Background: Degenerative cervical myelopathy (DCM) manifests as the primary cause of spinal cord dysfunction and is non-traumatic, chronic and progressive in nature. Decompressive surgery is typically utilised to halt further disability and neurological dysfunction. The limitations of current diagnostic options surrounding assessment and prognostic potential render DCM still largely a clinical diagnosis. Aims: To outline the limitations of current diagnostic techniques, present evidence behind novel quantitative MRI (qMRI) techniques for assessing spinal cord integrity in DCM and suggest future directions. Method: Articles published up to November 2021 were retrieved from Medline, EMBASE and EBM using key search terms: spinal cord, spine, neck, MRI, magnetic resonance imaging, qMRI, T1, T2, T2*, R2*, DTI, diffusion tensor imaging, MT, magnetisation transfer, SWI, susceptibility weighted imaging, BOLD, blood oxygen level dependent, fMRI, functional magnetic resonance imaging, functional MRI, MRS, magnetic resonance spectroscopy. Results: A total of 2057 articles were retrieved with 68 articles included for analysis. The search yielded 2 articles on Quantitative T1 mapping which suggested higher T1 values in spinal cord of moderate-severe DCM; 43 articles on DTI which indicated a strong correlation of fractional anisotropy and modified Japanese Orthopaedic Association scores; 15 articles on fMRI (BOLD) which demonstrated positive correlation of functional connectivity and volume of activation of various connections in the brain with post-surgical recovery; 6 articles on MRS which suggested that Choline/N-acetylaspartate (Cho/NAA) ratio presents the best correlation with DCM severity; and 4 articles on MT which revealed a preliminary negative correlation of magnetisation transfer ratio with DCM severity. Notably, most studies were of low sample size with short timeframes within 6 months. Conclusions: Further longitudinal studies with higher sample sizes and longer time horizons are necessary to determine the full prognostic capacity of qMRI in DCM.

Summary: The mechanism and physiology of orbital cavity remodeling after orbital fractures is not well described. This poses a challenge in the delayed operative treatment of orbital floor fractures due to variations from expected anatomy and may risk injury to critical structures during exploration as well as misguided reconstruction, causing persistent ocular dystopia. We report a case where significant orbital remodeling caused unexpected challenges to orbital floor reconstruction, highlighting the need for further research in this field. A 23-year-old previously healthy man was treated conservatively for a left orbital floor fracture sustained during a rugby match. At a 4-month follow-up, the patient was found to have significant ocular dystopia with vertical diplopia and cosmetically significant enophthalmos. A discrepancy of 4 mm was noted on exophthalmometry. Intraoperatively, the neo-floor was found to have fully healed but with significant downsloping angulation and clinically appreciable depression. Furthermore, no fracture ledges were able to be used to guide the height of the titanium reconstruction plate, posing a significant challenge. Therefore, a 3-dimensional printed model of the orbit using a recent computed tomography scan was used to conform the plate to the required dimensions. The patient made a good recovery without ocular symptoms. Fracture remodeling of the orbital cavity is poorly described and may not be considered in the delayed treatment of orbital fractures. Further research to describe the mechanism and pattern of how this occurs is necessary. Computer-assisted design with 3-dimensional printing is a useful tool that can help overcome technical challenges in complex maxillofacial cases.

Background: Calvarial exposure is a recognised complication of surgical and radiotherapeutic treatment of scalp skin cancers. Exposure of the calvarium from this treatment may result in bone desiccation, infection and sequestration, which can pose significant risk to patient morbidity and mortality, and be resource-intensive to treat. Aim: To investigate the risk factors and report the incidence of calvarial exposure in the treatment of scalp malignancies. Methods: A retrospective review of all patients presenting to Liverpool Cancer Therapy Centre between 2016–2022 was conducted. Patients (>18 years) with scalp skin cancers stage T2 or T3 (n = 150) were identified via electronic medical records. Associations between surgical and radiotherapeutic treatment were studied using descriptive statistics. Results: Dual-therapy patients were found to have the highest incidence of calvarial exposure followed by radiotherapy-only patients, with 7.69 per cent of dual-therapy patients, 6.06 per cent of radiotherapy-only patients and 3.95 per cent of surgery-only patients experiencing calvarial exposure. A comparison using the Charlson Comorbidity Index (CCI) was statistically significant, with radiotherapy patients having an average CCI score 0.97 points higher than surgical patients (p < 0.05). In the radiotherapy cohort, the calvarial-exposure population on average received a 23.03 Gy higher dose compared to the non-exposure population. This difference was statistically significant (p = 0.0011). In the surgical cohort, calvarial exposure only occurred in patients treated with skin grafts, either as sole coverage or as part of a transposition flap. Healing was only achieved in calvarial exposure patients who were treated with surgery. Conservative treatment with dressings did not lead to healing. Conclusion: The data indicates a trend towards patients receiving dual-therapy being at higher risk of calvarial exposure than those who receive surgery-only or radiotherapy-only. It also indicates that the incidence of calvarial exposure following treatment of scalp cancer is relatively low. Larger skin surface-area resections, larger radiotherapy doses and a higher CCI score are identified risk factors.

Timing of oral feeding following head and neck mucosal free-flap reconstruction is a highly contentious issue. The typical 6-12 days "nil-by-mouth' primarily revolves around the concern for post-operative complications. Conversely, early feeding has been shown to reduce the patient's stress response, optimise physiological function, and facilitate recovery and healing. Nevertheless, the optimum time of oral feeding is unknown, and the impact of early feeding on post-operative complications and length of hospital stay (LOS) remains controversial. A systematic review was conducted across the databases; Medline (Pubmed), EMBASE, Cochrane Central, and Scopus for studies comparing the outcomes of early (≤5 days) and/or late (>5 days) oral feeding following reconstructive head and neck surgery involving mucosal free-flaps. Fixed and random-effects meta-analyses were utilised. The search yielded 1283 articles, of which thirteen met the inclusion criteria, encompassing a total of 1657 patients. Early feeding was significantly associated with lower risk of fistulas (3.66% vs 11.35%) (RR 0.37, 95%CI 0.22 to 0.64; P = 0.0004) and lower risk of pneumonia (6.31% vs 12.38%) (RR = 0.53, 95%CI 0.33 to 0.87; P = 0.011) compared to late feeding. Early feeding significantly reduced LOS compared to late feeding (x̄=9.85 vs 13.11 days) (MD -4.10, 95%CI -7.07 to -1.14; P=0.0067). The incidence of flap-failure, haematoma and dehiscence was similar between the two groups. Early oral feeding initiation appears to be safe and associated with improved or similar patient outcomes and reduced LOS. Surgeons should consider early oral feeding in a carefully selected population.

Introduction and importance: Pituitary apoplexy is a clinical syndrome that occurs secondary to abrupt haemorrhage or infarction and can cause a presentation with headache, visual disturbances, and various neurological deficits. Pituitary apoplexy is a rare clinical syndrome that is often misdiagnosed or discovered late in its clinical course due to its relatively nonspecific clinical presentation. Case presentation: The case describes patient with a giant prolactinoma which developed haemorrhagic progression in the context of previously undiagnosed coagulopathy from idiopathic thrombocytopaenia. Transcranial (rather than transnasal) surgery was performed for evacuation and debulking. Conclusion: The case highlights the management of an exceedingly large adenoma in the context of coagulopathy contributing to rapid clinical progression, as well as a positive clinical outcome in a patient with restored vision and pituitary function. Highlights: