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Hazewinkel MH, Knoedler L, Mathew PG, Remy K, Austen WG, Gfrerer L. Surgical Management of Headache Disorders - A Systematic Review of the Literature. Curr Neurol Neurosci Rep 2024; 24:191-202. [PMID: 38833038 DOI: 10.1007/s11910-024-01342-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE OF REVIEW This review article critically evaluates the latest advances in the surgical treatment of headache disorders. RECENT FINDINGS Studies have demonstrated the effectiveness of innovative screening tools, such as doppler ultrasound, pain drawings, magnetic resonance neurography, and nerve blocks to help identify candidates for surgery. Machine learning has emerged as a powerful tool to predict surgical outcomes. In addition, advances in surgical techniques, including minimally invasive incisions, fat injections, and novel strategies to treat injured nerves (neuromas) have demonstrated promising results. Lastly, improved patient-reported outcome measures are evolving to provide a framework for comparison of conservative and invasive treatment outcomes. Despite these developments, challenges persist, particularly related to appropriate patient selection, insurance coverage, delays in diagnosis and surgical treatment, and the absence of standardized measures to assess and compare treatment impact. Collaboration between medical/procedural and surgical specialties is required to overcome these obstacles.
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Affiliation(s)
- Merel Hj Hazewinkel
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, USA
| | - Leonard Knoedler
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Paul G Mathew
- Harvard Medical School, Boston, USA
- Department of Neurology, Mass General Brigham Health, Foxborough, USA
- Department of Neurology, Atrius Health, Quincy, USA
| | - Katya Remy
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - William G Austen
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, USA.
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Remy K, Hazewinkel MHJ, Knoedler L, Sneag DB, Austen WG, Gfrerer L. Etiologies of iatrogenic occipital nerve injury: And outcomes following treatment with nerve decompression surgery. J Plast Reconstr Aesthet Surg 2024; 95:349-356. [PMID: 38959621 DOI: 10.1016/j.bjps.2024.06.012] [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: 02/16/2024] [Revised: 06/04/2024] [Accepted: 06/06/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION This study analyzed the etiologies and treatment of iatrogenic occipital nerve injuries. METHODS Patients with occipital neuralgia (ON) who were screened for occipital nerve decompression surgery were prospectively enrolled. Patients with iatrogenic occipital nerve injuries who underwent nerve decompression surgery were identified. Data included surgical history, pain characteristics, and surgical technique. Outcomes included pain frequency (days/month), duration (h/day), intensity (0-10), migraine headache index (MHI), and patient-reported percent-resolution of pain. RESULTS Among the 416 patients with ON, who were screened for occipital nerve decompression surgery, 12 (2.9%) cases of iatrogenic occipital nerve injury were identified and underwent surgical treatment. Preoperative headache frequency was 30 (±0.0) days/month, duration was 19.4 (±6.9) h, and intensity was 9.2 (±0.9). Neuroma excision was performed in 5 cases followed by targeted muscle reinnervation in 3, nerve cap in 1, and muscle burial in 1. In patients without neuromas, greater occipital nerve decompression and/or lesser occipital nerve neurectomy were performed. At the median follow-up of 12 months (IQR 12-12 months), mean pain frequency was 4.0 (±6.6) pain days/month (p < 0.0001), duration was 6.3 (±8.9) h (p < 0.01), and intensity was 4.4 (±2.8) (p < 0.001). Median patient-reported resolution of pain was 85% (56.3%-97.5%) and success rate was (≥50% MHI improvement) 91.7%. CONCLUSIONS Iatrogenic occipital nerve injuries can be caused by various surgical interventions, including craniotomies, cervical spine interventions, and scalp tumor resections. The associated pain can be severe and chronic. Iatrogenic ON should be considered in the differential diagnosis of post-operative headaches and can be treated with nerve decompression surgery or neuroma excision with reconstruction of the free nerve end.
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Affiliation(s)
- Katya Remy
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Merel H J Hazewinkel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Weill Cornell Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Leonard Knoedler
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - William G Austen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Weill Cornell Medicine, Weill Cornell Medical College, New York, NY, USA.
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Ormseth BH, ElHawary H, Huayllani MT, Weber KD, Blake P, Janis JE. Comparing Migraine Headache Index versus Monthly Migraine Days after Headache Surgery: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2024; 153:1201e-1211e. [PMID: 37285213 DOI: 10.1097/prs.0000000000010800] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Nerve deactivation surgery for the treatment of migraine has evolved rapidly over the past 2 decades. Studies typically report changes in migraine frequency (attacks/month), attack duration, attack intensity, and their composite score-the Migraine Headache Index-as primary outcomes. However, the neurology literature predominantly reports migraine prophylaxis outcomes as change in monthly migraine days (MMD). The goal of this study was to foster common communication between plastic surgeons and neurologists by assessing the effect of nerve deactivation surgery on MMD and motivating future studies to include MMD in their reported outcomes. METHODS An updated literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The National Library of Medicine (PubMed), Scopus, and Embase were systematically searched for relevant articles. Data were extracted and analyzed from studies that met the inclusion criteria. RESULTS A total of 19 studies were included. There was a significant overall reduction in MMDs [mean difference (MD), 14.11; 95% CI, 10.95 to 17.27; I 2 = 92%], total migraine attacks per month (MD, 8.65; 95% CI, 7.84 to 9.46; I 2 = 90%), Migraine Headache Index (MD, 76.59; 95% CI, 60.85 to 92.32; I 2 = 98%), migraine attack intensity (MD, 3.84; 95% CI, 3.35 to 4.33; I 2 = 98%), and migraine attack duration (MD, 11.80; 95% CI, 6.44 to 17.16; I 2 = 99%) at follow-up (range, 6 to 38 months). CONCLUSION This study demonstrates the efficacy of nerve deactivation surgery on the outcomes used in both the plastic and reconstructive surgery and neurology literature.
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Affiliation(s)
| | - Hassan ElHawary
- Division of Plastic and Reconstructive Surgery, McGill University Health Center
| | | | - Kevin D Weber
- Neurology, Ohio State University Wexner Medical Center
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Hazewinkel MHJ, Remy K, Black G, Tseng S, Mathew PG, Schoenbrunner A, Janis JE, Austen WG, Jotwani R, Gfrerer L. Treatment delay from onset of occipital neuralgia symptoms to treatment with nerve decompression surgery: a prospective cohort study. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:334-343. [PMID: 37995295 DOI: 10.1093/pm/pnad154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/16/2023] [Accepted: 11/10/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND The aims of this study were to (1) evaluate the time between onset of occipital neuralgia symptoms and nerve decompression surgery, (2) perform a cost comparison analysis between surgical and nonsurgical treatment of occipital neuralgia, and (3) report postoperative results of nerve decompression for occipital neuralgia. METHODS Subjects (n = 1112) who underwent screening for nerve decompression surgery were evaluated for occipital neuralgia. Of those, 367 patients (33%) met the inclusion criteria. Timing of occipital neuralgia symptom onset and pain characteristics were prospectively collected. Cost associated with the nonsurgical treatment of occipital neuralgia was calculated for the period between onset of symptoms and surgery. RESULTS A total of 226 patients (73%) underwent occipital nerve decompression. The average time between onset of occipital neuralgia and surgery was 19 years (7.1-32). Postoperatively, the median number of pain days per month decreased by 17 (0-26, 57%) (P < .001), the median pain intensity decreased by 4 (2-8, 44%) (P < .001), and median pain duration in hours was reduced by 12 (2-23, 50%) (P < .001). The annual mean cost of nonsurgical occipital neuralgia treatment was $28 728.82 ($16 419.42-$41 198.41) per patient. The mean cost during the 19-year time frame before surgery was $545 847.75($311 968.90-$782 769.82). CONCLUSION This study demonstrates that patients suffer from occipital neuralgia for an average of 19 years before undergoing surgery. Nerve decompression reduces symptom severity significantly and should be considered earlier in the treatment course of occipital neuralgia that is refractory to conservative treatment to prevent patient morbidity and decrease direct and indirect health care costs.
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Affiliation(s)
- Merel H J Hazewinkel
- Department of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY 10065, United States
| | - Katya Remy
- Department of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Grant Black
- Department of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY 10065, United States
| | - Sierra Tseng
- Department of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Paul G Mathew
- Harvard Medical School, Boston, MA 02115, United States
- Department of Neurology, Mass General Brigham Health, Foxborough, MA 02035, United States
- Department of Neurology, Harvard Vanguard Medical Associates, Braintree, MA 02184, United States
| | - Anna Schoenbrunner
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Jeffrey E Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - William G Austen
- Department of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Rohan Jotwani
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Lisa Gfrerer
- Department of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY 10065, United States
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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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Gomez-Eslava B, Raasveld FV, Hoftiezer YAJ, McCarty JC, Daddario JL, Valerio IL, Heng M, Eberlin KR. Pain Sketches to Predict Pain following Primary Targeted Muscle Reinnervation in Amputees. Plast Reconstr Surg 2024; 153:1162-1171. [PMID: 37252909 PMCID: PMC10676444 DOI: 10.1097/prs.0000000000010762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Numeric scales are validated methods to report pain outcomes after targeted muscle reinnervation (TMR) but do not include the assessment of qualitative pain components. This study evaluates the application of pain sketches within a cohort of patients undergoing primary TMR and describes differences in pain progression according to early postoperative sketches. METHODS This study included 30 patients with major limb amputation and primary TMR. Patients' drawings were categorized into four categories of pain distribution [focal pain (FP), radiating pain (RP), diffuse pain (DP), or no pain (NP)] and interrater reliability was calculated. Second, pain outcomes were analyzed for each category. Pain scores were the primary outcome, and Patient-Reported Outcomes Measurement Information System (PROMIS) instruments were the secondary outcome. RESULTS The interrater reliability for the sketch categories was good (overall kappa coefficient of 0.8). The NP category reported a mean decrease in pain of 4.8 points, followed by the DP (2.5 points) and FP categories (2.0 points). The RP category reported a mean increase in pain of 0.5 points. For PROMIS Pain Interference and Pain Intensity, the DP category reported a mean decrease of 7.2 and 6.5 points, respectively, followed by the FP category (5.3 and 3.6 points). The RP category reported a mean increase of 2.0 points in PROMIS Pain Interference and a mean decrease of 1.4 points in PROMIS Pain Intensity. Secondary outcomes for the NP category were not reported. CONCLUSION Pain sketches demonstrated reliability in pain morphology assessment and might be an adjunctive tool for pain interpretation in this setting.
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Affiliation(s)
| | - Floris V Raasveld
- From the Hand and Arm Center, Department of Orthopaedic Surgery
- Department of Plastic, Reconstructive, and Hand Surgery, Erasmus Medical Center
| | - Yannick A J Hoftiezer
- From the Hand and Arm Center, Department of Orthopaedic Surgery
- Department of Plastic, Reconstructive, and Hand Surgery, Radboud University Medical Center
| | - Justin C McCarty
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Jenna L Daddario
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Marilyn Heng
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine
- Orthopaedic Trauma Service, Jackson Memorial Ryder Trauma Center
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard Medical School
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Peled ZM, Gfrerer L. Introduction to VSI: Migraine surgery in JPRAS open. JPRAS Open 2024; 39:217-222. [PMID: 38293285 PMCID: PMC10827495 DOI: 10.1016/j.jpra.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 12/13/2023] [Indexed: 02/01/2024] Open
Affiliation(s)
- Ziv M. Peled
- Peled Plastic Surgery, 2100 Webster Street, Suite 109, San Francisco, CA 94115, United States
| | - Lisa Gfrerer
- Surgery Plastic and Reconstructive Surgery Weill Cornell Medicine, 425 East 61st Street, 10th Floor, New York, NY 10065, United States
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Saad M, Connor L, Hazewinkel M, Peled Z, Hagan R, Gfrerer L, Kassis S. Pearls for Starting a Headache Surgery Practice in Academic and Private Practice. JPRAS Open 2024; 39:127-131. [PMID: 38235265 PMCID: PMC10792448 DOI: 10.1016/j.jpra.2023.12.003] [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: 11/28/2023] [Accepted: 12/03/2023] [Indexed: 01/19/2024] Open
Abstract
There has been a growing body of evidence indicative of the effectiveness of headache surgery in treating patients with refractory headache disorders. The American Society of Plastic Surgeons issued a Policy Statement in 2018 stating that peripheral nerve decompression surgery for the treatment of refractory chronic headache disorders in select patients is considered a standard of care treatment. This endorsement sparked the interest of numerous plastic surgeons into initiating their own headache surgery practices. However, establishing a headache surgery clinic introduces challenges and considerations. This report outlines the key pillars for launching a successful headache surgery practice in academic and private practice environments.
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Affiliation(s)
- M. Saad
- Vanderbilt University Medical Center, Department of Plastic Surgery, Nashville, TN
| | - L. Connor
- Vanderbilt University Medical Center, Department of Plastic Surgery, Nashville, TN
| | - M.H.J. Hazewinkel
- Weill Cornell Medicine, Division of Plastic and Reconstructive Surgery, New York, NY
| | - Z.M. Peled
- Peled Plastic Surgery, San Francisco, CA
| | | | - L. Gfrerer
- Weill Cornell Medicine, Division of Plastic and Reconstructive Surgery, New York, NY
| | - S.A. Kassis
- Vanderbilt University Medical Center, Department of Plastic Surgery, Nashville, TN
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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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Knoedler L, Chartier C, Casari ME, Amador RO, Odenthal J, Gfrerer L, Austen WG. Relative Pain Reduction and Duration of Nerve Block Response Predict Outcomes in Headache Surgery: A Prospective Cohort Study. Plast Reconstr Surg 2023; 152:1319-1327. [PMID: 37067978 DOI: 10.1097/prs.0000000000010552] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
BACKGROUND Experts agree that nerve block (NB) response is an important tool in headache surgery screening. However, the predictive value of NBs remains to be proven in a prospective fashion. METHODS Pre-NB and post-NB visual analogue pain scores (0 to 10) and duration of NB response were recorded prospectively. Surgical outcomes were recorded prospectively by calculating the Migraine Headache Index (MHI) preoperatively and postoperatively at 3 months, 12 months, and every year thereafter. RESULTS The study population included 115 patients. The chance of achieving MHI percentage improvement of 80% or higher was significantly higher in subjects who reported relative pain reduction of greater than 60% following NB versus less than or equal to 60% [63 of 92 (68.5%) versus 10 of 23 (43.5%); P = 0.03]. Patients were more likely to improve their MHI 50% or more with relative pain reduction of greater than 40% versus 40% or less [82 of 104 (78.8%) versus five of 11 (45.5%); P = 0.01]. In subjects with NB response of greater than 15 days, 10 of 13 patients (77.0%) experienced MHI improvement of 80% or greater. Notably, all of these patients (100%) reported MHI improvement of 50% or greater, with mean MHI improvement of 88%. Subjects with a NB response of 24 hours or more achieved significantly better outcomes than patients with a shorter response (72.7% ± 37.0% versus 46.1% ± 39.7%; P = 0.02). However, of 14 patients reporting NB response of less than 24 hours, four patients had MHI improvement of 80% or greater, and seven, of 50% or greater. CONCLUSIONS Relative pain reduction and duration of NB response are predictors of MHI improvement after headache surgery. NBs are a valuable tool to identify patients who will benefit from surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Leonard Knoedler
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Christian Chartier
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Maria E Casari
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Ricardo O Amador
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Jan Odenthal
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Lisa Gfrerer
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine
| | - William G Austen
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
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Bink T, Hazewinkel MHJ, Hundepool CA, Duraku LS, Drenthen J, Gfrerer L, Zuidam JM. Feasibility of Ultrasound Measurements of Peripheral Sensory Nerves in Head and Neck Area in Healthy Subjects. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5343. [PMID: 37829106 PMCID: PMC10566885 DOI: 10.1097/gox.0000000000005343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/06/2023] [Indexed: 10/14/2023]
Abstract
Background Current diagnostic methods for nerve compression headaches consist of diagnostic nerve blocks. A less-invasive method that can possibly aid in the diagnosis is ultrasound, by measuring the cross-sectional area (CSA) of the affected nerve. However, this technique has not been validated, and articles evaluating CSA measurements in the asymptomatic population are missing in the current literature. Therefore, the aim of this study was to determine the feasibility of ultrasound measurements of peripheral extracranial nerves in the head and neck area in asymptomatic individuals. Methods The sensory nerves of the head and neck in healthy individuals were imaged by ultrasound. The CSA was measured at anatomical determined measurement sites for each nerve. To determine the feasibility of ultrasound measurements, the interrater reliability and the intrarater reliability were determined. Results In total, 60 healthy volunteers were included. We were able to image the nerves at nine of 11 measurement sites. The mean CSA of the frontal nerves ranged between 0.80 ± 0.42 mm2 and 1.20 ± 0.43 mm2, the mean CSA of the occipital nerves ranged between 2.90 ± 2.73 mm2 and 3.40 ± 1.91 mm2, and the mean CSA of the temporal nerves ranged between 0.92 ± 0.26 mm2 and 1.40 ± 1.11 mm2. The intrarater and interrater reliability of the CSA measurements was good (ICC: 0.75-0.78). Conclusions Ultrasound is a feasible method to evaluate CSA measurements of peripheral extracranial nerves in the head and neck area. Further research should be done to evaluate the use of ultrasound as a diagnostic tool for nerve compression headache.
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Affiliation(s)
- Thijs Bink
- From the Department of Plastic, Reconstructive Surgery and Hand Surgery, Erasmus Medical Center Rotterdam, the Netherlands
| | - Merel H J Hazewinkel
- From the Department of Plastic, Reconstructive Surgery and Hand Surgery, Erasmus Medical Center Rotterdam, the Netherlands
| | - Caroline A Hundepool
- From the Department of Plastic, Reconstructive Surgery and Hand Surgery, Erasmus Medical Center Rotterdam, the Netherlands
| | - Liron S Duraku
- Department of Plastic, Reconstructive Surgery and Hand Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Judith Drenthen
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center, New York, N.Y
| | - J Michiel Zuidam
- From the Department of Plastic, Reconstructive Surgery and Hand Surgery, Erasmus Medical Center Rotterdam, the Netherlands
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Artificial Intelligence-Enabled Evaluation of Pain Sketches to Predict Outcomes in Headache Surgery. Plast Reconstr Surg 2023; 151:405-411. [PMID: 36696328 DOI: 10.1097/prs.0000000000009855] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Recent evidence has shown that patient drawings of pain can predict poor outcomes in headache surgery. Given that interpretation of pain drawings requires some clinical experience, the authors developed a machine learning framework capable of automatically interpreting pain drawings to predict surgical outcomes. This platform will allow surgeons with less clinical experience, neurologists, primary care practitioners, and even patients to better understand candidacy for headache surgery. METHODS A random forest machine learning algorithm was trained on 131 pain drawings provided prospectively by headache surgery patients before undergoing trigger-site deactivation surgery. Twenty-four features were used to describe the anatomical distribution of pain on each drawing for interpretation by the machine learning algorithm. Surgical outcome was measured by calculating percentage improvement in Migraine Headache Index at least 3 months after surgery. Artificial intelligence predictions were compared with clinician predictions of surgical outcome to determine artificial intelligence performance. RESULTS Evaluation of the data test set demonstrated that the algorithm was consistently more accurate (94%) than trained clinical evaluators. Artificial intelligence weighted diffuse pain, facial pain, and pain at the vertex as strong predictors of poor surgical outcome. CONCLUSIONS This study indicates that structured algorithmic analysis is able to correlate pain patterns drawn by patients to Migraine Headache Index percentage improvement with good accuracy (94%). Further studies on larger data sets and inclusion of other significant clinical screening variables are required to improve outcome predictions in headache surgery and apply this tool to clinical practice.
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Olla DR, Kemper KM, Brown AL, Mailey BA. Single midline incision approach for decompression of greater, lesser and third occipital nerves in migraine surgery. BMC Surg 2022; 22:232. [PMID: 35715794 PMCID: PMC9204865 DOI: 10.1186/s12893-022-01675-z] [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: 04/21/2021] [Accepted: 05/31/2022] [Indexed: 11/10/2022] Open
Abstract
Background The traditional approach for occipital migraine surgery encompasses three separate surgical incisions in the posterior neck to decompress the greater occipital nerves (GON), lesser occipital nerves (LON), and third occipital nerves (TON). Other incisions have been investigated, including singular transverse incisions. We sought to evaluate a single, vertical midline incision approach for decompression of all six occipital nerves. Methods Using 10 cadaveric hemi-sides (5 fresh cadaver head and necks). Anatomic landmarks and the location of the bilateral GON, LON, and TON were marked according to previous anatomic studies. A single, midline 9-cm incision was made, and lateral skin flaps were raised to decompress or avulse all six nerves. Results Through the midline incision, the GON and TON were identified at 3.5 and 6.2 cm, respectively, inferior to a line bisecting the external auditory canal (EAC) and 1.5 cm lateral to the midline. The LON was identified as 6-cm inferior and 6.5-cm medial to a line bisecting the EAC in the plane just above the investing layer of the deep cervical fascia until the posterior border of the sternocleidomastoid was encountered. The LON had the greatest amount of variation but was identified lateral to the posterior border of the SCM. Conclusions A single midline incision approach allows for successful identification and decompression of all six occipital nerves in migraine surgery.
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Affiliation(s)
- Danielle R Olla
- Institute for Plastic and Reconstructive Surgery, Department of Surgery, Southern Illinois University, 747 N. Rutledge St, Springfield, IL, 62702, USA
| | - Kortni M Kemper
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Amanda L Brown
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Brian A Mailey
- Institute for Plastic and Reconstructive Surgery, Department of Surgery, Southern Illinois University, 747 N. Rutledge St, Springfield, IL, 62702, USA.
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RPNI, TMR, and Reset Neurectomy/Relocation Nerve Grafting after Nerve Transection in Headache Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4201. [PMID: 35350148 PMCID: PMC8955094 DOI: 10.1097/gox.0000000000004201] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/14/2022] [Indexed: 11/26/2022]
Abstract
In the context of headache surgery, greater occipital nerve (GON) transection is performed when the nerve appears severely damaged, if symptoms are recurrent or persistent, and when neuromas are excised. Lesser occipital nerve (LON) excision is commonly performed during the primary decompression surgery. Advanced techniques to address the proximal nerve stump after nerve transection such as regenerative peripheral nerve interface (RPNI), targeted muscle reinnervation (TMR), relocation nerve grafting, and reset neurectomy have been shown to improve chronic pain and neuroma formation. These techniques have not been described in the head and neck region.
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Reply: Muscle Fascia Changes in Patients with Occipital Neuralgia, Headache, or Migraine. Plast Reconstr Surg 2021; 148:851e. [PMID: 34610002 DOI: 10.1097/prs.0000000000008455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Identify patients who are candidates for headache surgery. 2. Counsel the patient preoperatively with regard to success rates, recovery, and complications. 3. Develop a surgical plan for primary and secondary nerve decompression. 4. Understand the surgical anatomy at all trigger sites. 5. Select appropriate International Classification of Diseases, Tenth Revision, and CPT codes. SUMMARY Headache surgery encompasses release of extracranial peripheral sensory nerves at seven sites. Keys to successful surgery include correct patient selection, detailed patient counseling, and meticulous surgical technique. This article is a practical step-by-step guide, from preoperative assessment to surgery and postoperative recovery. International Classification of Diseases, Tenth Revision, and CPT codes, in addition to complications and salvage procedures, are discussed. Intraoperative photographs, videos, and screening questionnaires are provided.
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