Intractable occipital neuralgia and peripheral neurectomies: a series of 20 patients with 23 operations

ABSTRACT

Occipital neuralgia is a disabling condition. It presents with episodic, sharp, occipital pains and suboccipital tenderness aggravated by neck motions. Paroxysms of stabbing/lancinating pain, radiate from the sub-occipital area towards vertex, auricle or angle of the jaw. The pain is often superimposed upon dull continuous pain. Authors present results of an analysis of 23 peripheral [greater, lesser occipital nerve and greater auricular nerve] avulsions-neurectomies in 20 patients with intractable occipital neuralgia. In these cases, secondary causes of suboccipital pain were excluded. Patients had become refractory to medical management prior to peripheral avulsion neurectomies. In immediate post-operative period results indicated that the severe occipital pain was either relieved [19/21 primary operations] or significantly reduced [2/21], ameliorating the distress. At six-weeks following surgery, two patients had recurrence of severe disabling pain, and were re-operated upon. In one, a tiny painful neuroma at the site of previous surgery and in another incomplete neurectomy at the first procedure were the main causes of early recurrence. Eighteen months following surgery, 14 patients were completely free of severe pains, 3 patients had occasional episode of mild occipital pains requiring symptomatic therapy whereas two patients had frequent occipital pains requiring regular analgesics. One patient developed scalp hypersensitivity and dysesthesia, which were treated with amitryptiline and analgesics. Peripheral neurectomy is a simple, safe and minor operation, which provides rapid effective pain relief in the majority of the patients in immediate post-operative period, whereas pain relief is achieved in 90% of cases at the six weeks and in 70% cases on a long term basis. The dramatic relief from the occipital pain and distress is much appreciated by the patients. However, in 30% of patients recurrence of pain, scalp hypersensitivity, dysesthesia and neuroma formation may occur, singly or in combination, which must be explained to the patients prior to the surgery