Kinematic measurements of the cervical spine by gender and age (Reproduced from Dvorak et al., 1992).
\r\n\t
",isbn:"978-1-80356-822-5",printIsbn:"978-1-80356-821-8",pdfIsbn:"978-1-80356-823-2",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"8bcc7b0888f751d6a309eb0c6b8af509",bookSignature:"Dr. Morufu Olalekan Olalekan Raimi, Dr. Oyeyemi Abisoye Sunday, Dr. Henry Olawale Sawyerr and Prof. Teddy Charles Adias",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11683.jpg",keywords:"Environmental Health Management, Epidemiological Measures, Health Impact Assessment, Social Responsibility, Continued Surveillance, Cumulative Incidence, Health Education, Health Care, Universal Precautions, Anthropometric Measurement, Population Intervention, Ethical Concern",numberOfDownloads:13,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 30th 2022",dateEndSecondStepPublish:"June 7th 2022",dateEndThirdStepPublish:"August 6th 2022",dateEndFourthStepPublish:"October 25th 2022",dateEndFifthStepPublish:"December 24th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Raimi's work on groundwater pollution in the Niger Delta, amongst others, is opening a new path of scientific knowledge and research in pollution control management and related fields. He is a reviewer and an editorial board member of many scientific journals and is also a member of many societies among which are the Canadian Association for Global Health (CAGH) and Solid Waste Association of North America (SWANA).",coeditorOneBiosketch:"Dr. Abisoye Oyeyemi won the J.D. Soleye’s Prize for being the best candidate in the 2010 Parts II FMCPH Examinations with the best dissertation and also won the Adetokunbo O. Lucas Prize for the best candidate in 2010 Part II FMCPH Examinations. Between 2003 and 2005, Dr. Oyeyemi served as Site Supervisor (rural site) for the first-ever PMTCT project in Bayelsa State – a partnership between Bayelsa State Government, UNICEF, and Nigerian Agip Oil Company.",coeditorTwoBiosketch:"Dr. Sawyerr is a member of the African Academy of Environmental Health Professionals and the Alliance of Hazardous Materials Professionals, the U.S.A. He has authored over seven training manuals for Environmental Health Science, has published in over eighty-seven scientific journals, and has attended several scientific conferences both nationally and internationally.",coeditorThreeBiosketch:"Dr. Adias is a Fellow of the Institute of Biomedical Science (FIBMS), London, UK. His current research interest is focused on Transfusion immunology, safety, alternatives, and hematology of infectious diseases. Recent publications have included articles in Journals such as the Journal of Blood Medicine, Transfusion Clinique et Biologique, Pathology and Laboratory, and Medicine International amongst others.",coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"338653",title:"Dr.",name:"Morufu",middleName:"Olalekan",surname:"Olalekan Raimi",slug:"morufu-olalekan-raimi",fullName:"Morufu Olalekan Raimi",profilePictureURL:"https://mts.intechopen.com/storage/users/338653/images/system/338653.jpg",biography:"Sanitarian RAIMI, Morufu Olalekan 15 years’ career includes expertise in environmental health ethics and policy, emergency preparedness and response, environmental health informatics, environmental auditing, monitoring and scanning, Health Impact Assessment (HIA). A registered and licences environmental health officer. Sanitarian Raimi Morufu Olalekan received his M.Phil in Environmental Health Science from Kwara State University in August 2018 and MSc in Environmental Health Management from the University of Uyo in March 2017, Diploma in Environmental Health from Public Health Training Institute and Bsc in Geography and Environmental Management from Niger Delta University. \nHe has taught classes at the Niger Delta University (department of community medicine), University of Maiduguri (department of geography), University of Uyo (center for wetlands and waste management studies) and Kwara State University (department of environmental health). Raimi Morufu Olalekan is the author or coauthor of more than 100 scientific publications and expert papers in American, European and Asian journal to his credit, 20 research projects under way including cumulative impact assessment of air quality and assessment of digital debris management in health Institutions in South-South, Nigeria. He has served as a key note speaker in many International and Local Conferences and has attended a number of certified educational seminars, participants of numerous symposiums in Nigeria and abroad. His H index is 20, i10 - index is 51, had 1164 Google citations, https://scholar.google.com/citations?user=nRBW82AAAAAJ&hl=en, SSRN citation 172, crossref citation 10 and download 2865, https://ssrn.com/author=2891311. San. Raimi Morufu Olalekan has successfully supervised more than (5) Master degrees candidates, two (2) doctorate degrees and currently supervising a number of Master and Doctorate degree candidates. His work on ground water pollution in the Niger Delta amongst others is opening new path of scientific knowledge and research in pollution control management and related fields. He is a reviewer and an editorial board member to many Scientific Journals viz: American Journal of Environmental Sciences, American Public Health Association (APHA), Plos One, Heliyon, Earth Science & Environment Research Journal (OMSP International), Science Publishing Group, CPQ Medicine, Acta Scientific Agriculture, MAR Microbiology, Journal of Environmental Science and Research, International Journal on Research Case Reports and Case Series, Journal of Education and Learning Management, African Journal of Humanities and Social Sciences,, Continental Journal of Applied Sciences, Continental Journal of Biological Sciences, Open Access Journal of Biomedical Engineering and Biosciences, Journal of Medical Care Research and Review, Journal of Nursing and Primary Care, Journal of Medical Reviews, New International Journal of Medicine and Science (NIJMS), Ecuadorian Journal of Science Research and Innovation, Academic Research Journal on Health Information Management, Journal of Research in Food Science and Nutrition, IMPACT: International Journal of Research in Humanities, Arts and Literature, American Journal of Epidemiology and Public Health, Pollution and Public Health, Advanced Journal of Toxicology: Current Research, International Journal of Case Reports & Short Reviews (IJCRSR), Journal of Research in Environmental Science and Toxicology, Journal of Community Medicine & Public Health Care, Journal of Bacteriology Research (JBR), Journal of Public Health and Epidemiology, Citizen Science: Theory and Practice, Agricultural Sciences Research Journal [ARJ], ES Journal of Public Health, American Journal of Environmental Protection, Elixir International Journal etc. and has also published several academic papers in academic International Journals, author of few books related to water pollution in the Niger Delta title: Assessment of Trace Elements in Surface and Ground Water Quality (Lambert academic publishing 2017, First edition) and member of a number learned societies. \nHis current research interests focus on pollution control management, water pollution and management, Environmental Impact Assessment, Waste management, institutional capacity building, policy and governance issues, environmental management, risk and vulnerability assessment, hazard mitigation, and resilience building. His taught courses include: Anthropogenic climate, Introduction to Environmental Health, Waste Management, Environmental Air Pollution and Human Health, Environmental Land Pollution and Human Health, Demography, Disaster Management, The Socio-Economic Environment, Biological and Physical Environment etc.",institutionString:"Saving One Million Lives Program for Results (SOML PforR) Bayelsa State Ministry of Health",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"0",institution:null}],coeditorOne:{id:"452612",title:"Dr.",name:"Oyeyemi",middleName:"Abisoye",surname:"Sunday",slug:"oyeyemi-sunday",fullName:"Oyeyemi Sunday",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003N9ZMfQAN/Profile_Picture_1643704495237",biography:"Dr. Abisoye Oyeyemi is an Associate Professor at the Niger Delta University and a Consultant Public Health Physician at the Niger Delta University Teaching Hospital. 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These unique features make the CVJ more mobile than any of the other joints in the cervical spinal column, and important biomechanical properties must be understood in order to properly accommodate instrumentation to stabilize the spine after trauma, neoplasm, or degenerative disease. Each joint (Occiput-C1 and C1-C2) has its own unique biomechanical properties; at the occiput-C1 joint, bony structures are most responsible for stability and motion, while at the C1-C2 joint, ligamentous structures provide greater stability and motion compared to the bony elements.
A fundamental understanding of the biomechanics of the CVJ is important for spinal surgeons, physical therapists, and biomechanical engineers. In this chapter, we will review basic biomechanical and physiological properties of the CVJ, and then discuss common changes in biomechanics that occur via trauma and degenerative disease. This will provide the foundation for a brief discussion on techniques for the fixation of the craniovertebral junction.
The biomechanical features of the CVJ arise from the unique characteristics of the structures that comprise this region. It is first important to examine the osteology, joints, ligamentous structures, and blood supply that make up the CVJ.
The osteology of the CVJ consists of three unique bones: the occiput, atlas (C1), and axis (C2). The occiput is the most inferior bone of the skull. The atlas and axis are the first and second cervical vertebrae, respectively.
The occiput is a thin bone that contributes to the calvaria and base of the skull. Its posterior surface is firmly attached to the parietal bones through the lamboid suture. Its lateral surfaces are attached to the temporal bones through the occipitomastoid sutures. Anteriorly, the occiput is attached to the sphenoid bone. On the posterior surface, a large, vertically oriented protuberance projects outwards, which at its highest point is referred to as the inion, which forms the attachment of the ligamentum nuchae. The occiput is especially notable for a large, triangular shaped hole in its inferior surface known as the foramen magnum, through which the brainstem and spinal cord connect at the cervicomedullary junction. A pair of occipital condyles lie anterolateral to the foramen magnum, and constitute the articulation points for the atlas. These articulation points are relatively flat, which limits the axial rotation of the atlanto-occipital joint.
Sagittal view of the occiput, atlas, and axis.
The atlas is ring-shaped, and contains two upward projecting lateral masses. These lateral masses articulate superiorly with the occipital condyles, forming the atlanto-occipital joint. Inferiorly, they form the atlanto-axial joint by articulating with the superior articular process of the axis. Through these two joints, they form a bridge between occiput and axis. The lateral masses are connected to each other by an anterior and a posterior arch that form a round outline to the spinal canal. The anterior arch is thinner than the posterior arch and is remarkable for a smoothed articulation point that is opposed to the odontoid process of the axis. In a small number of patients, the posterior arch may have a small cleft or rarely, it may have partial or complete aplasia (Gehweiler et al., 1983). The atlas does not have a vertebral body, as the embryological body becomes the odontoid process (dens) of the axis. Consequently, no intervertebral disk exists between the atlas and the axis. Transverse processes protrude horizontally from both sides of the atlas, and they extend more laterally than the transverse processes of the other cervical vertebrae. The foramen transversaria pierce these processes and create a channel through which the vertebral artery flows.
The axis is thicker and narrower than the atlas. On the anterior side, the vertebral body is flanked by two lateral masses. The odontoid process protrudes upwards from the center of the body to articulate with the posterior arch of the atlas, forming the key articulation point for axial rotation of the cervical spine. The lateral masses articulate superiorly with the inferior articular processes of the atlas. The vertebral arch defines the posterior borders of the vertebrae, and encloses a triangular-shaped spinal canal. On the inferior surface of the vertebral arch, the inferior articular processes of the axis protrude downward and articulate with the superior articular processes of C3. These are located posterior to the superior articular processes of the axis, approximately equidistant from the anterior and posterior portions of the bone. Small transverse processes protrude laterally from between the articular processes and contain transverse foramen. The lamina and spinous process constitute the remainder of the vertebral arch. The spinous process is often, but not always, bifid (Martin et al., 2010).
Articulation between the atlas and the axis.
The CVJ consists of two synovial joints: the atlanto-occipital joint and the atlanto-axial joint. Each of these joints has unique anatomical and functional characteristics that contribute to the complex motion of the CVJ.
The atlanto-occipital joint is formed from articulation between the occipital condyles and the superior articular processes of the atlas. The articular processes of this joint are flat, which limits axial rotation and stabilizes flexion and extension. Each articulation forms a synovial joint surrounded by capsular ligaments.
The atlanto-axial joint has two distinct articulation points that act together to enable axial rotation. The first is a set of lateral articulations that are formed between the inferior articular processes of the atlas and the superior articular processes of the axis. The second set of articulations is formed between the odontoid process of the axis and the anterior arch of the atlas. The odontoid process functions as a pivot, and the lateral articulations permit ample rotation. Unlike the relatively flattened articular surfaces of the atlanto-occipital joint, the articular processes of the atlanto-axial joint are biconcave (Swartz et al., 2005). Loose and thin capsular joint ligaments surround the articulations in the CVJ complex, permitting a wide range of motion (Debernardi et al., 2011).
Eight main ligaments support the CVJ: the tectorial membrane, the alar ligament, the cruciate ligament, the apical ligament, capsular joints, accessory atlantoaxial ligament, and the anterior and posterior atlanto-occipital membranes (Debernardi et al., 2011).
The tectorial membrane is a longitudinal ligament that begins inferiorly as part of the posterior longitudinal ligament of the vertebral column and extends upward to become continuous with the cranial dura mater. It was initially thought that the tectorial membrane functioned to limit extension of the CVJ. However, more recent evidence suggests that the tectorial membrane prevents anterior spinal cord compression by the odontoid process (Tubbs et al., 2007).
The alar ligament is shaped like a flattened V and connects the anterior and superior portion of the odontoid process to the lateral masses of the atlas and to the occiput. (Debernardi et al., 2011). It functions to limit axial rotation of the atlanto-axial joint (Dvorak & Panjabi, 1987).
The cruciate ligament is a thick, cross-shaped ligament with vertical and transverse components. The vertical component travels from the body of the axis to the clivus, while the transverse component (also called the transverse atlantal ligament or transverse ligament) extends from the medial side of the lateral masses of the axis and encloses the articulation formed between the odontoid process and the anterior arch of the atlas. The transverse portion of the cruciate ligament functions as an anatomical seatbelt, pulling the odontoid process tight against its articulation surface on the atlas. The transverse ligament also limits flexion of the CVJ (Debernardi et al., 2011; Panjabi et al., 1991c).
The apical ligament runs between the vertical portion of the cruciate ligament and the anterior atlanto-occipital membrane, connecting the anterior rim of the foramen magnum to the tip of the odontoid process. Some studies suggest that it may be congenitally absent in up to 20% of patients (Tubbs et al., 2000).
The capsular joints enclose the articulations between the occipital condyles and superior articular processes of the atlas, and between the inferior articular processes of the atlas and the superior articular processes of the axis. They also enclose the synovial fluid surrounding the joint and function to limit axial rotation in both joints of the CVJ (Debernardi et al., 2011).
The accessory atlantoaxial ligament connects the body of the axis to the lateral masses of the atlas and then continues cephalad to the occipital bone. In the past, this ligament was thought to be part of the tectorial membrane. However, studies now show that the fibers of these two ligaments are discontinuous (Tubbs et al., 2004). This ligament appears to check the rotation of both CVJ joints. However, its role in preventing hyperrotation is secondary to the function of the alar ligaments (Brolin & Halldin, 2004; Debernardi et al., 2011).
The anterior and posterior atlanto-occipital membranes travel downward to connect the anterior and posterior rims of the foramen magnum to the anterior and posterior arches of the atlas. These ligaments, however, do not appear to be an important contributor to biomechanical stability of the CVJ (Debernardi et al., 2011).
Blood is principally supplied to the CVJ through branches from the vertebral arteries. The vertebral arteries arise from the subclavian arteries and travel superiorly through the transverse foramen of the cervical spinal column. Upon leaving the transverse foramen of C2, the vertebral artery is only minimally protected by dorsal bony structures as compared to when the artery runs through the subaxial spine. It also travels laterally to tunnel through the more lateral transverse foramen of the atlas. Upon leaving the atlas, the vertebral artery turns medially and pierces through the posterior ligaments and dura before ascending through the foramen magnum. As these arteries approach the alar ligament, they anastomose with the apical arcade that surrounds the odontoid process. Because the odontoid process is attached to the body of the axis by a cartilaginous plate, no vascular communication occurs between these portions of the axis (Menezes & Traynelis, 2008).
The CVJ plays an important role in the overall motion of the cervical spine, accounting for 25% of the flexion and extension and up to 50% of the axial rotation of the neck (Menezes & Traynelis, 2008). Although the CVJ consists of two distinct joints (atlanto-occipital and atlanto-axial), it still functions as a single mobile unit, with the atlas acting like a washer between the cervical spine and the occiput. Each of these joints, however, has unique kinematic properties that contribute to the complex motion of the CVJ.
Plain films of the cervical spine in neutral, extension, and flexion positions.
The kinematics of the cervical spine are well established. In one classic study, the range of motion of 150 asymptomatic adults of both genders was determined using a three-dimensional motion measuring device. Each subject was seated in a chair that immobilized the subcervical spine and then subjected to five passive motions: flexion/extension, lateral bending, axial rotation, axial rotation out of maximum flexion, and axial rotation out of maximum extension (table 1). On average, women had a greater range of motion than men. Overall, range of motion decreased with age. Evaluation of these motions is an important component in the examination of patients with suspected cervical injury (Dvorak et al., 1992).
152.7 | 149.3 | 101.1 | 100.0 | 183.8 | 182.4 | 75.5 | 72.6 | 161.8 | 171.5 | |
141.1 | 155.9 | 94.7 | 106.3 | 175.1 | 186.0 | 66.0 | 74.6 | 158.4 | 165.8 | |
131.1 | 139.8 | 83.7 | 88.2 | 157.4 | 168.2 | 71.5 | 85.2 | 146.2 | 153.9 | |
136.3 | 126.9 | 88.3 | 76.1 | 166.2 | 151.9 | 77.7 | 85.6 | 145.8 | 132.4 | |
116.3 | 133.2 | 74.2 | 79.6 | 145.6 | 154.2 | 79.4 | 81.3 | 130.9 | 154.5 |
Kinematic measurements of the cervical spine by gender and age (Reproduced from Dvorak et al., 1992).
Although the atlanto-occiptal joint contributes to flexion, extension, lateral bending, and rotation, cadaveric studies indicate that its principle motion is flexion and extension. This motion is primarily restricted by bony elements (Wolfla, 2006). Approximately 24.5 degrees of motion is possible in flexion and extension, with the majority of motion in the direction of extension (Panjabi et al., 1988). Flexion is ultimately restricted by contact between the odontoid process and the occiput, while extension may be limited by the tectorial membrane. However, some evidence suggests that the tectorial membrane is not involved in limiting extension, but that it may act to reduce spinal cord compression by the odontoid process (Tubbs et al., 2007).
Rotation and lateral bending are both restricted by bony articulation points, tight alar ligaments, and the capsular ligaments, causing them to account for 2.5-7.2 and 3.5-5.5 degrees of motion in a single direction, respectively (Debernardi et al., 2011; Goel et al., 1988; Panjabi et al., 1988). In the horizontal plane, the instantaneous axis of rotation for the atlanto-axial joint is located in the anteromedial foramen magnum (Iai et al., 1993).
The atlanto-axial joint also contributes to flexion, extension, lateral bending, and rotation. However, its primary function has been demonstrated to be rotation. These motions are primarily restricted by ligamentous elements (Wolfla, 2006). In a cadaver, axial rotation in one direction can account for 23.3-38.9 degrees (Goel et al., 1988; Panjabi et al., 1988). Using radiographic studies of live patients, one group confirmed a 38 degree motion, accounting for 77% of the 49 degrees of axial rotation of the cervical spine. Rotation in C3-C7 accounted for an additional 15 degrees, while a 4 degree negative rotation in the atlanto-occipital joint accounted for the remainder of the motion. In other words, rotation of the atlanto-axial joint is accompanied by a smaller rotation of the atlanto-occipital joint in the opposite direction. The odontoid process acts as a pivot point for rotation, with the instantaneous axis of rotation located at the center of this process (Iai et al., 1993). The contralateral alar ligament is pulled tight during rotation, limiting motion. Thus the right alar ligament limits rotation to the left, and the left alar ligament limits rotation to the right (Dvorak & Panjabi, 1987). Capsular joint ligaments also play an important role in limiting atlanto-axial rotation (Debernardi et al., 2011). The accessory atlantoaxial ligament also functions to check rotation. However, its contributions are of questionable significance in the presence of functional alar ligaments (Brolin & Halldin, 2004).
Flexion and extension of the atlanto-axial joint account for a total of 10.1-22.4 degrees of motion, with both directions accounting for about the same range of mobility (Goel et al., 1988; Panjabi et al., 1988). The transverse portion of the cruciate ligament holds the dens tight against the anterior arch of the atlas and limits flexion of the C1-C2 joint. Extension is limited by the bony articulation points, and possibly by the tectorial membrane. An in vivo radiographic study demonstrated that the instantaneous axis for flexion and extension of the atlanto-axial joint is on the posterior surface of the odontoid process, approximately halfway between the base and the tip (Dvorak et al., 1991).
Lateral bending accounts for 6.7-11 degrees of motion in one direction (Iai et al., 1993; Panjabi et al., 1988). As in the atlanto-occipital joint, the alar ligaments, bony articulation points, and capsular ligaments are responsible for maintaining lateral rigidity (Dvorak et al., 1988).
The biomechanical properties of the CVJ can be disrupted by trauma, degenerative disease, neoplasm, infection, iatrogenic injury, and congenital defects. In this chapter, we focus on disruptions due to trauma, rheumatoid arthritis, and Down syndrome..
Trauma to the cervical spine typically occurs through high energy events such as falls, sports injuries, motor vehicle crashes, and diving accidents. CVJ instability should be suspected if there is weakness in the arms, dislocation, subluxation, or any of the radiographic findings listed in table 2 (White & Panjabi, 1990). Destabilization can occur due to fractures of any of the bones and some of the supporting ligaments of the CVJ.
"/>8° | Axial rotation C0-C1 to one side |
"/>1 mm | C0-C1 translation (sagittal plane) |
"/>7 mm | Overhang C1-C2 (total right and left) |
"/>45° | Axial rotation C1-C2 to one side |
"/>4 mm | C1-C2 translation (sagittal plane) |
<13 mm | Posterior body C2-posterior ring of C1 |
Avulsed transverse ligament |
Criteria for CVJ instability (Reproduced from White & Panjabi, 1990)
Although many occipital condyle fractures are asymptomatic, some have the potential to cause major CVJ destabilization. These fractures are classified as type I, type II, and type III fractures. Type I fractures occur from comminution of the occipital condyle without significant bone fragment displacement into the foramen magnum. Excessive axial loading is believed to be the biomechanical cause of these injuries. In rare cases the alar ligament may also be damaged to produce instability. However, a competent contralateral alar ligament and tectorial membrane are generally more than sufficient to maintain stability. Type II fractures occur when a linear fracture crosses over from the base of the skull with extension to the occipital condyle. These fractures remain attached to the base of the skull and are typically stable. Type III fractures occur from condylar avulsion due to excess force form lateral bending or axial rotation (Karam & Traynelis, 2010). The alar ligaments are often compromised in type III fracture, causing them to generally be considered unstable, and the condylar fragments can be displaced into the crowded foramen magnum, which can cause neurovascular injury (Anderson & Montesano, 1988). Damage to the occipital condyle has been modelled in cadaveric studies with progressive, unilateral condylectomies. Hypermobility was noted in all of the motions of the atlanto-occipital joint (flexion, extension, axial rotation, and lateral bending) with a fifty percent resection of the condyle. In the atlanto-axial joint, hypermobility was achieved with 25% resection for flexion and extension, 75% resection for axial rotation, and 100% resection for lateral bending. Taken together, these results indicate that condylar injuries have great potential to disrupt the stability of the atlanto-occipital joint (Vishteh et al., 1999).
Fractures of the atlas most commonly occur in the anterior or posterior arches. The Jefferson fracture, first characterized by Geoffrey Jefferson in 1919, is a lesion of both arches that has unique biomechanical significance (Jefferson, 1919). A classical Jefferson fracture is characterized by two fractures in each of the vertebral arches, resulting in four distinct bone fragments. However, significant variability exists, resulting in fractures with two to five fragments. This fracture can occur as the result of hyperextension of the neck causing a blow to the back of the head which transmits significant force to the CVJ. Alternatively, strong axial forces from an extraphysiological load—such as would occur in a dive into shallow water—cause axial loading on the skull which translates force to the cervical spine through the occipital condyles. This downward load causes the lateral masses of the atlas to spread apart, introducing strain and potential fracture into the thin anterior and posterior arches (Bozkus et al., 2001). In a cadaveric study of atlantal fractures, high-speed axial force produced fragmentation in the classical pattern described by Jefferson. These cervical segments also had significant destabilization, resulting in range of motion increases of 40% in flexion and extension, and 20% in lateral bending (Panjabi et al., 1991b). The axial loading that causes Jefferson fractures is also implicated in the genesis of transverse ligament damage, and the identification of a coexisting ligament injury is of utmost clinical importance. These two pathologies often coexist, causing significantly increased cervical destabilization. The biomechanical changes associated with transverse ligament damage are explained below.
The axis is susceptible to three categories of fractures: fractures of the odontoid process, fractures of the pars interarticularis, and fractures of the axis body. Fractures of the odontoid process and pars interarticularis are the most common, and have the largest effects on CVJ instability.
Fractures of the odontoid process are the most common traumatic lesion of the axis. These are categorized by the location of the fracture, and occur near the tip of the odontoid process (type I), at the junction between the body and the odontoid process (type II), or within the body of the axis (type III). Of these, type II fractures are the most common and the most unstable. One finite element model of type II odontoid fractures suggests that a combination of lateral force and axial rotation are responsible for this fracture. Lateral force causes displacement of the first two vertebrae and places the inferior articular process of the atlas on the odontoid process. Axial rotation in turn puts tension on the alar ligament, placing torque on the dens. These two forces together contribute to fracture and potential displacement of bone into the spinal canal (Puttlitz et al., 2000).
Damage to the pars interarticularis of the axis is referred to as Hangman’s fracture or traumatic spondylolisthesis of the axis. The name Hangman’s fracture has its origins due tothe similarities these axial fractures have to lesions reported in judicial hangings (Rayes et al., 2011). Although once widely believed to contribute to death in many hangings, a study of cervical vertebrae from 34 judicial hanging victims revealed only 6 axial fractures, of which only 3 were Hangman’s fractures (James & Nasmyth-Jones, 1992). However, the biomechanical mechanism of injury is clear. In a judicial hanging, the submental knot pulls upward on the jaw, jerking the head backwards in relation to the neck. The more extensible atlanto-occipital joint is not affected by this movement and the hanging body causes distraction and extension of the subaxial spine. This causes the atlanto-axial joint to undergo abrupt hyperextension, causing compression and fracture in the pars interarticularis. Today, hangman’s fracture is most commonly seen in head-on collisions between automobiles. When a car crashes, the head continues forward relative to the restrained body. This motion, however, cannot explain the hangman’s fracture. When modelled in primates, this form of trauma resulted in antlanto-occipital dislocation, but never axial fracture. The more likely explanation for the hangman’s fracture is rapid backwards deceleration of the head from contact with the steering wheel or dashboard. This results in compressive hyperextension that affects only the craniovertebral junction, causing the axis to fracture (Penning, 1995).
Fractures of the odontoid process.
Of all axial lesions, the biomechanics of surgically-induced transoral odontoidectomy may be the best understood. This procedure is normally used to treat cervicomedullary compression. In a study of cadaveric human spines, transoral odontoidectomy was found to significantly increase translational motion from less than one millimeter in all directions to 10.2, 6.7, and 2.0 millimeters in the anterior-posterior, lateral, and superior-inferior directions, respectively. Surprisingly, axial rotation had no quantitative change. However, lateral bending, flexion, and extension increased by 95%, 71%, and 104%, respectively. Each of these changes was principally due to expansion of the neutral zone (Dickman et al., 1995).
Damage to the transverse ligament can occur in isolation, but it usually accompanies damage to other regions of the CVJ, especially fractures of the atlas. Likewise, associated damage to the alar and apical ligaments is also common. The transverse ligament is susceptible to midsubstance tearing, or it can be disrupted by avulsion from the lateral mass of the atlas. In one study, axial loading was shown to cause damage to the transverse ligament, both with and without fractures of the atlas (Panjabi et al., 1991b). Other reports suggest that neck flexion can also cause transverse ligament disruption (Jackson et al., 2002). This explains why head-on collisions are more likely to result in transverse ligament injury than rear-end crashes (Debernardi et al., 2011). Experimental damage to the transverse ligament produces biomechanical instability that is similar to iatrogenic odontoidectomy, resulting in substantially increased translational motion, lateral bending, flexion, and extension (Saldinger et al., 1990).
The alar ligament is most susceptible to injury in rear-end collisions. In this situation, a sudden, unexpected collision of a slightly rotated head induces maximal rotation and whiplash flexion. Since the limitation of axial rotation is the most important function of the alar ligament, this pathological motion produces overstretch and potential rupture (Saldinger, 1990). In cadaveric models, unilateral transection of the alar ligament produced a small increase in axial rotation in the atlanto-axial joint. However, bilateral transection was linked to significant increases in axial rotation, flexion, extension, and lateral bending (Panjabi et al., 1991a).
In the absence of trauma or surgery, the craniovertebral junction tends to remain stable over time. Some congenital conditions can cause CVJ instability and some degenerative conditions, such as osteoporosis, do make the CVJ much more susceptible to fracture with age. Two of the most significant disorders that contribute to CVJ instability are rheumatoid arthritis and Downs syndrome.
Severe rheumatoid arthritis can cause erosion of the bony components of the CVJ. In particular, these degenerative changes can affect the insertions of the transverse ligament into the atlas, causing ligamentous laxity and atlanto-axial instability in 20-86% of patients with rheumatoid arthritis (Krauss et al., 2010). These osteoarthropathies may contribute further instability as they progress to include disruption of the alar ligament, the occipital condyles and the odontoid process. This condition, known as basilar impression, is hallmarked by translation of the odontoid process in the cranial direction and subluxation or dislocation of the atlanto-occipital joint (Martin et al., 2010). Additionally, an odontoid pannus often develops, which has the potential to compress the spinal cord (Krauss et al., 2010). A recent study using computed tomography (CT) of patients with rheumatoid arthritis in the cervical spine reported instability in sagittal translation in a large percentage of patients. In this study, 8 of 24 patients had occipital condyle deformity, while 15 of 24 had lesions in one or more lateral masses of the axis. Damage to the condyles caused the atlanto-occipital joint to undergo translation in the posterior direction during flexion. In contrast, deformity in the lateral masses caused the atlanto-axial joint caused translation in the anterior and inferior directions during flexion. These movements contribute to pathological instability that should be considered when working with rheumatoid arthritis patients (Takatori et al., 2010).
Down syndrome is a relatively common genetic disease which is associated with craniocervical instability. Although the majority of these cases are asymptomatic, radiographic screening is still recommended before competition in athletic events like the Special Olympics. Instability can be due to abnormalities in either the atlanto-occipital or atlanto-axial junction (Hankinson & Anderson, 2010). Two main hypotheses have been proposed to explain the instability of the atlanto-axial joint. First, the occipital condyles and the superior articular processes of the atlas remain flatter than in children without Down syndrome. CT data clearly suggests that the flattened surfaces of these condyles become more rounded as children age. In principle, this abnormal bone formation fails to restrict the lateral and anterior motions of the atlanto-axial joint, resulting in instability (Browd et al., 2006, 2008). The second theory suggests that ligamentous laxity is the principle cause of instability in these patients. However, it is currently unknown which of these two theories explains the majority of the effect. Instability of the atlanto-axial joint is generally due to a loose articulation between the odontoid process and the anterior arch of the atlas. This results in marked instability in rotation, flexion, and extension. The cause of this instability is probably due to a combination of factors. These may include disconnection of the odontoid process from the body of the axis (os odontoideum) and ligamentous laxity due to collagen defects and chronic inflammation. Proper management of these instabilities is essential before these patients compete in contact sports or organized, strenuous events (Hankinson & Anderson, 2010).
The complex anatomy of the CVJ introduces significant challenges to appropriate fixation. Fortunately, many of the fractures of the cervical spine can be treated nonsurgically with orthosis alone. However, multiple fractures, fracture displacement, instability and neurological compression are all factors that can require surgical intervention. Although a thorough treatment of CVJ fixation is beyond the scope of this chapter, it is important that certain principles of fixation be understood when considering proper surgical fixation of the CVJ.
Fixation to the occiput is best accomplished through the use of screws and rods/plates. In pull-out experiments, bicortical screws resisted 50% more force than unicortical screws or wires. The most stable location for screw placements was within the midline keel of the occiput (Haher et al., 1999). The thickness of the occipital protuberance decreases significantly in the lateral and caudal bone. Therefore, screws placed at or just lateral to the keel have the most pullout resistance. In one cadaveric study, constructs utilizing screws placed in the lateral occiput were found to better resist lateral bending, while screws placed more medially were better for resisting axial rotation. These considerations make the evaluation of individual patient characteristics vital in the selection of fixation technique (Anderson et al., 2006; Steinmetz et al., 2010).
The atlas can be a challenging site for fixation, especially when it is disrupted by CVJ pathology. Although the lateral masses can accept sublaminar wiring, lateral mass screws withstand greater pullout forces. Bicortical placement should also be utilized, as it also appears to enhance pullout resistance (Steinmetz et al., 2010). However, caution should be used when using bicortical screws, as the internal carotid artery can be at risk for puncture in a subset of patients (Currier et al., 2008). Another successful approach has been to place screws that penetrate both the posterior arch and the lateral mass (Tan et al., 2003).
Fixation to the axis can be accomplished through sublaminar wiring, or through screws placed in the pedicle or lamina. Alternatively, screws may be placed transarticularly, allowing them to span both the atlas and the axis (Steinmetz et al., 2010).
Once a plan has been made to place screws, wires, rods or plates, constructs and longitudinal members must be developed to stabilize the CVJ. Since the atlanto-axial joint is responsible for the axial rotation, stabilization of pathological rotation can be accomplished by fixation of the atlas to the axis. This is best accomplished through transarticular screws (Oda et al., 1999). A screw that goes through the lateral mass of the atlas and then through the axis can also be effective, although this method has been shown to provide significantly less stiffness (Finn et al., 2008). Although the principle motion of the atlanto-occipital joint is flexion and extension, stabilization of this motion cannot be adequately prevented with fixation of the occiput to the atlas. However, fixation of the occiput to the axis can produce optimal stabilization of aberrant flexion and extension (Hurlbert et al., 1999; Steinmetz et al., 2010).
The craniovertebral junction is an intricate structure with unique anatomy and complex biomechanical characteristics. These characteristics allow for significant flexion, extension, and axial rotation with remarkable stability under normal circumstances. However, trauma, degenerative disease, and some congenital disorders can cause instability in this region. A thorough understanding of the biomechanics of the CVJ is necessary to design strategies to stabilize the pathologies of the upper cervical spine.
Hysterectomy is one of the most commonly performed surgeries in the United States. In fact, Merrill et al. reported a 45% lifetime risk of hysterectomy [1] with an overall rate of 5.4 per 1000 women per year. The majority of hysterectomies are performed for benign gynecologic conditions—that is, the presence of fibroids. Other indications include abnormal uterine bleeding, uterovaginal prolapse, and pelvic pain. Hysterectomy can be performed via multiple routes—abdominally, laparoscopically (including robotic approach), or vaginally. Vaginal and laparoscopic procedures are considered minimally invasive surgical approaches based on the ability to avoid a large abdominal incision. These routes of hysterectomy are associated with shortened hospitalization and postoperative recovery when compared to the abdominal approach. As a result, analysis of U.S. surgical data demonstrates evolving practice patterns with an increase in minimally invasive hysterectomies and a decrease in abdominal hysterectomies [2, 3].
The Centers for Disease Control and Prevention defines surgical site infection (SSI) as an infection that occurs after surgery near the surgical site within 30 days following surgery or 90 days where an implant is involved. They can range from superficial infections involving skin, or more serious infections involving tissues underneath the skin, organs, or implanted materials. As such, SSI is classified as superficial, deep, or organ/space. The CDC monitors SSI via the National Healthcare Safety Network with reported SSI rates of 1.7% and 0.9% after abdominal and vaginal hysterectomy respectively [4].
In a retrospective cohort study of 23,366 patients undergoing laparoscopic and abdominal hysterectomy between the years 2005 and 2011, 783 (3%) developed a surgical site infection. The majority of these were wound infections with approximately ¼ of cases being infections of the organ space which represents 0.7% of the entire cohort [5]. A more recent large cohort study examining patients between the years 2012 and 2015 demonstrated a 2% incidence of postoperative infection after hysterectomy [6]. When stratified between abdominal versus minimally invasive approaches, the incidence of SSI in the abdominal hysterectomy group exceeded 1%, while the incidences in the other groups were 0.2–0.3% [7, 8, 9].
It is well known that postoperative infections are associated with increased patient morbidity and mortality, and may result in additional costs, extended hospital stays, and prolonged antibiotic use. On average, patients who had an SSI following hysterectomy incur twice the cost of care of their counterparts who did not have an SSI. In a study examining the clinical and economic burden of surgical site infection following hysterectomy, the highest cost owing to SSI ($19,203; 95% CI 17,260–21,365) was for abdominal hysterectomy. In addition, those who had SSI had a mean length of stay (LOS) that was between three and fivefold the LOS of those who did not have an SSI irrespective of surgical approach [10]. SSI following index surgery is also associated with a significantly greater percentage of hospital readmissions. Surgical site infections after hysterectomy have serious implications on patient care and healthcare as a whole. This chapter will review the current literature on surgical site infection (SSI) after hysterectomy for benign indications and address various methods of prevention and treatment.
There are a variety of factors that influence the route of hysterectomy including informed patient preference, accessibility of the uterus, extent of extrauterine disease, size and shape of the vagina and uterus, concurrent procedures, available hospital technology and support, the nature of the case
Evidence supports that the vaginal approach is associated with better outcomes when compared with other approaches to hysterectomy. A Cochrane review analyzing 47 randomized control trials with a total of 5,102 women determined that vaginal hysterectomy resulted in quicker return to normal activity when compared to abdominal hysterectomy. There was no difference in satisfaction, quality of life, and surgical complications. Similarly, laparoscopic hysterectomy also resulted in more rapid recovery, fewer febrile episodes, and lower incidence of SSI when compared to the abdominal approach [12]. In this systematic review, there were no advantages of laparoscopic over vaginal hysterectomy. In addition, the laparoscopic approach was associated with longer operating times and increased rates of urinary tract injuries [13]. As a result, a vaginal approach continues to be the preferred route of hysterectomy.
When it is not feasible to perform a vaginal hysterectomy, a surgeon must choose between a laparoscopic or an open abdominal approach. A Cochrane review demonstrated faster return to normal activity, shorter hospital stay, fewer infections, and improved quality of life in patients undergoing laparoscopic versus abdominal hysterectomy. However, operating times were longer with higher rates of lower urinary tract (bladder and ureter) injuries in the laparoscopy group [13].
When stratified by the type of hysterectomy
When stratified into various forms of laparoscopic hysterectomy including robotic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and single-port hysterectomy, the authors concluded that more research was needed to determine if there is in fact, a benefit over conventional laparoscopic approaches. The largest study available on single port laparoscopy in gynecology was a retrospective study from Cleveland Clinic reviewing a total of 908 cases. The authors concluded that single port access was safe and feasible in gynecologic surgery inclusive of both malignant and premalignant conditions with a low rate of adverse outcomes. Perhaps the most prevalent adverse outcome is an increased risk of incisional hernia with a rate of 5.5% [15, 16]. Well-designed studies that compare outcomes of alternative hysterectomy routes (robotic, laparoscopic assisted vaginal, and single-port) are needed to determine if patients may benefit from these other approaches.
Although minimally invasive routes to hysterectomy remain the preferred approach, open abdominal hysterectomy is still an important surgical option for some patients. Open abdominal hysterectomy may become necessary in a variety of clinical scenarios including failure of to maintain a minimally invasive approach.
Preoperative medical optimization is critically important in risk reduction for SSI prior to hysterectomy. Eliminating particular risk factors for SSI contributes vastly to perioperative care. This includes taking an in-depth medical history, performing a comprehensive physical exam, and addressing the patient’s medical comorbidities. Patients should be counseled on modifiable and nonmodifiable risk factors such as smoking status, diabetes stabilization, anatomic anomalies, renal comorbidities, hydrosalpinx, endometrioma, prior laparotomy, and untreated pelvic inflammatory disease (PID) or bacterial vaginosis [17, 18, 19, 20]. Optimal diabetes control is critical in preventing postoperative SSI with both spot glucose levels ≤200 mg/dl and hemoglobin A1C levels below 8.5–9.0% [21, 22].
Preoperative screening for genital tract infections is generally not necessary; however, certain types of infections are clinically important prior to hysterectomy. It has been well established that bacterial vaginosis (BV) is associated with an increased risk of postoperative cuff cellulitis and subsequent pelvic abscess formation after hysterectomy [23]. Treatment of BV prior to scheduled hysterectomy will decrease this risk.
Practicing safe, high-quality, evidence-based operating room care begins first with accurate identification of the patient, surgical site, and procedure.
In an AAGL white paper, “Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery”, infection prophylaxis can be achieved via the implementation of SSI prevention bundles [24]. Quality or safety bundles provide a framework for the implementation of evidence-based practices. They have been validated across multiple disciplines to actually decrease SSI [25, 26, 27, 28]. The ACOG Council on Patient Safety in Women’s Health Care has published a consensus bundle on prevention of SSI prior to gynecologic surgery. This provides a framework for hospitals to develop, implement, and practice evidence-based prevention of SSIs [29].
An example of a hysterectomy bundle is as follows:
The degree of contamination at the time of surgery is classified using the National Healthcare Safety Network (NHSN) wound class. Hysterectomy is a clean-contaminated procedure and as a result, is unavoidably associated with a relatively higher risk of infection as the procedure breaches the genital tract. Common sites of infection after hysterectomy include the abdominal wall, the vaginal cuff, bladder, and pelvic floor. Related complications include pelvic abscess or infected hematoma and sepsis. A patient’s individual susceptibility to infection depends on a variety of factors including bacterial virulence, extent of surgery-related tissue trauma and fluid collection, the effectiveness of the patient’s immune system, age, nutritional status, presence of diabetes, smoking, coexistent infection or colonization with microorganisms. Perhaps the most important factors in SSI prevention in hysterectomy are timely administration of appropriate preoperative antibiotics and meticulous surgical technique. Use of β-lactam alternatives in patients who do not report an anaphylactic reaction can lead to increased antimicrobial resistance. In fact, a retrospective cohort study involving over 21,000 women undergoing hysterectomy demonstrated that the use of standard β-lactam antibiotics had a lower risk of SSI compared to those who received an alternative regimen [23]. Thus, we advise judicious use of β-lactam alternatives for patients with a history of IgE-mediated penicillin hypersensitivity. The most common organisms isolated from vaginal cuff infections are anaerobes. In a large retrospective cohort study with over 18,000 patients undergoing hysterectomy of any type, those receiving cefazolin or a second-generation cephalosporin have more than double the SSI risk compared with those receiving combined treatment with cefazolin and metronidazole [25]. This is likely related to enhanced anaerobic coverage with the addition of metronidazole. We recommend that all patients undergoing hysterectomy receive metronidazole in addition to the standard intraoperative antibiotics.
The CDC also advises that the entire body be cleansed with either soap or antiseptic the night prior to the procedure. Intraoperatively, alcohol-based chlorhexidine is more effective for skin preparation when compared to iodine solutions [30, 31]. With regards to vaginal preparation, either povidone-iodine or chlorhexidine gluconate (4%) with a low concentration of isopropyl alcohol is acceptable, as both significantly reduce rates of postoperative infectious morbidity [32].
In general, our practice will have patients return for short-term postoperative evaluation within 2 weeks following their hysterectomy. Patients are counseled to maintain pelvic rest for a minimum of 8 weeks. Postoperative blood and other secretions from the vaginal cuff may raise the vaginal pH and as a result, increase the risk of bacterial vaginosis. Many patients with vaginal cuff infections present more than 2 weeks following hysterectomy, which suggests a late ascending spread of vaginal microorganisms. As a result, our patients return for a second postoperative appointment and vaginal cuff check approximately 4–6 weeks after their hysterectomy.
Gynecological surgical site infections are polymicrobial with a mix of both anaerobic and aerobic infections. Common pathogens contain gram-negative bacilli, enterococci, streptococci, and anaerobes
Wound exploration and debridement are pillars in the management of superficial and deep-incisional SSIs. This includes not only opening the wound, debridement of necrotic and devitalized tissue, but also involves the culture of the wound to allow for speciation of potential pathogens to assist in antibiotic therapy.
The mortality and morbidity of organ/space SSI tend to be higher than superficial or deep SSI. The primary objective in management is to achieve source control. Computed tomography and ultrasound are employed to guide placement of closed suction percutaneous drains into abscess collections when feasible. The initial approach in treatment of post-hysterectomy pelvic abscess depends on three factors: (1) hemodynamic stability, (2) abscess size, and (3) abscess location. Hemodynamically unstable patients require prompt surgical intervention and intensive care monitoring.
Patients who are hemodynamically stable with a post-hysterectomy pelvic abscess should be treated empirically with parenteral broad-spectrum antibiotics. Initial antimicrobial regimens can be tailored to subsequent culture and sensitivity results. If the patient does not respond within 48–72 hours, percutaneous drainage or infectious disease consultation may be warranted. An argument can be made for earlier percutaneous drainage. In fact, a systematic review comparing the success rates of 3 modalities of minimally invasive management of tubo-ovarian abscesses—laparoscopy, ultrasound-guided drainage and computed tomography-guided drainage
Treatment failure is defined as persistent fever, leukocytosis, pain or lack of abscess resolution. Risk factors include residual fluid collection after drainage and increasing patient age. Surgical management is recommended at this time.
The most common reason for unplanned readmission after surgery is surgical site infection. SSIs are associated with increased morbidity, mortality, transfer to an intensive care setting, prolonged hospitalization, hospital readmission, and increased healthcare costs. In addition, the development of SSI negatively impacts patient experience.
The majority of postoperative issues can be anticipated and prevented preoperatively. Systematically addressing these issues at the preoperative evaluation may result in greater patient satisfaction and fewer complications. Thus, prevention of SSI after hysterectomy begins with a calculation of perioperative risk followed by addressing those risk factors prior to the procedure. Intraoperative measures aimed at SSI prevention include the implementation of evidence-based SSI prevention bundles, proper administration of intraoperative antibiotic prophylaxis, and proper skin/vaginal preparation. Postoperatively, hysterectomy patients should be followed closely.
Thanks to the faculty, residents, fellows, and medical students of the Zucker School of Medicine.
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The CC BY 3.0 and CC BY 4.0 license permits Works to be freely shared in any medium or format, as well as the reuse and adaptation of the original contents of Works (e.g. figures and tables created by the Authors), as long as the source Work is cited and its Authors are acknowledged in the following manner:
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\n\nAll Works published on the IntechOpen platform and in print are licensed under a Creative Commons Attribution 3.0 Unported and Creative Commons 4.0 International License, a license which allows for the broadest possible reuse of published material.
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The CC BY 3.0 and CC BY 4.0 license permits Works to be freely shared in any medium or format, as well as the reuse and adaptation of the original contents of Works (e.g. figures and tables created by the Authors), as long as the source Work is cited and its Authors are acknowledged in the following manner:
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\n\nDISCLAIMER: Neither the CC BY 3.0 license, CC BY 4.0, nor any other license IntechOpen currently uses or has used before, applies to figures and tables reproduced from other works, as they may be subject to different terms of reuse. In such cases, if the copyright holder is not noted in the source of a figure or table, it is the responsibility of the User to investigate and determine the exact copyright status of any information utilised. Users requiring assistance in that regard are welcome to send an inquiry to permissions@intechopen.com.
\n\nAll rights to Books and Journals and all other compilations published on the IntechOpen platform and in print are reserved by IntechOpen.
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\n\nAll Book cover design elements, as well as Video image graphics are subject to copyright by IntechOpen.
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\n\nAll Video Lectures under IntechOpen's production are subject to copyright and are property of IntechOpen, unless defined otherwise, and are licensed under the Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) license. This grants all others the right to:
\n\nShare — copy and redistribute the material in any medium or format
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\n\nAll software used on the IntechOpen platform, any used during the publishing process, and the copyright in the code constituting such software, is the property of IntechOpen or its software suppliers. As such, it may not be downloaded or copied without permission.
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Stienen, Pooyan Sadr-Eshkevari, Nora Prochnow, Nora Sandu, Benham Bohluli and Bernhard Schaller",authors:[{id:"78171",title:"Prof.",name:"Bernhard",middleName:null,surname:"Schaller",slug:"bernhard-schaller",fullName:"Bernhard Schaller"},{id:"78525",title:"Mr.",name:"Amr",middleName:null,surname:"Abdulazim",slug:"amr-abdulazim",fullName:"Amr Abdulazim"},{id:"78530",title:"Dr",name:"Pooyan",middleName:null,surname:"Sadr-Eshkevari",slug:"pooyan-sadr-eshkevari",fullName:"Pooyan Sadr-Eshkevari"},{id:"126039",title:"Dr.",name:"Martin",middleName:"Nikolaus",surname:"Stienen",slug:"martin-stienen",fullName:"Martin Stienen"},{id:"126040",title:"Dr.",name:"Nora",middleName:null,surname:"Prochnow",slug:"nora-prochnow",fullName:"Nora Prochnow"},{id:"126041",title:"Dr.",name:"Benham",middleName:null,surname:"Bohluli",slug:"benham-bohluli",fullName:"Benham Bohluli"}]},{id:"26863",doi:"10.5772/26362",title:"The Bearing Surfaces in Total Hip Arthroplasty – Options, Material Characteristics and Selection",slug:"the-bearing-surfaces-in-total-hip-arthroplasty-options-material-characteristics-and-selection",totalDownloads:9531,totalCrossrefCites:10,totalDimensionsCites:21,abstract:null,book:{id:"938",slug:"recent-advances-in-arthroplasty",title:"Recent Advances in Arthroplasty",fullTitle:"Recent Advances in Arthroplasty"},signatures:"Hamid Reza Seyyed Hosseinzadeh, Alireza Eajazi and Ali Sina Shahi",authors:[{id:"66361",title:"Dr.",name:"Alireza",middleName:null,surname:"Eajazi",slug:"alireza-eajazi",fullName:"Alireza Eajazi"},{id:"74857",title:"Dr.",name:"Hamid Reza",middleName:null,surname:"Seyyed Hosseinzadeh",slug:"hamid-reza-seyyed-hosseinzadeh",fullName:"Hamid Reza Seyyed Hosseinzadeh"},{id:"173207",title:"Dr.",name:"Alisina",middleName:null,surname:"Shahi",slug:"alisina-shahi",fullName:"Alisina Shahi"}]}],mostDownloadedChaptersLast30Days:[{id:"65467",title:"Anesthesia Management for Large-Volume Liposuction",slug:"anesthesia-management-for-large-volume-liposuction",totalDownloads:6231,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"The apparent easiness with which liposuction is performed favors that patients, young surgeons, and anesthesiologists without experience in this field ignore the many events that occur during this procedure. Liposuction is a procedure to improve the body contour and not a surgery to reduce weight, although recently people who have failed in their plans to lose weight look at liposuction as a means to contour their body figure. Tumescent liposuction of large volumes requires a meticulous selection of each patient; their preoperative evaluation and perioperative management are essential to obtain the expected results. The various techniques of general anesthesia are the most recommended and should be monitored in the usual way, as well as monitoring the total doses of infiltrated local anesthetics to avoid systemic toxicity. The management of intravenous fluids is controversial, but the current trend is the restricted use of hydrosaline solutions. The most feared complications are deep vein thrombosis, pulmonary thromboembolism, fat embolism, lung edema, hypothermia, infections and even death. The adherence to the management guidelines and prophylaxis of venous thrombosis/thromboembolism is mandatory.",book:{id:"6221",slug:"anesthesia-topics-for-plastic-and-reconstructive-surgery",title:"Anesthesia Topics for Plastic and Reconstructive Surgery",fullTitle:"Anesthesia Topics for Plastic and Reconstructive Surgery"},signatures:"Sergio Granados-Tinajero, Carlos Buenrostro-Vásquez, Cecilia\nCárdenas-Maytorena and Marcela Contreras-López",authors:[{id:"273532",title:"Dr.",name:"Sergio Octavio",middleName:null,surname:"Granados Tinajero",slug:"sergio-octavio-granados-tinajero",fullName:"Sergio Octavio Granados Tinajero"}]},{id:"42855",title:"Critical Care Issues After Major Hepatic Surgery",slug:"critical-care-issues-after-major-hepatic-surgery",totalDownloads:8939,totalCrossrefCites:2,totalDimensionsCites:2,abstract:null,book:{id:"3164",slug:"hepatic-surgery",title:"Hepatic Surgery",fullTitle:"Hepatic Surgery"},signatures:"Ashok Thorat and Wei-Chen Lee",authors:[{id:"52360",title:"Prof.",name:"Wei-Chen",middleName:null,surname:"Lee",slug:"wei-chen-lee",fullName:"Wei-Chen Lee"},{id:"157213",title:"Dr.",name:"Ashok",middleName:null,surname:"Thorat",slug:"ashok-thorat",fullName:"Ashok Thorat"}]},{id:"72175",title:"Fontan Operation: A Comprehensive Review",slug:"fontan-operation-a-comprehensive-review",totalDownloads:1308,totalCrossrefCites:3,totalDimensionsCites:3,abstract:"Since the first description of the Fontan operation in the early 1970s, a number of modifications have been introduced and currently staged, total cavopulmonary connection with fenestration has become the most commonly used multistage surgery in diverting the vena caval blood flow into the lungs. The existing ventricle, whether it is left or right, is utilized to supply systemic circuit. During Stage I, palliative surgery is performed, usually at presentation in the neonatal period/early infancy, on the basis of pathophysiology of the cardiac defect. During Stage II, a bidirectional Glenn procedure is undertaken in which the superior vena caval flow is diverted into the lungs at an approximate age of 6 months. During Stage IIIA, the blood flow from the inferior vena cava (IVC) is rerouted into the pulmonary arteries, typically by an extra-cardiac conduit along with a fenestration, generally around 2 years of age. During Stage IIIB, the fenestration is closed by transcatheter methodology 6–12 months after Stage IIIA. The evolution of Fontan concepts, the indications for Fontan surgery, and the results of old and current types of Fontan operation form the focus of this review.",book:{id:"9585",slug:"advances-in-complex-valvular-disease",title:"Advances in Complex Valvular Disease",fullTitle:"Advances in Complex Valvular Disease"},signatures:"P. Syamasundar Rao",authors:[{id:"68531",title:"Dr.",name:"P. Syamasundar",middleName:null,surname:"Rao",slug:"p.-syamasundar-rao",fullName:"P. Syamasundar Rao"}]},{id:"45712",title:"Serdev Sutures® in Middle Face",slug:"serdev-sutures-in-middle-face",totalDownloads:4967,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"2989",slug:"miniinvasive-face-and-body-lifts-closed-suture-lifts-or-barbed-thread-lifts",title:"Miniinvasive Face and Body Lifts",fullTitle:"Miniinvasive Face and Body Lifts - Closed Suture Lifts or Barbed Thread Lifts"},signatures:"Nikolay Serdev",authors:[{id:"32585",title:"Dr.",name:"Nikolay",middleName:null,surname:"Serdev",slug:"nikolay-serdev",fullName:"Nikolay Serdev"}]},{id:"55812",title:"Postural Restoration: A Tri-Planar Asymmetrical Framework for Understanding, Assessing, and Treating Scoliosis and Other Spinal Dysfunctions",slug:"postural-restoration-a-tri-planar-asymmetrical-framework-for-understanding-assessing-and-treating-sc",totalDownloads:7712,totalCrossrefCites:0,totalDimensionsCites:1,abstract:"Current medical practice does not recognize the influence of innate, physiological, human asymmetry on scoliosis and other postural disorders. Interventions meant to correct these conditions are commonly based on symmetrical models of appearance and do not take into account asymmetric organ weight distribution, asymmetries of respiratory mechanics, and dominant movement patterns that are reinforced in daily functional activities. A model of innate, human asymmetry derived from the theoretical framework of the Postural Restoration Institute® (PRI) explicitly describes the physiological, biomechanical, and respiratory components of human asymmetry. This model is important because it gives an accurate baseline for understanding predisposing factors for the development of postural disorders, which, without intervention, will likely progress to structural dysfunction. Clinical tests to evaluate tri-planar musculoskeletal relationships and function, developed by PRI, are based on this asymmetric model. These tests are valuable for assessing patient’s status in the context of human asymmetry and in guiding appropriate exercise prescription and progression. Balancing musculoskeletal asymmetry is the aim of PRI treatment. Restoration of relative balance decreases pain, restores improved alignment, and strengthens appropriate muscle function. It can also halt the progression of dysfunction and improve respiration, quality of life, and appearance. PRI’s extensive body of targeted exercise progressions are highly effective due to their basis in the tri-planar asymmetric human model.",book:{id:"5816",slug:"innovations-in-spinal-deformities-and-postural-disorders",title:"Innovations in Spinal Deformities and Postural Disorders",fullTitle:"Innovations in Spinal Deformities and Postural Disorders"},signatures:"Susan Henning, Lisa C. Mangino and Jean Massé",authors:[{id:"204825",title:"Dr.",name:"Susan",middleName:null,surname:"Henning",slug:"susan-henning",fullName:"Susan Henning"},{id:"206242",title:"Dr.",name:"Lisa C",middleName:null,surname:"Mangino",slug:"lisa-c-mangino",fullName:"Lisa C Mangino"},{id:"206245",title:"Dr.",name:"Jean",middleName:null,surname:"Massé",slug:"jean-masse",fullName:"Jean Massé"}]}],onlineFirstChaptersFilter:{topicId:"202",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"82020",title:"Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Novel Technique and Technology with Case Series",slug:"minimally-invasive-transforaminal-lumbar-interbody-fusion-a-novel-technique-and-technology-with-case",totalDownloads:6,totalDimensionsCites:0,doi:"10.5772/intechopen.105187",abstract:"Minimally invasive spine surgery (MIS) transforaminal lumbar interbody fusion (MI-TLIF) has been utilized to treat a variety of spinal disorders. Like other minimally invasive spine surgery techniques and technology, the MI-TLIF approach has the potential to limit the morbidity associated with larger exposures required for open surgery. The MI-TLIF approach has a number of advantages over many other minimally invasive spine surgery approaches including direct decompression of neural elements, collection of morselized autograph from the surgical site to achieve high fusion rates, restoration of spinal canal diameter, foraminal diameter, disk height, and reduction of spondylolisthesis. In this chapter, we discuss a novel technique for performing MI-TLIF developed by the senior author who is a leading minimally invasive spine surgeon. The technique and technology illustrated in this chapter were developed out of a recognition of a need to reduce the learning curve for performing MI-TLIF, as well as need for a cost-effective method that provides a high fusion rate, excellent clinical outcomes, and low complication rate. The indications, surgical planning, postoperative care, complications, and patient outcomes in a large series will be reviewed using this novel MI-TLIF technique.",book:{id:"10634",title:"Minimally Invasive Spine Surgery - Advances and Innovations",coverURL:"https://cdn.intechopen.com/books/images_new/10634.jpg"},signatures:"Mick Perez-Cruet, Ramiro Pérez de la Torre and Siddharth Ramanathan"},{id:"78335",title:"Safety and Efficiency of Cervical Disc Arthroplasty in Ambulatory Surgery Centers",slug:"safety-and-efficiency-of-cervical-disc-arthroplasty-in-ambulatory-surgery-centers",totalDownloads:5,totalDimensionsCites:0,doi:"10.5772/intechopen.99589",abstract:"Introduction Anterior cervical surgeries have been safely performed in ambulatory surgery centers since 1995 with the first cases being one level anterior cervical discectomies without fusion, then in 1996, one level anterior cervical discectomies with fusion (ACDF). When it is was certain that outpatient fusion was safe, the number of ACDF levels slowly and methodically were increased to the now standard outpatient maximum of four level ACDF. During this evolution, with the introduction of arthroplasty surgery, one level arthroplasties were considered appropriate for outpatient surgery and now two-level outpatient cervical arthroplasties are routine and some three level arthroplasties have been performed with no additional morbidity compared to one level procedures. The author first reported a series of 27 patients in 2010 who underwent cervical disc replacement at an ASC. (Wohns, R. Safety and cost-effectiveness of outpatient cervical disc arthroplasty. Surg. Neurol. Int. 1, 77, 2010). The average operative time was 40 minutes and the patients were observed over a period of three hours prior to discharge. None of the patients had major complications and there were no reports of worsening or persistent pain. The results of a Delphi study in 2018 compared the safety and efficiency of one-level and two-level arthroplasty procedures performed in an ASC and in a hospital setting. (Gornet et al. Safety and Efficiency of Cervical Disc Arthroplasty in Ambulatory Surgery Centers vs Hospital Settings. Int’l J of Spine Surgery. Vol. 12, No.5, 2018, pp. 557-564). The study analyzed outcomes of 145 ASC patients, 348 hospital outpatients and 65 hospital inpatients and the conclusion was that both one and two-level arthroplasties may be performed safely in an ASC. Surgeries in ASCs are of shorter duration and performed with less blood loss without increased AEs. At the present time, there does not appear to be any contra-indication to performing the vast majority of cervical arthroplasties in an ambulatory surgery center (ASC). Furthermore, the cost of an outpatient arthroplasty is commonly 30% to 50% of the cost of hospital-based procedures.",book:{id:"10634",title:"Minimally Invasive Spine Surgery - Advances and Innovations",coverURL:"https://cdn.intechopen.com/books/images_new/10634.jpg"},signatures:"Richard N.W. Wohns"},{id:"82255",title:"Minimally Invasive Laminectomy for Lumbar Stenosis with Case Series of Patients with Multi-level (3 or More Levels) Stenosis",slug:"minimally-invasive-laminectomy-for-lumbar-stenosis-with-case-series-of-patients-with-multi-level-3-o",totalDownloads:28,totalDimensionsCites:0,doi:"10.5772/intechopen.105186",abstract:"Lumbar stenosis is the most common pathology seen and treated by spine surgeons. It is often seen in the elderly population who frequently have multiple medical co-morbidities. Traditional approaches remove the spinous process and detach paraspinous muscles to achieve adequate canal decompression. This approach can damage the posterior tension band leading to permanent muscle damage, scar tissue formation, iatrogenic flatback syndrome, and increase risk of adjacent segment disease requiring reoperation. Performing lumbar laminectomy in a cost-effective manner is critical in effectively treating patients with lumbar stenosis. This chapter reviews a minimally invasive muscle-sparing approach to treating lumbar stenosis. The technique is performed through a tubular retractor. Direct decompression of the spinal stenosis is achieved while preserving the paraspinous muscle attachments and spinous process. This technique has multiple advantages and can potentially reduce load stress on adjacent levels and subsequent adjacent level pathology leading to further surgical intervention. In addition, the procedure shows how facet fusion is performed using the patient’s own locally harvested drilled morselized autograph to achieve bilateral facet fusion. By fusing the facets, we have shown that restenosis at the operative level is less likely to occur. This chapter will review a case series of multilevel lumbar stenosis including clinical outcomes.",book:{id:"10634",title:"Minimally Invasive Spine Surgery - Advances and Innovations",coverURL:"https://cdn.intechopen.com/books/images_new/10634.jpg"},signatures:"Mick Perez-Cruet, Ramiro Pérez de la Torre and Siddharth Ramanathan"},{id:"80705",title:"Cervical Arthroplasty",slug:"cervical-arthroplasty",totalDownloads:38,totalDimensionsCites:0,doi:"10.5772/intechopen.102964",abstract:"Technological advances have allowed spine surgery to follow the trend toward minimally invasive surgery in general. Specifically, we have seen a corresponding rise in the popularity of cervical arthroplasty. For the treatment of cervical disc disease, arthroplasty is a less invasive option than the gold standard of cervical discectomy and arthrodesis, which by nature is more disruptive to surrounding tissues. Arthroplasty preserves the facets, maintains motion, and reduces the rate of adjacent segment breakdown. These factors counteract the negative impacts of fusion while maintaining the benefits. Arthroplasty implants themselves have become more streamlined to implant as well with less native bone destruction, and biomechanics more compatible with the native disc. While initial implants were ball and socket devices with complex fixation and plane-specific movements, later devices incorporated such motions as translation and compression. Viscoelastic components and materials more closely resembling native tissues afford a more biocompatible implant profile. Until cell-based therapies can successfully reproduce native tissue, we will rely on artificial components that closely resemble and assimilate them.",book:{id:"10634",title:"Minimally Invasive Spine Surgery - Advances and Innovations",coverURL:"https://cdn.intechopen.com/books/images_new/10634.jpg"},signatures:"Jason M. Highsmith"},{id:"80605",title:"Minimally Invasive Treatment of Spinal Metastasis",slug:"minimally-invasive-treatment-of-spinal-metastasis",totalDownloads:45,totalDimensionsCites:0,doi:"10.5772/intechopen.102485",abstract:"Advancements in the treatment of systemic cancer have improved life expectancy in cancer patients and consequently the incidence of spinal metastasis. Traditionally, open spinal approaches combined with cEBRT (conventional external beam radiation therapy) allowed for local tumor control as well as stabilization and decompression of the spine and neural elements, but these larger operations can be fraught with one complications and delayed healing as well as additional morbidity. Recently, minimally invasive spine techniques are becoming increasingly popular in the treatment of spinal metastasis for many reasons, including smaller incisions with less perioperative complications and potential for expedited time to radiation therapy. These techniques include kyphoplasty with radiofrequency ablation, percutaneous stabilization, laminectomy, and epidural tumor resection through tubular retractors, as well as minimally invasive corpectomy. These techniques combined with highly conformal stereotactic radiosurgery have led to the advent of separation surgery, which allows for decompression of neural elements while creating space between neural elements and the tumor so adequate radiation may be delivered, improving local tumor control. The versatility of these minimally invasive techniques has significantly improved the modern management of metastatic disease of the spine by protecting and restoring the patient’s quality of life while allowing them to quickly resume radiation and systemic treatment.",book:{id:"10634",title:"Minimally Invasive Spine Surgery - Advances and Innovations",coverURL:"https://cdn.intechopen.com/books/images_new/10634.jpg"},signatures:"Eric R. Mong and Daniel K. Fahim"},{id:"76620",title:"Minimally Invasive Lateral Approach for Anterior Spinal Cord Decompression in Thoracic Myelopathy",slug:"minimally-invasive-lateral-approach-for-anterior-spinal-cord-decompression-in-thoracic-myelopathy",totalDownloads:146,totalDimensionsCites:0,doi:"10.5772/intechopen.97669",abstract:"Myelopathy can result from a thoracic disc herniation (TDH) compressing the anterior spinal cord. Disc calcification and difficulty in accessing the anterior spinal cord pose an operative challenge. A mini-open lateral approach to directly decompress the anterior spinal cord can be performed with or without concomitant interbody fusion depending on pre-existing or iatrogenic spinal instability. Experience using stand-alone expandable spacers to achieve interbody fusion in this setting is limited. Technical advantages, risks and limitations of this technique are discussed. We conducted a retrospective chart review of all patients with thoracic and upper lumbar myelopathy treated with a lateral mini-open lateral approach. Review of the literature identified 6 other case series using similar lateral minimally invasive approaches to treat thoracic or upper lumbar disc herniation showing efficient and safe thoracic disc decompression procedure for myelopathy. This technique can be combined with interbody arthrodesis when instability is suspected.",book:{id:"10634",title:"Minimally Invasive Spine Surgery - Advances and Innovations",coverURL:"https://cdn.intechopen.com/books/images_new/10634.jpg"},signatures:"Edna E. Gouveia, Mansour Mathkour, Erin McCormack, Jonathan Riffle, Olawale A. Sulaiman and Daniel J. Denis"}],onlineFirstChaptersTotal:12},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:11,numberOfPublishedChapters:91,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:108,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:333,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:14,numberOfPublishedChapters:145,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:11,numberOfPublishedChapters:144,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:126,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:23,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:13,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}}]},series:{item:{id:"11",title:"Biochemistry",doi:"10.5772/intechopen.72877",issn:"2632-0983",scope:"Biochemistry, the study of chemical transformations occurring within living organisms, impacts all areas of life sciences, from molecular crystallography and genetics to ecology, medicine, and population biology. Biochemistry examines macromolecules - proteins, nucleic acids, carbohydrates, and lipids – and their building blocks, structures, functions, and interactions. Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. This Biochemistry Series will address the current research on biomolecules and the emerging trends with great promise.",coverUrl:"https://cdn.intechopen.com/series/covers/11.jpg",latestPublicationDate:"August 17th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:33,editor:{id:"31610",title:"Dr.",name:"Miroslav",middleName:null,surname:"Blumenberg",slug:"miroslav-blumenberg",fullName:"Miroslav Blumenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/31610/images/system/31610.jpg",biography:"Miroslav Blumenberg, Ph.D., was born in Subotica and received his BSc in Belgrade, Yugoslavia. He completed his Ph.D. at MIT in Organic Chemistry; he followed up his Ph.D. with two postdoctoral study periods at Stanford University. Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"14",title:"Cell and Molecular Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/14.jpg",isOpenForSubmission:!0,editor:{id:"165627",title:"Dr.",name:"Rosa María",middleName:null,surname:"Martínez-Espinosa",slug:"rosa-maria-martinez-espinosa",fullName:"Rosa María Martínez-Espinosa",profilePictureURL:"https://mts.intechopen.com/storage/users/165627/images/system/165627.jpeg",biography:"Rosa María Martínez-Espinosa is a Full Professor of Biochemistry and Molecular Biology at the University of Alicante, Spain, and has been the vice president of International Relations and Development Cooperation at this university since 2010. She created the research group in applied biochemistry in 2017 (https://web.ua.es/en/appbiochem/), and from 1999 to the present has made more than 200 contributions to Spanish and international conferences. Furthermore, she has around seventy-five scientific publications in indexed journals, eighty book chapters, and one patent to her credit. Her research work focuses on microbial metabolism (particularly on extremophile microorganisms), purification and characterization of enzymes with potential industrial and biotechnological applications, protocol optimization for genetically manipulating microorganisms, gene regulation characterization, carotenoid (pigment) production, and design and development of contaminated water and soil bioremediation processes by means of microorganisms. This research has received competitive public grants from the European Commission, the Spanish Ministry of Economy and Competitiveness, the Valencia Region Government, and the University of Alicante.",institutionString:"University of Alicante",institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"15",title:"Chemical Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",isOpenForSubmission:!0,editor:{id:"441442",title:"Dr.",name:"Şükrü",middleName:null,surname:"Beydemir",slug:"sukru-beydemir",fullName:"Şükrü Beydemir",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003GsUoIQAV/Profile_Picture_1634557147521",biography:"Dr. Şükrü Beydemir obtained a BSc in Chemistry in 1995 from Yüzüncü Yıl University, MSc in Biochemistry in 1998, and PhD in Biochemistry in 2002 from Atatürk University, Turkey. He performed post-doctoral studies at Max-Planck Institute, Germany, and University of Florence, Italy in addition to making several scientific visits abroad. He currently works as a Full Professor of Biochemistry in the Faculty of Pharmacy, Anadolu University, Turkey. Dr. Beydemir has published over a hundred scientific papers spanning protein biochemistry, enzymology and medicinal chemistry, reviews, book chapters and presented several conferences to scientists worldwide. He has received numerous publication awards from various international scientific councils. He serves in the Editorial Board of several international journals. 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He is a member of the Turkish Biochemical Society, American Chemical Society, and German Genetics society. Dr. Ekinci published around ninety scientific papers, reviews and book chapters, and presented several conferences to scientists. He has received numerous publication awards from several scientific councils. 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Kendrekar, MSc, MBA, Ph.D., is currently a visiting scientist at the Lipid Nanostructure Laboratory, University of Central Lancashire, England. He previously worked as a post-doctoral fellow at the Ben-Gurion University of Negev, Israel; University of the Free State, South Africa; and Central University of Technology Bloemfontein, South Africa. He obtained his Ph.D. in Organic Chemistry from Nagaoka University of Technology, Japan. He has published more than seventy-four journal articles and attended several national and international conferences as speaker and chair. Dr. Kendrekar has received many international awards. He has several funded projects, namely, anti-malaria drug development, MRSA, and SARS-CoV-2 activity of curcumin and its formulations. He has filed four patents in collaboration with the University of Central Lancashire and Mayo Clinic Infectious Diseases. His present research includes organic synthesis, drug discovery and development, biochemistry, nanoscience, and nanotechnology.",institutionString:"Visiting Scientist at Lipid Nanostructures Laboratory, Centre for Smart Materials, School of Natural Sciences, University of Central Lancashire",institution:null},{id:"428125",title:"Dr.",name:"Vinayak",middleName:null,surname:"Adimule",slug:"vinayak-adimule",fullName:"Vinayak Adimule",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/428125/images/system/428125.jpg",biography:"Dr. Vinayak Adimule, MSc, Ph.D., is a professor and dean of R&D, Angadi Institute of Technology and Management, India. He has 15 years of research experience as a senior research scientist and associate research scientist in R&D organizations. He has published more than fifty research articles as well as several book chapters. He has two Indian patents and two international patents to his credit. Dr. Adimule has attended, chaired, and presented papers at national and international conferences. He is a guest editor for Topics in Catalysis and other journals. He is also an editorial board member, life member, and associate member for many international societies and research institutions. His research interests include nanoelectronics, material chemistry, artificial intelligence, sensors and actuators, bio-nanomaterials, and medicinal chemistry.",institutionString:"Angadi Institute of Technology and Management",institution:null},{id:"284317",title:"Prof.",name:"Kantharaju",middleName:null,surname:"Kamanna",slug:"kantharaju-kamanna",fullName:"Kantharaju Kamanna",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284317/images/21050_n.jpg",biography:"Prof. K. Kantharaju has received Bachelor of science (PCM), master of science (Organic Chemistry) and Doctor of Philosophy in Chemistry from Bangalore University. He worked as a Executive Research & Development @ Cadila Pharmaceuticals Ltd, Ahmedabad. He received DBT-postdoc fellow @ Molecular Biophysics Unit, Indian Institute of Science, Bangalore under the supervision of Prof. P. Balaram, later he moved to NIH-postdoc researcher at Drexel University College of Medicine, Philadelphia, USA, after his return from postdoc joined NITK-Surthakal as a Adhoc faculty at department of chemistry. Since from August 2013 working as a Associate Professor, and in 2016 promoted to Profeesor in the School of Basic Sciences: Department of Chemistry and having 20 years of teaching and research experiences.",institutionString:null,institution:{name:"Rani Channamma University, Belagavi",country:{name:"India"}}},{id:"158492",title:"Prof.",name:"Yusuf",middleName:null,surname:"Tutar",slug:"yusuf-tutar",fullName:"Yusuf Tutar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/158492/images/system/158492.jpeg",biography:"Prof. Dr. Yusuf Tutar conducts his research at the Hamidiye Faculty of Pharmacy, Department of Basic Pharmaceutical Sciences, Division of Biochemistry, University of Health Sciences, Turkey. He is also a faculty member in the Molecular Oncology Program. He obtained his MSc and Ph.D. at Oregon State University and Texas Tech University, respectively. He pursued his postdoctoral studies at Rutgers University Medical School and the National Institutes of Health (NIH/NIDDK), USA. His research focuses on biochemistry, biophysics, genetics, molecular biology, and molecular medicine with specialization in the fields of drug design, protein structure-function, protein folding, prions, microRNA, pseudogenes, molecular cancer, epigenetics, metabolites, proteomics, genomics, protein expression, and characterization by spectroscopic and calorimetric methods.",institutionString:"University of Health Sciences",institution:null},{id:"180528",title:"Dr.",name:"Hiroyuki",middleName:null,surname:"Kagechika",slug:"hiroyuki-kagechika",fullName:"Hiroyuki Kagechika",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180528/images/system/180528.jpg",biography:"Hiroyuki Kagechika received his bachelor’s degree and Ph.D. in Pharmaceutical Sciences from the University of Tokyo, Japan, where he served as an associate professor until 2004. He is currently a professor at the Institute of Biomaterials and Bioengineering (IBB), Tokyo Medical and Dental University (TMDU). From 2010 to 2012, he was the dean of the Graduate School of Biomedical Science. Since 2012, he has served as the vice dean of the Graduate School of Medical and Dental Sciences. He has been the director of the IBB since 2020. Dr. Kagechika’s major research interests are the medicinal chemistry of retinoids, vitamins D/K, and nuclear receptors. He has developed various compounds including a drug for acute promyelocytic leukemia.",institutionString:"Tokyo Medical and Dental University",institution:{name:"Tokyo Medical and Dental University",country:{name:"Japan"}}},{id:"94311",title:"Prof.",name:"Martins",middleName:"Ochubiojo",surname:"Ochubiojo Emeje",slug:"martins-ochubiojo-emeje",fullName:"Martins Ochubiojo Emeje",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94311/images/system/94311.jpeg",biography:"Martins Emeje obtained a BPharm with distinction from Ahmadu Bello University, Nigeria, and an MPharm and Ph.D. from the University of Nigeria (UNN), where he received the best Ph.D. award and was enlisted as UNN’s “Face of Research.” He established the first nanomedicine center in Nigeria and was the pioneer head of the intellectual property and technology transfer as well as the technology innovation and support center. Prof. Emeje’s several international fellowships include the prestigious Raman fellowship. He has published more than 150 articles and patents. He is also the head of R&D at NIPRD and holds a visiting professor position at Nnamdi Azikiwe University, Nigeria. He has a postgraduate certificate in Project Management from Walden University, Minnesota, as well as a professional teaching certificate and a World Bank certification in Public Procurement. Prof. Emeje was a national chairman of academic pharmacists in Nigeria and the 2021 winner of the May & Baker Nigeria Plc–sponsored prize for professional service in research and innovation.",institutionString:"National Institute for Pharmaceutical Research and Development",institution:{name:"National Institute for Pharmaceutical Research and Development",country:{name:"Nigeria"}}},{id:"436430",title:"Associate Prof.",name:"Mesut",middleName:null,surname:"Işık",slug:"mesut-isik",fullName:"Mesut Işık",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/436430/images/19686_n.jpg",biography:null,institutionString:null,institution:{name:"Bilecik University",country:{name:"Turkey"}}},{id:"268659",title:"Ms.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/268659/images/8143_n.jpg",biography:"Dr. Zhan received his undergraduate and graduate training in the fields of preventive medicine and epidemiology and statistics at the West China University of Medical Sciences in China during 1989 to 1999. He received his post-doctoral training in oncology and cancer proteomics for two years at the Cancer Research Institute of Human Medical University in China. In 2001, he went to the University of Tennessee Health Science Center (UTHSC) in USA, where he was a post-doctoral researcher and focused on mass spectrometry and cancer proteomics. Then, he was appointed as an Assistant Professor of Neurology, UTHSC in 2005. He moved to the Cleveland Clinic in USA as a Project Scientist/Staff in 2006 where he focused on the studies of eye disease proteomics and biomarkers. He returned to UTHSC as an Assistant Professor of Neurology in the end of 2007, engaging in proteomics and biomarker studies of lung diseases and brain tumors, and initiating the studies of predictive, preventive, and personalized medicine (PPPM) in cancer. In 2010, he was promoted to Associate Professor of Neurology, UTHSC. Currently, he is a Professor at Xiangya Hospital of Central South University in China, Fellow of Royal Society of Medicine (FRSM), the European EPMA National Representative in China, Regular Member of American Association for the Advancement of Science (AAAS), European Cooperation of Science and Technology (e-COST) grant evaluator, Associate Editors of BMC Genomics, BMC Medical Genomics, EPMA Journal, and Frontiers in Endocrinology, Executive Editor-in-Chief of Med One. He has\npublished 116 peer-reviewed research articles, 16 book chapters, 2 books, and 2 US patents. His current main research interest focuses on the studies of cancer proteomics and biomarkers, and the use of modern omics techniques and systems biology for PPPM in cancer, and on the development and use of 2DE-LC/MS for the large-scale study of human proteoforms.",institutionString:null,institution:{name:"Xiangya Hospital Central South University",country:{name:"China"}}},{id:"40482",title:null,name:"Rizwan",middleName:null,surname:"Ahmad",slug:"rizwan-ahmad",fullName:"Rizwan Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/40482/images/system/40482.jpeg",biography:"Dr. Rizwan Ahmad is a University Professor and Coordinator, Quality and Development, College of Medicine, Imam Abdulrahman bin Faisal University, Saudi Arabia. Previously, he was Associate Professor of Human Function, Oman Medical College, Oman, and SBS University, Dehradun. Dr. Ahmad completed his education at Aligarh Muslim University, Aligarh. He has published several articles in peer-reviewed journals, chapters, and edited books. His area of specialization is free radical biochemistry and autoimmune diseases.",institutionString:"Imam Abdulrahman Bin Faisal University",institution:{name:"Imam Abdulrahman Bin Faisal University",country:{name:"Saudi Arabia"}}},{id:"41865",title:"Prof.",name:"Farid A.",middleName:null,surname:"Badria",slug:"farid-a.-badria",fullName:"Farid A. Badria",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41865/images/system/41865.jpg",biography:"Farid A. Badria, Ph.D., is the recipient of several awards, including The World Academy of Sciences (TWAS) Prize for Public Understanding of Science; the World Intellectual Property Organization (WIPO) Gold Medal for best invention; Outstanding Arab Scholar, Kuwait; and the Khwarizmi International Award, Iran. He has 250 publications, 12 books, 20 patents, and several marketed pharmaceutical products to his credit. He continues to lead research projects on developing new therapies for liver, skin disorders, and cancer. Dr. Badria was listed among the world’s top 2% of scientists in medicinal and biomolecular chemistry in 2019 and 2020. He is a member of the Arab Development Fund, Kuwait; International Cell Research Organization–United Nations Educational, Scientific and Cultural Organization (ICRO–UNESCO), Chile; and UNESCO Biotechnology France",institutionString:"Mansoura University",institution:{name:"Mansoura University",country:{name:"Egypt"}}},{id:"329385",title:"Dr.",name:"Rajesh K.",middleName:"Kumar",surname:"Singh",slug:"rajesh-k.-singh",fullName:"Rajesh K. Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329385/images/system/329385.png",biography:"Dr. Singh received a BPharm (2003) and MPharm (2005) from Panjab University, Chandigarh, India, and a Ph.D. (2013) from Punjab Technical University (PTU), Jalandhar, India. He has more than sixteen years of teaching experience and has supervised numerous postgraduate and Ph.D. students. He has to his credit more than seventy papers in SCI- and SCOPUS-indexed journals, fifty-five conference proceedings, four books, six Best Paper Awards, and five projects from different government agencies. He is currently an editorial board member of eight international journals and a reviewer for more than fifty scientific journals. He received Top Reviewer and Excellent Peer Reviewer Awards from Publons in 2016 and 2017, respectively. He is also on the panel of The International Reviewer for reviewing research proposals for grants from the Royal Society. He also serves as a Publons Academy mentor and Bentham brand ambassador.",institutionString:"Punjab Technical University",institution:{name:"Punjab Technical University",country:{name:"India"}}},{id:"142388",title:"Dr.",name:"Thiago",middleName:"Gomes",surname:"Gomes Heck",slug:"thiago-gomes-heck",fullName:"Thiago Gomes Heck",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/142388/images/7259_n.jpg",biography:null,institutionString:null,institution:{name:"Universidade Regional do Noroeste do Estado do Rio Grande do Sul",country:{name:"Brazil"}}},{id:"336273",title:"Assistant Prof.",name:"Janja",middleName:null,surname:"Zupan",slug:"janja-zupan",fullName:"Janja Zupan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/336273/images/14853_n.jpeg",biography:"Janja Zupan graduated in 2005 at the Department of Clinical Biochemistry (superviser prof. dr. Janja Marc) in the field of genetics of osteoporosis. Since November 2009 she is working as a Teaching Assistant at the Faculty of Pharmacy, Department of Clinical Biochemistry. In 2011 she completed part of her research and PhD work at Institute of Genetics and Molecular Medicine, University of Edinburgh. She finished her PhD entitled The influence of the proinflammatory cytokines on the RANK/RANKL/OPG in bone tissue of osteoporotic and osteoarthritic patients in 2012. From 2014-2016 she worked at the Institute of Biomedical Sciences, University of Aberdeen as a postdoctoral research fellow on UK Arthritis research project where she gained knowledge in mesenchymal stem cells and regenerative medicine. She returned back to University of Ljubljana, Faculty of Pharmacy in 2016. She is currently leading project entitled Mesenchymal stem cells-the keepers of tissue endogenous regenerative capacity facing up to aging of the musculoskeletal system funded by Slovenian Research Agency.",institutionString:null,institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"357453",title:"Dr.",name:"Radheshyam",middleName:null,surname:"Maurya",slug:"radheshyam-maurya",fullName:"Radheshyam Maurya",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/357453/images/16535_n.jpg",biography:null,institutionString:null,institution:{name:"University of Hyderabad",country:{name:"India"}}},{id:"418340",title:"Dr.",name:"Jyotirmoi",middleName:null,surname:"Aich",slug:"jyotirmoi-aich",fullName:"Jyotirmoi Aich",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038Ugi5QAC/Profile_Picture_2022-04-15T07:48:28.png",biography:"Biotechnologist with 15 years of research including 6 years of teaching experience. Demonstrated record of scientific achievements through consistent publication record (H index = 13, with 874 citations) in high impact journals such as Nature Communications, Oncotarget, Annals of Oncology, PNAS, and AJRCCM, etc. Strong research professional with a post-doctorate from ACTREC where I gained experimental oncology experience in clinical settings and a doctorate from IGIB where I gained expertise in asthma pathophysiology. A well-trained biotechnologist with diverse experience on the bench across different research themes ranging from asthma to cancer and other infectious diseases. An individual with a strong commitment and innovative mindset. Have the ability to work on diverse projects such as regenerative and molecular medicine with an overall mindset of improving healthcare.",institutionString:"DY Patil Deemed to Be University",institution:null},{id:"349288",title:"Prof.",name:"Soumya",middleName:null,surname:"Basu",slug:"soumya-basu",fullName:"Soumya Basu",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035QxIDQA0/Profile_Picture_2022-04-15T07:47:01.jpg",biography:"Soumya Basu, Ph.D., is currently working as an Associate Professor at Dr. D. Y. Patil Biotechnology and Bioinformatics Institute, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India. With 16+ years of trans-disciplinary research experience in Drug Design, development, and pre-clinical validation; 20+ research article publications in journals of repute, 9+ years of teaching experience, trained with cross-disciplinary education, Dr. Basu is a life-long learner and always thrives for new challenges.\r\nHer research area is the design and synthesis of small molecule partial agonists of PPAR-γ in lung cancer. She is also using artificial intelligence and deep learning methods to understand the exosomal miRNA’s role in cancer metastasis. Dr. Basu is the recipient of many awards including the Early Career Research Award from the Department of Science and Technology, Govt. of India. She is a reviewer of many journals like Molecular Biology Reports, Frontiers in Oncology, RSC Advances, PLOS ONE, Journal of Biomolecular Structure & Dynamics, Journal of Molecular Graphics and Modelling, etc. She has edited and authored/co-authored 21 journal papers, 3 book chapters, and 15 abstracts. She is a Board of Studies member at her university. She is a life member of 'The Cytometry Society”-in India and 'All India Cell Biology Society”- in India.",institutionString:"Dr. D.Y. Patil Vidyapeeth, Pune",institution:{name:"Dr. D.Y. Patil Vidyapeeth, Pune",country:{name:"India"}}},{id:"354817",title:"Dr.",name:"Anubhab",middleName:null,surname:"Mukherjee",slug:"anubhab-mukherjee",fullName:"Anubhab Mukherjee",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y0000365PbRQAU/ProfilePicture%202022-04-15%2005%3A11%3A18.480",biography:"A former member of Laboratory of Nanomedicine, Brigham and Women’s Hospital, Harvard University, Boston, USA, Dr. Anubhab Mukherjee is an ardent votary of science who strives to make an impact in the lives of those afflicted with cancer and other chronic/acute ailments. He completed his Ph.D. from CSIR-Indian Institute of Chemical Technology, Hyderabad, India, having been skilled with RNAi, liposomal drug delivery, preclinical cell and animal studies. He pursued post-doctoral research at College of Pharmacy, Health Science Center, Texas A & M University and was involved in another postdoctoral research at Department of Translational Neurosciences and Neurotherapeutics, John Wayne Cancer Institute, Santa Monica, California. In 2015, he worked in Harvard-MIT Health Sciences & Technology as a visiting scientist. He has substantial experience in nanotechnology-based formulation development and successfully served various Indian organizations to develop pharmaceuticals and nutraceutical products. He is an inventor in many US patents and an author in many peer-reviewed articles, book chapters and books published in various media of international repute. Dr. Mukherjee is currently serving as Principal Scientist, R&D at Esperer Onco Nutrition (EON) Pvt. 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