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Inadequate temporal muscle (TM) reconstruction after surgery may hesitate in potentially severe functional and aesthetic sequelae, making it of paramount importance to carefully consider TM reconstruction even in case of small deformities. The authors describe the combined temporal muscle augmentation technique (CTMA), an innovative technique for TM augmentation for muscle reconstruction in case of small to medium substance loss. A cadaver study was conducted as preclinical validation of the technique for the assessment of CTMA coverage capability. CTMA consists in a combination of 2 techniques for muscle surface coverage (MSC) increase: the radial (RA) and the longitudinal augmentation (LA), which enables to harvest a radial (RF) and a longitudinal flap (LF), respectively. Each flap derives from a different muscle-bundle, spearing TM segmentation and functional performance, and are supplied by a specific neuro-vascular peduncle, which makes flaps functionally independent. A surgical case is reported to demonstrate the feasibility of the technique. Combined temporal muscle augmentation technique provides an overall coverage surface of 6.5 ± 0.6 cm2, which corresponds to a gap distance of 2.5 ± 0.2 cm, with RF providing a statistically significant larger surface of coverage compared to LF (×2.1; P = 0.0001). Combined temporal muscle augmentation technique is easy and fast to perform displaying a good reconstructive capability with complete preservation of temporal muscle anatomic compartmentalization and segmental vasculature. It might be considered as a safe and effective alternative in the reconstruction of small-to medium TM defects.

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Early brain injury and cerebral vasospasm during the 14 days after the subarachnoid hemorrhage (SAH) are considered the main causes of poor outcome. The primary injury induces a cascade of events, including increased intracranial pressure (ICP), cerebral vasospasm and ischemia, glutamate excitotoxicity, and neuronal cell death. The objective of this study was to monitor the time course of glutamate, aspartate, and glutamate-associated enzymes such as glutamate-oxaloacetate transaminase (GOT1), glutamate-pyruvate transaminase (GPT) in cerebrospinal fluid (CSF) and serum, during the first weeks after SAH, and to assess their prognostic value. A total of 74 participants participated in this study: 45 participants with SAH and 29 controls. Serum and CSF were sampled up to 14 days after SAH. The clinical and neurological status of SAH participants were assessed at hospitalization, at discharge from the hospital, and 3 months after SAH.Our results demonstrated that serum and CSF glutamate levels were consistently elevated after SAH. Furthermore, high serum glutamate levels displayed a positive correlation with the worst neurological status at admission, and with the cerebral ischemia and poor neurological outcome. CSF GOT1 was elevated in SAH participants and positively correlated with intracranial hypertension, with cerebral ischemia and poor neurological outcome post-SAH.

IFDHs (intraforaminal disc herniations) represent a heterogeneous and relatively uncommon disease; their treatment is technically demanding due to the anatomic relationships with nerve roots and vertebral joints. Over time, several approaches have been developed without reaching a consensus about the best treatment strategy. Authors comparatively analyze surgical operability and exposure in terms of quantitative variables between the different microsurgical approaches to intraforaminal lumbar disc herniations (IFDH), defining the impact of each approach on surgical maneuverability and exposure on specific targets. A comparative microanatomical laboratory investigation was conducted. The operability score (OS) was applied for quantitative analysis of surgical operability. Trans-articular and combined translaminar-trans-pars-interarticularis approaches result in providing the best surgical exposure and maneuverability on all targets with surgical controls on both nerve roots, at the expense of a higher risk of iatrogenic instability. Trans-pars-interarticularis approach reaches comparable levels of operability, even limited to the pure foraminal area (lateral compartment); similar findings were recorded for partial facetectomy on the medial compartment. The contralateral interlaminar approach provides good visualization of the foramen without consensual favorable maneuverability, which should be considered as the main drawback. Approach selection has to consider disease location, the possible migration of disc fragments, the degree of nerve root involvement, and risk of iatrogenic instability. According to the findings, authors propose an operative algorithm to tailor the surgical strategy, based both on the precise definition of anatomic boundaries of exposure of each approach, as well as surgical maneuverability on specific targets.

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