Case Study: Young Woman with Post-Assault Chronic Headaches

Case Study highlights a young woman plagued by chronic headaches after being assaulted.

This is a 25-year-old nursing student who has been suffering from severe headache and neck pain since being assaulted approximately one year ago. She had had some occasional headaches with no particular severity prior to this, but since the assault where the back of her head impacted a hard surface she has suffered the pain continuously. These symptoms are exacerbated when sitting or when writing. She additionally has pain radiating to behind her right ear since a recent surgery. There have been a variety of evaluations and treatments, including a series of blocks, radiofrequency treatments, cold treatments, and finally prior surgery for bilateral C2 ganglion section.

Based on the history, physical examination, data and findings it seems that she may have suffered nerve entrapment or neuroma formation along the nuchal line during the assault. It is recommended to proceed with MR Neurography to confirm impressions and subsequently plan to proceed with Interventional MR guided blocks to the back of the head.

Soft-Tissue MR Neurography with three dimensional analysis at the C1-C2 level, reveals there is a prominent fluid-like intense structure dorsal lateral and dorsal to the cal sac extending into the dorsal C1-C2 interspace. Superiorly this fluid collection extends along the dorsal aspect of the left C1 lamina and inferiorly the fluid collection extends dorsal and lateral to the C3 lamina and overlying the C4 spinous process. This fluid collection is noted to infiltrate into the expected region of the C1-C2 neuroforamina bilaterally, and closely abuts the epidural space and dura at this level. There is, however, no compromise in the cal sac or dura at the upper cervical spine. The dura appears to be grossly intact. The remainder of the skull base demonstrates no additional abnormalities. The dorsal scalp appears unremarkable. Of incidental note are scattered reactive adenopathy in the deep cervical, perimandibular and suboccipital chains bilaterally.

Interventional MR procedure is carried out as a first stage to re-operative surgery. The right nuchal line was examined and a similar approach for a three-point injection was planned. The first set of injections was in the right paramedian soft tissues medial to the transverse skin incision. At this point, following local anesthesia, Marcaine and Kenalog were injected into the deep and superficial layers of the scalp. The second point of injection was just superior and along the lateral border of the transverse skin incision, using a similar technique. The third point was approximately 2.5 cm lateral to the second point in the right post auricular soft tissues.

Based on the MR Neurography and Interventional MR procedure results a surgery for right occipital exploration for auricular nerve neuroplasty is performed. Post surgery the patient has really done quite well since her surgery 6 months ago. Many of her symptoms have resolved. She has been able to complete school and has recently decided to move to Southern California, where she is actually starting work as a nurse shortly. Her current progress and status are noted with plans to follow up again in 3 months to ensure that all pre operative pain conditions have resolved.