(Ivanhoe Newswire) - As many as 3.8 million athletes suffer concussions each year in the U.S.. These injuries can cause serious brain damage, and for many, another problem but now there's a new way to relieve the pain.
"It was awful. It's a parent's worst nightmare," says Anita Byer, whose daughter suffered a concussion.
This is Hollie Byer's first soccer game since suffering her fourth concussion.
The last one caused painful headaches that just wouldn't go away.
"It would go from the back of my neck all the way up to the front of my head," Hollie Byer told Ivanhoe.
The concussion not only injured Hollie's brain, but it also flattened nerves in the back of her head. When medications didn't relieve the pain, Georgetown plastic surgeon Ivica Ducic suggested surgery to decompress the nerve – essentially "unbuttoning" it.
"The equivalent of unbuttoning a shirt and tie because it's just too tight, and you can't breathe or speak normally," explained Dr. Ducic.
The doctor cuts the muscles that surround the damaged nerve giving it room to expand. This relieves pressure and pain. One study found nearly 85% of patients who underwent this procedure had at least a 50 percent reduction in symptoms.
"Changing somebody's quality of life is really, really rewarding," Dr. Ducic said to Ivanhoe.
Hollie's headaches were gone the day after her surgery.
"No more pain. It's been great," said Hollie.
Now she's thrilled to be back in the game.
"So excited! I just woke up with a smile on my face, like, I'm playing tonight!" continues Holly.
An athlete who doesn't have to play through the pain any longer.
The doctor says there's no way to know how many concussion patients report having headaches, but he sees at least two each week. He says the problem is under-reported and under recognized. Research suggests if someone has already suffered a concussion, they are one to two times more likely to suffer a second. The doctor believes there are less than 100 surgeons in the country performing the nerve procedure.
BACKGROUND: A concussion is a traumatic brain injury that alters the way your brain functions. Effects are usually temporary, but can include problems with headache, concentration, memory, judgment, balance and coordination. Although concussions usually are caused by a blow to the head, they can also occur when the head and upper body are violently shaken. These injuries can cause a loss of consciousness, but most concussions do not. Because of this, some people have concussions and don't realize it. Concussions are common, particularly if you play a contact sport, such as football. But every concussion injures your brain to some extent. This injury needs time and rest to heal properly. Luckily, most concussive traumatic brain injuries are mild, and people usually recover fully. (Source: MayoClinic)
TYPES/SIGNS: Signs and symptoms of a concussion may include: Headache or a feeling of pressure in the head, temporary loss of consciousness, confusion or feeling as if in a fog, amnesia surrounding the traumatic event, dizziness or "seeing stars", ringing in the ears, nausea or vomiting, slurred speech, and fatigue. (Source: MayoClinic)
TREATMENT: Rest is the best way to allow your brain to recover from a concussion. The American Academy of Pediatrics recommends both physical and mental rest for children. This means avoiding general physical exertion as well as activities that require mental concentration, such as playing video games, watching TV, texting or using a computer. School workloads should also be temporarily reduced. For headaches, use acetaminophen (Tylenol, others). Avoid other pain relievers such as ibuprofen (Advil, Motrin, others) and aspirin, as there's a possibility these medications may increase the risk of bleeding. If you or your child sustained a concussion while playing competitive sports, ask your doctor or your child's doctor when it is safe to return to play. Resuming sports too soon increases the risk of a second concussion and of lasting, potentially fatal brain injury. No one should return to play or vigorous activity while signs or symptoms of a concussion are present. Experts recommend that children and adolescents not return to play on the same day as the injury. (Source: MayoClinic)
NEW SURGERY FROM THE DOCTOR'S PERSPECTIVE: "What we do is make an incision after the opening which is accessing just plain sub continuous tissues, and then you are approaching the areas were nerves actually live," Ivica Ducic, M.D., Ph.D., Professor of Plastic Surgery and Neurosurgery, Director of Peripheral Neurosurgery in Georgetown, told Ivanhoe. " You free the fasual layer, which is just a coat over the muscles, but due to trauma it gets to be stiffer. Instead of just being a nice envelope around the nerve, it starts pinching the nerve and pressing it, and the nerve protests and gives you the headache or migraine. If the oson atomically intra-operatively defines variations or pressure by any other structure of vessels or a portion of tFhe muscle, we would free up that as well."
Ivica Ducic, M.D., Ph.D., Professor of Plastic Surgery and Neurosurgery, Director of Peripheral Neurosurgery in Georgetown, talks about concussions and a new surgery that could help those suffering from the consequences.
How common are concussions?
Dr. Ducic: I really don't know the true incidence of that. We do know that approximate 28 million Americans are suffering from chronic migraines headaches. One form of the chronic migraine headaches is the trigeminal frontal and temporal neuralgia pain in the front and side of the head, and the occipital neuralgia in the back of the head. What percentage of those patients really belong to those plus concussions patients we really don't know. I think it's quite underreported. We actually right now are trying to get a grasp on how to help these patients because by this time most of them were told or were managed according to the post-concussion protocols. We are finding out that in addition to the traumatic injury to the brain, patients also can have a peripheral nerve problem that can continue to give them chronic migraines, or headaches, or neuralgia meaning pains are in the front, side, or back of the head.
How can that kind of pain interfere with their life?
Dr. Ducic: It significantly affects the quality of their life. It varies certainly from person to person, but patients have difficulty functioning professionally, socially, and personally. It really tremendously affects the quality of the patient's life.
Why the concussion leads to the headaches?
Dr. Ducic: Brain injury itself and concussions are one part of their traumatic history. The other part is either direct trauma to the nerves in respect of anatomical areas or so-called traction stretch injuries to the nerves, which means that due to the motion at the time of the trauma itself certain nerves in an anatomical area of the front, side or back of the head can be stretched and pinched. That causes swelling of the nerve, and ultimately malfunctioning of the nerve thereby giving people chronic migraine or neuralgia.
Does that happen because the brain kind of shifts? Hits those nerves?
Dr. Ducic: The brain itself in terms of concussion has its own type of physiology with the movement that happens with the post-concussion injury. Nerves are outside of the skull and they have their own mechanism of how they get to be injured. The issue is that we are now recognizing and acknowledging in sense of treatment is that those two separate anatomical structures are affected, but they happen at the same time of the trauma. Until now we were only considering the trauma to the brain to be the main factor responsible for their other problems after the fact.
Traditionally what has been done for these patients?
Dr. Ducic: Traditionally these patients would see specialized neurologists and a medical provider who would perform a proper diagnostic workup, perform proper radiological studies, and prescribe proper medications. For the most part, once the brain injury hopefully settles those patients I expect to do well. If the concussion is happening together with contusion of the brain then the most scarring in the brain can happen. Synapsis between the brain cells can be disturbed to higher levels and unfortunately both cognitive and any other functional problems can occur after that.
What would they take for their pain, would they take medicines?
Dr. Ducic: Medical treatment certainly would be applied for those problems, and one of the problems that happen is there are a fairly limited number of drugs that can be used. The neurology colleagues use for, let's say, cognitive impairments and learning disabilities, different methods that they can try to bring those patients to as functional conditions as could be. For the pain, for example, obviously narcotics and other medications including migraine medications are prescribed for these patients. As we know they can help up to a certain degree, not to mention the patients at one point will become tolerant to them and they need to increase their doses, which increases the potential of the side-affects and ultimately worsens the patients' quality of life despite taking medications and despite having good medical doctors taking care of them. They are still not getting where they want to get either professionally, personally, or socially.
What is this surgery that you perform?
Dr. Ducic: After these patients went through the logical sequence of events in terms of the work up by the medical provider and medical treatment, and they continue to have problems for at least three months, the new teaching now is the involvement of a trained peripheral nerve surgeon who look for the tenderness over the nerves that are passing in that anatomical region and that can give you the chronic pain or headache. So, in the front area they're just above your eyebrows; on the side of the head there are two nerves and in the back of the head there are three nerves on each side. Once we look for the tenderness of those nerves in patients who very precisely tell you ‘yes, it hurts me right there,' then we can go to the next step and obtain the nerve block temporarily dis-inhibiting that nerve; basically doing a diagnostic block. So the patient with this history and tenderness of the nerves would actually experience relief from the headaches or migraines or neuralgia. This would be indirect confirmation that that nerve is directly involved in the patho-physiology of their migraines or occipital neuralgia or any sort of headache they would be presenting, in which case we then proceed with surgical intervention.
What actually do you do during that surgery?
Dr. Ducic: What we do with surgical intervention depends on the mechanism of the injury. If the mechanism of the injury has caused direct trauma with cuts and open skin requiring sutures in that anatomical region, I might need to remove that nerve although it is a sensory nerve. The only deficit after that would be numbness in that respective area because these nerves have nothing to do with any motion of the face, arms, or legs and besides that they're not in the brain. We don't go into either the brain or the spine; incisions made over the front part of the head, side, and back part of the head are rather superficial and scars are mainly hidden by hair. If the trauma has not directly damaged the nerves and scarred them, but rather just disturbed them to the degree that they can cause some swelling and different three-dimensional spacing that can cause malfunction of the nerve, what they would do then is decompress those nerves. It's the equivalent of unbuttoning shirt and tie because it's too tight and you can't breathe or speak normal. So that phenomenon in the example has been done for carpal tunnel for centuries and it can now be applied very easily in the treatment of the post-traumatic headaches and migraines.
Is that would you did with Holly, the patient that we talked to?
Dr. Ducic: That's exactly what we did with her, yes.
When you say decompress what actually is going on there?
Dr. Ducic: What we do is make an incision after the opening which is accessing just plain sub continuous tissues, and then you are approaching the areas were nerves actually live; in her case in the back of the head. Then you would go ahead and free the fascial layer which is just a coat over the muscles but due to trauma it gets to be stiffer. So instead of just being a nice envelope around the nerve, it starts pinching the nerve and pressing it, and obviously the nerve protests and gives you the headache or migraine. If intra-operatively atomically variations or pressure by any other structure of vessels or a portion of the muscle, are identified, we would free up that as well.
How common is the procedure for patients?
Dr. Ducic: Well, the first surgery I've done was in February of 2005 and so far I've done about 1275 of them. So, I certainly do see lots of patients for this problem, but I believe that this problem is quite underreported and under recognized.
Just with concussions or are you talking about all of your patients?
Dr. Ducic: I would say overall, but for post-concussion sports injury related patients I would say it's definitely overlooked and underappreciated because everybody is probably trying to focus on their concussion treatment and explaining all of their symptoms as post-concussion consequences. At the same time these patients can have traction stretch injury or direct injury to their peripheral nerve in respect to the anatomical part of the head that can completely account for them having a headache or a migraine or a combination.
Is that particular surgery widespread around the country? Are other surgeons performing it?
Dr. Ducic: It is a fairly new surgery. A number of colleagues across the country are certainly catching up and trying to do it. A certain level of technical expertise and comfort is needed and I'm fortunate enough to have one year of the peripheral nerve surgery fellowship training specifically geared toward nerves, so I'm very comfortable doing it. As time goes on, certainly colleagues across the country will probably catch up on it as well.
How rewarding for you as a physician is it when patients come in and have horrible pain and then you're able to fix it for them?
Dr. Ducic: Well, that's what it's all about frankly. Changing somebody's quality of life is really rewarding. First of all, it confirms everything that you've thought about and that your thought process of applying the treatment was right. Second, seeing people you know taking a turn towards the better is certainly gratifying and motivating for doing it even more.
Sometimes, like in the case of Holly, they're able to go out and do what they love even though it's what caused the injury to begin with, like it was soccer for her or some other sport.
Dr. Ducic: That is certainly great, but I would say an even bigger and more important thing that they don't even realize initially is what we are preventing for those patients. Certainly it's great to see happy patients and get a hug from a patient who says, ‘my life is back; I can play sports, I can study again, I can work.' That is great, but on the other hand what we don't verbalize is if we hadn't done that for the patient then that person would be suffering tremendously and be deprived of accomplishing something in life, either in their sports careers, their academic careers, or in their family life. So I would say the prevention of forcible negatives, for me, is even more important than the obvious positive that we see and get acknowledgement from the patient about.
You said you don't work directly with concussions other than doing this surgery, but is there anything about concussion that you could share; a myth or a misconception that people might have?
Dr. Ducic: Well the misconception in medicine unfortunately happens quite often just because we are used to globalizing the thinking. For example, with the concussion everybody is so focused on the brain and all explanations would actually end up being the relationship of a trauma and the brain's response with trauma. Now we are widening the spectrum and stepping back a little bit and looking at what else would be in our view that could explain patients' symptoms. If your brain was affected by concussion then certainly it is difficult to explain why somebody complained just about the pain, let's say, at the back of the head when their injury was on the opposite side at the front of the head or on the same side of the side of the head. So no direct trauma might have been applied at all to the anatomical area the patient is actually complaining of. This stepping back and widening of the thinking process, I think, is probably the biggest contribution to the resolution of some of the misconceptions. Neurology colleagues are as good as they can be and they're doing a great job and without them we wouldn't be able to accomplish what we're accomplishing. Yet on the other hand, this interdisciplinary approach of why they need the team involvement and applying also surgical treatment when appropriate becomes crucial for these patients. I've been fortunate enough to work with a number of different specialists in neurology, especially with Dr. Maureen Moriarty in the Washington area, and Dr. Kevin Crutchfield in the Baltimore area who is head of the concussion program there who worked with me very closely on treating these patients. Without the understanding of a physician like that my job would be impossible because if I don't see these patients on time, if they have not been properly worked up and treated, then successive surgery wouldn't even work with a team approach. Timely recognition, timely referral, an interdisciplinary team approach, and thinking out of the ordinary are basically what make it happen for these patients.
For more information about the surgical treatment of patients with chronic migraine, headaches or neuralgia, following sports injuries or concussions, please visit Dr. Ducic's website: www.DrDucicPlasticSurgery.com
Tuesday, December 10 2013 5:15 PM EST2013-12-10 22:15:07 GMT
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