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ElHawary H, Kavanagh K, Janis JE. The Positive and Negative Predictive Value of Targeted Diagnostic Botox Injection in Nerve Decompression Migraine Surgery. Plast Reconstr Surg 2024; 153:1133-1140. [PMID: 37285182 DOI: 10.1097/prs.0000000000010806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Nerve decompression surgery is an effective treatment modality for patients who experience migraines. Botulinum toxin type A (Botox) injections have been traditionally used as a method to identify trigger sites; however, there is a paucity in data regarding its diagnostic efficacy. The goal of this study was to assess the diagnostic capacity of Botox in successfully identifying migraine trigger sites and predicting surgical success. METHODS A sensitivity analysis was performed on all patients receiving Botox for migraine trigger site localization followed by a surgical decompression of affected peripheral nerves. Positive and negative predictive values were calculated. RESULTS A total of 40 patients met our inclusion criteria and underwent targeted diagnostic Botox injection followed by a peripheral nerve deactivation surgery with at least 3 months' follow-up. Patients with successful Botox injections (defined as at least 50% improvement in Migraine Headache Index scores after injection) had significantly higher average reduction in migraine intensity (56.7% versus 25.8%; P = 0.020), frequency (78.1% versus 46.8%; P = 0.018), and Migraine Headache Index (89.7% versus 49.2%; P = 0.016) postsurgical deactivation. Sensitivity analysis shows that the use of Botox injection as a diagnostic modality for migraine headaches has a sensitivity of 56.7% and a specificity of 80.0%. The positive predictive value is 89.5% and the negative predictive value is 38.1%. CONCLUSIONS Diagnostic targeted Botox injections have a very high positive predictive value. It is therefore a useful diagnostic modality that can help identify migraine trigger sites and improve preoperative patient selection. CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, II.
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Affiliation(s)
- Hassan ElHawary
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre
| | - Kaitlin Kavanagh
- Department of Plastic and Reconstructive Surgery, Ohio State University, Wexner Medical Center
| | - Jeffrey E Janis
- Department of Plastic and Reconstructive Surgery, Ohio State University, Wexner Medical Center
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Stearns SA, Xun H, Haddad A, Rinkinen J, Bustos VP, Lee BT. Therapeutic Options for Migraines in the Microsurgical Patient: A Scoping Review. Plast Reconstr Surg 2024; 153:988e-1001e. [PMID: 37337332 DOI: 10.1097/prs.0000000000010861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND There exists an increasing array of treatments proposed to prevent, alleviate, and abort symptoms of a migraine; however, for patients who undergo reconstructive microsurgery, caution must be taken to preserve vascular integrity. This study is the first-to-date scoping review of vascular and bleeding risk of current migraine therapies, with the purpose of identifying potential therapeutic agents for postoperative migraine management appropriate for microsurgical patients. METHODS Currently available migraine therapeutics were compiled from the UpToDate software system and the American Academy of Family Physicians. A PubMed literature review was performed for each therapeutic's effect on bleeding or vascular involvement. Data were compiled into tables of abortive, symptom-controlling and prophylactic, and nonpharmacologic treatments. Expert microsurgeons reviewed the data to provide recommendations for optimized patient care. RESULTS Triptans and other ergot derivatives demonstrated strong evidence of vasoconstriction and were greatly advised against for immediate postmicrosurgical use. Novel pharmaceutical therapies such as lasmiditan and calcitonin gene-related peptide antagonists have no literature indicating potential for vasoconstriction or hematoma and remain an investigational option for abortive medical treatment. For symptom control, acetaminophen appears the safest option, with clinical judgment and further research needed for use of nonsteroidal antiinflammatory drugs. Alternative treatment techniques may include migraine prophylaxis with botulinum toxin injection or nutraceutical treatment by means of magnesium supplementation or coenzyme Q10 administration, minimizing the need for additional medication in the postoperative setting. CONCLUSIONS Patients undergoing reconstructive microsurgery have a unique medical profile limiting the therapeutic options available to treat migraines. This review provides preliminary evidence to be considered as a guide for prescribing therapeutics for migraine in the postoperative setting.
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Affiliation(s)
| | - Helen Xun
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Anthony Haddad
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Jacob Rinkinen
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Valeria P Bustos
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Bernard T Lee
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
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Janis JE, Hehr J, Huayllani MT, Khansa I, Gfrerer L, Kavanagh K, Blake P, Gokun Y, Austen WG. Functional outcomes between headache surgery and targeted botox injections: A prospective multicenter pilot study. JPRAS Open 2023; 38:152-162. [PMID: 37920284 PMCID: PMC10618225 DOI: 10.1016/j.jpra.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 09/20/2023] [Indexed: 11/04/2023] Open
Abstract
Introduction Chronic migraine headaches (MH) are a principal cause of disability worldwide. This study evaluated and compared functional outcomes after peripheral trigger point deactivation surgery or botulinum neurotoxin A (BTA) treatment in patients with MH. Methods A long-term, multicenter, and prospective study was performed. Patients with chronic migraine were recruited at the Ohio State University and Massachusetts General Hospital and included in each treatment group according to their preference (BTA or surgery). Assessment tools including the Migraine Headache Index (MHI), Migraine Disability Assessment Questionnaire (MIDAS) total, MIDAS A, MIDAS B, Migraine Work and Productivity Loss Questionnaire-question 7 (MWPLQ7), and Migraine-Specific Quality of Life Questionnaire (MSQ) version 2.1 were used to evaluate functional outcomes. Patients were evaluated prior to treatment and at 1, 2, and 2.5 years after treatment. Results A total of 44 patients were included in the study (surgery=33, BTA=11). Patients treated surgically showed statistically significant improvement in headache intensity as measured on MIDAS B (p = 0.0464) and reduced disability as measured on MWPLQ7 (p = 0.0120) compared to those treated with BTA injection. No statistical difference between groups was found for the remaining functional outcomes. Mean scores significantly improved over time independently of treatment for MHI, MIDAS total, MIDAS A, MIDAS B, and MWPLQ 7 (p<0.05). However, no difference in mean scores over time was observed for MSQ. Conclusions Headache surgery and targeted BTA injections are both effective means of addressing peripheral trigger sites causing headache pain. However, lower pain intensity and work-related disabilities were found in the surgical group.
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Affiliation(s)
- Jeffrey E. Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jason Hehr
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Maria T. Huayllani
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ibrahim Khansa
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass, USA
| | - Kaitlin Kavanagh
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Pamela Blake
- Headache Center of River Oaks, Houston, TX, USA
- University of Texas Health Science Center, Houston, TX, USA
| | - Yevgeniya Gokun
- Center for the Biostatistics, Department of Biomedical Informatics, The Ohio State University Wexner Center, Columbus, OH, USA
| | - William G. Austen
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass, USA
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Hazewinkel MH, Remy K, Knoedler L, Tseng S, Schoenbrunner A, Janis J, Austen WG, Hundepool CA, Zuidam JM, Gfrerer L. Treatment Delay in Patients Undergoing Headache Surgery (Nerve Decompression Surgery). JPRAS Open 2023; 38:226-236. [PMID: 37929065 PMCID: PMC10624566 DOI: 10.1016/j.jpra.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 11/07/2023] Open
Abstract
Background Although headache surgery has been shown to be an effective treatment option for refractory headache disorders, it has not been included as part of the headache disorder management algorithm by non-surgical providers. This study aims to evaluate the delay in surgical management of patients with headache disorders. In addition, a cost comparison analysis between conservative and operative treatment of headache disorders was performed, and the surgical outcomes of headache surgery were reported. Methods Among 1112 patients who were screened, 271 (56%) patients underwent headache surgery. Data regarding the onset of headache disorder and pre- and postoperative pain characteristics were prospectively collected. To perform a cost comparison analysis, direct and indirect costs associated with the conservative treatment of headache disorders were calculated. Results The median duration between onset of headache disorder symptoms and headache surgery was 20 (8.2-32) years. The annual mean cost of conservative treatment of headache disorders was $49,463.78 ($30,933.87-$66,553.70) per patient. Over the 20-year time period before surgery, the mean cost was $989,275.65 ($618,677.31-$1,331,073.99). In comparison, the mean cost of headache surgery was $11,000. The median pain days per month decreased by 16 (0-25) (p<0.001), the median pain intensity reduced by 4 (2-7) (p<0.001), and the median pain duration decreased by 11 hours (0-22) (p<0.001). Conclusion This study shows that patients experience symptoms of headache disorders for an average of 20 years prior to undergoing headache surgery. Surgical treatment not only significantly improves headache pain but also reduces healthcare costs and should be implemented in the management algorithm of headache disorders.
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Affiliation(s)
- Merel H.J. Hazewinkel
- Weill Cornell Medicine, Division of Plastic and Reconstructive Surgery, New York, NY
- Erasmus Medical Center Rotterdam, Department of Plastic, Reconstructive Surgery and Hand surgery, The Netherlands
| | - Katya Remy
- Harvard Medical School, Department of Plastic Surgery, Hand Surgery, and Peripheral, Nerve Surgery, Boston, MA
| | - Leonard Knoedler
- Harvard Medical School, Department of Plastic Surgery, Hand Surgery, and Peripheral, Nerve Surgery, Boston, MA
| | - Sierra Tseng
- Harvard Medical School, Department of Plastic Surgery, Hand Surgery, and Peripheral, Nerve Surgery, Boston, MA
| | - Anna Schoenbrunner
- Ohio State University Wexner Medical Center, Department of Plastic and Reconstructive Surgery, Columbus, OH
| | - Jeffrey Janis
- Ohio State University Wexner Medical Center, Department of Plastic and Reconstructive Surgery, Columbus, OH
| | - William G. Austen
- Harvard Medical School, Department of Plastic Surgery, Hand Surgery, and Peripheral, Nerve Surgery, Boston, MA
| | - Caroline A. Hundepool
- Erasmus Medical Center Rotterdam, Department of Plastic, Reconstructive Surgery and Hand surgery, The Netherlands
| | - J. Michiel Zuidam
- Erasmus Medical Center Rotterdam, Department of Plastic, Reconstructive Surgery and Hand surgery, The Netherlands
| | - Lisa Gfrerer
- Weill Cornell Medicine, Division of Plastic and Reconstructive Surgery, New York, NY
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Choi YJ, Kim HJ. New anatomical insights of the superficial branch of the zygomaticotemporal nerve for treating temporal migraines: An anatomical study. Clin Anat 2023; 36:406-413. [PMID: 36199172 DOI: 10.1002/ca.23962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/29/2022] [Accepted: 10/02/2022] [Indexed: 11/07/2022]
Abstract
The zygomaticotemporal nerve is known to contribute to temporal migraines; however, its precise anatomy remains unknown. The potential accessory branches of the zygomaticotemporal nerve may be considered a cause of continued temporal migraines after surgical procedures. In this study, we defined the novel superficial branch of the zygomaticotemporal nerve (sZTN) and investigated its anatomical course, distribution, and clinical implications. Twenty-two hemifaces from 11 fixed Korean cadavers (six males, five females; mean age, 78.3 years) were used in this study. The piercing points of the sZTN through the deep and superficial layers of the deep temporal fascia, and the superficial temporal fascia were defined as P1, P2, and P3, respectively. The distance of each point from the zygomatic tubercle was measured using an image analysis software. The sZTN ascended between the bone and the temporalis after emerging from the zygomaticotemporal foramen. It then pierced the deep temporal fascia without penetrating the temporalis. After then, it pierced the superficial layer of the deep temporal fascia and turned superiorly toward the upper posterior temple. When the sZTN passed through the superficial temporal fascia, it intersected with the superficial temporal artery in every case. The novel findings of the sZTN may help in the treatment of intractable temporal migraines refractory to injection or surgical procedure. Based on our findings, targeting the sZTN may be applied as an alternative treatment strategy for patients who do not show significant improvement with treatment targeted to trigger sites.
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Affiliation(s)
- You-Jin Choi
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, Seoul, South Korea
| | - Hee-Jin Kim
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, Seoul, South Korea.,Department of Materials Science and Engineering, College of Engineering, Yonsei University, Seoul, South Korea
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Migraine Surgery and Determination of Success over Time by Trigger Site: A Systematic Review of the Literature. Plast Reconstr Surg 2023; 151:120e-135e. [PMID: 36251961 DOI: 10.1097/prs.0000000000009775] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Migraine headache is a debilitating disorder that produces high costs and compromises patient quality of life. This study aimed to evaluate surgery success and the longevity of the surgical benefit by trigger site. METHODS A systematic literature review was performed by querying the PubMed, Embase, Scopus, and Web of Science databases. The keywords "surgery," "migraine," "outcomes," "headache index," and synonyms in titles and abstracts were used to perform the search. RESULTS A total of 17 articles published between 2009 and 2019 met the inclusion criteria. Six studies were prospective and 11 were retrospective. Most of the studies (77.8%, 77.8%, and 80%, respectively) reported success of migraine surgery at 12-month follow-up for trigger sites I, II, and III, respectively. For trigger site IV, the greatest Migraine Headache Index reduction (93.4%) was observed at 12-month follow-up, and the earliest Migraine Headache Index reductions (80.3% and 74.6%) were observed at 6-month follow-up. All studies that evaluated trigger sites V and VI identified surgery success at 12-month follow-up. Migraine surgery was found to remain beneficial at 22 months for trigger sites I, II, III, and IV. CONCLUSIONS The symptomatic improvement may initially be evident at 6 months for trigger site IV and at 12 months for trigger sites I, II, III, V, and VI. Surgical benefit in trigger sites I, II, III, and IV can persist after 22 months. Further studies are required to evaluate results at longer follow-up.
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Schoenbrunner A, Konschake M, Zwierzina M, Egro FM, Moriggl B, Janis JE. The Great Auricular Nerve Trigger Site: Anatomy, Compression Point Topography, and Treatment Options for Headache Pain. Plast Reconstr Surg 2022; 149:203-211. [PMID: 34807011 DOI: 10.1097/prs.0000000000008673] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Peripheral nerve decompression surgery can effectively address headache pain caused by compression of peripheral nerves of the head and neck. Despite decompression of known trigger sites, there are a subset of patients with trigger sites centered over the postauricular area coursing. The authors hypothesize that these patients experience primary or residual pain caused by compression of the great auricular nerve. METHODS Anatomical dissections were carried out on 16 formalin-fixed cadaveric heads. Possible points of compression along fascia, muscle, and parotid gland were identified. Ultrasound technology was used to confirm these anatomical findings in a living volunteer. RESULTS The authors' findings demonstrate that the possible points of compression for the great auricular nerve are at Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle in the dense connective tissue before entry into the parotid gland (point 2), and within its intraparotid course (point 3). The mean topographic measurements were as follows: Erb's point to the mastoid process at 7.32 cm/7.35 (right/left), Erb's point to the angle of the mandible at 6.04 cm/5.89 cm (right/left), and the posterior aspect of the sternocleidomastoid muscle to the mastoid process at 3.88 cm/4.43 cm (right/left). All three possible points of compression could be identified using ultrasound. CONCLUSIONS This study identified three possible points of compression of the great auricular nerve that could be decompressed with peripheral nerve decompression surgery: Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle (point 2), and within its intraparotid course (point 3).
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Affiliation(s)
- Anna Schoenbrunner
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University; Department of Plastic, Reconstructive, and Aesthetic Surgery, Center of Operative Medicine, and Department of Anatomy, Histology, and Embryology, Institute of Clinical and Functional Anatomy, Medical University of Innsbruck; and Department of Plastic Surgery, University of Pittsburgh
| | - Marko Konschake
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University; Department of Plastic, Reconstructive, and Aesthetic Surgery, Center of Operative Medicine, and Department of Anatomy, Histology, and Embryology, Institute of Clinical and Functional Anatomy, Medical University of Innsbruck; and Department of Plastic Surgery, University of Pittsburgh
| | - Marit Zwierzina
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University; Department of Plastic, Reconstructive, and Aesthetic Surgery, Center of Operative Medicine, and Department of Anatomy, Histology, and Embryology, Institute of Clinical and Functional Anatomy, Medical University of Innsbruck; and Department of Plastic Surgery, University of Pittsburgh
| | - Francesco M Egro
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University; Department of Plastic, Reconstructive, and Aesthetic Surgery, Center of Operative Medicine, and Department of Anatomy, Histology, and Embryology, Institute of Clinical and Functional Anatomy, Medical University of Innsbruck; and Department of Plastic Surgery, University of Pittsburgh
| | - Bernhard Moriggl
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University; Department of Plastic, Reconstructive, and Aesthetic Surgery, Center of Operative Medicine, and Department of Anatomy, Histology, and Embryology, Institute of Clinical and Functional Anatomy, Medical University of Innsbruck; and Department of Plastic Surgery, University of Pittsburgh
| | - Jeffrey E Janis
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University; Department of Plastic, Reconstructive, and Aesthetic Surgery, Center of Operative Medicine, and Department of Anatomy, Histology, and Embryology, Institute of Clinical and Functional Anatomy, Medical University of Innsbruck; and Department of Plastic Surgery, University of Pittsburgh
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Bhoopalam M, Manson PN, Grant M, Reddy SK. Neuroma of The Supraorbital Nerve Following Forehead Flap Reconstruction - Presentation and Surgical Management. J Craniofac Surg 2021; 32:1515-1516. [PMID: 34111880 DOI: 10.1097/scs.0000000000007566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Localized pain or headache from neuroma formation is a rare and challenging complication of forehead flap surgery. Here the authors present a patient who developed local pain and dysesthesia following iatrogenic injury to the left supraorbital nerve during forehead flap elevation. Following a diagnostic nerve block in clinic, surgical excision of the neuroma was performed through an upper blepharoplasty approach. The patient had immediate postoperative pain relief and remains pain free at fifteen-month follow-up. The authors describe etiology, workup, and surgical management of sensory nerve injury during forehead flap reconstruction.
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Affiliation(s)
| | | | - Michael Grant
- Department of Plastic and Reconstructive Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Sashank K Reddy
- Department of Plastic and Reconstructive Surgery.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine
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The Use of Botulinum Toxin in Pain Management: Basic Science and Clinical Applications. Plast Reconstr Surg 2020; 145:629e-636e. [DOI: 10.1097/prs.0000000000006559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Migraine Surgery at the Frontal Trigger Site: An Analysis of Intraoperative Anatomy. Plast Reconstr Surg 2020; 145:523-530. [PMID: 31985652 DOI: 10.1097/prs.0000000000006475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The development of migraine headaches may involve the entrapment of peripheral craniofacial nerves at specific sites. Cadaveric studies in the general population have confirmed potential compression points of the supraorbital and supratrochlear nerves at the frontal trigger site. The authors' aim was to describe the intraoperative anatomy of the supraorbital and supratrochlear nerves at the level of the supraorbital bony rim in patients undergoing frontal migraine surgery and to investigate associated pain. METHODS PATIENTS: scheduled for frontal-site surgery were enrolled prospectively. The senior author (W.G.A.) evaluated intraoperative anatomy and recorded variables using a detailed form and operative report. The resulting data were analyzed. RESULTS One hundred eighteen sites among 61 patients were included. The supraorbital nerve traversed a notch in 49 percent, a foramen in 41 percent, a notch plus a foramen in 9.3 percent, and neither a notch nor a foramen in one site. The senior author noted macroscopic nerve compression at 74 percent of sites. Reasons included a tight foramen in 24 percent, a notch with a tight band in 34 percent, and supraorbital and supratrochlear nerves emerging by means of the same notch in 7.6 percent or by means of the same foramen in 4.2 percent. Preoperative pain at a site was significantly associated with nerve compression by a foramen. CONCLUSIONS The intraoperative anatomy and cause of nerve compression at the frontal trigger site vary greatly among patients. The authors report a supraorbital nerve foramen prevalence of 50.3 percent, which is greater than in previous cadaver studies of the general population. Lastly, the presence of pain at a specific site is associated with macroscopic nerve compression.
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