1. Pre-op 13.03.2019 NS-2

2. HISTORY 63yr male k/c/o DM,HTN and CAD on medications for past 20yrs presented to hospital with chief c/o right sided nape of neck pain which is sharp shooting type and tingling and burning sensation along with headache on right side c/o restricted neck movements no h/o weakness of limbs/paraesthesias No h/o B/B disturbances No h/o trauma Patient under went C2 block for the pain

3. EXAMINATION Gc –fair Afebrile Pulse -80/min BP – 140/90mmhg Rs –BAE+ CVS – S1,S2+ Tone is normal in all 4 limbs Power -5/5 in all 4 limbs DTR – 2+ Planters- b/l downgoing

4. X RAY

9. MRI

13. CT

14. DIAGNOSIS Right sided C2 Neuralgia refractory to medical management.

15. PLAN Right C2 Ganglionectomy

16. POSITION prone with the neck gently flexed and the head secured in a Mayfield headrest.

17. STEPS A midline incision was made over the posterior C1-2 level, and the lamina of C1 and C2 were exposed. For decompression, the C2 nerve root and ganglion were carefully identified and dissected free by removal of ligament, adjacent scar, and venous elements; inferior hemilaminotomies of C1 were performed as needed. For ganglionectomy, the C2 ganglion was identified as a large bulge proximal to the C2 primary rami; a foraminotomy was not always required to expose the C2 ganglion. After identification of the C2 ganglion, neural elements just proximal and distal to the ganglion were incised sharply, and the C2 ganglion was removed en bloc.

21. Occipital neuralgia is a distinct type of headache characterized by piercing, throbbing, or electric-shock-like chronic pain in the upper neck, back of the head, and behind the ears, usually on one side of the head. Typically, the pain of occipital neuralgia begins in the neck and then spreads upwards.

22. COMPLICATIONS

24. SYMPTOMS Aching, burning, and throbbing pain that typically starts at the base of the head and radiates to the scalp Pain on one or both sides of the head Pain behind the eye Sensitivity to light Sensitivity to sound Slurred speech Pain when moving the neck Difficulty with balance and coordination Tender scalp Nausea and/or vomiting Nauseavomiting

30. Mechanism of cervicogenic headache

33. Two Major Types of Occipital Neuralgia or C2 Neuralgia: Greater Occipital Neuralgia: Greater occipital neuralgia is a common type of posttraumatic headache, but is also seen in patients without injury. The pressure, aching, stabbing, or throbbing pain may be in a nuchal- occipital, temporal, parietal, frontal, periorbital, or retro-orbital distribution. The headache may last for minutes or hours to days and can be unilateral or bilateral.posttraumatic headache Lesser Occipital Neuralgia: Lesser occipital neuralgia is similar to that of greater occipital neuralgia, but the pain generally refers more laterally over the head.

35. Surgical Treatment Occipital Nerve Stimulation: A neurostimulator is used to deliver electrical impulses to the occipital nerves. These impulses help in blocking the pain messages to the brain. Microvascular Decompression: During this procedure, pain is relieved by identifying and adjusting the blood vessels that may be compressing the nerve.