Page 43 - WNS 2024 -e-Program Edition_Neat

A Novel Case of Occipital Neuralgia Caused by Atlantoaxial
Facet Cyst: Do They Need a Fusion?
Brian R. Gantwerker, MD, FAANS, FACS
The Craniospinal Center of Los Angeles
Presented here is a novel case of an atlantoaxial facet cyst causing occipital
neuralgia in a 78 year-old woman.

Introduction: Facet cysts are inflammatory entities that result from
irritation and propagation of synovial fluid into the joint capsule. The
capsule expands and a cascade of reactions occur that enlarge the synovium
into a redundant tissue “bag” that becomes adherent to adjacent structures.
More commonly seen in the lumbar spine, they are not as commonly
described in the cervical spine. In this patient, a facet cyst formed in the left
atlantoaxial joint that became adherent to the left C2 ganglion and nerve
root, resulting in classic, severe, constant, refractory occipital neuralgia
pain.
Methods: Surgically, the patient was positioned prone in a military tuck
and a standard, midline incision was made on the nuchal line. Near-
bloodless dissection was carried out. The left atlantoaxial joint was
identified by following the left lateral mass of C2 and the ring of C1. The left
C2 nerve root, ganglion and an adherent cyst was identified.

A large, dilated vein was positioned superoposteriorly on the C2 ganglion.
Dissection along the nerve root was carried out under the microscope and
the root was free circumferentially by sharp dissection with a microscissors
and microcurette.
After the dissection was done, Separafilm was place deep and also above the
freed C2 root. Finally, the dilated vein on the C2 root was carefully
coagulated using microbipolar cautery. Standard closure was carried out. A
drain was not used, nor any fusion performed.
Results: The patient was extubated after being re-positioned supine and
taken to recovery. On her first postoperative appointment her pain was
2/10.
At her 6 month and 1 year appointment her pain was 0/10 and she was off of
gabapentin.

Conclusions: Facet cysts are a rare source of occipital neuralgia and
reemphasizes the need to scan patients for other causes other than sclerosis,
vessels, or lymph nodes as a source for occipital neuralgia. Finally, this case
demonstrated a motion-preserving method for freeing the nerve root can
have durable and effective results.

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