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Chiropractic management of greater occipital neuralgia
Clinical Chiropractic (2003) 6, 120—128
CASE REPORT
Chiropractic management of greater occipital neuralgia L. Comley* Berkhamstead Chiropractic Clinic, Coleshill House, 69 High Street, Berkhamstead, Hertfordshire HP4 2DE, UK Received 1 August 2003; accepted 12 September 2003
KEYWORDS Cephalalgia; Cervical spine; Chiropractic; Greater occipital neuralgia; Human adult female; Spinal manipulative therapy
Abstract Greater occipital neuralgia (GON) is the term used to describe signs and symptoms of irritation to the greater occipital nerve. Neuralgic pain is characteristically sharp and shooting in nature and distributed over the area of the nerve affected. In the case of GON, pain is typically located in the sub-occipital region and radiates superiorly to the posterior aspect of the skull. GON due to unilateral C1—2 degenerative joint disease (DJD) is a recognised clinical syndrome. Arthrosis of the C1—2 zygoapophyseal articulation can cause irritation of the C2 dorsal ramus due to their close approximation. The signs and symptoms of GON can vary widely between sufferers. The most common symptoms are unilateral sub-occipital pain accompanied by neuralgic pain travelling superiorly to the posterior aspect of the skull. Headache, dizziness, tinnitus, visual blurring and occular pain as well as other complaints can accompany this. The signs of GON as a result of C1—2 DJD are a decrease in cervical range of motion (particularly rotation); tenderness in the occipital region, particularly over the C1—2 articulation and exacerbation of pain with cervical spine motion. There is no uniformly effective treatment for this condition, once conservative treatment fails, surgery is the next option but there are many reported side effects and failed surgical cases. This case demonstrates how this syndrome was relieved in one patient by chiropractic management. The possible mechanisms by which manipulation can effect improvement in this condition are discussed. ß 2003 Published by Elsevier Ltd on behalf of The College of Chiropractors.
Introduction It is commonplace for a chiropractic opinion to be sought regarding neck pain and headaches. When presented with non-specific symptoms, such as unilateral sub-occipital pain, a thorough history and examination must be carried out to determine the cause. A number of differential diagnoses must always be considered that typically will include both commonly encountered conditions such as ‘tension’ headache, migraine and cervicogenic headache as well as more sinister causes such as sub-arachnoid *
Tel.: þ44-1442-863800; fax: þ44-1442-870844. E-mail address: [email protected] (L. Comley).
haemorrhage or other space occupying lesions.1 Although not a common cause of neck pain and headache, greater occipital neuralgia (GON) should also be added to the list of possible diagnoses. Greater occipital neuralgia is characterised by pain in the occipitocervical region and one-sided headache at the back of the head.1—4 The symptoms of greater occipital neuralgia are attributed to irritation of the greater occipital nerve (GONv). Pain is of a neuralgic character, that is a sharp, severe shooting pain, characteristically radiating over the area of the nerve involved. The possible symptoms associated with GON are detailed in Table 1. Patients with this type of pain often present initially to their general practitioner (GP). If a
1479-2354/$30.00 ß 2003 Published by Elsevier Ltd on behalf of The College of Chiropractors. doi:10.1016/j.clch.2003.09.008
Chiropractic management of greater occipital neuralgia
Table 1 Symptoms associated with greater occipital neuralgia.2 Headache (unilateral or bilateral) Facial pain Neck ache Pain/pressure behind eyes Pains in temperomandibular joint Dizziness Tinnitus Sinus pain Tissue hyperalgesia Dull occipital pain Decreased and painful cervical range of motion Shoulder pain Trigger points Photophobia
diagnosis of greater occipital neuralgia is made, then, initially, the complaint will be dealt with conservatively using rest, immobilization with a soft collar, non-steroidal anti-inflammatory drugs (NSAIDs) and local anaesthetic injections.4 If these treatments fail, then there are other options involving specific surgical procedures, depending on the cause of the neuralgia. There are no previous reports in the literature of chiropractic intervention for this condition. The most common aetiology for greater occipital neuralgia is from direct trauma to the nerve via flexion/extension injuries, although any disorder or disease process that can affect the nerve, from carcinoma to diabetes, could result in this condition.2 It is also possible for the nerve to be affected by the structures that surround it. Therefore, greater occipital neuralgia can also result from DJD of the cervical spine as was the instance in this case.4
Case presentation Mrs. M, a 56-year-old mother of four, presented to a chiropractor with pain in the left sub-occipital region. Mrs. M had suffered neck pain 10 years prior to this episode due to a whiplash injury; she had also suffered prior injury to the cervical region as a result of physical abuse. Aside from this, she had enjoyed good health throughout her life, although suffering from the occasional migraine on the right side of her head. Mrs. M had a family history of cerebro-vascular incidents. The patient stated that her pain had begun 10 months prior to presentation. One morning, when putting on her mascara (i.e., with the cervical spine held in extension), she noticed a sudden, sharp shooting pain that traveled vertically from the base
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of the left occiput up the posterior aspect of the left side of the head. This pain was rated by the patient at ‘‘10/10’’. Following this, the pain became a constant, dull ache in the left sub-occipital region; this ongoing pain was rated at 6/10. Although Mrs. M still suffered left sub-occipital pain, she had not suffered any of the ‘‘neuralgic’’ attacks for a number of months. The main aggravating factor for her pain was movement of the head and neck. Three months following the onset of this pain, she consulted her GP due to a bout of dizziness. The dizzy spell lasted 15 min and occurred whilst raising the head after sewing (i.e., performing cervical extension after a period of sustained cervical flexion). There was no associated vomiting or visual disturbance. The GP diagnosed Mrs. M with ‘‘cervical spondylosis’’ (based on patient history rather than examination or investigation) and referred her to a physiotherapist. She was subsequently given a series of neck exercises that mainly involved chin retraction. As she felt ‘‘queasy’’ when performing the exercise supine, she was advised to do these against a wall, standing. Mrs. M felt that the exercises did help ease the pain during the day, however, the pain was still present and unaltered at night. As a consequence, the patient decided to seek the help of a chiropractor as this form of management had successfully alleviated the neck pain she suffered following her previous whiplash injury.
Examination findings On examination of the cervical spine range of motion, Mrs. M was found to have restriction and pain in extension and left rotation. Cervical compression reproduced pain in the left sub-occipital region, as did Jackson’s test. All other routine orthopaedic tests for the neck region were negative. Sensory, motor and reflex testing was unremarkable for the upper and lower limbs. Cranial nerve examination was also normal. De Kleyn’s test for vertebrobasilar artery insufficiency was negative bilaterally. Palpation of the neck revealed tenderness in the left sub-occipital region and over the left cervical facet joints. No active trigger points were detected in the sub-occipital region. Chiropractic analysis demonstrated extensive segmental restriction (vertebral subluxation complex) at multiple levels throughout the cervical spine.
Diagnosis The history and clinical examination pointed to two main differential diagnoses, greater occipital
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neuralgia, perhaps as a result of an old whiplash injury; or upper cervical facet syndrome with associated myofascial syndromes. Due to the shooting or neuralgic character of the pain previously described and, in the absence of overt trigger points in the sub-occipital musculature, the former diagnosis was considered the more likely. However, because the patient had not suffered from this type of pain recently, this could not be regarded as conclusive. At no time during the initial examination was it possible to reproduce the neuralgic pain. Because the patient was over 50 years of age and had a history of significant multiple trauma, X-ray examination of the cervical spine was performed.
X-ray findings X-ray examination revealed significant change in cervical lordosis (Fig. 1). Between C2 and C6, this actually constituted a lordotic reversal of approximately 98. Decreased disc height was noted at C5—6 and C6—7 with anterior osteophytes present at the anterior joint space of C5—6. The posterior joint space of C6—7 was severely decreased with subchondral sclerosis at this site. There was a loss of joint space between the lateral mass of C1 and the
facet joint of C2 on the left (Fig. 2). There were also osteophytes at the lateral aspects of these segments accompanied by subchondral sclerosis. These findings resulted in a diagnosis of degenerative joint and disc disease (C5—7) with left, unilateral DJD at C1/2. Anteroposterior lower cervical radiographs were also taken but were diagnostically non-contributory.
Treatment Mrs. M was initially treated with cervical mobilisation in the form of cervical ‘stair-step’ technique and soft tissue work accompanied by trigger point therapy and stretching. This technique was chosen in order to avoid the cervical extension that had previously triggered her dizziness. In addition to the above treatment, Mrs. M was given passive stretching exercises for the sub-occipital muscles and told she should do these at home at least twice a day, holding for 10—20 s, each time. Mrs. M failed to respond to five treatments of this type over a 10-day period. It was then decided that cervical manipulative therapy (CMT) would be the next treatment of choice. Mrs. M was made aware of the risk factors of this type of treatment, especially in regard to her personal and familial history.
Figure 1 Mrs. M–—lateral Cx spine.
Chiropractic management of greater occipital neuralgia
Figure 2
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Mrs. M–—anteroposterior open mouth.
Twenty days (treatment number 9) into treatment, Mrs. M reported that, following a hairdresser’s appointment, the neuralgic pain had returned and she also had experienced numbness at the back of the head. At treatment session number 10 (25 days into treatment plan), Mrs. M again reported numbness on the left side at the back of the head that radiated to the inferior aspect of her zygomatic arch on the left. During treatment number 11, an adjustment of the C1—2 articulation into left rotation (contacting the right side) reproduced this neuralgic pain. This was the first occasion that this particular segment had been adjusted. Therefore, it was decided that adjustments of the C1—2 vertebrae were only to be carried out into right rotation in order to gap the C1—2 articulation on the left, avoiding irritation to or compression of the GONv.
Outcome Following four-and-a-half weeks of CMT administered to the upper cervical spine, the patient quantified her pain as ‘‘95% improved’’. There was no neuralgic pain and she reported only a very mild, intermittent ache located at the base of the left occiput. Re-examination demonstrated a full and pain-free cervical range of motion. Very slight relative restriction into left rotation was still, however, noted. Cervical compression gave only very mild discomfort in the left sub-occipital region.
Discussion To fully understand this case, the anatomy of the GONv is of fundamental importance. The GONv arises from the C2 dorsal ramus. The C2 dorsal
ramus passes between the lateral C1—2 articulation (through the lateral capsule6) and obliquus inferior muscle. The medial branch of the C2 dorsal ramus continues as the GONv as shown in Fig. 3. This nerve runs transversely and superiorly to rectus capitus posterior major. Half way up its course along this muscle, the nerve turns dorsally to eventually pass above the aponeurotic sling between the trapezius and sternocleidomastoid muscles along with the occipital artery. From here, the GONv divides into its terminal branches. The medial branches supply the occipital skin and the lateral branches supply the area posterior to the pinna. Intermediate branches run up and across the top of the skull.7,8 As mentioned, the dorsal ramus of C2 passes through the joint capsule of the C1—2 articulation, the C2 dorsal root ganglion is constantly related to the dorsal aspect of the atlanto-axial joint (Fig. 4).6,8 Because of this, close approximation changes at this joint can potentially affect the nerve. The pain is thought to come from an irritative, biochemically mediated phenomenon at the joint, rather than actual physical compression of the nerve.6 Greater occipital neuralgia (or occipital neuralgia as it may be termed) due to C1—2 lateral mass osteoarthritis is recognised as a distinct clinical syndrome.3,4,6 Atlanto-axial osteoarthrotic syndrome is not rare; it is more common in women and is present in symptomatic form in 4% of a population with peripheral osteoarthritis or degenerative joint disease (DJD) of the spine.1,3 Considering this, GON is a frequently overlooked cause of head pain.13 Any primary care practitioner should consider this diagnosis when faced with a patient with headaches and degenerative changes to the cervical spine. The most common reported cause of GON is trauma leading to significant cervical arthritic osteophytic spurs.11 One study reports 25% of patients having a history of trauma that preceded the headache.1
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Figure 3
The greater occipital nerve (adapted from Netter7).
As previously shown in Table 1, there are a number of symptoms that could point to a diagnosis of greater occipital neuralgia. The most widely described symptoms are occipital pain, ‘jabbing’ pain in the distribution of the greater occipital nerve, diminished sensation in the affected area and cervical crepitus.1—3,12 The most common signs associated with this syndrome are a decrease in cervical range of motion, exacerbation of pain with cervical rotation and extension, pain on pressure over the C1/2 articulation, tenderness in the occi-
pital area and an abnormal head position.3,6 In a patient population describing occipital neuralgia, the incidence of the most frequent signs and symptoms identified are detailed in Table 2. Tinel’s sign applied at the base of the occiput (tapping the area with a reflex hammer in order to reproduce neuralgic type pain) is regarded as a useful diagnostic test for GON by Kuhn et al.1 who also regard anaesthetic block of the GONv eliminating pain as the best method of confirmation of a diagnosis of GON.1 According to Halla and
Chiropractic management of greater occipital neuralgia
Figure 4
The dorsal ramus of C2 (adapted from Netter7).
Hardin,3 the pathognomic sign for occipital neuralgia due to atlanto-axial osteoarthritis is a decrease of more than 50% in rotation of the cervical spine. Radiological evaluation should be carried out when GON is suspected. An anterior—posterior open mouth view of the upper cervical spine is diagnostic.3,4 Table 3 compiles the possible indicators for radiological evaluation of the cervical spine. Clinical recognition of occipital neuralgia and the C1—2 arthrosis syndrome is important for effective treatment. The differential diagnoses that must be ruled out before commencing treatment are detailed in Table 4. Careful history taking and physical examination should enable the practitioner to differentiate most of these conditions. It is possible for myofascial pain to present clinically as occipital neuralgia.10 When this is the case, palpation of trigger points in the sub-occipital muscles will reproduce the pain. In this case, no active trigger points were found in the sub-occipital area, although there was tenderness over the lateral musculature of the cervical spine. In this case, Table 2 Incidence of signs and symptoms (%) in patient population describing occipital neuralgia.1
Tinel’s sign over occipital nerve Visual disturbance Occular pain Vertigo/dizziness Nausea Tinnitus Scalp paraesthesia
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100 67 67 50 42 33 33
the first four treatments consisted only of soft tissue work and trigger point therapy to the suboccipital region; these treatments provided no relief. It can therefore be assumed that myofascial pain was not the cause of this patient’s symptoms. As discussed, one of the methods of confirmation of GON is anaesthetic block of the greater occipital nerve. This treatment is administered by simply injecting the sire of tenderness,1 although this would seems not to differentiate between inactivating the trigger points and performing an actual nerve block. This patient followed the expected initial treatment algorithm of a person with this type of pain.4 Initially, the GP was consulted who gave a diagnosis of spondylosis and prescribed physiotherapy. Initial conservative management is aimed at providing symptomatic relief using mild analgesics, physical Table 3 Reasons for radiological evaluation of the cervical spine.1
History of neuralgic type pain Tenderness over nerve Relief of headache with local anaesthetic Persistent or recurrent pain after local anaesthetic Reproduction or alteration of headache with neck movement Abnormal posture of head/neck Sub-occipital or nuchal tenderness Abnormal motility at cranio-cervical junction Significant and painful decreased range of motion Signs and symptoms referable to lower medulla, upper cervical cord or upper cervical nerve roots
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Table 4
L. Comley
Differential diagnoses for GON.1,2,4—6,11
Arnold-Chiari malformation Basilar artery thrombosis Diabetic mononeuropathy Gout Mastoiditis Metastatic cancer Migraine Myofascial pain syndromes Other cervical nerve lesion Paget’ disease of the skull Polyneuropathies Rheumatic nodules Systemic infections Temporal arteritis Tension headache Traumatic scars Vertebral artery thrombosis
therapy, heat treatment and a decrease in activity.1 However, the literature suggests that the effectiveness of this protocol is largely unsupported.4 Orthodox treatment for occipital neuralgia that cannot be managed conservatively is fusion (Gallie’s technique9) or C2 rhizotomy.5 A proposed operation for occipital neuralgia consisting of removal of the compressive forces to the nerve, that is bony spurs or ligamentous structures, is also described in the Table 5
literature.11 Patients with occipital neuralgia due to a previous whiplash injury have been treated with occipital nerve release13 whereby the course of the GONv was followed and any areas in which it was restricted are surgically widened. The research into the various types of surgical treatment for this condition is reasonably extensive. Table 5 summarizes the research found and shows results for some different types of treatment. As outlined in this table, some treatments can have the desired effect, however, the results are not guaranteed. Although this is also the case with chiropractic care, the risks and possible side effects of treatment are much lower. It was stated in 1983 that current operations at this time left a neurological deficit.11 Collectively, the side affects or possible risks that can be brought about by any type of the discussed procedures are: paraesthesia or anaesthesia in the involved area, allodynia, hypaesthesia, dizziness and nausea, vertigo, recurrence of pain, post-surgical urinary tract infection, post-surgical protracted ileus and transient ataxia.4,5,11,12 In one patient, there was also a cerebrospinal fluid leak. Rhizotomy has also led to a loss of proprioceptive afferentation from the C1—2 facet joints and rotary muscles of the cervical spine.5 There are also many side effects to the anaesthetic used. If surgery can be avoided, it is
Research into surgical treatment for occipital neuralgia once conservative care has failed.
Reference
Number of subjects
Treatment given
Results Treatment in one case resorted to C2 rhizotomy combined with C1/2 fusion. Permanent relief resulted Immediate relief and no recurrence of pain 11 months following patient pain free No patient experienced complete pain relief. 38.9% of patients reported results as excellent No recurrences of pain at 2-year follow up No pain in 7 patients. Fifty percent reduction of pain in 3 patients. Poor results in 2 patients. NB. This is a demanding procedure with 71% likelihood of long-term relief 1 patient suffered recurrence of original pain following 26 months post surgery type 1. Surgery type 2 was therefore performed. All patients then had immediate and complete relief of their pain 52% pain free. 16% no improvement
Ehni and Benner6
3
C2 rhizotomy
Mathur13
1
Ligation of the occipital artery
Poletti11 Magnusson et al.12
Joseph and Kumar9 Dubuisson5
Stechison and Mullin14
Oh et al.15
1 13–—post whiplash 4 14
5
31
C2 and C3 root decompression Surgical occipital nerve release at signs of compression Gallie’s fusion of C1—2 Partial posterior rhizotomy at C1—3
2 subjects–—atlanto-epistrophic ligament decompression of C2 dorsal root ganglion and nerve (1) 4 subjects–—C2 ganglionotomy (2)
Surgical section of greater or lesser occipital nerve
Chiropractic management of greater occipital neuralgia
likely that the patient will opt for this choice. Selflimitation of the disease is unsupported by data, however spontaneous fusion of a severely arthrotic joint may alleviate symptoms, as should surgical fusion of the joint.6 This patient had improvement of 95% following 4 weeks (10 treatments) of chiropractic adjustments to the cervical spine. There was no longer any type of neuralgic pain present and the left sub-occipital pain had significantly decreased. A search of MedLine, PubMed, Amed and the Index to Chiropractic Literature failed to find any literature regarding chiropractic and greater occipital neuralgia. One of the mainstays of the chiropractic approach to health care is that the source or cause of the problem should be addressed rather than simply eliminating the symptoms.18 By maximizing the function of the C1—2 articulation, chiropractic can potentially stop the neuralgic pain at its source. The adjustment is designed and applied so as to increase motion at a joint. In this case, the C1—2 articulation was only adjusted into right rotation after an adjustment into left rotation reproduced symptoms. This reproduction of symptoms shows a definite link between the C1—2 articulation and the neuralgic pain traveling into the head, adding weight to the working diagnosis. The mechanism by which chiropractic adjustment ameliorates the nerve root irritation is a subject of much debate amongst both chiropractors and neurophysiologists. There are a number of mechanical and reflex results of manipulation described.16 Amongst these is the effect that manipulation has on chronic nerve compression and irritation. Joint dysfunction directly compresses or irritates nerves. In this case, the joint dysfunction occurred at the left C1—2 articulation and its function was restored via manipulation. Interestingly, at treatment number 14 there was no restriction found at the C1/2 articulation (contrary to each previous treatment visit), therefore no manipulation was performed at this level. Another reason for the decrease in pain could be that joint cavitation and increased range of motion causes inhibition or reduction of pain. In simple terms, the pain perception is decreased by greater proprioceptive input to the spinal cord. The facet joints are richly innervated with this type of nerve fibre and therefore are excellent conductors of this information when stimulated.16 The residual problem that this patient has is loss of cervical rotation to the left. As most rotation in the cervical spine takes place at the atlanto-axial articulation (30—358 in each direction17), the loss of cervical rotation in patients suffering from this unilateral disorder is easily explained. Decrease in rotation was one of the most consistent findings on
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physical examination of patients with greater occipital neuralgia.3
Conclusion This case describes how chiropractic treatment of one patient decreased the signs and symptoms of greater occipital neuralgia. By comparison with surgery, chiropractic could potentially offer an effective, cheap and low-risk treatment option but, unlike surgery, there is no evidence on which to evaluate this. Based on this single case study, chiropractors can begin to look at the effect that they can have on the C1/2 arthrosis syndrome and can provide more research to enable the patient and/or GP to explore alternative treatment choices. It is understood that chiropractic treatment cannot reverse the degenerative changes that have occurred in the C1—2 articulation, but can possibly limit the effect of these changes on the function of the joint and therefore stop the irritation to the C2 dorsal ramus. In this case, specific diagnostic procedures were not carried out at the initial consultation due to the practitioner’s lack of experience with this complaint. Although the correct diagnosis was determined at an early stage, it would have been beneficial to carry out more specific testing initially for a more definitive follow-up assessment. This case study will help chiropractors or other primary health care practitioners with assessment and treatment procedures in the future.
Acknowledgements This case is published courtesy of the College of Chiropractors’ Provisional Registration Training Scheme of which it formed a part requirement.
References 1. Kuhn WF, Kuhn SC, Gilberstadt H. Occipital neuralgias: clinical recognition of a complicated headache. A case series and literature review. J Orofac Pain 1997;11(2):158—65. 2. Brown CR. Pain management. Occipital neuralgia: symptoms, diagnosis and treatment. Practical Periodontics 1996;8(6): 587—8. 3. Halla JT, Hardin JG. Atlantoaxial (C1—C2) facet joint osteoarthritis: a distinctive clinical syndrome. Arthritis Rheum 1987;30(5):577—82. 4. Star MJ, Curd JG, Thorne RP. Atlantoaxial lateral mass osteoarthritis. A frequently overlooked cause of severe occipital neuralgia. Spine 1992;17(6 Suppl):S71—6. 5. Dubuisson D. Treatment of occipital neuralgia by partial posterior rhizotomy at C1—3. J Neurosurg 1995;82:581—6. 6. Ehni G, Benner B. Occipital neuralgia and the C1—2 arthrosis syndrome. J Neurosurg 1984;61(5):961—5.
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7. Netter F. Atlas of human anatomy. New Jersey: ICON Learning Systems; 1997. 8. Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine 1982;7(4):319—30. 9. Joseph B, Kumar B. Gallie’s fusion for atlantoaxial arthrosis with occipital neuralgia. Spine 1994;19(4):454—5. 10. Graff-Radford SB, Jaeger B, Reeves JL. Myofascial pain may present clinically as occipital neuralgia. Neurosurgery 1986; 19(4):610—3. 11. Poletti CE. Proposed operation for occipital neuralgia: C-2 and C-3 root decompression. Case report. Neurosurgery 1983; 12(2):221—4. 12. Magnusson T, Ragnarsson T, Bjornsson A. Occipital nerve release in patients with whiplash trauma and occipital neuralgia. Headache 1996;36:32—6.
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13. Mathur JG. Treatment of occipital neuralgia. Med J Aust 1980;2(2):102. 14. Stechison MT, Mullin BB. Surgical treatment of greater occipital neuralgia: an appraisal of strategies (abstract–— article in German). Acta Neurochir (Wein) 1994;131(3/4): 236—40. 15. Oh S, Tok S, Allemann J, Prevost A, Schmid UD. Exeresis in occipital neuralgia (abstract–—article in German). Neurochirurgia (Stuttgart) 1983;26(2):47—50. 16. Chapman-Smith D. The chiropractic profession. Toronto, Canada: Harmony Printing Ltd; 2000. 17. Oliver J, Middleditch A. Functional anatomy of the spine. Oxford: Butterworth-Heinemann; 1991. 18. http://www.neuronet.pitt.edu/groups/ctr-innov/spine7. htm.
CASE REPORT
Chiropractic management of greater occipital neuralgia L. Comley* Berkhamstead Chiropractic Clinic, Coleshill House, 69 High Street, Berkhamstead, Hertfordshire HP4 2DE, UK Received 1 August 2003; accepted 12 September 2003
KEYWORDS Cephalalgia; Cervical spine; Chiropractic; Greater occipital neuralgia; Human adult female; Spinal manipulative therapy
Abstract Greater occipital neuralgia (GON) is the term used to describe signs and symptoms of irritation to the greater occipital nerve. Neuralgic pain is characteristically sharp and shooting in nature and distributed over the area of the nerve affected. In the case of GON, pain is typically located in the sub-occipital region and radiates superiorly to the posterior aspect of the skull. GON due to unilateral C1—2 degenerative joint disease (DJD) is a recognised clinical syndrome. Arthrosis of the C1—2 zygoapophyseal articulation can cause irritation of the C2 dorsal ramus due to their close approximation. The signs and symptoms of GON can vary widely between sufferers. The most common symptoms are unilateral sub-occipital pain accompanied by neuralgic pain travelling superiorly to the posterior aspect of the skull. Headache, dizziness, tinnitus, visual blurring and occular pain as well as other complaints can accompany this. The signs of GON as a result of C1—2 DJD are a decrease in cervical range of motion (particularly rotation); tenderness in the occipital region, particularly over the C1—2 articulation and exacerbation of pain with cervical spine motion. There is no uniformly effective treatment for this condition, once conservative treatment fails, surgery is the next option but there are many reported side effects and failed surgical cases. This case demonstrates how this syndrome was relieved in one patient by chiropractic management. The possible mechanisms by which manipulation can effect improvement in this condition are discussed. ß 2003 Published by Elsevier Ltd on behalf of The College of Chiropractors.
Introduction It is commonplace for a chiropractic opinion to be sought regarding neck pain and headaches. When presented with non-specific symptoms, such as unilateral sub-occipital pain, a thorough history and examination must be carried out to determine the cause. A number of differential diagnoses must always be considered that typically will include both commonly encountered conditions such as ‘tension’ headache, migraine and cervicogenic headache as well as more sinister causes such as sub-arachnoid *
Tel.: þ44-1442-863800; fax: þ44-1442-870844. E-mail address: [email protected] (L. Comley).
haemorrhage or other space occupying lesions.1 Although not a common cause of neck pain and headache, greater occipital neuralgia (GON) should also be added to the list of possible diagnoses. Greater occipital neuralgia is characterised by pain in the occipitocervical region and one-sided headache at the back of the head.1—4 The symptoms of greater occipital neuralgia are attributed to irritation of the greater occipital nerve (GONv). Pain is of a neuralgic character, that is a sharp, severe shooting pain, characteristically radiating over the area of the nerve involved. The possible symptoms associated with GON are detailed in Table 1. Patients with this type of pain often present initially to their general practitioner (GP). If a
1479-2354/$30.00 ß 2003 Published by Elsevier Ltd on behalf of The College of Chiropractors. doi:10.1016/j.clch.2003.09.008
Chiropractic management of greater occipital neuralgia
Table 1 Symptoms associated with greater occipital neuralgia.2 Headache (unilateral or bilateral) Facial pain Neck ache Pain/pressure behind eyes Pains in temperomandibular joint Dizziness Tinnitus Sinus pain Tissue hyperalgesia Dull occipital pain Decreased and painful cervical range of motion Shoulder pain Trigger points Photophobia
diagnosis of greater occipital neuralgia is made, then, initially, the complaint will be dealt with conservatively using rest, immobilization with a soft collar, non-steroidal anti-inflammatory drugs (NSAIDs) and local anaesthetic injections.4 If these treatments fail, then there are other options involving specific surgical procedures, depending on the cause of the neuralgia. There are no previous reports in the literature of chiropractic intervention for this condition. The most common aetiology for greater occipital neuralgia is from direct trauma to the nerve via flexion/extension injuries, although any disorder or disease process that can affect the nerve, from carcinoma to diabetes, could result in this condition.2 It is also possible for the nerve to be affected by the structures that surround it. Therefore, greater occipital neuralgia can also result from DJD of the cervical spine as was the instance in this case.4
Case presentation Mrs. M, a 56-year-old mother of four, presented to a chiropractor with pain in the left sub-occipital region. Mrs. M had suffered neck pain 10 years prior to this episode due to a whiplash injury; she had also suffered prior injury to the cervical region as a result of physical abuse. Aside from this, she had enjoyed good health throughout her life, although suffering from the occasional migraine on the right side of her head. Mrs. M had a family history of cerebro-vascular incidents. The patient stated that her pain had begun 10 months prior to presentation. One morning, when putting on her mascara (i.e., with the cervical spine held in extension), she noticed a sudden, sharp shooting pain that traveled vertically from the base
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of the left occiput up the posterior aspect of the left side of the head. This pain was rated by the patient at ‘‘10/10’’. Following this, the pain became a constant, dull ache in the left sub-occipital region; this ongoing pain was rated at 6/10. Although Mrs. M still suffered left sub-occipital pain, she had not suffered any of the ‘‘neuralgic’’ attacks for a number of months. The main aggravating factor for her pain was movement of the head and neck. Three months following the onset of this pain, she consulted her GP due to a bout of dizziness. The dizzy spell lasted 15 min and occurred whilst raising the head after sewing (i.e., performing cervical extension after a period of sustained cervical flexion). There was no associated vomiting or visual disturbance. The GP diagnosed Mrs. M with ‘‘cervical spondylosis’’ (based on patient history rather than examination or investigation) and referred her to a physiotherapist. She was subsequently given a series of neck exercises that mainly involved chin retraction. As she felt ‘‘queasy’’ when performing the exercise supine, she was advised to do these against a wall, standing. Mrs. M felt that the exercises did help ease the pain during the day, however, the pain was still present and unaltered at night. As a consequence, the patient decided to seek the help of a chiropractor as this form of management had successfully alleviated the neck pain she suffered following her previous whiplash injury.
Examination findings On examination of the cervical spine range of motion, Mrs. M was found to have restriction and pain in extension and left rotation. Cervical compression reproduced pain in the left sub-occipital region, as did Jackson’s test. All other routine orthopaedic tests for the neck region were negative. Sensory, motor and reflex testing was unremarkable for the upper and lower limbs. Cranial nerve examination was also normal. De Kleyn’s test for vertebrobasilar artery insufficiency was negative bilaterally. Palpation of the neck revealed tenderness in the left sub-occipital region and over the left cervical facet joints. No active trigger points were detected in the sub-occipital region. Chiropractic analysis demonstrated extensive segmental restriction (vertebral subluxation complex) at multiple levels throughout the cervical spine.
Diagnosis The history and clinical examination pointed to two main differential diagnoses, greater occipital
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neuralgia, perhaps as a result of an old whiplash injury; or upper cervical facet syndrome with associated myofascial syndromes. Due to the shooting or neuralgic character of the pain previously described and, in the absence of overt trigger points in the sub-occipital musculature, the former diagnosis was considered the more likely. However, because the patient had not suffered from this type of pain recently, this could not be regarded as conclusive. At no time during the initial examination was it possible to reproduce the neuralgic pain. Because the patient was over 50 years of age and had a history of significant multiple trauma, X-ray examination of the cervical spine was performed.
X-ray findings X-ray examination revealed significant change in cervical lordosis (Fig. 1). Between C2 and C6, this actually constituted a lordotic reversal of approximately 98. Decreased disc height was noted at C5—6 and C6—7 with anterior osteophytes present at the anterior joint space of C5—6. The posterior joint space of C6—7 was severely decreased with subchondral sclerosis at this site. There was a loss of joint space between the lateral mass of C1 and the
facet joint of C2 on the left (Fig. 2). There were also osteophytes at the lateral aspects of these segments accompanied by subchondral sclerosis. These findings resulted in a diagnosis of degenerative joint and disc disease (C5—7) with left, unilateral DJD at C1/2. Anteroposterior lower cervical radiographs were also taken but were diagnostically non-contributory.
Treatment Mrs. M was initially treated with cervical mobilisation in the form of cervical ‘stair-step’ technique and soft tissue work accompanied by trigger point therapy and stretching. This technique was chosen in order to avoid the cervical extension that had previously triggered her dizziness. In addition to the above treatment, Mrs. M was given passive stretching exercises for the sub-occipital muscles and told she should do these at home at least twice a day, holding for 10—20 s, each time. Mrs. M failed to respond to five treatments of this type over a 10-day period. It was then decided that cervical manipulative therapy (CMT) would be the next treatment of choice. Mrs. M was made aware of the risk factors of this type of treatment, especially in regard to her personal and familial history.
Figure 1 Mrs. M–—lateral Cx spine.
Chiropractic management of greater occipital neuralgia
Figure 2
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Mrs. M–—anteroposterior open mouth.
Twenty days (treatment number 9) into treatment, Mrs. M reported that, following a hairdresser’s appointment, the neuralgic pain had returned and she also had experienced numbness at the back of the head. At treatment session number 10 (25 days into treatment plan), Mrs. M again reported numbness on the left side at the back of the head that radiated to the inferior aspect of her zygomatic arch on the left. During treatment number 11, an adjustment of the C1—2 articulation into left rotation (contacting the right side) reproduced this neuralgic pain. This was the first occasion that this particular segment had been adjusted. Therefore, it was decided that adjustments of the C1—2 vertebrae were only to be carried out into right rotation in order to gap the C1—2 articulation on the left, avoiding irritation to or compression of the GONv.
Outcome Following four-and-a-half weeks of CMT administered to the upper cervical spine, the patient quantified her pain as ‘‘95% improved’’. There was no neuralgic pain and she reported only a very mild, intermittent ache located at the base of the left occiput. Re-examination demonstrated a full and pain-free cervical range of motion. Very slight relative restriction into left rotation was still, however, noted. Cervical compression gave only very mild discomfort in the left sub-occipital region.
Discussion To fully understand this case, the anatomy of the GONv is of fundamental importance. The GONv arises from the C2 dorsal ramus. The C2 dorsal
ramus passes between the lateral C1—2 articulation (through the lateral capsule6) and obliquus inferior muscle. The medial branch of the C2 dorsal ramus continues as the GONv as shown in Fig. 3. This nerve runs transversely and superiorly to rectus capitus posterior major. Half way up its course along this muscle, the nerve turns dorsally to eventually pass above the aponeurotic sling between the trapezius and sternocleidomastoid muscles along with the occipital artery. From here, the GONv divides into its terminal branches. The medial branches supply the occipital skin and the lateral branches supply the area posterior to the pinna. Intermediate branches run up and across the top of the skull.7,8 As mentioned, the dorsal ramus of C2 passes through the joint capsule of the C1—2 articulation, the C2 dorsal root ganglion is constantly related to the dorsal aspect of the atlanto-axial joint (Fig. 4).6,8 Because of this, close approximation changes at this joint can potentially affect the nerve. The pain is thought to come from an irritative, biochemically mediated phenomenon at the joint, rather than actual physical compression of the nerve.6 Greater occipital neuralgia (or occipital neuralgia as it may be termed) due to C1—2 lateral mass osteoarthritis is recognised as a distinct clinical syndrome.3,4,6 Atlanto-axial osteoarthrotic syndrome is not rare; it is more common in women and is present in symptomatic form in 4% of a population with peripheral osteoarthritis or degenerative joint disease (DJD) of the spine.1,3 Considering this, GON is a frequently overlooked cause of head pain.13 Any primary care practitioner should consider this diagnosis when faced with a patient with headaches and degenerative changes to the cervical spine. The most common reported cause of GON is trauma leading to significant cervical arthritic osteophytic spurs.11 One study reports 25% of patients having a history of trauma that preceded the headache.1
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Figure 3
The greater occipital nerve (adapted from Netter7).
As previously shown in Table 1, there are a number of symptoms that could point to a diagnosis of greater occipital neuralgia. The most widely described symptoms are occipital pain, ‘jabbing’ pain in the distribution of the greater occipital nerve, diminished sensation in the affected area and cervical crepitus.1—3,12 The most common signs associated with this syndrome are a decrease in cervical range of motion, exacerbation of pain with cervical rotation and extension, pain on pressure over the C1/2 articulation, tenderness in the occi-
pital area and an abnormal head position.3,6 In a patient population describing occipital neuralgia, the incidence of the most frequent signs and symptoms identified are detailed in Table 2. Tinel’s sign applied at the base of the occiput (tapping the area with a reflex hammer in order to reproduce neuralgic type pain) is regarded as a useful diagnostic test for GON by Kuhn et al.1 who also regard anaesthetic block of the GONv eliminating pain as the best method of confirmation of a diagnosis of GON.1 According to Halla and
Chiropractic management of greater occipital neuralgia
Figure 4
The dorsal ramus of C2 (adapted from Netter7).
Hardin,3 the pathognomic sign for occipital neuralgia due to atlanto-axial osteoarthritis is a decrease of more than 50% in rotation of the cervical spine. Radiological evaluation should be carried out when GON is suspected. An anterior—posterior open mouth view of the upper cervical spine is diagnostic.3,4 Table 3 compiles the possible indicators for radiological evaluation of the cervical spine. Clinical recognition of occipital neuralgia and the C1—2 arthrosis syndrome is important for effective treatment. The differential diagnoses that must be ruled out before commencing treatment are detailed in Table 4. Careful history taking and physical examination should enable the practitioner to differentiate most of these conditions. It is possible for myofascial pain to present clinically as occipital neuralgia.10 When this is the case, palpation of trigger points in the sub-occipital muscles will reproduce the pain. In this case, no active trigger points were found in the sub-occipital area, although there was tenderness over the lateral musculature of the cervical spine. In this case, Table 2 Incidence of signs and symptoms (%) in patient population describing occipital neuralgia.1
Tinel’s sign over occipital nerve Visual disturbance Occular pain Vertigo/dizziness Nausea Tinnitus Scalp paraesthesia
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100 67 67 50 42 33 33
the first four treatments consisted only of soft tissue work and trigger point therapy to the suboccipital region; these treatments provided no relief. It can therefore be assumed that myofascial pain was not the cause of this patient’s symptoms. As discussed, one of the methods of confirmation of GON is anaesthetic block of the greater occipital nerve. This treatment is administered by simply injecting the sire of tenderness,1 although this would seems not to differentiate between inactivating the trigger points and performing an actual nerve block. This patient followed the expected initial treatment algorithm of a person with this type of pain.4 Initially, the GP was consulted who gave a diagnosis of spondylosis and prescribed physiotherapy. Initial conservative management is aimed at providing symptomatic relief using mild analgesics, physical Table 3 Reasons for radiological evaluation of the cervical spine.1
History of neuralgic type pain Tenderness over nerve Relief of headache with local anaesthetic Persistent or recurrent pain after local anaesthetic Reproduction or alteration of headache with neck movement Abnormal posture of head/neck Sub-occipital or nuchal tenderness Abnormal motility at cranio-cervical junction Significant and painful decreased range of motion Signs and symptoms referable to lower medulla, upper cervical cord or upper cervical nerve roots
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Table 4
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Differential diagnoses for GON.1,2,4—6,11
Arnold-Chiari malformation Basilar artery thrombosis Diabetic mononeuropathy Gout Mastoiditis Metastatic cancer Migraine Myofascial pain syndromes Other cervical nerve lesion Paget’ disease of the skull Polyneuropathies Rheumatic nodules Systemic infections Temporal arteritis Tension headache Traumatic scars Vertebral artery thrombosis
therapy, heat treatment and a decrease in activity.1 However, the literature suggests that the effectiveness of this protocol is largely unsupported.4 Orthodox treatment for occipital neuralgia that cannot be managed conservatively is fusion (Gallie’s technique9) or C2 rhizotomy.5 A proposed operation for occipital neuralgia consisting of removal of the compressive forces to the nerve, that is bony spurs or ligamentous structures, is also described in the Table 5
literature.11 Patients with occipital neuralgia due to a previous whiplash injury have been treated with occipital nerve release13 whereby the course of the GONv was followed and any areas in which it was restricted are surgically widened. The research into the various types of surgical treatment for this condition is reasonably extensive. Table 5 summarizes the research found and shows results for some different types of treatment. As outlined in this table, some treatments can have the desired effect, however, the results are not guaranteed. Although this is also the case with chiropractic care, the risks and possible side effects of treatment are much lower. It was stated in 1983 that current operations at this time left a neurological deficit.11 Collectively, the side affects or possible risks that can be brought about by any type of the discussed procedures are: paraesthesia or anaesthesia in the involved area, allodynia, hypaesthesia, dizziness and nausea, vertigo, recurrence of pain, post-surgical urinary tract infection, post-surgical protracted ileus and transient ataxia.4,5,11,12 In one patient, there was also a cerebrospinal fluid leak. Rhizotomy has also led to a loss of proprioceptive afferentation from the C1—2 facet joints and rotary muscles of the cervical spine.5 There are also many side effects to the anaesthetic used. If surgery can be avoided, it is
Research into surgical treatment for occipital neuralgia once conservative care has failed.
Reference
Number of subjects
Treatment given
Results Treatment in one case resorted to C2 rhizotomy combined with C1/2 fusion. Permanent relief resulted Immediate relief and no recurrence of pain 11 months following patient pain free No patient experienced complete pain relief. 38.9% of patients reported results as excellent No recurrences of pain at 2-year follow up No pain in 7 patients. Fifty percent reduction of pain in 3 patients. Poor results in 2 patients. NB. This is a demanding procedure with 71% likelihood of long-term relief 1 patient suffered recurrence of original pain following 26 months post surgery type 1. Surgery type 2 was therefore performed. All patients then had immediate and complete relief of their pain 52% pain free. 16% no improvement
Ehni and Benner6
3
C2 rhizotomy
Mathur13
1
Ligation of the occipital artery
Poletti11 Magnusson et al.12
Joseph and Kumar9 Dubuisson5
Stechison and Mullin14
Oh et al.15
1 13–—post whiplash 4 14
5
31
C2 and C3 root decompression Surgical occipital nerve release at signs of compression Gallie’s fusion of C1—2 Partial posterior rhizotomy at C1—3
2 subjects–—atlanto-epistrophic ligament decompression of C2 dorsal root ganglion and nerve (1) 4 subjects–—C2 ganglionotomy (2)
Surgical section of greater or lesser occipital nerve
Chiropractic management of greater occipital neuralgia
likely that the patient will opt for this choice. Selflimitation of the disease is unsupported by data, however spontaneous fusion of a severely arthrotic joint may alleviate symptoms, as should surgical fusion of the joint.6 This patient had improvement of 95% following 4 weeks (10 treatments) of chiropractic adjustments to the cervical spine. There was no longer any type of neuralgic pain present and the left sub-occipital pain had significantly decreased. A search of MedLine, PubMed, Amed and the Index to Chiropractic Literature failed to find any literature regarding chiropractic and greater occipital neuralgia. One of the mainstays of the chiropractic approach to health care is that the source or cause of the problem should be addressed rather than simply eliminating the symptoms.18 By maximizing the function of the C1—2 articulation, chiropractic can potentially stop the neuralgic pain at its source. The adjustment is designed and applied so as to increase motion at a joint. In this case, the C1—2 articulation was only adjusted into right rotation after an adjustment into left rotation reproduced symptoms. This reproduction of symptoms shows a definite link between the C1—2 articulation and the neuralgic pain traveling into the head, adding weight to the working diagnosis. The mechanism by which chiropractic adjustment ameliorates the nerve root irritation is a subject of much debate amongst both chiropractors and neurophysiologists. There are a number of mechanical and reflex results of manipulation described.16 Amongst these is the effect that manipulation has on chronic nerve compression and irritation. Joint dysfunction directly compresses or irritates nerves. In this case, the joint dysfunction occurred at the left C1—2 articulation and its function was restored via manipulation. Interestingly, at treatment number 14 there was no restriction found at the C1/2 articulation (contrary to each previous treatment visit), therefore no manipulation was performed at this level. Another reason for the decrease in pain could be that joint cavitation and increased range of motion causes inhibition or reduction of pain. In simple terms, the pain perception is decreased by greater proprioceptive input to the spinal cord. The facet joints are richly innervated with this type of nerve fibre and therefore are excellent conductors of this information when stimulated.16 The residual problem that this patient has is loss of cervical rotation to the left. As most rotation in the cervical spine takes place at the atlanto-axial articulation (30—358 in each direction17), the loss of cervical rotation in patients suffering from this unilateral disorder is easily explained. Decrease in rotation was one of the most consistent findings on
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physical examination of patients with greater occipital neuralgia.3
Conclusion This case describes how chiropractic treatment of one patient decreased the signs and symptoms of greater occipital neuralgia. By comparison with surgery, chiropractic could potentially offer an effective, cheap and low-risk treatment option but, unlike surgery, there is no evidence on which to evaluate this. Based on this single case study, chiropractors can begin to look at the effect that they can have on the C1/2 arthrosis syndrome and can provide more research to enable the patient and/or GP to explore alternative treatment choices. It is understood that chiropractic treatment cannot reverse the degenerative changes that have occurred in the C1—2 articulation, but can possibly limit the effect of these changes on the function of the joint and therefore stop the irritation to the C2 dorsal ramus. In this case, specific diagnostic procedures were not carried out at the initial consultation due to the practitioner’s lack of experience with this complaint. Although the correct diagnosis was determined at an early stage, it would have been beneficial to carry out more specific testing initially for a more definitive follow-up assessment. This case study will help chiropractors or other primary health care practitioners with assessment and treatment procedures in the future.
Acknowledgements This case is published courtesy of the College of Chiropractors’ Provisional Registration Training Scheme of which it formed a part requirement.
References 1. Kuhn WF, Kuhn SC, Gilberstadt H. Occipital neuralgias: clinical recognition of a complicated headache. A case series and literature review. J Orofac Pain 1997;11(2):158—65. 2. Brown CR. Pain management. Occipital neuralgia: symptoms, diagnosis and treatment. Practical Periodontics 1996;8(6): 587—8. 3. Halla JT, Hardin JG. Atlantoaxial (C1—C2) facet joint osteoarthritis: a distinctive clinical syndrome. Arthritis Rheum 1987;30(5):577—82. 4. Star MJ, Curd JG, Thorne RP. Atlantoaxial lateral mass osteoarthritis. A frequently overlooked cause of severe occipital neuralgia. Spine 1992;17(6 Suppl):S71—6. 5. Dubuisson D. Treatment of occipital neuralgia by partial posterior rhizotomy at C1—3. J Neurosurg 1995;82:581—6. 6. Ehni G, Benner B. Occipital neuralgia and the C1—2 arthrosis syndrome. J Neurosurg 1984;61(5):961—5.
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7. Netter F. Atlas of human anatomy. New Jersey: ICON Learning Systems; 1997. 8. Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine 1982;7(4):319—30. 9. Joseph B, Kumar B. Gallie’s fusion for atlantoaxial arthrosis with occipital neuralgia. Spine 1994;19(4):454—5. 10. Graff-Radford SB, Jaeger B, Reeves JL. Myofascial pain may present clinically as occipital neuralgia. Neurosurgery 1986; 19(4):610—3. 11. Poletti CE. Proposed operation for occipital neuralgia: C-2 and C-3 root decompression. Case report. Neurosurgery 1983; 12(2):221—4. 12. Magnusson T, Ragnarsson T, Bjornsson A. Occipital nerve release in patients with whiplash trauma and occipital neuralgia. Headache 1996;36:32—6.
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13. Mathur JG. Treatment of occipital neuralgia. Med J Aust 1980;2(2):102. 14. Stechison MT, Mullin BB. Surgical treatment of greater occipital neuralgia: an appraisal of strategies (abstract–— article in German). Acta Neurochir (Wein) 1994;131(3/4): 236—40. 15. Oh S, Tok S, Allemann J, Prevost A, Schmid UD. Exeresis in occipital neuralgia (abstract–—article in German). Neurochirurgia (Stuttgart) 1983;26(2):47—50. 16. Chapman-Smith D. The chiropractic profession. Toronto, Canada: Harmony Printing Ltd; 2000. 17. Oliver J, Middleditch A. Functional anatomy of the spine. Oxford: Butterworth-Heinemann; 1991. 18. http://www.neuronet.pitt.edu/groups/ctr-innov/spine7. htm.