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SPORTS CONCUSSIONS AND OCCIPITAL NEURALGIA

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Anyone that likes to watch professional football on TV has probably read at least one news story about concussions and the subsequent traumatic brain injury that can occur after prolonged and repeated blows to the head and neck. Sadly, this phenomenon is not limited to football and can be seen in any number of sports from volleyball and soccer, to equestrian and car racing. Moreover, the pathology from such injuries is not limited to the brain. It has now been noted in a few papers in the published literature that occipital neuralgia can occur following sports-related injury. The etiology, at least in my mind, is most likely a traction (i.e. stretch) injury to the occipital nerves. What exactly happens as a result of this type of injury remains unclear, but there are several possibilities.

Studies of concussion patients using advanced imaging techniques that are not yet widely available have shown that there can be disruption of the myelin sheath of neurons in the brain. This sheath represents an important component of nerve support and insulation that allows physiologic conduction of nerve impulses. A similar event could happen as a result of trauma to a peripheral nerve and represents one possible cause for neuralgia. Another possibility is post-injury scarring reducing the space through which these nerves have to glide and thereby causing compression. Third, the scarring may be intra-neural (i.e. within the nerve) thus, in effect making the nerve stiffer and unable to glide smoothly with certain movements. These latter two possibilities may help explain why people who develop ON following sports-related concussions often report increasing pain or triggering of their pain with certain movements such as head rotation. Finally, if left untreated, prolonged compression has itself been shown to cause thinning or elimination of the myelin sheath and eventually neuronal cell death.

Remarkably, there are over five million Americans living with the sequelae of concussions. Even more frightening is that post-traumatic headache has been estimated to occur in almost 90% of such patients and is one of the more long-lasting symptoms, causing significant disability. Certainly, conservative measures are the first line of treatment and include modalities such as pharmacologic agents, massage, and physiotherapy. However, as with migraines, these modalities are not always successful. Happily, surgical decompression has also been shown to be effective in such patients with positive results reported in up to 88% of those treated. In addition, I personally believe that if occipital nerve compression is suspected, the sooner it is addressed, the quicker nerve function will be restored and the greater the ultimate degree of recovery will be since the amount of neuronal cell death can be limited. This latter postulate has not yet been studied, but certainly makes sense given what we know about chronic compression of peripheral nerves in the upper extremities. Therefore, anyone with such symptoms should look into the possibility of occipital nerve injury and have a frank discussion with their treating clinician regarding a timeline within which to evaluate the current treatment plan and what to do if there are no results within a certain period of time. Always trying to leave on a positive note, the take home message is that there may be a lifeline if chronic post-concussive headaches appear to be refractory to more conventional methods.

For more information on how nerve surgery can help with chronic migraines or the aftermath of concussions, visit www.peledmigrainesurgery.com or call 415-751-0583 to schedule a consultation with Dr. Peled.

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Chronic Pain and Dementia

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There is a lot of discussion, both in the media and in the medical literature, of the direct medical costs of chronic headaches which is a prototypical form of chronic pain. However, one thing that often gets overlooked is the indirect costs of these conditions. By indirect costs I mean, for example, lost productivity/income from work absences secondary to pain and/or increased costs for care of children and significant others secondary to an inability to perform these tasks oneself. Moreover, and perhaps most significantly, there are the psychological, emotional and physiologic tolls that chronic pain such as chronic headaches/migraines take on patients. In a fascinating study back in 2003, Susan Turner-Bowker surveyed over 7500 people with various health conditions and specifically analyzed a metric known as the health-related quality of life (HRQOL). What she discovered was that migraineurs’ HRQOL was similar to those patients suffering from congestive heart failure, hypertension and diabetes – all devastating illnesses. These results highlight the fact that chronic pain such as chronic headaches/migraines have significant negative impacts on functional health and well-being.

Unfortunately, the data correlating chronic pain with negative physiologic effects continues to mount. Just this week, a study in JAMA Internal Medicine looked at a cohort of over 10,000 elderly patients and followed them for a period of over 12 years. Remarkably, the people in this study who said that they were persistently troubled by moderate or severe pain demonstrated a nearly 10% faster decline in memory function over the subsequent 10 years. In addition, the statistical analysis implied that these same people would have a 16% higher relative risk of inability to manage other medications and an almost 12% higher relative risk of inability to manage their financial situation independently. It was therefore concluded that persistent pain was associated with accelerated memory decline and an increased probability of dementia. These numbers are significant because it has been estimated that as many as 1 in 3 elderly people experience chronic pain. The results seen with this current study are likely multifactorial, but may include the use of medication for pain, whether opioids or even NSAIDs (e.g. ibuprofen, Aleve) both of which have been shown in other studies to be associated with dementia risk. Alternatively, it has been suggested that the cognitive dysfunction associated with chronic pain may be secondary to diminished ability to focus on other functions as a result of the need to manage the discomfort, an effect that has been particularly noticeable on short-term memory. Another possible explanation may be that the stress associated with chronic pain may lead to cognitive decline via cortisol-based mechanisms.

While this particular study focused on elderly patients, it is reasonable to wonder whether or not the same mechanisms leading to cognitive decline suggested in this study also have effects on younger patients. I wonder, for example, if chronic pain beginning that begins at an earlier age leads to an earlier onset of cognitive dysfunction such as dementia. In either case, there is clearly a need to do more for patients than we are currently doing. Perhaps using conventional therapies as well as “thinking outside the box” at other possible causes for pain (e.g. peripheral nerve pathology) will allow us to manage these illnesses more effectively with less of a pharmacopeia. The ray hope from studies such as this one comes in the possibility that there is so much potential for benefit in overall health as well as quality of life even with small improvements in our understanding of these conditions.

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Hurry Up and Wait...

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I saw an interesting question posted today – something to the effect of, ‘If you have nerve decompression and/or transection, shouldn’t you feel immediate relief?” This question is a very important one, but the answer may not be intuitively obvious. The nervous system is truly complex and often quite difficult even for medical professionals to understand. Therefore, in an effort to explain why it can often take many months before a patient experiences the hoped for improvement, I’ll use an analogy to which many people can hopefully relate.

Most everyone has at some point, had the experience of falling asleep on their arm and waking up with slightly numb fingers. Upon waking, you notice the altered sensation in the fingers, shake them out and within a few seconds, sensation returns to normal. Many people have also had the experience of waking up after having fallen asleep on their arm for a longer time, getting up and realizing that they not only have very numb fingers, but also that they have difficulty moving their elbow, wrist and/or fingers very well. “Oh my gosh, did I just have a stroke?!?”, often comes to mind. In this scenario, you try to shake out the arm as best you can and it often takes a few minutes before things start to move again and sensation returns to the digits. Moreover, once the blood starts flowing again and sensation begins to recover, there is often a period of hypersensitivity before things settle down.

The difference in these two scenarios is the degree of pressure and the duration of pressure on the nerves in the upper extremity, obviously worse in the second scenario. Given the overall greater amount of pressure in this second scenario where you’ve probably slept on your arm for a few hours, it takes longer for the nerves to recover. Now take this second scenario and stretch it out much longer. In other words, let’s assume you’ve had pressure on your upper extremity for several years? Would the nerves be expected to recover in a few hours or days following decompression? Given what we know from the above examples, the answer is, ‘Probably not’. Recovery in these cases can take many months. The situation with neurectomy is a little bit different in mechanism, but the same in practicality. When you transect a nerve proximal (i.e. upstream) from an injured segment, you now have a “live” nerve end that you bury within the local muscle. However, doing so is not the same as turning off a fuse to an outlet with a short where the sparks stop immediately. Remember that this nerve is still attached to the spinal cord and therefore the brain, so impulses will still travel back and forth to that “live” end. However, with time, that sensory nerve end will likely make connections with other motor nerves within the muscle and in effect this “fools” that sensory nerve into thinking that it has found its downstream counterpart. You now have a sensory nerve connected to a motor nerve, a situation in which the impulses travel as they normally would, but have no effect on the muscle since the muscle only responds to motor nerve impulses. It would be like me having written this post in Sanskrit (which hopefully nobody reading this post understands). You might recognize it as writing, but it would make no sense and therefore would elicit no reaction. That being said, this process takes time which is the reason that relief following neurectomy with muscle implantation is often not immediate. The take home message is that recovery from any nerve operation is a process, not a moment in time. Hopefully that helps.

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BOTULINUM TOXIN AND HEADACHES

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Botulinum toxin has been used for quite some time to manage chronic migraines, specifically as a preventative agent. Like any treatment modality, the possibility for variable results exists. Certainly some people have had great results with treatment, but many have not. Very recently people have asked what their results with this treatment modality mean. Unfortunately, the answer is not straightforward for a number of reasons that I will delineate below.   Please keep in mind that these thoughts/opinions are general comments and not meant to be interpreted as specific to any particular patient’s situation. You will have to have a discussion with your treating physician as to how to interpret your specific results.

Botlinum toxin is most commonly used according to what’s known as the PREEMPT protocol. Briefly, this protocol calls for 31 injections for a total of approximately 155 units of botulinum toxin with some modifications allowed at the discretion of the treating physician. The PREEMPT protocol has been discussed in a number of journal articles, including a major article published back in 2010 in the journal Headache. In this study, patients were given either injections of botulinum toxin or placebo (both patients and physicians were blinded as to what was being given) and then followed for a total of 24 weeks. Botlinum toxin was injected at time 0 and again at 12 weeks with the final endpoint metrics assessed at 24 weeks. The authors demonstrate statistically significant differences in migraine and headache frequency (among other metrics) during the treatment period, in those patients receiving botulinum toxin as compared with placebo-treated patients. They conclude that botulinum toxin is a useful treatment modality for prevention of migraine headaches. So why doesn’t everyone use it? In my opinion, I believe there are a couple of very relevant criticisms of this study and the conclusions you can draw from it.

First, while clearly disclosed on the title page, the authors of this study are either employees of, have received research dollars from, or are paid consultants for the company that makes the specific form of botulinum toxin used; certainly a potential a conflict of interest although one that doesn’t necessarily invalidate the data presented. Second, while the data are somewhat obtuse and I am certainly no mathematician, if my calculations are correct (and I have redone them several times just to check) the patients in the Botox arm of the study had about 5 fewer headache days in about 6 months compared with those that were injected with placebo. If I told you as a patient that I would poke you with a needle 62 times over two visits and that if you were lucky and responded, you would have 5 fewer headache days in 6 months, would that be worth it? Perhaps and it’s better than nothing, but this result is hardly the wow factor many clinicians make it out to be. Second, let’s play devil’s advocate and say that a huge number of Botox patients had a complete response and had no headaches for the entire 24 weeks. My question to them would be: ‘Which of the 31 injections you got in each round was responsible for the great results?’ The answer would be impossible to give because botulinum toxin doesn’t work right away (it takes several days to become effective) and you got all 31 injections at the same time. So do you really need 31 injections or just 21, or perhaps just 5? You would have no idea. Third and going along with this line of thinking, if you had a great result with Botox, the presumption would be that you would need to continue with this type of therapy in perpetuity - not such a great proposition if you’ve got 40 years of injections to look forward to. I have also wondered what would happen to the neck muscles if they were constantly relaxed by botulinum toxin. Would they atrophy and weaken over time and if so, how would that affect your posture and your ability to lift your head? I don’t know the answer, but I would not want to find out on myself. The take home message is that you should have an open and honest discussion with your treating clinician about what you/they hope to accomplish with the results of any treatment you select along with the potential risks and benefits. Hope that helps.

For more information on headaches and headache relief, visit www.peledmigrainesurgery.com or call 415-751-0583 to make an appointment.

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THE TEAM APPROACH

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This post is a rather long one, but an important one nonetheless in my humble opinion. Over the years that I have been performing headache surgery, I have heard from so many patients that they are frustrated with their current treating physicians because their symptoms are not under control to the degree that they would like. Anyone who has been on these forums for a few hours has certainly run into a post or several posts describing a bad patient-physician interaction or a bad patient-health system interaction. To all of those people - I completely empathize and you have every right to feel as you do. Having been a patient on several occasions myself, I know what it’s like to speak with a physician or an insurance adjustor and feel like you are talking to the clouds. It is very frustrating and can often leave you feeling helpless – and I’m a surgeon. As a peripheral nerve surgeon, especially one that operates on people with chronic, intractable headaches, I have often heard criticisms from other practitioners whom I don’t feel even understand what it is that I do. However, in those situations I often find myself trying to put myself into the shoes of the doctor across from me. What I have found is that there is always common ground to be had somewhere and that understanding their perspective can help me find it. In addition, since we are (or should be) on the same side, I have found that viewing things from a team perspective is particularly and practically very helpful.

Breast cancer is sadly a disease that touches too many people throughout the world. Over the past few decades, the medical profession has made incredible strides in fighting this dreaded disease and we now have cancer remission rates that were once thought impossible. One of the biggest factors in helping this development along has been the team approach. In our community, a patient with a new breast cancer diagnosis is immediately given a team of physicians and clinicians to help them navigate the process that is dealing with this pathology. To be sure, there is a “captain of the ship”, usually the breast surgeon or oncoplastic surgeon who is coordinating all of the moving parts, but every member of the team is critical to ensuring success. While the breast surgeon may remove the cancer physically, there is often a plastic surgeon to help reconstruct the resultant defect, a radiation oncologist who will help ensure that any disease that might have spread locally is controlled and a medical oncologist who will determine if the risk of distant disease is high enough to warrant a regimen of chemotherapy or hormonal therapy, There is also often a psychologist and nurse navigator who can help the patient deal emotionally and psychologically with the fear often accompanying a cancer diagnosis. Only when you put all of these components together, do you get the wonderful results that modern medicine has been able to achieve.   If you think about it, the same team principles apply to a football team (American football as well as soccer), a dance troupe or a team of scientists working to find a cure for something. So what the heck does this diatribe have to do with headache surgery?

Well, for years I have been saying to my patients that hopefully someday soon, we will realize that chronic pain should be best treated with a multi-modality approach as with breast cancer. Chronic headaches are a form of chronic pain. There are certainly many patients for whom medical management works very well. Those people do not need any injections or surgical intervention. There are those for whom pharmacologic agents are simply ineffective and in those cases, nerve decompression may be a good option. However, for most, a combination of therapies is necessary to control the underlying symptoms. I have heard from countless patients who tell me that prior to surgery their medication (say Imitrex) was inconsistently helpful. “I could flip a coin” they would tell me, take it early in the middle or late in a headache attack, but they could never figure out why sometimes it was effective and sometimes not. Following surgery, their headache attacks are much less frequent and often much less severe, but what was interesting to me was that they would tell me that when they would get an attack, the Imitrex was almost always effective. “Why is that?” they would ask. Well….it is likely that they have two problems contributing to their headache symptom complex. One is a chemical imbalance that medication would treat, and the other is a mechanical compression of the nerve(s). Pre-operatively, when you had a headache, you reached for what you had which was Imitrex, but if it was the mechanical compression that was irritating the nerve that day, you didn’t get any better. If it was the chemical imbalance aggravating the nerve, you did get better. Post-operatively, the mechanical compression has been relieved so the headache frequency and severity are much less, but there are still headaches. However, now when you take the Imitrex, lo and behold it almost always works, because it is actually treating the underlying chemical imbalance that is causing those residual symptoms. The take home message is that patients still often need to have those pain management physicians and neurologists involved to manage those medicines so that their symptoms remain under optimal control. Those that have seen me know that I often like to communicate with the very same such doctors prior to surgery to ensure we can optimize the post-operative recovery period which certainly can have its share of ups and downs. In the end, we all have to partner in this endeavor together as a team.

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CHRONIC PAIN AND THE OPIOID EPIDEMIC, PART I

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I was recently invited to attend a meeting on the use of multimodality therapy to decrease the use of opioids in the US population.  Unless you’ve been away on a remote island for a long time or completely eschew any sort of media including newspapers and TV, you’ve probably heard that we have a problem with opioid use in this country.  I knew the numbers were bad, but frankly I came away from this meeting completely floored. Here are some statistics that should make you pause and take notice:

1. Americans account for only 4.6% of the world’s population yet have been consuming 80% of the world’s opioid supply and 99% of the world’s hydrocodone supply. 

Pain Physician. 2012; 15(3 suppl):ES9-ES38.

2. 1 in 15 patients will become chronic opioid users after surgery. 

Carroll I, et al, A pilot study of the determinants of longitudinal opioid use after surgery. Anesth Analg. 2102; 115(3): 694-702.  NIH, National Institute on Drug Abuse. Prescription and over-the-counter medications. Drug Facts. Revised Nov 2015. http://www.drugabuse.gov/publications/drugfacts/prescription-over-the-countermedications. Accessed 08/24/16.

3. 1 year following elective cervical spine surgery, approximately 1/3 of all patients were still using opioids.  

Wang M, et al. Predictors of 12-month opioid use after elective cervical spine surgery for degenerative changes [abstract]. Spine. 2103; 13(suppl): S6-S7.

4. 3 out of 4 people who misuse prescription painkillers,use medication that had been prescribed for someone else. 

Manchikanti L, et al. Opioid epidemic in the United States. Pain Physician. 2012; 15(3 suppl): ES9-ES38.  Office of National Drug Control Policy. 2013 Drug overdose mortality data announced: prescription opioid deaths level; heroin-related deaths rise[press release]. 01/12/15. http://www.whitehouse.gov/ondcp/news-releases/2013-mortality-data. Accessed 08/24/16.

5. Abuse of prescription painkillers like Oxycontin and Vicodinleads to eventual heroin use in 14% of people.

Busch S, et al. Abuse of prescription medication risks heroin use. Infographic created for: National Institute on Drug Abuse. http://www.drugabuse.gov/related-topics/trends-statistics/infographics/abuse-prescription-pain-medication-risks-heroin-useAccessed 08/24/16.

6. In 2012, 259 million prescriptions were written for opioids in the US. This number represents enough narcotics so that every American could have a full bottle of pills sufficient to take 5 mg of hydrocodone every 6 hours for 45 days.

7. The problem is obviously worse in some parts of this country than others.  For example, 1 in 6 PEOPLE (not patients, people!) in the state of Tennessee are on opioids. (Presentation at this meeting)

Obviously, given the scope of the problem, you might suspect that there is no one or easy answer and you would be correct.  There is plenty of blame to go around on all sides of this major issue, but that also means there may be many avenues from which to address the problem. The people in the conference today are at the forefront of this epidemic and have a number of interesting ideas and strategies as to how to begin to tackle this problem.  Stay tuned….

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The Headache Pain Caused by the Common Cold

The Headache Pain Caused by the Common Cold

An interesting thought occurred to me the other day as I was finishing up a particular headache surgical procedure.   Something that has come up over the years is that patients tell me that their headaches are worse when they are sick with the cold, flu or some other such issue. I have been pondering why this symptom change might be taking place for a long time. As with many of my blog posts, there are several possible causes for this phenomenon in my opinion and so I have decided to delineate these possibilities below.

One reason is that people who are sick are often more stressed either because of or as a cause of their illness. It is considered reasonable that stress, of whatever type, can weaken the immune system and thus mitigate the body’s ability to fight various pathogens. These pathogens can cause all manner of irritation and inflammation in various tissues such as muscles hence the muscle discomfort with the flu, for example. If one type of tissue is irritated, the surrounding tissues might suffer the same fate. In addition, when we are stressed, our blood pressure often rises. Since many of the nerves which we address during our operations are compressed by surrounding blood vessels, it follows that when these vessels beat harder (i.e. during a period of relative hypertension) the nerves which are already irritated may become even more so. But another, third thing happens during an infectious scenario, one to which most people can also relate. Have you ever felt your neck when you feel you have a sore throat or the sniffles? If so, you have probably noticed that the lymph nodes in the area are swollen and often tender. That is because these lymph nodes are the factories for pathogen-fighting cells and they ramp up production (hence swell) when you are sick. As I was dissecting this person’s greater occipital and lesser occipital nerves, I noticed several enlarged lymph nodes located within the already crowded spaces through which these nerves passed. Bear in mind that we don’t operate on people who are sick so these nodes were particularly enlarged given that fact alone. The nodes were further compressing these poor nerves which were already pressured by the surrounding blood vessels and scarred connective tissue. I could only imagine what occurs to these nerves if that person were to contract the flu. Those nodes would surely swell, sometimes quite dramatically and place even further pressure in the area causing even further pain. With pain comes higher blood pressure, hence more compression and so begins the upward spiral. One recurring question from patients is, “What is compressing my nerves?” The answer used to be possibly spastic muscle, tight/scarred connective tissue, enlarged or aberrant blood vessels. It now also includes abnormally large and/or poorly localized lymph nodes. Happily these nodes can be removed carefully and selectively to further relieve pressure during a decompression procedure and many of the patients in whom this lymph node removal was necessary have gone on to do quite well. Finally, none of the nodes which I have biopsied to date have revealed any evidence for malignancy or other pathology, further happily capping a saga that has resulted in many positive outcomes.

So if you suffer from headaches, please visit us at www.peledmigrainesurgery.com or call us at 415-751-0583 and 925-933-5700 to setup an appointment to find out if we can reduce or eliminate your migraines. We look forward to hearing from you!

 

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California Headache Surgery With Dr. Ziv Peled

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Surgery for chronic headaches in California is here.  People often call me from cities outside of San Francisco wondering if we can help them.  Happily, many times if they need it, I can help them, no matter where they come from! We have seen patients from all across the United States, and as far away as Brazil, New Zealand and Finland. Since chronic headaches occur in every part of the world, we are excited to help people in even further-flung areas and want to extend an invitation to everyone in California and abroad that we may be able to help reduce or eliminate their “migraines”with peripheral nerve surgery.

I have successfully performed many of these operations using my knowledge and experience in peripheral nerve surgery to ease the pain caused by compressed, irritated or injured nerves in the head that can lead to the excruciating “migraines” that people have been forced to live with for many years. My practice has developed a system to help with travel and lodging  and to ensure that each patient has as seamless an experience as possible.  We have also developed protocols utilizing Skype to confer with patients to discuss the potential for these often life-changing procedures. 

I also firmly believe that care doesn’t end with the surgical procedure. Of course, we do everything we can to ensure that the operation itself is successful, but continue a dialogue with patients often lasting many months following their procedures. While we ourselves cannot be everywhere, the ability to speak with and interact with your surgeon is important to deal with any issues that might arise during the post-operative and recovery phases. While these times can be challenging, our practice has refined the process to ask the right questions and determine if any further action is needed.  With Peled Plastic surgery, you won't be left on your own after your operation.

So if you suffer from chronic headaches or “migraines”, please visit us at www.peledmigrainesurgery.com or call us at 415-751-0583 and 925-933-5700 to set up an appointment to find out if we can reduce or eliminate your symptoms. We look forward to hearing from you!

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Los Angeles Can Get Headache Surgery

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Los Angeles is home to just under 4 million people. Since 18% of women and 6% of men suffer from debilitating migraines, this means that almost 720,000 women and 240,000 men suffer from the headaches. Where can these people turn to for treatment of migraines?

Up the coast in San Francisco, Dr. Ziv Peled specializes in migraine and headache surgery, giving Californians an opportunity for migraine relief. Dr. Peled uses peripheral nerve surgery to relieve the tension around the nerves that are causing the migraines.

Surgical decompression for chronic headaches is performed as an outpatient procedure at an accredited surgery center or in the outpatient department of the California Pacific Medical Center. The procedures can last anywhere from 1 hour to 3 hours depending on the number and locations of the nerves being treated. There are few restrictions following the procedure and discomfort is usually very well tolerated with oral pain medication. 

As an outpatient surgery, you can come to our San Francisco offices or we can perform the surgery at a center near you. You can be back home that night, well on your way to recovery from your migraines. Dr. Peled has performed hundreds of these procedures. Our testimonials page is filled with patients thanking Dr. Peled for changing their lives for the better.

If you are in Los Angeles, Rancho Palos Verdes, Pacific Palisades, Burbank, Alhambra, Carson, Glendale, Hawthorne, Inglewood, Lancaster, Pasadena, Pomona, Santa Clarita, Santa Monica, West Covina, or any of the surrounding areas and are suffering from migraines, we can help.

Call Dr. Peled today at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about how peripheral nerve surgery can help you with your headaches. Headache surgery in Los Angeles can be a phone call away.

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Los Angeles Migraine and Headache Surgery

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We are asked quite a bit whether we will see patients from Los Angeles for migraine surgery, or if we’ll see out-of-town patients as well. Of course we do!  Anyone may be able to achieve significant and lasting relief no matter where they call home! We have helped patients from all across the United States, and as far away as India and Brazil. We are excited to help people from all over the globe as peripheral nerve surgery is an area to which I have dedicated a large portion of my practice and is something about which I remain very passionate. We wish to extend an invitation to everyone anywhere to look us up and decide for themselves whether we might be able to help to reduce or eliminate their chronic headaches with peripheral nerve surgery.

I have performed hundreds of decompression procedures on nerves for chronic headaches with high success rates. Many of these people had been living with their headaches for decades and had resigned themselves to a life of chronic pain despite medication. Happily, we proved that was not the case. Furthermore, because we see so many foreign and out of town patients, we have developed a system to help make your overall experience as seamless as possible. We can assist with travel planning, lodging, transportation to and from the operating room and even post-operative nursing care if required. In addition, Dr. Peled is available for initial record review and evaluations via Skype or Google+ to help determine if a trip from home is a worthwhile endeavor. Finally, because post-operative follow-up is an extremely important part of the surgical experience and critical to achieving optimal outcomes, we use these same modalities to keep tabs on our patients after they have gone home and remain available to discuss issues with your local treating physicians if needed. This important time can be hard for patients as well as doctors that can't see their patients directly, but our practice has refined this process to ask the right questions and determine if any further action is needed.

So if you suffer from chronic headaches, please visit us at www.peledmigrainesurgery.com or call us at 415-751-0583 or 925-933-5700 to find out if we can reduce or eliminate your migraines. We look forward to hearing from you!

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Dr. Peled Speaks at Plastic Surgery The Meeting 2016

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Dr. Ziv M. Peled, M.D. was recently a lecturer, injector and surgical trainer at the largest plastic surgery meeting in the world. Plastic Surgery The Meeting 2016, held in Los Angeles, CA in September and sponsored by the American Society of Plastic Surgeons, is the premier meeting for plastic surgeons globally. Dr. Peled gave four talks in two sessions over two days on subjects ranging from occipital nerve surgery to coding for headache surgery. The talks were well received and are likely to be repeated in future meetings and to include an expanded curriculum on additional aspects of this exciting treatment option for chronic headaches refractory to conventional therapy.

For more information on how headache surgery can help reduce your "migraine" symptoms, visit www.peledmigrainesurgery.com or call 415-751-0583 to schedule an appointment with Dr. Peled.

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Migraine Nerve Decompression With Peripheral Nerve Surgery

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What exactly is meant by the term, ‘peripheral nerve surgery’? Peripheral nerve surgery specifically refers to operations performed on nerves within the peripheral nervous system, in other words those nerves located outside of the brain and spinal cord (aka the central nervous system). It also helps to think of these nerves as being located in the periphery of the body such as the arms and legs although it also includes nerves located in trunk and scalp/face regions. Pathology causing problems within the peripheral nervous system can take many forms. There can be pressure on a nerve as it passes through its normal route from the brain and spinal cord to its final location, for example at the toes or back of the scalp. There may be pressure on a nerve from a tumor within the nerve itself or from a tumor external to the nerve. A nerve may have been cut from a prior accident or prior surgical procedure. There can also be injuries to nerves that have been excessively stretched such as may occur following a whiplash-type of injury.

The procedures performed on these peripheral nerves ultimately depend upon the pathology in question. If there is external pressure on the nerves causing irritation, this external pressure is relieved. An example of this type of procedure is that performed during a nerve decompression to treat chronic headaches. If there is a tumor within the nerve, it can often be removed and the nerve preserved or in other cases reconstructed to preserve sensation and function.   If a nerve has been cut, it may be able to be repaired surgically.

Plastic surgeons with peripheral nerve experience have been performing peripheral nerve surgery for years to correct a common and well-known malady known as carpal tunnel syndrome, where the surrounding tissue pinches the one of the main nerves at the wrist. These surgeons decompress or un-pinch the nerve by adjusting the tissue surrounding it, leaving the nerve intact. This procedure has a very high success rate. Recent research has demonstrated that just like at the wrist, there are nerves within the head and neck that are compressed and that decompressing them, can produce significant or even complete relief from chronic headaches that can be permanent. The results with these latter procedures have been quite dramatic. In one study out of Georgetown University, data from 190 patients with chronic pain/headaches in the back of the head who underwent surgical decompression were analyzed. One year after surgery, the patients were evaluated and over 80% of patients reported at least 50% pain relief and over 43% of patients experienced complete relief of their headaches! In February 2011, the five-year results of such procedures were published in the medical journal, Plastic and Reconstructive Surgery. This study demonstrated that five years following their headache operation, 88% of patients were still reporting greater than 50% improvement in their headache symptoms and 29% were completely headache-free!

To find out more about these exciting developments, please visit http://peledmigrainesurgery.com or call us at (415)751-0583 to schedule a formal consultation.

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How long does recovery take following nerve decompression surgery for chronic headaches?

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How long does recovery take following nerve decompression surgery for chronic headaches? The answer to that question can be quite variable and depends on a number of parameters, but a few general principles apply.

How long does recovery take following nerve decompression surgery for chronic headaches? The answer to that question can be quite variable and depends on a number of parameters, but a few general principles apply. First and foremost, each patient is different in terms of their tolerance for discomfort. What may be a 9 out of 10 pain to one person may only be a 5 out of 10 pain to another person. Secondly, the number/distribution of the nerves which are decompressed is also unique to each individual. Obviously, if someone has 8 nerves decompressed in one procedure they are likely to have more discomfort than someone who only had one nerve decompressed. Finally, surgical technique and appropriate post-operative care are also important in achieving optimal results with minimal discomfort and downtime.

Generally speaking, most patients have mild-to-moderate discomfort following surgery. Pain medication and anti-nausea medication are prescribed to help patients manage these symptoms in the first few days-weeks following their procedure. The comment I hear most often from patients describing the first few weeks following their operation is that the chronic headache-type pain that they’ve always had is now gone, but that they now have discomfort at the site of the operation, which is expected. After a few weeks, this incisional discomfort diminishes and patients really start to feel great. I just saw a patient today who was 3 weeks post-decompression of both greater occipital nerves and the left lesser occipital nerve. She used to have severe headaches often lasting hours and even several days at a time and which would come on every other or every day. Over the intervening 3 weeks, she only reported 3 minor headaches which lasted a few minutes. Her surgical pain had diminished to a point where she had not required any narcotic medication after the 5 day following her procedure. Now that her incisional discomfort was at a minimum, she stated that she felt like a new person. The only restriction following her operation was avoiding strenuous exercise for 3-4 weeks. After that, her activity level can gradually be increased to its baseline level over a period of another 2-3 weeks. Patients may eat and drink whatever they like immediately following surgery and can shower in 48 hours. This type of response is fairly typical among my patient population. There are almost never any sutures to remove as they are all dissolvable. After a few weeks, a new you!

To find out more about peripheral nerve surgery and how it may help your migraines, please visit http://peledmigrainesurgery.comor call us at (415)751-0583 to schedule a formal consultation.

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"Cell Phone Neck" and Occipital Neuralgia

I was recently asked an interesting question: “If you have bad posture and have a decompression procedure, won’t the results eventually diminish as the bad posture would re-injure the nerves?” There was actually a recent, non-scientific article in a different publication (http://gizmodo.com/my-smartphone-gave-me-a-painful-neurological-condition-1711422212) which suggested that posture secondary to cell phone use was a factor in the development of ON in some people.  As you might suspect, I don’t know of anyone who would argue with the concept that good posture is important for any number of reasons.  However, can it cause ON to recur after an adequate decompression procedure?  Not likely.

As the article above suggests, even a little flexion or extension in the neck can lead to significant increases in pressure on the nuchal structures.  The reason is that many of these structures, such as the nerves, pass through very small spaces on their way to the scalp.  When those spaces which are tight to begin with are narrowed even just a little bit, the increase in pressure on the nerve can be dramatic.  However, it is not the bending or as to the point here, the bad posture that causes the neuralgia, it is the tight space becoming tighter.  When these narrow spaces are opened up, the reverse is also true - the pressure on the nerves can dramatically decrease.  The two pictures of the greater occipital nerve below illustrate the concept (warning- not for the easily grossed out).


                           BEFORE                                                                     AFTER

Before-After

In the picture on the left, you can see the greater occipital nerve (long arrow) bulging out of the semispinalis muscle (short arrow) - a well-described compression point for this nerve. After removal of a small amount of said muscle (the upper and lower edges of which are denoted by the limbs of the “V”) you can see the GON more clearly.  What is also dramatic is that the nerve appears much smaller even though the picture on the right is at slightly higher magnification.  This all happens within a few minutes in the OR.  Anyone who has ever tied a rubber band tightly around the base of their finger for a minute and had a nice purple digit knows exactly what happens when the rubber band is released. The key here is balance.  As a surgeon I want to make enough space so that the nerve can now move freely with almost any position or posture, but not so much space that I remove too much muscle and cause some imbalance or weakness.  Moreover, when patients move their heads post-operatively, which I insist my patients do gently right away, the gliding prevents significant scar formation and re-narrowing of these spaces. Hence, if done correctly, persistent poor posture following decompression should not cause the ON to return. Hope that helps.

For more information, or to make an appointment, call Peled Migraine Surgery at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about migraine relief through surgery. 

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WHAT TO LOOK FOR WHEN CHOOSING A “HEADACHE SURGEON”

WHAT TO LOOK FOR WHEN CHOOSING A “HEADACHE SURGEON”

1. One of the first things to assess is whether your surgeon has significant and specific training in peripheral nerve surgery. Since the operationS for chronic headaches/neuralgia potentially involve many nerves within the peripheral nervous system, the person performing such operations should have had focused training on the workup, evaluation and management of patients with any number of peripheral nerve problems (chronic headaches included). Because peripheral nerve surgery is performed on all parts of the body (e.g. arms, legs, trunk and head), your surgeon should ideally have experience and training with many of these types of nerve procedures because they provide the procedural foundation now employed in the operations designed for chronic headaches. A sample question that a patient might ask is what percentage of the surgeon’s practice is focused on peripheral nerve surgery. Dr. Peled has operated upon numerous patients involving many nerves in the forehead, temple and occipital regions with great success. Approximately 60% of his practice is devoted solely to peripheral nerve surgery.

2. Another important thing to ask your surgeon is how many of these procedures they have performed. In addition to the specific number of cases s/he has performed, the surgeon should also have experience with the wide breadth of peripheral nerves that are known to be potential causes of chronic, severe headaches. These include nerves within the forehead, temple and occipital regions.

3. Is your surgeon and member of the American Society for Peripheral Nerve (ASPN)? This society is the leading academic society for peripheral nerve surgeons. Its mission is to stimulate and encourage study and research in the field of neural regeneration, to provide a forum for the presentation of the latest research and relevant clinical information and to serve as a unifying authority on all areas of neural regeneration and restorative neuroscience. In order to become a member there are a number of qualifications that a surgeon must meet.  For example, a candidate has to be nominated by two of their peripheral nerve surgical peers and have published at least one scholarly, peer-reviewed paper on some aspect of peripheral nerve surgery. Looking for ASPN membership can serve as an objective vetting factor in deciding between several surgeons.  It also demonstrates a true commitment to the study of peripheral nerve problems and a genuine interest in advancing the field. Look for the ASPN logo on your surgeon’s website or communication forms. Dr. Peled has been a member of this Society for several years and has published several papers about various aspects of peripheral nerve surgery.  He is also currently involved in additional studies to advance the field which will hopefully be published in the near future.

4. Your surgeon should also be able to provide you with references for the type of procedure(s) he or she is recommending.  Not only does this give you the chance to speak with someone who has gone through what you will likely experience, it demonstrates that the surgeon has actually performed the procedure at least once before.

5. Finally, you should choose a surgeon with whom you have the best rapport.  This is the hardest concept to describe or discern.  While there are so few of us who perform these operations, realize that there still may be several qualified surgeons technically capable of performing the right operation for the correct indications.  However, just like every patient is different, so too is every surgeon.  Is their office staff professional and pleasant?  Does the doctor answer your questions in a manner that you can understand and make you feel at ease that they understand your particular situation?  Do they spend time actually listening to you and your symptoms?  Are they realistic in setting your expectations for what will happen before, during and after your procedure?  These factors can make the difference between simply a good outcome and a good outcome with a good experience along the way.

For more straight talk about how surgery can help you, contact Peled Migraine Surgery at 415-751-0583 and visit www.peledmigrainesurgery.com today.

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Japan and Australia Can Get Migraine Relief Surgery!

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We are asked quite a bit whether we will see patients from Japan or Australia for migraine surgery, or if we’ll see out-of-town patients as well. Of course we do!  Anyone may be able to achieve significant and lasting relief no matter where they call home! We have helped patients from all across the United States, and as far away as India and Brazil. We are excited to help people from all over the globe as peripheral nerve surgery is an area to which I have dedicated a large portion of my practice and is something about which I remain very passionate. We wish to extend an invitation to everyone anywhere to look us up and decide for themselves whether we might be able to help to reduce or eliminate their chronic headaches with peripheral nerve surgery.

 

I have performed hundreds of decompression procedures on nerves for chronic headaches with high success rates. Many of these people had been living with their headaches for decades and had resigned themselves to a life of chronic pain despite medication. Happily, we proved that was not the case. Furthermore, because we see so many foreign and out of town patients, we have developed a system to help make your overall experience as seamless as possible. We can assist with travel planning, lodging, transportation to and from the operating room and even post-operative nursing care if required. In addition, Dr. Peled is available for initial record review and evaluations via Skype or Google+ to help determine if a trip from home is a worthwhile endeavor. Finally, because post-operative follow-up is an extremely important part of the surgical experience and critical to achieving optimal outcomes, we use these same modalities to keep tabs on our patients after they have gone home and remain available to discuss issues with your local treating physicians if needed. This important time can be hard for patients as well as doctors that can't see their patients directly, but our practice has refined this process to ask the right questions and determine if any further action is needed.

 

So if you suffer from chronic headaches, please visit us at www.peledmigrainesurgery.com or call us at 415-751-0583 or 925-933-5700 to find out if we can reduce or eliminate your migraines. We look forward to hearing from you!

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Phantom Pain - How Come It Hurts If It’s Numb?

Nerve Pain

It seems that almost daily, I get a question from some patient somewhere wondering why their (insert body part here) hurts when they’ve had a nerve injury despite the fact that the area feels numb to the touch. This phenomenon can be seen in patients suffering from diabetic neuropathy (most commonly noted in the lower extremities), amputees with phantom limb pain and anyone with a sensory nerve injury anywhere else (e.g. the head/neck region). I will qualify my remarks below by saying that this topic is a huge one and cannot be covered in its entirety in a brief post or even a book chapter. There are whole journals published monthly devoted to the study of such clinical dilemmas. The goal here however is to provide a general understanding of why one might have these types of sensations and as a launch point for discussion with your treating physician about what can be done. I will also use phantom limb pain as the template for understanding this problem as it is one of the most common manifestations of this problem and the one most conceptually accessible to a non-physician.

First of all, what is phantom limb pain? Simply put, it is the sensation of pain from a body part that no longer exists. For example, a right below-knee amputee feels as if the right foot is being squeezed and is painful, even though that very foot was removed a long time ago. But how is this possible? Phantom limb pain has traditionally been hypothesized to occur as a consequence of abnormal mutability of signals within the brain (specifically the cerebral cortex) as a result of lost input from a limb. Translating from medicalese, since the sensory input from a limb no longer exists, the neurons within the brain that used to map to that part of the body re-organize themselves in an abnormal way thus leading to the perception of pain. Another potential mechanism is that the nerve ends from those nerves that used to go to the foot and now reside in the amputation stump are irritated in some way, but still go to that part of the brain which mediated right foot sensation. Therefore, again, when those peripheral nerves fire, the patient perceives that they have right-sided foot pain even though there is no right foot because those signals ultimately still end up in the right-foot-part of the brain (which of course still exists). This situation might occur if you strike the nerves within the stump (e.g. while wearing an ill-fitting prosthesis) of if they are neuromatous. It might also occur if a nerve end that has been implanted into a muscle in the neck is “tweaked” by that muscle. There are other theories as well which state that nerves within the spinal cord that receive sensory input from an absent limb fire abnormally, thus ultimately sending messages to the brain that one is experiencing pain. So which theory is correct?

Well, as with many things in life this problem is not a zero-sum game. In other words it’s not that one theory is absolutely right and the others are all wrong. The overall pain sensations are likely due to a combination of factors. In fact, I was just reviewing an article in a prominent pain journal in which they demonstrate that blocking a peripheral nerve in an amputation stump leads to some persistence of phantom limb pain, whereas blocking nerves in the spinal cord leading to that limb resulted in temporary, but complete cessation of said pain. This result would suggest that it is these spinal nerves that mediate this pain. However, the authors then go on to admit that electric charges emanating from peripheral nerves within a stump are likely responsible for the sensation of phantom pain when a person bears weight, such as while wearing their prosthesis. My take home message from this paper is therefore that there are several components to this phantom pain. One component may occur at rest or at night when no pressure is placed on the stump. This component of the phantom pain is important and may be treated by addressing those spinal nerves. However, if you are an amputee, you’ll likely want to walk using a prosthesis at some point. If so, those peripheral nerves at the stump also need to be addressed so that this component of phantom pain gets better allowing the patient to ambulate. Indeed, this latter mechanism is the partial rationale behind targeted muscle re-innervation in the extremities. Therefore, in any individual patient, the optimal pain relief will probably only be achieved by several specialties working together to attack the problem from a number of angles.

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New Paper Published - Anatomic and Compression Topography of the Lesser Occipital Nerve.

My newest paper, Anatomic and Compression Topography of the Lesser Occipital Nerve co-authored with Giorgio Pietramaggiori MD and Saja Scherer MD has been published by PRS Global Open, the International Open Access Journal of the American Society of Plastic Surgeons!  The paper, discussing how the knowledge of LON (Lesser Occipital Nerve) anatomy can aid in nerve dissection and preservation, thereby leading to successful outcomes without requiring neurectomy.  The article can be found here and is printed in entirety below.

 


 

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FREEZING THE NERVE

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There have been a number of interesting posts this week about a new device that has recently been introduced to the US market and I thought it might be an interesting subject for a brief synopsis.  I have used this device on a number of patients for a number of indications over the past six or seven months and the results are quite promising.  The name of the device is Iovera and while the concept is not new, the delivery mechanism is quite unique and efficient.  Iovera is different from past, similar treatments because although cold has been used for many years to treat several clinical conditions, the ability to precisely regulate the temperature and area treated have been problems which this device manages quite well.

Basically, the device delivers a stream of liquid nitrous oxide (which is very cold, about -56ºC) through a closed mechanism to the tips of the probe used.  In other words, nothing is actually injected into the patient - the liquid nitrous oxide simply flows through the device and the tip(s) becomes very cold thus causing the natural bodily fluids around it to freeze and essentially creating a tic-tac-sized ice ball near the target nerve.  What actually happens to the nerve is akin to what is known as a Sunderland II axonotmesis.  Say that three times fast.  In layman’s terms, there is some degeneration of the (axons of the) neurons downstream from the treatment site, but the overall structure (i.e. scaffold) of the nerve remains the same.  This type of “insult” allows the neurons to eventually re-grow in their typical configuration, back down through the treatment site over a period of a few weeks or months, thus ultimately restoring nerve function.  One thing to point out here is that the nerve is theoretically not “destroyed” as some have suggested.  Therefore, the term cryoablation is not really appropriate in my opinion because to ablate something as I have mentioned elsewhere (https://www.facebook.com/Peled-Migraine-Surgery-326501717396487/?fref=nf) means to excise or destroy.  I prefer to use the term cryo-neuromodulation because it is more precise what you are actually doing which is modulating the actions of the nerve on a temporary basis. These phenomena and concepts pose some really interesting questions about the role of such a device in any number of clinical scenarios, but since we’re particularly focused on chronic headaches such as ON…..here goes.

The fact that the nerve is not completely “destroyed” may be bad or good depending on your perspective.  In the case of painful conditions like ON or TN, one might argue that since the nerve will work again, this is a temporary fix.  In fact, at this point, Iovera is being used as a management tool.  Even if the results last 2-3 months at a time, you will still need to come in several times per year for treatment.  However, I personally believe that combined with other treatment modalities, there is real promise for this device.  As a lot of you know, many patients have a hard time for several months following surgical decompression or transection because the nerves are inflamed secondary to surgical manipulation and the baseline injury/pathology.  Now just imagine if one were able to modulate those nerves by essentially shutting them down for three months by precisely targeting them intra-operatively. It’s tempting to think of how potentially comfortable (albeit numb) a patient might feel in those first 90 days while at the same time taking comfort in knowing that the numbness should eventually fade away.  Even though decompressing a nerve improves the nerve physiologically following recovery, it is also tempting to think about the possibility that the cold stimulus may actually improve or simply speed up the regeneration and recovery process as another inducement to do so.  Moreover, there is the really tempting idea of also using the Iovera device on the nerve(s) to the surgical incision itself or the surgically dissected areas to minimize the typical post-operative pain.  In fact, a very early study in total knee replacement patients suggested that post-operative opioid requirements were decreased in patients treated this way.  Finally, if a nerve or patient are not candidates for surgical intervention, this device could represent a big arrow in the quiver of non-surgical treatment options.  My short post just scratches the surface of the many questions and possibilities raised by this device.  While the available data and the overall experience with cryo-neuromodulation using Iovera is limited at this point, I do believe it device has a substantive role in treating ON, perhaps TN and potentially many other disorders….time will tell. 

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POSTURE AND OCCIPITAL NEURALGIA

I was recently asked an interesting question: “If you have bad posture and have a decompression procedure, won’t the results eventually diminish as the bad posture would re-injure the nerves?” There was actually a recent, non-scientific article in a different publication (http://gizmodo.com/my-smartphone-gave-me-a-painful-neurological-condition-1711422212) which suggested that posture secondary to cell phone use was a factor in the development of ON in some people.  As you might suspect, I don’t know of anyone who would argue with the concept that good posture is important for any number of reasons.  However, can it cause ON to recur after an adequate decompression procedure?  Not likely.

As the article above suggests, even a little flexion or extension in the neck can lead to significant increases in pressure on the nuchal structures.  The reason is that many of these structures, such as the nerves, pass through very small spaces on their way to the scalp.  When those spaces which are tight to begin with are narrowed even just a little bit, the increase in pressure on the nerve can be dramatic.  However, it is not the bending or as to the point here, the bad posture that causes the neuralgia, it is the tight space becoming tighter.  When these narrow spaces are opened up, the reverse is also true - the pressure on the nerves can dramatically decrease.  The two pictures of the greater occipital nerve below illustrate the concept (warning- not for the easily grossed out).


                           BEFORE                                                                     AFTER

Before-After

In the picture on the left, you can see the greater occipital nerve (long arrow) bulging out of the semispinalis muscle (short arrow) - a well-described compression point for this nerve. After removal of a small amount of said muscle (the upper and lower edges of which are denoted by the limbs of the “V”) you can see the GON more clearly.  What is also dramatic is that the nerve appears much smaller even though the picture on the right is at slightly higher magnification.  This all happens within a few minutes in the OR.  Anyone who has ever tied a rubber band tightly around the base of their finger for a minute and had a nice purple digit knows exactly what happens when the rubber band is released. The key here is balance.  As a surgeon I want to make enough space so that the nerve can now move freely with almost any position or posture, but not so much space that I remove too much muscle and cause some imbalance or weakness.  Moreover, when patients move their heads post-operatively, which I insist my patients do gently right away, the gliding prevents significant scar formation and re-narrowing of these spaces. Hence, if done correctly, persistent poor posture following decompression should not cause the ON to return. Hope that helps.

For more information, or to make an appointment, call Peled Migraine Surgery at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about migraine relief through surgery.  

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Testimonials

  • Thank you very much! Carson is happier than he has been in over a year! We are so thankful that you do what you do.

    D and P

  • Cary Anne and Dr. Peled, I want to thank you both for all your help in making my life so much better! In SO many ways. Again thank you for making my life something I treasure and look forward to daily.

    Victoria

  • Dr. Peled is the real deal. His technical skills should be seen as elite. My headaches and neck pain are gone as a result of the surgery.

    PJHCali Mar 1st, 2013

  • I visited Dr. Peled and he fixed my terrible migraine problem! This surgery was excellent, and he is so knowledgable, he put me completely at ease!

    TF

  • Dr. Peled gave me my life back! Before my nerve surgery I was having headache/migraines amost every day for almost 15 years. After my surgery I am now only having headaches twice a month.

    R.J.

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