Neurovascular Bundle Research Articles

Use of Preoperative Spinal Angiography in Severe Spinal Deformity Patients Who Require Thoracic 3 Column Osteotomy: A Case Series and Review of the Literature.

Three-column osteotomy (3CO) offers substantial spinal deformity correction. Thoracic neurovascular bundle sacrifice is often required, and anterior spinal artery (ASA) perfusion can be compromised. Spinal angiography allows localization of variable ASA vascular contribution. This study's objective was to describe a series of patients who underwent preoperative spinal angiography and discuss the impact on surgical planning and execution of thoracic 3CO for deformity correction. Patients who underwent preoperative spinal angiograms and thoracic 3CO for deformity correction were reviewed. Preoperative, angiographic, and postoperative information was recorded. A literature review on preoperative spinal angiography in deformity surgery was performed. Eight patients were identified: single-level pedicle subtraction osteotomies (1), single-level vertebral column resections (2), and multilevel vertebral column resections (5). The average age was 40.0 years, and 75.0% were female. Thoracic scoliosis ranged from 0 to 105° preoperatively and 0 to 45.1° postoperatively. Thoracic kyphosis ranged from 29° to 120° preoperatively and 20.6° to 54.9° postoperatively. Twelve ASA supply vessels were identified bilaterally in 6 patients. Four patients had nontraditional ASA supply at T4 (1), T6 (1), and L2 (2), and 4 had multiple ASA feeders. Based on angiographic results, osteotomy site was changed (1), and neurovascular bundles were spared (2), a 37.5% rate of surgical plan alteration. There were no permanent neuromonitoring changes or postoperative neurologic deficits. No articles reported on using spinal angiography specifically for deformity surgery. Spinal angiography is low risk and provides critical information regarding ASA supply to potentially mitigate ischemic risk during neurovascular bundle takedown during thoracic 3CO. Further case series are warranted to evaluate the benefits in larger populations, but its clinical applications appear practical.

Neuroplasticity and Content of Structural Elements in the Axoplasm of the Trigeminal Nerve During the Eruption of Permanent Teeth in Humans

The aim of the presented study was to identify the features of the quantitative formation of axoplasmic organelles with a primary analysis of the components of the axonal cytoskeleton (microtubules and neurofilaments) of myelinated and non-myelinated nerve fibers in the dental pulp during the eruption of permanent teeth in humans. Material and methods. The neurovascular bundle of dental pulp was studied in children aged 5, 10 and 14 years. On ultramicrographs of pulp sections at a magnification of ×40000, the diameters of myelin and non-myelin conductors were measured; per 1 µm2 of axoplasm of nerve conductors, the density of axoplasmic organelles, the number of microtubules and neurofilaments were calculated. The reliability of differences between groups was assessed using multivariate analysis of variance (MANOVA), the significance of average values was assessed using the Tukey test, correlation analysis was carried out using the Pearson criterion. Results. The process of eruption of permanent teeth was accompanied by a gradual increase in the number of organelles per unit cross-sectional area of the nerve, regardless of its characteristics (myelinated or nonmyelinated fiber type). The highest density of organelles was observed in large-diameter fibers of both myelinated and non-myelinated conductors throughout the indicated segment of ontogenetic development. The presence of myelin in the nerve sheath correlates positively with microtubule saturation in fibers of large (r=0.267, p=0.001) and small (r=0.314, p=0.000) diameters, and negatively in fibers with medium diameter (r=-0.246, p=0.002). The proportion of neurofilaments represented among the axoplasmic organelles of the neuroplasm as a whole was especially high in myelinated and unmyelinated nerve fibers of small diameter, averaging up to 70%. The presence of the myelin sheath and fiber diameter are not associated with neurofilament density with the exception of medium-diameter fibers (r=0.195, p=0.001). Conclusion. The process of eruption of permanent teeth is accompanied by an increase in the number of organelles, cytoskeletal elements in the axoplasm of nerve fibers innervating the dental pulp, providing the morphological substrate of neuroplasticity, which must be taken into account, for example, in the process of dental implantation and dental prosthetics.

Imaging Retrospective Study Regarding the Variability of the Osseous Landmarks for IAN Block.

Background/Objectives: The aim of this study is to identify the most accurate and consistent landmarks for determining the precise location of the mandibular foramen (MF) and the mandibular ramus, suggesting appropriate adjustments to anesthesia techniques based on these variations in order to improve the success rate of the inferior alveolar nerve (IAN) block. Methods: CT scans of the mandibles from 100 patients were analyzed to measure the distance between the MF and various landmarks, including the sigmoid notch, gonion, posterior and anterior margins of the ramus, temporal crest, and the mandibular ramus height from the condyle to the gonion. The width of the mandibular ramus was also assessed, with correlations made to age and gender. Results: The MF was found to be closer to the sigmoid notch (mean = 21.2 mm), p = 0.393, than to the gonion (mean = 22.6 mm), p = 0.801, and closer to the posterior margin of the ramus (mean = 13.1 mm), p = 0.753, than to the anterior margin of the ramus. Additionally, the MF was closer to the temporal crest. Age also influenced the position of the MF, with a posterior and superior movement of the foramen, reducing the distance between the MF and the posterior margin of the ramus as well as the MF and the sigmoid notch (p < 0.001). Conclusions: A precise understanding of the MF's location will help dentists and oral and maxillofacial surgeons improve the success of the IAN block, avoid injury to the inferior alveola neurovascular bundle, and minimize surgical complications such as paresthesia, permanent anesthesia, and hemorrhage.

Bone lesion cryotherapy: pictorial review and review of current evidence.

Over the last two decades the development of small probes has enabled percutaneous use of cryotherapy. Cryotherapy, also known as cryoablation, enables the treatment of much larger lesions than other thermal ablation techniques, particularly when using multiple evenly spaced probes. Using rapid cooling to as low as -200 degrees Celsius (at the tip of the probe), reliable, and predictable necrosis can be induced. Probes are usually percutaneously inserted under computed tomography (CT) guidance under sedation or general anaesthesia, often as a day case. The procedure is safe with severe complications occurring rarely; the commonest complication is neural injury in lesions closely related to neurovascular bundles. Cryotherapy has been applied to the symptomatic and occasionally curative treatment of bone metastases and a range of primary bone lesions. This review summarises the published evidence base for the use of cryotherapy in metastatic and primary bone lesions and describes the experience with cryotherapy at the Royal Orthopaedic Hospital, Birmingham, a quaternary bone tumour referral hospital, where cryotherapy has been used for 3 years.

Under-representation for Female Pelvis Cancers in Commercial Auto-segmentation Solutions and Open-source Imaging Datasets.

Artificial intelligence (AI) based auto-segmentation aids radiation therapy (RT) workflows and is being adopted in clinical environments facilitated by the increased availability of commercial solutions for organs at risk (OARs). In addition, open-source imaging datasets support training for new auto-segmentation algorithms. Here, we studied if the female and male anatomies are equally represented among these solutions. Inquiries were sent to eight vendors regarding their clinically available OAR auto-segmentation solutions for each gender. The Cancer Imaging Archive (TCIA) was also screened for publicly available imaging datasets specific to the female and the male anatomy. All vendors provided AI based auto-segmentation solutions for the male pelvis and female breasts, while 5/8 vendors provided solutions for the female pelvis. The female breast and the female pelvis solutions were released at a median of 0.6 years and 2.3 years, respectively, after the release of the male pelvis solutions. Among 27 TCIA datasets identified, 15 involved the female anatomy (breast: 10; pelvis: 5) and 12 involved the male pelvis but no female-specific dataset included OAR segmentations, while three male pelvis datasets included OARs (ejaculatory duct, neurovascular bundle, penile bulb and verumontanum). Commercial AI auto-segmentation solutions and open-source imaging datasets include considerably more solutions and OAR segmentations for male cancer over female cancer sites. This gender disparity is likely to propagate throughout the RT pipeline.

Cadaveric Study Evaluating the Potential for Hindfoot Endoscopy and Flexor Hallucis Longus Tendoscopy Using a 1.9-mm Diameter Needle Arthroscope.

Hindfoot endoscopy is an effective treatment for posterior ankle impingement syndrome (PAIS) and flexor hallucis longus (FHL) tendon disorders. However, FHL tendoscopy, especially from the posteromedial portal, carries a risk of tibial nerve damage. A needle-arthroscopic system with a 1.9-mm-diameter arthroscope, a semirigid frame, and a 0-degree direction of view has been introduced. This study aimed to evaluate the efficacy and safety of this system in visualizing and reaching significant structures in hindfoot endoscopy and FHL tendoscopy through the posteromedial and posterolateral portals using a cadaveric model. The 1.9-mm-diameter arthroscopic system (NanoScope, Arthrex) was used to perform hindfoot endoscopy in 6 human donor ankles (3 pairs). The arthroscope tube is 9.5 cm long, semirigid, and has an outer diameter of 1.9 mm, a 0-degree direction of view, and a 120-degree field of view. Posteromedial and posterolateral portals were established. Visualization and operative reach were recorded, including the posterolateral talar process, posterior talofibular ligament, intermalleolar ligament, subtalar joint, and FHL tendon. The neurovascular bundle and FHL tendon were examined for kinks or damage. All significant structures were successfully visualized in all specimens. The wide 120-degree field of view facilitated adequate visualization of all structures. In all specimens, the FHL tendon was visualized from the ankle joint to the knot of Henry (zones 1 and 2), and the flexor digitorum longus tendon was observed via both portals. There were no signs of neurovascular damage from either the posterolateral or posteromedial portals. In this cadaver experiment without known pathology, use of a 1.9-mm-diameter needle-arthroscopy with a 0-degree direction of view provided effective visualization of all significant structures in treating PAIS and FHL tendon disorders. It appears that FHL tendoscopy can be performed from the level of the ankle joint to the knot of Henry via both the posterolateral and posteromedial portals.

Radiological safety atlas of minimally invasive midfoot fusion: A cadaver study.

The popularity of minimally invasive (MIS) foot surgery continues to grow. However, it comes with certain limitations that present notable challenges. One significant hurdle is the absence of direct visualization of neurovascular structures and tendons. The objective of this study is to present fluoroscopic heatmaps that illustrate the trajectories of major structures encountered during MIS midfoot procedures. Sequential dissection was performed on nine below-knee cadaveric specimens and critical structures were identified and marked, including anterior tibialis tendon (ATT), extensor hallucis longus tendon (EHL), extensor digitorum longus tendon (EDL), superficial peroneal nerve (SPN) and dorsal neurovascular bundle (DNVB) were dissected. Subsequently, flexible wires were positioned and securely placed adjacent to the medial and/or lateral borders of these structures to visualize their trajectories on X-ray imaging. Anteroposterior (AP) and oblique fluoroscopic images of the foot, featuring a calibration marker, were obtained alongside standard photographs. All fluoroscopy images were adjusted to a uniform scale and standardized to a single foot fluoroscopy. The coordinates of the structures were marked on these standardized foot AP and oblique fluoroscopic views. These coordinates were then utilized to generate heatmaps. Successfully generated heatmaps encompassed the DNVB, ATT, EDL, EHL, and SPN, on AP and oblique fluoroscopic images of the foot. The color gradient used visually represents varying magnitudes, with red indicating the most frequent locations of the structures and blue signifying lower occurrences. These heatmaps also illustrate the highest-risk areas for iatrogenic injury to the structures during MIS procedures. This study can empower surgical navigation and improve safety in MIS midfoot procedures by providing surgeons with a fluoroscopic heatmap detailing the trajectories of major anatomical structures. The findings from this study present a valuable opportunity to improve surgical accuracy and safety.

Not Just Another Trigger Finger.

Open A1 pulley release for trigger finger has generally been considered a minor procedure with infrequent complications. Most reported complications are minor, including scar pain and tenderness, mild extension lag, and recurrence of triggering. Rates of major complications, such as bowstringing, neurovascular bundle injury, and infection requiring reoperation, are less than 1% to 4%. We aimed to describe the potentially devastating sequelae of these major complications and the subsequent consequences. Three patients underwent open trigger finger release, which were all complicated by severe postoperative surgical site infection requiring multiple subsequent procedures. We review our initial management, subsequent reconstructive options, and outcomes with up to 19 years follow-up. All 3 adult patients who underwent open A1 pulley release for trigger finger developed a surgical site infection, leading to flexor tenosynovitis requiring urgent operative debridement and multiple subsequent procedures. Two patients were poorly controlled diabetics, and the third patient was otherwise healthy. Each patient ultimately developed distinct consequences from their postoperative course-finger stiffness and contracture, disabling bowstringing requiring the use of a pulley ring, and flexor tendon rupture requiring staged tendon reconstruction, respectively. All 3 patients at final follow-up had a permanent functional deficit. Major complications after trigger finger release are infrequent. However, if left untreated, particularly in diabetic patients, there can be disastrous consequences, resulting in permanent loss of function. This case series highlights the importance of accurate diagnosis of postoperative infections and expedient treatment thereafter.

Magnetic Resonance imaging evaluation of the distance to the popliteal artery in arthroscopic popliteus tendon versus posterior cruciate ligament reconstruction.

Wide acceptance of arthroscopically treating posterolateral corner injuries has not occurred. There remains a fear of neurovascular (NV) injury while arthroscopically performing these reconstructions. The study's aim is to compare on Magnetic Resonance Scans the distance of the tibial tunnel in an arthroscopic popliteus tendon reconstruction (APB) and arthroscopic posterior cruciate ligament (PCL) reconstruction (APC) to the popliteal neurosvascular bundle. MRI scans of 93 patients were evaluated. The tibial tunnel exit point of an APB and an APC reconstruction was marked. The smallest distance of the center of the exit point of these tunnels to the NV bundle was assessed. Mean variances and distances were assessed. A Welch's unpaired t-test was calculated. The difference in variances was also assessed. Mean distance to NV bundle from the tibial tunnel in an APB procedure was 15.9mm. The mean distance to the NV bundle from an APC tibial tunnel was 11.2mm. The Welch's unpaired t-test p-value was <0.0001. The p-value of the test for equality of variances was 0.0002. The distance to the NV bundle from the tibial tunnel of an APB is significantly higher than the distance to the NV bundle from the tibial tunnel of a APC. However, there is a significantly larger variance in distance to the NV bundle in an APB. Drilling a tibial tunnel during an APB should therefore not be considered more dangerous than drilling the tibial tunnel during an APC.Level 4 LOE.

Comparison of Da Vinci XI and Da Vinci SI Surgical Systems in Robot-Assisted Radical Prostatectomy

Introduction. Robot-assisted radical prostatectomy is considered to be the “gold standard” for the radical treatment of prostate cancer, achieving excellent oncological outcomes with a low incidence of complications.Aim. To analyze and compare the efficiency of Da Vinci Xi and Da Vinci Si surgical systems applied in performing robot-assisted radical prostatectomy. Materials and methods. 165 patients were divided into two groups: Xi-group (n = 77) and Si-group (n = 88). The perioperative characteristics and oncological outcomes were analyzed and compared.Results. The demographic, clinical, and oncological characteristics of the two patient groups appeared similar and comparable. Interventions involving the preservation of the neurovascular bundle, the pelvic fascia, and the puboprostatic ligament were performed using Xi system significantly more often. The surgery duration was significantly shorter in the Xi-group. The postoperative recovery time and the incidence of postoperative complications appeared to be identical across both groups. No differences were revealed in the rates of positive surgical margins or biochemical recurrence.Discussion. Reasons behind the reduced operative time were considered as follows: first, the docking of the Xi system is more user-friendly, resulting in decreased docking time; second, the operational efficiency of the Xi system had been enhanced, thereby leading to reduced workflow times; third, a number of collisions between robotic arms was significantly lower during the procedure, which accelerates the surgical process.Conclusion. A robot-assisted radical prostatectomy performed by an experienced professional, using the Da Vinci Xi or Da Vinci Si surgical systems, appears to be safe and feasible without an increased risk of serious complications. However, the Xi system ensures better perioperative outcomes with comparable oncological results.

Impact of neurovascular bundle preservation on biochemical recurrence after robot-assisted radical prostatectomy for high-risk prostate cancer.

To evaluate functional and oncological outcomes in patients who underwent unilateral or bilateral nerve-sparing (NS) robot-assisted radical prostatectomy (RARP) for high-risk prostate cancer. The cohort comprised 2683 patients with clinical stage T1-4, N0M0 high-risk prostate cancer who underwent RARP in Japanese tertiary care centers from August 2011 to April 2023. High risk was defined using the European Association of Urology risk stratification criteria. Patients were classified as high risk if they had clinical stage T2c-T4, a serum prostate-specific antigen concentration (PSA) of > 20ng/dL, or an International Society of Urological Pathology (ISUP) grade of 4-5. Patients were grouped into NS and non-NS surgery groups. Propensity score matching was performed (1:1 ratio) to reduce confounding bias. The primary outcome was biochemical recurrence (BCR)-free survival (BCR-FS). The impact of NS surgery on BCR-FS was examined in the propensity score-matched cohort using Cox proportional hazards regression. The propensity score-matched cohort comprised 1722 patients. In the matched cohort, median follow-up was 31.9months. The 5-year BCR-FS was 70.2% in the NS group and 71.9% in the non-NS group (HR 1.05; 95% confidence interval, 0.85-1.29). NS surgery did not increase the risk of BCR in subgroups of patients stratified according to ISUP grade, T stage, percent cancer core involvement, and PSA. Neurovascular bundle preservation during RARP for high-risk prostate cancer appears feasible without increasing the BCR rate. However, the retrospective study design carries the potential influence of selection bias.

Phrenic Nerve Block for Management of Post-Thoracic Outlet Decompression Cough: A Case Report and Literature Review

Introduction Thoracic outlet syndrome is a group of disorders arising from compressive forces on the neurovascular bundle in that region due to different etiologies. This study aims to present a case with an intractable cough as a complication of the surgery and its management. Case presentation A 41-year-old woman had a 15-year history of bilateral upper limb pain and numbness. The pain worsened over the last two months. Tests and imaging confirmed thoracic outlet syndrome. Physiotherapy had no effect. She underwent thoracic outlet decompression (TOD) under general anesthesia via a supraclavicular incision. Post-surgery, she developed uncontrollable cough that didn't respond to medication. Two days after the operation, a bupivacaine (5%) injection near the phrenic nerve resolved the cough. Literature review The literature review identified several cases of TOD complications, including right phrenic nerve paralysis resolving in 3-6 months, unilateral right diaphragm dysfunction, and lung herniation successfully treated with thoracoscopic reduction. These cases underscore the diverse presentations and outcomes of TOD complications, highlighting the importance of early diagnosis and tailored management strategies. Conclusion A possible complication of surgical decompression for thoracic outlet syndrome is an intractable cough that can be relieved by the injection of local anesthesia into the area of the phrenic nerve.

Location of the Digital Neurovascular Bundle in Relation to a Mid-axial Incision Line: A Cadaveric Study

Background The digital mid-axial incision is commonly used in hand surgery. When correctly placed, the proper digital nerves should lie protected in the volar skin flap. The purpose of this study was to evaluate the distance of the digital neurovascular (NV) bundle from a mid-axial incision. Methods A standardized mid-axial incision along both sides of each digit was made on five fresh-frozen cadaver hands. The distance from the margin of the incision to the NV bundle was measured at the proximal interphalangeal joint (PIP) and the distal interphalangeal joint (DIP) levels on radial and ulnar sides. The same protocol was performed at the interphalangeal joint (IP) of each thumb. Results A total of 90 measurements were taken on five cadaveric hands. In the fingers, the average distance was 3.96 mm from the mid axial incision, with no measurement less than 2.97 mm. This distance was an average of 6.58 mm in the thumb, with no measurement less than 5.98 mm. The NV bundle on the radial side of the fingers was found to be farther from the mid axial incision than those on the ulnar side. The thumb displayed the opposite relationship, with the ulnar side having larger measurements. Conclusions The digital nerves of the fingers and thumb are safe during a mid-axial approach, with a safe zone of approximately 3mm in the fingers and 6mm in the thumb. Knowing these anatomic relationships will aid surgeons in safely approaching the digits while minimizing the risk of NV injury.

The Amount of Orthodontic Force Reaching the Dental Pulp and Neuro-Vascular Bundle During Orthodontic Movements in the Intact Periodontium.

Background and Objectives: Most orthodontic forces are absorbed-dissipated before reaching the dental pulp and its neuro-vascular bundle (NVB); however, no data are available about their amounts. The objective of this study was to assess the amount of orthodontic force that reaches the dental pulp and its NVB during orthodontic movements in a healthy periodontium. Materials and Methods: This study involved the second lower premolars of nine patients and 180 numerical simulations. Five orthodontic movements (intrusion, extrusion, rotation, translation, and tipping) under 0.5 N/5 KPa and 4 N/40 KPa were assessed. The numerical methods included only two failure criteria suitable for dental tissue (of ductile resemblance): Von Mises (VM) (overall, homogenous) and Tresca (shear, non-homogenous). Results: Both forces displayed a similar color-coded stress display for the two methods. The Tresca quantitative results were 1.11 times higher than the VM but lower than the maximum physiological hydrostatic circulatory pressure. The biomechanical behavior of the pulp and NVB showed that, in the intact periodontium, the NVB-induced stress was 5.7 higher than in the pulp. Quantitatively, the rotation movement seemed to be the most stressful for the NVB, closely followed by intrusion and extrusion. For the dental pulp, rotation remained the most stressful, closely followed by tipping and translation. Tissue deformations were visible for NVB areas during intrusion and extrusion. The dental pulp showed pulpal stresses under translation and rotation. The numerical simulations with the two methods showed that, in the intact periodontium, only a small amount of the initial orthodontic load produced effects in the NVB and dental pulp. Only about 2.85% of the initial orthodontic load of 40 KPa/4 N applied at the bracket level induced stresses in the NVB, while the dental pulp was reached by 0.5% of the applied force. A similar distribution was seen at 5 KPa/0.5 N. Conclusions: The absorption-dissipation ability of the dental tissue varies between 97.15 and 99.98%.

Digital design combined with endoscopic minimally invasive extraction of impacted mandibular third molars with roots in contact with the mandibular canal

Objective: To study the clinical efficacy of digital design combined with three-dimensional (3D) printing model minimally invasive extraction of complex impacted mandibular third molars. Methods: Eight patients who visited the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology from April 2023 to March 2024 were included, including 3 males and 5 females, aged from 27 to 57 years old. The impacted mandibular third molars of all patients were closely related to the mandibular canal, and part of the dental tissue entered the mandibular canal. Preoperative digital design was used to simulate the intraoperative tooth segmentation and bone removal operation of the power system and the segmented tooth dislocation path, and analyze the tooth extraction resistance. The mandibular teeth, mandibular canal and mandibular model were three-dimensionally printed using light-curing resin inkjet. During the operation, an endoscope was used combined with the 3D printed model to minimally invasively extract the impacted mandibular third molar. Quantitative sensory testing of the patient's lower lip skin on the operated side was performed before surgery, 2 days after surgery, and 7 days after surgery. Clinical data such as operation time were collected. A paired sample t test was performed on the 2 and 7 days postoperative data and the preoperative data to compare the data differences. Results: All 8 patients successfully completed preoperative design, model printing and minimally invasive surgery. The number of teeth segmented in the preoperative design was (4.4±1.3), and the number of teeth segmented in the actual operation was (4.0±1.1). The operation time was (33.3±13.0) min. None of the patients had postoperative numbness of the lower lip or other postoperative complication. It was observed endoscopically that the inferior alveolar neurovascular bundle was exposed in the extraction socket during the operation. The patient's pressure pain threshold 2 days after surgery (0.601±1.170) was significantly lower than before surgery (1.251±1.109) (t=2.83, P=0.025). Conclusions: For complicated impacted mandibular third molars, digital design combined with 3D printing model can be used to perform minimally invasive extraction with the assistance of an endoscope.

Beyond the hernia in groin ultrasound.

Groin discomfort is one of the most common presenting complaints in health care and often requires ultrasound to detect hernias. However, such singular emphasis leads to over diagnosing hernia and other significant aetiologies in and around the groin are overlooked. The article elaborates on the key areas a sonographer needs to focus on and presents a range of conditions responsible for groin pain other than hernia. In addition to evaluating for hernia, a groin ultrasound should evaluate structures in the inguinal canal, the adductor muscles and symphyseal region, the superficial inguinal lymph nodes, the femoral neurovascular bundle, the hip joint with periarticular regions and the structures in the right iliac fossa. Sonographers must have a methodical approach, a good knowledge of normal anatomy and pathologies and a comprehensive understanding of the various types of groin abnormalities for a thorough examination.

Localisation of the Infraorbital and Mental Foramen in Orthognathic Surgery: a CBCT Study.

To establish precise positional references for orthognathic surgery by examining the relative positioning of the infraorbital foramen (IOF) in relation to the anterior nasal spine (ANS) and the mental foramen (MF) in relation to the pogonion (Pog). A cohort of 115 patients with CBCT images was randomly selected for analysis. Distances and positional relationships between the IOF and ANS, as well as the MF and Pog, were measured using 3D reconstruction images. On average, the ANS was situated 21.40 mm below the IOF, with a horizontal distance of 26.42 mm. The horizontal and vertical distances between the MF and Pog were 23.57 and 9.71 mm, respectively. Scatter plots centred on the ANS indicated that 83% (191/230) of the IOF were distributed in a 30- to 45-degree fan shape, the radius of which ranged from 30 to 40 mm. Similarly, 98% (226/230) of the MF occupied a 45-degree fan shape within a 20 to 30 mm radius in the bilateral superior quadrant centred on the Pog. During maxillary osteotomy, there is a potential risk of damaging the infraorbital neurovascular bundle located 21.40 mm above the ANS. To mitigate the risk of IOF injury, caution is advised, particularly when retracting the flap below a 30-degree fan shape within a 30 to 40 mm radius centred on the ANS and a 45-degree fan shape within a 20 to 30 mm radius centred on the Pog. Special attention is warranted during flap elevation in this specified area.

Clinical case report of non-surgical and surgical endodontic treatment (apicoectomy)

Endodontic treatment, both non-surgical and surgical, aims to eliminate the neurovascular bundle and the microbiota present within the root canal system and the extraradicular region. This study reports the clinical management of a 31-year-old female patient with odontalgia in tooth #46. Following clinical and radiographic evaluation, a periapical radiolucent lesion approximately 5 mm in diameter was identified. Initially, conventional endodontic treatment was performed using the Reciproc Blue mechanized system, followed by an apicoectomy due to persistent symptoms associated with a high bacterial load. The therapeutic approach was based on the review of 12 scientific articles to establish an accurate pulp and periapical diagnosis and to select appropriate techniques and materials. Treatment outcomes demonstrated adequate healing and periapical repair, with resolution of clinical symptoms and functional improvement of the treated tooth. It is concluded that the integration of non-surgical and surgical treatments is essential in cases of pulp necrosis and chronic periapical abscess with high bacterial load. This complementary approach optimizes therapeutic outcomes, preserves the tooth, and improves the patient’s quality of life

Neurovascular Structure-adjacent Frozen-section Examination (NeuroSAFE) During Radical Prostatectomy: A Systematic Review and Meta-analysis.

A standardized intraoperative frozen section analysis of the prostate resection margin adjacent to the neurovascular bundle according to the NeuroSAFE technique is performed to maximize nerve sparing during radical prostatectomy (RP) for prostate cancer (PCa). The aim of this review was to analyze oncological and functional outcomes of NeuroSAFE. A systematic search of the Medline, Embase, and Web of Science databases until July 2024 was performed. Studies were eligible if these included men undergoing RP with NeuroSAFE for PCa, and reported on oncological and/or functional outcomes. A cumulative analysis with random-effect models for oncological outcomes was conducted using Review Manager software, together with a narrative analysis of the procedure and functional outcomes. We analyzed 14 studies with nine distinct patient populations; 7505 out of 15 446 patients underwent NeuroSAFE. The number of nerve-sparing procedures was higher for patients with NeuroSAFE than for controls in all studies. Cumulative analyses showed a statistically significantly lower risk of positive surgical margins (PSMs) in favor of NeuroSAFE (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.51-0.91, I2=79%) and no difference in 2-yr biochemical recurrence (BCR; OR 0.79, 95% CI 0.53-1.18, I2=63%). All studies with control groups showed higher potency rates in the NeuroSAFE group; none reported significant difference in continence rates. Adverse events were scarce. Limitations of the studies include a lack of randomization resulting in a selection bias; the overall risk of bias judgment ranged from low to serious. We present the first systematic review on NeuroSAFE during RP. The level of evidence is weak. The increased rate of nerve-sparing surgery, reduced PSMs, similar BCR, and low adverse event rates imply that NeuroSAFE is an oncologically safe technique. NeuroSAFE seems to improve functional outcomes, especially potency, but results of randomized trials are awaited. We know that for patients with prostate cancer who undergo an operation to remove the prostate, sparing the nerve bundles next to each side of the prostate improves continence and erectile function. In this literature review, we evaluated a technique (NeuroSAFE) that aids surgeons in deciding whether they can spare these nerve bundles safely while still operating radically, for example, remove all cancer. We found that the technique is oncologically safe. Furthermore, the impact on potency appears promising but needs further study.

Patient reported health related quality of life outcomes after viable cryopreserved umbilical tissue placement directly over spared neurovascular bundles after robotic assisted radical prostatectomy.

Incontinence and sexual dysfunction remain common side effects from robotic-assisted radical prostatectomy (RARP) despite nerve sparing (NS) and bladder neck reconstruction techniques. Placing growth factors and anti-inflammatory substances over neurovascular bundles is an emerging technique to enhance recovery of continence and potency. Viable cryopreserved umbilical tissue (vCUT) is FDA-approved for surgery. The objective is to determine if vCUT use in NS-RARP accelerates return of continence and sexual function. A retrospective cohort of 176 patients undergoing NS-RARPs with and without vCUT from 2015 to 2020 was identified through the Michigan Urological Surgery Improvement Collaborative (MUSIC). Return to social urinary continence at 3, 6, and 12months, postoperatively was evaluated using MUSIC patient-reported outcomes (PRO), a validated questionnaire assessing urinary and sexual quality of life at baseline and post-treatment. A distinct cohort of 65 patients undergoing NS-RARP with and without vCUT was assessed for erections firm enough for intercourse at 12 and 24months post-operatively using MUSIC-PRO. The association between vCUT use and social continence at 3months was assessed via multivariable logistic regression. A descriptive analysis among patients with quality erections prior to surgery assessed the association between vCUT use and erection quality. Continence was achieved by 3months post-op in 86% (99/115) of vCUT patients versus 74% (45/61) in non-vCUT patients (p = 0.044). In a multivariable analysis, although not reaching conventional statistical significance, vCUT patients were more likely to achieve continence than non-vCUT patients (OR = 2.21, p = 0.073). At 24months post-op, 32% of vCUT patients reported good sexual function versus 33% in non-vCUT patients (p = 0.9). vCUT use during NS-RARP is associated with quicker return to social urinary continence. However, no differences were seen in return of potency. Further studies with longer follow-up and larger sample sizes may further evaluate effectiveness of vCUT in accelerating return of postoperative continence and potency.