Occipital Nerve Stimulation for the Treatment of Occipital Neuralgia—Eight Case Studies

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ABSTRACT

Objective

The aim of this study was to examine the hypothesis that subcutaneous occipital stimulation influences pain due to occipital neuralgia.

Materials and Methods

Between 2001 and 2004 eight patients with intractable occipital neuralgia were referred to our center. Their records were reviewed. Each patient was interviewed over the telephone. They were all offered a trial of stimulation using a percutaneous lead over 1 week. If they achieved 50% pain reduction a permanent lead was implanted. The impact of occipital stimulation was measured by pain score, analgesic requirements, and employment status.

Results

Seven proceeded to a permanent stimulator. There was a reduction in the visual analog score postimplantation in five of the seven patients. The total quantity of opiates taken after implantation showed a marked reduction. Of the seven who had a permanent implant two acquired full-time employment.

Conclusion

Occipital neuralgia is a useful and reversible treatment for intractable occipital neuralgia.

Section snippets

INTRODUCTION

According to the International Association for the Study of Pain (IASP), occipital neuralgia is described as “pain, usually deep and aching, in the distribution of the second cervical dorsal root”(1). An understanding of the complex anatomy of the cervical plexus should precede the diagnosis of occipital neuralgia.

The nerves of interest are the upper three cervical nerves. The anterior rami of the upper four cervical nerves unite by a series of loops to form the cervical plexus. This supplies

MATERIALS AND METHODS

Between 2001 and 2004 patients with intractable occipital neuralgia were referred to our Nepean Pain Management Center. These patients are referred to our tertiary referral center because they have failed conventional treatment.

Their diagnosis was confirmed by 1) pain-deep and aching in the distribution of the second cervical dorsal root; 2) scalp hyperesthesia; 3) chronic and recurrent episodes of pain; and 4) analgesia and reduction of headache on subcutaneous infiltration of local anesthetic

RESULTS

Eight patients were offered a trial of occipital nerve stimulation. One failed the trial and seven proceeded to a permanent stimulator. Those who had a permanent implant are discussed below.

The follow-up after permanent implant averaged 25 months with a range of 6–47 months. Three women and four men proceeded to a permanent stimulator. The average age at implantation was 46 years (range 30–65 years).

Five patients had unilateral and two had bilateral occipital neuralgia. Comorbidities included

DISCUSSION

Treatment options for occipital neuralgia include medications and interventions following diagnostic local anesthetic blockade of the greater and lesser occipital nerves. This technique is well-described in a recent paper by Ward (11).

The local anesthetic blockade with or without steroid is sufficient to provide temporary analgesia and a diagnosis. However, inevitably the pain returns. Many patients are subsequently referred to a neurosurgical service. Surgical treatments have employed

CONCLUSION

Occipital stimulation for treatment of intractable occipital neuralgia is emerging as an attractive treatment option. The pitfalls such as lead migration, sepsis, and opiate dependency should be considered. It is a technique that is easy to trial and is reversible should problems arise. Lead implantation is also straight-forward for those physicians who have interventional practices.

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