Technical refinements of the scapular tip-free flap for mandibular reconstruction.

BACKGROUND: The use of scapular tip chimeric free flaps (STFFs) for reconstructing mandibular defects has recently become popular, but its utility relative to other bone-containing free flaps remains debatable. The aim of the report is to describe how technical modification of STFF impacted in its use for mandibular reconstruction also commenting results obtained in a unicentric series of patients. PATIENTS AND METHODS: Patients undergoing mandibular reconstruction using an STFF from January 1, 2014 to June 1, 2022 were retrospectively enrolled in this report. We collected data on chimeric flap type, bone management, vascular pedicles, and the final outcomes. In total, 31 patients (13 men and 18 women) with a mean age of 68 years were enrolled. According to the classification system of Urken, 15 patients had body defects, while 7 had ramus defects, another 7 had symphysis defects, and 2 had both ramus and bodily defects. STFF was always harvested working in two equips simultaneously, in supine position. Dissection included preparation of chimeric components of the flap as latissimus dorsi, serratus and scapular tip. After pedicle dissection scapular bone was cut basing on reconstructive needing with a rectangular (stick) shape including the border of the scapula. In cases of longer bone harvesting, circumflex pedicle was also included to perfuse the upper portion of the scapular border. In five cases, the STFF was harvested with only the scapular angle component, and was thus a composite osteomuscular flap; for the remaining 26 cases, a chimeric STFF was used. Circumflex pedicle was included for eight patients. Six of the seven patients with symphyseal defects underwent a single osteotomy. RESULTS: The average length of the harvested was 69.92 mm (maximum length = 104 mm). The average height of transplanted bone was 26.78 mm (maximum height = 44.2 mm). Mouth-opening was normal in 25 patients, limited in 6 patients, and severely impaired in no patients. The cosmetic results were rated as excellent by 20 patients, good by 8 patients, and poor by 3 patients. CONCLUSION: The STFF is an excellent option for mandibular reconstruction when other flaps are not available and for patients in poor general condition. Technical innovations here presented made possible to harvest long bone segments with accurate shape thanks to osteotomies if needed and with adequate soft tissues components of the chimeric flap, ensuring satisfactory functional and cosmetic results.

The Evolution of Foreign Bodies Management in a Case of Near-fatal Penetrating Neck Injury.

Penetrating wounds of the neck with foreign bodies retention are frequent and often life-threatening events, and their management has changed in recent years from an open approach to a conservative approach thanks to the possibility of performing minimally invasive radiologically guided surgery. We present a case of penetrating glass injury to zone III of the neck in which the foreign body go through the parotid region passing near, but without injuring, the facial nerve and the external and internal carotid arteries.

Controversies in the treatment of early-stage oral squamous cell carcinoma.

The treatment of early-stage oral squamous cell carcinoma (OSCC) is still a controversial issue. Thanks to the 8th edition of TNM by AJCC there is a better distinction between the stages of OSCC. However, Stages I and II still share the same treatment protocol, even if the prognosis is radically different. A retrospective study has been conducted including 70 previously untreated patients with Stage I or II OSCC, treated with tumorectomy and selective neck dissection. The study focuses on the link between pT1/2 and various other factors, particularly histological grading, vascular and perineural invasion, local and cervical recurrence, surgical margins and overall survival. These data reveal significant differences between pT1 and pT2 in histological grade, perineural invasion, cervical recurrence, surgical margins, and overall survival, emphasizing the necessity of different treatment protocols for T1 and T2 OSCC. Distinct strategies should be proposed to treat Stage I and II OSCC, with Stage II patients possibly benefitting from more aggressive treatments: following these data, a wait-and-see strategy should only be considered in Stage I, while certain treatments at the cervical level - such as prophylactic neck dissection and sentinel node biopsy - should always be considered for Stage II tumors.

Changes in hospital admissions for facial fractures during and after COVID 19 pandemic: national multicentric epidemiological analysis on 2938 patients.

PURPOSE: The objective of this multicenter study was to examine the differences in maxillo-facial fractures epidemiology across the various phases of the SARS-CoV-2 pandemic. METHODS: This is a retrospective study on patients who underwent surgery for facial bone fractures in 18 maxillo-facial surgery departments in Italy, spanning from June 23, 2019, to February 23, 2022. Based on the admission date, the data were classified into four chronological periods reflecting distinct periods of restrictions in Italy: pre-pandemic, first wave, partial restrictions, and post-pandemic. Epidemiological differences across the groups were analysed. RESULTS: The study included 2938 patients. A statistically significant difference in hospitalization causes was detected between the pre-pandemic and first wave groups (p = 0.005) and between the pre-pandemic and partial restriction groups (p = 0.002). The differences between the pre- and post-pandemic groups were instead not significant (p = 0.106). Compared to the pre-pandemic period, the number of patients of African origin was significantly higher during the first wave and the post-pandemic period. No statistically significant differences were found across the periods concerning gender, age, fracture type, treatment approach, and hospital stay duration CONCLUSIONS: The COVID-19 pandemic brought about significant changes in fracture epidemiology, influenced by the restrictive measures enforced by the government in Italy. Upon the pandemic's conclusion, the fracture epidemiology returned to the patterns observed in the pre-pandemic period.

Rehabilitation after lumbar spine surgery in adults: a systematic review with meta-analysis.

BACKGROUND: The role of rehabilitation after surgery in patients with low back pain is well recognized. The aim of this systematic review is to summarize and update the existing evidence according to the type of clinical condition and rehabilitation approach. METHODS: This systematic review included RCTs on the effectiveness of rehabilitation after surgery for lumbar disc herniation, spinal stenosis, and spondylolisthesis. We searched the literature for randomized controlled trials indexed in MEDLINE, Embase, CINHAL, CENTRAL, Scopus, PEDro, and Web of Science databases, up to April 15, 2023. We used Cochrane Risk of Bias 2.0 tool to assess each study. We conducted a quantitative synthesis when population, intervention, control, and outcome were sufficiently homogeneous; otherwise, we conducted a qualitative analysis. RESULTS: Forty-five studies (3.036 subjects) were included and analyzed according to the population considered: lumbar stenosis (1 trial), spondylolisthesis (3 trials), and disc herniation (41 trials). Regarding lumbar stenosis, a supervised active exercise program appears to improve outcomes related to pain, disability, and quality of life both in the short- and mid-term (1 study, n = 60). Concerning spondylolisthesis, kinesiophobia is reduced in the home exercises group compared to usual care, at 3-months follow-up (3 studies, n = 98). For disk herniation, supervised exercises are better than non-supervised exercises to reduce pain (MD -1.14; 95% CIs -1.65, -0.62; 5 trials, n = 250) and disability (SMD -0.70; 95% CIs -1.14, -0.26; 4 trials, n = 175). Supervised exercises are better than advice in reducing pain (SMD -0.91; 95% CIs -1.61, -0.21; 5 trials, n = 341) and disability (SMD -0.80; 95% CIs -1.59, -0.01; 4 trials, n = 261), in the short-term. Supervised exercises are equal to no treatment in reducing pain and disability, at 3 and 6 months after intervention (2 trials, n = 166). These results are supported by a very low to low quality of evidence. CONCLUSIONS: Our research suggests that supervised exercise may be effective in improving patient's pain and disability after lumbar surgery, but RCTs regarding lumbar spinal stenosis and lumbar spondylolisthesis are still scarce, with significant heterogeneity of proposed interventions.

The ability of the eighth edition of the TNM staging system plus minor invasion criteria to predict the biological behaviour of oral cavity carcinomas.

BACKGROUND: Oral squamous cell carcinoma (OSCC) treatment is based largely on the TNM stage. The eighth edition includes important new prognostic parameters (extranodal extension and depth of invasion), while it does not consider tumour molecular characteristics or minor invasion criteria (perineural and lymphovascular invasion, grading and resection margins). This study evaluated how well the TNM eighth edition predicts the biological behaviour of OSCC, considering survival and risk of locoregional recurrence. MATERIALS AND METHODS: Data from 217 patients treated for OSCC were analysed, including epidemiologic characteristics, histological features and treatment. RESULTS: No significant correlations with overall survival or tumour recurrence were found for pT stages and the type of treatment, while different pN stages had significant differences in recurrence, but not in overall survival. We found significant correlations between overall survival and tumour grade and lymphovascular and perineural invasion and a significant correlation between tumour resection margins and the risk of recurrence. CONCLUSIONS: The current TNM staging system is a necessary but not sufficient tool for predicting the overall survival and risk of recurrence of OSCC. It could be improved by considering other factors, such as minor invasion criteria and biological markers.

Double Arterialized Scapular Tip Free Flap for Mandibular Reconstruction.

INTRODUCTION: Scapular tip free flap (STFF) has become today one of the workhorse flaps for maxillary reconstruction; recently, the possibility of extending the vascular supply by adding to the angular branch of the circumflex pedicle up to its periosteal entrance in the lateral border of the scapula has been proposed as a reliable technique to improve the length of perfused bone when STFF is used for mandibular reconstruction. The purpose of this study was to evaluate the patients who had received microvascular reconstruction of the mandible with STFF vascularized by both the circumflex scapular artery via the periosteal branch and the thoracodorsal artery via the angular artery. METHODS: A retrospective chart review was conducted for all patients who underwent reconstruction with an STFF for mandibular defect between January 2016 and December 2020 at the University Hospital of Parma. The outcome was evaluated by assessing dietary intake (unrestricted, soft, liquid, and tube feed) and speech (normal, intelligible, partially intelligible, and unintelligible). RESULTS: The final study sample included 9 patients (5 men and 4 women). The average patient age was 68.9 years (range, 59.9-74.8 y) at the time of surgery. There was no flap loss. A 1-year postoperative computed tomography scan revealed full osteointegration of the flap. CONCLUSIONS: Our results show that the STFF is a valuable reconstructive option, especially in patients with complex head and neck defects requiring soft and hard tissues.

Diagnosis and Management of Parotid Gland Cancer with Focus on the Role of Preoperative Fine-Needle Aspiration Cytology: A 10-Year-Long Retrospective Study with 5-Year Follow-Up.

Introduction: Salivary gland cancers represent a rare heterogeneous group of neoplasms with complex clinicopathological characteristics and distinct biological behaviour. The appropriate diagnosis and management of parotid gland cancer are challenging and should be based on the clinical, imaging, cytological, and histological features. The present study analysed the use of preoperative fine-needle aspiration cytology (FNAC) and intraoperative frozen section (FS) to guide the appropriate surgical and postoperative treatment of parotid gland cancers. Materials and Methods: We selected 48 patients with primary malignancy of the parotid gland surgically treated between 1 January 2008 and 30 June 2017 at the Maxillo-Facial Surgery Division, University Hospital of Parma, Italy. The patients had postoperative histological diagnosis of malignant parotid cancer and were followed up for longer than 5 years. Results: The 48 patients included in this study had a mean age of 56.7 years. The most frequent type of parotid gland cancer was carcinoma ex pleomorphic adenoma (22.9%), followed by mucoepidermoid carcinoma (16.7%) and acinic cell carcinoma (14.6%). All 48 patients underwent preoperative FNAC: 29 (60.4%) and 19 (39.6%) were suggestive of malignant and benign lesions, respectively. In 31 patients, intraoperative FS was performed. Discussion: Compared to previous studies, the present study showed significantly lower diagnostic sensitivity of FNAC for parotid gland cancers. The preoperative diagnostic accuracy for suspected malignant cases may be improved by repeat analysis of the cytological specimen by experts, preoperative core needle biopsy, and/or intraoperative FS analysis of the suspected mass.

Double osseous flaps for simultaneous midfacial and mandible reconstruction: Automation in surgical complexity within an entirely computerized workflow.

Introduction: Broad maxillofacial surgical resections involving both the midface and the mandible represent a challenge in terms of reconstruction. Although several papers have explored the possibility of simultaneously using two microsurgical flaps, reports on the implementation of a dual osseous flap strategy are limited, and mainly addressed to static anatomical reconstruction, regardless of functional implications. In particular, there is a lack in the literature of a unifying protocol which illustrates how technology including virtual planning, statistical shape modeling, virtual occlusion, 3D-printing and patient-specific implants can address the functional and accuracy needs required for an optimal reconstruction. Materials and methods: In this paper, the Authors present their preliminary experience in a two-center study, showing how broad maxillofacial defects, requiring a simultaneous reconstruction in both the mandible and the midface, can be successfully reconstructed using the combination of two osseous flaps in an automated sequence in which all steps are anticipately defined in a virtual plan, accounting for the optimal alignment of temporomandibular joint, predicting the final occlusion and defining a mandibular shape according to a statistical shape model. Results: Average RMSE for the iliac bone crest flap was of 3.2 ± 0.36 mm; for the fibula flap, RMSE value was of 2.3 ± 0.65 mm, for patient-specific implants, for mandibular prostheses the average RMSE was 2.46 mm with 0.76 mm standard deviation. Temporomandibular joint function increased when a TMJ prosthesis was placed. Conclusions: Double bone free flap is a valuable resource to reconstruct wide defects that simultaneously involve two thirds of the cranio-maxillo-facial skeleton, but a careful virtual planning study should be always performed before approaching this surgical option.

A Modified Technique for Harvesting Scapular Tip Flap and to Allow 2 Teams to Work at the Same Time.

AIM: The main aim of the present report is to describe a modified technique of tip scapular flap harvesting to allow 2 surgical teams to work at the same time and to shorten surgical times. MATERIALS AND METHODS: The medical records of 25 patients that had undergone maxillary or mandibular reconstruction by using a free scapular tip flap were retrospectively reviewed to identify the possible advantages and disadvantages of this type of flap. RESULTS: Thirteen patients analyzed in this series underwent maxillary reconstruction with tip scapular flap, while the other 12 patients underwent mandibular reconstruction. No failures, partial failures, or infections were evidenced in this series. Scapular tip flap allowed for acceptable esthetic and functional outcomes. In all cases, the patient was placed supine. No major complications were observed at the donor site during follow-up. CONCLUSION: Scapular tip flap might be extremely useful for head and neck reconstruction. Pedicle length, versatility, and reliability represent the major advantages of this reconstructive recourse. Moreover, the resistance of the scapular vascular system to atherosclerosis could be helpful in patients showing contraindications to free fibula flaps.

Sexual Disability in Low Back Pain: Diagnostic and Therapeutic Framework for Physical Therapists.

BACKGROUND: The literature shows a relationship between sexual activity and low back pain (LBP). The aim of this work is to provide a theoretical framework and practical proposal for the management of sexual disability in individuals with LBP. METHODS: Based on a literature review, a team of specialized physical therapists developed a pattern for the management of LBP-related sexual disability. RESULTS: A patient reporting LBP-related sexual disability may be included in one of four clinical decision-making pathways corresponding to one of the following: #1 standard physical therapy (PT); #2 psychologically informed physical therapy (PIPT); #3 PIPT with referral; or #4 immediate referral. Standard PT concerns the management of LBP-related sexual disability in the absence of psychosocial or pathological issues. It includes strategies for pain modulation, stiffness management, motor control, stabilization, functional training, pacing activities comprising education, and stay-active advice. PIPT refers to patients with yellow flags or concerns about their relationship with partners; this treatment is oriented towards a specific psychological approach. "PIPT with referral" and "Immediate referral" pathways concern patients needing to be referred to specialists in other fields due to relationship problems or conditions requiring medical management or pelvic floor or sexual rehabilitation. CONCLUSIONS: The proposed framework can help clinicians properly manage patients with LBP-related sexual disability.

Impact of histological tumor grade on the behavior and prognosis of squamous cell carcinoma of the oral cavity.

INTRODUCTION: Unlike other types of cancers, the prognostic value of histological tumor grade is not well determined for oral squamous cell carcinoma (OSCC). This study therefore aimed to evaluate the impact of tumor differentiation on prognosis and overall survival of patients affected by squamous cell carcinoma of the oral cavity. MATERIALS AND METHOD: A retrospective analysis was conducted using the records of patients diagnosed with squamous cell carcinoma of the oral cavity between 2010 and 2015. The study included 162 patients treated with a tumorectomy and selective neck dissection. The influence of histological tumor grade on several prognostic factors such as T-Stage, N-stage, recurrence rate, perineural invasion, vascular invasion, surgical margins, and overall survival was analyzed. RESULTS: Histological grade strongly correlated with N-stage, recurrence rate, perineural invasion, vascular invasion, surgical margins, and overall survival. Overall survival was 71.6% in patients with well-differentiated tumors and 43.2% in those with moderately and poorly differentiated tumors. CONCLUSIONS: Histological grade represents an important prognostic factor for OSCC. Therefore, various treatment strategies based on this histological parameter could improve the overall survival rate of patients affected by oral squamous cell carcinoma.

Efficacy and characteristics of physiotherapy interventions in patients with lumbar spinal stenosis: a systematic review.

PURPOSE: To determine the efficacy of physiotherapy approaches used in the treatment of LSS and compare their delivery characteristics. METHODS: A systematic search was conducted using MEDLINE/PubMed, EMBASE, Scopus, PEDro, CINAHL and Web of Science databases, from inception until March 2021. Inclusion criteria were clinical diagnosis of LSS confirmed through imaging techniques, RCTs written in English comparing physiotherapy interventions among them or versus placebo or usual care without restrictions on treatment and follow-up duration, outcomes related to pain, physical function, disability and quality of life. Two independent reviewers assessed records for eligibility and methodological quality (PEDro scale) and extracted participants' characteristics, interventions details and outcome measures at each timepoint. Pooled or un-pooled findings were reported as mean difference with 95% confidence interval, depending on heterogeneity. Evidence quality was rated using the GRADE approach. RESULTS: Twelve studies (944 patients, mean PEDro score 7.6, range 5-9) were included. Three weeks of weight-supported walking improved pain and disability, while 8 weeks of aquatic exercises improved pain and walking tolerance (very low evidence). Six weeks of cycling reduced disability compared to weight-supported walking (low evidence). Six weeks of manual therapy plus exercise was not superior to supervised exercises (low evidence), but improved pain, walking tolerance, disability and quality of life compared to home/group exercises (moderate to very low evidence). Very low evidence supported 2 weeks of electromagnetic fields, whereas TENS (low evidence) and ultrasounds (very low evidence) revealed no effects. CONCLUSIONS: These findings may assist clinicians in delivering effective physiotherapy interventions in LSS patients.

Mandibular osteosarcoma: diagnosis and treatment.

PURPOSE OF REVIEW: This article presents a review of the literature on mandibular osteosarcoma, focusing on the main aspects of its management, including diagnosis, histotype, and treatment. The literature published in the last 5 years was considered but because of the rarity of mandibular osteosarcoma, major publications from the past have also been included. RECENT FINDINGS: Management of mandibular osteosarcoma still lacks a clear standard of care, and treatment has not changed markedly over the past several years. The mainstay of treatment is surgical resection with free margins, but chemotherapy has recently begun to play a role in both adjuvant and neoadjuvant settings. SUMMARY: Mandibular osteosarcoma is a rare tumor and extensive randomized trials are not available in the international literature. Therefore, the standard of care is not defined, and diagnosis and treatment protocols have been extrapolated from analysis of multiple reports that are often discordant. This makes an interdisciplinary approach mandatory for the management of these patients, to provide the best care possible based on tumor size, site, and patient characteristics.

Low back pain and sexual disability from the patient's perspective: a qualitative study.

PURPOSE: The aim of this qualitative study is to investigate, from patient's perspective, the aspects of the relationship between low back pain and sexual life on physical, psychological and social aspects of individual's life. In addition, this study aims to explore patients' opinions on the role of health care providers in addressing and treating low back pain-related sexual problems. MATERIALS AND METHODS: Semi-structured interviews were conducted with 26 outpatients referred to physical therapy for subacute or chronic non-specific low back pain; the questions investigated the presence of sexual disability and aspects related to patient's behaviour. Two independent physical therapists, supervised by a third expert physical therapist and a clinical psychologist proficient in qualitative methodology, performed thematic content analysis to identify categories and themes. RESULTS: Patients with low back pain consider sexual disability severely limiting and correlated to pain. This study emphasized the perception of invalidity, the importance of the relationship with the partner, the emotions and gender roles in the couple, and the relevance for health care providers to take part in the clinical management. The physical therapist is believed to be a qualified figure to address this issue and specific suggestions on sexual activity could be useful. CONCLUSION: Sexual disability in patients with subacute or chronic LBP acquires an important and individual meaning that can be investigated within the therapeutic context, especially by physical therapists.Implications for RehabilitationSexual disability related to low back pain is considered an important and meaningful topic from the patient's perspective.This reflects the importance of the emotional relationship with the partner.Within the therapeutic context, it is important to provide information to help manage pain during sexual activity.The physical therapist is seen to be a qualified figure to address this issue.

Lumbar spondylolisthesis: STATE of the art on assessment and conservative treatment.

INTRODUCTION: There is weak relationship between the presence of lumbar spondylolisthesis [SPL] and low back pain that is not always associated with instability, either at the involved lumbar segment or at different spinal levels. Therefore patients with lumbar symptomatic SPL can be divided into stable and unstable, based on the level of mobility during flexion and extension movements as general classifications for diagnostic and therapeutic purposes. Different opinions persist about best treatment (conservative vs. surgical) and among conservative treatments, on the type, dosage, and progression of physical therapy procedures. PURPOSE AND IMPORTANCE TO PRACTICE: The aim of this Masterclass is to provide clinicians evidence-based indications for assessment and conservative treatment of SPL, taking into consideration some subgroups related to specific clinical presentations. CLINICAL IMPLICATIONS: This Masterclass addresses the different phases of the assessment of a patient with SPL, including history, imaging, physical exam, and questionnaires on disability and cognitive-behavioral components. Regarding conservative treatment, self- management approaches and graded supervised training, including therapeutic relationships, information and education, are explained. Primary therapeutic procedures for pain control, recovery of the function and the mobility through therapeutic exercise, passive mobilization and antalgic techniques are suggested. Moreover, some guidance is provided on conservative treatment in specific clinical presentations (lumbar SPL with radiating pain and/or lumbar stenosis, SPL complicated by other factors, and SPL in adolescents) and the number/duration of sessions. FUTURE RESEARCH PRIORITIES: Some steps to improve the diagnostic-therapeutic approach in SPL are to identify the best cluster of clinical tests, define different lumbar SPL subgroups, and investigate the effects of treatments based on that classification, similarly to the approach already proposed for non-specific LBP.

The deep circumflex iliac artery free flap in maxillofacial reconstruction: a comparative institutional analysis.

PURPOSE: The aim of the present study was to perform a comparative analysis of the utility, outcomes, and complications of DCIA (deep circumflex iliac artery) flap for the reconstruction of maxillofacial defects between two institutions that continue to use the DCIA flap as a reconstructive resource. MATERIALS AND METHODS: This retrospective analysis included a total of 68 patients (mean age 51.1 years) at the University Hospital of Parma, Parma, Italy, and the University of Maryland, Baltimore, USA, between January 2010 and April 2019. RESULTS: No statistical differences were found in relation to the site of reconstruction (p = 0.09), bone graft quantity (p = 0.93), rehabilitation with dental implants (p = 0.464), length of hospitalization (p = 0.086), BMI (0.677), swallow function (p = 0.419), medical comorbidities (p = 0.933), pre-existing radiation (p = 0.691), adjuvant treatment (p = 0.298), ECOG-PS pre-and post-surgery (p = 0.329; p = 0.545), and flap failure: one partial failure observed (p = 0.412) and donor site morbidities (p = 0.742). A noted trend to increased risk of hernia without the use of a primary mesh repair was observed (p = 0.059). CONCLUSION: The DCIA free flap represents a useful and reliable reconstructive flap for maxillofacial reconstruction. Reconstructive microvascular surgeons should be proficiently trained in this flap technique for its consideration as a first-line option in maxillofacial reconstruction.

Maxillary reconstruction with scapular tip chimeric free flap.

PURPOSE: Purpose of the article is to discuss the use of the scapular tip free flap (STFF) for the reconstruction of maxillary defects. METHODS: A retrospective evaluation of patients who underwent maxillary reconstruction with STFF is presented. Patients were evaluated with respect to complications, function, and cosmesis. RESULTS: Study population consisted of 53 patients. All flaps survived and partial bone resorption only occurred in a young patient. Minor complications included two instances of partial muscular necrosis. The donor site was primarily closed in all patients. Mouth opening was assessed as good (>3 cm) in 41 patients, partially limited (2-3 cm) in 9 patients, and limited (<2 cm) in 3 patients. Dental rehabilitation was achieved in 35 patients; esthetic results were assessed by patient as excellent in 19 patients, good in 28 patients, and poor in 6 patients. CONCLUSIONS: The scapular tip chimeric free flap represents an indispensable tool for reconstructive head and neck microsurgery. The main advantages of this technique are very low donor site morbidity and a long pedicle, as well as the potential for harvesting multiple flaps in a chimeric design; STFF represents the first choice for treatment of small postero-lateral defects of the maxilla, and of wide and complex through-and-through defects involving all components of the midface.

Clinical behavior of T1-T2 squamous cell carcinoma of the oral cavity.

OBJECTIVES: The main aim of the present study is to analyze the differences in the clinical behavior of pT1 and pT2 oral squamous cell carcinoma of the oral cavity and the importance of tumor thickness in these groups of patients. METHODS: A retrospective analysis was conducted using the records of patients diagnosed with pT1 and pT2 oral squamous cell carcinoma between 2006 and 2015 to identify significant differences between these two groups of patients. Several pathological features such as T-stage, N-stage, tumor thickness, surgical margins, and locoregional failure were analyzed. RESULTS: 194 patients were included in this study. Tumor thickness >0.4 cm was significantly related with nodal involvement and overall survival (p < 0.001). T and N stage, tumor thickness, extracapsular spread and surgical margins were associated with poorer outcomes in terms of overall survival (p < 0.001). CONCLUSION: Tumor thickness represents an extremely important prognostic factor and to include depth of invasion (DOI) in the staging of oral squamous cell carcinoma will help in the choice of better treatment strategies and to improve overall survival.

Conservative Treatment and Percutaneous Pain Relief Techniques in Patients with Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations.

BACKGROUND: Degenerative lumbar spinal stenosis (LSS) is a progressive disease with potentially dangerous consequences that affect quality of life. Despite the detailed literature, natural history is unpredictable. This uncertainty presents a challenge making the correct management decisions, especially in patients with mild to moderate symptoms, regarding conservative or surgical treatment. This article focused on conservative treatment for degenerative LSS. METHODS: To standardize clinical practice worldwide as much as possible, the World Federation of Neurosurgical Societies Spine Committee held a consensus conference on conservative treatment for degenerative LSS. A team of experts in spinal disorders reviewed the literature on conservative treatment for degenerative LSS from 2008 to 2018 and drafted and voted on a number of statements. RESULTS: During 2 consensus meetings, 14 statements were voted on. The Committee agreed on the use of physical therapy for up to 3 months in cases with no neurologic symptoms. Initial conservative treatment could be applied without major complications in these cases. In patients with moderate to severe symptoms or with acute radicular deficits, surgical treatment is indicated. The efficacy of epidural injections is still debated, as it shows only limited benefit in patients with degenerative LSS. CONCLUSIONS: A conservative approach based on therapeutic exercise may be the first choice in patients with LSS except in the presence of significant neurologic deficits. Treatment with instrumental modalities or epidural injections is still debated. Further studies with standardization of outcome measures are needed to reach high-level evidence conclusions.