Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

The Occipital Artery Compressing The Occipital Nerve

Occipital Nerve Occipital Artery

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

 

 

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

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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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HOW COME THE MEDICATION WORKS BETTER NOW?

 

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

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

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

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THE MRI WAS NEGATIVE…..NOW WHAT?!?

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

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


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

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

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

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

 

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

 

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

 

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

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

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

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

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

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More Information On the Occipital Artery and Greater Occipital Nerve

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

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WHAT CAUSES OCCIPITAL NERVES TO MALFUNCTION?

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

 

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

 

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

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Worldwide Migraine Headache Relief

Do you have to live in the San Francisco Bay Area to get relief from your severe, chronic headaches? No, anyone may be able to achieve significant and lasting relief no matter where they call home! We have helped patients from all across the United States, and as far away as India and Brazil. We are excited to help people from all over the globe as peripheral nerve surgery is an area to which I have dedicated a large portion of my practice and is something about which I remain very passionate. We wish to extend an invitation to everyone anywhere to look us up and decide for themselves whether we might be able to help to reduce or eliminate their chronic headaches with peripheral nerve surgery.

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

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

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Why Do Nerves Take So Long To Recover?

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

 

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

 

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

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Why Are Plastic Surgeons Doing Nerve Surgery?

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

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

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

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

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What Are The Long-Term Effects Of Botox?

My name is Dr Ziv Peled. Welcome to the blog for my practice, Peled Migraine Surgery. My work as a Plastic Surgeon at Peled Migraine Surgery.has given me the experience needed to treat nerve and migraine issues here in San Francisco.
Several people have recently asked about the long-term effects of Botox treatment.  Happily or unhappily (depending on your perspective) this will be a relatively short post as very little is known about the long-term effects of repeated Botox injections.  There are likely a number of reasons for this fact. First, keep in mind that Botox is used for many different clinical conditions such as chronic headaches, blepharospasm (spams of the eyelid - the condition for which Botox was first developed and studied), spastic paresis in cerebral palsy and of course for cosmetic reasons. Secondly and because of the first reason, Botox is used in many different doses, places and frequencies making its long-term effects hard to study.  Even for chronic migraines, there are many different treatment algorithms (i.e. dosages and patterns of injection) amongst clinicians using Botox. Third, there are now three FDA approved versions of botulinum toxin type A (Botox® made by Allergan, Dysport® made by Ipsen, and Xeomin® made by Merz) each with slightly different formulations and hence clinical properties.

Botox InjectionOne of the few truly long-term follow-up studies I have found regarding botulinum toxin type A (in this case Botox®) was out of Jordan, Turkey and the University of Cincinnati.  In this study, chart reviews were performed on 32 patients who were being treated for hemi-facial spasm and blepharospasm and had had at least one Botox injection annually for at least 10 years (some patients had been treated for 20 years).  The findings demonstrated a need for a slightly higher dose of Botox to be effective over time and a decrease in the number of adverse effects (i.e. complications) over time. No life-threatening or systemic complications were reported, only localized ones likely relating to the function of the drug at the site of injection. Several other studies with follow-up between 6-15 years have found similar results.  The latter finding is likely a function of greater experience treating patients after many years and improved injection techniques.  The former finding can be related to a number of potential causes.

Prolonged treatment with botulinum toxin type A has been shown to result in the development of neutralizing antibodies which are thought to decrease the efficacy of the toxin.  Risk factors for the development of such antibodies are the formulation of the toxin, the frequency and dosage of the injections and the conditions for which the injections are being used.  Decreased efficacy (and hence the need for higher doses) may also be a reflection of the progressive nature of the disease being treated.  In other words, if the nerves are progressively injured by the disease process, they may require higher doses of Botox for clinical effectiveness. The take home message would be that Botox appears to be relatively safe and effective in long-term use although very few studies have been done to test this concept formally and none with occipital neuralgia.  Therefore, in my hands botulinum toxin type A remains a diagnostic test which, if effective, means that no more botulinum toxin type A needs to be injected - the patient is a candidate for decompression.  After all, in ON we are talking about a mechanical compression of the nerve(s) by a physical structure (muscle, fascia, blood vessels) and no amount of medicine will make that go away.

For more information on the effects of Botox, and how Migraine Surgery can help relieve Migraine symptoms and pain, visit www.peledmigrainesurgery.com today, and call (415) 751-0583 for an appointment.  Contact the author at This email address is being protected from spambots. You need JavaScript enabled to view it..

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WHAT’S THIS TRIGEMINAL NEURALGIA THING?

Several people have recently asked about trigeminal neuralgia (TN) and how it may relate to chronic headaches.  Trigeminal neuralgia is classically thought of as being caused by compression of the trigeminal nerve (root) near the pons (a part of the brain) or the trigeminal sensory ganglion (its sensory component) in the middle cranial fossa (another part of the inner skull) near another part of the brain.  The primary cause of TN is thought to be compression of the trigeminal nerve by an abnormal blood vessel inside the skull.  There is sometimes another term used, trigeminal neuropathy, which usually relates to TN caused by issues other than blood vessel compression such as herpes zoster, post-traumatic pain, or other space occupying lesions such as brain tumors, benign or malignant. Hence this problem is typically thought of as a central nervous system issue.  Again, the central nervous system to doctors simply means brain or spinal cord.

The symptoms of trigeminal neuralgia are very narrowly defined and include severe, unilateral, paroxysmal, electric or stabbing attacks that last a few seconds to a few minutes, in the distribution of one or more divisions of the trigeminal nerve and in the absence of other identifiable neurologic disorders.  In this regard, TN is very much like occipital neuralgia whose symptoms are defined in extremely specific ways.  These two disorders thus stand in sharp contradistinction to other headache disorders like migraines, cluster headaches and tension headaches whose symptoms are often generic, quite varied and hence overlap significantly.  It is for this reason among others that I feel ON and TN are extremely misunderstood and underdiagnosed.

So how does TN relate to headaches?  Well, the trigeminal nerve is the primary sensory nerve to the face, forehead and temporal scalp.  Therefore, injury to this nerve can cause facial pain, or frontal/temporal pain, the latter often perceived as forehead or temporal headaches. The supraorbital, supratrochlear, auriculotemporal and zygomaticotemporal nerves are all branches of the trigeminal nerve. The first two are responsible for sensation to the forehead and above/between the eyes and the latter two for sensation to the anterior and posterior temporal scalp.  Hence compression or irritation of these sensory nerve branches can cause pain in their distributions.  For example, as I have posted before (photos included), the auriculotemporal nerve is often compressed by the adjacent superficial temporal artery.

Hence there can be compression both in the central nervous system as noted above and in the peripheral nervous system as in the example just cited, but both involving the trigeminal nerve.  The former requires a neurosurgeon because in order to access the compressive element (blood vessel or tumor) near the brain, the skull must be cut and the compressive element removed.  This compression usually involves the entire trigeminal nerve or a large part thereof. The latter doesn’t require anything be done to the skull and is performed on the tissues (e.g. nerves, blood vessels, connective tissue) external to it, addressing one or more trigeminal nerve branches. Therefore, I believe the more precise term for compression/irritation of these peripheral nerves should be trigeminal branch neuralgia and it is these compression syndromes that I and Drs. Guyuron, Ducic, Hagan, Janis, etc. treat with our decompression procedures.

One last point: several people have wondered whether these peripheral nerve decompression procedures are “minimally invasive” and the answer is, “It’s all relative”.  I guess compared with using a saw to remove part of the skull and exposing the brain and other nerve roots, the answer is yes. That type of procedure is done in a hospital and often requires a multi-day hospital stay.  However, even though the peripheral nerve decompression procedures noted above are outpatient cases and are performed at accredited surgery centers, they are real operations and are not to be taken lightly.  They require skill and experience as the nerves are quite small peripherally.  They require general anesthesia because the patient must be positioned carefully and be perfectly still because the nerves are so small. And they require incisions, so compared with an MRI or trigger point injection, they are invasive.  Having said that, like the procedures for ON, they can be very effective with relatively low complication rates and risks.

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

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

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

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

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

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

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

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Whiplash and Occipital Neuralgia: What’s The CONNECTION?

My name is Dr Ziv Peled. Welcome to the blog for my practice, Peled Migraine Surgery. I live in San Francisco, CA and work as an Plastic Surgeon at Peled Migraine Surgery.
I 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!

 

headache - mediumOne 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 straight talk about how surgery can help you, contact Peled Migraine Surgery at 415-751-0583 and visit www.peledmigrainesurgery.com today.  Reach the author at This email address is being protected from spambots. You need JavaScript enabled to view it.

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WHAT TO LOOK FOR WHEN CHOOSING A “HEADACHE SURGEON”

My name is Dr Ziv Peled. Welcome to the home page for my practice, Peled Migraine Surgery.: www.peledmigrainesurgery.com I live in San Francisco, CA and work as an Plastic Surgeon at Peled Migraine Surgery.

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

 

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

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

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

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

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

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

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

I’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.

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Neuroma 101

Neuroma 101

First of all, what is a neuroma? A neuroma can be defined in one of two ways. One, as a tumor composed of nerve tissue such as an acoustic neuroma. Almost overwhelmingly, these tumors are benign. The more common usage of the term neuroma means a mass of nerve tissue consisting of regenerating nerve fibers that have been previously severed or injured somehow. When a nerve is injured, it tries to re-grow - that’s what nerves do. If that nerve re-grows into the scar at the skin, it can cause exquisite pain even with light touch in the area. This situation would be akin to having a cavity (which hurts because the nerve at the root of the tooth is exposed) and eating ice cream - ouch! So if a nerve is severed or injured in some other way, how do you prevent a neuroma from occurring?

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Medication Overuse Headache (MOH) or ‘Rebound Headaches”

Medication Overuse Headache (MOH) or ‘Rebound Headaches”

I have been asked recently to write a little something about so-called “rebound headaches”.  This topic can be quite confusing, and as you will read, is not very well understood.  The precise medical term for this disorder is Medication Overuse Headache (MOH) or analgesic rebound headache.  The prevalence of this problem is about 1% in the general population and as with many types of headaches, is higher in women than in men.  The underlying mechanisms for MOH are unknown, but as with many medical problems, are oftentimes multifactorial.  It is known that there can be a genetic predisposition to MOH.   In addition, long-term exposure to opiates is known to cause changes in the nervous system through increased expression of specific cytokines (chemicals, e.g. Calcitonin Gene-Related Peptide) and increased activity of certain neural pathways felt to modulate the sensation of pain.  Some people also feel that addictive personality disorders are associated with MOH. Interestingly, migraines are the thought to be the most common “primary headache disorder” that has been linked to MOH. The bad news is that just about any medication used to treat chronic headaches has the potential to lead to MOH.

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BLOCKS & STIMULATORS & DECOMPRESSION, OH MY?!?

BLOCKS & STIMULATORS & DECOMPRESSION, OH MY?!?

I’ve noted that there has been some confusion lately over the roles of nerve blocks, nerve stimulators and nerve decompression in the treatment of chronic headaches. To be sure, there will be variations in how each clinician may use these modalities, if only because each patient presents a unique clinical dilemma.  While I certainly can't speak to the ways in which others utilize these modalities, I can offer general guidelines as to how I use them in my practice.  Hopefully this information will also provide some insight into the advantages and disadvantages of each.

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