Treatment of occipital neuralgia by partial posterior rhizotomy at C1–3

Abstract

To minimize the sensory loss associated with intradural posterior rhizotomy for medically refractory occipital neuralgia, partial sectioning of the upper cervical posterior rootlets was performed in 11 patients. The ventrolateral aspect of each posterior rootlet from C-1 to the upper portion of C-3 was divided at the root entry zone. In three patients with bilateral neuralgia, the procedure was performed on both sides, for a total of 14 partial rhizotomy procedures in the 11 patients. This resulted in satisfactory preservation of scalp sensation in all cases. Pain within the territory of the greater occipital nerve was consistently reduced or abolished by this procedure. The overall degree of pain relief was rated good or excellent after 10 of the 14 procedures. The other four procedures alleviated pain in the territory of the greater occipital nerve, but the results were marred by persistent periorbital or temporal pain. Two patients subsequently underwent complete C1-3 posterior rhizotomy without further improvement. Although partial posterior rhizotomy at C1-3 did not always relieve pain in the periorbital and temporal regions, this procedure did provide consistent long-term relief of severe occipital pain with minimal risk of postoperative vertigo, scalp anesthesia, or deafferentation syndrome.

Occipital Neuralgia With Atypic Symptoms: A Case Report

“…Among the secondary etiologies affecting cervical region, infectious conditions such as herpes zoster, neurosyphillis; inflammatory conditions such as osteoarthritis, myositis and fibrositis; vasculitides such as temporal arteritis; demyelinating diseases such as multiple sclerosis; systemic diseases such as arteriovenous malformations in craniocervical junction, Chiari malformation, trauma, gastrointestinal system tumor metastases, diabetes and gout; discopathies causing root or nerve compression; and primary and/ or secondary tumors of bone or cartilage affecting C2-C3 nerve root ganglia can be considered (3,4,5,17). In ON manifestations due to lesions capable of forming masses, such as Shwannom osteochondroma and artrosis, the intensity of the pain increases with neck motion due to mass effect and increase over time while being irresponsive to symptomatic treatments (14,15,16,17). In that context, treatment unresponsiveness and massage induced exacerbation, should suggest the differential diagnosis for cervical region metastases among the secondary etiologies in an older cases with ON.…”

Long-term outcomes of intradural cervical dorsal root rhizotomy for refractory occipital neuralgia

“…Dubuisson and others have contended that complications such as vertigo or imbalance, secondary to the loss of afferent branches serving neighboring joints and muscle, can be avoided by selective sectioning of the ventrolateral fibers in the nerve root. 8,35 In our series, no patient reported symptoms of ataxia or vertigo after the surgery (Table 6). Moreover, no patients sustained severe and chronic neuropathic pain in regions of numbness.…”

“…2) of ON. 1,8 Cases of postinfectious and postherpetic ON are also documented in the literature, 5,15,19 but they are relatively uncommon. Two patients in our sample reported ON developing after a cerebral ischemic event.…”

“…8,35 After conducting an extensive survey of spinal fibers at the dorsal root entry zone adjacent to the spinal cord, Sindou's team discovered that small-caliber fibers carrying nociceptive information are organized ventrolaterally at the dorsal root entry zone. In contrast, larger-caliber fibers that serve cutaneous sensation and proprioception are organized dorsomedially.…”

“…Multiple series on RF only have evaluated ON patients at a mean of 6-and 8-month end points, 4,40 and other studies investigating neurectomy and dorsal root rhizotomy-intradural sectioning of dorsal nerve roots-have reported on small patient samples (n < 20) over median follow-up periods of less than 24 months. 8,17,20 The present report on CDR provides a relatively long-term insight into a large population of patients receiving a standardized treatment.…”