Anatomical Variations of the Occipital Nerves: Implications for the Treatment of Chronic Headaches

Sir: We read with interest the article titled “Anatomical Variations of the Occipital Nerves: Implications for the Treatment of Chronic Headaches” (Plast Reconstr Surg. 2009:123:859–863). We would like to congratulate Drs. Ducic, Moriarty, and Al-Attar for their publication, reporting critical anatomical findings on a large series and implications for nerve blocks and surgery. These “unconventional” findings and anatomical variations confirm the importance of trigger points in each particular case for the appropriate localization and treatment of the occipital nerve. General considerations about the pathogenesis of occipital neuralgia and our experience led us to observe that, in cases of posttraumatic or postsurgical scar entrapment, the anatomical pathways could be further altered. This could explain a significant occurrence of aggressive, chronic, and unresponsive forms, leading patients to psychological distress, depression, and sometimes suicide attempts. Patients often report having been treated empirically with heat, rest, physical therapy including massage, nonsteroid antiinflammatory drugs, myorelaxants, oral anticonvulsant drugs, percutaneous nerve blocks, occipital nerve stimulation, and surgical decompression. Ineffectiveness of treatments and frequent recurrences in these forms are largely attributable to anatomical alterations with scar entrapment. After appropriate assessment of the alterations by history, clinical examination, trigger point localization, and magnetic resonance imaging, it is important to plan the proper treatment. A challenging debate about regenerative surgery and related research has focused on the new clinical applications of lipostructure (autologous fat graft following Coleman's technique1), extending to unexpected fields. In our studies, we observed scar remodeling by lipostructure in more than 250 patients.2–4 Not only did the softness, elasticity, texture, and pliability of injured skin clinically improve, but histologic studies and magnetic resonance imaging findings showed better differentiation and structural organization of superficial soft tissues. In addition, pain relief has been observed in patients who had this complaint.2,5 Thus, we decided to treat a patient with a severe form of postsurgical, chronic, unresponsive occipital neuralgia by lipostructure of the area corresponding to the clinical tender point and to the anatomical scar entrapment. No complications occurred. Magnetic resonance imaging 2 weeks after surgery showed the appearance of areas of fatty tissue in the treated scar. The patient reported a significant and persistent improvement of pain on the visual analogue scale and Neck Pain Disability Index at 1-year follow-up. We hypothesize that autologous fat graft gave an amount of mesenchymal stem cells, yielding not only architectural remodeling of scar tissue by fat and loose connective regeneration, but probably molecular changes in the microenvironment and secretion of substances able to give prolonged analgesia. In conclusion, we would like to point out that the complex anatomical alterations in severe forms of occipital neuralgia are often attributable to posttraumatic or postsurgical etiopathogenic mechanisms. In such cases, regenerative surgery provides new perspectives of treatment, leading also to scar entrapment release and anatomical remodeling. Marco Klinger, M.D. Federico Villani, M.D. Francesco Klinger, M.D. Cattedra di Chirurgia Plastica Università degli Studi di Milano, and U.O. Chirurgia Plastica 2 Paolo Gaetani, M.D. U.O. Neurochirurgia IRCCS Istituto Clinico Humanitas Riccardo Rodriguez y Baena, M.D. Daniel Levi, M.D. U.O.