【原】枕神经痛与颈源性头痛的诊断与治疗（二）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Barmherzig R, Kingston W. Occipital Neuralgia and Cervicogenic Headache: Diagnosis and Management. Curr Neurol Neurosci Rep. 2019 Mar 19;19(5):20.本次学习由阎芳副主任医师主讲。

   Complementary studies have mapped the distribution of referred  pain related to the atlantoaxial and zygapophysial (facet) joints of the upper cervical spine. Stimulation at the C1 level experimentally was found to evoke occipital or cervical pain in those without migraine, although was more likely to evoke periorbital and frontal pain in patients with a history of migraine . C2 and C3 stimulation was found to refer pain to the occipital or cervical region. Although studies have not supported middle or lower cervical lesions (below C4) as being contributory to headache, anastomosis between the spinocervicothalamic tract and the trigeminocervical complex may support this possibility .

  The greater occipital nerve (GON) originates from the medial aspect of the dorsal ramus of C2, where it branches out to become the largest pure sensory nerve in the body. From its origin, the GON travels downward and laterally, bending around the inferior oblique muscle. After traversing the inferior oblique, the GON travels between the inferior oblique and the deep surface of semispinalis capitis, piercing the semispinalis capitis muscle inferior to the inion. The GON then pierces the trapezius aponeurosis, where it exits and travels through multiple superficial branches to supply the integument of the scalp overlying the posterior skull to the vertex. Clinically, the superficial portion of the nerve can be palpated approximately at the medial 1/3rd of a line between the external occipital protuberance (EOP) to the mastoid process (MP). This is roughly 3 cm below the EOP and 1.5 cm from the midline. There is some inter-individual variability in the anatomy of the GON, particularly along the vertical axis, and this remains a consideration in clinically locating the ON; it may be reasonable to palpate 1–2 cm superiorly and inferiorly to determine the point of tenderness,which can assist in localization.

另一些研究对与寰枢椎和上段颈椎关节突关节（小关节）相关的头部牵涉性疼痛进行了定位。实验发现，在没有偏头痛的患者中，C1水平的刺激会引起枕部或颈部疼痛，而在有偏头痛病史的患者中更可能引起眶周和额部疼痛。C2和C3的刺激导致枕部或颈部区域的牵涉痛。尽管研究不支持中下段颈椎病变（C4以下）会导致头痛，但颈髓-丘脑束和三叉神经-颈髓复合体之间的吻合可能支持这种可能性。

枕大神经（GON）起源于C2后支的内侧支，是人体中最大的纯感觉神经。GON发出后向下外走行，弯曲绕过头下斜肌。在穿过下斜肌后，GON在下斜肌和头半棘肌的深面之间行进，在枕外隆突下方穿过头半棘肌。然后，GON穿过斜方肌筋膜，穿出后发出多个浅支，支配颅骨后侧及顶部的头皮。临床上，神经的浅表部分可以在枕外隆突（EOP）和乳突（MP）连线的中内1/3交界处触及。这大约在EOP下方3厘米处，距离中线1.5厘米处。GON的解剖结构存在一些个体间变异，特别是沿着垂直轴，临床中定位ON也要考虑到这一点；上下各1～2cm触诊可确定压痛点，有助于定位。

 

     The lesser occipital nerve (LON) arises from the ventral ramus of C2 and C3 in the cervical plexus. The LON hooks around the spinal accessory nerve and travels upwards along the posterior border of the sternocleidomastoid muscle before exiting through the deep fascia at the occiput. The LON then branches to supply the integument of the scalp, the posterior third of the temporal fossa, and the neck posterior and superior to the auricle. Clinically, the superficial portion of the LON can be palpated at the lateral 1/3rd of the EOP to MP line. This is roughly 4–6 cm below the EOP and 6–7 cm from the midline

    The third occipital nerve arises from the dorsal ramus of C3 and innervates the integument of the lower occipital scalp and upper neck.

枕小神经（LON）起源于颈丛C2和C3的腹侧支。LON绕过副神经，沿着胸锁乳突肌的后沿向上行进，然后穿过头后部的深筋膜。LON发出分支支配头皮、颞窝的后三分之一以及耳廓后上方的颈部皮肤。临床上，LON的浅表部分可以在EOP至MP连线的中外1/3处触及。这大约在EOP下方4-6厘米，距离中线6-7厘米。

第三枕神经起源于C3的后支，支配枕下头皮和上颈部的皮肤。