Superficial Nerve Decompression Surgery for Chronic Headache

• Pamela Blake, MD• Director, Headache Center of Northwest• Houston, TX

• Carlton Perry, MD• River Oaks Plastic Surgery Center• Houston, TX

Outline

• Background• Review of anatomy and the surgical procedure • The clinical presentation of chronic headache due to nerve

compression• Pre-operative evaluation and patient selection• Data of clinical trial • Future directions

background

central vs. peripheral

Support for the role of peripheral nerves in the etiology of headache

• Occipital and trigeminal nerve blocks• Sphenopalatine ganglion blocks• Botulinum toxin• Peripheral neurostimulators• Monoclonal antibodies to CGRP

Experience with nerve decompression surgery• 1995: fellowship at JHH neuro-ophthalmology• 1999: faculty at Georgetown; NIH Cognitive Neuroscience Section • Many patients with chronic, refractory headache pain in the occipital

nerve distribution, with good but brief response to ONB• 2004 Ivica Ducic, board-certified Plastic and Reconstructive surgeon

with fellowship training in Peripheral Nerve surgery

Experience with nerve decompression surgery• Poster by Bahman Guyuron* regarding occipital nerve decompression• 2004 pt – S. O. – graduate student in Chemistry, refractory headaches,

brief response to ONB; about to leave PhD program• Decompression of bilateral Greater Occipital Nerves• Good but incomplete response – still with pain in temples• Return to OR for Lesser Occipital Nerve decompression• Better response; able to remain in program

Experience with nerve decompression surgery• 2004-2006, over 100 patients underwent occipital nerve

decompression at GUH with Ivica Ducic• About 70% of pts had reduction in headache (>50% reduction in

severity)• Moved from DC to TX in 2006• Subsequent follow-up of pts by other headache specialists in DC

showed some of the pts had ongoing headaches, but ongoing response in others. Compelling enough to continue to offer this treatment and to work toward understanding mechanism.

Houston experience

• 2006 – collaboration with Carlton Perry, MD, Plastic and Reconstructive Surgeon with extensive reconstructive experience

• May 2007 – first pt in Houston• 2007 – present - > 700 nerve decompression procedures • Clinical: Ongoing modification of program to identify appropriate

surgical candidates, modification of surgical technique, and development of program of post-operative management for optimal outcome

Houston experience

• Additional collaboration with other plastic surgeons, Bardia Amirlak in Dallas, Jason Hall in TN

• 2009: Research with Rami Burstein on the inflammatory tissue observed at time of surgery, with data of inflammatory process involved in the mechanism of superficial nerve involvement, presented at 2013 IHS meeting

Nerve Decompression Surgery experience

(1) Nerve Decompression Surgery is very helpful for a subset of patients with chronic headaches(2) Nerve compression involves an anatomic predisposition for muscular or fascial compression with an associated inflammatory process, resulting in chronic pain in the distribution of the involved nerves (3) Correct patient selection is the single most important step in the process

Case example : EM

• EM: 48 year old woman from San Antonio, accountant, 2004 onset of chronic headache. Changed job to work from home, 6-7/10 pain daily.

• Failed to respond to 9 preventative medications (gabapentin, verapamil, Sansert, Doxepin, valproic acid, nortriptyline, amitriptyline, topiramate, Lyrica)

• Triptans ineffective• Treated at quaternary headache clinic with PNS 2006. Good response initially, but

developed autoimmune response to the device, requiring multiple revisions and eventually removal (8 surgeries total)

• Jan 2012 – pt seen at HCNW. Pain is daily, constant, 7-8/10, working part-time from home. Pain in the occiput and radiating up the back of the head. Significant tenderness to touch on the occiput. Feels slow mentally, unable to control pain, prolonged time to accomplish tasks.

EM cont’d

• Feb 2012: Good response to ONB, effects waned • July 2012: decompression of bilateral lesser and greater occipital

nerves• October 2012: 20% reduction in headache pain• January 2013: 40 % reduction in headache pain• April 2013: 55% reduction in headache pain• August 2013: 85-90% reduction in headache pain• April 2014: 80-85% reduction of headache pain

EM cont’d

• Massage in April 2014 aggravated pain resulting in a temporary increase in pain baseline, reduced with Medrol dose pack.

• April 2014- present: no preventative medication, Ibuprofen for acute pain, no headache related disability

• July 2015: ongoing 80-85% reduction in pain severity. Daily pain is 2-3/10. EM pleased with result.

review of anatomy, and surgical procedure and pathology

clinical presentation of chronic headache due to nerve compression

Headaches due to superficial nerve compression• Frequency – usually daily with no pain-free periods; intensity of pain

typically fluctuates• Location of pain – for occipital nerve involvement, usually

predominantly occipital but typically radiates to the vertex, temples, or retro-orbital

• Sometimes pain is more prominent frontally• Rarely pain is only in frontal locations

• Characteristics of pain- typically pressure, squeezing, tightness; very rarely neuropathic. As pain radiates to frontal/trigeminal areas, more throbbing, pulsating, with migrainous features

Headache due to superficial nerve compression• Often tender to pressure on the back of the head• Patients often awaken at night with pain• Have to sit up in bed to get head off the pillow; sometimes sleep in

recliner• Often buy various pillows trying to find the best one• Can have pain with resting occiput against back of chair or sofa• Often apply ice to occiput

Headaches due to superficial nerve compression• Usually have trapezius muscle spasm• Aggravating factors - turning head to side, prolonged cervical flexion

or extension, lifting eg grocery bags, strong smells• Alleviating factors – avoidance of movement• Acute medications – can respond to triptans, esp the frontal

involvement• Preventative medications – usually not helpful

Headaches due to superficial nerve compression• Patients may respond to nerve blocks, usually temporarily; some

patients who do not respond to nerve blocks can go on to do well with surgery

• Some degree of disability usually present• Some degree of mood disorder usually present• Some degree of medication overuse often present (MOH must be

ruled out prior to referring for surgery)

preoperative psychological assessment

Psychological factors in headache

• Mood disorders• Somatic Symptom Disorder• Residual effects of childhood trauma

Mood disorders

• Presentation and PMH• In office screens (PHQ-9, Hamilton, Perceived Stress Scale, etc)• Psychological evaluation• Amenable to treatment with medications, therapy

Somatic Symptom Disorder

• Revised in DSM-V• Symptoms that are distressing and affect function• Excessive and disproportionate thoughts, feelings and behaviors• > 6 months• While not required by DSM-V, often accompanied by other ailments

eg IBS, pelvic pain etc• MMPI and directed clinical interview helpful

Residual effects of childhood trauma

• Association between childhood sexual and physical abuse reported in many publications

• ACE Study – 1998• <17,000 patients at Kaiser questioned re: exposure to a variety of

traumatic experiences, family dysfunction• Traumatic exposures compared to 10 risk factors associated with

adult morbidity and mortality – smoking, obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, drug abuse, STDs etc

Residual effects of childhood trauma

• Additionally relationship between ACEs and common causes of mortality incl ischemic heart disease, cancer, stroke, COPD, diabetes. Hepatitis, fractures

• One question…”Are you troubled by frequent headaches?”• The relationship between ACEs and adult risk factor and illness was

strong and dose-related

Fig. 2

American Journal of Preventive Medicine 1998 14, 245-258DOI: (10.1016/S0749-3797(98)00017-8)

ACE and headaches

• 2011 Tietjen and the original authors of the ACE examined the relationship between ACEs and headache

• Each ACE assoc with an increased risk of headache• Dose response relationship – as the number of ACEs increased, so did

the likelihood of headache• Consistent with previous reports of higher rates of abuse in headache

populations

Canst thou not minister to a mind diseased?Pluck from the memory a rooted sorrow,

raze out the written troubles of the brain,and with some sweet oblivious antidote,

cleanse the stuffed bosom of that perilous stuffwhich weighs upon the heart?

-Macbeth

Psychological evaluation - progression• Initially none • → psychological assessment with MMPI post-op in pts who did not

improve • → pre-op psych assessment (POPA) with MMPI in pts with possible

psych issues • → POPA in all pts • → POPA in all pts with initiation of therapy if indicated for SSD for 2

months prior to surgery • → POPA with ACE in all pts pre-op, initiation of therapy for 2 months if

indicated.

Psychological factors in headache surgery• Always a frank conversation with pt and family that surgery may not

be helpful if there are significant psychological co-morbidities• Unexpected emotional effects following surgery with headache

reduction:• Pt having to deal with ‘back-burner’ issues that have accumulated

during period of pain and disability• Higher expectations of function by family members• Return to school in adolescents cause significant stress and can

worsen headache

Clinical trial

Nerve Decompression Surgery experience

(1) Nerve Decompression Surgery is very helpful for a subset of patients with chronic headaches(2) Nerve compression involves an anatomic predisposition for muscular or fascial compression with an associated inflammatory process, resulting in chronic pain in the distribution of the involved nerves (3) Correct patient selection is the single most important step in the process