I recently had the pleasure of taking care of a nice, young woman who came to see me from a far away country. She had been suffering from occipital neuralgia for many years and no one in her area was able to manage her pain. Of course, she had been tried on numerous medications, and even nerve stimulators, all without success. She had even undergone two operations to try and manage her pain, but without any relief. One operation even targeted a nerve with no known compression points. This woman came to see me in obvious distress stating that the prior nerve blocks she had received were unsuccessful and that they didn’t even result in any numbness following the injections. That means the target nerves were missed. Somehow, despite these results (or lack thereof) a decision was made to operate and yet despite an operative report, it was unclear exactly what was done. Moreover, the incisions used were in such a location that made it difficult to believe that the surgeon had addressed the nerves in question. She had successful nerve blocks with me (numbness and all) and we ultimately decided to operate on her.
In the operating room, I made my usual incisions and found a huge neuroma of the greater occipital nerve. The nerve itself had been severed but left in the subcutaneous tissue where it caused a lot of residual pain. People often ask me what exactly a neuroma is. Basically, from a medical perspective, a neuroma consists of regenerating nerve fibers and scar tissue. Nerves will always try to regenerate when they are injured and when they grow back in the subcutaneous tissue, they usually cause significant pain and hypersensitivity. This patient had to wear a lidocaine patch because her skin hurt so much. There are many unfortunate components to this story, most notably the fact that a person had to suffer for so long with such severe pain and also that it was unclear whether or not the nerve ever had to be severed in the first place. But just as sad is the fact that had the nerve been buried in the muscle in the first place, her problems might have been resolved many years earlier. During her operation, we cut the greater occipital nerve where it was healthy and buried that healthy end in the muscle where it would eventually become quiescent. We also operated on two other nerves that were also injured.
As of this writing, the patient is about 2 weeks post-op and doing very well. The pain she had prior to her operation is now completely gone and she is enjoying the numbness without having to wear any patches or taking much in the way of pain medicine. Time will tell if her pain relief is permanent, but there is a very high likelihood she will now be a different person. I tell this story because it illustrates several important points. One, the surgeon should know what to do with a nerve if it is severed so ask your potential surgeon what s/he is planning before your operation. Two, the surgeon should understand what a neuroma presents like in the office and should perform blocks to determine whether this is the case. If so, then the nerve needs to be re-explored and the neuroma dealt with so ask your surgeon what they would do if a neuroma occurs. It happens to even the best surgeons. Third, always look for solutions and never give up hope. It comes even despite tremendous hardship but is all the more worth it if it requires effort.
We reached out to our patient and she responded with this:
I am doing really well. Used 10mg oxy for 2-3 days, then 5 mg 2 days, then nothing. Surgical pain mainly gone. More a tight feeling. End of LON incision is raised,sore, not infected though. I had trigeminal and supraorbital neuralgia pain yesterday and the day before. Gone today. The area behind the top of my ear is tender to touch. I am doing gentle neck and shoulder stretches and using a fine hairbrush on my crown. Today I dropped from 450mg a day to 375mg. No difference noticed. Hoorah
I know that there are more changes ahead, and that they may not all be positive. Just observing now, but so far very happy. I can even sleep lying flat on the back of my head, first time in 5 years, makes me cry
I cannot express the magnitude of my appreciation adequately in words. Thank you is not enough
Oh, and I forgot (how?) to mention...NO OCCIPITAL PAIN!!!! Amazing