NERVE SURGERY

Slider

CHRONIC HEADACHES

NEUROPATHY

CHRONIC PAIN FOLLOWING SURGERY

CHRONIC HEADACHES

Current estimates place the number of migraine sufferers in the United States at over 28 million! Sadly, this number does not take into account those who suffer from other types of headaches such as cluster headaches and tension headaches. Recently, an outpatient procedure has been described which has been shown in numerous patients to significantly reduce the frequency, severity and/or duration of migraine headaches and in some cases, to eliminate them permanently.

IS PERMANENT RELIEF FROM CHRONIC HEADACHES POSSIBLE?

YES!

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

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

HOW DO I KNOW IF A PINCHED NERVE IS THE CAUSE OF MY HEADACHES?

During your consultation with Dr. Peled, he will take a thorough history focusing specifically on your headache symptoms. We will discuss all the prior treatments which you have tried in the past and go over any old imaging studies. Dr. Peled will then perform a comprehensive physical examination to elucidate if there are any physical findings that suggest that a pinched nerve in the head or neck could be causing your headache. Further imaging studies (i.e. MRIs or CT scans) may be required and if so, they will be ordered accordingly. A series of simple injections with Botox will then be performed in the office. Depending on the results with these various steps, a decision will be made as to whether your headaches could be caused by a pinched nerve and hence your suitability for surgical decompression.

WHY USE BOTOX?

Although it might seem a bit odd, Botox is very useful in the work-up to determine whether surgery will be successful. Many of the nerves which can cause headaches are compressed by muscles. Since Botox works by relaxing muscles, it may produce results similar to what may be experienced with surgery. However, these injections must be performed in a very specific way, by someone with a thorough understanding of the anatomy which is being addressed. As a plastic surgeon, Dr. Peled had injected Botox hundreds of times for cosmetic reasons. As a peripheral nerve surgeon, he has similarly injected Botox numerous times, often successfully as a prelude to surgical decompression. Furthermore, as a peripheral nerve surgeon, he has an intimate understanding of the anatomy of the peripheral nerves within the head and neck.

IF I’M A CANDIDATE FOR THIS TYPE OF SURGERY, HOW IS IT PERFORMED?

Surgical decompression for chronic headaches is performed as an outpatient procedure at an accredited surgery center or in the outpatient department of the California Pacific Medical Center. The procedures can last anywhere from 1 hour to 3 hours depending on the number and locations of the nerves being treated. There are few restrictions following the procedure and discomfort is usually very well tolerated with oral pain medication. For more specific information, please contact us for a formal consultation.

WHAT ARE THE RESULTS WITH THIS TYPE OF SURGERY?

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

NEUROPATHY

Conventional wisdom states that peripheral neuropathy is progressive and irreversible. However, this dictum may not always be true. In many cases, the symptoms of peripheral neuropathy may be due in part to a pinched nerve in the leg, foot, arm, forearm or hand. If you or one of those patients, then an outpatient surgical procedure to “un-pinch” those nerves may be effective in reducing or even eliminating the pain, tingling and numbness often associated with neuropathy secondary to diabetes, hypothyroidism, exposure to chemotherapy and other conditions.

HOW DO I KNOW IF A PINCHED OR INJURED NERVE IS INVOLVED IN MY CASE?

During your consultation with Dr. Peled, he will take a thorough history focusing specifically on your neuropathy symptoms. We will discuss all the prior treatments which you have tried in the past, which ones were successful and which ones were unsuccessful and go over any imaging studies or diagnostic tests that you may have had. Dr. Peled will then perform a comprehensive physical examination to elucidate if there are any physical findings that suggest that a pinched nerve could be causing your pain. Sometimes, a nerve block will be used to confirm whether or a suspected nerve is actually the culprit in your particular case. Other times a different type of test will be recommended. If the information gathered from these various sources suggests that there is a peripheral nerve which is compressed (i.e. “pinched”) and is contributing to your neuropathy symptoms, you may become a candidate for surgery to decompress (i.e. “un-pinch”) the injured nerve.

HOW ARE THESE TYPES OF OPERATIONS PERFORMED?

Almost universally, surgery to decompress injured nerves in neuropathy patients can be performed on an outpatient basis. On rare occasions, a 23-hour overnight stay at a hospital may be necessary. During the procedure, Dr. Peled carefully exposes the injured nerves and removes any excessive scar tissue and connective tissue which may be compressing them. It is important to remember that the nerves themselves are not cut so as to minimize the chance of neuroma formation following surgery and to preserve as much function and sensation as possible. If the injured nerves in your particular case happen to be in your upper or lower extremities, only one extremity can be operated upon at one time because you will then favor that extremity and use the other side more. We want to make sure that the first side is fully healed before we operate on the other side because the reverse will be true following that second procedure. There is usually very little in the way of post-operative, confining dressings and/or restrictions and patients are able to eat and drink whatever they like immediately following their procedure. Pain medicine is prescribed for post-operative discomfort which is usually very well tolerated.

HOW LIKELY AM I TO SEE A BENEFIT FROM THESE TYPES OF PROCEDURES?

The ultimate outcome from an operation to decompress one or more nerves is dependent on numerous factors such as the nerves in question, the patient’s age and co-morbidities, the duration and severity of symptoms as well as other factors. With respect to diabetic neuropathy (the most common form in the United States as well as worldwide) the published results suggest that in appropriately selected patients, success rates in terms of good relief of pain and restoration of sensation can be above 70%. Depending on your specific history, the particular type of procedure you have had performed and which nerve or nerves have been addressed in your particular case, recovery times can also vary. Generally speaking, a procedure is not considered unsuccessful until at least a year has gone by as nerves can often take many months to recover and patients can often see steady improvement for many months following their operations. A much more specific and accurate answer to this question can be provided once we know the particulars of your situation which is why it is so important to have a formal consultation and examination with Dr. Peled.

CHRONIC PAIN FOLLOWING SURGERY

There are literally millions of surgical procedures performed in the United States each year and while most of them are successful, there is a small, but significant number of patients who end up with debilitating pain. Similar symptoms can also result from accidents such as falls, motor vehicle crashes, firearm injuries and sports-related injuries. Luckily, many of these cases are attributable to injury of one or more peripheral nerves often be treated with a significant reduction in pain.

I FINALLY FOUND SOMEONE WHO UNDERSTOOD THE CHRONIC PAIN I HAD

Surgical procedures are performed with the goal of making us feel better and fixing the cause of a specific problem. Unfortunately, sometimes chronic pain is an unintended consequence of the operation and this pain can occur even if the procedure in question was done correctly. Why would this occur and how could it be remedied? In order to answer this question, we must first recognize the saying that, ‘All pain comes from nerves’. The corollary to this adage is that if one can identify the specific nerve(s) causing the pain and what is wrong with them, perhaps something can be done to improve the pain.

There are many, common surgical procedures which can result in chronic pain. Examples include inguinal (groin) hernia repair, appendectomy, hysterectomy, Caesarian section, vasectomy, and certain types of breast reconstruction. As a cosmetic as well as reconstructive plastic surgeon, I was trained to work from head to toe and hence acquired an intimate understanding of the anatomy of the entire body. As a peripheral nerve surgeon, my specific knowledge of peripheral nerves and how such nerves may be injured, surgically manipulated and repaired has given me an appreciation for defining when nerves have been injured and whether or not they are amenable to surgical treatment.

The nerves that are often injured during the surgical procedures mentioned above are extremely small and can vary in their exact anatomic location. For these reasons, sometimes these nerves are accidentally cut, stretched or burned without the initial operative surgeon realizing that an injury has occurred. In addition, sometimes during the normal wound healing process scar tissue beneath the skin can envelop small nerves and cause compression which, in turn, can lead to chronic pain. Only when this pain does not subside many weeks or months following the initial operative procedure, do clinicians recognize that something has gone awry. Fortunately, certain general principles and compression points exist that allow a peripheral nerve surgeon to determine whether or not a particular nerve may have been injured.

HOW DO I KNOW IF A PINCHED OR INJURED NERVE IS THE CAUSE OF MY PAIN?

During your consultation with Dr. Peled, he will take a thorough history focusing specifically on your pain symptoms. We will discuss all the prior treatments which you have tried in the past, which ones were successful and which ones were unsuccessful and go over any imaging studies or diagnostic tests that you may have had. Dr. Peled will then perform a comprehensive physical examination to elucidate if there are any physical findings that suggest that a pinched nerve could be causing your pain. Oftentimes, a nerve block will be used to confirm whether or a suspected nerve is actually the culprit in your particular case. If the nerve block is successful in significantly reducing or limiting your pain then you may become a candidate for surgery to decompress, repair or remove the injured nerve.

HOW IS THIS TYPE OF SURGICAL PROCEDURE PERFORMED?

Almost universally, surgery to decompress, repair or remove injured nerves can be performed on an outpatient basis. On rare occasions, a 23-hour overnight stay at a hospital may be necessary. There is usually very little in the way of post-operative, confining dressings and/or restrictions and patients are able to eat and drink whatever they like immediately following the procedure. Pain medicine is prescribed for a post-operative discomfort which is usually very well tolerated. Depending on your specific history, the particular type of procedure you have had performed and which nerve or nerves have been addressed in your particular case full recovery can vary. Generally speaking, a procedure is never considered unsuccessful until at least a year has gone by as nerves can often take many months to recover and patients can often see steady improvement for many months following their procedures.

HOW CAN YOU TELL IF A NERVE NEEDS TO BE DECOMPRESSED, REMOVED OR REPAIRED?

This question is one that I get asked quite often and it is a very good question. While there are certain clinical signs and symptoms that suggest whether a nerve has been permanently injured or is simply pinched, there is no way to tell with absolute certainty which is the case. Ultimately, the decision as to what exactly needs to be done is made in the operating room once the nerve or nerves have been exposed and the pathology visualized directly.

WHAT TYPE OF RESULTS CAN I EXPECT FROM SURGERY?

Is not possible to say as a general rule, what your expected recovery will be in terms of pain relief, restored sensation or improved function. The reason for this situation is simply because there are so many variables that ultimately impact the final outcome such as the particular nerve or nerves injured, a patient’s age and other medical problems, the amount of time since the injury occurred, the degree of pressure which has been present and other factors. However, we are able to help most patients who come to see us and have certainly had many patients whose pain has been completely eliminated, whose function has improved significantly and whose sensation has been restored to near-normal. A much more specific and accurate answer to this question can be provided once we know the particulars of your situation which is why it is so important to have a formal consultation and examination with Dr. Peled

SCHEDULE A CONSULTATION

We provide a range of emergency, medical, general, residential, and community health services.