Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

Dr. Ziv M Peled Wins Most Outstanding Paper at CSPS

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

 

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Ziv Presents

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

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

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

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

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WHAT IF I STILL HAVE HEADACHES?

What If I Still Have Headaches?

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

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

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

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

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CHRONIC MIGRAINE RELIEF

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

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

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

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Hey Dr Peled, What Is Peripheral Nerve Surgery?

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

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


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

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Aneurysmal Superficial Temporal Artery Compressing the Auriculotemporal Nerve

 

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

 

 

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

 

 

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

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

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

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

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

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

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Whiplash and Occipital neuralgia: what’s the CONNECTION?

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

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

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

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

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

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WHAT CAUSES OCCIPITAL NERVES TO MALFUNCTION?

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

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

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

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

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HOW MANY HEADACHES IS TOO MANY?

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

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

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

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

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

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

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

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

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

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

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Migraine Relief May Be Closer Than You Think

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

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

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

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

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A Better Nerve Picture

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

 

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

 

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

 

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

 

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

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What Kinds of Results Can I Expect From Migraine Surgery

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

The results with these types of procedures have been quite dramatic. In one study out of Georgetown University, data from 190 patients with pain/headaches in the back of the head who underwent surgical decompression were analyzed. Over 80% of patients experienced at least 50% pain relief and over 43% of patients experienced complete relief of their headaches! In February 2011, the five-year results of such procedures were published in the medical journal, Plastic and Reconstructive Surgery. These results demonstrated five years following their operation, 88% of patients still reported greater than 50% improvement in their headache symptoms and 29% were completely headache-free!

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

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Is Migraine Relief Available Outside of San Francisco?

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

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

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

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Does One Nerve Operation Fit For All Cases?

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

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

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

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

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

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

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

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

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What Happens After The Nerve Burial?

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

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Can Stress Make Occipital Neuralgia Worse?

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

 

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

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

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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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