Patient Position: Supine.

Indications: Postherpetic neuralgia and headaches secondary to greater occipital neuralgia.

Needle Size: 25-gauge, 88-mm Quincke needle.

Medication/Volume: 1 to 2 mL of 0.5% bupivacaine plus 40 mg of Depo-Medrol (Pharmacia Canada, Inc., Hamilton, Ontario, Canada).

Anatomic Landmarks: The posterior arch of C1 and C2 vertebrae.

Approach and Technique: The cervical region is prepared and draped using sterile techniques. Using fluoroscopy, the lateral view identifies the posterior arch of C1 vertebra (the atlas) and a dome shape between C1 and C2 dorsally. The needle is placed parallel to the x-ray beam and advanced slowly. After the position of the needle is confirmed by a lateral view, 1 to 2 mL of water-soluble contrast media such as Isovue-200 (Bracco Diagnostics, Princeton, NJ) is injected. This injection should not be associated with any intravascular runoff or epidural or subarachnoid propagation. The local anesthetic mixture is slowly injected. An anteroposterior view (Fig. 65-1) is taken and the needle is advanced to the midfacet line between the C1 and C2 vertebrae. Figure 65-2 presents an oblique view.