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Raposio G, Raposio E. Temporal aneurysms and migraine surgery. JPRAS Open 2024; 41:9-13. [PMID: 38808225 PMCID: PMC11130996 DOI: 10.1016/j.jpra.2024.05.001] [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: 03/19/2024] [Accepted: 05/02/2024] [Indexed: 05/30/2024] Open
Abstract
The present study reports two cases of chronic migraines associated with superficial temporal artery aneurysms. The patients received aneurysm's ligation, with no other surgical maneuvers. In the six months following surgery, both patients were disease-free and did not experience any migraine attacks. Evidence-based medicine ranking: Level V.
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Affiliation(s)
- Giorgio Raposio
- Plastic Surgery Chair, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Italy
| | - Edoardo Raposio
- Plastic Surgery Chair, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Italy
- Plastic and Reconstructive Surgery Division, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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2
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Saad M, Manzanera Esteve IV, Evans AG, Karagoz H, Kesayan T, Brooks-Horrar K, Sengupta S, Robison R, Johnson B, Dortch R, Thayer WP, Assi P, Gfrerer L, Kassis S. Preoperative visualization of the greater occipital nerve with magnetic resonance imaging in candidates for occipital nerve decompression for headaches. Sci Rep 2024; 14:15248. [PMID: 38956162 PMCID: PMC11219832 DOI: 10.1038/s41598-024-65334-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/19/2024] [Indexed: 07/04/2024] Open
Abstract
Occipital nerve decompression is effective in reducing headache symptoms in select patients with migraine and occipital neuralgia. Eligibility for surgery relies on subjective symptoms and responses to nerve blocks and Onabotulinum toxin A (Botox) injections. No validated objective method exists for detecting occipital headache pathologies. The purpose of the study is to explore the potential of high-resolution Magnetic Resolution Imaging (MRI) in identifying greater occipital nerve (GON) pathologies in chronic headache patients. The MRI protocol included three sequences targeting fat-suppressed fluid-sensitive T2-weighted signals. Visualization of the GON involved generating 2-D image slices with sequential rotation to track the nerve course. Twelve patients underwent pre-surgical MRI assessment. MRI identified four main pathologies that were validated against intra-operative examination: GON entanglement by the occipital artery, increased nerve thickness and hyperintensity suggesting inflammation compared to the non-symptomatic contralateral side, early GON branching with rejoining at a distal point, and a connection between the GON and the lesser occipital nerve. MRI possesses the ability to visualize the GON and identify suspected trigger points associated with headache symptoms. This case series highlights MRI's potential to provide objective evidence of nerve pathology. Further research is warranted to establish MRI as a gold standard for diagnosing extracranial contributors in headaches.
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Affiliation(s)
- Mariam Saad
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | | | - Adam G Evans
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Huseyin Karagoz
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Tigran Kesayan
- Department of Anesthesiology, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Krista Brooks-Horrar
- Department of Neurology, Tennessee Valley Healthcare System, Nashville, TN, 37212, USA
| | - Saikat Sengupta
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Ryan Robison
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
- Philips Healthcare, Nashville, TN, 37219, USA
| | - Brian Johnson
- Philips Healthcare, Nashville, TN, 37219, USA
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | | | - Wesley P Thayer
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Patrick Assi
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Weill Cornell, New York, NY, 10065, USA
| | - Salam Kassis
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
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Hazewinkel MH, Knoedler L, Mathew PG, Remy K, Austen WG, Gfrerer L. Surgical Management of Headache Disorders - A Systematic Review of the Literature. Curr Neurol Neurosci Rep 2024; 24:191-202. [PMID: 38833038 DOI: 10.1007/s11910-024-01342-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE OF REVIEW This review article critically evaluates the latest advances in the surgical treatment of headache disorders. RECENT FINDINGS Studies have demonstrated the effectiveness of innovative screening tools, such as doppler ultrasound, pain drawings, magnetic resonance neurography, and nerve blocks to help identify candidates for surgery. Machine learning has emerged as a powerful tool to predict surgical outcomes. In addition, advances in surgical techniques, including minimally invasive incisions, fat injections, and novel strategies to treat injured nerves (neuromas) have demonstrated promising results. Lastly, improved patient-reported outcome measures are evolving to provide a framework for comparison of conservative and invasive treatment outcomes. Despite these developments, challenges persist, particularly related to appropriate patient selection, insurance coverage, delays in diagnosis and surgical treatment, and the absence of standardized measures to assess and compare treatment impact. Collaboration between medical/procedural and surgical specialties is required to overcome these obstacles.
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Affiliation(s)
- Merel Hj Hazewinkel
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, USA
| | - Leonard Knoedler
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Paul G Mathew
- Harvard Medical School, Boston, USA
- Department of Neurology, Mass General Brigham Health, Foxborough, USA
- Department of Neurology, Atrius Health, Quincy, USA
| | - Katya Remy
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - William G Austen
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, USA.
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Ormseth BH, ElHawary H, Huayllani MT, Weber KD, Blake P, Janis JE. Comparing Migraine Headache Index versus Monthly Migraine Days after Headache Surgery: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2024; 153:1201e-1211e. [PMID: 37285213 DOI: 10.1097/prs.0000000000010800] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Nerve deactivation surgery for the treatment of migraine has evolved rapidly over the past 2 decades. Studies typically report changes in migraine frequency (attacks/month), attack duration, attack intensity, and their composite score-the Migraine Headache Index-as primary outcomes. However, the neurology literature predominantly reports migraine prophylaxis outcomes as change in monthly migraine days (MMD). The goal of this study was to foster common communication between plastic surgeons and neurologists by assessing the effect of nerve deactivation surgery on MMD and motivating future studies to include MMD in their reported outcomes. METHODS An updated literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The National Library of Medicine (PubMed), Scopus, and Embase were systematically searched for relevant articles. Data were extracted and analyzed from studies that met the inclusion criteria. RESULTS A total of 19 studies were included. There was a significant overall reduction in MMDs [mean difference (MD), 14.11; 95% CI, 10.95 to 17.27; I 2 = 92%], total migraine attacks per month (MD, 8.65; 95% CI, 7.84 to 9.46; I 2 = 90%), Migraine Headache Index (MD, 76.59; 95% CI, 60.85 to 92.32; I 2 = 98%), migraine attack intensity (MD, 3.84; 95% CI, 3.35 to 4.33; I 2 = 98%), and migraine attack duration (MD, 11.80; 95% CI, 6.44 to 17.16; I 2 = 99%) at follow-up (range, 6 to 38 months). CONCLUSION This study demonstrates the efficacy of nerve deactivation surgery on the outcomes used in both the plastic and reconstructive surgery and neurology literature.
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Affiliation(s)
| | - Hassan ElHawary
- Division of Plastic and Reconstructive Surgery, McGill University Health Center
| | | | - Kevin D Weber
- Neurology, Ohio State University Wexner Medical Center
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Hazewinkel MHJ, Remy K, Black G, Tseng S, Mathew PG, Schoenbrunner A, Janis JE, Austen WG, Jotwani R, Gfrerer L. Treatment delay from onset of occipital neuralgia symptoms to treatment with nerve decompression surgery: a prospective cohort study. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:334-343. [PMID: 37995295 DOI: 10.1093/pm/pnad154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/16/2023] [Accepted: 11/10/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND The aims of this study were to (1) evaluate the time between onset of occipital neuralgia symptoms and nerve decompression surgery, (2) perform a cost comparison analysis between surgical and nonsurgical treatment of occipital neuralgia, and (3) report postoperative results of nerve decompression for occipital neuralgia. METHODS Subjects (n = 1112) who underwent screening for nerve decompression surgery were evaluated for occipital neuralgia. Of those, 367 patients (33%) met the inclusion criteria. Timing of occipital neuralgia symptom onset and pain characteristics were prospectively collected. Cost associated with the nonsurgical treatment of occipital neuralgia was calculated for the period between onset of symptoms and surgery. RESULTS A total of 226 patients (73%) underwent occipital nerve decompression. The average time between onset of occipital neuralgia and surgery was 19 years (7.1-32). Postoperatively, the median number of pain days per month decreased by 17 (0-26, 57%) (P < .001), the median pain intensity decreased by 4 (2-8, 44%) (P < .001), and median pain duration in hours was reduced by 12 (2-23, 50%) (P < .001). The annual mean cost of nonsurgical occipital neuralgia treatment was $28 728.82 ($16 419.42-$41 198.41) per patient. The mean cost during the 19-year time frame before surgery was $545 847.75($311 968.90-$782 769.82). CONCLUSION This study demonstrates that patients suffer from occipital neuralgia for an average of 19 years before undergoing surgery. Nerve decompression reduces symptom severity significantly and should be considered earlier in the treatment course of occipital neuralgia that is refractory to conservative treatment to prevent patient morbidity and decrease direct and indirect health care costs.
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Affiliation(s)
- Merel H J Hazewinkel
- Department of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY 10065, United States
| | - Katya Remy
- Department of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Grant Black
- Department of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY 10065, United States
| | - Sierra Tseng
- Department of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Paul G Mathew
- Harvard Medical School, Boston, MA 02115, United States
- Department of Neurology, Mass General Brigham Health, Foxborough, MA 02035, United States
- Department of Neurology, Harvard Vanguard Medical Associates, Braintree, MA 02184, United States
| | - Anna Schoenbrunner
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Jeffrey E Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - William G Austen
- Department of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Rohan Jotwani
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Lisa Gfrerer
- Department of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY 10065, United States
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ElHawary H, Kavanagh K, Janis JE. The Positive and Negative Predictive Value of Targeted Diagnostic Botox Injection in Nerve Decompression Migraine Surgery. Plast Reconstr Surg 2024; 153:1133-1140. [PMID: 37285182 DOI: 10.1097/prs.0000000000010806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Nerve decompression surgery is an effective treatment modality for patients who experience migraines. Botulinum toxin type A (Botox) injections have been traditionally used as a method to identify trigger sites; however, there is a paucity in data regarding its diagnostic efficacy. The goal of this study was to assess the diagnostic capacity of Botox in successfully identifying migraine trigger sites and predicting surgical success. METHODS A sensitivity analysis was performed on all patients receiving Botox for migraine trigger site localization followed by a surgical decompression of affected peripheral nerves. Positive and negative predictive values were calculated. RESULTS A total of 40 patients met our inclusion criteria and underwent targeted diagnostic Botox injection followed by a peripheral nerve deactivation surgery with at least 3 months' follow-up. Patients with successful Botox injections (defined as at least 50% improvement in Migraine Headache Index scores after injection) had significantly higher average reduction in migraine intensity (56.7% versus 25.8%; P = 0.020), frequency (78.1% versus 46.8%; P = 0.018), and Migraine Headache Index (89.7% versus 49.2%; P = 0.016) postsurgical deactivation. Sensitivity analysis shows that the use of Botox injection as a diagnostic modality for migraine headaches has a sensitivity of 56.7% and a specificity of 80.0%. The positive predictive value is 89.5% and the negative predictive value is 38.1%. CONCLUSIONS Diagnostic targeted Botox injections have a very high positive predictive value. It is therefore a useful diagnostic modality that can help identify migraine trigger sites and improve preoperative patient selection. CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, II.
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Affiliation(s)
- Hassan ElHawary
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre
| | - Kaitlin Kavanagh
- Department of Plastic and Reconstructive Surgery, Ohio State University, Wexner Medical Center
| | - Jeffrey E Janis
- Department of Plastic and Reconstructive Surgery, Ohio State University, Wexner Medical Center
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Stearns SA, Xun H, Haddad A, Rinkinen J, Bustos VP, Lee BT. Therapeutic Options for Migraines in the Microsurgical Patient: A Scoping Review. Plast Reconstr Surg 2024; 153:988e-1001e. [PMID: 37337332 DOI: 10.1097/prs.0000000000010861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND There exists an increasing array of treatments proposed to prevent, alleviate, and abort symptoms of a migraine; however, for patients who undergo reconstructive microsurgery, caution must be taken to preserve vascular integrity. This study is the first-to-date scoping review of vascular and bleeding risk of current migraine therapies, with the purpose of identifying potential therapeutic agents for postoperative migraine management appropriate for microsurgical patients. METHODS Currently available migraine therapeutics were compiled from the UpToDate software system and the American Academy of Family Physicians. A PubMed literature review was performed for each therapeutic's effect on bleeding or vascular involvement. Data were compiled into tables of abortive, symptom-controlling and prophylactic, and nonpharmacologic treatments. Expert microsurgeons reviewed the data to provide recommendations for optimized patient care. RESULTS Triptans and other ergot derivatives demonstrated strong evidence of vasoconstriction and were greatly advised against for immediate postmicrosurgical use. Novel pharmaceutical therapies such as lasmiditan and calcitonin gene-related peptide antagonists have no literature indicating potential for vasoconstriction or hematoma and remain an investigational option for abortive medical treatment. For symptom control, acetaminophen appears the safest option, with clinical judgment and further research needed for use of nonsteroidal antiinflammatory drugs. Alternative treatment techniques may include migraine prophylaxis with botulinum toxin injection or nutraceutical treatment by means of magnesium supplementation or coenzyme Q10 administration, minimizing the need for additional medication in the postoperative setting. CONCLUSIONS Patients undergoing reconstructive microsurgery have a unique medical profile limiting the therapeutic options available to treat migraines. This review provides preliminary evidence to be considered as a guide for prescribing therapeutics for migraine in the postoperative setting.
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Affiliation(s)
| | - Helen Xun
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Anthony Haddad
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Jacob Rinkinen
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Valeria P Bustos
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Bernard T Lee
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
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Raposio E, Raposio G, Baldelli I, Peled Z. Active Occipital Motion with Digipressure as Preoperative Screening in Migraine Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5784. [PMID: 38699286 PMCID: PMC11062714 DOI: 10.1097/gox.0000000000005784] [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: 02/06/2024] [Accepted: 03/18/2024] [Indexed: 05/05/2024]
Abstract
Background Modern surgical therapy of chronic headaches/migraines is essentially based on the release/neurolysis of extracranial nerves, which, when compressed or inflamed, act as trigger points and, as such, trigger headache attacks. The aim of this article was to describe a novel maneuver we use as an aid in the preoperative planning of occipital trigger sites. Methods In the period of January 2021-September 2023, we operated on 32 patients (11 men, 21 women, age range: 26-68 years), who underwent migraine surgery for occipital trigger point release. All patients were evaluated using the described preoperative maneuver. In a dedicated card, the levels of tenderness at each point were marked accordingly, differentiating them by intensity as nothing (-), mild (+), medium (++), or high (+++). Patients were then operated on at the points corresponding only to the ++ and +++ signs. Results At 6-month follow-up, we observed significant improvement (>50%) in 29 patients (91%), with complete recovery in 25 patients (78%). Conclusions In our experience, the maneuver described, in addition to being very simple, has been shown to have good sensitivity and reproducibility. We therefore recommend its use, especially for those surgeons beginning their practice in this particular area of plastic surgery.
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Affiliation(s)
- Edoardo Raposio
- From the Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genova, Italy
- Plastic and Reconstructive Surgery Division, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giorgio Raposio
- From the Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genova, Italy
| | - Ilaria Baldelli
- From the Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genova, Italy
- Plastic and Reconstructive Surgery Division, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Ziv Peled
- Peled Plastic Surgery, San Francisco, Calif
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Fila M, Przyslo L, Derwich M, Pawlowska E, Blasiak J. Potential of focal cortical dysplasia in migraine pathogenesis. Cereb Cortex 2024; 34:bhae158. [PMID: 38615241 DOI: 10.1093/cercor/bhae158] [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] [Received: 02/14/2024] [Revised: 03/21/2024] [Accepted: 03/23/2024] [Indexed: 04/15/2024] Open
Abstract
Focal cortical dysplasias are abnormalities of the cerebral cortex associated with an elevated risk of neurological disturbances. Cortical spreading depolarization/depression is a correlate of migraine aura/headache and a trigger of migraine pain mechanisms. However, cortical spreading depolarization/depression is associated with cortical structural changes, which can be classified as transient focal cortical dysplasias. Migraine is reported to be associated with changes in various brain structures, including malformations and lesions in the cortex. Such malformations may be related to focal cortical dysplasias, which may play a role in migraine pathogenesis. Results obtained so far suggest that focal cortical dysplasias may belong to the causes and consequences of migraine. Certain focal cortical dysplasias may lower the threshold of cortical excitability and facilitate the action of migraine triggers. Migraine prevalence in epileptic patients is higher than in the general population, and focal cortical dysplasias are an established element of epilepsy pathogenesis. In this narrative/hypothesis review, we present mainly information on cortical structural changes in migraine, but studies on structural alterations in deep white matter and other brain regions are also presented. We develop the hypothesis that focal cortical dysplasias may be causally associated with migraine and link pathogeneses of migraine and epilepsy.
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Affiliation(s)
- Michal Fila
- Department of Developmental Neurology and Epileptology, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Łódzkie, Poland
| | - Lukasz Przyslo
- Department of Developmental Neurology and Epileptology, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Łódzkie, Poland
| | - Marcin Derwich
- Department of Developmental Dentistry, Medical University of Lodz, Pomorska 251, 90-647 Lodz, Łódzkie, Poland
| | - Ezbieta Pawlowska
- Department of Developmental Dentistry, Medical University of Lodz, Pomorska 251, 90-647 Lodz, Łódzkie, Poland
| | - Janusz Blasiak
- Faculty of Medicine, Collegium Medicum, Mazovian Academy in Plock, Plac Generała Dabrowskiego 2, 09-420 Plock, Mazowieckie, Poland
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Kaleeny J, Janis J. Correspondence: Morphological features of the greater occipital nerve and its possible importance for interventional procedures. J Anat 2024; 244:676-677. [PMID: 38073361 PMCID: PMC10941553 DOI: 10.1111/joa.13990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/22/2023] [Indexed: 03/16/2024] Open
Abstract
This response applauds Saglam et al.'s (2023) recent study on the greater occipital nerve's anatomy while urging readers to consider earlier pivotal studies overlooked. It emphasizes how prior research has significantly shaped headache treatments and provides valuable insights for future practices and discussions.
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Ormseth BH, Kavanagh KJ, Saffari TM, Palettas M, Janis JE. Assessing the Relationship between Obesity and Trigger Point-specific Outcomes after Headache Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5629. [PMID: 38486715 PMCID: PMC10939604 DOI: 10.1097/gox.0000000000005629] [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: 12/19/2023] [Accepted: 01/08/2024] [Indexed: 03/17/2024]
Abstract
Background Trigger point deactivation surgery is a safe and effective treatment for properly selected patients experiencing migraine, with 68.3%-100% experiencing symptom improvement postoperatively. However, it is still unknown why certain patients do not respond. Obesity has been shown to be associated with worsened migraine symptoms and a decreased response to select pharmacotherapies. This study aimed to determine whether obesity may also be associated with an attenuated response to surgery. Methods A retrospective chart review was conducted to identify patients who had undergone trigger point deactivation surgery for migraine. Patients were split into obese and nonobese cohorts. Obesity was classified as a body mass index of 30 or higher per Centers for Disease Control and Prevention guidelines. Outcomes and follow-up periods were determined with respect to individual operations. Outcomes included migraine attack frequency, intensity, duration, and the migraine headache index. Differences in demographics, operative characteristics, and operative outcomes were compared. Results A total of 62 patients were included in the study. The obese cohort comprised 31 patients who underwent 45 total operations, and the nonobese cohort comprised 31 patients who underwent 34 operations. Results from multivariable analysis showed no impact of obesity on the odds of achieving a more than 90% reduction in any individual outcome. The overall rates of improvement (≥50% reduction in any outcome) and elimination (100% reduction in all symptoms) across both cohorts were 89.9% and 65.8%, respectively. Conclusion Obese patients have outcomes comparable to a nonobese cohort after trigger point deactivation surgery for migraine.
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Affiliation(s)
- Benjamin H. Ormseth
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kaitlin J. Kavanagh
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Tiam M. Saffari
- Department of Surgery, Rutgers New Jersey Medical School, Newark, N.J
| | - Marilly Palettas
- Department of Biomedical Informatics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jeffrey E. Janis
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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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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Ormseth BH, ElHawary H, Janis JE. The Fragility of Landmark Randomized Controlled Trials in the Plastic Surgery Literature. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5352. [PMID: 38235350 PMCID: PMC10793969 DOI: 10.1097/gox.0000000000005352] [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: 05/19/2023] [Accepted: 08/24/2023] [Indexed: 01/19/2024]
Abstract
Background Randomized controlled trials (RCTs) are integral to the progress of evidenced-based medicine and help guide changes in the standards of care. Although results are traditionally evaluated according to their corresponding P value, the universal utility of this statistical metric has been called into question. The fragility index (FI) has been developed as an adjunct method to provide additional statistical perspective. In this study, we aimed to determine the fragility of 25 highly cited RCTs in the plastic surgery literature. Methods A PubMed search was used to identify the 25 highest cited RCTs with statistically significant dichotomous outcomes across 24 plastic surgery journals. Article characteristics were extracted, and the FI of each article was calculated. Additionally, Altmetric scores were determined for each study to determine article attention across internet platforms. Results The median FI score across included studies was 4 (2-7.5, interquartile range). The two highest FI scores were 208 and 58, respectively. Four studies (16%) had scores of 0 or 1. Three studies (12%) had scores of 2. All other studies (72%) had FI scores of 3 or higher. The median Altmetric score was 0 (0-3). Conclusion The FI can provide additional perspective on the robustness of study results, but like the P value, it should be interpreted in the greater context of other study elements.
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Affiliation(s)
- Benjamin H. Ormseth
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Hassan ElHawary
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, Canada
| | - Jeffrey E. Janis
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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14
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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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15
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Chang IA, Wells MW, Wang GM, Tatsuoka C, Guyuron B. Nonpharmacologic Treatments for Chronic and Episodic Migraine: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2023; 152:1087-1098. [PMID: 36940145 DOI: 10.1097/prs.0000000000010429] [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: 03/21/2023]
Abstract
BACKGROUND Minimally invasive techniques for treatment-resistant migraine have been developed on recent insights into the peripheral pathogenesis of migraines. Although there is a growing body of evidence supporting these techniques, no study has yet compared the effects of these treatments on headache frequency, severity, duration, and cost. METHODS PubMed, Embase, and Cochrane Library databases were searched to identify randomized placebo-controlled trials that compared radiofrequency ablation, botulinum toxin type A (BT-A), nerve block, neurostimulation, or migraine surgery to placebo for preventive treatment. Data on changes from baseline to follow-up in headache frequency, severity, duration, and quality of life were analyzed. RESULTS A total of 30 randomized controlled trials and 2680 patients were included. Compared with placebo, there was a significant decrease in headache frequency in patients with nerve block ( P = 0.04) and surgery ( P < 0.001). Headache severity decreased in all treatments. Duration of headaches was significantly reduced in the BT-A ( P < 0.001) and surgery cohorts ( P = 0.01). Quality of life improved significantly in patients with BT-A, nerve stimulator, and migraine surgery. Migraine surgery had the longest lasting effects (11.5 months) compared with nerve ablation (6 months), BT-A (3.2 months), and nerve block (11.9 days). CONCLUSIONS Migraine surgery is a cost-effective, long-term treatment to reduce headache frequency, severity, and duration without significant risk of complication. BT-A reduces headache severity and duration, but it is short-lasting and associated with greater adverse events and lifetime cost. Although efficacious, radiofrequency ablation and implanted nerve stimulators have high risks of adverse events and explantation, whereas benefits of nerve blocks are short in duration.
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Affiliation(s)
| | | | - Gi-Ming Wang
- Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine
| | - Curtis Tatsuoka
- Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine
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16
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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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17
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Talwar AA, Niu EF, Broach RB, Nelson JA, Fischer JP. Patient-reported outcomes: A primer for plastic surgeons. J Plast Reconstr Aesthet Surg 2023; 86:35-47. [PMID: 37688832 DOI: 10.1016/j.bjps.2023.08.008] [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] [Received: 03/27/2023] [Revised: 07/23/2023] [Accepted: 08/13/2023] [Indexed: 09/11/2023]
Abstract
Surgical care today is no longer evaluated only on clinical outcomes but also on holistic patient wellbeing. Patient-reported outcomes (PROs) are a representation of the patient's perspective on their results and wellbeing. The aim of this review is to establish PROs as the center of healthcare and plastic surgery, to delineate important PROs in plastic surgery practice and research, to discuss the future of PROs within our discipline, and to encourage surgeons to incorporate PROs into their practice. PROs are an important parallel of clinical outcomes in that they can use the patient's perspective to 1) support clinical findings, 2) detect differences in care when there are no clear clinical differences, 3) track progress longitudinally, and 4) support systemic improvements in healthcare. Plastic surgery as a field is naturally aligned with PROs because, as a discipline, we focus on patient form and function. The emerging forefronts of plastic surgery such as lymphedema care, gender-affirming care, peripheral nerve surgery, migraine surgery, and breast implant illness are critically dependent on PROs. In the next decade, we predict that there will be a continued proliferation of robust PRO measures and integration into healthcare delivery. Outcomes research in surgery should continue to evolve as surgeons provide increasingly more benefits to improve patient wellbeing. Plastic surgeons must continue to play a prominent role in the future of PROs.
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Affiliation(s)
- Ankoor A Talwar
- Division of Plastic Surgery, University of Pennsylvania, United states
| | - Ellen F Niu
- Division of Plastic Surgery, University of Pennsylvania, United states
| | - Robyn B Broach
- Division of Plastic Surgery, University of Pennsylvania, United states
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, United States
| | - John P Fischer
- Division of Plastic Surgery, University of Pennsylvania, United states.
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18
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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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19
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Hwang CD, Chegireddy V, Remy K, Irwin TJ, Valerio IL, Gfrerer L, Austen WG. The Use of Nerve Caps after Nerve Transection in Headache Surgery: Cadaver and Case Reports. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5234. [PMID: 37662472 PMCID: PMC10473362 DOI: 10.1097/gox.0000000000005234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/11/2023] [Indexed: 09/05/2023]
Abstract
Background Nerve transection with nerve reconstruction is part of the treatment algorithm for patients with refractory pain after greater occipital nerve (GON) and lesser occipital nerve (LON) decompression or during primary decompression when severe nerve injury or neuroma formation is present. Importantly, the residual nerve stump is often best addressed via contemporary nerve reconstruction techniques to avoid recurrent pain. As a primary aim of this study, nerve capping is explored as a potential viable alternative that can be utilized in certain headache cases to mitigate pain. Methods The technical feasibility of nerve capping after GON/LON transection was evaluated in cadaver dissections and intraoperatively. Patient-reported outcomes in the 3- to 4-month period were compiled from clinic visits. At 1-year follow-up, subjective outcomes and Migraine Headache Index scores were tabulated. Results Two patients underwent nerve capping as a treatment for headaches refractory to medical therapy and surgical decompressions with significant improvement to total resolution of pain without postoperative complications. These improvements on pain frequency, intensity, and duration remained stable at a 1-year time point (Migraine Headache Index score reductions of -180 to -205). Conclusions Surgeons should be equipped to address the proximal nerve stump to prevent neuroma and neuropathic pain recurrence. Next to known contemporary nerve reconstruction techniques such as targeted muscle reinnervation/regenerative peripheral nerve interface and relocation nerve grafting, nerve capping is another viable method for surgeons to address the proximal nerve stump in settings of GON and LON pain. This option exhibits short operative time, requires only limited dissection, and yields significant clinical improvement in pain symptoms.
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Affiliation(s)
- Charles D. Hwang
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
| | - Vishwanath Chegireddy
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
| | - Katya Remy
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
| | - Timothy J. Irwin
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
| | - Ian L. Valerio
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
| | - Lisa Gfrerer
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medical College, New York, N.Y
| | - William G. Austen
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
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20
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Zhu K, Ha M, Finkelstein ER, Chaudry S, Hricz N, Ngaage LM, Rasko Y. The Surgical Management of Migraines and Chronic Headaches: A Cross-sectional Review of American Insurance Coverage. Ann Plast Surg 2023; 90:592-597. [PMID: 37311314 DOI: 10.1097/sap.0000000000003563] [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: 06/15/2023]
Abstract
BACKGROUND Migraine headache can be an extremely debilitating condition, with pharmacotherapy for prophylaxis or treatment of acute symptoms being unsuccessful in a large proportion of patients. Surgical management of migraine has recently gained popularity as an alternative to pharmacotherapy for severe disease. However, the novel nature of these procedures may lead to variable insurance coverage, limiting access to care. METHODS A cross-sectional analysis of 101 US insurance companies was conducted. Companies were chosen based on greatest market share and enrollment per state. A Web-based search or phone call identified whether each company had a publicly available policy on nonsurgical or surgical management of migraine or headache. For companies with an available policy, coverage was categorized into covered, covered on a case-by-case basis, or never covered, with criteria required for coverage collected and categorized. RESULTS Of the 101 evaluated insurers, significantly fewer companies had a policy on surgical treatment for migraine or headache (n = 52 [52%]) compared with nonsurgical treatment (n = 78 [78%]) (P < 0.001). For companies with a policy, the most frequently covered nonsurgical treatments were biofeedback (n = 23 [92%]) and botulism toxin injections (n = 61 [88%]). Headaches were an approved indication for occipital nerve stimulation in 4% (n = 2) of company policies and nerve decompression in 2% (n = 1) of policies. Migraines were never offered preauthorized coverage for surgical procedures. CONCLUSION Approximately half of US insurance companies have a publicly available policy on surgical management of migraine or headache. Surgical treatment was seldom covered for the indication of headache and would never receive preauthorized coverage for migraine. Lack of coverage may create challenges in accessing surgical treatment. Additional prospective, controlled studies are necessary to further support the efficacy of surgical treatment.
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Affiliation(s)
- Kevin Zhu
- From the Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Michael Ha
- From the Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Emily R Finkelstein
- Division of Plastic and Reconstructive Surgery, University of Miami, Miami, FL
| | - Salman Chaudry
- Department of General Surgery, Anne Arundel Medical Center, Annapolis
| | - Nicholas Hricz
- From the Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | - Yvonne Rasko
- From the Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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21
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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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22
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Robert C, Wilson CS. Thirty-year survey of bibliometrics used in the research literature of pain: Analysis, evolution, and pitfalls. FRONTIERS IN PAIN RESEARCH 2023; 4:1071453. [PMID: 36937565 PMCID: PMC10017016 DOI: 10.3389/fpain.2023.1071453] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 02/08/2023] [Indexed: 03/05/2023] Open
Abstract
During the last decades, the emergence of Bibliometrics and the progress in Pain research have led to a proliferation of bibliometric studies on the medical and scientific literature of pain (B/P). This study charts the evolution of the B/P literature published during the last 30 years. Using various searching techniques, 189 B/P studies published from 1993 to August 2022 were collected for analysis-half were published since 2018. Most of the selected B/P publications use classic bibliometric analysis of Pain in toto, while some focus on specific types of Pain with Headache/Migraine, Low Back Pain, Chronic Pain, and Cancer Pain dominating. Each study is characterized by the origin (geographical, economical, institutional, …) and the medical/scientific context over a specified time span to provide a detailed landscape of the Pain research literature. Some B/P studies have been developed to pinpoint difficulties in appropriately identifying the Pain literature or to highlight some general publishing pitfalls. Having observed that most of the recent B/P studies have integrated newly emergent software visualization tools (SVTs), we found an increase of anomalies and suggest that readers exercise caution when interpreting results in the B/P literature details.
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Affiliation(s)
| | - Concepción Shimizu Wilson
- School of Information Systems, Technology and Management, University of New South Wales, UNSW Sydney, Sydney, NSW, Australia
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23
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Blake P, ElHawary H, Janis JE. Increasing Collaboration between Headache Medicine and Plastic Surgery in the Surgical Management of Chronic Headache. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4479. [PMID: 36032365 PMCID: PMC9400943 DOI: 10.1097/gox.0000000000004479] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/27/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Chronic headache is one of the most disabling conditions afflicting humankind. The management of chronic headaches has, to date, been only partially successful. The goal of this paper is to highlight the importance of collaboration between surgeons and headache physicians in treating this condition. METHODS We present a narrative review of migraine pathophysiology, its medical and surgical treatment options, and the important role of collaboration between headache physicians and surgeons. RESULTS Migraine headaches can be treated with both medication-based regimens and surgery. Novel medications such monoclonal antibodies directed at the CGRP molecule or its receptor have recently been FDA approved as an effective treatment modality in chronic migraines. However, these medications are associated with a high cost, and there is a paucity in data regarding effectiveness compared to other treatment modalities. The pathophysiology of headache likely exists along a spectrum with peripheral - extracranial and meningeal - factors at one end and central - brain - factors at the other, with anatomic and physiologic connections between both ends. Recent evidence has clearly shown that surgical decompression of extracranial nerves improves headache outcomes. However, appropriate patient selection and preoperative diagnosis are of paramount importance to achieve excellent outcomes. CONCLUSIONS Surgeons and headache physicians who are interested in providing treatment for patients with chronic headache should strive to form a close collaboration with each other in order to provide the optimal plan for migraine/headache patients.
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Affiliation(s)
- Pamela Blake
- From the Headache Center of River Oaks, Houston, Tex
- University of Texas Health Science Center, Houston, Tex
| | - Hassan ElHawary
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jeffrey E. Janis
- Department of Plastic and Reconstructive Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
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24
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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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25
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Olla DR, Kemper KM, Brown AL, Mailey BA. Single midline incision approach for decompression of greater, lesser and third occipital nerves in migraine surgery. BMC Surg 2022; 22:232. [PMID: 35715794 PMCID: PMC9204865 DOI: 10.1186/s12893-022-01675-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/31/2022] [Indexed: 11/10/2022] Open
Abstract
Background The traditional approach for occipital migraine surgery encompasses three separate surgical incisions in the posterior neck to decompress the greater occipital nerves (GON), lesser occipital nerves (LON), and third occipital nerves (TON). Other incisions have been investigated, including singular transverse incisions. We sought to evaluate a single, vertical midline incision approach for decompression of all six occipital nerves. Methods Using 10 cadaveric hemi-sides (5 fresh cadaver head and necks). Anatomic landmarks and the location of the bilateral GON, LON, and TON were marked according to previous anatomic studies. A single, midline 9-cm incision was made, and lateral skin flaps were raised to decompress or avulse all six nerves. Results Through the midline incision, the GON and TON were identified at 3.5 and 6.2 cm, respectively, inferior to a line bisecting the external auditory canal (EAC) and 1.5 cm lateral to the midline. The LON was identified as 6-cm inferior and 6.5-cm medial to a line bisecting the EAC in the plane just above the investing layer of the deep cervical fascia until the posterior border of the sternocleidomastoid was encountered. The LON had the greatest amount of variation but was identified lateral to the posterior border of the SCM. Conclusions A single midline incision approach allows for successful identification and decompression of all six occipital nerves in migraine surgery.
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Affiliation(s)
- Danielle R Olla
- Institute for Plastic and Reconstructive Surgery, Department of Surgery, Southern Illinois University, 747 N. Rutledge St, Springfield, IL, 62702, USA
| | - Kortni M Kemper
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Amanda L Brown
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Brian A Mailey
- Institute for Plastic and Reconstructive Surgery, Department of Surgery, Southern Illinois University, 747 N. Rutledge St, Springfield, IL, 62702, USA.
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Knoedler L, Chartier C, ElHawary H, Kehrer A, Muehlberger T. Letter to the Editor: The Case for Publicly Funded Headache Surgery in Germany. JPRAS Open 2021; 30:157-159. [PMID: 34703872 PMCID: PMC8526409 DOI: 10.1016/j.jpra.2021.09.001] [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: 09/01/2021] [Accepted: 09/06/2021] [Indexed: 11/26/2022] Open
Abstract
Headache surgery has become a considerable therapeutic option in headache treatment and is of rising interest in the German medical sector. This viewpoint outlines the need for reimbursement of headache surgery in the German healthcare system and demonstrates its cost-effectiveness. Using state-of-the-art patient selection algorithms, the authors found headache surgery to be cost-effective within 7.2 to 6.3 years. Of note, the approach presented is not limited to the German healthcare system.
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Affiliation(s)
- Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | | | - Hassan ElHawary
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, Canada
| | - Andreas Kehrer
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Muehlberger
- Department of Plastic Surgery and Hand Surgery, DRK-Kliniken Berlin Westend, Humboldt University Berlin, Berlin, Germany
- Migraine Surgery Centre, Harley Street, London, W1G 9PF, United Kingdom
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