Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

WHY DO NERVES TAKE SO LONG TO RECOVER?

WHY DO NERVES TAKE SO LONG TO RECOVER

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

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

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

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TRANSFORMING HEADACHE CARE

TRANSFORMING HEADACHE CARE

Chronic headaches continue to be a huge burden on the American healthcare system accounting for tens of billions of dollars in both direct and indirect costs annually.  These financial considerations don’t even take into account the psychological and emotional toll that this form of chronic pain has on those who suffer with it. Migraines themselves are felt to afflict as many as 12% of the US population.  As much as 2% of the world’s population suffers from chronic migraines, which by definition, means that traditional treatment modalities have failed. As I sat on the plane coming back from a recent conference, I began to reflect on the fact that we really need to step back and re-think how we approach this problem.

Over the years that I’ve been operating on patients for chronic headaches, a consistent thread is peoples’ frustration with their current care because their symptoms are not under control.  I hear constantly about confrontational patient-physician interactions or negative patient-health system interactions as these patients express that they feel their doctors aren’t listening to them or keep going around in circles with regard to treatment.  The “best” of these interactions seem to be when their doctors plainly tell them they don’t know what more they can do – itself a frustrating and demoralizing thing to hear.  To all of those patients I say that I completely empathize and validate that they have every right to feel as they do.  Having been a patient on several occasions myself, I know what it’s like to speak with a physician or an insurance adjustor and feel like you are talking to the wall - and I’m a healthcare practitioner.

As a peripheral nerve surgeon, especially one that operates on people with chronic, intractable headaches, I have heard criticisms from other doctors whom I don’t feel even understand what it is that I do.  However, I’ve learned that by putting myself into the shoes of that doctor across from me I can almost always find common ground.  Happily, that common ground is as advocates for our patients. After all, we physicians are (or should be) on the same side as our patients in trying to treat any medical condition. Therefore, I believe that teamwork is particularly and practically helpful and there are already paradigms for this approach that work very well.

Breast cancer is sadly a disease that touches too many people throughout the world.  Over the past few decades, the medical profession has made incredible strides in fighting this dreaded disease and we now have cancer remission rates that were once thought impossible.  One of the biggest factors in helping this development along has been the team approach.  In our community, a patient with a new breast cancer diagnosis is immediately given a team of physicians and clinicians to help them navigate the process that is current treatment.  To be sure, there is a “captain of the ship”, usually the breast surgeon or oncoplastic surgeon who is coordinating all of the moving parts, but every member of the team is critical to ensuring success.  The breast surgeon may remove the actual tumor, the plastic surgeon will help reconstruct the resultant defect, a radiation oncologist will ensure that any disease that might have spread locally is controlled and a medical oncologist will determine if the risk of distant disease is high enough to warrant a regimen of chemotherapy or hormonal therapy. There is also often a psychologist and nurse navigator who can help the patient deal emotionally and psychologically with the emotional rollercoaster accompanying a cancer diagnosis.  Only when you put all of these components together, do you get the wonderful results that modern medicine has been able to achieve.

For years I have been hopefully telling my patients that someday soon, we will realize that chronic pain (of which chronic headaches are a prime example) is also best treated with a multi-modality approach.  There are certainly many patients for whom medication works very well.  Those people do not need injections or surgical intervention.  There are those for whom pharmacologic agents are simply ineffective and in those cases, nerve decompression may be a good option.  However, for most, a combination of therapies is necessary to control the underlying symptoms.  I have heard from countless patients who tell me that prior to surgery their medication was inconsistently helpful.  Following operative intervention, their headaches are much less frequent and often much less severe, but what was interesting to me was that they would tell me that when they would get an attack, the medication they’d been using for years was now consistently effective.  “Why is that?” they would ask.  I felt it was likely that they had two problems contributing to their headache symptom complex.  One was a chemical imbalance that medication would treat, and the other was a mechanical compression of a nerve(s).  Only when both conditions were adequately treated, would the symptoms be optimally managed. 

The take home message is that many medical conditions are best managed when we work together.  Not just as patients and physicians, but as physicians and physicians. I have had great success locally with neurologists and pain management physicians as we not only refer to each other, but also actually talk to each other about our shared patients, recognizing that we each have a role in their care. Those that have seen me know that I often like to communicate with the very same such doctors prior to surgery to ensure we can optimize the post-operative recovery period which certainly can have its share of ups and downs. In the end, we all have to partner in this endeavor together as a team if we hope to triumph.

 To learn more about Migraine Surgery and Relief, visit www.peledmigrainesurgery.com today, and follow us on FacebookTwitterInstagramLinkedIn and YouTube for more information.

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WHIPLASH AND OCCIPITAL NEURALGIA: WHAT IS THE CONNECTION?

WHIPLASH AND OCCIPITAL NEURALGIA WHAT IS THE CONNECTION

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

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

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

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

To learn more about Migraine Surgery and Occipital Neuralgia, visit www.peledmigrainesurgery.com today and follow us on FacebookTwitterInstagramLinkedIn and YouTube for more information.

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OCCIPITAL & TRIGEMINAL NEURALGIA: CAN THEY CO-EXIST?

OCCIPITAL TRIGEMINAL NEURALGIA CAN THEY CO EXIST

Someone recently asked this question on one of the forums and I thought it was a very good question the answers for which may not be immediately clear. First of all, I think it is important to define exactly what is meant by ‘neuralgia’. The prefix ‘neur’ simply refers to a nerve and the term ‘algia’ means pain. Therefore, simply put, neuralgia means pain cause by a nerve or nerves. The question always becomes which ‘neur’’ is causing the ‘algia’? Then, if you can answer that question, can you then do something about it?

Occipital neuralgia (ON) is a neurological condition in which the occipital nerves are irritated or compressed (i.e. pinched) and hence cause pain. The typical symptoms are episodic (i.e. paroxysmal) bouts of “lightning-like” pain in the back of the head although as many of you know and as I have blogged about many times, the symptoms can vary widely. Because each person is unique, they will each experience pain differently. Similarly, trigeminal neuralgia (TN) is a neurological condition in which the main trigeminal nerve trunk is compressed. Not surprisingly, the classic symptoms are episodic bouts of “lightning-like” pain in the face which are the areas innervated by the various branches of the trigeminal nerve. These sets of nerves are not physically connected so why is it that ON often co-exists with TN? The answer lies in the anatomy. I will have a picture of a peripheral nerve included in this post to help illustrate the points I make below.

Many people don’t know that that the upper-most, neural elements in the neck (e.g. the occipital nerves) have a common connection zone in the medulla (part of the brain stem) with nerve cell bodies that become the trigeminal nerve. This zone is known as the cervico-trigeminal complex and can potentially explain why discomfort from lesser occipital neuralgia may sometimes be referred to trigeminal nerve territories anteriorly. Referring to the image of a neuron (i.e. nerve cell) below, you can see that when the long part (axon) of the nerve is injured (e.g. in a whiplash accident), the whole nerve becomes inflamed including the cell body. This injury is depicted in #1 in the attached image. When the cell body of a cervical nerve (e.g. one that becomes the greater occipital nerve) is chronically inflamed, the adjacent cell bodies (e.g. those that become a trigeminal nerve branch – for example, the supraorbital nerve) also become inflamed. This injury is depicted in #2 & #3 in the attached image. Then the axons of those latter nerves cause pain in their respective nerve distributions (e.g. in the forehead in the case of the supraorbital nerve). This injury is depicted in #4 in the attached image. In this way, an injury to the GON can ultimately result in forehead discomfort. To use an analogy close to home here in California, think of it as a forest fire that has burned too long and the embers from one part of the forest jump the clearing to the adjacent wooded area and cause a fire there.

Hopefully, it now becomes clear why ON and TN often co-exist. It is usually the case that one begets the other and I have seen countless patients in my office whose pain started in the neck area and eventually spread elsewhere. Fortunately, the process can also reverse itself if the inflammation/irritation of the involved nerve branches can be addressed.

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IS OCCIPITAL NEURALGIA A HEADACHE, A MIGRAINE OR SOMETHING ELSE?

IS OCCIPITAL NEURALGIA A HEADACHE A MIGRAINE OR SOMETHING ELSE

A couple of weeks ago, we talked about the definition of a migraine, which in many practical instances is simply a name given to a constellation of symptoms.  We also spoke about occipital (meaning back of the head) and neuralgia (meaning nerve pain). When all is said and done, however, the real question is: “Can you figure out which ‘neur’ (i.e. nerve) is causing the ‘algia’ (i.e. pain)?”  Is occipital neuralgia therefore considered a headache?

Well, yes and no. occipital neuralgia can give you symptoms of a headache because it can cause head pain and any head pain is by definition a “head ache”. Can occipital neuralgia fall under the definition of or be considered a migraine? The answer to that question is also technically, “yes”’ because all the clinician and patient will “see” is the presence or complaints of head pain that is this level of severity, this frequent (often constant), associated with these other sensations (e.g. pulsation/throbbing, light sensitivity, nausea) and this duration (usually several hours or more at least).  These characteristics are now established, but say nothing about the cause of the headaches. Is it a chemical imbalance, an issue of an inflamed blood vessel or a compressed nerve?

The upshot is that so many of the patients who come to see me have been diagnosed with migraines which is not necessarily inaccurate, it’s just not very specific.  Many people who have been diagnosed with migraines do find a conventional treatment modality that works for them (e.g. medication).

However, there are also many millions who don’t have success with these traditional modalities and the reason is because the diagnosis of “migraine” doesn’t tell you what’s causing the problem and therefore how to fix it.  Those people end up being treated “empirically”; in other words, it’s like throwing darts at a dartboard - try this drug, or that drug or these drugs together or these drugs with massage, PT, acupuncture, etc. to see if you can find something that works.

What practitioners are really trying to do is figure out what problem - chemical imbalance, muscle tightness etc - is causing the issue by eliminating factors one by one using trial and error. At its essence, actual occipital neuralgia is the result of pressure on a peripheral nerve(s) in the occipital region.  If you can figure out which nerve(s) is involved, in many cases, the headaches can be significantly improved or completely relieved by surgical intervention.

To learn more about Occipital Migraines or schedule a consult with Ziv M. Peled, M.D. visit www.peledmigrainesurgery.com today.

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A Ray of Hope

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These days, whenever I read the news or look online, the world can seem like a pretty bleak place. The political divide remains, natural disasters abound, and trade wars are imminent. However, just when things seem pretty dark, little rays of light seem to peak through the clouds. This past weekend, I had the distinct honor and privilege to serve on a panel about migraine/headache surgery at the international meeting of the World Society for Reconstructive Microsurgery in Bologna, Italy. I was speaking and interacting with several esteemed colleagues in this burgeoning field from around the world. Amongst the highlights of this event (and there were many) was the feeling amongst several of my colleagues that a few neurology counterparts in their communities had begun to embrace the idea that surgical intervention might just have a role in the treatment of chronic headaches.

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It reminded me of the time Dr. Pamela Blake spoke on our on our panel teaching headache/migraine surgery at the American Society of Plastic Surgeons annual meeting two years ago. Dr. Blake is a board-certified neurologist, an active member of the American Headache Society & International Headache Society and former Director of the Headache Clinic at Georgetown University. She remains active in research in behavioral neurology and cognitive science and served as volunteer faculty at the Cognitive Neurosciences Section at the National Institutes of Neurological Disorders and Stroke at the National Institute of Health. As impressive as this resume is, perhaps the most impressive thing to me, however, is that Dr. Blake is a firm believer in the concept that peripheral nerve pathology is a very under-recognized factor in the generation of chronic headaches for many people. Just last year, she published an article detailing some success with the surgical approach in Cephalalgia, a peer-reviewed journal and the official Journal of the International Headache Society. 

While this fact may seem trivial to many, I cannot overstate what it means to those of us who have been banging on this door for over ten years. Since 2000, there have been over 80 scientific articles from numerous centers across the US, Europe and Asia detailing positive outcomes from nerve decompression surgery for chronic headaches such as migraines. Last year the American Society of Plastic Surgeons issued a formal policy statement that headache/migraine should no longer be considered “experimental” when other treatment modalities have failed.

 If someone with Dr. Blake’s background and training can be convinced by the available evidence and our results with headache surgery patients that we are onto something, then perhaps others can be convinced similarly. In my humble opinion, this change would be nothing short of revolutionary as it would finally give peripheral nerve surgery a seat at the table in the armamentarium of modalities that could be considered in the treatment of chronic headaches in particular and perhaps chronic pain in general. Perhaps in the not-too-distant future we will see positive position statements from various other societies and if things go really well…. a change in the overall medical establishment’s perspective. When I think of the hundreds of thousands of people who may find relief from the scourge of chronic headaches like migraines, a big smile begins to creep across my face. Dare to dream big….. I remain ever hopeful, but more optimistic with each passing day. The longest journeys begin with the smallest steps.

 To learn more about Migraine Surgery and Relief, visit www.peledmigrainesurgery.com today, and follow us on Facebook, Twitter, Instagram, LinkedIn and YouTube for more information.

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Why and How Did I Get Occipital Neuralgia?

Why and how did I ge Occipital Neuralgia

The title of this post is really the $60,000 question.  I have posted many times in the past about how ON can be caused by compression from spastic neck muscles, compression by tight connective tissue (i.e. fascia) and/or compression from surrounding blood vessels.  Many of the patients I see have had headaches ever since they can remember. However, there are just as many for whom the headaches began seemingly spontaneously one day. The question for these folks remains: What happened?  Why now?

There have been recent articles that hint at possible answers to these questions and they may surprise you. I have attached a link to one of the more interesting ones as part of this post. One of the most surprising comments contained therein was that craning the neck downward only 60º puts as much as 60 pounds of pressure on the cervical spine and neck muscles.  With that kind of pressure, you can imagine that nerves (among other structures) would be compressed. So the explanation as to why you might all of a sudden develop ON can almost be summed up in one word - overuse. This explanation is one of the potential causes of carpal tunnel syndrome, the most common compression neuropathy recognized (even by neurologists). Why could that not be the case for ON?  Nerves are very susceptible to chronic compression (see post - ‘What Causes Occipital Nerves to Malfunction’) even if intermittent. The occipital nerves take very circuitous routes through all of the nuchal soft tissues. When you add to that fact the constant motion of our necks that require the nerves to glide constantly and then compound those factors with an additional 60 pounds of added pressure, there are many things that may occur to those nerves.

One, they may simply get kinked as they make their way through the neck to the scalp.  Not a week goes by when I don’t see a patient in the office who, in describing their headaches contorts their head to recapitulate their symptoms and when they get it just right, it’s like a thunderbolt of pain.  Two, even if not kinked, the pressure will compress the vasa nervorum - the microscopic blood vessels within the nerves themselves that supply blood to those nerves. After numerous episodes of compression, especially if for prolonged periods, these blood vessels can clot and the nerves become ischemic (i.e. choked).  The neurons that comprise that nerve then die off and try to regenerate causing the hyperesthetic symptoms so typical of ON. Three, even if the nerves recover from each successive insult, the additive microtrauma will likely result in some inflammation and the subsequent formation of scar tissue in the surrounding structures, thus closing off already tight corridors through which these nerves must pass - another compressive force. While no one has demonstrated these possibilities in real time, I see the sequelae of them in the OR weekly.

So what do we do?  Good posture, stretching and avoidance of triggering activities seem to make common sense.  In addition, as many of you know and as intimated in the article, steroids seem to be the mainstay of treatment amongst some practitioners, but as also stated, the effects are often not permanent.  The reason is obvious - the compressive forces remain, even if inflammation is temporarily suppressed. Therefore, I continue to believe that decompression (or neurectomy & implantation for permanently injured nerves) are reasonable options as they are safe and effective.  Moreover, they address the underlying problem, the mechanical compression of these poor nerves caused by our ever more technologically demanding lifestyles. So next time you pick up your smartphone, remember to pick up your head as well.

Learn more about Occipital Neuralgia and Migraine Surgery from Ziv M. Peled, M.D. at www.peledmigrainesurgery.com now.

http://gizmodo.com/my-smartphone-gave-me-a-painful-neurological-condition-1711422212

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How Diabetes Affects Peripheral Nerves

How Diabetes Affects Peripheral Nerves

The relationship between diabetes and peripheral nerves is an important one.  As many people already know, diabetes is the leading cause of neuropathy, which in its simplest definition means some pathology of the nerves.  Therefore, diabetes obviously negatively affects nerves, but how? There are a number of ways in which diabetes can affect a peripheral nerve.

In a diabetic, despite the best glucose control there is always more glucose in the bloodstream as compared with a non-diabetic.  This excess glucose is taken up by many cells in the body, among them nerve cells. When inside the nerve cell, the glucose is metabolized into another sugar called sorbitol which then acts as an osmotic load (e.g. as a sponge) , drawing more water into the nerve cell. In effect, because of this excess water in the nerve cells, diabetic nerves are swollen.  When any object swells inside a fixed space which cannot expand, that object is under pressure. This process partly explains why carpal tunnel syndrome is more common in diabetics than in non-diabetics and it stands to reason that the same process would affect the symptoms of another nerve compression problem, ON. Although the correlation between diabetes and ON has never formally been elucidated, several studies have hinted at a causal relationship. Another way in which diabetes can affect peripheral nerves is by causing a low grade inflammation of the blood vessels within the nerves.  With inflammation comes swelling and the process noted above worsens even further.

Two other processes have also been identified, but with very different mechanisms.  Diabetes has been associated with increased molecular cross-linking of certain proteins within the nerve cells walls.  This cross linking effectively makes the nerves “stiffer” than they otherwise would be which causes then to bang around more within their tight spaces and resulting in more micro-trauma.  This process is especially true around joints such as the wrist (carpal tunnel) or at the base of the neck (ON) where all of the structures are moving around, hopefully gliding smoothly past one another. When coupled with an impaired ability to repair themselves secondary to decreased axoplasmic flow, repeated micro-trauma likely results in scar build-up over time thereby decreasing already tight spaces even further. While I’m sure that other processes have also been identified, the bottom line is that diabetes has multiple negative effects on peripheral nerves and is the reason why in a diabetic patient, optimal glucose control is the first line of therapy. Poor glucose control is likely to exacerbate nerve-related symptoms (whether carpal tunnel or ON) for all of the reasons noted above.  Despite tight controls on sugar levels, diabetics still have symptoms and sometimes these even worsen over time. In these cases, I believe that a meticulous search for nerve compression is important because if found, decompression can potentially be very beneficial symptomatically.

To learn more about Migraine Surgery, visit www.peledmigrainesurgery.com today.

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Why Does It Hurt So Much After the Injections?!?

Why Does It Hurt So Much After the Injections

A number of patients have come to the office over the years consistently telling me that they had worse pain AFTER their injections with their other doctor.  This phenomenon seems to occur irrespective of what is being injected, whether 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, these 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 noted above 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 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.

To learn more about Migraine Surgery and the treatment of Migraines, visit www.peledmigrainesurgery.com today.

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Migraine Surgery: The Staged Approach

Migraine Surgery The Staged Approach

I was recently asked why some people require more than one operation to obtain optimal relief.  As usual, the answer has many components to it so I will try to delineate some of these issues below.  Let me preface these remarks by stating that what I write below is my opinion only and how I approach patients, but should not be considered dogma.  While a number of colleagues also use this approach, it is not necessarily shared by every peripheral nerve surgeon, some of whom will be more aggressive and some less aggressive.

In situations where there are many nerves that will require surgical intervention to achieve an optimal result, there are number of reasons why I prefer to stage the operations.  First, patients often say that one area usually flares up initially and when very severe or uncontrollable, causes the headache and discomfort to spread to other areas. For example, s/he will state that their neck gets tight, they get occipital headache pain and if medication is unable to help, the headache spreads to the temples and forehead.  In these particular cases, there may be a reasonable assumption that the occipital area is triggering the frontal and temporal headaches.  Therefore, theoretically if the occipital nerves are appropriately addressed, with time and healing, those triggering nerves should calm down such that the frontal and temporal areas are only triggered infrequently and hopefully to a much lesser degree.  In other words, if you can remove the fuse, the dynamite stick will never explode and therefore an operation to address the frontal and temporal nerves may never be required. Even if this patient continues to have some degree of headaches, these headaches may be so infrequent and/or relatively mild that they feel the remaining symptoms are easily manageable and don’t want another operation.  As I’ve said in prior posts, no one should tell you whether or not you should live with whatever pain you have. Doing so is making a value judgment - only the patient can and should make that determination.

Second, let’s assume that a person has the appropriate operation over the occipital nerves and has a successful outcome with respect to their posterior headaches, but the temporal and frontal headaches persist even after several months of recovery.  In those cases, while another operation may be required to address the temporal and frontal nerves, there is now good reason to believe that the second procedure is likely to be successful. The converse is also true - if the occipital procedure is performed correctly and for the right indications, but yields no result, I would question whether or not a temporal/frontal procedure would be indicated.  I would be less confident surgical intervention in those areas would be successful since the same approach was unsuccessful over the occipital area, thereby precluding the potential for complications in areas where surgical intervention may not be successful. Therefore, staging an operation has the potential to give you information about whether or not a second procedure will be helpful.

A third reason for staging these operations relates to the safety of an operation.  While I obviously agree that neuralgia (occipital or trigeminal branch) is a significant medical problem, these operations are elective.  Therefore, the most important thing we can do for the patient is give them a safe operation and try to minimize complications while maximizing the potential for a successful outcome.  From a technical standpoint, the longer a surgical procedure takes, the greater the chance for complications or issues arising from anesthesia. While long operations can certainly be done safely, when it comes to elective surgery, the more efficient a procedure can be the better.  Therefore, if I had a choice between one 8-hour operation or two 4-hour operations, I would choose the latter because there is likely a lower risk for deep vein thrombosis (blood clots in the legs that can embolize), the need for an in-patient stay, post-operative nausea and other anesthesia-related issues.

A fourth reason for staging operations has to do with recovery.  In my opinion (and as many of my patients will attest), one of the hardest parts of the surgical experience is the post-operative recovery which often has many ups and downs apart from the immediate, peri-operative surgical discomfort.  With respect to the latter, if you have incisions on the front, the sides and the back of your head bilaterally, I can only imagine how uncomfortable the whole head must feel and I often wonder how these patients rest at night since sleeping on any portion of the scalp is likely to result in discomfort.  Rest post-operatively is critical and lack thereof is potentially problematic. In addition, as decompressed or transected nerves are manipulated in the operating room, the normal, post-operative inflammation can lead to many nerve-related symptoms which, if they occur all over the scalp as opposed to just posteriorly or over the temples, is likely to be quite uncomfortable.  More discomfort often leads to increased opioid use which can lead to a whole host of other issues such as constipation, cognitive impairment (e.g. sedation), nausea etc.

One last comment: I don’t use any one of these contra-indications in isolation.  They are all considered together as part of the overall clinical impression when I go over a patient’s records, examine him/her and perform whatever diagnostic maneuvers are necessary.  It is for these reasons among many others that I always recommend a consultation with a peripheral nerve surgeon when deciding if surgical intervention (whether decompression/neuroplasty or neurectomy/implantation) is appropriate.  

I also believe that among the many questions patients should ask their potential surgeons is how they will approach the surgery. It is important for patients to understand their surgeons’ plan, particularly if their case will involve more than one or two incisions, and make an informed decision about the path forward.

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WHY ARE MECHANICALLY-TRIGGERED MIGRAINES SO UNDER-DIAGNOSED?

WHY ARE MECHANICALLY TRIGGERED MIGRAINES SO UNDER DIAGNOSED

In my humble opinion, the possibility that mechanical compression of a peripheral nerve in the head and neck can cause headaches is vastly underestimated.  I realize this is a big statement, but I think it is legitimate. It is primarily for this reason, that the diagnoses of occipital neuralgia and trigeminal branch neuralgia are not made nearly as often as they should. What is particularly fascinating is that many practitioners will use nerve blocks to provide temporary relief from headaches successfully.  

What do those practitioners think is happening when they temporarily and chemically inactivate a peripheral nerve or nerves and the headache improves significantly or goes away, albeit for a short period of time - usually until the numbness wears off?  What exactly does one conclude from this information? In my mind, the most obvious answer is that the nerve(s) that was blocked must be involved in the generation of headache symptoms. So why is this concept so foreign to so many? I believe there are a number of reasons for this phenomenon and I will delineate some of these reasons below.

The first is that the central concept of chronic headaches has been around a long time.  It is generally widely accepted that most chronic headaches (e.g. migraines) are caused by chemical or vascular imbalances in the brain.  And yet, if we understand the chemical imbalances, how come we not only have dozens of drugs to treat ‘migraines’, but numerous classes of drugs.   Pharmacologic treatment of migraines includes the use of anti-depressants, neuroleptics, serotonin-modulating agents, CGRP-modulating agents, opiates, muscle relaxants, anti-seizure medications, anti-hypertension medicines, anti-anxiety drugs and others.  

If there is a clear chemical problem, how come there aren’t one or two classes of drugs that treat that problem effectively? I will say that these medicines work for many, but the problem is so prevalent (more than 36 million people in the US are diagnosed with migraines), that even if they fail for just 20%, that means more than 7 million people continue to suffer.  The point is that the central concept of chronic headaches is deeply ingrained in medical teaching and hard to overcome. Therefore, the notion of peripheral nerve compression causing these problems would be somewhat of a paradigm shift - something that doesn’t occur easily and without some resistance.

A second issue is that this concept is being championed by primarily plastic surgeons.  One of my mentors once told me, “Ziv, don’t go into plastic surgery unless you are willing to spend the rest of your life apologizing for your colleagues.”  While I disagree with this blanket statement, I understood his point - when most people think of plastic surgeons, they think only of cosmetic surgery.

Yet, plastic surgeons reconstruct breasts after mastectomies, repair difficult lacerations, fix cleft lips/palates, provide coverage for difficult wounds following trauma, do face transplants and replant fingers, forearms and whole arms (including nerves) after accidents.  Some of us have made peripheral nerve surgery a focus of our practices and spend time teaching others what we know, publishing our work for others to read and critique and educating patients so that they can be more informed. Yet I suppose if a neurologist came up to me and told me that I was doing my tummy tucks incorrectly and that they had a better way to do it, I might look at them slightly askance at first. Skepticism is always healthy, especially when it comes to surgical intervention,  so it makes sense that practitioners who care about their patients wouldn’t want them to do something they were unsure of.

Third, we who do these operations need to continue to publish our data, educate other medical professionals (as well as the public) and hopefully build bridges between the various specialties so that ultimately patient care is optimized.  While a reasonable number of surgically-treated patients experience elimination of their headaches, many continue to have symptoms albeit significantly reduced in frequency, severity and duration. So we all still need our neurologists, pain managements docs and physical therapists to help manage the remaining issues.  This multimodality approach remains elusive in headache care, but is a dream of mine before I retire. Because peripheral nerve surgery is the newest and smallest voice at this potential table, the things we have to offer are often not acknowledged.

Despite these hurdles, the shift to wider acceptance of this concept is underway. There are board-certified neurologists now writing about “nerve compression headaches”, which are not currently listed in the International Classification of Headache Disorders as a distinct clinical entity to my knowledge. So while the wheels of change slowly turn, patients have to be advocates for themselves. If the pharmacologic agents, injections and conservative modalities are not giving lasting relief, then seeking a qualified surgeon to test for mechanical compression may be the next course of action…...and the solution.

To learn more about migraine surgery, visit www.peledmigrainesurgery.com today!

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POST-TRAUMATIC HEADACHES

POST TRAUMATIC HEADACHESJust a few days ago, I read an Instagram post that discussed post-traumatic headaches. There was a description of someone who had suffered a head injury following an assault and suffered a skull fracture that healed without surgery. This person subsequently began to experience headaches that were unremitting. The MRIs of the brain and neck did not identify any pathology and the patient had failed physical therapy and massage treatments. He was diagnosed as having a concussion and treated accordingly, but the headaches persisted.

The remainder of the post went on to detail how, over the ensuing years, he was presumed to have developed ‘migraines’ and tried on various medications, all unsuccessful. There were descriptions of altered brain activity, presumed (but never identified) problems with the blood vessels in the brain and various suspected chemical abnormalities (hence all the drugs). During this entire time, the patient was complaining of consistent pain in a specific area of the head/scalp.

Unfortunately, this story resonated with me because it sounded all too familiar. The remarkable thing for me was that no time during the entire saga did anyone even entertain the possibility that there might be a peripheral nerve in the scalp that had been injured with the fracture and subsequent scarring that occurred. It struck me as odd that if the same thing had happened in the forearm with an ulnar bone fracture and the patient began to experience hand pain in the small finger, the concept of a nerve injury would be at the top of the possible causes. The fact of the matter is that this person might just have an entrapped peripheral nerve in the scalp that is causing the pain.

I wanted to reach into the phone and suggest to this patient that he consider this possibility.  He should have a nerve block and if, successful, perhaps an outpatient procedure might just fix the issue permanently.  This whole scenario also got me thinking about why people don’t consider the peripheral nervous system in these cases. I think there are many explanations for that observation. More about that topic in an upcoming post.

To learn more about migraine surgery, visit www.peledmigrainesurgery.com today!

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Is there a Problem If You Can't See It?

Is there a Problem If You Can't See It

As with many things in life, there are positive and a negative ways 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 a 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 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 step 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 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 MRN technology, most insurance companies still consider such tests “experimental”. 

To learn more about Migraines and Post Traumatic Headaches, visit www.peledmigrainesurgery.com today.

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Is Occipital Neuralgia (ON) Truly Idiopathic or is the Cause More Often Than Not Some Sort of Compression?

Is occipital neuralgia ON truly idiopathic or is the cause more often than not some sort of compression

One of the most common questions that I get from my patients when they come into the office to see if they are a candidate for nerve decompression surgery goes along the lines of, “Gee Doc, I hope you find something! What if you get in there and don’t find anything wrong? What will you do?”

I have never encountered a patient on the operating table where there hasn’t been some element of nerve compression. Sometimes this is seen in the form of how the occipital nerve interacts with the occipital artery where the latter wraps around the nerve a bit like an anaconda. Sometimes, compression can be caused by a spastic muscle and sometimes, compression can be caused when the connective tissue tunnel through which an occipital nerve passes in the neck to the base of the skull is excessively narrow.

While some element of compression has always been present, there are a couple of caveats to these observations:

  1. We don’t have an empirical method for measuring occipital nerve compression. If a patient suffers from a critical condition like compartment syndrome in the leg, in which when pressure builds up, there are established tools to measure what critical pressure is and when to operate. A similar baseline has yet to be established for nerve compression causing head pain, so there is no defined way to measure the degree or severity of the compression that we see.
  2. Secondly, we also don’t know what degree of compression will cause symptoms of pain. This amount of pressure will likely vary based on a number of parameters such as which nerve is involved.  For example, the greater occipital nerve is a much larger and heartier nerve and therefore is likely to be able to tolerate more pressure before becoming symptomatic as compared with the lesser occipital nerve.  
  3. Lastly, we don’t ever operate on people who don’t have symptoms nor where candidacy for surgery has been not been verified via history, physical examination and nerve blocks. In other words, when you only have symptoms on the right side, I’m not going to dissect and open the left side of the neck just to look so that I have a comparison of what “normal” supposedly looks like.  Doing so exposes those left-sided nerves to potential injury unnecessarily. That being said, there was an important study conducted by Dr. Guyuron several years ago to validate the outcomes of headache surgery. It was what was known as a sham surgical trial, 76 patients knowingly participated with 49 patients undergoing the actual nerve decompression procedure and the remainder undergoing what’s called a sham operation. On the day of the surgery, Dr. Guyuron would open an envelope and it would tell him if the patient was having the real surgery or not. The sham surgeries had to seem like they could be real, so these patients were still induced under anesthesia, were cut open and their nerves exposed, but ultimately left alone for a typical time that the operation would take. The patients who had the actual surgery did statistically better in terms of frequency, severity and duration of their headaches when compared to the sham surgical patients. In addition, while there was some placebo effect, none of the patients who received the sham surgery were headache-free, while a statistically greater percentage in the actual surgical group did report this outcome.

The take home message is this:  There is still much work to be done in order to establish a measurable baseline for nerve compression that leads to head pain.  However, in the meantime we can work with what we know and that is if a patient experiences chronic pain, has exhausted all non-surgical methods of treatment and responds well to nerve blocks, they are reasonably good candidates for nerve decompression surgery.

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What Is a Migraine?

What Is a Migraine

Many people consider a migraine to be a really bad headache. The truth is, it is a severe, neurologic condition. However, when perusing the medical literature, it becomes apparent that the term ‘migraine’ in many practical instances, is actually a name that we have given to a constellation of symptoms as opposed to a specific medical issue with a specific, identifiable cause.

If you go to WebMD or the Mayo Clinic or just Google the term “migraines”, what you’ll consistently find is that they are defined as very severe headaches. You’ll also find that they have all sorts of descriptive characteristics.  For example, they mostly affect women between ages 25 to 55, and can last anywhere from 4 to 72 hours, etc. Migraines typically have 4 phases:

  1. Prodrome - where people start to feel a bit off before their head pain sets in
  2. Aura – a period during which some patients experience symptoms such as flashing lights, unusual smell and sound sensitivity, etc.
  3. Headache - the actual experience of head pain; however, there are acephalalgic (i.e. painless) patients or atypical expressions of this stages where people experience, for example, primarily nausea and dizziness without the head pain
  4. Post-drome - which is akin to a post-seizure state during which the actual head pain has either abated or gone away, but the patient is left with acute after-effects such as drowsiness, confusion and/or irritability

While we have a broad range of characteristics that describe these headaches, at the end of the day, the question that migraine sufferers most want answered is ‘What causes them?’ In most cases, we don’t really know. This fact is demonstrated by the sheer number of medications and numerous classes of medications that are used to treat migraines. Examples of the latter include anti-seizure medications, pain medications, muscle relaxants, neuroleptics, antidepressants, serotonin-modulating drugs (like all the triptans), the new range of CGRP receptor antagonists and several others.  Generally speaking, in life as well as in medicine, when there are multiple different ways of treating a problem, one can rest assured that not one of those methods is supremely effective, otherwise everyone would be using it. I say to my patients that two most important questions for any diagnosis is to figure what is causing that problem and if you can figure that out, what can you do about it.

Peripheral nerve surgeons treat headaches differently when compared with the traditional way physicians are taught to think about these problems. We focus on specific peripheral nerve triggers that might be causing your headache.  Hence when we use the term occipital (meaning back of the head) neuralgia (meaning nerve pain), the real question is: “Can you figure out which ‘neur’ (i.e. nerve) is causing the ‘algia’ (i.e. pain). That is the crux of the diagnostic work up when a patient comes to see me for this issue.  At the end of the evaluation, with the help of a thorough history, physical examination and set of peripheral nerve blocks, I will have a much better sense of which nerve or nerves might be involved in your headache symptom complex and whether or not surgical intervention might be of benefit. 

The take home message is that the term “migraine” is often very non-specific and not often helpful.  While people with headaches caused by pinched nerves in the occipital area technically have “migraines” from a purely definitional standpoint, the more accurate diagnosis is ‘occipital neuralgia’ or even more specifically greater (and/or lesser, third) occipital neuralgia.  The reason the latter diagnosis is more useful is that it points to a specific cause which can be treated.  That is the reason we have these diagnostic terms in the first place.

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Ziv M. Peled M.D. Discusses Migraine Awareness Month

 MHAM D1 video

 

 

Ziv M. Peled M.D. discusses what migraines are and how they affect people's health and well-being. To learn more about Migraine Surgery and Migraines, visit https://peledmigrainesurgery.com today.

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Burning Migraine Questions with Becky Ellefsen May 16 2019

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In Episode 10 of Burning Migraine Questions, Ziv M. Peled, MD talks to Becky Ellefsen about her journey from a whiplash injury to chronic head pain to relief.

They discuss the challenges faced by sufferers of headaches that don't find relief from medication, how it feels not to be believed by your practitioner, that the prescribed medications are often insufficient and the courage needed to face the fact that you can be fired by your practitioner for pursuing an alternate course of treatment.

Dr. Peled reiterates that "surgery is never the first option" and talks about the importance of patient advocacy for raising awareness of this approach when other treatments have failed.

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FEARS AND MISCONCEPTIONS ABOUT HEADACHE/MIGRAINE SURGERY – PART 2

FEARS AND MISCONCEPTIONS ABOUT HEADACHEMIGRAINE SURGERY PART 2

In this second installment about fears and misconceptions about headache/migraine surgery, I’ll address several other concerns people have raised when considering these procedures. As before, hopefully these discussions are helpful in making a more informed choice about whether such procedures are right for you.

  • Misconception 3 – The results of surgery are only temporary and the pain will eventually recur. I often tell patients that it may be scar tissue that is pressing on their nerves or preventing them from gliding back and forth as they move their neck and hence cause pain.  Patients naturally ask why more scar tissue wouldn’t form after their operation.  This question is a good one.  The answer is that scar tissue always forms after any operation, but excessive scar tissue that re-entraps nerves can be mitigated by creating sufficient space around the nerves during the operation and by allowing/instructing the patient to move their neck normally as soon as they wake up.  We know from our work on tendon injuries in the hand that as little as 5 mm of gliding can prevent clinically significant adhesions and the same physiology holds true in other parts of the body and with respect to nerves.  To back this fact, the 5-year results from these operations were actually published back in February 2011.  In this study, 5 years following their operations, 88% of patients were still reporting at least a 50% reduction in frequency, severity and/or duration of their symptoms and 29% were completely migraine-free.  In the medical cancer literature, if you are free of your disease after 5 years, you are typically considered to be in remission.   Similarly, if you are significantly better or migraine-free after 5 years, we consider these essentially permanent results.
  • Misconception 4 – My insurance considers these operations experimental which means they are unproven. Sorry, but I get on a bit of a soap box about this one.  In my humble opinion, insurance companies are not the arbiters of what is medically appropriate.  That decision is between the doctor and the patient – period.  Your insurance company doesn’t know you, hasn’t examined you, hasn’t spoken with you about your condition and hasn’t evaluated your records. The American Society of Plastic Surgeons put out a formal position statement regarding headache surgery which clearly states that when more conventional modalities have failed, that these operations are not only reasonable, but should be considered the standard of care.  This 13-page document is exhaustively researched and cites 89, peer-reviewed articles in high-impact factor journals, which speak to the efficacy of this approach to chronic migraines/headaches.  It continues to boggle my mind why insurance companies claim this treatment approach is unproven because it is simply untrue.

https://www.plasticsurgery.org/Documents/Health-Policy/Positions/ASPS-Statement_Migraine-Headache-Surgery.pdf

  • Misconception 6 – I had a nerve block with another doctor which was unsuccessful and therefore I am not a candidate for these procedures. Results of the nerve block will vary based upon several parameters: what you inject, how much of it you inject, where and how you inject, and for what reason you are injecting.  I can’t tell you how many patients have told me that they had a nerve block of the greater occipital nerve which was unsuccessful, but when I ask them if the back of their head was numb at all, they reply ‘no’.  If you have no numbness following a nerve block, that means the nerve was not blocked and simply put, you have had no idea whether or not numbing that target nerve would give you a successful result.  Therefore, if nothing else, if the nerve block which was performed initially was unsuccessful, then may be a repeat block performed in a slightly different way with a slightly different technique may be successful.  It is thus important to have these blocks performed sequentially and by a clinician with a reasonable amount of experience with these procedures.

Hope these explanations help to some degree.  In a future blog post, I plan to address still other misconceptions that seem to strike fear in the hearts of those considering an operation for relief of their chronic headache pain.

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Ziv M. Peled, M.D. Presents Burning Migraine Questions Episode 9 May 2, 2019

 

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In Episode 9 of Burning Migraine Questions, Ziv M. Peled, MD talks to Ronny Ead about what has happened since The Doctors was taped a year ago, why they didn't discuss Occipital Neuralgia or Trigeminal Neuralgia on the show and why these mechanically-triggered conditions are so under-diagnosed. They also discuss extra-cranial surgery being designated as the standard of care for head pain, when other treatment modalities have failed. Dr. Peled advocates for medical and paramedical practitioners coming together as a treatment team to address the chronic pain epidemic.

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Ziv M. Peled, M.D. on The Doctors!

Ziv M Peled MD on The Doctors

I was proud to appear in today's episode of The Doctors, where I discussed my patient Ronny's surgery and recovery, and how peripheral nerve surgery had helped eliminate his migraines.

With more than 37 million migraine sufferers in the United States, you probably know someone who is suffering from debilitating headaches.  Ronny was one of these 37 million Americans until he came to see me.  He shared his story with The Doctors and let the show into the operating room with us as he had his peripheral nerve surgery to rid him of migraines.

Ronny's migraines had been steadily worsening since 14, and had pain coming from the back of his neck that would spread to the front of the forehead and to his eyes and his temples.  He also suffered from extreme nausea, leaving him unable to get out of bed and having trouble working.

After trying many different meds and therapies, like acupuncture and massage, Ronny also went through changes to how he went about his regular life.  Even stress management and diet changes brought no relief.  After seeing over 15 doctors and dentists, he was at the end of his patience.  Then he came to our office.

The most common misconception about migraines is that an abnormality inside the brain is the cause.  This is not always true.  They can also be caused by nerve compression outside of the brain, where scar tissue, abnormal blood vessels or spastic muscles can impinge on the nerve.  This was what Ronny was dealing with.

I operated on Ronny to release the nerves at the back of his head and get them away from the spastic muscles.  We showed this procedure in the video that was shared with The Doctors as I operated on the nerves in the front of the head and the temples.

We then joined the studio panel for The Doctors, where Ronny shared his story, and that he is nearly 100 percent pain-free after the surgery.  I was asked by Plastic Surgeon Dr. Andrew Orton why Ronny was such a good candidate for this surgery.

To me, the ideal candidate:

  1. Has been diagnosed with migraines by a board-certified neurologist or headache specialist
  2. Has failed conventional therapies including various drugs and injections
  3. Has a good physical exam that shows there's a peripheral nerve that is casing the headaches
  4. Has responded well to an injection of a numbing agent or a local anesthetic in the office.  For example, the headache goes from 9 to 1 on the pain scale

When the patient has been numbed in the office, I can identify the problem nerves and the patient also gets the chance to "test drive" their results, to see where they would be numb if we did cut those nerves.

While Ronny was afraid of having his nerves cut prior to the surgery, the pain was awful enough that he felt he had no choice but to undergo the procedure.  He does report some numbness behind his ear and in his forehead, but says he hasn't had any really noticeable side effects form the surgery, and in fact, doesn't even think about it any more!

If you're dealing with migraines and want to know if migraine surgery can help you. here's how to find the right surgeon for you:

  1. Look for someone with specific training in peripheral nerve surgery during either a residency or fellowship.
  2. Use a surgeon who has done nerve surgery not just in the head and neck but all over the body
  3. Preferably find a surgeon with specific training in this headache operation 
  4. Utilize a surgeon who could provide patient references, ideally from several years out, to show the results are lasting
  5. You can use the American Society for Peripheral Nerve to look for members

While Medicare covers migraine surgery, many insurance policies don't because the surgery is new.  Always discuss insurance with your surgeon's office because they will help you understand the costs, what is covered and what is not. 

 
We then joined the studio panel for The Doctors, where Ronny shared his story, and that he is nearly 100 percent pain-free after the surgery.  I was asked by Plastic Surgeon Dr. Andrew Orton why Ronny was such a good candidate for this surgery.
 
To me, the ideal candidate:
 
  1. Has been diagnosed with migrianes by a board-certified neurologist or headache specialist
  2. Has failed conventional therapies including various drugs and injections
  3. Has a good physical exam that shows there's a peripheral nerve that is casing the headaches
  4. Has responded well to an injection of a numbing agent or a local anasthetic in the office.  For example, the headache goes from 9 to 1 on the pain scale

When the patient has been numbed in the office, I can identify the problem nerves and the patient also gets the chance to "test drive" their results, to see where they would be numb if we did cut those nerves.

While Ronny was afreaid of having his nerves cut prior to the surgery, the pain was awful enough that he felt he had no choice but to undergo the procedure.  He does report some numbness behind his ear and in his forehead, but says he hasn't had any really noticeable side effects form the surgery, and in fact, doesn't even think about it any more!

If you're dealing with migraines and want to know if migraine surgery can help you. here's how to find the right surgeon for you:

  1. Look for someone with specific training in peripheral nerve surgery during either a residency or fellowship.
  2. Use a surgeon who has done nerve surgery not just in the head and neck but all over the body
  3. Preferably find a surgeon with specific training in this headache operation 
  4. Utilize a surgeon who could provide patient references, ideally from several years out, to show the results are lasting
  5. You can use the American Society for Peripheral Nerve to look for members

While Medicare covers migraine surgery, many insurance policies don't because the surgery is new.  Always discuss insurance with your surgeon's office because they will help you understand the costs, what is covered and what is not. 

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