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| LETTER TO EDITOR |
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| Year : 2020 | Volume
: 68
| Issue : 6 | Page : 1490-1492 |
Iatrogenic Occipital Neuralgia: How to Avoid Injury in Retromastoid Approach?
Parth Jani1, Manjul Tripathi1, Babita Ghai2, Ninad Patil1, Aman Batish1, Sandeep Mohindra1
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 Publication | 19-Dec-2020 |
Correspondence Address:
Dr. Manjul Tripathi
Department of Neurosurgery, Neurosurgery Office, Post Graduate Institute of Medical Education and Research, Chandigarh - 160012
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.304093
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 |
Sir,
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)
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 | 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)
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Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| » References | |  |
| 1. | McLaughlin MR, Jannetta PJ, Clyde BL. Microvascular decompression of cranial nerves: Lessons. J Neurosurg 1999;90:1-8.  |
| 2. | 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. |
| 3. | Silverman DA, Hughes GB, Kinney SE. Technical modifications of suboccipital craniotomy for prevention of postoperative headache. Skull Base 2004;14:77-84. |
| 4. | 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. |
| 5. | Matthies C, Samii M. Management of 1000 vestibular schwannomas (acoustic neuromas): Clinical presentation. Neurosurgery 1997;40:1-9. |
[Figure 1], [Figure 2]
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