Temporary Nerve Injury Research Articles

Limited Incision Facelifts: A Contemporary Review of Approaches and Complications.

Limited incision facelifts (LIFs) have gained popularity as an alternative to traditional facelift procedures. While surgical techniques vary, these approaches share a common goal: to rejuvenate the face while minimizing scar visibility. Previous studies also suggest that the reduced tissue dissection in LIFs can lead to decreased postoperative swelling, shorter recovery periods, and fewer complications. In this systematic review we delved into the literature on LIFs, shedding light on the various surgical approaches and their respective safety profiles. A systematic review was conducted by independent evaluators who followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A random-effects model was utilized to summarize complications data, and meta-regressions were conducted to analyze associations with operative variables. The analysis encompassed a total of 20 articles, comprising data from 4451 patients. The vast majority (84%) of these patients underwent either local wide-awake surgery or conscious sedation, while the remaining 16% underwent general anesthesia. Our analysis revealed an overall complication frequency of 3.2%, with hematoma being the most common complication (2%), followed by temporary nerve injury (0.2%), and skin necrosis or wounds (0.06%). Notably, hematomas rarely required operating room interventions. Use of drains or tissue sealants was associated with an 86% decrease in complications. Limited incision facelifts can be performed with a low complication rate, utilizing a variety of techniques. Utilization of tissue sealants and drains may limit hematoma formation, which is the most common complication.

Safety and Effectiveness of Limited Incision Facelifts: A Systematic Review and Meta-analysis

Abstract Goals/Purpose Limited incision facelifts offer a less invasive approach compared to a standard facelift and allow for the procedure to be completed under local anesthesia. While there have been various types of limited incision facelifts described, there have been no systematic reviews of their evidence. The purpose of this study is to systematically review the limited incision facelift literature, describe the various surgical approaches and their indications, and summarize their safety and effectiveness. Methods/Technique A systematic review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines and registered with the PROSPERO international prospective register of systematic reviews. The MEDLINE (Pubmed), EMBASE, and Cochrane Central Register of Trials were queried. Screening and full-text review of studies was conducted by two independent evaluators using predetermined inclusion and exclusion criteria. Data obtained from each eligible study included information on author specialty, Oxford Centre for Evidence-Based Medicine level of evidence, and patient demographics. Operative data included anesthetic approach, operative duration, incisional pattern, SMAS technique, concomitant procedures, and drain or tissue sealant use. Complication frequencies were calculated from those studies that specifically described complication data and included the prevalence of hematoma, wounds or skin necrosis, infection, nerve injuries, and revision surgery. Data on patient- and provider-reported outcomes were also collected. Meta-analyses were performed using aggregated data. Proportions are provided with the corresponding 95% confidence interval. A Random-effects model was used to summarize complications data and meta-regressions were conducted to analyze associations with operative variables. Results/Complications A total of 1137 articles were retrieved using the pre-specified search criteria. Following the removal of duplicates, 758 studies were screened using titles and/or abstracts, and 144 articles underwent full-text review. Review yielded twenty articles that met inclusion criteria. Using the Oxford Centre for Evidence-Based Medicine guidelines, 17 (85%) articles provided level IV evidence while three (15%) provided level III evidence. Articles included a total of 4451 patients with an average age of 56 years. Ninety-four percent were women while 6% were men. Forty-two percent of patients underwent surgery awake under local anesthesia, 24% under IV sedation, 18% under intramuscular sedation, and 16% under general anesthesia. Incisional patterns varied but were categorized as limited to pre-auricular (5%), pre-and retro-auricular (10%), pre-auricular with horizontal sideburn extension (30%), pre-auricular with temporal extension (35%), and pre- plus retro-auricular with temporal extension (20%) (Figure). SMAS technique included plication (33%), purse-string suspension (28%), plication plus SMASectomy (11%), plication plus SMASectomy and purse-string suspension (11%), SMASectomy only (6%), or other (18%). Forty-five percent of articles described using drains and 10% described using a tissue sealant. The overall complication frequency was 4.0% (95% CI 2.8-5.2%). The use of a drain or sealant was associated with a decreased complication frequency of 2.6% (95%CI 1.0-4.2%) compared to 5.0% (95% CI 3.4-6.6%) in studies using no drain or sealant (p=0.04). There were no associations found between complications and incision type or anesthetic approach. Eighteen studies described hematoma frequencies. Among these articles, there was a 2.3% hematoma frequency (95% CI 1.5-3.0%). Twenty-seven patients (1.5%) had hematomas that were treated with conservative management like needle aspiration while eight (0.4%) required a return to the operating room. The next most common complication described was temporary nerve injury or neuropraxia with a rate of 0.2% (95% CI 0.1%-0.4%­­­). The frequency of skin necrosis or non-healing wounds was 0.2% (95% CI 0.1%-0.04%). No permanent nerve injuries were described. Other less commonly described complications included widening or hypertrophic scars, dog ear deformities (all within patients undergoing pre-auricular limited incisions), skin dimpling, three cases of parotid fistula, and a DVT in a patient undergoing multiple concomitant body procedures. Seven articles (35%) provided data on patient-reported outcomes while three (15%) provided data on provider-based outcomes, such as ratings of postoperative results. Conclusion To our knowledge, this is the first systematic review and meta-analysis of limited incision facelifts. This surgical approach offers an alternative to traditional rhytidectomy for the properly selected candidate. Meta-analysis demonstrates a low postoperative complication rate which is further reduced in studies using a drain or tissue sealant. This meta-analysis provides plastic surgeons and their patients with an evidence-based reference for complication data and can improve the preoperative counseling process. Future studies should focus on incorporating validated patient-reported outcome measures and comparing surgical approaches.

Surgical Complications of Orthognathic Surgery

Objectives: Orthognathic surgery is popular and provides patients with improved aesthetics and functionality. The procedure is considered safe and predictable. Possible complications do exist and can be life-threatening. The aim of this study is to assess the prevalence of intra- and post-operative complications, and to define possible correlations between diagnoses. Study Design: Medical records of 103 patients who underwent orthognathic surgery in a 4.5-year period (2013–2017), at the Baruch Padeh “Tzafon” Medical Center in Poriya (PMC), Israel, were retrospectively collected. The data were analyzed for descriptive statistics and non-parametrical tests. Results: In total, there were 56 complications in 45 patients (43.7% probability of complication per patient). Major complication occurred in only one case (1%), moderate complications appeared in 8.7% of the cases, while the most prevalent minor complications were temporary nerve injury and hardware issues (17.5% and 15.5%, respectively). Statistical analysis revealed that bi-max surgery has significantly higher (OR 1.34, CI 99% 1.05–1.69, p = 0.019) prevalence of complications than one-jaw surgery, as did skeletal class II patients (OR 2.75, CI 99% 2.25–3.35, p = 0.022), as compared to skeletal class III patients. Conclusions: Serious complications seem to be rare in orthognathic surgery at PMC.

Asian Face Lift with the Composite Face Lift Technique.

The composite face lift is becoming increasingly popular following recent advances in understanding of facial anatomy that enable safe sub-superficial musculoaponeurotic system (SMAS) dissection. This article presents the authors' technique for composite face lift in Asian patients and reviews their experience and outcome with this procedure. Composite face lifts were performed on 128 Asian patients between January of 2010 and June of 2020. Ninety-four were primary face lifts, and 34 were secondary or tertiary face lifts. The authors' surgical technique and adaptations for the specific requirements of Asian patients are described in detail. The mean follow-up was 26 months (range, 6 to 108 months). Fat grafting was an integral part of our procedure, with 95 percent having concomitant facial fat grafting with their face lift. Patients were followed up in accordance with a standardized schedule. The majority of patients reported high satisfaction with the aesthetic outcome of the technique, with natural, long-lasting results. The face lift plane of dissection is through the facial soft-tissue spaces, which provide atraumatic sub-SMAS access with precise release of the intervening retaining ligaments for effective flap mobilization. By emphasizing tension on the composite flap with no tension on the skin closure, the scars were discrete in the great majority of patients. Complications were few, with no hematomas or skin flap necrosis. The temporary nerve injury rate was 1.5 percent, with no patient having a permanent nerve injury. The composite face lift is an ideal technique for Asian patients, as it delivers natural, long-lasting results; a quick recovery; and high patient satisfaction. Therapeutic, IV.

Percutaneous transaxillary access for endovascular aortic procedures in the multicenter international PAXA registry

BackgroundThe aim of the study was to demonstrate the safety and effectiveness of a suture-mediated vascular closure device to perform hemostasis after an axillary artery access during endovascular procedures on the aortic valve, the aorta and its side branches. MethodsA physician-initiated, international, multicenter, retrospective registry was designed to evaluate the success rate (VARC-2 reporting standards) of percutaneous transaxillary access closure with a suture-mediated closure device. Secondary end points were minor access vascular complications, transient peripheral nerve injury, stroke, and influence on periprocedural outcomes of puncture technique. ResultsThree hundred thirty-one patients (median age, 76 years; 69.2% males) in 11 centers received a percutaneous transaxillary access during endovascular cardiac (n = 166) or vascular (n = 165) procedures. The closure success rate was 84.6%, with 5 open conversions (1.5%), 45 adjunctive endovascular procedures (13.6%), and 1 nerve injury (0.3%). Secondary closure success was obtained in 325 patients (98%) after 7 bare stenting, 37 covered stenting, and 1 thrombin injection. Introducer sheaths 16F or larger (odds ratio, 3.70; 95% confidence interval, 1.22-11.42) and balloon-assisted hemostasis (odds ratio, 4.45; 95% confidence interval, 1.27-15.68) were associated with closure failure. A threshold of five percutaneous axillary accesses was associated with decreased rates of open conversion, but not with increased primary closure success. Primary closure success was 90.3% in the 175 patients with sheaths smaller than 16F, performed after the first 5 procedures in each center. Temporary nerve injury and stroke were observed in 2% and 4% of patients, respectively. ConclusionsPercutaneous transaxillary aortic procedures, in selected patients, can be performed with low rates of open conversion. The need for additional endovascular bailout procedures is not negligible when introducers sheaths 16F or larger are required.

INFERIOR ALVEOLAR NERVE DEFICIT AFTER REMOVAL OF LOWER THIRD MOLARS-FREQUENCY AND FACTORS AFFECTING NERVE DAMAGE IN PROSPECTIVE CLINICAL STUDY OF 1487 EXTRACTIONS IN 1185 PATIENTS

Objective:
 To determine the Frequency of inferior alveolar nerve injury and to assess the relationship of the nerve deficit with contributory risk factors like causes of removal, patient’s age, and anesthetic modality.
 Materials and Methods:
 All the procedures were carried out in Maroof International Hospital from January 2016 to August 2020. About 1185 consecutive patients were included in the study who were treated over a period of 5 years. A total of 1487 surgical extractions were performed. Surgery was done either under local anesthesia (72.1%) or IV sedation with local anesthesia (27.9%). All the procedures were performed by the same single senior consultant with the same two nurses. Follow up was done at one, three, and six weeks and six months.
 Results:
 Eight cases (0.53%) had temporary inferior alveolar nerve deficit which settled within six weeks. No permanent neurological damage was observed. Cases with pericoronitis were significantly associated with postoperative temporary nerve damage (p<0.001). Age, gender, and anesthetic modality were not significantly related to nerve injury.
 Conclusion:
 Patients with preoperative pathology like pericoronitis have more chances of temporary nerve injury after removal. Preoperative counseling about possible nerve damage shall be done.

Complications of Hip Endoscopy in the Treatment of Subgluteal Space Pathologies

To assess complications of hip endoscopy in patients with subgluteal space pathologies. This was a retrospective study of patients diagnosed with sciatic nerve entrapment (SNE), ischiofemoral impingement (IFI), and rupture of the proximal origin of the hamstring muscles (RHM) who underwent a hip endoscopy from January 2012 to December 2018, after a minimum of 3 months of conservative management without satisfactory results. Complications were documented and graded using the adapted system of Clavien-Dindo. Revision surgeries were classified as treatment failures. Function was evaluated by the Western Ontario McMaster Universities Osteoarthritis Index before and 12 months after the surgical procedure. A total of 97 hips with subgluteal space pathologies were treated with hip endoscopy. This total consisted of 77 hips with SNE, 5 with IFI, 12 with SNE+ IFI, and 3 hips with RHM. Minor (Clavien-Dindo I-II) and major (Clavien-Dindo III-V) complications occurred in 7.22% (7) (95% confidence interval 3.54%-14.15%) and 12.37% (12) (95% confidence interval 7.22%-20.39%). Grade II, III, and IV complications were reported in 7.22% (7), 7.22%, and 5.15% (5) hips, respectively. Temporary nerve injury of the sciatic nerve, hematoma, and permanent nerve injury of the posterior femoral cutaneous nerve were the most common grade II, grade III, and grade IV complications, respectively. The revision rate was 6.19% (6) and entrapment of the sciatic nerve was the main cause of reoperation. No statistically significant differences were found between cases with and without complications in the Western Ontario McMaster Universities Osteoarthritis Index scores evaluated before and after surgery (P > .05). A high rate of complications associated with hip endoscopy were observed in patients with SNE, IFI, and RHM. Sciatic nerve and posterior femoral cutaneous nerve injury were the most frequent events. IV, case series type.

3:18 PM Abstract No. 252 Efficacy of cryoablation in treating osteoid osteoma in the pediatric population

Osteoid osteoma (OO) is a benign bone tumor that can cause significant pain and negatively affect daily life for patients. Surgical resection and multiple percutaneous techniques have been utilized in the treatment of osteoid osteomas. We report our institutional experience with cryoablation in the treatment of OO in pediatric patients. A retrospective review of 11 patients from 2014-2017 with a confirmed OO and who underwent cryoablation by a single interventional radiologist was completed. Demographic, subjective, clinical, imaging, and pathological information were collected. Pre- and post-pain scales were recorded to determine if symptom relief was achieved. Bone biopsies were analyzed for concordance with clinical/imaging diagnosis. Details of the procedure, such as imaging modality used, technical success, procedure time, radiation exposure, and complications of each procedure were analyzed. All patients presented with classical symptoms with an average age of 12.1, and 82% were male. The average duration of pain was 11 months and 91% reported regular NSAID use prior to cryoablation. The average nidus size was 9.7 mm. A 100% technical success rate was achieved with 60% of patients having a concordant biopsy. There was a significant reduction in numeric pain scales from an average of 7 out of 10 before to an average of 0 after the procedure (p = 0.003). A total of 3 self-limiting complications were reported after the procedure: one patient reported skin blistering and two presented with temporary nerve injury. There was no significant difference in procedure time, radiation exposure, and technical success between the two types of CT scanners used (p > 0.05). Adequate symptom relief can be achieved with percutaneous cryoablation, which is an effective alternative to other percutaneous techniques or surgical resection in the treatment of osteoid osteoma.

Long-term follow-up after bilateral percutaneous epiphysiodesis around the knee to reduce excessive predicted final height

ContextPercutaneous epiphysiodesis (PE) around the knee to reduce predicted excessive final height. Studies until now included small numbers of patients and short follow-up periods.Objective and designThis Dutch multicentre, long-term, retrospective,...

Routine central lymph node dissection with total thyroidectomy for papillary thyroid cancer potentially minimizes level VI recurrence

Treatment strategies for papillary thyroid cancer remain controversial due to the lack of large, randomized controlled trials. The purpose of this study was to review the benefit of routine bilateral central lymph node dissection (CLND) by analyzing local recurrence and complication rates from a single institution over a 15-year period. A retrospective, institutional review board-approved review of the Baylor Scott & White Tumor Registry was performed on all patients who underwent operation for papillary thyroid cancer between 2000 and 2015. Patients were evaluated by age, sex, tumor size, operation performed, pathologic findings, adjuvant therapy, and date of recurrence. Primary outcomes were cancer recurrence, recurrent laryngeal nerve injury, and hypoparathyroidism. Total thyroidectomy with CLND was performed in 266 patients. Metastases to level VI lymph nodes were present in 106/266 (39.8%) patients. Average follow-up after thyroidectomy was 46months (range 1-125months). Papillary thyroid cancer recurred in 4 patients after thyroidectomy with CLND for primary tumors with mean size of 1.6cm (range 1.0-2.0cm). Two patients with T4 tumors had local recurrence in the paratracheal soft tissues, and 2 patients presented with recurrence in the lateral neck. Temporary nerve injuries occurred in 9/266 (3.4%) and permanent nerve injuries in 1/266 (0.4%) of CLND. Permanent hypoparathyroidism occurred in 4/266 (1.5%) patients. Total thyroidectomy with CLND can safely be performed routinely for treatment of papillary thyroid cancer in the hands of experienced endocrine surgeons. Dissection of level VI lymph nodes does not increase the risk of recurrent laryngeal nerve injury when performed routinely. Bilateral CLND with total thyroidectomy for papillary thyroid cancer potentially minimizes recurrence in the level VI compartment.

Dissection of Levels II Through V Is Required for Optimal Outcomes in Patients with Lateral Neck Lymph Node Metastasis from Papillary Thyroid Carcinoma

Completeness of surgical resection is an important determinant of outcomes in patients with papillary thyroid carcinoma and regional lymph node metastasis. The extent of therapeutic lateral neck dissection remains controversial. This study aims to assess the impact of modified radical neck dissection of levels II to V in a large patient series. Retrospective analysis of consecutive patients with papillary thyroid carcinoma who underwent lateral neck dissection at a single institution from June 1, 2006 to December 31, 2014 was performed. A total of 241 lateral neck dissections were performed in 191 patients (118 [62%] women; median age 46 years [range 6 to 87 years]; median follow-up 14.3 months [range 0.1 to 107 months]). Overall, 202 initial neck dissections (195 modified radical neck dissections and 7 less extensive dissections) were performed. Among these initial dissections, 137 (68.8%), 132 (65.7%), 105 (52.0%), and 33 (16.9%) had positive lymph nodes in levels II, III, IV, and V, respectively. Ipsilateral lymph node persistence or recurrence occurred after 22 (10.9%) initial dissections, at level II in 10 (45.5%), level III in 8 (36.4%), level IV in 7 (31.8%), and level V in 3 (13.6%). Thirty-nine reoperative lateral neck dissection were performed, including 18 cases of persistence and recurrence after our initial dissections. In reoperative dissections, positive lymph nodes were confirmed in levels II, III, IV, and V in 18 (46.2%), 10 (25.6%), 13 (33.3%), and 5 (12.8%) dissections, respectively. Temporary nerve injury occurred in 6 (3.0%) initial and 4 (10.3%) reoperative dissections, respectively. There were no permanent nerve injuries. Omitting levels II and V during lateral neck dissection for papillary thyroid carcinoma potentially misses level II disease in two-thirds of patients and level V disease in one-fifth of patients. Formal modified radical neck dissection is necessary to avoid the morbidity of reoperative surgery.

Complications in Hip Arthroscopy

The primary objective of this study was to determine the minor and major complication rate of hip arthroscopy. The secondary objective was to provide strategies for avoiding complications. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. Therapeutic hip arthroscopy investigations that reported on adverse events or complications were included. Narrative and other systematic reviews, meta-analyses, conference abstracts or proceedings, and level V evidence studies were excluded. No follow-up minimum was imposed. The results yielded 53 studies (8189 hip arthroscopies in 8071 subjects). Most studies were level IV evidence (74%) with a mean of 2.2±2.1 years follow-up. Femoroacetabular impingement (FAI) and labral pathology were the 2 most common indications for surgery, and osteochondroplasty for FAI and labral treatment were the 2 most common procedures performed. The minor and major complication rates were 7.9% and 0.45%, respectively. Iatrogenic chondrolabral damage and temporary nerve injury were the 2 most common minor complications. Extra-articular fluid extravasation was the most common major complication encountered. Minor complications associated with hip arthroscopy are generally technical in nature and may be related to the learning curve associated with hip arthroscopy. As surgeon experience increases and patient selection improves, a corresponding decline should be observed in minor complications. Strategies to prevent complications include careful preoperative planning, appropriate surgical indications, attention to detail in the operating room, and proper postoperative rehabilitation.

Establishing safety standards in liver transplantation operating room nursing care

ObjectiveThe liver transplant operation is a lengthy procedure where the operating room (OR) nurse is expected to maintain adequate safety measures to protect the patient from physical injuries such as hypothermia, position-related injuries and thermal-related injuries from electrocautery. Our aim is to review the effectiveness of our perioperative patient care precautions. MethodsA retrospective review of all perioperative liver transplant records from January 2006 to December 2008 of recipients and live liver donors was performed. From January 2007 onwards, a standardized nursing care protocol designated for liver transplant-related patients was developed by the nursing department. Perioperative injuries related to poor nursing preparation were recorded. ResultsA total of 462 patients were included. There were a total of 13 (13.5%) perioperative nursing complications which included 7 skin integrity defects, 3 temporary nerve injuries, and 3 hypothermia episodes below 36°C. All these injuries (13 out of 96 patients) were seen from January to December 2006 prior to the implementation of a standardized perioperative nursing protocol. From 2007 onwards, physical facilities׳ improvement was instituted with the acquisition of leg compression cuffs and silicon-based cushions. The OR air conditioning was improved by self-adjusting monitoring devices to keep the OR temperature and humidity at 24°C and 50%, respectively. There has been no reported complication from January 2007 to December 2008. ConclusionThe establishment of objectively assessable perioperative OR nursing care standards in liver transplantation operation is important to avoid installation-related complications.

Renal Function Changes Following Fenestrated EVAR

Conclusions: This large study of CBTs demonstrates the importance of determining the CBT’s distance to the BOS as well as the Shamblin classification. Shamblin classification predicts the need for vascular reconstruction and the risk of bleeding and temporary nerve injury, and distance to BOS predicts bleeding risk and permanent nerve injury. Preoperative EMB is more often performed for CBTs located higher in the neck but may not reduce bleeding in CBTs that are located lower in the neck. Distance to BOS should be calculated in all patients with CBTs to provide precise preoperative counseling of risks.

Facial nerve injury following surgery for temporomandibular joint ankylosis: A prospective clinical study

The purpose of this prospective study was to evaluate the incidence and degree of facial nerve damage and time taken for its recovery following surgery for temporomandibular joint (TMJ) ankylosis. A total of 30 subjects with the TMJ ankylosis with or without history of previous surgery were included in this prospective study. House-Brackmann grading system was used to assess the function of the facial nerve post-operatively. Most of the subjects were in the age range of 13-15 years. Eight subjects had bilateral ankylosis and remaining 22 had unilateral ankylosis. Out of 32 joints in which gap arthroplasty was performed, 4 had Grade 1 injury, 14 had Grade 2 injury, 12 had Grade 3, and 2 with the Grade 4 injury 24 h post-operatively. Whereas, out of 6 cases of interpositional arthroplasty 4 had Grade 1 injury and 2 had Grade 4 injury. According to House-Brackmann grading system, at 24 h, 78.9% patients had different grades of facial nerve injury, which gradually improved and came to normal limits within 1-3 months post-operatively. Comparison of change in the Grade of injury at 3 months follow-up as compared to baseline (24 h) showed full recovery in all the cases (100%) showing a statistically significant difference from baseline (P < 0.001). When proper care is taken during surgery for TMJ ankylosis, permanent facial nerve injury is rare. However, the incidence and degree of temporary nerve injury could be either due to the heavy retraction causing compression and or stretching of nerve fiber resulting in neuropraxia.

Extracranial Carotid Artery Aneurysms: Long-term Results of Open Repair

Extracranial carotid artery (ECA) aneurysms are rare, but the potential risk of rupture or thromboembolism argues for early treatment. Our goal was to determine complications and long-term outcome of open surgical repair. Clinical data of 27 patients (13 women, 14 men; mean age, 65 years) treated for ECA aneurysm at our institution between 1990 and 2009 were retrospectively reviewed. The mean ECA aneurysm size was 3.9 cm (range, 1.2-6.5 cm). Etiology in the 27 patients was pseudoaneurysm after prior carotid surgery (37%), fibromuscular dysplasia (14%), trauma (19%), atherosclerosis (19%), infection (7%), and Marfan syndrome (4%). The 22 nontraumatic aneurysms involved the internal carotid artery (ICA), and the 5 traumatic aneurysms involved the common carotid artery. Pulsatile neck mass was present in 16 patients (59%), an audible bruit was identified in 12 (44%), and 14 (56%) had a documented preoperative transient ischemic attack or stroke. Nine patients (33%) presented with concomitant aneurysms, most commonly involving the abdominal aorta. All patients underwent elective open surgical repair, including resection in 22, with interposition bypass grafting (50%), end-to-end primary repair (23%), or patch angioplasty (27%); carotid ligation in 3; and aneurysmorrhaphy in 2. There were no perioperative deaths. One patient (3.7%) sustained a neurologic embolic event with permanent visual field deficits. Transient cranial nerve injury occurred in three patients (14%), all associated with repeat surgery or high cervical lesions. During a mean follow-up of 7 years, no strokes, neurologic events, or recurrent aneurysms occurred, and five patients died of cardiac causes. Open surgical repair of ECA aneurysms can be accomplished with minimal morbidity and excellent long-term results. For most patients, open repair remains the gold standard of treatment. Patients requiring redo surgery or with distal cervical lesions have increased risk of temporary nerve injury and, therefore, may be a subgroup that would benefit from percutaneous treatment.

The Impact of Intraoperative Neuromonitoring (IONM) on Surgical Strategy in Bilateral Thyroid Diseases: Is it Worth the Effort?

Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve and the vagal nerve can detect nonfunctioning nerves (recurrent laryngeal nerve palsy, RLNP) that are visibly intact. The use of IONM is questionable, however, as we still lack evidence that it reduces the rate of postoperative nerve injuries. Since negative IONM results after thyroid dissection of the first side could change our surgical strategy and thus could prevent patients from bilateral RLNP, we questioned whether IONM results are reliable enough to base changes in surgical strategy and whether this has any effect on surgical outcome. We retrospectively analyzed the data of 1333 consecutive patients with suggested benign bilateral thyroid disease who had been operated on under a defined protocol, including the use of a specific IONM technique (tube electrodes and stimulation of the vagal nerve and the inferior recurrent nerve before and after thyroid resection), between January 1, 2006 and December 31, 2008. In four patients the IONM system did not work, two nerves had not been found, and in eight patients the tube had to be readjusted. Of five permanent nerve injuries, four were visible during surgery and one was suspected. Sensitivity of IONM in detecting temporary nerve injuries of macroscopically normal-appearing nerves was 93%. Specificity was 75-83% at first side of dissection and 55-67% at the second side, with an overall specificity of 77%. In 11 of 13 patients (85%) with known nerve injury (preexisting or visible) and in 20 of 36 patients (56%) with negative IONM stimulation at the first side of dissection, the surgical strategy was changed (specific surgeon or restricted resection) with no postoperative bilateral RLNP. This was in contrast to 3 of 18 (17%) bilateral RLNP (p < 0.05), when surgeons were not aware of a preexisting or highly likely nerve injury at the first side of thyroid dissection. Failed IONM stimulation of the vagal or recurrent laryngeal nerve after resection of the first thyroid lobe is specific enough to reconsider the surgical strategy in patients with bilateral thyroid disease to surely prevent bilateral RLNP.

Prevention of Nerve Injuries Using a Safety-Driven Step-Wise Technique for Arthroscopic Capsulectomy of the Elbow (SS-23)

The risk of nerve injury is of concern in arthroscopic elbow release, but has not previously been described in a large series. We report a series of 502 arthroscopic capsular releases over 15 years by a single surgeon, using a standardized technique, with specific focus on neurological outcomes. There were no permanent nerve injuries, with 23 patients (4.6%) noted to have transient nerve palsies due to varied factors such as tourniquet time, retraction, or medial skin incisions. In this series, a standardized safety-driven approach and experience of the surgeon decreased the risk of nerve injury. Release of contracture is a common indication for elbow arthroscopy. The major factor limiting use of arthroscopy for contracture release is the concern about nerve injury, but the risk of nerve injury has not been documented in a large series. The purpose of this report is to document the risk of nerve injury in arthroscopic contracture release using a safety-driven step-wise technique. A retrospective review was performed of 502 consecutive cases of arthroscopic contracture release in 464 patients by one surgeon during a 15 year period. The safety-driven step-wise technique evolved during the first 100 cases from detaching to incising to completely excising the capsule. For the next 402 cases arthroscopic capsulectomy was performed in a standardized sequence: (1) Get In and Establish a View, (2) Create a Space in Which to Work, (3) Bone Removal, and (4) Capsulectomy. Retractors were used to maintain space and to protect the nerves. Suction was detached from the shavers and burrs. Cases included complex and revision contracture releases. Transient sensory motor nerve palsies that resolved within three days developed in three cases (0.6%), two from blunt retraction and one from local anesthetic injection. Two medial antebrachial cutaneous nerve injuries from portal sites occurred but resolved completely within 3 and 18 months respectively. Thus, 5 nerve palsies (1%) occurred as a direct result of the arthroscopy itself. Eleven patients (2.2%) experienced transient diffuse sensory motor nerve palsies involving 2 or 3 major nerves that were associated with prolonged tourniquet times; all resolved within 3 days. Two patients (0.4%) had a transient partial sensory motor after ulnar nerve transposition that resolved completely within 1-3 days. Seven patients experienced sensory dysesthesia of the skin innervated by the posterior branch of the medial antebrachial cutaneous nerve due to a posterior medial incision for decompression of the ulnar nerve. These involved the skin in the region of the olecranon and six of seven (1.4%) resolved completely within three months to two years. The final patient was lost to follow-up. Thus, a total of 19 cases (3.8%) experienced nerve palsies indirectly related to the arthroscopy (due to other factors such as prolonged tourniquet time, ulnar nerve transposition, or a posteromedial skin incision). Overall, 23 of the 502 cases (4.6%) experienced transient nerve palsies that resolved completely with 1 additional patient (0.2%) having a cutaneous nerve dysesthesia but was lost to follow-up. There were no permanent nerve injuries. Temporary nerve injuries are a definite risk with arthroscopic elbow contracture release. They occur due to tourniquet palsies, compression by instruments and retractors. However, under the conditions in this study, we found permanent nerve injuries to be a minimal risk, with a surgeon highly experienced in open and arthroscopic elbow surgery, the adherence to a safety-driven step-wise technique, the routine use of retractors and avoidance of suction on shavers. The risk of nerve injury is more related to the experience and expertise of the operating team and facility than to the severity of the contracture.

Thermal Capsulorrhaphy for the Treatment of Shoulder Instability

Thermal capsulorrhaphy has been used to treat many different types of shoulder instability, including multidirectional instability, unidirectional instability, and microinstability in overhead-throwing athletes. A device that delivers laser energy or radiofrequency energy to the capsule tissue causes the collagen to denature and the capsule to shrink. The optimal temperature to achieve the most shrinkage without causing necrosis of the tissue is between 65° and 75° centigrade. This treatment causes a significant decrease in mechanical stiffness for the first 2 weeks, and then, after the tissue undergoes active cellular repair from the surrounding uninjured tissue, the mechanical properties return to near normal by 12 weeks. If the thermal energy is applied in a grid pattern, then the tissue heals with more stiffness by 6 weeks. Clinical studies on thermal capsulorrhaphy for the treatment of multidirectional instability have shown a high rate of recurrent instability (12%-64%). The clinical studies on unidirectional instability showed much better recurrence rates (4%-25%), but because most of the patients also underwent concomitant Bankart repairs and superior labral anterior posterior lesion repairs, the efficacy of the thermal treatment cannot be ascertained. A randomized controlled trial would be needed to assess whether instability with Bankart lesions requires augmentation with thermal capsulorrhaphy. For the patients with microinstability who are overhead-throwing athletes, thermal capsulorrhaphy has shown varying results from a 97% rate of return to sports to a 62% rate of return to sports. Complications of this technique include temporary nerve injuries that usually involve the sensory branch of the axillary nerve and thermal necrosis of the capsule, which is rare.

Increased tendency to temporary nerve damage with lingual retractor use

Question: Does use of lingual retractor increase risk of nerve damage in third molar retraction? Objective To review the incidence and recovery of lingual nerve damage after the removal of the third molar by three different techniques.Data sources Medline, Health Star, Current Contents, Allied and Alternative Medicine, Life Sciences, Web of Science, Nursing Allied Health and the Cochrane library, up to May 1999. The index of the Journal of Oral and Maxillofacial Surgery Clinics of North America 1989–1998 was also searched together with the bibliographies of identified studies.Study selection Original cases of lingual nerve damage due to third molar removal with >6 months follow-up and clinically objective sensory testing. Three different surgical methods were evaluated: buccal approach with lingual retraction (BA+), buccal approach without lingual retraction (BA−) and lingual split technique (LS).Results Although 51 studies addressed the issue of lingual nerve damage only eight met the inclusion criteria. All comparisons of temporary nerve injury rates between the three surgical groups were significant (P<0.001). A summary of the results is presented below (Table 1).Conclusion The current literature does not show or support any significant advantage for the use of a lingual flap retractor to protect the lingual nerve during third molar surgery. It does show an increased tendency for temporary injury, however.