Alternative Approach for Occipital Headache Surgery: The Use of a Transverse Incision and “W” Flaps

Abstract

Summary: The most commonly used approach for a greater occipital nerve decompression is through a vertical midline incision, with multiple authors reporting favorable long-term outcomes. A transverse approach to the occipital nerves has been described, yet it does not include the use of fat flaps to insulate the decompressed nerves. In this study, we describe the use of a single transverse incision with modified “W” fat flaps to decompress both the greater and lesser occipital nerves. This allows for wider exposure of the nerves without the need for an additional incision to access the lesser occipital nerve. The described technique provides increased reach and versatility of the fat flap, allowing for coverage over a longer course of the nerve and further cephalad, close to the bony skull base. In addition, the fat flaps cover the greater occipital nerve closer to its native position, as opposed to bringing the nerve into a subcutaneous position. This, theoretically, keeps the nerve in a more protected deep position and technically makes it easier to avoid any tendency for kinking the nerves while wrapping them with the fat flap. Our experience has demonstrated that this modified technique is not only safe but also efficacious in affecting a statistically significant reduction (70% improvement, P = 0.004) in migraine headache index and HIT-6 scores. This study provides further evidence that nerve decompression for headache following the principles described by Guyuron is an efficacious and reproducible procedure and that a proper nerve decompression is effective in reducing headache.

“Migraine Surgery and Determination of Success Over Time by Trigger Site: A Systematic Review of the Literature”

“…All articles were cohort studies, and most of them (nine of 17) had a Newcastle-Ottawa Scale score of 5 of 9 (Table 2). 8,11,23–37 These nine studies lost 4 points (1 point in selection, 2 points in comparability, and 1 point in outcome), and the remaining eight lost 3 points (1 point in outcome and 2 points in comparability). The loss of points in selection was attribtutable to the lack of comparative group, whereas the loss of points in comparability was attribtutable to the lack of adjustment for confounders.…”

Outcomes of Surgical Treatment of Migraines: A Systematic Review & Meta-Analysis

“…Surgery at this area was later described as Site IV surgery by Guyuron et al 50 in 2005 and includes release of 6 recognized sites of occipital nerve compression: (1) between semispinalis capitis and obliques capitis inferior muscles, (2) as the nerve enters and (3) exits the semispinalis capitis muscle, (4) as the nerve enters the trapezius muscle, and (5) exits the trapezius fascia, and (6) by the occipital artery when it courses adjacent to the GON. 51,52…”

“…9 The LON has had 3 possible points of compression identified by Peled et al 61 in 2016: (1) as the LON emerges from deep fascia to be behind the sternocleidomastoid, (2) as the LON ascends along with the SCM, (3) and at the branch point of the LON. The LON may be approached through an incision on the posterior sternocleidomastoid, 41,52 although Ducic et al in 2009 and Afifi et al 52,62 in 2019 reported a transversely oriented incision for occipital surgery, 2.5 cm caudal to the occipital protuberance, which allows access to both Sites IV and VI.…”

“…Surgery at this area was later described as Site IV surgery by Guyuron et al 50 in 2005 and includes release of 6 recognized sites of occipital nerve compression: (1) between semispinalis capitis and obliques capitis inferior muscles, (2) as the nerve enters and (3) exits the semispinalis capitis muscle, (4) as the nerve enters the trapezius muscle, and (5) exits the trapezius fascia, and (6) by the occipital artery when it courses adjacent to the GON. 51,52 In a 2009 RCT by Guyuron et al 27 a semispinalis capitis myectomy and subcutaneous flap procedure to protect the nerve were superior to nerve exposure alone. Most studies have reported using Guyuron's surgical method to Site IV surgery, 27,30,50,[52][53][54] which has been previously described, 55 although GON excision or neurolysis have also been reported as surgical options such as in patients who fail initial GON decompression.…”

“…51,52 In a 2009 RCT by Guyuron et al 27 a semispinalis capitis myectomy and subcutaneous flap procedure to protect the nerve were superior to nerve exposure alone. Most studies have reported using Guyuron's surgical method to Site IV surgery, 27,30,50,[52][53][54] which has been previously described, 55 although GON excision or neurolysis have also been reported as surgical options such as in patients who fail initial GON decompression. 10,48,54 The role of occipital artery excision remains a topic of debate.…”