Ganglionectomy of C-2 for the Treatment of Medically Refractory Occipital Neuralgia

Michael Y. Wang, MD, Allan D. O. Levi, MD, PhD

Disclosures

Neurosurg Focus. 2002;12(1) 

In This Article

Origin of Pain in Occipital Neuralgia

Although the underlying cause of occipital neuralgia remains unclear, it is likely that there are various causes for abnormal neuronal activity. Whereas mechanical irritation of the nerve is a commonly proposed explanation, this entity has been associated with temporal arteritis,[6] neurosyphilis,[13] vascular compression,[4] and herpetic neuralgia. Occipital neuralgia has also been reported to be associated with arthrosis of the C1-2 facet joint[2] and scarring from previous surgeries in the area.

The dorsal ramus of the C-2 nerve is unique in its anatomical relationship to neighboring osseous and soft-tissue structures, and it has been postulated that the C-2 nerve is susceptible to mechanical compression at three sites: 1) the exit zone between the cervical laminae, 2) the perforation of the atlantoaxial membrane, and 3) the tendinous portions of the trapezius muscle. Hunter and Mayfield[5] proposed that because the C-2 nerve root and ganglion are unique in not being protected by surrounding bone, they are susceptible to mechanical trauma. Rotation and extension of the atlantoaxial joint was thought to irritate these nervous structures. This original explanation was concluded to be unlikely in normal patients by the authors of cadaveric studies who found that movement in this region did not cause nerve compression.[1] Degeneration of the spine producing abnormal articulations between C-1 and C-2, however, has been shown to produce mechanical nerve root compression. Atlantoaxial subluxation, as seen in cases of rheumatoid arthritis, can compress nervous structures between the laminae,[3] and hypertrophy of the atlantoepistrophic ligament can entrap the exiting C-2 root.[11]

Vascular engorgement of the vertebral venous plexus has also been postulated to cause transient occipital pain. In patients with this entity, painful exacerbations are associated with the Valsalva maneuver.[4] Arterial compression of the C-2 root by an ectatic vertebral artery has also been described.[12]

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