Atypical Presentation of Occipital Neuralgia

We report two patients presenting with intermittent, sharp, posterior shoulder and neck pain as a result of injury, who had failed conventional treatments, responding to an occipital nerve block. Patient A was injured after he landed on his right shoulder and neck while water tubing. He was placed in a sling for five days following injury and subsequent MRI, CT, and bone scan were negative for bony fractures or muscle contusion. His shoulder pain was intermittent and persisted for over two years. He tried numerous medications including Neurontin, Naproxen, and Oxycodone in addition to physical therapy without significant symptom relief. He was seen in the pain clinic and received a right greater occipital nerve block on two separate occasions. The first injection greatly improved his neck and shoulder pain, and his shoulder pain was completely resolved after the second nerve block. Patient B is a 47 year-old male with a long history of left acromioclavicular joint arthritis and a previous history of two cervical spine fusions complained of left shoulder and lateral neck pain after a fall from a chair landing on his left shoulder and head. Imaging results were essentially normal including x-ray and MRI of the left shoulder. He received a left acromioclavicular joint injection with minimal relief of his shoulder symptoms. Oral pain medications did not provide adequate pain control. A subsequent left greater occipital nerve block resulted in improved neck symptoms and resolution of his shoulder pain. Patients with occipital neuralgia typically complain of a headache that originates in the suboccipital area and radiates to the posterior or lateral scalp. Although shoulder pain is generally not a common presenting symptom of occipital neuralgia, it must be considered in the differential diagnosis. This is specifically true when shoulder pain is associated with a traumatic event.