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The Surgical Management of Chronic Pain Following Acoustic Neuroma Resection; A Novel Approach
Matthew Endara, MD; John Felder; Ivica Ducic, MD, PhD
Georgetown University Hospital, Washington, DC, USA
Background: Chronic headache following acoustic neuroma resection via the retrosigmoid approach is a common morbidity of the surgery that is tightly linked to a poor postoperative quality of life. Despite widespread recognition of the condition, no reports have examined the cause of this condition or offered therapies targeted towards its etiology. The authors present a series of acoustic neuroma patients with chronic postoperative headache, where the pattern of pain was consistent with injury to the occipital sensory nerves, and describe the results of surgical management via nerve decompression or excision.
Materials and Methods: A retrospective review was performed on all patients who underwent either decompression or excision of cutaneous nerves of the scalp for headache from January 2003 to March 2011. Patients who attributed their pain to resection of an acoustic neuroma were identified. Preoperative data from clinic records was gathered including medical comorbidities, time from acoustic neuroma excision to presentation, preoperative headache frequency and pain intensity, number and type of preoperative pain medications. Primary outcomes examined were change in migraine headache index (days/month x intensity x duration), change in number of pain medications used on a regular basis, whether or not there was continued use of narcotics postoperatively, patient satisfaction with peripheral nerve surgery, and change in quality of life. These data were obtained by review of postoperative clinic records and by telephone interview.
Results: Seven patients underwent excision of the greater and lesser occipital nerves. All met diagnostic criteria for occipital neuralgia and failed conservative treatment by a neurologist. Operative and pathology reports showed occipital neuroma or scar entrapment in all cases. Average migraine headache index before surgery was 245, and post-op was 53.5. Number of pain medications used per patient decreased from an average of 6 to 2, and 5/7 patients achieved independence from narcotics. Following surgery, six of seven patients experienced greater than 80% improvement in quality of life and reported being very satisfied with treatment with an average followup of 32 months.
Conclusion: Our results suggest that at least some cases of chronic postoperative headache following acoustic neuroma resection by the retrosigmoid approach are consistent with neuralgia from occipital nerve injury. In properly selected patients, peripheral nerve surgery provides effective management for this condition by addressing the etiology as well as symptoms. Further studies are indicated to confirm these early, encouraging findings. The senior author’s algorithm for evaluating and treating these patients is presented.
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