Ultrasound-guided needle-knife release for treatment-refractory cervicogenic headache: a case report

Introduction

Cervicogenic headache (CEH) is a type of secondary headache caused by pathological changes in the cervical spine or cervical soft tissues (1). The pain typically originates from structures innervated by the upper cervical nerves—particularly the C1–C3 segments—and may radiate to the occipital, temporal, and periorbital regions (2). The clinical manifestations of CEH are complex and often accompanied by restricted cervical mobility. The pain is usually described as persistent or intermittent dull or distending in nature and may sometimes be pulsatile (3). Due to symptom overlap with primary headaches such as migraine and tension-type headache, CEH is frequently misdiagnosed or undertreated in clinical practice.

Current treatment modalities for CEH include pharmacotherapy (e.g., nonsteroidal anti-inflammatory drugs, muscle relaxants, and neurotrophic agents), physical therapy, nerve blocks, radiofrequency ablation, and surgical decompression (4). However, a portion of patients continue to experience residual pain or symptom recurrence despite these standard therapies, suggesting a complex pathophysiology and considerable interindividual variation in the pain-generating structures. In cases of refractory CEH, inaccurate localization of the pain source often leads to suboptimal therapeutic outcomes.

In recent years, ultrasound-guided needle-knife therapy has been applied to various pain and soft tissue disorders. The needle-knife is a specialized microsurgical instrument derived from traditional Chinese medicine, characterized by a flat, blade-like tip at the distal end of the needle body. This unique design combines the functions of an acupuncture needle and a scalpel, allowing the operator to not only puncture but also cut, strip, and release adhered or thickened soft tissues. Real-time imaging enables clinicians to avoid critical neurovascular structures and precisely target pathological tissues (5-7). Needle-knife therapy, as a minimally invasive technique that represents an intermediate level of invasiveness between acupuncture and small-incision surgery, can alleviate pain by releasing adhesions in cervical fascia, muscles, and ligaments; improving local biomechanical environments; and reducing neurovascular compression (8).

The patient in this case had a 15-year history of intractable CEH and had previously undergone a variety of treatments—including medication, acupuncture, nerve blocks, radiofrequency ablation, intervertebral disc surgery, and blind needle-knife therapy—all with unsatisfactory outcomes. After comprehensive physical examination and imaging evaluation, we performed targeted intervention on the soft tissues near the transverse process of the atlas using ultrasound-guided needle-knife release combined with nerve block. This approach aimed to achieve improved pain control through precise intervention. The diagnostic and therapeutic process of this case may provide a reference for individualized treatment strategies in similar cases of refractory soft tissue-related CEH. We present this article in accordance with the CARE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1794/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal. A 32-year-old male patient was admitted to the outpatient clinic of the Department of Acupuncture and Moxibustion with the main complaint of left-sided head pain, described as a pulsatile dull pain accompanied by a sense of heaviness and numbness. The patient held a doctoral degree. In his first year of high school, he experienced cervical compression due to improper posture during a back-over high jump, resulting in pain located in the same area as the reported symptoms. The pain gradually worsened and stabilized in his second year of high school. Since then, he began seeking medical evaluation and treatment. Magnetic resonance imaging (MRI) from an outside hospital indicated sinusitis. He underwent sinus puncture, nasal irrigation, and cyst fluid flushing. Subsequently, symptoms such as nasal discharge were essentially cured, but the headache was not relieved.

He tried analgesics and traditional Chinese acupuncture treatments, but the effect was limited, and 80% of the headache symptoms persisted. During high school, due to academic pressure, the headache was not well controlled and significantly affected his studies and daily life. During his undergraduate and graduate studies in Beijing, he visited multiple hospitals and neurology departments, underwent MRI, and was diagnosed with tension-type headache. The treatment consisted of analgesics and neurotrophic drugs.

Six years prior to admission, he was diagnosed with CEH in a pain clinic of an outside hospital and received C2 segment nerve blocks once a week for 3 months (a total of 12 sessions). The pain intensity reduced by 20%. However, the effect gradually diminished until it became ineffective. Three years previously, he underwent plasma radiofrequency ablation of the greater occipital nerve in an outside hospital’s pain clinic, but the effect was unsatisfactory. Two years previously, he underwent intervertebral percutaneous intradiscal ozone injection (anterior approach) at the C2–C3 level in another outside hospital, which yielded suboptimal results. Over a year previously, he received nonvisualized needle-knife treatment in an outside hospital once a week for more than 10 sessions, which achieved a degree of effect, with a 50% reduction in pain, but further treatment failed to provide better results. Therefore, the patient visited the Department of Acupuncture at China-Japan Friendship Hospital seeking further diagnosis and treatment, hoping that visualized needle-knife therapy could provide more precise and efficacious treatment.

The patient first visited the Department of Acupuncture at China-Japan Friendship Hospital in June 2024, bringing MRI scans from outside hospitals. The imaging revealed no significant soft tissue abnormalities (e.g., muscle edema or tears) in the suboccipital region, likely due to the chronicity of the injury. Imaging also excluded vascular lesions. Physical examination revealed continuous pulsatile dull pain on the left side of the head, radiating to the left occipital, frontal-temporal, and periorbital regions. There was no tenderness or rebound pain. Cervical flexion was 45° without obvious abnormalities. Extension was limited, and pain increased at 30°. Left flexion and right lateral flexion were both 45°, and left and right rotation showed no abnormalities. There was no dizziness, tinnitus, blurred vision, photophobia, phonophobia, or symptoms of anxiety or depression. Two years previously, he was diagnosed with hypertension, and his blood pressure remained stable with antihypertensive medication. He had no allergy history and did not smoke or drink alcohol. Based on the medical history, physical examination, and imaging data, the patient was diagnosed with CEH, and diagnostic treatment was initiated.

According to previous experience and guideline recommendations, at the patient’s first visit, we performed a C2 nerve root block combined with visualized needle-knife release. One week after the first treatment, we repeated the same procedure, but the effect was poor. The patient reported a 20% reduction in pain symptoms.

The limited therapeutic effect prompted us to conduct a more detailed physical examination. We found that deep palpation of the posterior arch of the atlas elicited a vague tenderness, suggesting that release at the posterior arch of the atlas might be needed. Therefore, in the third week, we performed the third treatment, targeting soft tissue around the transverse process of the atlas using ultrasound-guided needle-knife release. The specific treatment method was as follows:

The ultrasound device used was the VINNO6 color Doppler ultrasound system (VINNO Technology, Suzhou, China). The patient was placed in the right lateral position, with the occiput supported. After disinfection and draping, a high-frequency probe was selected and wrapped with a sterile protective cover (as shown in Figure 1A,1B). The probe was placed along the long axis of the body, with a frequency of 4.5 MHz. The distal occipital bone was used to locate the wave-like section of the facet joint, and by pushing the probe slightly ventrally, we could visualize the transverse process of the atlas. In Figure 1C, the hyperechoic area indicated by the green arrow is the transverse process of the atlas, and the yellow arrow indicates the vertebral body. Color Doppler was then activated to sweep the area and detect potential blood vessels through the swinging of the probe, as shown in Figure 1D.

Figure 1 Ultrasound scan and color Doppler images. (A) Sterile draping of the surgical area. (B) Placement of the ultrasound probe. (C) Grayscale ultrasound scan of the cervical region. The blue arrow indicates the occipital bone, the green arrow indicates the transverse process of the atlas (C1), and the yellow arrow indicates the vertebral body (C2). (D) Color Doppler imaging. This image is published with the participant’s consent.

A 1% lidocaine solution was first used for surface anesthesia. Subsequently, a puncture needle (0.35 mm × 90 mm) was used to perform local infiltration anesthesia directly above the transverse process of the atlas via an out-of-plane ultrasound-guided approach. When the transverse process was reached, 3 mL of 0.25% lidocaine containing 0.1 mL dexamethasone was injected, as shown in Figure 2A.

Figure 2 Ultrasound-guided injection and needle-knife release procedure. (A) Ultrasound-guided injection. (B) Ultrasound-guided needle-knife release. Blue arrow: occipital bone; green arrow: transverse process of atlas (C1); purple arrow: transverse process of axis (C2); white arrow: fluid distribution; red line segment: path of needle-knife release. This image is published with the participant’s consent.

Next, a 1.0 mm × 80 mm needle-knife (Lao Zongyi Medical Instrument Co., Ltd., Nanchang, China) was used. Under ultrasound guidance (out-of-plane approach), the needle was inserted perpendicular to the bone surface of the transverse process to facilitate longitudinal release along the superior, inferior, and lateral margins of the transverse process of the atlas. During the release process, the needle-knife blade was kept in constant contact with the bone surface to avoid damaging nerves and blood vessels, as shown in Figure 2B. During the procedure, the patient reported both increased pain and a relieving sensation. After withdrawal of the needle-knife, hemostasis was achieved by compression, and the site was covered with sterile dressing.

After this treatment, the patient reported a 50% reduction in pain. Subsequently, he received one treatment per week for five more sessions. After the final treatment, the patient reported a 90% reduction in pain.

Patient perspective

Follow-up assessments conducted at 1, 3, and 6 months (February 2025) posttreatment revealed sustained therapeutic efficacy. The patient reported 90% headache reduction without recurrence, stating the following: “My previously headache-disrupted academic and occupational functioning has resolved. Headaches are now virtually absent during daily activities, with significant quality-of-life improvement.” He further indicated the intervention to be successful.

Discussion

CEH is among the common secondary headache types encountered in clinical practice. Its etiology is generally related to pathological changes of the upper cervical zygapophyseal joints, muscles, and ligaments (9). The prevailing theory involves the trigeminocervical convergence mechanism, in which cervical disorders may trigger trigeminal neuralgia-like symptoms (10). The atlas (C1), as a unique anatomical structure of the cervical spine, contains multiple pain-sensitive structures around its posterior arch and transverse process, including joint capsules, ligaments, tendon attachments, and adjacent muscles. Once these structures undergo chronic injury, fibrosis, or adhesion, they may act as a persistent nociceptive source (11,12).

In the case described in this report, the patient had chronic, unilateral, and pulsatile headache that was nonparoxysmal, but he did not have photophobia, phonophobia, nausea, or vomiting; however, there were positive cervical signs, and so migraine was excluded. The headache was characterized by a dull pain with a sense of pressure distributed across the frontal, temporal, and occipital regions that was unilateral in nature. Psychological assessment revealed no significant anxiety or depression. Compared with that of tension-type headache, the pain intensity was more severe, allowing for a differential diagnosis. Additionally, the patient had a history of cervical trauma due to an unsuccessful high jump attempt, and MRI excluded intracranial lesions and vascular abnormalities, thereby supporting the diagnosis of CEH. Specifically, the clinical presentation satisfied the following criteria for CEH outlined in the third edition of the International Classification of Headache Disorders (ICHD-3): (I) clinical/imaging evidence of a disorder within the cervical spine or soft tissues (specifically tenderness at the C1 posterior arch); (II) evidence of causation demonstrated by the abolition of headache following the diagnostic blockade and release; and (III) unilateral headache without side shift. We acknowledge, however, that the initial partial response to the C2 blockade introduced a degree of diagnostic uncertainty, which was resolved only after the C1 transverse process was targeted.

The disease course extended for 15 years, during which multiple therapeutic approaches—including pharmacological treatment, acupuncture, nerve block, radiofrequency ablation, disc surgery, and blind needle knife release—failed to provide lasting relief. This suggested that the patient’s pain likely originated from specific anatomical structures that had not been adequately identified and addressed. The lack of significant effect from the initial two sessions targeting the C2 nerve root through conventional blockade and needle-knife release prompted further follow-up and examination, ultimately revealing a concealed tender point in the deep posterior arch of the atlas. This indicated that the soft tissue attachments in this region—specifically the rectus capitis posterior minor muscle and the posterior atlanto-occipital membrane—could constitute the critical pain generators.

Given that the transverse process of the atlas is adjacent to several important nerves and vessels, conventional blind needle-knife therapy carries limitations in precision and safety. Ultrasound guidance enables real-time visualization of the atlas transverse process and surrounding soft tissues, as well as identification of vascular pathways, thereby substantially improving the accuracy and safety of the procedure. In our case, an out-of-plane approach was used under ultrasound guidance, with local anesthetic and corticosteroid injection followed by longitudinal needle-knife release. This effectively relieved soft tissue adhesions and improved local biomechanics. During treatment, the patient experienced both pain provocation and subsequent relief, a typical clinical response confirming the involvement of the targeted structures.

Therefore, in the management of refractory soft tissue-related CEH, precise localization of pain generators and individualized treatment strategies are of paramount importance. This case highlights the necessity of considering upper cervical structures, particularly atlas-associated soft tissues, as potential pain sources in patients unresponsive to conventional therapies. It further demonstrates the value of ultrasound-guided minimally invasive interventions under safe conditions. Needle-knife therapy causes minimal trauma, requiring only 3 days of postprocedure wound care (with the puncture site being kept dry and clean) and offers advantages of simplicity, efficiency, and minimal invasiveness.

The superior efficacy of this procedure compared to the patient’s previous treatments (specifically acupuncture and blind needle-knife) can be attributed to distinct mechanistic differences. First, regarding the therapeutic tool, chronic soft tissue injuries often lead to dense fibrosis and scar tissue formation. Although acupuncture needles primarily induce neuromodulation, they lack the mechanical strength to physically disrupt these chronic adhesions. The needle knife, functioning as a microscalpel, can mechanically dissect and release the entrapped tissues. Second, regarding safety and depth, the transverse process of the atlas is anatomically complex and adjacent to the vertebral artery. In “blind” needle-knife procedures, practitioners often restrict the depth and range of manipulation to ensure safety, potentially failing to reach the deep pathological attachments. Ultrasound guidance overcomes this limitation through visualization of the neurovascular structures, allowing the operator to safely perform precise release directly on the bone surface where the adhesion is most severe. This “visualized precision” likely explains why previous similar therapies failed to provide lasting relief. Furthermore, considering that patients with CEH often exhibit poor posture, we suggest that minimally invasive interventions be complemented by rehabilitation, such as posture correction and cervical core muscle strengthening, to maintain long-term efficacy.

Certain limitations to this case report should be addressed. To begin, there was a lack of objective ultrasound or functional quantitative assessments before and after treatment. Additionally, pain improvement was reported as a subjective percentage reduction rather than through standardized retrospective scoring (e.g., Visual Analog Scale or Numerical Rating Scale), which limited the quantitative precision of the outcome. Further validation of the efficacy and safety of ultrasound-guided acupotomy in soft tissue CEH may be achieved through studies in larger sample sizes and the implementation of objective outcome measures.

Conclusions

Determination of CEH etiology should involve the consideration of soft tissue abnormalities, with the transverse process of the atlas being a relatively rare therapeutic target. This requires detailed physical examination and precise treatment. In such refractory cases, ultrasound-guided percutaneous needle-knife therapy may be a viable therapeutic option.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1794/rc

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1794/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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