The authors acknowledge the technical assistance of Alexandra Curchod, Yuliethe Martins, and the Filmatik Global team. This work was funded in its entirety by the Global Medical Institute.

The data collection was conducted as a retrospective quality assessment study and the analysis of the results was approved by the internal review board at University of Padua. All procedures were performed in accordance with the ethical standards of the national research committee and the 1964 Helsinki Declaration and its later amendments. All patients have signed an informed consent allowing the authors to anonymously use the retrospective data. For this study, 87 patients were included.
1. Selection of candidates
<ol>
	<li>Select patients based on a constellation of symptoms compatible with occipital neuralgia, including at least three of the following characteristics: aching, burning, and throbbing pain, starting in the pit between the insertion of the trapezius muscle and the sternocleidomastoid muscle (here defined as the occipital triangle); the pain travels in the scalp along the trajectory of the occipital nerves from the back of the head to the temples and front on one or both sides of the head; the pain can resemble an electrical shock; the pain can be elicited/worsened by particular positions of the head (hyperextension of the neck, rotation of the head, etc.) also while sleeping; the pain often is felt behind the eyes; the scalp can exhibit allodynia; patients may have migraines and cluster headaches in addition to occipital neuralgia.</li>
	<li>To be included, ensure patients respond with at least 50% decrease in pain after selective blocks of the occipital nerves.</li>
	<li>Use the following exclusion criteria: pain started after trauma like whiplash injury; pain started after surgery or radiotherapy with direct or indirect nerve injury; patients not responding to selective nerve blocks.</li>
</ol>
2. Nerve block procedure
<ol>
	<li>Prepare the infiltration mixture as 1.5 mL of 1% lidocaine with epinephrine (1% Rapidocain 10 mg/mL) and 1 cc of 40 mg Triamcinolone (40 mg/mL) in a 5 cc syringe prepared with a 30G needle.</li>
	<li>Transfer the mixture into a 5 mL syringe (Luer Lock) with a 30G needle (0.3 mm x 13 mm).</li>
	<li>Identify the site of injection by palpation. Identify the lateral edge of the proximal trapezius insertion and medial edge of the proximal sternocleidomastoid (SCM) muscle insertion, just below the nuchal line. The pit between these structures corresponds to the target injection point.</li>
	<li>Palpate the occipital artery passage above the nuchal line. Confirm the occipital neurovascular bundle (greater and lesser occipital nerve and occipital artery) position below the nuchal line using Doppler (10 MHz). Move the doppler probe caudally toward the occipital triangle and confirm the passage of the artery in this place by an arterial signal.</li>
	<li>Perform gentle aspiration with the syringe before injection (if blood is aspirated the needle is retracted a few mm) to prevent intravascular injection. If the patient feels electric shocks along the occipital nerve path, withdraw the needle a few mm to avoid intraneural injection and nerve damage.</li>
	<li>To ensure that the nerve block has been performed correctly, palpate the back scalp to allow the patient to confirm decreased sensation.</li>
</ol>
3. Preparation of the instrumentation table
<ol>
	<li>Drape the instrumentation table with laminar flow with sterile clothing. Prepare the following instruments: Surgical knife with blade No. 15, surgical Hudson forceps, needle holder, dissection scissors, bipolar forceps, lighted retractor, Nylon 5/0 suture, sterile gloves, Chlorhexidine disinfection, sterile paper tape.</li>
</ol>
4. Patient preparation
<ol>
	<li>Identify the most tender point with the patient sitting upright using palpation within the area where the nerve block was performed.</li>
	<li>Mark the incision site with a 2 to 3 cm oblique incision line across the tender area. Shave the area comprising the incision line and 1 cm around with a surgical shaver.</li>
</ol>
5. Surgeon preparation
<ol>
	<li>The surgeon wears 2.5x - 3.5x magnifying loops, surgical cap, and mask. Wash hands with soap and disinfect hands with antiseptic solution.</li>
</ol>
6. Surgical technique
<ol>
	<li>Patient positioning: Position the patients either laterally (in case of one-sided ON) or prone (for bilateral ON) on the surgical table.</li>
	<li>Local anesthesia: Administer local anesthesia, consisting of 5 mL of lidocaine with epinephrine, injected along the incision line via a 30G needle.</li>
	<li>Incision: Make an oblique, beveled incision, measuring 2.5 to 3.5 cm, centered in a region defined as the occipital triangle, bordered cranially by the nuchal line, medially by the lateral edge of the trapezius, and laterally by the medial edge of the sternocleidomastoid muscle using a No. 15 surgical blade.</li>
	<li>Nuchal line exposure: Incise the superficial layer of the nuchal line with the scalpel and dissect with dissection scissors to expose the greater occipital nerve (GON), occipital artery, and lymph nodes.</li>
	<li>Nerve exploration: Follow the GON meticulously along all points of possible compression using dissection scissors to create the space. Perform proximal release of the inferior fascia of the trapezius muscle with dissection scissors, semispinalis muscle fascia, and distal nuchal line fibers.</li>
	<li>Vascular and lymphatic structures: In instances where the occipital artery and lymph nodes come into contact with the nerves, reposition or excise these structures delicately with Hudson&#39;s surgical forceps. Gently disengage the adventitial and periarterial tissues with Hudson&#39;s surgical forceps, abundant in afferent and efferent autonomic nervous system fibers, in all cases (arteriolysis).</li>
	<li>Addressing neurovascular contact points: When a non-otherwise addressable conflict is found (such as a branch of the artery passing through the nerve fibers), divide this arterial segment (arteriotomy).</li>
	<li>Nerve blocks: Before closure, perform nerve blocks using 1% lidocaine with epinephrine sprayed directly on the nerve branches via a 30G needle. Ask the patient to move the head and talk to confirm complete decompression.</li>
	<li>Closure: Repair skin with single stitches of 5-0 nylon sutures. Dress the opening with moisture permeable spray dressing and sterile gauzes, held in place by paper tape.</li>
</ol>
7. Postoperative protocol
<ol>
	<li>Postoperative head movements: After the procedure, ask the patient to gently move the head in all directions at least 3x a day to prevent the formation of adhesions between the nerve fibers and the scar for a period of 2 to 3 weeks.</li>
	<li>Suture removal: Remove sutures 10 days after the procedure.</li>
	<li>Ask patients to continue their medications in case of headaches. Tell the patient to expect decreased sensation or anesthesia in the territory of the greater occipital nerve for a variable period between a few hours and a few days after the operation.</li>
	<li>Instruct patients to take ibuprofen 400-600 mg, 3x day for 3 days after the procedure.</li>
</ol>

Relieving Occipital Neuralgia: Nerve and Muscle-Preserving Decompression

<ol>
	<li>IHS. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+international+classification+of+headache+disorders,+3rd+edition.">The international classification of headache disorders, 3rd edition.</a> Cephalalgia. 38 (1), 1-211 (2018).</li><li>Mosser, S. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+anatomy+of+the+greater+occipital+nerve:+implications+for+the+etiology+of+migraine+headaches.">The anatomy of the greater occipital nerve: implications for the etiology of migraine headaches.</a> Plast Reconstr Surg. 113 (2), 693-697 (2004).</li><li>Janis, J. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Neurovascular+compression+of+the+greater+occipital+nerve:+implications+for+migraine+headaches.">Neurovascular compression of the greater occipital nerve: implications for migraine headaches.</a> Plast Reconstr Surg. 126 (6), 1996-2001 (2010).</li><li>Guyuron, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Five-year+outcome+of+surgical+treatment+of+migraine+headaches.">Five-year outcome of surgical treatment of migraine headaches.</a> Plast Reconstr Surg. 127 (2), 603-608 (2011).</li><li>Blake, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tracking+patients+with+chronic+occipital+headache+after+occipital+nerve+decompression+surgery:+A+case+series.">Tracking patients with chronic occipital headache after occipital nerve decompression surgery: A case series.</a> Cephalalgia. 39 (4), 556-563 (2019).</li><li>Pietramaggiori, G., Scherer, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+nerve-+and+muscle-sparing+surgical+decompression+for+occipital+neuralgia.">Minimally invasive nerve- and muscle-sparing surgical decompression for occipital neuralgia.</a> Plast Reconstr Surg. 151 (1), 169-177 (2023).</li><li>Tobin, J., Flitman, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+of+migraine+with+occipital+nerve+blocks+using+only+corticosteroids.">Treatment of migraine with occipital nerve blocks using only corticosteroids.</a> Headache. 51 (1), 155-159 (2011).</li><li>Seyed Forootan, N. S., Lee, M., Guyuron, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Migraine+headache+trigger+site+prevalence+analysis+of+2590+sites+in+1010+patients.">Migraine headache trigger site prevalence analysis of 2590 sites in 1010 patients.</a> J Plast Reconstr Aesthet Surg. 70 (2), 152-158 (2017).</li><li>Pietramaggiori, G., Scherer, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Minimally invasive surgery for chronic pain management. , (2020).</li><li>Janis, J. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+anatomy+of+the+greater+occipital+nerve:+Part+II.+Compression+point+topography.">The anatomy of the greater occipital nerve: Part II. Compression point topography.</a> Plast Reconstr Surg. 126 (5), 1563-1572 (2010).</li><li>Ducic, I., Moriarty, M., Al-Attar, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anatomical+variations+of+the+occipital+nerves:+implications+for+the+treatment+of+chronic+headaches.">Anatomical variations of the occipital nerves: implications for the treatment of chronic headaches.</a> Plast Reconstr Surg. 123 (3), 859-863 (2009).</li><li>Junewicz, A., Katira, K., Guyuron, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraoperative+anatomical+variations+during+greater+occipital+nerve+decompression.">Intraoperative anatomical variations during greater occipital nerve decompression.</a> J Plast Reconstr Aesthet Surg. 66 (10), 1340-1345 (2013).</li><li>Scherer, S. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+greater+occipital+nerve+and+obliquus+capitis+inferior+muscle:+Anatomical+interactions+and+implications+for+occipital+pain+syndromes.">The greater occipital nerve and obliquus capitis inferior muscle: Anatomical interactions and implications for occipital pain syndromes.</a> Plast Reconstr Surg. 144 (3), 730-736 (2019).</li><li>Koopman, J. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incidence+of+facial+pain+in+the+general+population.">Incidence of facial pain in the general population.</a> Pain. 147 (1-3), 122-127 (2009).</li><li>Mathew, P. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevalence+of+occipital+neuralgia+at+a+community+hospital-based+headache+clinic.">Prevalence of occipital neuralgia at a community hospital-based headache clinic.</a> Neurol Clin Pract. 11 (1), 6-12 (2021).</li></ol>

The authors declare no competing financial interests.

Occipital neuralgia is one of the most debilitating forms of headaches, mainly due to the chronic pain that is unremitting. A study on the prevalence of facial pain in 2009, which is often used as a reference for occipital neuralgia, found an ON prevalence of 3.2 per 100,00014. These statistics largely underestimate the problem, knowing that ON is responsible for facial pain in only 8.3% of the cases and that up to 25% of the cases of emergency room admittance are for headaches due to occipital neuralgia15.
We find in our practice that ON alone or in combination with other migraines is one of the most prevalent forms of chronic headaches, possibly due to morbid posture with the neck in flexion in front of computers and smartphones several hours per day, sedentary lifestyle, and limited time outdoors. 
The surgical approach outlined here offers a highly efficient means of accessing the occipital nerves under local anesthesia. Greater occipital neuralgia may coexist with lesser occipital neuralgia as these nerves have communicating branches and their territories overlap. By using the same surgical approach, both nerves can be explored and decompressed when indicated6. Patient acceptance of the procedure has been favorable, with an average duration of approximately 45 to 60 min required for completion per side.
The meticulous identification and preservation of nerve fibers constitute a hallmark of this approach. Thanks to the minimally invasive nature of the procedure that can be performed in local anesthesia, the operator assesses the efficacy of decompression at the end of the procedure by instructing the patient to engage in head movement and conversation, thereby ensuring the absence of residual compression points.
A crucial facet of this procedure lies in the emphasis on early and frequent head mobilization, conducted multiple times daily. This practice serves to deter the formation of adhesions between nerve fibers and the surgical scar, which may otherwise impede recovery.
It is essential to acknowledge that not all patients are suitable candidates for this technique. Notably, individuals with fragility or heightened anxiety levels may not tolerate the procedure comfortably under pure local anesthesia. In certain cases, patients may experience sudden discomfort, as even the slightest manipulation of an inflamed occipital nerve can trigger nerve firing. In these cases, local anesthesia is sprayed directly on the nerve fibers with immediate relief. 
This surgical approach represents a less invasive alternative compared to previously proposed decompression techniques. Its capacity to spare both nerve and muscle fibers contributes to a notable reduction in complication rates. We posit that this minimally invasive, yet highly effective methodology will broaden the accessibility of surgical decompression as a definitive treatment option for occipital neuralgia, offering hope to a wider spectrum of patients.

Occipital neuralgia (ON) is a chronic headache condition causing persistent dull pain in the back of the head1. The pain, which differs from typical migraines, is often resistant to standard migraine treatments due to mechanical compression on the occipital nerves2, particularly along their course through the nuchal line3. On the other hand, surgical options may be effective but involve invasive procedures and extended recovery times4,5. We present here a novel approach to the occipital nerves, allowing for minimally invasive decompression, minimal downtime, and preservation of muscle and sensitive nerve branches6.
Diagnosing ON relies on targeted nerve blocks, which temporarily reduce pain and help pinpoint the exact area of nerve compression7, guiding surgical decompression8,9. Unlike typical migraine management, our approach targets the root mechanical cause of ON, providing a viable therapeutic option beyond medication.
Numerous clinical and anatomical studies have led to the occipital nerve decompression technique as described in2,3,10,11,12,13. Although this technique has been proven safe and effective, the advantages of the minimally invasive technique presented here include reduced patient morbidity, abbreviated postoperative recovery periods, and lesser risks of iatrogenic-induced pain due to potential neuroma formation. In particular, the preservation of neural and muscular structures contributes to prompt and favorable outcomes. The greater and lesser occipital nerves can be exposed and decompressed via the described approach. For the purpose of this paper, only greater occipital nerve decompression is described to improve occipital neuralgia, which is due to lesser occipital neuralgia. The third occipital nerve is responsible for rare cases of occipital neuralgia in our practice, which are addressed with a separate approach due to its medial localization. The described technique includes the systematic exploration of the passage of the greater occipital nerve through the semispinalis capitis which may represent a compression point. Further research and clinical validation are warranted to ascertain the full scope of its efficacy and safety.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>30G Needle</td>
			<td>0.3x13 mm, BD Microlance 3, Spain</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Bipolar Forceps</td>
			<td>McPerson, bipolar forceps, Erbe, Switzerland</td>
			<td>20195</td>
			<td></td>
		</tr>
		<tr>
			<td>Chlorhexidine</td>
			<td>Hibidil, Chlorhexidini digluconas 0.5 mg/mL, Switzerland</td>
			<td>120099</td>
			<td></td>
		</tr>
		<tr>
			<td>dissection scissors</td>
			<td>Jarit supercut, Integra Lifescience, USA</td>
			<td>323720</td>
			<td></td>
		</tr>
		<tr>
			<td>Doppler</td>
			<td>Dopplex DMX Digital Doppler, High Sensitivity 10MHz probe, Huntleigh Healthcare, Wales, United Kingdom</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Ethilon 5/0 Suture</td>
			<td>Ethicon, USA</td>
			<td>698 G</td>
			<td></td>
		</tr>
		<tr>
			<td>Lidocaine ephinephrine 1%</td>
			<td>Rapidocain 1% 10 mg/mL, Sintetica, Switzerland</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Lighted retractor</td>
			<td>Electro Surgical Instrument Company, Rochester, NY</td>
			<td>08-0195</td>
			<td></td>
		</tr>
		<tr>
			<td>Magnifying loops</td>
			<td>Design for vision, USA</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Opsity spray</td>
			<td>Smith &#38; Nephew, USA</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sterile gloves</td>
			<td>Sempermed sintegra IR, Ireland</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sterillium</td>
			<td>Sterillium disinfectant, Switzerland</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical blade n.15</td>
			<td>Carbon steel surgical blades, Swann-Morton, England)</td>
			<td>205</td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical drapes and gauzes</td>
			<td>Halyard Universal pack, USA</td>
			<td>88761</td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical instruments</td>
			<td>Bontempi medical Italy</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical shaver</td>
			<td>Carefusion, USA</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Syringe 5cc</td>
			<td>BBraun, Omnifix Luer Lock Solo, Switzerland</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Triamcinolone 10mg</td>
			<td>Triamcort depot 40 mg/mL, Zentiva Czech Republic</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

minimally invasive surgical decompression of occipital nerves

Occipital neuralgia (ON) stands out as one of the most distressing forms of headache disorders, distinguished by persistent pain at the base of the skull, recurring occipital headaches, and scalp dysesthesia or allodynia. ON is notorious for its unrelenting agony, severely impacting the lives of those afflicted. The incessant pain, often radiating upward from the base of the skull to the scalp, can be profoundly debilitating. Patients frequently endure excruciating occipital headaches, making even routine daily activities a formidable challenge. The added burden of scalp dysesthesia or allodynia, where seemingly innocuous stimuli elicit severe pain, compounds the suffering. This neuralgia primarily arises from the mechanical compression exerted on the occipital nerves along the nuchal line. In this paper, we present a minimally invasive nerve and muscle-preserving technique aimed at relieving this compression on the occipital nerves. Accurate diagnosis and effective treatment are paramount in providing relief for individuals battling this condition. Nerve blocks with local anesthesia have become a cornerstone of diagnosis, serving as both a confirmation of occipital neuralgia and a potential therapeutic intervention. These procedures offer crucial insights into the source of the pain while offering transient respite. However, the true breakthrough lies in the innovative technique we propose - a procedure that addresses the mechanical compression at the nuchal line, which is a prominent contributing factor to occipital neuralgia. By carefully decompressing the affected occipital nerves while preserving their integrity and surrounding muscle tissue, this minimally invasive approach offers patients a potential path to sustained relief. Remarkably, the procedure can be performed under local anesthesia, reducing the invasiveness of traditional surgeries and minimizing patient downtime.

At 1 year after the surgical decompression, there was a noteworthy reduction in chronic pain days, with a substantial decrease from an initial average of 25 days to 4.3 days (p &#60;0.01), reflecting an 80.5% reduction (a 5.8-fold decrease) in chronic pain frequency (Figure 1)6. Furthermore, the number of pain crisis days per month exhibited a remarkable decline, plummeting from 19 days to 3.7 days (p &#60;0.01), signifying an 82.8% reduction (a 5.1-fold decrease) in the frequency of pain crises (Figure 1 and Figure 2)6.
Patients reported an average background pain intensity of 3.7 on a scale of 10 before surgery, which substantially improved to 0.7 (p &#60;0.01) post-surgery, corresponding to an impressive 76.1% reduction (a 5.2-fold decrease) in background pain intensity6. Moreover, the peak pain intensity experienced during crises significantly diminished from 8.8/10 to 2.1/10 after surgery (p &#60;0.01), reflecting a substantial 81.1% reduction (a 4.2-fold decrease) in peak pain intensity (Figure 1 and Figure 2)6.
Remarkably, there was a significant reduction in the utilization of all types of drugs, including NSAIDs, triptans, and disease-modifying drugs, following the surgical intervention6 (not shown).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/66214/66214fig01.jpg" /> 
Figure 1: Clinical outcome after minimally invasive surgical decompression. After surgical decompression, chronic pain days decreased 5.8x. The pain crisis days/month decreased 5.1x. Background pain intensity decreased after surgery 5.2x, and pain intensity peaks during crises decreased 4.2x. (*p &#60;0.01, Two-tailed paired t tests, n=87). This figure has been modified from6. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66214/66214fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/66214/66214fig02.jpg" /> 
Figure 2: Illustration of the anatomy of the occipital area pre- and post-decompression. In the pre-decompression picture, the external layer of the nuchal aponeurosis covers the occipital nerves and blood vessels. After decompression, the greater occipital nerve and occipital artery are visible. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66214/66214fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Author Spotlight: Minimally Invasive Relief for Occipital Neuralgia at the Nuchal Line

The manuscript presents a minimally invasive nerve and muscle-sparing surgical protocol to decompress occipital nerves aiming to improve occipital neuralgia.

Minimally Invasive Surgical Decompression of Occipital Nerves

Occipital neuralgia (ON) stands out as one of the most distressing forms of headache disorders, distinguished by persistent pain at the base of the skull, ...

minimally-invasive-surgical-decompression-of-occipital-nerves

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JoVE Journal

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1.6K Views.  Global Medical Institute. The manuscript presents a minimally invasive nerve and muscle-sparing surgical protocol to decompress occipital nerves aiming to improve occipital neuralgia.

Video: Author Spotlight: Minimally Invasive Relief for Occipital Neuralgia at the Nuchal Line

Microvascular Decompression: Salient Surgical Principles and Technical Nuances

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports indicate that 80-90% of cases are related to compression of the trigeminal nerve by an adjacent vessel. The majority of patients with trigeminal neuralgia eventually require surgical management in order to achieve remission of symptoms. Surgical options for management include ablative procedures (e.g., radiosurgery, percutaneous radiofrequency lesioning, balloon compression, glycerol rhizolysis, etc.) and microvascular decompression. Ablative procedures fail to address the root cause of the disorder and are less effective at preventing recurrence of symptoms over the long term than microvascular decompression. However, microvascular decompression is inherently more invasive than ablative procedures and is associated with increased surgical risks. Previous studies have demonstrated a correlation between surgeon experience and patient outcome in microvascular decompression. In this series of 59 patients operated on by two neurosurgeons (JSN and PEK) since 2006, 93% of patients demonstrated substantial improvement in their trigeminal neuralgia following the procedure&#x2014;with follow-up ranging from 6 weeks to 2 years. Moreover, 41 of 66 patients (approximately 64%) have been entirely pain-free following the operation.
In this publication, video format is utilized to review the microsurgical pathology of this disorder. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed.

There are many available options for management of the patient with trigeminal neuralgia. Microvascular decompression, while the most invasive of all options, is also the most effective at achieving long term remission of symptoms. Video instruction on how to maximize efficacy and minimize complications with this procedure is described.

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports ...

Minimally Invasive Establishment of Murine Orthotopic Bladder Xenografts

Orthotopic bladder cancer xenografts are the gold standard to study molecular cellular manipulations and new therapeutic agents&#160;in vivo. Suitable cell lines are inoculated either by intravesical instillation (model of nonmuscle invasive growth) or intramural injection into the bladder wall (model of invasive growth). Both procedures are complex and highly time-consuming. Additionally, the superficial model has its shortcomings due to the lack of cell lines that are tumorigenic following instillation. Intramural injection, on the other hand, is marred by the invasiveness of the procedure and the associated morbidity for the host mouse.
With these shortcomings in mind, we modified previous methods to develop a minimally invasive approach for creating orthotopic bladder cancer xenografts. Using ultrasound guidance we have successfully performed percutaneous inoculation of the bladder cancer cell lines UM-UC1, UM-UC3 and UM-UC13 into 50 athymic nude. We have been able to demonstrate that this approach is time efficient, precise and safe. With this technique, initially a space is created under the bladder mucosa with PBS, and tumor cells are then injected into this space in a second step. Tumor growth is monitored at regular intervals with bioluminescence imaging and ultrasound. The average tumor volumes increased steadily in in all but one of our 50 mice over the study period.
In our institution, this novel approach, which allows bladder cancer xenograft inoculation in a minimally-invasive, rapid and highly precise way, has replaced the traditional model.

The established technique to inoculate primary invasive orthotopic bladder cancer xenografts requires laparotomy and mobilization of the bladder. This procedure inflicts significant morbidity on the mice, is technically challenging and time-consuming. We therefore developed a high-precision, percutaneous approach utilizing ultrasound guidance.

Orthotopic bladder cancer xenografts are the gold standard to study molecular cellular manipulations and new therapeutic agents&#160;in vivo. Suitable ...

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients &#8804;55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged &#8804;55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

Minimally invasive thumb-sized pterional craniotomy for aneurysm clipping has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve ...

Minimal Invasive Surgical Procedure of Inducing Myocardial Infarction in Mice

Myocardial infarction still remains the main cause of death in western countries, despite considerable progress in the stent development area in the last decades. For clarification of the underlying mechanisms and the development of new therapeutic strategies, the availability of valid animal models are mandatory. Since we need new insights into pathomechanisms of cardiovascular diseases under in vivo conditions to combat myocardial infarction, the validity of the animal model is a crucial aspect. However, protection of animals are highly relevant in this context. Therefore, we establish a minimally invasive and simple model of myocardial infarction in mice, which assures a high reproducibility and survival rate of animals. Thus, this models fulfils the requirements of the 3R principle (Replacement, Refinement and Reduction) for animal experiments and assure the scientific information needed for further developing of therapeutical strategies for cardiovascular diseases.

A highly reproducible model for myocardial infarction in mice with minimal invasive manipulations is described. The model can be easily performed, resulting in a high reproducibility and survival rate. Thus, the described model will reduce the number of required animals as requested by the 3R principle (Replacement, Refinement and Reduction).

Myocardial infarction still remains the main cause of death in western countries, despite considerable progress in the stent development area in the last ...

Encapsulation Thermogenic Preadipocytes for Transplantation into Adipose Tissue Depots

Cell encapsulation was developed to entrap viable cells within semi-permeable membranes. The engrafted encapsulated cells can exchange low molecular weight metabolites in tissues of the treated host to achieve long-term survival. The semipermeable membrane allows engrafted encapsulated cells to avoid rejection by the immune system. The encapsulation procedure was designed to enable a controlled release of bioactive compounds, such as insulin, other hormones, and cytokines. Here we describe a method for encapsulation of catabolic cells, which consume lipids for heat production and energy dissipation (thermogenesis) in the intra-abdominal adipose tissue of obese mice. Encapsulation of thermogenic catabolic cells may be potentially applicable to the prevention and treatment of obesity and type 2 diabetes. Another potential application of catabolic cells may include detoxification from alcohols or other toxic metabolites and environmental pollutants.

Here, we present a protocol for encapsulation of catabolic cells, which consume lipids for heat production in intra-abdominal adipose tissue and increase energy dissipation in obese mice.

Cell encapsulation was developed to entrap viable cells within semi-permeable membranes. The engrafted encapsulated cells can exchange low molecular ...

Minimally Invasive Transverse Aortic Constriction in Mice

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard open-chest transverse aortic constriction (TAC). Although transverse aortic constriction is a highly functional method for the induction of high pressure in the left ventricle, it is a more difficult and lengthy procedure due to its use of artificial ventilation with tracheal intubation. TAC is oftentimes also less survivable, as the newer method, MTAC, neither requires the cutting of the ribs and intercostal muscles nor tracheal intubation with a ventilation setup. In MTAC, as opposed to a thoracotomy to access to the chest cavity, the aortic arch is reached through a midline incision in the anterior neck. The thyroid is pulled back to reveal the sternal notch. The sternum is subsequently cut down to the second rib level, and the aortic arch is reached simply by separating the connective tissues and thymus. From there, a suture can be wrapped around the arch and tied with a spacer, and then the sternal cut and skin can be closed. MTAC is a much faster and less invasive way to induce left ventricular hypertension and enables the possibility for high-throughput studies. The success of the constriction can be verified using high-frequency trans-thoracic echocardiography, particularly color Doppler and pulsed-wave Doppler, to determine the flow velocities of the aortic arch and left and right carotid arteries, the dimension of the blood vessels, and the left ventricular function and morphology. A successful constriction will also trigger significant histopathological changes, such as cardiac muscle cell hypertrophy with interstitial and perivascular fibrosis. Here, the procedure of MTAC is described, demonstrating how the resulting flow changes in the carotid arteries can be examined with echocardiography, gross morphology, and histopathological changes in the heart.

Minimally invasive transverse aortic constriction (MTAC) conserves the essentials of regular transverse aortic constriction (TAC) while eliminating the use of a ventilator with tracheal intubation. It proves to be a highly desirable method for high-throughput studies on left ventricular overload, particularly in translational studies.

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard ...

An Anatomical Study of Nerves at Risk During Minimally Invasive Hallux Valgus Surgery

The growing popularity of minimally invasive surgical (MIS) procedures makes it necessary that new anatomical references arise, to aid in tridimensional orientation and localization of structures that are not directly visible to the surgeon. This is especially critical for structures at risk like nerves or blood vessels. Optimization of the handling of cadaveric material and the combination of multiple techniques compensate for the limited availability of adequate specimens. The described protocol combines anatomical plane-by-plane dissection and sectional anatomy of fresh-frozen specimens to help localize relevant structures, such as nerves, arteries, veins and to correctly position the portals during MIS procedures. Depiction of these structures in anatomy textbooks can differ from what is encountered in the surgical field; and for this reason, new anatomical studies with a surgical orientation are needed. However, this is a complex, time-consuming technique requiring specific training. The anatomical references described with the so-called 'clock method' provide the surgeon with an easy and reproducible system to locate the path of the nerves at risk in Hallux Valgus MIS procedures. This model can be extrapolated to many other minimally invasive surgical procedures.

Minimally invasive surgical (MIS) procedures rely on anatomical references to localize structures not directly visible to the surgeon. This manuscript describes a combined method of plane-by-plane dissection and sectional anatomy of fresh-frozen specimens to locate the structures at risk during MIS procedures.

The growing popularity of minimally invasive surgical (MIS) procedures makes it necessary that new anatomical references arise, to aid in tridimensional ...

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal deviation. It has a long history with multiple variations. In this article, a modified endoscopic septoplasty procedure using the limited two-line resection (2LoRs) technique at the posterior and inferior junction of the cartilaginous and bony septum is presented based on embryologic and anatomic knowledge of the nasal septum and the biomechanics of cartilaginous behavior. With this procedure, the quadrangular cartilage can be preserved as much as possible, which is helpful in retaining the supporting framework and rigidness of the septum. 2LoRs has been proven effective and sound for the correction of nasal septal deviation with rare complications. This modified procedure can be applied to correct the deviated nasal septum in the absence of any external nasal deformity to improve nasal patency or to improve access to the middle meatus or to the axillary region of the middle turbinate. It may also be used to expand the indications of septoplasty to children and adolescents because of its minimally invasive approach.

Endoscopic septoplasty is a time-honored surgical procedure with multiple variations. This paper focuses on a step-by-step surgical approach to perform a modified septoplasty procedure known as limited two-line resection. This surgical technique can be applied to correct a deviated nasal septum in the absence of an external nasal deformity.

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal ...

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Presented here is a protocol for lung nodule localization using dye marking via electromagnetically navigated transthoracic needle access. The technique described here can be accomplished in the peri-operative period to optimize nodule localization and to successful resection when performing minimally invasive thoracic surgery.

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or ...

A Pre-clinical Rat Model for the Study of Ischemia-reperfusion Injury in Reconstructive Microsurgery

Ischemia-reperfusion injury is the main cause of flap failure in reconstructive microsurgery. The rat is the preferred preclinical animal model in many areas of biomedical research due to its cost-effectiveness and its translation to humans. This protocol describes a method to create a preclinical free skin flap model in rats with ischemia-reperfusion injury. The described 3 cm x 6 cm rat free skin flap model is easily obtained after the placement of several vascular ligatures and the section of the vascular pedicle. Then, 8 h after the ischemic insult and completion of the microsurgical anastomosis, the free skin flap develops the tissue damage. These ischemia-reperfusion injury-related damages can be studied in this model, making it a suitable model for evaluating therapeutic agents to address this pathophysiological process. Furthermore, two main monitoring techniques are described in the protocol for the assessment of this animal model: transit-time ultrasound technology and laser speckle contrast analysis.

Here, we describe a pre-clinical animal model for studying the pathophysiology of ischemia-reperfusion injury in reconstructive microsurgery. This free skin flap model based on the superficial caudal epigastric vessels in the rat may also allow for the evaluation of different therapies and compounds to counteract ischemia-reperfusion injury-related damage.

Ischemia-reperfusion injury is the main cause of flap failure in reconstructive microsurgery. The rat is the preferred preclinical animal model in many ...