AUCTORES
Case Reports
*Corresponding Author: Luis Cardoso, Department of Neurosurgery Hospital de São José - Centro Hospitalar e Universitario de Lisboa Central Lisbon, Portugal.
Citation: Luis Cardoso, Ricardo Nogueira, Lino Fonseca, Pedro Branco, Pedro Barros, Miguel Correia, Pedro Roque (2019) Spinal Epidural Lipomatosis - Description of the first case operated by minimally invasive access "over the top" in a patient with neurogenic claudication. J Spinal Dis Res 2(1): Doi: 10.31579/ 2642-1690/015
Copyright: © Luis Cardoso. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 15 November 2019 | Accepted: 29 November 2019 | Published: 04 December 2019
Keywords: ,
,
Spinal epidural lipomatosis (SEL) is defined as an abnormal accumulation of unencapsulated adipose tissue in the spinal epidural space. It was first described by Lee et al in 1975 and although it is a relatively rare and sometimes underdiagnosed condition in occidental countries, it is a well-known pathology in Asian [1-2].
In certain situations, the volume of adipose tissue may exert direct compression over the intracanalar structures, causing a spinal canal stenosis and root compression. Clinical manifestations may be similar to degenerative stenosis, with progressive symptoms of low back pain that may irradiate to the lower limbs, accompanied by paresthesia, weakness, and neurogenic claudication gait [3].
According to it aetiology, SEL can be categorized into 5 main groups: exogenous steroid use, endogenous steroid hormonal disease, obesity, surgery-induced and idiopathic. The etiological basis of SEL should be considered on the treatment choice [1, 4].
The treatment adopted may consist on conservative or surgical approach. However, even if the first approach is conservative, about 90% of cases will be operated on, mainly if there is spinal cord compression at the thoracic level. In patients with lumbar disease, only about 65% are operated on [5].
For patients undergoing corticotherapy, the reduction or discontinuation of medication may gradually reduce the associated neurological effects. Similarly, patients with primary endocrinological disease may have remission of symptoms after clearing the underlying disease, such as obese patients after a significant reduction in body mass índex (BMI) [6-8].
When conservative treatment fails or when patients present with acute symptomatology associated with neurological deficit, surgical treatment is usually adopted [9-10]. As Keonhee Kim et al [1] shows in his study, the surgical treatment consist in laminectomy only, without removal of epidural fat. On the other hand, in comparison with other reviewed cases, in which laminectomy was performed with removal of excess adipose tissue, it was considered that this option is the most acceptable for patients with acute compression or in those who have failed conservative management [1].
Nevertheless, some studies argue that because of the possible instability that can be generated after the laminectomy, it becomes necessary to make spinal fusion [11].
Given this rare pathology, the authors propose to describe a surgical technique that allows the direct decompression of the duro-radicular structures, by a minimally invasive approach, without the need for bone decompression that would induce a possible risk of instability.
The authors report a case of a 66-year-old male patient with a clinical history of hypercholesterolemia and BMI 32.2, who was referred to Neurosurgery consultation for presenting gait claudication, with about 2 years of evolution and progressive deterioration, mostly in the previous 3 months. He also reported paresthesia in L5 and S1 dermatomes bilaterally and had a 4+/5 strength in his lower extremities.
A lumbosacral magnetic resonance imaging (MRI), was performed which revealed at T1 and T2 weights a central-canal positioning of the dural sac at L4 and L5 in the sagittal plane. In the T1-weighted axial plane, a dural-radicular square stellate pattern was observed at the site of greater stenosis, with the presence of adipose epidural tissue conditioning the above mentioned stenosis of the dural sac. At the adjacent levels, it is possible to observe dilatation of the dural sac by the cerebrospinal fluid (see image 1).
Conservative treatment with weight and cholesterol reduction was tried, but after 6 months the symptoms persisted. After the analytical study, there was no endocrinopathy and surgical treatment was chosen.
In order to achieve decompression of neurological structures in the L4L5 and L5S1 levels, unilateral minimally invasive approach with bilateral decompression was planned.
For this purpose, with the patient under general anesthesia, in prone position and with the aid of fluoroscopy, a skin incision of 3 cm of longitudinal length was made, 1.5 cm from the midline to the left. After a paramedian incision in the muscular aponevrosis, a blunt dissection of the muscular plane was performed in order to obtain an ipsilateral posterior arc exposure centered on the L5 lamina. With the support of microscopy, a left L5S1 fenestration was initially performed, with contralateral removal of the yellow ligament, preserving the interspinous ligament. After exposure of the epidural adipose tissue, a dissection of the plane between the lipoma and the dura mater was performed, with easy detachment between the structures. As a safe dissection plan was obtained, adipose tissue was removed with the aid of a rongeur-type microsurgical disc forceps.
After removal of the adipose tissue posteriorly to the dura mater, dissection and removal of the fat was performed on the left (homolateral). With the space created by the decompression it was allowed to gentely mobilize the dural sac and the roots, in order to perform a contralateral approach "over the top" and finally the ventral component to the dura mater, obtaining the lesion removal in these compartments. The procedure was also performed in the L4L5 space by simple and precise upper soft tissue retraction. After a microscopic total removal of intracanal adipose tissue, dural sac dilation was verified. During the procedure an easily dissection between planes was noted, facilitated by the avascular nature of the removed tissue. No complications were reported during surgery or postoperatively.
After surgery the patient had a very favorable clinical improvement, with recovery of walking ability, without claudication, only with residual low back pain (VAS 2/10) and with discharge at day 1 pos op.
Histopathological results were compatible with non-encapsulated adipose tissue.
At 30-day evaluation the patient presented no neurological deficits, no low back pain and favorable healing of the surgical wound.
Patient underwent control lumbosacral-MRI at the end of first month which revealed adequate central canal decompression without significant muscle injury.
Spinal epidural lipomatosis is a clinical entity characterized by the excess accumulation of adipose tissue in the spinal epidural space, with consequent compression of neurological structures.
Depending on the possible causes that may be associated (corticosteroid therapy, endogenous steroid endocrinopathy, obesity, previous local or idiopathic surgery), the patient's treatment should be guided by specific factors [1]. The first line of treatment should be targeted to the underlying cause, with surgery reserved for cases refractory to conservative treatment or when the neurological deficit has an acute or severe presentation [1].
Regarding conservative treatment, Robertson et al published an article recommending a weight loss of 15 kg in patients with SEL to control symptoms [12]. In patients with suspected obesity-induced SEL, weight loss appears to be effective in controlling symptoms [5].
In the most recently published study on conservative treatment of SEL, Nagahama et al, describes the case of a 51-year-old female patient who presented with gait claudication and reduced lower limb strength. She had hypercholesterolemia and a BMI of 36.8. Although the surgical decompression was considered, conservative treatment was adopted, so that after 4 months the patient had a reduction in BMI to 31.8 (lost 13.6kg in weight). There was a pain remission, maintaining a strength of 4 + / 5, similar to the initial clinical condition. In control MRI, fat accumulation in the epidural space was reduced [13].
In patients with endocrinopathy or use of exogenous steroids, correction of the underlying cause (resection of endocrinal tumor ...) should be attempted, and patients with symptom relief after control have been reported in the literature [7].
In 2018, Walker et al published, an algorithm that allows to calculate the volume of adipose tissue in the epidural space. The relevance of this tool is related to the measurement of adipose tissue volume and is a possibility to objectively confirm the response to conservative treatment. In this study, it was also found that the accumulation of adipose tissue is more frequent in the lower spine segment (L4 -L5-S1) [14].
In the other, there are several studies reporting that patients may have a fast recovery and pain relief after surgical decompression [9, 10, 15]. In most reviews and published series, the surgical option always involves decompressive laminectomy. According to Ferlic et al, laminotomy is also effective in symptomatic pain relief of patients [15].
However, there are no cases described in the literature that refer a lumbar canal decompression, without lamina removal. Also, there is no reference to minimally invasive surgery to remove epidural lipomatosis at 1 or 2 affected levels. It is in this sense that this article arises, as the purpose of the authors is to demonstrate another safe and effective surgery approach.
Based on the case presented in this article, the authors demonstrate that, in a patient with epidural lumbar lipomatosis with symptoms refractory to conservative treatment, whose location of fat accumulation obeys a prevalent topography (L4L5 and L5S1) described in the literature [14], is viable to perform a unilateral minimally invasive surgery without lamina removal. This approach is centered on the L5 lamina and allow to perform, under microscopy, a homolateral fenestration with complete flavectomy, safe dissection and intracanalar adipose tissue removal. With a simple cranial or caudal soft tissue retraction, it is possible to approach the level adjacent to the first approach. With this technique it is possible to perform a recalibration of the lumbar canal, with removal of the compressible adipose mass safely, with the advantages of: smaller incision, lower risk of infection, less blood loss, less back pain in the post-operative and less risk of spinal instability, specially because the majority of the patients are overweight, because the osteoarticular structures fundamental to stability were not altered.
Spinal epidural lipomatosis is a multifactorial clinical entity characterized by the accumulation of adipose tissue in the epidural space, most prevalent at L4L5 and L5S1 levels. Its treatment begins by identifying and controlling the causal factors of the disease, and when it is not possible to improve the clinical condition or when it is severe or acute, surgery is indicated.
The present article demonstrates the adaptation of the unilateral minimally invasive spinal surgical technique over the top to remove lipomatosis, achieving effective decompression and rapid clinical recovery of the patient.
For technical reasons, the images of the rest of the surgery, namely the over the top approach, were lost, so they could not be presented in this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.