Microsurgical right-sided occipital neurectomy for intractable neuralgia

Background: Occipital neuralgia (ON) is unilateral or bilateral paroxysmal shooting/stabbing pain in the occipital part of the scalp. It may be accompanied by dysesthesia and tenderness over the involved nerve(s). Possible pain generators include the greater occipital nerve (GON) (90%), lesser occipital nerve, and third occipital nerve (10%). Management includes non-surgical and various surgical approaches. Case Description: A 28-year-old female presented with severe right-sided ON that failed conservative management. The unilateral pain was paroxysmal in the sensory distribution of the right GON. The cervical spine magnetic resonance imaging was unremarkable. Initial treatment consisted of 6-months of pharmacological therapy without sustained benefit. Three therapeutic right-sided GON blocks resulted in consistent, but short-lived pain relief; this supported the diagnosis of a peripheral nerve-mediated pain mechanism. The patient opted for a microsurgical neurectomy of the right GON; it included division of the right C2 dorsal ramus (GON), preserving the ventral ramus and dorsal root ganglion. Postoperatively, the patient’s pain resolved (i.e., with the anticipated sensory deficit in the affected nerve territory). At 1-year follow-up, the patient remained pain-free with partial sensory recovery, (i.e., likely due to compensatory innervation). Conclusion: This video demonstrates how to perform a microsurgical occipital neurectomy that provided durable pain relief in this 28-year-old patient who suffered from intractable ON.