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Latest Entries

Dr. Peled Speaks at Plastic Surgery The Meeting 2016

by Dr Ziv Peled
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on Monday, 03 October 2016
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Dr. Ziv M. Peled, M.D. was recently a lecturer, injector and surgical trainer at the largest plastic surgery meeting in the world. Plastic Surgery The Meeting 2016, held in Los Angeles, CA in September and sponsored by the American Society of Plastic Surgeons is the premier meeting for plastic surgeons globally. Dr. Peled gave four talks in two sessions over two days on subjects ranging from occipital nerve surgery to coding for headache surgery. The talks were well received and are likely to be repeated in future meetings and to include an expanded curriculum on additional aspects of this exciting treatment option for chronic headaches refractory to conventional therapy.

For more information on how headache surgery can help reduce your "migraine" symptoms, visit www.peledmigrainesurgery.com or call 415-751-0583 to schedule an appointment with Dr. Peled.

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What is the Difference Between Occipital Neuralgia and Cervicogenic Headaches?

by Dr Ziv Peled
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on Friday, 16 September 2016
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I recently read a comment from a patient asking a very interesting question - “What is the difference between occipital neuralgia (ON) and cervicogenic headaches (CH)?”

Unfortunately the answer to this question is not a straightforward one. It has been postulated that pain in the head/neck region can be referred from problems in the bony or soft tissues of the neck, but there is still some controversy as to whether cervicogenic headache constitutes a distinct clinical entity. The upper-most cervical nerves and their branches are the most commonly cited sources of CH with the most common source being the C2/C3 levels. The actual definition of cervicogenic headaches is also not firmly established. One accepted way of defining this disorder is by its clinical characteristics. Specifically, it is a unilateral pain of variable severity that is not stabbing and radiates from posterior to anterior. It doesn’t shift from side to side, is brought on by unusual head position or neck motion and may be associated with shoulder or upper extremity pain on the same side. The biggest issue with this definition is that it overlaps with many of the characteristics of other headache disorders such as tension headaches and migraines without aura. Another way of defining CH is by demonstrating a cervical source of pain and confirming that source with a nerve block.

Diagnostic criteria for CH have been established by the Cervicogenic Headache International Study Group (CHISG) and by the International Headache Society (IHS). The former’s criteria require signs or symptoms brought on by awkward head movements or positioning or by pressure over the occipital nuchal structures and possibly confirmed by anesthetic blockade. The IHS criteria mandate that the pain be referred from an identifiable and plausible source in the head/neck (as demonstrated on imaging such as MRI) or by successful blockade of a nerve or cervical structure. Moreover, the pain must resolve within 90 days of successful treatment of the underlying problem. However, the IHS criteria do not define when, where, and how much pain is caused by CH (i.e. the clinical features).

In contrast, most neurologists would define ON in a very specific way. The classic description is that of paroxysmal pain in the distribution of the occipital nerves, sometimes, but not always accompanied by changes in skin sensation in the back of the scalp. The symptoms of ON are also thought to have a character of burning or hypersensitivity that may be constant on top of the intermittent shooting pains described above. These symptoms should be temporarily relieved by occipital nerve blocks.

So what to do with all of this information? Unfortunately, I find these definitions and descriptions minimally helpful since many of the symptoms of ON and other headache disorders for that matter can overlap with those of CH. For example, many of my patients with ON who have been successfully treated with decompression had exacerbation of their pain with awkward head positions and motions because these positions further compressed and irritated the occipital nerves. There are many patients who have unilateral ON. Therefore is ON a subset of CH? From my reading of the literature, most neurologists would seem to disagree, but I am uncertain as to why. Is CH a distinct clinical disorder? As stated above, there is disagreement as to whether it is versus just a descriptor of where the pain is coming from.

All of which brings me to the take home message. When it comes to any disorder, but especially chronic headaches, the only relevant questions in my humble opinion are: 1) can you figure out what’s causing it and 2) if you can, can you do anything about it? You can call the headache whatever you like - migraines without aura, CH, George - the names are irrelevant. With that in mind, I believe that the literature has shown that accurate diagnosis of ON with nerve blocks or Botox is a good predictor of a good result with surgical decompression. Moreover, surgical decompression has been shown to be very effective and have a very low complication rate with good long term results.

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POSTURE AND OCCIPITAL NEURALGIA

by DrZiv
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I was recently asked an interesting question: “If you have bad posture and have a decompression procedure, won’t the results eventually diminish as the bad posture would re-injure the nerves?” There was actually a recent, non-scientific article in a different publication (http://gizmodo.com/my-smartphone-gave-me-a-painful-neurological-condition-1711422212) which suggested that posture secondary to cell phone use was a factor in the development of ON in some people.  As you might suspect, I don’t know of anyone who would argue with the concept that good posture is important for any number of reasons.  However, can it cause ON to recur after an adequate decompression procedure?  Not likely.

As the article above suggests, even a little flexion or extension in the neck can lead to significant increases in pressure on the nuchal structures.  The reason is that many of these structures, such as the nerves, pass through very small spaces on their way to the scalp.  When those spaces which are tight to begin with are narrowed even just a little bit, the increase in pressure on the nerve can be dramatic.  However, it is not the bending or as to the point here, the bad posture that causes the neuralgia, it is the tight space becoming tighter.  When these narrow spaces are opened up, the reverse is also true - the pressure on the nerves can dramatically decrease.  The two pictures of the greater occipital nerve below illustrate the concept (warning- not for the easily grossed out).


                           BEFORE                                                                     AFTER

BeforeAfter

In the picture on the left, you can see the greater occipital nerve (long arrow) bulging out of the semispinalis muscle (short arrow) - a well-described compression point for this nerve. After removal of a small amount of said muscle (the upper and lower edges of which are denoted by the limbs of the “V”) you can see the GON more clearly.  What is also dramatic is that the nerve appears much smaller even though the picture on the right is at slightly higher magnification.  This all happens within a few minutes in the OR.  Anyone who has ever tied a rubber band tightly around the base of their finger for a minute and had a nice purple digit knows exactly what happens when the rubber band is released. The key here is balance.  As a surgeon I want to make enough space so that the nerve can now move freely with almost any position or posture, but not so much space that I remove too much muscle and cause some imbalance or weakness.  Moreover, when patients move their heads post-operatively, which I insist my patients do gently right away, the gliding prevents significant scar formation and re-narrowing of these spaces. Hence, if done correctly, persistent poor posture following decompression should not cause the ON to return. Hope that helps.

 

For more information, or to make an appointment, call Peled Migraine Surgery at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about migraine relief through surgery.  

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The Staged Approach to Migraine Pain Relief

by DrZiv
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on Wednesday, 09 December 2015
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headache -_medium

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.  The first is that in many cases, patients often say that one area usually flares up first and when very severe or unable to be controlled, 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 the 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 such 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.  Secondly, 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, however, in that if the occipital procedure is performed correctly and for the right indications, but yields no result, I would wonder whether or not a temporal/frontal procedure would be indicated since I would be less confident surgical intervention in those areas would be successful if 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 given 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.  Greater degrees of discomfort often lead to increased opioid use which, as many people will agree, 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 patient’s should ask their potential surgeons is how they approach patient and why, especially if their case will involve more than one or two incisions.  I hope that these thoughts are helpful.

For more information, or to make an appointment, call Peled Migraine Surgery at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about migraine relief through surgery.  

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Forest Spa Boutique and Peled Plastic Surgery

by DrZiv
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on Wednesday, 30 September 2015
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31283963 ml

Peled Plastic Surgery is proud to announce our affiliation with Forest Spa Boutique!  Bianca de Jong, Forest Spa Boutique’s owner and senior esthetician will be in our office to provide facial therapy and hair removal services to our patients by appointment.  Bianca’s esthetic work has been featured in a 2014 issue of Caviar Affair Magazine, an international travel magazine and on CBS for best places to visit for facials in the South Bay. Bianca holds a California Esthetician License and has, in addition, completed the requirements for European Facial training. This arrangement is reciprocal, as Dr. Peled also performs Botox and/or Juvederm by appointment at their Forest Spa Boutique location in Palo Alto. Appointments for services can be made by contacting the front desk of Forest Spa Boutique at (408) 759-0576 or with Cary-Anne at Peled Plastic Surgery at (415) 751-0583.

Dates Available:

Dr. Peled will be on location at Forest Spa Boutique on October 23rd and December 4th

Bianca de Jong will be on location at Peled Plastic Surgery on October 6, 20, November 3, 17, and December 1, 15

About Forest Spa Boutique in San Francisco

Bianca performs an in-depth skin analysis and then specifically selects skin care products that will properly address your skin's needs. An extensive selection signature anti-aging facials, peeling facials, sensitive skin facials, and diamond dermabrasion address your everyday needs and deliver an unsurpassed spa experience. Depending on your skin type each facial contains appropriate skin resurfacers (peels), includes signature extractions, works on blood circulation, improves the lymph flow, gives detailed attention to the eye and neck area, and uses a variety of serums to improve your overall skin condition. For facial and body hair removal services Bianca works with the gentlest Italian wax depilatory available. She is extensively trained in Brazilian waxing techniques and has significant experience with this method. A silky after-wax application will calm and hydrate your skin.

www.forestspaboutique.com

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Dr. Ziv Peled Invited To Speak At Plastic Surgery 2015

by DrZiv
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Ziv Peled, MD has been invited to be a Panelist at ‘Plastic Surgery 2015’ in Boston, Massachusetts on October 17 – 20, 2015 held by the American Society of Plastic Surgeons (ASPS).  This meeting is the largest and most prominent plastic surgical meeting internationally.  This panel is sponsored by ASPS and held in cooperation with the Plastic Surgery Foundation (PSF) and the American Society of Maxillofacial Surgeons (ASMS).  Dr. Peled will speak on his established experience with surgical intervention for chronic headaches. A specific emphasis of the program will be on incorporating the latest in plastic surgical techniques in order to understand what the future holds for plastic surgery as a profession and medicine in general. 

 

Dr. Peled’s panel will teach the participants to:

  1. 1.Identify current and emerging issues and advances affecting the diagnosis and delivery of treatment for plastic surgical problems and assess their potential practice applications.
  2. 2.Compare and contrast therapeutic options to determine appropriate recommendations for patient treatment.
  3. 3.Incorporate into practice, new technical knowledge, state-of-the-art procedures, advanced therapeutic agents and medical device uses.
  4. 4.Communicate current practice management and regulatory issues necessary for the efficient and safe delivery of patient care.
  5. 5.Translate expanded knowledge into practice for the improvement of patient outcomes and satisfaction

 

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. During that time, Dr. Peled not only helped establish Dr. Longaker’s laboratory at Stanford, but was also awarded a 5-year NIH grant for his work in keloid biology and scarless wound repair. Ziv then completed a prestigious and highly sought-after plastic surgical residency at Harvard University. While there, he was awarded an “Excellence in Teaching” award from the Harvard medical students. Dr. Peled continued to hone his specialty skills with an additional year of training in peripheral nerve surgery at the Dellon Institute for Peripheral Nerve and Plastic Surgery. He is Board-Certified by the American Board of Plastic Surgery, which means that he graduated from an accredited medical school, completed numerous years of residency training, and successfully passed a series of comprehensive written and oral examinations. The American Board of 
Plastic Surgery is one of only a select few specialty boards recognized by the American Board of Medical Specialties (ABMS) and is the only ABMS board which certifies candidates in the specialty of plastic surgery of the entire body. Dr. Peled is also a member of the California Society of Plastic Surgeons.

In addition to his cosmetic and reconstructive work, Dr. Peled helped to found a peripheral nerve surgery institute here in San Francisco. In that institute, he served as Director and Chief Plastic & Peripheral Nerve Surgeon. His specific training enables him to perform a unique set of surgical procedures designed specifically to restore sensation and minimize/eliminate pain in patients suffering from chronic headaches as well as neuropathy due to diabetes, chemotherapy and thyroid disorders.  He has also treated many patients with various forms of nerve trauma as well as many other types of nerve disorders. Dr. Peled has authored and co-authored over 40 manuscripts and book chapters on all aspects of plastic surgery and has presented his work at numerous national and international meetings. He has performed several hundred peripheral nerve procedures of various kinds.  Ziv is an Active Member of the American Society of Plastic Surgeons and a member of the American Society for Peripheral Nerve. This honor recognizes and highlights Dr. Peled's breadth of work with peripheral nerve patients suffering from migraines and diabetes as well as his published work on peripheral nerve surgery.  He continues to volunteer for the American Diabetes Association and has recently traveled to South America to provide reconstructive surgery to underprivileged children. In his spare time, he actively competes in both Half-Ironman and Ironman-distance triathlons.

 

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WHICH CAME FIRST THE MUSCLE OR THE NERVE?

by DrZiv
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on Friday, 14 August 2015
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Does your pain come from muscle or nerve pain?

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Why Did I Get Occipital Neuralgia?

by DrZiv
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on Tuesday, 23 June 2015
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headacheThe title of this post is really the $60,000 question. I have posted many times in the past about how Occipital Neuralgia 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. One of the most surprising comments 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 to 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.

For more information, read http://peledmigrainesurgery.com/blog/entry/whiplash-and-occipital-neuralgia-what-s-the-connection-1.html and visit www.peledmigrainesurgery.com for information on how to reduce your migraines and nerve pain.

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Dr. Peled Co-author On New Paper

by DrZiv
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on Friday, 12 June 2015
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The paper, 'Supraorbital Neuroma: A Rare and Unreported Complication Following Blepharoplasty' co-authored by Giorgio Pietramaggiori, MD, PhD, Sandra Saja Scherer, MD, Ziv M. Peled MD and Raffoul Wassim, MD has been accepted for publication by the Journal of Reconstructive Microsurgery (Theime Medical Publishers, Inc). This manuscript describes a novel approach for managing a supraorbital branch neuroma following blepharoplasty - a very popular aesthetic procedure. A short excerpt from this article is shown below with the full text to be published soon.  

Supraorbital 1

 

Supraaorbital 2

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Dr Ziv M Peled Wins Most Outstanding Paper award at CSPS

by DrZiv
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Dr Ziv M Peled Wins Most Outstanding Paper award at CSPS!

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To Decompress Or Transect: That Is The Question

by DrZiv
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on Friday, 10 April 2015
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There continue to be questions raised both in my office as well as online about the difference between neurectomy/implantation (transection of the nerve and implanting it in the local muscle) and decompression. Along with these questions come many misconceptions about the advantages and disadvantages to each. This post hopes to address some of those issues.

To decompress a nerve means simply to remove some form of external compression that is putting excess pressure on the structure. As has been mentioned previously, compression can be a result of scar tissue, tight muscles, abnormal blood vessel anatomy, connective tissue, etc. Decompression also means that the nerve is left intact and that hopefully, once the effects of the operation (e.g. swelling) and the effects of the compression wear off, the nerve will function well again. There are advantages to decompression. The most obvious advantage is that the nerve is preserved so hopefully sensation to that area will also be preserved. Secondly, since the nerve is not cut, the chances of a post-operative neuroma are theoretically low. There also disadvantages to this approach. First, the surgeon and/or patient make a judgement call that the nerve will recover if simply decompressed, but this doesn’t always occur. I believe that this is the primary reason some people who have decompression ultimately require neurectomy and implantation Second, just because the chances of a neuroma are low it doesn’t mean that they are zero - you can still get a neuroma-in-continuity, especially if there is a lot of manipulation required to adequately decompress a nerve. Third, if the compression has been severe and long-standing, the nerve may take many months to fully recover. Fourth, if recovery does occur, there is no guarantee that sensation to the relevant area will be “normal”. It may always feel a little bit off.

The biggest misconception with a neurectomy is that it is like pulling the plug out of a wall outlet. However, the injured nerve is not ripped out of the spinal cord. A better analogy is that the injured portion of the nerve is identified and the area just upstream where the nerve appears healthier is where the nerve is transected. This maneuver is just like cutting the central portion of a power cord to a lamp where the wires have frayed. The downstream part of the nerve (e.g. that which goes to the skin) is now irrelevant just like the part of the cord that is still attached to the lamp. There is no longer any electricity going though that part so the bulb will not turn on. However, that upstream cut end is still a live wire as it is still connected to the wall outlet and therefore must be capped. In the human being the same goal is achieved by implanting the upstream (proximal) nerve end (which is still getting nerve impulses from the spinal cord) into the local muscle. There are advantages and disadvantages to this approach. One advantage is that you may see immediate improvement in symptoms although not always. Sometimes, people continue to experience pain in that nerve even though when they touch their skin they are numb. This situation exists because the nerve that used to go to that area of skin is getting impulses from the spinal cord and brain albeit ending within the muscle and so your brain thinks that part of the skin hurts even though when you touch it is numb. Eventually in most cases, the nerve end in the muscle calms down and the pain improves. Another potential advantage is less dissection because the downstream area of the nerve doesn’t need to be dissected once transected as it is now irrelevant. There are potential disadvantages as well such as persistent nerve pain if the implanted nerve doesn’t calm down, a neuroma if the nerve comes out of the muscle and the obvious numbness in that nerve distribution. Another misconception is that neurectomy is a guaranteed, home-run result which is not true for those reasons mentioned above. There are clearly other nuances that exist which is why discussing these issues with your peripheral nerve surgeon is so important. Just as each patient is unique, each person will have different tolerances for different post-operative outcomes so a good discussion is useful both for the patient and the surgeon.

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The Bionic Arm

by DrZiv
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on Wednesday, 18 March 2015
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I recently read with interest the work of Dr. Oskar Aszmann and colleagues in Vienna, Austria regarding bionic reconstruction of the hand (The Lancet , February 2015). I have been listening to Oskar speak about this work for the past several years at our annual meetings and it is great to finally see it in publication. My hope is that this research will raise awareness of the possibilities for nerve reconstruction in the near future as well as what we are capable of doing today.

 

For those that haven’t seen or heard about this paper, it describes three patients who had severe brachial plexus injuries. The brachial plexus is the network of nerves in the neck and shoulder regions that mediate all of our upper extremity function and sensation. All three patients had failed traditional reconstruction methods and the patients were left with minimally functioning upper extremities. Something else had to be done. To simplify it, the wiring of the remaining upper extremity was reconfigured using a combination of nerve transfers and bringing in muscles from other parts of the body along with their nerves so that the remaining, functional nerves could intuitively and predictably innervate the upper extremity muscles. Then, by following a specific rehabilitation protocol, the patients re-learned how to use this re-wired musculature. This protocol included the use of a hybrid myoelectric (i.e. robotic) prosthetic which was attached to the native, non-functional hand so that the patients could appreciate how much additional function they had with the robotic hand as compared with their native hand which was often minimally functional and insensate. After adequately learning how to control this myoelectric (i.e. robotic) hand, each patient underwent elective amputation of the native hand and permanent fitting of the same myoelectric prosthetic which they had been learning to use. Post-operatively all three patients demonstrated significantly improved upper extremity function, decreased pain as well as improvements in quality of life according to well established measures.

 

Oskar’s work is exciting for a number of reasons. First of all, it wonderfully demonstrates the degree to which we are able to restore function in the upper extremity for those with previously devastating injuries that were once thought to be irreparable. Secondly, while these surgical procedures are not for everyone and can be complex, the technical challenges that we face in the operating room are being greatly aided by improvements in electronic prosthetic development. Already in the works are myoelectric prosthetics with vastly more degrees of freedom (i.e. independently moveable joints) and signal processing capabilities which will ultimately allow a very precise level of function at the wrist, hand and finger levels beyond those which are available today. Third, I believe that in the not too distant future, we will see prosthetics that can actually be surgically implanted and will not need to be taken on and off as we have today, thereby removing a psychological downside to prostheses in general. Fourth, such procedures and prosthetics may ultimately provide us with a level of functionality that even a “normal person” doesn’t have. While there are certainly moral and ethical implications to consider with these possibilities, the concepts and potential are exciting indeed.

 

In many ways, this type of work represents the ultimate melding of computer science/engineering and modern medicine/surgery. Dr. Darrell Brooks and I have performed several similar procedures, so far with very encouraging results. We sincerely hope that the publication of this paper and hopefully soon others like it will encourage peripheral nerve surgeons to pursue even greater achievements. I believe that in time and in collaboration with our engineering/biomedical colleagues, devastating injuries suffered by those returning from war or after accidents will no longer mean a lifetime of dysfunction.

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What Happens After The Nerve Burial?

by DrZiv
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on Saturday, 11 October 2014
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This is really the million dollar question for human kind, but in the case of nerves, I believe we have some ideas. 

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CAN STRESS MAKE OCCIPITAL NEURALGIA WORSE?

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on Friday, 22 August 2014
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This post will be a relatively short one, but this question is very important. I have been queried about this phenomenon numerous times. Peripheral compression of the occipital nerves can come from muscles in the neck, scar, fascia (a tough type of connective tissue) and blood vessels, specifically branches of the occipital artery. When the latter are involved, the pathology to the nerve is much like that of an anaconda strangling its prey if the blood vessel is wrapped around the nerve or alternatively that of a jackhammer if the artery lies next to the nerve in a small and fixed space. In both cases, when the blood pumps through the artery with greater force, the pulsations will pound the nerve with greater force. Hence, when blood pressure increases, so does the pulsatile force against the nerve and hence the pain.

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

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

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For more information, please visit www.peledmigrainesurgery.com today!

by DrZiv
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on Wednesday, 18 June 2014
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This post has been a long time coming.  It seems that almost daily, I get a question from some patient somewhere wondering why their (insert body part here) hurts when they’ve had a nerve injury despite the fact that the area feels numb to the touch.  This phenomenon can be seen in patients suffering from diabetic neuropathy (most commonly noted in the lower extremities), amputees with phantom limb pain and anyone with a sensory nerve injury anywhere else (e.g. the head/neck region).  I will qualify my remarks below by saying that this topic is a huge one and cannot be covered in its entirety in a brief post or even a book chapter.  There are whole journals published monthly devoted to the study of such clinical dilemmas.  The goal here however is to provide a general understanding of why one might have these types of sensations and as a launch point for discussion with your treating physician about what can be done. I will also use phantom limb pain as the template for understanding this problem as it is one of the most common manifestations of this problem and the one most conceptually accessible to a non-physician.

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WHAT’S THIS TRIGEMINAL NEURALGIA THING?

by DrZiv
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on Friday, 14 March 2014
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WHAT’S THIS TRIGEMINAL NEURALGIA THING?

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

by DrZiv
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on Thursday, 02 January 2014
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WHY DOES IT HURT SO MUCH AFTER THE INJECTION?!?

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

 

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

 

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

 

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


For more information about how Botox injections can help with your cosmetic or pain issue, please visit www.peledplasticsurgery.com or call 415-751-0583 today to make an appointment.

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NEUROMA 101 and Why They Cause You Pain

by DrZiv
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on Friday, 20 December 2013
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First of all, what is a neuroma?  A neuroma can be defined in one of two ways.  One, as a tumor composed of nerve tissue such as an acoustic neuroma.  Almost overwhelmingly, these tumors are benign. The more common usage of the term neuroma means a mass of nerve tissue consisting of regenerating nerve fibers that have been previously severed or injured somehow.  When a nerve is injured, it tries to re-grow - that’s what nerves do.  If that nerve re-grows into the scar at the skin, it can cause exquisite pain even with light touch in the area.  This situation would be akin to having a cavity (which hurts because the nerve at the root of the tooth is exposed) and eating ice cream - ouch!  So if a nerve is severed or injured in some other way, how do you prevent a neuroma from occurring?

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Medication Overuse Headache (MOH) or ‘Rebound Headaches”

by DrZiv
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on Friday, 13 December 2013
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I have been asked recently to write a little something about so-called “rebound headaches”. This topic can be quite confusing, and as you will read, is not very well understood. The precise medical term for this disorder is Medication Overuse Headache (MOH) or analgesic rebound headache. The prevalence of this problem is about 1% in the general population and as with many types of headaches, is higher in women than in men. The underlying mechanisms for MOH are unknown, but as with many medical problems, are oftentimes multifactorial. It is known that there can be a genetic predisposition to MOH. In addition, long-term exposure to opiates is known to cause changes in the nervous system through increased expression of specific cytokines (chemicals, e.g. Calcitonin Gene-Related Peptide) and increased activity of certain neural pathways felt to modulate the sensation of pain. Some people also feel that addictive personality disorders are associated with MOH. Interestingly, migraines are the thought to be the most common “primary headache disorder” that has been linked to MOH.
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BLOCKS & STIMULATORS & DECOMPRESSION, OH MY?!?

by DrZiv
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on Monday, 25 November 2013
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I’ve noted that there has been some confusion lately over the roles of nerve blocks, nerve stimulators and nerve decompression in the treatment of chronic headaches. To be sure, there will be variations in how each clinician may use these modalities, if only because each patient presents a unique clinical dilemma.  While I certainly can't speak to the ways in which others utilize these modalities, I can offer general guidelines as to how I use them in my practice.  Hopefully this information will also provide some insight into the advantages and disadvantages of each.
Axon 01To start with the most straightforward, nerve blocks in my hands are used as diagnostic, not treatment tools.  If, based upon your history and physical exam it is felt that nerve X may be contributing to your chronic headache symptoms, I would propose to block nerve X.  After a few minutes, if your headache symptoms are either gone or significantly improved, it strongly suggests that this nerve is somehow injured and would benefit from surgical treatment.  The local anesthetics used in nerve blocks only last a few hours. Therefore, it is fully expected that the headache symptoms will return after the block wears off.  However,  the results of the block help identify which nerve or nerves may be involved and give an approximation of the numbness that one might have permanently, if those nerves are removed.  The numbness should not be permanent if the nerves are simply decompressed and then recover as expected.
As for nerve stimulators, let me first begin by saying that I am no expert on this subject nor do I implant stimulators myself. Having said that, the general idea behind the nerve stimulators is to implant leads around a particular nerve that the physician believes is causing symptoms. The leads are then hooked up to a generator that is often implanted under the skin in a distant location. When activated, this generator produces an electrical current between the leads, hopefully affecting the desired nerve. In doing so, the thought is to put the desired nerve "to sleep" so that symptoms are minimized. Think of this modality as a “pacemaker” for your nerves. As you might imagine, placing a permanent nerve stimulator is a surgical procedure, albeit a relatively minor one. If successful, it is presumed that the patient will have this foreign body within them permanently. Moreover, since no foreign body ever lasts forever (e.g. breast implants, cardiac pacemakers, hip replacements, heart valves) it is likely that another procedure will be required at some point in the future to address issues that come up such as placing new batteries in the generator or fixing leads that may have migrated. My personal view on nerve stimulators is that they should be used as a last resort for all the reasons mentioned above. So I am more apt to consider surgical decompression or neurectomy prior to consideration of an implantable, permanent stimulator.
With respect to nerve decompression or neurectomy, the concept is relatively simple. If there is mechanical pressure on a nerve from, for example, a spastic muscle, tight fascia or a compressive blood vessel, these structures are removed and the pressure on the nerve eliminated. During the operation, the nerves themselves are examined very closely under high-powered loupe magnification. If the nerves themselves are deemed to be too injured and therefore unlikely to recover (resulting in persistent pain) then a decision can be made to excise the nerve and implant the proximal nerve end into the local muscle to prevent future neuroma formation.  While no treatment modality is perfect, the published results with nerve decompression and/or neurectomy are quite good, the rates of complications very low and the complications themselves are very well tolerated if they occur. Therefore, putting this information all together, I use diagnostic nerve blocks quite often to decide who is a surgical candidate. A personalized decision is made in each case as to which nerves to treat and whether or not nerve decompression or neurectomy is recommended. I overwhelmingly do the former as I’ve found that nerves often recover even in cases when patients don't think they will and it always leaves me with a fallback option (not taken or stated lightly) of another procedure to excise the nerve(s). When all else fails, a nerve stimulator trial can be performed and if successful, a permanent stimulator could be placed.

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