Case report of an occipital neuralgia caused by a vertebral artery loop: surgical strategies from a rare neurovascular conflict.

Background: Occipital neuralgia secondary to cervical nerve root compression is most commonly associated with degenerative or post-traumatic foraminal stenosis. In contrast, neurovascular conflict caused by an aberrant vertebral artery loop represents a rare and underrecognized etiology. Optimal surgical management remains variable, with multiple surgical techniques with risks and level of invasiveness. Case description: A 74-year-old woman presented with a five-year history of severe, progressively worsening left-sided occipital neuralgia refractory to conservative treatment. The pain was characterized as sharp and lancinating, with paroxysmal, electric shock-like exacerbations, resulting in substantial impairment of quality of life. Imaging with MRI and CTA demonstrated a dominant left vertebral artery forming a foraminal loop at C2-C3, directly compressing the exiting C3 nerve root. Microsurgical decompression was performed through a posterior paramedian approach in a hybrid operating room setting. Although arterial transposition was initially considered, intraoperative findings revealed limited vessel mobility in the context of vertebral artery dominance, necessitating modification of the surgical strategy. Adequate osseous and neurovascular decompression was achieved, and an interpositional spacer was placed between the artery and the nerve root. Intraoperative angiography confirmed preserved arterial patency without evidence of flow compromise. At three months, the patient reported complete resolution of pain, with no new neurological deficits or signs of cervical instability. Conclusion: Aberrant vertebral artery loops should be considered in the differential diagnosis of refractory occipital neuralgia, particularly when conventional etiologies fail to explain persistent symptoms. Surgical treatment must be individualized and guided by intraoperative anatomical and functional findings. In selected cases, minimally invasive, targeted decompression without arterial transposition may achieve effective and durable symptom relief while reducing the risk of vascular injury and structural instability.