0:31 I had a nerve block done about a week or so ago and haven't seen any benefit. How long should it take to kick in?
5:30 I had a decompression surgery with a physician in March 2016. I had pain relief for 1 year and now the pain is back non-stop. How long should I wait for this situation to calm down before considering another decompression surgery or resection?
9:40 Do you need to have a recent MRI of the cervical spine?
12:40 Have you seen more bleeding or pain control issues in redheads?
13:45 How far can a lead migrate if you get into a car accident after you have has a spinal stimulator or peripheral nerve stimulator implanted? Isn't there an anchor that will stop it moving too far? How far can a lead migrate before a lead no longer works?
15:55 Does the cause and duration of one's pain affect potential outcomes?
20:40 At what level of pain is a surgery not worth it?
23:14 What is the biggest risk of an excision?
ANATOMIC VARIATIONS IN OCCIPITAL NERVES
A couple of days ago I had another interesting case that highlights the variations in anatomy of the occipital nerves that we see from time to time. In the 1st picture, we see the classic anatomy of the right, greater occipital nerve (white arrow) which has now been decompressed from the surrounding semispinalis muscle. You can easily see the intact vasa nervorum (those red lines within the nerve which represent intact blood vessels indicating a healthy nerve. On the left side, you can see a bifurcated (i.e. split) greater occipital nerve with two branches (grey arrows) and an intervening piece of semispinalis muscle (the two thin black lines).
In the 2nd and 3rd pictures the intervening piece of semispinalis muscle is retracted medially (picture 2) and laterally (picture 3) to better demonstrate the two branches of the left GON. In the 4th picture, the intervening piece of semispinalis muscle has been removed and the two branches of the left GON are now meeting at a main trunk (white arrow). This case demonstrates that phrase I often tell my patients which is that “everyone is literally wired differently”. I hope you like these case presentations and that they are instructive as well as helpful in understanding the anatomy involved.
Click Photos To Enlarge.
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We are excited to have the results from our combined work on nerve grafting and preservation at the time of nipple-sparing mastectomy and implant reconstruction published in the open access arm of the largest international plastic surgery journal. The study describes our combined work to improve sensation for women who go through mastectomies and implant reconstruction for breast cancer or breast cancer risk-reduction. While other plastic surgeons have previously published studies looking at nerve grafting for breast reconstruction sensation with free flaps using women’s abdominal tissue for reconstruction, this is the first published study doing nerve grafting for women having implant reconstruction. This is important because many women either are not good candidates for flap reconstruction or would prefer not to have the additional recovery and surgical site required for flap reconstruction. Additionally, not all reconstructive surgeons routinely perform flap reconstruction, and thus the vast majority of women who have breast reconstruction have implants used.
Our study included both women having nipple-sparing mastectomies for cancer treatment and women having prophylactic mastectomies for genetic mutations or strong family history. We found that with carefully preserving breast skin nerves and doing nerve grafting to the nipples, most of the women in our study had close to complete return of breast skin sensation and feeling in their nipples after surgery.
To Read The Entire Article Click Here
For more information on this novel procedure, please contact our office at:
What is the biggest risk of an excision?
Can the vagus nerve be affected in the case of Occipital Neuralgia, stemming from dysfunction of the Atlas or the neck?
I had an Occipital Nerve stimulator and radiofrequency ablation (RFA) at many levels from C2 to C6 and my headaches are worse. After that I unfortunately fell. How long should I wait to come for a consultation?
If I'm a responder to occipital nerve blocks, would I be a candidate for this procedure?
I've suffered for 3 years with constant pressure and stabbing. It started as a weird pressure feeling then there was dizziness and balance issues. I have tried many different treatments. Is it possible that there is an artery or muscle that is compressing that nerve that is creating the pressure?
Do I need to have a recent MRI of my cervical spine?
Do you repair spinal stenosis?
If there is ongoing pain around the ears and jaws, with occasional flares of the occipital area, is the cause easily determined for surgery?
Have you seen more bleeding and / or pain control issues in redheads?
Before After After
What is your name? – Jodi Oldes
Where are you from? – Sacramento, CA
What was happening in your life before the headaches became chronic? – I don’t really recall a time when I didn’t have chronic headaches. I have had them as long as I can remember.
Describe a good day with chronic pain. – A good day would be a slight and controllable pain and the ability to be in the sun, smell a fragrance, and get through the day without triggering intense pain. Describe a bad day. What does/did the pain feel like. It felt like a vice on my head that was cinched tight with no relief, no position to sit, and then an ice pick feeling at the top of the cinched area.
Where did you experience the pain? – It was above my right eye moving up into the top of my skull or a band across the top of my head from ear to ear.
What meds were you taking? – all of them. Most recent was Imitrex, Maxalt, muscle relaxers, and a new shot.
Did you have any success with other pain relief methods besides medication? – I did chiropractic, massage, essential oils, magnesium supplements, vitamins, creams, IV fluids with vitamins, and cut my hair short.
How did you hear about Dr Peled? – I had researched Dr. Anne Peled for a different health issue. During my consultation with her, she referred me to her husband, Dr. Ziv Peled for my migraines. She requested that I be seen in his office, last-minute that same day, since I was coming from out of town.
What inspired you to speak with him? – I was on intermittent disability and my work was getting frustrated by my frequent absences. I needed to do something. I was spending 3 to 4 days a week in a dark room with a debilitating migraine. I had one month to figure out something or go on full disability.
Tell me about your surgery, including when you had it, what happened. – I had it the Friday before Christmas 2018. Recovery went well, slight bruising and little pain.
Do you remember how you felt in the first few days after surgery? – I kept up on my meds, slept, rested and felt good.
How are you feeling now? – Feeling fantastic. I get nervous when I get a slight headache but take Tylenol and it subsides.
How has your life changed as a result of this surgery? – I can go in the sun, I can work up a sweat without fear of a migraine. I can travel and know that I wilI be able to enjoy the trip. I am living a normal life.
What is next for you? – Continued living!
What would you say to anyone wondering whether to meet Dr Peled? – Don’t wait.
Describe your overall experience with Dr. Peled and his office. – The office team, Cary-Anne and Christina, couldn’t be nicer or more helpful!
Do you have any advice for prospective patients who are thinking of coming to the practice? – Don’t be scared. Ziv is a PHENOMINAL surgeon.
Ziv M. Peled , M.D. Presents Burning Migraine Questions for July 11, 2019. Dr. Peled discussed he following questions:
0:55 Following an Occipital Nerve Block I ended Up With a Pronounced Dent In the Back Of My Head
3:11 Can the Nerves That You Separate Go Back Together
5:03 My Neurologist Said He Didn't Want to Cut My Nerves Because He Said I Would Have A Burning Sensation All of the Time
7:16 Is it True That Autoimmune Diseases Can Make Occipital neuralgia Worse?
11:18 My Neurologist Says This Is Experimental - I Feel Guilty Going Against Their Best Judgement
19:14 What If Compression Is Done Higher Up On the Scalp?
As many of you are likely aware, there is a general disagreement between plastic/peripheral nerve surgeons and neurologists with regard to nerve decompression or transection and implantation as a treatment for chronic headaches. The main issue stems from the fact that chronic headaches such as migraines are considered to be centrally-mediated. What that means is that the headaches arise from any number of complex mechanisms within the central nervous system (i.e. brain or spinal cord).
From the viewpoint of the neurology community, this concept of chronic headaches (e.g. migraines) accounts for the overwhelming majority of the various headache subtypes recognized clinically (e.g. cervicogenic headaches, new daily persistent headaches, etc.). In contrast, surgical decompression (e.g. of the occipital nerves) is performed on the peripheral nervous system (i.e. nerves outside the brain and spinal cord). The possibility that peripherally mediated factors can cause or contribute to chronic headaches is relatively new, but has been around for over 20 years.
Plastic/peripheral nerve surgeons who perform headache operations feel that in some patients (e.g. those that have failed traditional treatment modalities, those that respond to nerve blocks and those that have a specific set of findings on physical exam), peripheral nerve compression is a critical causative factor in headache symptoms. Historically, these two camps have been at odds, but that dictum may be changing.
In a recent article in a prominent neurology journal (Blake and Burstein, The Journal of Headache and Pain, (2019) 20:76), two prominent neurologists, discuss the concepts and science behind peripheral nerve factors in the generation of headaches. Furthermore, they elaborate on the fact that some patients who have what they term ‘unremitting head and/or neck pain’ (UHNP) share many clinical features of patients diagnosed with other headache disorders (e.g. chronic migraine, NDPH).
The authors conclude among other things, that we lack an accurate classification system and nomenclature to describe these patients and that peripheral nerve surgery may be a reasonable treatment option for this subgroup of people. The scientific possibilities underlying these conclusions are also discussed in some detail.
I cannot emphasize how critical this paper is to those of us who have been championing the concept of headache surgery as a viable treatment option. It is also a huge milestone for headache patients themselves. I believe this manuscript is one of the first cracks in the dam that separates neurologists from peripheral nerve surgeons and might ultimately lead to wider acceptance of peripheral nerve causes for chronic headaches.
Working together, both neurologists and peripheral nerve surgeons have the best chance of convincing their respective colleagues that this notion is valid and advocate/work together to lobby for better insurance coverage and more scientific studies to further refine the patient population who would best benefit from surgical intervention as a primary or adjunctive treatment modality. I applaud Pamela Blake and Rami Burstein for their courage in putting their thoughts to paper in what I am sure will be a somewhat controversial topic amongst their own neurology colleagues, but one which will ultimately benefit millions of headache patients.
There 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 that 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 a human being the “capping” 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, 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.
One of the questions I find myself answering again and again is how I make the decision as to what to do with a nerve once I see it in the operating room. Do I perform a neurectomy and muscle implantation or do I stop at a decompression? There are a lot of factors that go into making that decision so I will elaborate on a few of these in the lines that follow.
To begin, there are certain ultrastructural characteristics that indicate a relatively healthy nerve. One, you should have an intact vasa nervorum – the blood vessels within the nerve. These can be seen under loupe magnification as fine red lines and indicate good blood flow to the nerve itself. Blood flow is usually a sign of life and this nerve should be considered for decompression and preservation. Another characteristic is the feel of the nerve. A healthy nerve should feel like a soft, wet noodle. If a nerve is firm like a banjo string, it usually means that there is at least scarring of the epineurium (the outermost covering of the nerve) and often the structures contained within. In these cases, an internal neurolysis to separate the healthy from unhealthy fascicles is required and if the scarring affects too many fascicles, a neurectomy with muscle implantation is probably the better part of valor. Third, the fascicular pattern should be visible. Think of nerve fascicles like bundles of wire (e.g. the blue one vs the red one in all of those movies in which the hero is trying to defuse a bomb) within an electrical cord. Stated differently, what you’re looking at when you look at a cord plugged into a wall is a rubber tube - the actual wires are the copper fibers inside that rubber housing. Those copper wires are analogous to the individual neurons (i.e. nerve cells) and in an electrical wire, are often arranged into bundles. In a nerve, those bundles of neurons are called fascicles. However, unlike the cord plugged into the wall, in a healthy nerve, the “rubber housing” should be transparent and the fascicular pattern should be visible. If it isn’t, the nerve isn’t completely healthy and those fascicles may be permanently damaged. Take a look at the attached picture of a recent patient whose supraorbital nerve branches (multiple black lines) and supratrochlear nerve (arrowhead) are visualized. Notice how white the supratrochlear nerve towards the right of the picture is and the lack of any fascicular pattern. In contrast, the supraorbital nerve branches towards the left are pink indicating an intact vasa nervorum and the fascicular pattern is visible if you look very carefully (and likely magnify the picture on your computer). Fortunately for this patient, the vasa nervorum re-constituted and the fascicular pattern became more pronounced once the supratrochlear nerve was decompressed and a few minutes were given for the nerve to declare itself – yet another nuance of technique. Therefore, both nerves were able to be preserved in this particular case.
Yet another factor to consider when deciding what to do with a nerve in the operating room is the actual function of the nerve itself. For example, the greater occipital nerve, as its name suggests, has the largest area of sensory distribution of any nerve in the occipital region. Therefore, performing a greater occipital neurectomy would leave the patient with a relatively large area of numbness. Personally, I have a relatively high threshold for transecting the GON. By contrast, the third (a.k.a. least) occipital nerve is many times smaller than the GON and has a minimal area of sensory distribution that is often also supplied in a redundant fashion by the GON. Therefore, if the third occipital nerve is damaged, I have a lower threshold for performing a neurectomy since it is likely the patient wouldn’t have much numbness, if at all, were that nerve to be cut and buried in a muscle. Lastly, is what I would call the “x factor”, in other words clinical decision making. I’m often reminded of a saying I heard once that went something like this, “Good judgement comes from experience and experience comes from bad judgement”. In other words, experience counts and takes into account a myriad of other variables before ultimately making decision A versus decision B. What was the mechanism of injury and how long ago did it occur? What other treatments have they had that might have affected the nerve along its length (e.g. RFA or cryoablation) and how many times have those modalities been performed? How did the patient respond to the numbness from the nerve blocks? How old is the patient and how likely is it that they would tolerate a repeat procedure if decompression fails? Alternatively, how young is the patient and what is their regenerative potential? If you cut that young person’s nerve, how would they tolerate 50 years of numbness as opposed to the 70 year-old patient who may only live with it for a few years and has many other medical problems more pressing than a little hypoesthesia. The take home message is that electing to perform a neurectomy as opposed to a decompression involves a multifactorial decision making process so have a frank discussion with your surgeon about how s/he will decide which path to take.
If I only had a dollar for every time I’ve heard this question…! I think this is a very reasonable and understandable query and gets at the heart of what it truly means to be a plastic surgeon. It reminds me of what one of my mentors once told me, which is: “Ziv, don’t go into plastic surgery unless you want to spend your whole career apologizing for your colleagues.” This mentor is a Full Professor of Plastic Surgery at Stanford University and is a full-time researcher. He has published over 1000 scientific articles in some of the top scientific journals (e.g. Nature, JAMA, Science) and is a member of the National Academy of Science. The problem with this question is that it implies that plastic surgeons are only known for performing cosmetic surgery. However, we do so much more.
If you have breast cancer, it is a plastic surgeon who will reconstruct your breast. If you are shot and have a large hole in your leg that requires tissue be moved from your back to cover the hole in your leg, it is a plastic surgeon who will perform that operation. If you have a cleft lip or palate, it is a plastic surgeon who will repair it. If you have a child born with a prematurely fused skull, it is a plastic surgeon who will fix it. If you need a face or arm transplant, it is a plastic surgeon who will lead that surgical team. If you cut a finger or arm off, it is a plastic surgeon who will replant it.
As you might appreciate given the breadth of these cases, we as plastic surgeons operate all over the body, on both young and old patients alike and on many of the bodily tissues such as skin, muscle, fat, bone, and of course, nerves (e.g. in the replantation of an extremity or face transplant). Some of us have dedicated the majority of our practices to peripheral nerve surgery and perform operations on hundreds of nerves each year. That background gives us a unique skill set and degree of experience that is shared by few others.
When it comes to headaches and migraines, they are generally considered to be disorders triggered within the central nervous system and many patients are successfully treated in this way. However, for those who have head pain as a result of mechanical compression of nerves, causing occipital neuralgia or trigeminal branch neuralgia, the treatment needs to occur within the peripheral nervous system. Neurosurgeons predominantly operate on the brain and spinal cord. There are exceptions to be sure, but the majority of neurosurgeons have an expertise in the physiology and surgical treatment of the central nervous system. In contrast, many plastic surgeons have significant experience with peripheral nerves, and thus are much better positioned to work in the peripheral nervous system.
Hope that helps clear up some of the confusion. We clearly need to do a better job as a society, telling the world what exactly it is that plastic surgeons really do.
I hear this question quite often 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 and or neurolysis procedure.
As 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 nerve swelling after an operation is similar to pouring water into the drywall in your house near the electrical wires – doing so will cause the lights to flicker on and off until the water dries up because the fluid is interfering with efficient electrical conductivity. 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 several 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 (sometimes decades) - 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, we don’t immobilize our heads after surgery because doing so would stiffen all the joints and increase the likelihood that the nerve will become re-entrapped in scar. As a result, the nerves will glide right away after we manipulate them and also likely contributes to the lengthy 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.
Chronic headaches continue to be a huge burden on the American healthcare system accounting for tens of billions of dollars in both direct and indirect costs annually. These financial considerations don’t even take into account the psychological and emotional toll that this form of chronic pain has on those who suffer with it. Migraines themselves are felt to afflict as many as 12% of the US population. As much as 2% of the world’s population suffers from chronic migraines, which by definition, means that traditional treatment modalities have failed. As I sat on the plane coming back from a recent conference, I began to reflect on the fact that we really need to step back and re-think how we approach this problem.
Over the years that I’ve been operating on patients for chronic headaches, a consistent thread is peoples’ frustration with their current care because their symptoms are not under control. I hear constantly about confrontational patient-physician interactions or negative patient-health system interactions as these patients express that they feel their doctors aren’t listening to them or keep going around in circles with regard to treatment. The “best” of these interactions seem to be when their doctors plainly tell them they don’t know what more they can do – itself a frustrating and demoralizing thing to hear. To all of those patients I say that I completely empathize and validate that they have every right to feel as they do. Having been a patient on several occasions myself, I know what it’s like to speak with a physician or an insurance adjustor and feel like you are talking to the wall - and I’m a healthcare practitioner.
As a peripheral nerve surgeon, especially one that operates on people with chronic, intractable headaches, I have heard criticisms from other doctors whom I don’t feel even understand what it is that I do. However, I’ve learned that by putting myself into the shoes of that doctor across from me I can almost always find common ground. Happily, that common ground is as advocates for our patients. After all, we physicians are (or should be) on the same side as our patients in trying to treat any medical condition. Therefore, I believe that teamwork is particularly and practically helpful and there are already paradigms for this approach that work very well.
Breast cancer is sadly a disease that touches too many people throughout the world. Over the past few decades, the medical profession has made incredible strides in fighting this dreaded disease and we now have cancer remission rates that were once thought impossible. One of the biggest factors in helping this development along has been the team approach. In our community, a patient with a new breast cancer diagnosis is immediately given a team of physicians and clinicians to help them navigate the process that is current treatment. To be sure, there is a “captain of the ship”, usually the breast surgeon or oncoplastic surgeon who is coordinating all of the moving parts, but every member of the team is critical to ensuring success. The breast surgeon may remove the actual tumor, the plastic surgeon will help reconstruct the resultant defect, a radiation oncologist will ensure that any disease that might have spread locally is controlled and a medical oncologist will determine if the risk of distant disease is high enough to warrant a regimen of chemotherapy or hormonal therapy. There is also often a psychologist and nurse navigator who can help the patient deal emotionally and psychologically with the emotional rollercoaster accompanying a cancer diagnosis. Only when you put all of these components together, do you get the wonderful results that modern medicine has been able to achieve.
For years I have been hopefully telling my patients that someday soon, we will realize that chronic pain (of which chronic headaches are a prime example) is also best treated with a multi-modality approach. There are certainly many patients for whom medication works very well. Those people do not need injections or surgical intervention. There are those for whom pharmacologic agents are simply ineffective and in those cases, nerve decompression may be a good option. However, for most, a combination of therapies is necessary to control the underlying symptoms. I have heard from countless patients who tell me that prior to surgery their medication was inconsistently helpful. Following operative intervention, their headaches are much less frequent and often much less severe, but what was interesting to me was that they would tell me that when they would get an attack, the medication they’d been using for years was now consistently effective. “Why is that?” they would ask. I felt it was likely that they had two problems contributing to their headache symptom complex. One was a chemical imbalance that medication would treat, and the other was a mechanical compression of a nerve(s). Only when both conditions were adequately treated, would the symptoms be optimally managed.
The take home message is that many medical conditions are best managed when we work together. Not just as patients and physicians, but as physicians and physicians. I have had great success locally with neurologists and pain management physicians as we not only refer to each other, but also actually talk to each other about our shared patients, recognizing that we each have a role in their care. Those that have seen me know that I often like to communicate with the very same such doctors prior to surgery to ensure we can optimize the post-operative recovery period which certainly can have its share of ups and downs. In the end, we all have to partner in this endeavor together as a team if we hope to triumph.
I have been asked many times 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 an 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.
Someone recently asked this question on one of the forums and I thought it was a very good question the answers for which may not be immediately clear. First of all, I think it is important to define exactly what is meant by ‘neuralgia’. The prefix ‘neur’ simply refers to a nerve and the term ‘algia’ means pain. Therefore, simply put, neuralgia means pain cause by a nerve or nerves. The question always becomes which ‘neur’’ is causing the ‘algia’? Then, if you can answer that question, can you then do something about it?
Occipital neuralgia (ON) is a neurological condition in which the occipital nerves are irritated or compressed (i.e. pinched) and hence cause pain. The typical symptoms are episodic (i.e. paroxysmal) bouts of “lightning-like” pain in the back of the head although as many of you know and as I have blogged about many times, the symptoms can vary widely. Because each person is unique, they will each experience pain differently. Similarly, trigeminal neuralgia (TN) is a neurological condition in which the main trigeminal nerve trunk is compressed. Not surprisingly, the classic symptoms are episodic bouts of “lightning-like” pain in the face which are the areas innervated by the various branches of the trigeminal nerve. These sets of nerves are not physically connected so why is it that ON often co-exists with TN? The answer lies in the anatomy. I will have a picture of a peripheral nerve included in this post to help illustrate the points I make below.
Many people don’t know that that the upper-most, neural elements in the neck (e.g. the occipital nerves) have a common connection zone in the medulla (part of the brain stem) with nerve cell bodies that become the trigeminal nerve. This zone is known as the cervico-trigeminal complex and can potentially explain why discomfort from lesser occipital neuralgia may sometimes be referred to trigeminal nerve territories anteriorly. Referring to the image of a neuron (i.e. nerve cell) below, you can see that when the long part (axon) of the nerve is injured (e.g. in a whiplash accident), the whole nerve becomes inflamed including the cell body. This injury is depicted in #1 in the attached image. When the cell body of a cervical nerve (e.g. one that becomes the greater occipital nerve) is chronically inflamed, the adjacent cell bodies (e.g. those that become a trigeminal nerve branch – for example, the supraorbital nerve) also become inflamed. This injury is depicted in #2 & #3 in the attached image. Then the axons of those latter nerves cause pain in their respective nerve distributions (e.g. in the forehead in the case of the supraorbital nerve). This injury is depicted in #4 in the attached image. In this way, an injury to the GON can ultimately result in forehead discomfort. To use an analogy close to home here in California, think of it as a forest fire that has burned too long and the embers from one part of the forest jump the clearing to the adjacent wooded area and cause a fire there.
Hopefully, it now becomes clear why ON and TN often co-exist. It is usually the case that one begets the other and I have seen countless patients in my office whose pain started in the neck area and eventually spread elsewhere. Fortunately, the process can also reverse itself if the inflammation/irritation of the involved nerve branches can be addressed.
A couple of weeks ago, we talked about the definition of a migraine, which in many practical instances is simply a name given to a constellation of symptoms. We also spoke about occipital (meaning back of the head) and neuralgia (meaning nerve pain). When all is said and done, however, the real question is: “Can you figure out which ‘neur’ (i.e. nerve) is causing the ‘algia’ (i.e. pain)?” Is occipital neuralgia therefore considered a headache?
Well, yes and no. occipital neuralgia can give you symptoms of a headache because it can cause head pain and any head pain is by definition a “head ache”. Can occipital neuralgia fall under the definition of or be considered a migraine? The answer to that question is also technically, “yes”’ because all the clinician and patient will “see” is the presence or complaints of head pain that is this level of severity, this frequent (often constant), associated with these other sensations (e.g. pulsation/throbbing, light sensitivity, nausea) and this duration (usually several hours or more at least). These characteristics are now established, but say nothing about the cause of the headaches. Is it a chemical imbalance, an issue of an inflamed blood vessel or a compressed nerve?
The upshot is that so many of the patients who come to see me have been diagnosed with migraines which is not necessarily inaccurate, it’s just not very specific. Many people who have been diagnosed with migraines do find a conventional treatment modality that works for them (e.g. medication).
However, there are also many millions who don’t have success with these traditional modalities and the reason is because the diagnosis of “migraine” doesn’t tell you what’s causing the problem and therefore how to fix it. Those people end up being treated “empirically”; in other words, it’s like throwing darts at a dartboard - try this drug, or that drug or these drugs together or these drugs with massage, PT, acupuncture, etc. to see if you can find something that works.
What practitioners are really trying to do is figure out what problem - chemical imbalance, muscle tightness etc - is causing the issue by eliminating factors one by one using trial and error. At its essence, actual occipital neuralgia is the result of pressure on a peripheral nerve(s) in the occipital region. If you can figure out which nerve(s) is involved, in many cases, the headaches can be significantly improved or completely relieved by surgical intervention.
To learn more about Occipital Migraines or schedule a consult with Ziv M. Peled, M.D. visit www.peledmigrainesurgery.com today.
These days, whenever I read the news or look online, the world can seem like a pretty bleak place. The political divide remains, natural disasters abound, and trade wars are imminent. However, just when things seem pretty dark, little rays of light seem to peak through the clouds. This past weekend, I had the distinct honor and privilege to serve on a panel about migraine/headache surgery at the international meeting of the World Society for Reconstructive Microsurgery in Bologna, Italy. I was speaking and interacting with several esteemed colleagues in this burgeoning field from around the world. Amongst the highlights of this event (and there were many) was the feeling amongst several of my colleagues that a few neurology counterparts in their communities had begun to embrace the idea that surgical intervention might just have a role in the treatment of chronic headaches.
It reminded me of the time Dr. Pamela Blake spoke on our on our panel teaching headache/migraine surgery at the American Society of Plastic Surgeons annual meeting two years ago. Dr. Blake is a board-certified neurologist, an active member of the American Headache Society & International Headache Society and former Director of the Headache Clinic at Georgetown University. She remains active in research in behavioral neurology and cognitive science and served as volunteer faculty at the Cognitive Neurosciences Section at the National Institutes of Neurological Disorders and Stroke at the National Institute of Health. As impressive as this resume is, perhaps the most impressive thing to me, however, is that Dr. Blake is a firm believer in the concept that peripheral nerve pathology is a very under-recognized factor in the generation of chronic headaches for many people. Just last year, she published an article detailing some success with the surgical approach in Cephalalgia, a peer-reviewed journal and the official Journal of the International Headache Society.
While this fact may seem trivial to many, I cannot overstate what it means to those of us who have been banging on this door for over ten years. Since 2000, there have been over 80 scientific articles from numerous centers across the US, Europe and Asia detailing positive outcomes from nerve decompression surgery for chronic headaches such as migraines. Last year the American Society of Plastic Surgeons issued a formal policy statement that headache/migraine should no longer be considered “experimental” when other treatment modalities have failed.
If someone with Dr. Blake’s background and training can be convinced by the available evidence and our results with headache surgery patients that we are onto something, then perhaps others can be convinced similarly. In my humble opinion, this change would be nothing short of revolutionary as it would finally give peripheral nerve surgery a seat at the table in the armamentarium of modalities that could be considered in the treatment of chronic headaches in particular and perhaps chronic pain in general. Perhaps in the not-too-distant future we will see positive position statements from various other societies and if things go really well…. a change in the overall medical establishment’s perspective. When I think of the hundreds of thousands of people who may find relief from the scourge of chronic headaches like migraines, a big smile begins to creep across my face. Dare to dream big….. I remain ever hopeful, but more optimistic with each passing day. The longest journeys begin with the smallest steps.
The title of this post is really the $60,000 question. I have posted many times in the past about how ON 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. I have attached a link to one of the more interesting ones as part of this post. One of the most surprising comments contained therein 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 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.
Learn more about Occipital Neuralgia and Migraine Surgery from Ziv M. Peled, M.D. at www.peledmigrainesurgery.com now.