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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.

    Why Migraine Surgery Can Help

    Migraine Surgery St Louis

    Migraine headaches, real, chronic migraines, can ruin your life. That’s not hyperbole, it’s the truth. When you get migraines regularly, you know that they can cause you to miss work, school, or social events. You can end up curled up in bed for the day, in excruciating pain. Migraine headaches are a scourge on those that suffer from them. But what if there was a way to relieve these nightmares?

    Nerve compression surgery can help. 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. Surgery by Dr. Robert Hagan of the Neuropax Clinic can help relieve the symptoms and causes of severe headaches, allowing the recipient to suffer far reduced migraines, or possibly end the headaches altogether.

    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 have persistent signs and symptoms suggestive of migraine pain, especially if they interfere with your normal activities and sleep patterns, see your doctor. If you leave the condition untreated, they'll only get worse.  For more information or to make an appointment with Neuropax Clinic, call us at 314-434-7784 or visit www.neuropaxclinic.com today to learn more.  Don't live with Migraine Pain any longer than you have to.

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    Carpal Tunnel of the Hip or Meralgia Paresthetica

    Meralgia Paresthetica is a constellation of symptoms caused by a compression neuropathy (pinched nerve) of the Lateral Femoral Nerve (LFN).  The LFN arises from the second and third lumbar spinal levels (L2,L3). As the LFN travels from the spine to the thigh region, the nerve can be pinched at the anterior pelvic tunnel. This tunnel is made by the bone of anterior superior iliac spine, the dense fibers of the inguinal ligament and overlaying musculature.  Pressure on this nerve causes feelings of burning, pain and numbness along the front and lateral part of the thigh, extending all the way from anterior and lateral hip, groin and gluteal area to the knee. In some, there can even be very deep groin and testicular or labial pain.

    It is not uncommon for the severity of symptoms to be significantly debilitating, especially if the problem is not addressed. It is important to understand that this a very treatable problem. Its like having carpal tunnel of your hip. Early or old teachings that suggest there is nothing to do, still permeate the medical community regarding this problem.

    This compression neuropathy (pinched nerve condition) can be caused by several different mechanisms. Anatomical studies have shown that at least 5% of the population has an abnormal nerve tunnel. This anatomic variant is highly vulnerable for compression but any nerve can become compressed or damaged. History of pelvic fracture, Blunt trauma in or near the nerve and tunnel, can cause direct trauma to the nerve or trauma to the surrounding tissues that leads to compression of the nerve as well.  

    Even just having surgery in the area of the hip, groin or abdomen can lead to changes in the tissue surrounding the nerve and lead to compression. Prior hip surgery, hernia surgery, bone graft harvest, cesarean sections are some of the most common.

    Some professional activities (i.e. police officers, firefighters and construction workers, etc.) require wearing heavy and loaded belts around the waist. This exposes the nerve to excess and repetitive pressure, especially if anatomical nerve path abnormalities already exist. Various sports like karate/kickboxing, football, soccer, rugby and others can all produce injuries that result in this problem.  Body habitus such as abdominal obesity or pregnancies can also contribute to repetitive stress and stretching of the nerve.

    It is also important to recognize the affects of diabetes on this clinical problem. Diabetic patients, due to abnormal glucose metabolism, may develop swelling of the nerve, as well as narrowing of the tunnel itself. This alters the normally perfect relationship between the nerve and its tunnel, making it now too narrow for the more swollen nerve, resulting in lateral femoral cutaneous nerve neuropathy. Therefore, diabetic patients are at much higher risk for experiencing symptoms of Meralgia Paresthetica than the general population.

    Once you have been identified to have symptoms consistent with Meralgia Paresthetica or compression of the Lateral Femoral Nerve (LFN) several diagnostic points should be addressed. In some cases, lower spine or lumbar spine pathology should be ruled out with an MRI. This study can also include a study of the pelvis to rule out any mass or tumor causing compression to the nerve along its course. Ultrasound guided, site specific, diagnostic injections are routinely utilized for confirming the diagnosis. In some cases, the addition of steroid to this injection can provide symptomatic relief for some variable length of time. If there is no spinal or pelvic pathology and the severity of symptoms are not too severe, conservative care is a very appropriate initial treatment. This may include: nerve modulator medicines (i.e. neurontin, amitriptyline, etc. ), topical compound cream, lifestyle changes, weight loss and physical therapy. If conservative therapies have been tried and fail after 3 months, surgical decompression should be considered. Accessory treatment modalities such as radio frequency ablation(RFA), sclerosing or spinal cord stimulators do not treat the problem and should not be utilized for this clinical problem.

    Surgical decompression of the nerve is successful in 80-85% of cases. In the residual population that fail decompression, 80% of these patients will respond to going back and resecting (neurectomy) the nerve.

    The success of the surgery depends on how long the nerve has been compressed, the severity of the compression, the extent of nerve damage due to injury and the possible presence of underlying medical or spine problems.

    The surgery performed in an outpatient setting. The surgical incision is generally very small, however body habitus can dictate a larger incision. The post-operative course is consistent but is affected by the amount of decompression required. In general, people can return to light duty work after 2 to 3 weeks and unlimited/unrestricted activity at 6 weeks.

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    What Is Carpal Tunnel Syndrome?

    What is carpal tunnel syndrome

    Carpal tunnel syndrome (CTS) is a condition brought on by increased pressure on the median nerve at the wrist. In effect, it is a pinched nerve at the wrist. Symptoms may include numbness, tingling, and pain in the arm, hand, and fingers. There is a space in the wrist called the carpal tunnel where the median nerve and nine tendons pass from the forearm into the hand (see Figure 1). Carpal tunnel syndrome happens when pressure builds up from swelling in this tunnel and puts pressure on the nerve. When the pressure from the swelling becomes great enough to disturb the way the nerve works, numbness, tingling, and pain may be felt in the hand and fingers (see Figure 2).

    What causes carpal tunnel syndrome?

    Usually the cause is unknown. Pressure on the nerve can happen several ways: swelling of the lining of the flexor tendons, called tenosynovitis; joint dislocations, fractures, and arthritis can narrow the tunnel; and keeping the wrist bent for long periods of time. Fluid retention during pregnancy can cause swelling in the tunnel and symptoms of carpal tunnel syndrome, which often go away after delivery. Thyroid conditions, rheumatoid arthritis, and diabetes also can be associated with carpal tunnel syndrome. There may be a combination of causes.

    Signs and symptoms of carpal tunnel syndrome

    Carpal tunnel syndrome symptoms usually include pain, numbness, tingling, or a combination of the three. The numbness or tingling most often takes place in the thumb, index, middle, and ring fingers. The symptoms usually are felt during the night but also may be noticed during daily activities such as driving or reading a newspaper. Patients may sometimes notice a weaker grip, occasional clumsiness, and a tendency to drop things. In severe cases, sensation may be permanently lost and the muscles at the base of the thumb slowly shrink (thenar atrophy), causing difficulty with pinch.

    ( Although carpal tunnel is commonly found as an isolated condition, it can frequently co-exist with other compressed or pinched nerves. These can be in the wrist arm or neck regions.  For example, if you have numbness in the small finger as well, the Ulnar nerve needs to be checked.  Nerves are like long wires coming off the spine and can be pinched at more than one site along their path. Comprehensive evaluation by a peripheral nerve surgeon is ideal for these conditions.  See section on peripheral nerve decompression)

    Diagnosis of carpal tunnel syndrome

    A detailed history including medical conditions, how the hands have been used, and whether there were any prior injuries is important. An x-ray may be taken to check for the other causes of the complaints such as arthritis or a fracture. In some cases, laboratory tests may be done if there is a suspected medical condition that is associated with CTS. Electrodiagnostic studies (NCV–nerve conduction velocities and EMG–electromyogram) may be done to confirm the diagnosis of carpal tunnel syndrome as well as to check for other possible nerve problems.

    ( It is very important to understand that the electrodiagnostic studies are not always needed to confirm the diagnosis of carpal tunnel syndrome.  This is a diagnostic study that should be utilized only if necessary.  Further, like other diagnostic tests it has it own rate of false negative and false positive results. The whole clinical picture should be considered in diagnosing nerve compression syndromes, "pinched nerves", like carpal tunnel) 

    Treatment of carpal tunnel syndrome

    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.

    Figure 1:  The carpal tunnel is found at the base of the palm. It is formed by the bones of the wrist and the transverse carpal ligament. Increased pressure in the tunnel affects the function of the median nerve.

    Figure 2:  Aspects of median nerve function.

    Figure 3:  The goal of surgery is to free the ligament to allow more room for the median nerve in the carpal tunnel.


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    Don't Be Scared To Talk About Diabetic Neuropathy

    Don't Be Scared to Talk About 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.

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    Migraine Relief and Migraine Surgery in Kansas City

    pexels photo 236151

    Migraine headaches, real, chronic migraines, can ruin your life. That’s not hyperbole, it’s the truth. When you get migraines regularly, you know that they can cause you to miss work, school, or social events. You can end up curled up in bed for the day, in excruciating pain. Migraine headaches are a scourge on those that suffer from them. But what if there was a way to relieve these nightmares?

    Nerve compression surgery can help. 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. Surgery by Dr. Robert Hagan of the Neuropax Clinic can help relieve the symptoms and causes of severe headaches, allowing the recipient to suffer far reduced migraines, or possibly end the headaches altogether.

    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 have persistent signs and symptoms suggestive of migraine pain, especially if they interfere with your normal activities and sleep patterns, see your doctor. If you leave the condition untreated, they'll only get worse.  For more information or to make an appointment with Neuropax Clinic, call us at 314-434-7784 or visit www.neuropaxclinic.com today to learn more.  Don't live with Migraine Pain any longer than you have to.

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    Relieve Carpal Tunnel Surgery Pain in St. Louis

    Relieve Carpal Tunnel Surgery Pain In St. Louis

    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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    Migraine Surgery Signs in St. Louis

    Migraine Surgery Signs in St. Louis

    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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    Diabetic Neuropathy Is a Serious Disease

    Diabetic Neuropathy

    Peripheral Diabetic Neuropathy (PDN) is a major, long-term complication of Type 1 and Type 2 Diabetes. Diabetic neuropathy often presents as tingling, loss of sensation, pain and numbness in the legs, feet, arms and hands. This loss of sensation can preclude sensation of injury, leading to development of wounds or ulcerations. When not adequately treated, the risks of infection and ultimately amputation are high.

    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. To schedule an appointment, visit www.neuropaxclinic.com and call 314-434-7784 for more information.

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    Are You Suffering With Migraines?

    Migraine Headache

    You probably do if you’re reading this.

    Right now, there are 180 different kinds of headaches defined. Almost everyone gets headaches from time to time. If they are chronic, daily or even continual, you may be suffering from migraines. There are at least 30 million US citizens currently suffering from some kind of chronic migraines. Some of these are responsive to medicine, and some are debilitating and med resistant.

    At least 13% of migraines are believed to be caused by occipital neuralgia. This is a symptom where the Greater occipital nerve is impinged, with tissue causing pressure on the nerve. If 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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    Your Phone Habits Can Lead to Migraine Surgery

    Your Phone Habits Can Lead to Migraine Surgery

    While eyestrain and stress can give you headaches from looking at your phone too much, the real danger isn’t the screen. It’s your posture. Your phone can give you migraines just by how it makes you stand to look at it, and you may not notice until it’s too late.

    Looking down is a natural neck motion. It’s one of the things your body was designed to do, certainly. However, you are not built to look straight down at your phone, laptop, tablet, or smart watch for hours on end, which is what we have started to develop. While Twitter and Facebook are interesting, you need to take a break from them to relax your neck and give your posture a chance to reset.

    Migraines are caused by impingement on the occipital nerve. This nerve, when it is pushed or pulled in a direction that it’s not used to, causes migraine headaches. Yes, you can get severe migraines by looking down at your phone for too long.

    The cure? Well, take a break from your phone. Look where you’re going when you walk. Hold your phone up to your face when you’re watching a YouTube video (not too close, don’t ruin your eyesight too), but just don’t let your neck sit in an awkward position for too long. Children are getting their occipital nerves twisted at a young age and it can affect the rest of their lives.

    If you damage the occipital nerve and are getting migraines, though, they can be fixed. Peripheral nerve surgery for migraines and headache surgery can fix these issues by relieving the pressure on the occipital nerve, which can reduce or end these headaches and stop them from ruining your life.

    If you suffer from migraines, call the offices of Dr. Robert Hagan at Neuropax Clinic. You can reach them at 314-434-7784 or visit www.neuropaxclinic.com to make an appointment. Don’t live with migraines any linger than you have to.

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    Nerve Decompression Surgery for Migraines in Kansas City

    Nerve Decompression Surgery for Migraines in Kansas City

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

    Recently I had an article published along with my colleagues Michael A. Fallucco, MD, FACS, and Jeffrey E. Janis, MD, FACS‡  on Supraorbital Rim Syndrome: Definition, Surgical Treatment, and Outcomes for Frontal Headache.  We wanted to share it with you so we have reprinted it in its entirety here for you.

    Migraine headaches directly affect 11% or more of the adult population (almost 35 million Americans).1There 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 groups913 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.

    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.

    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.

    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 (Fig. (Fig.1).1). If a bony foramen provides the SON frontal exit (27%), this point is a definite closed, nonexpanding site of potential compression (Fig. (Fig.2).2). 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 (Fig. (Fig.3).3). 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.

    An external file that holds a picture, illustration, etc.Object name is gox-4-e795-g001.jpg

    A, SON neurovascular bundle first compression point within a dense periosteal sleeve (pointed out with suction tip) as the SON transitions from its intraconal pathway and exits onto the forehead through a bony foramen. B, Decompressed supraorbital foramen and fascial sleeve (corrugator myofascial component still intact).

    An external file that holds a picture, illustration, etc.Object name is gox-4-e795-g002.jpg

    A, Supraorbital nerve compression site at bony foramen with subperiosteal exposure. B, Complete foraminotomy is completed, as well as coagulation of the supraorbital artery and vein. Myofascial release at corrugator and periosteal sleeve release are also accomplished.

    An external file that holds a picture, illustration, etc.Object name is gox-4-e795-g003.jpg

    Cadaver demonstration (A) of common IIIA fascial band variant. B, Classification for the SON morphology as it exits the supraorbital rim. Knowledge of these potential compression sites proximal to the glabellar myofascial complex enables complete nerve decompression. Supporting decompression at the orbital rim even when true foramen is not present. Note the separate fascial band exit site for supratrochlear nerve along orbital rim. Reprinted with permission from Fallucco M, Janis JE, Hagan RR. The anatomical morphology of the supraorbital notch: clinical relevance to the surgical treatment of migraine headaches. Plast Reconstr Surg. 2012;130:1227–1233. Promotional and commercial use of the material in print, digital, or mobile device format is prohibited without the permission from the publisher Wolters Kluwer Health (a href="mailto:dev@null" data-email="a href="/>moc.rewulksretlow@snoissimrephtlaeh</a>" class="oemail" style="unicode-bidi: bidi-override; direction: rtl; white-space: nowrap; color: rgb(100, 42, 143);">moc.rewulksretlow@snoissimrephtlaeh).

    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%) (Fig. (Fig.44).19,20 Fig. Fig.55 shows a decompressed SON and STN.

    An external file that holds a picture, illustration, etc.Object name is gox-4-e795-g004.jpg

    A, Supratrochlear nerve branching within the orbital and entering the supraorbital rim through a bony foramen. B, A STN foraminotomy was performed allowing nerve decompression of this proximal compression site that is proximal to the glabellar myofascial complex. The second arrow shows the SON foramen.

    An external file that holds a picture, illustration, etc.Object name is gox-4-e795-g005.jpg

    Example of supraorbital and supratrochlear decompression at the orbital rim. Note the quality changes of the nerves at the compression levels.

    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 Fig. Fig.6.6. 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 (Fig. (Fig.7).7). 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.

    An external file that holds a picture, illustration, etc.Object name is gox-4-e795-g006.jpg

    A, Presurgical markings for a direct transpalpebral approach to the supraorbital and supratrochlear nerves (vertical marks within the eyebrow correspond to the location of the supraorbital notch/foramen) with direct crow’s feet incision to access the zygomaticotemporal nerve. B, Anterior hairline or temporal incision for younger patients without periorbital rhytides.

    An external file that holds a picture, illustration, etc.Object name is gox-4-e795-g007.jpg

    A, SON decompression sequence via direct transpalpebral incision. Dissection is carried down to the supraorbital rim lateral to the SON via the decussation between the orbicularis oculi and corrugator supercilii muscle fibers. B, The periosteum of the orbital rim is reflected allowing intraconal view of the orbital roof for full visualization of the SON and STN as the nerve divide from the frontal branch of the trigeminal nerve. C, A foraminotomy is performed with a rongeur, vessels are coagulated, the nerve is mobilized, and the periosteal sleeve is released allowing herniation of the orbital fat. D, The local, vascularized, medial fat pad is mobilized on its pedicle and transposed into the orbital rim defect, allowing healthy vascularized tissue to surround the decompressed SON.

    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 (Fig. (Fig.7D).7D). 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.21The nerve is located inferior to the sentinel vein (Fig. (Fig.8).8). Once identified, a neurectomy is performed. Often, some of the anterior temporalis fibers are divided as well to look for any duplicate aberrant branches.

    An external file that holds a picture, illustration, etc.Object name is gox-4-e795-g008.jpg

    Example of the zygomaticotemporal nerve as it emerges from the deep temporal fascia. Approach can be through crow’s feet incision or as a lateral extension of the transpalpebral incision if upper lid skin excision is planned. Alternatively, a temporal scalp incision can be used in the younger patient with a forward hairline.

    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.

    Statistical Analysis

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

    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; Fig. Fig.9).9). 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.

    An external file that holds a picture, illustration, etc.Object name is gox-4-e795-g009.jpg

    Presurgical and 3- and 12-month postsurgical MIDAS. Statistical analysis was performed with a paired t test for preoperative and postoperative MIDAS scores. After surgical intervention, MIDAS scores decreased significantly at both 3 and 12 months postoperatively (P < 0.0001 vs baseline).

    We analyzed at percentage change in the MIDAS and divided these into 4 categories noted in Table Table1.1. 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.

    Table 1.

    Percent Improvement of MIDAS Scores at 12 mo Postoperatively

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    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.

    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 (Table (Table2).2). 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 Table Table33.

    Table 2.

    Benefits of Direct or Transpalpebral Approach for the Nerves Involved in SORS

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    Table 3.

    Pearls for Surgical Treatment of SORS

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    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.

    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.

    ACKNOWLEDGMENTS

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

    Footnotes

    Disclosures: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

    REFERENCES

    1. Scher AI, Stewart SW, Lipton RB. Migraine and headache: a meta-analytic approach. In: IK C, editor. In: Epidemiology of Pain. Seattle: IASP Press; 1999. pp. 159–170.
    2. Silberstein SD, Holland S, Freitag F, et al. Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Evidence-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. Neurology. 2012;78:1337–1345.[PMC free article] [PubMed]
    3. Olesen J, Burstein R, Ashina M, et al. Origin of pain in migraine: evidence for peripheral sensitisation. Lancet Neurol. 2009;8:679–690. [PubMed]
    4. Lambert GA. The lack of peripheral pathology in migraine headache. Headache. 2010;50:895–908.[PubMed]
    5. Lipton RB. Disability assessment as a basis for stratified care. Cephalalgia. 1998;18(Suppl 22):40–43.discussion 43–46. [PubMed]
    6. Lipton RB, Silberstein SD. The role of headache-related disability in migraine management: implications for headache treatment guidelines. Neurology. 2001;56(6 Suppl 1):S35–S42. [PubMed]
    7. Dellon AL. Nerve entrapment syndromes. In: Hentz VR, Mathes SJ, editors. In: The Hand and Upper Limb, Part 2. Vol VIII. China: Saunders Elsevier; 2006. pp. 875–928.
    8. Dellon AL. Painful neuromas. In: Hentz VR, Mathes SJ, editors. In: The Hand and Upper Limb, Part 2.Vol VIII. China: Saunders Elsevier; 2006. pp. 929–948.
    9. Guyuron B, Varghai A, Michelow BJ, et al. Corrugator supercilii muscle resection and migraine headaches. Plast Reconstr Surg. 2000;106(2):429–434. discussion 435–437. [PubMed]
    10. Janis JE, Ghavami A, Lemmon JA, et al. The anatomy of the corrugator supercilii muscle: part II. Supraorbital nerve branching patterns. Plast Reconstr Surg. 2008;121:233–240. [PubMed]
    11. Chepla KJ, Oh E, Guyuron B. Clinical outcomes following supraorbital foraminotomy for treatment of frontal migraine headache. Plast Reconstr Surg. 2012;129:656e–662e. [PMC free article] [PubMed]
    12. Liu MT, Chim H, Guyuron B. Outcome comparison of endoscopic and transpalpebral decompression for treatment of frontal migraine headaches. Plast Reconstr Surg. 2012;129:1113–1119. [PubMed]
    13. Gfrerer L, Maman DY, Tessler O, et al. Nonendoscopic deactivation of nerve triggers in migraine headache patients: surgical technique and outcomes. Plast Reconstr Surg. 2014;134:771–778. [PubMed]
    14. Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973;2:359–362.[PubMed]
    15. Mackinnon SE. Double and multiple “crush” syndromes. Double and multiple entrapment neuropathies. Hand Clin. 1992;8:369–390. [PubMed]
    16. Fallucco M, Janis JE, Hagan RR. The anatomical morphology of the supraorbital notch: clinical relevance to the surgical treatment of migraine headaches. Plast Reconstr Surg. 2012;130:1227–1233.[PubMed]
    17. Bovim G, Sand T. Cervicogenic headache, migraine without aura and tension-type headache. Diagnostic blockade of greater occipital and supra-orbital nerves. Pain. 1992;51:43–48. [PubMed]
    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 Anaesthesiol. 2002;16:499–504. [PubMed]
    19. Janis JE, Hatef DA, Hagan R, et al. Anatomy of the supratrochlear nerve: implications for the surgical treatment of migraine headaches. Plast Reconstr Surg. 2013;131:743–750. [PubMed]
    20. Janis JE, Ghavami A, Lemmon JA, et al. Anatomy of the corrugator supercilii muscle: part I. Corrugator topography. Plast Reconstr Surg. 2007;120:1647–1653. [PubMed]
    21. Peled ZM. A novel surgical approach to chronic temporal headaches. Plast Reconstr Surg. 2016;137:1597–1600. [PubMed]
    22. Stewart WF, Lipton RB, Dowson AJ, et al. Development and testing of the Migraine Disability Assessment (MIDAS) questionnaire to assess headache-related disability. Neurology. 2001;56(6 Suppl 1):S20–S28. [PubMed]
    23. Wolff H. Headache and Other Head Pain. New York: Oxford University Press; 1948.
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    Migraine Pain in St. Louis and When to Get Help

    headache medium

    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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    Carpal Tunnel Syndrome Warning Signs in Indianapolis

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    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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    Get Migraine Surgery in Indianapolis at Neuropax Clinic

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    Migraine headaches, real, chronic migraines, can ruin your life. That’s not hyperbole, it’s the truth. When you get migraines regularly, you know that they can cause you to miss work, school, or social events. You can end up curled up in bed for the day, in excruciating pain. Migraine headaches are a scourge on those that suffer from them. But what if there was a way to relieve these nightmares?

    Nerve compression surgery can help. 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. Surgery by Dr. Robert Hagan of the Neuropax Clinic can help relieve the symptoms and causes of severe headaches, allowing the recipient to suffer far reduced migraines, or possibly end the headaches altogether.

    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 have persistent signs and symptoms suggestive of migraine pain, especially if they interfere with your normal activities and sleep patterns, see your doctor. If you leave the condition untreated, they'll only get worse.  For more information or to make an appointment with Neuropax Clinic, call us at 314-434-7784 or visit www.neuropaxclinic.com today to learn more.  Don't live with Migraine Pain any longer than you have to.

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    Kansas City Open Carpal Tunnel Surgery

    Figure 3 Carpal TunnelCarpal 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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    Are You Suffering From Migraines?

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    You probably do if you’re reading this.

    Right now, there are 180 different kinds of headaches defined. Almost everyone gets headaches from time to time. If they are chronic, daily or even continual, you may be suffering from migraines. There are at least 30 million US citizens currently suffering from some kind of chronic migraines. Some of these are responsive to medicine, and some are debilitating and med resistant.

    At least 13% of migraines are believed to be caused by occipital neuralgia. This is a symptom where the Greater occipital nerve is impinged, with tissue causing pressure on the nerve. If 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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    Get Migraine Surgery in Kansas City at Neuropax Clinic

    Get Migraine Surgery in Kansas City at Neuropax Clinic

    Migraine headaches, real, chronic migraines, can ruin your life. That’s not hyperbole, it’s the truth. When you get migraines regularly, you know that they can cause you to miss work, school, or social events. You can end up curled up in bed for the day, in excruciating pain. Migraine headaches are a scourge on those that suffer from them. But what if there was a way to relieve these nightmares?

    Nerve compression surgery can help. 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. Surgery by Dr. Robert Hagan of the Neuropax Clinic can help relieve the symptoms and causes of severe headaches, allowing the recipient to suffer far reduced migraines, or possibly end the headaches altogether.

    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 have persistent signs and symptoms suggestive of migraine pain, especially if they interfere with your normal activities and sleep patterns, see your doctor. If you leave the condition untreated, they'll only get worse.  For more information or to make an appointment with Neuropax Clinic, call us at 314-434-7784 or visit www.neuropaxclinic.com today to learn more.  Don't live with Migraine Pain any longer than you have to.

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    Carpal Tunnel Syndrome Warning Signs In Kansas City

    Carpal Tunnel Syndrome Warning Signs In Kansas City

    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 in Kansas City 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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    Peripheral Nerve Problems Leading To Kansas City Migraines

    Kansas City Migraines

    Migraines that are caused by peripheral nerves can be treated with peripheral nerve surgery. The surgery involves freeing the nerve from the surrounding tissue to relieve the irritation. This can alleviate, reduce, or even end the pain of migraines once and for all. Peripheral nerve problems leading to migraines in Kansas City are a problem that can be solved.

    What causes this pain? Just like with any peripheral nerve issue, there can be multiple causes. Some people are born with a proclivity toward migraines through physiology or build, and they develop them naturally.

    Another is lifestyle. It is no coincidence that migraines have increased as we have become more dependent on screens and phones, items that cause our bodies to contort to strange shapes to utilize properly.

    Looking down at a screen all day can cause an impingement of the occipital nerve in the neck that can lead to migraines and pain. All it takes is a bit of pressure on the occipital nerve and you can be debilitated for hours.

    Migraines are a real health problem. They can lead to job loss and loss of quality of life, as they can cause sufferers intense pain and remove their ability to concentrate or work.

    It can make you irritable or short-tempered, with the need to get away and lie in a dark room more important than spending time with your family. Migraines have a cascading effect on the rest of your life, but they can be fixed.

    Repairing a damaged or impinged peripheral nerve can be a lifechanging experience and lead to a better life, and can also be often held as an outpatient surgery with a short recovery time.

    If you suffer from migraines, call the offices of Dr. Robert Hagan at Neuropax Clinic. You can reach them at 314-434-7784 or visit www.neuropaxclinic.com to make an appointment. Don’t live with migraines any linger than you have to.

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