Peled Migraine Surgery Blog

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.

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.

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.

I recently read a comment from a patient asking a very interesting question - “What is the difference between occipital neuralgia (ON) and cervicogenic headaches (CH)?”

Unfortunately the answer to this question is not a straightforward one. It has been postulated that pain in the head/neck region can be referred from problems in the bony or soft tissues of the neck, but there is still some controversy as to whether cervicogenic headache constitutes a distinct clinical entity. The upper-most cervical nerves and their branches are the most commonly cited sources of CH with the most common source being the C2/C3 levels. The actual definition of cervicogenic headaches is also not firmly established. One accepted way of defining this disorder is by its clinical characteristics. Specifically, it is a unilateral pain of variable severity that is not stabbing and radiates from posterior to anterior. It doesn’t shift from side to side, is brought on by unusual head position or neck motion and may be associated with shoulder or upper extremity pain on the same side. The biggest issue with this definition is that it overlaps with many of the characteristics of other headache disorders such as tension headaches and migraines without aura. Another way of defining CH is by demonstrating a cervical source of pain and confirming that source with a nerve block.

Diagnostic criteria for CH have been established by the Cervicogenic Headache International Study Group (CHISG) and by the International Headache Society (IHS). The former’s criteria require signs or symptoms brought on by awkward head movements or positioning or by pressure over the occipital nuchal structures and possibly confirmed by anesthetic blockade. The IHS criteria mandate that the pain be referred from an identifiable and plausible source in the head/neck (as demonstrated on imaging such as MRI) or by successful blockade of a nerve or cervical structure. Moreover, the pain must resolve within 90 days of successful treatment of the underlying problem. However, the IHS criteria do not define when, where, and how much pain is caused by CH (i.e. the clinical features).

In contrast, most neurologists would define ON in a very specific way. The classic description is that of paroxysmal pain in the distribution of the occipital nerves, sometimes, but not always accompanied by changes in skin sensation in the back of the scalp. The symptoms of ON are also thought to have a character of burning or hypersensitivity that may be constant on top of the intermittent shooting pains described above. These symptoms should be temporarily relieved by occipital nerve blocks.

So what to do with all of this information? Unfortunately, I find these definitions and descriptions minimally helpful since many of the symptoms of ON and other headache disorders for that matter can overlap with those of CH. For example, many of my patients with ON who have been successfully treated with decompression had exacerbation of their pain with awkward head positions and motions because these positions further compressed and irritated the occipital nerves. There are many patients who have unilateral ON. Therefore is ON a subset of CH? From my reading of the literature, most neurologists would seem to disagree, but I am uncertain as to why. Is CH a distinct clinical disorder? As stated above, there is disagreement as to whether it is versus just a descriptor of where the pain is coming from.

All of which brings me to the take home message. When it comes to any disorder, but especially chronic headaches, the only relevant questions in my humble opinion are: 1) can you figure out what’s causing it and 2) if you can, can you do anything about it? You can call the headache whatever you like - migraines without aura, CH, George - the names are irrelevant. With that in mind, I believe that the literature has shown that accurate diagnosis of ON with nerve blocks or Botox is a good predictor of a good result with surgical decompression. Moreover, surgical decompression has been shown to be very effective and have a very low complication rate with good long term results.

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

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. 

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.

The title of this post is really the $60,000 question. I have posted many times in the past about how Occipital Neuralgia can be caused by compression from spastic neck muscles, compression by tight connective tissue (i.e. fascia) and/or compression from surrounding blood vessels. Many of the patients I see have had headaches ever since they can remember. However, there are just as many for whom the headaches began seemingly spontaneously one day. The question for these folks remains: What happened? Why now?

There have been recent articles that hint at possible answers to these questions and they may surprise you. One of the most surprising comments was that craning the neck downward only 60º puts as much as 60 pounds of pressure on the cervical spine and neck muscles. With that kind of pressure, you can imagine that nerves (among other structures) would be compressed. So the explanation as to why you might all of a sudden develop ON can almost be summed up in one word - overuse. This explanation is one of the potential causes of carpal tunnel syndrome, the most common compression neuropathy recognized (even by neurologists). Why could that not be the case for ON. Nerves are very susceptible to chronic compression (see post - ‘What Causes Occipital Nerves to Malfunction’) even if intermittent. The occipital nerves take very circuitous routes through all of the nuchal soft tissues. When you add to that fact the constant motion of our necks that require the nerves to glide constantly and then compound those factors with an additional 60 pounds of added pressure, there are many things that may occur to those nerves.

One, they may simply get kinked as they make their way through the neck to the scalp. Not a week goes by when I don’t see a patient in the office who, in describing their headaches contorts their head to recapitulate their symptoms and when they get it just right, it’s like a thunderbolt of pain. Two, even if not kinked, the pressure will compress the vasa nervorum - the microscopic blood vessels within the nerves themselves that supply blood to those nerves. After numerous episodes of compression, especially if for prolonged periods, these blood vessels can clot and the nerves become ischemic (i.e. choked). The neurons that comprise that nerve then die off and try to regenerate causing the hyperesthetic symptoms so typical of ON. Three, even if the nerves recover from each successive insult, the additive microtrauma will likely result in some inflammation and the subsequent formation of scar tissue in the surrounding structures, thus closing off already tight corridors through which these nerves must pass - another compressive force. While no one has demonstrated these possibilities in real time, I see the sequelae of them in the OR weekly.

So what to do we do? Good posture, stretching and avoidance of triggering activities seem to make common sense. In addition, as many of you know and as intimated in the article, steroids seem to be the mainstay of treatment amongst some practitioners, but as also stated, the effects are often not permanent. The reason is obvious - the compressive forces remain, even if inflammation is temporarily suppressed. Therefore, I continue to believe that decompression (or neurectomy & implantation for permanently injured nerves) are reasonable options as they are safe and effective. Moreover, they address the underlying problem, the mechanical compression of these poor nerves caused by our ever more technologically demanding lifestyles. So next time you pick up your smartphone, remember to pick up your head as well.

For more information, read http://peledmigrainesurgery.com/blog/entry/whiplash-and-occipital-neuralgia-what-s-the-connection-1.html and visit www.peledmigrainesurgery.com for information on how to reduce your migraines and nerve pain.

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!

 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 recently 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.

I was recently asked why some people require more than one operation to obtain optimal relief.  As usual, the answer has many components to it so I will try to delineate some of these issues below.  Let me preface these remarks by stating that what I write below is my opinion only and how I approach patients, but should not be considered dogma.  While a number of colleagues also use this approach, it is not necessarily shared by every peripheral nerve surgeon, some of whom will be more aggressive and some less aggressive. 

In situations where there are many nerves that will require surgical intervention to achieve an optimal result, there are number of reasons why I prefer to stage the operations.  The first is that in many cases, patients often say that one area usually flares up first and when very severe or unable to be controlled, causes the headache and discomfort to spread to other areas.  For example, s/he will state that their neck gets tight, they get occipital headache pain and if the medication is unable to help, the headache spreads to the temples and forehead.  In these particular cases, there may be a reasonable assumption that the occipital area is triggering the frontal and temporal headaches.  Therefore, theoretically if the occipital nerves are appropriately addressed, with time and healing, those triggering nerves should calm down such that the frontal and temporal areas are only triggered infrequently and hopefully to a much lesser degree.  In other words, if you can remove the fuse, the dynamite stick will never explode and therefore an operation to address the frontal and temporal nerves may never be required.  Even if this patient continues to have some degree of headaches, these headaches may be so infrequent and/or relatively mild such that they feel the remaining symptoms are easily manageable and don’t want another operation.  As I’ve said in prior posts, no one should tell you whether or not you should live with whatever pain you have.  Doing so is making a value judgment - only the patient can and should make that determination.  Secondly, let’s assume that a person has the appropriate operation over the occipital nerves and has a successful outcome with respect to their posterior headaches, but the temporal and frontal headaches persist even after several months of recovery.  In those cases, while another operation may be required to address the temporal and frontal nerves, there is now good reason to believe that the second procedure is likely to be successful.  The converse is also true, however, in that if the occipital procedure is performed correctly and for the right indications, but yields no result, I would wonder whether or not a temporal/frontal procedure would be indicated since I would be less confident surgical intervention in those areas would be successful if the same approach was unsuccessful over the occipital area, thereby precluding the potential for complications in areas where surgical intervention may not be successful.  Therefore, staging an operation has the potential to give you information about whether or not a second procedure will be helpful.

A third reason for staging these operations relates to the safety of an operation.  While I obviously agree that neuralgia (occipital or trigeminal branch) is a significant medical problem, these operations are elective.  Therefore, the most important thing we can do for the patient is given them a safe operation and try to minimize complications while maximizing the potential for a successful outcome.  From a technical standpoint, the longer a surgical procedure takes, the greater the chance for complications or issues arising from anesthesia.  While long operations can certainly be done safely, when it comes to elective surgery, the more efficient a procedure can be the better.  Therefore, if I had a choice between one 8-hour operation or two 4-hour operations, I would choose the latter because there is likely a lower risk for deep vein thrombosis (blood clots in the legs that can embolize), the need for an in-patient stay, post-operative nausea and other anesthesia-related issues. 

A fourth reason for staging operations has to do with recovery.  In my opinion (and as many of my patients will attest), one of the hardest parts of the surgical experience is the post-operative recovery which often has many ups and downs apart from the immediate, peri-operative surgical discomfort.  With respect to the latter, if you have incisions on the front, the sides and the back of your head bilaterally, I can only imagine how uncomfortable the whole head must feel and I often wonder how these patients rest at night since sleeping on any portion of the scalp is likely to result in discomfort.  Rest post-operatively is critical and lack thereof is potentially problematic.  In addition, as decompressed or transected nerves are manipulated in the operating room, the normal, post-operative inflammation can lead to many nerve-related symptoms which, if they occur all over the scalp as opposed to just posteriorly or over the temples, is likely to be quite uncomfortable.  Greater degrees of discomfort often lead to increased opioid use which, as many people will agree, can lead to a whole host of other issues such as constipation, cognitive impairment (e.g. sedation), nausea etc.

One last comment: I don’t use any one of these contra-indications in isolation.  They are all considered together as part of the overall clinical impression when I go over a patient’s records, examine him/her and perform whatever diagnostic maneuvers are necessary.  It is for these reasons among many others that I always recommend a consultation with a peripheral nerve surgeon when deciding if surgical intervention (whether decompression/neuroplasty or neurectomy/implantation) is appropriate.  I also believe that among the many questions patient’s should ask their potential surgeons is how they approach patient and why, especially if their case will involve more than one or two incisions.  I hope that these thoughts are helpful.

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. 

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.

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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We are asked quite a bit whether we will see Beverly Hills patients 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!

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. 

I was recently asked why some people require more than one operation to obtain optimal relief.  As usual, the answer has many components to it so I will try to delineate some of these issues below.  Let me preface these remarks by stating that what I write below is my opinion only and how I approach patients, but should not be considered dogma.  While a number of colleagues also use this approach, it is not necessarily shared by every peripheral nerve surgeon, some of whom will be more aggressive and some less aggressive. 

In situations where there are many nerves that will require surgical intervention to achieve an optimal result, there are number of reasons why I prefer to stage the operations.  The first is that in many cases, patients often say that one area usually flares up first and when very severe or unable to be controlled, causes the headache and discomfort to spread to other areas.  For example, s/he will state that their neck gets tight, they get occipital headache pain and if the medication is unable to help, the headache spreads to the temples and forehead.  In these particular cases, there may be a reasonable assumption that the occipital area is triggering the frontal and temporal headaches.  Therefore, theoretically if the occipital nerves are appropriately addressed, with time and healing, those triggering nerves should calm down such that the frontal and temporal areas are only triggered infrequently and hopefully to a much lesser degree.  In other words, if you can remove the fuse, the dynamite stick will never explode and therefore an operation to address the frontal and temporal nerves may never be required.  Even if this patient continues to have some degree of headaches, these headaches may be so infrequent and/or relatively mild such that they feel the remaining symptoms are easily manageable and don’t want another operation.  As I’ve said in prior posts, no one should tell you whether or not you should live with whatever pain you have.  Doing so is making a value judgment - only the patient can and should make that determination.  Secondly, let’s assume that a person has the appropriate operation over the occipital nerves and has a successful outcome with respect to their posterior headaches, but the temporal and frontal headaches persist even after several months of recovery.  In those cases, while another operation may be required to address the temporal and frontal nerves, there is now good reason to believe that the second procedure is likely to be successful.  The converse is also true, however, in that if the occipital procedure is performed correctly and for the right indications, but yields no result, I would wonder whether or not a temporal/frontal procedure would be indicated since I would be less confident surgical intervention in those areas would be successful if the same approach was unsuccessful over the occipital area, thereby precluding the potential for complications in areas where surgical intervention may not be successful.  Therefore, staging an operation has the potential to give you information about whether or not a second procedure will be helpful.

A third reason for staging these operations relates to the safety of an operation.  While I obviously agree that neuralgia (occipital or trigeminal branch) is a significant medical problem, these operations are elective.  Therefore, the most important thing we can do for the patient is given them a safe operation and try to minimize complications while maximizing the potential for a successful outcome.  From a technical standpoint, the longer a surgical procedure takes, the greater the chance for complications or issues arising from anesthesia.  While long operations can certainly be done safely, when it comes to elective surgery, the more efficient a procedure can be the better.  Therefore, if I had a choice between one 8-hour operation or two 4-hour operations, I would choose the latter because there is likely a lower risk for deep vein thrombosis (blood clots in the legs that can embolize), the need for an in-patient stay, post-operative nausea and other anesthesia-related issues. 

A fourth reason for staging operations has to do with recovery.  In my opinion (and as many of my patients will attest), one of the hardest parts of the surgical experience is the post-operative recovery which often has many ups and downs apart from the immediate, peri-operative surgical discomfort.  With respect to the latter, if you have incisions on the front, the sides and the back of your head bilaterally, I can only imagine how uncomfortable the whole head must feel and I often wonder how these patients rest at night since sleeping on any portion of the scalp is likely to result in discomfort.  Rest post-operatively is critical and lack thereof is potentially problematic.  In addition, as decompressed or transected nerves are manipulated in the operating room, the normal, post-operative inflammation can lead to many nerve-related symptoms which, if they occur all over the scalp as opposed to just posteriorly or over the temples, is likely to be quite uncomfortable.  Greater degrees of discomfort often lead to increased opioid use which, as many people will agree, can lead to a whole host of other issues such as constipation, cognitive impairment (e.g. sedation), nausea etc.

One last comment: I don’t use any one of these contra-indications in isolation.  They are all considered together as part of the overall clinical impression when I go over a patient’s records, examine him/her and perform whatever diagnostic maneuvers are necessary.  It is for these reasons among many others that I always recommend a consultation with a peripheral nerve surgeon when deciding if surgical intervention (whether decompression/neuroplasty or neurectomy/implantation) is appropriate.  I also believe that among the many questions patient’s should ask their potential surgeons is how they approach patient and why, especially if their case will involve more than one or two incisions.  I hope that these thoughts are helpful.

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.  

I recently read a comment from a patient asking a very interesting question - “What is the difference between occipital neuralgia (ON) and cervicogenic headaches (CH)?”

Unfortunately the answer to this question is not a straightforward one. It has been postulated that pain in the head/neck region can be referred from problems in the bony or soft tissues of the neck, but there is still some controversy as to whether cervicogenic headache constitutes a distinct clinical entity. The upper-most cervical nerves and their branches are the most commonly cited sources of CH with the most common source being the C2/C3 levels. The actual definition of cervicogenic headaches is also not firmly established. One accepted way of defining this disorder is by its clinical characteristics. Specifically, it is a unilateral pain of variable severity that is not stabbing and radiates from posterior to anterior. It doesn’t shift from side to side, is brought on by unusual head position or neck motion and may be associated with shoulder or upper extremity pain on the same side. The biggest issue with this definition is that it overlaps with many of the characteristics of other headache disorders such as tension headaches and migraines without aura. Another way of defining CH is by demonstrating a cervical source of pain and confirming that source with a nerve block.

Diagnostic criteria for CH have been established by the Cervicogenic Headache International Study Group (CHISG) and by the International Headache Society (IHS). The former’s criteria require signs or symptoms brought on by awkward head movements or positioning or by pressure over the occipital nuchal structures and possibly confirmed by anesthetic blockade. The IHS criteria mandate that the pain be referred from an identifiable and plausible source in the head/neck (as demonstrated on imaging such as MRI) or by successful blockade of a nerve or cervical structure. Moreover, the pain must resolve within 90 days of successful treatment of the underlying problem. However, the IHS criteria do not define when, where, and how much pain is caused by CH (i.e. the clinical features).

In contrast, most neurologists would define ON in a very specific way. The classic description is that of paroxysmal pain in the distribution of the occipital nerves, sometimes, but not always accompanied by changes in skin sensation in the back of the scalp. The symptoms of ON are also thought to have a character of burning or hypersensitivity that may be constant on top of the intermittent shooting pains described above. These symptoms should be temporarily relieved by occipital nerve blocks.

So what to do with all of this information? Unfortunately, I find these definitions and descriptions minimally helpful since many of the symptoms of ON and other headache disorders for that matter can overlap with those of CH. For example, many of my patients with ON who have been successfully treated with decompression had exacerbation of their pain with awkward head positions and motions because these positions further compressed and irritated the occipital nerves. There are many patients who have unilateral ON. Therefore is ON a subset of CH? From my reading of the literature, most neurologists would seem to disagree, but I am uncertain as to why. Is CH a distinct clinical disorder? As stated above, there is disagreement as to whether it is versus just a descriptor of where the pain is coming from.

All of which brings me to the take home message. When it comes to any disorder, but especially chronic headaches, the only relevant questions in my humble opinion are: 1) can you figure out what’s causing it and 2) if you can, can you do anything about it? You can call the headache whatever you like - migraines without aura, CH, George - the names are irrelevant. With that in mind, I believe that the literature has shown that accurate diagnosis of ON with nerve blocks or Botox is a good predictor of a good result with surgical decompression. Moreover, surgical decompression has been shown to be very effective and have a very low complication rate with good long term results.

We are asked quite a bit whether we will see Beverly Hills patients 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!

My paper, "A Novel Surgical Approach to Chronic Temporal Headaches" has been accepted into for publication in Plastic and Reconstructive Surgery!  This is a huge honor and  will help me reach a large audience to let them know what you already know if you've been following our site - Chronic Temporal Headaches can be relieved with surgery.  If you suffer from migraines or chronic headaches, there is a way to help.

Keep an eye on this blog and our Facebook and Twitter pages to read the article in full when it's released.  If you have questions about migraines or nerve surgery, you can read all about them here at peledmigrainesurgery.com or call us to talk about it at 415-751-0583 on San Francisco or 925-933-5700 in Walnut Creek.  You don't have to live with chronic migraines any more.  Don't spend another day in pain.

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

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.  

I was recently asked why some people require more than one operation to obtain optimal relief.  As usual, the answer has many components to it so I will try to delineate some of these issues below.  Let me preface these remarks by stating that what I write below is my opinion only and how I approach patients, but should not be considered dogma.  While a number of colleagues also use this approach, it is not necessarily shared by every peripheral nerve surgeon, some of whom will be more aggressive and some less aggressive. 

In situations where there are many nerves that will require surgical intervention to achieve an optimal result, there are number of reasons why I prefer to stage the operations.  The first is that in many cases, patients often say that one area usually flares up first and when very severe or unable to be controlled, causes the headache and discomfort to spread to other areas.  For example, s/he will state that their neck gets tight, they get occipital headache pain and if the medication is unable to help, the headache spreads to the temples and forehead.  In these particular cases, there may be a reasonable assumption that the occipital area is triggering the frontal and temporal headaches.  Therefore, theoretically if the occipital nerves are appropriately addressed, with time and healing, those triggering nerves should calm down such that the frontal and temporal areas are only triggered infrequently and hopefully to a much lesser degree.  In other words, if you can remove the fuse, the dynamite stick will never explode and therefore an operation to address the frontal and temporal nerves may never be required.  Even if this patient continues to have some degree of headaches, these headaches may be so infrequent and/or relatively mild such that they feel the remaining symptoms are easily manageable and don’t want another operation.  As I’ve said in prior posts, no one should tell you whether or not you should live with whatever pain you have.  Doing so is making a value judgment - only the patient can and should make that determination.  Secondly, let’s assume that a person has the appropriate operation over the occipital nerves and has a successful outcome with respect to their posterior headaches, but the temporal and frontal headaches persist even after several months of recovery.  In those cases, while another operation may be required to address the temporal and frontal nerves, there is now good reason to believe that the second procedure is likely to be successful.  The converse is also true, however, in that if the occipital procedure is performed correctly and for the right indications, but yields no result, I would wonder whether or not a temporal/frontal procedure would be indicated since I would be less confident surgical intervention in those areas would be successful if the same approach was unsuccessful over the occipital area, thereby precluding the potential for complications in areas where surgical intervention may not be successful.  Therefore, staging an operation has the potential to give you information about whether or not a second procedure will be helpful.

A third reason for staging these operations relates to the safety of an operation.  While I obviously agree that neuralgia (occipital or trigeminal branch) is a significant medical problem, these operations are elective.  Therefore, the most important thing we can do for the patient is given them a safe operation and try to minimize complications while maximizing the potential for a successful outcome.  From a technical standpoint, the longer a surgical procedure takes, the greater the chance for complications or issues arising from anesthesia.  While long operations can certainly be done safely, when it comes to elective surgery, the more efficient a procedure can be the better.  Therefore, if I had a choice between one 8-hour operation or two 4-hour operations, I would choose the latter because there is likely a lower risk for deep vein thrombosis (blood clots in the legs that can embolize), the need for an in-patient stay, post-operative nausea and other anesthesia-related issues. 

A fourth reason for staging operations has to do with recovery.  In my opinion (and as many of my patients will attest), one of the hardest parts of the surgical experience is the post-operative recovery which often has many ups and downs apart from the immediate, peri-operative surgical discomfort.  With respect to the latter, if you have incisions on the front, the sides and the back of your head bilaterally, I can only imagine how uncomfortable the whole head must feel and I often wonder how these patients rest at night since sleeping on any portion of the scalp is likely to result in discomfort.  Rest post-operatively is critical and lack thereof is potentially problematic.  In addition, as decompressed or transected nerves are manipulated in the operating room, the normal, post-operative inflammation can lead to many nerve-related symptoms which, if they occur all over the scalp as opposed to just posteriorly or over the temples, is likely to be quite uncomfortable.  Greater degrees of discomfort often lead to increased opioid use which, as many people will agree, can lead to a whole host of other issues such as constipation, cognitive impairment (e.g. sedation), nausea etc.

One last comment: I don’t use any one of these contra-indications in isolation.  They are all considered together as part of the overall clinical impression when I go over a patient’s records, examine him/her and perform whatever diagnostic maneuvers are necessary.  It is for these reasons among many others that I always recommend a consultation with a peripheral nerve surgeon when deciding if surgical intervention (whether decompression/neuroplasty or neurectomy/implantation) is appropriate.  I also believe that among the many questions patient’s should ask their potential surgeons is how they approach patient and why, especially if their case will involve more than one or two incisions.  I hope that these thoughts are helpful.

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.