in sports related concussions and resulting occipital headaches, the role of posterior scalp nerve decompression by Dr. Rajiv Iyer. So thanks very much for the opportunity to speak today. I'm a sixth year neurosurgery resident at Johns Hopkins. Oof. So as we are all familiar, brain injuries in the pediatric population are quite common. In fact, about 15% of children have had at least one head injury requiring medical attention by the age of 10. And as a result, the constellation of symptoms may occur known as post-concussion syndrome, a major component of which is post-concussive headaches that in rare cases can persist even months to years after the injury for unknown reasons causing significant morbidity. The trigemino-cervical complex, which involves the trigeminal sensory nucleus extends down to the high cervical levels and may be the anatomic substrate for some of these headaches. Whiplash injuries and repetitive trauma and damage or anything that affects the greater or lesser occipital nerves can contribute to cervicogenic headaches. This nucleus also receives information from the trigeminal nerve, so it may be a convergent pathway for that. The treatment of post-concussion headaches is multidisciplinary and begins with a conservative lifestyle modifications and preventative and abortive medications. Other procedures listed here such as occipital nerve blocks, high cervical root rhizotomies or ganglionectomies or radiofrequency ablation is also possible. But in our group, we've performed a retrospective study investigating athletes under the age of 21 years who suffered from post-concussive headaches that were medically refractory and who failed injections with steroids and Botox who were then referred by an independent neurologist for the treatment of these headaches for the majority of time for consideration of a surgery which was mostly greater occipital nerve neuralysis and lesser and dorsal occipital nerve transection and muscle bearing. Preoperatively, all the patients had to have had a positive response to occipital nerve block and we evaluated pre and post-operative visual analog scores. In brief, the surgical technique most often involves bilateral greater occipital nerve neuralysis and decompression starting at the trapezial tunnel and extending superiorly and inferiorly as well as transection of the lesser occipital nerves found at the posterior border of the SCM and then muscle bearing to prevent neuroma formation and a trapdoor incision around the external occipital protuberance provides good access to all these structures. A total of 48 patients were treated with a mean age of 18 years old. Mean time to surgery from injury was about nine months and the mean follow-up was about six months. At last follow-up, visual analog scores were significantly improved and the number of headache medications were significantly reduced in this population. 75% of patients returned to their sport of choice and when surveyed, all patients would have undergone the surgery again in retrospect when surveyed. There were no wound complications in our cohort. One patient who underwent an initial dorsal occipital neuralysis required re-operation for greater occipital nerve neuralysis and dorsal occipital neurectomy with subsequent pain improvement. So in conclusion, children with sports-related post-concussive headaches should be evaluated in a multidisciplinary fashion. Medically refractory cases with a strong occipital component should be considered for possibly a nerve, with a positive nerve block response should be considered for possible intervention with neuralysis and transection of these peripheral nerves. But large studies across centers and increased attention to this topic by neurosurgery will aid in determining the most appropriate role for these interventions compared to other ones. Some acknowledgments and references. Thank you very much. Thank you.

neurosurgery

occipital headaches

post-concussion syndrome

surgical interventions

headache medications