Indications

Pain in the area of the posterior cervical spine without point of maximal intensity, not related to specific muscles, frequently including hyper-pathia of the skin

Pain when actively flexing the neck, increasing against resistance

Increased pain with passive flexion

Differential Diagnoses

Arthrosis of the cervical facet joints

Myalgia of the deep neck extensors

Interspinous neoarthrosis (pain is absent during passive flexion)

Material

Local anesthetic: 10 mL

Needle: 0.4 × 20 mm

Technique

The tips of the spinous processes are marked. The injections sites are located 2 cm paramedially to the right and to the left, at the level of the tips of the spinous processes. The needle is inserted vertically.

The depth of insertion is 1–2 cm and each injection site receives 0.5 mL of a local anesthetic.

Risks

None

Concomitant Therapies

Stretching of the posterior cervical muscles

Glisson traction

Local heat application

Neck compress

Progressive muscle relaxation

Indications

Distinct segmental pain in the posterior neck, increasing during active and passive neck flexion and remaining unchanged during neck extension

Differential Diagnoses

Tendinosis at the insertion of the deep neck muscles

Irritation of the vertebral joints

Material

Local anesthetic: 2 mL

Needle: 0.4 × 20 mm

Technique

The patient is seated, shoulders are relaxed, and the cervical spine is extended. The spinous process of C 7 is palpated; from there palpation moves upward until the painful segment is identified. To confirm the finding, the neck is passively extended, which must produce the characteristic pain.

The injection site is located between the palpable tips of the spinous processes. The needle is inserted at a 20° angle cranially. The depth of insertion is 1.5–2 cm. Distinct resistance is felt when the nuchal ligament is penetrated.

Risks

Injections into the nuchal ligament frequently produce intense pain; therefore, injection is discontinued in cases of high resistance.

Advancing the needle excessively creates the risk of an epidural injection. The extended position of the neck allows the interlaminar gap to widen. Therefore, longer needles must not be used.

Concomitant Therapies

Passive traction of the cervical spine

Orthopedic brace extending the cervical spine

Administration of NSAIDs with systemic effect

Indications

Pain in the posterior shoulder, frequently non-specific and dull, cannot be exactly localized by the patient

Characteristic trigger point in the area of the muscle’s superior border at the tip of the medial scapula, frequently radiating across the superior border of the trapezius

Differential Diagnoses

Facet irritation in the C 5/C 6 segment

Irritation of the suprascapular nerve with compression in the area of the suprascapular notch caused by the transverse scapular ligament

Costovertebral joint block at the level of T 3

Material

Local anesthetic: 3 mL

Needle: 0.4 × 20 mm

Technique

The tip of the medial scapula is located and is usually very sensitive to pressure. The most important injection site is in the center of this painful area. Two additional injection sites are located on a transverse line in the craniomedial direction, each 3 cm apart.

Each site receives 1 mL of a local anesthetic injected 2 cm deep.

Risks

None

Concomitant Therapies

Cryogenic friction massage at the insertion site of the levator scapulae