case_images: PMC10657245_01
case_images: Schematic drawing showing the distribution of characteristics of chronic pain. (a) The grey areas over bilateral periorbital, gums, malar, mental, and submental area indicate the distribution of pain that occurred 4 years ago. The nature of pain was throbbing and tightening, which lasted all day. (b) The location (gray areas) of temporal-occipital and parietal pain concurrent with facial and submental pain. It has also spread to the nape of the neck and shoulders. When the pain was severe, it was accompanied by a stabbing pain in the bilateral ear canal (black circles). (c) The location of spontaneous paresthesia in the right medial forearm and hand that occurred one year after onset of facial and occipital pain. Subsequently, spontaneous pain and numbness extended to the lower back and both legs.
case_images: CRINM2023-1099222.001.jpg
case_images: PMC10657245_01_CRINM2023-1099222.001.jpg
case_images: fig1
case_images: The patient reported that throbbing and tightening pain gradually developed on both sides of her gums, at the angle of the jaw, and under the jaw four years ago (Figure 1). In fact, six years before the onset of pain in the head and face, she had been suffering from aching pain in both the nape of the neck and shoulders (Figure 1). One year after the onset of jaw and occipital pain, paresthesia suddenly developed in her right forearm and hand for no apparent reason (Figure 1). At the same time, a foreign body sensation as if there was sand in the eye occurred in both eyes and stabbing pain occurred in both malar areas (Figure 1). In addition, numbness and pain developed gradually in her back and both legs (Figure 1).
case_images: MRI images of the greater occipital nerve (GON). (a) Sagittal (A) and coronal (B) MR images of the right GON (white arrow) in the current case. The left image represents a sagittal T2-weighted image (t2_de3d_we,_iso 0.7 mm, MPR, Magnetom Terra, Siemens, Germany) of the right GON taken along the distal portion path within the trapezial tunnel. The image on the right is a coronal MR image (t2_de3d_we, iso 0.7 mm, MPR) showing the course of the right and left (white arrowhead) GONs within the trapezial tunnel. SsCM; semispinalis capitis muscle. (b) Sagittal (A) and coronal (B) MR images of the right GON (white arrow) taken with the same MR sequence (t2_de3d_we,_iso 0.7 mm, MPR) in a patient suffering from right trigeminal neuralgia. This is presented for comparison with images from patients with GON entrapment. The image on the right is a coronal MR image (t2_de3d_we, iso 0.7 mm, MPR) showing the course of the right and left (white arrowhead) GONs within the trapezial tunnel. This MRI image shows that it is still difficult to clearly diagnose GON entrapment even with high-resolution MRI. SsCM, semispinalis capitis muscle.
case_images: CRINM2023-1099222.002.jpg
case_images: PMC10657245_01_CRINM2023-1099222.002.jpg
case_images: fig2
case_images: No abnormalities were identified in the path and signal intensity of the GON in suboccipital space (Figure 2).
case_images: Intraoperative images showing the entrapment of the greater occipital nerve (GON) during the decompression. (a) Intraoperative images showing severe entrapment of the right GON (black arrows) by the fibrous, aponeurotic edge of the trapezius muscle (white arrows) along the superior nuchal line. The inset shows the direction of the image and the location of the incision. (b) Intraoperative image after decompression of the right GON (black arrows) with division of the trapezial aponeurosis (white arrows). The most severe part of the GON constriction is indicated by a white arrowhead. (c) Intraoperative image showing an entrapment of the left GON (black arrows) with elevation of the aponeurotic edge of the trapezius muscle (white arrows). The inset shows the direction of the image and the location of the incision. (d) Intraoperative image after decompression of the left GON (white arrows) with division of the trapezial aponeurosis (white arrows). The maximal compression area (white arrowhead) of the left GON shows reddish discoloration and constriction.
case_images: CRINM2023-1099222.003.jpg
case_images: PMC10657245_01_CRINM2023-1099222.003.jpg
case_images: fig3
case_images: Tracing the small visible branch of the GON in the subcutaneous tissue revealed the main branch of the GON, which was compressed against the tendinous aponeurotic edge of the trapezius (Figure 3). The path was released by dissecting the semispinalis capitis muscle located under the trapezius to the point of GON emergence (Figure 3).