Erector Spinae Plane Block Reduces Immediate Postoperative Pain and Opioid Demand After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Matched cohort comparison. OBJECTIVE: To determine perioperative outcomes of erector spinae plane (ESP) block for minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). SUMMARY OF BACKGROUND DATA: There is a paucity of data on the impact of lumbar ESP block on perioperative outcomes and its safety in MI-TLIF. MATERIALS AND METHODS: Patients who underwent 1-level MI-TLIF and received the ESP block (group E ) were included. An age and sex-matched control group was selected from a historical cohort that received the standard-of-care (group NE). The primary outcome of this study was 24-hour opioid consumption in morphine milligram equivalents. Secondary outcomes were pain severity measured by a numeric rating scale, opioid-related side effects, and hospital length of stay. Outcomes were compared between the two groups. RESULTS: Ninety-eight and 55 patients were included in the E and NE groups, respectively. There were no significant differences between the two cohorts in patient demographics. Group E had lower 24-hour postoperative opioid consumption ( P = 0.117, not significant), reduced opioid consumption on a postoperative day (POD) 0 ( P = 0.016), and lower first pain scores postsurgery ( P < 0.001). Group E had lower intraoperative opioid requirements ( P < 0.001), and significantly lower average numeric rating scale pain scores on POD 0 ( P = 0.034). Group E reported fewer opioid-related side effects as compared with group NE, although this was not statistically significant. The average highest postoperative pain score within 3 hours postprocedurally was 6.9 and 7.7 in the E and NE cohorts, respectively ( P = 0.029). The median length of stay was comparable between groups with the majority of patients in both groups being discharged on POD 1. CONCLUSIONS: In our retrospective matched cohort, ESP blocks resulted in reduced opioid consumption and decreased pain scores on POD 0 in patients undergoing MI-TLIF. LEVEL OF EVIDENCE: Level 3.

The Role of Intraoperative Neuromonitoring Modalities in Anterior Cervical Spine Surgery.

Background: Intraoperative neuromonitoring (IONM) is frequently used during spine surgery to mitigate the risk of neurological injuries. Yet, its role in anterior cervical spine surgery remains controversial. Without consensus on which anterior cervical spine surgeries would benefit the most from IONM, there is a lack of standardized guidelines for its use in such procedures. Purpose: We sought to assess the alerts generated by each IONM modality for 4 commonly performed anterior cervical spinal surgeries: anterior cervical diskectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), cervical disk replacement (CDR), or anterior diskectomy. In doing so, we sought to determine which IONM modalities (electromyography [EMG], motor evoked potentials [MEP], and somatosensory evoked potentials [SSEP]) are associated with alert status when accounting for procedure characteristics (number of levels, operative level). Methods: We conducted a retrospective review of IONM data collected by Accurate Neuromonitoring, LLC, a company that supports spine surgeries conducted by 400 surgeons in 8 states, in an internally managed database from December 2009 to September 2018. The database was queried for patients who underwent ACCF, ACDF, anterior CDR, or anterior diskectomy in which at least 1 IONM modality was used. The IONM modalities and incidence of alerts were collected for each procedure. The search identified 8854 patients (average age, 50.6 years) who underwent ACCF (n = 209), ACDF (n = 8006), CDR (n = 423), and anterior diskectomy (n = 216) with at least 1 IONM modality. Results: Electromyography was used in 81.3% (n = 7203) of cases, MEP in 64.8% (n = 5735) of cases, and SSEP in 99.9% (n = 8844) of cases. Alerts were seen in 9.3% (n = 671), 0.5% (n = 30), and 2.7% (n = 241) of cases using EMG, MEP and SSEP, respectively. In ACDF, a significant difference was seen in EMG alerts based on the number of spinal levels involved, with 1-level ACDF (6.9%, n = 202) having a lower rate of alerts than 2-level (10.0%, n = 272), 3-level (15.2%, n = 104), and 4-level (23.4%, n = 15). Likewise, 2-level ACDF had a lower rate of alerts than 3-level and 4-level ACDF. A significant difference by operative level was noted in EMG use for single-level ACDF, with C2-C3 having a lower rate of use than other levels. Conclusions: This retrospective review of anterior cervical spinal surgeries performed with at least 1 IONM modality found that SSEP had the highest rate of use across procedure types, whereas MEP had the highest rate of nonuse. Future studies should focus on determining the most useful IONM modalities by procedure type and further explore the benefit of multimodal IONM in spine surgery.

Orthopaedic Surgery Boot Camp: An Immersion Course for Medical Students.

Introduction There is a substantial need for orthopaedic surgery-specific boot camps due to the limited orthopaedic and musculoskeletal education in medical school, which inadequately prepares medical students for their orthopaedic surgery sub-internships. The aim of this study is to identify the impact of the novel orthopaedic surgery boot camp on medical students' confidence with key orthopaedic topics. Methods A cross-sectional study was conducted using an anonymous online survey distributed to medical students attending the novel orthopaedic surgery boot camp. The boot camp consisted of a four-day immersion course into the basics of orthopaedic surgery principles through both didactic and skills-based educational series. The medical students' confidence in orthopaedic surgery clinical and technical skills were assessed by comparing the students' survey responses before and after attending each of the sessions. Results Twelve fourth-year medical students and 15 second-year medical students attended the boot camp. All the sessions attended by the medical students were statistically significant in improving their confidence in the subject matter and skills-based training. Hundred percent (100%) of the fourth-year medical students recommend future orthopaedic surgery-bound medical students to attend this boot camp. Conclusion A dedicated orthopaedic surgery boot camp focused on clinical and technical skills plays a key role in increasing medical students' confidence with key orthopaedic topics by providing an opportunity to practice these skills in a supervised environment with real-time feedback. This novel boot camp can provide a framework for creating a longitudinal course for medical students to augment the musculoskeletal education taught in medical school education.

Association of Surgical Approach With Treatment Burden, Oncological Effectiveness, and Perioperative Morbidity in Adrenocortical Carcinoma.

MICROABSTRACT: In the National Cancer Database (NCDB), patients treated with minimally invasive adrenalectomy (MIA) for adrenocortical carcinoma (ACC) had similar oncological outcomes and cumulative treatment burden with less morbidity compared with open adrenalectomy (OA). Although OA remains the standard of care for adrenal lesions concerninge for malignancy, MIA in appropriately selected patients may offer equivalent oncological outcomes. INTRODUCTION/BACKGROUND: We investigated the cumulative treatment burden, oncological effectiveness, and perioperative morbidity in patients undergoing MIA compared with (OA) for patients with ACC. PATIENTS AND METHODS: We reviewed the NCDB for patients undergoing surgical resection (MIA vs. OA) for ACC from 2010 to 2017. Inverse probability of treatment weighted logistic regression, negative binomial, and Cox proportional hazards models were fit to assess for an association of surgical approach with cumulative treatment burden (any adjuvant therapy, radiation therapy [RT], and systemic therapy), oncological effectiveness (positive surgical margins [PSM], lymph node yield [LNY], and overall survival [OS]), and perioperative morbidity (length of stay [LOS] and readmission) as appropriate. RESULTS: We identified 776 patients that underwent adrenalectomy for ACC, of which 307 underwent MIA. We noted patients with larger tumors (OR 0.82, 95% CI 0.78-0.86, P < .001) were less likely to have MIA prior to IPTW. We did not appreciate a significant association of MIA with cumulative treatment burden or the use of any adjuvant therapy (OR 0.85, 95% CI 0.60-1.21, P = .375), adjuvant RT (OR 0.94, 95% CI 0.59-1.50, P = .801), or adjuvant systemic therapy (OR 0.84, 95% CI 0.58-1.21, P = .352). Patients undergoing MIA had similar oncological effectiveness of surgery and OS when compared with patients which underwent OA. Patients that underwent MIA had a significantly shorter LOS (IRR: 0.74, 95% CI 0.62-0.88, P = .001) and lower odds of readmission (OR 0.46, 95% CI 0.23-0.91, P = .026). CONCLUSIONS: Although the standard of care for adrenal lesions suspicious for ACC remains OA, in appropriately selected patients, MIA may offer similar oncological effectiveness and cumulative treatment burden, with less morbidity, than OA.

A comparison of healing and complication rates between common flaps utilized in total knee arthroplasty: a review of the literature.

BACKGROUND: Flap reconstruction with perforator, fasciocutaneous, muscular, and/or free microvascular flaps is utilized to cover wound defects and improve vascularization and antibiotic/nutrient delivery. Flap use in revision procedures for total knee arthroplasty has been explored previously; however, current data are limited and studies comparing healing and complication rates between different flap types are lacking. METHODS: A literature review was performed using PubMed on 13 January 2022. Studies were included if they reported healing and complication rates for either gastrocnemius, rectus abdominis, latissimus dorsi, fasciocutaneous, chimeric, or gracilis flaps in the setting of revision total knee arthroplasty (TKA). RESULTS: The final cohort included gastrocnemius (n = 421, healing rate 73.8%, complication rate 59.9%), gracilis (n = 9, healing rate 93%, complication rate 55.6%), latissimus dorsi (n = 41, healing rate 67%, complication rate 46.3%), rectus abdominis (n = 3, healing rate 100%, complication rate 0%), fasciocutaneous (n = 78, healing rate 70%, complication rate 19.2%), and chimeric flaps (n = 4, healing rate 100%, complication rate 25%). There was no significant difference when comparing healing rates across flap types (p = 0.39). There was a significant difference when comparing complication rates across flap types (p < 0.0001), with a significant difference being noted between gastrocnemius and fasciocutaneous complication rates (p < 0.0001). All other comparisons between flap types by complication rate were not significantly different. CONCLUSIONS: Gastrocnemius flaps are the workhorse flap in the setting of revision TKA, as evidenced by this review. Healing rates did not vary significantly across flap types, which suggests that determining the appropriate flap for coverage of soft-tissue defects in revision TKA should be driven by defect size and location as well as physician experience and patient tolerance.

The Delayed Nephrogram: Point-of-care Quantitative Measurement, Validation as an Indicator of Obstruction, and Novel Use as a Predictor of Renal Functional Impairment.

BACKGROUND: The diagnostic value of delayed nephrograms on contrast-enhanced computed tomography has not been studied rigorously. OBJECTIVE: To develop a method for quantitatively assessing delayed and diminished nephrograms (DDNs) easily at the point of care and to assess the association of DDNs with renal obstruction and renal function. DESIGN, SETTING, AND PARTICIPANTS: Data were reviewed from 76 patients who underwent a contrast-enhanced computed tomography scan within 30 days of a technetium-99m mercaptoacetyltriglycine diuretic renal scintigraphy (MAG3-DRS) which showed at least one kidney to have normal drainage (T1/2 <10 min) between 2010 and 2021 at a tertiary academic center. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Attenuations of the renal cortex and medulla were measured using circular regions of interest. These attenuations were compared between kidneys to compute several measures of DDN in the kidney with a greater concern for obstruction. Renal parenchymal volume and anterior-posterior renal pelvis diameter (APD) were estimated using simple linear measurements. Inter-rater reliability was computed using the intraclass correlation coefficient (ICC), correlations were computed using Spearman's R, and the relationships between DDN, APD, and renal function of the subject kidney were estimated using linear regression. RESULTS AND LIMITATIONS: Measures of DDN were highly reliable between raters (ICC 0.71-0.87). DDN was almost always associated with prolonged drainage on MAG3-DRS (90-100%); however, 33-52% of patients with prolonged drainage on MAG3-DRS had no appreciable DDN, depending on the measure of the DDN chosen. All measures of DDN were associated with decreased renal function (<0.001). APD did not significantly predict renal function when controlling for a DDN. CONCLUSIONS: DDNs on contrast-enhanced computed tomography are associated with renal obstruction and can easily and accurately be quantified at the point of care. A DDN is more closely associated with renal dysfunction than renal pelvic dilation and therefore may be useful in assessing the severity of upper tract obstruction. PATIENT SUMMARY: In this report, we confirm that a "delayed nephrogram", a classic x-ray finding thought to be associated with kidney blockage, is associated with blockage of the affected kidney. Furthermore, we show that a delayed nephrogram indicates that the affected kidney is not functioning as well as we would expect for a normal kidney of the same size. Since the severity of a delayed nephrogram predicts this decreased function better than the degree of dilation of the kidney, which is a different measurement often used to measure the severity of kidney blockage, the delayed nephrogram may be a better way of measuring the severity of kidney blockage in clinical practice.

Oncologic Outcomes of cT1 and cT2 Micropapillary Variant Compared with cT1 and cT2 Conventional Urothelial Carcinoma Treated with Radical Cystectomy.

INTRODUCTION: Our objective was to estimate the difference in outcomes for patients with clinical T stage 1 (cT1) and 2 (cT2) micropapillary (MPBC) and urothelial carcinoma (UCBC) bladder cancer treated with radical cystectomy (RC). METHODS: We reviewed the National Cancer Database for patients with cT1/2N0M0 MPBC and UCBC treated with RC from 2004-2016. Patients were classified by cT stage and histology. Outcomes of interest included upstaging to advanced pathological stage (pT3/4), pathologically node positive disease (pN+), and overall survival (OS). The Kaplan-Meier method was used to estimate 5-year OS probability. Multivariable logistic regression models were fit to test for an association between cT stage and histology with outcomes. RESULTS: We identified 23,871 patients, of whom 384 had MPBC and 23,487 had UCBC. More patients with cT1 and cT2 MPBC had advanced pathological stage and pN+ (cT1: 31% and 34%; cT2: 44% and 60%, respectively) compared with cT1 and cT2 UCBC (cT1: 18% and 14%; cT2: 27% and 24%, respectively). Compared with cT2 UCBC, patients with cT1 MPBC had similar odds of advanced pathological stage (OR: 0.96, 95% CI: 0.63-1.45, p=0.837) and increased odds of pN+ (OR: 1.62, 95% CI: 1.03-2.56, p=0.038). Five-year OS estimates for cT1 MPBC and UCBC were similar (58% and 60%, respectively) while cT2 MPBC had worse OS than cT2 UCBC (33% and 45%, respectively). CONCLUSIONS: In a cohort of patients undergoing RC, cT1/2 MPBC had worse outcomes than cT1/2 UCBC. Patients and surgeons should consider aggressive therapies for patients with cT1 MPBC due to the risk of inferior outcomes associated with cT2 MPBC disease.

Arthroscopic Versus Open Management of Diffuse-Type Tenosynovial Giant Cell Tumor of the Knee: A Meta-analysis of Retrospective Cohort Studies.

BACKGROUND: Whether arthroscopic or open surgical management for diffuse-type tenosynovial giant cell tumor (D-TGCT) of the knee is associated with a lower rate of recurrence is unknown. METHODS: PubMed, Scopus, Web of Science, Cochrane, and EMBASE were searched on December 3, 2020. Retrospective studies that reported on recurrence rates for arthroscopic versus open management of D-TGCT were included. A total of 16 studies evaluating 1143 patients with D-TGCT of the knee were included (nopen = 551, narthroscopic = 350 patients, and narthroscopic/open = 23 patients). Random-effects meta-analyses were used to summarize and compare the reported recurrence rates, stratified by approach and overall recurrence. The meta-analysis was registered with PROSPERO. RESULTS: The recurrence rate per year (incidence) for arthroscopic procedures was 0.11 (95% CI 0.08 to 0.16, P < 0.0001) and for open procedures was 0.07 (95% CI 0.04 to 0.13, P < 0.0001). There was a 1.56 times (95% CI 1.04 to 2.34, P = 0.0332) increased risk of recurrence when treating D-TGCT of the knee with an arthroscopic approach. When evaluating only the subset of studies that had data for both arthroscopic and open approaches, the incidence rate per year for arthroscopic procedures was 0.17 (95% CI 0.11 to 0.27, P < 0.0001) and for open procedures was 0.11 (95% CI 0.06 to 0.19, P < 0.0001). The rate of overall complications was 0.04 (95% CI 0.01 to 0.08, P < 0.0001). CONCLUSION: Arthroscopic surgical management of D-TGCT of the knee in our study resulted in a 1.56 times risk of recurrence as compared with the open approach. The percent of overall complications was minimal.

Assessing the recognition of female orthopaedic surgeons in Castle Connolly's "America's Top Doctors" from 2000 to 2020.

BACKGROUND: The field of orthopaedic surgery has one of the lowest percentages of practicing female physicians. Studies have shown disparities in various academic societies' award recipients by sex. Given the recent increased use of physician rating platforms by patients and focus on consumer-driven healthcare, our aim was to assess the recognition of female orthopaedic surgeons. METHODS: A twenty-year quantitative analysis was performed comparing the rate of top female orthopaedic surgeons listed on Castle Connolly's "America's Top Doctors" to the percentage of practicing female orthopaedic surgeons as reported by the American Academy of Orthopaedic Surgeons. RESULTS: From 2000 to 2020, there was a statistically significant increase in the percentage of top female orthopaedic surgeons listed on Castle Connolly (1.3%-5.3%), as well as an increase in overall practicing AAOS female members (2.7%-5.8%). When comparing the rate of top female orthopaedic surgeons listed on Castle Connolly to the proportion of practicing female AAOS members from 2000 to 2020, there were no statistically significant differences. CONCLUSIONS: The increase in the rate of top female orthopaedic surgeons recognized by Castle Connolly was proportionate to the increase in percentage of practicing female AAOS members over the past 20 years. This study highlights the persistence of a gender discrepancy in the academic sector of orthopaedic surgery.

Identification of oncological characteristics associated with improved overall survival in patients with adrenocortical carcinoma treated with adjuvant radiation therapy: Insights from the National Cancer Database.

OBJECTIVES: To test for an association between oncological risk factors and overall survival in patients with non-metastatic adrenocortical carcinoma treated with adjuvant radiation therapy at high-risk for recurrence per NCCN guidelines. MATERIALS AND METHODS: We analyzed data from patients undergoing surgical resection with or without aRT in the NCDB from 2004 to 2017. A multivariable Cox proportional hazards model was fit to assess for an association of aRT and OS. To determine whether aRT was associated with improved OS in patients with specific NCCN risk factors, we fit three multivariable Cox proportional hazard models with an interaction term between NCCN risk factors and the use of aRT. RESULTS: We identified 1,433 patients treated surgically for adrenocortical carcinoma with at least one risk factor. 259 patients received adjuvant radiation therapy (18%) while 1,174 (82%) patients did not. After adjustment, we noted a significant association between adjuvant radiation therapy and overall survival in the entire cohort in the multivariable Cox proportional hazards model (HR 0.68, 95% CI 0.55-0.85, P = 0.001). Adjuvant radiation therapy was associated with increased overall survival in patients with positive surgical margins (HR 0.47, 95% CI 0.35-0.65, P < 0.001), large tumor size ≥6 cm (HR 0.69, 95% CI 0.55-0.87, P = 0.002), and high-grade disease (HR 0.61, 95% CI 0.37-0.99, P = 0.046). CONCLUSIONS: Patients with ACC at high-risk for recurrence were associated with improved overall survival when treated with adjuvant radiation therapy. These data may help identify which patients should consider aRT after resection of clinically localized ACC.

Isolated Metastasis to the Brain From Upper Tract Urothelial Carcinoma.

Isolated brain metastasis from cancers of urothelial origin are rare, especially after a long recurrence-free interval with few reports in the literature. We herein present the case of a 62 year old male with history of recurrent bladder cancers treated in 2004 and 2005 and a left distal ureteral high grade pT3aN1M0 urothelial cancer treated with distal ureterectomy and reimplant followed by adjuvant chemotherapy in 2014 who presented after a 5 year recurrence-free interval with tonic-clonic seizure. Further workup revealed an isolated 12.0 mm x 18.0 mm x 8.0 mm mass overlying the left parietal lobe with no other metastatic sites. The patient was treated with resection of the mass and adjuvant radiation therapy with pathology confirming metastatic carcinoma of urothelial origin. Though prognosis for patients with such a presentation remains poor, we provide a review of the current literature with respect to incidence, presentation and therapeutic considerations for such patients.

Endoscopic Removal of an Intrauterine Device in the Left Distal Ureter.

Background: Intrauterine device (IUD) migration to the ureter is rare. Symptoms can vary, but often mimic renal colic. Radiographic imaging may aid the diagnosis of a foreign body in the ureter. Reports on endoscopic managements of a migrated IUD are not well described. Case Presentation: We present a 36-year-old woman with a history of IUD insertion. Her symptoms included hematuria, dysuria, and suprapubic/abdominal pressure. After the removal of her IUD by her gynecologist, her hematuria eventually stopped, but she presented again with persistent pain. CT revealed a radiopaque foreign body in the distal left ureter protruding into the bladder. A careful resection with a resectoscope uncovered a long cylindrical shaped foreign body, suspicious of a broken piece of the IUD. Conclusion: Although not always feasible and long-term results remain to be determined, endoscopic management is a safe and effective method of identifying and removing a retained IUD in the ureter. When evaluating a woman with abdominal pain who has an indwelling IUD, a spontaneous migration of the IUD should be considered in the differential diagnosis.

Intraoperative transradial angiography augments safe hysterectomy for uterine fibroids in the setting of ambiguous arterial anatomy: a case report.

BACKGROUND: Transfemoral access is the traditional gold standard for uterine artery angiography; however, transradial access is gaining in popularity because of its decreased complication profile and patient preference. We present a case of a patient who underwent successful total abdominal hysterectomy for symptomatic uterine fibroids with ambiguous pelvic vasculature that would have been otherwise aborted if it were not for intraoperative transradial access angiography. CASE PRESENTATION: A 52-year-old Caucasian woman presented to her gynecologist for an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. During preoperative imaging, a 15-cm mass consistent with a uterine fibroid was identified, and the patient's gynecologist decided to treat her with surgical resection, given the fibroid's size. The procedure was halted upon discovery of a complicated vascular plexus at the fundus of the uterus, and an intraoperative vascular consult was requested. The vascular operator used a transradial access to perform pelvic angiography in real time to identify the complicated pelvic vasculature, which allowed the gynecologist to surgically resect the uterine fibroid. The patient was discharged on postoperative day 4 without any complications. CONCLUSIONS: Intraoperative imaging is a useful technique for the identification of complicated anatomical structures during surgical procedures. The successful outcome of this case demonstrates an additional unique benefit of transradial access and highlights an opportunity for interdisciplinary collaboration for management of complicated surgical interventions.

Physiological response of cardiac tissue to bisphenol A: alterations in ventricular pressure and contractility.

Biomonitoring studies have indicated that humans are routinely exposed to bisphenol A (BPA), a chemical that is commonly used in the production of polycarbonate plastics and epoxy resins. Epidemiological studies have shown that BPA exposure in humans is associated with cardiovascular disease; however, the direct effects of BPA on cardiac physiology are largely unknown. Previously, we have shown that BPA exposure slows atrioventricular electrical conduction, decreases epicardial conduction velocity, and prolongs action potential duration in excised rat hearts. In the present study, we tested if BPA exposure also adversely affects cardiac contractile performance. We examined the impact of BPA exposure level, sex, and pacing rate on cardiac contractile function in excised rat hearts. Hearts were retrogradely perfused at constant pressure and exposed to 10(-9)-10(-4) M BPA. Left ventricular developed pressure and contractility were measured during sinus rhythm and during pacing (5, 6.5, and 9 Hz). Ca(2+) transients were imaged from whole hearts and from neonatal rat cardiomyocyte layers. During sinus rhythm in female hearts, BPA exposure decreased left ventricular developed pressure and inotropy in a dose-dependent manner. The reduced contractile performance was exacerbated at higher pacing rates. BPA-induced effects on contractile performance were also observed in male hearts, albeit to a lesser extent. Exposure to BPA altered Ca(2+) handling within whole hearts (reduced diastolic and systolic Ca(2+) transient potentiation) and neonatal cardiomyocytes (reduced Ca(2+) transient amplitude and prolonged Ca(2+) transient release time). In conclusion, BPA exposure significantly impaired cardiac performance in a dose-dependent manner, having a major negative impact upon electrical conduction, intracellular Ca(2+) handing, and ventricular contractility.

Discuss the factors that affect the outcome of endodontic treatment.

Factors affecting the outcome of endodontic treatment are discussed from the theoretical viewpoint (microbes, foreign bodies and epithelium) and from a clinical aspect (preoperative factors, intraoperative factors and miscellaneous factors). The following conditions favour endodontic success significantly: the absence of a periapical infection, a well-condensed root filling, the root filling extending to 2 mm within the radiographic apex and not beyond, a satisfactory coronal restoration, use of a rubber dam during treatment and cases involving primary root canal treatment as opposed to retreatment. Other factors have the potential to affect success rates, but these have not yet been quantified. Although there is an array of potential factors that influence the outcome of endodontic treatment, success is most significantly dependent upon the elimination of root canal infection present when treatment starts and the prevention of contamination during treatment.