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Cervicogenic headache (CGH) is a challenging clinical condition that straddles the boundaries of neurology, pain management, and musculoskeletal medicine. Though often misdiagnosed as migraine or tension-type headache, CGH originates from the cervical spine and can cause persistent, disabling head pain that radiates from the neck to the occipital, temporal, or even orbital regions. In a landmark review published in Current Opinion in Anesthesiology, Dr. Samer Narouze consolidates decades of anatomical and clinical research to position the C2 dorsal root ganglion (DRG) as the central hub for both the pathogenesis and treatment of CGH. His review emphasizes the importance of the C2 DRG, myodural bridges (MDBs), and suboccipital musculature in understanding and managing cervicogenic headaches. What is a cervicogenic headache? Cervicogenic headache is defined as head pain referred from a source in the cervical spine, typically the upper three cervical nerves (C1–C3). It is often unilateral, non-throbbing, and provoked by neck movement. The International Classification of Headache Disorders, 3rd edition (ICHD-3) provides clear criteria for diagnosing CGH, including: Radiological or clinical evidence of cervical pathology Temporal relationship between the cervical lesion and headache onset Symptom resolution with local anesthetic blocks Pain provoked by neck movements or pressure on cervical structures Epidemiology and clinical impact General population prevalence: 0.4% to 2.5% Prevalence in chronic headache patients: Up to 20% In patients undergoing cervical spine surgery: 21% meet CGH criteria Given these figures, CGH is likely under-recognized and undertreated, particularly in patients labeled with chronic migraines or non-specific headaches. Clinical features of CGH Distinctive signs include: Occipital pain that may radiate anteriorly Side-locked headache (consistently one-sided) Pain aggravated by neck movement or sustained posture Reduced cervical range of motion Tenderness over C2–C3 joints or suboccipital muscles Common mimics include: Migraine (due to overlapping distribution) Tension-type headache Occipital neuralgia (may coexist) Why is the […]
November 21, 2025
Securing a child’s airway during general anesthesia is a high-stakes procedure. For pediatric anesthesiologists, recognizing the nuances of a child’s anatomy, underlying health, and procedure-specific factors is critical. A new landmark study from Japan sheds light on when and why airway complications occur, and how to prevent them. A multicenter, prospective observational study, known as the J-PEDIA study (Japan Pediatric Difficult Airway in Anesthesia), has analyzed over 17,000 airway management procedures across 10 tertiary care hospitals. The findings are both reassuring and enlightening, offering practical strategies for improving safety in pediatric anesthesia. Key findings at a glance Adverse event rate during airway management: 2.0% Respiratory-specific events: 1.1% Desaturation events (≥ 10% SpO₂ drop): 2.3% Higher risk in neonates, infants, and children with difficult airway features Lower risk when supraglottic devices or muscle relaxants were used Why airway management matters in children Children are anatomically and physiologically distinct from adults: Smaller airway diameters Higher oxygen consumption Reduced apnea tolerance These factors contribute to an increased likelihood of life-threatening events if the airway is not secured quickly and effectively during anesthesia. About the J-PEDIA study Study design: Period: June 2022 – January 2024 Institutions: 10 tertiary centers (6 pediatric, 4 mixed adult-pediatric) Population: 16,695 children; 17,007 airway management encounters Objective: To evaluate the incidence of adverse events during airway-securing procedures and identify modifiable and non-modifiable risk factors. What qualifies as an adverse event? The study tracked both hemodynamic and airway-related events, including: Laryngospasm Bronchospasm Esophageal intubation Vomiting with aspiration Pulmonary edema Cardiac arrhythmia Stridor Desaturation (≥ 10% drop in SpO₂) These were assessed from preoxygenation through successful device placement, ensuring the child was stable both respiratorily and hemodynamically. Which children are most at risk? The data revealed several high-risk groups for airway-related adverse events: Age-related risk Neonates: 5.8% experienced adverse events; 21.4% […]
November 20, 2025
A comprehensive international systematic review and Bayesian network meta-analysis, published in Regional Anesthesia & Pain Medicine (2025), has provided definitive evidence supporting the clinical superiority of ultrasound-guided neuraxial puncture over traditional landmark-guided approaches. This large-scale analysis, encompassing 71 randomized controlled trials (RCTs) and 7,153 adult patients, found that both real-time ultrasound and preprocedural ultrasound significantly enhance the efficacy, safety, and patient-centered outcomes of neuraxial access procedures. These findings have substantial implications for anesthetic practice, particularly for spinal and epidural anesthesia, which are foundational techniques in surgical, obstetric, and chronic pain management. Rationale for clinical comparison Neuraxial puncture remains a core skill in anesthesiology, employed in spinal anesthesia, epidural anesthesia, and combined spinal-epidural (CSE) procedures. While effective, these techniques can be hindered by anatomical variability, patient-specific challenges (e.g., obesity, scoliosis), and the operator’s experience. Traditionally, practitioners rely on landmark palpation to identify intervertebral spaces. However, evidence suggests that in challenging cases, the failure rate for landmark-based puncture can reach as high as 30–40%, with increased risks of multiple attempts, needle redirections, and procedural complications. Ultrasound guidance addresses these limitations by enabling direct visualization of spinal structures, which facilitates more precise needle placement and reduces the reliance on palpation-based estimations. Study methodology The meta-analysis employed a Bayesian framework for network meta-analysis, supplemented by trial sequential analysis (TSA) to evaluate the cumulative evidence strength. Key characteristics of the analysis: Inclusion of 71 RCTs across 21 countries (2001–2023) Adult patients undergoing neuraxial puncture for anesthesia, analgesia, or diagnostic interventions Comparison of three approaches: Landmark-guided palpation Preprocedural ultrasound Real-time ultrasound Outcomes assessed: Primary: First-attempt failure Secondary: Total puncture failure, failure within two attempts, number of needle redirections, procedure time, complication rates, and patient satisfaction The risk of bias (RoB) was assessed using the Cochrane RoB 2 tool, and the certainty of evidence was evaluated using […]
November 18, 2025
