Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

Three Reasons Why Nerves Become Compressed

nerves-3115722_1280

nerves 3115722 1280

Patients are often asking me why nerves become compressed and what causes the compression. Many different structures can cause nerve compression and there are any number of biologic processes that can also result in nerve pressure on a nerve. However, after distilling it down to its basic essence, there are, in my humble opinion, three reasons why nerves can become compressed and I will list those below.   The key thing to remember is that all peripheral nerves travel some distance going from the spinal cord to the structure(s) they innervate.  Along the course of their travels, they pass along many other structures and through many little spaces.  The most common example is the carpal tunnel.  Most people have heard the term ‘carpal tunnel syndrome’ and this clinical entity occurs when the median nerve experiences undue pressure as it passes through a normal anatomic canal known as the carpal tunnel in going from the wrist to the hand. 

Using the carpal tunnel example, the first basic thing that can cause pressure on a nerve is if the nerve swells within a fixed space.  The carpal tunnel is bounded, by bone and ligaments and like the skull, will not expand.  Hence when the median nerve is swollen passing through that fixed space, there is pressure on that nerve that didn’t exist when the nerve was not swollen. As the wrist flexes back and forth, that nerve is asked to glide back and forth as well and because it no longer glides as easily, there can be trauma to that nerve that may further exacerbate the damage caused directly by the pressure. 

Nerve Surgery Before

Nerve Surgery After

Another basic factor that can cause nerve compression is if the nerve is passing through a fixed space, but that space becomes narrowed.  A prime example of this phenomenon would be arthritis.  Recall that any ’itis is an inflammation of something.  Mastitis is inflammation of the breast, colitis an inflammation of the colon and so forth.  Arthritis is an inflammation of the joints and the wrist joint is one prime example.  Therefore if a normal sized median nerve is trying to pass through an inflamed wrist joint, there is less room to allow passage and once again the nerve becomes compressed.  Similarly as in the above example, as the wrist moves back and forth, the nerve is unable to glide as easily and the same pathologic processes noted above likely occur.

The final basic factor that can result in nerve compression is a combination of swelling of the nerve and narrowing of the space through which it is trying to pass. In this case, the nerve is often very compressed.  Putting these three basic principles into play, one can also see that there are many structures that can cause these problems.  For example, in the case of the greater occipital nerve, it often passes through a narrow fascial window comprised of the insertion of the trapezius muscle at the base of the skull. At around this level, the GON also passes in close proximity to the occipital artery.  If the artery is enlarged (e.g. aneurysmal secondary to trauma) the space through which the nerve passes is by definition narrowed.  Moreover, the beating of that larger blood vessel against the GON may be one reason why many people report a “pounding” headache.  Alternatively, the supraorbital nerve is theoretically supposed to pass from the back/top of the eye socket to the forehead through a notch in the frontal (i.e. forehead bone) known as the supraorbital notch.  In some patients, however, that notch is actually a bony foramen - in other words the nerve is completely surrounded by bone.  Bone is therefore the culprit here and the treatment is to convert that foramen into a notch.  I have attached two pictures that illustrate this maneuver.  The take home message is that the causes of nerve compression are actually simple in their most basic form, but a thorough knowledge of peripheral nerve anatomy and experience in peripheral nerve surgery are key factors in putting these principles into action and in achieving a good outcome from surgical intervention.

Continue reading
  5921 Hits
1 Comment
5921 Hits
  1 Comment

An Olympic Crash and Migraines

An Olympic Crash and Migraines

If you’ve been paying attention to the Winter Olympics in South Korea, you might have seen American luger Emily Sweeney crash on her fourth and final run at approximately 68 miles per hour.  It was clear that she was initially stunned, but happily was able to get up and walk away on her own.  Sometime later, she was being interviewed by a reporter from NBC and stated that she was ok adding that she was also very sore and stiff and was about to get an x-ray of her back.  Obviously, we all hope that Ms. Sweeney has no significant, permanent injuries and we all respect her courage and toughness in competing at a difficult sport at such a high level, especially when faced with the prospect of injury.  However, in watching her interview, I couldn’t help, but feel that there was some continued suffering in her affect and voice.

If you watch her actual crash, you can’t help but notice the impact of the speed and ice on her body as you see her hit her head and the contortions that follow.  Sadly, I see people who have had similar injuries from motor vehicle accidents, falls from horses and other types of sports who suffer from chronic headaches.  Many of these people have been diagnosed with “whiplash” which tends to be a basket diagnosis when someone has continued chronic pain, usually headaches, but whose workup including x-rays and MRIs don’t show any pathology and whose etiology remains unclear.  Unfortunately, at this point in time x-rays and MRIs (even magnetic resonance neurograms) are often not sensitive enough to pick up injuries in very tiny nerves that can cause significant pain.  In the case of neck injuries following which people experience chronic headaches, I believe that many of these symptoms are caused by traction (i.e. stretch) injuries of the various occipital nerves resulting in scar impingement around the nerves or actual tears within the nerves themselves.  These tears then heal with scar impacting nerve conduction and resulting in numbness, tingling and/or pain.  As a result, these patients end up seeing many different types of doctors who often prescribe many different types of drugs and give many types of injections in the hopes of treating this pain permanently. 

However, whenever there is a mechanical injury of a nerve, for example, compression secondary to scar tissue formation, a mechanical solution needs to be found.  For these patients, a simple nerve block (i.e. injection of local anesthetic) used in a diagnostic manner, will not only provide temporary relief, but allow the experienced peripheral nerve surgeon to discern which nerve or nerves may be involved in that particular person’s symptoms thereby pointing the way to a potential surgical solution which is often permanent.  Sadly, peripheral nerve pathology as a cause for many cases of whiplash or sports concussions with resulting headaches remains very unrecognized.  However, some physicians including some prominent neurologists are actually coming around to recognizing that structures outside of the brain and spinal cord can cause debilitating headaches.  Happily, they refer these patients to a trained peripheral nerve surgeon for appropriate diagnostic workup and ultimately treatment.  Hopefully Ms. Sweeney will not require surgical intervention of any kind, but if she were to experience chronic headaches with no other identifiable cause, I would hope that her trainers and doctors consider the possibility that a stretch injury to a peripheral nerve may be the underlying etiology which will save her and perhaps many others years of suffering.

To learn more about how migraine surgery can help with migraines caused by peripheral nerve damage from sports injuries or whiplash, visit www.peledmigrainesurgery.com today or call (415) 751-0583 to make an appointment.  Don't live with migraines if you don't have to. 

Continue reading
  2572 Hits
7 Comments
Recent Comments
Ziv M. Peled, MD
Kathy. Thank you for your comment. Actually, the GON and TON are both accessed through the same midline incision since they are ... Read More
Monday, 19 February 2018 14:51
Ziv M. Peled, MD
With regards to the above reply, this first picture demonstrates the larger GON more cephalically and the TON more caudally. The ... Read More
Monday, 19 February 2018 17:58
Ziv
Kathy, I'm not sure the gist of your last question, but whether you're doing excision or decompression the nerves are accessed thr... Read More
Wednesday, 21 February 2018 17:04
2572 Hits
  7 Comments

WORKING HOURS

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

SAN FRANCISCO

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

WALNUT CREEK

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

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