Ivica Ducic, MD, Associate Professor of Plastic Surgery and the Director of Peripheral Nerve Surgery at Georgetown is a pioneer in surgery to eliminate or reduce headaches following concussion. Dr. Ducic says that two different kinds of pain-producing nerves may be affected by a concussion: intracranial nerves that traverse the membranes covering the brain (which she does not touch) and peripheral nerves that lie outside the skull in the muscles of the forehead, temple, and base of the head. With regard to the peripheral nerves of of the face and head, Dr. Ducic says they may be damaged by stretch injury occuring during the event that causes the concussion by means of whiplash, head rotation or even contact between the face or head with a hard surface.
When medication fails to stop post-concussive headaches after three months, she will evaluate the patient to see if one or more peripheral nerves are tender to the touch and if the headache can be stopped temporarily by a pain block injection to the involved nerve(s). The areas of interest lie just above the eyebrows; on the sides of the head by the ear and jaw; and along the sides of the base of the head at the junction with the neck. If the nerve is tender and if the pain can be relieved by a nerve block injection, she will discuss surgery with the patient.
According to 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.”
Dr. Ducic has done the decompression surgery more than 1,200 times. He says this surgery relieves headaches in many patients. The way He describes it is as follows: “What we do is make an incision after the opening which is accessing just plain sub-cutaneous, 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.”
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