Management of the Greater Occipital Neuropathy Syndrome

Neuropathy of the greater occipital nerve may present clinically with suboccipital pain and unilateral headache. This syndrome involves the sensory root of the second cervical nerve which supplies sensation to the major portion of the scalp and a portion of the face. Areas of sensory innervation are shared with the trigeminal nerve in supplying the scalp. The second cervical nerve surfaces behind the lateral articular masses between the atlas and the axis. In this exposed position, its posterior primary ramus continues on to the scalp as the greater occipital nerve. Here the greater occipital nerve may be compressed by any movement which approximates the edges of the laminae between which it passes.

The greater occipital nerve may be compressed by an extreme rotary movement of the neck combined with hyperextension. Any history of a respective injury resulting from a motion of this character should suggest this clinicopathology as a principle component in the differential diagnosis. Also, atlantoaxial degenerative joint disease should be investigated as an associated etiology.

Most commonly, the patient complains of constant suboccipital discomfort superimposed upon paroxysms of hemicranial pain, which are exquisitely painful and appear to arise in the suboccipital region. These painful paroxysms radiate to the temporal area, the vertex, and in a periorbital manner affecting the eye on the ipsilateral side, and occur most often at night. Lacrimation, diaphoresis, and congestion of the nasal mucosa may also be present ipsilaterally. Paresthesias, in the form of tingling and numbness, in the parieto-occipital area ipsilaterally may also be common complaints. Roentgenographic findings may, or may not, be contributory findings, other than osseous disrelationship.

Differential diagnosis must include vertebral artery syndrome, intracranial and intraspinal masses, spinal stenosis, and cervical discopathy.

Conservative care may involve prolonged cervical traction with appropriate angles for the respective levels of the cervical spine being tractioned. C1 (atlas) and C2 (axis) should be tractioned at 90 degrees to the base line, or straight up, and a 20 to 30 degree anterior angle applied to the remainder of the cervical segments. Traction may be applied b.i.d., or t.i.d., for 30 minutes applying as much weight as possible without resulting in countertractional muscle spasm. Thermal therapy, in the form of hydrocollator packs, or silicone gel wrap, is recommended for no more than 25 minutes per application, p.r.n., being careful to avoid erythema ab igne. This author recommends hydrocortisone (1.0 percent) /lidocaine (2.5 percent) phonophoresis at 0.6W/cm2, b.i.d., or p.r.n. pain and reduced ROM. Although it is of therapeutic advantage to maintain the cervical spine in flexion to avoid radicular compression, this may be impractical for the patient unless clinical symptoms demand this application. When applying phonophoresis, the transducer head should be applied in such a manner to direct the cone of the ultrasonic beam into the ipsilateral suboccipital region involved; pulsed ultrasonic energy should be used in this process.

If the neuropathy remains intractable to care, referral to an orthopedic surgeon or neurosurgeon for consultation relative to nerve root sectioning may be necessary. In this author's experience, this is a rare necessity.

References

1. Davis RV. Therapeutic Modalities for the Clinical Health Sciences, 2nd ed., 1989. Library of Congress Card #TXU-389-661.

    

2. Griffin JE and Karsalis TC. Physical Agents for Physical Therapists, 2nd ed. Springfield: Charles C. Thomas, 1982.

    

3. Krusen, Kottke, Ellwood. Handbook of Physical Medicine & Rehabilitation, 2nd ed. Philadelphia: W.B. Saunders Company, 1971.

    

4. Schriber WA. A Manual of Electrotherapy, 4th ed. Philadelphia: Lea & Feibiger, 1975.

    

5. Turek. Orthopedics -- Their Principles and Application, 3rd ed. Lippincott.