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

11. Cervicogenic headache and occipital neuralgia

INTRODUCTION

Cervicogenic headache (CEH) and occipital neuralgia (ON) are headaches originating in the occiput and that radiate to the vertex. Because of the intimate relationship between structures based in the occiput and those in the upper cervical region, there is significant overlap between the presentation of CEH and ON. Diagnosis starts with a headache history to assess for diagnostic criteria formulated by the International Headache Society. Physical examination evaluates range of motion of the neck and the presence of tender areas or pressure points.

METHODS

The literature for the diagnosis and treatment of CEH and ON was searched from 2015 through August 2022, retrieved, and summarized.

RESULTS

Conservative treatment includes pain education and self-care, analgesic medication, physical therapy (such as reducing secondary muscle tension and improving posture), the use of TENS (transcutaneous electrical nerve stimulation), or a combination of the aforementioned treatments. Injection at various anatomical locations with local anesthetic with or without corticosteroids can provide pain relief for a short period. Deep cervical plexus block can result in improved pain for less than 6 months. In both CEH and ON, an occipital nerve block can provide important diagnostic information and improve pain in some patients, with PRF providing greater long-term pain control. Radiofrequency ablation of the cervical facet joints can result in improvement for over 1 year. Occipital nerve stimulation (ONS) should be considered for the treatment of refractory ON.

CONCLUSION

The treatment of CEH preferentially consists of radiofrequency treatment of the facet joints, while for ON, pulsed radiofrequency of the occipital nerves is indicated. For refractory cases, ONS may be considered.

Clinical Efficacy of Pulsed Radiofrequency Treatment Targeting the Mid-cervical Medial Branches for Intractable Cervicogenic Headache

OBJECTIVE

Cervicogenic headache has been known to originate from the convergence of the upper 3 cervical and trigeminal afferents. The administration of conservative treatments, interventional procedures, and more recently, pulsed radiofrequency, has been used to relieve cervicogenic headache. In this study, the authors evaluated the clinical efficacy and safety of pulsed radiofrequency targeting the mid-cervical medial branches.

MATERIALS AND METHODS

From September 2012 until December 2017, 395 patients were diagnosed with cervicogenic headache based on the third edition of the International Classification of Headache Disorders. The authors treated them conservatively at first, and those patients with nonresolution of pain were treated with mid-cervical medial branches block applied from C3 to C5 twice. Subsequently, if any patient continued to experience persistent pain, the authors classified them as having intractable cervicogenic headache and performed pulsed radiofrequency treatment targeting the mid-cervical medial branches from C3 to C5 bilaterally. The authors analyzed their demographics and used a Visual Analogue Scale to assess their pain for 12 months.

RESULTS

Fifty-seven patients were enrolled in this study. The mean age was 49.8 years, and the mean duration of symptoms was 47.7 months. The mean Visual Analogue Scale score was 6.21 before pulsed radiofrequency treatment, and it improved to 1.54 immediately after the procedure without the symptoms recurring for a minimum of 12 months. There were no severe complications, such as vascular or nerve injuries.

CONCLUSIONS

In patients with intractable cervicogenic headache, pulsed radiofrequency treatment targeting the mid-cervical medial branches resulted in a satisfactory, long-lasting outcome without serious complications.

Can axial pain be helpful to determine surgical level in the multilevel cervical radiculopathy?

Spine surgeons are required to differentiate symptomatic cervical disc herniation with asymptomatic radiographic herniation. Although the dermatomal sensory dysfunction of upper extremity is the most important clue, axial pain including cervicogenic headache and parascapular pain may be helpful to find surgical target level. However, there is no review article about the axial pain originated from cervical spondylotic radiculopathy and relieved by surgical decompression. The purpose is to review the literatures about the axial pain, which can be utilized in determining target level to be decompressed in the patients with cervical radiculopathy at multiple levels. Cervicogenic headaches of suboccipital headaches, retro-orbital pain, retro-auricular pain, or temporal pain may be associated with C2, C3, and C4 radiculopathies. The pain around scapula may be associated with C5, C6, C7, and C8 radiculopathies. However, there is insufficient evidence to make recommendations for the use in clinical practice because they did not evaluate sensitivity and specificity.

C2 spondylotic radiculopathy: the nerve root impingement mechanism investigated by para-sagittal CT/MRI, dynamic rotational CT, intraoperative microscopic findings, and treated by microscopic posterior foraminotomy

PURPOSE

C2 radiculopathy is known to cause occipito-cervical pain, but their pathology is unclear because of its rarity and unique anatomy. In this paper, we investigated the mechanism of C2 radiculopathy that underwent microscopic cervical foraminotomies (MCF).

METHODS

Three cases with C2 radiculopathy treated by MCF were investigated retrospectively. The mean follow-up period was 24 months. Pre-operative symptoms, imaging studies including para-sagittal CT and MRI, rotational dynamic CT, and intraoperative findings were investigated.

RESULTS

There were 1 male and 2 females. The age of patients were ranged from 50 to 79 years. All cases had intractable occipito-cervical pain elicited by the cervical rotation. C2 nerve root block was temporally effective. There was unilateral spondylosis in symptomatic side without obvious atlatoaxial instability. Para-sagittal MRI and CT showed severe foraminal stenosis at C1-C2 due to the bony spur derived from the lateral atlanto-axial joints. In one case, dynamic rotational CT showed that the symptomatic foramen became narrower on rotational position. MCF was performed in all cases, and the C2 nerve root was impinged between the inferior edge of the C1 posterior arch and bony spur from the C1-C2 joint. After surgery, occipito-cervical pain disappeared.

CONCLUSION

This study demonstrated that mechanical impingement of the C2 nerve root is one of the causes of occipito-cervical pain and it was successfully treated by microscopic resection of the inferior edge of the C1 posterior arch. Para-sagittal CT and MRI, rotational dynamic CT, and nerve root block were effective for diagnosis.

Investigation of meningomyovertebral structures within the upper cervical epidural space: a sheet plastination study with clinical implications

BACKGROUND CONTEXT

Over the past two decades, soft-tissue structures communicating with the dura mater within the epidural space have become the focus of many anatomical and histopathologic studies. The relationship between these bridging structures has yet to be evaluated in situ.

PURPOSE

This is the first study that used E12 sheet plastination to investigate the epidural space of the upper cervical spine in situ and its associated bridging structures. Given the complexity of this space, this study may prove useful to clinical anatomists and surgeons who operate within this region.

STUDY DESIGN

Anatomical and microscopic analyses of structures that communicate with the dura mater within the upper cervical region were carried out.

METHODS

Gross dissection in conjunction with microscopy was used to evaluate bridging communications of the upper cervical spine in 10 cadavers. To evaluate the in situ arrangement of these structures, E12 sheet plastination was used on 13 cadavers.

RESULTS

In all 23 specimens, suboccipital fascia coalesced with the dorsal meningovertebral ligament of the atlas, and inserted directly into the posterior surface of the dura as a single but separable laminar layer. At the level of the atlantoaxial interspace, suboccipital fasciae combined and coalesced with the dorsal meningovertebral ligament of the atlas and the axis. These structures inserted into the posterior surface of the dura mater as a single but separable layer. Microscopy validated these findings and E12 sheet plastination revealed the in situ organization of these soft-tissue structures. E12 sheet plastination also provided new information on dural arrangement at the craniocervical junction, which was observed to be composed of periosteum from the occiput but consisted mainly of deep fascia from the rectus capitis posterior minor.

CONCLUSIONS

E12 sheet plastination has provided in situ visualization of bridging structures within the cervical epidural space and offers new insight into these structures, as well as the composition and arrangement of the posterior atlantooccipital membrane and cerebrospinal dura at the craniocervical junction. This study aims to expand on the anatomical understanding of the upper cervical region while defining structures that may reduce neurosurgical complications, and aid in the understanding of the pathophysiology of certain neurogenic disorders.

Long-term outcome and prognostic factors after C2 ganglion decompression in 68 consecutive patients with intractable occipital neuralgia

BACKGROUND

Occipital neuralgia is a rare cause of severe headache characterized by paroxysmal shooting or stabbing pain in the distribution of the greater occipital or lesser occipital nerve. In cases of intractable occipital neuralgia, a definite cause has not been uncovered, so various types of treatment have been applied. The aim of this study is to evaluate the prognostic factors, safety, and long-term clinical efficacy of second cervical (C2) ganglion decompression for intractable occipital neuralgia.

METHODS

Retrospective analysis was performed in 68 patients with medically refractory occipital neuralgia who underwent C2 ganglion decompression. Factors based on patients' demography, pre- and postoperative headache severity/characteristics, medication use, and postoperative complications were investigated. Therapeutic success was defined as pain relief by at least 50 % without ongoing medication.

RESULTS

The visual analog scale (VAS) score was significantly reduced between the preoperative and most recent follow-up period. One year later, excellent or good results were achieved in 57 patients (83.9 %), but poor in 11 patients (16.1 %). The long-term outcome after 5 years was only slightly less than the 1-year outcome; 47 of the 68 patients (69.1 %) obtained therapeutic success. Longer duration of headache (over 13 years; p = 0.029) and presence of retro-orbital/frontal radiation (p = 0.040) were significantly associated with poor prognosis.

CONCLUSIONS

In the current study, C2 ganglion decompression provided durable, adequate pain relief with minimal complications in patients suffering from intractable occipital neuralgia. Due to the minimally invasive and nondestructive nature of this surgical procedure, C2 ganglion decompression is recommended as an initial surgical treatment option for intractable occipital neuralgia before attempting occipital nerve stimulation. However, further study is required to manage the pain recurrence associated with longstanding nerve injury.

Occipital peripheral nerve stimulation in the management of chronic intractable occipital neuralgia in a patient with neurofibromatosis type 1: a case report

Introduction

Occipital peripheral nerve stimulation is an interventional pain management therapy that provides beneficial results in the treatment of refractory chronic occipital neuralgia. Herein we present a first-of-its-kind case study of a patient with neurofibromatosis type 1 and bilateral occipital neuralgia treated with occipital peripheral nerve stimulation.

Case presentation

A 42-year-old Caucasian woman presented with bilateral occipital neuralgia refractory to various conventional treatments, and she was referred for possible treatment with occipital peripheral nerve stimulation. She was found to be a suitable candidate for the procedure, and she underwent implantation of two octapolar stimulating leads and a rechargeable, programmable, implantable generator. The intensity, severity, and frequency of her symptoms resolved by more than 80%, but an infection developed at the implantation site two months after the procedure that required explantation and reimplantation of new stimulating leads three months later. To date she continues to experience symptom resolution of more than 60%.

Conclusion

These results demonstrate the significance of peripheral nerve stimulation in the management of refractory occipital neuralgias in patients with neurofibromatosis type 1 and the possible role of neurofibromata in the development of occipital neuralgia in these patients.

6. Cervicogenic headache

Cervicogenic headache is mainly characterized by unilateral headache symptoms which arise from the neck radiating to the fronto-temporal and possibly to the supra-orbital region. Physical examination to find evidence of a disorder known to be a valid cause of headache encompasses movement tests of the cervical spinal column and segmental palpation of the cervical facet joints and soft tissues of the neck. Injection of the nervus occipitalis major is recommended after unsatisfactory results with conservative treatments (1 B+). In the case of an unsatisfactory outcome after injection of the nervus occipitalis major, radiofrequency treatment of the ramus medialis (medial branch) of the cervical ramus dorsalis can be considered (2 B+/-). If the result is unsatisfactory pulsed radiofrequency treatment of the ganglion spinale (dorsal root ganglion) of C2 and/or C3 can be considered in a study context (O).

Cervical plexus block helps in diagnosis of orofacial pain originating from cervical structures

Headache associated with cervical lesions is called cervicogenic headache and involves the occiput but not the orofacial region. However, patients occasionally present with orofacial pain accompanied by neck symptoms. This study investigates whether orofacial pain can originate from the neck and whether cervical plexus block can help in diagnosis. We enrolled eight patients suffering from chronic orofacial pain that had not been relieved by dental treatment. Radiographic and magnetic resonance imaging revealed abnormal findings in the neck in seven of them. To identify the origin of the orofacial pain, we firstly blocked peripheral sensory input from the oral cavity and surrounding tissues, followed by that from deep cervical structures. We injected local anesthetics around the painful orofacial region, then to the tender points in the masticatory and superficial cervical muscles (trigger point injection), and consequently around the cervical plexus. Pain was assessed using a pain relief score compared with pre-treatment control values. Local anesthesia in the painful oral region provided insufficient relief whereas trigger point injection significantly relieved pain. The amount of pain relief generated by the deep cervical plexus block was more significant than that produced by any other procedures. We conclude that certain types of orofacial pain originate from cervical structures and that a deep cervical plexus block can be helpful in differentially diagnosing such pain.

Upper cervical anterior diskectomy and fusion improves discogenic cervical headaches

STUDY DESIGN

Retrospective patient identification and prospective data collection were performed.

OBJECTIVE

To evaluate the outcome of anterior cervical diskectomy and fusion for discogenic cervical headaches.

SUMMARY OF BACKGROUND DATA

Cervicogenic headaches affect up to 2.5% of the population. One cause is discogenic pain. Because anterior cervical diskectomy and fusion may improve neck pain, the effect of this procedure on discogenic cervical headaches was evaluated.

METHODS

Nine patients with severe refractory cervicogenic headaches who underwent anterior cervical diskectomy and fusion of the upper cervical discs were retrospectively identified on the basis of clinical, radiographic, and diskography findings. Pain was measured by a numerical rating scale, and function by the Oswestry Disability Index.

RESULTS

The study involved six women and three men with a mean age of 52 (range, 35-72 years) and a mean follow-up period of 37 months (range, 24-49 months). Anterior cervical diskectomy and fusion was performed at both C2-C3 and C3-C4 in seven patients, at C2-C3 in one patient, and at C2-C3, C3-C4, and C4-C5 in one patient. Associated symptoms included nausea, arm pain, dizziness, and visual disturbances. All the patients improved. All stated that they would have the same surgery again for the same outcome. The mean numerical rating score improved from 8 (range, 5-10) to 2.7 (range, 0-7) ( < 0.001), and five patients (56%) had total headache relief. The mean Oswestry Disability Index improved from 62 (range, 42-87) to 35 (range, 2-82) ( < 0.009). The associated symptoms resolved in all the patients. There was early moderate to severe dysphagia in three patients, and mild dysphagia in four patients. At the final follow-up assessment, five patients evidenced mild dysphagia.

CONCLUSIONS

Anterior cervical diskectomy and fusion appears to be quite effective for discogenic cervical headache, but should be reserved for patients who are extremely impaired and refractory to all other treatments.

Cervicogenic headache: diagnostic evaluation and treatment strategies

Cervicogenic headache is a chronic, hemicranial pain syndrome in which the source of pain is located in the cervical spine or soft tissues of the neck but the sensation of pain is referred to the head. The trigeminocervical nucleus is a region of the upper cervical spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve converge with sensory fibers from the upper cervical roots. This convergence of upper cervical and trigeminal nociceptive pathways allows the referral of pain signals from the neck to the trigeminal sensory receptive fields of the face and head. The clinical presentation of cervicogenic headache suggests that there is an activation of the trigeminovascular neuroinflammatory cascade, which is thought to be one of the important pathophysiologic mechanisms of migraine. Another convergence of sensorimotor fibers has been described involving intercommunication between the spinal accessory nerve (CN XI), the upper cervical nerve roots, and ultimately the descending tract of the trigeminal nerve. This neural network may be the basis for the well- recognized patterns of referred pain from the trapezius and sternocleidomastoid muscles to the face and head. Diagnostic criteria have been established for cervicogenic headache but its presenting characteristics may be difficult to distinguish from migraine, tension-type headache, or hemicrania continua. A multidisciplinary treatment program integrating pharmacologic, nonpharmacologic, anesthetic, and rehabilitative interventions is recommended. This article reviews the clinical presentation of cervicogenic headache, its diagnostic evaluation, and treatment strategies.

Cervicogenic headache: manual and manipulative therapies

This article reviews current literature on the role of manual medicine in the diagnosis and treatment of cervicogenic headache. Manual diagnostic procedures and treatment procedures are described for the cervical spine. Emphasis is placed on accurate diagnosis using a biomechanical model and precise localization of forces. Muscle energy technique is suggested as a safe and effective treatment when somatic dysfunction of the cervical spine is found in association with the diagnostic criteria for cervicogenic headache. Lastly, a suggested clinical approach to this problem from a manual medicine perspective is given.

Cervicogenic headaches: a critical review

BACKGROUND CONTEXT

The notion that headaches may originate from disorders of the cervical spine and can be relieved by treatments directed at the neck is gaining recognition among headache clinicians but is often neglected in the spine literature.

PURPOSE

To review and summarize the literature on cervicogenic headaches in the following areas: historical perspective, diagnostic criteria, epidemiology, pathogenesis, differential diagnosis, and treatment.

STUDY DESIGN/SETTING

A systematic literature review of cervicogenic headache was performed.

METHODS

Three computerized medical databases (Medline, Cumulative Index to Nursing and Allied Health Literature [CINAHL], Mantis) were searched for the terms "cervicogenic" and "headache." After cross-referencing, we retrieved 164 unique citations; 48 citations were added from other sources, for a total of 212 citations, although all were not used.

RESULTS

Hilton described the concept of headaches originating from the cervical spine in 1860. In 1983 Sjaastad introduced the term "cervicogenic headache" (CGH). Diagnostic criteria have been established by several expert groups, with agreement that these headaches start in the neck or occipital region and are associated with tenderness of cervical paraspinal tissues. Prevalence estimates range from 0.4% to 2.5% of the general population to 15% to 20% of patients with chronic headaches. CGH affects patients with a mean age of 42.9 years, has a 4:1 female disposition, and tends to be chronic. Almost any pathology affecting the cervical spine has been implicated in the genesis of CGH as a result of convergence of sensory input from the cervical structures within the spinal nucleus of the trigeminal nerve. The main differential diagnoses are tension type headache and migraine headache, with considerable overlap in symptoms and findings between these conditions. No specific pathology has been noted on imaging or diagnostic studies which correlates with CGH. CGH seems unresponsive to common headache medication. Small, noncontrolled case series have reported moderate success with surgery and injections. A few randomized controlled trials and a number of case series support the use of cervical manipulation, transcutaneous electrical nerve stimulation, and botulinum toxin injection.

CONCLUSIONS

There remains considerable controversy and confusion on all matters pertaining to the topic of CGH. However, the amount of interest in the topic is growing, and it is anticipated that further research will help to clarify the theory, diagnosis, and treatment options for patients with CGH. Until then, it is essential that clinicians maintain an open, cautious, and critical approach to the literature on cervicogenic headaches.