Cervical Branch Research Articles

333. TECHNICAL CONSIDERATIONS IN UPPER-GI RECONSTRUCTION – A CASE SERIES

Abstract Background Oesophageal reconstruction post-oesophagectomy is performed for both benign and malignant pathologies. Generally, the stomach is the conduit of choice due to its simplicity, requiring only one anastomosis. However, in some cases the stomach may not be a viable option immediately or at all, and alternatives must be considered. We describe a case where the stomach was not immediately viable and two cases where alternative conduits were sought. Furthermore, we discuss techniques such as ‘supercharging’ and ‘superdrainage’ which enhance arterial flow and venous drainage respectively, in order to prevent ischaemia and related complications of the anastomosis site. Methods and Results Case 1 presents a 72-year-old with an incarcerated para-oesophageal hernia leading to necrosis of the distal oesophagus and proximal stomach. After resection, a feeding jejunostomy and a loop oesophagostomy in the neck was created. Months later, the oesophagostomy was closed, and the residual stomach was carefully mobilised into the thorax while preserving the gastro-epiploic arcade, and oesophago-gastric anastomosis was performed. Case 2 involves a 68-year-old female who had elective Nissen fundoplication for a hiatus hernia, which recurred early with strangulation of the distal oesophagus and proximal stomach requiring emergency oesophago-gastrectomy. She later underwent a colonic interposition using the left colon, with superdrainage through an anastomosis between a branch of the middle colic vein to the left external jugular vein. Case 3 describes a 61-year-old male with a gastro-oesophageal adenocarcinoma treated with an Ivor-Lewis oesophagectomy. A year later, he suffered from a strangulated diaphragmatic hernia causing necrosis of the gastric conduit. This was replaced with an isoperistaltic colonic interposition using the transverse and left colon with super drainage. Unfortunately, three years later, this was again complicated with pancreatitis and perforated gall bladder with associated ischaemia of the colonic conduit. A re-do of the colonic interposition using the right colon was done with an arterial graft between the right transverse cervical artery and branch of ileal artery and super drainage via a branch of the ileal and right external jugular veins. Conclusion Primary and in particular secondary re-constructions of the UGI tract are complex procedures and individual approaches are needed as residual anatomy varies. Consequently, such cases require meticulous planning and a multidisciplinary approach involving the cardio-thoracic, plastic and vascular surgeons and adequate support by the anaesthetic and intensive care team. Although associated with significant morbidity and mortality, reestablishment of a swallowing passage is often desired by patients to maintain quality of life.

Comparison between Zone 2 and Zone 3 distal anastomoses for aortic arch replacement in terms of invasiveness.

Zone 2 anastomosis with total cervical branch reconstruction for acute type A aortic dissection and aortic arch aneurysms became possible after stent-graft introduction. This may be an easier procedure and reduce the risk of recurrent laryngeal nerve palsy. Therefore, this study aimed to compare the outcomes between Zone 2 and Zone 3 distal anastomoses. After evaluating the patient data in our institute between April 2016 and April 2022, the patients in whom distal anastomosis was performed at Zone 2 with a stent-graft were defined as the Zone 2 group (n = 70). The patients in whom distal anastomosis was performed at Zone 3 were defined as the Zone 3 group (n = 24). The incidence of new-onset recurrent nerve palsy was one patient (1.4%) in the Zone 2 group and six patients (25.0%) in the Zone 3 group (p < 0.001). The lower body perfusion arrest time was 44.3 ± 9.1min in the Zone 2 group and 52.9 ± 12.8min in the Zone 3 group (p = 0.005). There were no significant differences in in-hospital mortality and morbidities. Multivariable analysis showed that only age was an independent predictor of overall mortality. Performing distal anastomosis at Zone 2 with a frozen elephant trunk or stent-graft reduced the lower body perfusion arrest time and possibly prevented recurrent nerve palsy.

Anatomical Insights on the Cervical Nerve for Contemporary Face and Neck Lifting: A Cadaveric Study.

Despite the significant roles it plays in the functions of the platysma and lower lip, the cervical branch of the facial nerve is often overlooked compared to other branches, but its consideration is critical for ensuring the safety of neck surgeries. The aim of this study was to clarify the anatomical discrepancies associated with the cervical branch of the facial nerve to enhance surgical safety. The study utilized 20 fresh-frozen hemiheads. A 2-stage surgical procedure was employed, beginning with an initial deep-plane facelift including extensive neck dissection, followed by a superficial parotidectomy on fresh-frozen cadavers. This approach allowed for a thorough exploration and mapping of the cervical nerve in relation to its surrounding anatomical structures. Upon exiting the parotid gland, the cervical nerve consistently traveled beneath the investing layer of the deep cervical fascia for a brief distance, traversing the deep fascia to travel within the areolar connective tissue before terminating anteriorly in the platysma muscle. A single branch was observed in 2 cases, while 2 branches were noted in 18 cases. The cervical nerve's relatively deeper position below the mandible's angle facilitates a safer subplatysmal dissection via a lateral approach for the release of the cervical retaining ligaments. Due to the absence of a protective barrier, the nerve is more susceptible to injuries from direct trauma or thermal damage caused by electrocautery, especially during median approaches.

Prospective evaluation of the safety of ultrasound-guided cervical medial branch blocks using the in-plane technique

BackgroundWhile fluoroscopic guidance is currently the imaging standard for cervical medial branch blocks (CMBBs), ultrasound guidance (USG) offers several potential safety advantages such as real-time needle visualization and the ability...

Accuracy and efficacy of ultrasound-guided puncture (vs. computed tomography-guided) in cervical medial branch blocks for cervicogenic pain: A randomized controlled study.

Cervical medial branch block (CMBB) has been recognized as an effective treatment for cervicogenic pain. Previous studies mostly used ultrasound-guided out-of-plane puncture for CMBB, while this prospective study was designed to investigate the efficacy of ultrasound-guided in-plane puncture, specifically focusing on the new target of CMBB for cervical pain. This study includes two parts: the accuracy study (N = 15, CMBB was completed by ultrasound and confirmed by computed tomography [CT], in which a good distribution percentage of the analgesic solution was observed) and the efficacy study (N = 40, CMBB was completed by ultrasound or CT, while the proportion of pain relief (numerical rating scale) decrease by more than 50% postoperatively was analyzed). The results showed that the good distribution percentage of the analgesic solution was 97.8%. Furthermore, in the early period (30 min and 2 h postoperatively), the proportion of patients with pain relief was lower in the ultrasound group than that in the CT group, especially at 2 h postoperatively (52% vs. 94%). However, at 24 h postoperatively and later, the proportion of patients with pain relief gradually stabilized to about 60%-70%, and lasted for about 2 weeks to 1 month. Therefore, the new target for CMBB, guided by ultrasound in-plane, offers high visibility and accuracy. A single CMBB performed under ultrasound guidance resulted in pain relief comparable to that of a CT-guided procedure (1 day to 1 month postoperatively). This study indicated that CMBB guided by ultrasound in-plane could be regarded as a promising approach for treatment of cervicogenic pain.

Outcomes of thoracic endovascular aortic repair using fenestrated stent grafts in patients with thoracic aortic distal arch aneurysms.

Thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysms is challenging because of anatomical restrictions and the presence of cervical branches. Revascularization of the cervical branch is required when conventional commercial stent grafts are used. TEVAR using fenestrated stent grafts (FSG) often does not require additional procedures to revascularize cervical branches. This study aimed to evaluate the features and initial and midterm outcomes of TEVAR using fenestrated stent grafts. From April 2007 to December 2016, 101 consecutive patients underwent TEVAR using fenestrated stent grafts for distal aortic arch aneurysms at a single centre. Technical success, complications, freedom from aneurysm-related death, secondary intervention and aneurysm progression were retrospectively investigated. All the patients underwent TEVAR using fenestrated stent grafts. The 30-day mortality rate was zero. Cerebral infarction, access route problems and spinal cord injury occurred in 4, 3 and 2 patients, respectively. Each type of endoleak was observed in 38 of the 101 patients during the course of the study; 20/38 patients had minor type 1 endoleaks at the time of discharge. The endoleak disappeared in 2 patients and showed no significant change in 8 patients; however, the aneurysm expanded over time in 10 patients. Additional treatment was performed in 8 of the 10 patients with type 1 endoleaks and dilatation of the aneurysm. The rate of freedom from aneurysm-related death during the observation period was 98%. TEVAR with FSG is a simple procedure, with few complications. Additional treatment has been observed to reduce aneurysm-related deaths, even in patients with endoleaks and enlarged aneurysms. Based on this study, the outcomes of endovascular repair of aortic arch aneurysms using a fenestrated stent graft seem acceptable.

Investigation of the anatomical course of articular branches to the thoracic zygapophysial joints

BackgroundRecent studies have questioned the validity of targeting the thoracic medial branch via anesthetic blocks or radiofrequency neurotomy for the diagnosis or treatment of pain from the thoracic zygapophysial joints. PurposeTo define the origin and course of the articular branches to the thoracic zygapophysial joints at all levels. DesignCadaveric dissection. SettingThe Gross Anatomy Laboratory at the University of New England College of Osteopathic Medicine. SubjectsOne cadaveric thoracic spine. MethodsGross and stereoscopic dissection of the bilateral dorsal rami T1–T12 was performed on one embalmed cadaver. The medial and lateral branches were traced from their cutaneous distribution to the origin at the dorsal ramus. The articular branches were identified using stereoscopic dissection by tracing their origin from the dorsal ramus or medial branch to the capsule of the zygapophysial joint. The images were recorded using digital photography. ResultsTwenty-two of the twenty-four articular branches were identified in a single cadaveric specimen. Articular branches at T7 on the right side and T9 on the left side were not identified. 5 of the 22 (18%) articular branches were observed to arise from the proximal segment of the medial branch of the dorsal ramus. Of the remainder, 17 of the 22 (78%) articular branches were observed to arise from the dorsal primary ramus itself. At levels T1-9, the articular branch coursed inferiorly along the lamina to reach the joint capsule. At levels T10-T12, the articular branch traversed the intervertebral foramen to reach the facet joint. The T12 medial branch on the left was seen to travel inferior to innervate the L1/L2 zygapophysial joint. ConclusionThe source of the innervation for the thoracic zygapophysial is variable and can arise from the dorsal ramus itself or from the proximal segment of the medial branch. Unlike the cervical and lumbar medial branches, which innervate two joints each, in this case, the thoracic dorsal rami appear to innervate only the zygapophysial joint at the level of the nerve exit. It should be noted that the findings may be limited in their generalizability due to the reliance on a single cadaver study.

Transcutaneous cervical vagus nerve stimulation improves sensory performance in humans: a randomized controlled crossover pilot study

Accurate senses depend on high-fidelity encoding by sensory receptors and error-free processing in the brain. Progress has been made towards restoring damaged sensory receptors. However, methods for on-demand treatment of impaired central sensory processing are scarce. Prior invasive studies demonstrated that continuous vagus nerve stimulation (VNS) in rodents can activate the locus coeruleus-norepinephrine system to rapidly improve central sensory processing. Here, we investigated whether transcutaneous VNS improves sensory performance in humans. We conducted three sham-controlled experiments, each with 12 neurotypical adults, that measured the effects of transcutaneous VNS on metrics of auditory and visual performance, and heart rate variability (HRV). Continuous stimulation was delivered to cervical (tcVNS) or auricular (taVNS) branches of the vagus nerve while participants performed psychophysics tasks or passively viewed a display. Relative to sham stimulation, tcVNS improved auditory performance by 37% (p = 0.00052) and visual performance by 23% (p = 0.038). Participants with lower performance during sham conditions experienced larger tcVNS-evoked improvements (p = 0.0040). Lastly, tcVNS increased HRV during passive viewing, corroborating vagal engagement. No evidence for an effect of taVNS was observed. These findings validate the effectiveness of tcVNS in humans and position it as a method for on-demand interventions of impairments associated with central sensory processing dysfunction.

A Comparison of Precision and Safety using Three Recognized Ultrasound-Guided Approaches to Cervical Medial Branch Blocks: A Cadaver Study

BACKGROUND: Ultrasound (US) guidance is widely used for needle positioning for cervical medial branch blocks (CMBB) and radiofrequency ablation, however, limited research is available comparing different approaches. OBJECTIVE: We aimed to assess the accuracy and safety of 3 different US-guided approaches for CMBB. STUDY DESIGN: A cadaveric study divided into ultrasound-guided needle placement and fluoroscopy evaluation stages. SETTING: Department of Pathology, Forensic, and Insurance Medicine, Semmelweis University. METHODS: Sonographically guided third occipital nerve (TON), C3, C4, C5 and C6 medial branch injections and radiology evaluations were performed. The 3 approaches compared were: 1. ES (published by Eichenberger-Siegenthaler): US probe in the coronal plane to visualize the cervical articular pillars, needle approach out of the plane, from anterior to posterior. 2. Fi (published by Finlayson): US probe in the transverse plane to visualize a cervical articular pillar and its lamina, needle approach in the plane, from posterior to anterior. 3. FiM (Modified Finlayson approach): Needles are placed as in Fi, but then adjusted with a coronal view of the cervical articular pillars. Fluoroscopy images were taken and later evaluated, for “crude”, “high precision” and “dangerous” placement. RESULTS: One hundred and fifty-five needle placements were assessed (10 were excluded, as no anterior-posterior fluoroscopy images were saved). Interobserver agreement on position of needle placement between the 5 observers was very high; the Fleiss’ Kappa was 0.921. For crude placement, no significant differences were identified between various approaches; (77.6%, 79.5%, and 75.6% for the ES, Fi, and FiM respectively). However, for placement in predefined high-precision zones, ES resulted in significantly more success (ES: 42.9%, Fi: 22.7%, and FiM: 24.4%, P = 0.032). Fi and FiM resulted in no dangerous placements, while ES led to the potential compromise of the exiting nerve root and vertebral artery on three occasions. In 10% of the placements, the levels were identified wrongly, with no difference between the various approaches. LIMITATIONS: Feedback from a live patient, may prevent some existing nerve root injections, unlike in a cadaver. Though a higher number of needles were placed in this study than in most available publications, the number is still low at each individual medial branch level. CONCLUSION: Fi proved safer than ES. Fi was equally successful in targeting the articular pillar, however, ES proved the most successful in placing the needle in the center of the articular pillar. Adding another, (coronal) US view to check needle position in FiM did not improve safety or precision. Identifying CMB levels with the US is challenging with all approaches, therefore we still recommend using fluoroscopy for level identification. While there were pros and cons with either procedure, the efficacy findings of previous papers were not replicated on elderly cadavers with arthritic necks. KEY WORDS: Cervical facet, medial branch block, safety, accuracy, ultrasound, fluoroscopy

Variability of the Cervical Branch Depending on the Facial Nerve Branching Pattern and Anthropometric Type of the Head.

(1) Background: Considering that the specialty literature supplies only general data about the variability of the cervical branch of the facial nerve, this study aimed to determine this branch's variation and individual peculiarities depending on the nerve branching pattern and anthropometric type of the head. (2) Methods: The study was conducted on 75 hemifaces of adult formalized cadavers. Ahead of anatomical dissection, each head was measured to establish the anthropometric type, according to Franco and colleagues. The branching patterns were then distributed according to the Davis classification. (3) Results: The number of cervical branches (CB) of the facial nerve varied from one to five branches, with the following rate: 1 CB (61.3%), 2 CB (28%), 3 CB (6.7%), 4 CB (2.7%), and 5 CB (1.3%). Seven branching patterns of the facial nerve were revealed: Type I in 18.7%, Type II in 14.7%, Type III in 20%, Type IV in 14.6%, Type V in 5.3%, Type VI in 18.7%, and Type NI in 8% (bizarre types). According to the branching pattern, the mean numbers of the cervical branches were as follows: Type I-1.6 ± 1.02; Type II-1.4 ± 0.50; Type III-1.4 ± 0.50; Type IV-1.4 ± 0.67; Type V-2.0 ± 1.41; Type VI-1.8 ± 1.12; and Type-NI-1.8 ± 0.75; p = 0.599. According to the anthropometric type of the head, the mean number of CB in the mesocephalic type (MCT) was 1.5 ± 0.82, in the dolichocephalic type (DCT), 1.7 ± 0.87, and in the brachycephalic type, (BCT) 1.8 ± 1.04; p = 0.668. (4) Conclusions: The cervical branch of the facial nerve varies depending on the facial nerve branching pattern and the anthropometric type of the head. The highest degree of variation was characteristic of BCT and Type V and the lowest, of MCT and Types II, III, and IV.

Subdiaphragmatic vagal nerve stimulation attenuates the development of hypertension and alters nucleus of the solitary tract transcriptional networks in the spontaneously hypertensive rat.

Augmented vagal signaling may be therapeutic in hypertension. Most studies to date have used stimulation of the cervical vagal branches. Here, we investigated the effects of chronic intermittent electric stimulation of the ventral subdiaphragmatic vagal nerve branch (sdVNS) on long-term blood pressure, immune markers, and gut microbiota in the spontaneously hypertensive rat (SHR), a rodent model of hypertension characterized by vagal dysfunction, gut dysbiosis, and low-grade inflammation. We evaluated the effects of sdVNS on transcriptional networks in the nucleus of the solitary tract (NTS), a major cardioregulatory brain region with direct gut vagal projections. Male juvenile SHRs were implanted with radiotelemetry transmitters and vagal nerve cuffs for chronic intermittent electric sdVNS, applied three times per day for 7 consecutive weeks followed by 1 wk of no stimulation. Blood pressure was measured once a week using telemetry in the sdVNS group as well as age-matched sham-stimulated SHR controls. At the endpoint, colonic and circulating inflammatory markers, corticosterone, and circulating catecholamines were investigated. Bacterial 16 s sequencing measured gut bacterial abundance and composition. RNA sequencing evaluated the effects of sdVNS on transcriptional networks in the NTS. SHRs that received sdVNS exhibited attenuated development of hypertension compared with sham animals. No changes in peripheral inflammatory markers, corticosterone, or catecholamines and no major differences in gut bacterial diversity and composition were observed following sdVNS, apart from decreased abundance of Defluviitaleaceale bacterium detected in sdVNS SHRs compared with sham animals. RNA sequencing revealed significant sdVNS-dependent modulation of select NTS transcriptional networks, including catecholaminergic and corticosteroid networks.NEW & NOTEWORTHY We show that stimulation of the ventral subdiaphragmatic vagal nerve branch may be a promising potential approach to treating hypertension. The data are especially encouraging given that rodents received only 30 min per day of intermittent stimulation therapy and in view of the potential of long-term blood pressure effects that are not stimulus-locked.

EGS P11 Super-charged colonic interposition after Upper Gastrointestinal tract resections: technical considerations from both benign and malignant cases and review of literature

Abstract Background Oesophageal reconstruction is performed after an oesophagectomy, for either malignant or benign pathology. During reconstruction, variables include choice of conduit, route of reconstruction, and site of anastomosis. The stomach is preferred for neo-oesophageal reconstruction. However, when the stomach is not viable, alternatives including colon, jejunum, skin, or anterolateral thigh (ALT) musculocutaneous flaps are considered. Of these, colon is preferred for its ability to provide long-length grafts and reliable vascular supply. However, complications remain significant problems, including ischaemia at the anastomosis. To address this, 'supercharging’ and ‘super drainage' techniques are used to enhance arterial flow and venous drainage via microvascular anastomosis. Methods Case 1 involves a 61-year-old male who underwent an oesophagectomy for GOJ adenocarcinoma. A year later he developed a strangulated diaphragmatic hernia with an ischaemic gastric conduit, which was replaced with an isoperistaltic colonic interposition using transverse and left colon with super-drainage. 3 years later, the patient presented with pancreatitis, perforated gallbladder, and duodenum. Diffuse ischaemic changes of the interposed colon were recognised. A re-do colonic interposition using right colon with an arterial graft between the right transverse cervical artery and branch of ileal artery and super-drainage via a branch of the ileal and right external jugular veins was created. Results Case 2 involves a 68-year-old female who underwent an elective hiatus hernia repair with Nissen’s fundoplication. She deteriorated shortly post-operatively where re-look surgery found early hernia recurrence causing strangulation of the distal oesophagus and proximal stomach leading to ischaemia, necrosis, and perforation. She underwent a laparotomy and resection of the ischaemic distal oesophagus and proximal stomach, oesophagostomy and feeding jejunostomy. 16 months later, she underwent interposition of the right colon between the proximal oesophagus and remaining stomach. Arterial flow was adequate and supercharging was performed between the left external jugular vein and a branch of the middle colic vein. Conclusions There is limited literature on methods of both supercharging and super-drainage, as well as the optimal choice of organ for neo-oesophageal reconstruction. Currently, no established treatment protocols exist. There is evidence that supercharging and super-drainage are associated with longer operative times. However, benefits include lower leak incidence, shorter duration to oral intake, and reduced length of stay in relation to interposition without supercharge. Associated venous congestion may contribute to anastomotic leak, and may be prevented by super-drainage. Whilst supercharging has been reported worldwide, our case series adds to the UK practice showing it improves patient outcomes in an NHS setting.

End-on versus parallel radiofrequency lesioning for neurotomy of the cervical medial branch nerves: a study protocol of a prospective, randomized, double-blind clinical trial: the “EndPaRL” study

BackgroundCervical facet joint disease is a common source of neck pain and its prevalence increases with aging. Conservative multimodal management options (e.g., strengthening of neck muscles, non-steroidal anti-inflammatory medications, massage, and thermal modalities) often fail to relieve pain. Cervical medial branch nerve (CMBN) radiofrequency neurotomy (RFN) is an effective minimally invasive technique for treating chronic neck pain secondary to facet joint disease. An end-on approach for this procedure has been proposed that may be technically easier and require less time while reducing post-procedural discomfort. The protocol presented here is for a study that aims to compare the efficacy of a new end-on approach using multi-tined cannulae, against the conventional parallel technique that employs straight cannulae for RFN of the CMBN in patients with chronic neck pain due to cervical facet joint disease.MethodsA multicentre randomized, non-inferior, active comparator-controlled trial will be conducted with two parallel groups and blinding of participants and outcome assessor. The study will include 72 adults with chronic neck pain secondary to facet joint disease who are candidates for RFA of the CMBN. Participants will be randomized to either the conventional parallel or the end-on approach in a 1:1 ratio. The intensity of pain and pain-related domains (function, quality of life, sleep, adverse effects of the interventions, analgesic intake) will be measured at 1, 3, 6, and 12 months after the procedure.DiscussionNeck pain secondary to cervical facet joint disease is prevalent and RFA of the CMBN is a validated treatment for relieving it. The conventional parallel technique can be technically challenging, and it can be associated with adverse effects while the newer end-on approach has the potential of being a simpler technique with less adverse effects. This trial will be the first non-inferiority study to compare the clinical efficacy of the end-on approach against the conventional parallel approach for RFN of CMBN in patients with chronic neck pain due to cervical facet joint disease.Trial registrationClinicalTrials.gov NCT05818774. Registered on April 20, 2023.

Total arch replacement with frozen elephant trunk technique for Kommerell’s diverticulum with a right-sided aortic arch and aberrant left subclavian artery

BackgroundKommerell’s diverticulum with a right-sided aortic arch and aberrant left subclavian artery is uncommon. We perforemed a single-stage procedure with the frozen elephant trunk technique.Case presentationA 62-year-old man underwent aortic dissection a year ago, and computerized tomographic angiography performed at that time revealed a right aortic arch, Kommerell’s diverticulum (42 mm), and an aberrant left subclavian artery. We performed one-stage repair through median sternotomy. The cervical branches were exposed during the operation, and a deep hypothermic circulatory arrest with antegrade cerebral perfusion was established. The aorta was transected distally to the origin of the left carotid artery. We inserted a stent graft into the aorta, followed by peripheral anastomosis using a premade 5-branch Dacron graft. The right subclavian artery and the aorta were reconstructed, and the remaining cervical branches were reconstructed after the cross-clamp had been released.ConclusionsTotal arch replacement through median sternotomy was performed for the right aortic arch, Kommerell’s diverticulum, and aberrant left subclavian artery. The frozen elephant trunk technique is allowed to perform a one-stage operation safely.

Exploration of transcutaneous vagus nerve stimulation as a treatment option for adjuvant cancer and heart failure therapy

Vagus nerve stimulation (VNS) has gained prominence in the treatment of various clinical disorders such as migraine, depression, and tinnitus. Based on increased scientific knowledge of the VNS and insights into the vagus nerve (VN) function and anatomy/conduction, robust treatment approaches have been developed. There are both noninvasive and invasive VNS (iVNS) techniques. Currently, only iVNS techniques are approved by the US Food and Drug Administration (FDA). In contrast, transcutaneous VNS (tVNS) is a new treatment option that is receiving increasing attention. The tVNS application uses the cutaneous distribution of afferent VN fibers in the auricle, the auricular branch of the VN (ABVN), or in the neck, the cervical branch of the VN (CBVN). However, the tVNS technique has not yet been sufficiently researched in its application and mode of action to be used clinically on a large scale. Moreover, the stimulation parameters of the VN vary widely in different studies. Despite the growing number of research papers on this topic, more coherence in neurostimulation research and neuroanatomical basis is needed. The aim of this review is to highlight new clinical treatment options based on existing clinically applied treatment options. In this article, current clinical applications of tVNS are analyzed and important stimulation parameters are highlighted. Based on this data, useful new tVNS therapies are recommended. The focus will be placed on the study of inflammatory processes associated with cancer and on applications to cardiovascular events such as heart failure.

A rare variation in the origin of the lingual artery: thyro-linguo-laryngeal trunk.

The anatomy of the external carotid artery and its variations are of ground significance in head and neck surgery. During a dissection of a male cadaver, an undescribed common trunk between superior thyroid, superior laryngeal, and lingual arteries was found. The variations of the anterior cervical branches of the external carotid artery and their clinical implications are discussed. The described unusual branching pattern of the external carotid artery must always be considered in invasive or non-invasive procedures because it may lead to unexpected complications.

Letter to the Editor Regarding “Comparative Outcome of Lidocaine versus Bupivacaine for Cervical Medial Branch Block in Chronic Cervical Facet Arthropathy: A Randomized Double-Blind Study”

Letter to the Editor Regarding “Comparative Outcome of Lidocaine versus Bupivacaine for Cervical Medial Branch Block in Chronic Cervical Facet Arthropathy: A Randomized Double-Blind Study”

In Reply to the Letter to the Editor Regarding “Comparative Outcome of Lidocaine versus Bupivacaine for Cervical Medial Branch Block in Chronic Cervical Facet Arthropathy: A Randomized Double-Blind Study”

In Reply to the Letter to the Editor Regarding “Comparative Outcome of Lidocaine versus Bupivacaine for Cervical Medial Branch Block in Chronic Cervical Facet Arthropathy: A Randomized Double-Blind Study”

Facelift: Assessment of Total Platysma Muscle Transection to Prevent the Recurrence of Platysmal Bands

IntroductionDetermining which facelift technique yields the most effective long-term rejuvenation results and ensures optimal stability over time remains a significant question in cosmetic surgery: Does the most invasive surgery lead to the best long-term outcomes? This study aims to evaluate the authors’ approach using total platysma muscle transection to prevent platysma band recurrence, and to provide anatomical observations supporting and justifying their procedure.Material and MethodsA preliminary study in anatomical basic sciences was conducted to establish the rationale for our method. A prospective single-blind study was conducted, involving eighty patients seeking facial rejuvenation with platysmal band correction. They underwent face and neck-lift procedures with total platysma transection by the same surgeon between May 2013 and May 2016. Cosmetic outcomes were assessed using the Face and Neck-Lift Objective Photo-Numerical Assessment Scale. Scores by three blind evaluators before surgery, at 1 and 5 years postoperatively, were compared using a matched T Test (p < 0.05).ResultsThe preliminary anatomical study revealed a consistent anastomotic system between the cervical branch of the facial nerve and the branches of the cervical plexus. Incomplete platysma section during a facelift might contribute to platysma band recurrence. The clinical study demonstrated satisfactory outcomes, with significant overall appearance improvement (p < 0.00001) and no platysma band recurrence. Complication rate was low.ConclusionThe authors’ technique achieved satisfactory long-term results with minimal complications. However, due to the lengthy operating time and steep learning curve, it should be reserved for highly motivated patients.Level of Evidence IIThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Comparison of 18F-FDG PET Findings of Pegfilgrastim-Induced Aortitis With Other Types of Large-Vessel Vasculitis: A Retrospective Observational Study.

To elucidate the PET/CT findings of pegfilgrastim-induced aortitis (PFIA) and compare them with those of other large-vessel vasculitis. We enrolled 45 patients diagnosed with the following: PFIA, n = 8; Takayasu arteritis (TA), n = 12; giant cell arteritis (GCA), n = 6; and immunoglobulin G4-related aortitis (IgG4-A), n = 19. Records of PET/CT performed before treatment initiation were collected. The aorta and its branches were divided into 16 anatomic regions. Presence of abnormal 18F-FDG uptake in each region was determined and measured. The 18F-FDG-positive areas of PFIA were distributed in the regions of the ascending aorta to the suprarenal abdominal aorta, cervical branches of the aorta, and external iliac arteries, similar to those of TA. However, TA had a higher proportion of 18F-FDG-positive areas than PFIA in almost all anatomic regions. These areas of GCA were widespread throughout the entire aorta and the upper and lower limbs, whereas those of IgG4-A were observed from the abdominal aorta to iliac arteries. SUVmax, SUVpeak, metabolic volume, and total lesion glycolysis were higher in GCA than in PFIA, TA, and IgG4-A. Pegfilgrastim-induced aortitis distribution on PET/CT was frequently observed in the aorta, cervical branches, and extra iliac arteries. The low proportion of 18F-FDG-positive areas in PFIA was different from that of TA, GCA, and IgG4-A. These findings may help identify and differentiate various aortitis types in clinical practice.