No abstract

Successful treatment of the painful neuroma is a particular challenge to the nerve surgeon. Historically, symptomatic neuromas have primarily been treated with excision and implantation techniques, which are inherently passive and do not address the terminal end of the nerve. Over the past decade, the surgical management of neuromas has undergone a paradigm shift synchronous with the development of contemporary techniques aiming to satisfy the nerve end. In this article, we describe the important features of surgical treatment, including the approach to diagnosis with consideration of neuroma type and the decision of partial versus complete neuroma excision. A comprehensive list of the available surgical techniques for management following neuroma excision is presented, the choice of which is often predicated upon the availability of the terminal nerve end for reconstruction. Techniques for neuroma reconstruction in the presence of an intact terminal nerve end include hollow tube reconstruction and auto- or allograft nerve reconstruction. Techniques for neuroma management in the absence of an intact or identifiable terminal nerve end include submuscular or interosseous implantation, centro-central neurorrhaphy, relocation nerve grafting, nerve cap placement, use of regenerative peripheral nerve interface, “end-to-side” neurorrhaphy, and targeted muscle reinnervation. These techniques can be further categorized into passive/ablative and active/reconstructive modalities. The nerve surgeon must be aware of available treatment options and should carefully choose the most appropriate intervention for each patient. Comparative studies are lacking and will be necessary in the future to determine the relative effectiveness of each technique.

Neurolysis of the greater occipital nerve appears to provide safe, durable pain relief in the majority of selected patients with chronic headaches caused by occipital neuralgia.

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.

Among the potential complications associated with the use of breast implants are the risks of periprosthetic infection and device extrusion. There is little published information about the effective management of these situations. Conservative recommendations include antibiotic therapy and removal of the implant until resolution of the infection or until the wound has healed. A retrospective review identified patients with periprosthetic infection or threatened or actual device exposure treated by the senior author. Twenty-four patients encompassing 26 affected prostheses were available for review and were classified into seven groups based on initial presentation as follows: group 1, mild infection (n = 8); group 2, severe infection (n = 4); group 3, threatened exposure without infection (n = 3); group 4, threatened exposure with mild infection (n = 3); group 5, threatened exposure with severe infection (n = 1); group 6, actual exposure without clinical infection (n = 5); and group 7, actual exposure with infection (n = 2). To salvage the prosthesis in these patients, various treatment strategies were utilized. All patients with a suspected infection or device exposure were started immediately on appropriate antibiotic therapy (oral antibiotics for mild infections and parenteral antibiotics for severe infections). Salvage methods included one or more of the following: antibiotic therapy, débridement, curettage, pulse lavage, capsulectomy, device exchange, primary closure, and/or flap coverage. Twenty (76.9 percent) of 26 threatened implants with infection or threatened or actual prosthesis exposure were salvaged after aggressive intervention. The presence of severe infection adversely affected the salvage rate in this series. A statistically significant difference exists among those patients without infection or with mild infection only (groups 1, 3, 4, and 6); successful salvage was achieved in 18 (94.7 percent) of 19 patients, whereas only two of seven of those implants with severe infection (groups 2, 5, and 7) were salvaged (p = 0.0017). Ten (90.9 percent) of 11 devices with threatened or actual exposure, not complicated by severe infection (groups 3, 4, and 6), were salvaged. Several treatment strategies were developed for periprosthetic infection and for threatened or actual implant exposure. Patients with infection were placed on oral or intravenous antibiotics; those who responded completely required no further treatment. For persistent mild infection or threatened or actual exposure, operative intervention was required, including some or all of the following steps: implant removal, pocket curettage, partial or total capsulectomy, débridement, site change, placement of a new implant, and/or flap coverage; the menu of options varied with the precise circumstances. No immediate salvage was attempted in five cases, due to either severe infection, nonresponding infection with gross purulence, marginal tissues, or lack of options for healthy tissue coverage. Based on the authors' experience, salvage attempts ...

The course of these two nerves differs in several critical aspects from that described in classic anatomical reports. These findings have direct implications for application of nerve blocks and surgical decompression of these nerves.

Therapeutic, III.(Figure is included in full-text article.).

There are six compression points along the greater occipital nerve. These can be located using the data from this study, serving as a guide for surgeons interested in treating patients with migraine headaches originating in these areas. Long-term relief from migraine headaches has been demonstrated clinically by using both noninvasive and surgical decompression of these points.