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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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2
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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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3
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Pietramaggiori G, Bastin A, Ricci F, Bassetto F, Scherer S. Minimally invasive nerve and artery sparing surgical approach for temporal migraines. JPRAS Open 2024; 39:32-41. [PMID: 38162535 PMCID: PMC10755679 DOI: 10.1016/j.jpra.2023.11.005] [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: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 01/03/2024] Open
Abstract
Background Temporal migraines (TM) present with throbbing, pulsating headaches in the temporal area. Different surgical techniques ranging from resecting the auriculotemporal nerve (ATN) and or ligating the superficial temporal artery (STA) have shown similar good results to decrease TM symptoms. No conclusive data supports a specific disease of the STA in TM patients. A minimally invasive technique is proposed to preserve both vascular and nerve structures. Methods Patients with drug resistant TM were selected and treated with two techniques: nerve sparing and nerve and artery sparing. The study included 57 patients with TM, with an average age of 47.5 years. TM improvement was quantified after at least one year of follow up time. STA biopsies were sent for histological analysis. Results Forty-two patients underwent nerve-sparing decompression, with a therapeutic success rate of 78.6%, corresponding to 22.1 days with migraine per month decreasing to 6.2. Histological analysis of the STA showed varying degrees of endofibrosis in 75% of the samples. Histological results do not correlate with the intensity of symptoms before or after surgery. Fifteen patients underwent nerve and artery sparing arteriolysis, with an overall therapeutic success rate of 86.6% of which 80% had >90% improvement. The average migraine days dropped from 24 to 2.5 days per month in this group. Conclusion Minimally invasive nerve sparing approaches are an effective and safe treatment to improve drug resistant TM symptoms. Endofibrosis of the STA was present in 75% of the cases, but it was found to be unrelated to pre-operative symptoms and outcome. Results are promising, but the limited numbers of patients treated with artery and nerve sparing technique needs further investigations.
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Affiliation(s)
- Giorgio Pietramaggiori
- Global Medical Institute, Division of Aesthetic and Migraine Surgery, Avenue Jomini 8, 1004 Lausanne, Switzerland
| | - Alessandro Bastin
- University of Padua, Department of Neurosciences, Division of plastic Surgery, Via Giustiniani 2, 35128 Padova, Italy
| | - Federico Ricci
- University of Padua, Department of Neurosciences, Division of plastic Surgery, Via Giustiniani 2, 35128 Padova, Italy
| | - Franco Bassetto
- University of Padua, Department of Neurosciences, Division of plastic Surgery, Via Giustiniani 2, 35128 Padova, Italy
| | - Saja Scherer
- Global Medical Institute, Division of Aesthetic and Migraine Surgery, Avenue Jomini 8, 1004 Lausanne, Switzerland
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Saffari S, Saffari TM, Janis JE. Secondary Trigger Point Deactivation Surgery for Nerve Compression Headaches: A Scoping Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5620. [PMID: 38405132 PMCID: PMC10887444 DOI: 10.1097/gox.0000000000005620] [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: 10/11/2023] [Accepted: 01/09/2024] [Indexed: 02/27/2024]
Abstract
Background Primary trigger point deactivation surgery has been successful in reducing or eliminating nerve compression headaches between 79% and 90% of the time. The aim of this review article was to discuss the factors that contribute to index trigger point deactivation surgery failure, the importance of reevaluating trigger points following failure, and the options for secondary surgery. Methods A literature search was performed using a combination of keywords involving "chronic headache" and "nerve deactivation surgery," in databases until February 2023. Results Data of 1071 patients were evaluated and included (11 articles). The failure rate after index trigger point deactivation surgery occurs is approximately 12%, primarily due to incomplete primary trigger point deactivation. Secondary trigger points may not appear until the primary trigger is eliminated, which occurs in 17.8% of patients. Reevaluation of previously diagnosed trigger points as well as uncovered trigger points and additional preoperative testing is indicated to help determine candidacy for further surgical deactivation. To address scarring that could contribute to failure, corticosteroid injection, acellular dermal matrix, adipofascial fat, or expanded polytetrafluoroethylene sleeves have been described with beneficial effects. For neuroma management, regenerative peripheral nerve interface, targeted muscle reinnervation, a combination of both, relocation nerve grafting, or nerve capping have also been described. Neurectomy can be performed when patients prefer anesthesia and/or paresthesia over current pain symptoms. Conclusion Secondary trigger point deactivation surgery is indicated when there is suspicion of incomplete deactivation, internal scarring, neuroma, or newly-diagnosed trigger points.
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Affiliation(s)
- Sara Saffari
- From the Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minn
- Department of Plastic Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Tiam M. Saffari
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jeffrey E. Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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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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6
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Peled ZM, Gfrerer L, Hagan R, Al-Kassis S, Savvides G, Austen G, Valenti A, Chinta M. Anatomic Anomalies of the Nerves Treated during Headache Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5439. [PMID: 38025616 PMCID: PMC10662871 DOI: 10.1097/gox.0000000000005439] [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: 06/05/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023]
Abstract
Background Headache surgery is a well-established, viable option for patients with chronic head pain/migraines refractory to conventional treatment modalities. These operations involve any number of seven primary nerves. In the occipital region, the surgical targets are the greater, lesser, and third occipital nerves. In the temporal region, they are the auriculotemporal and zygomaticotemporal nerves. In the forehead, the supraorbital and supratrochlear are targeted. The typical anatomic courses of these nerves are well established and documented in clinical and cadaveric studies. However, variations of this "typical" anatomy are quite common and relatively poorly understood. Headache surgeons should be aware of these common anomalies, as they may alter treatment in several meaningful ways. Methods In this article, we describe the experience of five established headache surgeons encompassing over 4000 cases with respect to the most common anomalies of the nerves typically addressed during headache surgery. Descriptions of anomalous nerve courses and suggestions for management are offered. Results Anomalies of all seven nerves addressed during headache operations occur with a frequency ranging from 2% to 50%, depending on anomaly type and nerve location. Variations of the temporal and occipital nerves are most common, whereas anomalies of the frontal nerves are relatively less common. Management includes broader dissection and/or transection of accessory injured nerves combined with strategies to reduce neuroma formation such as targeted reinnervation or regenerative peripheral nerve interfaces. Conclusions Understanding these myriad nerve anomalies is essential to any headache surgeon. Implications are relevant to preoperative planning, intraoperative dissection, and postoperative management.
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Affiliation(s)
- Ziv M. Peled
- From the Peled Plastic Surgery, San Francisco, Calif
| | - Lisa Gfrerer
- Department of Plastic Surgery, New York Presbyterian Weill Cornell Medical Center, New York, N.Y
| | | | - Salam Al-Kassis
- Division of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Georgia Savvides
- Department of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Gerald Austen
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Mass
| | - Alyssa Valenti
- Department of Plastic Surgery, New York Presbyterian Weill Cornell Medical Center, New York, N.Y
| | - Malini Chinta
- Department of Plastic Surgery, New York Presbyterian Weill Cornell Medical Center, New York, N.Y
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Macionis V. Neurovascular Compression-Induced Intracranial Allodynia May Be the True Nature of Migraine Headache: an Interpretative Review. Curr Pain Headache Rep 2023; 27:775-791. [PMID: 37837483 DOI: 10.1007/s11916-023-01174-7] [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: 09/15/2023] [Indexed: 10/16/2023]
Abstract
PURPOSE OF REVIEW Surgical deactivation of migraine trigger sites by extracranial neurovascular decompression has produced encouraging results and challenged previous understanding of primary headaches. However, there is a lack of in-depth discussions on the pathophysiological basis of migraine surgery. This narrative review provides interpretation of relevant literature from the perspective of compressive neuropathic etiology, pathogenesis, and pathophysiology of migraine. RECENT FINDINGS Vasodilation, which can be asymptomatic in healthy subjects, may produce compression of cranial nerves in migraineurs at both extracranial and intracranial entrapment-prone sites. This may be predetermined by inherited and acquired anatomical factors and may include double crush-type lesions. Neurovascular compression can lead to sensitization of the trigeminal pathways and resultant cephalic hypersensitivity. While descending (central) trigeminal activation is possible, symptomatic intracranial sensitization can probably only occur in subjects who develop neurovascular entrapment of cranial nerves, which can explain why migraine does not invariably afflict everyone. Nerve compression-induced focal neuroinflammation and sensitization of any cranial nerve may neurogenically spread to other cranial nerves, which can explain the clinical complexity of migraine. Trigger dose-dependent alternating intensity of sensitization and its synchrony with cyclic central neural activities, including asymmetric nasal vasomotor oscillations, may explain the laterality and phasic nature of migraine pain. Intracranial allodynia, i.e., pain sensation upon non-painful stimulation, may better explain migraine pain than merely nociceptive mechanisms, because migraine cannot be associated with considerable intracranial structural changes and consequent painful stimuli. Understanding migraine as an intracranial allodynia could stimulate research aimed at elucidating the possible neuropathic compressive etiology of migraine and other primary headaches.
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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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9
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Tereshko Y, Belgrado E, Lettieri C, Gigli GL, Valente M. Botulinum Toxin Type A for the Treatment of Auriculotemporal Neuralgia-A Case Series. Toxins (Basel) 2023; 15:toxins15040274. [PMID: 37104212 PMCID: PMC10141838 DOI: 10.3390/toxins15040274] [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: 03/14/2023] [Revised: 03/23/2023] [Accepted: 03/30/2023] [Indexed: 04/28/2023] Open
Abstract
Auriculotemporal neuralgia is a rare pain disorder in which anesthetic nerve blockade is usually effective but not always resolutive. Botulinum toxin type A has proven to be effective in treating neuropathic pain, and patients with auriculotemporal neuralgia could also benefit from this treatment. We described nine patients with auriculotemporal neuralgia treated with botulinum toxin type A in the territory of auriculotemporal nerve innervation. We compared the basal NRS and Penn facial pain scale scores with those obtained 1 month after BoNT/A injections. Both Penn facial pain scale (96.67 ± 24.61 vs. 45.11 ± 36.70, p 0.004; mean reduction 52.57 ± 36.50) and NRS scores (8.11 ± 1.27 vs. 4.22 ± 2.95, p 0.009; mean reduction 3.89 ± 2.52) improved significantly at one month after treatment. The mean duration of the effect of BoNT/A on pain was 95.00 ± 53.03 days and no adverse effects were reported.
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Affiliation(s)
- Yan Tereshko
- Clinical Neurology Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Enrico Belgrado
- Neurology Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Christian Lettieri
- Neurology Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Gian Luigi Gigli
- Clinical Neurology Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
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10
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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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11
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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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12
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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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Cirillo G, Negrete-Diaz F, Yucuma D, Virtuoso A, Korai SA, De Luca C, Kaniusas E, Papa M, Panetsos F. Vagus Nerve Stimulation: A Personalized Therapeutic Approach for Crohn's and Other Inflammatory Bowel Diseases. Cells 2022; 11:cells11244103. [PMID: 36552867 PMCID: PMC9776705 DOI: 10.3390/cells11244103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/03/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Inflammatory bowel diseases, including Crohn's disease and ulcerative colitis, are incurable autoimmune diseases characterized by chronic inflammation of the gastrointestinal tract. There is increasing evidence that inappropriate interaction between the enteric nervous system and central nervous system and/or low activity of the vagus nerve, which connects the enteric and central nervous systems, could play a crucial role in their pathogenesis. Therefore, it has been suggested that appropriate neuroprosthetic stimulation of the vagus nerve could lead to the modulation of the inflammation of the gastrointestinal tract and consequent long-term control of these autoimmune diseases. In the present paper, we provide a comprehensive overview of (1) the cellular and molecular bases of the immune system, (2) the way central and enteric nervous systems interact and contribute to the immune responses, (3) the pathogenesis of the inflammatory bowel disease, and (4) the therapeutic use of vagus nerve stimulation, and in particular, the transcutaneous stimulation of the auricular branch of the vagus nerve. Then, we expose the working hypotheses for the modulation of the molecular processes that are responsible for intestinal inflammation in autoimmune diseases and the way we could develop personalized neuroprosthetic therapeutic devices and procedures in favor of the patients.
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Affiliation(s)
- Giovanni Cirillo
- Division of Human Anatomy, Neuronal Morphology Networks & Systems Biology Lab, Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli, 80138 Naples, Italy
| | - Flor Negrete-Diaz
- Neurocomputing & Neurorobotics Research Group, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigaciones Sanitarias (IdISSC), Hospital Clinico San Carlos de Madrid, 28040 Madrid, Spain
| | - Daniela Yucuma
- Neurocomputing & Neurorobotics Research Group, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Andalusian School of Public Health, University of Granada, 18011 Granada, Spain
| | - Assunta Virtuoso
- Division of Human Anatomy, Neuronal Morphology Networks & Systems Biology Lab, Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli, 80138 Naples, Italy
| | - Sohaib Ali Korai
- Division of Human Anatomy, Neuronal Morphology Networks & Systems Biology Lab, Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli, 80138 Naples, Italy
| | - Ciro De Luca
- Division of Human Anatomy, Neuronal Morphology Networks & Systems Biology Lab, Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli, 80138 Naples, Italy
| | | | - Michele Papa
- Division of Human Anatomy, Neuronal Morphology Networks & Systems Biology Lab, Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli, 80138 Naples, Italy
- SYSBIO Centre of Systems Biology ISBE-IT, University of Milano-Bicocca, 20126 Milan, Italy
- Correspondence: (M.P.); (F.P.)
| | - Fivos Panetsos
- Neurocomputing & Neurorobotics Research Group, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigaciones Sanitarias (IdISSC), Hospital Clinico San Carlos de Madrid, 28040 Madrid, Spain
- Silk Biomed SL, 28260 Madrid, Spain
- Correspondence: (M.P.); (F.P.)
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14
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Evaluation of Patient Comfort and Impact of Different Anesthesia Techniques on the Temporomandibular Joint Arthrocentesis Applications by Comparing Gow-Gates Mandibular Block Anesthesia with Auriculotemporal Nerve Block. Pain Res Manag 2022; 2022:4206275. [PMID: 36090766 PMCID: PMC9453085 DOI: 10.1155/2022/4206275] [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: 04/05/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 11/24/2022]
Abstract
Aim Temporomandibular disorders (TMDs) are clinical situations that are characterized by pain, sound, and irregular movements of the temporomandibular joints. The most common method in the treatment of TMDs is arthrocentesis. This study aims to compare the effect of conventional extraoral auriculotemporal nerve block (ANB) and Gow-Gates (GG) mandibular anesthesia techniques on patient comfort in an arthrocentesis procedure. Materials and Methods We performed this study on 40 patients who underwent TMJ arthrocentesis with ANB (n = 20) or GG (n = 20) mandibular anesthesia techniques at the Marmara University Faculty of Dentistry between 2016 and 2019. The predictor variable was the type of an anesthesia technique, and the outcome variables included were pain, maximum mouth opening (MMO), and protrusive movement (PM). They were compared at the preoperative period and 3rd and 6th month periods. Statistical analysis included means with standard deviations, a one-way ANOVA for continuous data, and the results were evaluated at the significance level of p < 0.05. Results No statistically significant difference was observed between the VAS values, MMO, and PM averages of preoperative, 3rd and 6th months of ANB and GG (p=0.142, p=0.209, and p=0.148). Conclusion Both anesthesia techniques have provided effective results in terms of pain and functional jaw movements in the postoperative period in arthrocentesis treatment.
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Tirado CF, Washburn SN, Covalin A, Hedenberg C, Vanderpool H, Benner C, Powell DP, McWade MA, Khodaparast N. Delivering transcutaneous auricular neurostimulation (tAN) to improve symptoms associated with opioid withdrawal: results from a prospective clinical trial. Bioelectron Med 2022; 8:12. [PMID: 35978394 PMCID: PMC9385243 DOI: 10.1186/s42234-022-00095-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background As pharmacological treatments are the primary option for opioid use disorder, neuromodulation has recently demonstrated efficacy in managing opioid withdrawal syndrome (OWS). This study investigated the safety and effectiveness of transcutaneous auricular neurostimulation (tAN) for managing OWS. Methods This prospective inpatient trial included a 30-minute randomized, sham-controlled, double-blind period followed by a 5-day open-label period. Adults with physical dependence on opioids were randomized to receive active or sham tAN following abrupt opioid discontinuation. The Clinical Opiate Withdrawal Scale (COWS) was used to determine withdrawal level, and participants were required to have a baseline COWS score ≥ 13 before enrollment. The double-blind period of the study occurred during the first 30-minutes to assess the acute effects of tAN therapy compared to a sham control. Group 1 received active tAN during both the 30-minute double-blind period and the 5-day open-label period. Group 2 received passive sham tAN (no stimulation) during the double-blind period, followed by active tAN during the 5-day open-label period. The primary outcome was change in COWS from baseline to 60-minutes of active tAN (pooled across groups, accounting for 30-minute delay). Secondary outcomes included difference in change in COWS scores between groups after 30-minutes of active or sham tAN, change in COWS scores after 120-minutes of active tAN, and change in COWS scores on Days 2–5. Non-opioid comfort medications were administered during the trial. Results Across all thirty-one participants, the mean (SD) COWS scores relative to baseline were reduced by 7.0 (4.7) points after 60-minutes of active tAN across both groups (p < 0.0001; Cohen’s d = 2.0), demonstrating a significant and clinically meaningful reduction of 45.9%. After 30-minutes of active tAN (Group 1) or sham tAN (Group 2), the active tAN group demonstrated a significantly greater COWS score reduction than the sham tAN group (41.7% vs. 24.1%; p = 0.036). Participants across both groups achieved an average COWS reduction up to 74.7% on Days 2–5. Conclusion Results demonstrate tAN is a safe and effective non-opioid approach for reducing symptoms of OWS. This study supported an FDA clearance. Clinical trial registration clinicaltrials.gov/ct2/show/NCT04075214, Identifier: NCT04075214, Release Date: August 28, 2019.
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Affiliation(s)
- Carlos F Tirado
- CARMAhealth Management, Inc., 630 W 34th St #301, Austin, TX, 78705, USA
| | | | - Alejandro Covalin
- Spark Biomedical, Inc., 18208 Preston Road, Ste D9-531, Dallas, TX, 75252, USA
| | - Caroline Hedenberg
- CARMAhealth Management, Inc., 630 W 34th St #301, Austin, TX, 78705, USA
| | - Heather Vanderpool
- Spark Biomedical, Inc., 18208 Preston Road, Ste D9-531, Dallas, TX, 75252, USA
| | - Caroline Benner
- Spark Biomedical, Inc., 18208 Preston Road, Ste D9-531, Dallas, TX, 75252, USA
| | - Daniel P Powell
- Spark Biomedical, Inc., 18208 Preston Road, Ste D9-531, Dallas, TX, 75252, USA
| | - Melanie A McWade
- Spark Biomedical, Inc., 18208 Preston Road, Ste D9-531, Dallas, TX, 75252, USA
| | - Navid Khodaparast
- Spark Biomedical, Inc., 18208 Preston Road, Ste D9-531, Dallas, TX, 75252, USA.
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Raposio E, Raposio G, Duchetto DD, Tagliatti E, Cortese K. Morphologic Vascular Anomalies detected during Migraine Surgery. J Plast Reconstr Aesthet Surg 2022; 75:4069-4073. [DOI: 10.1016/j.bjps.2022.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/11/2022] [Accepted: 08/16/2022] [Indexed: 10/31/2022]
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Gebara MA, Iwanaga J, Dumont AS, Tubbs RS. Nervous Interconnection Between the Lesser Occipital and Auriculotemporal Nerves. Cureus 2022; 14:e25643. [PMID: 35795503 PMCID: PMC9251152 DOI: 10.7759/cureus.25643] [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] [Accepted: 06/03/2022] [Indexed: 11/17/2022] Open
Abstract
The auriculotemporal nerve is one branch of the mandibular portion of the trigeminal nerve, which itself divides into several branches in the temporal and retromandibular regions. The lesser occipital nerve is a cutaneous branch of the cervical plexus and is sometimes implicated in cases of cervicogenic headaches, occipitoparietal headaches, and occipital neuralgia, in general. Here, we present a case of unilateral neural interconnection between the auriculotemporal and lesser occipital nerves thus illustrating the joining of the cervical plexus and trigeminal nerve. A better understanding of the aforementioned nervous anatomy may be valuable for facial reconstructive and nerve transfer procedures, as well as for a variety of other head and neck disorders, e.g., occipital neuralgia.
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Raposio G, Cortese K, Raposio E. An easy and reliable way to preoperatively identify the auriculo-temporal nerve in migraine surgery. J Plast Reconstr Aesthet Surg 2022; 75:2387-2440. [PMID: 35504787 DOI: 10.1016/j.bjps.2022.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 02/24/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022]
Abstract
In this paper, we describe a simple and reliable way to preoperatively localize the auriculotemporal nerve in migraine surgery. We measured the correspondence of this cutaneous landmark and the ATN in twelve migraine patients operated at Site V. Our findings demonstrated a very high concordance between the described point and the underlying auriculotemporal nerve. This method might be of some utility in the preoperative planning of Site V Migraine surgery, in the strive of reducing the length of cutaneous incision and the invasiveness of the procedure.
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Affiliation(s)
- Giorgio Raposio
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Plastic Surgery Chair, L.go R. Benzi 10, Genoa 16132, Italy
| | - Katia Cortese
- Department of Experimental Medicine (DIMES), University of Genova, Human Anatomy Unit, Italy.
| | - Edoardo Raposio
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Plastic Surgery Chair, L.go R. Benzi 10, Genoa 16132, Italy; IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Raposio G, Raposio E. Temporal surgery for chronic migraine treatment: A minimally-invasive perspective. Ann Med Surg (Lond) 2022; 76:103578. [PMID: 35495408 PMCID: PMC9052296 DOI: 10.1016/j.amsu.2022.103578] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/31/2022] [Accepted: 03/31/2022] [Indexed: 11/06/2022] Open
Abstract
In this paper, we describe our mini-invasive approach for the deactivation of the auriculotemporal nerve in migraine surgery. After a mean follow-up of 21 months (range, 3–67 months), patients complaining for temporal MH had 83% positive surgical outcome (50% complete MH elimination, 33% significant improvement). Only rare minor complications are usually reported (eg, oedema, paresthesia hematoma/ecchymosis, and numbness).
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Efficacy and Safety of Migraine Surgery: A Systematic Review and Meta-analysis of Outcomes and Complication Rates. Ann Surg 2022; 275:e315-e323. [PMID: 35007230 DOI: 10.1097/sla.0000000000005057] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The objectives of this study are to assess the efficacy and safety of peripheral nerve surgery for migraine headaches and to bibliometrically analyze all anatomical studies relevant to migraine surgery. SUMMARY BACKGROUND DATA Migraines rank as the second leading cause of disability worldwide. Despite the availability of conservative management options, individuals suffer from refractive migraines which are associated with poor quality of life. Migraine surgery, defined as the peripheral nerve decompression/trigger site deactivation, is a relatively novel treatment strategy for refractory migraines. METHODS EMBASE and the National Library of Medicine (PubMed) were systematically searched for relevant articles according to the PRISMA guidelines. Data was extracted from studies which met the inclusion criteria. Pooled analyses were performed to assess complication rates. Meta-analyses were run using the random effects model for overall effects and within subgroup fixed-effect models were used. RESULTS A total of 68 studies (38 clinical, 30 anatomical) were included in this review. There was a significant overall reduction in migraine intensity (P < 0.001, SE = 0.22, I2 = 97.9), frequency (P < 0.001, SE = 0.17, I2 = 97.7), duration (P < 0.001, SE = 0.15, I2 = 97), and migraine headache index (MHI, P < 0.001, SE = 0.19, I2 = 97.2) at follow-up. A total of 35 studies reported on migraine improvement (range: 68.3%-100% of participants) and migraine elimination (range: 8.3%-86.5% of participants). 32.1% of participants in the clinical studies reported complications for which the most commonly reported complications being paresthesia and numbness, which was mostly transient, (12.11%) and itching (4.89%). CONCLUSION This study demonstrates improved migraine outcomes and an overall decrease in MHI as well as strong evidence for the safety profile and complication rate of migraine surgery.
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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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22
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Clinical Effectiveness of Peripheral Nerve Blocks for Diagnosis of Migraine Trigger Points. Plast Reconstr Surg 2021; 148:992e-1000e. [PMID: 34847126 DOI: 10.1097/prs.0000000000008580] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND With a 13 percent global prevalence, migraine headaches are the most commonly diagnosed neurologic disorder, and are a top five cause of visits to the emergency room. Surgical techniques, such as decompression and/or ablation of neurovasculature, have shown to provide relief. Popular diagnostic modalities to identify trigger loci include handheld Doppler examinations and botulinum toxin injection. This article aims to establish the positive predictive value of peripheral nerve blocks for identifying therapeutic surgical targets for migraine headache surgery. METHODS Electronic medical records of 36 patients were analyzed retrospectively. Patients underwent peripheral nerve blocks using 1% lidocaine with epinephrine and subsequent surgery on identified migraine headache trigger sites. Patients were grouped into successful and unsuccessful blocks and further categorized into successful and unsuccessful surgery subgroups. Group analysis was performed using paired t tests, and positive-predictive value calculations were performed on subgroups. RESULTS The preoperative Migraine Headache Index of patients with positive blocks was 152.71, versus 34.26 postoperatively (p < 0.001). Each index component also decreased significantly: frequency (22.11 versus 15.06 migraine headaches per month; p < 0.001), intensity (7.43 versus 4.12; p < 0.001), and duration (0.93 versus 0.55 days; p < 0.001). The positive-predictive value of diagnostic peripheral nerve blocks in identifying a migraine headache trigger site responsive to surgical intervention was calculated to be 0.89 (95 percent CI, 1 to 0.74). CONCLUSIONS To the authors' knowledge, this is the first study to investigate the positive-predictive value of peripheral nerve blocks as used in the diagnostic workup of patients with chronic migraine headaches. Peripheral nerve blocks serve as a reliable clinical tool in mapping migraine trigger sites for surgical intervention while offering more flexibility in their administration and recording as compared to established diagnostic methods. . CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, IV.
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A Correlation between Upper Extremity Compressive Neuropathy and Nerve Compression Headache. Plast Reconstr Surg 2021; 148:1308-1315. [PMID: 34847118 DOI: 10.1097/prs.0000000000008574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Compressive neuropathies of the head/neck that trigger headaches and entrapment neuropathies of the extremities have traditionally been perceived as separate clinical entities. Given significant overlap in clinical presentation, treatment, and anatomical abnormality, the authors aimed to elucidate the relationship between nerve compression headaches and carpal tunnel syndrome, and other upper extremity compression neuropathies. METHODS One hundred thirty-seven patients with nerve compression headaches who underwent surgical nerve deactivation were included. A retrospective chart review was conducted and the prevalence of carpal tunnel syndrome, thoracic outlet syndrome, and cubital tunnel syndrome was recorded. Patients with carpal tunnel syndrome, cubital tunnel syndrome, and thoracic outlet syndrome who had a history of surgery and/or positive imaging findings in addition to confirmed diagnosis were included. Patients with subjective report of carpal tunnel syndrome/thoracic outlet syndrome/cubital tunnel syndrome were excluded. Prevalence was compared to general population data. RESULTS The cumulative prevalence of upper extremity neuropathies in patients undergoing surgery for nerve compression headaches was 16.7 percent. The prevalence of carpal tunnel syndrome was 10.2 percent, which is 1.8- to 3.8-fold more common than in the general population. Thoracic outlet syndrome prevalence was 3.6 percent, with no available general population data for comparison. Cubital tunnel syndrome prevalence was comparable between groups. CONCLUSIONS The degree of overlap between nerve compression syndromes of the head/neck and upper extremity suggests that peripheral nerve surgeons should be aware of this correlation and screen affected patients comprehensively. Similar patient presentation, treatment, and anatomical basis of nerve compression make either amenable to treatment by nerve surgeons, and treatment of both entities should be an integral part of a formal peripheral nerve surgery curriculum.
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Totonchi A, Guyuron B, Ansari H. Surgical Options for Migraine: An Overview. Neurol India 2021; 69:S105-S109. [PMID: 34003155 DOI: 10.4103/0028-3886.315999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objective The goal of this manuscript was to provide a comprehensive review of the surgical treatment for migraine headaches with a focus on trigger points and their clinical presentations, and to emphasize the importance of appropriate patient selection. Background Migraine is a prevalent neurological disease with headache being a disabling component of it. Surgical treatment for migraine headache became available two decades ago, which is based on proper identification and the deactivation of the specific trigger sites in the head and neck area. Design This manuscript reviews the discovery and evolution of migraine surgery with changes in patients' selection throughout the years. Conclusion Patients with migraine headaches who do not respond or cannot tolerate the medical treatment might benefit from trigger site deactivation surgery. The success of the surgery is closely related to proper identification of trigger point (s) and close collaboration with a neurologist or a headache specialist. This collaboration would enhance patients' positive outcomes and help to rule out other causes of the headache.
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Affiliation(s)
- Ali Totonchi
- Associated Professor of Plastic surhery Case Western Reserve University, Metro health Hospital, Cleveland, USA
| | - Bahman Guyuron
- Editor In Chief, Aesthetic Plastic Surgery Journal Professor Emeritus, Plastic Surgery Case School of Medicine Zeeba Clinic, Lyndhurst, OH, USA
| | - Hossein Ansari
- Director of Headache and Facial Pain Clinic Kaizen Brain Center, Associate Professor of Neuroscience University of California 9500 Gilman Drive La Jolla, California, USA
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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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Chen G, You H, Juha H, Lou B, Zhong Y, Lian X, Peng Z, Xu T, Yuan L, Woralux P, Hugo AB, Jianliang C. Trigger areas nerve decompression for refractory chronic migraine. Clin Neurol Neurosurg 2021; 206:106699. [PMID: 34053808 DOI: 10.1016/j.clineuro.2021.106699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/19/2021] [Accepted: 05/11/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chronic migraine refractory to medical treatment represents a common debilitating primary neurovascular disorder associated with great disability, high financial costs, reduced rates of productivity and impaired health-related quality of life. OBJECTIVE To demonstrate the feasibility of scalp (trigger areas) nerve decompression as a treatment alternative in the management of refractory CM patients METHODS: From January 2005 to January 2020, we retrospectively collected data of 154 patients diagnosed with chronic migraine that underwent trigger site nerve decompression. These trigger areas were divided according the nerve compromise as frontal (supraorbital nerve), temporal (auriculotemporal nerve), occipital (greater occipital nerve). Following extensive clinical evaluation, the surgical treatment was performed after under local anesthesia and required the release of the affected nerve from surrounding connective tissue adhesions, and vascular conflicts. RESULTS Of the total amount of patients, 91 (59.09%) patients underwent auriculotemporal nerve decompression, 27 (13.63%) cases supraorbital nerve decompression, 15 (9.74%) patients greater occipital nerve decompression, and the remaining 21 (13.63%) patients had more than one procedure of nerve decompression. At 1-year follow or latest follow-up, 96 (62.2%) patients were considered as cured, 29 cases (18.83%) reported improvement of their symptoms, 21 (13.64%) patients considered only a partial symptomatic remission and 5 (3.25%) patients reported no change or failed surgical treatment. CONCLUSION Nerve decompression of trigger site areas (frontal, temporal, occipital) by removal of tissue, muscles and vessels in patients with medically refractory CM is a feasible alternative treatment modality with a high success of up to 80.5.
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Affiliation(s)
- Guiwen Chen
- Department of neurosurgery, the Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 518033, Guangdong Province, China
| | - Hengxing You
- Department of neurosurgery, the Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 518033, Guangdong Province, China
| | - Hernesniemi Juha
- Department of Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, Henan, China; Henan Provincial People's, Hospital, Zhengzhou, Henan, China; Cerebrovascular Disease Hospital, Zhengzhou, Henan, China; Henan University People's, Hospital, Zhengzhou, Henan, China
| | - Bin Lou
- Department of neurosurgery, the Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 518033, Guangdong Province, China
| | - Yuanqiang Zhong
- Department of neurosurgery, the Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 518033, Guangdong Province, China
| | - Xiaowen Lian
- Department of neurosurgery, the Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 518033, Guangdong Province, China
| | - Zhitao Peng
- Department of neurosurgery, the Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 518033, Guangdong Province, China
| | - Ting Xu
- Department of neurosurgery, the Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 518033, Guangdong Province, China
| | - Li Yuan
- Department of neurosurgery, the Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 518033, Guangdong Province, China
| | | | - Andrade-Barazarte Hugo
- Department of Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, Henan, China; Henan Provincial People's, Hospital, Zhengzhou, Henan, China; Cerebrovascular Disease Hospital, Zhengzhou, Henan, China; Henan University People's, Hospital, Zhengzhou, Henan, China.
| | - Chen Jianliang
- Department of neurosurgery, the Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 518033, Guangdong Province, China.
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Zetlaoui PJ, Gauthier E, Benhamou D. Ultrasound-guided scalp nerve blocks for neurosurgery: A narrative review. Anaesth Crit Care Pain Med 2020; 39:876-882. [DOI: 10.1016/j.accpm.2020.06.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 12/19/2022]
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Gfrerer L, Hansdorfer MA, Amador RO, Nealon KP, Chartier C, Runyan GG, Zarfos SD, Austen WG. Patient Pain Sketches Can Predict Surgical Outcomes in Trigger-Site Deactivation Surgery for Headaches. Plast Reconstr Surg 2020; 146:863-871. [PMID: 32970009 PMCID: PMC7505156 DOI: 10.1097/prs.0000000000007162] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 04/24/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patient selection for headache surgery is an important variable to ensure successful outcomes. In the authors' experience, a valuable method to visualize pain/trigger sites is to ask patients to draw their pain. The authors have found that there are pathognomonic pain patterns for each site, and typically do not operate on patients with atypical pain sketches, as they believe such patients are poor surgical candidates. However, a small subset of these atypical patients undergo surgery based on other strong clinical findings. In this study, the authors attempt to quantify this clinical experience. METHODS Patients were prospectively enrolled and completed pain sketches at screening. One hundred six diagrams were analyzed/categorized by two independent, blinded reviewers as follows: (1) typical (pain over nerve distribution, expected radiation); (2) intermediate (pain over nerve distribution, atypical radiation); or (3) atypical (pain outside of normal nerve distribution, atypical radiation). Preoperative and postoperative Migraine Headache Index was compared between subgroups using unpaired t tests. RESULTS Migraine Headache Index improvement was 73 ± 38 percent in the typical group, 78 ± 30 percent in the intermediate group, and 30 ± 40 percent in the atypical group. There was a significant difference in Migraine Headache Index between the typical and atypical groups (p = 0.03) and between the intermediate and atypical groups (p < 0.01). The chance of achieving Migraine Headache Index improvement greater than 30 percent in the atypical group was 20 percent. CONCLUSIONS Patient pain sketches classified as atypical (facial pain, atypical pain point origin, diffuse pain) can predict poor outcomes in headache surgery. As the authors continue to develop patient selection criteria for headache surgery, patient sketches should be considered as an effective, cheap, and simple-to-interpret tool for selecting candidates for surgery.
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Affiliation(s)
- Lisa Gfrerer
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Marek A. Hansdorfer
- 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
| | - Kassandra P. Nealon
- 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
| | - Gem G. Runyan
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Samuel D. Zarfos
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - William Gerald Austen
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
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A Comprehensive Review of Surgical Treatment of Migraine Surgery Safety and Efficacy. Plast Reconstr Surg 2020; 146:187e-195e. [PMID: 32740592 DOI: 10.1097/prs.0000000000007020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent clinical experience with migraine surgery has demonstrated both the safety and the efficacy of operative decompression of the peripheral nerves in the face, head, and neck for the alleviation of migraine symptoms. Because of the perceived novelty of these procedures, and the paranoia surrounding a theoretical loss of clinical territory, neurologists have condemned the field of migraine surgery. The Patient Safety Subcommittee of the American Society of Plastic Surgeons ventured to investigate the published safety track record of migraine surgery in the existing body of literature. METHODS A comprehensive review of the relevant published literature was performed. The relevant databases and literature libraries were reviewed from the date of their inception through early 2018. These articles were reviewed and their findings analyzed. RESULTS Thirty-nine published articles were found that demonstrated a substantial, extensively replicated body of data that demonstrate a significant reduction in migraine headache symptoms and frequency (even complete elimination of headache pain) following trigger-site surgery. CONCLUSIONS Migraine surgery is a valid method of treatment for migraine sufferers when performed by experienced plastic surgeons following a methodical protocol. These operations are associated with a high level of safety. The safety and efficacy of migraine surgery should be recognized by plastic surgeons, insurance companies, and the neurology societies.
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Site V Surgery for Temporal Migraine Headaches. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2886. [PMID: 32766051 PMCID: PMC7339250 DOI: 10.1097/gox.0000000000002886] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/10/2020] [Indexed: 01/08/2023]
Abstract
Background: Auriculotemporal nerve is demonstrated to contribute to migraine pain in temporal area. In particular, its relationship with the superficial temporal artery in the soft tissues superficial to the temporal parietal fascia has attracted researchers’ attention for many decades. The objective of this review was to explore whether site V nerve surgical decompression is effective for pain relief in temporal area. Methods: A literature search, according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, was conducted to evaluate the surgical treatment of auriculotemporal migraine. Inclusion was based on studies written in English, published between 2000 and February 2020, containing a diagnosis of migraine in compliance with the classification of the International Headache Society. The treatment must consist of surgical procedures involving the auriculotemporal nerve and/or arteries in site V, with outcome data available for at least 3 months. Results: Three hundred twenty-four records were identified after duplicates were removed, 31 full-text articles were assessed for eligibility, and 2 records were selected for inclusion. A total of 77 patients were included in the review. A direct approach at the anatomical site identified with careful physical examination and confirmed with a handheld Doppler probe is generally performed under local anesthesia. Blunt dissection to the superficial temporal fascia to expose the auriculotemporal nerve and the superficial temporal artery is followed by artery cauterization/ligament and eventual nerve transection/avulsion. Site V surgery results in a success rate from 79% to 97%. Conclusions: Despite the recent advances in extracranial trigger site surgery and a success rate (>50% improvement) from 79% to 97%, site V decompression is still poorly described. Elaborate randomized trials are needed with accurate reporting of patient selection, surgical procedure, adverse events, recurrencies or appearance of new trigger points, quality of life outcome, and longer follow-up times.
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Chang B, Zhu W, Zhu J, Li S. Long-term efficacy of superficial temporal artery ligation and auriculotemporal nerve transection for temporal cluster headache in adolescent. Childs Nerv Syst 2019; 35:2385-2389. [PMID: 31289856 DOI: 10.1007/s00381-019-04277-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 06/25/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Cluster headache is a primary headache disorder, which has affected up to 0.1% population. Superficial temporal artery ligation combined with auriculotemporal nerve transection (SLAT) is one of the surgical alternatives to treat the drug-resistant temporal cluster headache (TCH). The current work aimed to assess the effect of SLAT on TCH patients based on the very long-term clinical follow-up. METHODS The current retrospective study had enrolled 20 adolescent TCH patients undergoing SLAT between December 2016 and January 2018. The headache diaries as well as the pain severity questionnaire of the visual analog scale (VAS) had been collected to measure the pain severity before and after surgery. RESULTS The pain-free rates 3 days, as well as 1, 6, and 12 months, after SLAT surgery were 2.00%, 10.00%, 25.00%, and 70.00%, respectively. The frequency of TCH attack daily was found to be markedly reduced on the whole; besides, the pain degree was also remarkably decreased. CONCLUSIONS Results in this study indicate that the sustained headache can be relieved after SLAT in adolescent patients with intractable TCH.
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Affiliation(s)
- Bowen Chang
- Department of Neurosurgery, XinHua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200092, China
| | - Wanchun Zhu
- Department of Neurosurgery, XinHua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200092, China
| | - Jin Zhu
- Department of Neurosurgery, XinHua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200092, China
| | - Shiting Li
- Department of Neurosurgery, XinHua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200092, China.
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Shauly O, Gould DJ, Patel KM. Cost-Utility Analysis of Surgical Decompression Relative to Injection Therapy for Chronic Migraine Headaches. Aesthet Surg J 2019; 39:NP462-NP470. [PMID: 30868158 DOI: 10.1093/asj/sjz069] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Common treatments for chronic migraine headaches include injection of corticosteroid and anesthetic agents at local trigger sites. However, the effects of therapy are short term, and lifelong treatment is often necessary. In contrast, surgical decompression of migraine trigger sites accomplishes the same goal yet demonstrates successful long-term elimination of chronic migraines. OBJECTIVES Our primary objective was to perform a cost-utility analysis to determine which patients would benefit most from available treatment options in a cost-conscious model. METHODS A cost-utility analysis was performed, taking into consideration costs, probabilities, and health state utility scores of various interventions. RESULTS Injection therapy offered a minor improvement in quality-adjusted life-years (QALYs) compared with surgical decompression (QALY Δ = 0.6). However, long-term injection therapy was significantly costlier to society than surgical decompression: injection treatment was estimated to cost $106,887.96 more than surgery. The results of our cost-utility analysis thus conferred a positive incremental cost-utility ratio of $178,163.27 in favor of surgical decompression. CONCLUSIONS Surgery provides a durable intervention and has been shown in this study to be extremely cost effective despite a very minor QALY deficit compared with injection therapy. If patients are identified who require treatment in the form of injections for less than 8.25 years, they may fall into a group that should not be offered surgery.
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Affiliation(s)
- Orr Shauly
- Department of Plastic and Reconstructive Surgery, Keck Hospital of USC, Los Angeles, CA
| | - Daniel J Gould
- Department of Plastic and Reconstructive Surgery, Keck Hospital of USC, Los Angeles, CA
| | - Ketan M Patel
- Department of Plastic and Reconstructive Surgery, Keck Hospital of USC, Los Angeles, CA
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Abstract
Supplemental Digital Content is available in the text. This article is a practical and technical guide for plastic surgeons interested in or practicing migraine surgery. It discusses the goals of migraine surgery including selection of appropriate candidates (screening form contained), pertinent anatomy, and surgical techniques with text summary, intraoperative photographs, and videos. In addition, pearls and pitfalls, the most common complications, and current procedural terminology (CPT) coding are detailed.
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Efficacy of Local Anesthesia in the Face and Scalp: A Prospective Trial. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2243. [PMID: 31333967 PMCID: PMC6571352 DOI: 10.1097/gox.0000000000002243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/08/2019] [Indexed: 11/26/2022]
Abstract
Background The use of local anesthesia has allowed for the excision and repair of lesions of the head and neck to be done in an office-based setting. There is a gap of knowledge on how surgeons can improve operative flow related to the onset of action. A prospective trial was undertaken to determine the length of time for full anesthesia effect in the head and neck regions. Methods Consecutive patients undergoing head and neck cutaneous cancer resection over a 3-month period were enrolled in the study. Local anesthesia injection and lesion excision were all done by a single surgeon. All patients received the standard of care of local anesthesia injection. Results Overall, 102 patients were included in the prospective trial. The upper face took significantly longer (153.54 seconds) compared with the lower face and ears (69.37 and 60.2 seconds, respectively) (P < 0.001) to become fully anesthetized. In addition, there was no significant difference found when adjusting for the amount of local anesthesia used, type, and size of lesion (P > 0.05). Using the time to full anesthesia effect for each local injection, a heat map was generated to show the relative times of the face and scalp to achieve full effect. Conclusions This prospective trial demonstrated that for the same local anesthetic and concentration, upper forehead and scalp lesions take significantly longer to anesthetize than other lesions in the lower face and ear. This can help surgeons tailor all aspects of their practice, which utilizes local anesthesia to help with patient satisfaction and operative flow.
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Konschake M, Burger F, Zwierzina M. Peripheral Nerve Anatomy Revisited: Modern Requirements for Neuroimaging and Microsurgery. Anat Rec (Hoboken) 2019; 302:1325-1332. [DOI: 10.1002/ar.24125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/21/2019] [Accepted: 01/29/2019] [Indexed: 01/11/2023]
Affiliation(s)
- Marko Konschake
- Division of Clinical and Functional Anatomy, Department for Anatomy, Histology and EmbryologyMedical University of Innsbruck (MUI) Innsbruck Austria
| | - Florian Burger
- Division of Clinical and Functional Anatomy, Department for Anatomy, Histology and EmbryologyMedical University of Innsbruck (MUI) Innsbruck Austria
| | - Marit Zwierzina
- Department of Plastic, Reconstructive and Aesthetic Surgery, Center of Operative MedicineMedical University of Innsbruck (MUI) Innsbruck Austria
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Therapeutic Role of Fat Injection in the Treatment of Recalcitrant Migraine Headaches. Plast Reconstr Surg 2019; 143:877-885. [DOI: 10.1097/prs.0000000000005353] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Discussion. Plast Reconstr Surg 2019; 143:564-565. [DOI: 10.1097/prs.0000000000005262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Efficacy of Surgical Treatment of Migraine Headaches Involving the Auriculotemporal Nerve (Site V). Plast Reconstr Surg 2019; 143:557-563. [DOI: 10.1097/prs.0000000000005261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gfrerer L, Raposio E, Ortiz R, Austen WG. Surgical Treatment of Migraine Headache: Back to the Future. Plast Reconstr Surg 2019; 142:1036-1045. [PMID: 30252818 DOI: 10.1097/prs.0000000000004795] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Understanding the history and evolution of ideas is key to developing an understanding of complex phenomena and is the foundation for surgical innovation. This historical review on migraine surgery takes us back to the beginnings of interventional management for migraine centuries ago, and reflects on present practices to highlight how far we have come. From Al-Zahrawi and Ambroise Paré to Bahman Guyuron, two common themes of the past and present have emerged in the treatment of migraine headache. Extracranial treatment of both nerves and vessels is being performed and analyzed, with no consensus among current practitioners as to which structure is involved. Knowledge of past theories and new insights will help guide our efforts in the future. One thing is clear: Where we are going, there are no roads. At least not yet.
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Affiliation(s)
- Lisa Gfrerer
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School; and the Plastic Surgery Unit, Department of Medicine and Surgery, University of Parma
| | - Edoardo Raposio
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School; and the Plastic Surgery Unit, Department of Medicine and Surgery, University of Parma
| | - Ricardo Ortiz
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School; and the Plastic Surgery Unit, Department of Medicine and Surgery, University of Parma
| | - William Gerald Austen
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School; and the Plastic Surgery Unit, Department of Medicine and Surgery, University of Parma
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Surgical Therapy of Temporal Triggered Migraine Headache. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1980. [PMID: 30656098 PMCID: PMC6326627 DOI: 10.1097/gox.0000000000001980] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 08/22/2018] [Indexed: 12/14/2022]
Abstract
Background The auriculotemporal and zygomaticotemporal nerves are the 2 primary trigger points in the temporal area of migraine headache. Different surgical approaches are described in literature, either open or endoscopic ones. Methods We described and delineated the currently adopted strategies to treat temporal trigger points in migraine headache. Furthermore, we reported our personal experience in the field. Results Regardless of the type of approach, outcomes observed were similar and ranged from 89% to 67% elimination / >50% reduction rates. All procedures are minimally invasive and only minor complications are reported, with an incidence ranging from 1% to 5%. Conclusions Just like upper limb compressive neuropathies, migraine headache is believed to be caused by chronic compression of peripheral nerves (ie, the terminal branches of trigeminal nerve) caused by surrounding structures (eg, muscles, vessels, and fascial bands) the removal of which eventually results in improvement or elimination of migraine attacks. Particular attention should be paid to the close nerve/artery relationship often described in anatomical studies and clinical reports.
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Lee HJ, Choi YJ, Lee KW, Kim HJ. Positional Patterns Among the Auriculotemporal Nerve, Superficial Temporal Artery, and Superficial Temporal Vein for use in Decompression Treatments for Migraine. Sci Rep 2018; 8:16539. [PMID: 30409986 PMCID: PMC6224382 DOI: 10.1038/s41598-018-34765-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/23/2018] [Indexed: 11/28/2022] Open
Abstract
This study aimed to clarify intersection patterns and points among the superficial temporal artery (STA), superficial temporal vein (STV), and auriculotemporal nerve (ATN) based on surface anatomical landmarks to provide useful anatomical information for surgical decompression treatments of migraine headaches in Asians. Thirty-eight hemifaces were dissected. The positional patterns among the ATN, STA, and STV were divided into three morphological types. In type I, the ATN ran toward the temporal region and superficially intersected the STA and STV (n = 32, 84.2%). In type II, the ATN ran toward the temporal region and deeply intersected the STA and STV (n = 4, 10.5%). In type III, the ATN ran toward the temporal region and deeply intersected the STV alone (n = 2, 5.3%). The intersection points of types II and III were 10.3 ± 5.6 mm (mean ± SD) and 10.4 ± 6.1 mm anterior and 42.1 ± 21.6 mm and 41.4 ± 18.7 mm superior to the tragus, respectively. The ATN superficially intersected the STA and STV in all the Korean cadaver, while the ATN deeply intersected the STA and STV in 15% of the Thai cadavers. The pattern of the ATN deeply intersecting the STA and STV was less common in present Asian populations than in previously-reported Caucasian populations, implying that migraine headaches (resulting from the STA and STV compressing the ATN) are less common in Asians.
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Affiliation(s)
- Hyung-Jin Lee
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 PLUS Project, Yonsei University College of Dentistry, Seoul, South Korea
| | - You-Jin Choi
- Department of Anatomy, Yonsei University College of Medicine, Seoul, South Korea
| | - Kang-Woo Lee
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 PLUS 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 PLUS Project, Yonsei University College of Dentistry, Seoul, South Korea. .,Department of Materials Science & Engineering, College of Engineering, Yonsei University, Seoul, South Korea.
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Ganglion Cyst of the Temporomandibular Joint Mimicking Auriculotemporal Neuralgia. J Craniofac Surg 2018; 29:e680-e682. [PMID: 30169451 DOI: 10.1097/scs.0000000000004864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Ganglion cysts within the temporomandibular joint (TMJ), although uncommon, typically present with swelling, pain, trismus, and difficulty with mastication. The authors report an unusual case of a ganglion cyst in the TMJ of a 52-year-old man who presented with chief complaints of severe headaches and dizziness that had not subsided following treatment with medication, trigger point injections, or sphenopalatine ganglion blocks. The cyst appeared as a nonenhancing, T2 hyperdensity adjacent to the left TMJ condyle on magnetic resonance imaging, supported by the presence of chronic erosion and remodeling of the anterior aspect of the left condylar head on computed tomography. The cyst was surgically removed, and the patient reported that the migraines and accompanying dizziness had ceased 6 months postoperatively. The patient's presentation and improvement following surgery suggest that the location of the cyst in the TMJ and its proximity to the course of the auriculotemporal nerve may have caused auriculotemporal neuralgia, mimicking the symptoms of migraine.
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Amirlak B, Chung MH, Pezeshk RA, Sanniec K. Accessory Nerves of the Forehead. Plast Reconstr Surg 2018; 141:1252-1259. [DOI: 10.1097/prs.0000000000004320] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ultrasound-Guided Intervention for Treatment of Trigeminal Neuralgia: An Updated Review of Anatomy and Techniques. Pain Res Manag 2018; 2018:5480728. [PMID: 29808105 PMCID: PMC5902000 DOI: 10.1155/2018/5480728] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/15/2018] [Indexed: 12/13/2022]
Abstract
Orofacial myofascial pain is prevalent and most often results from entrapment of branches of the trigeminal nerves. It is challenging to inject branches of the trigeminal nerve, a large portion of which are shielded by the facial bones. Bony landmarks of the cranium serve as important guides for palpation-guided injections and can be delineated using ultrasound. Ultrasound also provides real-time images of the adjacent muscles and accompanying arteries and can be used to guide the needle to the target region. Most importantly, ultrasound guidance significantly reduces the risk of collateral injury to vital neurovascular structures. In this review, we aimed to summarize the regional anatomy and ultrasound-guided injection techniques for the trigeminal nerve and its branches, including the supraorbital, infraorbital, mental, auriculotemporal, maxillary, and mandibular nerves.
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47
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Abstract
Reconstruction of partial ear defects represents one of the most challenging areas within reconstructive surgery of the head and neck. Each case of auricular reconstruction is unique and warrants a systematic approach that accounts for defect size and location, the quality of the surrounding skin, patient preference, and operator experience. In this article, the authors outline different reconstructive approaches for defects of the upper-, middle-, and lower-third of the auricle. The relevant anatomy is discussed in detail. Successful outcomes in auricular reconstruction rely on the surgeon's careful analysis of the defect as well as knowledge of the different reconstructive options available.
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Affiliation(s)
- Brent B Pickrell
- Division of Plastic Surgery, Harvard Medical School, Boston, Massachusetts
| | | | - Renata S Maricevich
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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In-Depth Review of Symptoms, Triggers, and Treatment of Occipital Migraine Headaches (Site IV). Plast Reconstr Surg 2017; 139:1333e-1342e. [DOI: 10.1097/prs.0000000000003395] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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49
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Janis JE, Barker JC, Palettas M. Targeted Peripheral Nerve-directed Onabotulinumtoxin A Injection for Effective Long-term Therapy for Migraine Headache. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1270. [PMID: 28458982 PMCID: PMC5404453 DOI: 10.1097/gox.0000000000001270] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 01/25/2017] [Indexed: 11/25/2022]
Abstract
Background: Onabotulinumtoxin A (BOTOX) is an FDA-approved treatment for chronic migraine headaches (MHs) that involves on-label, high-dose administration across 31 anatomic sites. Anatomically specific peripheral nerve trigger sites have been identified that contribute to MH pathogenesis and are amenable to both BOTOX injection and surgical decompression. These sites do not always correlate with the on-label FDA-approved injection pattern, but represent a more targeted approach. The efficacy of peripheral nerve–directed BOTOX injection as an independent long-term therapeutic option has not been investigated. Methods: The technique for peripheral nerve–directed therapeutic long-term BOTOX injection is described. A retrospective review was subsequently completed for 223 patients with MH. Sixty-six patients elected to proceed with diagnostic BOTOX injections. Of these, 24 continued long-term therapeutic BOTOX injections, whereas 42 matriculated to surgery. Outcomes were tracked. Results: Initial outcomes included significant improvement in migraine headache index (MHI) (53.5 ± 83.0, P < 0.006), headache days/mo (9.2 ± 12.7, P < 0.0009), and migraine severity (2.6 ± 2.5, P < 0.00008) versus baseline. MHI improved from the initiation of diagnostic injections to the establishment of steady-state injections (P < 0.002), and further improved over time (P < 0.05, mean follow-up 615 days) with no desensitization observed. Decompressive surgery resulted in significant improvement in MHI (100.8 ± 109.7, P < 0.0000005), headache days/mo (10.8 ± 12.7, P < 0.000002), migraine severity (3.0 ± 3.8, P < 0.00001), and migraine duration in hours (16.8 ± 21.6, P < 0.0007). MHI improvement with surgery was better than long-term BOTOX injections (P < 0.05). Conclusions: Though inferior to surgical decompression, preliminary data demonstrate that targeted peripheral nerve–directed BOTOX injection is an effective primary therapy for MH representing a possible alternative to nondirected BOTOX injection with decreased dosage requirements and potentially decreased cost.
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Affiliation(s)
- Jeffrey E Janis
- Department of Plastic Surgery, The Ohio State University Medical Center, and Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio
| | - Jenny C Barker
- Department of Plastic Surgery, The Ohio State University Medical Center, and Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio
| | - Marilly Palettas
- Department of Plastic Surgery, The Ohio State University Medical Center, and Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio
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Anatomical Regional Targeted (ART) BOTOX Injection Technique: A Novel Paradigm for Migraines and Chronic Headaches. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 4:e1194. [PMID: 28293532 PMCID: PMC5222677 DOI: 10.1097/gox.0000000000001194] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 11/08/2016] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Migraine headaches are a debilitating disease that causes significant socioeconomic problems. One of the speculated etiologies of the generation of migraines is peripheral nerve irritation at different trigger points. The use of Onabotulinum toxin A (BOTOX), although initially a novel approach, has now been determined to be a valid treatment for chronic headaches and migraines as described in the Phase III Research Evaluating Migraine Prophylaxis Therapy trials that prompted the approval by the Food and Drug Administration for treatment of chronic migraines. The injection paradigm established by this trial was one of a broad injection pattern across large muscle groups that did not always correspond to the anatomical locations of nerves. The senior author developed the Anatomical Regional Targeted BOTOX injection paradigm as an alternative to the current injection model. This technique targets both the anatomical location of nerves known to have causal effects with migraines and the region where the pain localizes, to provide relief across a wide distribution of the peripheral nerve. This article serves as a guide to the Anatomical Regional Targeted injection technique, which, to our knowledge, is the first comprehensive BOTOX injection paradigm described in the literature for treatment of migraines that targets nerves and nerve areas rather than purely muscle groups. This technique is based on the most up-to-date anatomical and scientific studies and large-volume migraine surgery experience.
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