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Splenius Capitis
MUSCLE SYNDROME
This syndrome-a commonly occurring headache, neck ache,
and facial pain disorder-typically mimics the respective pain
patterns of temporal tendonitis and migraine headache.
By Edwin A. Ernest III, DMD, FAANaOS and Mark W. Ernest, BA
his article describes a very painful
and commonly occurring pain
syndrome associated with the sple­
nius capitis muscle insertion. This syn­
drome was first described in the 1980's
by this author. The onset of pain is often
caused by motor vehicular trauma, blunt
trauma, falls, and, in particular, postural
situations where superior and inferior
lateral oblique movements of the head on
the neck occur. This type of excessive
repetitive movement can cause an over­
use i~ury where small focal, degenera­
tive changes in the insertion fibers can
occur. This is, in practical terms, similar
to the histopathologic process of inser­
tion tendinosis seen at other narrow bony
processes. Bony processes include the
mandibular coronoid process tip, I and
the greater cornu of the hyoid bone,' as
described by this author in other articles
demonstrating photomicroscopic evi­
dence of degenerative change in inser­
tion fibers.
T
Anatomy
Gray' describes the origin of the splenius
capitis muscle to begin on the spinous
processes ofvertebrae from C-7 to T-3 and
the ligamentum nuchae. The insertion
extends from the medial edge of the mas­
toid process and the lateral part of the su­
perior nuchal line. Dissection of the in­
sertion area shows the splenius capitis
lying under the triangle formed by the
trapezius and sternocleidomastoid mus­
cles (see Figure 1). The nerve supply to
the splenius capitis is provided by lateral
branches of the posterior rami of the mid­
dle and lower cervical spinal nerves.
Functioli
Bilaterally, the splenius capitis muscles ex­
tend and hyper-extend the head and neck.
However, acting unilaterally, the muscle
flexes and rotates the head and neck to the
same side; particularly in the superior and
inferior lateral oblique movements. The
muscle can he felt to tighten in the
mandibular protrusive movement and in
the wide opening movement of the lower
jaw. The dynamic relationship of the
cranio-celvico-mandibular-hyoid muscu­
lature is perhaps one of the most complex
inter-relationships of muscle groups in the
human body.
Pain Pattern
Splenius Capitis Muscle Syndrome typi­
cally mimics the respective pain reference
patterns of temporal tendinitis and mi­
graine headache. The painful headache
starts at the lateral margin of the superi­
or nuchal line and medial to the mastoid
process. The reference areas of pain are
described as follows (see Figure 2):
1. Rear of head aches and hurts.
2. Lateral temple headache.
3. Retro-orbital headache and pressure.
4. Aching pain above the eye.
5. Aching pain at cheekbone under eye.
6. Eye hurts and is sensitive to bright
light.
7. Pain radiating to neck, shoulder
and arm at times.
8. Nausea and vomiting when pain is
intense.
Differential Diagnosis
The test to determine if the pain complex
is primarily a muscular rather than a pri-
Practical PAIN MANAGEMENT, JUly/August 2006
IIlary sensory nerve problem utilizes the
effect oflocal anesthetic infiltration in the
insertion area of the splenius capitis mus­
cle. A local anesthetic infiltration in the
muscle should not create a defined region
of sensory loss at the scalp. If a clinician
blocks the greater occipital nerve/5 the
block would cause a defined geographic
area of anesthesia on the scalp. Similari­
ly, a block of the lesser occipital nerve
would cause a defined region of scalp
anesthesia lateral to the greater occipital
pattern of sensory distribution.
Again, a block of the insertion fibers of
the splenius capitis muscleo (see Figure 3)
does not cause a numbness of the scalp as
does a hlock of the greater or lesser oc­
cipital nerves.
Confirming Diagnosis And Treatment
The most effective way to confirm the di­
agnosis of Splenius Capitis Muscle Syn­
drome is to put digital pressure at t~le su­
perior nuchal line between the trapezius
and sternocleidomastoid mucles at the
nuchal line. If the area is painful and/or
stimulates the pain referral pattern, then
the source of the headache and pain may
have been located. Next, inject one cc of
a non-vasoconstrictor local anesthetic
into the painful insertion zone, first aspi­
rating to assure that the needle tip is not
in a vessel. Then slowly i~ect 0.8 cc local
anesthetic (see Figure 3). Within one
minute the pain pattern should be remit­
ted if the diagnosis is correct and if there
are no other concurrent pain disorders
present. With the pain remitted, inject a
1/8 to 1/4 cc of cortisone into the area.
Hopefully, the pain will not return. How­
29
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1-­
Splenius
Capitis
Muscle Syndrome
region of the insertion zone of the sple­
nius capitis muscle, its function, distribu­
tion of the pain pattern, differential diag­
nosis, methods of testing, and treatment.
When repeated cortisone injections fail
to provide relief, the author has found that
surgical management of the pain utilizing
radiofrequency thennoneurolysis is a safe
and proven pain management tool. 910 111
FIGURE
1. Site ofsplenius capitis muscle injury.
FIGURE 2.
Pain referral pattem.
r-·
Dr. Edwin Emest completed his Doctor ofDen­
tal Medicine degree at the University of Al­
abama in Birmingham Medical Center. He
then completed a three year Clinical Practice
Progmm in Temporomandibular Joint Prob­
lems and Craniofacial Pain. Dr. Emest's dis­
coveries include Ernest Syndrome (Hyperex­
tension injury of the Stylomandibular liga­
ment), Tempoml Tendinitis, TMJ Neumlgia,
and Splenius Capitis Muscle Syndrome, and
seveml other disorders. Dr. Ernest's work has
been referenced in Neurology, Neurosurgery,
Plastic & Reconstructive Surgery, ENT med­
icine progmms and articles, and the dental lit­
emture.
Mark W Emest, BA, is a pre-med student,
East Tennessee State University,johnson City,
Tennessee
References
FIGURE
3. Site of local anesthetic injection.
evel~ if it does, repeat the process two or
three times. This will help to determine
if the insertion fibers are damaged and
may require radiofrequency thermoneu­
rolysis (RFTN) to "turn off" the terminal
sensory nerve end organs.
If radiofrequency thermoneurolysis is
indicated, an RFTN unit, such as the Owl
RF Generator Model URF-2AP (Canadian
Medical Devices, Toronto, Canada), is uti­
lized. A typical technique is to create three
RFTN heat lesions (see Figure 4) on a hor­
izontal axis to try to assure "coverage" of
the damaged insertion fibers. Prior to le­
sioning, use the stimulus mode of the RF
Generator to assure the probe tip is not
on an unexpected motor or sensory nerve
branch. The RFTN should not create any
sensory deficit at the scalp since the local
anesthetic block did not do so.
Discussion
This syndrome typically produces pain in
the face, temple and cheek area, thus a
diagnostic work up may need to include
the pain management dentist as well as
30
FIGURE 4.
Site of radiofrequency lesions.
the pain management physician. The dif­
ferential diagnosis of headache may be
simple to make at times. However, the di­
agnostic effort may be confounded by a
more complex condition presented by
the patient. In the more complex situa­
tion, referral and more advanced testing
may be required. An example is the pos­
sible need for a cervical facet joint block
with local anesthetic. A neurosurgeon' or
anesthesiologist would be needed for a
facet block to assist in the diagnosis of
headache and referred pain to the cheek­
bone and temple emanating from cervi­
cal facet joint disease. The complex pain
patient may present with one or more fa­
cial pain syndromes,8 a temporo­
mandibular joint injury or neuralgia,
and/or other cervical pain syndromes as
well. This type of patient may have great
difficulty in receiving comprehensive
care in the absence of a mUltidisciplinary
team environment.
Conclusion
This article has described the anatomical
Practical PAIN MANAGEMENT, July/August 2006
1. Ernest III EA, Martinez ME, Rydzewski DB, and
Salter EG. Photomieroscopic evidence of insertion
tendinosis: The etiologic factor in pain for temporal
tendinitis. J. Prosthetic Dent. 1991. 65:127-131.
2. Ernest III EA and Saiter EG, Hyoid Bone
drome:a degenerative injury of the middle phflryrlgel11!
constrictor muscle with photomicroscopic
of insertion tendinosis. J Prosthetic Dent. July 1991.
66(1):78-83,
3. Gray H Anatomy 01 the Human Body. 23rd Ed ..
Philadelphia, Lee & Febiger, 1936.
4, Biume HG. Greater Occipital Nerve Block:
oiogy of Diagnosis & Treatment of Cervicogenic
Headaches; An International Authorative Determina­
tion. Scientilic Newsietter. December, 1997. I-'I-'.,OV-'JU,;:'.
5. Ernest III EA. Temporomandibular Joint & Craniola­
ciai Pain-An Orthopedic & Neurologic'll Approach to
Diagnosis and Management. 3st Edition. 1983. pp
81,91,
6, Ernest III EA Splenius Capitis Muscle Syndrome
Brochure. Diagnosis and Treatment with RFTN.
Publications. 1988.
7. Schaerer JP. Radiofrequency Facet Denervation in
Treating Headaches associated with chronic Neck
Pain. J Cranio pract. 1983. Vol. 1, pp. 78-81.
8. Jannetta P. (Professor of Neurosurgery, Allegheny
General Hospital, West Penn Health System). Web­
site, "Our area of focus" 1) Face Pain (Facial
gia and other disorders with similar symptoms:
Ernest Syndrome: Temporal Tendinitis) URL:
www.wpahs.org/agh/neuro/jannettaiFacepain.htm.
Last visited 5/22/06.
9. Ernest ill EA, Temporal Tendinitis: Migraine
J Practical Pain Management, May-June, 2006.
6(4)58-60.
10. Ernest III, EA Ernest Syndrome Caused by
Vehicular Trauma. To be published in the J Practical
Pain Management. September, 2006. 6(6).