Search Results (1,242)

Background: The greater omentum is a highly vascularized and biologically active structure with drainage, immunomodulatory, proangiogenic, and proregenerative properties. Although it is widely used in abdominal surgery, its extra-abdominal application in dogs and cats remains less standardized. Methods: This review summarizes the available veterinary literature on extra-abdominal omentalization in small animals, including case reports, case series, experimental studies, and selected comparative data, supplemented by relevant evidence from human reconstructive surgery. Results: Two main surgical strategies are described: transposition of a pedicled omental flap with preservation of vascular continuity and free omental grafting, with or without microvascular anastomosis. Reported applications include thoracic surgery, chronic and infected wounds, orthopedic conditions associated with impaired healing, head and neck reconstruction, and experimental neurosurgical procedures. The omentum may support healing by improving vascularization, filling dead space, promoting drainage, and contributing to infection control. Conclusions: Current evidence suggests that extra-abdominal omentalization may be valuable as an adjunctive technique in selected complex cases, particularly when infection, poor vascularization, dead space, or delayed healing are present. However, further clinical studies are needed to define indications, outcomes, and safety more precisely. Full article

Botulinum toxin, once known only as the cause of botulism, has become a versatile therapeutic agent whose use in children now extends across many medical and surgical specialties. This narrative review synthesises the clinical use of botulinum toxin in patients up to eighteen years of age. We describe its pharmacology, the non-interchangeable commercial preparations, and the weight-based dosing and safety principles specific to childhood, then examine its applications by organ system. Gastrointestinal uses include functional constipation and internal anal sphincter achalasia, persistent obstruction after surgery for Hirschsprung disease, anal fissure, and achalasia. Urological uses centre on neurogenic and idiopathic detrusor overactivity and on sphincter-directed injection for dysfunctional voiding. Neurological uses are dominated by cerebral palsy spasticity and, on considerably weaker evidence, dystonia, while head and neck uses include sialorrhoea, congenital muscular torticollis, and strabismus. We also address neonatal brachial plexus palsy together with hyperhidrosis and aesthetic use in adolescents. The evidence supporting these uses is markedly uneven. Randomised controlled trials exist for only a small number of paediatric indications, chiefly spasticity in cerebral palsy, neurogenic detrusor overactivity, and chronic sialorrhoea, whereas most remaining applications rest on observational cohorts, small case series, or extrapolation from adult practice, and we grade the certainty of evidence separately for every indication. Only a few indications are formally approved, and most remain off-label, though increasingly supported. Botulinum toxin is a reversible and generally safe adjunct, but rigorous paediatric trials are still needed. Full article

Background/Objectives: Natural head position (NHP) is an important reference for orthodontic and orthognathic assessment. Although postoperative changes in head posture have been reported previously, simultaneous three-dimensional changes across yaw, pitch, and roll in different skeletal classes remain incompletely characterized. This exploratory study quantified six-month changes in three-dimensional head orientation and compared their direction and magnitude between skeletal Class II and Class III patients. Methods: Fifty-four adults (17 Class II, 37 Class III) undergoing Le Fort I osteotomy and bilateral sagittal split osteotomy were evaluated preoperatively (T0) and 6 months postoperatively (T1). Standardized 3D facial surface acquisitions were obtained using a calibrated structured-light scanner and a fixed external Cartesian laser reference. T0 and T1 datasets were registered using stable upper-facial landmarks (nasion and bilateral exocanthia), and changes in yaw, pitch, and roll were calculated within the common external reference system. Results: Statistically significant T0–T1 changes were observed across all three axes in both skeletal groups (p < 0.01). Class II patients showed mean changes of +2.28° in yaw, −1.30° in pitch, and +2.89° in roll, whereas Class III patients showed +4.61°, +1.96°, and +4.04°, respectively. Between-group differences were significant for yaw, pitch, and roll, with an opposite mean pitch direction and larger mean yaw and roll changes in Class III. Conclusions: At six months, this retrospective cohort demonstrated direction-specific changes in three-dimensional head orientation. Because repeated acquisitions, study-specific observer-reliability and measurement-error analyses, an untreated comparator, an independent validation cohort, and functional or patient-reported outcomes were not available, the findings should be interpreted as exploratory measurements rather than evidence of physiological normalization, neuromuscular adaptation, or clinical benefit. Formal prospective validation is required before the workflow can support predictive or patient management recommendations. Full article

Background/Objectives: This study aimed to compare the incidence, extent, and time to diagnosis of osteonecrosis of the femoral head (ONFH) between Femoral Neck System (FNS) and multiple cannulated screw (CS) fixation in patients with femoral neck fractures (FNFs) at a minimum follow-up of 24 months, as well as to identify factors associated with ONFH after FNS fixation. Methods: A retrospective cohort study was conducted at a single university hospital involving patients aged ≥18 years with isolated FNFs treated by closed reduction and internal fixation using either FNS or multiple CS. Reduction quality, fracture union, incidence and extent of ONFH (measured by Kerboul angle), and revision surgery due to ONFH or other causes were assessed as outcome measures. Logistic regression analyses were conducted to identify factors associated with ONFH after FNS fixation. Results: Eighty-seven patients were included, comprising 48 in the FNS group and 39 in the CS group. No significant differences were found between the groups in reduction quality, union rate, or time to union (p > 0.05 for all). The incidence of ONFH did not differ significantly between the FNS and CS groups (p = 0.314). However, the FNS group showed a significantly greater extent of ONFH (p = 0.031) and longer mean time to ONFH diagnosis (p = 0.001). No significant differences were observed in revision surgery rates due to ONFH (p = 1.000) or other causes (p = 0.624). Multivariate analysis identified fracture displacement (Garden classification stages III and IV) and poor reduction quality (“Broken S” by Lowell’s criteria) as significant predictors of ONFH after FNS fixation. Conclusions: ONFH following FNS fixation tended to exhibit a larger necrotic area and a delayed radiographic onset compared to CS fixation; however, the overall incidence and revision rates were comparable between implants. These differences may be due to initial fracture displacement and baseline severity, rather than the FNS implant itself. In the FNS group, the mean time to radiographic diagnosis of ONFH was 13.1 months, and initial fracture displacement and reduction quality were identified as risk factors for the development of ONFH following FNS fixation. Therefore, long-term and vigilant follow-up is essential after FNS fixation, particularly in patients with displaced fractures. Achieving optimal reduction quality and anatomical femoral neck alignment remains paramount to mitigating the risk of ONFH after FNS fixation. Full article

Background/Objectives: Endotracheal intubation can cause postoperative voice disturbances, even after short procedures. These effects have been documented in head and neck surgery, but direct comparisons between head/neck and abdominal surgeries are lacking. We sought to compare short-term postoperative voice changes in patients undergoing head/neck and abdominal surgery and to evaluate their association with intubation parameters and patient factors. Methods: We prospectively studied 80 adults (mean age X ± SD) undergoing either head–neck surgery (parotidectomy or total thyroidectomy) or abdominal surgery. Voice acoustic parameters (fundamental frequency (F₀), jitter, shimmer, intensity, maximum phonation time (MFT)) were measured preoperatively and on postoperative days 2, 14, and 30. Anesthetic parameters were recorded during the perioperative period. Anesthesiologists were blinded to the ongoing investigation. We used repeated-measures ANCOVA (with sex as a covariate) to test for group-by-time interactions and main effects. Effect sizes were calculated. Results: Eighty patients were included. All acoustic parameters showed significant postoperative changes (p < 0.001). The most pronounced alterations occurred in the early postoperative period, with decreased F₀, intensity, and MFT, and increased jitter and shimmer. Significant interaction effects between time and type of surgery were observed for F₀ (ηp² = 0.445), shimmer (ηp² = 0.210), intensity (ηp² = 0.267), and MFT (ηp² = 0.149), indicating distinct recovery patterns across groups. Patients undergoing abdominal surgery showed less pronounced and more rapidly resolving changes, whereas head and neck surgery was associated with greater and more persistent impairment. Among all parameters, shimmer demonstrated the largest overall effect size (ηp² = 0.338), suggesting high sensitivity to short-term voice changes. Perioperative factors, including duration of surgery, endotracheal tube size, and BMI, were significantly associated with the extent of voice changes. Conclusions: Short-duration endotracheal intubation can lead to measurable short-term voice changes, which are more pronounced after head/neck surgery (particularly total thyroidectomy). Objective acoustic analysis detected these subclinical alterations even when patients were asymptomatic. These findings underscore the importance of monitoring voice outcomes and optimizing intubation techniques, although future work is needed to correlate acoustic changes with laryngeal exam findings. Full article

Background: Pediatric head trauma is a common reason for emergency department presentation. Although most children have minor injuries, a small proportion harbor clinically important traumatic brain injuries requiring urgent intervention. Artificial intelligence (AI) may offer structured support in computed tomography (CT) decision making, but evidence regarding the performance of general-purpose large language models in pediatric head trauma remains limited. Objective: To evaluate the association between AI-based cranial CT recommendations and clinically meaningful outcomes in pediatric patients with blunt head trauma and to assess the diagnostic performance and clinical utility of the model. Methods: This retrospective single-center observational study included pediatric patients younger than 18 years with blunt head trauma who underwent cranial CT imaging and had complete outcome data. A general-purpose large language model generated binary CT recommendations (“CT recommended” or “CT not recommended”) using structured clinical information available at the time of emergency department presentation. The primary outcome was a composite adverse clinical outcome defined as the occurrence of at least one of the following: emergency surgical intervention, intensive care unit admission, intubation, neurological sequelae or mortality. Diagnostic performance metrics, calibration analysis and decision curve analysis were performed. Results: A total of 819 pediatric patients were included, and the AI model recommended CT in 530 patients (64.7%). The primary outcome occurred in 143 patients (17.5%) and was significantly more frequent in the CT-recommended group than in the CT-not recommended group (24.5% vs. 4.5%; OR 6.90, 95% CI 3.82–12.45; p < 0.001). Abnormal CT findings, emergency surgery, intubation and neurological sequelae were also significantly more common in patients for whom CT was recommended by the AI system. For the primary outcome, the AI recommendation demonstrated a sensitivity of 90.9%, specificity of 40.8%, positive predictive value of 24.5% and negative predictive value of 95.5%. Calibration analysis showed acceptable agreement between predicted probabilities and observed event rates. Decision curve analysis demonstrated greater net benefit than both the “treat-all” and “treat-none” strategies across a range of threshold probabilities. Conclusions: In this clinically selected cohort of pediatric patients with blunt head trauma who underwent cranial CT imaging, AI-based CT recommendations were strongly associated with adverse clinical outcomes and demonstrated high sensitivity and negative predictive value for identifying children at risk of clinically important events. These findings suggest that, within a clinically selected cohort of children who underwent cranial CT imaging, AI-generated CT recommendations were associated with clinically meaningful outcomes. However, these results should not be interpreted as validation of CT decision making in the broader pediatric head trauma population and require prospective validation in unselected cohorts. Full article

Background: Recent evidence suggests that gut microbiome plays a role in the development of pancreatic ductal adenocarcinoma (PDAC) and influences treatment response. However, the association of tumor location and preoperative biliary stenting (PBS) with gut microbial composition and diversity remains poorly understood. Methods: Preoperative stool specimens were prospectively collected from patients with PDAC undergoing surgery between March 2020 and July 2021 at the Department of Surgery, Heidelberg University Hospital, Germany. Whole-genome shotgun metagenomic sequencing was performed. Microbial diversity was assessed using the Shannon index and Bray–Curtis dissimilarity with principal coordinates analysis. Results: A total of 63 preoperative stool samples were analyzed from 40 patients with pancreatic head (63.5%) and 23 with body/tail tumors (36.5%). Baseline characteristics were comparable between groups. Microbial community composition differed significantly between tumor locations (Bray–Curtis, p = 0.005), with enrichment of Ruminococcus bromii in body/tail tumors. Among patients with pancreatic head tumors, PBS was associated with reduced alpha diversity (Shannon index, p = 0.04) and depletion of taxa including Eubacteriales and Clostridiales taxa, and members of the genera Raoultella and Prevotella. PBS was associated with a higher rate of major complications > 3a according to the Clavien–Dindo classification (28.6% vs. 3.8%; p = 0.04). Conclusions: PBS was associated with reduced microbial diversity and distinct taxonomic alterations of the gut microbiome. These findings suggest that biliary stenting is associated with microbiome alterations that may be relevant for perioperative risk stratification and warrant further investigation. Full article

Background: Accurate three-dimensional positioning of dental implants is fundamental for long-term prosthetic success. While static guided surgery and traditional dynamic navigation present intrinsic limitations related to physical bulk or hand–eye coordination (the “look-away” phenomenon), Augmented Reality (AR) via Head-Mounted Displays (HMDs) promises to overcome these barriers by superimposing virtual holograms directly onto the surgical field. Objectives: The aim of this scoping review is to map the existing literature to evaluate the positioning accuracy, workflow efficiency, and ergonomic/technical barriers of HMD-based AR navigation systems in implant dentistry. Methods: A systematic search was conducted across the PubMed, Scopus, Web of Science, and Cochrane Library databases, following the PRISMA-ScR guidelines. In vitro, ex vivo, and clinical studies utilizing AR headsets (e.g., HoloLens) for implant guidance, reporting quantitative data on accuracy and/or qualitative data on usability issues, were included. Results: Eleven studies were included (7 in vitro, 1 ex vivo, 3 clinical). Accuracy showed a strong dependence on case complexity: for standard implants, the mean error at the entry point ranged between 0.33 and 1.51 mm, which is comparable to s-CAIS techniques. However, in complex scenarios (zygomatic implants), significant deviations were reported (up to 5.64 mm and 9.60°). The main barriers to routine adoption identified include tracking instability due to line-of-sight interruption, device weight, and the vergence–accommodation conflict. Conclusions: AR dynamic navigation demonstrates promising potential. Nevertheless, current evidence relies predominantly on in vitro studies that fail to fully replicate real-world surgical complexities. Persistent technical and ergonomic barriers, such as tracking instability and hardware limitations, indicate that the technology remains largely in a preclinical phase and is not yet suitable for routine clinical application. Further advancements toward markerless tracking systems, lighter headsets, and rigorous in vivo trials are required. Full article

Background and Clinical Significance: Oropharyngeal squamous cell carcinoma (OPSCC) and small-cell neuroendocrine carcinoma (SCNEC) are biologically distinct entities with markedly different prognostic and therapeutic implications. While HPV-negative OPSCC carries worse outcomes than HPV-positive disease, SCNEC is exceedingly rare, highly aggressive, and prone to early systemic dissemination. Their synchronous occurrence in the head and neck (HN) is exceptional and poses major diagnostic and therapeutic challenges. Case Presentation: A 54-year-old male, smoker and alcohol consumer, presented with a left tonsillar lesion and cervical lymphadenopathy. Biopsy confirmed p16-negative OPSCC. He underwent transoral robotic surgery with modified radical neck dissection. Histopathology unexpectedly revealed two distinct malignancies: keratinizing OPSCC in the tonsil and high-grade SCNEC in a cervical lymph node, confirmed by immunohistochemistry (synaptophysin, CD56, Ki-67 80%). Postoperative FDG-PET/CT performed within two months showed rapid systemic spread, including paravertebral, pulmonary, and pelvic nodal metastases. Despite recommendation for systemic therapy, the patient deteriorated quickly and died shortly thereafter. Conclusions: This study reports coexistence of p16-negative OPSCC and high-grade SCNEC in the HN. It highlights the diagnostic complexity, staging limitations, and therapeutic dilemmas of discordant histologies, while illustrating the fulminant clinical course typical of SCNEC of unknown origin. Early recognition, comprehensive pathology, and multidisciplinary management are essential, although prognosis remains dominated by the aggressive neuroendocrine component. Full article

Background: Postoperative bleeding and prolonged drainage after head and neck surgery may delay drainage tube removal and hospital discharge, increasing complication risk and resource utilization. Optimizing intra and postoperative hemostasis is essential to facilitate early recovery and support enhanced recovery after surgery (ERAS) pathways. This study aimed to identify factors associated with postoperative drainage and length of hospital stay, with particular focus on energy-based device and fibrin sealant use. Methods: Adult patients who underwent neck surgery under general anesthesia with inpatient admission at a tertiary medical center between January 2024 and December 2025 were retrospectively analyzed. Surgical procedures included thyroidectomy (n = 99), parotidectomy (n = 43), submandibular gland excision (n = 25), neck dissection (n = 27) and other procedures (n = 22). Clinical variables, surgical factors, use of energy-based device, hemostatic agents, postoperative drainage volume, and length of hospital stay were collected. Logistic regression analysis was performed to evaluate predictors of early discharge (defined as discharge on postoperative day 1). Results: A total of 216 patients were included. Surgical procedure type was strongly associated with operative duration, postoperative day 1 drainage volume, and length of hospital stay. Neck dissection and total thyroidectomy were associated with increased drainage and prolonged hospitalization. The use of fibrin sealants was independently associated with lower postoperative drainage volume, shorter hospital stay, and a significantly higher likelihood of early discharge (adjusted odds ratio: 4.43, 95% CI 1.92–10.23, p < 0.001). Energy-based device use and patient-controlled analgesia were not associated with early discharge. Conclusions: Incorporating fibrin sealant into perioperative management may facilitate safer and earlier discharge, improve patient turnover, and optimize resource utilization within ERAS-based care pathways. Full article

Intraoperative monitoring systems play a vital role in surgical safety and decision-making. This study explored whether high-resolution physiological signals routinely available during surgery can be leveraged by deep learning to predict adverse events after head and neck free flap reconstruction. In this retrospective study, intraoperative waveforms, including arterial pressure, plethysmography, and electrocardiogram, from 187 patients who underwent free flap surgery were analyzed. A deep learning model based on the Mamba architecture was trained to predict three outcomes: flap failure, return to the operating room for exploration, and other surgical complications. Conventional logistic regression using static clinical variables and feature-based machine learning models were evaluated for comparison. On a patient-wise stratified held-out test set, the deep learning model achieved AUROCs of 0.86, 0.62, and 0.93 for flap failure, re-exploration, and other complications, respectively. Precision was 0.50, 0.40, and 1.00, whereas recall was 0.50, 0.40, and 0.25, indicating high precision but modest recall. Predictive performance varied across outcomes. These findings demonstrate the feasibility of waveform-based deep learning for perioperative risk stratification in reconstructive surgery, although the preliminary nature, limited sample size, and lack of external validation should be considered. Full article

Background: Displaced pediatric radial neck fractures are challenging injuries. Adequate reduction can be difficult to achieve via closed methods. Open reduction has been associated with avascular necrosis and growth arrest due to soft tissue stripping during surgery. We describe a modified technique that adopts lessons learned from subcapital realignment procedures of the proximal femur, prioritising preservation of the periosteal sleeve with the aim of reducing complications associated with open reduction. Methods: The modified technique includes visualisation of the radial neck fracture through the torn periosteum, preserving intact periosteum, limited shortening of the diaphyseal fracture site, followed by open reduction and fixation with retrograde elastic intramedullary nailing. A retrospective chart review of 15 patients treated with this technique was undertaken to report early clinical and radiographic outcomes. Results: Mean age at injury was 7.7 years (range 4–11). Mean follow-up was 9.9 months (range 4.5 to 20 months). There was 100% fracture union achieved at mean 9.3 weeks (SD 4.9) post-surgery. Mean flexion was 139° (SD 9°), extension 1° (SD 7°), supination 66° (SD 23°) and pronation 79° (SD 21°). There were no cases of postoperative radial head deformity or instability. One patient showed radiological signs of avascular necrosis. Six of 15 patients experienced at least one complication, including heterotopic ossification, stiffness requiring release, physeal closure and nail migration requiring revision. Conclusions: We describe a technique that aims to preserve periosteal blood supply during open reduction and fixation of pediatric radial neck fractures. Early clinical experience suggests promising results, but longer-term follow-up is required before any advantage over existing open reduction techniques can be concluded. Full article

Background: Radial head arthroplasty is commonly used for unreconstructable radial head fractures, particularly in cases associated with elbow instability. Both loose-fit monobloc and cemented bipolar radial head prostheses are available, but comparative evidence regarding their clinical and radiographic outcomes remains limited. This study aimed to compare mid-term outcomes between these two implant designs. Methods: A retrospective observational study was conducted on 26 patients who underwent radial head arthroplasty for acute radial head fractures between November 2020 and October 2023. Fourteen patients received a loose-fit monobloc radial head prosthesis, while twelve received a cemented bipolar prosthesis. Clinical, functional, and radiographic outcomes were assessed at a minimum follow-up of 24 months. Outcome measures included range of motion, pain, elbow stability, satisfaction, ADL (activities of daily living), IADL (instrumental activities of daily living), SF-12 (12-Item Short Form Health Survey), Oxford Elbow Score, Mayo Elbow Performance Score, DASH (disability of the arm, shoulder and hand score) score, implant loosening, heterotopic ossification, and complications. Results: No statistically significant differences were observed between the two groups in pain, satisfaction, range of motion, elbow stability, functional scores, radiographic loosening, or complication rates. The cemented bipolar group showed slightly better flexion–extension and pronation–supination values, whereas the loose-fit group showed a numerically lower rate of elbow instability; however, these differences were not statistically significant. No cases of aseptic loosening, periprosthetic osteolysis, or undesired implant loosening were observed. The complication rate was 36% in the loose-fit group and 33% in the cemented group. One patient in the loose-fit group required revision surgery due to implant overstuffing. Conclusions: Both loose-fit monobloc and cemented bipolar radial head prostheses provided acceptable mid-term functional scores; however, the relatively high overall complication rate (33–36%) highlights the need for careful implant selection, particularly with loose-fit implants, to avoid overstuffing and postoperative stiffness. Given the small cohort, these findings do not imply therapeutic equivalence. Full article

The carotid and vertebral arteries are critical components of the cerebral circulation, supplying the brain and spinal cord. Their embryologic development involves complex transformations of the aortic arches, paired dorsal aortae, and cervical intersegmental arteries. Congenital anomalies and variations involving their origin, course, and branching patterns are relatively common and are increasingly recognized using modern imaging. While many of these variants are incidental, some carry important clinical implications, particularly in contexts of stroke imaging, head and neck surgery, and neurointerventional procedures. This article reviews the embryologic development of the carotid and vertebral arterial systems, highlights normal and variant anatomy, and presents a case-based, illustrated overview of these congenital anomalies. Emphasis is placed on key findings utilizing computed tomography angiography (CTA), magnetic resonance angiography (MRA), and catheter angiography. Particular attention is given to structural and pathway variations, including vessel agenesis or hypoplasia, the aberrant internal carotid artery within the temporal bone, abnormal branching patterns, fenestrations, and persistent fetal anastomoses (such as the primitive trigeminal, hypoglossal, and proatlantal intersegmental arteries). Ultimately, familiarity with these anomalies, their embryological origins, and their distinct imaging characteristics is essential for ensuring accurate interpretation and avoiding diagnostic pitfalls and procedural complications. Full article

Background and Clinical Significance: Anti–myelin-associated glycoprotein (MAG) antibody polyneuropathy is a rare, chronic IgM-mediated demyelinating peripheral neuropathy predominantly affecting sensory nerves in older adults, commonly in association with monoclonal gammopathy of undetermined significance. Reports describing anesthetic management in patients with this condition remain extremely limited, and no specific guidelines currently exist regarding neuromuscular blocking agent (NMBA) use or neuromuscular monitoring in this population. Case Presentation: A 79-year-old man with anti-MAG antibody polyneuropathy (diagnosed in 2007) and IgM monoclonal gammopathy of undetermined significance developed disproportionate progressive lower-extremity weakness and became wheelchair-dependent following COVID-19 infection in 2020. Preoperative evaluation revealed mildly reduced left ventricular function (ejection fraction 49%), mild chronic kidney disease, and marked intrinsic hand muscle atrophy with absent deep tendon reflexes. He was scheduled for robot-assisted radical cystectomy with ileal conduit diversion under combined general and thoracic epidural anesthesia. Before NMBA administration, neuromuscular monitoring was systematically attempted at the ulnar nerve (electromyography and acceleromyography, up to 60 mA/300 μs) and the corrugator supercilii; despite visible muscle contractions following peripheral nerve stimulation, neither modality produced reliable responses at either site. Given the inability to establish reliable monitoring, the administration of NMBAs was considered to carry an unacceptable risk of a prolonged, undetectable blockade. Anesthesia was maintained with deep sevoflurane (2.0–2.5% end-tidal) and remifentanil infusion without NMBAs, titrated to a bispectral index of 40–60. Tracheal intubation was accomplished via video laryngoscopy without NMBA. The 7 h and 30 min surgery was completed without patient movement or surgical compromise. Postoperatively, the patient developed transient upper airway obstruction attributed to glossoptosis, managed successfully with head elevation and nasopharyngeal airway insertion; supplemental oxygen was required until postoperative day 3, and the patient was discharged from the high-dependency unit on postoperative day 5. Conclusions: No measurable quantitative neuromuscular response could be obtained in this patient with advanced anti-MAG antibody neuropathy, despite appropriate application of electromyography- and acceleromyography-based monitoring and the presence of visible muscle contractions following peripheral nerve stimulation. In such circumstances, avoiding NMBA administration in favor of deep volatile or intravenous anesthesia with opioid supplementation may represent a reasonable, hypothesis-generating approach in carefully selected patients; this observation does not establish the general superiority of an NMBA-free strategy, and caution is warranted before generalizing it to procedures such as robotic surgery, in which profound neuromuscular blockade is often considered desirable. Full article