occipital trial side effect

[bedrock]

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Story and question for the board.

Recently did a bilateral occipital trial on an ideal candidate for occipital stim.
Very nice, normal, healthy, active pt, with no psych history, in his 30s with several years of severe bilateral occipital pain after a box fell on the back of his head. Pt doesn't want narcs, has failed trials of every headache med imaginable, Botox, etc.

Consistently obtained 95% relief with occipital blocks for duration of local, sometimes a couple extra days.
Failed cervical epidurals by another doc, and TON, C3, C4 blocks X 2 by myself. Head CT normal. Cervical MRI unremarkable for age.

I do the bilateral occipital trial, pt tolerates trial without difficulty, leads in ideal placement and obtain good bilateral coverage.

However... during the trial whenever he turns on the stim he develops pain at the top of his head, and some frontal headache, which is about as intense as his previous occipital pain (occipital pain is concurrently relieved by 80%, while the stim is on). If he turns off the stim, most of his superior/frontal pain goes away, but his occipital pain returns at its usual high intensity.
(This patient never had frontal/superior headache prior to trial.) No fever, excessive bleeding etc, during trial.

Basically damned if you do and damned if you don't.

Any thoughts/suggestions? Reluctant to take him to permanent occipital implant with this new issue. He never had superior/frontal headaches before and doing supraorbital leads seems much too aggressive and cosmetically unappealing for this young active male.

I plan to see him back in several weeks and reevaluate.

 

[pmrmd]

Did you try injecting the O-A joint? It's common enough as a headache generator. Supine traction works well and is becoming a lost art with the switch to pneumatic bladder units too.

 

[bedrock]

Did you try injecting the O-A joint? It's common enough as a headache generator. Supine traction works well and is becoming a lost art with the switch to pneumatic bladder units too.

Did not inject the 0-A joint.

Generally I thought that was a fairly rare source of pain in a young patient, but with a trauma history like my guy, it's something to consider.

 

[Aether2000]

OA arthropathy is indeed rare given the large relatively size of the 4 condyles and limited motion of the joint. Injection should be performed with extreme caution since the vertebral artery frequently crosses directly over the joint posteriorly.

There is a connection in some people between the occipital nerve and supraorbital nerves at the vertex: this may be the source of the transmitted pain.

 

[PinchandBurn]

OA arthropathy is indeed rare given the large relatively size of the 4 condyles and limited motion of the joint. Injection should be performed with extreme caution since the vertebral artery frequently crosses directly over the joint posteriorly.

There is a connection in some people between the occipital nerve and supraorbital nerves at the vertex: this may be the source of the transmitted pain.

I saw a patient that had a AA injection somewhere else. They then developed literally CRPS 2 like symptoms in the distribution of the Occipital Nerves. Thinking of doing occ stim trial as other providers have done everything else under the sun for her .

 

[bedrock]

I saw a patient that had a AA injection somewhere else. They then developed literally CRPS 2 like symptoms in the distribution of the Occipital Nerves. Thinking of doing occ stim trial as other providers have done everything else under the sun for her .

They probably speared the C2 nerve on the way in.

 

[Aether2000]

Agree, or worse, the DRG....

 

[PinchandBurn]

Agree, or worse, the DRG....

Yah...i feel bad. I dont like throwing another MD under the bus ever (espeically since this guy is well trained,etc....I mean things like this unfortunately can happen to any of us).

I just told her these are my findings now. I cant comment on what happened or didnt happened. I can just say what I see now. Sad situation.........