New Technique for Cryoneuroablation of the Proximal Greater Occipital Nerve

STUDY DESIGN: Description of a new technique. OBJECTIVES: To describe a safe ultrasound (US)-guided cryoneuroablation technique of the proximal greater occipital nerve (GON). BACKGROUND: Cryoneuroablation is a treatment option for occipital neuralgia, providing more sustained relief when steroid injections fail. US can identify the proximal GON between the C2 spinous and C1 transverse process over the inferior oblique capitis muscle (IOCM), where the GON is clearly visualized. US-guided GON injections are often performed with an out-of-plane approach; however, that approach is difficult with cryoneuroablation, because the probe has no opening (prohibiting hydrodissection), and the size and dullness of the probe hinders easy manipulation. SETTING: University-based outpatient pain clinic. METHODS: We provide a description of the procedure based on experience in the authors' clinic. With the patient in the prone position, the US probe is placed parallel to the IOCM. The GON is seen on top of the IOCM; a midline 2-mm incision allows access to the bilateral GONs with a single skin entry. Using an in-plane approach, the cryo probe is advanced to the nerve in a medial-to-lateral direction, with constant US visualization, staying far away from the spinal cord and vertebral artery, which increases safety. CONCLUSIONS: Based on anecdotal evidence from the authors' clinic, cryoneuroablation of the proximal GON can be performed safely at the level of the IOCM. LIMITATIONS: The procedure described is based on anecdotal evidence from a small number of patients; however, the procedure is promising and formal study is warranted.