Abstract
Occipital neuralgia generally responds to medical or invasive procedures. Repeated invasive procedures generate increasing complications and are often contraindicated. Stereotactic radiosurgery (SRS) has not been reported as a treatment option largely due to the extracranial nature of the target as opposed to the similar, more established trigeminal neuralgia. A dedicated phantom study was conducted to determine the optimum imaging studies, fusion matrices, and treatment planning parameters to target the C2 dorsal root ganglion which forms the occipital nerve. The conditions created from the phantom were applied to a patient with medically and surgically refractory occipital neuralgia. A dose of 80 Gy in one fraction was prescribed to the C2 occipital dorsal root ganglion. The phantom study resulted in a treatment achieved with an average translational magnitude of correction of 1.35 mm with an acceptable tolerance of 0.5 mm and an average rotational magnitude of correction of 0.4° with an acceptable tolerance of 1.0°. For the patient, the spinal cord was 12.0 mm at its closest distance to the isocenter and received a maximum dose of 3.36 Gy, a dose to 0.35 cc of 1.84 Gy, and a dose to 1.2 cc of 0.79 Gy. The brain maximum dose was 2.20 Gy. Treatment time was 59 min for 18, 323 MUs. Imaging was performed prior to each arc delivery resulting in 21 imaging sessions. The average deviation magnitude requiring a positional or rotational correction was 0.96 ± 0.25 mm, 0.8 ± 0.41°, whereas the average deviation magnitude deemed within tolerance was 0.41 ± 0.12 mm, 0.57 ± 0.28°. Dedicated quality assurance of the treatment planning and delivery is necessary for safe and accurate SRS to the cervical spine dorsal root ganglion. With additional prospective study, linear accelerator‐based frameless radiosurgery can provide an accurate, noninvasive alternative for treating occipital neuralgia where an invasive procedure is contraindicated.
Highlights
Occipital neuralgia is a neurological condition characterized by paroxysms of intense pain transmitted by the greater occipital nerves in the back of the head and neck often accompanied by a dull ache.[1,2,3,4]
Medical management for patients diagnosed with occipital neuralgia generally includes analgesics or anti-inflammatories which proves effective for most patients
The radiation oncologist remained throughout the treatment delivery and provided immediate physician review of the intrafractional imaging
Summary
Occipital neuralgia is a neurological condition characterized by paroxysms of intense pain transmitted by the greater occipital nerves in the back of the head and neck often accompanied by a dull ache.[1,2,3,4] The condition is differentially diagnosed from other headache types by using patient descriptions of the pain, noting the location of tenderness associated with pain episodes, and achieving prompt relief of pain following an anesthetic block of the greater occipital nerve.[5,6] The incidence of occipital neuralgia in the general population remains unknown but is thought to be less than that of trigeminal neuralgia and glossopharyngeal neuralgia which have an incidence of 20/ 100,000 per year and 0.7/100,000 per year, respectively.[7]Medical management for patients diagnosed with occipital neuralgia generally includes analgesics or anti-inflammatories which proves effective for most patients. Occipital neuralgia is a neurological condition characterized by paroxysms of intense pain transmitted by the greater occipital nerves in the back of the head and neck often accompanied by a dull ache.[1,2,3,4] The condition is differentially diagnosed from other headache types by using patient descriptions of the pain, noting the location of tenderness associated with pain episodes, and achieving prompt relief of pain following an anesthetic block of the greater occipital nerve.[5,6] The incidence of occipital neuralgia in the general population remains unknown but is thought to be less than that of trigeminal neuralgia and glossopharyngeal neuralgia which have an incidence of 20/ 100,000 per year and 0.7/100,000 per year, respectively.[7]. Numerous treatment options may be warranted for patients with continued disabling and intractable pain despite temporary treatments or when invasive therapies such as surgical incision, radiofrequency ablation, injected neurotoxin facilitated nerve blocking, implanted nerve stimulator, or surgically decompressing the nerve fail to provide relief.[6,8,9,10] If the condition continues to be refractory, nerve sparing procedures are utilized in preference to neurodestructive surgeries.[11,12,13,14] Neurodestructive procedures, such as neurectomies, are highly invasive and carry some degree of risk of permanent complication.[15,16] For those patients whose pain recurs following an invasive procedure, a secondary invasive procedure is often contraindicated due to compounding risk.[6]
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