B260 Tourette’s syndrome cervical dystonia induced occipital neuralgia remedied by peripheral nerve stimulation: a case report

Abstract

<h3>Background and Aims</h3> Dystonia is an uncommon complication of Tourette’s syndrome, with a prevalence of 1352 per 1,000,000. Occipital neuralgia caused by Tourette’s-related dystonia is more rare. It causes continuous and reproducible shooting-like pain beginning at the occiput and spreading up the posterior scalp. Tourette’s dystonia with occipital neuralgia can severely affect quality of life. Occipital nerve stimulation (ONS) is a therapeutic alternative because it is adjustable, reversible, and minimally invasive. Our case demonstrates that ONS provides long-term pain relief. <h3>Methods</h3> A thirty-four-year-old male with poorly-controlled Tourette’s cervical dystonia had severe occipital neuralgia. The pain was sharp and stabbing at the skull base and elicited by touch. Multiple treatments were attempted including propranolol, gabapentin, hydrocodone-acetaminophen, and amitriptyline. He underwent bilateral third occipital nerve rhizotomies, cervical epidural injections, botulinum injections, and occipital nerve blocks. He received physical therapy and chiropractic care. Each provided moderate but temporary relief. Occipital nerve blocks at C2-C3 and C3-C4 were minimally effective, but distal nerve blocks at the occipital protuberance provided the most analgesia. Therefore, an ONS trial was done, and a peripheral nerve stimulator was placed. Both provided equal relief. On follow-up, he reported drastic alleviation with no complications. <h3>Results</h3> <h3>Conclusions</h3> Our case illustrates neuromodulation benefits for a rare presentation of occipital neuralgia secondary to Tourette’s-related dystonia. In refractory cases like our’s, ONS should be considered, which is more indicated for occipital neuralgia. Occipital nerve stimulators are safer, relatively easy to place, and clinically beneficial. However, there are risks such as lead migration, which should be further studied.