Use of Fat Grafting for Chronic Headache of Cervical Origin Treatment

Fig. 16.1

(a) Preoperative MRI scan of the occipital nerve on a patient with occipital neuralgia. (b) Postoperative MRI scan after fat grafting. Note the increase in the thickness of subcutaneous tissue leading to the nerve release at the level of the trigger point (black arrow)

Preoperatively, we mark one or multiple trigger points posteriorly at the origin of the occipital nerve in order to identify the exact injection site (Fig. 16.2). The surgery is performed under local anesthesia. After tumescent infiltration of 100 mL of saline solution, 75 mg of levobupivacaine, 40 mg of mepivacaine, and 0.5 mL of epinephrine 1:1000, we perform a liposuction of the subumbilical area by means of a 10 mL syringe in order to harvest the fat (hips and trochanteric areas represent other possible donor sites). Afterwards, we process the fat according to Coleman’s technique (centrifugation at 3000 rpm for 5 min) [13]. The fat obtained is now purified and ready for injection.

../images/481431_1_En_16_Chapter/481431_1_En_16_Fig2_HTML.png — Fig. 16.2

Preoperative marking of the trigger point where the nerve entrapment is located

A 3–10 mL of fat is usually sufficient for the occipital area. We inject the fat using 18-gauge angiographic needles with a snap-on wing, and the location of the injection should be the dermal-subdermal junction at the occipital notch. We inject the fat in the proximity of the nerve emergence where the trigger point previously marked is located, which is generally 3 cm below the occipital notch and 1.5 cm lateral to the midline (Fig. 16.3) [10, 23].

../images/481431_1_En_16_Chapter/481431_1_En_16_Fig3_HTML.png — Fig. 16.3

Fat injection at the level of the trigger point

As reported in our study [33], nearly 80% of the patients undergoing fat grafting for ON or CCH experienced a significant clinical response with a substantial pain relief at 3 months postoperatively with an important improvement in quality of life indexes and a decreased need of pharmacologic support.

16.3 State of the Art of Headache of Cervical Origin Treatment

As reported and identified intraoperatively by Ducic et al. [10], the most frequent site of occipital nerve entrapment is located at the level of the passage of occipital nerve at the trapezoid tunnel (where the occipital nerve penetrates through the trapezoid fascial attachment to the occipital bone). The trapezoid tunnel is covered by the semispinalis capitis muscle, generally 3 cm below the occipital notch and 1.5 cm lateral to the midline. Furthermore, the passage of the occipital nerve through the semispinalis muscle and the inferior oblique muscle are other important trigger points of nerve entrapment. Currently, a standard therapeutic approach is not established, and the treatment is often empirical including physical therapy such as massage or local heat, nonsteroidal anti-inflammatory drugs, myorelaxants, and oral anticonvulsant drugs. Even though percutaneous nerve blocks are often useful in relieving pain, their effect is usually shortlasting. Surgical decompression of C2 nerve root, ganglion, and/or postganglionic nerve may be considered when the pain is chronic, severe, and unresponsive to conservative treatments [24, 25]. Nevertheless, open surgery is often associated with inconstant and disappointing results showing a great variability among patients [25, 26]. Hunter and Mayfield reported early recurrence of pain and postoperative scalp hypersensitivity and dysesthesias following ON neurotomy [11–24]. Moreover, Pikus and Philips and Ducic reported, respectively, a 33% and 43% rate of complete pain relief after C2 root decompression [10–27]. Furthermore, Slavin et al. [30] reported positive results with occipital nerve stimulation [28, 29] in regard to pain relief and decrease of medication intake. Finally, other authors described promising results with the use of botulin toxin type-A in order to release the chronic myofascial spasm constantly involved in the pathophysiology of this condition at the nerve trigger point [31].

Our regenerative approach to ON treatment with fat grafting, as defined by Daar and Greenwood, reflects the philosophy of “repairing tissue or organ to restore impaired function” [32]. The rationale of the application of fat grafting for headache of cervical origin lays on the regenerative properties of adipose-derived stem cells in promoting fibrous tissue release, thus reducing the adherence causing the constant nerve compression at the level of the trigger points. The mechanisms leading to tissue release and regeneration have been extensively investigated even though further studies are necessary in order to precisely assess the role of stromal mesenchymal stem cells and their mediators in tissue regeneration.

16.4 Conclusion

In conclusion, fat grafting represents a promising and effective treatment for headache of cervical origin in patients unresponsive to pharmacological treatment. The analgesic effect appears to be stable over time with low recurrence rate and a substantial improvement in quality of life. The technique is minimally invasive, easy, and fast, with low morbidity and complication rate, thus making it the ideal treatment for resistant cases.