion: The LON and TON distribution areas were biased to the lateral side below the superior nuchal line, although these nerves exhibited multiple interconnections or overlapping areas with the GON. Furthermore, a nerve rarified zone in the shape of an inverted triangle was identified in the middle occipital area. Our findings improve our understanding of the occipital nerve anatomy and will aid in the management of occipital pain in clinical practice. Keywords: greater occipital nerve, lesser occipital nerve, third occipital nerve, Sihler’s stain, whole mount nerve staining, occipital neuralgi