Surgical treatment of non-responsive cervicogenic headache.

OBJECTIVE 102 patients suffering from long-lasting, very severe cervicogenic headache (CEH), non-responsive to physical or drug therapy, were surgically treated. METHODS Different diagnostic procedures and their significance for determining the advisability of surgery are summarised. The particular importance of the patient history and local anaesthesia together with the clinical examination is outlined. Different surgical approaches are described: ganglionectomy, ventral and dorsal decompressive operation. RESULTS CEH can be triggered by vascular or scar tissue compression of the C2 root and ganglion and irritation of other upper cervical nerve roots (C3, C4). Vascular compression is caused by: (a) the sinusoidal venous plexus, which surrounds the ganglion and nerve root like a cuff and may be dilated upon raised venous pressure; (b) further on by arterial loops throbbing against the ganglion; and (c) (rarely) by arteriovenous (AV) malformations. Nerve fibre degeneration is demonstrated morphologically by electron optical investigation. Afferences from ganglion C2 to the brain stem, as documented by experimental investigation on cats using the injection of HRP into the C2-ganglion, can explain the reference of pain from the neck to the fronto-ocular region and could at the same time elucidate the genesis of accompanying symptoms. Degenerative diseases such as disc protrusion and retrospondylosis have been shown to be other trigger mechanisms evoking CEH, as is well known from facet joint arthrosis. Degenerative diseases usually cause dura compression with narrowing of the spinal canal and frequently, in addition, instability. Evocation of CEH could be explained by the irritation, by those degenerative diseases, of structures with pain-conducting nerve fibres (facet joint capsule, nerve root, longitudinal ligaments, spinal dura, disc). About 80% of our surgically treated patients were relieved of pain or improved during a long period of follow up. The recurrence of degenerative alterations with new irritation from pain-conducting structures is thought to be responsible for the recurrence of headache. Further surgical approaches for the treatment of patients with the recurrence of pain are discussed. CONCLUSION Various surgical treatments are suggested to treat long-lasting severe CEH in patients not responsive to any physical or drug therapy.