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.
To 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.
As promised, more info on Dysport. Basically, this new product is the identical substance as that found in Botox - Botulinum Toxin type A. It carries pretty much the same indications as Botox does according to the FDA. It is formulated slightly differently which basically accounts for the minimal differences in results with Dysport. So far, much of the published clinical cosmetic experience with Dysport is in the form of a few initial studies. The bottom line from these studies is that results with Dysport are very similar to those with Botox. Dysport has a slightly quicker onset of action, but not significantly so. In equivalent doses, the effects of Dysport lasted a bit longer than those with Botox, but again the results were not significantly different. Finally, there were no significant differences in side effects between the two products. The upside of Dysport is that it is a bit less expensive than Botox at present and with the initial promotion from Ipsen BioPharm (the company that makes Dysport), the prices are even sweeter. The only real downside at present is that there is relatively little experience with Dysport as compared with Botox, so theoretically you are taking a small chance with a newer product, although the risks are minor.
Hyperhydrosis or excessive sweating is a problem that can be a real source of frustration and embarrassment. Until now, when the usual deodorant and antipersperants have failed, the only next option was an operation to physically remove the offending sweat glands. Now, however, it has been realized that BOTOX (yes that BOTOX) can be used to treat this problem with great effectiveness. The overwhelming majority of patients treated in this way had a significant decrease in the sweat produced by these glands (usually in the armpit) that lasted over 6 months. Patients can be treated in the office with minimal downtime and the procedure is minimally invasive and uncomfortable. If you would like to learn more about this exciting new treatment, please feel free to call the office.
Ziv M. Peled, MD
Plastic Surgery News, a publication of the American Society of Plastic Surgeons, recently published an article describing the unethical practices of well known company called Lifestyle Lift. According to the article, this company was “charged with ‘astroturfing’ - publishing fake, online reviews of its procedure using employees who posed as independent consumers to express their ’satisfaction’ with the company and it’s product.” In fact, Andrew Cuomo, the Attorney General of New York stated on his website (http://www1.plasticsurgery.org/ebusiness4/OnlineCourse/CourseInfo.aspx?Id=12791) “this company’s attempt to generate business by duping consumers was cynical, manipulative and illegal.”
I am posting this blog because I am often asked by my patients seeking facial rejuvenation about the Lifestyle Lift procedure. In plastic surgery, as in life, you get what you pay for. While we are all looking to save money these days, your body and health are the few things which you only get one of and simply searching out the least expensive alternative can often have distastrous consequences. Among board-certified (American Board of Plastic Surgery) plastic surgeons, this company has a dubious reputation as one that refuses to do state exactly which techniques their physicians use to achieve their results, thereby potentially opening themselves to criticism as those of us who publish in scientific, peer-reviewed journals do all the time. Therefore, the company’s methods are suspect from the outset and stories like the one above are not that surprising. Buyer, and patient beware!
New Surgical Procedure Holds Promise for Permanent Relief from Migraines
Existing treatments for migraines, such as oral medication or injected drugs, have been shown to temporarily alleviate symptoms in some, but not all, patients. In some instances, these treatments, whether effective or not, have unwanted side effects. But now there is good news for the more than 28 million Americans who suffer from migraines: According to a recent study, an outpatient surgical procedure provided 80% of patients with pain relief at or above 50%, and over 43% with complete and lasting relief from their migraines, altogether.
Over the past few years, several studies have been performed to test a recent theory that migraines are caused by nerve compression: Nerves in the neck, temples or forehead that are pinched as they pass through various anatomic structures or canals. As a result, the severe and recurring pain is similar in origin to carpal tunnel syndrome, a commonly diagnosed condition for which surgical decompression is frequently performed. This surgical method has now been adapted for headaches caused by neuralgia, or trapped nerves.
I am a San Francisco-based, Harvard-trained plastic surgeon with specific training and experience in a variety of different peripheral nerve operations, including successful nerve decompression to treat migraines. I have performed well over 100 different peripheral nerve procedures and feel fortunate to be among the few surgeons in the world with the background and training to perform these delicate operations. Moreover, most procedures can be done as an out-patient. For example, in a patient with the most common site of pain originating in the back of the head/scalp, the procedure involves a small incision on the nape of the neck, just above the hairline. Once the surgical site has healed, typically in a couple of weeks, patients report significantly fewer headaches, lower headache severity, and shorter headache duration in those who still report headaches at all.
Just this month in Plastic and Reconstructive Surgery (the leading plastic surgery journal in the world), Dr. Guyuron published his five-year results with surgical decompression for migraine surgery. The findings of this study show that relief of headaches persists even five years from the time of surgery. More specifically, at five years post-surgery, the average number of migraines per month were reduced to 4 from 11, average migraine intensity decreased from 8.5 out of 10 to 4.5 out of 10 and the average duration of a migraine if and when it occurred was reduced from 1.4 days to 8 hours. Just as impressive were the findings that 88% of patients still reported a significant decrease in their headaches after five years and that 29 reported elimination of their migraines altogether! These results suggest that surgical decompression can produce a lasting if not permanent degree of relief from the debilitating headaches that affect so many people worldwide. If you suffer from migraines and would like to learn if you are a candidate for decompression surgery, please contact our office at (415) 751-0583 or (925) 933-5700.