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    Dr Robert Hagan's Thoughts

    For news and information on Diabetic Neuropathy, Chronic Pain and Surgical Procedures to fix them!

    Dr. Robert R. Hagan received his MD from Saint Louis University School of Medicine. He received his general surgery training at The Lahey Clinic in Boston, Massachusetts and his plastic surgery training at The Lahey Clinic and Harvard Medical School hospitals. He continued his education as a fellow at Harvard Medical School in Boston, Massachusetts specializing in hand and microsurgery. Upon returning to the Midwest he completed a craniofacial fellowship at Washington University in St. Louis, MO.


    Currently, Dr. Hagan maintains a private practice at Neuropax Clinic in St. Louis, MO. He has special interests in peripheral nerve surgery and hand/extremity surgery. His diverse training in plastics, hand, peripheral nerve, craniofacial, reconstructive and microsurgery has served him well to understand the many challenges of today's pain and peripheral nerve disorders.


    Peripheral nerve itself includes diabetic neuropathy, compression neuropathies (carpal tunnel, cubital tunnel, tarsal tunnel, etc.), nerve trauma, chronic joint pain, chronic groin pain, chronic migraines, and RSD/causalgia.
     
    Dr. Hagan is committed to the research and further development of peripheral nerve surgery. Neuropax Clinic provides a multi-center platform for clinical research and advancement of surgical techniques. Dr. Hagan has many ongoing studies focused on improving the diagnosis of and treatment of peripheral nerve and pain disorders.


    Dr. Hagan and Neuropax Clinic together provide fellowship training in peripheral nerve surgery to teach other surgeons their advanced diagnostic and surgical techniques. He is also a clinical instructor for the Saint Louis University, Department of Surgery, Division of Plastic Surgery.
     
    Dr. Robert Hagan's professional hospital appointments include Missouri Baptist Hospital, St. Luke's Hospital, St. John's Mercy Medical Center; all located in St. Louis, Missouri.

    Diabetic Neuropathy On the Rise in St. Louis

    diabetes 2058045 1280

    With Type 1 and Type 2 Diabetes rates climbing, the sufferers of diabetic neuropathy increase as well.  These patients suffer from debilitating pain that radiates from the hands, feet, legs and arms.  It has been referred to for years as an irreversible disease, and treated as such by physicians.  They look to prevent the disease's progression, and minimize pain with medication, or specialized footwear.

    However, new breakthroughs in the field of nerve decompression have opened up pathways to new treatments for the pain of diabetic neuropathy.  Nerve decompression works to ease the pain that inflamed tissue puts on the nerves in the extremities and has shown to be VERY effective in the fight against diabetic neuropathy.  Clinical trials and studies back nerve decompression as a breakthrough treatment.

    The goals are simple for this surgery:  restore sensation and eliminate the pain.  When the sensation is restored, it severely reduces the risk for ulceration and infection that leads to amputation.  Many patients find that their need for the medications is lessened after the surgery is complete.

    If you suffer from diabetic neuropathy, physicians from Neuropax Clinic can determine whether surgery might be appropriate for you. A comprehensive evaluation will be performed to determine whether you have compressed nerves that may respond to surgery. We have already helped many patients regain sensation and get relief from pain with this surgical approach.

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    Do You Have Carpal Tunnel Syndrome in St. Louis?

    Carpal Tunnel Syndrome is caused by repeated and frequent pressure on the median nerve. This is the nerve that gives feeling and movement to the different part of the hand, and it’s located in the wrist. Carpal Tunnel is common in people that work primarily with their hands, fingers and wrists with repetitive actions. Carpal Tunnel Syndrome warning signs are there to be found.

    treatment 1327811 1280

    If we watch for these early signs, we can keep on top of it. A really early sign is tingling or numbness in the palm, thumb, middle, ring and index fingers. If you start to notice these, you may have inflammation in the tissues of the wrist pressing on the median nerve. This causes the increased pain and numbness in the palm and fingers.

    Also watch for fine finger coordination issues. If you find yourself dropping or carrying things awkwardly, you may have carpal tunnel syndrome. You can also watch for weakened hand grip.

    Severe cases will give you a stiffening, locking or tightening of the hand, wrist, forearm and elbow. This can be so bad that it’s difficult to sleep or concentrate.

    Keep track of loss of strength or even muscle atrophy in the palm and fingers, noticeably in the thumb. If you suddenly can’t open a pickle jar, you could be experiencing the extreme signs of Carpal Tunnel Syndrome.

    If you feel that you may be suffering from Carpal Tunnel Syndrome, please call the office at Neuropax Clinic at 314-434-7784 to make an appointment. Don’t live in pain another day if you don’t have to. Visit www.neuropaxclinic.com for more information.

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    Nerve Decompression Surgery for Migraines in St. Louis

    woman 2775271 1280

    Migraines are a scourge. They can ruin your entire life if untreated. A migraine can leave you lying in a dark room or home early from work. Nerve compression surgery for migraines can help.

    There are 180 different defined types of headaches. Headaches are common in the US, with a variety of different causes. Chronic, daily or even continual headaches can be from migraines. There are over 30 million people believed to be suffering from migraines today. While some can be treated with medication and therapy, some require surgery.

    13% or more of migraines are thought to be related to occipital neuralgia. When the Greater occipital nerve is impinged, with tissue causing pressure on the nerve, the symptoms begin. If they remain untreated, it leads to migraine headaches.

    Although the Greater occipital nerve is the most common nerve involved, other nerves can be involved as well. The lesser occipital nerve and dorsal (or least) occipital nerve which are located in the back of the head/scalp. Headaches may originate from the forehead or frontal region as well. The nerves involved in this area include the supra-orbital and zygomatico-temporal nerves.

    When no other underlying diseases or conditions are found, you may be a candidate for a nerve decompression surgery that can reduce or end your migraine headaches.  This is an outpatient surgery with short recovery times. Results are often immediately evident but may take several weeks. Neuropax surgeons can assess if nerve decompression surgery would help to alleviate or significantly reduce your debilitating symptoms.

    If you feel that you may be suffering from migraines, please call the office at Neuropax Clinic at 314-434-7784 to make an appointment. Don’t live in pain another day if you don’t have to. Visit www.neuropaxclinic.com for more information.

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    Carpal Tunnel Syndrome Warning Signs

     treatment 1327811 1280

    Carpal Tunnel Syndrome is caused by repeated and frequent pressure on the median nerve. This is the nerve that gives feeling and movement to the different part of the hand, and it’s located in the wrist. Carpal Tunnel is common in people that work primarily with their hands, fingers and wrists with repetitive actions. Carpal Tunnel Syndrome warning signs are there to be found.

    If we watch for these early signs, we can keep on top of it. A really early sign is tingling or numbness in the palm, thumb, middle, ring and index fingers. If you start to notice these, you may have inflammation in the tissues of the wrist pressing on the median nerve. This causes the increased pain and numbness in the palm and fingers.

    Also watch for fine finger coordination issues. If you find yourself dropping or carrying things awkwardly, you may have carpal tunnel syndrome. You can also watch for weakened hand grip.

    Severe cases will give you a stiffening, locking or tightening of the hand, wrist, forearm and elbow. This can be so bad that it’s difficult to sleep or concentrate.

    Keep track of loss of strength or even muscle atrophy in the palm and fingers, noticeably in the thumb. If you suddenly can’t open a pickle jar, you could be experiencing the extreme signs of Carpal Tunnel Syndrome.

    If you feel that you may be suffering from Carpal Tunnel Syndrome, please call the office at Neuropax Clinic at 314-434-7784 to make an appointment. Don’t live in pain another day if you don’t have to. Visit www.neuropaxclinic.com for more information.

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    Signs You Have Thoracic Outlet Syndrome

    pexels photo 275768

    Thoracic outlet syndrome refers to a group of conditions that develop when the blood vessels or nerves in the thoracic outlet become compressed. The thoracic outlet is the narrow space between your collarbone and first rib. Blood vessels, nerves, and muscles that extend from the back to the arms pass through this area. If the space in the thoracic outlet is too narrow, these structures can become compressed. The increased pressure on the blood vessels and nerves may cause pain in your shoulders, neck, and arms. It can also cause numbness or tingling in your hands.

    pain in parts of the neck, shoulder, arm, or hand

    numbness in the forearm and fingers

    weakness of the hand

    Compressed blood vessels can cause:

    swelling of the arm

    redness of the arm

    hands or arms that feel cold to the touch

    hands or arms that become easily fatigued

    You may also find it difficult to lift objects above your head. You might also have a limited range of motion in your shoulders and arms.

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    Peripheral Neuropathy Needs To Be Treated

    diabetes 2058045 1280

    Peripheral neuropathy is the most common form of diabetic neuropathy. Your feet and legs are often affected first, followed by your hands and arms. Signs and symptoms of peripheral neuropathy are often worse at night, and may include:

    • Numbness or reduced ability to feel pain or temperature changes
    • A tingling or burning sensation
    • Sharp pains or cramps
    • Increased sensitivity to touch — for some people, even the weight of a bed sheet can be agonizing
    • Muscle weakness
    • Loss of reflexes, especially in the ankle
    • Loss of balance and coordination
    • Serious foot problems, such as ulcers, infections, deformities, and bone and joint pain

    Seek medical care if you notice:

    • A cut or sore on your foot that doesn't seem to be healing, is infected or is getting worse
    • Burning, tingling, weakness or pain in your hands or feet that interferes with your daily routine or your sleep
    • Dizziness
    • Changes in your digestion, urination or sexual function

    Diabetic neuropathy can cause a number of serious complications, including:

    • Loss of a limb. Because nerve damage can cause a lack of feeling in your feet, cuts and sores may go unnoticed and eventually become severely infected or ulcerated — a condition in which the skin and soft tissues break down. The risk of infection is high because diabetes reduces blood flow to your feet. Infections that spread to the bone and cause tissue death (gangrene) may be impossible to treat and require amputation of a toe, foot or even the lower leg.
    • Charcot joint. This occurs when a joint, usually in the foot, deteriorates because of nerve damage. Charcot joint is marked by loss of sensation, as well as swelling, instability and sometimes deformity in the joint itself. Early treatment can promote healing and prevent further damage.
    • Urinary tract infections and urinary incontinence. Damage to the nerves that control your bladder can prevent it from emptying completely. This allows bacteria to multiply in your bladder and kidneys, leading to urinary tract infections. Nerve damage can also affect your ability to feel when you need to urinate or to control the muscles that release urine.
    • Hypoglycemia unawareness. Normally, when your blood sugar drops too low — below 70 milligrams per deciliter (mg/dL), or 3.9 millimoles per liter (mmol/L) — you develop symptoms such as shakiness, sweating and a fast heartbeat. Autonomic neuropathy can interfere with your ability to notice these symptoms.
    • Low blood pressure. Damage to the nerves that control circulation can affect your body's ability to adjust blood pressure. This can cause a sharp drop in pressure when you stand after sitting (orthostatic hypotension), which may lead to dizziness and fainting.
    • Digestive problems. Nerve damage in the digestive system can cause constipation or diarrhea — or alternating bouts of constipation and diarrhea — as well as nausea, vomiting, bloating and loss of appetite. It can also cause gastroparesis, a condition in which the stomach empties too slowly or not at all. This can interfere with digestion and cause nausea, vomiting and bloating, and severely affect blood sugar levels and nutrition.
    • Sexual dysfunction. Autonomic neuropathy often damages the nerves that affect the sex organs, leading to erectile dysfunction in men and problems with lubrication and arousal in women.
    • Increased or decreased sweating. When the sweat glands don't function normally, your body isn't able to regulate its temperature properly. A reduced or complete lack of perspiration (anhidrosis) can be life-threatening. Autonomic neuropathy may also cause excessive sweating, particularly at night or while eating.

    Diabetic neuropathy has been considered an irreversible disorder with traditional treatments focused on preventing the progression of the condition; or reducing the pain symptoms with drugs or specialized footwear.  However, treatment with nerve decompression surgery to address the symptoms of diabetic peripheral neuropathy now have an established clinical track record.  Many clinical studies have been published reporting the value of nerve decompression surgery in the treatment of peripheral diabetic neuropathy.

    Goals of the surgery are to restore sensation to the hands or feet, reduce or eliminate pain and to regain strength. If sensation is restored to the feet, the risk of having an ulceration or infection leading to an amputation is nearly eliminated.  Many patients are able to discontinue their medications relating to neuropathy after this procedure. 

    If you suffer from diabetic neuropathy, physicians from Neuropax Clinic can determine whether surgery might be appropriate for you. A comprehensive evaluation will be performed to determine whether you have compressed nerves that may respond to surgery. We have already helped many patients regain sensation and get relief from pain with this surgical approach.

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    Don't Live With Diabetic Neuropathy In St. Louis

    diabetes 2058045 1280

    With Type 1 and Type 2 Diabetes rates climbing, the sufferers of diabetic neuropathy increase as well.  These patients suffer from debilitating pain that radiates from the hands, feet, legs and arms.  It has been referred to for years as an irreversible disease, and treated as such by physicians.  They look to prevent the disease's progression, and minimize pain with medication, or specialized footwear.

    However, new breakthroughs in the field of nerve decompression have opened up pathways to new treatments for the pain of diabetic neuropathy.  Nerve decompression works to ease the pain that inflamed tissue puts on the nerves in the extremities and has shown to be VERY effective in the fight against diabetic neuropathy.  Clinical trials and studies back nerve decompression as a breakthrough treatment.

    The goals are simple for this surgery:  restore sensation and eliminate the pain.  When the sensation is restored, it severely reduces the risk for ulceration and infection that leads to amputation.  Many patients find that their need for the medications is lessened after the surgery is complete.

    If you suffer from diabetic neuropathy, physicians from Neuropax Clinic can determine whether surgery might be appropriate for you. A comprehensive evaluation will be performed to determine whether you have compressed nerves that may respond to surgery. We have already helped many patients regain sensation and get relief from pain with this surgical approach.

    Continue reading
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    Repetitive Motion Can Lead to Carpal Tunnel

    grinder 2175150 1280

    If you’ve been diagnosed with a repetitive strain injury, you probably have something like carpal tunnel syndrome, tendonitis or "dorsal wrist syndrome." Millions of Americans suffer these maladies, but each person’s cause can be different. Any job has different requirements that may cause repetitive stress to a different part of the body that may not be designed for it.

    Repetitive strain damage comes from structural changes in the muscle fibers and decreased blood flow in the affected areas. It may be a nerve problem, but the nerve ISN’T the problem! If you have these issues, it’s because inflamed tissue around the nerve is impinging on the nerve. Some activity is moving the joint or muscles in a way that they aren’t supposed to, and it’s causing the inflammation.

    Symptoms may often be relieved without surgery. Identifying and treating medical conditions, changing the patterns of hand use, or keeping the wrist splinted in a straight position may help reduce pressure on the nerve. Wearing wrist splints at night may relieve the symptoms that interfere with sleep. A steroid injection into the carpal tunnel may help relieve the symptoms by reducing swelling around the nerve.
     
    When symptoms are severe or do not improve, surgery may be needed to make more room for the nerve. Pressure on the nerve is decreased by cutting the ligament that forms the roof (top) of the tunnel on the palm side of the hand (see Figure 3). Incisions for this surgery may vary, but the goal is the same: to enlarge the tunnel and decrease pressure on the nerve.
    Following surgery, soreness around the incision may last for several weeks or months. The numbness and tingling may disappear quickly or slowly. It may take several months for strength in the hand and wrist to return to normal. Carpal tunnel symptoms may not completely go away after surgery, especially in severe cases.


    If you feel that you have a repetitive stress issue, please call the office at Neuropax Clinic at 314-434-7784 to make an appointment. Don’t live in pain another day if you don’t have to. Visit www.neuropaxclinic.com for more information.

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    Relief For Diabetic Neuropathy

    Peripheral neuropathy is the most common form of diabetic neuropathy. Your feet and legs are often affected first, followed by your hands and arms. Signs and symptoms of peripheral neuropathy are often worse at night, and may include:

    • Numbness or reduced ability to feel pain or temperature changes
    • A tingling or burning sensation
    • Sharp pains or cramps
    • Increased sensitivity to touch — for some people, even the weight of a bed sheet can be agonizing
    • Muscle weakness
    • Loss of reflexes, especially in the ankle
    • Loss of balance and coordination
    • Serious foot problems, such as ulcers, infections, deformities, and bone and joint pain

    Seek medical care if you notice:

    • A cut or sore on your foot that doesn't seem to be healing, is infected or is getting worse
    • Burning, tingling, weakness or pain in your hands or feet that interferes with your daily routine or your sleep
    • Dizziness
    • Changes in your digestion, urination or sexual function

    Diabetic neuropathy can cause a number of serious complications, including:

    • Loss of a limb. Because nerve damage can cause a lack of feeling in your feet, cuts and sores may go unnoticed and eventually become severely infected or ulcerated — a condition in which the skin and soft tissues break down. The risk of infection is high because diabetes reduces blood flow to your feet. Infections that spread to the bone and cause tissue death (gangrene) may be impossible to treat and require amputation of a toe, foot or even the lower leg.
    • Charcot joint. This occurs when a joint, usually in the foot, deteriorates because of nerve damage. Charcot joint is marked by loss of sensation, as well as swelling, instability and sometimes deformity in the joint itself. Early treatment can promote healing and prevent further damage.
    • Urinary tract infections and urinary incontinence. Damage to the nerves that control your bladder can prevent it from emptying completely. This allows bacteria to multiply in your bladder and kidneys, leading to urinary tract infections. Nerve damage can also affect your ability to feel when you need to urinate or to control the muscles that release urine.
    • Hypoglycemia unawareness. Normally, when your blood sugar drops too low — below 70 milligrams per deciliter (mg/dL), or 3.9 millimoles per liter (mmol/L) — you develop symptoms such as shakiness, sweating and a fast heartbeat. Autonomic neuropathy can interfere with your ability to notice these symptoms.
    • Low blood pressure. Damage to the nerves that control circulation can affect your body's ability to adjust blood pressure. This can cause a sharp drop in pressure when you stand after sitting (orthostatic hypotension), which may lead to dizziness and fainting.
    • Digestive problems. Nerve damage in the digestive system can cause constipation or diarrhea — or alternating bouts of constipation and diarrhea — as well as nausea, vomiting, bloating and loss of appetite. It can also cause gastroparesis, a condition in which the stomach empties too slowly or not at all. This can interfere with digestion and cause nausea, vomiting and bloating, and severely affect blood sugar levels and nutrition.
    • Sexual dysfunction. Autonomic neuropathy often damages the nerves that affect the sex organs, leading to erectile dysfunction in men and problems with lubrication and arousal in women.
    • Increased or decreased sweating. When the sweat glands don't function normally, your body isn't able to regulate its temperature properly. A reduced or complete lack of perspiration (anhidrosis) can be life-threatening. Autonomic neuropathy may also cause excessive sweating, particularly at night or while eating.

    Diabetic neuropathy has been considered an irreversible disorder with traditional treatments focused on preventing the progression of the condition; or reducing the pain symptoms with drugs or specialized footwear.  However, treatment with nerve decompression surgery to address the symptoms of diabetic peripheral neuropathy now have an established clinical track record.  Many clinical studies have been published reporting the value of nerve decompression surgery in the treatment of peripheral diabetic neuropathy.

    Goals of the surgery are to restore sensation to the hands or feet, reduce or eliminate pain and to regain strength. If sensation is restored to the feet, the risk of having an ulceration or infection leading to an amputation is nearly eliminated.  Many patients are able to discontinue their medications relating to neuropathy after this procedure. 

    If you suffer from diabetic neuropathy, physicians from Neuropax Clinic can determine whether surgery might be appropriate for you. A comprehensive evaluation will be performed to determine whether you have compressed nerves that may respond to surgery. We have already helped many patients regain sensation and get relief from pain with this surgical approach.

    Continue reading
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    Do You Have a Migraine?

    If you think you’re suffering from migraines, it’s very frustrating. Many people just take Tylenol and deal with them. For some, it’s not something that can be managed, but needs to be treated by a doctor. Here’s when to see a doctor about migraine pain.

    Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different.

    If you start to see symptoms like these, make an appointment immediately or go to the emergency room, as you may have severe migraine issues:

    • An abrupt, severe headache like a thunderclap
    • Headache with fever, stiff neck, mental confusion, seizures, double vision, weakness, numbness or trouble speaking
    • Headache after a head injury, especially if the headache gets worse
    • A chronic headache that is worse after coughing, exertion, straining or a sudden movement
    • New headache pain if you're older than 50

    Many migraines go completely untreated. If you’re experiencing migraine attack symptoms, keep notes on what you do to deal with them, and how effective it is. Then call Neuropax Clinic to discuss your headaches.

    Dr. Robert Hagan of Neuropax Clinic is ready to help with your migraine attacks. Call the office today at 314-434-7784 to schedule an appointment to talk about how peripheral nerve surgery can help with your migraine pain. Don’t live with migraines a day longer than you have to. Let us help.

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    Did Repetitive Stress Give You Carpal Tunnel?

    pexels photo 392018

    If you’ve been diagnosed with a repetitive strain injury, you probably have something like carpal tunnel syndrome, tendonitis or "dorsal wrist syndrome." Millions of Americans suffer these maladies, but each person’s cause can be different. Any job has different requirements that may cause repetitive stress to a different part of the body that may not be designed for it. Repetitive strain damage comes from structural changes in the muscle fibers and decreased blood flow in the affected areas. It may be a nerve problem, but the nerve ISN’T the problem! If you have these issues, it’s because inflamed tissue around the nerve is impinging on the nerve. Some activity is moving the joint or muscles in a way that they aren’t supposed to, and it’s causing the inflammation. Symptoms may often be relieved without surgery. Identifying and treating medical conditions, changing the patterns of hand use, or keeping the wrist splinted in a straight position may help reduce pressure on the nerve. Wearing wrist splints at night may relieve the symptoms that interfere with sleep. A steroid injection into the carpal tunnel may help relieve the symptoms by reducing swelling around the nerve. When symptoms are severe or do not improve, surgery may be needed to make more room for the nerve. Pressure on the nerve is decreased by cutting the ligament that forms the roof (top) of the tunnel on the palm side of the hand (see Figure 3). Incisions for this surgery may vary, but the goal is the same: to enlarge the tunnel and decrease pressure on the nerve. Following surgery, soreness around the incision may last for several weeks or months. The numbness and tingling may disappear quickly or slowly. It may take several months for strength in the hand and wrist to return to normal. Carpal tunnel symptoms may not completely go away after surgery, especially in severe cases. If you feel that you have a repetitive stress issue, please call the office at Neuropax Clinic at 314-434-7784 to make an appointment. Don’t live in pain another day if you don’t have to. Visit www.neuropaxclinic.com for more information.

    Continue reading
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    Diabetic Neuropathy in St. Louis

    nerves 346928 1280

    With Type 1 and Type 2 Diabetes rates climbing, the sufferers of diabetic neuropathy increase as well.  These patients suffer from debilitating pain that radiates from the hands, feet, legs and arms.  It has been referred to for years as an irreversible disease, and treated as such by physicians.  They look to prevent the disease's progression, and minimize pain with medication, or specialized footwear.

    However, new breakthroughs in the field of nerve decompression have opened up pathways to new treatments for the pain of diabetic neuropathy.  Nerve decompression works to ease the pain that inflamed tissue puts on the nerves in the extremities and has shown to be VERY effective in the fight against diabetic neuropathy.  Clinical trials and studies back nerve decompression as a breakthrough treatment.

    The goals are simple for this surgery:  restore sensation and eliminate the pain.  When the sensation is restored, it severely reduces the risk for ulceration and infection that leads to amputation.  Many patients find that their need for the medications is lessened after the surgery is complete.

    If you suffer from diabetic neuropathy, physicians from Neuropax Clinic can determine whether surgery might be appropriate for you. A comprehensive evaluation will be performed to determine whether you have compressed nerves that may respond to surgery. We have already helped many patients regain sensation and get relief from pain with this surgical approach.

    Continue reading
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    Why Does My Wrist Hurt?

    patient 1080405 1920

    Carpal Tunnel Release Surgery, or Carpal Tunnel Surgery, is a procedure designed to release the pressure or impingement on the median nerve, relieving the symptoms of carpal tunnel syndrome. This syndrome is expressed by pain and numbness in the hand and wrist, and is often caused by repetitive stress and holding the hand/wrist in an awkward position. People who type often, use a hammer, or work in a factory setting are all candidates for this syndrome.

    During the surgery, an incision on the base of the hand is made, letting us examine the transverse carpal ligament. We are then able to clean up the area, suture the wound, and you are usually released that day. Carpal tunnel surgery is not typically an overnight hospital stay and is usually done under local anesthesia. It’s a one-day procedure and you should sleep in your own bed that night.

    After the procedure, you need to keep the hand wrapped for 10-14 days, until the stitches are removed. The pain and numbness may go away right away, or may linger for a few months. You really should take it easy with the wrist for at least 3 months. If it’s your dominant hand, you want to give it a little longer to rest before returning to work. Non-dominant hand surgery patients can usually return to non-physical labor in a day or two, but if it’s your dominant hand or you have a very physical job, you may need physical therapy and more rest than that.

    The surgery is generally recommended after nonsurgical treatment has failed. Braces and anti-inflammatory medicines can help the situation, along with rest, but surgery is the last step. This also assumes that there is no nerve damage. Nerve damage patients should have surgery more quickly to avoid the situation becoming worse.

    If you feel that you are suffering from carpal tunnel syndrome and you are ready to do something about it, Neuropax Clinic and Dr. Robert Hagan are ready to help. If you suffer from numbness or pain in your wrist or hand, call us at 314-434-7784 to schedule an appointment or visit www.neuropaxclinic.com for more information. Don’t live with wrist pain any longer than you have to.

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    Am I Having a Migraine?

    headache 1910649 1280

    Thousands of people suffer from migraines every day. They are debilitating headaches that can cause you to shut down your entire day to deal with them. How do you know if you’re dealing with a migraine or a regular headache?

    A migraine attack can last anywhere from four to 72 hours if you leave it untreated. There’s no set time for the definition. Likewise, there’s no set amount of migraine attacks that you will see per month. Some people can see one a month, some people can suffer from them daily. However frequent, there are signs that it is actually a migraine. Look for:

    Pain on one side or both sides of your head – You can experience intense, throbbing or pulsing pain across your entire head, or it can be localized in certain areas of your head.

    Sensitivity to light, sounds, and sometimes smells and touch – You may want to find a dark, quiet room to ride it out. A cold compress across the eyes can also help give you some relief.

    Nausea and vomiting – Headaches bad enough to generate vomiting and nausea are generally going to be referred to as migraines, although not every vomiting spell comes from a migraine.

    Blurred vision – Your eyesight doubles and you have trouble seeing, often leading to balance issues.

    Lightheadedness, sometimes followed by fainting – when you have this, it’s time to stop moving. Get off the road if you’re driving, sit down if you’re walking, and get someplace safe.

    If you find yourself with these symptoms and repeated headaches, you may be suffering from migraines. Call Dr. Robert Hagan at Neuropax Clinic today to make an appointment to see if peripheral nerve surgery in our office can help. Call us at 314-434-7784 to make an appointment. Don’t live another day with migraines. Let us help.

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    Migraine Symptoms and Relief

    headache 1910649 1280

    Migraines are debilitating headaches that strike without warning and can ruin your life. They often occur with no buildup. Not every headache is a migraine, though. There are very specific signs that what you are experiencing is a migraine.

    They occur in various combinations and include:

    • Moderate to severe pain (often described as pounding, throbbing pain) that can affect the whole head, or can shift from one side of the head to the other
    • Sensitivity to light, noise or odors
    • Blurred vision
    • Nausea or vomiting, stomach upset, abdominal pain
    • Loss of appetite
    • Sensations of being very warm or cold
    • Paleness
    • Fatigue
    • Dizziness
    • Fever (rare)
    • Bright flashing dots or lights, blind spots, wavy or jagged lines (aura)

    It is estimated that up to 13 % (likely even higher) of all chronic headaches are related to occipital nerve neuralgia. Neuralgia is a general term for pain or irritation along the course of a nerve. We are addressing the irritation caused by nerve compression in this situation.

    Although the Greater occipital nerve is the most common nerve involved, other nerves can be involved as well. The lesser occipital nerve and dorsal (or least) occipital nerve which are located in the back of the head/scalp. Headaches may originate from the forehead or frontal region as well. The nerves involved in this area include the supra-orbital and zygomatico-temporal nerves.

    When no other underlying diseases or conditions are found, you may be a candidate for a nerve decompression surgery that can reduce or end your migraine headaches. This is an outpatient surgery with short recovery times. Results are often immediately evident but may take several weeks. Neuropax surgeons can assess if nerve decompression surgery would help to alleviate or significantly reduce your debilitating symptoms.

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    The Anatomical Morphology of the Supraorbital Notch: Clinical Relevance to the Surgical Treatment of Migraine Headaches

    Abstract:

    Background: Current literature for surgical deactivation of frontal migraine trigger points does not incorporate decompression of the supraorbital foramen or fascial bands at the supraorbital rim (frontal exit) as part of the surgical procedure. To evaluate this primary compression site for the supraorbital nerve, anatomical dissections were performed and a classification system was developed.

    Methods: Sixty supraorbital regions from 30 ethylene glycol–preserved cadaveric heads were dissected. Particular attention was focused on the morphology of the supraorbital rim, specifically, the presence of a supraorbital notch or supraorbital foramen. The presence or absence of a fascial band completing the notch and the patterns of fascial band variations were documented.

    Results: A supraorbital foramen was identified 27 percent of the time and a notch was identified 83 percent of the time. When a notch was encountered, a fascial band forming the floor of the notch that completed the encirclement of the supraorbital nerve was noted in 86 percent of supraorbital regions. A classification system was developed to categorize the four common fascial band variation patterns observed.

    Conclusions: This study verifies the presence of a primary compression site for the supraorbital nerve that is proximal to the glabellar myofascial complex. Knowledge of this compression site and its possible anatomical variations will enable surgeons to perform a more complete supraorbital nerve decompression for migraine amelioration.

    Read the full article at http://journals.lww.com/plasreconsurg/Abstract/2012/12000/The_Anatomical_Morphology_of_the_Supraorbital.10.aspx

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    Anatomy of the Supratrochlear Nerve: Implications for the Surgical Treatment of Migraine Headaches

    Abstract:

    Background: Migraine headaches have been linked to compression, irritation, or entrapment of peripheral nerves in the head and neck at muscular, fascial, and vascular sites. The frontal region is a trigger for many patients' symptoms, and the possibility for compression of the supratrochlear nerve by the corrugator muscle has been indirectly implied. To further delineate their relationship, a fresh tissue anatomical study was designed.

    Methods: Dissection of the brow region was undertaken in 25 fresh cadaveric heads. The corrugator muscle was identified on both sides, and its relationship with the supratrochlear nerve was investigated.

    Results: The supratrochlear nerve was found in all 50 hemifaces. Three potential points of compression were uncovered in this investigation: the nerve entrance into the brow through the frontal notch or foramen, the entrance of the nerve into the corrugator muscle, and the exit of the nerve from the corrugator muscle. The nerve generally bifurcates within the retro–orbicularis oculi fat pad, and these branches enter into one of four relationships with the corrugator muscle: both branches enter the muscle, one branch enters the muscle and one remains deep, both branches remain deep, and the branches further branch into ever smaller filaments that cannot be identified cranially.

    Conclusions: Some patients are nonresponders to migraine decompression techniques that address the supraorbital nerve. The supratrochlear nerve may be compressed in these patients. A standard corrugator resection that comes more medially within 1.8 cm of the midline may be beneficial. The morphology of the frontal notch/foramen must be examined and addressed if necessary.

     

    Read the full article at http://journals.lww.com/plasreconsurg/Abstract/2013/04000/Anatomy_of_the_Supratrochlear_Nerve___Implications.14.aspx

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    Supraorbital Rim Syndrome: Definition, Surgical Treatment, and Outcomes for Frontal Headache

    Migraine headaches directly affect 11% or more of the adult population (almost 35 million Americans).1 There are significant direct implications to our healthcare and social systems related to the treatment of these migraine patients and indirect effects because of impaired work performance, detrimental family consequences, social interactions, and quality of life. As far as we have come in defining this symptom complex, the debate continues regarding the true origin. Understanding the origin of migraine headache pain is important to guide acute and preventative treatment strategies as recommended by the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society.2

    The peripheral trigger point theory of migraine headaches has gained much support.3 However, a common argument from the centrally triggered theorists is that there are no consistent causative peripheral pathologies.4 In the setting of frontal migraines, we feel the activation of peripheral nociceptors by a nerve compression localized to the supraorbital rim, and involving the branches of the frontal nerve and zygomaticotemporal nerve (ZTN) provides a consistent cause.

    The identification of focal peripheral nerve compression sites as a frontal migraine generator adds an option to the stratified care model for migraine treatment.5,6 Current medical treatment options are incomplete for those patients whose supraorbital rim anatomy sensitizes them to migraine headaches. This stimulus originates from the supraorbital nerve (SON), supratrochlear nerve (STN), and ZTN as they exit the orbit.7,8

    Peripheral nerve decompression for headaches is not a novel idea. Decompression of the greater occipital nerve was first reported in the neurosurgical literature in the 1960s. In the past decade, several different groups9–13 have described success when performing peripheral nerve decompression to treat headaches. As we know from upper and lower extremity peripheral nerve compression syndromes, there can be multiple sites of potential compression along the same nerve.14,15 The same concept applies to head and neck peripheral nerve anatomy as we demonstrated in cadaver studies for the SON and STN, establishing the more proximal compression to the glabellar myofascial unit.16

    We propose the diagnosis of a supraorbital rim syndrome (SORS) as a peripheral nerve compression syndrome contributing to frontal-triggered migraine and headache pain and disability. This article reviews the proximal compression sites of the frontal nerve divisions at the bony supraorbital rim in addition to the glabellar myofascial unit and the contribution of the ZTN to this pain syndrome. Furthermore, we add strategies to facilitate diagnosis and evidence to support the surgical treatment of SORS patients using the stratified care guidelines set forth by the US Headache Consortium.

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    METHODS

    A retrospective review of 276 patients, who underwent nerve decompression/neurectomy procedures for frontal or occipital headache by a single surgeon (R.R.H.), was performed. All surgeries were performed in outpatient setting between 2008 and 2014. Of the 276 patients, treatment of 96 patients included frontal or periorbital deactivation or neuroma resection. This study is an examination of the pure frontal deactivation population of 45 patients.

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    Diagnosis of SORS

    Diagnosis of SORS was based on history of pain emanating from this region, physical examination with tenderness to palpation, and response to diagnostic blocks, demonstrating significant relief of symptoms. Baseline preinjection discomfort was assessed using a standard visual analogue scale. Injections were performed in a step-wise manner with a combination of 1% lidocaine and 0.25% Marcaine17,18 when a patient presented with active pain. Injection of epinephrine-containing solutions was not included in the diagnostic process. Blockade of the SON/STN on the side with the most consistent pain was performed using a 30-gauge needle to inject 0.5 mL at the orbital rim and 0.5 mL within the myofascial component surrounding the nerve. To address the ZTN, 2 mL was injected deep into the temporal fascia to avoid dispersion to the frontal branch of the facial nerve. If needed, a block of the contralateral SON, STN, and ZTN was performed. We have found that those who experience an immediate near total or total relief of symptoms are excellent candidates for surgery.

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    Anatomy of Frontal Nerve Proximal Compression Sites

    The frontal nerve (first division of the trigeminal nerve) is the largest of 3 named branches from the ophthalmic nerve as it enters the posterior orbit at the superior orbital fissure. From the posterior orbit, the frontal nerve begins its intraconal pathway between the levator palpebrae superioris and the periosteum. Along its intraconal route, the frontal nerve branches into the SON and STN.

    The SON anatomical variations along its intraconal path to its frontal exit point on the rim account for various potential compression sites. The periosteum provides the first site of compression during the intraconal/frontal exit transition (). If a bony foramen provides the SON frontal exit (27%), this point is a definite closed, nonexpanding site of potential compression (). If a notch provides the SON frontal exit (73%), there can be 1 of 4 variants of fascial bands that complete a carpal tunnel-like ring around the SON (). The SON may branch into the superficial (medial) and deep (lateral) division either proximal or distal to the supraorbital exit, thus the intraconal branching pattern can account for multiple compression sites.

     

    The proximal STN potential compression site is more consistent as it is held in most cases by a periosteal band along the supraorbital rim (76%). More rarely, there is a true bony foramen for STN exit onto the forehead (18%) ().19,20 shows a decompressed SON and STN.

     
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    Surgical Method

    All patients included in this study underwent direct, transpalpebral approach and decompression of the SON and STN at the orbital rim and corrugator myofascial sleeve. In addition, zygomaticotemporal neurectomy was performed through a direct approach in all subjects. SON, STN, and ZTN were identified in every case, and possible compressive etiologies were identified, documented, and released.

    The standard transpalpebral incision is designed along the upper component of a blepharoplasty incision. In some cases, removal of redundant skin was performed in addition to nerve decompression. Simple direct incisions, without skin excision, are shown in . The dissection continues to the decussation of the orbicularis and corrugator where the muscle is divided, exposing the rim. Working from lateral to medial, starting at the lateral limbus line, a subperiosteal dissection along the bony orbital rim is performed; staying right on the rim will protect the lateral SON branch. The SON foramen or notch is first identified followed by the identification of STN rim morphology. Intraconal nerve inspection is used when high or aberrant branches are identified. Although infrequent, the direct approach allows for this inspection easily. A supraorbital foraminotomy is performed, if present, with a small rongeur (). The thickened periosteal sleeve is removed, and the bundle is mobilized. The artery and vein are selectively coagulated with bipolar cautery. If a SON notch is identified, the tight ligament is removed along with partial bony resection. The myofascial unit is best addressed using a freer to identify the fascial sleeve through the muscle, releasing the corrugator muscle fibers superficial to the nerve. The freer is also placed alongside of the lateral (deep) branch of the SON, and its dense attachments are released on the lateral forehead near the temporal fusion line.

     

    The STN is addressed in a similar fashion. The STN most consistently exits below a dense broad periosteal or fascial band but may also enter onto the rim through a bony foramen.19,20 Many times, it is easier to find it intraconally and follow it to the orbital rim exit. Careful attention should be given to the trochlea when dissecting this nerve. Full decompression should be accomplished at the rim and corrugator muscle. On occasion, if the STN is quite small, a neurectomy proximal to the orbital rim exit is performed with the end buried within the deeper orbit fat.

    A local pedicled, fat flap is fashioned from the medial compartment and transposed in to the defect from the corrugator release (). This also provides benefit to the nerve as this positions vascularized fat to protect and heal the nerve.

    The ZTN incision can be a small extension of the transpalpebral incision into a crow’s feet rhytid or can be a direct incision into the rhytid when no upper lid skin is being excised. An alternative is the temporal scalp incision, which works well in a younger patient who lacks periorbital rhytides and has a forward hairline.21 The nerve is located inferior to the sentinel vein (). Once identified, a neurectomy is performed. Often, some of the anterior temporalis fibers are divided as well to look for any duplicate aberrant branches.

     
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    Migraine Disability Assessment Questionnaire

    All patients filled out a Migraine Disability Assessment Questionnaire (MIDAS)22 at their initial evaluation and on the day of surgery. Postoperative MIDAS scores were collected at 3 and 12 months.

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    Statistical Analysis

    Statistical analysis was performed with a paired t test for preoperative and postoperative MIDAS scores.

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    RESULTS

    A retrospective review of 276 patients who underwent nerve decompression/neurectomy procedures to relieve headache pain was performed by a single surgeon. Within this group, treatment of 96 patients included frontal or periorbital deactivation or neuroma resection. The pure frontal deactivation population of 45 patients was examined in this study. Thirty-four of the procedures were bilateral, and 11 were unilateral. In total, 79 orbits were surgically treated with this technique, involving 237 nerves. The patients were predominantly women with ages ranging from 18 to 77 years, averaging 47 years old.

    The average preoperative MIDAS score was 134. Postoperatively, MIDAS scores decreased significantly at 3 months to 25 and remained at 24, when measured at 12 months postoperatively (P < 0.0001 vs baseline; ). Adverse events were infrequent and included persistent swelling (n = 2 patients; resolved by 6 weeks), hematoma (n = 1 patient; a minor subcutaneous hematoma that resolved on its own), infection/cellulitis (n = 1 patient), and neuroma (n = 1 patient; treated with a short course of amitriptyline); all of these were resolved without further surgery.

     

    We analyzed at percentage change in the MIDAS and divided these into 4 categories noted in . Types 1 and 2 equate to true functional life improvements. Type 3 represents intermediate improvement. Type 4 represents less than 50% MIDAS reduction and essentially failure to respond to surgical deactivation.

     

    Ten percent of patients reduced their MIDAS score to 0, meaning a 100% reduction. Sixty-seven percent reduced their MIDAS by more than 90%. Eight-two percent of patients decreased their MIDAS by more than 75%. Ninety-one percent of patients decreased their MIDAS by more than 50%. Nine percent of patients had less than 50% reduction in their MIDAS, which we considered failure to respond. Of interest, 1 of the 4 (type 4) failures maintains that they would still have surgery. Three of the 4 type 3 patients maintain that they would still have surgery given some benefit.

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    DISCUSSION

    Compression of the peripheral nerves of the supraorbital rim (SON, STN, and ZTN) can have varying underlying etiologies.23 Decompression of these nerves by addressing muscle, fascia, bone, or vessel can result in significant improvement in headache pain. Decompression of the SON at the supraorbital rim with positive results on patients with frontal pain syndromes has been reported by Sjaastad et al24 in 1999. Sjaastad et al24 correctly identified a “fascial band or bony extension” at the supraorbital notch, which they removed in 5 patients. This article provides additional evidence that decompression of the myofascial sleeve of the SON and STN combined with the more proximal decompression of fascial and/or bony elements at the supraorbital rim represents a more complete decompression.

    In both our published cadaver dissections and clinical experience, we have identified critical anatomical points. A true foramen and notch with a band both provide a fixed, nonexpanding bony aperture for supraorbital neurovascular passages and represent a natural compression point. In our clinical experience, this represents the most consistent anatomic compression point. Also, a confluence of periosteum often tightly ensleeves the SON as it transitions from its intraconal pathway to the frontal exit, which when present, should be removed. When a notch is present, there are 4 variations of the fascial band morphology and potential compression. However, whether the fascial band represents an extension of the arcus marginalis or is of its own embryonic origin (such as with a persistent band in radial dysplasia) is unknown. Understanding the variations of horizontal and vertical septa that may be present is important clinically to achieve complete decompression of the nerve. For instance, if the SON branches into its superficial and deep branches proximal to notch exit, horizontal or vertical septa would provide a separate tunnel for each branch. Incomplete decompression of only the fascial band surrounding the medial (superficial) branch will still perpetuate a pain syndrome from the lateral (deep) branch. Furthermore, we have consistently performed a conservative muscle resection when addressing the myofascial units within the corrugator, releasing only the fibers superficial to the nerve. This approach is supported by how we decompress nerves in the extremities. For instance, we do not resect the entire pronator muscle when decompressing a proximal median compression.7

    The frontal exit of the STN is more consistent as an extension of the arcus marginalis and has been previously demonstrated to have notch and foramen variants as well.19 These findings support the presence of compression at both the orbital rim and the myofascial unit just like the SON, which emphasizes the importance of releasing both sites.

    We postulate that variable, asymmetric rim morphologies in the same patient may represent the unilaterality or one-sided dominance in this type of peripherally triggered headache syndrome.

    We feel that the transpalpebral approach is optimal given its easily concealed incision and gives adequate, direct exposure to the nerve at the intraconal space, orbital rim, and the myofascial levels (). Complete evaluation of the supraorbital rim anatomy and notch/foramen morphology, as well as the release of the fascial band or foraminotomy, often requires maneuvers that, in most hands, would be more challenging via the endoscopic approach. Also, it is not uncommon for these patients to have significant upper lid excess that contributes to a hypercontracted/dynamic forehead and brow musculature, which secondarily can potentially cause unwanted traction on the already irritated/sensitized nerve. The direct approach allows us to easily incorporate a traditional upper lid skin excision to address this. Pearls for the surgical treatment of SORS are shown in .

     

    The MIDAS questionnaire has been shown to correlate with both physician’s assessment of treatment need and outcomes of treatment.22 The MIDAS questionnaire categorizes patients into 4 grades based on their illness severity. With obvious selection bias as a surgical tertiary referral, our patients all fall into the severe disability or MIDAS grade 4. All of our patients to date have a MIDAS score that is well above the severe disability grade. These grade 4 patients represent a subset of migraine headache pain patients who have received an accurate diagnosis but are not receiving suitable therapy through medical or alternative medicine treatment arms.25 It is this subset of patients that surgical intervention should be considered and incorporated into individualized management and not thought of as a last resort.

    We acknowledge that the ultimate patient sample size in this study is limited. However, this subpopulation represents a pure population of patients who underwent this specific surgical technique within our larger, comprehensive headache surgery experience and is not confounded by the performance of alternative skin incisions, surgical approaches, and treatment of other trigger sites. Furthermore, it does however represent a larger number than other studies for these specific trigger sites. Nonetheless, the early experience with this technique is significant and sets the stage for continued studies on this topic.

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    CONCLUSIONS

    Understanding that head and neck nerve compressions share conceptual similarities with extremity compression syndromes allows us to apply the concept of multiple anatomical points of compression to the pathology of migraine triggers or chronic headaches. In those patients whose disability is related to frontal pain, we offer insight into consistent anatomical points at the supraorbital rim that, if decompressed, has shown to offer significant relief to these patients. Cadaver and clinical experience points to a fixed (bone/ligament) and dynamic (myofascial) compression site at the supraorbital rim, causing a SORS, which is treatable in the outpatient setting. In our population of 45 patients, surgical intervention resulted in significantly decreased MIDAS scores.

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    ACKNOWLEDGMENTS

    We thank Joanne McAndrews, PhD, for assistance with the preparation of this article.

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    REFERENCES

    1. Scher AI, Stewart SW, Lipton RBIK CMigraine and headache: a meta-analytic approach.In: Epidemiology of Pain1999SeattleIASP Press159–170
    2. Silberstein SD, Holland S, Freitag F, et al.Quality Standards Subcommittee of the American Academy of Neurology and the American Headache SocietyEvidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society.Neurology2012781337–1345
    3. Olesen J, Burstein R, Ashina M, et al.Origin of pain in migraine: evidence for peripheral sensitisation.Lancet Neurol20098679–690
    4. Lambert GAThe lack of peripheral pathology in migraine headache.Headache201050895–908
    5. Lipton RBDisability assessment as a basis for stratified care.Cephalalgia199818Suppl 2240–43discussion 43–46
    6. Lipton RB, Silberstein SDThe role of headache-related disability in migraine management: implications for headache treatment guidelines.Neurology2001566 Suppl 1S35–S42
    7. Dellon ALHentz VR, Mathes SJNerve entrapment syndromes.In: The Hand and Upper Limb, Part 22006Vol VIIIChinaSaunders Elsevier875–928
    8. Dellon ALHentz VR, Mathes SJPainful neuromas.In: The Hand and Upper Limb, Part 22006Vol VIIIChinaSaunders Elsevier929–948
    9. Guyuron B, Varghai A, Michelow BJ, et al.Corrugator supercilii muscle resection and migraine headaches.Plast Reconstr Surg20001062429–434discussion 435–437
    10. Janis JE, Ghavami A, Lemmon JA, et al.The anatomy of the corrugator supercilii muscle: part II. Supraorbital nerve branching patterns.Plast Reconstr Surg2008121233–240
    11. Chepla KJ, Oh E, Guyuron BClinical outcomes following supraorbital foraminotomy for treatment of frontal migraine headache.Plast Reconstr Surg2012129656e–662e
    12. Liu MT, Chim H, Guyuron BOutcome comparison of endoscopic and transpalpebral decompression for treatment of frontal migraine headaches.Plast Reconstr Surg20121291113–1119
    13. Gfrerer L, Maman DY, Tessler O, et al.Nonendoscopic deactivation of nerve triggers in migraine headache patients: surgical technique and outcomes.Plast Reconstr Surg2014134771–778
    14. Upton AR, McComas AJThe double crush in nerve entrapment syndromes.Lancet19732359–362
    15. Mackinnon SEDouble and multiple “crush” syndromes. Double and multiple entrapment neuropathies.Hand Clin19928369–390
    16. Fallucco M, Janis JE, Hagan RRThe anatomical morphology of the supraorbital notch: clinical relevance to the surgical treatment of migraine headaches.Plast Reconstr Surg20121301227–1233
    17. Bovim G, Sand TCervicogenic headache, migraine without aura and tension-type headache. Diagnostic blockade of greater occipital and supra-orbital nerves.Pain19925143–48
    18. Dimitriou V, Iatrou C, Malefaki A, et al.Blockade of branches of the ophthalmic nerve in the management of acute attack of migraine.Middle East J Anaesthesiol200216499–504
    19. Janis JE, Hatef DA, Hagan R, et al.Anatomy of the supratrochlear nerve: implications for the surgical treatment of migraine headaches.Plast Reconstr Surg2013131743–750
    20. Janis JE, Ghavami A, Lemmon JA, et al.Anatomy of the corrugator supercilii muscle: part I. Corrugator topography.Plast Reconstr Surg20071201647–1653
    21. Peled ZMA novel surgical approach to chronic temporal headaches.Plast Reconstr Surg20161371597–1600
    22. Stewart WF, Lipton RB, Dowson AJ, et al.Development and testing of the Migraine Disability Assessment (MIDAS) questionnaire to assess headache-related disability.Neurology2001566 Suppl 1S20–S28
    23. Wolff HHeadache and Other Head Pain1948New YorkOxford University Press
    24. Sjaastad O, Stolt-Nielsen A, Pareja JA, et al.Supraorbital neuralgia. On the clinical manifestations and a possible therapeutic approach.Headache199939204–212
    25. Edmeads J, Láinez JM, Brandes JL, et al.Potential of the Migraine Disability Assessment (MIDAS) questionnaire as a public health initiative and in clinical practice.Neurology2001566 Suppl 1S29–S34
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    Denervation of the Periosteal Origin of the Adductor Muscles in Conjunction with Adductor Fasciotomy in the Surgical Treatment of Refractory Groin Pull

    Abstract

    Background: The purpose of this study was to determine whether resection of the nerve that innervates the origin of the adductor muscle group in addition to an adductor fasciotomy will decrease pain and improve function in patients with a chronic “groin pull.”

    Methods: The authors conducted a retrospective multicenter chart review of 12 patients presenting with refractory groin pull. In two patients, the problem was bilateral. There were eight female and four male patients. Injuries were related to sports (n = 6), gynecologic procedures (n = 3), and other injuries (n = 3). Surgery included adductor fasciotomy plus resection of a nerve to the periosteal origin of the adductor muscles. Cadaver dissections were performed to identify the nerve's origin.

    Results: In 13 of the 14 patient specimens, nerves were identified histologically: each of the five cadaver dissections demonstrated the anterior branch of the obturator nerve to be this nerve's origin. At a mean of 16.7 months after surgery, 11 of the 12 patients (92 percent) and 13 of the 14 limbs (93 percent) responded with relief of pain and improved activities of daily living. Of the 14 patients, eight had an excellent result (67 percent), three had a good result (25 percent), and one experienced a failure (7 percent).

    Conclusions: Chronic impairment related to a groin pull injury may be considered caused by a contracture of the adductor muscle group, which can be treated with fasciotomy. A branch of the obturator nerve is shown to innervate the origin of these muscles, and denervation can be performed simultaneously with fasciotomy, improving pain and function.

    Read the full report at http://journals.lww.com/plasreconsurg/Abstract/2011/10000/Denervation_of_the_Periosteal_Origin_of_the.23.aspx

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    A Review of Current Evidence in the Surgical Treatment of Migraine Headaches

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    Migraines affect 18% of women and 6% of men and result in an estimated $1 billion in medical costs and $16 billion productivity loss in the United States annually. Migraine headaches persist as a problem of this scale because pharmacologic treatments for migraines are frequently incompletely effective, resulting in a population of patients with significant residual disability. In the last decade, novel approaches to the treatment of migraines have been developed based on the theory that extracranial sensory branches of the trigeminal and cervical spinal nerves can be irritated, entrapped, or compressed at points throughout their anatomic course, ultimately leading to the cascade of physiologic events that results in migraine. Botulinum toxin (Botox) injection and surgical decompression of these trigger points have been shown to reduce or eliminate migraines in patients who are incompletely treated by traditional medical management. Despite the recent advances made with Botox, this treatment strategy most commonly results in only temporary migraine prevention. However, the evidence supporting the efficacy and safety of permanent surgical decompression of peripheral trigger points is accumulating rapidly, and the overall success rate of surgery has approached 90%. In addition, an abundance of literature investigating the precise anatomical dissections associated with trigger points has been published concurrently. This article reviews the most up-to-date clinical and anatomic evidence available and seeks to provide a comprehensive, concise resource for the current state of the art in the surgical treatment of migraine headaches.

    Read the full article at http://journals.lww.com/plasreconsurg/Abstract/2014/10002/A_Review_of_Current_Evidence_in_the_Surgical.21.aspx

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