Efficacy analysis of combined nerve combing and decompression for occipital neuralgia based on the classification of neurovascular relationships

Objective This study set occipital pain improvement as the primary endpoint, and overall headache relief, migraine index, medication use and complication rate as secondary endpoints, to evaluate the efficacy and safety of neural combing plus decompression guided by four neurovascular relationship subtypes for drug-resistant occipital neuralgia (ON).Methods We retrospectively reviewed 53 patients with drug-resistant ON who underwent unilateral or bilateral greater occipital nerve (GON) combing and decompression. All had ineffective drug treatment for ≥1 year and follow-up ≥12 months. Efficacy was evaluated by comparing monthly pain days, Visual Analog Scale (VAS), medication use and migraine index pre- and postoperatively. Complications were recorded.Results Postoperatively, 88.7% (47/53) of patients achieved ≥50% ON improvement, and 67.9% (36/53) had complete pain remission. Monthly chronic pain days fell by 72.6%, attack days by 85.0%. Baseline VAS decreased from 2.6 to 1.0, peak attack VAS from 6.4 to 0.8. Medication use dropped by 70%, with significant reductions in NSAIDs, triptans and opioids (P < 0.01). Only one minor complication occurred, with no severe adverse events.Conclusion The combined GON combing and decompression technique guided by the four subtypes of neurovascular relationships enables the precise release of nerve compression points while preserving neural structures. It significantly improves pain symptoms and quality of life in patients with drug-resistant ON, offering minimal trauma and fewer complications. Hence, this technique is a safe and valuable minimally invasive therapeutic option for the invasive treatment of drug-resistant ON, which warrants further prospective comparative studies and wider clinical application.