Table 2.
Studies Included in Qualitative Synthesis
| Study/Ref No. | Year | Surgical Strategy | Results | Complications |
|---|---|---|---|---|
| Chmielewski et al34 | 2013 | General anesthesia, prone position, midline occipital incision Removal of a small portion of the semispinalis capitis muscle between the midline and the nerve Releasing of the fascia overlying the nerve till to the subcutaneous plane Shielding of the nerve with a subcutaneous flap |
There was no significant difference between sex, mean age, follow-up, and concomitant surgery sites between the 2 groups Preoperative variables: Frequency, MH/mo (OAR, 19.3 ± 8.4 versus control, 14.6 ± 9.4; P = 0.002) Duration, days (OAR, 0.71 ± 0.72 versus control: 1.24 ± 1.42; P = 0.011) Intensity, analog scale (0–10) (OAR, 8.0 ± 2.9 versus control, 8.2 ± 1.9; P = 0.682) Postoperative variables: Frequency, MH/mo (OAR, 9.9 ± 9.8 versus control: 5.1 ± 7.6; P = 0.001) Duration, days (OAR, 0.44 ± 0.73 versus control, 0.42 ± 0.91; P = 0.888) Intensity, analog scale (0–10) (OAR, 4.7 ± 3.1 versus control, 4.1 ± 3.7; P = 0.307 Occipital artery resection patients, (n = 55): n = 44 (80.0%) success (>50% reduction) n = 21 (38.2%) elimination of occipital migraine headache Control patients (n = 115): n = 105 (91.3%) success n = 74 (64.3%) elimination of occipital migraine headache The control group had significantly higher success (P = 0.047) and elimination rates (P = 0.002) compared with the occipital artery resection group Comparison of sides in unilateral arterectomy patients: of the 17 patients who underwent bilateral greater occipital nerve decompression but unilateral arterectomy, 15 experienced equal relief on both sides. Both of the 2 remaining patients who experienced asymmetrical relief after surgery experienced a slightly greater reduction in migraine frequency on the non arterectomy side There was no significant difference between the success rates (P = 0.357) and elimination rates (P = 0.675) of patients with daily continuous occipital migraine headache in the 2 groups |
Not described |
| Lineberry et al35 | 2015 | Local anesthesia (1% lidocaine with 1:100,000 epinephrine), prone position with the neck flexed, a 4-cm vertical midline incision Incision of the trapezius fascia 0.5 cm to the right of the midline and dissection of an approximately 2-cm full-thickness length of muscle medial to the nerve. Removal of a small amount of trapezius fascia or muscle overlying the GON laterally Dissection/removal of any fascial bands remained above the nerve Removal of any arteries in the vicinity of the nerve In the triamcinolone acetonide group: 0.3 mL of triamcinolone acetonide is injected along the entire course of the GON, with a small amount injected into the nerve perineurium Elevation of an approximately 2 × 2 cm subcutaneous flap under the nerve on either side |
A significant reduction was found in the frequency of migraine headaches (−9.8 vs −8.0; P = 0.03) and the migraine headache index (−92.9 vs −65.2; P = 0.0065). There was no significant reduction in migraine headache duration (−0.50 vs −0.70; P = 0.10) or severity (−3.50 versus −3.80; P = 0.38) | Not described |
| Lee et al36 | 2013 | 4-cm midline raphe incision in hair-bearing caudal occipital regionIncision of the trapezius fascia about 0.5 cm lateral to the midlineAvulsion of the TON if encountered (allowed to retract into the proximal portion of the semispinalis capitis muscle)Dissection of the GON from surrounding muscle and fascial bands until the subcutaneous planeRemoval of 2-cm-long segment of the semispinalis capitis muscle between the nerve and the midline rapheLigation of the occipital artery when entangled with the nerve Elevation of a laterally based subcutaneous flap to separate the remaining muscle and nerve |
No statistical difference between the 2 groups in preoperative MH severity (TON R 8.0 versus TON NR 8.3; P = 0.35), MH frequency (TON R 18.1 versus TON NR 16.1; P = 0.09), or MH duration (TON R 0.9 versus TON NR 1.06; P = 0.44) No difference in complete overall MH elimination (TON R 26% versus TON NR 29%; P = 0.45) or overall MH surgery success (TON R 80% versus TON NR 81% group; P = 0.82) between the 2 groups No statistical difference between patients with bilateral or unilateral TON removal in preoperative MH severity, frequency, or duration No statistical difference in Site IV–specific MH elimination (unilateral 55% versus bilateral 60%; P = 0.73), overall MH elimination (unilateral 22.6% versus bilateral 29.3%; P = 0.24), or overall migraine surgery success (unilateral 75.5% versus bilateral 84.5%; P = 0.43) |
Neuroma formation after TON removal did not reach clinical significance |
| Raposio and Bertozzi37 | 2019 | Local assisted anesthesia (40 mL of diluted carbocaine 1% + 40-mL NaCl 0.9%, and 20-mL sodium bicarbonate 8.4%), patient prone, no trichotomy, horizontal occipital scalp incisions of 5 cm in length along the superior nuchal line, at the location of arterial signal detected preoperatively by the handheld DopplerDissection of occipital, trapezius, splenius capitis, and semispinalis capitis muscles to identify the GON and vascular bundle (OA)(1) In case of dilated (or frankly aneurysmatic) OA in close connection with the GON: ligation of the vessel without any other surgical maneuvers(2) In the remaining cases: execution of a conservative neurolysis of the GON and LON with undermining of occipital, trapezius, splenius capitis, and semispinalis capitis muscles along the nerves course until their emergence into the subcutaneous tissue | 94.9% positive response (86.8% complete; 8.1% significant improvement); 5.1% no relief Group underwent OA ligation: 95.5% positive response (90% complete; 5.5% significant improvement); 4.5% no relief Group not underwent OA ligation: 91% positive response (76% complete; 15% significant improvement); 9% no relief All the patients without improvement of the symptoms after OA ligation (4.5%) who suffered from unilateral occipital migraine had complete relief after contralateral secondary surgery Fourteen patients (8.3%) experienced secondary trigger point emergence following primary migraine surgery. Among these, 12 patients had 2 trigger points (10 occipital and frontal, 2 occipital and temporal), whereas 2 patients had all 3 trigger points |
No concerning side effects were reported |
| Ducic et al38 | 2009 | General anesthesia, patient prone, a central horizontal 5- to 6-cm incision approximately 3 cm below the occipital protuberance Exposition of the trapezius and vertical incision of its fascia where 1–3 mm of vertically oriented muscle fibers are present Resection of the small branch of the dorsal occipital nerve if identified Identification of the greater occipital nerve, emerging from the semispinalis capitis muscle. Removal of a little piece of semispinalis and releasing of obliquus capitis fibers overlying the GON Realizing of the trapezial fascial tunnel, any lymphatic structures, occipital artery and vein crossing the GON (dissected free and ligated) If unilateral lesser occipital nerve excision is performed concurrently, a 3-cm incision is made at a separate site lateral to the first incision If bilateral greater occipital nerve decompression and lesser occipital nerve excision are performed, 2 separate incisions are made |
n = 190 (92 %) GON neurolysis alone; n = 12 (6%) GON and LON excision; n = 4 (2 %) LON excision aloneAverage preoperative visual analog scale score was 7.9 ± 1.4 (range: 4–10). Postoperative score was 1.9 ± 1.8 (range, 0–8), a reduction of 6 (76%) (P < 0.0001)Average preoperative migraine headache index was 287 ± 14.9. Postoperative migraine headache index was 24 ± 11.8 (P < 0.0001)n = 166/206 (80.5%) >50% relief of pain, n = 72/166 (43.4%) complete relief, n = 40/206 (19.5%) <50% relief |
n = 2 incisional cellulitis resolved with oral antibiotics. |
| Li et al39 | 2011 | Local anesthesia with monitoring, lateral position, direct skin incision approachMusculofascial decompression at the aponeurosis/tendon of the trapezius muscle. Sometimes, dissection of parts of the muscles (inferior capitis oblique, semispinalis, trapezius)Dissection of swollen lymphnodes and malformed vascular branches twining the great occipital nerve or its branches | n = 68 (76.4%) complete pain relief, n = 5 (6.6%) significant relief without medical treatment. n = 3 (3.9%) recurrence: 1 (1.3%) repeat nerve decompression 6 mo after and 2 (2.6%) experienced recurrence 7 and 13 mo after surgical decompression, respectively |
Hypoesthesia of the innervated area of the great occipital nerve gradually recovered within 1–6 mo after surgery No postsurgical complication besides hypoesthesia |
| Afifi et al40 | 2019 | A horizontal incision (2.5-cm caudal to the external occipital protuberance), for bilateral cases, from the posterior edge of 1 sternocleidomastoid muscle to the other Raising of a deep fat, medially attached, rectangular flap off of the trapezius fascia The trapezius fascia and muscle are then divided vertically just lateral to the base of the flap Identification and decompression of the GON Identification of the LON and execution of a neurectomy or decompression according to the size of the nerve The fat flap is then used to wrap the GON |
Average migraine headache index was 191 preoperatively and 55 postoperatively (P = 0.004), with a mean improvement of 70% 92% of patients experienced at least a 50% reduction in migraine headache index. Migraine frequency, intensity, and duration improved by a mean of 44.25 % (P = 0.0008), 51% (P = 0.01), and 58.4% (P = 0.1), respectively Mean Headache Impact Test (HIT-6) score improved from 67 preoperatively to 57 postoperatively (P < 0.0001) |
One case of wound infection, no cases of seroma or alopecia |
| Guyuron et al41 | 2009 | Under general anesthesia, patient in prone position, 4-cm incision in the midline occipital area(1) Mere exposure of the nerve with the muscle left intact(2) Removal of a segment of the semispinalis capitis muscle medial to the GON (1 × 2.5 cm). Subcutaneous flap interposition to avoid impingement of the nerve | Compared with the sham group, the actual surgery group demonstrated statistically significant improvements in all validated migraine headache measurements at 1 yearImprovement at 12 mo Treatment versus Sham: Frequency, MH/month [8.7 ± 6.1 (<0.001); 5.7 ± 5.6 (0.04)]; Intensity, [4.2 ± 3.4 (<0.001); 1.3 ± 3.2 (0.45)]; Duration, [0.54 ± 0.55 (0.009); 3.37 ± 7.7 (0.34)]; Migraine headache index, [37.1 ± 48.1 (0.03); 8.5 ± 15.1 (0.18)]; MIDAS, [1.5 ± 1.5 (0.01); 0.86 ± 1.7 (0.22)]; MSQEM, [56.0 ± 51.0 (0.005); 18.1 ± 33.2 (0.20)]; MSQPRE, [−24.5 ± 26.9 (0.013); −7.1 ± 19.8 (0.39)]; MSQRES, [−29.2 ± 26.9 (0.005); −11.4 ± 9.1 (0.02)]; SFPH, [−2.1 ± 5.6 (0.24); −8.7 ± 8.6 (0.4)] |
All patients reported some degree of paresthesia in the immediate postoperative period. No neuromas were observed One patient reported some neck stiffness 1 year postoperatively in treatment group No adverse events were observed in the sham surgery group |
| Jose et al42 | 2018 | T-shaped incision was made 1 cm below the occipital protuberanceRemoval of a small medial piece of semispinalis capitis muscle abutting the greater occipital nerveReleasing of the muscle in the trapezial fascia as the nerve runs through it toward the occiput. If the occipital artery was found impinging on the nerve at the supero-lateral end it was dissected and ligatedTen patients underwent unilateral nerve decompression while 1 required bilateral surgeryNo LON decompression | Mean pain episodes reported by the patients before surgery were 17.1 ± 5.63 episodes per month. This reduced to 4.1 ± 3.51 episodes per month (P < 0.0036) postsurgery. The mean intensity of pain also reduced from a preoperative 7.18 ± 1.33 to a postoperative of 1.73 ± 1.95 (P < 0.0033)Postoperative questionnaire: n = 3 (27.3%) complete elimination of pain n = 6 (54.5%) significant relief of their symptoms (positive outcome: 81.8%) N = 2 (18.2%) no significant improvement |
Six patients reported temporary surgical site paraesthesia. No other complications were noted |