Intra-arterial Stem Cell Therapy Diminishes Inflammasome Activation After Ischemic Stroke: a Possible Role of Acid Sensing Ion Channel 1a.

Studies from our lab demonstrated that 1 × 105 intra-arterial mesenchymal stem cells (IA MSCs) at 6 h following ischemic stroke are efficacious owing to its maximum homing due to elevated stromal derived factor 1 (SDF1) in the tissue. Further, IA MSCs could abate the infarct progression, improve functional outcome, and decrease expression of calcineurin by modifying neuronal Ca2+ channels following ischemic stroke. Since stroke pathology also encompasses acidosis that worsens the condition; hence, the role of acid sensing ion channels (ASICs) in this context could not be overlooked. ASIC1a being the major contributor towards acidosis triggers Ca2+ ions overload which progressively contributes towards exacerbation of neuronal injury following ischemic insult. Inflammasome involvement in ischemic stroke is well reported as activated ASIC1a increases the expression of inflammasome in a pH-dependent manner to trigger inflammatory cascade. Hence, the current study aimed to identify if IA MSCs can decrease the production of inflammasome by attenuating ASIC1a expression to render neuroprotection. Ovariectomized Sprague Dawley (SD) rats exposed to middle cerebral artery occlusion (MCAo) for 90 min were treated with phosphate-buffered saline (PBS) or 1 × 105 MSCs IA at 6 h to check for the expression of ASIC1a and inflammasome in different groups. Inhibition studies were carried out to explore the underlying mechanism. Our results demonstrate that IA MSCs improves functional outcome and oxidative stress parameters, and decreases the expression of ASIC1a and inflammasomes in the cortical brain region after ischemic stroke. This study offers a preliminary evidence of the role of IA MSCs in regulating inflammasome by modulating ASIC1a.

Lateral Lumbar Interbody Fusion Revisited: Complication Avoidance and Outcomes with the Mini-Open Approach.

OBJECTIVE: To discuss lessons learned from an initial lateral lumbar interbody fusion (LLIF) experience with a focus on evolving surgical technique, complication avoidance, and new motor and sensory outcomes after implementation of a modified surgical approach. METHODS: A retrospective analysis of a prospectively collected series of all patients undergoing LLIF by the senior author (A.D.L.) from January 2010 to January 2018 after implementation of a modified surgical mini-open technique, compared with previously reported institutional results with the originally recommended percutaneous technique. LLIF-specific complications examined included groin/thigh sensory dysfunction, flank bulge/pseudohernia, psoas-pattern weakness, and femoral nerve injury. RESULTS: The incidence (19%, n = 98 patients) of groin/thigh sensory dysfunction in our cohort was significantly lower than that of the historical control (60%, n = 59) (P < 0.0001). The incidence of abdominal flank bulge/pseudohernia (2.0%, n = 98 patients) in our cohort was improved but not significantly lower than that of the historical control (4.2%, n = 118) (P = 0.36). The incidence of psoas-pattern weakness (3.1%, n = 98) in our cohort was significantly lower than that of the historical control (23.7%, n = 59) (P = 0.0001). The incidence of femoral nerve injury (0%, n = 98 patients) in our cohort was improved but was not significantly lower than that of the historical control (1.7%, n = 118) (P = 0.20). CONCLUSIONS: The adoption of an exclusive mini-open muscle-splitting approach with first-look inspection of the lumbosacral plexus nerve elements may improve motor and sensory outcomes in general and the incidence of postoperative groin/thigh sensory dysfunction and psoas-pattern weakness in particular.

Neurosensory recovery after trauma to the orbital floor: a prospective trial with dexamethasone.

Our aims were to document the occurrence of neurosensory disturbances of the infraorbital nerve six months after operation for an orbital blow-out fracture, and to find out whether dexamethasone facilitates neurosensory regeneration. Patients were randomly assigned to one of two groups: the study group was given a total of dexamethasone 30mg, whereas the control group were given neither glucocorticoid nor placebo. Each patient's infraorbital neurosensory state was recorded preoperatively, immediately postoperatively, and six months later. A total of 18 patients were included, eight of whom had neurosensory disturbances six months after the initial trauma that was not affected by dexamethasone. Six of the seven patients who had a delay of seven days or more between trauma and operation had significantly prolonged disturbance at the 180-day clinical follow up compared with those in whom it was less than seven days (p=0.005). Other possible predictors made no significant difference. Although dexamethasone did not facilitate sensory recovery, its benefits in the management of pain and reduction of swelling may justify its use in the management of facial trauma in selected patients.

Impaired Nociception in the Diabetic Ins2+/Akita Mouse.

The mechanisms responsible for painful and insensate diabetic neuropathy are not completely understood. Here, we have investigated sensory neuropathy in the Ins2+/Akita mouse, a hereditary model of diabetes. Akita mice become diabetic soon after weaning, and we show that this is accompanied by an impaired mechanical and thermal nociception and a significant loss of intraepidermal nerve fibers. Electrophysiological investigations of skin-nerve preparations identified a reduced rate of action potential discharge in Ins2+/Akita mechanonociceptors compared with wild-type littermates, whereas the function of low-threshold A-fibers was essentially intact. Studies of isolated sensory neurons demonstrated a markedly reduced heat responsiveness in Ins2+/Akita dorsal root ganglion (DRG) neurons, but a mostly unchanged function of cold-sensitive neurons. Restoration of normal glucose control by islet transplantation produced a rapid recovery of nociception, which occurred before normoglycemia had been achieved. Islet transplantation also restored Ins2+/Akita intraepidermal nerve fiber density to the same level as wild-type mice, indicating that restored insulin production can reverse both sensory and anatomical abnormalities of diabetic neuropathy in mice. The reduced rate of action potential discharge in nociceptive fibers and the impaired heat responsiveness of Ins2+/Akita DRG neurons suggest that ionic sensory transduction and transmission mechanisms are modified by diabetes.

Sensory preservation in neck dissection: outcomes of a sub-sternocleidomastoid approach.

OBJECTIVE: Cutaneous anesthesia in early postoperative period is common after neck dissection even if the cervical nerve (CN) rootlets are preserved. The aim of this study was to evaluate if the preservation of the terminal branches of CNs using sub-sternocleidomastoid (SCM) approach combined with medially placed skin incision can prevent early postoperative anesthesia. MATERIAL AND METHODS: A retrospective chart review was performed on 129 neck dissections in 87 head and neck cancer patients. RESULTS: The early postoperative sensory preservation rates for the ear tab, submandibular, lateral neck, and sub-clavicular areas of CN rootlet-preserved necks (n = 86) were 75.6%, 20.9%, 74.4%, and 86.0%, respectively, compared with 37.2%, 2.3%, 2.3%, and 4.7%, respectively, in CN rootlet-resected necks (n = 43). In CN rootlet-preserved necks, the sub-SCM approach (n = 54) showed 81.5%, 27.8%, 92.6%, and 94.4% preservation rates, respectively, compared with 65.6%, 9.4%, 43.8%, and 71.9%, respectively, using the conventional subplatysmal approach (n = 32). The rates were significantly better in the submandibular, lateral neck, and sub-clavicular areas after sub-SCM approach. CONCLUSIONS: Preservation of CN rootlets is a required element for sensory preservation in neck dissection. The sub-SCM approach can effectively prevent early postoperative cutaneous anesthesia following CN-preserving neck dissection.

The influence of dexamethasone on postoperative swelling and neurosensory disturbances after orthognathic surgery: a randomized controlled clinical trial.

BACKGROUND: Orthognathic surgery is associated with considerable swelling and neurosensory disturbances. Serious swelling can lead to great physical and psychological strain. A randomized, prospective, controlled clinical trial was realized in order to evaluate the effect of a preoperative intravenous dexamethasone injection of 40 mg on postoperative swelling and neurosensory disturbances after orthognathic surgery. METHODS: Thirty-eight patients (27 male and 11 female) patients, all with the indication for an orthognathic surgery, were enrolled in this study (mean age: 27.63 years, range: 16-61 years) and randomly divided into two groups (study group/ control group). Both groups underwent either maxillary and/or mandibular osteotomies, resulting in three subgroups according to surgical technique (A: LeFort I osteotomy, B: bilateral sagittal split osteotomy (BSSO), C: bimaxillary osteotomy). The study group received a single preoperative intravenous injection of 40 mg dexamethasone. Facial edema was measured by 3D surface scans on the 1st, 2nd, 5th, 14th and 90th postoperative day. Furthermore, neurosensory disturbances on the 2nd, 5th, 14th and 90th postoperative day were investigated by thermal stimulation. RESULTS: Facial edema after LeFort I osteotomy, BSSO and bimaxillary osteotomy showed a significant decrease in the study group compared to the control group (P = 0.048, P = 0.045, P < 0.001). The influence of dexamethasone on neurosensory disturbances was not significant for the inferior alveolar nerve (P = 0.746) or the infraorbital nerve (P = 0.465). CONCLUSIONS: Patients undergoing orthognathic surgery should receive a preoperative injection of dexamethasone in order to control and reduce edema. However, there was no influence of dexamethasone on reduction of neurosensory disturbances. TRIAL REGISTRATION: DRKS00009033 .

Complications following harvesting of patellar tendon or hamstring tendon grafts for anterior cruciate ligament reconstruction: Systematic review of literature.

Anterior cruciate ligament (ACL) reconstruction can be performed with an autograft, which is most often harvested from the patient's hamstring tendon (HT) or patellar tendon (PT). However, autograft harvesting leads to morbidity that is by no means insignificant. A systematic review of literature was performed to define the incidence of complications related to graft harvesting and the methods to prevent these complications. In March 2017, a systemic review of literature was performed using the keywords"harvesting", "harvest", "morbidity", "complication", "cruciate ligament". No time limit was applied. The studies had to be written in French or English with their abstract available online. This initial search based on the title and abstract identified 133 articles. Two independent observers analyzed each article entirely, including the references. In all, 36 articles were retained. The main complication of HT harvesting was sensory deficit because of damage to the infrapatellar branches of the saphenous nerve. This complication occurred in 39.7% to 88% of patients. This risk can be reduced by using a horizontal or oblique incision. The main complication following PT harvesting is anterior knee pain, reported in up to 46% of patients. There are substantial numbers of short-, medium- and long-term complications related to the harvesting of the two main ACL autografts. Effective means of prevention exist to reduce the risk of these complications. LEVEL OF EVIDENCE: II Systematic review of literature.

Persistent pain and neurosensory disturbance after dental implant surgery: prevention and treatment.

Nerve trauma caused by dental implant placement is associated with altered sensation and chronic pain. Complete or partial loss of sensation is often reported by patients who have experienced nerve trauma during implant surgery. Some patients report persistent pain and neurosurgery disturbance long after the normal healing time has passed. In addition, neuropathic pain is reported after implant surgery. Practitioners who place dental implants must be familiar with the differential diagnosis, prevention, and management of neuropathic pain. This article provides insights into the prevention and management of neurosensory deficits and chronic persistent neuropathic pain and considerations for patient referral.

Attachment rate of the inferior alveolar nerve to buccal plate during bilateral sagittal split osteotomy influences self-reported sensory impairment.

This study was aimed to investigate a modified buccal osteotomy technique and whether the integrity of the lingual part of the lower border influences the attachment of the neurovascular bundle to the proximal segment of the mandible during a sagittal split osteotomy without increasing the number of bad splits. The presence of self-reported sensibility disturbance in the lower lip at the last follow-up visit was assessed. This study included 220 and 133 patients with bilateral sagittal split osteotomy undergoing the classical and the new modified buccal osteotomy techniques, respectively. In the new technique, the lower border is divided into a lingual fragment that remains incorporated in the tooth-bearing fragment and a buccal fragment that comes with the proximal fragment (buccal plate). In the classical technique, the inferior alveolar nerve was attached to the proximal segment of the mandible in more than one third of operation sites (36.36% on the right and 40.91% on the left) compared with less than one fourth of the operation sites using the new technique (9.73% on the right and 23.01% on the left). The overall figure of self-reported changed sensibility was 09.40% (12/128) in the new technique compared to 15.12% in the classical technique. We present a suitable improvement to the classical buccal osteotomy technique that allows less manipulation and injury of the inferior alveolar nerve with consequent reduction in self-reported postoperative changes in lower lip sensation

Effectiveness of piezoelectric surgery in reducing surgical complications after bilateral sagittal split osteotomy.

Our aim was to investigate the effectiveness of piezoelectric surgery, where the osteotomy is made using ultrasonic vibration, in reducing surgical complications after bilateral sagittal split osteotomy (BSSO). Fifty-nine patients with skeletal mandibular prognathism who had mandibular setback with BSSO between January 2009 and April 2011 were included in the study. Piezosurgery was used in 29 cases, and the bone was split using a separator. In the remaining 30 cases, a Lindeman bur was used for the osteotomy and a chisel was used to split the bone. The amount of intraoperative bleeding and the Semmes Weinstein test scores were used as objective variables to evaluate the degree of neurosensory disturbance, and sex, age, use of piezosurgery, degree of setback, operating time, and method of fixation were used as explanatory variables. We used analysis of covariance (ANCOVA) to assess the significance of differences. Intraoperative bleeding was significantly less with age (p=0.003), and longer when operating time was prolonged (p=0.017), and was not influenced by the use of piezosurgery. The Semmes Weinstein test score significantly increased with age (p=0.01), and was significantly greater when piezoelectric surgery was used (p=0.008), and at 3 months, there were signs of more neurosensory disturbance in older patients and those who had had piezoelectric surgery. In this retrospective non-random study piezoelectric surgery reduced neither blood loss nor the incidence of neurosensory disturbance in BSSO.

[Potential of using inertial sensors in high level sports].

The article thoroughly covers development of wireless inertial sensors technology in medicine. The authors describe main criteria of diagnostic value of inertial sensors, advantages and prospects of using these systems in sports medicine, in comparison with other conventional methods of biomechanical examination in sports medicine. The results obtained necessitate further development of this approach, specifically creation of algorithms and methods of biomechanic examination of highly qualified athletes in high achievements sports.

Elimination of permanent injuries to the inferior alveolar nerve following surgical intervention of the "high risk" third molar.

We aimed to find out whether improved preoperative assessment and surgical planning with cone beam computed tomography (CT) could reduce damage to the inferior alveolar nerve when high risk impacted mandibular third molars are extracted. We recorded the presence or absence of postoperative neuropathy after extraction of 200 lower third molars in 185 patients (where cone beam CT had shown contact between the nerve and root) after treatment in the oral surgery department of King's College Hospital. All patients had had cone beam CT of the teeth after panoramic radiography had indicated increased risk of injury to the nerve during extraction. Experienced oral surgeons did all the operations and postoperative reviews. Patients reported temporary alteration of sensation after operation in 12% of teeth but it resolved in all cases and no patient reported permanent loss of sensation. Permanent sensory disturbance in the distribution of the inferior alveolar nerve after third molars have been removed can be eliminated in high risk cases if operations are planned carefully (including cone beam CT), and the procedure is done by a skilled surgeon who has an appreciation of the anatomy of the nerve and roots, and an insight into the mechanical effect of their surgical manipulation. The incidence of permanent neurosensory dysfunction in this study was zero even though all teeth were intimately related to the inferior alveolar canal.

Interdisciplinary perspectives on the management of the unsettled baby: key strategies for improved outcomes.

The objectives of this study were to analyse the perspectives of key informants with clinical expertise in the care of unsettled babies in the first few months of life and their families, concerning changes required to improve outcomes. The research used a purposive selection strategy and thematic analysis of key informant interviews of24 health professionals from 11 disciplines. Informants were selected for extensive experience in the management of unsettled babies and their families. Participants corroborated existing evidence that post-birth care in Australia is fragmented. All held the view that, first, early primary care intervention for unsettled infants and their families, and second, improved cross-professional communication, are vital if the burden of this problem to the infant, family and health system are to be minimised. There was consensus, third, that significant gaps exist in health professionals' knowledge base and management behaviours. The development of education resources, best practice guidelines, shared assessment frameworks for primary care practitioners and strategies for improved cross-professional communication are necessary to improve the health outcomes and decrease the burden of this common yet complex post-birth problem.

Evaluation of risk of injury to the inferior alveolar nerve with classical sagittal split osteotomy technique and proposed alternative surgical techniques using computer-assisted surgery.

Neurosensory disturbance after sagittal split osteotomy is a common complication. This study evaluated the course of the mandibular canal at three positions using computed tomography (CT), assessed the risk of injury to the inferior alveolar nerve in classical sagittal split osteotomy, based on the proximity of the mandibular canal to the external cortical bone, and proposed alternative surgical techniques using computer-assisted surgery. CT data from 102 mandibular rami were evaluated. At each position, the distance between the mandibular canal and the inner surface of the cortical bone was measured; if less than 1mm or if the canal contacted the external cortical bone it was registered as a possible neurosensory compromising proximity. The course of each mandibular canal was allocated to a neurosensory risk or a non-neurosensory risk group. The mandibular canal was in contact with, or within 1mm of, the lingual cortex in most positions along its course. Neurosensory compromising proximity of the mandibular canal was observed in about 60% of sagittal split ramus osteotomy sites examined. For this group, modified classic osteotomy or complete individualized osteotomy is proposed, depending on the position at which the mandibular canal was at risk; they may be accomplished with computer-assisted navigation.

Relationship between inferior alveolar nerve imaging and neurosensory impairment following bilateral sagittal split osteotomy in skeletal Class III cases with mandibular prognathism.

Postoperative inferior alveolar nerve (IAN) neurosensory impairment was prospectively evaluated in 20 consecutive patients with mandibular prognathism who underwent bilateral sagittal split osteotomy. Routine presurgical imaging was obtained for all patients in study and control groups (10 patients each). Cone beam CT of the mandibular ramus and body was performed in 10 randomly selected patients (study group) and the precise location of the IAN was determined preoperatively and intraoperatively. Nerve sensation was evaluated by subjectively monitoring the physical feeling of the lower lip and the chin skin preoperatively and at different times postoperatively. Exact nerve location was successfully determined in all 10 cases in the study group. There were almost no significant differences between patients' sensation scores at the chin skin and lip sites. No significant differences were found between the two sides of the 20 patients. A significant increase in the score trend along the timeframes, in both groups, could be clearly seen together with a statistically significant difference (P≤0.004) between the study and the control groups. In conclusion, precisely locating the IAN using CT is a significant means for efficiently minimizing nerve damage during sagittal split osteotomy.

Inferior alveolar nerve injury in implant dentistry: diagnosis, causes, prevention, and management.

Inferior alveolar nerve injury is one of the most serious complications in implant dentistry. This nerve injury can occur during local anesthesia, implant osteotomy, or implant placement. Proper understanding of anatomy, surgical procedures, and implant systems and proper treatment planning is the key to reducing such an unpleasant complication. This review discusses the causes of inferior alveolar nerve injury and its diagnosis, prevention, and management.

The use of piezosurgery to mobilize the mandibular alveolar nerve followed immediately by implant insertion: a case series evaluating neurosensory disturbance.

One of the therapeutic options proposed for reconstruction of the atrophic posterior mandible is inferior alveolar nerve (IAN) mobilization with simultaneous implant placement. However, studies on the functionality of this neurovascular bundle after its mobilization have shown mixed results. This variability can be attributed both to the test methodology, which typically requires subjective answers from patients, and to the surgical procedure itself, which is highly dependent on operator technique. This article reports on a series of 10 cases of IAN mobilization using a device specifically engineered to simplify bone surgery. This device enables the oral surgeon to avoid overstretching the nerve by creating a smaller bone window and using an apicocoronal inclination of instruments to capture the neurovascular bundle. Evaluation by means of neurosurgery function tests over a 36-month period found that all patients had a return to normal sensation after a brief period of neurosensory disturbance. Subjective responses to a patient questionnaire confirmed these findings. The implant success rate was 100%.

Preoperative sensorimotor mapping in brain tumor patients using spontaneous fluctuations in neuronal activity imaged with functional magnetic resonance imaging: initial experience.

OBJECTIVE: To describe initial experience with resting-state correlation mapping as a potential aid for presurgical planning of brain tumor resection. METHODS: Resting-state blood oxygenation-dependent functional magnetic resonance imaging (fMRI) scans were acquired in 17 healthy young adults and 4 patients with brain tumors invading sensorimotor cortex. Conventional fMRI motor mapping (finger-tapping protocol) was also performed in the patients. Intraoperatively, motor hand area was mapped using cortical stimulation. RESULTS: Robust and consistent delineation of sensorimotor cortex was obtained using the resting-state blood oxygenation-dependent data. Resting-state functional mapping localized sensorimotor areas consistent with cortical stimulation mapping and in all patients performed as well as or better than task-based fMRI. CONCLUSION: Resting-state correlation mapping is a promising tool for reliable functional localization of eloquent cortex. This method compares well with "gold standard" cortical stimulation mapping and offers several advantages compared with conventional motor mapping fMRI.