"Whiplash"-injury of the 2nd cervical ganglion and nerve

Occipital Neuralgia: Advances in the Operative Management

Background

Occipital neuralgia (ON) is a primary headache disorder characterized by sharp, shooting, or electric shock-like pain in the distribution of the greater, lesser, or third occipital nerves.

Aim

To review the existing literature on the management of ON and to describe our technique of an endoscopic-assisted approach to decompress the GON proximally in areas of fibrous and muscular compression, as well as distally by thorough decompression of the occipital artery from the nerve.

Methods

Relevant literature on the medical and surgical management of ON was reviewed. Literature on the anatomical relationships of occipital nerves and their clinical relevance were also reviewed.

Results

While initial treatment of ON is conservative, peripheral nerve blocks and many surgical management approaches are available for patients with pain refractory to the medical treatment. These include greater occipital nerve blocks, occipital nerve stimulation, Botulinum toxin injections locally, pulsed radiofrequency ablation, cryoneuroablation, C-2 ganglionectomy, and endoscopic-assisted ON decompression.

Conclusion

Patients of ON refractory to medical management can be benefitted by surgical approaches and occipital nerve blocks. Endoscopic-assisted ON decompression provides one such approach for the patients with vascular, fibrous or muscular compressions of occipital nerves resulting in intractable ON.

C2 nerve root on magnetic resonance imaging of occipital neuralgia

STUDY DESIGN

Review and grade the morphology of the C1-C2 neural foramina, from the MR images of patients who underwent C1-C2 spinal surgery, and determine the relationship with ON.

OBJECTIVE

To evaluate the feasibility of MRI for C1-C2 neural foramen evaluation with a new grading system and to correlate the C1-C2 neural foramen grade with ON.

SUMMARY OF BACKGROUND DATA

There have been no MRI studies of patients with and without ON in relation to C2 nerve root ganglion findings.

METHODS

Among the registry of 124 patients who underwent C1-C2 spinal surgery between July 2004 and May 2012 in Seoul National University Bundang Hospital, we enrolled 101 patients who had information about ON and a relevant preoperative cervical spine MR image. A total of 202 neural foramina were evaluated with our new C1-C2 neural foramen grading system (grade, 0-3) using consensus reading by 2 experienced radiologists who were blinded to the clinical information. The relationship between the C1-C2 grading system and ON was assessed using a χ test and Fisher exact test. Inter- and intraobserver reliability agreement was assessed using the κ statistic.

RESULTS

All C1-C2 neural foramina were delineated on T2 parasagittal images. Among 202 C1-C2 neural foramina, grade zero was found in 49 foramina (24.3%), grade 1 in 95 (47.0%), grade 2 in 30 (14.9%), and grade 3 in 28 (13.9%). Grade 1 stenosis was most frequently noted. The grade 2 group had the most frequent prevalence of ON (43.3%), followed by grade 3 (35.7%), grade zero (30.6%), and grade 1 (29.5%). However, the relationship between the grade and ON was not statistically significant. Inter- and intraobserver agreements were substantially high.

CONCLUSION

C1-C2 neural foramina can be depicted on MR image. However, the relationship between the new grading system for C1-C2 neural foramina and ON was not statistically significant.

LEVEL OF EVIDENCE

4.

Pain relief after cervical ganglionectomy (C2 and C3) for the treatment of medically intractable occipital neuralgia

Occipital neuralgia (ON) presents a diagnostic challenge because of the wide variety of symptoms, surgical findings, and postsurgical outcomes. Surgical removal of the second (C2) or third (C3) cervical sensory dorsal root ganglion is an option to treat ON. The goal of this study was to evaluate the short-term and the long-term efficacy of these procedures for management of cervical and occipital neuropathic pain. Twenty patients (mean age 48.7 years) were identified who had undergone C2 and/or C3 ganglionectomies for intractable occipital pain and a retrospective chart review undertaken. Patients were interviewed regarding pain relief, pain relief duration, functional status, medication usage and procedure satisfaction, preoperatively, immediately postoperative, and at follow-up (mean 42.5 months). C2, C3 and consecutive ganglionectomies at both levels were performed on 4, 5, and 11 patients, respectively. All patients reported preoperative pain relief following cervical nerve blocks. Average visual analog scale scores were 9.4 preoperatively and 2.6 immediately after procedure. Ninety-five percent of patients reported short-term pain relief (<3 months). In 13 patients (65%), pain returned after an average of 12 months (C2 ganglionectomy) and 8.4 months (C3 ganglionectomy). Long-term results were excellent, moderate and poor in 20, 40 and 40% of patients, respectively. Cervical ganglionectomy offers relief to a majority of patients, immediately after procedure, but the effect is short lived. Nerve blocks are helpful in predicting short-term success, but a positive block result does not necessarily predict long-term benefit and therefore cannot justify surgery by itself. However, since 60% of patients report excellent-moderate results, cervical ganglionectomy continues to have a role in the treatment of intractable ON.

THE HISTORY OF NEUROSURGERY AT THE HOSPITAL FOR SICK CHILDREN IN TORONTO

The tradition of selfless charity for children in Toronto was established by Elizabeth McMaster, founder of the Hospital for Sick Children, or "Sick Kids," in 1875. The tradition of fortitude and perseverance in trying to cure children who were deemed incurable by others was sealed into the history of the Hospital by early pioneering surgeons, including Drs. Clarence Starr, A.W. Farmer, and William Gallie. Dr. William Gallie recognized the importance of neurosurgery for the future of the Hospital and encouraged Dr. William Keith to acquire training in pediatric neurosurgery in Chicago and London. Dr. Keith began the practice of pediatric neurosurgery at Sick Kids in 1935 and worked in the primordial phase of the subspecialty for the next 20 years until he was joined by Dr. E. Bruce Hendrick in 1955. In time, Dr. Hendrick was joined by Drs. Harold Hoffman and Robin Humphreys who led a decidedly strong pediatric neurosurgery unit between 1975 and 1995. During this epoch, the pediatric neurosurgery service grew to become one of the busiest and most progressive units in the world. Over the years, numerous neurosurgery fellows and faculty from all over the world have trained at or have visited Sick Kids to learn how pediatric neurosurgery is practiced in Toronto. The purpose of this article is to review the history of the individuals who founded the Hospital for Sick Children and its Division of Neurosurgery.

Preoperative greater occipital nerve block in total thyroidectomy patients can reduce postoperative occipital headache and posterior neck pain

Patients undergoing thyroidectomy with neck fully extended usually experience occipital headache and posterior neck pain. We have attempted to evaluate the effect of preoperative greater occipital nerve (GON) block on occipital headache and posterior neck pain after thyroidectomy. Eighty-two patients undergoing elective total thyroidectomy were randomly allocated to two groups. In block group, bilateral GON blocks with 0.25% bupivacaine were performed. The control group did not have any prior block. Occipital headache and posterior neck stiffness were assessed using the visual analogue scale (VAS) and verbal rating scale. VAS of occipital headache and posterior neck pain in block group was significantly lower compared to that in the control group at postoperative 12 and 24 hours (p < 0.05). In addition, the proportion of patients reporting moderate or severe occipital headache and posterior neck pain at postoperative 12 and 24 hours in block group was significantly lower than that in control group (p < 0.001). No side effects were observed during and after GON block. We conclude that preoperative GON block with 0.25% bupivacaine is an effective technique to reduce occipital headache and posterior neck pain after thyroid surgery.

An anatomic and morphometric study of C2 nerve root ganglion and its corresponding foramen

STUDY DESIGN

Exposing and measuring the dorsal root ganglion of the second cervical spinal nerve (C2 ganglion) and the second intervertebral space, which is present between posterior arch of atlas (APA) and lamina of axis (LA).

OBJECTIVES

This study aims to investigate the shape, size, and relation of the C2 ganglion with the adjacent structures that limits the corresponding intervertebral space and the alterations of relation between C2 ganglion and APA and between C2 ganglion and LA with the movements of the head bilaterally.

SUMMARY OF BACKGROUND DATA

In previous studies, the position and the heights of the C2 ganglion have been described. But the shape of the C2 ganglion and its relation to APA and LA by the movement of the head had not been considered previously.

METHODS

Upper cervical spines of 20 cadavers were dissected posteriorly. The muscles attaching to the atlas and axis were resected to ease the head movements. The heights of the C2 ganglion and space were measured in anatomic position and in hyperextension with opposite rotation position of the head. Originally in this study, plastic dough casts were used to obtain reliable outcomes.

RESULTS

The shape of the ganglions was defined in three types: 70% were oval, 20% were spindle-like, and 10% were spherical. The height of the C2 ganglion was 4.97 +/- 0.92 mm on the right side and 4.6 +/- 0.84 mm on the left side. The height of the intervertebral space in anatomic position and in hyperextension with rotation to the opposite position of the head were, respectively, 9.74 +/- 1.77 mm and 7.48 +/- 1.44 mm on the right side and 9.64 +/- 1.47 mm and 7.12 +/- 0.96 mm on the left side. There was no bone contact or impact to the ganglion in each position of the head.

CONCLUSION

The C2 ganglions are confident in their place between APA and LA. No bone contact to the C2 ganglion was detected in either normal limited or in forced head motions.

The relationship of neck injury and post-traumatic headache

Although there may be several causes of post-traumatic headache, neck injury is perhaps the most common. This paper primarily reviews the relationship of neck injury, whiplash, and post-traumatic headache. Mechanisms may include structural damage from acceleration or extension of the neck, development of myofascial pain and trigger points, interaction of the trigeminal nociceptive system with the upper cervical (occipital) nerves, and psychologic and emotional factors. Although some healing will occur, the outcome may depend on a number of human factors (awareness of an impending collision) and the fact that repaired tissue is different from normal, uninjured tissue.

Medicolegal issues: headache

This article addresses headache-related topics in which medicolegal issues have occurred or in which they are likely to occur. Where possible, an actual case has been presented. Most sections of this article are divided into three parts: principle of care, case history, and discussion and recommendations. When appropriate, American Academy of Neurology guidelines have been noted.

Microsurgical C-2 ganglionectomy for chronic intractable occipital pain

OBJECT

The authors evaluated the effectiveness of microsurgical C-2 ganglionectomy in 39 patients with medically refractory chronic occipital pain. In this procedure the neurons transmitting sensory inputs from the occiput are removed and, unlike peripheral nerve ablation, axonal regeneration is not possible.

METHODS

The patients in this series had symptoms for 1 to 43 years. In 22 patients the occipital pain was caused by trauma; in 17 patients the pain was spontaneous. Pain relief failed in 17 patients who had undergone a previous occipital neurectomy or C-2 rhizolysis. Twenty-three patients experienced pain that was described as shocklike, electric, shooting, jabbing, stabbing, sharp, or exploding (Group I). Eight patients described their pain as dull, pounding, aching, throbbing, or pressurelike (Group II). The patients underwent unilateral or bilateral C-2 open microsurgical ganglionectomies. The postoperative follow-up period ranged from 19 to 48 months. Nineteen patients experienced an excellent result (> 90% reduction in pain). Pain caused by trauma or that described using Group I terms responded best to ganglionectomy (80% good or excellent response). In contrast, the majority of the patients with nontraumatic pain or those described using Group II descriptors did not achieve favorable results.

CONCLUSIONS

The authors conclude that: 1) patients who suffer from chronic occipital pain after having sustained injury obtain worthwhile benefit from microsurgical C-2 ganglionectomy; 2) patients suffering from migraine, tension, and vascular headaches involving the occipital area are most often not helped by this operation; and 3) terms such as "shock," "electric," "shooting," "jabbing," and "sharp" used to describe occipital pain predict a favorable pain outcome following a C-2 ganglionectomy.

Anatomic considerations of C2 nerve root ganglion

STUDY DESIGN

Dissection and observation of the dorsal root ganglion of the second cervical spinal nerve bilaterally.

OBJECTIVES

To determine the position of the C2 dorsal root ganglion and the heights of the C2 ganglion and its corresponding foramen.

SUMMARY OF BACKGROUND DATA

The dorsal root ganglion has been well studied in the middle and lower cervical spine and in the lumbar spine. In no previous study are the position and height of the C2 dorsal root ganglion and its corresponding foramen described.

METHODS

Fifteen cadaveric cervical spines were exposed posteriorly. The C2 nerve roots and ganglia were dissected between the arch of the atlas and the lamina of the axis. The heights of the C2 ganglion and foramen were measured. The location of the C2 ganglion was also macroscopically observed.

RESULTS

The heights of the C2 ganglion and foramen are 5.7 +/- 0.8 mm and 7.7 +/- 1.2 mm, respectively. The C2 ganglion occupies 76% of the foramen height. All C2 dorsal root ganglia are confined within foramens between the arch of the atlas and the lamina of the axis.

CONCLUSIONS

The C2 dorsal dorsal root ganglia are all proximally placed and occupy most of the foramen height, which may render the C2 ganglion vulnerable to entrapment.

Outcome of surgical decompression of the second cervical root for cervicogenic headache

OBJECTIVE

There is limited information on the surgical treatment of cervicogenic headache (CH). The objective of this study is to analyze the utility of microsurgical decompression of the second cervical (C2) root and ganglion as a treatment for CH.

METHODS

Thirty-nine sequential C2 root and ganglion decompressions, performed for the treatment of CH on 35 patients at the Dartmouth-Hitchcock Medical Center during a 70-month period, were analyzed retrospectively. Preoperative factors and intraoperative findings were evaluated with respect to outcome.

RESULTS

At a mean follow-up of 21 months, 12 patients (13 sides) were pain free, and 15 were adequately improved (18 sides). Treatment eventually failed in eight patients. No patient, however, was worse after surgical intervention. There was no major morbidity or mortality associated with the operation. The eight patients with unsatisfactory outcome were evaluated for a possible second operation, and four underwent it. One patient of the four is pain free after 28 months, and two gained adequate improvement at 3 and 12 months. The fourth patient required a third operation but has achieved adequate relief at 6 months. Thus, the overall success rate (either pain free or with adequate improvement) was 90%. No specific prognostic factors could be established, other than the accepted diagnostic criteria and successful anesthetic blockade of the C2 root and ganglion.

CONCLUSION

The results suggest that microsurgical decompression of the C2 root and ganglion has some utility in treating CH. The accepted diagnostic criteria and success of anesthetic blockade of C2 should identify the subset of patients with CH predominantly caused by C2 root or ganglion effect at this level, which may favor surgical treatment.

Diagnosis, physiology, pathology and rehabilitation of traumatic brain injuries

Accumulating clinical and experimental studies continue to elucidate and further define the significance of intra- and extra-cranial factors which determine outcome of traumatic brain injury. These factors include severity of injury, age of the patient, presence or absence of premorbid brain insults, and associated pathophysiological events such as anoxia, respiratory arrest, hemorrage, edema, contrecoup and Wallerian degeneration. Following resolution of acute temporary symptoms, delayed complications include seizures, neurotic and psychotic disorders, earlier onset of stroke, earlier senescence, increased suicide risk, reduced life expectancy, progressive intellectual deterioration and development of symptoms comprising the post-traumatic syndrome. In spite of these diverse initial and later pathological sequelae, the reserve capacities of the brain for establishment of compensatory mechanisms can provide bases for a remarkable degree of spontaneous cerebral reorganization and recovery. The accumulating findings in patients with traumatic brain injuries reflect principles and factors underlying the organization, disorganization and reorganization of human brain function.

Cervicogenic headache: anesthetic blockades of cervical nerves (C2-C5) and facet joint (C2/C3)

In a series of 14 patients with cervicogenic headache, cervical nerve blockades (C2-C5 and facet joint C2/C3) have been carried out in order to elucidate possible underlying mechanisms and to evaluate the diagnostic potential of these procedures. Blockade of the C2 nerve resulted in freedom from pain in 5 of 10 patients and seemed to be the most informative procedure. Two patients out of 9 reported freedom from pain following C2/C3 facet joint injection. No patients experienced complete pain relief following C3, C4 or C5 blockades. C4 and C5 nerve blockades are probably of little value in the work-up of such patients. When evaluating the C2/C3 facet joint injection, one has to take possible leakage of anesthetic agent from the joint into consideration, since the third occipital nerve which runs close to the facet joint may be anesthetized through the leakage.

C2 and C3 pain dermatomes in man

This report defines the C2 and C3 pain dermatomes by the distribution of: the hypalgesia clearing after surgical root decompression; the dysaesthesias produced by electrical root stimulation; and the hypalgesia produced by anaesthetic root block. The C2 pain dermatome, so defined, consists of an occipital parietal area 6-8 cm wide, ascending paramedially from the subocciput to the vertex. The C3 pain dermatome is a craniofacial area including the scalp around the ear, the pinna, the lateral cheek over the angle of the jaw, the submental region and the lateral and anterior aspects of the upper neck. These C2 and C3 pain dermatomes do not overlap and are smaller than the C2 and C3 tactile dermatomes described in the literature.