A Review of the Recent Findings in Minimally Invasive Treatment Options for the Management of Occipital Neuralgia

Case Report: Percutaneous Peripheral Nerve Stimulation for the Treatment of Occipital Neuralgia

Headaches are among the most prevalent medical complaints globally. Occipital neuralgia is a chronic headache disorder characterized by unilateral or bilateral severe pain originating in the neck or skull base and radiating up along the occipital nerve distribution. Effective treatment options for occipital neuralgia can be challenging and some patients may prove to be refractory to conventional medical and interventional therapies. We present a case report on a patient with severe occipital neuralgia that was refectory to conventional therapies that responded to percutaneous peripheral nerve stimulation.

Effective Acupuncture in Treating Decade-Long Occipital Neuralgia in an Elderly Patient

BACKGROUND Occipital neuralgia is a headache caused by irritation or damage to the occipital nerves situated at the rear of the head and neck. It is characterized by sharp, stinging, or electric shock-like pain in the distribution area of the occipital nerve, which often causes patients acute pain and discomfort. To report on the feasibility of non-drug therapy in addressing this condition, we present a case report showcasing the remarkable improvement in occipital neuralgia symptoms achieved with a single acupuncture session, followed by a brief period of care. CASE REPORT The patient was a 76-year-old man who had persistent head pain for over a decade. This pain significantly disrupted his daily activities and diminished his quality of life. Seeking to avoid pharmacological treatments, with their associated adverse effects, and invasive surgical procedures, the patient opted for acupuncture treatments. Over a period of 12 days, the patient underwent 6 acupuncture sessions, each carefully planned and performed by a skilled acupuncturist, ensuring utmost safety and precision. Astonishingly, following the very first session, the patient reported significant alleviation from his head pain. CONCLUSIONS Although the initial approach to managing occipital neuralgia often primarily revolves around conservative drug treatment, acupuncture has emerged as a highly effective modality in alleviating pain symptoms associated with this condition. The favorable outcome of this case report provides convincing evidence that acupuncture can serve as a highly advantageous treatment approach for occipital neuralgia. This case report acts as an encouraging starting point, facilitating the investigation of non-invasive and non-pharmacological pain management strategies.

Image-guided peripheral nerve interventions- applications and techniques

Interventional radiology continues to be at the forefront of acute and chronic pain management. Our unique imaging expertise and ability to target difficult to reach structures allows for the continuous development of new ways to treat a variety of pain generators. In addition, the advent of thermal ablation techniques and technologies has provided a unique opportunity to offer patients more durable and predictable options to treat their pain. This is particularly important during the opioid epidemic, as multiple local and international governmental bodies push for physicians to create ways to manage pain while reducing the need for long-term opioid dependence. This article aims to review various image-guided techniques and tools for the treatment of pain related to peripheral pain generators, with a focus on the extremities, lumbosacral and pelvic region, and the chest wall. For each target and pathology, we will discuss general etiology, anatomy, procedural approach, and briefly evaluate the supporting literature in each clinical situation.

Novel Ultrasound-Guided Hydrodissection with 5% Dextrose for the Treatment of Occipital Neuralgia Targeting the Greater Occipital Nerve

BACKGROUND

Occipital neuralgia is a debilitating condition, and traditional treatments often provide limited or temporary relief. Recently, ultrasound-guided hydrodissection of the greater occipital nerve (GON) has emerged as a promising minimally invasive approach.

OBJECTIVES

To describe two novel ultrasound-guided hydrodissections with 5% dextrose for GON and discuss their advantages, disadvantages, and considerations.

METHODS

Two cases are reported. Case 1 describes a lateral decubitus approach for hydrodissecting the GON between the semispinalis capitis (SSC) and obliquus capitis inferior (OCI) muscles. Case 2 details a cranial-to-caudal approach for hydrodissecting the GON within the SSC and upper trapezius (UT) muscles when the GON passes through these two muscles.

RESULTS

Both patients experienced significant and sustained pain relief with improvements in function.

CONCLUSIONS

Ultrasound-guided GON hydrodissection using 5% dextrose is a promising treatment for occipital neuralgia. The lateral decubitus and cranial-caudal approaches provide additional options to address patient-specific anatomical considerations and preferences.

Imaging of Cranial Neuralgias

Cranial neuralgia (CN) can cause significant debilitating pain within a nerve dermatome. Accurate diagnosis requires detailed clinical history and examination, understanding of pathophysiology and appropriate neuroimaging to develop an optimal treatment plan. The objective of this article is to review and discuss some of the more common CNs including trigeminal neuralgia and its associated painful neuropathies, occipital neuralgia, and less common glossopharyngeal neuralgia (GPN). The neuroanatomy, pathophysiology, diagnostic imaging, and treatment of each of these pathologies are reviewed with emphasis on the role of CT and MR imaging findings in guiding diagnosis. Although CT is often used to initially identify an underlying cause such as neoplasm, infection, or vascular malformation, MRI is optimal. Clinical history and examination findings along with MRI constructive interference steady state/fast imaging employing steady-state acquisition sequences and MRA of the brain can be used to distinguish between primary and secondary cranial neuropathies and to discern the best treatment option. Pharmacologic and noninvasive therapy is the first-line of treatment of these cranial and cervical neuralgias. If symptoms persist, stereotactic radiosurgery is an option for some patients, although microvascular decompression surgery is the most curative option for both trigeminal and GPN. Refractory occipital neuralgia can be treated with a nerve block, an ablative procedure such as neurectomy or ganglionectomy, or more recently occipital nerve stimulation.

Cranial Neuralgias in Children and Adolescents A review of the literature

Cranial neuralgias are a well-established cause of headache-related morbidity in the adult population. These disorders are poorly studied in general due to their relative rarity, particularly in children and adolescents, and they are likely underdiagnosed in these populations. Recognizing these disorders and differentiating them from more common headache disorders, such as migraine, is important, as secondary disease is common. This review will cover the basic epidemiology, diagnosis, and treatment of trigeminal, occipital, glossopharyngeal and other, less common, cranial neuralgias. We have reviewed pediatric case reports of these conditions. For trigeminal neuralgia, the most common of these disorders, we have compiled the clinical features and treatment response of previous reports.

An Update on the Diagnosis, Treatment, and Management of Occipital Neuralgia

ABSTRACT

This report intends to summarize the underlying pathophysiology, relevant symptoms, appropriate diagnostic workup, necessary imaging, and medical and surgical treatments of occipital neuralgia (ON). This was done through a comprehensive literature review of peer-reviewed literature throughout the most relevant databases. The current understanding of ON is that it causes neuropathic pain in the distribution of the greater occipital nerve, the lesser occipital nerve, the third occipital nerve or a combination of the 3. It is currently a subset of headaches although there is some debate if ON should be its own condition. Occipital neuralgia causes chronic, sharp, stabbing pain in the upper neck, back of the head, and behind the ears that can radiate to the front of the head. Diagnosis is typically clinical and patients present with intermittent, painful episodes associated with the occipital region and the nerves described above. Most cases are unilateral pain, however bilateral pain can be present and the pain can radiate to the frontal region and face. Physical examination is the first step in management of this disease and patients may demonstrate tenderness over the greater occipital and lesser occipital nerves. Anesthetics like 1% to 2% lidocaine or 0.25% to 0.5% bupivacaine can be used to block these nerves and anti-inflammatory drugs like corticosteroids can be used in combination to prevent compressive symptoms. Other treatments like botulinum toxin and radiofrequency ablation have shown promise and require more research. Surgical decompression through resection of the obliquus capitis inferior is the definitive treatment however there are significant risks associated with this procedure.

Efficacy and Safety of Cryoneurolysis for Treatment of Chronic Head Pain Secondary to Occipital Neuralgia: A Pilot Study

Purpose

Treatment of chronic pain associated with occipital neuralgia (ON) is complex, and no consensus statement or guidelines have been published for ON management. This pilot study evaluated the efficacy and safety of cryoneurolysis for management of ON-associated chronic pain.

Patients and Methods

The study was a prospective, multicenter, nonrandomized cohort study assessing the degree and duration of clinical effect of cryoneurolysis therapy for reducing pain in patients diagnosed with unilateral or bilateral ON. The primary outcome measure was improvement in pain due to ON from baseline to day 7, measured on an 11-point numeric rating scale for pain. Secondary outcome measures included duration of treatment effects and safety events, including anticipated observations and adverse events. Treatment effect was assessed at days 7, 30, and 56 by asking the patient if they were continuing to experience a treatment effect, with potential responses of “effect,” “no effect,” or “no longer effective.” A posttreatment questionnaire evaluated patient satisfaction.

Results

Twenty-six patients (9 men, 17 women) with a mean age of 49.1 years enrolled and completed the study. A total of 64% (16/25) of participants reported a clinically important improvement of ≥2 points in numeric rating scale pain scores at day 7; similar results persisted to day 30. Treatment effects were reported by 50% (13/26) of participants at day 30, with a continued effect reported by 35% (9/26) of participants at day 56. Overall, ~70% of participants were satisfied with treatment at 7, 30, and 56 days. No serious anticipated observations, adverse events, or unanticipated adverse device effects were reported.

Conclusion

Cryoneurolysis provided significant relief from pain associated with ON ≤30 days after treatment and had an acceptable safety profile.

Cranial Neuralgias

PURPOSE OF REVIEW

This article discusses the differential diagnosis, evaluation, and management of trigeminal neuralgia and reviews other neuralgias of the head and neck, including those that contribute to neuralgic ear pain.

RECENT FINDINGS

Most cases of trigeminal neuralgia are related to vascular compression, a demyelinating plaque, or a compressive mass affecting the trigeminal nerve. However, recent studies have shown that up to 11% of patients have a family history of trigeminal neuralgia, suggesting that some patients may have a genetic predisposition to demyelination or nerve hyperexcitability. In these patients, trigeminal neuralgia may occur at a younger age, on both sides of the face, or in combination with other neuralgias.

SUMMARY

When a patient presents with neuralgic pain, the diagnosis is made by careful history and neurologic examination, with attention to the dermatome involved, the triggers, and the presence of any associated sensory deficit. All patients with new neuralgia or neuropathic facial pain warrant a careful evaluation for a secondary cause. The presence of sensory deficit on bedside examination is particularly concerning for an underlying secondary etiology.

Botulinum Toxin Type-A (Botulax®) Treatment in Patients with Intractable Chronic Occipital Neuralgia: A Pilot Study

Intractable chronic occipital neuralgia (ON) is an uncommon type of headache often experienced by patients in outpatient neurological clinics. Among patients unresponsive to oral neuralgia medications, needling or injections with several drugs were suggested alternatives for treating chronic ON. This study aimed to determine the effectiveness and safety of botulinum toxin type-A (BTX-A) injection treatments, where eight patients with unilateral chronic ON received BTX-A injections at the pain sites. The pain relief effect was observed 2 weeks after receiving the injections, gradually showing improvements up to 12 weeks after injection. There were no adverse events or changes from baseline in serologic studies and vital signs in any of the participants. The treatment’s pain-relieving effects were confirmed through regular, 12-week follow-ups, confirming the safety and effectiveness of BTX-A on chronic ON and suggesting that this method is an effective, novel alternative option for chronic ON treatment.

A device review of Relivion®: an external combined occipital and trigeminal neurostimulation (eCOT-NS) system for self-administered treatment of migraine and major depressive disorder

Introduction: Many patients with migraine are non-responsive or intolerant to pharmaceutical or surgical interventions. Peripheral nerve stimulation (PNS) offers a potential solution for these patients. This review discusses the external combined occipital and trigeminal neurostimulation (eCOT-NS) provided by the Relivion®, a multi-channel head-mounted device for self-administered PNS.Areas covered: Challenges and advantages of PNS systems for the treatment of migraine and depression are introduced, followed by an overall review of clinical evidence of the efficacy of the Relivion® system in treating migraine. The supporting smartphone app and cloud-based analytics which enable remote treatment management by the health care provider are also discussed. Recent empirical indications for the potency of this PNS combination for the treatment of depression are also summarized.Expert opinion: Relivion® is an eCOT-NS system, featuring Food and Drug Administration-approved, noninvasive, self-administered, customizable, multi-focal PNS for the treatment of migraine. In accordance with current telehealth trends, the Relivion® also enhances remote disease management and personalization using digital-monitoring, cloud-based technology, and artificial intelligence. As research on this system progresses, it may become the preferred treatment for the management of a number of neurological and psychiatric diseases, with migraine and major depressive disorders as precedents.