PMC7463402_01
Schematic diagram demonstrating the distribution and characteristics of pain over the years. (a) The gray areas over the left preauricular temporal area indicate the distribution of paroxysmal lancinating pain that started in 2014. Pain initially began as a persistent aching pain in the left molars and gums (light gray area). (b) In 2016, paroxysmal pain occurred in the left preauricular temporal region, and at the same time in the left vertex (obliquely hatched area) and the left deep ear (black circle). (c) It was not until 2018, four years after the occurrence of paroxysmal pain, that the stabbing pain in the retroauricular occipital area (transversely hatched area) occurred as pain in the left temporal region (gray area), left vertex (obliquely hatched area), and left deep ear (black circle).
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Paroxysmal pain continued to occur even when she was resting and was more severe when she moved her jaw or spoke or lightly touched the front part of her left ear and temporal region (Figure 1(a)). This time, paroxysmal pain occurred in the left vertex and deep in the left ear at the same time as the left temporal region (Figure 1(b)). Two months later, in January 2019, pain of the same nature recurred to the left temporal and gum region, inside the ear canal, and parieto-occipital vertex (Figure 1(b)). Specifically, this time, the pain also occurred in the occipital area behind the ear, in the distribution area of the greater occipital nerve (Figure 1(c)).
Intraoperative photographs during the decompression of the greater occipital nerve (GON). (a) Intraoperative photograph showing severe entrapment of the GON (white arrowheads) by the aponeurotic fibrous attachment of the trapezius (white arrows) at the superior nuchal line. The maximal compression point (black arrow) is seen by lifting the trapezial aponeurotic edge. The inset shows the direction of the photo and the location of the incision. (b) Intraoperative photograph after decompression of the left GON (white arrow heads) with the division of the trapezial aponeurosis (white arrows). Even after decompressing the upper side, the GON was still depressed by the lower fascial aponeurosis (black arrowheads). (c) Intraoperative photograph after complete decompression of the left GON (white arrowheads). Its proximal and distal courses are addressed.
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The GON was found to be severely entrapped by the aponeurotic arch of the trapezius, showing an indentation of chronic entrapment (Figures 2(a) and 2(b)). A small tributary of the occipital artery was found to constrict the distal course of the GON, which was cut off, resulting in complete decompression of the left GON (Figure 2(c)).