Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

WHICH CAME FIRST THE MUSCLE OR THE NERVE?

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Just this week, several patients have asked about the tight muscles in their necks and upper backs. They have all wondered at some point whether it’s the tight muscles that are irritating the nerves or the nerves that are irritating the muscles and causing them to spasm. In most cases, this question ends up being like the one about the chicken or the egg - in other words difficult if not impossible to answer with certainty.  I do, however have several thoughts on the matter that I figured I would share as I believe them to be relevant to peoples’ understanding of their condition. First of all, spastic muscles irritating or compressing occipital nerves can certainly cause ON and an irritated nerve can certainly cause pain in the nuchal region, leading to both voluntary and involuntary guarding and spasm of neck muscles.  These factors feed on one another and as the pain increases, the muscles often contract more, causing more irritation/compression and hence more pain which leads to greater contraction and so on.  Second, in most patients, these processes have been happening for years and it is often difficult to remember which factor precipitated the other. None of this is to say that since we can’t always figure out “what started the ON”, that we therefore can’t do anything about it. For example, many of my patients have tried muscle relaxants as part of their medical regimens, often without success. In addition, my typical patient has not only tried and failed many different pharmacologic agents, but also many different non-operative treatment modalities.  PT, massage, Active Release Techniques (ART) are just some examples of therapies that focus on the muscles and which are common components of patients’ past medical histories.  The point is that if you’ve unsuccessfully tried to release, lengthen or relax your neck muscles in a number of different ways and still suffer from occipital neuralgia, then perhaps attempting to address another component of the ON symptom complex is also reasonable. In these same people, I often find that a well-placed nerve block or blocks not only seems to relieve their pain, but several minutes after the block has really set in, they are able to move in ways they have not been able to in years.  I use long-acting blocks and then have those same patients leave the office and engage in several provocative maneuvers to try and exacerbate their ON.  Many of them find that those typical “triggers” now don’t bother them and they remain relaxed until the blocks wear off.  What do these results tell you?  Among other things, they suggest that if the nerve, which has been chemically and temporarily “calmed”, can be treated permanently, perhaps the muscles that have relaxed will also benefit secondarily.  Moreover, they suggest that other distant muscles in other parts of the body may also benefit as they no longer have to compensate for spastic and ineffective muscles in the neck.  The take home message is that just because you can’t figure out which came first, the chicken or the egg, doesn’t mean that you can’t still treat the problem of occipital neuralgia effectively.

To learn more, visit www.peledmigrainesurgery.com today, or call 415-751-0583 to schedule an appointment.

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Why Did I Get Occipital Neuralgia?

headache - mediumThe 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.

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Dr. Peled Co-author On New Paper

The paper, 'Supraorbital Neuroma: A Rare and Unreported Complication Following Blepharoplasty' co-authored by Giorgio Pietramaggiori, MD, PhD, Sandra Saja Scherer, MD, Ziv M. Peled MD and Raffoul Wassim, MD has been accepted for publication by the Journal of Reconstructive Microsurgery (Theime Medical Publishers, Inc). This manuscript describes a novel approach for managing a supraorbital branch neuroma following blepharoplasty - a very popular aesthetic procedure. A short excerpt from this article is shown below with the full text to be published soon.

Supraorbital 1

 

Supraorbital 2

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Dr. Ziv M Peled Wins Most Outstanding Paper at CSPS

Dr. Ziv M. Peled's paper entitled, "A Novel Surgical Approach to Chronic Temopral Headaches" won the 'Most Outstanding Paper Award' at the 2015 California Society of Plastic Surgeons annual meeting this past weekend in Monterey, CA! The paper was presented by Dr. Peled during the 4-day event that featured the top plastic surgeons in California giving presentations on their areas of expertise. Dr. Peled's paper was chosen from dozens of nominees as the top paper overall.

 

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CSPS Title

 

Ziv Presents

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Why Is the Recovery So Long, Sometimes?

migraine4This post is a modification of one I did about one year ago, but is a question I still hear a lot. It relates to any nerve procedure, not just those for headaches. The answer to this question has many components: the technical aspects of the surgical procedure, the physiology of peripheral nerves, the wound healing process itself and the overall physiology of the patient. To begin, 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 can be a fair bit of manipulation required (albeit with microneurosurgical techniques) during any decompression procedure. You may realize that as part of the normal wound healing process, there is swelling. With the above factors in mind, 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, when the swelling has subsided, this “unusual firing” abates and the nerves “calm down”, but the final result may not be realized until 12 month following the operation as changes to the nerve continue to occur. 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, in some cases it can take many 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). In addition, 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.

Finally there are the patients themselves. Everyone’s physiology is different. Some people are older, others younger, some otherwise quite healthy, others with multiple other medical problems. We heal slower as we age and other medical problems (e.g. diabetes or multiple sclerosis) can have effects not only on the nerves, but on healing following surgery. Moreover, since we are really talking about a chronic pain condition, there is the issue of medication use both pre and post-operatively. Some patients are taking relatively little medication before their procedures while others are taking a lot more. These medicines do have systemic effects and while some can be stopped “cold-turkey”, others often need to be weaned very gradually and carefully post-operatively. It is therefore reasonable to conclude that they can impact how people feel following their operations. 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) and the same would true of a facelift or breast augmentation. You are unique so be patient with yourself and do what you need to give your body time to heal. After all, many years of nerve pathology may not be undone after a three-hour procedure. 

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Can You Get Migraine Relief Outside of San Francisco As Well?

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!

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To Decompress Or Transect: That Is The Question

Axon -mediumThere continue to be questions raised both in my office as well as online about the difference between neurectomy/implantation (transection of the nerve and implanting it in the local muscle) and decompression. Along with these questions come many misconceptions about the advantages and disadvantages to each. This post hopes to address some of those issues.

To decompress a nerve means simply to remove some form of external compression that is putting excess pressure on the structure. As has been mentioned previously, compression can be a result of scar tissue, tight muscles, abnormal blood vessel anatomy, connective tissue, etc. Decompression also means that the nerve is left intact and that hopefully, once the effects of the operation (e.g. swelling) and the effects of the compression wear off, the nerve will function well again. There are advantages to decompression. The most obvious advantage is that the nerve is preserved so hopefully sensation to that area will also be preserved. Secondly, since the nerve is not cut, the chances of a post-operative neuroma are theoretically low. There also disadvantages to this approach. First, the surgeon and/or patient make a judgement call that the nerve will recover if simply decompressed, but this doesn’t always occur. I believe that this is the primary reason some people who have decompression ultimately require neurectomy and implantation Second, just because the chances of a neuroma are low it doesn’t mean that they are zero - you can still get a neuroma-in-continuity, especially if there is a lot of manipulation required to adequately decompress a nerve. Third, if the compression has been severe and long-standing, the nerve may take many months to fully recover. Fourth, if recovery does occur, there is no guarantee that sensation to the relevant area will be “normal”. It may always feel a little bit off.

The biggest misconception with a neurectomy is that it is like pulling the plug out of a wall outlet. However, the injured nerve is not ripped out of the spinal cord. A better analogy is that the injured portion of the nerve is identified and the area just upstream where the nerve appears healthier is where the nerve is transected. This maneuver is just like cutting the central portion of a power cord to a lamp where the wires have frayed. The downstream part of the nerve (e.g. that which goes to the skin) is now irrelevant just like the part of the cord that is still attached to the lamp. There is no longer any electricity going though that part so the bulb will not turn on. However, that upstream cut end is still a live wire as it is still connected to the wall outlet and therefore must be capped. In the human being the same goal is achieved by implanting the upstream (proximal) nerve end (which is still getting nerve impulses from the spinal cord) into the local muscle. There are advantages and disadvantages to this approach. One advantage is that you may see immediate improvement in symptoms although not always. Sometimes, people continue to experience pain in that nerve even though when they touch their skin they are numb. This situation exists because the nerve that used to go to that area of skin is getting impulses from the spinal cord and brain albeit ending within the muscle and so your brain thinks that part of the skin hurts even though when you touch it is numb. Eventually in most cases, the nerve end in the muscle calms down and the pain improves. Another potential advantage is less dissection because the downstream area of the nerve doesn’t need to be dissected once transected as it is now irrelevant. There are potential disadvantages as well such as persistent nerve pain if the implanted nerve doesn’t calm down, a neuroma if the nerve comes out of the muscle and the obvious numbness in that nerve distribution. Another misconception is that neurectomy is a guaranteed, home-run result which is not true for those reasons mentioned above. There are clearly other nuances that exist which is why discussing these issues with your peripheral nerve surgeon is so important. Just as each patient is unique, each person will have different tolerances for different post-operative outcomes so a good discussion is useful both for the patient and the surgeon.

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The Bionic Arm

I recently read with interest the work of Dr. Oskar Aszmann and colleagues in Vienna, Austria regarding bionic reconstruction of the hand (The Lancet , February 2015). I have been listening to Oskar speak about this work for the past several years at our annual meetings and it is great to finally see it in publication. My hope is that this research will raise awareness of the possibilities for nerve reconstruction in the near future as well as what we are capable of doing today.

 

For those that haven’t seen or heard about this paper, it describes three patients who had severe brachial plexus injuries. The brachial plexus is the network of nerves in the neck and shoulder regions that mediate all of our upper extremity function and sensation. All three patients had failed traditional reconstruction methods and the patients were left with minimally functioning upper extremities. Something else had to be done. To simplify it, the wiring of the remaining upper extremity was reconfigured using a combination of nerve transfers and bringing in muscles from other parts of the body along with their nerves so that the remaining, functional nerves could intuitively and predictably innervate the upper extremity muscles. Then, by following a specific rehabilitation protocol, the patients re-learned how to use this re-wired musculature. This protocol included the use of a hybrid myoelectric (i.e. robotic) prosthetic which was attached to the native, non-functional hand so that the patients could appreciate how much additional function they had with the robotic hand as compared with their native hand which was often minimally functional and insensate. After adequately learning how to control this myoelectric (i.e. robotic) hand, each patient underwent elective amputation of the native hand and permanent fitting of the same myoelectric prosthetic which they had been learning to use. Post-operatively all three patients demonstrated significantly improved upper extremity function, decreased pain as well as improvements in quality of life according to well established measures.

 

Oskar’s work is exciting for a number of reasons. First of all, it wonderfully demonstrates the degree to which we are able to restore function in the upper extremity for those with previously devastating injuries that were once thought to be irreparable. Secondly, while these surgical procedures are not for everyone and can be complex, the technical challenges that we face in the operating room are being greatly aided by improvements in electronic prosthetic development. Already in the works are myoelectric prosthetics with vastly more degrees of freedom (i.e. independently moveable joints) and signal processing capabilities which will ultimately allow a very precise level of function at the wrist, hand and finger levels beyond those which are available today. Third, I believe that in the not too distant future, we will see prosthetics that can actually be surgically implanted and will not need to be taken on and off as we have today, thereby removing a psychological downside to prostheses in general. Fourth, such procedures and prosthetics may ultimately provide us with a level of functionality that even a “normal person” doesn’t have. While there are certainly moral and ethical implications to consider with these possibilities, the concepts and potential are exciting indeed.

 

In many ways, this type of work represents the ultimate melding of computer science/engineering and modern medicine/surgery. Dr. Darrell Brooks and I have performed several similar procedures, so far with very encouraging results. We sincerely hope that the publication of this paper and hopefully soon others like it will encourage peripheral nerve surgeons to pursue even greater achievements. I believe that in time and in collaboration with our engineering/biomedical colleagues, devastating injuries suffered by those returning from war or after accidents will no longer mean a lifetime of dysfunction.

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WHAT IF I STILL HAVE HEADACHES?

What If I Still Have Headaches?

Over the years, as I have operated on more and more patients with chronic headaches, my impression of this problem has changed somewhat. Time and again, I would see patients who had severe, frequent, long-lasting headaches who underwent surgery with me and did extremely well. Their headache frequency, severity and duration decreased significantly after their procedure and they were extremely happy.  However, many patients still experienced severe headaches from time to time and the question that was posed to be on many occasions was, "What does it mean that I still have some severe headaches after surgery?" As I have talked with numerous such patients on many occasions and drilled down on their remaining symptoms and their treatment of these symptoms, an interesting observation occurred to me.

One obvious conclusion is that there are other trigger points that have yet to be treated surgically and were not detected prior to the operation in question.  In some cases, operating on many trigger points is done in a staged manner on purpose because recovery after release of, for example, 16 different nerve trigger points throughout the head, neck and scalp would be a very prolonged and rather uncomfortable post-operative recovery process.  In other cases, once the primary and most painful trigger were adequately treated, areas that were and remained less severely compressed and therefore less noticeable reared their ugly heads. In these instances the treatment was to work up these additional potential trigger points as I did the primary trigger points and treat them surgically if deemed necessary.

A second possibility also occurred to me quite some time ago as I spoke to patients about how they treated their residual headaches. There are a number of patients who have told me that pre-operatively they would take whatever preventative or abortive medication(s) they were prescribed by their treating physicians and that the medicine would work “approximately 50%” of the time. In other words flip a coin.  Post-operatively, however, when these same patients experienced severe headaches, they found that the same medications almost always worked. I would hear this refrain over and over again and many a patient was puzzled by the change.

If you think about it, however, the answer actually makes perfect sense.  I believe that some patients actually have a combination of mechanical compression over one or more nerves in addition to chemical imbalances within the brain that cause their headaches. Once a surgical procedure has treated the former, the latter is all that remains.  Therefore, when a post-op patient experiences a severe headache that cannot be attributed to a persistently compressed nerve in another area, it could be secondary to a chemical imbalance.  If that is true, then medication will help and explains why medication seems to be more effective after surgery, when needed.  With this combination of treatment modalities, patients tell me on a consistent basis that their chronic headaches have gone from a debilitating to a very manageable problem.

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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!

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Hey Dr Peled, What Is Peripheral Nerve Surgery?

How does peripheral nerve surgery help my life, and what can it mean for my migraines?

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


The procedures performed on these peripheral nerves ultimately depend upon the pathology in question. If there is external pressure on the nerves causing irritation, this external pressure is relieved. An example of this type of procedure is that performed during a nerve decompression to treat chronic headaches. If there is a tumor within the nerve, it can often be removed and the nerve preserved or in other cases reconstructed to preserve sensation and function. If a nerve has been cut, it may be able to be repaired surgically.
Plastic surgeons with peripheral nerve experience have been performing peripheral nerve surgery for years to correct a common and well-known malady known as carpal tunnel syndrome, where the surrounding tissue pinches the one of the main nerves at the wrist. These surgeons decompress or un-pinch the nerve by adjusting the tissue surrounding it, leaving the nerve intact. This procedure has a very high success rate. Recent research has demonstrated that just like at the wrist, there are nerves within the head and neck that are compressed and that decompressing them, can produce significant or even complete relief from chronic headaches that can be permanent. The results with these latter procedures have been quite dramatic. In one study out of Georgetown University, data from 190 patients with chronic pain/headaches in the back of the head who underwent surgical decompression were analyzed. One year after surgery, the patients were evaluated and over 80% of patients reported at least 50% pain relief and over 43% of patients experienced complete relief of their headaches! In February 2011, the five-year results of such procedures were published in the medical journal, Plastic and Reconstructive Surgery. This study demonstrated that five years following their headache operation, 88% of patients were still reporting greater than 50% improvement in their headache symptoms and 29% were completely headache-free!
To find out more about these exciting developments, please visit http://peledmigrainesurgery.com or call us at (415)751-0583 to schedule a formal consultation.

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Aneurysmal Superficial Temporal Artery Compressing the Auriculotemporal Nerve

 

A short video showing the Aneurysmal superficial temporal artery compressing the auriculotemporal nerve.  Click on the images below to get an annotated view of what you're looking at.

 

 

Aneurysmal superficial temporal artery compressing the auriculotemporal nerve2Aneurysmal superficial temporal artery compressing the auriculotemporal nerve  1

 

 

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WHY DOES IT HURT SO MUCH AFTER THE INJECTION?!?

Botox InjectionI’ve heard from so many people over the years who consistently tell me that they had worse pain AFTER their injections - whether it is Botox, a local anesthetic (such as is used in nerve blocks) and/or steroids. Remarkably, despite numerous queries to their treating clinicians, their physicians have never had a good answer for them as to why this problem happens. Actually, the answers are quite simple. Worse pain after injections such as those done to diagnose ON can occur for several reasons.

One reason is that the injections done for ON are performed within muscle. Injections into muscle cause a little muscle inflammation/swelling no matter what you inject (even saline) and this inflammation causes discomfort. Anyone who has ever had a tetanus shot into the shoulder muscle (deltoid) knows exactly what I’m talking about. Their shoulder can be sore for 7-10 days afterwards. Fortunately, the discomfort is temporary and only lasts a few hours or days as the inflammation/swelling subsides.

Second, keep in mind that the injections, by design, are performed AROUND (not into) nerves which means that you are injecting several mL of fluid around a nerve. This fluid causes some irritation of the nerve itself because of the mechanical pressure from the fluid, not so much the make-up of the fluid itself and hence theoretically would be equivalent with Botox, local anesthetics or steroids so long as the same volume was used with each. If a local anesthetic is used, the effects of the anesthetic provide relatively immediate, albeit temporary relief when injected properly. Yet when the effects of the local anesthetic wear off, the nerve irritation from the fluid pressure often remains and can cause worse pain for a few hours or days afterward. Once again, this situation is usually temporary as the residual fluid is absorbed by the body, although the discomfort can last several days on occasion.

A third reason an injection can cause pain afterwards is some complication from the injection itself. For example, following any violation of the skin (e.g. surgery, injections, IV placement) an infection can occur. With infection comes the inflammation mentioned above several times often causing localized pain from irritation of the nerve endings in the surrounding skin as well as from irritation of the target nerve. A hematoma (a collection of blood) can result from an injection although it is quite uncommon. Blood is a great culture medium and can be a factor in promoting infection (see above) as well as a mechanical force impacting the local tissues (e.g. the target nerve). One potential sign of a hematoma is significant bruising following an injection, especially one involving a small needle and a small injection volume. Finally, and fortunately very rarely, an intra-neural injection (into the nerve itself) can be the culprit. If a significant volume of anything is injected into the nerve itself, it can disrupt the microscopic blood supply to the nerve and cause permanent damage, which can result in permanent problems. However, since nerves are usually quite small, since the injection needles are small and since the required injection volumes are low, intra-neural injections are about as common as finding a needle in a haystack or a four leaf clover. The take home message for my patients: knowledge is power. If patients are told what MAY happen following their injection, they are much calmer if and when it does occur and hence better prepared to deal with the situation.

For more information, visit www.peledmigrainesurgery.com and call 415-751-0583 for appointments.

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Whiplash and Occipital neuralgia: what’s the CONNECTION?

headI have been asked recently about the relationship between whiplash and occipital neuralgia. First of all, what is whiplash? Simply put, it is a sudden jerking of the head, usually in a backward/forward direction or sometimes side to side. Common causes of whiplash include motor vehicle accidents, sports related injuries and any other violent motions such a shaking a baby too hard or even a big roller coaster ride. Motor vehicle accidents are by far the most common cause with an estimated incidence of over 1,000,000/year although the true number is hard to gauge since many cases of whiplash are not reported. In 2008, the total estimated cost to the healthcare system of whiplash injury was over 40 billion dollars!

One of the most common sequelae (consequences) of whiplash is chronic neck pain/headaches. Why do these symptoms occur? Likely, because the nuchal muscles will suddenly tighten as the head is rocked violently and the soft structures that pass through and around these muscles are affected. Nerves are like wet noodles - they are soft and pliable, but the neck muscles and fascia that covers these muscles is tough and tight to begin with to allow stabilization and efficient mobilization of those bowling balls we call our heads. If you think about the force it would take to tear a wet noodle, you get a sense for how easy it could be to injure an occipital nerve.

However, as many out there can attest the work up of these patients is often negative. Why is that? The answer lies in what I believe to be the underlying cause of this chronic pain/headache which is a traction (i.e. stretch) injury to the occipital nerves. Even with high resolution MRIs (see previous post on why the MRI may be negative), the relatively small occipital nerves (greater, lesser and third) are hard to image accurately. Therefore, a negative MRI may rule out an injury to the nuchal ligaments, bones, and/or muscles, but it cannot rule out a small tear to already tiny nerve(s). Moreover, since the above-mentioned occipital nerves are purely sensory (i.e. they don’t move any muscles, only provide sensation to the scalp and back of the ears), the primary symptoms tend to be pain which cannot be objectively measured with a CT scan/MRI or blood test. Since many practitioners don’t recognize the impact of a traction injury to these sensory nerves, management is often empirical.

For these reasons and others, patients are often treated with a combination of pharmacologic agents, PT, chiropractic manipulation, cervical collars, etc. Certainly many patients do get better with these conservative modalities, but given the sheer numbers we are talking about, many thousands do not. However, if you believe as I do that the issue may be a tear within a small nerve causing intra-neural scarring, or a small tear within a muscle surrounding that nerve that causes subsequent scarring and narrowing of the canals through which these nerves usually pass (hence compression), then the above-mentioned modalities will not work for obvious reasons. If there is mechanical compression on a nerve, that compression must be physically and precisely removed or permanent damage may occur. The take home message is that when all other potential causes of chronic neck pain/headaches post-whiplash have been ruled out, think of occipital neuralgia as a possible cause. A consultation with an experienced peripheral nerve surgeon should then follow and ON ruled out as a possible cause. The good news is that if ON is felt to be the culprit, there are safe and effective procedures that can provide significant relief.

For more information, visit www.peledmigrainesurgery.com today and call 415-751-0583 for appointments.

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WHAT CAUSES OCCIPITAL NERVES TO MALFUNCTION?

Axon -mediumAs 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?

Well, 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, please visit www.peledmigrainesurgery.com today, and call 415-751-0583 for appointments.

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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.

In 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, please visit www.peledmigrainesurgery.com and call 415-751-0583 to set up an appointment.

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HOW MANY HEADACHES IS TOO MANY?

headache surgeryOver the past year or so, I’ve noticed that many patients are being told by their other treating “headache doctors” that they shouldn’t consider surgery for their problem because their headaches are “not bad enough”. Patients are often so struck by these remarks that many wonder whether this statement represents actual medical fact and repeat it to me as if it were empirically true. They then ask me if I agree with that concept. My answer is always the same, “The only person who can say whether the pain you’re having is too much, is YOU.”

Pain by definition is a subjective experience. There is no objective way to measure it such as with a blood test or an MRI. This fact represents one of the biggest challenges in treating people with pain. Moreover, what I’ve gleaned is that it’s not only the actual episodes of pain that often constitute the greatest burden to people. Many times it is the constant lifestyle adjustments and manipulations often required to stave off the onset of pain that are the most difficult for people to manage. Patients often have to avoid social situations they’d like to be in, avoid foods they love to eat, and avoid activities they used to love participating in. To add insult to injury, I’ve also been informed by patients that their other “headache doctors” told them that they would terminate them as patients if they undergo surgical decompression.

I find such statements quite sad because they often leave patients very conflicted perhaps due to the fact that this other doctor has provided some measure of relief that they are afraid they will lose if they pursue other options. It also goes against my general opinion of how chronic headache pain (and all chronic pain for that matter) should be managed. I believe that a multi-modality approach that yields the best results. Just like in breast cancer treatment during which a patient often has surgery to remove the cancer with a breast surgeon, chemotherapy/hormone therapy with a medical oncologist and radiation treatment with a radiation oncologist. Only when these physicians work together do patients derive the optimal benefit.

Who then is anyone else to say how much any individual person should suffer? I believe that the role of the physician in these cases should be to establish a diagnosis if possible and formulate a treatment plan to address the pathology in question if possible often in combination with other clinicians. The physician should then educate the patient about his/her diagnosis and the possible treatment options. Patients must then decide for themselves based upon an evaluation of the potential risks and benefits of the proposed treatments which treatment options are best for them. The take home message - don’t let anyone else make a value judgment for you. They can’t.

To learn more about migraine treatments and peripheral nerve surgery, call 415-751-0583 and visit www.peledmigrainesurgery.com to set up an appointment!

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Is it true that because I’ve had RFA to my occipital nerves, that I’m not a candidate for surgery?

headache, migraine surgeryThis statement represents a common misconception. First of all, let’s define ‘RFA’ or radiofrequency ablation. Simply put, this treatment modality uses radio waves at a high frequency to ablate a structure, in this case a nerve. The term ‘ablation’ actually means to surgically remove a body part or organ, but since RFA is performed with probes through the skin (i.e. percutaneously) it essentially means to destroy the nerve. The probe tip is hopefully placed close enough to the nerve in one or more places such that when the radio waves are passed through it, the tip heats up and completely destroys the nerve which theoretically should be equivalent to surgically excising the nerve.

In reality however, this approach has a number of significant drawbacks. First, if the RFA probe tip is not placed in the exact correct position, the nerve is not completely destroyed. As a peripheral nerve surgeon who routinely uses high powered loupe magnification and operative microscopes in the operating room to find, decompress and/or repair nerves I can emphatically state that nerves are often small and very difficult to find, even when looking at them directly with magnification. Moreover, they are often encased in scar tissue which is tough and can be difficult to penetrate with a scalpel or scissors, much less a tiny probe. Thus if the RFA probe tip doesn’t target the nerve just right to completely destroy it, it creates a thermal zone of injury around the nerve. Sometimes this “stuns” the nerve (i.e. neurapraxia) and there is temporary relief (a few days, weeks or months) until the nerve recovers at which point the pain can return. Other times the thermal zone of injury is far enough away from the nerve that the nerve itself is not affected. In this case, not only can the original pain remain unchanged, but other structures around the nerve can be damaged secondary to formation of scar tissue thus leading to more pain. In addition, one of the maneuvers required when intentionally cutting a nerve is to bury the proximal nerve end into muscle because doing so can significantly reduce the chances of a painful neuroma forming. A neuroma is a regenerating nerve that can cause significant pain. Think of a downed power line in the middle of the street writhing like a snake with high voltage sparks coming out of it. Hence, even if the RFA probe successfully ablates a nerve, but does so in an area where the remaining viable nerve is not surrounded by muscle, a painful neuroma can form leading to more pain.

Now, no procedure is foolproof and peripheral nerve surgery for headaches requires general anesthesia and all the risks that the former and latter entail. But, performed in an accredited institution by a properly trained surgeon, the rates of complications are very low and the complications that do occur are relatively minor. I also believe that the best way to determine whether a nerve is salvageable and can be decompressed or is too injured and must be either excised and buried or reconstructed is to look at it directly in the operating room. So what to do if you’ve had RFA and still have pain? See a peripheral nerve surgeon for a formal evaluation to determine whether surgery is possible and if so, have a frank discussion of the operative plan beforehand. After all, even if the nerve is found to be severely damaged in the operating room, there are still options which can lead to significant pain relief.

For more information, please call 415-751-0583 to setup an appointment and visit www.peledmigrainesurgery.com today to learn more about peripheral nerve surgery.

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Migraine Relief May Be Closer Than You Think

The nerves causing your headaches are typically located in one of four different locations within the head and neck region. The first site is between the eyebrows, also known as the glabella. The nerves that can become compressed in this area are known as the supraorbital and supratrochlear nerves. These nerves can become pinched by the muscles within this region that cause the frown lines with which many of us are familiar. The next site is the temple region and the nerves which can be compressed in this area are called the zygomaticotemporal nerves and auriculotemporal nerves. These nerves can become compressed by one of the muscles used for chewing (the temporalis muscle) or by an artery which can wrap itself around one of these two nerves or its branches. The third area that can be a trigger zone for chronic headaches is the back of the head and the nerves in this area which can be the cause of trouble are known as the greater, lesser and third (or least) occipital nerves. These nerves can be compressed (i.e. pinched) by the strong neck muscles which can be in spasm, by the sinew that surrounds them or by other small blood vessels which can wrap themselves around these nerves as well. Finally, nerves within the inner lining of the nose can also become irritated and result in chronic headaches such as migraines.

Once the nerve or nerves causing the problem have been correctly identified, an outpatient surgical procedure can be performed to remove the mechanical compression causing the nerve irritation. This procedure is performed by making an incision through the skin, identifying the offending nerves, safely protecting them and removing any of the mechanically compressive tissues. In some situations, if the nerves are too damaged, they are actually removed, but only in areas where very little loss of sensation would occur. In many of these cases, patients often never know that a nerve has actually been excised.

A recent study from Georgetown University followed 190 patients who had migraines secondary to occipital neuralgia (i.e. peripheral nerve compression) and who underwent surgical decompression. At an average follow-up of one year, 80.5% of patients experienced 50% or greater pain relief and over 40% of the patients experienced complete relief of their headaches (Ducic, et al, Plastic and Reconstructive Surgery, May, 2009, 1453-1461). In addition, another study published just last year demonstrated that at 5 years post-surgery, these benefits persist with continued reductions in headache severity, frequency, and/or duration (Guyuron, et al, Plastic and Reconstructive Surgery, February, 2011, 603-608). Dr. Peled’s results are comparable to these results and as you can see by going to the ‘Testimonials’ page, many of his patients are now headache-free. It is estimated that migraines afflict over 35 million people in the United States alone. The annual cost to the healthcare system in terms of ER visits, medications, injections and lost productivity is estimated to be in the range of $15 billion per annum. Fortunately, the surgical treatment noted above has shown extremely promising results.

To learn more about migraine relief surgery, visit www.peledmigrainesurgery.com today and call 415-751-0583 to set up an appointment to see Dr. Ziv Peled.

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A Better Nerve Picture

Axon -mediumThis post will be a little different in scope than my usual ones, but I am excited about it nonetheless. One of you out there (LPC) recently posted an article about high-resolution ultrasound (HRUS) as an imaging modality for the lesser occipital nerves. I first want to say congratulations for posting this article. It is so wonderful to see people educating themselves in this manner. Of course, I immediately went and pulled the whole article myself, read it including several of the cited references and have a few thoughts. These points are not meant to be pejoratively critical; quite the contrary, I commend the authors on using this new modality in a novel way and think/hope their efforts will continue so that it may be available to many people in the future. So here goes….

 

1.)HRUS certainly looks promising as an imaging modality, but also has a few drawbacks. The technology requires a user with many years of experience, because even in the images demonstrated, the structures that are noted to be the LON and the surrounding muscles are not exactly clear. Two, as any formerly pregnant woman would tell you, US imaging often requires moderate pressure on the area being imaged to optimally delineate the structures being sought out and if you have ON, this pressure might be prohibitive. Three, likely one of the reasons even simple US is not used more commonly is that the companies selling these devices charge a hefty premium for them. I would guess that a HRUS machine would likely run between $85,000 - $150,000 or more making it a prohibitive purchase for most practices, especially when insurance reimbursements are decreasing. Hopefully as then technology improves and more studies demonstrate their utility and accuracy, costs will come down and you’ll see more of these machines around.

 

2.)The authors describe several patients in whom they sonographically identified lymph nodes as possible compression structures for the LON, but I can personally attest that after many such cases, I rarely find a lymph node in my travels and dissections. This experience is vetted by the published literature from Dr. Guyuron cited in the article. I would therefore, wonder if what the authors presume is a lymph node is actually another structure. The authors also don’t mention any vascular compression which I have seen on a number of occasions (perhaps a function of this being a new modality for a new application - see above). Future studies will tell.

 

3.)It is hard to tell how far cranially and caudally the authors went in imaging the LON. In other words, I would wonder if you could image the nerve behind the sternocleidomastoid muscle as I have found fascial bands in that area which compress the nerve. Therefore a negative HRUS may not mean there is no compression, as is the case with any diagnostic modality. Having said all of the above, I really believe that HRUS has potential to be a wonderful adjunctive imaging modality. As peripheral nerve surgeons, we could use it to visualize structures pre-operatively and perhaps help in diagnostic blocks as well as in following patients post-operatively, both those who improve (you can see if their nerves change in imaging characteristics post-op) as well as those that don’t.

 

4.)Finally and most importantly, this article appears in the journal Cephalalgia, an important clinical neurology publication and one, I believe, associated in some way with the International Headache Society. The manuscript and others like it that are slowly appearing in such journals represent some acceptance of the peripheral nerve compression paradigm as a cause for headaches. Many of the cited references are from articles by peripheral nerve surgeons. Hopefully this acceptance will expand as more such articles come out. Furthermore, I believe that credit for this progress comes in large part secondary to the efforts of the people in forums like this one. As you search for answers yourselves, you will find a lot of good and reliable information and I encourage you to share that information with your other treating physicians. The good ones will appreciate it. Kudos and keep up the good work. For more information, please read some of our other blog posts and follow us on Facebook and Twitter, and check out some of the available resources on www.peledmigrainesurgery.com to learn more.

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