Greater Occipital Nerve Cushioning with Muscle Flap versus Fat Flap results in Lower Reoperation Rates

Greater Occipital Nerve (GON) neurolysis, based on the original description of the procedure, is followed by elevation of a subcutaneous fat flap that is wrapped around the nerve for cushioning. However, this technique places the nerve in a more superficial and exposed position, and may increase the susceptibility to mechanical stimuli and traction, with risk for recurrent pain or injury. More recently, techniques to bury the nerve under the trapezius or semispinalis muscle have been employed to position the nerve beneath protective soft tissues. In this article, both techniques are discussed and postoperative results are compared.

Patients who underwent primary GON decompression surgery at three centers were included. Pain frequency, intensity and duration was collected preoperatively and postoperatively in a prospective fashion. Manual chart review was performed to collect data regarding type of flap used, complications and reoperations.

391 patients underwent GON decompression surgery. A fat flap was used in 203 (52%) and a muscle flap in 188 (48%) patients. Postoperative complications were similar between groups (p=0.116). The reoperation rate was significantly higher in the fat flap group as compared to the muscle flap group (n=26 (13%) vs n=9 (4.7%); p=0.007). Postoperative pain characteristics between the fat and the muscle flap group after the last intervention were not significantly different (p>0.05).

In comparing fat versus muscle flap techniques for GON decompression, both methods effectively reduced pain. However, the muscle flap approach resulted in a lower reoperation rate, suggesting this option may provide better long-term pain relief.