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Bell's palsy is the most common cause of facial weakness involving the facial nerve. While brain MRI is often acquired to evaluate for pathology along the intracranial course of the facial nerve, evaluation of inflammation affecting the extracranial segments of the facial nerve, particularly the intraparotid segments, is uncommon. We present a case report of acute Bell's palsy in a 35-year-old pregnant patient at 38 weeks’ gestation. A double-echo steady state MR neurography technique, MENSA (Multi-Echo iN Steady-state Acquisition), acquired with a conformable prototype neck coil, was utilized to visualize abnormal enlargement and signal hyperintensity of the left intraparotid facial nerve. The case highlights a presentation of Bell's palsy affecting the extracranial segments of the facial nerve. This technique may be useful for longitudinal monitoring of Bell's palsy, planning of targeted treatments, and for evaluating other pathologies affecting the facial nerve.

Background. Due to dysfunction of the facial nerve (CN VII), Bell’s palsy occurs which is a facial paralysis of unknown cause, but viral infection is suspected. The study aims to determine the prevalence of facial nerve palsy in a private clinic in Basrah. Methods. The study was conducted at a private clinic and involved sixty-five patients with facial nerve palsy. It was a cross-sectional study in which any patient who attended the clinic and exhibited signs and symptoms of lower motor neuron facial nerve palsy underwent an examination to confirm the diagnosis and, if confirmed, were included in the study. While patients with other neurological disorders were excluded. Data collection started between October 1, 2022, and April 30, 2023. A total of 65 patients from the private clinic—males and females—aged from 4 to 70 years old were confirmed as having lower motor neuron facial nerve palsy. Results. This study at a private clinic found that Bell’s palsy was the most common facial paralysis, affecting more males than females and most of the patients in the age range of 18-39 years, also affecting mostly the left side, with onset more frequent during hot and cool weather conditions. Diabetes was significantly related to the onset of Bell’s palsy and weather temperature at the time of the clinic visit. Conclusion. Bell’s palsy has a peak age prevalence in the second and third decades of life, and temperature variations have no effect on the occurrence of Bell’s Palsy. Further studies are needed for an accurate estimation of the number of cases, to assess the severity, impact, and efficacy of Bell’s palsy management.

Abstract Objective The aim of this study was to report the incidence and clinical course of a series of patients who were misdiagnosed with Bell’s palsy and were eventually proven to have occult neoplasms. Methods Two hundred forty patients with unilateral facial paralysis who were assessed at the facial nerve reanimation clinic, Victoria Hospital, London Health Science Centre, from 2008 through 2017 were reviewed. Persistent paralysis without recovery was the presenting complaint. Results Nine patients (3.8%) who were proven to have occult neoplasms initially presented with a diagnosis of Bell’s palsy. The mean diagnostic delay was 43.5 months. Four patients were proven to have skin cancers, 3 patients had parotid cancers, and 2 patients had facial nerve schwannomas as a final diagnosis. Initial magnetic resonance imaging (MRI) was performed in all 9 patients and 8 underwent a follow-up MRI. An occult tumor was identified upon review of the original MRI in one patient and at follow-up MRI in 8 patients. The mean time interval between the initial and follow-up imaging was 30.8 months. The disease status at most recent follow-up were no evidence of disease in 2 patients (22%) and alive with disease in 7 patients (78%). An irreversible, progressive pattern of facial paralysis combined with pain, multiple cranial neuropathies or history of skin cancer were predictable risk factors for occult tumors. Seven out of the 9 patients (77.8%) underwent at least one type of facial reanimation surgery, and the final subjective results by the surgeon were available for 5 patients. Three out of the 5 (60%) patients who were available for final subjective analysis were reported as Grade III according to the modified House-Brackmann scale. Conclusion Occult facial nerve neoplasm should be suspected in patients with progressive and irreversible facial paralysis but the diagnosis may only become evident with follow-up imaging. Facial reanimation surgery is a satisfactory option for these patients. Graphical abstract

Bell’s palsy is the common name for the inflammation of the cranial nerve VII. The peculiar geniculate ganglion inflammation is idiopathic and causes hemifacial paralysis. Patients who suffer from this paralysis may have their symptoms dissipate between 3 weeks and 3 months. For certain patients whose facial paralysis persist, botulinum toxin type- A might be an efficient treatment. Depending on the severity of the muscular palsy, different treatments can be offered including surgery, steroid, and anti-viral treatment as well as Botox. This review article’s purpose is to dive into the possible correlation of viral pathogens with the activation of the facial nerve inflammation, and how patients with Bell’s palsy can benefit from Botox type-A as treatment.

Objective:To investigate the prognostic value of the magnetic resonance imaging in Bell’s palsy patients.Methods:Patients who were diagnosed and treated with Bell’s palsy between October 2013 and March 2016 retrospectively selected. House–Brackmann grades, pre- and post-treatment pure tone audiograms, stapedial reflexes were analyzed and magnetic resonance imaging (MRI) scans with gadolinium-based contrast agents were evaluated. Contrast-enhanced segments of the facial nerve were determined. MRI findings were compared statistically with pre- and post-treatment grade, recurrence rate of Bell’s palsy, MRI scanning timing, presence of stapes reflexes and posttreatment recovery data.Results:No significant correlation was observed between pretreatment House–Brackmann grades and enhancement (p>0.05). Similarly, there was no significant correlation between clinical recovery and enhancement (p>0.05). Also, no significant correlation was observed between MRI scanning time, the recurrence rate of Bell’s palsy and MRI findings (p>0.05). None of the MRIs showed neoplastic contrast enhancement.Conclusion:The routine use of the contrast-enhanced temporal MRI is not recommended in the diagnosis and monitoring of Bell’s palsy patients, because the contrast enhancement pattern of the facial nerve has no effect on the prognosis of Bell’s palsy. MRI should be used in cases that do not heal despite treatment, for the differential diagnosis of facial nerve tumors and in patients who are candidates for surgical decompression.

الملخص: يعتبر شلل العصب الوجهي عند الأطفال حالة سريرية نادرة يمكن أن تؤدي إلى مضاعفات خطيرة. بسبب ندرة حدوثه، هذه الأورام خاصة في الزاوية المخيخية الجسرية، يمكن ألا تُلحظ. نبلغ عن حالة ورم في الزاوية المخيخية الجسرية عند طفل ذكر عمره ۸ أعوام حضر بشلل العصب الوجهي في الجانب الأيمن من نوع العصبون الحركي السفلي. كما أظهر الفحص رأرأة ثنائية خفيفة. ولكن، تم تضليله بالتشخيص الأولي بشلل بيل، كان هناك تأخير في إجراء التصوير بالرنين المغناطيسي التشخيصي للدماغ، والذي أظهر ورم كبير في الزاوية المخيخية الجسرية. لاحقا، وبعد ستة أسابيع من حضوره الأولي، مات الطفل من المرض. توضح هذه الحالة أن الفحص السريري الدقيق حتى في الحالات التي تبدو بسيطة أمرا ضروريا لتجنب أخطاء التشخيص. Abstract: Facial nerve paralysis in children is a rare clinical condition that can lead to serious complications. Due to their rare occurrence, tumours, especially in the cerebellopontine angle, may be overlooked. We report a case of cerebellopontine angle tumour in an 8-year-old boy who presented with a right-sided lower motor neuron type of facial nerve palsy. Further examination showed a mild bilateral nystagmus. However, misled by the initial diagnosis of Bell's palsy, there was a delay in performing diagnostic magnetic resonance imaging of the brain, which showed a large mass in the cerebellopontine. Subsequently, six weeks after his initial presentation, the boy succumbed to the disease. This case illustrates that careful clinical examination, even in a seemingly simple case, is imperative to avoid diagnostic errors.

Objective: To investigate if routine audiometry in Bell’s palsy patients has prognostic value. Methods: Retrospective case review was conducted on all Bell’s palsy patients (n=191) seen at the tertiary otolaryngology specialist outpatient clinic from 2015 to 2017. Correlation of ipsilesional audiometric thresholds with patients’ time-to-recovery and initial clinical severity (measured by House-Brackmann (HB) scoring) were used for the prognostic outcome measure. Audiometry results were analyzed using three contiguous frequency pure-tone average (1kHz, 2kHz, 4kHz). Statistical analysis was done via Stata (v13.1), significance tests were 2-sided at 5% significance level. Results: There was no significant difference between audiometric thresholds between the ipsilesional ear and the contralateral ear (p=0.87). Time-to-recovery was significantly longer for patients with severe initial presentation as compared to mild and moderate severity (p

Abstract COVID‐19 has been associated with several neurological complications. We presented a case of Bell's palsy as a possible neurological complication of COVID‐19 infection. Further research should be conducted to clarify the association, correlation, or causality between COVID‐19 and neuroimmunological diseases.

(1) Background: This study aims to assess the diagnostic accuracy of parameters based on a combination of transcranial magnetic stimulation (TMS) and electrical stimulation (ES) in the differentiation between idiopathic and secondary facial palsy in a large cohort of patients. (2) Methods: Patients with unilateral facial palsy ≤7 days after symptom onset were included. Compound muscle action potential (CMAP) amplitudes were measured after stimulation of both facial nerves at (A) the internal acoustic meatus using TMS, CMAP-TMS, and (B) at the stylomastoid foramen using electrical stimulation, CMAP-ES. To express the degree of nerve dysfunction in the facial canal specifically, the amplitude reduction of the CMAP-TMS in relation to CMAP-ES was calculated and expressed as a percentage (amplitude reduction over the facial canal, ARFC). Receiver Operating Characteristic (ROC) curves were constructed to assess the diagnostic accuracy of ARFC as a marker to discriminate between patients with idiopathic and secondary facial palsy. (3) Results: Data from 498 patient records were analyzed. Idiopathic facial palsy was diagnosed in 424 patients, and secondary facial palsy in 74 patients. The area under the ROC curve for ARFC was 0.398. (4) Conclusions: The overall diagnostic accuracy of this method to differentiate secondary from idiopathic facial palsy is low.

Amaç: Bu çalışma Bell paralizisi sekeli olan hastaların akupunktur tedavisi öncesinde ve sonrasındaki klinik ve morfometrik farklılıkları değerlendirmek ve fasiyal hareketlerdeki iyileşmeyi belirlemek için yapılmıştır. Gereç ve Yöntem: Bu çalışmaya Bell paralizisi sekeli olan 40 hasta (20 akupunktur grubu-20 kontrol grubu) dahil edildi. Akupunktur grubu Bell paralizisi sekeli olan ve akupunktur tedavisi (12 seans) alacak olan hastalardan oluşturuldu. Kontrol grubu ise Bell paralizisi sekeli olan ve bekletilecek olan hastalardan oluşturuldu. Tüm hastaların detaylı tıbbi öyküleri alındı. Morfometrik ölçümler dinlenme ve gülümseme pozisyonlarında yüzlerin hem etkilenmiş hem de etkilenmemiş taraflarındaki belirlenmiş anatomik noktalara göre uygulandı. Çalışmanın sonunda klinik değerlendirmeler ve morfometrik ölçümler tekrarlandı ve sonuçlar istatistiksel olarak analiz edildi.Bulgular: Akupunktur grubu hastalarının baş ağrısı semptomlarında klinik değerlendirmeler açısından anlamlı farklılık gözlendi. Akupunktur grubunda, dinlenme ve gülümseme pozisyonlarında etkilenmiş tarafın tedavi öncesi ve sonrası değerlerinde istatistiksel olarak anlamlı farklılık vardı. Ayrıca akupunktur grubundaki hastaların yüzün etkilenmiş taraflarındaki klinik semptomlarda ve fasiyal hareketlerde önemli değişiklikler vardı.Sonuç: Akupunktur tedavisinin Bell paralizisi sekelindeki fasiyal hareketlerin değişiminde özellikle de klinik ve morfometrik açıdan önemli terapötik etkiye sahip olduğu düşünülebilir.

Abstract This case series highlights a possible association between isolated facial nerve palsy and SARS‐CoV‐2. Caution should be exercised in the use of steroids in patients with COVID‐19 as its impact is still not well established.

BackgroundThe intensity of electrical acupoint stimulation such as electroacupuncture (EA) and transcutaneous electrical nerve stimulation (TENS) is regulated by the observation of skin shivering or the participant’s comfort response. However, the specific intensity and spatial scope following EA or TENS stimulation are unclear.ObjectiveThis study aimed to test the stimulatory current intensities of lower and upper sensation thresholds in TENS- and EA-based treatment of Bell’s palsy patients. Also, the spatial scope of the stimulation at these current intensities was simulated and measured quantitatively.MethodsA total of 19 Bell’s palsy patients were recruited. Six acupoints on the affected side of the face were stimulated by TENS and EA successively at 30-min intervals. During the stimulation, the current intensity was regulated gradually from 0 to 20 mA, and we simultaneously measured the lower (sensory) and upper (tolerability) sensations. After the treatment by TENS and EA, the modified Chinese version of the Massachusetts General Hospital Acupuncture Sensation Scales (C-MMASS) was applied to survey the de-qi sensations during stimulation. Additionally, we analyzed the correlation between current intensities and C-MMASS and comfort scores. Finite element models were established to depict the spatial distribution of electric field gradients at the lower and upper thresholds.ResultsThe mean sensory and tolerability thresholds of TENS were 3.91–4.37 mA and 12.33–16.35 mA, respectively. The median sensory and tolerability thresholds of EA were 0.2 mA and 2.0–3.2 mA, respectively. We found a significant correlation between total C-MMASS scores and the current intensities at the tolerability threshold of TENS. The finite element model showed that the activated depths of TENS and EA at the lower threshold were 3.8 and 7 mm, respectively, whereas those at the upper threshold were both 13.8 mm. The cross-sectional diameter of the activated area during TENS was 2.5–4 times larger than that during EA.ConclusionThis pilot study provided a method for exploring the current intensity at which the de-qi sensations can be elicited by TENS or EA. The finite element analysis potentially revealed the spatial scope of the electrical stimulation at a specific current intensity.

Facial muscle activities are essential for the appearance and communication of human beings. Therefore, exploring the activation patterns of facial muscles can help understand facial neuromuscular disorders such as Bell’s palsy. Given the irregular shape of the facial muscles as well as their different locations, it should be difficult to detect the activities of whole facial muscles with a few electrodes. In this study, a high-density surface electromyogram (HD sEMG) system with 90 electrodes was used to record EMG signals of facial muscles in both healthy and Bell’s palsy subjects when they did different facial movements. The electrodes were arranged in rectangular arrays covering the forehead and cheek regions of the face. The muscle activation patterns were shown on maps, which were constructed from the Root Mean Square (RMS) values of all the 90-channel EMG recordings. The experimental results showed that the activation patterns of facial muscles were distinct during doing different facial movements and the activated muscle regions could be clearly observed. Moreover, two features of the activation patterns, 2D correlation coefficient (corr2) and Centre of Gravity (CG) were extracted to quantify the spatial symmetry and the location of activated muscle regions respectively. Furthermore, the deviation of activated muscle regions on the paralyzed side of a face compared to the healthy side was quantified by calculating the distance between two sides of CGs. The results revealed that corr2 of the activated facial muscle region (classified into forehead region and cheek region) in Bell’s palsy subjects was significantly (p < 0.05) lower than that in healthy subjects, while CG distance of activated facial region in Bell’s palsy subjects was significantly (p < 0.05) higher than that in healthy subjects. The correlation between corr2 of these regions and Bell’s palsy [assessed by the Facial Nerve Grading Scale (FNGS) 2.0] was also significant (p < 0.05) in Bell’s palsy subjects. The spatial information on activated muscle regions may be useful in the diagnosis and treatment of Bell’s palsy in the future.

Abstract Background This study aims to assess the effectiveness of delayed facial nerve decompression for Bell’s palsy (BP). Methods We performed a retrospective case review of all patients having undergone facial nerve decompression for severe refractory BP between 1984 and 2009 at our tertiary referral center. Demographics, timing between onset of symptoms and surgical decompression, degree of facial nerve dysfunction pre- and post-operatively, follow-up length after surgery and postoperative complications were recorded. Facial nerve dysfunction was assessed using the House-Brackmann (HB) scale. Electroneuronography, electromyography and imaging results were assessed when available. Results Eighteen patients had surgery between 21 and 60 days after onset of BP (group I), and 18 patients had surgery more than 60 days after onset of symptoms (group II). In group II, 11 patients had surgery between 61 and 89 days and 7 patients after 90 days. Groups I and II showed similar functional gain and rates of improvement to HB 3 or better (11/18 vs. 11/18, p > 0.05). In group II, patients operated 60 to 89 days after onset of BP showed a significantly higher rate of improvement to HB 3 or better (9/11 vs. 2/6, p = 0.049) with higher functional gain compared to those operated after 90 days (p = 0.0293). Conclusions When indicated, facial nerve decompression for BP is usually recommended within the first 2 weeks of onset of facial paralysis. Nonetheless, our results suggest that patients with severe BP could benefit from decompression surgery within 90 days after onset of symptoms in the absence of an opportunity to proceed earlier to surgery. Further investigation is still required to confirm our findings. Trial registration Retrospective registered. IRB# 2016–6154, CE 15.154 – CA

Idiopathic (Bell’s) palsy is the commonest cause of unilateral facial paralysis in children. Although being idiopathic by definition, possible infectious, inflammatory, and ischemic triggers have been suggested. Bell’s palsy is thought to be responsible for up to three-fourths of cases of acute unilateral facial paralysis worldwide. The diagnosis has to be reached after other causes of acute peripheral palsy have been excluded. However, it is rarely described in neonates and young infants. Steroids may have some role in treatment, but antiviral therapies have doubtful evidence of benefit. Prognosis is good, though residual dysfunction is occasionally encountered. We report the case of a two-week-old neonate with no prior illnesses who presented with acute left facial palsy. Clinical findings and normal brain imaging were consistent with the diagnosis of Bell’s palsy. The patient had a good response to oral steroids.

Bell's palsy is considered as a disease of exclusion. It is a form of lower motor neuron paralysis affecting the facial muscles. Rapid onset of paralysis causes panic to the patients. For speedy recovery, correct diagnosis and early treatment are crucial. Here a case of Bell's palsy is reported and the literature on Bell's palsy is reviewed. [Cukurova Med J 2014; 39(3.000): 581-588]

Acute idiopathic peripheral facial paralysis (Bell's palsy) is the most common disorder of the facial nerve. Most patients recover completely, although some have permanent disfiguring facial weakness. Many studies have attempted to identify an infectious etiology for this disease. Although the cause of Bell's palsy remains unknown, recent studies suggest a possible association with Herpes Simplex Virus-1(HSV-1) infection. In this case-control study we investigated the presence of DNA of HSV in the saliva of 26 patients with Bells palsy in first and second weeks of disorder compared to normal population who were matched in sex, age, as well as history of diabetes mellitus, hypertension and labial herpes. In the case group 3 and 7 patients had positive polymerase chain reaction (PCR) for HSV in first and second weeks of disease respectively compared to 4 in controls. It means that there was not any relationship between Bell's palsy and HSV in saliva either in first or in second week. Two and 6 of positive results from the sample of first and second weeks were from patients with severe (grade 4-6) Bell's palsy. Although the positive results were more in second week in patient group and more in severe palsies, but a significant relationship between Bell's palsy or its severity and positive PCR for HSV was not detected (P >0.05).

OBJECTIVE: Bell’s palsy (BP) is the most common disease of the facial nerve. It is acute paralysis of the mimic muscles. The etiology and treatment of BP is not clear. As it is an aesthetic and functional problem, early prognostic diagnosis is more important. Electrophysiologic tests can be used for this purpose METHODS: 46 patients were included to the study. All patients were classified according to House-Brackman system. Facial nerve conduction and blink reflex were studied on 10-12th day of the onset of the BP. RESULTS: The patients who had increase of muscle response (M-response) latency on 10-12th day, had less recovery after one month. There was also no statistical difference between R1 latency on 10-12th day and clinical grade in first month. But there was significant difference between R2 latency on 10-12th day and clinical grade in first month. CONCLUSION: Prolonge of M-response latency and the absence of blink reflex showed poor prognosis

To determine the variability of the abnormalities found in the electroneurography (ENG) of the facial nerve in cases of Bell's palsy during the initial two week period was one of the objectives of the authors. A second one was to investigate the value of ENG as a tool to determine an early prognosis of recovery utilizing two different methods. In the first one the amplitude of the compound muscular action potential (CMAP) obtained on the paralyzed side was compared to this potential on the opposite (normal) side. The second method compared the CMAP on the paralyzed side to normal standardized data from normal individuals. A group of 33 patients with Bell's palsy was followed until total recovery or for at least 4 months, if the recovery was not achieved earlier. It was observed that amplitude of the CMAP become stable towards the sixth day of palsy and this is a good time to establish the prognosis. Another conclusion is that both methods were equivalent to determine the prognosis in Bell's palsy.O objetivo deste trabalho é determinar a variabilidade da eletroneurografia (ENG) do nervo facial na paralisia de Bell durante as primeiras duas semanas e investigar o valor da ENG na determinação de um prognóstico precoce utilizando-se dois métodos diferentes. O primeiro método compara a amplitude do potencial de ação muscular composto obtido no lado paralisado com o lado normal e o segundo método compara o potencial de ação muscular composto obtido no lado paralisado com valores normativos. Um grupo de 33 pacientes com paralisia de Bell foi seguido até a recuperação total ou pelo menos por quatro meses nos casos em que não houve recuperação. Observou-se que a amplitude do potencial de ação muscular composto estabiliza-se em torno do sexto dia e que este é um bom momento para se realizar o exame e se estabelecer um prognóstico. Outra conclusão é que ambos os métodos são equivalentes para determinação prognóstica.

Acute idiopathic peripheral facial paralysis (Bell's palsy) is the most common disorder of the facial nerve. Most patients recover completely, although some have permanent disfiguring facial weakness. Many studies have attempted to identify an infectious etiology for this disease. Although the cause of Bell's palsy remains unknown, recent studies suggest a possible association with Herpes Simplex Virus-1(HSV-1) infection. In this case-control study we investigated the presence of DNA of HSV in the saliva of 26 patients with Bells palsy in first and second weeks of disorder compared to normal population who were matched in sex, age, as well as history of diabetes mellitus, hypertension and labial herpes. In the case group 3 and 7 patients had positive polymerase chain reaction (PCR) for HSV in first and second weeks of disease respectively compared to 4 in controls. It means that there was not any relationship between Bell's palsy and HSV in saliva either in first or in second week. Two and 6 of positive results from the sample of first and second weeks were from patients with severe (grade 4-6) Bell's palsy. Although the positive results were more in second week in patient group and more in severe palsies, but a significant relationship between Bell's palsy or its severity and positive PCR for HSV was not detected (P >0.05).

Abstract Introduction: The exact etiology of Bell's palsy still remains obscure. The only authenticated finding is inflammation and edema of the facial nerve leading to entrapment inside the facial canal. Objective: To identify if there is any relationship between the grade of Bell's palsy and diameter of the facial canal, and also to study any possible anatomic predisposition of facial canal for Bell's palsy including parts which have not been studied before. Methods: Medical records and temporal computed tomography scans of 34 patients with Bell's palsy were utilized in this retrospective clinical study. Diameters of both facial canals (affected and unaffected) of each patient were measured at labyrinthine segment, geniculate ganglion, tympanic segment, second genu, mastoid segment and stylomastoid foramen. The House-Brackmann (HB) scale of each patient at presentation and 3 months after the treatment was evaluated from their medical records. The paired samples t-test and Wilcoxon signed-rank test were used for comparison of width between the affected side and unaffected side. The Wilcoxon signed-rank test was also used for evaluation of relationship between the diameter of facial canal and the grade of the Bell's palsy. Significant differences were established at a level of p = 0.05 (IBM SPSS Statistics for Windows, Version 21.0.; Armonk, NY, IBM Corp). Results: Thirty-four patients - 16 females, 18 males; mean age ± Standard Deviation, 40.3 ± 21.3 - with Bell's palsy were included in the study. According to the HB facial nerve grading system; 8 patients were grade V, 6 were grade IV, 11 were grade III, 8 were grade II and 1 patient was grade I. The mean width at the labyrinthine segment of the facial canal in the affected temporal bone was significantly smaller than the equivalent in the unaffected temporal bone (p = 0.00). There was no significant difference between the affected and unaffected temporal bones at the geniculate ganglion (p = 0.87), tympanic segment (p = 0.66), second genu (p = 0.62), mastoid segment (p = 0.67) and stylomastoid foramen (p = 0.16). We did not find any relationship between the HB grade and the facial canal diameter at the level of labyrinthine segment (p = 0.41), tympanic segment (p = 0.12), mastoid segment (p = 0.14), geniculate ganglion (p = 0.13) and stylomastoid foramen (p = 0.44), while we found significant relationship at the level of second genu (p = 0.02). Conclusion: We found the diameter of labyrinthine segment of facial canal as an anatomic risk factor for Bell's palsy. We also found significant relationship between the HB grade and FC diameter at the level of second genu. Future studies (MRI-CT combined or 3D modeling) are needed to promote this possible relevance especially at second genu. Thus, in the future it may be possible to selectively decompress particular segments in high grade BP patients.