Greater Occipital Nerve Excision for Occipital Neuralgia Refractory to Nerve Decompression

Abstract

Background: Patients who undergo occipital nerve decompression for treatment of migraine headaches due to occipital neuralgia have already exhausted medical options for treatment. When surgical decompression fails, it is unknown how best to help these patients. We examine our experience performing greater occipital nerve (GON) excision for pain relief in this select, refractory group of patients. Methods: A retrospective chart review supplemented by a follow-up survey was performed on all patients under the care of the senior author who had undergone GON excision after failing occipital nerve decompression. Headache severity was measured by the migraine headache index (MHI) and disability by the migraine disability assessment. Success rate was considered the percentage of patients who experienced a 50% or greater reduction in MHI at final follow-up. Results: Seventy-one of 108 patients responded to the follow-up survey and were included in the study. Average follow-up was 33 months. The success rate of surgery was 70.4%; 41% of patients showed a 90% or greater decrease in MHI. The MHI changed, on average, from 146 to 49, for an average reduction of 63% (P G 0.001). Migraine disability assessment scores decreased by an average of 49% (P G 0.001). Multivariate analysis revealed that a diagnosis of cervicogenic headache was associated with failure of surgery. The most common adverse effect was bothersome numbness or hypersensitivity in the denervated area, occurring in up to 31% of patients. Conclusions: Excision of the GON is a valid option for pain relief in patients with occipital headaches refractory to both medical treatment and surgical decompression. Potential risks include failure in patients with cervicogenic headache and hypersensitivity of the denervated area. To provide the best outcome to these patients who have failed all previous medical and surgical treatments, a multidisciplinary team approach remains critical.

Occipital neuralgia: Anatomic considerations

“…Radiofrequency ablation has also been a viable option for the treatment of TON neuralgia (Vanderhoek et al, 2013;Hamer and Purath, 2014). In cases of several TON neuralgia refractory to nerve decompression, surgical excision of the third occipital nerve may done as a last resort (Ashkenazi and Levin, 2004;Gille et al, 2004;Ducic et al, 2009Ducic et al, , 2014.…”

Surgical Treatment of Migraine Headaches: A Review of Surgical Technique, Clinical, Anatomical and Radiological Studies

“…[15][16][17] Migren ağrılarının periferik sinir basısı sebebiyle olduğu hastalarda cerrahi dekompresyon, sinir/arter eksizyonu veya seçilmiş sahalara yapılan ilaç enjeksiyonlarının uzun süreli ağrı kontrolü sağladığı gösterilmiştir. [18][19][20][21][22][23] Bu gelişmeler migren cerrahisinde " tedavi " ve " iyileşme " kelimelerinin sık telaffuz edilmeye başlanmasını sağlamıştır.…”

Interdisciplinary treatment of post‐concussion and post‐traumatic headaches

“…Specifically, occipital nerves as well as terminal branches of the orbital, maxillary, and mandibular divisions of the trigeminal nerve within the occipital, temporal, and frontal scalp have been implicated in the production and maintenance of chronic headaches. We have previously demonstrated the safety and efficacy of surgical decompression and excision of the greater, dorsal, and lesser occipital nerves for headache pain centered in the occiput . Paramount to the selection of appropriate candidates for surgery is a physical exam confirming tenderness along the peripheral nerves that trigger headaches as well as positive, although transient, relief from pain following a diagnostic nerve block with local anesthetic, or alternatively, a neuromodulatory agent.…”

“…We have previously demonstrated the safety and efficacy of surgical decompression and excision of the greater, dorsal, and lesser occipital nerves for headache pain centered in the occiput. 9,10 Paramount to the selection of appropriate candidates for surgery is a physical exam confirming tenderness along the peripheral nerves that trigger headaches as well as positive, although transient, relief from pain following a diagnostic nerve block with local anesthetic, or alternatively, a neuromodulatory agent.…”