Peled Migraine Surgery Blog

 This 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 fool proof 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.

Many potential chronic headache patients have asked if they are not surgical candidates because they have not responded to Botox® in the past. The answer is, “Not necessarily.” and the reason is because it depends on how and in what doses the Botox was used. The primary way in which Botox® is used by most neurologists and pain management physicians is based upon the PREEMPT protocol (see attached). It calls for using 155 units over 31 injection sites every three months in an effort to reduce the symptoms associated with chronic migraine headaches. There are several problems with this approach. 

First and most obvious is that the studies themselves were funded by Allergan, the makers of Botox®. Moreover, many of the study authors receive honoraria, speaking fees and consultancy fees from Allergan. While these issues are explicitly stated in the papers themselves, they are nevertheless conflicts of interest. Second, some of the results are not as exciting as the papers would suggest. For example, over the 24 week treatment period, the reported decrease in frequency of headache days was 8.4 in the Botox® group and 6.6 in the placebo group. In other words if you were injected with Botox® according to this protocol, over a 6-month period you would have had 1.8 fewer headache days than if you were injected with saline! And that assumes you actually responded to the Botox® and had no adverse effects. While these numbers were statistically significant, it is a perfect example of the difference between statistical significance and clinical significance. Stated differently, would you as a patient be willing to be injected 62 times (31 times every 3 months) for 1.8 fewer headache days? Maybe or maybe not, but hardly a compelling case. Third, the results of these studies demonstrate a very high placebo response rate that the authors do not fully explain. Fourth, if you think about it, injecting Botox® in a shotgun-like approach (i.e. in 31 different places) will certainly relax some muscles leading perhaps to some relief of symptoms. But the question then becomes, “Which of the 31 injections was responsible for that effect or were all or some of them necessary?” This approach is akin to going to the ER with abdominal pain and being given morphine via an IV. Would you feel better? Of course you would, but now that the medication is circulating all over the place, was the pain the result of a simple GI bug or a burst appendix? You have no idea. Botox® used according to the PREEMPT protocol tells you nothing about the cause of the problem and is therefore used as a treatment which you must continue with in perpetuity.
In order to assess whether or not you would be a candidate for surgery to treat occipital neuralgia with Botox®, it should be injected focally around the muscles that are compressing (i.e. pinching) the nerves causing the problem. If successful, the nerves which you have chemically decompressed with Botox® are the nerves that need to be treated with surgical decompression. The overall doses used are much less than 155 units, the injection sites are far fewer and the results are often more effective. I would not operate on a person who got as little benefit as the patients in the PREEMPT studies. I look for at least a 50% reduction in the frequency, duration or severity of headaches in order to make that determination. In addition, if you think about it, the Botox® is being used as a diagnostic test, not a treatment method. If it works to the degree noted above, you don’t need any more Botox®, you need surgery to hopefully give you the same level of relief on a permanent basis without the need for any more injections. So if you’ve failed treatment with Botox® in the past, there is still hope that surgical decompression might be an option for you.

Dr. Ziv Peled explains how to choose a peripheral nerve surgeon, what qualifications to look for and how to decide who is the best fit for you!

How can Botox help you with a smile that shows too much of your gums?  Is it an easy process, or does it require surgery? 

Dr. Ziv Peled, Peripheral Nerve and Plastic Surgeon, was recently asked to sit down and answer some questions about migraines and migraine relief.  Here is a transcript of the interview.

Another exciting honor for Dr. Ziv Peled!

How long does recovery take following nerve decompression surgery for chronic headaches? The answer to that question can be quite variable and depends on a number of parameters, but a few general principles apply.

One of the questions that I‘m frequently asked during consultations with patients regarding their chronic headaches is, "If I’ve had Botox injections done with other doctors in the past and they have failed, does this mean that Botox injections done with you would not work either?" This is an excellent question and the simple answer is, “No".

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

What do migraine headaches and peripheral nerve surgery have to do with each other?

A recently published study in Health Affairs demonstrated that many patients still have significant reservations about asking their doctors questions regarding their health care.

Several people have had questions about what ‘neurolysis’ actually means and how it might differ from the term ‘ablation’.

I just finished reading Dr. Guyuron's article on the finances associated with migraines in its entirety.  The numbers are truly staggering.  Did you know that:

1. Medical resource use for the treatment of migraine headaches is significant, with the fourth most common emergency room complaint being headaches.
2.Patients with migraine headaches generate nearly twice as many medical claims and nearly two and a half times as many pharmacy claims when compared with patients without migraine headaches.
3. Researchers have estimated the annual direct costs of migraine treatment to be as high as $7089 per patient and the annual indirect costs to be as high as $4453 per patient.
4. AFTER TAKING INTO ACCOUNT THE COST OF SURGERY (surgeon, anesthesia, facitlity fees) - the 5-year cost savings were over $11,000 per patient.
5. IN ADDITION, over 5 years, patients can expect to have 43.5 fewer doctor visits, 25 fewer alternative treatment sessions, and 40.25 fewer days missed from work!
6. OVER AND ABOVE ALL THAT, patients reported significant improvements in their overall quality of life on just about every parameter measured!

I guess none of this should be surprising, but it is rare to see numbers like this in the medical literature.  This type of treatment is truly a paradigm shift.

Over the past few months I have seen quite a number of patients who’ve told me that they believe their migraines began not long after a motor vehicle accident. Many of them said they were initially told they suffered from “whiplash” by their treating physicians. These patients tried and subsequently failed several treatment modalities such as physical therapy and muscle relaxant medications.

One of the most common refrains I hear from patients is that they are flummoxed by the lack of understanding from their neurologists or neurosurgeons

An interesting article was published just this month in the journal Plastic and Reconstructive Surgery. Members of the American Society of Plastic Surgeons (ASPS)

Peled Migraine Surgery is one of the foremost organizations in migraine pain relief surgery.  The surgery is nerve based and has been proven to lessen or eliminate migraine pain.  Ziv M. Peled, MD is a Board-Certified plastic surgeon trained to perform the full spectrum of aesthetic and reconstructive plastic surgical procedures. He completed his medical school training at the University of Connecticut School of Medicine where he earned honors in multiple surgical disciplines. He subsequently completed four years of rigorous general surgical training at the University of Connecticut during which he also completed an additional two-year, post-doctoral Basic Science Research Fellowship at Stanford University under the tutelage of Dr. Michael T. Longaker, a pioneer in the field of scarless wound healing.

Chronic pain is pain that continues a month or more beyond the usual recovery period for an injury or illness or that goes on for months or years due to a chronic condition. The pain is usually not constant but can interfere with daily life at all levels. per the American Chronic Pain Association.