Assessing the Relationship between Obesity and Trigger Point-specific Outcomes after Headache Surgery.

Background: Trigger point deactivation surgery is a safe and effective treatment for properly selected patients experiencing migraine, with 68.3%-100% experiencing symptom improvement postoperatively. However, it is still unknown why certain patients do not respond. Obesity has been shown to be associated with worsened migraine symptoms and a decreased response to select pharmacotherapies. This study aimed to determine whether obesity may also be associated with an attenuated response to surgery. Methods: A retrospective chart review was conducted to identify patients who had undergone trigger point deactivation surgery for migraine. Patients were split into obese and nonobese cohorts. Obesity was classified as a body mass index of 30 or higher per Centers for Disease Control and Prevention guidelines. Outcomes and follow-up periods were determined with respect to individual operations. Outcomes included migraine attack frequency, intensity, duration, and the migraine headache index. Differences in demographics, operative characteristics, and operative outcomes were compared. Results: A total of 62 patients were included in the study. The obese cohort comprised 31 patients who underwent 45 total operations, and the nonobese cohort comprised 31 patients who underwent 34 operations. Results from multivariable analysis showed no impact of obesity on the odds of achieving a more than 90% reduction in any individual outcome. The overall rates of improvement (≥50% reduction in any outcome) and elimination (100% reduction in all symptoms) across both cohorts were 89.9% and 65.8%, respectively. Conclusion: Obese patients have outcomes comparable to a nonobese cohort after trigger point deactivation surgery for migraine.

Functional outcomes between headache surgery and targeted botox injections: A prospective multicenter pilot study.

Introduction: Chronic migraine headaches (MH) are a principal cause of disability worldwide. This study evaluated and compared functional outcomes after peripheral trigger point deactivation surgery or botulinum neurotoxin A (BTA) treatment in patients with MH. Methods: A long-term, multicenter, and prospective study was performed. Patients with chronic migraine were recruited at the Ohio State University and Massachusetts General Hospital and included in each treatment group according to their preference (BTA or surgery). Assessment tools including the Migraine Headache Index (MHI), Migraine Disability Assessment Questionnaire (MIDAS) total, MIDAS A, MIDAS B, Migraine Work and Productivity Loss Questionnaire-question 7 (MWPLQ7), and Migraine-Specific Quality of Life Questionnaire (MSQ) version 2.1 were used to evaluate functional outcomes. Patients were evaluated prior to treatment and at 1, 2, and 2.5 years after treatment. Results: A total of 44 patients were included in the study (surgery=33, BTA=11). Patients treated surgically showed statistically significant improvement in headache intensity as measured on MIDAS B (p = 0.0464) and reduced disability as measured on MWPLQ7 (p = 0.0120) compared to those treated with BTA injection. No statistical difference between groups was found for the remaining functional outcomes. Mean scores significantly improved over time independently of treatment for MHI, MIDAS total, MIDAS A, MIDAS B, and MWPLQ 7 (p<0.05). However, no difference in mean scores over time was observed for MSQ. Conclusions: Headache surgery and targeted BTA injections are both effective means of addressing peripheral trigger sites causing headache pain. However, lower pain intensity and work-related disabilities were found in the surgical group.

Severe obesity is associated with increased migraine severity and frequency: A retrospective cohort study.

Migraine headaches and obesity are both prevalent disorders, resulting in a high socioeconomic burden. To better understand the relationship between obesity and migraine, the aim of this study was to investigate the association between migraine severity, metabolic syndrome and estrogen-associated variables. A retrospective analysis of adult patients with refractory migraine seen by our senior author (J.E.J.) was performed. Patient demographics and migraine characteristics, including migraine intensity, duration, and number of headaches per month were collected from medical records. Migraine headache index (MHI) was calculated by multiplying frequency, intensity and duration of headaches. Weight and height were used to calculate body mass index (BMI) and these were divided per Center for Disease Control (CDC) classifications. Univariate linear regression models were used to evaluate associations. Patients (n = 223) were predominantly female (78%) with a mean age of 44 years at presentation. Patients with a BMI higher than 40 (class 3 obesity) had a higher MHI (p = 0.01) and experienced a higher number of migraines per month (p = 0.007), compared to patients with a healthy BMI, respectively. Migraine frequency was found to be significantly higher in post-menopausal women compared to pre-menopausal women (p = 0.02). No other significant associations were found. This study found that severe obesity (BMI > 40) is associated with increased migraine severity and frequency. Post-menopausal patients are also found to have increased migraine frequency, which could be explained by the estrogen-withdrawal hypothesis. Future studies are needed to evaluate the outcomes of individuals with obesity after nerve deactivation surgery.

The Positive and Negative Predictive Value of Targeted Diagnostic Botox Injection in Nerve Decompression Migraine Surgery.

INTRODUCTION: Nerve decompression surgery is an effective treatment modality for patients who suffer from migraines. Botulinum toxin type A (BOTOX) injections have been traditionally used as a method to identify trigger sites, however there is a paucity in data regarding its diagnostic efficacy. The goal of this study was to assess the diagnostic capacity of BOTOX in successfully identifying migraine trigger sites and predicting surgical success. METHODS: A sensitivity analysis was performed on all patients receiving BOTOX for migraine trigger site localization followed by a surgical decompression of affected peripheral nerves. Positive and negative predictive values were calculated. RESULTS: A total of 40 patients met our inclusion criteria and underwent targeted diagnostic BOTOX injection followed by a peripheral nerve deactivation surgery with at least three months follow-up. Patients with successful BOTOX injections (defined as at least 50% improvement in Migraine Headache Index (MHI) scores post injection) had significantly higher average reduction in migraine intensity (56.7% vs 25.8%; p=0.020, respectively), frequency (78.1% vs 46.8%; p=0.018, respectively), and MHI (89.7% vs 49.2%; p=0.016, respectively) post-surgical deactivation. Sensitivity analysis shows that the use of BOTOX injection as a diagnostic modality for migraine headaches has a sensitivity of 56.7% and a specificity of 80.0%. The positive predictive value is 89.5% and the negative predictive value is 38.1%. CONCLUSION: Diagnostic targeted BOTOX injections have a very high positive predictive value. It is therefore a useful diagnostic modality that can help identify migraine trigger sites and improve pre-operative patient selection.

Optimizing the Timeliness of Surgical Therapy in Patients with Breast Cancer Undergoing Immediate Breast Reconstruction.

BACKGROUND: In breast cancer, coordination of surgical therapy with immediate breast reconstruction (IBR) has been found to significantly delay surgical therapy, which in turn can have an adverse effect on patient survival. The objective of this study was to investigate factors that impact the timeliness of surgical therapy in this setting, which may help to optimize the care of patients with breast cancer. PATIENTS AND METHODS: Patients with breast cancer undergoing surgical therapy for breast cancer and immediate reconstruction were reviewed. Patients were divided into two groups: those who underwent surgery ≤ 30 days (group A) and > 30 days (group B) after diagnosis. Multivariate statistical analysis of demographic, disease, surgical, and process of care factors was performed. RESULTS: A total of 348 cases met inclusion criteria, of which 255 (73.2%) were in group A and 93 (26.7%) were in group B. No significant differences were identified in clinical stage, oncologic procedure, or type of reconstruction. On multivariate analysis, an increased likelihood of undergoing surgery ≤ 30 days of diagnosis was observed, with shorter time intervals between surgical oncologist and plastic surgeon consultations [odds ratio (OR) 1.3; 95% confidence interval (CI) 1.1-1.6, p = 0.011]. The number of operating days in common between the surgical oncologist and plastic surgeon nor having the same clinic day impacted timeliness. CONCLUSIONS: Patients may undergo both breast conservation surgery and mastectomy with all major types of immediate reconstruction in a timely manner. Early initiation of plastic surgery referrals and surgeon flexibility to work outside the parameters of institutional schedules may help facilitate the timeliness of surgery.

Revisiting the Role of Occipital Artery Resection in Greater Occipital Nerve Decompression.

BACKGROUND: Greater occipital nerve surgery has been shown to improve headaches caused by nerve compression. There is a paucity of data, however, specifically regarding the efficacy of concomitant occipital artery resection. To that end, the goal of this study was to compare the efficacy of greater occipital nerve decompression with and without occipital artery resection. METHODS: This multicenter retrospective cohort study consisted of two groups: an occipital artery resection group (artery identified and resected) and a control group (no occipital artery resection). Preoperative, 3-month, and 12-month migraine frequency, duration, intensity, Migraine Headache Index score, and complications were extracted and analyzed. RESULTS: A total of 94 patients underwent greater occipital nerve decompression and met all inclusion criteria, with 78 in the occipital artery resection group and 16 in the control group. The groups did not differ in any of the demographic factors or preoperative migraine frequency, duration, intensity, or Migraine Headache Index score. Postoperatively, both groups demonstrated a significant decrease in migraine frequency, duration, intensity, and Migraine Headache Index score. The decrease in Migraine Headache Index score was significantly greater among the occipital artery resection group than the control group ( p = 0.019). Patients in both groups had no major complications and a very low rate of minor complications. CONCLUSION: Occipital artery resection during greater occipital nerve decompression is safe and improves outcomes; therefore, it should be performed routinely. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

2015 American Thyroid Association guidelines and thyroid-stimulating hormone suppression after thyroid lobectomy.

BACKGROUND: 2015 American Thyroid Association (ATA) guidelines recommended more conservative treatment in low-risk well-differentiated thyroid cancer (WDTC), stating that lobectomy alone may be sufficient. The guidelines further recommend mild thyroid-stimulating hormone (TSH) level suppression (0.5-2 mU/L) for this population. Our goal is to evaluate the natural history of patients undergoing lobectomy to determine the percentage that would require postoperative levothyroxine supplementation under these guidelines. METHODS: Retrospective chart review of 168 patients that underwent lobectomy between 2010 and 2019 was performed. Preoperative and postoperative TSH values and the rate of patients prescribed levothyroxine were analyzed. RESULTS: Thirty-five percent of patients were prescribed levothyroxine postoperatively. At 6 weeks postoperatively, 66% had TSH value of >2; this increased to 76% by 6 to 12 months. CONCLUSION: To adhere to ATA guidelines for WDTC managed with lobectomy alone, the majority of patients (76%) would require postoperative levothyroxine supplementation. Low preoperative TSH was found to be the most significant predictor for postoperative TSH < 2.

Development of a Patient-Reported Outcome Measure for Mohs Reconstruction.

Objective: There are currently no validated patient-reported outcome measures (PROMs) to specifically evaluate quality-of-life (QOL) outcomes for patients undergoing Mohs micrographic surgery (MMS) reconstruction. Therefore, the objective of this report was to develop a short PROM that can be used to evaluate the outcome after MMS reconstruction from the patient's perspective. Methods: Following established guidelines for PROM development, a comprehensive literature review, concept elicitation interviews (n = 25), and cognitive debriefing interviews (n = 5) were performed. These data were used to develop a preliminary survey to measure patient QOL throughout the MMS reconstruction process. Results: Participants identified many items from existing validated QOL instruments as being irrelevant to their situation, indicating that the sensitivity of existing instruments may be relatively low for patients undergoing MMS. There was significant overlap between what patients frequently identified and what expert physicians believed would be important in terms of factors that affect patient QOL throughout this process. Cognitive debriefing interviews indicated that the survey can be quickly and easily administered. Conclusions: Following accepted standards, we have created a 12-item disease- and treatment-specific QOL PROM for individuals undergoing the MMS reconstruction process. Given the prevalence of MMS, this PROM could be an important tool for clinicians to assess outcomes in future interventional studies aimed at minimizing morbidity and maximizing QOL for these skin cancer patients. Psychometric testing and validation of this newly developed PROM are currently underway.