Evidence-Based Patient Selection in Headache Surgery: Impact of Preoperative Radiofrequency Ablation on Surgical Outcomes

Background:Radiofrequency ablation (RFA) of the greater occipital nerve (GON) is a minimally invasive treatment option commonly used in patients with occipital neuralgia. Patients who undergo occipital surgery for headaches after failed RFA treatment present a unique opportunity to evaluate RFA-treated occipital nerves and determine the impact on headache surgery outcomes. Methods:Of 115 patients who underwent headache surgery at the occipital site, 29 had a history of RFA treatment. Migraine Headache Index, Pain Self- Efficacy Questionnaire, and Pain Health Questionnaire-2 outcome scores were recorded preoperatively and at follow-up visits. Intraoperative macroscopic nerve damage and surgical outcomes were compared between RFA-treated and non-RFA-treated patients. Results:RFA-treated patients had a higher rate of macroscopic nerve damage (45%) than non-RFA-treated patients (24%) (P = 0.03), and they were significantly more likely to require a second operation at the site of primary decompression (27.6% versus 5.8%; P = 0.001) and GON transection (13.8% versus 3.5%; P = 0.04). Outcome scores at the last follow-up visit showed no statistically significant difference between RFA-treated and non-RFA-treated patients (P = 0.96). Conclusions:RFA-treated patients can ultimately achieve outcomes that are not significantly different from non-RFA-treated patients in occipital headache surgery. However, a higher number of secondary operations at the site of primary decompression and nerve transection are required to treat refractory symptoms. RFA-treated patients should be counseled about an increased risk of same-site surgery and possible GON transection to achieve acceptable outcomes.