Awake Surgery for Left Posterior Insular Low-Grade Glioma Through the Parietorolandic Operculum: The Need to Preserve the Functional Connectivity. A Case Series

Objective: Surgical approach to low-grade glioma (LGG) involving the posterior insula is challenging, especially in the left hemisphere, with a high risk of sensorimotor, language, or visual deterioration. In this study, a case series of 5 right-handed patients harboring a left posterior insular LGG is reported, by detailing a transcorticosubcortical approach.Method: The five surgeries were achieved in awake patients using cortical and axonal electrostimulation mapping. The glioma was removed through the left rolandic and/or parietal opercula, with preservation of the subcortical connectivity.Results: The cortical mapping was positive in the five patients, enabling the selection of an optimal transcortical approach, via the anterolateral supramarginal gyrus in four patients and/or via the lateral retrocentral gyrus in three cases (plus through the left superior temporal gyrus in one case). Moreover, the white matter tracts were identified in all cases, i.e., the lateral part of the superior longitudinal fasciculus (five cases), the arcuate fasciculus (four cases), the thalamocortical somatosensory pathways (four cases), the motor pathway (one case), the semantic pathway (three cases), and the optic tract (one case). Complete resection of the LGG was achieved in two patients and near-total resection in three patients. There were no postoperative permanent sensorimotor, language, or visual deficits.Conclusion: A transcortical approach through the parietorolandic operculum in awake patients represents safe and effective access to the left posterior insular LGG. Detection and preservation of the functional connectivity using direct electrostimulation of the white matter bundles are needed in this cross-road brain region to prevent otherwise predictable postsurgical impairments.

Atypical Peripheral Ossifying Fibroma of the Mandible

Peripheral ossifying fibroma (POF) is a benign localized lesion originating from gingival and alveolar oral mucosa. Its origin can be cells of periodontal ligament. The lesions usually develop in women in their twenties. POF is a complex clinical and histological diagnosis due to its shared characteristics with many other conditions. In this paper, we presented a case of an atypical peripheral ossifying fibroma (POF) in the left lateral part of the mandible in a 70-year-old male patient who had two semicircular bridges supported on four implants in the upper and lower jaws. A review of CBCT and orthopedic imaging showed no visible intraosseous changes. Histological analysis revealed the diagnosis of POF. The case in question is interesting, as elaborated on in the discussion section of this paper because POF is usually found in female patients aged between 20 and 30 years.

Tomodensitometric Bone Anatomy of The Intervertebral Foramen of The Lower Cervical Spine: Measurements and Comparison of Foraminal Volume in Healthy Individuals and Patients Suffering from Cervicobrachial Neuralgia Due to Foraminal Stenosis.

Purpose Degenerative foraminal stenosis of the cervical spine can lead to cervicobrachial neuralgias. Computed tomography (CT)-scan assists in the diagnosis and evaluation of foraminal stenosis. The main objective of this study is to determine the bony dimensions of the cervical intervertebral foramen and to identify which foraminal measurements are most affected by degenerative disorders of the cervical spine. These data could be applied to the surgical treatment of this pathology, helping surgeons to focus on specific areas during decompression procedures. Methods A descriptive study was conducted between two groups: an asymptomatic one (young people with no evidence of degenerative cervical spine disorders) and a symptomatic one (experiencing cervicobrachial neuralgia due to degenerative foraminal stenosis). Using CT scans, we determined a method allowing measurements of the following foraminal dimensions: foraminal height (FH), foraminal length (FL), foraminal width in its lateral part ((UWPP, MWPP and IWPP (respectively Upper, Medial and Inferior Width of Pedicle Part)) and medial part (UWMP, MWMP and IWMP (respectively Upper, Medial and Inferior Width of Medial Part)), and disk height (DH). Foraminal volume (FV) was calculated considering the above data. Mean volumes were measured in the asymptomatic group and compared to the values obtained in the symptomatic group. Results Both groups were made up of 10 patients, and a total of 50 intervertebral discs (100 intervertebral foramina) were analyzed in each group. Comparison of C4C5, C5C6 and C6C7 levels between both groups showed several significant decreases in foraminal dimensions (p< 0,05) as well as in foraminal volume (p <0.001) in the symptomatic group. The most affected dimensions were UWPP, MWPP, UWMP, MWMP and FV. The most stenotic foraminal areas were the top of the uncus and the posterior edge of the lower plate of the overlying vertebra. Conclusion Using a new protocol for measuring foraminal volume, the present study refines the current knowledge of the normal and pathological anatomy of the lower cervical spine and allows us to understand the foraminal sites most affected by degenerative stenosis. Those findings can be applied to foraminal stenosis surgeries. According to our results, decompression of the foramen in regard of both uncus osteophytic spurs and inferior plate of the overlying vertebra might be an important step for nerve roots release.

Anatomical study of the inferior extensor retinaculum and the oblique superolateral band: implications for the Brostrom-Gould procedure

Purpose The Brostrom-Gould procedure is currently the gold standard surgical choice for the treatment of chronic ankle instability; it can significantly improve ankle function and stability in patients. However, recent studies have reported doubts regarding the feasibility of the inferior extensor retinaculum (IER) after Brostrom-Gould and therapeutic effects compared with the Brostrom procedure. The purpose of the present study was to observe the anatomical characteristics of the lateral part of the IER using cadaveric bodies in order to guide the surgical operation of chronic ankle instability. Methods Twenty-three cadaveric ankles were dissected. The morphology of the IER and its internal structure was observed and recorded for each ankle. The shortest distance between the Stem ligament of the IER and the anterior fibular periosteum (AFP) was measured and recorded, then attempts were made to suture the Stem to the AFP. Results Twelve of the cadaveric ankles were observed as having an oblique superolateral band (OSLB) that had a tough texture upward of the lateral IER connecting with SL, as are the characteristics of the oblique superolateral band (OSLB) reported in previous studies. The inner and outer membrane of the OSLB were connected with inner and outer membrane of Stem. The average value of the distance between the Stem and AFP was 11.60 ± 2.71 mm, and the maximum and the minimum distance were 19.04 mm and 6.53 mm, respectively. The P -value (P = 0.2) resulting from a single sample K-S test confirmed that the distribution of distances conformed to normality. None of the SL in the study could be sutured to the AFP. Conclusion The OSLB of the IER has a tough texture and connects with the Stem, and has the potential be utilised in the Brostrom-Gould procedure. However, we do not recommend utilization of the Stem in this operation regardless of the distance between the AFP and the Stem. When the Stem cannot be used to enhance repair in this operation, other solutions can be used for strengthening and to protect the repaired ATFL.

Clinical cases of late adhesive intestinal obstruction after liver and kidney transplantation in children and surgical methods of their treatment

Abdominal adhesions are one of the most common complications in abdominal surgery. In 56-70 % it is the cause of small bowel obstruction, which often requires repeated surgery. To date, a few cases of late adhesive intestinal obstruction (LAIO) as a complication of organ transplantation in children have been described. The purpose of the study was to investigate clinical cases of LAIO in a 9-year-old child after liver transplantation, and in an 8-year-old child after kidney transplantation. Materials and methods. Clinical case I. A 62-day-old girl was treated with Kasai procedure before a liver transplantation, according to type III atresia of the biliary tract. Orthotopic liver transplantation of the left-lateral section from living related donor was performed at the age of 9 months. The surgeries were accompanied by damage to the mesothelium and trauma of the serous membrane, which led to the formation of intraabdominal adhesions. With the growth of the child there was a growth of abdominal organs and adhesions stretching. LAIO was diagnosed 8 years after first surgery. Clinical case II. The boy was diagnosed with hypoplastic dysplasia of the right kidney, left-side ureterohydronephrosis, resulting in chronic end-stage renal disease. Peritoneal dialysis was performed at the age of 6 years. The effect of dialysate on the mesothelium led to the formation of small intestine pseudo-diverticula. At the age of 7 years a bilateral nephrectomy and kidney transplantation from a deceased donor were performed. At the age of 8 LAIO was diagnosed. In both cases, children underwent adhesiolysis. The peritoneum was sutured from the lower and upper edges of the wound to the middle, so that a hole remained in the middle of the wound. A Nelaton catheter was inserted through the hole and 250 ml of sodium hyaluronate solution "Defensal" was injected into the left-lateral part, small pelvis and right lateral abdominal cavity. Then anterior abdominal wall was sutured. Results. The successful surgical treatment of LAIO in children using local adhesiolysis in combination with sodium hyaluronate was performed. The careful handling of vascular anastomoses and changes in organ topography were required during surgery. The purpose of the surgery on LAIO was not only to restore the chyme transport in the gastrointestinal tract, but also to release the small intestine from the adhesions with the normal anatomy and function preservation. The observation of children for 5 years indicate the effectiveness of intraabdominal application of sodium hyaluronate solution.

Ultrasonographic evaluation of the median nerve: normal and variant anatomy and appearance

The median nerve is a mixed sensory and motor nerve that innervates part of the flexor muscles in the anterior compartment of the forearm and muscles in the lateral part of the hand; palmar cutaneous and digital cutaneous nerves branch from the median nerve, which provides sensory innervation to the skin on the radial side of the palm. Also, the median nerve is an object of interest because neuropathy of the median nerve at the level of the carpal tunnel is the most common entrapment neuropathy which increases dramatically in patients with diabetes. Neuromuscular ultrasound provides extensive diagnostic information and has proved itself as a useful complementary test to electrodiagnostic examinations in cases involving median nerve neuropathy. It often happens that the cause of nerve entrapment and neuropathy are variants of several anatomical structures along the course of the median nerve. It is important to be aware and report such anatomical variations of the median nerve in order to avoid damaging the nerve during surgical treatment. Despite the frequently documented abnormalities in the pathway of the brachial plexus and the median nerve, the anatomical variations are unusual to see and are rarely reported. Moreover, there are variations that do not fit under any of the classifications described in the literature.

Roughness Digital Characterization and Influence on Wear of Retrieved Knee Components

Tribological performance of knee components are strongly related to the surface characteristics. Primarily, the roughness and its 3D distribution on the surfaces affect the joint performance. One of the main limitations related to the tribological study of knee prostheses is that most of the research studies report in vitro or in silico results, as knee retrievals are difficult to find or are too damaged to be analyzed. This paper is focused on the roughness characterization of retrieved metal femoral components of total knee replacements (TKR) by means of a rugosimeter and involving digital methods to reconstruct the 3D topography of the studied surfaces. The aim of this study is to investigate how changes and distribution of roughness are correlated between the medial vs. the lateral part and how the resulting digital topography can give insights about the wear behavior.

Rare Metastasis to the Submandibular Gland in Oral Squamous Cell Carcinoma

PurposeIn the current recommendation of neck dissection in oral squamous cell carcinoma (OSCC), the submandibular gland (SMG) should also be removed. This study aimed to investigate the incidence and the patterns of SMG involvement in OSCC patients.MethodsPatients initially diagnosed with OSCC between January 2018 and October 2020 were included. The distribution of lymph nodes metastasis in level IB was analyzed.ResultsWe included 145 patients who underwent primary surgery and neck dissection in this study. All patients had level IB lymph node dissection and simultaneous removal of the SMG. Of these patients, only one patient (0.7%) had involvement in SMG by directly infiltrating from the primary tumor. A total of 18 positive lymph nodes were found in level IB in 16 patients, and no positive lymph nodes were located in the SMG. There were 6 lymph nodes located in the lateral part of the SMG and 12 lymph nodes located in the anterior of the SMG. Patients with tumors located in the buccal mucosa and N3 stage were the independent predictive factors associated with level IB nodal metastasis.ConclusionInvolvement of SMG in OSCC is quite rare. Preservation of the SMG during neck dissection in selected patients with OSCC seems to be feasible and oncologically safe.

Effect of Emissary Vein on Hemodynamics of the Transverse- Sigmoid Sinus Junction

Objective: To investigate the effect of the blood flow direction and afflux location of emissary veins (EVs) on the hemodynamics of the transverse-sigmoid sinus (TS-SS) junction.Methods: A patient-specific geometric model was constructed using computed tomography venography (CTV) and 4D flow MR data from a venous pulsatile tinnitus (PT) patient. New EV models were assembled with the afflux at the superior, middle and inferior portions of the SS from the original model, and inlet and outlet directions were applied. Computational fluid dynamics (CFD) simulation was performed to analyze the wall pressure and flow pattern of the TS-SS junction in each condition.Results: Compared to the model without EVs, the wall pressure was greatly increased in models with inlet flow and greatly decreased in models with outlet flow. The more closely the EV approached the TS-SS, the larger the pressure in models with inlet flow, and the smaller the pressure in models with outlet flow. The flow streamline in the lateral part of the TS-SS junction was smooth in all models. The streamlines in the medial part were regular spirals in outlet models and chaotic in inlet models. The streamlines showed no obvious changes regardless of afflux location. The velocity at the TS-SS junction of inlet models were uniform, medium-low flow rate, while in control and outlet models were the lateral high flow rate and the central low flow rate.Conclusion: The flow direction and afflux location of EVs affect the hemodynamics of the TS-SS junction, which may influence the severity of PT.

Cross-Streams Through the Ventral Posteromedial Thalamic Nucleus to Convey Vibrissal Information

Whisker detection is crucial to adapt to the environment for some animals, but how the nervous system processes and integrates whisker information is still an open question. It is well-known that two main parallel pathways through Ventral posteromedial thalamic nucleus (VPM) ascend to the barrel cortex, and classical theory suggests that the cross-talk from trigeminal nucleus interpolaris (Sp5i) to principal nucleus (Pr5) between the main parallel pathways contributes to the multi-whisker integration in barrel columns. Moreover, some studies suggest there are other cross-streams between the parallel pathways. To confirm their existence, in this study we used a dual-viral labeling strategy and high-resolution, large-volume light imaging to get the complete morphology of individual VPM neurons and trace their projections. We found some new thalamocortical projections from the ventral lateral part of VPM (VPMvl) to barrel columns. In addition, the retrograde-viral labeling and imaging results showed there were the large trigeminothalamic projections from Sp5i to the dorsomedial section of VPM (VPMdm). Our results reveal new cross-streams between the parallel pathways through VPM, which may involve the execution of multi-whisker integration in barrel columns.