Thread by @plasticsfella

Live Tweeting Dr Jeff Janis Webinar on "Surgical Management of Migraines"

Zoom: (us02web.zoom.us/w/82891733082?…)

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No doubt referring to his landmark publication -

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Will be a thread, followed by summary. Retweet or comment with discussions.

@jjanismd

Landmark Publication on Surgical Mx of Migraines

drjeffreyjanis.com/wp-content/upl…

1/ "Nerve Decompression Surgery for Headaches"
Jeffrey Janis, MD FACS, Prof Plastic Surgery

Why we should be interested? Because of the amount of patients presenting with migraines (35 million people in US alone)

2/ Current Treatments: 1/3 of patients are not help by standard therapies. Medication doesn't eliminate the condition, usually only reduces it.

3/ Traditional Treatments of Migraines: Medication to prevent, medication to abort them. For example, sumatriptan and propanolol, respectively. It's a "shotgun" approach and is a clue to further understanding is required. Disdav: compliance, cost, slow.

4/ Dr Bahmam Guyuron - improvement of migraine headaches. Unexpected outcome after cosmetic browlifts. Evolution of thought - "carpal tunnel syndrome of the head".

5/ Thought to be surpraorbital and supratrochlear nerve entrapment by the corrugator supercilli muscle. The initial thought process in the year 2000s by the leaders at the time.

6/ Etiology: Traditional - centrally mediated neurovascular phenomenon. New concept: peripherally mediated trigger points. Branches of the trigeminal nerve and their muscular investments. "Like saying eath flat vs earth round"

7/ Landmark publication "Corrugator Supercillii Muscle Resection and Migraine Headaches" by Guyruon, showed nearly 80% of patients had migraine improvement. It was a proof of concept study that led the path to modern-day treatments.

8/ Evolution of Technique: can't perform corrugator resection on everyone with a migraine, that's when Botox was introduced. FDA approved on-label use for Migraines.

9/ Anatomy: 3 common locations of migraine pain. Periorbital area, temples, and back of the neck. Trigger points are supra-orbital, supra-trochlear, zygomaticotemporal, greater occipital nerve, nasoseptal. Showed its muscle, fascia, cartilage are locations of compression.

10/ Frontal: corrugator muscle beings 3mm lateral to the midline, and extends 85% of the distance from nasion to lateral orbital rim. Important landmarks for injections and surgery.

11/ injecting the corrugator: 3 injection point technique from the mid-glabellar injection site. 30gauge, 1-inch needle, inject 12.5 units/corrugator (0.5cc). Inject parallel to muscle fibers. Allows complete denervation of the corrugator muscle.

12/ Supra-orbital nerve - 4 branching points. can be compressed at bone, fascia or muscle. presence of supra-orbital notch has a tight fascial band and is a common site of compression. Doing a supra-orbital foraminotomy will result in an improvement in these patients

13/ Endoscopic techniques: not suitable for bone decompression. Janis uses a 5 or 6 incision technique. The strategy evolved to involve a counter incision in the supra-orbital nerve. Very impressive surgical videos on show.

14/ Non-endoscopic deactivation of nerve triggers - consistent scientific evidence to support this technique (98% efficacy)

15/ Zygomatictemporal fascia - in the sulcus just lateral to the eyebrow. inject 18.75 units (0.75cc)/side. Diffuses up to 3cm.

16/ the best way to find out a trigger point - the index finger. ask the patient to point with their index finger where their pain begins.

17/ is the pain gone when you press on that area? If the patient can remove pain with compression, it is vascular compression. for example, the auriculotemporal nerve and superficial temporal vessel. doppler test is key.

18/ Occipital Area: 3cm inferior and 1.5cm to occipital protuberence. This is the emergency of the greater occipital nerve from the semi-spinalis muscle. This is the location of where to inject the botox (62% resolution - Guyuron)

19/ GON has 6 points of compression (includes muscle, fascia, vessel, bone). "routine removal of occipital artery may not be necessary". It a mechanical not inflammatory compression.

20/ Nose is also a trigger site - suspect when nasal or sinus pathology, for example - concha bullosa, turbinate hypertrophy.

21/ Patient selection: diagnose migraine by a neurologist prior to any surgery. it's not first-line treatment - refractory to medical treatment or disability.

22/ Choosing injection sites: where does pain begin, use index finger, and when does pain go. common locations are peri-orbital, temple, back of neck, retro-orbital.

23/ the definitive publication: a placebo-controlled trial fo the treatment of migraine headaches. PRS August 2009. "sham surgery" with high statistical significance - "top 10 articles of all time in plastic surgery"

24/ peripheral and central connection: sensory and pain fibers cross the calvarial bones through the cranial sutures connect the intracranial and extracranial axons. suggestions communications between peripheral and central structures.

25/ proven socioeconomic benefit: medial total cost reduction of nearly $4000/year. "surgery pays for itself in 2 years"

26/ average success rate is 90% with surgery. nerve decompression is better than alternative forms of treatment. the biggest barrier to adopting surgery options is MDT approach required.

27/ Q&A Time: how to get neurologists on board? you are there to augment their business, not steal it. would you consider a plastic surgeon as part of referral pathway for refractory patients.

28/ Q&A: No role for nerve conduction studies in pre-operative diagnosis. Big role for lidocaine nerve blocks to diagnose trigger points (must have active pain in that location prior to injection)

29/ Q&A: Post-op complications? 100% of patients will have a temporary complete loss of sensation that may be permanent (rare). Neuroma can be a potential complication. Incisional alopecia

30/ Q&A: Multiple trigger points? Yes they can. Often they can be linked. Cannot do pre-operative diagnostic nerve block to multiple trigger points as cant tell what the effective treatment location was. Trick: Diagnose 1 trigger point at a time.

31/ Q&A: Role for Imaging? Facial CT scan 3mm cuts with coronals to diagnose a nasal trigger point. Can see a "notch" vs a "foramen".

32/ Q&A: Is the timing of surgery important? Not really. A criterion for failure can be an older age of diagnosis for migraines.