Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 3316  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Resource Links
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (1,748 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this Article
   Article Figures

 Article Access Statistics
    PDF Downloaded12    
    Comments [Add]    

Recommend this journal


Table of Contents    
Year : 2020  |  Volume : 68  |  Issue : 6  |  Page : 1490-1492

Iatrogenic Occipital Neuralgia: How to Avoid Injury in Retromastoid Approach?

1 Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Anaesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication19-Dec-2020

Correspondence Address:
Dr. Manjul Tripathi
Department of Neurosurgery, Neurosurgery Office, Post Graduate Institute of Medical Education and Research, Chandigarh - 160012
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.304093

Rights and Permissions

How to cite this article:
Jani P, Tripathi M, Ghai B, Patil N, Batish A, Mohindra S. Iatrogenic Occipital Neuralgia: How to Avoid Injury in Retromastoid Approach?. Neurol India 2020;68:1490-2

How to cite this URL:
Jani P, Tripathi M, Ghai B, Patil N, Batish A, Mohindra S. Iatrogenic Occipital Neuralgia: How to Avoid Injury in Retromastoid Approach?. Neurol India [serial online] 2020 [cited 2021 Jan 27];68:1490-2. Available from:


Retro sigmoid suboccipital (RMSO) craniotomy is a preferred surgical corridor for a wide range of pathologies in cerebellopontine angle. This approach also carries a high risk of postoperative headache secondary to dural adhesions, bony defect, cerebrospinal fluid leak, or occipital nerve injury. Surgical planning of skin incision should include an insight towards course of occipital nerves for its better preservation.

We operated on a 53-year-old married female with medically refractory trigeminal neuralgia. She underwent left RMSO craniotomy with classical lazy “S” incision. Microvascular decompression of fifth nerve was done by putting Teflon graft between left superior cerebellar artery, and trigeminal nerve. The patient was pain free in immediate post-operative period. On follow-up visit after a week, she complained of bothering hyperesthesia and severe persistent lancinating pain just postero-superior to the upper end of lazy “S” skin incision in the distribution of lesser occipital nerve. The pain was refractory to analgesics. The patient underwent ultrasound guided lesser occipital nerve block with 0.25% bupivacaine and 10 mg of methylprednisolone. The patient is pain free after procedure at 6-months follow-up.

Occipital neuralgia is one of the common causes of postoperative headache, persisting or occurring after several weeks and months after an RMSO craniotomy. Post craniotomy headache starts in immediate postoperative period in the majority of the patients. An occipital neuralgia is typically in nerve distribution and mostly paroxysmal or lancinating pain with Tinel's sign and/or sensory changes compared to usual stereotyped postoperative headache. A persistent headache even after 3-months of surgery is mainly limited to iatrogenic nerve injury/postoperative nerve entrapment.

Preoperative planning of incision requires knowledge of anatomical course of various nerves in this region. Lesser occipital nerve (LON) and greater auricular (GA) nerves are the most commonly injured nerves during RMSO craniotomy [Figure 1]. The incisions for RMSO craniotomy range from wider standard linear incision,[1],[2] to modifications like curvilinear and lazy-S incisions,[3] to smaller incisions as modified reverse-U incision [Figure 2].[4] Prof. Samii prefers to give a small incision and cut the nerve.[5] Among all incisions and their variations, a curvilinear incision remains the best choice as it maximally avoids the sub occipital muscles, potentially saves neurovascular bundle, and is efficiently closed in a single layer. Nerve block under ultrasound guidance carries a diagnostic and therapeutic intent, but relief is mostly temporary in nature. Refractory cases may need neurolysis, neuroma excision, nerve graft, radiofrequency ablation, rhizotomy, occipital nerve stimulation, or C2-3 root decompression.[4]
Figure 1: Anatomical distribution of nerves at risk during retromastoid suboccipital craniotomy approach (EOP, external occipital protuberance; M.TIP, mastoid tip; GON, greater occipital nerve; LON, lesser occipital nerve; IML, intermastoid line)

Click here to view
Figure 2: Various incisions for retromastoid suboccipital approach with respective advantages and disadvantages. (CSF, cerebrospinal fluid; GAN, greater auricular nerve; GON, greater occipital nerve; LON, lesser occipital nerve)

Click here to view

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

McLaughlin MR, Jannetta PJ, Clyde BL. Microvascular decompression of cranial nerves: Lessons. J Neurosurg 1999;90:1-8.  Back to cited text no. 1
Aihara N, Yamada H, Takahashi M, Inagaki A. Postoperative headache after undergoing acoustic neuroma surgery via the retromastoid approach. Neurol Med Chir (Tokyo) 2017;57:634-40.  Back to cited text no. 2
Silverman DA, Hughes GB, Kinney SE. Technical modifications of suboccipital craniotomy for prevention of postoperative headache. Skull Base 2004;14:77-84.  Back to cited text no. 3
Kemp WJ, Cohen-Gadol AA. A review of skin incisions and scalp flaps for the retromastoid approach and description of an alternative technique. Sure Neurol Int 2011;2:143.  Back to cited text no. 4
Matthies C, Samii M. Management of 1000 vestibular schwannomas (acoustic neuromas): Clinical presentation. Neurosurgery 1997;40:1-9.  Back to cited text no. 5


  [Figure 1], [Figure 2]


Print this article  Email this article
Online since 20th March '04
Published by Wolters Kluwer - Medknow