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Coccydynia is pain in the coccyx that typically occurs idiopathically or from trauma. Most forms are self-limiting. However, if symptoms persist, nonsurgical treatment options can include offloading, NSAIDs, physical therapy, and steroid injections. If all treatment options fail, a growing body of evidence supports a coccygectomy for symptomatic relief. The standard approach for a coccygectomy involves a midline incision cephalad to the anus along the gluteal cleft. Historically, this method has had high rates of infection. To improve healing and decrease infection rate, we propose the paramedian approach to a coccygectomy. This approach has the benefit of distancing the surgical site from the anus, diminishing the crevice effect of the incision, and increasing the dermal and subdermal thickness for improved surgical closure. We present a case series study of 41 patients who underwent the paramedian approach coccygectomy using a 4 to 6 cm incision, approximately 0.5 to 1.5 cm lateral to the midline, for coccyx removal. These patients were evaluated postoperatively to determine infection rate and various outcome measures. Forty-one patients suffering from refractory coccydynia had a coccygectomy via the paramedian approach between 2011 and 2022 by the senior author. Outcome measures included self-reported measures (Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) pain scale and satisfaction with procedure), physiologic measures (presence of infection and treatment provided) and functional measures (return to vocation/avocation). Data was compiled and transferred to Microsoft Excel and analyzed. Two-tailed T-tests were used to compare the patient improvement in VAS and ODI as appropriate for statistical analysis. The patients' average age was 45.8 years. Patients' average body mass index was 27.9, with 71% of patients overweight or obese. A total of 68% of patients were female. Trauma was the most common precipitating factor (75.6%). Five patients presented with postoperative complications (12.1%), one requiring an incision and drainage, and four others were treated with antibiotics for wound erythema. Postoperative evaluations showed continual improvement, with the most significant improvement reported greater than 1-year postoperatively. The Visual Analogue Scale for pain dropped from 7.5 to 2.3 (p<.001), and the Oswestry Disability Index improved from 30.1 to 9.6 (p<.001). A total of 86.7% of patients reported either a good or excellent result. Coccygectomies via the midline approach have a variable infection rate, likely due to proximity of the incision to the anus and due to the crevice effect of the gluteal cleft in terms of aeration. These contributing factors are overcome in the paramedian approach, making it an effective option for treating refractory coccydynia that is nonresponsive to conservative management. [ABSTRACT FROM AUTHOR]

Introduction: Headache after spinal anesthesia is a common problem in pregnant women undergoing cesarean section with spinal anesthesia. Among the regional anesthesia methods, spinal anesthesia is one of the most common methods for cesarean section, which is mainly performed with median and paramedian techniques. Therefore, this systematic review study was conducted with aim to compare two methods of median and paramedian on the incidence of postdural puncture headache (PDPH ) in women under spinal anesthesia. Methods: In this systematic review study, to find the related articles, Scopus, PubMed, Magiran, SID, Medlib, Cochrane, Science Direct databases and Google Scholar search engine were searched using the keywords of median, paramedian, postdural puncture headache, caesarean section, and spinal anesthesia in both Persian and English languages without time limit until 20 May 2023. Jadad checklist was used to evaluate the quality of the articles. Results: The studies entered in the systematic review included 11 studies and the studies were conducted in 2009-2021. A total of 1195 patients with anesthesia class 1 and 2 were included in the study. In 4 studies, there was no statistically significant difference between the two groups of median and paramedian approaches. In 6 studies, the paramedian method caused fewer headaches than median method. In one study, median method caused fewer headaches than paramedian method. Conclusion: The use of the paramedian method compared to the median technique can cause a lower incidence of PDPH after cesarean surgery. It is suggested that anesthesiologists use the paramedian technique for spinal anesthesia for women undergoing cesarean surgery, if possible, in order to prevent or reduce the occurrence of PDPH after surgery in these patients.

Background The development of back pain following epidural analgesia is one reason for patient refusal of neuraxial analgesia. The primary endpoint of this study was to compare the incidence and severity of back pain following midline and paramedian epidural technique. The secondary endpoint was to identify the risk factors associated with the occurrence of back pain. Methods This prospective randomized study included 114 patients receiving thoracic epidural catheterization for pain management following upper abdominal or thoracic surgery. Patients were allocated to either the midline or the paramedian group by computer-generated randomization. An investigator who was blinded to the patient group interviewed patients at 24, and 48 h, and 3–5 days after surgery about the existence of back pain and its severity. Results The total incidence of back pain following epidural anesthesia was 23.8% in the midline group and 7.8% in the paramedian group. The numerical rating scale of back pain was not different between the two groups at 24 h and 4 days after surgery. The paramdian technique was associated with a lower incidence of back pain than the midline technique (95% confidence interval 0.05–0.74, odds ratio 0.2, P < 0.01). However, the number of attempts, surgical position, body mass index, and duration of surgery were not associated with back pain. Conclusions This study showed that the midline group of thoracic epidural analgesia demonstrated higher incidence of back pain than the paramedian group. However, the pain was mild in intensity and decreased with time in both groups.

Background: The median and the paramedian approaches are used to access the epidural space. Median approach is commonly used but can be technically difficult in certain patients. The paramedian approach is the alternative. Success rate during the blind procedure is determined by the skin to epidural distance (SED). SED in turn is affected by patients’ anthropometric characteristics. Prediction of the SED serves to determine the depth of needle advancement in order to improve the success rate. Objectives: The study compared the SED using median vs. paramedian approaches, the time required to access the epidural space, place the catheter, and investigate anthropometric factors which may have influenced this distance among the participants. Materials and Methods: The study was a blinded randomized controlled study. Following ethical approval and informed consent, 60 women scheduled for elective gynecological procedures were allocated to one of the two groups: Group M (median) (30) and Group PM (paramedian) (30). Results: The SED was longer using the PM approach. The mean time it took to gain access was shorter in the PM group. The mean SED increased as the body mass index increased in both groups (P < 0.0001). There was a significant association of anthropometric measurements with the SED using both approaches. Conclusion: The study showed that the SED was longer in the PM group. Also as the patient’s anthropometric measurements increased, so did the SED.

Background: Vertical Paramedian Hemispherotomy (VPH) is considered an effective surgical treatment for drug-resistant epilepsy with 80% of patients experiencing seizure freedom or worthwhile improvement. Identifying persistent connective tracts is challenging in failed VPH. Methods: We reviewed our series of consecutive patients undergoing VPH for hemispheric drug-resistant epilepsy and included cases with recurrent epileptic seizures undergoing second surgery with at least 6 months of postoperative follow-up. The cases were extensively assessed to propose a targeted complementary resection. Results: Two children suffering from seizure recurrence following hemispherotomy leading to second surgery were included. After complete assessment, persisting amygdala residue was suspected responsible for the epilepsy recurrence in both patients. Complementary resection of the amygdala residue led to seizure freedom for both patients (Engel IA/ILAE Class 1) without complication. Different diagnostic tools are used to assess patients after failed hemispherotomy including routine EEG, prolonged video EEG, MRI (particularly DTI sequences), SPECT or PET scans and clinical evaluation. These tools allow to rule out epileptic foci in the contralateral hemisphere and to localize a potentially persisting epileptogenic zone. Assessment of these patients should be as systematic and integrated as the initial workup. Although our two patients suffered from Rasmussen's encephalitis, seizure recurrence after VPH has been described in other pathologies. Conclusion: Lying deep and medially in the surgical corridor of VPH, the amygdala can be incompletely resected and cause recurrent epilepsy. Complementary selective resection of the amygdala residue may safely lead to success in epilepsy control.

Midline and paramedian mandibulotomies both have distinct anatomical and surgical strengths. A retrospective study was performed at Chang Gung Memorial Hospital, Linkou Branch between 2014 and 2019 to investigate how the osteotomy site (midline (n = 221) or paramedian (n = 44)) and type (straight, notched, or stair-stepped) affect postoperative and post-radiotherapy complications in patients undergoing wide excision of tongue cancer with flap reconstruction. Midline mandibulotomies were predominantly of the straight osteotomy type, while paramedian mandibulotomies were mostly notched type (P < 0.001). Comparably low elective tooth extraction rates were found in both approaches (P = 0.556). Paramedian mandibulotomy showed a higher osteoradionecrosis rate (P = 0.026), but there was no significance in the sub-analysis of individual types. Paramedian sites were associated with more early infection (P = 0.036) and plate exposure (P = 0.036) than midline sites with the straight osteotomy type, but complication rates did not differ significantly for the notched and stair-stepped types. Paramedian sites (P = 0.020) and notched types (P = 0.006) were associated with higher odds of osteoradionecrosis in the univariable logistic regression analysis, but only the notched type remained significant in the multivariable analysis (P = 0.048). In conclusion, paramedian sites increased the rate of osteoradionecrosis, and correlation with the osteotomy type resulted in more osteoradionecrosis in notched types and more complications in straight paramedian mandibulotomies. [ABSTRACT FROM AUTHOR]

The Artery of Percheron (AOP) is an uncommon anatomic variant that provides arterial supply to the paramedian region of the thalami and bilaterally to the rostral part of the midbrain; it is a solitary arterial trunk that branches from a proximal segment of the posterior cerebral artery (PCA). Although AOP infarction results in a characteristic pattern of ischemia, namely bilateral paramedian thalamic infarct with or without midbrain involvement, it may cause diagnostic difficulties due to the variety of its clinical presentations and wide differentials, as well as its small diameter and the difficulty of obtaining visualization through diagnostic imaging. Early neuroimaging of AOP infarction and correct diagnosis are mandatory for early initiation of the appropriate treatment and better patient outcomes. This study discusses the imaging patterns and imaging differentials of AOP infarction and its clinical presentation. A 55-year-old man presented to the emergency department unconscious with Glasgow Coma Scale score of 4. Pupillary light reflex on both eyes was poorly reactive with dilatated right pupil. The patient flexed his arm and extended his leg on painful stimulus. Laboratory tests and electrocardiogram were unremarkable. Emergency cerebral CT scan and transcranial Doppler ultrasound were normal. He gradually regained consciousness with residual somnolence, ptosis, and vertical gaze palsy. Second CT scan showed bilateral paramedian thalamic areas of hypodensity, CT angiography (CTA) was unremarkable. MRI showed bilateral high-signal intensity on paramedian thalami fast spin echo T2, FLAIR, and diffusion-weighted sequences, low signal on apparent diffusion coefficient sequence. MR angiography (MRA) revealed an abnormal tiny vessel arising from the P1 segment of the left posterior cerebral artery. Imaging findings were consistent with AOP infarction. Aspirin was started, 4 hours after admission the patient regained consciousness, and gradually improved on the following days till he was discharged on the 15th day, with mild neurologic deficit. AOP must be considered whenever paramedian thalamic infarction is noted in neuroimaging. The difficulty in visualizing the AOP using diagnostic imaging is due to its small diameter, leading to the limited abilities of MRA and CTA to diagnose AOP infarction. An absence of evidence of AOP infarction in MRA or even CTA does not exclude its diagnosis. Good knowledge of the imaging characteristics of AOP infarction will help in early diagnosis and the achievement of good patient outcomes.

Objective: This study aims to review the usage and complication of paramedian approach for CAPD catheter insertion. Material & Methods: This is a retrospective study. All ESRD patients ongoing CAPD at the Dialysis Clinic of Zainoel Abidin General Hospital in Aceh, Indonesia between January 1, 2009 and December 31, 2018 were included in the present study. Complication outcomes included mechanical and infectious complications are documented and reviewed. Results: A total of 190 ESRD patients had been performed CAPD catheter insertion using paramedian approach in this period. Out of these patients, complication occurred in 31 cases (16.32%). All the complication that occurred in this study are 5 cases of leakage (2.63%), 9 cases of infection (4.74%), 8 cases of drainage problem (4.21%), 9 cases of malposition (4.74%), and no case of bowel perforation. From total of 9 cases of infections, 1 patient had peritonitis from the catheter insertion. The other infection was exit site infection. Conclusion: CAPD catheter insertion using paramedian approach is safe with low complication rates. It could decrease post-operative complications and can be recommended for CAPD catheter insertion technique due to its safety.

Background and Aims: Routine use of pre-procedural ultrasound guided midline approach has not shown to improve success rate in administering subarachnoid block. The study hypothesis was that the routine use of pre-procedural (not real time) ultrasound-guided paramedian spinals at L5-S1 interspace could reduce the number of passes (i.e., withdrawal and redirection of spinal needle without exiting the skin) required to enter the subarachnoid space when compared to the conventional landmark-guided midline approach. Methods: After local ethics approval, 120 consenting patients scheduled for elective total joint replacements (Hip and Knee) were randomised into either Group C where conventional midline approach with palpated landmarks was used or Group P where pre-procedural ultrasound was used to perform subarachnoid block by paramedian approach at L5-S1 interspace (real time ultrasound guidance was not used). Results: There was no difference in primary outcome (difference in number of passes) between the two groups. Similarly there was no difference in the number of attempts (i.e., the number of times the spinal needle was withdrawn from the skin and reinserted). The first pass success rates (1 attempt and 1 pass) was significantly greater in Group C compared to Group P [43% vs. 22%, P = 0.02]. Conclusion: Routine use of paramedian spinal anaesthesia at L5-S1 interspace, guided by pre-procedure ultrasound, in patients undergoing lower limb joint arthroplasties did not reduce the number of passes or attempts needed to achieve successful dural puncture.

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Developing new surgical instruments is challenging. While making surgical instruments could be a good field of application for 3D printers, attempts to do so have proven limited. We designed a new endoscope-assisted spine surgery system, and using a 3D printer, attempted to create a complex surgical instrument and to evaluate the feasibility thereof. Developing the new surgical instruments using a 3D printer consisted of two parts: one part was the creation of a prototype instrument, and the other was the production of a patient model. We designed a new endoscope-assisted spine surgery system with a cannula for the endoscope and working instruments and extra cannula that could be easily added. Using custom-made patient-specific 3D models, we conducted discectomies for paramedian and foraminal discs with both the newly designed spine surgery system and conventional tubular surgery. The new spine surgery system had an extra portal that can be well bonded in by a magnetic connector and greatly expanded the range of access for instruments without unnecessary bone destruction. In foraminal discectomy, the newly designed spine surgery system showed less facet resection, compared to conventional surgery. We were able to develop and demonstrate the usefulness of a new endoscope-assisted spine surgery system relying on 3D printing technology. Using the extra portal, the usability of endoscope-assisted surgery could be greatly increased. We suggest that 3D printing technology can be very useful for the realization and evaluation of complex surgical instrument systems. [ABSTRACT FROM AUTHOR]

Introduction: Spinal anesthesia is usually preferred for short-time surgery; the side effects of the process can show difference with techniques. We aimed to compare early and late complications of median and paramedian techniques in spinal anesthesia.Methods: Eighty patients with American Society of Anesthesiologists (ASA) I–III were allocated into the following two groups: Group M (median) and Group P (paramedian). Demographic data of the patients, ASA score, number of spinal anesthesia application, total surgery time, discharge time from the hospital, heart rate, mean arterial blood pressure, and early complications were recorded from the medical records of patients. Late complications of patients were learned by calling.Results: The number of applying spinal anesthesia number and the duration of anesthesia were longer in Group P than in Group M, and the difference was statistically significant (p

Background: A side effect of spinal anesthesia is post-dural puncture backache (PDPB), which is characterized by ongoing discomfort at the location of the spinal puncture without any radicular pain. This study aims to compare the incidence and severity of post-dural puncture back pain following spinal anesthesia by median versus paramedian technique in obese female patients., Methods:  A prospective randomized comparative study on 120 female patients, aged 20-50 years with a BMI of 30-40 kg/m 2 and American Society of Anesthesiologists physical status II, scheduled for elective surgery under spinal anesthesia, was included in the study. Patients were randomly divided into two groups, with 60 patients in each group. Group P uses the paramedian approach for spinal anesthesia, and group M uses the midline approach for spinal anesthesia., Results: Low back pain incidence was lower in group P than in group M at seven days, but at one month and after, its incidence remained the same in both groups. No difference in the severity of pain was observed., Conclusions: The occurrence of back pain in the first seven days of surgery was significantly more frequent with the median approach. The pain severity decreased as the time passed from day seven to three months of follow-up. There is no difference in the severity of pain with either approach at different intervals., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Mishra et al.)

Background: The intensity of low back pain and functional disability in life is a common question of patients before spinal anesthesia. We aimed to compare acute and chronic back pain after spinal anesthesia in midline and paramedian approach. Methods: Two hundred twenty patients elective patients (25-65 year old) candidates for general, and urological surgery under spinal anesthesia, were allocated into the following two groups: Group M (midline) and Group P (paramedian). Spinal anesthesia was performed with hyperbaric bupivacaine 0.5% in the sitting position using a 25G Quincke needle in L3/L4 orL4/L5 level. During the operation, patients were placed in the supine position. The questionnaire assessed back pain and severity of pain with VAS score three days after spinal anesthesia. If the patients complained of back pain then, the effect of back pain on quality of life and the degree of patient's functional disability were assessed by Oswestry Disability Index on,45 and 90 days after surgery. Results: Forty-one patients (18%) had back pain after the operation, 22 patients were in the paramedian (54%) and 19 patients (46%) in the midline method of spinal anesthesia. (p=0.6). The mean intensity of back pain was 2.27vs1.45 (p=0.5) and the total number of mean functional disability index was less than five in both groups. Conclusion: The incidence of back pain was 18% and was not significantly different between the midline and paramedian methods. The severity of back pain decreased after three days, reaching to less than one on day the 45th and 90th, which does not affect daily patient’s functions.

Background and Aims: Routine use of pre-procedural ultrasound guided midline approach has not shown to improve success rate in administering subarachnoid block. The study hypothesis was that the routine use of pre-procedural (not real time) ultrasound-guided paramedian spinals at L5-S1 interspace could reduce the number of passes (i.e., withdrawal and redirection of spinal needle without exiting the skin) required to enter the subarachnoid space when compared to the conventional landmark-guided midline approach. Methods: After local ethics approval, 120 consenting patients scheduled for elective total joint replacements (Hip and Knee) were randomised into either Group C where conventional midline approach with palpated landmarks was used or Group P where pre-procedural ultrasound was used to perform subarachnoid block by paramedian approach at L5-S1 interspace (real time ultrasound guidance was not used). Results: There was no difference in primary outcome (difference in number of passes) between the two groups. Similarly there was no difference in the number of attempts (i.e., the number of times the spinal needle was withdrawn from the skin and reinserted). The first pass success rates (1 attempt and 1 pass) was significantly greater in Group C compared to Group P [43% vs. 22%, P = 0.02]. Conclusion: Routine use of paramedian spinal anaesthesia at L5-S1 interspace, guided by pre-procedure ultrasound, in patients undergoing lower limb joint arthroplasties did not reduce the number of passes or attempts needed to achieve successful dural puncture. [ABSTRACT FROM AUTHOR]

Introduction: Spinal anesthesia is usually preferred for short-time surgery; the side effects of the process can show difference with techniques. We aimed to compare early and late complications of median and paramedian techniques in spinal anesthesia. Methods: Eighty patients with American Society of Anesthesiologists (ASA) I-III were allocated into the following two groups: Group M (median) and Group P (paramedian). Demographic data of the patients, ASA score, number of spinal anesthesia application, total surgery time, discharge time from the hospital, heart rate, mean arterial blood pressure, and early complications were recorded from the medical records of patients. Late complications of patients were learned by calling. Results: The number of applying spinal anesthesia number and the duration of anesthesia were longer in Group P than in Group M, and the difference was statistically significant (p<0.05). Fifty-two early complications and 23 late complications were observed. The common early complication (21%) was hypotension, and late complication (8.7%) was post-spinal headache (Group P, six patients; Group M, one patient); there was no difference between the groups. Conclusion: There was no significant difference in complications of spinal anesthesia applied via both technical approaches and discharge in shortcontinuance surgical cases. Although we defined a tendency for post-spinal headache in Group P, there was no statistically significant difference in our study. [ABSTRACT FROM AUTHOR]

Background: Lesions of the superior cerebellar surface, pineal region, lateral and dorsal midbrain and mesial temporal lobe are challenging to treat and often require neurosurgical intervention. Methods: The paramedian variation of the supracerebellar infratentorial approach utilizes the downward slope of the cerebellum to facilitate exposure and the lower density of cerebellar bridging veins away from the midline decreases the need to sacrifice larger venous channels. We also discuss our experiences with the approach, and some of the drawbacks and nuances that we have encountered as it has evolved over the years. Conclusions: This approach is versatile and effective and the authors' surgical approach of choice for resecting these challenging lesions. [ABSTRACT FROM AUTHOR]

Background: Although different techniques have been developed for administering combined spinal epidural (CSE) anaesthesia, none can be described as an ideal one. Objectives: We performed a study to compare two popular CSE techniques: Double segment technique (DST) and single segment (needle through needle) technique (SST) with another alternative technique: Paramedian epidural and midline spinal in the same intervertebral space (single space dual needle technique: SDT). Methods: After institutional ethical clearance, 90 consenting patients undergoing elective lower limb orthopaedic surgery were allocated to receive CSE into one of the three groups (n=30 each): Group I: SST, Group II: SDT, Group III: DST using computerized randomization. The time for technique performance, surgical readiness, technical aspects of epidural and subarachnoid block (SAB) and morbidity were compared. Results: SDT is comparable with SST and DST in time for technique performance (13.42±2.848 min, 12.18±6.092 min, 11.63±3.243 min respectively; P=0.268), time to surgical readiness (18.28±3.624 min, 17.64±5.877 min, 16.87±3.137 min respectively; P=0.42) and incidence of technically perfect block (70%, 66.66%, 76.66%; respectively P=0.757). Use of paramedian route for epidural catheterization in SDT group decreases complications and facilitates catheter insertion. There was a significant number of cases with lack of dural puncture appreciation (SST=ten, none in SDT and DST; P=0.001) and delayed cerebrospinal fluid reflux (SST=five, none in SDT and DST; P=0.005) while performance of SAB in SST group. The incidence of nausea, vomiting, post-operative backache and headache was comparable between the three groups. Conclusion: SDT is an acceptable alternative to DST and SST.

Background: Pre-procedural ultrasound can be used to identify the subarachnoid space in difficult spinal procedures. However, multiple punctures can result in numerous complications, including post-dural puncture headache, neural trauma, and spinal and epidural haematoma. Thus, the following hypothesis was proposed: in contrast to the conventional blind paramedian dural puncture, pre-procedural ultrasound results in a successful dural puncture on the first attempt., Methods: In this prospective, randomised controlled study, 150 consenting patients were randomly assigned to one of the two groups: ultrasound-guided paramedian (UG) and conventional blind paramedian (PG). In the UG paramedian group, pre-procedural ultrasound was performed to mark the insertion site, whereas, in the PG group, the landmark technique was used. A total of 22 different anaesthesiology residents performed all subarachnoid blocks., Results: The time taken to perform spinal anaesthesia in the UG group was 38-49.5 s, which is shorter than the time taken in the PG group, which was 38-55 s, with a p-value < 0.046, which is statistically significant. The primary outcome of a successful dural puncture on the first attempt was not significantly higher in the UG group (49.33%) than in the PG group (34.67%), with a p-value < 0.068. The number of attempts taken for a successful spinal tap in the UG group was a median of 2.0 (1 to 2), and the PG group had a median of 2 (1 to 2.5), with a p-value < 0.096, which is statistically non-significant., Conclusion: Ultrasound guidance showed improvement in the success rate of paramedian anaesthesia. In addition, it improves the success rate of dural puncture and the rate of puncture on the first attempt. It also shortens the time required for a dural puncture. In the general population, the pre-procedural UG paramedian group did not outperform the PG paramedian group., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Gorle et al.)

Background: Pontine infarcts are common and often attributed to small vessel disease (''small deep infarcts'') or basilar branch atherosclerosis ("wedge shaped"). A well-described morphological differentiation using magnetic resonance images has not been reported. Furthermore, whether risk factors and outcomes differ by morphology, or whether infarct morphology should guide secondary prevention strategy, is not well characterized. Methods: All participants in the Secondary Prevention of Small Subcortical Strokes Study with magnetic resonance imaging-proven pontine infarcts were included. Infarcts were classified as well-circumscribed small deep (small deep infarct, i.e. lacunar), paramedian, atypical paramedian, or other based on diffusion-weighted imaging, T2/fluid-attenuated inversion recovery, and T1-magnetic resonance images. Inter-rater reliability was high (90% agreement, Cohen's kappa=0.84). Clinical and radiologic features independently associated with small deep infarct versus paramedian infarcts were identified (multivariable logistic regression). Differences in stroke risk and death were assessed using Cox proportional hazards. Results: Of the 3020 patients enrolled, 644 had pontine infarcts; 619 images were available: 302(49%) small deep infarct, 245 (40%) paramedian wedge, 35 (6%) atypical paramedian, and 37 (6%) other. Among vascular risk factors, only smoking (OR 2.1, 95% CI 1.3-3.3) was independently associated with small deep infarct versus paramedian infarcts; on neuroimaging, old lacunes on T1/fluid-attenuated inversion recovery (OR 1.8, 1.3-2.6) and intracranial stenosis (any location) -50% (OR 0.62, 0.41-0.96). Small deep infarct versus paramedian was not predictive of either recurrent stroke or death, and there was no interaction with assigned treatment. Conclusions: Pontine infarcts can be reliably classified based on morphology using clinical magnetic resonance images. Few risk factors differed between small deep infarct and paramedian infarcts with no differences in recurrent stroke or mortality. There was no difference in response to different antiplatelet or blood pressure treatment strategies between these two groups. [ABSTRACT FROM AUTHOR]

Objectives:The aim of the study is to evaluate the paramedian forehead flap in the reconstruction of the major nasal defects and to compare the results with other reconstruction methods.Materials and Methods:Paramedian forehead flap has been performed in reconstruction of 10 cases with major nasal defects between April 1997 and December 2000 in Istanbul University, Faculty of Medicine. All of the cases were surgically ablated cases due to nasal carcinomas.Results:The reconstruction in all cases revealed out satisfactory results. The main complication was the postoperative deformity which was encountered as a result of contraction of the inner lining of the nasal cavity.Conclusion:Paramedian forehead flap is a versatile and costeffective method for the reconstruction of defects following major surgical procedures of the nose.

Background: The essential role of the thalamus in neurocognitive processes has been well documented. In contrast, relatively little is known about its involvement in social cognitive processes such as recognition of emotion, mentalizing, or empathy. The aim of the study: This study was designed to compare the performance of eight patients (five males, three females, mean age ±SD: 63.7±7.9 years) at early stage of unilateral thalamic lesions and eleven healthy controls (six males, five females, 49.6±12.2 years) in neurocognitive tests (CogState Battery: Groton Maze Learning Test, GML; Groton Maze Learning Test- Delayed Recall, GML-DR; Detection Task, DT; Identification Task, IT; One Card Learning Task, OCLT; One Back Task, OBT; Two Back Task, TBT; Set-Shifting Task, S-ST) and other well-known tests (Benton Visual Retention Test, BVRT; California Verbal Learning Test, CVLT; The Rey-Osterrieth Complex Figure Test, ROCF; Trail Making Test, TMT part A and B; Color - Word Stroop Task, CWST; Verbal Fluency Test, VFT), and social cognitive tasks (The Penn Emotion Recognition Test, ER40; Penn Emotion Discrimination Task, EmoDiff40; The Penn Emotional Acuity Test, PEAT40; Reading the Mind in the Eyes Test, revised version II; Toronto Alexithymia Scale, TAS-20). Methods: Thalamic-damaged subjects were included if they experienced a single-episode ischemic stroke localized in right or left thalamus. The patients were examined at 3 weeks after the stroke onset. All were right handed. In addition, the following clinical scales were used: the Mini-Mental State Examination (MMSE), Spielberger State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI II). An inclusion criteria was a minimum score of 23/30 in MMSE. Results: Compared with the healthy controls, patients revealed significantly lower scores in CVLT, GML-DR, and VFT. Furthermore, compared to healthy controls, patients showed significantly delayed recognition of "happiness" in EmoDiff40 and significantly worse performance on Reading the Mind in the Eyes Test, revised version II. Neuropsychological assessment demonstrated some statistically significant deficits in learning and remembering both verbal and visual material, long-term information storing, problem solving, and executive functions such as verbal fluency. Conclusion: Patients at early stage of unilateral thalamic stroke showed both neurocognitive and social cognitive deficits. Further research is needed to increase understanding about diagnosis, early treatment, and prognosis of patients with thalamic lesions. [ABSTRACT FROM AUTHOR]

The objective of this study was to improve the evaluation of unilateral vocal fold paralyses (uVFP) by means of an area measurement of the glottic plane, which describes the position of the paralysed vocal fold. The area measurements were related to electromyographic findings and clinical outcome (recovery, voice quality). In 56 patients (33 women and 23 men), uVFP were confirmed by endolaryngeal electromyography (EMG) of the paralysed vocal fold and cricothyroid muscles (CT). The EMG response was classified on a 4-point scale (from 0 to 3). Vocal fold position was divided into 'paramedian' and 'intermediate' and additionally quantified by measurement of the glottic area. An 'area quotient' (AQ) was calculated and related to the EMG findings and clinical outcome. Voice qualities were objectified regarding their additive noise (breathiness) and irregularity (roughness) using the 'Göttingen Hoarseness Diagram'. The majority of uVFP was due to iatrogenic lesions. The AQ of classically graduated 'paramedian' and 'intermediate' vocal fold positions was significantly different but did not correlate with objective voice quality values. There were no significant correlations regarding EMG findings, duration or recovery from paralyses. Laryngeal EMG remains the gold standard for verifying uVFP. But EMG did not correlate significantly with AQ or functional outcome of uVFP. The measurement of an AQ is suitable for obtaining continuous data describing the position of paralysed vocal folds beyond the terms 'paramedian' or 'intermediate' and provides the basis for clinical evaluations of diagnostic tools and therapeutic interventions. [ABSTRACT FROM AUTHOR]

Background: Although different techniques have been developed for administering combined spinal epidural (CSE) anaesthesia, none can be described as an ideal one. Objectives: We performed a study to compare two popular CSE techniques: Double segment technique (DST) and single segment (needle through needle) technique (SST) with another alternative technique: Paramedian epidural and midline spinal in the same intervertebral space (single space dual needle technique: SDT). Methods: After institutional ethical clearance, 90 consenting patients undergoing elective lower limb orthopaedic surgery were allocated to receive CSE into one of the three groups (n=30 each): Group I: SST, Group II: SDT, Group III: DST using computerized randomization. The time for technique performance, surgical readiness, technical aspects of epidural and subarachnoid block (SAB) and morbidity were compared. Results: SDT is comparable with SST and DST in time for technique performance (13.42±2.848 min, 12.18±6.092 min, 11.63±3.243 min respectively; P=0.268), time to surgical readiness (18.28±3.624 min, 17.64±5.877 min, 16.87±3.137 min respectively; P=0.42) and incidence of technically perfect block (70%, 66.66%, 76.66%; respectively P=0.757). Use of paramedian route for epidural catheterization in SDT group decreases complications and facilitates catheter insertion. There was a significant number of cases with lack of dural puncture appreciation (SST=ten, none in SDT and DST; P=0.001) and delayed cerebrospinal fluid reflux (SST=five, none in SDT and DST; P=0.005) while performance of SAB in SST group. The incidence of nausea, vomiting, post-operative backache and headache was comparable between the three groups. Conclusion: SDT is an acceptable alternative to DST and SST. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to determine the frequency of complications in median and paramedian mandibulotomies. In addition, the interdental space in the median and paramedian region was calculated. Study design: Retrospective study. Setting: Tertiary care center. Methods: A retrospective chart review was performed for all cases where a mandibulotomy was performed from 2002 to 2010. 117 charts (61 paramedian and 56 median) were identified. We included data on complications, which fell in the following 2 categories: plate and dental complications. For our second objective, we evaluated 40 different patients with base of tongue or tonsillar cancer treated with intensity modulated radiation therapy (IMRT). The interdental space between the lateral incisors and the canines was electronically calculated on the digital Panorex images. Main outcome measures: Dental and plate complications were evaluated. We also assessed interdental space. Results: Patient characteristics were not significantly different. The median group had significantly more dental complications (p=0.0375, RD=0.19 and 95% CI (0.0139-0.3661)). The paramedian group had significantly more plate complications (p=0.0375, RD=0.082 and 95% CI (0.0131-0.1508). The distance between the central incisors was significantly less than the distance between the lateral incisors and canines both at the crestal and apical levels (p=0.0086 and p<0.001). Conclusions: There are significantly more dental complications in the median approach. There were significantly more plate complications in the paramedian group. In addition, there is significantly less space in the between the median region as compared to the paramedian region. This is the first study that documents the advantage of the paramedian approach for dental complications. [ABSTRACT FROM AUTHOR]

Background: The development of back pain following epidural analgesia is one reason for patient refusal of neuraxial analgesia. The primary endpoint of this study was to compare the incidence and severity of back pain following midline and paramedian epidural technique. The secondary endpoint was to identify the risk factors associated with the occurrence of back pain., Methods: This prospective randomized study included 114 patients receiving thoracic epidural catheterization for pain management following upper abdominal or thoracic surgery. Patients were allocated to either the midline or the paramedian group by computer-generated randomization. An investigator who was blinded to the patient group interviewed patients at 24, and 48 h, and 3-5 days after surgery about the existence of back pain and its severity., Results: The total incidence of back pain following epidural anesthesia was 23.8% in the midline group and 7.8% in the paramedian group. The numerical rating scale of back pain was not different between the two groups at 24 h and 4 days after surgery. The paramdian technique was associated with a lower incidence of back pain than the midline technique (95% confidence interval 0.05-0.74, odds ratio 0.2, P < 0.01). However, the number of attempts, surgical position, body mass index, and duration of surgery were not associated with back pain., Conclusions: This study showed that the midline group of thoracic epidural analgesia demonstrated higher incidence of back pain than the paramedian group. However, the pain was mild in intensity and decreased with time in both groups.

Background Current literature describes the forehead as one aesthetic subunit of the face. We argue for the usefulness of aesthetic forehead subunits when microvascular flap reconstruction is required. Key to utilization ofmicrovascular flaps for restoration of forehead subunits is an understanding of the patient population and defect characteristics most amiable to treatment. Methods We conducted an International Review Board--approved retrospective chart review of nine consecutive patients who had undergone free flap reconstruction for large forehead defects. Results The patients' foreheads included one paramedian defect; one central and paramedian defect; four central, paramedian, and lateral defects; and three lateral defects. Seven patients had ulnar forearm flaps and two had anterolateral thigh flaps. The success rate was 100%. Conclusion A forehead subunit classification system has been devised that provides a suitable option for cases that benefit from distant tissue replacement in a single stage, while preserving the principles of aesthetic replacement. [ABSTRACT FROM AUTHOR]

Summary: Background: Oblique and paramedian rare facial clefts impose a major reconstructive challenge and long-term assessments of the outcomes remain scarce. This study provides new details regarding surgical techniques and timing, influence of growth, and difficulties of this pathology on the long-term; a guideline for surgical treatment is given. Methods: Twenty-nine adults with an oblique or paramedian facial cleft and surgically treated in the authors’ unit between 1969 and 2009, were included. The long-term evaluation was based on series of photographs, 3D-CT’s, X-rays, operation data, and was specified per facial area. Results: The mean number of performed operations per patient was 10.6 (range: 1–26). Vertical dystopia is not caused by previous surgery, but by growth deficiencies of the maxilla. In all patients with vertical dystopia, its presence and severity were clear at the age of five, and it should ideally be treated shortly after that age. In mild cases grafting seems sufficient, but in more severe cases orbital translocation is necessary. Costochondral grafts showed the best long-term results in both orbital and nasal reconstructions. Major nose reconstruction is best delayed until adolescence. For an optimal final result in selected cases, correction of midface hypoplasia at adolescence is necessary. Conclusion: The three-dimensional underdevelopment of the midface region plays a central role in the deformities of most patients, but is complex and difficult to correct. The provided guideline should help to minimize the number of operations and ameliorate long-term results. [Copyright &y& Elsevier]

Abstract: Intestinal obstruction due to foreign body ingestion is one cause of colic in horses. Although it occurs more frequently in juveniles, adult horses also may be affected. The small colon is a common location in which foreign bodies can be found. Depending on the location of the obstruction in the small colon, different techniques to dislodge the foreign body toward areas where it can be safely exteriorized and removed can be attempted. Alternatively, different approaches to the abdomen can be performed to facilitate exteriorization of the obstructed segment and removal of the foreign body. This paper describes a case of large and small colon obstruction in an adult horse caused by two distinct foreign bodies. The large colon obstruction was removed through a pelvic flexure enterotomy using the ventral midline approach, and the small colon obstruction was removed through a small colon enterotomy using a paramedian approach. Information regarding signalment, history, clinical signs, surgical treatment, and follow-up status of the horse are described. [Copyright &y& Elsevier]

The dermatologic surgeon is continually faced with challenging cases that require innovative techniques for reconstruction. This review provides a brief description of a variety of repairs that the author uses in his practice. Some of these reconstructions are more established techniques, while others are described more recently. The author also presents refinements and variations of some of these repairs. Initially, the review will focus on flaps that he uses predominantly for nasal reconstruction, including the paramedian forehead flap, melolabial interpolation flap and turnover nasolabial flap. Other flaps, including the Cupid's bow mucosal advancement flap, dog-ear rotation flap, double O-Z flap and bilateral island pedicle flap are also discussed. The last portion of the article focuses on grafts: drumhead graft, clavicular graft and porcine heterograft. This article cannot cover the complete spectrum of reconstructive options but focuses on repairs the author has felt to be useful in his institution. [ABSTRACT FROM AUTHOR]

We describe three pacients in whom cerebral imaging showed bilateral paramedian thalamic infarcts inconstantly associated with bilateral rostral mesencephalic lesions ; in accordance with the radiological findings, these pacients also displayed a characteristic clinical picture. Although the pathogenesis of the syndrome is variable, the most likely and therefore first to be considered is the occlusion of an azygous arterial trunk with bilateral thalamic distribution, commonly known as the artery of Percheron; this peculiar artery is no more than a rare yet normal anatomic variant of the regional blood supply. [ABSTRACT FROM AUTHOR]

Background: The endoscopic supracerebellar-infratentorial (SCIT) approach is a viable method to access pathology of the posterior incisura, but a narrow working space and frequent instrument conflict can potentially limit its surgical efficacy. We planned an endoscopic-assisted paramedian infratentorial supracerebellar approach for pineal cyst. Case Description: Patient was placed in prone position under general anesthesia. His head was rotated to the left side slightly. The location of the transverse sinus was detected with navigation system. A 5 cm linear skin incision was performed, and a 2 cm craniectomy was performed about 2 cm left of the median. The transverse sinus was little bit exposed. Dura was incised in a U-shaped incision with the transverse sinus at the base. The endoscope was advanced along with the culmen. At that time, we observed inferior and superior vermian vein. After reaching to the thick arachnoid near by galenic system, the arachnoid membrane was incised and the CSF was evacuated. After that, the cerebellum became soft and the surgical corridor became large. The arachnoid membrane was incised widely. Pineal cyst, precentral cerebellar vein, bilateral internal occipital vein and great vein of galen were exposed. There were some small veins on the pineal cyst, but the adhesion was not so severe. The cyst was dissected from these small veins. There was no adhesion between the cyst and surrounding brain except for the pineal recess. Bilateral ICV was seen behind the cyst. There was feeding artery and draining vein on the antero-lateral part of the cyst. These vessels were coagulated and cut, then the cyst was removed. After the removal, we confirmed complete removal of the cyst and hemostasis. Conclusion: Endoscopic-assisted paramedian SCIT approach for pineal cyst in prone position is a reasonable and efficient access for posterior third ventricular lesions. The learning curve, maneuverability in small space, and instrument conflict limit efficacy. [ABSTRACT FROM AUTHOR]

Considering the highly variable vascular supply of the thalamic nuclei, MRI and clinical syndromes can be heterogeneous in ischemic diseases. We attempt to determine MRI pattern and to analyse neurological features and prognosis of paramedian infarcts. In a prospective case series within 5 years from 1999 to 2003, MRI, MRA and clinical symptoms of 38 consecutive patients were analysed. The inferomedial (posterior thalamoperforating artery) territory was affected in 89%, and lesions in the anterolateral (tuberothalamic artery) territory occurred in 42%. However, definite attribution to anterolateral or inferomedial territories was not possible in 13%. Neurological manifestations were somnolence (87%), hemisyndromes (79%), cognitive deficits (58%), oculomotor nerve palsies (53%) and vertical gaze palsies (39%). The most common aetiologies were cardiac embolism (42%), intraarterial embolism (16%), small vessel disease (13%) and large artery arteriosclerosis (13%). Pathological MRA findings were encountered in 55%, and in 18%, lesions were only visible on diffusion-weighted imaging. Correlation of MRI pattern and neurological symptoms points out anterolateral thalamic lesions as the cause of amnestic deficits. Intracranial MRA allows a non-invasive prediction of basilar tip occlusion. Our results underline the necessity of additional diffusion-weighted imaging in detecting small thalamic and midbrain lesions. [ABSTRACT FROM AUTHOR]

In order to determine the effectiveness of paramedian suboccipital transmeatal vestibular neurectomy, pre- and postoperative neurotological studies were conducted and questionnaire responses of 30 patients who underwent surgery were evaluated. Hearing was maintained within 10 dB of the preoperative level or improved in 54% of patients 2 years after surgery. Questionnaire responses indicated that all patients suffering from intractable vertigo experienced no vertiginous symptoms after surgery. Based on this study, we conclude that paramedian suboccipital transmeatal vestibular neurectomy is a sueful method for relieving ear-related vertigo. [ABSTRACT FROM AUTHOR]

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