Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

What Kinds of Results Can I Expect From Migraine Surgery

Patients often ask what they can expect, reasonably, from peripheral nerve surgery to relieve their migraine pain. While it differs with each patient and procedure, we are very confident in the procedure and the potential for the relief from headache pain and migraines.

The results with these types of procedures have been quite dramatic. In one study out of Georgetown University, data from 190 patients with pain/headaches in the back of the head who underwent surgical decompression were analyzed. Over 80% of patients experienced 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. These results demonstrated five years following their operation, 88% of patients still reported greater than 50% improvement in their headache symptoms and 29% were completely headache-free!

For more information, please dee our site at www.peledmigrainesurgery.com and call 415-751-0583 to schedule an appointment to see us, so that we can figure out the best course of treatment to help treat your migraines and chronic headaches.

Continue reading
  1294 Hits
0 Comments
1294 Hits

Is Migraine Relief Available Outside of San Francisco?

headache - mediumDo you have to live in the San Francisco Bay Area to get relief from your severe, chronic headaches? No, 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!

Continue reading
  1449 Hits
0 Comments
1449 Hits

Does One Nerve Operation Fit For All Cases?

headache, migraine surgeryThis post will not be a strictly medical one, but I believe is important in terms of general understanding and information, nonetheless. There have been numerous posts by various people asking some version of, “How much does NDS cost?” It is certainly a reasonable question and one that is totally appropriate to ask. However, the presumption in the question is that NDS is one operation which it most certainly is not. It is also quite a loaded question for a number of reasons, the least of which is what is meant by the term ‘cost’. Let expound on this concept a bit further.

There are at least 14 nerves that I can think of (7 on each side of the head) that can be addressed surgically to treat occipital neuralgia and/or (as I like to call it) trigeminal branch neuralgia (TBN). Concomitantly, there are many factors that go into deciding how and what to do with these nerves:
1. How many nerves are affected? 1 or 14; obviously the more nerves you have to treat, the longer the procedure is likely to take. If this is a revision procedure, it is likely to take longer as there is scarring in the operative field that must be accounted for in terms of deciding how long a procedure will take and how long to book for the case.
2. What will you do with those nerves - decompress them or transect them? If the latter, then you also have to figure into the mix burying them in the muscle.
3. What is the patient willing to tolerate in terms of post-operative sensation? In other words, does the patient mind the numbness associated with nerve transection or do they wish to preserve sensation to as great a degree as possible? Alternatively, will they leave that to the judgment of the surgeon at the time of surgery?
4. How many nerve blocks does it take to most accurately diagnose which nerves can/will need to be addressed?
5. What other co-morbidities does the patient have? The surgical procedure will take less time if you’re operating on one nerve in a thin woman with a long, swan neck, than it will on a 350 pound former NFL lineman (yes, a real patient of mine) with numerous nerves that need to be addressed. Also, the more medical problems one has, the more likely your procedure will need to take place in a hospital setting as compared with a surgery center.
6. What about facility fees? The facility will often charge or bill the insurance more for a longer operation than a shorter one as the former likely also involves more CPT codes (see above) than the latter.
7. What about anesthesia fees? Anesthesia groups typically bill by the hour.
8. The last two points are relevant if your insurance company considers these procedures “experimental” and hence are unlikely to authorize or pay for them.
9. What about opportunity costs (i.e. time off of work)? Clearly, the answer to this question will depend on how many nerves are being addressed, (which, in turn affects) how long the procedure takes, your pain tolerance, the nature of your profession, what support you have at home (e.g. family and friends who can help out, whether or not you have children) and your state’s/employer’s policies.
Please keep in mind that the list above is by no means exhaustive. However, the point is that NDS is not like an appendectomy (removal of the appendix). That type of case is virtually the same in everyone. There is always one appendix, it is always in the same place, and it always has to be removed if it is inflamed or ruptured. You can’t decompress it. The first thing to do is to be evaluated by a surgeon with experience in surgically treating ON or TBN and have a frank discussion about these issues. If you feel comfortable with the answers you receive, then perhaps you are in the right place.

If this article or anything in it sounds familiar, please contact us at Peled Migraine Surgery, at 415-751-0583 and visit our site at www.peledmigrainesurgery.com for more information on how peripheral nerve surgery may relieve your pain.

Continue reading
  2143 Hits
0 Comments
2143 Hits
  0 Comments

PHANTOM PAIN - HOW COME IT HURTS IF IT’S NUMB?

Migraine SurgeryThis post has been a long time coming. 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.

For more information on nerve pain and relief, visit www.peledmigrainesurgery.com today!

Continue reading
  1671 Hits
0 Comments
1671 Hits

What Happens After The Nerve Burial?

Axon -mediumThis is really the million dollar question for human kind, but in the case of nerves, I believe we have some ideas. I was recently asked why nerves are buried into muscle and what happens to them once they are in that location. Conventional wisdom states that by burying a transected nerve end into muscle, a neuroma will not form. This concept is based in large part on a paper written in 1985 which demonstrated in a non-human primate model that when a nerve is buried into muscle, the structure of the regenerating nerve fibers is different than a severed nerve left in the subcutaneous tissues. It is thought that this structural difference accounts for the relative paucity of symptoms post-operatively when a nerve is buried into muscle. However, as noted by some people, muscle burial isn’t always effective. Why is that? One possibility, of course is that the original theory is incorrect. Another is that the buried nerve has come out of the muscle which is why it is important to bury a good length of nerve into the muscle to minimize the chance of this occurrence. Another is that the amount of muscle covering the nerve is small and there is therefore still pain as a result of cutaneous pressure over the region.
A corollary to these questions is, “Why does it take a long period of time for the buried nerves to stop causing pain?” The simple answer to this question is that no one really knows however there are several plausible explanations. Keep in mind that a transected nerve is still attached to the spinal cord and the brain (we don’t rip them out of there) and therefore nerve impulses from the brain through the spinal cord to the nerve end continue to be generated. One reason that the patient might have discomfort following implantation is that the muscle into which the nerve is buried is still functioning which could irritate the nerve end thus sending messages back to the brain telling the patient that they have nerve irritation and hence pain. The original theory noted above would also presumably postulate that once the buried nerve has had a chance to regenerate in its non-neuromatous manner, the nerve would “calm down” and the pain would eventually decrease significantly or go away altogether, but this process doesn’t happen overnight. I personally believe that there is another potential explanation which comes from our recent experience with targeted re-innervation patients.
Re-innervation surgery literally involves rewiring the body’s peripheral nervous system, usually in an extremity, to alleviate the pain often caused by neuromas that form at an amputation stump. There are other goals of re-innervation, of course, but this goal is a primary focus. Among the steps performed in such operations is neuroma excision and coaptation (i.e. connection) of a sensory nerve to a motor nerve end within a muscle which is no longer relevant because of the amputation. An example would be a functional gastrocnemius (calf) muscle in a person who has a below-knee amputation. The calf muscle can still fire, but its purpose is to plantar flex the foot at the ankle (i.e. “step on the gas”); but the foot no longer exists, thereby making this muscle function irrelevant. My experience and the limited literature on this topic suggest that when a sensory nerve is connected to a motor nerve heading into a muscle (after removal of the injured portion, i.e. neuroma) the pain relief can be dramatic. While the muscle may not function as well (it is an irrelevant muscle as noted above), the signals from the sensory nerve attached to the motor nerve don’t match up; however a neuroma doesn’t form because the regenerating sensory nerve fibers have been given something to do, namely hook up with the motor nerve fibers downstream. Therefore, my feeling is that by burying a nerve end into muscle a neuroma doesn’t form because the nerve ends eventually make connections with motor nerves heading into that muscle. As above, however, such connections can take time to form which is why the patient may experience discomfort for several weeks-to-months after burial of a sensory nerve into a muscle.  For more information on how nerve surgery can help your pain, please visit www.peledmigrainesurgery.com and www.peledplasticsurgery.com today and call 451-751-0583 to make an appointment.

Continue reading
  4778 Hits
0 Comments
4778 Hits

Can Stress Make Occipital Neuralgia Worse?

This post will be a relatively short one, but this question is very important. I have been queried about this phenomenon numerous times. Peripheral compression of the occipital nerves can come from muscles in the neck, scar, fascia (a tough type of connective tissue) and blood vessels, specifically branches of the occipital artery. When the latter are involved, the pathology to the nerve is much like that of an anaconda strangling its prey if the blood vessel is wrapped around the nerve or alternatively that of a jackhammer if the artery lies next to the nerve in a small and fixed space. In both cases, when the blood pumps through the artery with greater force, the pulsations will pound the nerve with greater force. Hence, when blood pressure increases, so does the pulsatile force against the nerve and hence the pain.

 

headache - mediumWhat types of things can cause blood pressure to rise? Not surprisingly these forces are many of the same triggers that people report all the time: stress, exercise, caffeine ingestion, pain, etc. To illustrate the point, take a look at my recent post with a picture and a video of a greater occipital nerve in the process of being decompressed. During the dissection, I was able to demonstrate a pulsatile occipital artery branch passing right over the greater occipital nerve. In addition, once someone experiences pain, their blood pressure rises which in turn causes the arteries to pump harder thus causing more pain, which causes a further rise in blood pressure and setting in motion a terrible positive feedback loop. For these reasons, when we see vascular compression of the occipital nerves in the OR, we tie off and/or cauterize those vessels so that they no longer impact the nerves.

For more information on how nerve decompression can help solve your occipital neuralgia issues, visit www.peledmigrainesurgery.com and call 415-751-0583 for an appointment.

Continue reading
  9694 Hits
0 Comments
9694 Hits

What Causes Occipital Nerves To Malfunction?

As I have posted several times in the past, the occipital nerves can be compressed by a number of different structures such as blood vessels (e.g. the occipital artery), fascia, scar and muscle.  But someone recently asked me how these structures can cause pathologic changes in the nerve so I thought I’d put down a few thoughts.  First, there are changes that can occur after injury whether surgery or a stretch injury as one would get with “whiplash” (see post: “Whiplash and occipital neuralgia: what’s the connection?”, 01/21/14).  Many of the post-surgical changes are detailed in my more recent post, “WHY DO NERVES TAKE SO LONG TO RECOVER?”, 04/29/14) and will not be repeated here.  So what happens to a nerve after prolonged compression?

 

CaptureWell, way back in 1995, some of the first peripheral nerve surgeons were able to demonstrate exactly that in a non-human primate model.  They induced carpal tunnel syndrome in cynomologous monkeys and then biopsied the nerves at various time points thereafter.  They then also looked to see what happens when those same nerves were decompressed.  The results are seen in the attached picture.  In the upper left “normal”, you see a biopsy of the median nerve in a non-compressed animal.  The black rings are the thick myelin sheaths that surround the white spaces which are the nerve fascicles themselves and help the nerves conduct impulses more efficiently.  After six months of compression (upper right) you can see that the myelin sheaths are already beginning to thin out and the nerves no longer conduct as quickly.  Clinically that may manifest as intermittent numbness and tingling and on EMG you are likely to find prolonged conduction velocity.  With prolonged compression (12 months, bottom left) you not only see further thinning of the myelin sheaths, but fewer numbers of nerves (white spaces surrounded by thin black rings).  Now you may clinically have constant numbness and the EMG may find decreased amplitude since there are fewer nerve fibers actually conducting impulses. You can imagine what would happen if the nerve were left alone even longer.  After decompression (bottom right) you can see that the myelin sheaths never fully return, but the number of axons (nerve fibers) increases as the nerve recovers.  

 

So what does this have to do with ON?  The answer is that it really doesn’t matter what’s compressing the nerves (muscles, discs, fascia, blood vessels) the long-term effects are the same as those noted above.  Has this been proven directly for the greater occipital nerve, for example, - no, but there is no reason to suspect that the sequelae of compression of peripheral nerves in the head/neck would be different than those at the wrist. Therefore it stands to reason that if there is mechanical compression on a nerve, all the medicine in the world won’t relieve that pressure - it has to be removed.  If that is done within a timely fashion, the nerve could recover, if not, it won’t. How much pressure is too much and how much time is too much?  Those are questions we don’t have answers to and I’m not sure we will any time soon.  However, for most people suffering from the often debilitating pain of ON, it cannot be soon enough.  For more information on peripheral nerve surgery, visit us at www.peledmigrainesurgery.com today!

Continue reading
  3213 Hits
0 Comments
3213 Hits

The Occipital Artery Compressing The Occipital Nerve

Occipital Nerve Occipital Artery

This picture is from a case a few days ago and demonstrates very nicely the right greater occipital nerve being compressed by a pulsating occipital artery.  If you then look closely at the corresponding video, you can see the vessel pulsating in the video on the upper left and the pulsations corresponding to the beeping on the EKG monitor. I would hope that some of the doubters out there look at this and re-think the concept that there is nothing compressing these nerves.

 

 

For more information on how nerve decompression can help with your pain relief, please visit www.peledmigrainesurgery.com today and call 415-751-0583 to set up an appointment.

Continue reading
  4712 Hits
0 Comments
4712 Hits
  0 Comments

Chronic Migraine Relief

Migraine headaches have traditionally been thought to begin within the central nervous system (i.e. the brain and/or spinal cord) and then produce symptoms elsewhere such as throbbing in the back of the head, forehead or temples. There are many theories as to what exactly within the central nervous system is causing these chronic and often debilitating headaches. Some of these theories include pathologic blood vessel dilatation and constriction (loosening and tightening), abnormal firing of neurons within the brain, and abnormalities of various biologic substances (e.g. serotonin, calcitonin gene-related peptide). The fact that no one theory has been proven correct is likely one of the many reasons that there are so many different methods for the treatment of chronic headaches like migraines. In fact, from a medication standpoint alone, there are not only dozens of medications used to treat migraines, but dozens of classes of medications such as triptans, anti-depressants, muscle relaxants, blood pressure medications, narcotics, anesthetics, ergotamines, and so on. Fortunately, a different perspective on chronic headaches has produced remarkable results that have been previously unheard of.

This different school of thought suggests that peripheral nerve irritation (i.e. irritation of nerves outside of the brain and spinal cord such as those within the scalp or forehead) can cause irritation within the central nervous system thus leading to the perception of and symptoms of a headache. If this mechanism were in fact the culprit, then identifying and correcting the cause of such irritation could produce relief from the headache symptoms. Plastic surgeons have been doing exactly that with a common nerve irritation problem known as carpal tunnel syndrome. In this syndrome, a nerve within the wrist is compressed (i.e. pinched) and surgeons decompress (i.e. un-pinch) it thereby relieving the symptoms of pain with a greater than 90% 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 that is permanent.

For more information, please visit www.peledmigrainesurgery.com and call 415-751-0583 to setup an appointment!

Continue reading
  1688 Hits
0 Comments
1688 Hits
  0 Comments

HOW COME THE MEDICATION WORKS BETTER NOW?

 

Someone recently posted about the fact that they still occasionally get headaches following surgical decompression or excision (I cannot recall which). What was interesting about their post was the comment that their usual headache medication (whether abortive or preventative) seemed to work better. This comment was almost made in passing, but I think it is rather profound. I have heard this same refrain from patients many times and I believe there is a good explanation for this phenomenon.

Many people likely have chronic headaches secondary to a combination of chemical imbalances as well as mechanical compression. In this case, when you take a medication because of a severe headache, you are uncertain whether it is the mechanical compression or the chemical abnormality that is responsible for your symptoms at that time. If the latter, then the medication will likely have a beneficial effect; if the former, it will have little to no effect. I strongly believe that this scenario is why many people tell me when I first meet them that you can flip a coin as to whether their medication will be effective. “50% of the time it works and the other 50% of the time it doesn’t” is a phrase I’ve heard more times than I can remember.

So let’s say that this same person now undergoes decompression surgery. Following recovery, the only abnormality left is the chemical imbalance. Now this person typically has far fewer headaches, with far less severity and/or of much shorter duration. However, from time to time, they will still experience a bad headache because the chemical abnormalities still exist. Remarkably, these same people will now state that their usual medications are more effective and the reason is hopefully more obvious. This medication is now more effective because it’s treating the problem every time - the chemical wrong it is supposed to right.

Continue reading
  1545 Hits
0 Comments
1545 Hits

THE MRI WAS NEGATIVE…..NOW WHAT?!?

As with many things in life, there is a positive and a negative way to perceive anything. Just because the MRI was negative, clearly doesn’t mean that there’s nothing wrong. Let me explain why below. First, however, let’s look on the bright side. You don’t have a brain tumor. You don’t have an aneurysm. It doesn’t appear as if you’ve had a stroke. And you don’t have lesions on your brain that might be suggestive of multiple sclerosis, Alzheimer’s or ALS (Lou Gehrig’s disease)….all good things NOT to have.

So what do you have and if it’s so bad, how come you can’t see it. Well, with standard MRI sequences, nerves are often not visualized as well as other structures such as muscle and bone. However, there are certain modifications which the MRI technician and radiologist can perform (if knowledgeable enough) to highlight nervous tissue. There are a special set of MRI sequences collectively called magnetic Resonance Neurography (MRN for short) that when combined can produce high resolution images that preferentially highlight nerves and their pathology. Unfortunately, this type of technology is still relatively new and is certainly not available at every hospital.


There are a couple of technical considerations when deciding whether or not a suspected nerve can be evaluated with MRN. The first is the strength of the coil (magnet) within the MRI machine. Standard MRI uses a 1.5 Tesla (1.5T) coil to image routine structures. More recently there has been an prevalence of 3T coils and these machines are sometimes considered “high resolution” MRI scanners. The images they produce are more refined and specific. Think of it as the difference between the images from a VHS player versus a DVD player. There is even a well-known, local institution that supposedly has a 7T scanner. The image quality will probably be that of a Blue-Ray player. The second issue at play is the size of the nerves being imaged. The larger the nerve, the easier it is to detect any pathology. MRN has been shown to be quite effective and useful in imaging larger nerve bundles such as nerve roots emerging from the spine, the sciatic nerve in the thigh and even the brachial plexus in the neck and upper arm. It has been less well-studied in the more peripheral and hence smaller nerves such as those involved in carpal tunnel syndrome and occipital neuralgia. The third rate-limiting step in imaging the nerves is interpreting the images - this maneuver requires a good radiologist. The more experienced they are in reading such images, the more likely they are to pick up fine details that may represent true pathology.

So if the MRI is “negative”, it may be because the optimal MRI sequences were not used - perhaps the radiologist thought you were really looking for a brain tumor and simply didn’t find see one. Make sure the ordering physician specifies that they think you may have ON and are looking for compression of, for example, the greater occipital nerve. If the MRI is “negative”, it may be because the MRI machine is not capable of producing high resolution images that would highlight small nerves such as the greater occipital or supraorbital. If the MRI is “negative”, it may be because the radiologist interpreting the images is not experienced enough in MRN to pick up subtle differences in the appearance of a compressed small nerve versus a normal one. Knowledge is power in these cases. One final note: given the novel nature of this technology, most insurance companies still consider such tests “experimental”.

Continue reading
  2456 Hits
0 Comments
2456 Hits

Phantom Pain or How Come It Hurts When It's Numb?

This post has been a long time coming.  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.

 

For more information, please visit www.peledmigrainesurgery.com today!

Continue reading
  2007 Hits
0 Comments
2007 Hits

How Diabetes Affects Peripheral Nerves

The relationship between diabetes and peripheral nerves is an important one.  As many people already know, diabetes is the leading cause of neuropathy, which in its simplest definition means some pathology of the nerves.  Therefore, diabetes obviously negatively affects nerves, but how? Happily, the concepts are not too hard to understand. There are a number of ways in which diabetes can affect a peripheral nerve.

 

Diabetic Neuropathy Peripheral NerveIn a diabetic, despite the best glucose control there is always more glucose in the bloodstream as compared with a non-diabetic.  This excess glucose is taken up by many cells in the body, among them nerve cells.  When inside the nerve cell, the glucose is metabolized into another sugar called sorbitol which then acts as an osmotic load, drawing more water into the nerve cell. In effect, because of this excess water in the nerve cells, diabetic nerves are swollen.  When any object swells inside of a fixed space which cannot expand, that object is under pressure.  This process partly explains why carpal tunnel syndrome is more common in diabetics than in non-diabetics and it stands to reason that the same process would affect the symptoms of another nerve compression problem, ON.  Although the correlation between diabetes and ON has never formally been elucidated, several studies have hinted at a causal relationship. Another way in which diabetes can affect peripheral nerves is by causing a low grade inflammation of the blood vessels within the nerves.  With inflammation comes swelling and the process noted above worsens even further.

 

Two other processes have also been identified, but with very different mechanisms.  Diabetes has been associated with increased molecular cross-linking of certain proteins within the nerve cells walls.  This cross linking effectively makes the nerves “stiffer” than they otherwise would be which causes then to bang around more within their tight spaces and resulting in more micro-trauma.  This process is especially true around joints such as the wrist (carpal tunnel) or at the base of the neck (ON) where all of the structures are moving around, hopefully gliding smoothly past one another. When coupled with an impaired ability to repair themselves secondary to decreased axoplasmic flow, repeated micro-trauma likely results in scar build-up over time thereby decreasing already tight spaces even further. While I’m sure that other processes have also been identified, the bottom line is that diabetes has multiple negative effects on peripheral nerves and is the reason why in a diabetic patient, optimal glucose control is the first line of therapy. Poor glucose control is likely to exacerbate nerve-related symptoms (whether carpal tunnel or ON) for all of the reasons noted above.  Despite tight controls on sugar levels, diabetics still have symptoms and sometimes these even worsen over time.  In these cases, I believe that a meticulous search for nerve compression is important because if found, decompression can potentially be very beneficial symptomatically. For more information about peripheral nerves and neuropathy, please visit us at www.peledmigrainesurgery.com or call 415-751-0583 or 925-933-5700 to speak to us about how we can help ease your pain.

Continue reading
  1783 Hits
0 Comments
1783 Hits
  0 Comments

Trigger Point Injections Vs Nerve Blocks - What's the Difference?

This question is a very interesting one. Basically, nerve blocks are injections of local anesthetics, pure and simple.  Where things get a little more complicated is the amount and type of local anesthetic used and if it is mixed with anything else.  Each type of local anesthetic has a distinct pharmacologic profile primarily affecting the duration of action and onset of action of the drug. Two common types of local anesthetic are lidocaine - quick onset, short duration and Bupivacaine (AKA Marcaine/Sensorcaine) - longer onset, but much longer duration of action. Sometimes these agents are injected by themselves and sometimes they are used together with or without epinephrine (to prolong the duration of action). Oftentimes, nerve blocks also include steroids (e.g. Kenalog) which are intended to reduce inflammation locally.  Typically when people add steroids they are using the blocks as treatments, not as diagnostic tests, but like any medication, the effects are often temporary (a few days to a few months) and then the symptoms typically return. Steroids also have side effects that preclude their use chronically and at too high doses. Local anesthetics are usually metabolized within a few hours so theoretically, you could have one every day without any long-term problems (not done in practice except perhaps at Guantanamo Bay ).

Trigger point injections are a bit trickier.  They are, in my opinion, relatively poorly defined, but basically consist of a focal infiltration of local anesthetic +/- steroid in the soft tissues in an area of pain (i.e. the trigger point).  Unlike nerve blocks which are supposed to be used to block specific nerves (hence the name), trigger point injections are used within muscle or other soft tissue to treat pain by modulating local pain signals in some other way.  Practically speaking, trigger point injections are used to as treatments in the hopes that blocking the pain signals in this other way will lead to some permanent degree of relief.  

So why so some people require one shot and others 10?  Well, it depends on what’s being done and the pathology being addressed.  I don’t do trigger point injections since frankly, I’ve not seen a definitive explanation regarding exactly how they’re supposed to work or why they’re supposed to work so I’ll speak to nerve blocks.  If you come to my office and based upon your history and physical exam I think you have right sided greater occipital neuralgia, I will block the right GON.  If I’m correct, the 10/10 headache you came in with will be significantly better if not gone just by blocking that one nerve.  If, however, I think you have bilateral greater, lesser and third occipital neuralgia, I will tell you ahead of time that you might require three sets of shots in that session.  The first set of shots will be in what I deem to be your primary source of pain.  Let’s say your headache is 10/10 and I think that your primary source of pain is the GONs - I will inject those and wait 10 minutes.  If your headache disappears, I’m done.  If your headache only gets 33% better, now I’ll inject another potential source, let’s say the LONs.  If your headache is now gone, I will operate on both the GONs and LONs since blocking both gave you incremental and total or near-total relief.  If you’re only 66% improved, I will inject the third occipital nerves and if now your headache is gone, I have to operate on all three nerves bilaterally.  You cannot inject all three nerves on both sides at the same time, because if you get complete relief after injecting all at once, you literally have no idea which nerve block gave you that result. Therefore, the number of shots with regard to nerve blocks depends on: how many nerves you think you’ll need to knock out to get the result you hope to achieve with an operation and your injection technique/experience.  For more information, please visit www.peledmigrainesurgery.com today and call 415-751-0583 or 925-933-5700 to talk to us directly!

Continue reading
  11733 Hits
0 Comments
11733 Hits
  0 Comments

More Information On the Occipital Artery and Greater Occipital Nerve

That's not a brain, it's the soft tissues of the neck after a melanoma resection. What I'm showing in the video is the occipital artery which is pulsating if you look closely enough. Right next to this artery is the greater occipital nerve. You can see them clearly since the oncologic surgeon had to make a big hole, but you also notice that these two structures lie right next to one another. Therefore, without this big hole and if the space between these two structures is narrowed by scar or an enlarged vessel, that artery would be constantly banging against that nerve and can cause a lot of pain - i.e. occipital neuralgia.

Make sure to follow us on Facebook and Twitter to keep up with Dr. Peled's new Migraine and nerve information!

Continue reading
  2595 Hits
0 Comments
2595 Hits
  0 Comments

WHAT CAUSES OCCIPITAL NERVES TO MALFUNCTION?

As I have posted several times in the past, the occipital nerves can be compressed by a number of different structures such as blood vessels (e.g. the occipital artery), fascia, scar and muscle.  But someone recently asked me how these structures can cause pathologic changes in the nerve so I thought I’d put down a few thoughts.  First, there are changes that can occur after injury whether surgery or a stretch injury as one would get with “whiplash” (see post: “Whiplash and occipital neuralgia: what’s the connection?”, 01/21/14).  Many of the post-surgical changes are detailed in my more recent post, “WHY DO NERVES TAKE SO LONG TO RECOVER?”, 04/29/14) and will not be repeated here.  So what happens to a nerve after prolonged compression?

 

CaptureWell, way back in 1995, some of the first peripheral nerve surgeons were able to demonstrate exactly that in a non-human primate model.  They induced carpal tunnel syndrome in cynomologous monkeys and then biopsied the nerves at various time points thereafter.  They then also looked to see what happens when those same nerves were decompressed.  The results are seen in the attached picture.  In the upper left “normal”, you see a biopsy of the median nerve in a non-compressed animal.  The black rings are the thick myelin sheaths that surround the white spaces which are the nerve fascicles themselves and help the nerves conduct impulses more efficiently.  After six months of compression (upper right) you can see that the myelin sheaths are already beginning to thin out and the nerves no longer conduct as quickly.  Clinically that may manifest as intermittent numbness and tingling and on EMG you are likely to find prolonged conduction velocity.  With prolonged compression (12 months, bottom left) you not only see further thinning of the myelin sheaths, but fewer numbers of nerves (white spaces surrounded by thin black rings).  Now you may clinically have constant numbness and the EMG may find decreased amplitude since there are fewer nerve fibers actually conducting impulses. You can imagine what would happen if the nerve were left alone even longer.  After decompression (bottom right) you can see that the myelin sheaths never fully return, but the number of axons (nerve fibers) increases as the nerve recovers.  

 

So what does this have to do with ON?  The answer is that it really doesn’t matter what’s compressing the nerves (muscles, discs, fascia, blood vessels) the long-term effects are the same as those noted above.  Has this been proven directly for the greater occipital nerve, for example, - no, but there is no reason to suspect that the sequelae of compression of peripheral nerves in the head/neck would be different than those at the wrist. Therefore it stands to reason that if there is mechanical compression on a nerve, all the medicine in the world won’t relieve that pressure - it has to be removed.  If that is done within a timely fashion, the nerve could recover, if not, it won’t. How much pressure is too much and how much time is too much?  Those are questions we don’t have answers to and I’m not sure we will any time soon.  However, for most people suffering from the often debilitating pain of ON, it cannot be soon enough.  For more information on peripheral nerve surgery, visit us at www.peledmigrainesurgery.com today!

Continue reading
  2248 Hits
0 Comments
2248 Hits
  0 Comments

Worldwide Migraine Headache Relief

Do you have to live in the San Francisco Bay Area to get relief from your severe, chronic headaches? No, 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!

Continue reading
  1484 Hits
0 Comments
1484 Hits
  0 Comments

Why Do Nerves Take So Long To Recover?

I hear this question a lot from just about every patient I see, whether for chronic headaches or tarsal tunnel syndrome.  The answers have to do with the technical aspects of the surgical procedure, the physiology of peripheral nerves as well as the wound healing process itself.    As you can imagine, a compressed nerve is usually compressed on all sides because it is a three dimensional structure.  Therefore when decompressing a nerve, it has to be manipulated such that the superficial, deep, medial, lateral, cranial and caudal aspects of the nerve can be examined and released if necessary. In addition, there are often multiple compression points (the GON has up to 6 that have been described and often others that are noted intra-operatively).  Moreover, there are times when there is intra-neural scarring (scarring within the nerve, not just around it) which also requires removal.  Hence, there is a fair bit of manipulation usually required (albeit with microneurosurgical techniques) during any decompression procedure.

 

Axon -mediumAs part of the normal wound healing process, there is swelling.  The more neural manipulation required during the operation, the more swelling of the nerve you’re likely to have post-operatively.  I tell my patients to think of nerves as electrical wires, pure and simple.  All they do is conduct electrical signals back and forth, but it is the brain the interprets these signals as ‘hot’, ‘cold’, ‘painful’, ‘ticklish’ etc.  Therefore, if you think about pouring water into the drywall in your house near the electrical wires, it is likely that the lights will start to flicker on and off until the water dries up because the fluid is interfering with the electrical signals.  In the same way, swelling of the nerve can result in all sorts of “unusual firing” of the nerve and is one reason many patients may experience weird, sometimes painful sensations post-op.  However, if the nerves are going to recover, within a few weeks or months when the swelling has subsided, this “unusual firing” abates and the nerves “calm down”.  Just like with cutaneous scars (which also swell as part of the healing process) the time for swelling to decrease is usually longer than a few days or weeks.

 

Another reason why nerves may take a while to recover has to do with the severity and duration of compression.  I’m sure everyone has fallen asleep on their arm(s) at some point in their lives.  Sometimes, when you wake up, your hand is just a little numb and it takes about 10 seconds of shaking your hand to restore normal sensation.  Other times, however, when you wake up the entire arm seems paralyzed, weak and numb!  In these cases, aside from some transient agita, it takes up to 1-2 minutes of shaking the arm out for function and sensation to return fully.  Phew!  The difference between these two situations is that in the latter, the compression of the nerves to the arm has been present for longer and may have been more severe as compared with the former.  Therefore, it takes longer for sensation (and function) to return.  Now take that phenomenon and stretch the timeline out months and often years - that is how long many peoples’ nerves have been compressed.  Therefore, it can take weeks or months for function to return to “normal”.  Also, since the blood flow to the nerves in the latter scenario has been compromised for a longer period of time, they become more engorged with blood after flow is restored and then that extra blood takes time to return to its baseline levels.  It is for this reason that you often experience that sensation of tingling and pain after you remove pressure from the arm and as blood flow resumes. The same thing happens when blood flow is restored after decompression - (more intra-neural blood flow usually combined with more surgical manipulation).  Finally, since we don’t immobilize our heads after surgery (doing so would just stiffen all the joints), the nerves will glide right away after we do all of these things to them and also likely contributes to the recovery process. The take home message is that as patients and physicians, we have to be patient in assessing whether or not decompression has been successful as the final results may not be apparent for many months (as noted by many here).  After all, the same would true of a facelift or breast augmentation.  For more information, visit www.peledmigrainesurgery.com and call 415-751-0583 or 925-933-5700 to setup your appointment!

Continue reading
  5590 Hits
0 Comments
5590 Hits
  0 Comments

Why Are Plastic Surgeons Doing Nerve Surgery?

There have been several comments recently about how it seems strange that plastic surgeons are the leaders in peripheral nerve surgery, specifically as it relates to chronic headaches. Many have wondered why this type of procedure is not performed by neurosurgeons as would seem intuitive. As with any questions, there are often several components to the answers.

First, let me start by saying that I am not a neurosurgeon nor is anything in this post intended to disparage neurosurgeons. Their profession is a difficult and exquisitely complex one, but like many fields within medicine, typically limited to specific areas of focus. While I'm sure that there are neurosurgeons out there who do peripheral nerve work, most those with whom I have interacted and worked focus exclusively on the brain and spinal cord. Indeed, pathology within these two body parts are complex enough and could keep any practitioner busy for the rest of his/her career. Therefore, while nerves exist throughout the body, if you’ve never operated outside of the brain, spinal cord or immediate paraspinal regions repairing a nerve in the forearm would be difficult for a number of reasons. One, the anatomy is foreign and there are many structures which are unfamiliar and can be injured inadvertently resulting in worse pathology. Two, it is well-known that peripheral nerves are distinctly different than nerves within the central nervous system and therefore medical/surgical treatments which may be effective in one area, maybe ineffective in the other. Third, the operation is only a part of the overall treatment of a patient hence a surgeon must be able to manage the expectations of the patient prior to the operation and any complications/issues that might arise post-operatively.  These skills require specific experience with specific procedures (see above).

Second, I should explain why plastic surgeons are uniquely qualified to perform peripheral nerve surgical procedures. Plastic surgeons are known for, among other things, being able to operate on all parts of the body. When we perform reconstructive or aesthetic procedures, we operate everywhere from the head to the feet. As part of our reconstructive training we are taught how to move and mobilize tissue from one part of the body to fill defects created either by surgery or trauma in other parts of the body. We therefore often run into peripheral nerves during these dissections and are familiar with their locations, anatomic variations and surrounding anatomy throughout the body. For example, one main sub-field of plastic surgical training is hand surgery which obviously involves many, very critical nerves. Approximately 50% of all hand surgical procedures performed in this country are performed by plastic surgeons. A few decades ago, several plastic surgeons, a little bit older and far wiser than I, began to ask themselves, ‘If nerves can be manipulated within the upper extremities and hands to relieve pain, provide sensation or restore function, why would it not be possible to perform similar types of procedures in the legs, trunk, head or neck for the same purposes?’ These pioneers adapted the surgical principals they were using in the upper extremities to these other parts of the body and for some it became the focus of their careers. It also soon became apparent that many of the principals that are applied, for example, to release of the median nerve in a patient with carpal tunnel syndrome can be applied to nerves within the foot and ankle in a patient who has tarsal tunnel syndrome. A second-generation of plastic surgeons luckily recognized the potential of these procedures, learned from the prior generation and continued their work. I’d like to also believe that we’ve been able to advance the field by applying established peripheral nerve surgical principles to yet other nerves which were once thought untouchable (e.g. I routinely see patients in my office with meralgia paresthetica who were told they would have to live with their pain forever),  but have now been successfully operated upon.  In addition, we have tools that didn’t exist previously such as biologic nerve allografts and utilize newer techniques such as targeted re-innervation to give amputees relief of pain as well as the potential for use of functional myoelectric prostheses.  In short, peripheral nerve surgery is an exciting and burgeoning field within the larger realm of plastic surgery which will hopefully continue to grow and develop. While other surgeons may be able to perform such procedures, plastic surgeons have been and continue to be some of the pioneers in the field for the reasons noted above.

For more information on how we can help with your nerve related issues, please call us at (415) 751-0583 in San Francisco and (925) 933-5700 to set up an appointment, and visit www.peledmigrainesurgery.com today to read more about us!

Continue reading
  2120 Hits
0 Comments
2120 Hits

When Migraines Strike In San Francisco, Can Outpatient Surgery Help?

My name is Dr Ziv Peled. Welcome to the blog for my practice, Peled Migraine Surgery. I live in San Francisco, CA and work as an Plastic Surgeon at Peled Migraine Surgery. Contact the author at This email address is being protected from spambots. You need JavaScript enabled to view it.

When migraines strike, the first thought in many San Francisco residents' minds is "ouch".  After that, they think "medication".  But is medication really the answer to severe headache pain?  While some medication can help alleviate the pain of a migraine in some patients, sometimes they don’t work, they often require chronic use, and sometimes they only work for a short time and then stop working altogether.  When conservative modalities have failed, as they do for many, there is another option.  Peripheral nerve surgery has been clinically proven, when performed by a board-certified plastic surgeon with experience in such procedures, to reduce pain and change people's lives, potentially permanently.  

Axon -mediumLiving with chronic, severe headache pain can be a nightmare, and peripheral nerve surgery can help.  But what is a "peripheral nerve"?  A peripheral nerve simply refers to a nerve outside of the brain and spinal cord.  These nerves, and the surrounding tissue, can become inflamed, causing intense pain.  Such pain is not that different from the pain experienced by someone who steps on a tack with their big toe.  The nerves in the toe become activated and send pain signals back to the brain. If a peripheral nerve in the head/neck is activated because of compression or inflammation those same pain signals may develop and can be a source of migraines.  When it is determined that this is the issue, the problem can be alleviated with a surgical procedure that decompresses the nerve in the hopes of reducing those signals. 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 that can be permanent.

I have been performing peripheral nerve surgery all over the body in San Francisco for a number of years.   My practice now includes many former chronic headache patients who suffered from nerve compression very similar to that which I had been treating for years in the trunk, arms and legs.  I have operated on several hundred nerves in the head/neck and my very positive results with these patients has validated my choice to help people stricken with migraines and other forms of chronic headaches.  I firmly believe that peripheral nerve surgery can help people living with this condition live a more normal life, with significantly reduced or possibly no headache pain.  The gratitude expressed by these patients is the reason that I became a physician in the first place, and I hope that every physician feels the same way I do every day when I come into the office.

For more information about peripheral nerve surgery, and migraine surgery in San Francisco, CA, visit www.peledmigrainesurgery.com today, and call 415-751-0583 to schedule an appointment.

Continue reading
  1810 Hits
0 Comments
1810 Hits
  0 Comments

WORKING HOURS

Monday 9:00 am - 5:00 pm
tuesday 9:00 am - 5:00 pm
wednesday 9:00 am - 5.00 pm
thursday 9:00 am - 5:00 pm
friday 9:00 am - 5:00 pm

SAN FRANCISCO

  • 2100 Webster Street, Suite 109, San Francisco, CA 94115
    Open Map
  • 415-751-0583
  • 415-751-6814

WALNUT CREEK

  • 100 N Wiget Ln #160, Walnut Creek, CA 94598
    Open Map
  • 925-933-5700
  • 415-751-6814

This email address is being protected from spambots. You need JavaScript enabled to view it.