Terra, Bernardo Barcellos; Sassine, Tannus Jorge; Lima, Guilherme de Freitas; Rodrigues, Leandro Marano; Padua, David Victoria Hoffmann; Nadai, Anderson de
Fractures of the radial head and radial neck correspond to 1.7-5.4% of all fractures and approximately 30% may present associated injuries. In the literature, there are few reports of radial head fracture with posterior interosseous nerve injury. This study aimed to report a case of radial head fracture associated with posterior interosseous nerve injury.
Sigamoney, Kohila Vani; Rashid, Abbas; Ng, Chye Yew
The posterior interosseous nerve (PIN) is susceptible to a number of traumatic and atraumatic pathologies. In this article, we aim to review our current understanding of the etiology, pathology, diagnosis, treatment options, and published outcomes of atraumatic PIN palsy. In general, the etiology of atraumatic PIN palsy can be divided into mechanical, which is caused by an extrinsic compressive force on the nerve, and nonmechanical, which is caused by an intrinsic inflammatory reaction within the nerve. As per this discussion, there are 3 causes for atraumatic PIN palsy. These are entrapment neuropathy, Parsonage-Turner syndrome, and spontaneous "hourglass" constriction. The typical presentation of atraumatic PIN palsy is a patient with spontaneous onset of weakness of fingers/thumb metacarpophalangeal joints extension. However, the wrist extension is preserved with radial deviation due to preservation of extensor carpi radialis longus/brevis function. Magnetic resonance imaging is the imaging of choice and neurophysiology is indicated in all patients. If there is an obvious structural cause of the nerve palsy, prompt decompression and removal of the causative lesion are recommended to avoid irreversible damage to the nerve/muscles. Otherwise, in general, we would recommend consideration for exploration should there be no sign of recovery after 6 weeks of observation. Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Sonna, L A; Scott, B R
We report the case of a 19-year-old Infantryman who developed posterior interosseous nerve palsy and a transient sensory deficit in a radial distribution after prolonged carrying of an M60 machine gun. Posterior interosseous nerve palsy has been reported in association with a variety of activities involving forceful, repetitive pronation and supination; however, to our knowledge, no previous cases of this palsy have been reported in association with use of a military weapon.
Yang, Jin Seo; Kang, Suk Hyung; Choi, Eun Hi
The upper trunk of the brachial plexus is the most common area affected by neuralgic amyotrophy (NA), and paresis of the shoulder girdle muscle is the most prevalent manifestation. Posterior interosseous nerve palsy is a rare presentation in patients with NA. It results in dropped finger on the affected side and may be misdiagnosed as entrapment syndrome or compressive neuropathy. We report an unusual case of NA manifested as PIN palsy and suggest that knowledge of clinical NA phenotypes is crucial for early diagnosis of peripheral nerve palsies. PMID:26713154
Mokhtee, David B; Brown, Justin M; Mackinnon, Susan E; Tung, Thomas H
Surgical repair of distal biceps tendon rupture is a technically challenging procedure that has the potential for devastating and permanently disabling complications. We report two cases of posterior interosseous nerve (PIN) injury following successful biceps tendon repair utilizing both the single-incision and two-incision approaches. We also describe our technique of posterior interosseous nerve repair using a medial antebrachial cutaneous nerve graft (MABC) and a new approach to the terminal branches of the posterior interosseous nerve that makes this reconstruction possible. Finally, we advocate consideration for identification of the posterior interosseous nerve prior to reattachment of the biceps tendon to the radial tuberosity.
Serrano, Karen D; Rebella, Gregory S; Sansone, Jason M; Kim, Michael K
Radial head fractures are the most common fractures occurring about the elbow in adults, but there have been few reported cases of associated nerve injury. The little-known posterior interosseous nerve travels in close proximity to the radial head and is particularly susceptible to injury. The objectives of this case report include raising awareness of the possibility of posterior interosseous nerve palsy after radial head fracture and reviewing the clinical assessment of the posterior interosseous nerve to exclude occult injury. Here we report a case of a 21-year-old man who developed a posterior interosseous nerve palsy after a fracture of the radial head sustained during a wrestling match. He also sustained frostbite to the extremity due to overaggressive icing of the injury. Physicians should screen patients with radial head fractures for associated nerve injury. A thorough neurovascular examination with attention to the motor innervation patterns in the hand and wrist will help identify posterior interosseous nerve involvement. Careful discharge instructions will help prevent iatrogenic frostbite from overaggressive icing of injuries. Copyright © 2012 Elsevier Inc. All rights reserved.
Nishida, J; Shimamura, T; Ehara, S; Shiraishi, H; Sato, T; Abe, M
Lipomas are common benign soft tissue tumors which tend to be indolent, and symptoms caused by nerve compression are unusual. However, a parosteal lipoma, occurring adjacent to the proximal radius may easily cause paralysis of the posterior interosseous nerve because of a specific anatomical relationship of these structures in that area. Two cases of parosteal lipoma of the proximal radius causing paralysis of the posterior interosseous nerve are reported. CT and MR imaging demonstrate the characteristic fatty mass around the radius and are specific in making the diagnosis. Surgical excision should be promptly performed to ensure optimal recovery from the nerve paralysis.
Ochi, Kensuke; Horiuchi, Yukio; Tazaki, Kenichi; Takayama, Shinichiro; Matsumura, Takashi
There is no definition for fascicular constrictions of the spontaneous anterior interosseous nerve palsy (sAINP) and spontaneous posterior interosseous nerve palsy (sPINP). One surgeon has evaluated his findings in our 32 patients of sAINP/sPINP using either photographs or video tapes and proposed a definition. All patients had interfascicular neurolysis, and 87 case reports of "fascicular constriction" were also evaluated. Fascicular constriction was defined as every instance of thinning in the fascicle regardless to its extent. Thinning as a result of extrinsic compression was excluded. The fascicular constrictions were divided into four types: recessed, recessed-bulging, rotation, and rotation-bulging constriction. Two independent surgeons went through our findings to verify their repeatability. The relation between the fascicular constrictions and age at the onset of palsy was evaluated using Student's t test. We found 54 fascicular constrictions, with many variations. However, they could all be categorised by our method. The repeatability among the independent authors was 96%. The age at the onset of palsy was significantly younger in rotation-bulging than in rotation constriction (p = 0.0003). Our definition of describing fascicular constrictions was accurate, and should help to provide consensus in describing these palsies.
Monacelli, G; Ceci, F; Prezzemoli, G; Spagnoli, A; Lotito, S; Irace, S
The posterior interosseous nerve palsy is a neuropathy of radial nerve interesting its deep motor branch. The neuropathy can appear with a hollow in the proximal half of the forearm without significant swelling, a complete loss of extension of the fingers with radial deviation of the wrist during extension. In some cases, PIN compression may simulate tendon rupture in rheumatologic diseases, because the pain and the paralysis occur suddenly, so often can be difficult to make a diagnosis. The palsy is caused by compression of the posterior interosseous nerve from soft tissue tumours or tumour-like masses: ganglions, lipomas, rheumatoid synovitis, synovial chondromatosis, fibromas, neurofibromas, bursitis, synovial cysts of the elbow and radioulnar proximal joints. The aim of our research was to individuate the better treatment for the posterior interosseous nerve palsy. From 2002 to 2007 we examined 8 patients: 2 female and 6 male. Median age was 43 years. The diagnosis was made by clinical examination, ultrasound, nerve conduction studies and magnetic resonance imaging (MRI). Patients underwent to decompressing posterior interosseous nerve surgery. After the surgical exploration in 8 cases a globular mass of around 2.5 cm to 4.5 cm diameter was discovered. At the histological examination, a synovial cyst of the elbow joint was found in 7 out of 8 patients and an hemangioma tumor in the one remaining patient. 12 months was the median time for a complete recovery after the operation, confirmed by EMG. The surgical treatment offers a complete resolution in all cases.
Kele, Henrich; Xia, Annie; Weiler, Markus; Schwarz, Daniel; Bendszus, Martin; Pham, Mirko
Objective: To investigate the spatial pattern of lesion dispersion in posterior interosseous neuropathy syndrome (PINS) by high-resolution magnetic resonance neurography. Methods: This prospective study was approved by the local ethics committee and written informed consent was obtained from all patients. In 19 patients with PINS and 20 healthy controls, a standardized magnetic resonance neurography protocol at 3-tesla was performed with coverage of the upper arm and elbow (T2-weighted fat-saturated: echo time/repetition time 52/7,020 milliseconds, in-plane resolution 0.27 × 0.27 mm2). Lesion classification of the radial nerve trunk and its deep branch (which becomes the posterior interosseous nerve) was performed by visual rating and additional quantitative analysis of normalized T2 signal of radial nerve voxels. Results: Of 19 patients with PINS, only 3 (16%) had a focal neuropathy at the entry of the radial nerve deep branch into the supinator muscle at elbow/forearm level. The other 16 (84%) had proximal radial nerve lesions at the upper arm level with a predominant lesion focus 8.3 ± 4.6 cm proximal to the humeroradial joint. Most of these lesions (75%) followed a specific somatotopic pattern, involving only those fascicles that would form the posterior interosseous nerve more distally. Conclusions: PINS is not necessarily caused by focal compression at the supinator muscle but is instead frequently a consequence of partial fascicular lesions of the radial nerve trunk at the upper arm level. Neuroimaging should be considered as a complementary diagnostic method in PINS. PMID:27683851
Fujioka, Hiroyuki; Tsunemi, Kenjiro; Tsukamoto, Yoshitane; Oi, Takanori; Takagi, Yohei; Tanaka, Juichi; Yoshiya, Shinichi
We report a rare case of posterior interosseous nerve (PIN) paralysis in a tennis player. The PIN, a 2 cm section from a bifurcation point of the radial nerve, presented increased stiffness in the surgical findings and treated with free sural nerve grafting after excision of the degenerative portion of the PIN. We speculate that PIN paralysis associated with hourglass-like constriction can be caused and exacerbated by repetitive forearm pronation and supination in playing tennis.
Fujioka, Hiroyuki; Tsunemi, Kenjiro; Tsukamoto, Yoshitane; Oi, Takanori; Takagi, Yohei; Tanaka, Juichi; Yoshiya, Shinichi
We report a rare case of posterior interosseous nerve (PIN) paralysis in a tennis player. The PIN, a 2 cm section from a bifurcation point of the radial nerve, presented increased stiffness in the surgical findings and treated with free sural nerve grafting after excision of the degenerative portion of the PIN. We speculate that PIN paralysis associated with hourglass-like constriction can be caused and exacerbated by repetitive forearm pronation and supination in playing tennis. PMID:25104896
Calfee, Ryan P.; Wilson, Joyce M.; Wong, Ambrose H.W.
Background: The posterior interosseous nerve is at risk for iatrogenic injury during surgery involving the proximal aspect of the radius. Anatomic relationships of this nerve in skeletally intact cadavers have been defined, but variations associated with osseous and soft-tissue trauma have not been examined. This study quantifies the effect of a simulated diaphyseal fracture of the proximal aspect of the radius and of a radial neck fracture with an Essex-Lopresti injury on the posterior interosseous nerve. Methods: In twenty unembalmed cadaveric upper extremities, the distance from the radiocapitellar joint to the point where the posterior interosseous nerve crosses the midpoint of the axis of the radius (Thompson approach) was recorded in three forearm positions (supination, neutral, and pronation). Specimens were then treated with either proximal diaphyseal osteotomy (n = 10) or radial head excision with simulated Essex-Lopresti injury (n = 10), and the position of the nerve in each forearm position was remeasured. We evaluated the effect of the simulated trauma on nerve position and correlated baseline measurements with radial length. Results: In neutral rotation, the posterior interosseous nerve crossed the radius at a mean of 4.2 cm (range, 2.5 to 6.2 cm) distal to the radiocapitellar joint. In pronation, the distance increased to 5.6 cm (range, 3.1 to 7.4 cm) (p < 0.01). Supination decreased that distance to 3.2 cm (range, 1.7 to 4.5 cm) (p < 0.01). Radial length correlated with each of these measurements (r > 0.50, p = 0.01). Diaphyseal osteotomy of the radius markedly decreased the effect of forearm rotation, as the change in nerve position from supination to pronation decreased from 2.13 ± 0.8 cm to 0.24 ± 0.2 cm (p = 0.001). Proximal migration of the radius following radial head excision was accompanied by similar magnitudes of proximal nerve migration in all forearm positions. Conclusions: Forearm pronation has minimal effect on posterior interosseous
Sucher, B M; Cavanaugh, J A
A case of Guillain-Barre syndrome (GBS), with secondary entrapment of the posterior interosseous nerve bilaterally, is presented. It is felt that this was caused by the edema associated with the primary GBS, which led to compression with an anatomically narrowed supinator space, previously aggravated by repetitive pronation-supination. Diagnosis of such cases demands careful serial physical examinations, electromyography, and nerve conduction velocity studies. Appropriate splinting and careful exercise to balance muscle return are essential in physiatric management.
Fujioka, Hiroyuki; Futani, Hiroyuki; Fukunaga, Satoru; Okuno, Hiroaki; Kano, Masao; Tsukamoto, Yoshitane; Tanaka, Juichi; Yoshiya, Shinichi
We present a rare case report of a patient who presented with posterior interosseous nerve palsy caused by synovial chondromatosis. Synovial chondromatosis arising in the annular periradial recesses of the elbow joint was detected, and the mass developed two major portions constricted with the annular ligament. After surgical resection, posterior interosseous nerve palsy fully recovered and there was no recurrence of the lesion of synovial chondromatosis.
Wang, Pei-ji; Zhang, Yong; Zhao, Jia-ju; Zhou, Ju-pu; Zuo, Zhi-cheng; Wu, Bing-bing
Proximal or middle lesions of the ulnar or median nerves are responsible for extensive loss of hand motor function. This occurs even when the most meticulous microsurgical techniques or nerve grafts are used. Previous studies had proposed that nerve transfer was more effective than nerve grafting for nerve repair. Our hypothesis is that transfer of the posterior interosseous nerve, which contains mainly motor fibers, to the ulnar or median nerve can innervate the intrinsic muscles of hands. The present study sought to investigate the feasibility of reconstruction of the deep branch of the ulnar nerve and the thenar branch of median nerve by transferring the extensor indicis proprius branch of the posterior interosseous nerve obtained from adult cadavers. The results suggested that the extensor indicis proprius branch of the posterior interosseous nerve had approximately similar diameters and number of fascicles and myelinated nerve fibers to those of the deep branch of ulnar nerve and the thenar branch of the median nerve. These confirm the feasibility of extensor indicis proprius branch of posterior interosseous nerve transfer for reconstruction of the deep branch of the ulnar nerve and the thenar branch of median nerve. This procedure could be a novel and effective method for the functional recovery of the intrinsic muscles of hands after ulnar nerve or median nerve injury. PMID:28250760
Saratsiotis, John; Myriokefalitakis, Emmanouil
Peripheral nerve entrapments of the upper and lower extremity are commonly seen in practice. Chronically repetitive movement patterns lead to constriction of the nerve due to the development of local fibrosis within the soft tissues surrounding the nerve which also affects nerve traction, mobility, and function. A case is presented of a patient with motor weakness in the wrist and hand in order to illustrate the diagnosis and treatment of posterior interosseous nerve (PIN) syndrome. Using Active Release Techniques Soft Tissue Management and Peripheral Nerve Release Systems) the patient's symptomatology was resolved. Soft tissue-based management in conjunction with neural gliding may be beneficial in the conservative management of PIN syndrome. Further research into the pathophysiology of nerve entrapments will have immediate impact on the management of neuropathies and likely result in emphasizing conservative management and rehabilitation rather than surgical intervention particularly in cases not involving denervation or paralysis. Copyright © 2009 Elsevier Ltd. All rights reserved.
Maffulli, N; Maffulli, F
Eleven white male right handed violin players complained of transient muscular deficit of the extensor compartment of the left forearm during and after prolonged playing. This was associated with paraesthesiae and pain. Relief was achieved keeping the wrist and the elbow flexed, with the supinated forearm held by the contralateral hand. An anatomical study showed changes of the relationship of the posterior interosseous nerve with its surrounding structures with pronation and supination of the forearm. On the basis of the clinical features, the anatomical studies and the response to a simple physiotherapeutic regime, it is suggested that prolonged pronation of the forearm may cause transient entrapment of the nerve.
Maffulli, N; Maffulli, F
Eleven white male right handed violin players complained of transient muscular deficit of the extensor compartment of the left forearm during and after prolonged playing. This was associated with paraesthesiae and pain. Relief was achieved keeping the wrist and the elbow flexed, with the supinated forearm held by the contralateral hand. An anatomical study showed changes of the relationship of the posterior interosseous nerve with its surrounding structures with pronation and supination of the forearm. On the basis of the clinical features, the anatomical studies and the response to a simple physiotherapeutic regime, it is suggested that prolonged pronation of the forearm may cause transient entrapment of the nerve. Images PMID:1849172
Okwueze, Martina I; Cardwell, Nancy L; Wolfort, Sean L; Nanney, Lillian B
The prevalence of motor variations in the nerves supplying muscles of the first web space was evaluated by a visual dissection and immunohistochemical analysis from 56 cadaver hands. By microscopic visualization, 30% of the superficial radial nerves (SRNs) sent branches into muscles of the first web space. Since these unexpected penetrating branches were expected to be sensory or proprioceptive, markers of sensory and motor axons were used for confirmation. Positive identifications of motor axons (as identified by positive immunostaining for choline acetyltransferase) were made in 30% of SRNs and in 28.5% of posterior interosseous nerves. Classical teachings that the SRNs and PINs are exclusively sensory have been brought into question. Our data are in agreement with the rare clinical finding that motor function occasionally persists following devastating injury to both the ulnar and median nerves. Anatomic prevalence for this variation appears much higher than previous descriptions have indicated.
Lal, Hitesh; Bansal, Pankaj; Khare, Rahul; Mittal, Deepak
We report a case of tardy paralysis of the descending branch of the posterior interosseous nerve as a consequence of plate osteosynthesis for fracture of both bone forearms. The patient had been operated on 23 years earlier and palsy occurred after a gap of 19 years. The most probable antecedent cause of the palsy was the use of a high-profile implant. The patient was treated by removal of the plate and tendon transfer. Copyright 2010 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Maldonado, Andrés A; Howe, Benjamin M; Spinner, Robert J
Paralysis of the posterior interosseous nerve (PIN) secondary to compression is a rare clinical condition. Entrapment neuropathy may occur at fibrous bands at the proximal, middle, or distal edge of the supinator. Tumors are a relatively rare but well-known potential cause. The authors present 2 cases of PIN lesions in which compression by a benign lipoma at the level of the elbow resulted in near transection (discontinuity) of the nerve. They hypothesize a mechanism-a "sandwich effect"-by which compression was produced from below by the mass and from above by a fibrous band in the supinator muscle (i.e., the leading edge of the proximal supinator muscle [arcade of Fröhse] in one patient and the distal edge of the supinator muscle in the other). A Grade V Sunderland nerve lesion resulted from the advanced, chronic compression. The authors are unaware of a similar case with such an advanced pathoanatomical finding.
Ochi, Kensuke; Horiuchi, Yukio; Arino, Hiroshi; Toyama, Yoshiaki
A 55-year-old woman with incomplete spontaneous posterior interosseous nerve (PIN) palsy underwent interfascicular neurolysis and tendon transfer, 17 years after its onset. After one year, her nerve function partially recovered electrophysiologically. This case suggests that incomplete spontaneous PIN palsy may recover by interfascicular neurolysis, even with a long preoperative delay.
Wang, Jing; Chen, Min; Du, Jiang
Abstract Rationale: Elbow injury in children by improper treatment or a delay of more than 3 weeks could lead to old unreduced Monteggia fracture, which are difficult to manage. Conservative or normal surgical methods usually fail. Patient concerns: Herein, we present a 6-year-old boy with sustaining injury approximately 1 month to his left elbow. Activity in his elbow was restricted, and his ability to extend his wrist and fingers was impaired. Diagnoses: Type III Monteggia elbow fracture-dislocation consisting of radial head dislocation and malunion of the ulna associated with posterior interosseous nerve palsy were confirmed, which requiring surgical treatment. Interventions: A closed reduction was performed with hyperplastic scar tissues erased and the radial head relocated. Outcomes: Follow-up 4 months later showed satisfactory recovery of function. Lessons: Forearm fractures in children may be misjudged, and that early anatomical reduction rather than conservative treatment may be required. PMID:28296780
Ropars, M; Dréano, T; Siret, P; Belot, N; Langlais, F
Eighteen cases of tendon transfer for isolated radial or posterior interosseous nerve palsy have been carried out in our unit over a period of 21 years. Fifteen patients were reviewed with a mean follow-up of 9.5 years. Nine had sustained high and six low radial nerve injury. We achieved 11 excellent, two good, one fair and one bad result. The main problems were loss of power of gripping and the occurrence of radial deviation, particularly in patients with flexor carpi ulnaris transfer to the extensor digitorum communis. During this time, our technique has evolved, including changes of the tendons transferred. Our final preference is a modified Tsuge procedure, using the pronator teres to restore extension of the wrist, the flexor carpi radialis for extension of the fingers and the palmaris longus for extension of the thumb. Abduction of the thumb is restored by a tenodesis of the abductor pollicis longus to the brachioradialis. This review justifies the final policy, in particular the preservation of flexor carpi ulnaris to maintain wrist stability and flexion.
Kamineni, Srinath; Norgren, Crystal R; Davidson, Evan M; Kamineni, Ellora P; Deane, Andrew S
AIM To provide a “patient-normalized” parameter in the proximal forearm. METHODS Sixty-three cadaveric upper extremities from thirty-five cadavers were studied. A muscle splitting approach was utilized to locate the posterior interosseous nerve (PIN) at the point where it emerges from beneath the supinator. The supinator was carefully incised to expose the midpoint length of the nerve as it passes into the forearm while preserving the associated fascial connections, thereby preserving the relationship of the nerve with the muscle. We measured the transepicondylar distance (TED), PIN distance in the forearm’s neutral rotation position, pronation position, supination position, and the nerve width. Two individuals performed measurements using a digital caliper with inter-observer and intra-observer blinding. The results were analyzed with the Wilcoxon-Mann-Whitney test for paired samples. RESULTS In pronation, the PIN was within two confidence intervals of 1.0 TED in 95% of cases (range 0.7-1.3 TED); in neutral, within two confidence intervals of 0.84 TED in 95% of cases (range 0.5-1.1 TED); in supination, within two confidence intervals of 0.72 TED in 95% of cases (range 0.5-0.9 TED). The mean PIN distance from the lateral epicondyle was 100% of TED in a pronated forearm, 84% in neutral, and 72% in supination. Predictive accuracy was highest in supination; in all cases the majority of specimens (90.47%-95.23%) are within 2 cm of the forearm position-specific percentage of TED. When comparing right to left sides for TEDs with the signed Wilcoxon-Mann-Whitney test for paired samples as well as a significance test (with normal distribution), the P-value was 0.0357 (significance - 0.05) indicating a significant difference between the two sides. CONCLUSION This “patient normalized” parameter localizes the PIN crossing a line drawn between the lateral epicondyle and the radial styloid. Accurate PIN localization will aid in diagnosis, injections, and surgical
Kamineni, Srinath; Norgren, Crystal R; Davidson, Evan M; Kamineni, Ellora P; Deane, Andrew S
To provide a "patient-normalized" parameter in the proximal forearm. Sixty-three cadaveric upper extremities from thirty-five cadavers were studied. A muscle splitting approach was utilized to locate the posterior interosseous nerve (PIN) at the point where it emerges from beneath the supinator. The supinator was carefully incised to expose the midpoint length of the nerve as it passes into the forearm while preserving the associated fascial connections, thereby preserving the relationship of the nerve with the muscle. We measured the transepicondylar distance (TED), PIN distance in the forearm's neutral rotation position, pronation position, supination position, and the nerve width. Two individuals performed measurements using a digital caliper with inter-observer and intra-observer blinding. The results were analyzed with the Wilcoxon-Mann-Whitney test for paired samples. In pronation, the PIN was within two confidence intervals of 1.0 TED in 95% of cases (range 0.7-1.3 TED); in neutral, within two confidence intervals of 0.84 TED in 95% of cases (range 0.5-1.1 TED); in supination, within two confidence intervals of 0.72 TED in 95% of cases (range 0.5-0.9 TED). The mean PIN distance from the lateral epicondyle was 100% of TED in a pronated forearm, 84% in neutral, and 72% in supination. Predictive accuracy was highest in supination; in all cases the majority of specimens (90.47%-95.23%) are within 2 cm of the forearm position-specific percentage of TED. When comparing right to left sides for TEDs with the signed Wilcoxon-Mann-Whitney test for paired samples as well as a significance test (with normal distribution), the P-value was 0.0357 (significance - 0.05) indicating a significant difference between the two sides. This "patient normalized" parameter localizes the PIN crossing a line drawn between the lateral epicondyle and the radial styloid. Accurate PIN localization will aid in diagnosis, injections, and surgical approaches.
Menu, G; Hidalgo Diaz, J J; Pire, E; Clavert, P; Facca, S; Liverneaux, P
The purpose of this study was to determine in a cadaver model, whether transfer of the posterior interosseous nerve (PIN) to the superficial branch of the ulnar nerve (SBUN) by a single approach was feasible. The experiment was carried out on five fresh cadavers. The ulnar nerve was split into its motor branches and the SBUN. The PIN was collected behind the interosseous membrane and sutured to the SBUN on its anterior surface. All sutures were tensionless and technically possible with the PIN's diameter being at least 50% of the SBUN's diameter in all cases. Our results demonstrate that PIN to SBUN transfer through a single anterior approach is feasible in a cadaver model. Copyright © 2017 SFCM. Published by Elsevier Masson SAS. All rights reserved.
Cavadas, Pedro C; Thione, Alessandro; Rubí, Carlos
Several technical modifications have been described to avoid complications and simplify dissection. The authors describe some technical tips that make posterior interosseous flap dissection safer and more straightforward. Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Pronation can increase the pressure on the posterior interosseous nerve under the arcade of Frohse: a possible mechanism of palsy after two-incision repair for distal biceps rupture--clinical experience and a cadaveric investigation.
Links, Annie C; Graunke, Kyle S; Wahl, Christopher; Green, John R; Matsen, Frederick A
Posterior interosseous nerve palsy is a recognized complication of 2-incision distal biceps tendon repair. We hypothesize that intraoperative forearm pronation can cause compression of the posterior interosseous nerve beneath the supinator and arcade of Frohse. Six human male cadaver upper extremities were dissected. Pressure on the posterior interosseous nerve beneath the arcade of Frohse and supinator was measured with a Swan-Ganz catheter connected to a pressure transducer. Pressure was significantly elevated in maximal pronation in all specimens with the elbow in both flexion and extension. Pressures at full pronation were significantly higher than pressures measured at 60 degrees of pronation (5 +/- 2 mm Hg in 60 degrees of pronation and 90 degrees of flexion, P < .0001; 7 +/- 3 mm Hg in 60 degrees of pronation and extension, P < 005). Maximal pronation can cause increased pressure on the posterior interosseous nerve. The safety of 2-incision distal biceps repair may be increased by avoiding prolonged, uninterrupted periods of hyperpronation.
Saaiq, Muhammad; Siddiui, Saad
A 53-year old man presented with seven months history of progressive weakness of extension of the digits and the thumb of the left hand. The wrist extension was normal and sensations were also intact. The patient had also been noticing a progressively enlarging lump on the lower anterolateral aspect of the left antecubital fossa for the last three months. Physical examination andelectro diagnostic studies revealed motor deficit along the posterior interosseous nerve (PIN) distribution with preservation of sensations. Also a soft tissue solitary lump (measuring 6×5 cm in its greatest dimensions) was palpable in the left antecubital fossa. The magnetic resonance imaging (MRI) of the forearm revealed a well-defined, non-enhancing, homogenous, fat intensity lesion in the left antecubital fossa, attached to the proximal radius. The patient underwent surgical excision of the lump with decompression of the PIN in the radial tunnel. Histopathology confirmed the diagnosis of parosteal lipoma. Although the diagnosis was elusive at the very outset, yet prudent clinical judgment, appropriate ancillary investigations and timely surgical intervention resulted in optimal functional recovery of the hand drop. There was complete motor recovery at 4-months follow up with no recurrence of the lipomaafter one year. PMID:28289621
Angrigiani, C; Grilli, D; Dominikow, D; Zancolli, E A
The results of an anatomic investigation performed in 40 fresh cadaver specimens and 80 consecutive clinical cases of the posterior interosseous reverse forearm flap are reported. It was observed that there is a choke anastomosis between the recurrent dorsal branch of the anterior interosseous artery and the posterior interosseous artery at the level of the middle third of the posterior forearm. Ink injections through a catheter placed in the distal part of the anterior interosseous artery stained the distal and middle thirds of the posterior forearm, but the proximal third remained unstained; this secondary territory cannot be captured through the choke anastomosis between the anterior interosseous artery and the posterior interosseous artery. Intravital fluorescein injection into the distal arterior interosseous artery revealed (under ultraviolet light) that the distal third of the posterior forearm is irrigated by direct flow through the recurrent branch of the arterior interosseous artery (the traditionally called distal anastomosis of the interosseous arteries). Therefore, we can assume that the blood flow is not reversed when the so-called posterior interosseous reverse forearm flap is raised. From this point of view, this flap could be renamed as the recurrent dorsal anterior interosseous direct flap; however, the classical name is maintained for practical purposes. From the venous standpoint, the cutaneous area included in this flap belongs to an oscillating type of venous territory and is connected to the deep system through an interconnecting venous perforator that accompanies a medial cutaneous arterial branch located at 1 to 2 cm distal to the middle point of the forearm.(ABSTRACT TRUNCATED AT 250 WORDS)
COLASANTI, R.; IACOANGELI, M.; DI RIENZO, A.; DOBRAN, M.; DI SOMMA, L.; NOCCHI, N.; SCERRATI, M.
Background Posterior interosseous nerve (PIN) palsy may present with various symptoms, and may resemble cervical spondylosis. Case report We report about a 59-year-old patient with cervical spondylosis which delayed the diagnosis of posterior interosseous nerve (PIN) palsy due to an intermuscular lipoma. Initial right hand paraesthesias and clumsiness, together with MR findings of right C5–C6 and C6–C7 foraminal stenosis, misled the diagnostic investigation. The progressive loss of extension of all right hand fingers brought to detect a painless mass compressing the PIN. Electrophysiological studies confirmed a right radial motor neuropathy at the level of the forearm. Results Surgical tumor removal and nerve decompression resulted in a gradual motor deficits recovery. Conclusions A thorough clinical examination is paramount, and electrophysiology may differentiate between cervical and peripheral nerve lesions. Ultrasonography and MR offer an effective evaluation of lipomas, which represent a rare cause of PIN palsy. Surgical decompression and lipoma removal generally determine excellent prognoses, with very few recurrences. PMID:27142825
A rare case of median nerve compression syndrome is reported in a guitar player who had changed the posture and position of his instrument so that the edge of the guitar exerted sharp pressure on the median nerve close to the branching of the interosseous anterior nerve. There was partial paralysis of the interosseous anterior nerve with complete failure of the deep flexor of the index finger, while the flexor pollicis longus was intact. There was also paresthesia of the index finger. Treatment was conservative with a sleeve including a gel cushion which protected the forearm against the edge of the instrument. Function recurred completely within six weeks without ever interrupting instrument practice.
Koch, H; Kursumovic, A; Hubmer, M; Seibert, F J; Haas, F; Scharnagl, E
There are conditions that preclude the use of the posterior interosseous flap for reconstruction of the dorsum of the hand. Based on a series of 34 cases, these conditions are outlined and alternative solutions discussed. The posterior interosseous flap was employed for closure in 30 cases. In four cases different methods were used due to severe trauma to the wrist and distal forearm with potential impairment of the pedicle, a complex defect requiring a composite flap and an anatomical variation. Thin free flaps were employed alternatively. All flaps survived but there was marginal flap necrosis in two posterior interosseous flaps. The posterior interosseous flap proved its usefulness and reliability in reconstruction of the hand in this series. In four cases, free lateral arm and temporoparietal fascial flaps were employed. Flaps based on the main vessels of the forearm were not used due to their significant donor site morbidity.
Barrett, Kody K; Skaggs, David L; Sawyer, Jeffrey R; Andras, Lindsay; Moisan, Alice; Goodbody, Christine; Flynn, John M
It is unclear if pediatric patients with a supracondylar humeral fracture and isolated anterior interossous nerve injury require urgent treatment. A retrospective, multicenter study of 4409 patients with operatively treated supracondylar humeral fractures was conducted. Exclusion criteria were additional nerve injuries other than the anterior interosseous nerve, any sensory changes, pulselessness, ipsilateral forearm fractures, open fractures, less than two months of follow-up, or pathological fractures. Thirty-five of 4409 patients met inclusion criteria. The average time to surgery was 14.6 hours (range, two to thirty-six hours). No patient developed compartment syndrome. There was no significant difference in time to return of anterior interosseous nerve function relative to the time to surgical reduction and fixation (p = 0.668). A complete return of anterior interosseous nerve function occurred in all patients with an average time of forty-nine days (range, two to 224 days). Ninety percent of patients recovered anterior interosseous nerve function by 149 days. To our knowledge, this is the largest series to date of supracondylar humeral fractures with anterior interosseous nerve injuries. There is no evidence that a supracondylar humeral fracture with an isolated anterior interosseous nerve injury requires urgent treatment. A delay in treatment up to twenty-four hours was not associated with an increased time of nerve recovery or other complications. This series excluded patients with sensory nerve injuries, pulselessness, and ipsilateral forearm fractures, which all may require urgent surgery. Barring other clinical indications for urgent treatment of a supracondylar humeral fracture, an isolated anterior interosseous nerve injury (no sensory changes) may not by itself be an indication for urgent surgery. The anterior interosseous nerve injuries in this series showed complete recovery at a mean time of forty-nine days. Copyright © 2014 by The Journal of Bone
Maldonado, Andrés A; Amrami, Kimberly K; Mauermann, Michelle L; Spinner, Robert J
Different hypotheses have been proposed for the pathophysiology of anterior interosseous nerve palsy: compression, fascicular constriction, or nerve inflammation (Parsonage-Turner syndrome). The authors hypothesized that critical reinterpretation of electrodiagnostic studies and magnetic resonance imaging scans of patients with a diagnosis of anterior interosseous nerve palsy could provide insight into the pathophysiology and treatment. A retrospective review was performed of all patients with a diagnosis of nontraumatic anterior interosseous nerve palsy and an upper extremity magnetic resonance imaging scan. The original electrodiagnostic study and magnetic resonance imaging scan reports were reinterpreted by a neuromuscular neurologist and musculoskeletal radiologist, respectively, both blinded to the authors' hypothesis. Sixteen patients met the inclusion criteria as having "isolated" anterior interosseous nerve palsy. Physical examination revealed weakness in muscles not innervated by the anterior interosseous nerve in five cases (31 percent), and electrodiagnostic studies showed abnormalities not related to the anterior interosseous nerve in nine of 15 cases (60 percent). In all cases, reinterpretation of the magnetic resonance imaging scans demonstrated atrophy in at least one muscle not innervated by the anterior interosseous nerve and did not reveal any evidence of compression of the anterior interosseous nerve. All patients in the authors' series with presumed isolated anterior interosseous nerve palsy had magnetic resonance imaging evidence of a more diffuse muscle involvement pattern, without any radiologic signs of nerve compression of the anterior interosseous nerve branch itself. These data strongly support an inflammatory pathophysiology.
Dominici, F; Ginanneschi, F; Spidalieri, R; Rossi, A
Lipomas are common benign soft tissue tumours which tend to be indolent and risk free. Lipomas rarely spread in the deep soft tissue causing posterior interosseous nerve (PIN) neuropathy. We present two patients with multiple lipomatosis of the arms and PIN paralysis, with a brief review of the cases reported in literature. We emphasize the role of electromyographic study as unique methodical capable to reveal an early radial nerve damage, permitting an optimal post-surgical nerve function recovering.
Haflah, Nor Hazla Mohamed; Rashid, Abdul Halim Abd; Sapuan, Jamari
Anterior interosseous nerve palsy is rare. Isolated neuropraxia of its branch to the flexor pollicis longus is even rarer. We present a case of a 24-year-old man who presented with weakness of his left thumb flexion after sustaining closed fracture of the proximal third of his left radius. On exploration, the anterior interosseous nerve and its branches was found to be intact as was the flexor pollicis longus. Electrophysiological studies demonstrated acute left anterior interosseous nerve neuropathy. Electromyography showed discrete motor unit at the flexor pollicis longus. Two months later the patient had full recovery of the flexor pollicis longus. We would like to highlight this rare occurrence and present a detailed history of this case to increase awareness amongst clinicians regarding this condition.
Internullo, G; Marcuzzi, A; Busa, R; Cordella, C; Caroli, A
Anterior interosseous nerve syndrome is a rare occurrence. One particular case, in terms of its etiopathogenesis, and its clinical findings that involved isolated lesion of the long flexor muscle of the thumb is reported. Healing occurred after approximately 10 months. Medical and physiotherapeutic treatment were carried out.
Wagner, Pablo; Ortiz, Cristian; Vela, Omar; Arias, Paul; Zanolli, Diego; Wagner, Emilio
Tibialis posterior (TP) tendon transfer through the interosseous membrane is commonly performed in Charcot-Marie-Tooth disease. In order to avoid entrapment of this tendon, no clear recommendation relative to the interosseous membrane (IOM) incision size has been made. Analyze the TP size at the transfer level and therefore determine the most adequate IOM window size to avoid muscle entrapment. Eleven lower extremity magnetic resonances were analyzed. TP muscle measurements were made in axial views, obtaining the medial-lateral and antero-posterior diameter at various distances from the medial malleolus tip. The distance from the posterior to anterior compartment was also measured. These measurements were applied to a mathematical model to predict the IOM window size necessary to allow an ample TP passage in an oblique direction. The average tendon diameter (confidence-interval) at 15cm proximal to the medial malleolus tip was 19.47mm (17.47-21.48). The deep posterior compartment to anterior compartment distance was 10.97mm (9.03-12.90). Using a mathematical model, the estimated IOM window size ranges from 4.2 to 4.9cm. The IOM window size is of utmost importance in trans-membrane TP transfers, given that if equal or smaller than the transposed tendon oblique diameter, a high entrapment risk exists. A membrane window of 5cm or 2.5 times the size of the tendon diameter should be performed in order to theoretically diminish this complication. Copyright © 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Teo, T C; Richard, B M
In leprosy a functionally useless hand can be the sequelae of resorption of the sensation-impaired thumb and fingers resulting from repeated trauma and infection. When this process shortens the thumb to the level of the proximal phalanx or metacarpal, the effect is to produce a relatively shallow first web space which together with the shortening, can prevent the most basic hand manoeuvre of a pincer or pinch grip. The reconstructive procedure commonly used in this situation is to widen and deepen the web space with a z-plasty combined with excision of the second metacarpal but the result can be inadequate. We have used the posterior interosseous fasciocutaneous island flap, both as a simple and a compound flap, to solve this challenging problem and we report here our experience with four patients.
Li, Kuang-Wen; Liu, Jun; Liu, Ming-Jiang; Xie, Song-Lin; Liu, Chang-Xiong
The posterior interosseous artery (PIA) perforator flap can be used for reconstruction of soft-tissue defects of fingers. Based on the multiple perforators from the posterior interosseous artery, we describe a technique to reconstruct the multi-finger defect in the use of the free multilobed PIA perforator flap. PIA perforators from different areas of the forearm were used to design a free multilobed skin paddle for multi-finger skin defect reconstruction. Each paddle without the deep fascia had separate perforators. To increase the perforator pedicle length, the courses of the PIA perforators were dissected from the superficial layer of the deep fascia to the subcutaneous layer. The flap was raised as a unilateral free bilobed PIA perforator flap in 10 cases of two-finger defects, a free trilobed PIA perforator flap in two cases of three-finger defects, and a bilateral free bilobed PIA perforator flap in one case of four-finger defects. The average effective vascular pedicle length and trunk pedicle length were 8.3 and 3.1 cm, respectively, for the bilobed flap, and 6.3 and 4.0 cm, respectively, for the trilobed flap. All flaps survived except one paddle with tip necrosis. At 10.8 months (range, 4-27 months) after surgery, 10 cases showed satisfactory cosmetic appearance, while the fingers were bulky in the remaining three cases. The average score of static two-point discrimination in 10 innervated paddles was 12.9 mm. The remaining 20 paddles recovered only protective sensation. The average total active motion (TAM) of each finger was 164° before surgery and 187° at the latest follow-up. Free multilobed PIA perforator flap is a good candidate for reconstruction of multi-finger skin defect. Therapeutic, Ⅳ. Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Li, Hai-Ming; Liu, Xiao-Jun
To study clinical results of the manual reduction in treatment. From October 2010 to April 2013,39 children with Monteggia fracture associated with anterior interosseous nerve injury were treated by manual reduction and fixation on buckling rotation backward,including 17 females and 22 males with an average age of 6.3 years old ranging from 3.2 to 11 years old. Among them, 15 cases were on the right side and 24 cases on the left. The course of disease was 40 minutes to 8 days (averaged 1.5 days). There were 7 cases with skateboard injured, 13 cases with stumble injured, 11 cases with falling injured,8 cases with air bed injured. According to Bado classification, 13 cases were type II, 22 cases were type III, 4 cases were type IV. The distal forefinger showed exercise normally in 34 cases at 3 weeks after treatment, and the patients restored normal activities at 6 weeks after treatment. All patients were follow-up from 54 days to 6 months (averaged 67 days. According to Mayo elbow functional evaluation standard,the scoring result was 19.62±1.35 in activity, 45.00 ± 0.00 in pain, 9.87 ± 0.80 in stability, 25.00±0.00 in strength, 99.49 ±1.92 in total. The outcome of all patients was excellent and good evaluation results. If the anterior interosseous nerve injury could be identified early and treated timely, patients could gradually restore reasonable function and recover with satisfactory results. Raising understanding of anterior interosseous nerve injury can effectively reduce misdiagnosis.
El Domiaty, M A; Zoair, M M; Sheta, A A
fingers. The FPLah was found between the median nerve anteriorly and the anterior interosseous nerve posteriorly. Both FPLah and FDPah took their nerve supply mainly from the anterior interosseous nerve and, less frequently, from the median nerve. The mean values of the total lengths of FPLah and FDPah were 74.66 mm and 208.33 mm, respectively. Cadaveric dissection in this study confirmed the prevalence of the FPLah and FDPah in Egyptians and demonstrated the relationship of the FPLah to the median nerve and its anterior interosseous branch. These findings may provide the surgeon with information for the differential diagnosis of the causes and sites of anterior interosseous nerve syndrome and entrapment neuropathy of the median nerve in the forearm
Li, Kuang-Wen; Song, Da-Jiang; Liu, Jun; Xie, Song-Lin
The tripaddle posterior interosseous artery (PIA) flap can be used for multifinger defect resurfacing, but interpatient variations in perforator distribution remain an ongoing challenge when using this approach. This study aims to evaluate the efficacy of 3 different tripaddle PIA perforator flap designs according to the PIA perforator distribution for the repair of 3-finger defects. In accordance with the size of the 3-finger defects and the position of the perforators, a tripaddle flap was designed on the multiple perforators of the descending branch of the PIA in the distal two thirds of the forearm. Patients received 1 of 3 distinct tripaddle PIA perforator flap designs based on perforator distributions of the PIA. Three cases of 3-finger defects were repaired with type A trefoil-shaped tripaddle flaps, whereas 4 cases were repaired with type B modified trefoil-shaped tripaddle flaps, and the other 3 cases were repaired with type C chain-shaped tripaddle flaps. All flaps survived except 2 paddles with tip necrosis. After 9.1 months of mean follow-up, 9 of the 10 cases demonstrated satisfactory cosmetic appearance, whereas the last case required a debulking procedure in the second stage. The free tripaddle PIA perforator flap is an effective option for repairing 3-finger skin defects. Various flap designs based on the PIA perforator distribution allow for more individualized treatment approaches.
Saremi, Hossein; Shahryar-Kamrani, Reza; Ghane, Bahareh; Yavarikia, Alireza
Background Nonunion of distal radius fractures is disabling. Treatment is difficult and the results are not predictable. However, posterior interosseous bone flap (PIBF) has been successful in treating forearm nonunion. Objectives To treat distal radius fracture nonunion with PIBF as a new procedure. Patients and Methods This prospective non-randomized cohort study was performed at two hospitals in Tehran between January 2011 and September 2015. PIBFs were applied in nine patients (10 nonunions) with a mean age of 55 years. Union success rate, grip strength, wrist range of motion, and forearm rotation were then evaluated. Results Although four of the patients had a history of infection, all participants achieved fracture union at a mean time of 3.8 months. Grip strength improved by 12.4 kg. There was also 36° improvement in wrist flexion, 20° improvement in wrist extension, 60° improvement in forearm supination, and 46° improvement in forearm pronation. The range of motion and grip strength improvements were significant. Conclusions Pedicled PIBF is a new option for treating distal radius fracture nonunion. The results are predictable in achieving union and good function, and this technique can be successfully used in cases with extensive soft-tissue damage or infection. PMID:27703802
Sunagawa, Toru; Nakashima, Yuko; Shinomiya, Rikuo; Kurumadani, Hiroshi; Adachi, Nobuo; Ochi, Mitsuo
In recent operative cases of anterior interosseous nerve palsy (AINP), hourglass-like fascicular constrictions have been reported. We prospectively investigated the ultrasonographic history of these lesions to better understand the role of this lesion in AINP. Seven patients who were diagnosed with idiopathic AINP based on classic clinical findings and had hourglass-like fascicular constrictions found on ultrasonography were included. All but 1 patient selected surgery, and we followed up all patients clinically and with ultrasonography. In the 5 patients treated surgically in whom paralysis recovered to a level greater than M4, postoperative ultrasonography revealed less constriction. The other patient experienced little recovery after surgery, and the severe constriction remained. In a conservatively treated patient, the paralysis recovered completely, and upon ultrasonography, the constriction had lessened. Although the mechanism is still unknown, hourglass-like fascicular constriction lessened with relief of motor weakness both in operatively and conservatively treated patients. Muscle Nerve 55: 508-512, 2017. © 2016 Wiley Periodicals, Inc.
Shaker, Ayman A.; Elbarbary, Amir S.; Sayed, Mohamed A.; Elghareeb, Mohamed A.
Background: The purpose of this study is to decrease the incidence of venous congestion occurring in the reversed flow posterior interosseous artery flap used for coverage of hand defects. Methods: This may be achieved by studying the incidence of venous congestion in flaps including only 1 perforator and comparing the results with others including more than 1 perforator both in small and large sized flaps. Results: This study showed that inclusion of only 1 perforator in the flap decreased the incidence of venous congestion with complete flap loss in flaps to 5%. Also, it decreased the incidence of venous congestion with partial flap loss in flaps to 10%. Conclusions: The small sized reversed flow posterior interosseous artery flap should be less than 40 cm2 and should include only 1 perforator to decrease the incidence of venous congestion with partial and complete loss of the flap. The level of evidence for this study is the type II prospective comparative study. PMID:28293513
Steed, Jeremiah T; Drexler, Kathlyn; Wooldridge, Adam N; Ferguson, Matthew
Arthroscopic rotator cuff tendon repair is a common elective procedure performed by trained orthopaedic surgeons with a relatively low complication rate. Specifically, isolated neuropraxia of the anterior interosseous nerve (AIN) is a very rare complication of shoulder arthroscopy. An analysis of peer-reviewed published literature revealed only three articles reporting a total of seven cases that describe this specific complication following standard shoulder arthroscopic procedures. This article reports on three patients diagnosed with AIN neuropraxia following routine shoulder arthroscopy done by a single surgeon within a three-year period. All three patients also underwent open biceps tenodesis immediately following completion of the arthroscopic procedures. The exact causal mechanism of AIN neuropraxia following shoulder arthroscopy with biceps tenodesis is not known. This case report reviews possible mechanisms with emphasis on specific factors that make a traction injury the most likely etiology in these cases. We critically analyze our operating room setup and patient positioning practices in light of the existing biomechanical and cadaveric research to propose changes to our standard practices that may help to reduce the incidence of this specific postoperative complication in patients undergoing elective shoulder arthroscopy with biceps tenodesis.
Wooldridge, Adam N.
Arthroscopic rotator cuff tendon repair is a common elective procedure performed by trained orthopaedic surgeons with a relatively low complication rate. Specifically, isolated neuropraxia of the anterior interosseous nerve (AIN) is a very rare complication of shoulder arthroscopy. An analysis of peer-reviewed published literature revealed only three articles reporting a total of seven cases that describe this specific complication following standard shoulder arthroscopic procedures. This article reports on three patients diagnosed with AIN neuropraxia following routine shoulder arthroscopy done by a single surgeon within a three-year period. All three patients also underwent open biceps tenodesis immediately following completion of the arthroscopic procedures. The exact causal mechanism of AIN neuropraxia following shoulder arthroscopy with biceps tenodesis is not known. This case report reviews possible mechanisms with emphasis on specific factors that make a traction injury the most likely etiology in these cases. We critically analyze our operating room setup and patient positioning practices in light of the existing biomechanical and cadaveric research to propose changes to our standard practices that may help to reduce the incidence of this specific postoperative complication in patients undergoing elective shoulder arthroscopy with biceps tenodesis. PMID:28567319
Hawasli, Ammar H; Chang, Jodie; Reynolds, Matthew R; Ray, Wilson Z
Study Design Technical report. Objective To provide a technical description of the transfer of the brachialis to the anterior interosseous nerve (AIN) for the treatment of tetraplegia after a cervical spinal cord injury (SCI). Methods In this technical report, the authors present a case illustration of an ideal surgical candidate for a brachialis-to-AIN transfer: a 21-year-old patient with a complete C7 spinal cord injury and failure of any hand motor recovery. The authors provide detailed description including images and video showing how to perform the brachialis-to-AIN transfer. Results The brachialis nerve and AIN fascicles can be successfully isolated using visual inspection and motor mapping. Then, careful dissection and microsurgical coaptation can be used for a successful anterior interosseous reinnervation. Conclusion The nerve transfer techniques for reinnervation have been described predominantly for the treatment of brachial plexus injuries. The majority of the nerve transfer techniques have focused on the upper brachial plexus or distal nerves of the lower brachial plexus. More recently, nerve transfers have reemerged as a potential reinnervation strategy for select patients with cervical SCI. The brachialis-to-AIN transfer technique offers a potential means for restoration of intrinsic hand function in patients with SCI.
Hawasli, Ammar H.; Chang, Jodie; Reynolds, Matthew R.; Ray, Wilson Z.
Study Design Technical report. Objective To provide a technical description of the transfer of the brachialis to the anterior interosseous nerve (AIN) for the treatment of tetraplegia after a cervical spinal cord injury (SCI). Methods In this technical report, the authors present a case illustration of an ideal surgical candidate for a brachialis-to-AIN transfer: a 21-year-old patient with a complete C7 spinal cord injury and failure of any hand motor recovery. The authors provide detailed description including images and video showing how to perform the brachialis-to-AIN transfer. Results The brachialis nerve and AIN fascicles can be successfully isolated using visual inspection and motor mapping. Then, careful dissection and microsurgical coaptation can be used for a successful anterior interosseous reinnervation. Conclusion The nerve transfer techniques for reinnervation have been described predominantly for the treatment of brachial plexus injuries. The majority of the nerve transfer techniques have focused on the upper brachial plexus or distal nerves of the lower brachial plexus. More recently, nerve transfers have reemerged as a potential reinnervation strategy for select patients with cervical SCI. The brachialis-to-AIN transfer technique offers a potential means for restoration of intrinsic hand function in patients with SCI. PMID:25844283
Li, Xiuquan; Sun, Guangfeng; Wang, Dali; Wei, Zairong; Qi, Jianping; Nie, Kaiyu; Jin, Wenhu; Deng, Chengliang; Li, Hai
To explore the curative effect of reverse bi-pedicle posterior interosseous artery perforator flap in repairing skin and soft tissue defects on the wrist. Seven patients with soft tissue defects on the wrist, including simple skin and soft tissue defects in 4 cases and skin and soft tissue defects combined with radial tendon injury in 3 cases, were hospitalized from December 2010 to March 2012. The area of skin defect on the volar side of the wrist ranged from 4.8 cm x 4.0 cm to 6.2 cm x 4.5 cm, while that on the dorsal side ranged from 3.5 cm x 3.2 cm to 6. 5 cm x 5.4 cm. These wounds were respectively caused by traffic injury (3 cases), reamer injury (2 cases), burn (1 case), and tumor resection (1 case). Reverse bi-pedicle posterior interosseous artery perforator flaps were used to repair these defects, with area of one pedicle ranging from 2.5 cm x 2.0 cm to 3.5 cm x 2.5 cm and the area of the other pedicle ranging from 2.5 cm x 2.5 cm to 4.0 cm x 3.0 cm. The donor sites were closed by suturing. All flaps survived completely. Patients were followed up for 6 to 36 months. The color, texture, and appearance of all flaps were satisfactory. At last follow-up, distances of two-point discrimination of flaps ranged from 9 to 13 mm. The dorsal extension and palmar flexion functions of wrist were satisfactory. The results of function evaluation of 7 wrists were excellent in 6 cases and good in 1 case according to the tentative standards for the evaluation of upper extremity function of Society of Hand Surgery of Chinese Medical Association. A linear scar was formed at the donor site. The reverse bi-pedicle posterior interosseous artery perforator flap, with advantages of flexible design, easy to achieve, less injury to donor site, and reliable blood supply, etc., is another choice for repairing skin and soft tissue defects over the wrist.
Robb, Andrew; Sajko, Sandy
This report documents retrospectively a case of Posterior Interosseous Neuropathy (PIN) occurring in an elite baseball pitcher experiencing a deep ache in the radial aspect of the forearm and altered sensation in the dorsum of the hand on the throwing arm during his pitching motion. The initial clinical goal was to control for inflammation to the nerve and muscle with active rest, microcurrent therapy, low-level laser therapy, and cessation of throwing. Minimizing mechanosensitivity at the common extensor region of the right elbow and PIN, was achieved by employing the use of myofascial release and augmented soft tissue mobilization techniques. Neurodynamic mobilization technique was also administered to improve neural function. Implementation of a sport specific protocol for the purposes of maintaining throwing mechanics and overall conditioning was utilized. Successful resolution of symptomatology and return to pre-injury status was achieved in 5 weeks. A review of literature and an evidence-based discussion for the differential diagnoses, clinical examination, diagnosis, management and rehabilitation of PIN is presented.
Galloway, Kathleen M; Greathouse, David G; Olson, Ronald; Tracy, Mary
Foot intrinsic muscle innervation may demonstrate some variability. The first dorsal interosseous muscle (FDI) is innervated by the deep branch of the lateral plantar nerve (LPN) from the main trunk of the tibial nerve. Contribution from the deep fibular nerve (DFN) may also play a role in the supply of the FDI. Thirty healthy adult volunteers were studied to determine the presence and type of response in the FDI with stimulation of the tibial nerve/deep branch of the LPN and DFN. Both nerves were stimulated at the ankle and knee with a surface and needle recording from the FDI. Latency, amplitude, and conduction values were recorded for each nerve. The incidence of DFN supply to the FDI was 16.6% with a mean ankle amplitude of 152 microV. The incidence of tibial nerve/deep branch of the LPN supply to the FDI was 100%, with a mean ankle amplitude of 5.11 mV. The superficial branch of the LPN is most often studied when evaluating for tarsal tunnel syndrome because the standard recording site is the abductor digiti minimi (ADM). Recording from the ADM, however, frequently produces a less than desirable waveform, and the technical challenges encountered with this site make tarsal tunnel syndrome assessment difficult. It is also possible that selective involvement of the deep branch of the LPN may occur, and if so, recording from the FDI may prove valuable. Copyright 2004 Wiley-Liss, Inc.
Distal anterior interosseous nerve transfer to the deep ulnar nerve and end-to-side suture of the superficial ulnar nerve to the third common palmar digital nerve for treatment of high ulnar nerve injuries: experience in five cases.
Flores, Leandro Pretto
To demonstrate the results of a double nerve transfer at the level of the hand for recovery of the motor and sensory function of the hand in cases of high ulnar nerve injuries. Five patients underwent a transfer of the distal branch of the anterior interosseous nerve to the deep ulnar nerve, and an end-to-side suture of the superficial ulnar nerve to the third common palmar digital nerve. Two patients recovered strength M3 and three cases were graded as M4; recovery of protective sensation (S3+ in three patients and S4 in two) was observed in the fourth and fifth fingers, and at the hypothenar region. The monofilament test showed values of 3.61 or less in all cases and the two-point discrimination test demonstrated values of 7 mm in three cases and 5 mm in two. This technique of double nerve transfer is effective for motor and sensory recovery of the distal ulnar-innervated side of the hand.
Cugat, Ramon; Ares, Oscar; Cuscó, Xavier; Garcia, Montserrat; Samitier, Gonzalo; Seijas, Roberto
Ankle arthroscopy provides a minimally invasive approach to the diagnosis and treatment of certain ankle disorders. Neurological complications resulting from ankle arthroscopy have been well documented in orthopaedic and podiatric literature. Owing to the superficial location of the ankle joint and the abundance of overlying periarticular neurovascular structures, complications reported in ankle arthroscopy are greater than those reported for other joints. In particular, all reported neurovascular injuries following ankle arthroscopy have been the direct result of distractor pin or portal placement. The standard posteromedial portal has recognized risks because of the proximity of the posterior neurovascular structures. There can be considerable variability in the course of these portals and their proximity to the neurovascular structures. We found one report of intra-articular damage to the posterior tibial nerve as a result of ankle arthroscopy in the English-language literature and we report this paper as a second case described in the literature.
van Zyl, Natasha; Hahn, Jodie B; Cooper, Catherine A; Weymouth, Michael D; Flood, Stephen J; Galea, Mary P
Restoration of elbow extension, grasp, key pinch, and release are major goals in low-level tetraplegia. Traditionally, these functions are achieved using tendon transfers. In this case these goals were achieved using nerve transfers. We present a 21-year-old man with a C6 level of tetraplegia. The left upper limb was treated 6 months after injury with a triple nerve transfer. A teres minor nerve branch to long head of triceps nerve branch, brachialis nerve branch to anterior interosseous nerve, and supinator nerve branch to posterior interosseous nerve transfer were used successfully to reconstruct elbow extension, key pinch, grasp, and release simultaneously.
Efendić, Alma; Muharemović, Edin; Skomorac, Rasim; Bečulić, Hakija; Šestić, Sabina; Halilović, Benjamin; Mahmić-Kaknjo, Mersiha
Aim To define direct anatomical relations of the sphenoidal (alae minores), ethmoidal sinuses and optic nerve, with an emphasis on determining the effect of age on pneumatisation and dehiscence. Methods This retrospective, descriptive study involved 60 consecutive patients: 30 patients younger than 30 and30 patients older than 60 years of age. All patients underwent computerized tomography(CT). The relationship of the optic nerve and the sphenoidal and ethmoidal sinuses was classified. The presence of dehiscence in the bone structures, forming the optic canal, was checked. Dehiscence was defined as absence of visible bone density located between the sinus and the optic nerve. Protrusion of the optic nerve into the sphenoidal sinus was defined as optic nerve surrounded by pneumatised space. Results The most common type of relation between the optic nerve and sphenoidal sinus was type I, where the optic nerve was immediately adjacent to the lateral or superior wall of the sphenoidal sinus, without impression on the sinus wall. Dehiscence was documented in 15 (25%) cases, it was more common in older patients (8, 27%) than in younger ones (7, 23%). The pneumatisation processes were more frequent in patients over 60 (5, 17%) than in those younger than 30 years (4, 13%). Conclusion Surgeons and ophthalmologists should be aware of high frequency of dehiscence of sphenoidal sinus walls when treating adult patients in our population, especially when evaluating risks and complications of surgical procedures or when diagnosing inflammatory or tumorous processes in the close vicinity of posterior paranasal sinuses.
McMahon, Shane M; Chang, Che-Wei; Jackson, Meyer B
Cytosolic Ca(2+) buffers bind to a large fraction of Ca(2+) as it enters a cell, shaping Ca(2+) signals both spatially and temporally. In this way, cytosolic Ca(2+) buffers regulate excitation-secretion coupling and short-term plasticity of release. The posterior pituitary is composed of peptidergic nerve terminals, which release oxytocin and vasopressin in response to Ca(2+) entry. Secretion of these hormones exhibits a complex dependence on the frequency and pattern of electrical activity, and the role of cytosolic Ca(2+) buffers in controlling pituitary Ca(2+) signaling is poorly understood. Here, cytosolic Ca(2+) buffers were studied with two-photon imaging in patch-clamped nerve terminals of the rat posterior pituitary. Fluorescence of the Ca(2+) indicator fluo-8 revealed stepwise increases in free Ca(2+) after a series of brief depolarizing pulses in rapid succession. These Ca(2+) increments grew larger as free Ca(2+) rose to saturate the cytosolic buffers and reduce the availability of Ca(2+) binding sites. These titration data revealed two endogenous buffers. All nerve terminals contained a buffer with a Kd of 1.5-4.7 µM, and approximately half contained an additional higher-affinity buffer with a Kd of 340 nM. Western blots identified calretinin and calbindin D28K in the posterior pituitary, and their in vitro binding properties correspond well with our fluorometric analysis. The high-affinity buffer washed out, but at a rate much slower than expected from diffusion; washout of the low-affinity buffer could not be detected. This work has revealed the functional impact of cytosolic Ca(2+) buffers in situ in nerve terminals at a new level of detail. The saturation of these cytosolic buffers will amplify Ca(2+) signals and may contribute to use-dependent facilitation of release. A difference in the buffer compositions of oxytocin and vasopressin nerve terminals could contribute to the differences in release plasticity of these two hormones.
Notz, Gregory M.
A rare case of Bacillus panophthlamitis with extension to the prechiasmatic optic nerve secondary to hematogenous spreading after intravenous drug use is presented. A 27-year-old man with a recent history of trauma to the left eye presented with severe left eye pain following a binge of intravenous drug use. Visual acuity (VA) was LP. On examination he had chemosis, proptosis, elevated intraocular pressure, and a complete hyphema. CT-scan identified preseptal swelling, but no evidence of any posterior extension of the anterior process or orbital fractures. Topical and systemic therapy were initiated. On follow-up clinical examination less than 12 hours after presentation he had signs of a keratitis with worsening ophthalmoplegia and repeat imaging demonstrated posterior extension to the prechiasmatic optic nerve. Shortly after the cornea ruptured with cultures growing Bacillus. The patient underwent enucleation and has had no further progression of infection. To the best of our knowledge, this is the first report of Bacillus panophthalmitis presenting with signs of trauma with posterior extension to the prechiasmatic optic nerve. PMID:27994900
Adnot, J; Langlois, O; Tollard, E; Crahes, M; Auquit-Auckbur, I; Marie, J-P
Chondroblastoma is a rare tumor that can involve the temporal bone. Because it is a benign tumor, functional surgery must be proposed. We report a case of a patient with a massive chondroblastoma operated on with preservation of the facial nerve, and description of the surgical technique. A 37-year-old man presented with a 9-month history of a growing left pre-auricular mass and hearing loss. Neuroimaging showed an osteolytic mass invading the temporal bone and temporomandibular joint. Excision was performed via a transpetrosal and transcochlear approach with posterior transposition of the facial nerve. EMG monitoring was effective in preventing facial palsy. Four years later, no sign of recurrence was observed. Chondroblastoma is a locally aggressive tumor, especially when located in the petrous bone and temporomandibular joint. The suggested treatment is a complete excision. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
McMahon, Shane M.; Chang, Che-Wei
Cytosolic Ca2+ buffers bind to a large fraction of Ca2+ as it enters a cell, shaping Ca2+ signals both spatially and temporally. In this way, cytosolic Ca2+ buffers regulate excitation-secretion coupling and short-term plasticity of release. The posterior pituitary is composed of peptidergic nerve terminals, which release oxytocin and vasopressin in response to Ca2+ entry. Secretion of these hormones exhibits a complex dependence on the frequency and pattern of electrical activity, and the role of cytosolic Ca2+ buffers in controlling pituitary Ca2+ signaling is poorly understood. Here, cytosolic Ca2+ buffers were studied with two-photon imaging in patch-clamped nerve terminals of the rat posterior pituitary. Fluorescence of the Ca2+ indicator fluo-8 revealed stepwise increases in free Ca2+ after a series of brief depolarizing pulses in rapid succession. These Ca2+ increments grew larger as free Ca2+ rose to saturate the cytosolic buffers and reduce the availability of Ca2+ binding sites. These titration data revealed two endogenous buffers. All nerve terminals contained a buffer with a Kd of 1.5–4.7 µM, and approximately half contained an additional higher-affinity buffer with a Kd of 340 nM. Western blots identified calretinin and calbindin D28K in the posterior pituitary, and their in vitro binding properties correspond well with our fluorometric analysis. The high-affinity buffer washed out, but at a rate much slower than expected from diffusion; washout of the low-affinity buffer could not be detected. This work has revealed the functional impact of cytosolic Ca2+ buffers in situ in nerve terminals at a new level of detail. The saturation of these cytosolic buffers will amplify Ca2+ signals and may contribute to use-dependent facilitation of release. A difference in the buffer compositions of oxytocin and vasopressin nerve terminals could contribute to the differences in release plasticity of these two hormones. PMID:26880753
George, Anil Thomas; Maitra, Rudra Krishna; Maxwell-Armstrong, Charles
Neurostimulation remains the mainstay of treatment for patients with faecal incontinence who fails to respond to available conservative measures. Sacral nerve stimulation (SNS) is the main form of neurostimulation that is in use today. Posterior tibial nerve stimulation (PTNS)--both the percutaneous and the transcutaneous routes--remains a relatively new entry in neurostimulation. Though in its infancy, PTNS holds promise to be an effective, patient friendly, safe and cheap treatment. However, presently PTNS only appears to have a minor role with SNS having the limelight in treating patients with faecal incontinence. This seems to have arisen as the strong, uniform and evidence based data on SNS remains to have been unchallenged yet by the weak, disjointed and unsupported evidence for both percutaneous and transcutaneous PTNS. The use of PTNS is slowly gaining acceptance. However, several questions remain unanswered in the delivery of PTNS. These have raised dilemmas which as long as they remain unsolved can considerably weaken the argument that PTNS could offer a viable alternative to SNS. This paper reviews available information on PTNS and focuses on these dilemmas in the light of existing evidence.
Brodsky, M C
To determine whether posterior pituitary ectopia in children with optic nerve hypoplasia has a male predominance or an increased incidence of breech delivery. Retrospective analysis of 12 children with optic nerve hypoplasia and posterior pituitary ectopia. Eleven of 12 patients with posterior pituitary ectopia were boys. No child had a history of breech delivery. Two children had a history of breech positioning but were delivered by cesarean section. Posterior pituitary ectopia with optic nerve hypoplasia shows a strong male predominance but no association with breech delivery.
Barroso, Ubirajara; Viterbo, Walter; Bittencourt, Joana; Farias, Tiago; Lordêlo, Patrícia
Parasacral transcutaneous electrical nerve stimulation and posterior tibial nerve stimulation have emerged as effective methods to treat overactive bladder in children. However, to our knowledge no study has compared the 2 methods. We evaluated the results of parasacral transcutaneous electrical nerve stimulation and posterior tibial nerve stimulation in children with overactive bladder. We prospectively studied children with overactive bladder without dysfunctional voiding. Success of treatment was evaluated by visual analogue scale and dysfunctional voiding symptom score, and by level of improvement of each specific symptom. Parasacral transcutaneous electrical nerve stimulation was performed 3 times weekly and posterior tibial nerve stimulation was performed once weekly. A total of 22 consecutive patients were treated with posterior tibial nerve stimulation and 37 with parasacral transcutaneous electrical nerve stimulation. There was no difference between the 2 groups regarding demographic characteristics or types of symptoms. Concerning the evaluation by visual analogue scale, complete resolution of symptoms was seen in 70% of the group undergoing parasacral transcutaneous electrical nerve stimulation and in 9% of the group undergoing posterior tibial nerve stimulation (p = 0.02). When the groups were compared, there was no statistically significant difference (p = 0.55). The frequency of persistence of urgency and diurnal urinary incontinence was nearly double in the group undergoing posterior tibial nerve stimulation. However, this difference was not statistically significant. We found that parasacral transcutaneous electrical nerve stimulation is more effective in resolving overactive bladder symptoms, which matches parental perception. However, there were no statistically significant differences in the evaluation by dysfunctional voiding symptom score, or in complete resolution of urgency or diurnal incontinence. Copyright © 2013 American Urological
The close relationships between the cranial nerves and the arterial vessels in the posterior cranial fossa are one of the predisposing factors for artery-nerve compression. The aim of this study was to examine the relationships of the vertebral and basilar arteries to some skull and dural structures and the nerves in the posterior cranial fossa. For this purpose, the skull bases and brains of 70 cadavers were studied. The topographic relationships of the vertebral and basilar arteries to the cranial nerves in the posterior cranial fossa were studied and the distances between the arteries and some osseous formations were measured. The most significant variations in arterial position were registered in the lower half of the basilar artery. Direct contact with an artery was established for the hypoglossal canal, jugular tubercle, and jugular foramen. The results reveal additional information about the relationships of the nerves and arteries to the skull and dural formations in the posterior cranial fossa. New quantitative information is given to illustrate them. The conditions for possible artery-nerve compression due to arterial dislocation are discussed and two groups (lines) of compression points are suggested. The medial line comprises of the brain stem points, usually the nerve root entry/exit zone. The lateral line includes the skull eminences, on which the nerves lie, or skull and dural foramina through which they exit the cranial cavity. (c) 2008 Wiley-Liss, Inc.
Khalil, Ayman; Clerkin, James; Mandiwanza, Tafadzwa; Green, Sandra; Javadpour, Mohsen
Multiple cranial nerves palsies following a posterior fossa exploration confined to an extradural compartment is a rare clinical presentation. This case report describes a young man who developed a unilateral abducens and bilateral facial nerve palsies following a posterior fossa exploration confined to an extradural compartment. There are different theories to explain this presentation, but the exact mechanism remains unclear. We propose that this patient cranial nerve palsies developed following cerebrospinal fluid (CSF) leak, potentially as a consequence of rapid change in CSF dynamics. PMID:26951144
Wolter, J R
Following enucleation, an epithelioid type of malignant choroidal melanoma involving the posterior pole was grossly and histologically found to exhibit direct extraocular extension along the emissary for the long posterior ciliary artery and nerve on the temporal side. In addition to a small tumor nodule on the outside of the sclera, melanoma extension was found up to the cut end in the otherwise well preserved ciliary nerve. After tenonectomy, additional extraocular melanoma extension in the core of this long posterior ciliary nerve was demonstrated for a total distance of 5 mm. As a result of the present findings, intraneural melanoma extension into the orbit by the way of a ciliary nerve has to be added to the other possible ways of direct extraocular melanoma extension. Images FIGURE 5 FIGURE 1 FIGURE 2 FIGURE 3 FIGURE 4 FIGURE 6 FIGURE 7 FIGURE 8 FIGURE 9 FIGURE 10 FIGURE 11 PMID:6676977
Mikami, Takeshi; Minamida, Yoshihiro; Yamaki, Toshiaki; Koyanagi, Izumi; Nonaka, Tadashi; Houkin, Kiyohiro
Steady-state free precession is widely used for ultra-fast cardiac or abdominal imaging. The purpose of this work was to assess fast imaging employing steady-state acquisition (FIESTA) and to evaluate its efficacy for depiction of the cranial nerve affected by the tumor. Twenty-three consecutive patients with posterior fossa tumors underwent FIESTA sequence after contrast agent administration, and then displacement of the cranial nerve was evaluated. The 23 patients with posterior fossa tumor consisted of 12 schwannomas, eight meningiomas, and three cases of epidermoid. Except in the cases of epidermoid, intensity of all tumors increased on FIESTA imaging of the contrast enhancement. In the schwannoma cases, visualization of the nerve became poorer as the tumor increased in size. In cases of encapsulated meningioma, all the cranial nerves of the posterior fossa were depicted regardless of location. The ability to depict the nerves was also significantly higher in meningioma patients than in schwannoma patients (P<0.05). In cases of epidermoid, extension of the tumors was depicted clearly. Although the FIESTA sequence offers similar contrast to other heavily T2-weighted sequences, it facilitated a superior assessment of the effect of tumors on cranial nerve anatomy. FIESTA sequence was useful for preoperative simulations of posterior fossa tumors.
Kim, Deog-Im; Kim, Yi-Suk
Most of foot pain occurs by the entrapment of the tibial nerve and its branches. Some studies have reported the location of the tibial nerve; however, textbooks and researches have not described the posterior tibial artery and the relationship between the tibal nerve and the posterior tibial artery in detail. The purpose of this study was to analyze the location of neurovascular structures and bifurcations of the nerve and artery in the ankle region based on the anatomical landmarks. Ninety feet of embalmed human cadavers were examined. All measurements were evaluated based on a reference line. Neurovascular structures were classified based on the relationship between the tibial nerve and the posterior tibial artery. The bifurcation of arteries and nerves were expressed by X- and Y-coordinates. Based on the reference line, 9 measurements were examined. The most common type I (55.6%), was the posterior tibial artery located medial to the tibial nerve. Neurovascular structures were located less than 50% of the distance between M and C from M at the reference line. The bifurcation of the posterior tibial artery was 41% in X-coordinate, -38% in Y-coordinate, and that of the tibial nerve was 48%, and -10%, respectively. Thirteen measurements and classification showed statistically significant differences between both sexes (P<0.05). It is determined the average position of neurovascular structures in the human ankle region and recorded the differences between the sexes and amongst the populations. These results would be helpful for the diagnosis and treatment of foot pain. PMID:26140224
Malungpaishrope, Kanchai; Leechavengvongs, Somsak; Witoonchart, Kiat; Uerpairojkit, Chairoj; Boonyalapa, Artit; Janesaksrisakul, Disorn
This study reports the results of restoring the deltoid and triceps functions in patients with C5, C6, and C7 root avulsion injuries by simultaneously transferring 4 intercostal nerves to the anterior axillary nerve and the nerve to the long head of the triceps through the posterior approach. Nine patients with C5, C6, and C7 root avulsion injuries underwent spinal accessory nerve transfer to the suprascapular nerve combined with transfer of the third and fourth intercostal nerves to the anterior axillary nerve for shoulder reconstruction. Simultaneous transfer of the fifth and sixth intercostal nerves to the radial nerve branch of the triceps was done to restore elbow extension. For shoulder function, 8 patients had M4 recovery and 1 patient had M2 recovery. Average shoulder abduction and external rotation were 69° and 42°, respectively. For elbow extension, 3 patients achieved M3 recovery, 5 patients had M2 recovery, and 1 patient had M1 recovery. Reconstruction of 2 muscles with intercostal nerves is possible when both muscles act synergistically, such as shoulder abduction and elbow extension. Two intercostal nerves are adequate to transfer for deltoid reconstruction but not enough for elbow extension against gravity. Therapeutic IV. Copyright © 2012. Published by Elsevier Inc.
Volkova, N K; Andrianov, Iu N
Applying the axon-terminal degeneration method, the representation of the lateral line posterior nerve in acustico-lateral area of the dwarf sheatfish medulla oblongata was studied. The connections of the lateral line posterior nerve were demonstrated to be topically organized within the medial nucleus of the acustico-lateral area, however, within the limits of the nucleus the projections were not evenly distributed. The greatest degree of localization of the degenerated terminals was revealed in the dorsolateral area of the medial nucleus on the ipsilateral side, where previously, under adequate stimulation of the organs on the lateral line of the dwarf sheatfish, the greatest amount of responses was registered.
Park, C; Choi, J B; Lee, Y-S; Chang, H-S; Shin, C S; Kim, S; Han, D W
Posterior neck pain following thyroidectomy is common because full neck extension is required during the procedure. We evaluated the effect of intra-operative transcutaneous electrical nerve stimulation on postoperative neck pain in patients undergoing total thyroidectomy under general anaesthesia. One hundred patients were randomly assigned to one of two groups; 50 patients received transcutaneous electrical nerve stimulation applied to the trapezius muscle and 50 patients acted as controls. Postoperative posterior neck pain and anterior wound pain were evaluated using an 11-point numerical rating scale at 30 min, 6 h, 24 h and 48 h following surgery. The numerical rating scale for posterior neck pain was significantly lower in the transcutaneous electrical nerve stimulation group compared with the control group at all time points (p < 0.05). There were no significant differences in the numerical rating scale for anterior wound pain at any time point. No adverse effects related to transcutaneous electrical nerve stimulation were observed. We conclude that intra-operative transcutaneous electrical nerve stimulation applied to the trapezius muscle reduced posterior neck pain following thyroidectomy.
Boelens, Oliver B; Maatman, Robert C; Scheltinga, Marc R; van Laarhoven, Kees; Roumen, Rudi M
Most patients with chronic back pain suffer from degenerative thoracolumbovertebral disease. However, the following case illustrates that a localized peripheral nerve entrapment must be considered in the differential diagnosis of chronic back pain. We report the case of a 26-year-old woman with continuous excruciating pain in the lower back area. Previous treatment for nephroptosis was to no avail. On physical examination the pain was present in a 2 x 2 cm area overlying the twelfth rib some 4 cm lateral to the spinal process. Somatosensory testing using swab and alcohol gauze demonstrated the presence of skin hypo- and dysesthesia over the painful area. Local pressure on this painful spot elicited an extreme pain response that did not irradiate towards the periphery. These findings were highly suggestive of a posterior version of the anterior cutaneous nerve entrapment syndrome (ACNES), a condition leading to a severe localized neuropathic pain in anterior portions of the abdominal wall. She demonstrated a beneficial albeit temporary response after lidocaine infiltration as dictated by an established diagnostic and treatment protocol for ACNES. She subsequently underwent a local neurectomy of the involved superficial branch of the intercostal nerve. This limited operation had a favorable outcome resulting in a pain-free return to normal activities up to this very day (follow-up of 24 months).We propose to name this novel syndrome "posterior cutaneous nerve entrapment syndrome" (POCNES). Each patient with chronic localized back pain should undergo simple somatosensory testing to detect the presence of overlying skin hypo- and dysesthesia possibly reflecting an entrapped posterior cutaneous nerve.Key words: Chronic pain, back pain, posterior cutaneous nerve entrapment, peripheral nerve entrapment, surgical treatment for pain, anterior cutaneous nerve entrapment.
Bertelli, Jayme Augusto; Ghizoni, Marcos Flávio
OBJECT Results of radial nerve grafting are largely unknown for lesions of the radial nerve that occur proximal to the humerus, including those within the posterior cord. METHODS The authors describe 13 patients with proximal radial nerve injuries who were surgically treated and then followed for at least 24 months. The patients' average age was 26 years and the average time between accident and surgery was 6 months. Sural nerve graft length averaged 12 cm. Recovery was scored according to the British Medical Research Council (BMRC) scale, which ranges from M0 to M5 (normal muscle strength). RESULTS After grafting, all 7 patients with an elbow extension palsy recovered elbow extension, scoring M4. Six of the 13 recovered M4 wrist extension, 6 had M3, and 1 had M2. Thumb and finger extension was scored M4 in 3 patients, M3 in 2, M2 in 2, and M0 in 6. CONCLUSIONS The authors consider levels of strength of M4 for elbow and wrist extension and M3 for thumb and finger extension to be good results. Based on these criteria, overall good results were obtained in only 5 of the 13 patients. In proximal radial nerve lesions, the authors now advocate combining nerve grafts with nerve or tendon transfers to reconstruct wrist, thumb, and finger extension.
Liss, Frederic E
The interosseous muscles of the hand can be thought of as the cornerstone of hand function, as they provide a "foundation" for all intrinsic and extrinsic hand movements. Innervated by the ulnar nerve and organized in dorsal and palmar layers, these pivotal muscles have small excursion yet great impact on finger balance, grip, and pinch function, particularly when impaired by denervation and/or contracture. This article gives an overview of the functional anatomy and pathologic dysfunction of the interosseous muscles within the context of this Hand Clinics issue on the intrinsic muscular function of the hand. Copyright © 2012 Elsevier Inc. All rights reserved.
Naroji, Swetha; Belin, Laurence J; Maltenfort, Mitchell Gil; Vaccaro, Alexander R; Schwartz, Daniel; Harrop, James S; Weinstein, Michael
Background: Femoral nerve palsy is not a common adverse effect of lumbar spinal surgery. Objective: To report 3 unique cases of femoral nerve neuropathy due to instrumentation and positioning during complex anterior and posterior spinal surgery. Methods: Case series Results: All 3 patients demonstrated femoral nerve neuropathy. The first patient presented postoperatively but after 6 months, the palsy resolved. Femoral nerve malfunctioning was documented in the second and third patients intraoperatively; however, with rapid patient repositioning and removal of offending instrumentation, postoperative palsy was avoided. Conclusions: Use of motor evoked potential monitoring of the femoral nerve during surgery is vital for the prevention of future neuropathies, an avoidable complication of spinal surgery. PMID:19777866
Ki, Sae Hwi
The lateral arm free flap offers many advantages in reconstruction of soft tissue defect and reconstruction of extremities. However, this free flap is associated with sensory loss at the posterior forearm due to injury of the posterior antebrachial cutaneous nerve (PABCN).The PABCN-sparing lateral arm free flaps were performed in 19 patients with various soft tissue defects of the extremity, and the outcomes of free flap reconstructions using this modification are evaluated. All flaps survived without partial necrosis. Three patients experienced transient sensory loss in the posterior area of the forearm after flap harvest.In this study, lateral arm free flaps can be elevated without necessarily sacrificing the PABCN. This nerve-sparing modification decreases the donor-site morbidity of lateral arm free flaps and further increases the overall usefulness of this flap in soft tissue reconstructions of the extremities.
Eftekhar, Tahereh; Teimoory, Nastaran; Miri, Elahe; Nikfallah, Abolghasem; Naeimi, Mahsa; Ghajarzadeh, Mahsa
Overactive bladder (OAB) is a disabling disorder. Treatment of cases with OAB includes behavioral, pharmacological, surgical interventions and peripheral electrical stimulation. The goal of this study was to determine effects of posterior tibial nerve stimulation on sexual function and pelvic disorders in women with Overactive bladder (OAB). Fifty women were randomly assigned to PTNS (posterior tibial nerve stimulation) plus tolterodine or tolterodine alone treatment. Tolterodine group received 4 mg tolterodine daily for three months while the other group received this treatment plus percutaneous tibial nerve stimulation for 12 consequence weeks. Two in PTNS group and 8 in the control group withdrew from the study. Age, education level, and occupation status were not significantly different between two groups. Mean total FSFI and its subscales were not significantly different before and after treatment between two groups. Urine leakage associated with a feeling of urgency and loss of stool or gas from the rectum beyond patient's control became significantly different after treatment between two groups. Posterior tibial nerve stimulation could help urinary problems in women with a neurologic bladder.
Joshi, Dharmdev H; Thawait, Gaurav K; Del Grande, Filippo; Fritz, Jan
Neuropathy of the posterior femoral cutaneous nerve may manifest as pain and paresthesia in the skin over the inferior buttocks, posterior thigh, and popliteal region. Current treatment options include physical and oral pain therapy, perineural injections, and surgical neurectomy. Perineural steroid injections may provide short-term pain relief; however, to our knowledge, there is currently no minimally invasive denervation procedure for sustained pain relief that could serve as an alternative to surgical neurectomy. Percutaneous cryoablation of nerves is a minimally invasive technique that induces a sustained nerve conduction block through temporary freezing of the neural layers. It can result in long-lasting pain relief, but has not been described for the treatment of neuropathy-mediated PFCN pain. We report a technique of MR-guided cryoablation of the posterior femoral cutaneous nerve resulting in successful treatment of PFCN-mediated sitting pain. Cryoablation of the posterior femoral cutaneous nerve seems a promising, minimally invasive treatment option that deserves further investigation.
Onishi, H; Yamada, T; Saito, T; Emori, T; Fuchigami, T; Hasegawa, A; Nagaoka, T; Ross, M
We examined the effect of stimulus rate on somatosensory evoked potentials (SEPs) following stimulation of the common peroneal nerve (CPN) at the knee, and the posterior tibial nerve (PTN) and sural nerve (SN) at the ankle. We measured the amplitude of P40-N50 and N50-P60 in the PTN-SEP and corresponding amplitude of CPN-SEP and SN-SEP at the rate of 2.3, 3.4, 4.1, and 5.1 Hz. When the stimulation rate was increased from 2.3 to 5.1 Hz, the P40-N50 amplitude decreased by 50% for the CPN-SEP and 20% for the PTN-SEP. Also, the N50-P60 amplitude was reduced by 30% in the CPN-SEP and 20% in the PTN-SEP. In contrast, this change in stimulus rate produced no significant amplitude decline in the SN-SEP. Blocking the peroneal nerve with lidocaine just distal to the stimulating electrodes eliminated the descending peroneal nerve volley and abolished the amplitude attenuation observed with the faster stimulus rate. The findings suggest that at higher rates of stimulation, the afferent volleys induced by the movements that follow mixed nerve stimulation interfere with the SEP produced by electrical activation of the sensory afferents. The interference is greater when the more proximal site of the mixed nerve is stimulated.
Urasaki, E; Wada, S; Yokota, A; Tokimura, T; Yasukouchi, H
To identify the origin of short latency somatosensory evoked potentials (SSEPs) to posterior tibial nerve stimulation, direct recordings were made from the cervical cord, the ventricular system and the frontal subcortex during 8 neurosurgical operations. The origin of each component of SSEPs was also studied in 7 selected patients with various lesions in the central nervous system. In addition, SSEPs to median nerve stimulation were investigated in 4 of 8 surgical cases and all 7 cases of the lesion study group. Bilateral posterior tibial nerve stimulation in 10 normal subjects showed spinal N28 on the skin of the posterior neck and far-field P30 and N33 components followed by a cortical P38 component at the scalp. Direct recordings made to the mid-brain through the medulla oblongata showed a negative potential with gradually increasing latency. The peak of the negativity in the vicinity of the dorsal column nucleus showed almost the same latency as that of the scalp far-field P30, and positivity with a stationary peak was found above the dorsal column nucleus. Above the mid-pons, there was a stationary negativity with no latency shift, showing the same peak latency as that of scalp N33. The spatiotemporal distributions of P30 and N33 to posterior tibial nerve stimulation were analogous to those of P14 and N18 by median nerve stimulation. Transesophageal and direct cervical cord recordings showed that the spinal N13 phase to median nerve stimulation was reversed between the dorsal and ventral sides of the cervical cord. No such reversal occurred for the spinal N28 potential. Clinical lesion studies showed that changes in P30 and P14, and in N33 and N18 correlated with one another: that is, 1) prolongation of latency of N33 was also observed for N18; 2) absence of P30 was paralleled by the absence of P14. These data suggest that spinal N28 originates from ascending activity such as a dorsal column volley, and scalp P30 comes from activity near the dorsal column
Radius, R L
Fast axonal transport abnormalities in primate (Aotus trivirgatus) optic nerve were studied in ten eyes at various intervals after occlusion of the lateral short posterior ciliary circulation. Evidence of focal axonal ischemia, as indicated by swelling of mitochondria and dissolution of cytoplasmic detail, was noted as early as one hour after occlusion. Accumulation of mitochondria, microvesicles, and dense bodies, indicating focal interruption of axonal transport mechanisms, was noted in eyes examined at 2, 4, and 6 hours. This accumulation of organelles was limited to the region of the lamina cribrosa. Nerve head abnormalities were not seen in two eyes studied at two weeks.
Jackson, M B; Zhang, S J
1. A theoretical model was developed to investigate action potential propagation in posterior pituitary nerve terminals. This model was then used to evaluate the efficacy of depolarizing and shunting GABA responses on action potential propagation. 2. Experimental data obtained from the posterior pituitary with patch clamp techniques were used to derive empirical expressions for the voltage and time dependence of the nerve terminal Na+ and K+ channels. The essential structure employed here was based on anatomical and cable data from the posterior pituitary, and consisted of a long cylindrical axon (diameter, 0.5 mm) with a large spherical swelling (diameter, 4-21 mm) in the middle. 3. In the absence of an inhibitory conductance, simulated action potentials propagated with high fidelity through the nerve terminal. Swellings could block propagation, but only when sizes exceeded those observed in the posterior pituitary. Adding axonal branches reduced the critical size only slightly. These results suggested that action potentials invade the entire posterior pituitary nerve terminal in the absence of inhibition or depression. 4. The addition of inhibitory conductance to a swelling caused simulated action potentials to fail at the swelling. Depolarizing inhibitory conductances were 1.6 times more effective than shunting inhibitory conductances in blocking propagation. 5. Inhibitory conductances within the range of experimentally observed magnitudes and localized to swellings in the observed range of sizes were too weak to block simulated action potentials. However, twofold enhancement of GABA responses by neurosteroid resulted in currents strong enough to block propagation in realistic swelling sizes. 6. GABA could block simulated propagation without neurosteroid enhancement provided that GABA was present throughout a region in the order of a few hundred micrometres. For this widespread inhibition depolarizing conductance was 2.2 times more effective than shunting
Kozera, Katarzyna; Ciszek, Bogdan
The aim of this paper is to compare anatomic descriptions of posterior branches of the lumbar spinal nerves and, on this basis, present the location of these structures. The majority of anatomy textbooks do not describe these nerves in detail, which may be attributable to the fact that for many years they were regarded as structures of minor clinical importance. The state of knowledge on these nerves has changed within the last 30 years. Attention has been turned to their function and importance for both diagnostic practice and therapy of lower back pain. Summarising the available literature, we may conclude that the medial and lateral branches separate at the junction of the facet joint and the distal upper edge of the transverse process; that the size, course and area supplied differ between the lateral and the medial branch; and that facet joints receive multisegmental innervation. It has been demonstrated that medial branches are smaller than the respective lateral branches and they have a more constant course. Medial branches supply the area from the midline to the facet joint line, while lateral branches innervate tissues lateral to the facet joint. The literature indicates difficulties with determining specific anatomic landmarks relative to which the lateral branch and the distal medial branch can be precisely located. Irritation of sensory fibres within posterior branches of the lumbar spinal nerves may be caused by pathology of facet joints, deformity of the spine or abnormalities due to overloading or injury. The anatomic location and course of posterior branches of spinal nerves should be borne in mind to prevent damaging them during low-invasive analgesic procedures.
Rice, David C; Cata, Juan P; Mena, Gabriel E; Rodriguez-Restrepo, Andrea; Correa, Arlene M; Mehran, Reza J
Pain relief using regional neuroaxial blockade is standard care for patients undergoing major thoracic surgery. Thoracic epidural analgesia (TEA) provides effective postoperative analgesia but has unwanted side effects, including hypotension, urinary retention, nausea, and vomiting, and is highly operator dependent. Single-shot intercostal nerve and paravertebral blockade have not been widely used because of the short duration of action of most local anesthetics; however, the recent availability of liposomal bupivacaine (LipoB) offers the potential to provide prolonged blockade of intercostal nerves (72 to 96 hours). We hypothesized that a five-level unilateral posterior intercostal nerve block using LipoB would provide effective analgesia for patients undergoing thoracic surgery. We identified patients who underwent lung resection using intraoperative LipoB posterior intercostal nerve blockade and retrospectively compared them with a group of patients who had TEA and who were matched for age, sex, type of surgery, and surgical approach. We analyzed perioperative morbidity, pain scores and narcotic requirements. There were 54 patients in each group. Mean hospital stay was 3.5 days and 4.5 days (p = 0.004) for LipoB group and TEA group, respectively. There were no significant differences in perioperative complications, postoperative pain scores, or in narcotic utilization between LipoB group and TEA group. No acute toxicity related to LipoB was observed. Posterior intercostal nerve blockade using LipoB is safe and provides effective analgesia for patients undergoing thoracic surgery. It may be considered as a suitable alternative to TEA. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Mandeville, Ross M; Brown, Justin M; Gertsch, Jeffrey H; Allison, David W
It is well established that a mixed-agent general anesthetic regimen of volatile gas and intravenous anesthetic or total intravenous anesthetic (TIVA) is required to obtain adequate transcranial motor-evoked potentials (TcMEPs) to detect and hopefully prevent injury during brain, spinal cord, and peripheral nerve surgery. But even under ideal general anesthetic conditions, TcMEPs are not always detectable in every muscle monitored, and are prone to anesthetic fade, especially when neuropathic or injured tissue is monitored. TcMEP sensitivity to general anesthesia can be especially problematic during peripheral nerve surgery where there is often only one or a few essential muscles required to provide adequate monitoring; thus, maximum fidelity is essential. However, there is an anesthetic-resistant high-fidelity modality available to successfully monitor the motor component of distant peripheral nerves originating from the cauda equina. Percutaneus transabdominal electrical stimulation elicits a relatively anesthetic-resistant, robust motor response in muscles innervated by cauda equina nerve roots. We report the successful use of posterior root-muscle (PRM) reflex to monitor the decompression of the sciatic nerve at its bifurcation in a 22-year-old female with a history of severe sciatic nerve neuropathic pain and muscle weakness following benign thigh tumor resection.
Willemse, Ronald B; de Munck, Jan C; van't Ent, Dennis; Ris, Peterjan; Baayen, Johannes C; Stam, Cornelis J; Vandertop, W Peter
To study interhemispheric differences of somatosensory evoked field (SEF) characteristics and the spatial distribution of equivalent current dipole sources in patients with unilateral hemispheric lesions around the central sulcus region. In 17 patients with perirolandic lesions, averaged somatosensory responses after posterior tibial nerve stimulation at the ankle were recorded with magnetoencephalography. Dipole source solutions in the affected (AH) and unaffected (UH) hemispheres were analyzed and compared for latency, equivalent current dipole strength, root mean square, and spatial distribution in relation to clinical findings. Three main SEF components, P45m, N60m, and P75m, were identified in the hemisphere contralateral to the stimulated nerve. Dipole strength for the P45m component was significantly higher in the AH compared with the UH. SEF characteristics in the AH and UH showed no significant differences with respect to component latency or dipole strength of the N60m and P75m components. Interdipole location asymmetries exceeded 1.0 cm in 71% of the patients. Comparison of the posterior tibial nerve evoked responses (P45m and N60m) in patients with motor deficits and patients without deficits showed that these responses are enlarged in the AH when perirolandic lesions are present. Patients with motor deficits also showed an increased response for P45m in the UH. The results of posterior tibial nerve SEFs suggest spatial and functional changes in the somatosensory network as a result of perirolandic lesions with a possible relationship with clinical symptoms. The results can provide further basis for the evaluation of cortical changes in the presence of perirolandic lesions.
Guo, Zi-Yi; Chen, Jing; Liang, Qi-Zhou; Liao, Hai-Yan; Cheng, Qiong-Yue; Fu, Shui-Xi; Chen, Cai-Xiang; Yu, Dan
To evaluate the influence of high-resolution imaging obtainable with the higher field strength of 3.0 T on the visualization of the brain nerves in the posterior fossa. In total, 20 nerves were investigated on MRI of 12 volunteers each and selected for comparison, respectively, with the FSE sequences with 5 mm and 2 mm section thicknesses and gradient recalled echo (GRE) sequences acquired with a 3.0-T scanner. The MR images were evaluated by three independent readers who rated image quality according to depiction of anatomic detail and contrast with use of a rating scale. In general, decrease of the slice thickness showed a significant increase in the detection of nerves as well as in the image quality characteristics. Comparing FSE and GRE imaging, the course of brain nerves and brainstem vessels was visualized best with use of the three-dimensional (3D) pulse sequence. The comparison revealed the clear advantage of a thin section. The increased resolution enabled immediate identification of all brainstem nerves. GRE sequence most distinctly and confidently depicted pertinent structures and enables 3D reconstruction to illustrate complex relations of the brainstem. Copyright © 2013 Hainan Medical College. Published by Elsevier B.V. All rights reserved.
Hallahan, Katrina; Vinokur, Jessica; Demski, Sarah; Faulkner-Jones, Beverly; Giurini, John
Schwannoma is a benign tumor that arises from the peripheral nerve sheath. It presents as a discrete, often tender, and palpable nodule associated with neurogenic pain or paresthesia when compressed or traumatized. The growth rate is usually slow, and these lesions seldom exceed 2 cm in diameter. We report the case of a large schwannoma arising from the posterior tibial nerve located in the posterior medial ankle. The core needle biopsy findings were suggestive of a schwannoma, with spindle cells strongly and uniformly immunostaining for S-100 protein. The mass was marginally excised. The surgical specimen consisted of a grossly encapsulated white-yellow mass with irregular contours, measuring 3.7 × 3.5 × 2.7 cm. The cut surface showed areas of pin-point hemorrhage. The patient did not encounter any motor deficits; however, early results showed some subjective numbness. Few reports have been published of schwannomas arising from the tibial nerve. Marginal excision appears to be the recommended therapy for this tumor, without any evidence of recurrence at 9 months of follow-up.
Ohnishi, Yu-Ichiro; Ohkawa, Toshika; Ninomiya, Koshi; Moriwaki, Takashi; Yoshimine, Toshiki
Study Design A retrospective study. Purpose To assess the case files of patients who underwent surgery for cervical dumbbell schwannoma for determining the differences between schwannomas of the anterior and posterior nerve roots with respect to the incidence of postoperative radicular dysfunction. Overview of Literature The spinal roots giving origin to schwannoma are frequently nonfunctional, but there is a risk of postoperative neurological deficit once these roots are resected during surgery. Methods Fifteen patients with cervical dumbbell schwannomas were treated surgically. Ten men and 5 women, who were 35-79 years old (mean age, 61.5 years), presented with neck pain (n=6), radiculopathy (n=10), and myelopathy (n=11). Results Fourteen patients underwent gross total resection and exhibited no recurrence. Follow-ups were performed for a period of 6-66 months (mean, 28 months). Preoperative symptoms resolved in 11 patients (73.3%) but they persisted partially in 4 patients (26.7%). Six patients had tumors of anterior nerve root origin, and 9 patients had tumors of posterior nerve root origin. Two patients who underwent total resection of anterior nerve root tumors (33.3%) displayed minor postoperative motor weakness. One patient who underwent total resection of a posterior nerve root tumor (11.1%) showed postoperative numbness. Conclusions Appropriate tumor removal improved the neurological symptoms. In this study, the incidence of radicular dysfunction was higher in patients who underwent resection of anterior nerve root tumors than in patients who underwent resection of posterior nerve root tumors. PMID:25901239
Ouédraogo, D D; Daboiko, J C; Eti, E; Ouali, B; Ouattara, B; Gbané, M; Gbazi, C; Kouakou, N M
The purpose of this report is to describe the case of tuberculosis osteitis of the posterior vertebral arch in a 35-year-old man with recent history of pulmonary tuberculosis. Clinical findings were pain due to bilateral inflammation of the lumbar nerve roots, fistulised cold abcess and motor deficit in both lower extremities. The tomodensitometry demonstrated a lytic bone lesion involving the spinous process of the second lumbar vertebra in association with spondylitis and a large paravertebral abscess with calcification typical of tuberculosis. Cure was achieved by a single 12-month course of appropriate treatment.
Moya, P; Parra, P; Arroyo, A; Peña, E; Benavides, J; Calpena, R
Sacral nerve stimulation and percutaneous posterior tibial nerve stimulation have been described previously as effective treatments for fecal incontinence. Nevertheless, there does not exist any study that compares the efficiency of both. The aim of this study was to compare the use of SNS and PPTNS in males with FI. We conducted a prospective cohort study on men with FI treated with SNS or PTNS in the Coloproctology Unit of the University General Hospital of Elche and Reina Sofia of Murcia between January 2010 and December 2011. Preoperative assessment included physical examination, anorectal manometry, and anal endosonography. Anal continence was evaluated using the Wexner continence grading system. Quality of life was evaluated using the Fecal Incontinence Quality of life Scale. Nineteen patients were included (ten patients SNS and nine PPTNS). SNS improved FI in nine of the ten patients. The mean Wexner score decreased significantly from a median of 14 (12-16) (preoperative) to 4 (1-8) (6-month revision) (p = 0.007). PTNS improved FI in seven of the nine patients. The mean Wexner score decreased significantly from a median of 12 (11-19) (preoperative) to 5 (4-7) (6-month revision) (p = 0.018). Both treatments produced symptomatic improvement without statistical differences between them. Our study was nonrandomized with a relatively small number of patients. PPTNS had similar efficiency to the SNS in our men population. However, more studies are necessary to exclude selection bias and analyze long-term results.
Xie, Shaofei; Xiang, Bingren; Bu, Shoushan; Cao, Xiaojian; Ye, Ye; Lu, Jun; Deng, Haishan
A new rapid chemometric method has been developed to identify the anterior and posterior roots of cauda equina nerves by near-infrared (NIR) diffuse reflectance spectroscopy. NIR spectra of nerves were measured using a Fourier transform NIR spectrometer equipped with a fiber-optic probe. The result revealed no observable difference in the spectra between the anterior and posterior root samples, but the two roots could be identified by cluster analysis based on the differences of their spectral features. The overall accuracy of the cluster analysis model was 87.5%, and the accuracy for the actual anterior root and actual posterior root were 95% and 80%, respectively. The result suggested that NIR spectroscopy in combination with the chemometrics method (cluster analysis) could be used to classify the anterior and posterior roots of cauda equina nerves. The proposed method required only a few minutes, while classical methods commonly required at least one hour. It was demonstrated that the new method could provide a rapid, correct, nondestructive and low-cost potential means to quickly differentiate anterior and posterior roots in mixed cauda equina nerves, which would be helpful for surgeons to align nerve stumps correctly.
Crouch, Dustin L.; Plate, Johannes F.; Li, Zhongyu; Saul, Katherine R.
Purpose To determine if transfer to only the anterior branch of the axillary nerve will restore useful function following axillary nerve injury with persistent posterior deltoid and teres minor paralysis. Methods We used a computational musculoskeletal model of the upper limb to determine the relative contributions of posterior deltoid and teres minor to maximum joint moment generated during a simulated static strength assessment and to joint moments during 3 sub-maximal shoulder movements. Movement simulations were performed with and without simulated posterior deltoid and teres minor paralysis to identify muscles which may compensate for their paralysis. Results In the unimpaired limb model, teres minor and posterior deltoid accounted for 16% and 14% of the total isometric shoulder extension and external rotation joint moments, respectively. During the 3 movement simulations, posterior deltoid produced as much as 20% of the mean shoulder extension moment, while teres minor accounted for less than 5% of the mean joint moment in all directions of movement. When posterior deltoid and teres minor were paralyzed, the mean extension moments generated by the supraspinatus, long head of triceps, latissimus dorsi, and middle deltoid increased to compensate. Compensatory muscles were not fully activated during movement simulations when posterior deltoid and teres minor were paralyzed. Conclusions Reconstruction of the anterior branch of the axillary nerve only is an appropriate technique for restoring shoulder abduction strength following isolated axillary nerve injury. When shoulder extension strength is compromised by extensive neuromuscular shoulder injury, reconstruction of both the anterior and posterior branches of the axillary nerve should be considered. Clinical Relevance By quantifying the biomechanical role of muscles during sub-maximal movement, in addition to quantifying muscle contributions to maximal shoulder strength, we can inform pre-operative planning and
Fonseca, Neuber Martins; Ferreira, Fernando Xavier; Ruzi, Roberto Araújo; Pereira, Gulherme Carnaval Souza
The sciatic nerve may be blocked by several routes, all of them with advantages and disadvantages. It is the largest human nerve in diameter and length, being the prolongation of the upper sacral plexus fascicle (L4, L5, S2 and S3). It leaves the pelvis through the foramen ischiadicum majus, passing below the piriform muscle and going down between the greater trochanter and the ischial tuberosity, continuing along the femoral dorsum, anterior to biceps femoris and semitendinous muscles, to the lower femoral third, where it is divided in two major branches called tibial and common fibular nerves. It becomes superficial at the lower border of the gluteus maximus muscle. Based on this anatomic description, we developed a posterior approach with the following advantages: easy identification of the surface anatomy, superficial level of the nerve at this location; and less discomfort to patients since a 5 cm needle may be used. Seventeen ASA I - III patients aged 21 to 79 years, weighing 55 to 90 kg, undergoing leg or foot surgery were studied. After monitoring, patients were placed in the prone position and blockade was performed at the middle point of the sulcus gluteus (skin fold between nates and posterior thigh), with the aid of a neurostimulator, using 1% plain lidocaine (300 mg). Onset time, blockade performing time, and tibial, common fibular and cutaneous femoris posterior nerves anesthesia were evaluated. Saphenous nerve was also blocked with 5 ml of 1% lidocaine whenever needed. Adequate anesthesia was obtained in all cases. There was no patient with cutaneous femoris posterior nerve anesthesia. Blockade performing time was 8.58 +/- 5.71 min. Onset time was 5.88 +/- 1.6 min. Sensory and motor block duration was 4.05 +/- 1.1 and 2.9 +/- 0.8 hours, respectively. This new approach is effective and easy. However, it is not indicated when the cutaneous femoris posterior nerve anesthesia is necessary.
Toyota, Shingo; Taki, Takuyu; Wakayama, Akatsuki; Yoshimine, Toshiki
Objective To report a rare case of unruptured internal carotid-posterior communicating artery (IC-PC) aneurysm splitting the oculomotor nerve treated by clipping and to review the previously published cases. Case Presentation A 42-year-old man suddenly presented with left oculomotor paresis. Three-dimensional digital subtraction angiography (3D DSA) demonstrated a left IC-PC aneurysm with a bulging part. During surgery, it was confirmed that the bulging part split the oculomotor nerve. After the fenestrated oculomotor nerve was dissected from the bulging part with a careful microsurgical technique, neck clipping was performed. After the operation, the symptoms of oculomotor nerve paresis disappeared within 2 weeks. Conclusions We must keep in mind the possibility of an anomaly of the oculomotor nerve, including fenestration, and careful observation and manipulation should be performed to preserve the nerve function during surgery, even though it is very rare.
Toyota, Shingo; Taki, Takuyu; Wakayama, Akatsuki; Yoshimine, Toshiki
Objective To report a rare case of unruptured internal carotid-posterior communicating artery (IC-PC) aneurysm splitting the oculomotor nerve treated by clipping and to review the previously published cases. Case Presentation A 42-year-old man suddenly presented with left oculomotor paresis. Three-dimensional digital subtraction angiography (3D DSA) demonstrated a left IC-PC aneurysm with a bulging part. During surgery, it was confirmed that the bulging part split the oculomotor nerve. After the fenestrated oculomotor nerve was dissected from the bulging part with a careful microsurgical technique, neck clipping was performed. After the operation, the symptoms of oculomotor nerve paresis disappeared within 2 weeks. Conclusions We must keep in mind the possibility of an anomaly of the oculomotor nerve, including fenestration, and careful observation and manipulation should be performed to preserve the nerve function during surgery, even though it is very rare. PMID:25083381
Sirasanagandla, Srinivasa Rao; Nayak, Satheesha B; Rao KG, Mohandas; Patil, Jyothsna
The occurrence of the lesser occipital nerve (LON) at an anomalous location in the “carefree part” within the posterior triangle has been seldom reported in the literature. We are reporting a rare case of location of the LON in the “carefree part” of the posterior triangle, in a 55-year-old formalin embalmed male cadaver. LON, after emerging from the posterior margin of the sternomastoid muscle (SM), ran obliquely towards the trapezius muscle. Here, it hooked around the unusual separated muscle fasciculus of the trapezius, 7.5 cm below the superior nuchal line. Further, LON gave contributions to spinal accessory nerve (SAN); one deep into the SM and another one in the posterior triangle. The knowledge on the unusual location and course of the LON and its contribution to the SAN is significantly important while an anaesthetic blockade is being performed for the management of a cervicogenic headache and a super selective radical neck dissection. PMID:24959430
Patwardhan, Maneesha Anil
Isolated traumatic oculomotor nerve palsy caused by a trivial fall is extremely rare. We report a case of this condition. A 49-year-old woman had distal radius fracture and ptosis on the same side after having a trivial domestic fall. She did not show any clinical or radiological signs of head injury. Computerized tomography revealed a calcified posterior petroclinoid ligament which has direct anatomical and pathological relation with the oculomotor nerve.
Patwardhan, Maneesha Anil
Isolated traumatic oculomotor nerve palsy caused by a trivial fall is extremely rare. We report a case of this condition. A 49-year-old woman had distal radius fracture and ptosis on the same side after having a trivial domestic fall. She did not show any clinical or radiological signs of head injury. Computerized tomography revealed a calcified posterior petroclinoid ligament which has direct anatomical and pathological relation with the oculomotor nerve. PMID:25767590
Umemoto, Kanae; Saito, Toshiyuki; Naito, Munekazu; Hayashi, Shogo; Yakura, Tomiko; Steinke, Hanno; Nakano, Takashi
The acupuncture point BL23 is located in the region of the posterior ramus of the second lumbar spinal nerve (L2) and has historically been used to treat conditions such as lower back pain, pollakiuria, erectile dysfunction, dysmenorrhoea, tinnitus, and vertigo. Some of these treatment effects have been hypothesised to be mediated by the sympathetic nervous system. It was recently discovered that the posterior ramus of the spinal nerve (PRSN) at L2 forms not two but three branches. To examine the relationship between the acupuncture point BL23 and the L2 PRSN in order to consider the pathways possibly affected by BL23 acupuncture. Acupuncture needles were inserted through the skin at BL23 to a depth of 3 cm a total of 13 times in eight donor cadavers (seven right-sided, six left-sided). Leaving the needle in place, ventral dissection was performed to determine the PRSN anatomy between the L1 and L3 spinal segments. In four cadavers, the relationship between the L2 spinal nerve and sympathetic branches was additionally evaluated. Following dissection, three-dimensional (3D) data were acquired using a photo scanner and 3D structural images were created using 3D computer graphics software. One additional (female) cadaver was studied without insertion of an acupuncture needle (due to significant scoliosis). The L2 PRSN was divided into medial, intermediate and lateral branches. The needle inserted at BL23 came to lie in the region of the intermediate or lateral branches in all cases. Rami communicantes were found between the L2 spinal nerve and sympathetic trunk with fibres going on to supply the superior hypogastric plexus. Our findings suggest that acupuncture needles inserted at BL23 come into close proximity with the intermediate or lateral branch of the L2 PRSN, which could result in stimulation of both the somatic and sympathetic nervous systems. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence
Boya, Hakan; Ozcan, Ozal; Oztekin, Haluk H
Compression neuropathy of the posterior tibial nerve (PTN) and its branches in the tarsal tunnel is called tarsal tunnel syndrome (TTS) and has various aetiologies. Space-occupying lesions in the tunnel, such as neurilemomas, can cause such a disease. When a neurilemoma occupies the tarsal tunnel, it can compress the PTN directly or indirectly and results in restriction of the tunnel volume. Symptoms due to this restricted volume may vary in TTS. A case of neurilemoma of PTN in tarsal tunnel with a complaint of posteromedial ankle intermittent pain in a 20-year-old patient is presented here. A mass was observed at the ankle posteromedially during clinical examinations and the patient underwent magnetic resonance imaging (MRI) and radiological investigation. Radiographic evaluation of the ankle was normal. However, MRI was revealed a mass adjacent to the PTN in the tarsal tunnel. An ovoid, smooth-surfaced, encapsulated and eccentrically localized mass in the PTN was detected at surgery. The mass was excised from the nerve and pathological evaluation revealed a neurilemoma (schwannoma). Neurilemomas arising from the PTN in the tarsal tunnel should always be kept in mind as a differential diagnosis when a patient complains of a posteromedial ankle pain. Since it is a space-occupying lesion and encapsulated tumor in the tarsal tunnel, simple surgical resection is curative without a distinct morbidity.
Lowe, James B; Sen, Subhro K; Mackinnon, Susan E
After studying this article, the participant should be able to: 1. Identify all potential points of radial nerve compression and other likely causes of radial nerve injury. 2. Accurately diagnose both surgical and nonsurgical causes of radial nerve paralysis. 3. Define a safe and effective approach to the surgical release and reconstruction of the radial nerve. Radial nerve paralysis, which can result from a complex humerus fracture, direct nerve trauma, compressive neuropathies, neuritis, or (rarely) from malignant tumor formation, has been reported throughout the literature, with some controversy regarding its diagnosis and management. The appropriate management of any radial nerve palsy depends primarily on an accurate determination of its cause, severity, duration, and level of involvement. The radial nerve can be injured as proximally as the brachial plexus or as distally as the posterior interosseous or radial sensory nerve. This article reviews the etiology, prognosis, and various treatments available for radial nerve paralysis. It also provides a new classification system and treatment algorithm to assist in the management of patients with radial nerve palsies, and it offers a simple, five-step approach to radial nerve release in the forearm.
Mackinnon, Susan E; Roque, Brandon; Tung, Thomas H
The purpose of this study is to report a surgical technique of nerve transfer to restore radial nerve function after a complete palsy due to a proximal injury to the radial nerve. The authors report the case of a patient who underwent direct nerve transfer of redundant or expendable motor branches of the median nerve in the proximal forearm to the extensor carpi radialis brevis and the posterior interosseous branches of the radial nerve. Assessment included degree of recovery of wrist and finger extension, and median nerve function including pinch and grip strength. Clinical evidence of reinnervation was noted at 6 months postoperatively. The follow-up period was 18 months. Recovery of finger and wrist extension was almost complete with Grade 4/5 strength. Pinch and grip strength were improved postoperatively. No motor or sensory deficits related to the median nerve were noted, and the patient is very satisfied with her degree of functional restoration. Transfer of redundant synergistic motor branches of the median nerve can successfully reinnervate the finger and wrist extensor muscles to restore radial nerve function. This median to radial nerve transfer offers an alternative to nerve repair, graft, or tendon transfer for the treatment of radial nerve palsy.
Pamidi, Narendra; Nayak, Satheesha B; Jetti, Raghu; Thangarajan, Rajesh
Occurrence of vascular variations in the upper limb is not uncommon and is well described in the medical literature. However, occurrence of superficial ulnar artery associated with unusual origin of the common interosseous and ulnar recurrent arteries is seldom reported in the literature. In the present case, we report the anomalous origin of common trunk of common interosseous, anterior and posterior ulnar recurrent arteries from the radial artery, in a male cadaver. Further, ulnar artery had presented superficial course. Knowledge of anomalous arterial pattern in the cubital fossa reported here is clinically important during the angiographic procedures and plastic surgeries. PMID:27437201
Youssef, Tamer; Youssef, Mohamed; Thabet, Waleed; Lotfy, Ahmed; Shaat, Reham; Abd-Elrazek, Eman; Farid, Mohamed
The objective of this study was to evaluate the efficacy of transcutaneous electrical posterior tibial nerve stimulation in treatment of patients with chronic anal fissure and to compare it with the conventional lateral internal sphincterotomy. Consecutive patients with chronic anal fissure were randomly allocated into two treatment groups: transcutaneous electrical posterior tibial nerve stimulation group and lateral internal sphincterotomy group. The primary outcome measures were number of patients with clinical improvement and healed fissure. Secondary outcome measures were complications, VAS pain scores, Wexner's constipation and Peascatori anal incontinence scores, anorectal manometry, and quality of life index. Seventy-three patients were randomized into two groups of 36 patients who were subjected to transcutaneous electrical nerve stimulation and 37 patients who underwent lateral internal sphincterotomy. All (100%) patients in lateral internal sphincterotomy group had clinical improvement at one month following the procedure in contrast to 27 (75%) patients in transcutaneous electrical nerve stimulation group. Recurrence of anal fissure after one year was reported in one (2.7%) and 11 (40.7%) patients in lateral internal sphincterotomy and transcutaneous electrical nerve stimulation groups respectively. Resting anal pressure and functional anal canal length were significantly reduced after lateral internal sphincterotomy. Transcutaneous electrical posterior tibial nerve stimulation for treatment of chronic anal fissure is a novel, non-invasive procedure and has no complications. However, given the higher rate of clinical improvement and fissure healing and the lower rate of fissure recurrence, lateral internal sphincterotomy remains the gold standard for treating chronic anal fissure. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Ceccaroni, Marcello; Clarizia, Roberto; Roviglione, Giovanni; Ruffo, Giacomo
Efforts to improve approaches to the so called "parametrium" with minimally invasive and less dangerous techniques have led to a better study of the anatomic location and composition of that region. Nevertheless, many misconceptions and confusions about the anatomy of the posterior parametrium and its structures still remain. This study aimed to review anatomic and surgical data and to identify several clear landmarks and surgical steps for a nerve-sparing approach to posterior parametrectomy in the course of radical pelvic surgery with or without rectal resection. The literature and anatomic dissections of fresh, embalmed, and formalin-fixed female pelvis cadavers were reviewed. The authors' laparotomic and laparoscopic case series also was reviewed for deep-infiltrating endometriosis as well as uterine, ovarian, and rectal cancer. The anatomic entity commonly termed the "posterior parametrium" can be identified as the conjunction of three important anatomic structures (ligaments): the cranial structure (uterosacral ligaments), the caudad structure (rectovaginal ligaments), and the laterocaudad structure (lateral rectal ligaments). Identification of these structures (containing autonomic innervations for pelvic viscera) may allow an accurate nerve-sparing surgical approach in many radical pelvic operations. The incidences of urinary, rectal, and sexual morbidity after radical pelvic surgical procedures for oncologic diseases (rectal/ovarian cancer, advanced endometrial/cervical cancer, posterior pelvic recurrences) and deep severe endometriosis can be reduced by better knowing and dissecting the right embryo-anatomic planes of the so-called "posterior parametrium."
Kogan, Michael; Natarajan, Sabareesh K.; Kim, Nina; Sawyer, Robert N.; Snyder, Kenneth V.; Siddiqui, Adnan H.
Background: Common causes of oculomotor nerve palsy are diabetes, aneurysmal compression, and uncal herniation. A lesser-known cause of third nerve dysfunction is ischemia, often due to carotid artery dissection. Case Description: An 80-year-old man presented with an acute ischemic stroke with a National Institutes of Health Stroke Scale score of >20 from a high cervical internal carotid artery (ICA) dissection and a tandem ICA terminus embolic occlusion with extension of clot into the adjacent fetal posterior cerebral artery (PCA). We used a stentriever to perform selective PCA thrombectomy, with immediate postthrombectomy development of ipsilateral anisocoria. The anisocoria progressed into complete oculomotor nerve palsy over 8 h after the procedure. Conclusions: The clinical course described in this case is consistent with injury to the third nerve due to mechanical injury or occlusion of perforator supply to the nerve during thrombectomy. Oculomotor nerve palsy is a rare but known complication after ischemia; however, to our knowledge, this is the first case after thrombectomy for a PCA embolus. PMID:25525555
Singla, Himanshi; Alexander, Mohan
Local anesthesia has been a boon for dentistry to allay the most common fear of pain among dental patients. Several techniques to achieve anesthesia for posterior maxillae have been advocated albeit with minor differences. We compared two techniques of posterior superior alveolar nerve block (PSANB), the one claimed to be "most accurate" to the one "most commonly used." This study was conducted to assess and compare the efficacy as well as complications of "the straight needle technique" to that of "the bent needle technique" for PSANB. We conducted a prospective, randomised, double blind study on 120 patients divided into two groups, using a 26-gauge, 38 mm long needle with 2 ml of 2 % lignocaine hydrochloride with 1:200,000 adrenaline solution. Objective symptoms were evaluated by a single investigator. Cold test using ice was used to evaluate the status of pulpal anesthesia. Data thus obtained was subjected to statistical analysis. Out of the 120 blocks, 19 blocks failed. Statistical analysis found straight needle technique to be more successful than the bent needle technique (p = 0.002). Both the techniques were equally effective for the first molar region on both right and left side (p = 0.66 on right side and p = 0.20 on left side). However, in the second and third molar region technique A was more effective than B (p = 0.01) on right side only. On Left side, both techniques were equally effective (p = 0.08). Sensitivity of the cold test was 82 % which is quite high but the specificity was 68 % which seems to be falling in the above average range only. Positive predictive value of 75 and negative predictive value of 76 was observed. We did not encounter any complications in this study. To the best of our knowledge, this is the first randomised controlled clinical study on PSANB techniques. This study suggests that the PSANB using the straight needle technique as advocated by Malamed  can be routinely and safely used to achieve anesthesia in
Klein, Anita; van Leeuwen, Peter; Hoormann, Jörg; Grönemeyer, Dietrich
Stimulation of the posterior tibial nerve has been associated with different somatosensory evoked potentials (SEP) recorded along the spine and thorax. The aim of this study was to register and describe the magnetic fields corresponding to different components of spinal SEP after stimulation of tibial nerves. In nine healthy subjects, right and left posterior tibial nerves were transcutaneously electrostimulated at the ankles. Neuromagnetic fields were registered over a circular 800 cm2 area of the lumbosacral spine using a 61-channel biomagnetometer. Magnetic field maps were constructed and examined visually for dipolar patterns. Equivalent current dipoles (ECD) were calculated for each somatosensory evoked field (SEF) using a least-squares fit in a spherical model. In seven subjects dipolar SEF were detected over the lower back at two separate latencies and locations and propagating ECD could be localized. Both the first and second components found agreed anatomically and functionally with respect to propagation in the underlying nerve fibers. It was possible to record and identify SEF which correspond to the SEP described in the literature. Dipole localization based on an equivalent current dipole model allowed a basic evaluation of the plausibility of the measurements with respect to the processes being examined.
Park, Andrea M; Bhatt, Neel K; Paniello, Randal C
To investigate the efficacy of paclitaxel, a potent microtubule inhibitor with a more favorable therapeutic index as compared with vincristine, in preventing post-traumatic nerve regeneration of the recurrent laryngeal nerve into the posterior cricoarytenoid muscle in a canine laryngeal model. Experimental animal study. Forty-nine canine hemilaryngeal specimens were divided into five experimental groups. Under general anesthesia, a tracheostomy, recurrent laryngeal nerve (RLN) transection and repair, and laryngeal adductory pressures (LAP) were measured pre-RLN injury. The approach to the posterior cricoarytenoid (PCA) muscle for neurotoxin injection was transoral or open transcervical, at 0 or 3 months. At 6 months, postinjury LAPs were measured and the animals were sacrificed at 6 months to allow for laryngeal harvesting and analysis. Paclitaxel demonstrated increased mean laryngeal adductory pressures (70.6%) as compared with saline control (55.5%). The effect of paclitaxel was the same as observed with vincristine at 0 months and with a delayed injection at 3 months. There was no difference between transoral or open injection groups. PCA muscle injection with paclitaxel resulted in improved strength of laryngeal adduction. This effect was similar to that of vincristine at both 0 and 3 months following nerve injury. A single intramuscular injection of paclitaxel was well tolerated. Additional human studies are needed to determine the degree of clinical benefit of this intervention. NA Laryngoscope, 127:651-655, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.
Ing, Eliesa; Ivers, Kevin M.; Yang, Hongli; Gardiner, Stuart K.; Reynaud, Juan; Cull, Grant; Wang, Lin; Burgoyne, Claude F.
Purpose To use optical coherence tomography (OCT) to test the hypothesis that optic nerve head (ONH) “cupping” in the monkey optic nerve transection (ONT) model does not include posterior laminar deformation. Methods Five monkeys (aged 5.5–7.8 years) underwent ONH and retinal nerve fiber layer (RNFL) OCT imaging five times at baseline and biweekly following unilateral ONT until euthanization at ∼40% RNFL loss. Retinal nerve fiber layer thickness (RNFLT) and minimum rim width (MRW) were calculated from each pre- and post-ONT imaging session. The anterior lamina cribrosa surface (ALCS) was delineated within baseline and pre-euthanasia data sets. Significant ONT versus control eye pre-euthanasia change in prelaminar tissue thickness (PLTT), MRW, RNFLT, and ALCS depth (ALCSD) was determined using a linear mixed-effects model. Eye-specific change in each parameter exceeded the 95% confidence interval constructed from baseline measurements. Results Animals were euthanized 49 to 51 days post ONT. Overall ONT eye change from baseline was significant for MRW (−26.2%, P = 0.0011), RNFLT (−43.8%, P < 0.0001), PLTT (−23.8%, P = 0.0013), and ALCSD (−20.8%, P = 0.033). All five ONT eyes demonstrated significant eye-specific decreases in MRW (−23.7% to −31.8%) and RNFLT (−39.6% to −49.7%). Four ONT eyes showed significant PLTT thinning (−23.0% to −28.2%). The ALCS was anteriorly displaced in three of the ONT eyes (−25.7% to −39.2%). No ONT eye demonstrated posterior laminar displacement. Conclusions Seven weeks following surgical ONT in the monkey eye, ONH cupping involves prelaminar and rim tissue thinning without posterior deformation of the lamina cribrosa. PMID:27168368
Martins, Roberto Sergio; Siqueira, Mario Gilberto; Heise, Carlos Otto; Teixeira, Manoel Jacobsen
A new nerve transfer technique using a healthy fascicle of the posterior cord for suprascapular nerve reconstruction is presented. This technique was used in a patient with posttraumatic brachial plexopathy resulting in upper trunk injury with proximal root stumps that were unavailable for grafting associated with multiple nerve dysfunction. A 45-year-old man sustained a right brachial plexus injury after a bicycle accident. Clinical evaluation and electromyography indicated upper trunk involvement. Trapezius muscle function and triceps strength were normal on physical examination. The patient underwent a combined supra- and infraclavicular approach to the brachial plexus. A neuroma-in-continuity of the upper trunk and fibrotic C5 and C6 roots were identified. Electrical stimulation of the phrenic and spinal accessory nerves produced no response. The suprascapular nerve was dissected from the upper trunk, transected, and rerouted to the infraclavicular fossa. A healthy fascicle of the posterior cord to the triceps muscle was transferred to the suprascapular nerve. At the time of the 1-year follow-up evaluation, arm abduction against gravity and external rotation reached 40 and 34 degrees, respectively. The posterior cord can be used as a source of donor fascicle to the suprascapular nerve after its infraclavicular relocation. This new intraplexal nerve transfer could be applied in patients with isolated injury of the upper trunk and concomitant lesion of the extraplexal nerve donors usually used for reinnervation of the suprascapular nerve.
Kozera, Katarzyna; Ciszek, Bogdan; Szaro, Paweł
Posterior branches of the lumbar spinal nerves are the anatomic substrate of pain in the lower back, sacrum and the gluteal area. Such pain may be associated with various pathologies which cause pain in the posterior branches of the lumbar spinal nerves due to entrapment, mechanical irritation or inflammatory reaction and/or degeneration. The posterior branches are of significant functional importance, which is related to the function of the structures they supply, including facet joints, which are the basic biomechanical units of the spine. Low back pain caused by facet joint pathology may be triggered e.g. by simple activities, such as body rotations, unnatural positions, lifting heavy weights or excessive bending as well as chronic overloading with spinal hyperextension. Pain usually presents at the level of the lumbosacral junction (L 5 -S 1 ) and in the lower lumbar spine (L 4-5 , L 3-4 ). In the absence of specific diagnostic criteria, it is only possible to conclude that patients display tenderness at the level of the affected facet joint and that the pain is triggered by extension. Differential diagnosis for low back pain is difficult, since the pain may originate from various structures. The most reliable method of identifying Lumbar Facet Syndrome has been found to be a positive response to an analgesic procedure in the form of a block of the medial branch or intraarticular injection. There appear to be good grounds for conducting further studies and developing unequivocal diagnostic tests.
Boudaoud, Nadia; Binet, Aurélien; Line, Antoine; Chaouadi, Dalila; Jolly, Catherine; Fiquet, Caroline Francois; Ripert, Thomas; Merol, Marie Laurence Poli
To assess the objective efficacy of transcutaneous posterior tibial nerve stimulation in children presenting with overactive bladder resistant to well conducted treatment. This was a randomized, double-blind, controlled study on 20 children with OAB. All patients were previously treated with anticholinergic drugs associated with detrusor rehabilitation, diet advice, bladder-voiding hygiene and constipation treatment, with poor clinical results. Patients were randomized into two groups: -Group A: treatment with PTNS (n = 11). -Group B: sham treatment (n = 9). The program lasted 12 consecutive weeks with two 30-minutes sessions a week. Each patient underwent pre-stimulation urodynamic testing to validate bladder overactivity followed by a post-stimulation testing. Pre- and post-stimulation urodynamic parameters were compared in order to objectively evaluate the treatment's efficacy. The patients noted their incontinence episodes for 7 consecutive days in a diary before the beginning of the program, in the middle and at the end of it: this led to computing an incontinence score (score ranged from 0 to 13, from good to poor). The difference between the pre-stimulation and post-stimulation score enabled to express clinical results in terms of poor (less than a 3-point decrease), medium (a 3 to 5-point decrease), good (6 to 8-point decrease), very good (final score ranged between 0 and 3). Children were questioned regarding their impression of being stimulated or not. In Group A, there were five very good clinical results (45%), one medium (10%) and five poor results (45%). In group B, nine very good results (66%) and three poor results (33%) were noted. Regarding urodynamic testing, volume voided during urgency (184 mL to 265 mL), maximal cystomanometry volume (215 mL to 274 mL) and volume at the onset of the first overactive detrusor contraction (ODC) (48 mL to 174 mL) were significantly increased in Group A (p = 0.002, p = 0.024 and p = 0.001) and maximal bladder
Background Palsies involving the anterior interosseous nerve (AIN) comprise less than 1% of all upper extremity nerve palsies. Objectives This case highlights the potential vascular and neurological hazards of minimal penetrating injury of the proximal forearm and emphasizes the phenomenon of delayed presentation of vascular injuries following seemingly obscure penetrating wounds. Case Report We report a case of a 22-year-old male admitted for a minimal penetrating trauma of the proximal forearm that, some days later, developed an anterior interosseous syndrome. A Duplex study performed immediately after the trauma was normal. Further radiologic investigations i.e. a computer-tomographic-angiography (CTA) revealed a false aneurysm of the proximal portion of the interosseous artery (IA). Endovascular management was proposed but a spontaneous rupture dictated surgical revision with simple excision. Complete neurological recovery was documented at 4 months postoperatively. Conclusions/Summary After every penetrating injury of the proximal forearm we propose routinely a detailed neurological and vascular status and a CTA if Duplex evaluation is negative. PMID:20034382
Sajadi, Simin; Mansoori, Korosh; Raissi, Gholam R; Emami Razavi, Seyede Z; Ghajarzadeh, Mahsa
Recent studies have proposed posterior antebrachial cutaneous (PABC) nerve could help in interpretation of some conditions in upper limb electrodiagnostic study. This study aimed to establish these normal values and to assess the effect of sex, age, height, and body mass index on these normal values. Eligible participants were 84 healthy adult people aged between 22 and 75 years who underwent PABC nerve conduction studies. The mean ± SD values of the base-to-peak amplitude, peak latency, and nerve conduction velocity of all participants were 10.95 ± 2.90 μV, 2.08 ± 0.20 milliseconds, and 57.85 ± 7.83 m/second, respectively. There was a significant positive correlation between the subjects' age and the PABC onset latency, peak latency, and nerve conduction velocity (r = 0.64, P < 0.001; r = 0.6, P < 0.001; and r = 0.44, P < 0.001, respectively). A significant negative correlation was observed between age and base-to-peak amplitude and peak-to-peak amplitude of participants, as well (r = -0.38, r = -0.41, P < 0.001, respectively). The correlation of body mass index with base-to-peak amplitude and peak-to-peak amplitude were r = -0.36, P < 0.001 and r = -0.40, P < 0.001, respectively. This study has established normal values for PABC nerve conduction studies. Furthermore, age and body mass index must be taken into account for making diagnostic conclusion in PABC nerve conduction studies.
Ruiz-Tovar, Jaime; Llavero, Carolina
Current therapeutic guidelines for the treatment of chronic anal fissure establish a medical approach as the first step. Glyceryl trinitrate ointment is the most popular of the available topical treatments in Spain but it is associated with the appearance of headache. The purpose of this study was to compare the compliance rate among patients receiving glyceryl trinitrate treatment for chronic anal fissure with that among patients receiving percutaneous posterior tibial nerve stimulation. This was a prospective randomized study. The study was conducted at Garcilaso Clinic (Madrid, Spain). Subjects with persistent anal fissure despite hygiene and dietary measures applied over at least a 6-week period were included. Study interventions were perianal application of glyceryl trinitrate ointment (twice daily for 8 weeks) and percutaneous posterior tibial nerve stimulation (30-minute session 2 days per week for 8 weeks). Compliance with the treatment and healing rate of chronic anal fissure in patients receiving glyceryl trinitrate ointment or undergoing percutaneous posterior tibial nerve stimulation were evaluated. Forty patients were included in each group. In the glyceryl trinitrate ointment group, 15% of the patients discontinued treatment because of disabling headaches. There were no adverse effects or treatment withdrawals in the percutaneous posterior tibial nerve stimulation group (p = 0.033). After 8 weeks of treatment, the healing rate in the percutaneous posterior tibial nerve stimulation group was 87.5% vs 65.0% in the glyceryl trinitrate ointment group (p = 0.018). Because the patients were not blinded to the treatment, we cannot rule out a placebo effect derived from the needle insertion in the percutaneous posterior tibial nerve stimulation group. Percutaneous posterior tibial nerve stimulation is a safe and effective alternative that is in some ways superior to glyceryl trinitrate ointment for the treatment of chronic anal fissure.
Momoh, Adeyiza O.; Kumaran, Senthil; Lyons, Daniel; Venkatramani, Hari; Ramkumar, Sanjai; Chung, Kevin C.; Sabapathy, S. Raja
BACKGROUND Absence of plantar sensation is a critical factor considered in favor of amputation for patients with lower limb-threatening injuries. This study aims to assess outcomes of limb salvage in a group of patients with severe lower extremity injuries associated with posterior tibial nerve transection. METHODS We studied eight cases of limb salvage after traumatic injuries with documented tibial nerve laceration managed at Ganga Hospital, India. Functional and health-related quality of life outcomes were assessed. Outcomes from this case series were compared to outcomes of studies from a systematic literature review on salvage of the severely injured lower extremity. RESULTS Patients in this case series reported mild pain (median score 20 on a 100 scale visual analog scale) with some return of plantar sensation in patients with tibial nerve repairs (median score 2/5). Patients demonstrated a decrease in ankle motion (27.5 degrees plantar flexion, 10 degrees extension) and muscle strength (median heel flexor score 3/5). All patients could ambulate independently. Quality of life and function measured by validated instruments revealed minimal disability. We identified 1,767 articles on lower extremity trauma and 14 articles were systematically reviewed. Relative to the case series, published articles reported similarly diminished ankle motion and muscle strength, with reports of mild pain in select studies. Patient reported outcome instruments found variations in the degree of physical disability based on time from the injury. CONCLUSIONS Though limited in number, this case series demonstrates the value of limb salvage even for patients with posterior tibial nerve injury. PMID:26270902
Tsirikos, Athanasios I; Al-Hourani, Khalid
We present the transient long thoracic nerve (LTN) injury during instrumented posterior spinal arthrodesis for idiopathic scoliosis. The suspected mechanism of injury, postoperative course and final outcome is discussed. The LTN is susceptible to injury due to its long and relatively superficial course across the thoracic wall through direct trauma or tension. Radical mastectomies with resection of axillary lymph nodes, first rib resection to treat thoracic outlet syndrome and cardiac surgery can be complicated with LTN injury. LTN injury producing scapular winging has not been reported in association with spinal deformity surgery. We reviewed the medical notes and spinal radiographs of two adolescent patients with idiopathic scoliosis who underwent posterior spinal arthrodesis and developed LTN neuropraxia. Scoliosis surgery was uneventful and intraoperative spinal cord monitoring was stable throughout the procedure. Postoperative neurological examination was otherwise normal, but both patients developed winging of the scapula at 4 and 6 days after spinal arthrodesis, which did not affect shoulder function. Both patients made a good recovery and the scapular winging resolved spontaneously 8 and 11 months following surgery with no residual morbidity. We believe that this LTN was due to positioning of our patients with their head flexed, tilted and rotated toward the contralateral side while the arm was abducted and extended. The use of heavy retractors may have also applied compression or tension to the nerve in one of our patients contributing to the development of neuropraxia. This is an important consideration during spinal deformity surgery to prevent potentially permanent injury to the nerve, which can produce severe shoulder dysfunction and persistent pain. PMID:24379470
Tsirikos, Athanasios I; Al-Hourani, Khalid
We present the transient long thoracic nerve (LTN) injury during instrumented posterior spinal arthrodesis for idiopathic scoliosis. The suspected mechanism of injury, postoperative course and final outcome is discussed. The LTN is susceptible to injury due to its long and relatively superficial course across the thoracic wall through direct trauma or tension. Radical mastectomies with resection of axillary lymph nodes, first rib resection to treat thoracic outlet syndrome and cardiac surgery can be complicated with LTN injury. LTN injury producing scapular winging has not been reported in association with spinal deformity surgery. We reviewed the medical notes and spinal radiographs of two adolescent patients with idiopathic scoliosis who underwent posterior spinal arthrodesis and developed LTN neuropraxia. Scoliosis surgery was uneventful and intraoperative spinal cord monitoring was stable throughout the procedure. Postoperative neurological examination was otherwise normal, but both patients developed winging of the scapula at 4 and 6 days after spinal arthrodesis, which did not affect shoulder function. Both patients made a good recovery and the scapular winging resolved spontaneously 8 and 11 months following surgery with no residual morbidity. We believe that this LTN was due to positioning of our patients with their head flexed, tilted and rotated toward the contralateral side while the arm was abducted and extended. The use of heavy retractors may have also applied compression or tension to the nerve in one of our patients contributing to the development of neuropraxia. This is an important consideration during spinal deformity surgery to prevent potentially permanent injury to the nerve, which can produce severe shoulder dysfunction and persistent pain.
Kurokawa, R; Saito, R; Nakamura, Y; Kagami, H; Ichikizaki, K
An 81-year-old female presented with severe headache. Computed tomography revealed subarachnoid hemorrhage. She developed right facial nerve paresis on the next day. Angiography revealed a right vertebral artery-posterior inferior cerebellar artery aneurysm. The aneurysm was successfully occluded with interlocking detachable coils (IDCs) on the 7th day. Magnetic resonance (MR) imaging 1 month after IDC placement showed partially thrombosed aneurysm near the internal acoustic meatus. Ten months after the ictus, MR imaging revealed marked resolution of the intra-aneurysmal thrombus and reduction of the aneurysm size. Her facial nerve function gradually recovered during this period. Her facial nerve paresis was probably caused by acute stretching of the facial nerve by the ruptured aneurysm that was in direct contact with the nerve. Intra-aneurysmal thrombosis using coils can reduce aneurysm size and alleviate cranial nerve symptoms.
Hu, Shuaiyu; Zhuo, Lifan; Zhang, Xiaoming; Yang, Shengbo
To identify the optimal body surface puncture locations and the depths of nerve entry points (NEPs) in the deep posterior compartment muscles of the leg, 60 lower limbs of thirty adult cadavers were dissected in prone position. A curved line on the skin surface joining the lateral to the medial epicondyles of the femur was taken as a horizontal reference line (H). Another curved line joining the lateral epicondyle of the femur to the lateral malleolus was designated the longitudinal reference line (L). Following dissection, the NEPs were labeled with barium sulfate and then subjected to spiral computed tomography scanning. The projection point of the NEP on the posterior skin surface of the leg was designated P, and the projection in the opposite direction across the transverse plane was designated P'. The intersections of P on H and L were identified as PH and PL , and their positions and the depth of the NEP on PP' were measured using the Syngo system and expressed as percentages of H, L, and PP'. The PH points of the tibial posterior, flexor hallucis longus and flexor digitorum longus muscles were located at 38.10, 46.20, and 55.21% of H, respectively. The PL points were located at 25.35, 41.30, and 45.39% of L, respectively. The depths of the NEPs were 49.11, 54.64, and 55.95% of PP', respectively. The accurate location of these NEPs should improve the efficacy and efficiency of chemical neurolysis for treating spasticity of the deep posterior compartment muscles of the leg. Clin. Anat. 30:855-860, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.
Banshelkikar, Santosh; Nistane, Pruthviraj
Introduction: Peripheral nerve tumours are rarely acknowledged as a cause of radiating pain in lower limbs and suspicion is almost always pointed towards lumbo-sacral causes. Schwannomas are tumours of peripheral nerve sheaths occurring anywhere along the peripheral nervous system. Often it can produce symptoms, which can be misleading in cases where obvious swelling is not present. The diagnosis may therefore be delayed by several years of emergence of symptoms. Very few such cases have been reported previously and none of them had an intrasubstance location of the tumour as in our case. Case Report: We present a case of a middle aged female patient presenting with radiating pain in left lower limb, which was diagnosed and treated as lumbo-sacral radiculopathy for five years before an obvious swelling appeared, which on further investigations led to diagnosis of schwannoma of tibial nerve. Intraoperatively, the schwannoma was found to be intrasubstance in location which has never been reported in the past literatures making its excision, without damaging the conducting elements, a challenge. Conclusion: The possibility of peripheral nerve tumour should always be kept in mind while dealing with long standing cases diagnosed as radiculopathy and which do not get better with treatment on similar lines. A thorough clinical examination of the entire limb including Tinel’s sign can clinch the diagnosis earlier in cases where obvious swelling is not present. Even unusual presentations, as in our case, can be dealt surgically with good results. PMID:27299039
Lin, Haodong; Hou, Chunlin; Chen, Aimin; Xu, Zhen
Hand function is severely impaired in cases of lower root avulsion. In the present study, the authors investigated the clinical effectiveness and safety of phrenic nerve transfer to the posterior division of the lower trunk of the brachial plexus to recover thumb and finger extension. Between 2004 and 2006, 10 patients with brachial plexus palsy underwent phrenic nerve transfer as part of a strategy for surgical reconstruction of their plexuses. The mean patient age of was 27.2 years (range 18-44 years), and the mean interval from injury to surgery was 5.7 months (range 3-9 months). The phrenic nerve was always transferred to the posterior division of the lower trunk. The follow-up of the patients ranged from 2.5 to 4.4 years, with an average follow-up length of 3.5 years. There were no major complications related to the surgery. Eight patients recovered to Grade 3 or better (Medical Research Council grade) in extensor digitorum strength, and 7 patients recovered to Grade 3 or better in extensor pollicis strength. None of the patients had any clinical signs or symptoms of respiratory insufficiency. Satisfactory thumb and finger extension can be achieved by phrenic nerve transfer to the posterior division of the lower trunk of the brachial plexus. This procedure is simple and less traumatic than that of transferring the phrenic nerve to the radial nerve. It is indicated in cases in which the brachial plexus is relatively intact at the division level.
Hatipoğlu, Hatice Gül; Durakoğlugil, Tuğba; Ciliz, Deniz; Yüksel, Enis
The aim of this study was to compare 3D fast imaging with steady state acquisition (3D FIESTA) to fast spin echo T2-weighted (FSE T2W) MRI sequences in the imaging of cisternal parts of cranial nerves V-XII. We retrospectively evaluated the temporal MRI sequences of 50 patients (F:M ratio, 27:23; mean age, 44.5 +/- 15.9 years) who were admitted to our hospital with vertigo, tinnitus, and hearing loss. In all, we evaluated 800 nerves. Two radiologists, working independently, divided the imaging findings into 3 groups: 0 (not visualized), 1 (partially visualized), and 2 (completely visualized). The rate of visualization of these cranial nerves with FSE T2W and 3D FIESTA sequences, respectively, (partially and completely visualized) were as follows: nerve V (100% and 100%); nerve VI (43% and 98%); nerve VII (100% and 100%); nerve VIII (100% and 100%); nerve IX-XI complex (67% and 100%); nerve XII (2% and 91%). 3D FIESTA sequences are superior to FSE T2W sequences in the imaging of cisternal parts of the posterior fossa nerves. 3D FIESTA sequences may be used for obtaining high-resolution MR cisternography images.
Nkomozepi, Pilani; Xhakaza, Nkosi; Swanepoel, Elaine
Nerve entrapment syndromes occur because of anatomic constraints at specific locations in both upper and lower limbs. Anatomical locations prone to nerve entrapment syndromes include sites where a nerve courses through fibro-osseous or fibromuscular tunnels or penetrates a muscle. The median nerve (MN) can be entrapped by the ligament of Struthers; thickened biceps aponeurosis; between the superficial and deep heads of the pronator teres muscle and by a thickened proximal edge of flexor digitorum superficialis muscle. A few cases of MN neuropathies encountered are reported to be idiopathic. The superficial branchial artery (SBA) is defined as the artery running superficial to MN or its roots. This divergence from normal anatomy may be the possible explanation for idiopathic median nerve entrapment neuropathy. This study presents three cases with unilateral presence of the SBA encountered during routine undergraduate dissection at the University of Johannesburg. Case 1: SBA divided into radial and ulnar arteries. Brachial artery (BA) terminated as deep brachial artery. Case 2: SBA continued as radial artery (RA). BA terminated as ulnar artery (UA), anterior and posterior interosseous arteries. Case 3: SBA continued as UA. BA divided into radial and common interosseous arteries. Arteries that take an unusual course are more vulnerable to iatrogenic injury during surgical procedures and may disturb the evaluation of angiographic images during diagnosis. In particular, the presence of SBA may be a course of idiopathic neuropathies.
Ray, Wilson Z.; Mackinnon, Susan E.
Purpose In this study the authors evaluate the clinical outcomes in patients with radial nerve palsy who underwent nerve transfers utilizing redundant fascicles of median nerve (innervating the flexor digitorum superficialis and flexor carpi radialis muscles) to the posterior interosseous nerve and the nerve to the extensor carpi radialis brevis. Methods A retrospective review of the clinical records of 19 patients with radial nerve injuries who underwent nerve transfer procedures using the median nerve as a donor nerve were included. All patients were evaluated using the Medical Research Council (MRC) grading system. Results The mean age of patients was 41 years (range 17 – 78 years). All patients received at least 12 months of follow-up (20.3 ± 5.8 months). Surgery was performed at a mean of 5.7 ± 1.9 months post-injury. Post-operative functional evaluation was graded according to the following scale: grades MRC 0/5 - MRC 2/5 were considered poor outcomes, while MRC of 3/5 was a fair result, MRC grade 4/5 was a good result, and grade 4+/5 was considered an excellent outcome. Seventeen patients (89%) had a complete radial nerve palsy while two patients (11%) had intact wrist extension but no finger or thumb extension. Post-operatively all patients except one had good to excellent recovery of wrist extension. Twelve patients recovered good to excellent finger and thumb extension, two patients had fair recovery, five patients had a poor recovery. Conclusions The radial nerve is a commonly injured nerve, causing significant morbidity in affected patients. The median nerve provides a reliable source of donor nerve fascicles for radial nerve reinnervation. This transfer was first performed in 1999 and evolved over the subsequent decade. The important nuances of both surgical technique and motor re-education critical for to the success of this transfer have been identified and are discussed. PMID:21168979
Introduction Radial nerve compression by a ganglion in the radial tunnel is not common. Compressive neuropathies of the radial nerve in the radial tunnel can occur anywhere along the course of the nerve and may lead to various clinical manifestations, depending on which branch is involved. We present two unusual cases of ganglions located in the radial tunnel and requiring surgical excision. Case presentation A 31-year-old woman complained of difficulty in fully extending her fingers at the metacarpophalangeal joint for 2 weeks. Before her first visit, she had noticed a swelling and pain in her right elbow over the anterolateral forearm. The extension muscle power of the metacarpophalangeal joints at the fingers and the interphalangeal joint at the thumb had decreased. Sonography and magnetic resonance imaging of the elbow revealed a cystic lesion located at the area of the arcade of Frohse. A thin-walled ovoid cyst was found against the posterior interosseous nerve during surgical excision. Pathological examination was compatible with a ganglion cyst. The second case involved a 36-year-old woman complaining of numbness over the radial aspect of her hand and wrist, but without swelling or tumor in this area. The patient had slightly decreased sensitivity in the distribution of the sensory branch of the radial nerve. There was no muscle weakness on extension of the fingers and wrist. Surgical exposure defined a ganglion cyst in the shoulder of the division of the radial nerve into its superficial sensory and posterior interosseous components. There has been no disease recurrence after following both patients for 2 years. Conclusion Compression of nerves by extraneural soft tissue tumors of the extremities should be considered when a patient presents with progressive weakness or sensory changes in an extremity. Surgical excision should be promptly performed to ensure optimal recovery from the nerve palsy. PMID:19830153
Fukushima, Yuta; Imai, Hideaki; Yoshino, Masanori; Kin, Taichi; Takasago, Megumi; Saito, Kuniaki; Nakatomi, Hirofumi; Saito, Nobuhito
Oculomotor nerve palsy (ONP) due to internal carotid-posterior communicating artery (PcomA) aneurysm generally manifests as partial nerve palsy including pupillary dysfunction. In contrast, infundibular dilatation (ID) of the PcomA has no pathogenic significance, and mechanical compression of the cranial nerve is extremely rare. We describe a 60-year-old woman who presented with progressive ptosis due to mechanical compression of the oculomotor nerve by an ID of the PcomA. Three-dimensional computer graphics (3DCG) accurately visualized the mechanical compression by the ID, and her ptosis was improved after clipping of the ID. ID of the PcomA may cause ONP by mechanical compression and is treatable surgically. 3DCG are effective for the diagnosis and preoperative simulation.
Lin, Ming-Hung; Mau, Lian-Ping; Cochran, David L; Shieh, Yi-Shing; Huang, Po-Hsien; Huang, Ren-Yeong
To investigate the prevalence and morphological parameters of lingual concavity, and whether these factors are related to a higher risk of inferior alveolar nerve (IAN) injury when performing an immediate implant surgery in posterior mandible region. The CBCT images from 237 subjects (1008 teeth) were analysed the shape of the mandibles (C, P, U type), dimensional parameters of lingual concavity (angle, height, depth), and its relation to inferior alveolar canal (IAC) (A, B, C zone), RAC (distance from root apex to IAC) and probability of IAN injury. Multiple logistic regression modelling to determine the odds ratio of variables that made an important contribution to the probability of IAN injury and to adjust for confounding variables. The U type ridge (46.7%) and the most concave point located at C zone (48.8%) are most prevalent in this region. The mandibular second molar presents highest risk for IAN injury than other tooth type (p<0.001), which were 3.82 times to occur IAN injury than the mandibular second premolar. The concave point located at A zone and B zone were 7.82 and 3.52 times than C zone to have IAN damage, respectively. The probability of IAN injury will reduce 26% for every 1mm increase in RAC (p<0.001). The tooth type, morphological features of lingual concavities, and RAC are associated with risks of IAN injury during immediate implant placement. Pre-surgical mapping of the IAC and identification of its proximity relative to the lingual concavity in the posterior mandible regions may avoid unpleasant complications, specifically when performing immediate implant procedures. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.
Dursun, Erhan; Keceli, Huseyin Gencay; Uysal, Serdar; Güngör, Hamiyet; Muhtarogullari, Mehmet; Tözüm, Tolga Fikret
Inferior alveolar nerve lateralization (IANL) and short dental implants (SDI) are 2 viable implant-based treatment approaches in the presence of atrophied posterior mandible. Despite the risks of dysfunction, infection, and pathologic fractures in IANL, it becomes possible to place standard implants. The purpose of this study was to compare SDI and IANL approaches from clinical and radiographic aspects. Fifteen subjects having unilateral atrophic mandibles were allocated to SDI and IANL treatment groups. Following surgical procedures, early postoperative complications, implant survival, and periimplant clinical and radiographic parameters including probing pocket depth, attachment level, keratinized tissue amount, vertical tissue recession, and marginal bone loss were recorded at baseline and 1-year after prosthetic rehabilitation. In both groups, no implant was lost. Except usual postoperative complications, 2 patients had transient paraesthesia after IANL. According to time-dependent evaluation, both groups showed significant increase in probing pocket depth and attachment level at 1-year follow-up compared with baseline (P < 0.05). Except a slight but significant increase in mesial surface of SDI group (P < 0.05), no remarkable time-dependent change was identified in vertical tissue recession. Keratinized tissue amount did not exhibit any inter- or intragroup difference during whole study period. Marginal bone loss did not show any difference between IANL and SDI groups at follow-up. SDI placement or standard length implant placement with IANL can be considered promising alternatives in the treatment of atrophic mandibular posterior regions. However, SDI may be preferred in terms of lower complication risk.
Li, Zhongyu; Reynolds, Michael; Satteson, Ellen; Nazir, Omar; Petit, James; Smith, Beth P
To evaluate outcomes following transfer of the supinator motor branch of the radial nerve (SMB) to the posterior interosseous nerve (PIN) and the pronator teres motor branch of median (PTMB) to the anterior interosseous nerve (AIN) in patients with lower brachial plexus injuries. Since December 2010, 4 patients have undergone combined transfer of the SMB to PIN and PTMB to AIN for lower brachial plexus palsies. The study was prospectively designed, and the patients were followed for 4 years to monitor their functional improvement. One patient failed to return after his 4-month postoperative visit. The other 3 patients all regained M4 thumb and finger extension, and 2 recovered M4 thumb and finger flexion at the final evaluation, a mean 30 months after the nerve transfer surgeries. Combined transfer of the SMB to PIN and PTMB to AIN may lead to successful recovery of digital extrinsic flexion and extension in lower brachial plexus injuries. Therapeutic IV. Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Yongwei, Pan; Guanglei, Tian; Jianing, Wei; Shuhuan, Wang; Qingtai, Li; Wen, Tian
To present an uncommon lesion of radial nerve paralysis with multiple constrictions. Eight patients were treated in our department between January 1994 and August 2000. There were 4 men and 4 women with a mean age of 26 years (10-43 y). The radial nerves of all patients were explored. There were 1 to 5 segmental constrictive lesions at the main trunks of the radial nerves or the posterior interosseous nerves; no obvious extrinsic compression was noted. Epineurolysis was performed in 3 patients, in the other 5 patients the constricted portions of the nerves were resected, and neurorrhaphy was performed in 2 patients, nerve-grafting in 3. Histologic examination of the resected portions showed concentration of inflammatory cells around the vessels in the perineurium. The patients were followed-up for 6 months to 4 years after surgery. Seven patients had at least grade 4 muscle strength in the involved muscles. One patient who was treated by external neurolysis 15 months after onset had no signs of recovery 10 months after surgery. Nontraumatic paralysis of the radial nerve with multiple constrictions is very uncommon. The etiology may be a focal inflammatory response around the feeding arteries in the perineurium.
Fox, Ida K; Davidge, Kristen M; Novak, Christine B; Hoben, Gwendolyn; Kahn, Lorna C; Juknis, Neringa; Ruvinskaya, Rimma; Mackinnon, Susan E
Cervical spinal cord injury can result in profound loss of upper extremity function. Recent interest in the use of nerve transfers to restore volitional control is an exciting development in the care of these complex patients. In this article, the authors review preliminary results of nerve transfers in spinal cord injury. Review of the literature and the authors' cases series of 13 operations in nine spinal cord injury nerve transfer recipients was performed. Representative cases were reviewed to explore critical concepts and preliminary outcomes. The nerve transfers used expendable donors (e.g., teres minor, deltoid, supinator, and brachialis) innervated above the level of the spinal cord injury to restore volitional control of missing function such as elbow extension, wrist extension, and/or hand function (posterior interosseous nerve or anterior interosseous nerve/finger flexors reinnervated). Results from the literature and the authors' patients (after a mean postsurgical follow-up of 12 months) indicate gains in function as assessed by both manual muscle testing and patients' self-reported outcomes measures. Nerve transfers can provide an alternative and consistent means of reestablishing volitional control of upper extremity function in people with cervical level spinal cord injury. Early outcomes provide evidence of substantial improvements in self-reported function despite relatively subtle objective gains in isolated muscle strength. Further work to investigate the optimal timing and combination of nerve transfer operations, the combination of these with traditional treatments (tendon transfer and functional electrical stimulation), and measurement of outcomes is imperative for determining the precise role of these operations. Therapeutic, IV.
Lorei, M P; Hershman, E B
Peripheral nerve lesions are uncommon but serious injuries which may delay or preclude an athlete's safe return to sports. Early, accurate anatomical diagnosis is essential. Nerve lesions may be due to acute injury (e.g. from a direct blow) or chronic injury secondary to repetitive microtrauma (entrapment). Accurate diagnosis is based upon physical examination and a knowledge of the relative anatomy. Palpation, neurological testing and provocative manoeuvres are mainstays of physical diagnosis. Diagnostic suspicion can be confirmed by electrophysiological testing, including electromyography and nerve conduction studies. Proper equipment, technique and conditioning are the keys to prevention. Rest, anti-inflammatories, physical therapy and appropriate splinting are the mainstays of treatment. In the shoulder, spinal accessory nerve injury is caused by a blow to the neck and results in trapezius paralysis with sparing of the sternocleidomastoid muscle. Scapular winging results from paralysis of the serratus anterior because of long thoracic nerve palsy. A lesion of the suprascapular nerve may mimic a rotator cuff tear with pain a weakness of the rotator cuff. Axillary nerve injury often follows anterior shoulder dislocation. In the elbow region, musculocutaneous nerve palsy is seen in weightlifters with weakness of the elbow flexors and dysesthesias of the lateral forearm. Pronator syndrome is a median nerve lesion occurring in the proximal forearm which is diagnosed by several provocative manoeuvres. Posterior interosseous nerve entrapment is common among tennis players and occurs at the Arcade of Froshe--it results in weakness of the wrist and metacarpophalangeal extensors. Ulnar neuritis at the elbow is common amongst baseball pitchers. Carpal tunnel syndrome is a common neuropathy seen in sport and is caused by median nerve compression in the carpal tunnel. Paralysis of the ulnar nerve at the wrist is seen among bicyclists resulting in weakness of grip and
Kowalska, Berta; Sudoł-Szopińska, Iwona
Ultrasound (US) is one of the methods for imaging entrapment neuropathies, post-traumatic changes to nerves, nerve tumors and postoperative complications to nerves. This type of examination is becoming more and more popular, not only for economic reasons, but also due to its value in making accurate diagnosis. It provides a very precise assessment of peripheral nerve trunk pathology - both in terms of morphology and localization. During examination there are several options available to the specialist: the making of a dynamic assessment, observation of pain radiation through the application of precise palpation and the comparison of resultant images with the contra lateral limb. Entrapment neuropathies of the upper limb are discussed in this study, with the omission of median nerve neuropathy at the level of the carpal canal, as extensive literature on this subject exists. The following pathologies are presented: pronator teres muscle syndrome, anterior interosseus nerve neuropathy, ulnar nerve groove syndrome and cubital tunnel syndrome, Guyon's canal syndrome, radial nerve neuropathy, posterior interosseous nerve neuropathy, Wartenberg's disease, suprascapular nerve neuropathy and thoracic outlet syndrome. Peripheral nerve examination technique has been presented in previous articles presenting information about peripheral nerve anatomy [Journal of Ultrasonography 2012; 12 (49): 120-163 - Normal and sonographic anatomy of selected peripheral nerves. Part I: Sonohistology and general principles of examination, following the example of the median nerve; Part II: Peripheral nerves of the upper limb; Part III: Peripheral nerves of the lower limb]. In this article potential compression sites of particular nerves are discussed, taking into account pathomechanisms of damage, including predisposing anatomical variants (accessory muscles). The parameters of ultrasound assessment have been established - echogenicity and echostructure, thickness (edema and related increase
Ultrasound (US) is one of the methods for imaging entrapment neuropathies, post-traumatic changes to nerves, nerve tumors and postoperative complications to nerves. This type of examination is becoming more and more popular, not only for economic reasons, but also due to its value in making accurate diagnosis. It provides a very precise assessment of peripheral nerve trunk pathology – both in terms of morphology and localization. During examination there are several options available to the specialist: the making of a dynamic assessment, observation of pain radiation through the application of precise palpation and the comparison of resultant images with the contra lateral limb. Entrapment neuropathies of the upper limb are discussed in this study, with the omission of median nerve neuropathy at the level of the carpal canal, as extensive literature on this subject exists. The following pathologies are presented: pronator teres muscle syndrome, anterior interosseus nerve neuropathy, ulnar nerve groove syndrome and cubital tunnel syndrome, Guyon's canal syndrome, radial nerve neuropathy, posterior interosseous nerve neuropathy, Wartenberg's disease, suprascapular nerve neuropathy and thoracic outlet syndrome. Peripheral nerve examination technique has been presented in previous articles presenting information about peripheral nerve anatomy [Journal of Ultrasonography 2012; 12 (49): 120–163 – Normal and sonographic anatomy of selected peripheral nerves. Part I: Sonohistology and general principles of examination, following the example of the median nerve; Part II: Peripheral nerves of the upper limb; Part III: Peripheral nerves of the lower limb]. In this article potential compression sites of particular nerves are discussed, taking into account pathomechanisms of damage, including predisposing anatomical variants (accessory muscles). The parameters of ultrasound assessment have been established – echogenicity and echostructure, thickness (edema and related
Ammi, Myriam; Chautard, Denis; Brassart, Elena; Culty, Thibaut; Azzouzi, Abdel Rahmène; Bigot, Pierre
This study evaluated the efficacy and tolerability of transcutaneous posterior tibial nerve stimulation (TPTNS) in the treatment of overactive bladder (OAB) after failure of a first-line anticholinergic treatment. We performed a prospective observational study and included all patients treated in a single center for OAB persisting after first-line anticholinergic treatment from November 2010 to May 2013. The protocol consisted of daily stimulation at home. The efficacy end point was defined as improvement on the Urinary Symptom Profile (USP) and the French-validated urinary symptom score Mesure du Handicap Urinaire (MHU). We assessed 43 consecutive patients. TPTNS was successful following 1 month of treatment in 23 (53%) patients. Bladder capacity was the only predictive factor for treatment success (p = 0.044). For patients who showed improved symptoms (n = 23; 53%), mean MHU and USP decreased significantly, from 11.8 ± 2.8 to 5.6 ± 3 (p < 0.001) and from 14 ± 3.3 to 6.9 ± 3.2 (p < 0.001), respectively. After a mean follow-up of 10.8 ± 1.6 months, 21 (49%) patients continued the TPTNS. Mean MHU and USP scores were 4.4 ± 2.8 and 5.4 ± 3.5, respectively, and stayed lower than baseline (p < 0.001). Patients reported no adverse events. TPTNS is well tolerated and is effective in one half of the patients studied after they failed anticholinergic treatment. TPTNS could become a second therapeutic option before surgical treatment in the management strategy of OAB.
Hiwatashi, Akio; Yoshiura, Takashi; Yamashita, Koji; Kamano, Hironori; Honda, Hiroshi
Preoperative evaluation of small vessels without contrast material is sometimes difficult in patients with neurovascular compression disease. The purpose of this retrospective study was to evaluate whether 3D STIR MRI could simultaneously depict the lower cranial nerves--fifth through twelfth--and the blood vessels in the posterior fossa. The posterior fossae of 47 adults (26 women, 21 men) without gross pathologic changes were imaged with 3D STIR and turbo spin-echo heavily T2-weighted MRI sequences and with contrast-enhanced turbo field-echo MR angiography (MRA). Visualization of the cranial nerves on STIR images was graded on a 4-point scale and compared with visualization on T2-weighted images. Visualization of the arteries on STIR images was evaluated according to the segments in each artery and compared with that on MRA images. Visualization of the veins on STIR images was also compared with that on MRA images. Statistical analysis was performed with the Mann-Whitney U test. There were no significant differences between STIR and T2-weighted images with respect to visualization of the cranial nerves (p > 0.05). Identified on STIR and MRA images were 94 superior cerebellar arteries, 81 anteroinferior cerebellar arteries, and 79 posteroinferior cerebellar arteries. All veins evaluated were seen on STIR and MRA images. There were no significant differences between STIR and MRA images with respect to visualization of arteries and veins (p > 0.05). High-resolution STIR is a feasible method for simultaneous evaluation of the lower cranial nerves and the vessels in the posterior fossa without the use of contrast material.
The purpose of this study is to document the topographic anatomy of an extensor indicis (EI) muscle with a double tendon and the associated distribution of the deep branch of the radial nerve (DBRN). Both EI tendons were positioned deep to the tendons of the extensor digitorum as they traversed the dorsal osseofibrous tunnel. They then joined the medial slips of the extensor expansion of the second and third digits. In all other dissected forearms, a tendon of the EI muscle joined the medial slip of the extensor expansion to the index finger. The DBRN provided short branches to the superficial extensor muscles, long branches to the abductor pollicis longus and extensor pollicis brevis muscles, and terminated as the posterior interosseous nerve. Descending deep to the extensor pollicis longus muscle, the posterior interosseous nerve sent branches to the extensor pollicis brevis and EI muscles. Understanding of the topographic anatomy of an EI with a double tendon, and the associated distribution of the DBRN, may contribute to accurate diagnosis and treatment of hand lesions.
Escriva, Hector; Holland, Nicholas D.; Gronemeyer, Hinrich; Laudet, Vincent; Holland, Linda Z.
Amphioxus, the closest living invertebrate relative of the vertebrates, has a notochord, segmental axial musculature, pharyngeal gill slits and dorsal hollow nerve cord, but lacks neural crest. In amphioxus, as in vertebrates, exogenous retinoic acid (RA) posteriorizes the embryo. The mouth and gill slits never form, AmphiPax1, which is normally downregulated where gill slits form, remains upregulated and AmphiHox1 expression shifts anteriorly in the nerve cord. To dissect the role of RA signaling in patterning chordate embryos, we have cloned the single retinoic acid receptor (AmphiRAR), retinoid X receptor (AmphiRXR) and an orphan receptor (AmphiTR2/4) from amphioxus. AmphiTR2/4 inhibits AmphiRAR-AmphiRXR-mediated transactivation in the presence of RA by competing for DR5 or IR7 retinoic acid response elements (RAREs). The 5' untranslated region of AmphiTR2/4 contains an IR7 element, suggesting possible auto- and RA-regulation. The patterns of AmphiTR2/4 and AmphiRAR expression during embryogenesis are largely complementary: AmphiTR2/4 is strongly expressed in the cerebral vesicle (homologous to the diencephalon plus anterior midbrain), while AmphiRAR expression is high in the equivalent of the hindbrain and spinal cord. Similarly, while AmphiTR2/4 is expressed most strongly in the anterior and posterior thirds of the endoderm, the highest AmphiRAR expression is in the middle third. Expression of AmphiRAR is upregulated by exogenous RA and completely downregulated by the RA antagonist BMS009. Moreover, BMS009 expands the pharynx posteriorly; the first three gill slit primordia are elongated and shifted posteriorly, but do not penetrate, and additional, non-penetrating gill slit primordia are induced. Thus, in an organism without neural crest, initiation and penetration of gill slits appear to be separate events mediated by distinct levels of RA signaling in the pharyngeal endoderm. Although these compounds have little effect on levels of AmphiTR2/4 expression, RA
Escriva, Hector; Holland, Nicholas D.; Gronemeyer, Hinrich; Laudet, Vincent; Holland, Linda Z.
Amphioxus, the closest living invertebrate relative of the vertebrates, has a notochord, segmental axial musculature, pharyngeal gill slits and dorsal hollow nerve cord, but lacks neural crest. In amphioxus, as in vertebrates, exogenous retinoic acid (RA) posteriorizes the embryo. The mouth and gill slits never form, AmphiPax1, which is normally downregulated where gill slits form, remains upregulated and AmphiHox1 expression shifts anteriorly in the nerve cord. To dissect the role of RA signaling in patterning chordate embryos, we have cloned the single retinoic acid receptor (AmphiRAR), retinoid X receptor (AmphiRXR) and an orphan receptor (AmphiTR2/4) from amphioxus. AmphiTR2/4 inhibits AmphiRAR-AmphiRXR-mediated transactivation in the presence of RA by competing for DR5 or IR7 retinoic acid response elements (RAREs). The 5' untranslated region of AmphiTR2/4 contains an IR7 element, suggesting possible auto- and RA-regulation. The patterns of AmphiTR2/4 and AmphiRAR expression during embryogenesis are largely complementary: AmphiTR2/4 is strongly expressed in the cerebral vesicle (homologous to the diencephalon plus anterior midbrain), while AmphiRAR expression is high in the equivalent of the hindbrain and spinal cord. Similarly, while AmphiTR2/4 is expressed most strongly in the anterior and posterior thirds of the endoderm, the highest AmphiRAR expression is in the middle third. Expression of AmphiRAR is upregulated by exogenous RA and completely downregulated by the RA antagonist BMS009. Moreover, BMS009 expands the pharynx posteriorly; the first three gill slit primordia are elongated and shifted posteriorly, but do not penetrate, and additional, non-penetrating gill slit primordia are induced. Thus, in an organism without neural crest, initiation and penetration of gill slits appear to be separate events mediated by distinct levels of RA signaling in the pharyngeal endoderm. Although these compounds have little effect on levels of AmphiTR2/4 expression, RA
German, Iris Jasmin Santos; Buchaim, Daniela Vieira; Andreo, Jesus Carlos; Shinohara, Elio Hitoshi; Capelozza, Ana Lúcia Alvares; Shinohara, Andre Luis; Pereira, Mizael; Buchaim, Rogerio Leone
The aim of this study was to identify the shape and route of the bony canal of the posterior superior alveolar artery (PSAA) and posterior superior alveolar nerve (PSAN) using different identification methods, including computed tomography (CT), panoramic radiograph, and macroscopic evaluation (corpse and dry skull). Twenty-four patients were analyzed by CT and panoramic and posterior anterior (PA) radiographs; additionally, 90 dry skulls and 21 dissected anatomical specimens were examined. Three-dimensional-CT revealed that the lateral wall of the maxillary sinus resembled a tunnel format in 60% of the treated patients. Out of all 24 patients, the panoramic radiograph identified the bony canal in only one patient; whereas the PA radiograph identified it in 80% of the patients. The dry skulls showed tunnellike routes of the PSAA and PSAN in 65% of the cases. Moreover, the pathway was also visibly observed in the dissected anatomical specimens as a straight shape in 85% of the cases. Thus, our results demonstrated that the most common shape of the bony canal of the PSAA and PSAN is the tunnel format with a straight route by 3D-CT, posterior anterior radiography, and macroscopic evaluation. However, in the panoramic radiographs, it was difficult to identify this canal. PMID:25861685
Biazzo, A; González Del Pino, J
The lipofibrohamartoma is a rare entity of unknown origin that can affect any peripheral nerves, but mainly being found in the median nerve within the carpal tunnel. The lipofibrohamartoma is frequently associated with other conditions such as macrodactyly, the Proteus and Klippel-Trenaunay-Weber syndromes and multiple exostosis, among others. Two cases of lipofibrohamartoma in the carpal tunnel with associated median nerve palsy are described in the present article. They were treated by simple decompression of the median nerve by releasing the transverse carpal ligament and a palmaris longus tendon transfer to improve the thumb abduction (Camitz procedure). In one of the cases (a previously multi-operated median nerve entrapment at the carpal tunnel), a posterior interosseous skin flap was employed to improve the quality of the soft tissues on the anterior side of the wrist. A review of the literature is also presented on lipofibrohamartoma of the median nerve, covering articles from 1964 to 2010. The literature suggests that the most recommended treatment to manage this condition is simple release of the carpal tunnel, which should be associated with a tendon transfer when a median nerve palsy is noticed. Copyright © 2013 SECOT. Published by Elsevier Espana. All rights reserved.
Field potentials evoked by stimulation of the posterior semicircular canal nerve (PCN) were studied in the postcruciate dimple (PCD) in anesthetized cats. When weak stimulation was provided, field potentials composed of 3 components of small positive, large positive and large negative waves were observed on the surface of the PCD. The field potentials could be observed at the stimulus intensity weaker than 1.5 x N1T. The latencies of initiation of the 3 components were 2.32 +/- 0.75 (mean +/- S.D.; n = 37), 3.75 +/- 0.92 (mean +/- S.D.; n = 99) and 9.34 +/- 2.81 (mean +/- S.D.; n = 101), respectively. The large positive wave of the maximum amplitude was recorded in the lateral part of the PCD. In this point, the large and small positive waves reversed their polarity at the layer III and V, respectively, which located about 500 microns and 1000 microns deep from the surface. Stimulations of the whole vestibular nerve (WVN) and the deep radial nerve (DR) shared response areas of field potentials. These findings agreed with the previous results as to a neuronal convergence of the somatic and vestibular inputs in the cat.
A case of iatrogenic ulnar nerve laceration at the elbow is presented. Five subsequent surgeries over the course of the ensuing 20 months were performed to address this complication. The article examines the scientific basis for the various decisions needed to formulate a strategy that effectively addresses the problem. Emphasis is placed on the microsurgery of nerve topics: direct nerve repair, autogenous cable nerve grafting, biodegradable conduits, decellularized nerve allograft, and transfer of the anterior interosseous nerve to the ulnar motor branch. The discussion covers the relationship between choices made at the level of the original injury at the cubital tunnel to the timing and selection of distal reconstructive efforts, with specific attention to the distinction between end-to-end anterior interosseous to ulnar motor branch transfer as opposed to the supercharged end-to-side variation of this procedure.
Heller, A A; Shankland, W E
Local anesthesia block of the inferior alveolar nerve is routinely taught throughout dental education. This commonly used technique eliminates all somatosensory perception of the mandible, mandibular teeth, floor of the mouth, ipsilateral tongue, and all but the lateral (buccal) gingivae. Generally, the dentist or surgeon desires these structures to be anesthetized. However, in the placement of mandibular implants, it may be useful for the patient to be able to sense when the inferior alveolar nerve is in danger of being damaged, possibly producing permanent paresthesia. In this article, the technique of mandibular infiltration prior to mandibular implant placement in the mandible is discussed.
Infantolino, Benjamin W; Challis, John H
Muscle architecture is considered to reflect the function of muscle in vivo, and is important for example to clinicians in designing tendon-transfer and tendon-lengthening surgeries. The purpose of this study was to quantify the architectural properties of the FDI muscle. It is hypothesized that there will be consistency, that is low variability, in the architectural parameters used to describe the first dorsal interosseous muscle because of its clear functional role in index finger motion. The important architectural parameters identified were those required to characterize a muscle adequately by modeling. Specifically the mass, cross-sectional area, and length of the tendon and muscle were measured in cadavers along with the muscle fiber optimum length and pennation angle, and the moment arm of the first dorsal interosseous at the metacarpophalangeal joint. These parameters provide a characterization of the architecture of the first dorsal interosseous, and were used to indicate the inherent variability between samples. The results demonstrated a large amount of variability for all architectural parameters measured; leading to a rejection of the hypothesis. Ratios designed to describe the functioning of the muscles in vivo, for example the ratio of tendon to fiber optimum lengths, also demonstrated a large variability. The results suggest that function cannot be deduced from form for the first dorsal interosseous, and that subject-specific architectural parameters may be necessary for the formulation of accurate musculoskeletal models or making clinical decisions. PMID:20070422
Infantolino, Benjamin W; Challis, John H
Muscle architecture is considered to reflect the function of muscle in vivo, and is important for example to clinicians in designing tendon-transfer and tendon-lengthening surgeries. The purpose of this study was to quantify the architectural properties of the FDI muscle. It is hypothesized that there will be consistency, that is low variability, in the architectural parameters used to describe the first dorsal interosseous muscle because of its clear functional role in index finger motion. The important architectural parameters identified were those required to characterize a muscle adequately by modeling. Specifically the mass, cross-sectional area, and length of the tendon and muscle were measured in cadavers along with the muscle fiber optimum length and pennation angle, and the moment arm of the first dorsal interosseous at the metacarpophalangeal joint. These parameters provide a characterization of the architecture of the first dorsal interosseous, and were used to indicate the inherent variability between samples. The results demonstrated a large amount of variability for all architectural parameters measured; leading to a rejection of the hypothesis. Ratios designed to describe the functioning of the muscles in vivo, for example the ratio of tendon to fiber optimum lengths, also demonstrated a large variability. The results suggest that function cannot be deduced from form for the first dorsal interosseous, and that subject-specific architectural parameters may be necessary for the formulation of accurate musculoskeletal models or making clinical decisions.
van Breda, Hendrikje M K; Martens, Frank M J; Tromp, Johnny; Heesakkers, John P F A
This study was designed to investigate the safety and performance of a new implantable system for tibial nerve stimulation for overactive bladder symptoms. A battery-free stimulation device for tibial nerve stimulation (BlueWind Medical, Herzliya, Israel) was implanted in 15 patients. Safety and efficacy assessments were done at 3 months after activation with a 3-day bladder diary, a 24-hour pad test and 2 quality of life questionnaires. Two males and 13 females were enrolled in the study. Mean age was 54 years (range 19 to 72). Five of 15 patients were previously treated with percutaneous tibial nerve stimulation and 12 experienced urgency urinary incontinence. Median operative time was 34 minutes. At 3 months of followup a significant change was seen in 24-hour frequency from a mean ± SD of 11.8 ± 3.5 to 8.1 ± 2.0 times per day (p = 0.002), the number of severe urinary urgency episodes from 6.5 ± 5.1 to 2.0 ± 2.1 times per day (p = 0.002), the number of severe incontinence episodes from 2.8 ± 5.2 to 0.3 ± 0.4 episodes per day (p = 0.017), urinary loss per day from 243 ± 388 to 39 ± 55 gm (p = 0.038) and improvement in quality of life. After implantation, 3 patients received prolonged antibiotic treatment and 3 received pain medication for 1 week. In 1 patient the device was explanted due to pain and swelling suspicious for infection, although tissue cultures did not reveal a bacterial infection. This novel posterior tibial nerve stimulator is safe and easy to implant with good clinical results. Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
Comparative morphometry of the antebrachial and crural interosseous membranes: preliminary study for the use of the crural interosseous membrane in the surgical repair of the antebrachial interosseous membrane tears.
Elamrani, Driss; Aumar, Aurélien; Wavreille, Guillaume; Fontaine, Christian
Traumatic tears of the antebrachial interosseous membrane (AIOM) on its whole length are difficult to treat, particularly in the Essex-Lopresti syndrome. The number of ligamentoplasty techniques described in the literature witnesses the difficulty of its reconstruction and the absence of reliable and satisfying procedure. The aim of this study was to explore a new way of treatment, which consists in replacing the AIOM by the crural interosseous membrane (CIOM), harvested from the same patient. A morphometric study of the AIOM and CIOM has been conducted on both sides of 15 formalin preserved corpses (i.e. 30 AIOM and 30 CIOM). Studied data were: length of forearms and legs, length and width (at different locations) of the membranes, in situ and after harvesting, and orientation of their fibers. The thickness of membrane was also measured but only after harvesting. Concerning the AIOM, the mean length was 13.3 cm in situ and 12.8 cm after harvesting. Its width was maximal at the union of middle and distal thirds with an average value of 1.7 cm in situ and 1.45 cm after harvesting. Mean thickness was 1 mm. Anterior fibers were oblique distally and medially (20.5° ± 0.95°), and posterior fibers were oblique distally and laterally (40° ± 3.4°). Concerning the CIOM, the mean length was 24.75 cm in situ and 23.9 cm after harvesting. Its width was maximal at the union of proximal and middle thirds with an average value of 2.3 cm in situ and 1.85 cm after harvesting. Mean thickness was 0.5 mm. Obliquity of its fibers was reverse of that of the AIOM: the anterior fibers were quite oblique distally and laterally (13° ± 2.6°), and the posterior fibers oblique were oblique distally and medially (24.2° ± 2.48°). From these results, one may conclude that the largest length and width of the CIOM allow its use as substitute for the injured AIOM. The orientation of its fibers should necessitate either its reversal while using the same side or the use of the CIOM of the
Anjos, Rita; Vieira, Luisa; Costa, Livio; Vicente, André; Santos, Arnaldo; Alves, Nuno; Amado, Duarte; Ferreira, Joana; Cunha, João Paulo
ABSTRACT The purpose of this study is to evaluate the macular ganglion cell layer (GCL) and peripapillary retinal nerve fibre layer (RNFL) thickness in patients with unilateral posterior cerebral artery (PCA) ischaemic lesions using spectral-domain optical coherence tomography (SD-OCT). A prospective, case-control study of patients with unilateral PCA lesion was conducted in the neuro-ophthalmology clinic of Centro Hospitalar Lisboa Central. Macular and peripapillary SD-OCT scans were performed in both eyes of each patient. Twelve patients with PCA lesions (stroke group) and 12 healthy normal controls were included in this study. Peripapillary RNFL comparison between both eyes of the same subject in the stroke group found a thinning in the superior-temporal (p = 0.008) and inferior-temporal (p = 0.023) sectors of the ipsilateral eye and nasal sector (p = 0.003) of the contralateral eye. Macular GCL thickness comparison showed a reduction temporally in the ipsilateral eye (p = 0.004) and nasally in the contralateral eye (p = 0.002). Peripapillary RNFL thickness was significantly reduced in both eyes of patients with PCA compared with controls, affecting all sectors in the contralateral eye and predominantly temporal sectors in the ipsilateral eye. A statistically significant decrease in macular GCL thickness was found in both hemiretinas of both eyes of stroke patients when compared with controls (p < 0.05). This study shows that TRD may play a role in the physiopathology of lesions of the posterior visual pathway. PMID:27928376
Noble, David J; Scoffings, Daniel; Ajithkumar, Thankamma; Williams, Michael V; Jefferies, Sarah J
There is no consensus approach to covering skull base meningeal reflections-and cerebrospinal fluid (CSF) therein-of the posterior fossa cranial nerves (CNs VII-XII) when planning radiotherapy (RT) for medulloblastoma and ependymoma. We sought to determine whether MRI and specifically fast imaging employing steady-state acquisition (FIESTA) sequences can answer this anatomical question and guide RT planning. 96 posterior fossa FIESTA sequences were reviewed. Following exclusions, measurements were made on the following scans for each foramen respectively (left, right); internal acoustic meatus (IAM) (86, 84), jugular foramen (JF) (83, 85) and hypoglossal canal (HC) (42, 45). A protocol describes measurement procedure. Two observers measured distances for five cases and agreement was assessed. One observer measured all the remaining cases. IAM and JF measurement interobserver variability was compared. Mean measurement difference between observers was -0.275 mm (standard deviation 0.557). IAM and JF measurements were normally distributed. Mean IAM distance was 12.2 mm [95% confidence interval (CI) 8.8-15.6]; JF was 7.3 mm (95% CI 4.0-10.6). The HC was difficult to visualize on many images and data followed a bimodal distribution. Dural reflections of posterior fossa CNs are well demonstrated by FIESTA MRI. Measuring CSF extension into these structures is feasible and robust; mean CSF extension into IAM and JF was measured. We plan further work to assess coverage of these structures with photon and proton RT plans. Advances in knowledge: We have described CSF extension beyond the internal table of the skull into the IAM, JF and HC. Oncologists planning RT for patients with medulloblastoma and ependymoma may use these data to guide contouring.
Sathe, N; Gaikwad, N; Wadkar, G; Thakare, S
The use of interosseous wire to fix bone grafts is well known. Herein, we describe a technique for fixation of an iliac crest bone graft for nasal augmentation, using a stainless steel wire. A hole in the cancellous part of the graft guides the wire exactly into a groove in the cortical part, preventing slippage and ensuring rigid fixation. The wire is then threaded through a hollow spinal needle passed underneath the skin envelope; this avoids a dorsal incision and thus minimises scarring, reduces the risk of graft exposure and improves the aesthetic result. This technique has two distinct advantages: prevention of wire slippage and avoidance of a dorsal nasal incision. The described method uses an interosseous wire for rigid bone graft fixation, without a dorsal incision. This prevents wire slippage; it also achieves a good cosmetic result by improving the nasal contour via a cantilever effect which raises the nasal tip.
Rowbotham, Emma L; Freeston, Jane E; Emery, Paul; Grainger, Andrew J
The aim of this study was to establish the prevalence of tenosynovitis affecting the interosseous tendons of the hand in a rheumatoid arthritis (RA) population and to assess for association with metacarpophalangeal (MCP) joint synovitis, flexor tendon tenosynovitis or ulnar drift. Forty-four patients with RA underwent hand MRI along with 20 normal controls. Coronal 3D T1 VIBE sequences pre- and post-contrast were performed and reconstructed. The presence of interosseous tendon tenosynovitis was recorded alongside MCP joint synovitis, flexor tendon tenosynovitis and ulnar drift. Twenty-one (47.7%) patients with RA showed interosseous tendon tenosynovitis. Fifty-two (14.8%) interosseous tendons showed tenosynovitis amongst the RA patients. Interosseous tendon tenosynovitis was more commonly seen in association with adjacent MCP joint synovitis (p < 0.001), but nine MCP joints (5.1%) showed adjacent interosseous tenosynovitis in the absence of joint synovitis. Interosseous tendon tenosynovitis was more frequently seen in fingers which also showed flexor tendon tenosynovitis (p < 0.001) and in patients with ulnar drift of the fingers (p = 0.01). Tenosynovitis of the hand interosseous tendons was found in 47.7% of patients with RA. In the majority of cases this was adjacent to MCP joint synovitis; however, interosseous tendon tenosynovitis was also seen in isolation. • Tenosynovitis of the interosseous tendons of the hand occurs in rheumatoid arthritis. • Interosseous tendon tenosynovitis has a prevalence of 47.7% in patients with RA. • Interosseous tendon tenosynovitis is related to MCP joint synovitis in the adjacent joints.
Luchetti, R; Riccio, M; Papini Zorli, I; Fairplay, T
The aim of the study is to present our experience with fascial or fasciocutaneous pedicle and island flaps in the treatment of recurrences of CTS with and without median nerve lesions. From 1987 to 2006 we have operated on 25 patients (17 women and 8 men, ages ranging from 38 to 76 years with a mean age of 55 years) due to a recurrence of CTS. All the patients required nerve coverage using a local or distant flap. There were 19 hypothenar fat flaps; two forearm radial artery flaps, a forearm ulnar artery flap, an ulnar fascial-fat flap and a posterior interosseous flap. Patients were clinically and instrumentally evaluated before the operation. Assessments of the evaluation parameters were classified in excellent, good, fair and poor according to clinical and return to work criteria. Patients were evaluated after a mean follow-up of 51 months (12 to 168 months). The pain evaluation showed an improvement passing from a mean value of 9 to 4. The best results were for those patients in whom the median nerve was undamaged (mean value of 1). Eleven patients obtained excellent results; good results were obtained in twelve cases; two patients demonstrated fair results due to partial median nerve injury. In these cases, a hypothenar fat flap and an ulnar fascial-fat flap were used, respectively. Protective coverage of the median nerve by using fascial or fasciocutaneous flaps after failure of CTR and/or unsuccessful re-operations is a good solution to furnish to the median nerve a gliding tissue to avoid adherences with the surrounding tissue of previous surgery. The protection of the nerve can reduce painful symptoms even if it does not permit a return to a painless condition. However, the clinical results in terms of median nerve functional recovery cannot be predicted: if the median nerve is damaged, protective coverage of it by flaps cannot give a favourable result in terms of recovery of both sensory and motor deficits.
Fazal, Akil; Yoo, Andrew; Bendo, John A
Recent research describes the use of a nerve root sedimentation sign to diagnose lumbar spinal stenosis (LSS). The lack of sedimentation of the nerve roots (positive sedimentation sign) to the dorsal part of the dural sac is the characteristic feature of this new radiological parameter. To demonstrate how the nerve root sedimentation sign compares with other more traditional radiological parameters in patients who have been operated for LSS. A retrospective chart and image review. Preoperative magnetic resonance images (MRIs) were reviewed from 71 consecutive operative patients who presented with LSS and received spinal decompression surgery from 2006 to 2010. Preoperative T2-weighted MRIs were reviewed for each patient. One hundred thirty-four vertebral levels from L1 to L5 were measured for: sedimentation sign, cross-sectional area (CSA) and anterior/posterior (A/P) diameter of the dural sac, thickness of the ligamentum flavum, and Fujiwara grade of facet hypertrophy. Radiological measurements were made using Surgimap 22.214.171.124 software (Nemaris, Inc., New York, NY, USA). Statistical analyses were performed using the SPSS 17.0 statistical software (SPSS Inc., Chicago, IL, USA). Significance was demonstrated using unpaired t tests and chi-squared tests. Study funding was departmental. There were no study-specific conflicts of interest-associated biases. A positive sedimentation sign was determined in 120 operated levels (89.5%), whereas 14 levels (10.5%) had no sign (negative sedimentation sign). The mean CSA and A/P diameter were 140.62 mm(2) (standard deviation [SD]=53) and 11.76 mm (SD=3), respectively, for the no-sign group; the mean CSA and A/P diameter were 81.87 mm(2) (SD=35) and 8.76 mm (SD=2.2), respectively, for the sedimentation sign group (p<.001). We found that 60% of levels with Fujiwara Grade A facet hypertrophy did not have a sedimentation sign, whereas 86.3% of levels with Grade B, 93.2% of levels with Grade C, and 100.0% of levels with Grade D
Flachsenberger, W; Kerr, D I
Lack of effect of tetrodotoxin and of an extract from the posterior salivary gland of the blue-ringed octopus following injection into the octopus and following application to its brachial nerve. Toxicon 23, 997-999, 1985. Injections of the blue-ringed octopus salivary gland extract and tetrodotoxin into the blue-ringed octopus have no ill-effect on the animals. Similarly, in vitro nerve preparations from the animal were not affected by these materials although they are both extremely potent on bioelectrically excitable preparations from other species.
Hudson, Anna L; Taylor, Janet L; Gandevia, Simon C; Butler, Jane E
The neural drive to a muscle and its biomechanical properties determine the force at a joint. These factors may be centrally linked. We studied the relationship between the ability of first dorsal interosseous muscle (FDI) to generate index flexion force around the metacarpophalangeal joint and the neural drive it receives in a voluntary contraction. The role of FDI was assessed in two thumb postures, thumb ‘down’ (thumb abducted) and thumb ‘up’ (thumb extended), and at different thumb carpometacarpal angles. These postures were designed to change acutely the flexion moment arm for FDI. The flexion twitch force evoked by supramaximal stimulation of the ulnar nerve was measured in the two postures and the change in moment arm was assessed by ultrasonography. Subjects also made voluntary flexion contractions of the index finger of ∼5 N in both postures during which neural drive to FDI and the long finger flexor muscles was measured using surface EMG. Recordings of FDI EMG were normalized to the maximal M wave. Five of the 15 subjects also had a radial nerve block to eliminate any co-contraction of the extensor muscles, and extensor muscle EMG was monitored in subjects without radial nerve block. Compared to thumb up, flexion twitch force was ∼60% greater, and the flexion moment arm was ∼50% greater with the thumb down. There was minimal effect of altered carpometacarpal angle on flexion twitch force for either thumb posture. During voluntary flexion contractions, normalized FDI EMG was ∼28% greater with thumb down, compared to thumb up, with no consistent change in neural drive to the long flexors. Hence, the contribution of FDI to index finger flexion can be altered by changes in thumb position. This is linked to changes in neural drive to FDI such that neural drive increases when the mechanical contribution increases, and provides a central mechanism to produce efficient voluntary movements. PMID:19124540
Hudson, Anna L; Taylor, Janet L; Gandevia, Simon C; Butler, Jane E
The neural drive to a muscle and its biomechanical properties determine the force at a joint. These factors may be centrally linked. We studied the relationship between the ability of first dorsal interosseous muscle (FDI) to generate index flexion force around the metacarpophalangeal joint and the neural drive it receives in a voluntary contraction. The role of FDI was assessed in two thumb postures, thumb 'down' (thumb abducted) and thumb 'up' (thumb extended), and at different thumb carpometacarpal angles. These postures were designed to change acutely the flexion moment arm for FDI. The flexion twitch force evoked by supramaximal stimulation of the ulnar nerve was measured in the two postures and the change in moment arm was assessed by ultrasonography. Subjects also made voluntary flexion contractions of the index finger of approximately 5 N in both postures during which neural drive to FDI and the long finger flexor muscles was measured using surface EMG. Recordings of FDI EMG were normalized to the maximal M wave. Five of the 15 subjects also had a radial nerve block to eliminate any co-contraction of the extensor muscles, and extensor muscle EMG was monitored in subjects without radial nerve block. Compared to thumb up, flexion twitch force was approximately 60% greater, and the flexion moment arm was approximately 50% greater with the thumb down. There was minimal effect of altered carpometacarpal angle on flexion twitch force for either thumb posture. During voluntary flexion contractions, normalized FDI EMG was approximately 28% greater with thumb down, compared to thumb up, with no consistent change in neural drive to the long flexors. Hence, the contribution of FDI to index finger flexion can be altered by changes in thumb position. This is linked to changes in neural drive to FDI such that neural drive increases when the mechanical contribution increases, and provides a central mechanism to produce efficient voluntary movements.
Meals, Clifton G; Forthman, Christopher L; Segalman, Keith A
Reconstruction of the interosseous membrane (IOM) may play a role in the treatment of acute and chronic longitudinal forearm instability. Several reconstruction techniques have been proposed. Suture-button reconstruction is attractive because it obviates donor site morbidity and is relatively easy to perform. How this method compares to its alternatives, however, is unknown. We review literature describing reconstruction of the forearm axis. We describe how we perform suture-button reconstruction of the IOM, summarize our previously published biomechanical data on the subject, and offer a case report. A suture-button is implanted so as to approximate the course of the interosseous ligament. This may be accomplished percutaneously, or when grafting is desired, through an open approach. Data informing the choice of one reconstruction technique over another consist mostly of biomechanical studies and a small number of case reports. Suture-button reconstruction of the IOM may encourage anatomic healing of acute forearm axis injuries especially as an adjunct to radial head replacement or repair. Chronic injuries may benefit from a combination suture-button graft construct and ulnar shortening osteotomy.
Effects of using the posterior or anterior approaches to the lumbar plexus on the minimum effective anesthetic concentration (MEAC) of mepivacaine required to block the femoral nerve: a prospective, randomized, up-and-down study.
Cappelleri, Gianluca; Aldegheri, Giorgio; Ruggieri, Francesco; Carnelli, Franco; Fanelli, Andrea; Casati, Andrea
To evaluate if psoas compartment block requires a larger concentration of mepivacaine to block the femoral nerve than does an anterior 3-in-1 femoral nerve block. Forty eight patients undergoing anterior cruciate ligament repair were randomly allocated to receive an anterior 3-in-1 femoral block (femoral group, n = 24) or a posterior psoas compartment block (psoas group, n = 24) with 30 mL of mepivacaine. The concentration of the injected solution was varied for consecutive patients using an up-and-down staircase method (initial concentration: 1%; up-and-down steps: 0.1%). The minimum effective anesthetic concentration of mepivacaine blocking the femoral nerve in 50% of cases (ED(50)) was 1.06% +/- 0.31% (95% confidence interval [CI], 0.45%-1.68%) in the femoral group and 1.03% +/- 0.21% (95% CI, 0.6%-1.45%) in the psoas group (P = .83). The lateral femoral cutaneous and obturator nerves were blocked in 4 (16%) and 5 (20%) femoral group patients as compared with 20 (83%) and 19 (80%) psoas group patients (P = .005 and P = .0005, respectively). Intraoperative analgesic supplementation was required by 15 (60%) and 5 (20%) patients in the femoral and psoas groups, respectively (P = .01). Using a posterior psoas compartment approach to the lumbar plexus does not increase the minimum effective anesthetic concentration of mepivacaine required to block the femoral nerve as compared with the anterior 3-in-1 approach, and provides better quality of intraoperative anesthesia due to the more reliable block of the lateral femoral cutaneous and obturator nerves.
Glaus, Simone W; Johnson, Philip J; Mackinnon, Susan E
Reinnervation of a hand transplant ultimately dictates functional recovery but provides a significant regenerative challenge. This article highlights interventions to enhance nerve regeneration through acceleration of axonal regeneration or augmentation of Schwann cell support and discuss their relevance to composite tissue allotransplantation. Surgical techniques that may be performed at the time of transplantation to optimize intrinsic muscle recovery--including appropriate alignment of ulnar nerve motor and sensory components, transfer of the distal anterior interosseous nerve to the recurrent motor branch of the median nerve, and prophylactic release of potential nerve entrapment points--are also presented. Copyright Â© 2011 Elsevier Inc. All rights reserved.
Soubeyrand, M; Ciais, G; Wassermann, V; Kalouche, I; Biau, D; Dumontier, C; Gagey, O
Disruption of the interosseous membrane is easily missed in patients with Essex-Lopresti syndrome. None of the imaging techniques available for diagnosing disruption of the interosseous membrane are completely dependable. We undertook an investigation to identify whether a simple intra-operative test could be used to diagnose disruption of the interosseous membrane during surgery for fracture of the radial head and to see if the test was reproducible. We studied 20 cadaveric forearms after excision of the radial head, ten with and ten without disruption of the interosseous membrane. On each forearm, we performed the radius joystick test: moderate lateral traction was applied to the radial neck with the forearm in maximal pronation, to look for lateral displacement of the proximal radius indicating that the interosseous membrane had been disrupted. Each of six surgeons (three junior and three senior) performed the test on two consecutive days. Intra-observer agreement was 77% (95% confidence interval (CI) 67 to 85) and interobserver agreement was 97% (95% CI 92 to 100). Sensitivity was 100% (95% CI 97 to 100), specificity 88% (95% CI 81 to 93), positive predictive value 90% (95% CI 83 to 94), and negative predictive value 100%). This cadaveric study suggests that the radius joystick test may be useful for detecting disruption of the interosseous membrane in patients undergoing open surgery for fracture of the radial head and is reproducible. A confirmatory study in vivo is now required.
C2 spondylotic radiculopathy: the nerve root impingement mechanism investigated by para-sagittal CT/MRI, dynamic rotational CT, intraoperative microscopic findings, and treated by microscopic posterior foraminotomy.
Fujiwara, Yasushi; Izumi, Bunichiro; Fujiwara, Masami; Nakanishi, Kazuyoshi; Tanaka, Nobuhiro; Adachi, Nobuo; Manabe, Hideki
C2 radiculopathy is known to cause occipito-cervical pain, but their pathology is unclear because of its rarity and unique anatomy. In this paper, we investigated the mechanism of C2 radiculopathy that underwent microscopic cervical foraminotomies (MCF). Three cases with C2 radiculopathy treated by MCF were investigated retrospectively. The mean follow-up period was 24 months. Pre-operative symptoms, imaging studies including para-sagittal CT and MRI, rotational dynamic CT, and intraoperative findings were investigated. There were 1 male and 2 females. The age of patients were ranged from 50 to 79 years. All cases had intractable occipito-cervical pain elicited by the cervical rotation. C2 nerve root block was temporally effective. There was unilateral spondylosis in symptomatic side without obvious atlatoaxial instability. Para-sagittal MRI and CT showed severe foraminal stenosis at C1-C2 due to the bony spur derived from the lateral atlanto-axial joints. In one case, dynamic rotational CT showed that the symptomatic foramen became narrower on rotational position. MCF was performed in all cases, and the C2 nerve root was impinged between the inferior edge of the C1 posterior arch and bony spur from the C1-C2 joint. After surgery, occipito-cervical pain disappeared. This study demonstrated that mechanical impingement of the C2 nerve root is one of the causes of occipito-cervical pain and it was successfully treated by microscopic resection of the inferior edge of the C1 posterior arch. Para-sagittal CT and MRI, rotational dynamic CT, and nerve root block were effective for diagnosis.
Mugnai, R; Della Rosa, N; Tarallo, L
Injuries to the scapholunate interosseous ligament (SLIL) are the most common cause of carpal instability. A SLIL injury typically follows a fall on an outstretched hand, with the wrist in hyperextension, ulnar deviation and intercarpal supination. We hypothesize that repetitive axial loading on the wrist in hyperextension, during the reception and digging motions of volleyball, can lead to functional overloading of the SLIL. To identify patients and to determine the clinical history and surgical treatment performed, we analyzed hospital records, X-rays, electronic databases containing all the operations performed, and image files (including before and after surgery and follow-up). We identified three SLIL injury cases in national volleyball team players, also at the libero position, who were treated at our clinic between 2007 and 2013 for scapholunate instability. Open reduction and Berger capsulodesis was performed in all cases. At a mean follow-up of 3 years (range, 22-50 months), the mean pain level on VAS was 0.3 (range, 0-1) at rest and 1.7 (range 1-2) during sport activities. The mean DASH score was 4 (range 2-5). The mean wrist flexion was 60° (range 55-70°) and extension was 80° (range 75-85°). Given the greater susceptibility of these players for developing a SLIL injury, a high index of suspicion is needed when managing athletes presenting with wrist pain or instability. Copyright © 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved.
I, Hoseok; Jeong, Yeon Joo; Choi, Kyung Un; Kim, Yeong-Dae
We report a case of a symptomatic angioleiomyoma in the left posterior mediastinum. A 66-year-old woman presented with left back and flank pain for 6 months. Chest computed tomography (CT) and magnetic resonance imaging (MRI) revealed a well-circumscribed 4.3 cm round mass. The mass was initially diagnosed as nerve sheath tumor, because of her symptoms and its close location to the sympathetic trunk and intercostal nerve. It was uneventfully removed through video-assisted thoracoscopic surgery. The pathology revealed an angioleiomyoma.
Bolzoni, Francesco; Esposti, Roberto; Bruttini, Carlo; Zenoni, Giuseppe; Jankowska, Elzbieta; Cavallari, Paolo
Several studies demonstrated that transcutaneous direct current stimulation (DCS) may modulate central nervous system excitability. However, much less is known about how DC affects peripheral nerve fibres. We investigated the action of DCS on motor and sensory fibres of the human posterior tibial nerve, with supplementary analysis in acute experiments on rats. In forty human subjects, electric pulses at the popliteal fossa were used to elicit either M-waves or H-reflexes in the Soleus, before (15 min), during (10 min) and after (30 min) DCS. Cathodal or anodal current (2 mA) was applied to the same nerve. Cathodal DCS significantly increased the H-reflex amplitude; the post-polarization effect lasted up to ~ 25 min after the termination of DCS. Anodal DCS instead significantly decreased the reflex amplitude for up to ~ 5 min after DCS end. DCS effects on M-wave showed the same polarity dependence but with considerably shorter after-effects, which never exceeded 5 min. DCS changed the excitability of both motor and sensory fibres. These effects and especially the long-lasting modulation of the H-reflex suggest a possible rehabilitative application of DCS that could be applied either to compensate an altered peripheral excitability or to modulate the afferent transmission to spinal and supraspinal structures. In animal experiments, DCS was applied, under anaesthesia, to either the exposed peroneus nerve or its Dorsal Root, and its effects closely resembled those found in human subjects. They validate therefore the use of the animal models for future investigations on the DCS mechanisms. © 2017 Federation of European Neuroscience Societies and John Wiley & Sons Ltd.
Alagoz, Murat Sahin; Orbay, Hakan; Uysal, Ahmet Cagri; Comert, Ayhan; Tuccar, Eray
Utilization of the metatarsal bones and interosseous muscles in foot reconstruction should be based on the vascular anatomy of the metatarsal bones and interosseous muscles. We studied the vascular anatomy of the metatarsal bones and the interosseous muscles to design a split metacarpal musculoosseous flap and dorsal interosseous muscle flap. Twenty-two feet from eleven cadavers that had been embalmed in formalin were studied. Dissection was done using a dissection microscope (x3.5), delineating meticulously the arcuate artery, dorsal metatarsal arteries and the small branches arising from the metatarsal arteries. The dorsal metatarsal arteries do not course at the midline of the interosseous muscles. The first dorsal metatarsal artery proceeds close to the first metatarsal bone in the first metatarsal space. While proceeding to the distal, it shoots out a branch that individually feeds the lateral head of the first dorsal metatarsal muscle and medial face of the second metatarsus, thereby feeding muscle and bone. Except for this branch, the first dorsal metatarsal gives off segmental and periosteal branches that individually feed the medial heads of the first dorsal metatarsal muscle and first metatarsal bone. The second, third and fourth metatarsal arteries proceed close to the third, fourth and fifth metatarsal bones in the metatarsal spaces. In these courses, the arteries give out segmental branches to both faces of the interosseous muscles and periosteal branches to the medial face of metatarsal bones. For defects or disease of the ankle bones, the metatarsal bones can be split at the medial border distally, and a split metatarsal musculoosseous flap, based proximally on the dorsal metatarsal artery, can be done. Distal intermetatarsal anastomoses between the dorsal and plantar vascular networks enables a split metatarsal musculoosseous flap based distally, including the dorsal metatarsal artery for bony defects of the proximal phalanx.
Sato, Tatsuo; Koizumi, Masahiro; Kim, Ji Hyun; Kim, Jeong Hyun; Wang, Bao Jian; Murakami, Gen; Cho, Baik Hwan
Fetal development of human deep back muscles has not yet been fully described, possibly because of the difficulty in identifying muscle bundle directions in horizontal sections. Here, we prepared near-frontal sections along the thoracic back skin (eight fetuses) as well as horizontal sections (six fetuses) from 14 mid-term fetuses at 9–15 weeks of gestation. In the deep side of the trapezius and rhomboideus muscles, the CD34-positive thoracolumbar fascia was evident even at 9 weeks. Desmin-reactivity was strong and homogeneous in the superficial muscle fibers in contrast to the spotty expression in the deep fibers. Thus, in back muscles, formation of the myotendinous junction may start from the superficial muscles and advance to the deep muscles. The fact that developing intramuscular tendons were desmin-negative suggested little possibility of a secondary change from the muscle fibers to tendons. We found no prospective spinalis muscle or its tendinous connections with other muscles. Instead, abundant CD68-positive macrophages along the spinous process at 15 weeks suggested a change in muscle attachment, an event that may result in a later formation of the spinalis muscle. S100-positive intramuscular nerves exhibited downward courses from the multifidus longus muscle in the original segment to the rotatores brevis muscles in the inferiorly adjacent level. The medial cutaneous nerve had already reached the thoracolumbar fascia at 9 weeks, but by 15 weeks the nerve could not penetrate the trapezius muscle. Finally, we propose a folded myotomal model of the primitive transversospinalis muscle that seems to explain a fact that the roofing tile-like configuration of nerve twigs in the semispinalis muscle is reversed in the multifidus and rotatores muscles. PMID:21954879
Flores, Leandro Pretto
The prognosis for motor recovery associated with ulnar nerve injuries at a level proximal to the elbow is usually considered poor. Nerve transfers techniques were introduced as an alternative for the management of nerve lesions of the upper limb, aiming to improve the surgical results of those nerves for which direct reconstruction has not historically yielded good outcomes. A retrospective chart review was conducted to compare the outcomes obtained using nerve grafting (20 cases) with those of distal nerve transfer (15 patients) for the treatment of proximal injuries of the ulnar nerve. Nerve transfer combined the suture of the anterior interosseous nerve to the motor branch of the ulnar nerve and the cooptation of its sensory branch to the third common digital nerve via an end-to-side suture. The Medical Research Council M3/M4 outcomes were observed significantly more often in the nerve transfer group (80 vs. 22%), and the mean values for handgrip strength were higher (31.3 ± 5.8 vs. 14.5 ± 7.2 kg). The groups were similar in attaining good sensory recovery (40 vs. 30%) and mean two-point-discrimination (grafting: 11 ± 2 mm; nerve transfer: 9 ± 1 mm). The mean value of the disabilities of arm, shoulder, and hand for the nerve transfer group (23.6 ± 6.7) was significantly lower than for grafting (34.2 ± 8.3). Distal nerve transfer resulted in better motor and functional outcomes than nerve grafting. Both techniques resulted in similar sensory outcomes, and nerve grafting was demonstrated to be a better technique for managing the painful symptoms associated with the nerve injury. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
from surgically interrupted nerves . Posterior tibial /sural conduction block produced by this model as measured percutaneously persists for at least 14...R-F Burns, Contralateral ................. 20 Figure 1 Posterior Tibial Nerve Burned 24 Hours earlier (Pooled, N=6).. 21 Figure 2 Pooled posterior... tibial nerves (N=6) separated with hiqh pressure liquid chromatography ninety-six hours after burn injury
Deffontaines, Jean-Baptiste; Lussier, Bertrand; Bolliger, Christian; Bédard, Agathe; Doré, Monique; Blevins, William E.
A 10-year-old golden retriever dog was presented for chronic right forelimb lameness associated with a painful swelling at the lateral aspect of the proximal ulna. Proximal ulnar ostectomy and stabilization resulted in a good clinical outcome. The proposed diagnosis is chronic desmitis and enthesiophytosis of the radio-ulnar interosseous ligament. PMID:27152034
Yonemura, Hiroshi; Kaneko, Kazuo; Taguchi, Toshihiko; Fujimoto, Hideaki; Toyoda, Kouichiro; Kawai, Shinya
To investigate the nerve root distribution of deltoid and biceps brachii muscle, compound muscle action potentials (CMAPs) were recorded intraoperatively following nerve root stimulation in cervical spondylotic myelopathy. A total of 19 upper limbs in 12 patients aged 55-72 years (mean, 65.5 years) with cervical spondylotic myelopathy were examined. CMAPs were recorded from deltoid and biceps brachii muscle following C5 and C6 root stimulation. Although both C5 and C6 roots were innervated for deltoid and biceps brachii muscle in all subjects, the amplitude ratio of CMAPs (C5/C6) differed individually depending on the symptomatic intervertebral levels of the spinal cord. The C5 root predominantly innervated both deltoid and biceps brachii in patients with symptomatic cord lesions at the C4-C5 intervertebral level compared to patients with symptomatic cord lesions at the C5-C6 intervertebral level. Although no patients sustained postoperative radiculopathy in our study, severe weakness and unfavorable recovery are expected when the C5 root in patients with C4-C5 myelopathy is damaged. From the electrophysiological aspect, C4-C5 cord lesions are likely to be a potential risk factor for postoperative shoulder muscle weakness in patients with compressive cervical myelopathy.
Angrigiani, Claudio; Artero, Guillermo; Neligan, Peter C; Escudero, Ezequiel; Sereday, Carlos; Khouri, Roger K
Antegrade peroneal flaps can be rotated around the fibula to cover defects in the lower leg and lateral knee. However, these flaps cannot reliably cover the distal femur and anterior and medial knee. In the present article, the authors describe a novel technical modification that involves creating a tunnel through the interosseous membrane, through which the flap can be passed, circumventing the need to rotate around the fibula, allowing it to reach the entire knee and distal femur. An anatomical study was performed in five cadaveric specimens to measure the gain in pedicle reaching distance when the flap is tunneled compared to transferred around the fibula. A clinical study in 12 patients was also performed to measure the gain in pedicle reaching distance and the long-term viability of the tunneled interosseous flap. In the anatomical study, the mean reaching distance was 7.4 ± 0.9 cm for the flaps rotated around the fibula and 17.0 ± 1.6 for the tunneled interosseous flaps (p < 0.001). In the clinical study, the mean reaching distance was 2.6 ± 1.4 cm for the flaps rotated around the fibula and 11.4 ± 2.4 for the tunneled interosseous flaps (p < 0.0000000001). Patients were followed for up to 4 years (mean, 2.5 years). All flaps survived completely, and there were no complications. By passing the antegrade peroneal flap through the interosseous membrane, instead of around the fibula, the flap reaching distance can be increased by approximately 8 cm, allowing for effective coverage of distal femur and knee defects. Therapeutic, IV.
Martín-Oliva, X; Elgueta-Grillo, J; Veliz-Ayta, P; Orosco-Villaseñor, S; Elgueta-Grillo, M; Viladot-Perice, R
The tarsal tunnel is composed of the posterior border of the medial malleoulus, the posterior aspect of the talus and the medial aspect of the calcaneus. The medial calcaneal nerve emerges from the posterior aspect of the posterior tibial nerve in 75% of cases and from the lateral plantar nerve in the remaining 25%. Finally, the medial calcaneal nerve ends as a single terminal branch in 79% of cases and in numerous terminal branches in the remaining 21%. To describe the anatomical variants of the posterior tibial nerve and its terminal branches. To describe the steps for tarsal tunnel release. To describe Baxter nerve release. The anatomical variants of the posterior tibial nerve and its terminal branches within the tarsal tunnel were studied. Then the Lam technique was performed; it consists of: 1) opening of the laciniate ligament, 2) opening of the fascia over the abductor hallucis muscle, 3) exoneurolysis of the posterior tibial nerve and its terminal branches, identifying the emergence and pathway of the medial calcaneal branch, the lateral plantar nerve and its Baxter nerve branch and the medial plantar nerve. Baxter nerve was found in 100% of cases. In 100% of cases in our series the nerve going to the abductor digiti minimi muscle of the foot was found; 87.5% of cases had two terminal branches. The dissections proved that a crucial step was the release of the distal tarsal tunnel.
Job, Joici; Branstetter, Barton F
The posterior skull base can be involved by a variety of pathologic processes. They can be broadly classified as: traumatic, neoplastic, vascular, and inflammatory. Pathology in the posterior skull base usually involves the lower cranial nerves, either as a source of pathology or a secondary source of symptoms. This review will categorize pathology arising in the posterior skull base and describe how it affects the skull base itself and surrounding structures. Copyright Â© 2016 Elsevier Inc. All rights reserved.
Andro, C; Richou, J; Schiele, P; Hu, W; Le Nen, D
Recurrent ulnar nonunion challenges the functional prognosis and raises major problems concerning the best therapeutic strategy to follow. The case of a female patient presenting recurrent nonunion of the ulnar diaphysis despite successive treatments is reported. The radius graft pedicled on the anterior interosseous artery from a retrograde approach obtained bone union in 3 months with no functional sequelae. For the first time, we propose a therapeutic alternative calling on a proximally pedicled anterior interosseous flap. This technique can be performed under locoregional anesthesia and does not sacrifice the main artery of the forearm. However, the size of the graft does not entirely compensate for segmentary bone loss. The radius graft pedicled on the anterior interosseus artery is an inventive technique that can solve the problem of difficult ulna nonunions without the disadvantages of vascularized fibula harvesting.
Schneider, D; Hirsch, M
Acute calcific tendinopathy is one of the manifestations of hydroxyapatite crystal deposition disease. While it is more frequent in the shoulder, it has been described in virtually all areas of the body, but rarely in the muscles of the hand. Its etiopathogenesis is not yet fully understood and despite being a fairly frequent condition, it is commonly misdiagnosed. The onset of the disease is usually acute and resolves spontaneously. Acute calcific tendinitis of the interosseous tendons of the hand is an uncommon site of a frequent condition. The clinical presentation is similar to other entities, thus errors in diagnosis frequently occur, resulting in over-treatment or unnecessary tests. We describe a case of acute calcific tendinitis of the interosseous muscles of the hand with a brief review of the current literature with emphasis on diagnostic imaging methods.
Sander, H W; Quinto, C; Chokroverty, S
Median-ulnar anastomosis (Martin-Gruber anastomosis; MGA) is traditionally diagnosed based upon changes in compound muscle action potential (CMAP) amplitude following proximal stimulation. We describe a rare patient with a MGA innervating thenar, hypothenar, and first dorsal interosseous muscles. Proximal stimulation, however, evoked CMAPs with striking changes in morphology and area but only minimal amplitude changes, due to concomitant diagnoses of carpal tunnel syndrome and polyneuropathy. Collision studies were therefore required for diagnostic confirmation of the MGA.
Parhizkar, Nooshin; Hiltzik, David H; Selesnick, Samuel H
Facial nerve rerouting techniques were developed to facilitate re-section of extensive tumors occupying the skull base. Facial nerve rerouting has its own limitations and risks, requiring microsurgical expertise, additional surgical time, and often some degree of facial nerve paresis. This article presents different degrees of anterior and posterior facial nerve rerouting, techniques of facial nerve rerouting, and a comprehensive review of outcomes. It then reviews anatomic and functional preservation of the facial nerve in acoustic neuroma resection, technical aspects of facial nerve dissection, intracranial facial nerve repair options, and outcomes for successful acoustic neuroma surgery.
Morrison, Peter E; Hill, Robert V
Although anatomists generally agree upon the presence of four interosseous muscles in the human hand, the number and identity of the palmar interosseous muscles remains contentious. Recent studies suggest that a majority of human hands possess four palmar interossei, yet most contemporary texts suggest the presence of only three. The pollical palmar interosseous muscle (PPIM), associated with the first digit, has been alternatively interpreted as a distinct muscle, part of another hand muscle, or nonexistent. We examined 45 hands from 23 human cadavers to investigate the prevalence of this muscle and found it to occur in varying degrees of expression in 91% of specimens. We also tested the hypothesis that the PPIM forms the smaller part of a "parallel muscle combination" and is therefore ideally suited to act as a proprioceptive organ. Results do not show a significantly higher density of muscle spindles in the PPIM relative to the adjacent adductor pollicis, provisionally refuting this hypothesis. The presence of the PPIM, observed in the majority of hands from several populations, indicates that it should be regularly included in mainstream anatomy texts and atlases. Copyright © 2011 Wiley Periodicals, Inc.
Pajaczkowski, Jason A
Objective: To present the diagnostic features and response to treatment of an unreported clinical entity, first dorsal interosseous myofasopathy mimicking turf-toe. Clinical features: The salient features include an insidious onset of pain in the first MTP joint which compromises forceful propulsion in the absence of ecchymosis and joint effusion. Range of motion may be restricted in both instances, however muscular palpation and resisted manual muscle testing will reproduce the patient's complaints and isolate the first dorsal interosseous muscle as the culprit versus the fibrous plantar plate and joint capsule. Intervention and outcome: Treatment involves eliminating inflammation, reducing muscular hypertonicity, and restricting the offending activity. Active Release Technique® was utilized to remove adhesions and promote the restoration of normal tissue texture with excellent results. No other soft tissue treatment methods were implemented. Alternatively, other soft tissue techniques or modalities aimed at reducing inflammation and pain (i.e. ice, IFC, gentle stretching, etc. ...) may be useful. Conclusion: Although the etiology and epidemiology of first dorsal interosseous myofasopathy mimicking turf-toe has yet to be elucidated the clinical implications regarding misdiagnosis and treatment are extremely important to allopathic and chiropractic practitioners alike.
Zhang, Cheng-Gang; Dong, Zhen; Gu, Yu-Dong
Brachial plexus palsies of C7-T1 result in the complete loss of hand function, including finger and thumb flexion and extension as well as intrinsic muscle function. The task of reanimating such a hand remains challenging, and so far there has been no reliable neurological reconstructive method for restoring hand function. The authors aimed to establish a reliable strategy to reanimate the paralyzed hand. Two patients had sustained C7-T1 complete lesions. In the first stage of the operative procedure, a supinator motor branch to posterior interosseous nerve transfer was performed with brachialis motor branch transfer to the median nerve to restore finger and thumb extension and flexion. In the second stage, the intact brachioradialis muscle was used for abductorplasty to restore thumb opposition. Both patients regained good finger extension and flexion. Thumb opposition was also attained, and overall hand function was satisfactory. The described strategy proved effective and reliable in restoring hand function after C7-T1 brachial plexus palsies.
Benson, W E
Posterior scleritis must be considered in the differential diagnosis of many ocular conditions, including angle closure glaucoma, choroidal folds, optic disk edema, circumscribed fundus mass, choroidal detachment, and exudative retinal detachment. Because it is rare, a high index of suspicion is necessary. Anterior scleritis, pain, or a history of collagen-vascular disease, when present, help to alert the clinician to the correct diagnosis. Posterior scleritis affects women more often than men, but annular ciliochoroidal effusion and choroidal folds are more common in men. Exudative macular detachment and a circumscribed fundus mass are more common in women. This paper reviews the world literature on posterior scleritis and describes findings in a series of 43 patients seen at Wills Eye Hospital. It stresses the clinical features and ancillary diagnostic tests that help to establish the diagnosis.
Puzzilli, F.; Mastronardi, L.; Agrillo, U.; Nardi, P.
Complete resection with conservation of cranial nerves is the primary goal of contemporary surgery for lower cranial nerve tumors. We describe the case of a patient with a schwannoma of the left glossopharyngeal nerve, operated on in our Neurosurgical Unit. The far lateral approach combined with laminectomy of the posterior arch of C1 was done in two steps. The procedure allowed total tumor resection and was found to be better than classic unilateral suboccipital or combined supra- and infratentorial approaches. The advantages and disadvantages of the far lateral transcondylar approach, compared to the other more common approaches, are discussed. ImagesFigure 1Figure 2 PMID:17171083
Swallowing therapy--a prospective study on patients with neurogenic dysphagia due to unilateral paresis of the vagal nerve, Avellis' syndrome, Wallenberg's syndrome, posterior fossa tumours and cerebellar hemorrhage.
Prosiegel, M; Höling, R; Heintze, M; Wagner-Sonntag, E; Wiseman, K
No studies exist dealing with the outcome of dysphagic patients with posterior fossa (IV. ventricle) tumours (PFT) or cerebellar hemorrhage (CH), and the outcome of patients with Wallenberg's syndrome (WS) after functional swallowing therapy (FST) has so far not been studied in detail. Patients and methods. 208 patients with neurogenic dysphagia (ND) who were consecutively admitted for functional swallowing therapy (FST) over a 3 year period to our hospital were examined clinically, by use of a videofluoroscopic swallowing study (VFSS) and/or fibreoptic evaluation of swallowing (FEES). The most frequent etiology was stroke (48%), followed by CNS tumours (13%). In the present study we defined three groups. Group 1 comprised 8 patients with PFT or CH. Group 2 consisted of 27 patients with WS, which was the leading cause among patients with non-hemispheric stroke. Since in WS a vagal nerve paresis due to affection of the Nucleus ambiguus occurs, 8 patients with Avellis' syndrome or unilateral paresis of the vagal nerve served as controls and were defined as group 3. Findings. In the three groups, functional feeding status showed significant improvement after FST comprising methods of restitution, compensation and adaptation, each of which were applied in more than 80% of patients. Outcome was, however, significantly worse in group 1 as compared to group 2 and in group 2 as compared to group 3. Dysfunction of the upper esophageal sphincter and reflex triggering were significantly more severely disturbed in groups 1 and 2 as compared to group 3. Group 1 showed significantly more severe disturbances of the oral phase as compared to groups 2 and 3. After FST, more than 50% (5/8) of group 1 and 30% (8/27) of WS patients (group 2) were dependent on tube feeding, whereas all patients of group 3 were full-oral feeders. Interpretation. This is the first study dealing with the outcome of dysphagic patients with PFT or CH. Based on our results it can be assumed that in these
Squintani, Giovanna; Mezzina, Corrado; Lettieri, Christian; Critelli, Adriana; Eleopra, Roberto
We report an unusual case of Parsonage-Turner syndrome with relapses and simultaneous bilateral anterior interosseous neuropathy (AIN). A 66-year-old man, after a typical right brachial amyotrophic neuralgia few months previously, underwent surgery for left carpal tunnel syndrome. The day following surgery, wrist aching and bilateral weakness, even if prevalent on the right side, on thumb and index finger flexion appeared. Neurophysiology was consistent with bilateral AIN neuropathy and serology revealed anti-nucleus antibody positivity. Association of relapses with bilateral acute AIN involvement in the subject with autoantibody detection can suggest an immunological pathogenesis.
Joiner, Elizabeth R A; Skaggs, David L; Arkader, Alexandre; Andras, Lindsay M; Lightdale-Miric, Nina R; Pace, J Lee; Ryan, Deirdre D
Recent studies report the rate of iatrogenic nerve injury in operatively treated supracondylar humerus (SCH) fractures is 3% to 4%. A reliable neurological examination can be difficult to obtain in a young child in pain. We hypothesized that nerve injuries may be missed preoperatively, later noted postoperatively in a more compliant patient, and then falsely considered an iatrogenic injury. A prospective study was conducted on patients who presented between April 2011 and April 2013 with an extension-type SCH fracture that was managed surgically. A neurological examination was performed preoperatively, postoperatively, and at follow-up visits by a fellowship-trained attending pediatric orthopaedic surgeon. Only patients in whom the attending surgeon felt a reliable neurovascular examination was obtained were included in this study. Of the 100 patients, 16% had a nerve injury recognized on preoperative examination and 3% had a new nerve injury on postoperative examination (1 anterior interosseous, 1 median sensory, and 1 radial motor). The Gartland type (P=0.421), type of reduction (open vs. closed; P=0.720), and number of lateral-entry (P=0.898) or medial-entry (P=0.938) pins used were not associated with patients who had a new nerve injury found postoperatively. A trend was seen between fracture severity and rate of a preoperative nerve injury: type II 7% (2/28), type III 19% (9/58), and type IV 36% (5/14) (P=0.058). Preoperatively, nerve injuries were noted at the following rates: median 12% (12/100) (including 8 anterior interosseous nerve injuries), radial 8% (8/100), ulnar 3% (3/100). In this prospective study, in patients who were able to comply with a preoperative neurological examination done by an attending pediatric orthopaedic surgeon, the rate of iatrogenic nerve injury after operative treatment of SCH fractures is 3%. We conclude that this finding is true, and not a result of inadequate preoperative neurological examinations. Level I prognostic study.
Jepsen, Jorgen R; Thomsen, Gert
Background In a previous study of computer operators we have demonstrated the relation of upper limb pain to individual and patterns of neurological findings (reduced function of muscles, sensory deviations from normal and mechanical allodynia of nerve trunks). The identified patterns were in accordance with neural afflictions at three specific locations (brachial plexus at chord level, posterior interosseous and median nerve on elbow level). We have introduced an intervention program aiming to mobilize nerves at these locations and tested its efficacy. Methods 125 and 59, respectively, computer operators in two divisions of an engineering consultancy company were invited to answer a questionnaire on upper limb symptoms and to undergo a blinded neurological examination. Participants in one division were subsequently instructed to participate in an upper limb stretching course at least three times during workdays in a six month period. Subjects from the other division served as controls. At the end of the intervention both groups were invited to a second identical evaluation by questionnaire and physical examination. Symptoms and findings were studied in the right upper limb. Perceived changes of pain were recorded and individual and patterns of physical findings assessed for both groups at baseline and at follow-up. In subjects with no or minimal preceding pain we additionally studied the relation of incident pain to the summarized findings for parameters contained in the definition of nerve affliction at the three locations. Results Summarized pain was significantly reduced in the intervention group but unchanged in controls. After the intervention, fewer neurological abnormalities in accordance with nerve affliction were recorded for the whole material but no conclusion could be drawn regarding the relation to the intervention of this reduction. Incident pain correlated to findings in accordance with the three locations of nerve affliction. Conclusion A six month
Ayad, Micheal; Whisenhunt, Anumeha; Hong, EnYaw; Heller, Josh; Salvatore, Dawn; Abai, Babak; DiMuzio, Paul J
Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve within the tarsal tunnel. Its etiology varies, including space occupying lesions, trauma, inflammation, anatomic deformity, iatrogenic injury, and idiopathic and systemic causes. Herein, we describe a 46-year-old man who presented with left foot pain. Work up revealed a venous aneurysm impinging on the posterior tibial nerve. Following resection of the aneurysm and lysis of the nerve, his symptoms were alleviated. Review of the literature reveals an association between venous disease and tarsal tunnel syndrome; however, this report represents the first case of venous aneurysm causing symptomatic compression of the nerve.
Saleh, Essam A.; Taibah, Abdel Kader; Achilli, Vittorio; Aristegui, Miguel; Mazzoni, Antonio; Sanna, Mario
Posterior fossa meningioma is the second most common tumor in the cerebellopontine angle. It has a higher rate of postoperative morbidity and mortality compared to acoustic neuroma. Forty posterior fossa meningioma patients managed in our centers were reviewed. Thirty-nine patients were managed surgically with 42 surgical procedures. The approaches used were the translabyrinthine approach in 18 patients (43%), the modified transcochlear in 11 cases (26%), the petro-occipital transsigmoid in 5 cases (12%), the suboccipital in 4 cases (10%), the petro-occipital trassigmoid transcervical in 2 cases (5%), the petro-occipital transsigmoid transtentorial in 1 case (2%), and a subtemporal transtentorial for another case (2%). Facial nerve anatomical integrity was preserved in 87% of procedures but was interrupted in 5 cases, with 4 of the latter subsequently repaired. Total tumor removal was accomplished in 38 cases. A second-stage total tumor removal is planned for the remaining case. There was only one case of perioperative death and no cases of radiological recurrence so far. ImagesFigure 1Figure 2Figure 3Figure 4p206-bFigure 5p207-bFigure 5 PMID:17171173
Skelly-Smith, E; Ireland, J; Dyson, S
There have been no detailed descriptions of the radiological appearance of the centrodistal joint interosseous ligament region in horses with and without distal tarsal joint pain. To describe the normal radiological appearance of the centrodistal joint interosseous ligament region; to determine the prevalence of mineralisation or ossification of the interosseous ligament; and to describe radiological abnormalities surrounding the interosseous space and concurrent radiological abnormalities in the tarsus. The association between interosseous ligament region abnormalities and radiological evidence of osteoarthritis of the centrodistal joint was assessed. Retrospective study. Case records and radiographs of all horses/ponies (n = 700) that underwent radiographic examination of one/both tarsi over 7 years were reviewed. Case history, height, bodyweight and cause(s) of lameness were recorded. Factors associated with abnormalities of the centrodistal interosseous ligament region were assessed using logistic regression analysis. The normal interosseous space was an oval or circular-shaped radiolucent area bordered proximally and distally by a rim of bone of uniform opacity and thickness, which varied in thickness among animals. Abnormalities of the interosseous ligament region of the lame(r) limb were evident in 121/700 (17.3%; 95% confidence interval 14.5-20.1%) animals. Increasing bodyweight was associated with decreased odds of interosseous ligament region abnormalities. Forty-seven animals (6.7%; 95% confidence interval 4.9-8.6%) had radiological evidence of osteoarthritis of the centrodistal joint. A greater proportion of animals with interosseous ligament region abnormalities (36.4%) had radiological evidence of osteoarthritis of the centrodistal joint, compared to those with normal interosseous ligament regions (0.5%; P<0.001). Interosseous ligament region abnormalities and osteoarthritis of the centrodistal joint were not necessarily associated with distal
Carro, Luis Perez; Golanó, Pau; Vega, Jordi
Arthroscopic subtalar arthrodesis, as reported by Tasto, is done in the lateral decubitus position, and the portal sites are lateral. This report describes a new alternative method in which the patient is in the prone position and a posterior 2-portal approach is used, as described by van Dijk et al. The initial debridement and synovectomy are performed with 4- and 5-mm resectors. Debridement and decortication are done posterior to the interosseous ligament because only the posterior facet is fused. Denudation of the articular surfaces is performed with curettes, as well as 4.5- and 5.5-mm burs, to remove 2 mm of subchondral bone. Stabilization in 5 degrees of hindfoot valgus is accomplished with 2 percutaneous cannulated headless screws from the non-weight-bearing portion of the calcaneal tuberosity directed to a point 5 to 10 mm posterior to the anterior margin of the posterior facet. The advantages of this alternative treatment are better intra-articular visualization, more thorough preparation of the fusion site, and minimal bone removal of the lateral side with better control of the arthrodesis position and with less chance of malunion, as well as the possibility to perform a concomitant surgical fusion or debridement of the ankle joint during the same operative procedure with no need for additional portals or orientation.
Olarte, M; Adams, D
After apparently uncomplicated excision of benign lesions in the posterior cervical triangle, two patients had shoulder pain. In one, neck pain and trapezius weakness were not prominent until one month after surgery. Inability to elevate the arm above the horizontal without externally rotating it, and prominent scapular displacement on arm abduction, but not on forward pushing movements, highlighted the trapezius dysfunction and differentiated it from serratus anterior weakness. Spinal accessory nerve lesions should be considered when minor surgical procedures, lymphadenitis, minor trauma, or tumours involved the posterior triangle of the neck.
In a study of 42 tetraplegic patients, physiological, neurological, electrophysiological and radiological examinations were made in 11 patients with complete tetraplegia who had wrist pain after rehabilitation. Pain relief produced by a selective, posterior interosseous nerve lidocaine block indicated distal posterior interosseous nerve syndrome. This syndrome can sometimes be treated conservatively, but surgical excision was required after nerve scarification. Repetitive dorsiflexion, as in wheelchair handling, transfer and tenodesis-like movement, compresses the distal posterior interosseous nerve in some tetraplegic patients. Moreover, weakness of the wrist joint stabilizing muscles is likely to contribute to an increased weight load on the wrist joints. The aetiology of wrist pain in tetraplegia should be considered when there is carpal tunnel syndrome, Wartenberg syndrome, Kienböck syndrome or distal posterior interosseous nerve syndrome. The causes need to be adequately treated to reduce the negative impact of the resultant pain on carrying out the activities of daily life.
Riggenbach, Michael D; Wright, Thomas W; Dell, Paul C
The distal radioulnar ligament reconstruction is a technique that may be used for distal radioulnar joint instability without arthritis and failed nonsurgical management; clinical results demonstrate resolved or improved stability. Recent literature has focused on the distal oblique bundle of the interosseous membrane and its contributions to stability. This article describes a technically simple surgical technique to reconstruct the distal oblique bundle and restore distal radioulnar joint stability.
Giannini, Sandro; Buda, Roberto; Mosca, Massimiliano; Parma, Alessandro; Di Caprio, Francesco
Posterior ankle impingement is a common cause of chronic ankle pain and results from compression of bony or soft tissue structures during ankle plantar flexion. Bony impingement is most commonly related to an os trigonum or prominent trigonal process. Posteromedial soft tissue impingement generally arises from an inversion injury, with compression of the posterior tibiotalar ligament between the medial malleolus and talus. Posterolateral soft tissue impingement is caused by an accessory ligament, the posterior intermalleolar ligament, which spans the posterior ankle between the posterior tibiofibular and posterior talofibular ligaments. Finally, anomalous muscles have also been described as a cause of posterior impingement.
O'Rourke, M G; Tang, T S; Allison, S I; Wood, W
In the past decade surgeons have become increasingly aware of the morbidity caused by the division of the intercostobrachial nerve (ICBN) during axillary dissection. To prevent this problem and also to explain its variable occurrence, a detailed knowledge of the anatomy of the nerve is required. Twenty-eight axillary dissections were performed demonstrating the anatomy of the ICBN. In all dissections the nerve originated from the second intercostal space, with contributions from the first and third intercostal nerve each on one occasion. The posterior axillary branch was constant but may branch early, simulating a second nerve. The ICBN had a variable relationship to the lateral thoracic vein: anterior, posterior or wrapping around it. In 36% there was a connection to the medial cord of the brachial plexus in the axilla. In the upper arm the nerve lies in the subcutaneous fat; in the majority it supplied at least the proximal half of the arm, and in one-third it reached the level of the elbow joint. In 18% there was a connection to the medial cutaneous nerve of the arm. The ICBN and its main branch (the posterior axillary nerve) were constant in all dissections. But its origin, size, connection to the brachial plexus and medial cutaneous nerve of the arm were variable, as was its ultimate destination in the arm.
Milz, S; Aktas, T; Putz, R; Benjamin, M
The scapholunate interosseous ligament (SLIL) connects the scaphoid and lunate bones and plays a crucial role in carpal kinematics. Its rupture leads to carpal instability and impairment of radiocarpal joint function. As the ligament is one of the first structures affected in rheumatoid arthritis, we conducted an immunohistochemical study of cadaveric tissue to determine whether it contains known autoantigens for rheumatoid arthritis. We immunolabelled the ligament from one hand in 12 cadavers with monoclonal antibodies directed against a wide range of extracellular matrix (ECM) molecules associated with both fibrous and cartilaginous tissues. The labelling profile has also enabled us to comment on how the molecular composition of the ligament relates to its mechanical function. All regions of the ligament labelled for types I, III and VI collagens, chondroitin 4 and 6 sulphates, keratan sulphate, dermatan sulphate, versican, tenascin and cartilage oligomeric matrix protein (COMP). However, both entheses labelled strongly for type II collagen, aggrecan and link protein and were distinctly fibrocartilaginous. In some regions, the ligament attached to bone via a region of hyaline cartilage that was continuous with articular cartilage. Labelling for cartilage molecules in the midsubstance was most evident dorsally. We conclude that the SLIL has an ECM which is typical of other highly fibrocartilaginous ligaments that experience both tensile load and shear. The presence of aggrecan, link protein, COMP and type II collagen could explain why the ligament may be a target for autoantigenic destruction in some forms of rheumatoid arthritis. PMID:16761970
Yao, Wei; Ding, Guang-Hong
In vitro experiments have shown that subtle fluid flow environment plays a significant role in living biological tissues, while there is no in vivo practical dynamical measurement of the interstitial fluid flow velocity. On the basis of a new finding that capillaries and collagen fibrils in the interosseous membrane form a parallel array, we set up a porous media model simulating the flow field with FLUENT software, studied the shear stress on interstitial cells' surface due to the interstitial fluid flow, and analyzed the effect of flow on protein space distribution around the cells. The numerical simulation results show that the parallel nature of capillaries could lead to directional interstitial fluid flow in the direction of capillaries. Interstitial fluid flow would induce shear stress on the membrane of interstitial cells, up to 30 Pa or so, which reaches or exceeds the threshold values of cells' biological response observed in vitro. Interstitial fluid flow would induce nonuniform spacial distribution of secretion protein of mast cells. Shear tress on cells could be affected by capillary parameters such as the distance between the adjacent capillaries, blood pressure and the permeability coefficient of capillary's wall. The interstitial pressure and the interstitial porosity could also affect the shear stress on cells. In conclusion, numerical simulation provides an effective way for in vivo dynamic interstitial velocity research, helps to set up the vivid subtle interstitial flow environment of cells, and is beneficial to understanding the physiological functions of interstitial fluid flow.
Milz, S; Aktas, T; Putz, R; Benjamin, M
The scapholunate interosseous ligament (SLIL) connects the scaphoid and lunate bones and plays a crucial role in carpal kinematics. Its rupture leads to carpal instability and impairment of radiocarpal joint function. As the ligament is one of the first structures affected in rheumatoid arthritis, we conducted an immunohistochemical study of cadaveric tissue to determine whether it contains known autoantigens for rheumatoid arthritis. We immunolabelled the ligament from one hand in 12 cadavers with monoclonal antibodies directed against a wide range of extracellular matrix (ECM) molecules associated with both fibrous and cartilaginous tissues. The labelling profile has also enabled us to comment on how the molecular composition of the ligament relates to its mechanical function. All regions of the ligament labelled for types I, III and VI collagens, chondroitin 4 and 6 sulphates, keratan sulphate, dermatan sulphate, versican, tenascin and cartilage oligomeric matrix protein (COMP). However, both entheses labelled strongly for type II collagen, aggrecan and link protein and were distinctly fibrocartilaginous. In some regions, the ligament attached to bone via a region of hyaline cartilage that was continuous with articular cartilage. Labelling for cartilage molecules in the midsubstance was most evident dorsally. We conclude that the SLIL has an ECM which is typical of other highly fibrocartilaginous ligaments that experience both tensile load and shear. The presence of aggrecan, link protein, COMP and type II collagen could explain why the ligament may be a target for autoantigenic destruction in some forms of rheumatoid arthritis.
Zhou, Ping; Li, Xiaoyan; Rymer, William Zev
Motor unit number index (MUNIX) is a recently developed novel neurophysiological technique providing an index proportional to the number of motor units in a muscle. The MUNIX is derived from maximum M wave and voluntary surface electromyogram (EMG) recordings. The objective of this study was to address a practical question for computing MUNIX in the first dorsal interosseous (FDI), a multifunctional muscle that generates torque about the second metacarpophalangeal joint, i.e., how will different lines of muscle activation influence its MUNIX estimates? To address this question, the MUNIX technique was applied in the FDI muscle of 15 neurologically intact subjects, using surface EMG signals from index finger abduction and flexion, respectively, while the maximum M wave remained the same. Across all subjects, the average MUNIX value of the FDI muscle was 228 ± 45 for index finger abduction, slightly smaller than the MUNIX estimate of 251 ± 56 for index finger flexion. Different FDI muscle activation patterns resulted in an approximately 10% difference in MUNIX estimates. The findings from this study suggest that appropriate definition of voluntary activation of the FDI muscle should be kept to ensure consistency in measurements and avoid source of error. The current study is limited by only assessing neurologically intact muscles. It is important to perform a similar analysis for patients with amyotrophic lateral sclerosis (ALS), given that ALS is the primary intention of the MUNIX method as a potential follow-up measurement for motor unit loss.
Suresh, Nina; Kuo, Art; Heckman, C J; Rymer, William Zev
Earlier studies in multifunctional muscles such as the first dorsal interosseous (FDI) have demonstrated that the selection and control of motor units (MUs) can vary as a function of generated force direction. While directionally dependent motor unit recruitment and rate properties imply that there may also be differential mechanical action, this has yet to be directly demonstrated. Our objective was to determine whether there exists a range of force vectors from different motor units in the FDI muscle within individual subjects. We utilized the spike-triggered averaging (STA) method to derive force twitch estimates from single motor units. We derived MU twitch direction from the ratio of individual twitch estimates recorded concurrently from the load cell. Fifteen units from 2 subjects were used to determine MU force vectors. We were able to estimate force twitch vectors from 7-8 different MUs in each subject. The results of our study suggest that there is varied mechanical action of motor units in the FDI. It is thus possible that differential activation of individual MUs in the FDI is a function of varied mechanical action.
Zhang, Yun; Chen, Weijie; Xu, Yanping; Liu, Hang; Chen, Yunlin; Yang, Hanxuan; Yin, Yuehui
Sympathetic activation plays an important pathophysiological role in the progression of pulmonary artery hypertension. Although adrenergic vasomotor fibers are present in the adventitia of pulmonary arteries, the anatomy of the peri-arterial pulmonary nerves is still poorly understood. The aim of the current study was to determine the sympathetic nerve distribution in canine pulmonary arteries. A total of 2160 sympathetic nerves were identified in six Chinese Kunming canines. Nerve counts were greatest in the proximal segment, with a slight decrease in the distal segment; the middle segment showed the least number of nerves. In the left and right pulmonary arteries, 77.61% and 78.97% of the nerves were located within a 1-3-mm range, respectively. The number of nerves in the posterior region of the bifurcation and pulmonary trunk outnumbered those in the anterior region. Furthermore, 65.33% of the nerves were located in the first 2-mm range of the posterior region of bifurcation, and 89.62% of the nerves were located within the 1-3-mm range of the posterior region of the pulmonary trunk. In conclusion, a great abundance of sympathetic nerves occurred in the proximal and distal segments of the bilateral pulmonary arteries. There is a clear predominance of sympathetic nerve distribution in the posterior region of the bifurcation and pulmonary trunk. This anatomic distribution may have implications for the future development of percutaneous pulmonary artery denervation. PMID:27158332
Liu, Quan; Chen, Dongmei; Wang, Yonggang; Zhao, Xin; Zheng, Yang
OBJECTIVE: To analyze the distribution characteristics of cardiac autonomic nerves and to explore the correlation between cardiac autonomic nerve distribution and arrhythmia. DATA RETRIEVAL: A computer-based retrieval was performed for papers examining the distribution of cardiac autonomic nerves, using heart, autonomic nerve, sympathetic nerve, vagus nerve, nerve distribution, rhythm and atrial fibrillation as the key words. SELECTION CRITERIA: A total of 165 studies examining the distribution of cardiac autonomic nerve were screened, and 46 of them were eventually included. MAIN OUTCOME MEASURES: The distribution and characteristics of cardiac autonomic nerves were observed, and immunohistochemical staining was applied to determine the levels of tyrosine hydroxylase and acetylcholine transferase (main markers of cardiac autonomic nerve distribution). In addition, the correlation between cardiac autonomic nerve distribution and cardiac arrhythmia was investigated. RESULTS: Cardiac autonomic nerves were reported to exhibit a disordered distribution in different sites, mainly at the surface of the cardiac atrium and pulmonary vein, forming a ganglia plexus. The distribution of the pulmonary vein autonomic nerve was prominent at the proximal end rather than the distal end, at the upper left rather than the lower right, at the epicardial membrane rather than the endocardial membrane, at the left atrium rather than the right atrium, and at the posterior wall rather than the anterior wall. The main markers used for cardiac autonomic nerves were tyrosine hydroxylase and acetylcholine transferase. Protein gene product 9.5 was used to label the immunoreactive nerve distribution, and the distribution density of autonomic nerves was determined using a computer-aided morphometric analysis system. CONCLUSION: The uneven distribution of the cardiac autonomic nerves is the leading cause of the occurrence of arrhythmia, and the cardiac autonomic nerves play an important role in
Zhang, Yi; Liu, Hao; Liu, En-Zhong; Lin, You-Zhi; Zhao, Shi-Guang; Jing, Guo-Hua
This study was designed to provide anatomic data to help surgeons avoid damage to the ocular motor nerves during intraorbital operations. The microsurgical anatomy of the ocular motor nerves was studied in 50 adult cadaveric heads (100 orbits). Dissections were performed with a microscope. The nerves were exposed and the neural and muscular relationships of each portion of the nerve were examined and measured. The superior division of the oculomotor nerve coursed between the optic nerve and the superior rectus muscle after it left the annular tendon, and its branches entered into the superior rectus muscle and levator muscle. A mean of five fibers (range 3-7) innervated the superior rectus muscle, and a mean of one fiber (range 1-2) followed a medial direction (84%) or went straight through the superior rectus muscle (16%). The inferior division of the oculomotor nerve branched into the medial rectus, inferior rectus and inferior oblique muscles. The trochlear nerve ended on the orbital side of the posterior one-third of the superior oblique muscle in 76 specimens. The abducens nerve ended on the posterior one-third of the lateral rectus muscle in 86 specimens. If the belly of the lateral rectus muscle was divided into three superior-inferior parts, the nerve commonly entered into the middle one-third in 74 specimens. Based on the observed data, microanatomical relationships of the orbital contents were revised.
Kim, J; Dellon, A L
A neuroma of a calcaneal nerve has never been reported. A series of 15 patients with heel pain due to a neuroma of a calcaneal nerve are reviewed. These patients previously had either a plantar fasciotomy (n = 4), calcaneal spur removal (n = 2), ankle fusion (n = 2), or tarsal tunnel decompression (n = 7). Neuromas occurred on calcaneal branches that arose from either the posterior tibial nerve (n = 1), lateral plantar nerve (n = 1), the medial plantar nerve (n = 9), or more than one of these nerves (n = 4). Operative approach was through an extended tarsal tunnel incision to permit identification of all calcaneal nerves. The neuroma was resected and implanted into the flexor hallucis longus muscle. Excellent relief of pain occurred in 60%, and good relief in 33%. One patient (17%) had no improvement and required resection of the lateral plantar nerve. Awareness that the heel may be innervated by multiple calcaneal branches suggests that surgery for heel pain of neural origin employ a surgical approach that permits identification of all possible calcaneal branches.
Lui, Tun Hing
Different types of posterior calcaneal osteotomy are used for calcaneal realignment in the management of hindfoot deformity. We describe a percutaneous technique of posterior calcaneal osteotomy that can be either a Dwyer-type closing wedge osteotomy or displacement osteotomy.
Hofstede, D J; Ritt, M J; Bos, K E
A biomechanical cadaver study was performed to identify a potential bone-ligament-bone autograft from the foot for reconstruction of the scapholunate interosseous ligament (SLIL). In this study the biomechanical properties of 9 dorsal tarsal ligaments and the anterior tibiofibular ligament were investigated and compared with those of the dorsal part of the SLIL. Fifteen fresh-frozen human cadaver feet and 14 fresh-frozen human cadaver wrists were used. In a Monsanto Tensometer testing apparatus (Monsanto Limited Instruments, Dorean Swindon, England) the complexes were uniaxially elongated at a constant velocity of 6.35 mm/min until rupture occurred. The stiffness and strength values for each tarsal ligament were calculated and compared with those of the dorsal part of the SL ligament. Analysis indicated that the third dorsal tarsometatarsal ligament (143 +/- 42 N) and the dorsal calcaneocuboid ligament (149 +/- 41 N) were comparable to the dorsal part of the SL ligament (141 +/- 20 N) while all other ligaments were stronger. The stiffness values of the third dorsal tarsometatarsal ligament (67 +/- 17 N/mm) and the dorsal calcaneocuboid ligament (55 +/- 14 N/mm) were comparable to the dorsal part of the SL ligament (61 +/- 6 N/mm). All the other ligaments had values that were higher than the dorsal part of the SL ligament. The strongest ligament appeared to be the medial dorsal cuneonavicular ligament (479 +/- 65 N), which had a stiffness value of 127 +/- 19 N/mm. Although the third dorsal tarsometatarsal ligament and the dorsal calcaneocuboid ligament are biomechanically most similar to the dorsal part of the SLIL, at present it is unclear how strength and stiffness values of ligaments are sustained following transplantation. From this selection of tarsal ligaments, the medial dorsal cuneonavicular ligament is the strongest ligament and it is therefore concluded that this ligament is the most suitable ligament to be used as an autograft for reconstruction of the
Akataki, Kumi; Mita, Katsumi; Watakabe, Makoto; Itoh, Kunihiko
The aim of this study was to examine the mechanomyogram (MMG) and force relationship of the first dorsal interosseous (FDI) muscle as well as the biceps brachii (BB) muscle during voluntary isometric ramp contractions, and to elucidate the MMG responses resulting from the intrinsic motor unit (MU) activation strategy of FDI muscle with reference to the MMG of BB muscle. The subjects were asked to exert ramp contractions of FDI and BB muscle from 5% to 70% of the maximal voluntary contraction (MVC) at a constant rate of 10% MVC/s. In FDI muscle, the root-mean-squared amplitude (RMS) of the MMG decreased slowly with force up to 21%, and then a progressive increase was followed by a relatively rapid decrease beyond 41% MVC. The RMS/%MVC relationship in BB muscle consisted of an initial slow increase followed by a rapid increase from 23% MVC and a progressive decrease beyond 61% MVC. With respect to the mean power frequency (MPF), FDI muscle demonstrated no obvious inflection point in the MPF/%MVC relationship compared with that in BB muscle. Namely, the MPF of FDI muscle increased linearly through the force levels exerted. In contrast to FDI muscle, the MPF/%MVC relationship in BB muscle was decomposed into four specific regions: (1) a relative rapidly increase (<34% MVC), (2) a slow increment (34-53% MVC), (3) a temporary reduction (53-62% MVC), and (4) a further rapid increase (>62% MVC). The different MMG responses between FDI and BB muscles are considered to reflect the fact that the MU activation strategy varies among different muscles in relation to their morphology and histochemical type. Namely, the rate coding of the MUs plays a more prominent role in force production in relatively small FDI muscle than does MU recruitment compared with their respective roles in the relatively large BB muscle.
Flament, D; Goldsmith, P; Buckley, C J; Lemon, R N
1. The response of the first dorsal interosseous (1DI) muscle to non-invasive magnetic and scalp electrical stimulation of the brain have been investigated during performance of different manual tasks. 2. The six tasks tested required activation of the 1DI muscle, either in isolation (during abduction of the index finger) or as part of a more complex pattern of muscle synergies (e.g. during power grip). The level of 1DI EMG activity across tasks was kept constant by providing subjects with visual feedback of their muscle activity. 3. In every subject (n = 14) magnetic stimulation produced larger responses during performance of complex tasks than during the simple index abduction task. The pooled results from all subjects showed that four of the five complex tasks were associated with significantly larger 1DI responses (paired t test, P < 0.05). 4. These results were confirmed at the single motor unit level for nine motor units recorded from six subjects. Subjects were requested to produce a steady discharge of the same motor unit during performance of different tasks. The probability of motor unit discharge in response to magnetic stimulation was significantly greater during complex tasks (rotation or pincer grips) than during abduction. 5. Scalp electrical stimulation was performed in three subjects with the cathode at the vertex and the anode over the contralateral motor cortex. The pattern of response amplitudes in the different tasks tended to parallel that obtained for magnetic stimulation, but the task-related differences were smaller. 6. These results suggest that during performance of the different tasks, the corticospinal volleys evoked by magnetic stimulation may vary in amplitude. The task-related cortical mechanisms that may contribute to this variability are discussed.
Kachooei, Amir Reza; Rivlin, Michael; Wu, Fei; Faghfouri, Aram; Eberlin, Kyle R; Ring, David
To study the intraobserver and interobserver reliability of the diagnosis of interosseous ligament (IOL) rupture in a cadaver model. On 12 fresh frozen cadavers, radial heads were cut using an identical incision and osteotomy. After randomization, the soft tissues of the limbs were divided into 4 groups: both IOL and triangular fibrocartilage (TFCC) intact; IOL disruption but TFCC intact; both IOL and TFCC divided; and IOL intact but TFCC divided. All incisions had identical suturing. After standard instruction and demonstration of radius pull-push and radius lateral pull tests, 10 physician evaluators with different levels of experience examined the cadaver limbs in a standardized way (elbow at 90° with the forearm held in both supination and pronation) and were asked to classify them into one of the 4 groups. Next, the same examiners were asked to re-examine the limbs after randomly changing the order of examination. The interobserver reliability of agreement for the diagnosis of IOL injury (groups 2 and 3) was fair in both rounds of examination and the intraobserver reliability was moderate. The intra- and interobserver reliabilities of agreement for the 4 groups of injuries among the examiners were fair in both rounds of examination. The sensitivity, specificity, accuracy, positive, and negative predictive values were all around 70%. The likelihood of a positive test corresponding with the presence of IOL rupture (positive likelihood ratio) was 2.2. The likelihood of a negative test correctly diagnosing an intact IOL was 0.40. In cadavers, intraoperative tests had fair reliability and 70% accuracy for the diagnosis of IOL rupture using the push-pull and lateral pull maneuvers. The level of experience did not have any effect on the correct diagnosis of intact versus disrupted IOL. Although not common, some failure of surgeries for traumatic elbow fracture-dislocations is because of failure in timely diagnosis of IOL disruption. Copyright © 2015 American
Miller, Jonathan D; Herda, Trent J; Trevino, Michael A; Sterczala, Adam J; Ciccone, Anthony B; Nicoll, Justin X
To examine twitch force potentiation and twitch contraction duration, as well as electromyographic amplitude (EMGRMS) and motor unit mean firing rates (MFR) at targeted forces between young and old individuals in the first dorsal interosseous (FDI). Ultrasonography was used to assess muscle quality. Twenty-two young (YG) (age=22.6±2.7years) and 14 older (OD) (age=62.1±4.7years) individuals completed conditioning contractions at 10% and 50% maximal voluntary contraction, (MVC) during which EMGRMS and MFRs were assessed. Evoked twitches preceded and followed the conditioning contractions. Ultrasound images were taken to quantify muscle quality (cross-sectional area [CSA] and echo intensity [EI]). No differences were found between young and old for CSA, pre-conditioning contraction twitch force, or MFRs (P>0.05). However, OD individuals exhibited greater EI and contraction duration (P<0.05), and EMGRMS (YG=35.4±8.7%, OD=43.4±13.2%; P=0.034). Twitch force potentiation was lower for OD (0.311±0.15N) than YG (0.619±0.26N) from pre- to post-50% conditioning contraction (P<0.001). Lower levels of potentiation with elongated contraction durations likely contributed to greater muscle activation during the conditioning contractions in the OD rather than altered MFRs. Ultrasonography suggested age-related changes in muscle structure contributed to altered contractile properties in the OD. Greater muscle activation requirements can have negative implications on fatigue resistance at low to moderate intensities in older individuals. Copyright © 2017 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.
Illuminati, G; Calio, F G; Bertagni, A; Martinelli, V
The purpose of the present study was to retrospectively evaluate the results of anatomically tunneled grafts to the anterior tibial artery for distal revascularization in terms of patency and limb salvage rates as well as local morbidity, which can lengthen the postoperative hospital stay. Twenty-three patients received 24 bypasses to the anterior tibial artery, with grafts tunneled through the interosseous membrane. The mean age was 67 years; 10 patients were diabetic, 12 were smokers, 9 presented with significant coronary artery disease, and 2 with chronic renal insufficiency. The donor vessel was the common femoral artery in 17 cases, the superficial femoral artery in 4, and the infra-articular popliteal artery in 3. The graft material consisted in the reversed saphenous vein in 4 cases, the non-reversed devalvulated ex situ saphenous vein in 11, composite polytetrafluoroethylene (PTFE) + inversed saphenous vein in 6, and PTFE alone in 3 cases. No postoperative mortality was observed, nor was there postoperative graft occlusion or need for major amputation. The average postoperative length of stay in the hospital was 9.7 days. Two local surgical wound complications were observed, which did not necessitate a postoperative hospital stay exceeding 15 days. Cumulative primary patency and limb salvage rates at 3 years were 50% and 70%, respectively. Anatomic tunneling of grafts to the anterior tibial artery yields patency and limb salvage rates comparable to those reported in the literature for distal bypasses and, considered overall, an acceptably low local morbidity and short hospital stay. Definitive superiority over externally tunneled grafts, however, is not definitely demonstrated by this study and should be prospectively tested.
Gaspar, Michael P; Kane, Patrick M; Pflug, Emily M; Jacoby, Sidney M; Osterman, A Lee; Culp, Randall W
The purpose of this study was to report outcomes of interosseous membrane (IOM) reconstruction with a suture-button construct for treatment of chronic longitudinal forearm instability. We performed a retrospective review with prospective follow-up of patients who underwent ulnar shortening osteotomy and IOM reconstruction with the Mini TightRope device from 2011 through 2014. Bivariate statistical analysis was used for comparison of preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, range of motion, grip strength, and ulnar variance. Complications and patient satisfaction were also recorded. Ten patients (mean age, 45.3 years) satisfied inclusion criteria: 8 treated for post-traumatic sequelae of Essex-Lopresti-type injuries, 1 for forearm instability secondary to previous elbow surgery, and 1 for instability secondary to trauma and multiple elbow surgeries. Surgeries were performed an average of 28.6 months from initial injury. At mean follow-up of 34.6 months after surgery, significant improvement was observed in elbow flexion-extension arc (+23° vs. preoperatively; P = .007), wrist flexion-extension arc (+22°; P = .016), QuickDASH score (-48; P = .000), and ulnar variance (-3.3 mm; P = .006). Three patients required additional surgery: 1 revision ulnar shortening osteotomy for persistent impingement, 1 revision ulnar osteotomy and Mini TightRope removal for lost forearm supination, and 1 fixation of a radial shaft fracture after a fall. IOM reconstruction using a suture-button construct is an effective treatment option for chronic forearm instability. Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.
Shields, Christopher B.; Shields, Lisa B. E.; Jiang, Yi Dan; Yao, Tom; Zhang, Yi Ping; Sun, David A.
Background: Intraoperative monitoring with brainstem auditory evoked responses (BAER) provides an early warning signal of potential neurological injury and may avert tissue damage to the auditory pathway or brainstem. Unexplained loss of the BAER signal in the operating room may present a dilemma to the neurosurgeon. Methods: This paper documents two patients who displayed a unique mechanism of suppression of the BAER apparent within minutes following dural opening for resection of a posterior fossa meningioma. Results: In two patients with anterior cerebellopontine angle and clival meningiomas, there was a significant deterioration of the BAER soon after durotomy but prior to cerebellar retraction and tumor removal. Intracranial structures in the posterior fossa lying between the tumor and dural opening were shifted posteriorly after durotomy. Conclusion: We hypothesized that the cochlear nerve and vessels entering the acoustic meatus were compressed or stretched when subjected to tissue shift. This movement caused cochlear nerve dysfunction that resulted in BAER suppression. BAER was partially restored after the tumor was decompressed, dura repaired, and bone replaced. BAER was not suppressed following durotomy for removal of a meningioma lying posterior to the cochlear complex. Insight into the mechanisms of durotomy-induced BAER inhibition would allay the neurosurgeon's anxiety during the operation. PMID:25883849
Twenty-eight cases of posterior choroidal melanoma were treated with iodine-125 in gold eye plaques. Eleven cases were located within 3.0 mm of the optic nerve (group A), nine were within 3.0 mm of the fovea (group B), and eight were within 3.0 mm of the optic nerve and fovea (group C). The mean follow-up of group A was 46.3 months; group B, 25.5 months; and group C, 42.7 months. Complications included macular edema, cataract and tumor growth. Visual acuity remained within two lines of that tested preoperatively for 4 of 11 patients in group A, 4 of 9 in group B, and 5 of 8 in group C. These results with iodine-125 suggest it as an appropriate treatment for patients with choroidal melanoma located near optic nerve and/or macula.
Buschbacher, Ralph M
Nerve conduction studies are commonly performed to diagnose injuries of the peripheral nerves. In the past, normal ranges have been derived on relatively small samples of normal subjects. These ranges were often suboptimal for clinical use. Therefore, this series of articles was created to establish an improved database of normative values. It highlights the key contributions of a number of authors. In this foreword, the contributions of the various authors to the special issue on the development of an improved database for nerve conduction studies are described. The authors are introduced, including their training, gifts, and which articles they were involved in writing. In addition, there is a brief review of each of the articles in this special supplement. The fundamentals of ulnar motor nerve conduction to the first dorsal interosseous muscle are described, as is the contribution of Nate Prahlow, MD. In addition, the median motor nerve conduction to the pronator teres muscle and flexor carpi radialis muscle is highlighted including the contributions of Brian Foley, MD. The radial sensory nerve and dorsal ulnar cutaneous sensory nerve studies are described, as well as the contributions of Van Evanoff, Jr., MD, in creating this research. Median motor conduction to the lumbrical muscles and ulnar motor conduction to the palmar interosseous muscles are described, again highlighting the contributions of Dr. Foley. In addition, medial and lateral antebrachial cutaneous nerve studies are described, along with the contributions of Dr. Nathan Prahlow. Median and ulnar sensory conduction studies recording from the fourth digit, as well as median and radial sensory conduction to the first digit, are described, as are the contributions of James Lohman, MD, and Andrew Berkson, DO. The side-to-side differences in median and ulnar sensory conduction studies and the importance of performing such studies are described, as are the contributions in this research of Dr. Nathan
Immunohistochemical evidence for the coexistence of histidine decarboxylase-like and glutamate decarboxylase-like immunoreactivities in nerve cells of the magnocellular nucleus of the posterior hypothalamus of rats.
Takeda, N; Inagaki, S; Shiosaka, S; Taguchi, Y; Oertel, W H; Tohyama, M; Watanabe, T; Wada, H
Immunohistochemical staining of alternate consecutive sections revealed numerous histidine decarboxylase (L-histidine carboxy-lyase, EC 126.96.36.199)-like immunoreactive neurons that also contained glutamate decarboxylase (L-glutamate 1-carboxy-lyase, EC 188.8.131.52)-like immunoreactive structures in the tuberal magnocellular nucleus, the caudal magnocellular nucleus, and the postmammillary caudal magnocellular nucleus of the posterior hypothalamus of rats. Furthermore, in immunohistochemical double-staining procedures, almost all neurons in the magnocellular nuclei had both histidine decarboxylase-like and glutamate decarboxylase-like immunoreactivities. These results suggest the coexistence of histamine and gamma-aminobutyric acid in single neurons in these nuclei. Images PMID:6594708
Zhou, Ping; Suresh, Nina L.; Zev Rymer, William
The objective of this study was to determine whether a novel technique using high density surface electromyogram (EMG) recordings can be used to detect the directional dependence of muscle activity in a multifunctional muscle, the first dorsal interosseous (FDI). We used surface EMG recordings with a two-dimensional electrode array to search for inhomogeneous FDI activation patterns with changing torque direction at the metacarpophalangeal joint, the locus of action of the FDI muscle. The interference EMG distribution across the whole FDI muscle was recorded during isometric contraction at the same force magnitude in five different directions in the index finger abduction-flexion plane. The electrode array EMG activity was characterized by contour plots, interpolating the EMG amplitude between electrode sites. Across all subjects the amplitude of the flexion EMG was consistently lower than that of the abduction EMG at the given force. Pattern recognition methods were used to discriminate the isometric muscle contraction tasks with a linear discriminant analysis classifier, based on the extraction of two different feature sets of the surface EMG signal: the time domain (TD) feature set and a combination of autoregressive coefficients and the root mean square amplitude (AR+RMS) as a feature set. We found that high accuracies were obtained in the classification of different directions of the FDI muscle isometric contraction. With a monopolar electrode configuration, the average overall classification accuracy from nine subjects was 94.1 ± 2.3% for the TD feature set and 95.8 ± 1.5% for the AR+RMS feature set. Spatial filtering of the signal with bipolar electrode configuration improved the average overall classification accuracy to 96.7 ± 2.7% for the TD feature set and 98.1 ± 1.6% for the AR+RMS feature set. The distinct EMG contour plots and the high classification accuracies obtained from this study confirm distinct interference EMG pattern distributions as a
Lui, Tun Hing
Gouty tophus of the tarsal tunnel is a rare cause of posterior tarsal tunnel syndrome. We present a case of acute posterior tarsal tunnel syndrome due to gouty tophus that required early tarsal tunnel release in order to avoid irreversible nerve damage. The presence of background neuropathy resulted in a less favorable result than expected. Therapeutic, Level V: Case report. © 2014 The Author(s).
Susman, R L; Jungers, W L; Stern, J T
The evidence for two functional roles of M. accessorius interosseus can be adduced as follows: (1) abduction of the whole finger is clearly required to resist the force of the thumb against the index during pinch grasp (Fig. 4) and when greater resistance is applied to the food, activity increases in the muscle. (2) The muscle also flexes the metacarpophalangeal joint at the onset of grasp on the ladder rung. In hanging from the finger tips or from the cage top, with the metacarpophalangeal joints extended, the muscle goes silent. From the functional point of view, the name given by Huxley (1871) to the M. accessorius interosseus ('abductor tertii internodii secundi digiti') is perhaps the most appropriate one. For reasons of economy, however, we favour continued use of the nomen Musculus accessorius interosseus (Fitzwilliams, 1910) or accessory interosseous muscle. The name coined by Keith (1894; p. 299) which implies that this muscle is an extensor of the distal interphalangeal joint, and any suggestions that the muscle functions primarily to flex the proximal interphalangeal joint are less appropriate or in error. The EMG data reveal that the M. accessorius interosseus is primarily an abductor of the index finger in gibbons, and we suggest that it is a unique feature of lesser apes that has evolved in compensation for a deep thumb-index cleft and the loss of the radial moiety of the first dorsal interosseous muscle. The primary role of this specialized muscle is in thumb-index pinch grasping. Images Fig. 5 PMID:7076537
Joo, Wonil; Rhoton, Albert L
The trochlear nerve is the cranial nerve with the longest intracranial course, but also the thinnest. It is the only nerve that arises from the dorsal surface of the brainstem and decussates in the superior medullary velum. After leaving the dorsal surface of the brainstem, it courses anterolaterally around the lateral surface of the brainstem and then passes anteriorly just beneath the free edge of the tentorium. It passes forward to enter the cavernous sinus, traverses the superior orbital fissure and terminates in the superior oblique muscle in the orbit. Because of its small diameter and its long course, the trochlear nerve can easily be injured during surgical procedures. Therefore, precise knowledge of its surgical anatomy and its neurovascular relationships is essential for approaching and removing complex lesions of the orbit and the middle and posterior fossae safely. This review describes the microsurgical anatomy of the trochlear nerve and is illustrated with pictures involving the nerve and its surrounding connective and neurovascular structures.
Oliveira, M T; Marttos, A C; Fallopa, F
This study investigated an endoscopic technique of harvesting the sural nerve graft. Using endoscopic instrumentation, the sural nerve was harvested from six cadaveric legs. A 2-cm longitudinal incision was made immediately posterior to the lateral malleolus, and a 5-mm endoscope was introduced. The path of the nerve was followed to the popliteal space, and nerve dissection was performed from proximal to distal. Air inflation of a balloon was used to enlarge the endoscopic cavity. The cavity created around the nerve was insufflated with carbon dioxide gas, allowing complete nerve isolation. Using a 0.5-cm transverse incision, the nerve was cut and removed. This endoscopic sural nerve grafting approach offers potential advantages such as less injury to soft tissues, decreased pain, nerve integrity preservation, and good aesthetic results.
Aker, PD; O’Connor, SM; Mior, SA; Beauchemin, D
Ossification of the posterior longitudinal ligament (OPLL) has recently been recognized as a clinical entity. It is a rare condition, having a higher incidence in the Japanese population. It is characterized by hyperplasia of cartilage cells with eventual endochondral ossification of the posterior longitudinal ligament. The radiographic signs are characteristic and consist of a linear band of ossified tissue along the posterior margin of the vertebral body. OPLL can be associated with mild to serious neurological complications due to spinal cord or nerve root compression, or it may be asymptomatic. This paper reviews the radiological, clinical and therapeutic aspects of this rare condition. ImagesFigures 1 and 2Figures 3 and 4
Jensen, Nina Vendel; Dahlin, Lars B; Bojsen-Møller, Finn; Søe-Nielsen, Niels H
We describe a patient in whom the motor branch to the first dorsal interosseous muscle was injured by the pins of an fixator used to treat an unstable fracture of the distal radius. She was successfully treated by extensor indicis proprius transfer to the base of the proximal phalanx of the index finger.
... Sometimes the needle has to be inserted fairly deep to reach the nerve causing your problem. This ... understanding of the possible charges you will incur. Web page review process: This Web page is reviewed ...
Bu, Fanyu; Xue, Mingyu; Rui, Yongjun; Gu, Liming; Shou, Kuishui; Qiang, Li; Zhou, Xiao
To discuss the effectiveness of improved interosseous dorsal artery reversed island flap to repair dorsal skin and soft tissue defect of the hand. Between March 2009 and September 2012, 29 cases of dorsal skin and soft tissue defects were treated with improved interosseous dorsal artery reversed island flap. Of 29 cases, there were 17 males and 12 females, aged 23-71 years (mean, 47 years); and the left hand was involved in 12 cases and the right hand in 17 cases. There were 11 cases of avulsion injury, 9 cases of crushing injury, 5 cases of strangulation injury, and 2 cases of traffic accident injury; the interval of injury and admission was 1-7 hours (mean, 4 hours). Two patients had scar contracture. The locations of soft tissue defects were dorsal hands in 21 cases, first webs in 5 cases, and dorsal thumb in 3 cases. The size of soft tissue defects ranged from 4 cm x 3 cm to 10 cm x 8 cm. One-stage repair was performed in 11 cases, and two-stage repair in 18 cases. The size of flaps ranged from 5.5 cm x 4.5 cm to 12.0 cm x 10.0 cm. The donor sites were sutured directly or repaired by skin grafting. All flaps survived, and wounds healed in first stage. And the grafted skins at donor sites all survived, and incisions all healed in first stage. Twenty-six patients were followed up 3 months-3 years (mean, 19.5 months). Bulky flap was observed in 3 cases, and defatted operation was performed after 6 months; the other flaps had good appearance and texture, and wrist function was normal. According to total angle of motion (TAM) systematic evaluation, the results were excellent in 17 cases, good in 6 cases, and fair in 3 cases at 3 months after operation. Improved interosseous dorsal artery reversed island flap has the advantages of easy-to-obtain, simple operation, and high survival rate of flaps, so it is an effective method to repair dorsal skin and soft tissue defect of the hand.
Caetano, Edie Benedito; Sabongi, João José; Vieira, Luiz Ângelo; Caetano, Maurício Ferreira; Moraes, Daniel Vinhais
OBJECTIVE: The relationship of Gantzer muscle to the median and anterior interosseous nerve is debated. METHODS: Ìn an anatomical study with 80 limbs from 40 cadavers the incidence, origin, insertion, nerve supply and relations of Gantzer muscle have been documented. RESULTS: The muscle was found in 54 forearms (68% of limbs) and was supplied by the anterior interosseous nerve. It arose from the deep surface of the flexor digitorum superficialis muscle, (42 limbs), coronoid process (eight limbs) and medial epicondyle (seven limbs). Its insertion was to the ulnar part of flexor pollicis longus muscle. The Gantzer muscle always lay posterior to both the median and anterior interosseous nerve. CONCLUSION: The Gantzer muscle may contribute to the median nerve and anterior interosseous nerve compression. The muscle was found in 68% of limbs and should be considered a normal anatomical pattern rather than an anatomical variation. Level of Evidence IV, Case Series . PMID:27069404
Hendrix, Philipp; Griessenauer, Christoph J; Foreman, Paul; Shoja, Mohammadali M; Loukas, Marios; Tubbs, R Shane
The arterial supply to the upper cranial nerves is derived from a complex network of branches derived from the anterior and posterior cerebral circulations. We performed a comprehensive literature review of the arterial supply of the upper cranial nerves with an emphasis on clinical considerations. Arteries coursing in close proximity to the cranial nerves regularly give rise to small vessels that supply the nerve. Knowledge of the arteries supplying the cranial nerves is of particular importance during surgical approaches to the skull base. © 2014 Wiley Periodicals, Inc.
... Nerve Decompression Dacryocystorhinostomy (DCR) Disclosure Statement Printer Friendly Optic Nerve Decompression John Lee, MD Introduction Optic nerve decompression is a surgical procedure aimed at ...
Neuropathy - ulnar nerve; Ulnar nerve palsy; Mononeuropathy; Cubital tunnel syndrome ... compressed in the elbow, a problem called cubital tunnel syndrome may result. When damage destroys the nerve ...
Posterior ankle impingement syndrome is a clinical disorder characterized by posterior ankle pain that occurs in forced plantar flexion. The pain may be acute as a result of trauma or chronic from repetitive stress. Pathology of the os trigonum-talar process is the most common cause of this syndrome, but it also may result from flexor hallucis longus tenosynovitis, ankle osteochondritis, subtalar joint disease, and fracture. Patients usually report chronic or recurrent posterior ankle pain caused or exacerbated by forced plantar flexion or push-off maneuvers, such as may occur during dancing, kicking, or downhill running. Diagnosis of posterior ankle impingement syndrome is based primarily on clinical history and physical examination. Radiography, scintigraphy, computed tomography, and magnetic resonance imaging depict associated bone and soft-tissue abnormalities. Symptoms typically improve with nonsurgical management, but surgery may be required in refractory cases.
... tear. Contact sports. Athletes in sports such as football and soccer can tear their posterior cruciate ligament ... vehicle accident and participating in sports such as football and soccer are the most common risk factors ...
Sneag, Darryl B; Saltzman, Eliana B; Meister, David W; Feinberg, Joseph H; Lee, Steve K; Wolfe, Scott W
The role of MRI in identifying hourglass constrictions (HGCs) of nerves in Parsonage-Turner syndrome (PTS) is largely unknown. Six patients with PTS and absent or minimal recovery underwent MRI. Surgical exploration was performed at identified pathologic sites. The time between symptom onset and surgery was 12.4 ± 6.9 months; the time between MRI and surgery was 1.3 ± 0.6 months. Involved nerves included suprascapular, axillary, radial, and median nerve anterior interosseous and pronator teres fascicles. Twenty-three constriction sites in 10 nerves were identified on MRI. A "bullseye sign" of the nerve, identified immediately proximal to 21 of 23 sites, manifested as peripheral signal hyperintensity and central hypointensity orthogonal to the long axis of the nerve. All constrictions were confirmed operatively. In PTS, a bullseye sign on MRI can accurately localize HGCs, a previously unreported finding. Causes of HGCs and the bullseye sign are unknown. Muscle Nerve 56: 99-106, 2017. © 2016 Wiley Periodicals, Inc.
Georgiadis, G M; Aronson, D D
Posterior transfer of the tendon of the anterior tibial muscle through the interosseous membrane to the calcaneus to prevent or correct a calcaneus deformity was performed in twenty patients (thirty-nine feet) who had a myelomeningocele. The average age of the patients at the time of the operation was 4.6 years, and they were followed for an average of six years. Satisfactory clinical and radiographic results were obtained in thirty-seven (95 per cent) of the thirty-nine feet. Two patients, one who was unable to walk and one who walked at home only, had a mild equinus deformity of the left foot. No patient had a clinical calcaneus deformity, but there was radiographic evidence of talipes calcaneus in one patient (two feet). The anterior tibial muscle functioned more consistently when the operation was performed after the patient was four years old and in patients who had a fifth lumbar or first sacral motor level.
Gala, Foram B; Aswani, Yashant
Spinal epidural space is a real anatomic space located outside the dura mater and within the spinal canal extending from foramen magnum to sacrum. Important contents of this space are epidural fat, spinal nerves, epidural veins and arteries. Due to close proximity of posterior epidural space to spinal cord and spinal nerves, the lesions present with symptoms of radiculopathy and/or myelopathy. In this pictorial essay, detailed anatomy of the posterior epidural space, pathologies affecting it along with imaging pearls to accurately diagnose them are discussed. Various pathologies affecting the posterior epidural space either arising from the space itself or occurring secondary to vertebral/intervertebral disc pathologies. Primary spinal bone tumors affecting the posterior epidural space have been excluded. The etiological spectrum affecting the posterior epidural space ranges from degenerative, infective, neoplastic - benign or malignant to miscellaneous pathologies. MRI is the modality of choice in evaluation of these lesions with CT scan mainly helpful in detecting calcification. Due to its excellent soft tissue contrast, Magnetic Resonance Imaging is extremely useful in assessing the pathologies of posterior epidural space, to know their entire extent, characterize them and along with clinical history and laboratory data, arrive at a specific diagnosis and guide the referring clinician. It is important to diagnose these lesions early so as to prevent permanent neurological complication. PMID:27857455
Gala, Foram B; Aswani, Yashant
Spinal epidural space is a real anatomic space located outside the dura mater and within the spinal canal extending from foramen magnum to sacrum. Important contents of this space are epidural fat, spinal nerves, epidural veins and arteries. Due to close proximity of posterior epidural space to spinal cord and spinal nerves, the lesions present with symptoms of radiculopathy and/or myelopathy. In this pictorial essay, detailed anatomy of the posterior epidural space, pathologies affecting it along with imaging pearls to accurately diagnose them are discussed. Various pathologies affecting the posterior epidural space either arising from the space itself or occurring secondary to vertebral/intervertebral disc pathologies. Primary spinal bone tumors affecting the posterior epidural space have been excluded. The etiological spectrum affecting the posterior epidural space ranges from degenerative, infective, neoplastic - benign or malignant to miscellaneous pathologies. MRI is the modality of choice in evaluation of these lesions with CT scan mainly helpful in detecting calcification. Due to its excellent soft tissue contrast, Magnetic Resonance Imaging is extremely useful in assessing the pathologies of posterior epidural space, to know their entire extent, characterize them and along with clinical history and laboratory data, arrive at a specific diagnosis and guide the referring clinician. It is important to diagnose these lesions early so as to prevent permanent neurological complication.
... Like static on a telephone line, peripheral nerve disorders distort or interrupt the messages between the brain ... are more than 100 kinds of peripheral nerve disorders. They can affect one nerve or many nerves. ...
Vagus nerve stimulation Overview By Mayo Clinic Staff Vagus nerve stimulation is a procedure that involves implantation of a device that stimulates the vagus nerve with electrical impulses. There's one vagus nerve on ...
Nerve biopsy is the removal of a small piece of nerve for examination. Through a small incision, a sample ... is removed and examined under a microscope. Nerve biopsy may be performed to identify nerve degeneration, identify ...
Bertelli, Jayme A; Ghizoni, Marcos F
OBJECTIVE The purpose of this paper was to report the authors' results with finger flexion restoration by nerve transfer in patients with tetraplegia. METHODS Surgery was performed for restoration of finger flexion in 17 upper limbs of 9 patients (8 male and 1 female) at a mean of 7.6 months (SD 4 months) after cervical spinal cord injury. The patients' mean age at the time of surgery was 28 years (SD 15 years). The motor level according to the ASIA (American Spinal Injury Association) classification was C-5 in 4 upper limbs, C-6 in 10, and C-7 in 3. In 3 upper limbs, the nerve to the brachialis was transferred to the anterior interosseous nerve (AIN), which was separated from the median nerve from the antecubital fossa to the midarm. In 5 upper limbs, the nerve to the brachialis was transferred to median nerve motor fascicles innervating finger flexion muscles in the midarm. In 4 upper limbs, the nerve to the brachioradialis was transferred to the AIN. In the remaining 5 upper limbs, the nerve to the extensor carpi radialis brevis (ECRB) was transferred to the AIN. Patients were followed for an average of 16 months (SD 6 months). At the final evaluation the range of finger flexion and strength were estimated by manual muscle testing according to the British Medical Research Council scale. RESULTS Restoration of finger flexion was observed in 4 of 8 upper limbs in which the nerve to the brachialis was used as a donor. The range of motion was incomplete in all 5 of these limbs, and the strength was M3 in 3 limbs and M4 in 1 limb. Proximal retrograde dissection of the AIN was associated with better outcomes than transfer of the nerve to the brachialis to median nerve motor fascicles in the arm. After the nerve to the brachioradialis was transferred to the AIN, incomplete finger flexion with M4 strength was restored in 1 limb; the remaining 3 limbs did not show any recovery. Full finger flexion with M4 strength was demonstrated in all 5 upper limbs in which the nerve
Babal, Jessica C; Mehlman, Charles T; Klein, Guy
Supracondylar fractures of the humerus are the most common type of elbow fracture in children. Of all complications associated with supracondylar fractures, nerve injury ranks highest, although reports of the incidence of specific neurapraxia vary. This meta-analysis aims primarily to determine the risk of traumatic neurapraxia in extension-type supracondylar fractures as compared with that of flexion-type fractures; secondarily it aims to use subgroup analysis to assess the risk of iatrogenic neurapraxia induced by pin fixation. A literature search identified studies that reported the incidence of nerve injury presenting with displaced supracondylar fractures of the humerus in children. Meta-analysis was subsequently performed to evaluate the risk of traumatic neurapraxia associated with supracondylar fractures. Subgroup analysis of included articles was additionally performed to assess the risk of iatrogenic neurapraxia associated with lateral-only or medial/lateral pin fixation. Data from 5148 patients with 5154 fractures were pooled for meta-analysis. Among these patients, traumatic neurapraxia occurred at a weighted event rate of 11.3%. Anterior interosseous nerve injury predominated in extension-type fractures, representing 34.1% of associated neurapraxias; meanwhile, ulnar neuropathy occurred most frequently in flexion-type injuries, representing 91.3% of associated neurapraxias. Nerve injury induced by lateral-only pinning occurred at a weighted event rate of 3.4%, while the introduction of a medial pin elicited neurapraxia at a weighted event rate of 4.1%. Lateral pinning carried increased risk of median neuropathy, whereas the use of a medial pin significantly increased the risk of ulnar nerve injury. Of nerve injury associated with extension-type fractures, anterior interosseous neurapraxia ranks highest, whereas of flexion-type neuropathy, ulnar nerve injury predominates. We confirm that medial pinning carries the greater overall risk of nerve injury as
The tibialis posterior tendon is the largest and anteriormost tendon in the medial ankle. It produces plantar flexion and supination of the ankle and stabilizes the plantar vault. Sonographic assessment of this tendon is done with high-frequency, linear-array transducers; an optimal examination requires transverse retromalleolar, longitudinal retromalleolar, and distal longitudinal scans, as well as dynamic studies. Disorders of the posterior tibial tendon include chronic tendinopathy with progressive rupture, tenosynovitis, acute rupture, dislocation and instability, enthesopathies. The most common lesion is a progressive "chewing gum" lesion that develops in a setting of chronic tendinopathy; it is usually seen in overweight women over 50 years of age with valgus flat feet. Medial ankle pain must also be carefully investigated, and the presence of instability assessed with dynamic maneuvers (forced inversion, or dorsiflexion) of the foot. Sonography plays an important role in the investigation of disorders involving the posterior tibial tendon.
Severe, traumatic soft-tissue loss in the antecubital fossa and proximal forearm associated with radial and/or median nerve palsy: nerve recovery after coverage with a pedicled latissimus dorsi muscle flap.
Al-Qattan, M M
A total of 6 patients with complex, traumatic wounds of the antecubital fossa and proximal forearm were included in this study. All patients presented with radial and/or median nerve palsies in addition to their soft-tissue defect. Except for 1 patient with a 15-cm defect of the radial nerve, all other traumatized nerves appeared in-continuity at the time of surgery. However, the nerve injury was severe enough to induce Wallerian degeneration (i.e., axonotmesis in traumatized nerves in-continuity). Three patients required brachial artery reconstruction with a reverse saphenous vein graft. Wound coverage was accomplished using a pedicled latissimus dorsi muscle flap, which was covered with a split-thickness skin graft. Successful reconstruction was obtained in all patients. Follow-up ranged from 2 to 6 years. The range of motion at the elbow and forearm was considered excellent in 5 patients and good in the remaining patient who had an intra-articular fracture. Motor recovery of traumatized nerves in-continuity was observed in all but 1 patient who had persistent partial anterior interosseous nerve palsy. The grip strength of the injured hand measured 70% to 85% of the contralateral uninjured hand. Median nerve sensory recovery was excellent in all patients. The versatility of the pedicled latissimus dorsi muscle flap for coverage of these complex wounds with traumatized neurovascular bundles around the elbow is discussed.
Thimons, J J
Posterior vitreous detachment is an expected consequence of aging, but it can also be the initiating cause of a retinal detachment. To understand the mechanism of posterior vitreous detachment and its sequelae, it is necessary to appreciate the anatomy of the vitreous, its development, and the pathogenesis of vitreous degeneration. This paper is a discussion of these considerations, the types of complications that may result from vitreous detachment, the proper examination of patients who present with the symptoms of vitreous detachment, and appropriate patient management.
Zhu, J F; Crevoisier, R; King, D L; Henry, R; Mills, C M
Posterior crossbite, the most common malocclusion in young children, can be caused by a variety of skeletal, muscular, or dental factors. This condition produces insufficient maxillary arch width and is frequently associated with various oral sucking and postural habits. If left untreated, this problem can result in adverse skeletal growth changes. Various mechanical treatment modalities designed to expand the posterior maxillary arch width are available to correct this problem. The appropriate treatment method depends on the patient's age and level of cooperation as well as the determined etiology of the constriction.
Brandão, Lara A; Young Poussaint, Tina
Pediatric brain tumors are the leading cause of death from solid tumors in childhood. The most common posterior fossa tumors in children are medulloblastoma, atypical teratoid/rhabdoid tumor, cerebellar pilocytic astrocytoma, ependymoma, and brainstem glioma. Location, and imaging findings on computed tomography (CT) and conventional MR (cMR) imaging may provide important clues to the most likely diagnosis. Moreover, information obtained from advanced MR imaging techniques increase diagnostic confidence and help distinguish between different histologic tumor types. Here we discuss the most common posterior fossa tumors in children, including typical imaging findings on CT, cMR imaging, and advanced MR imaging studies.
Deshmukh, Vishwajit Ravindra; Mandal, Rabindra Prasad; Kusuma, Harisha
During the routine dissection classes for undergraduate students, uncommon variation in relation to the upper subscapular nerve of posterior cord of brachial plexus was observed. Normally upper subscapular nerve takes origin from the posterior cord, but in this case report, it arises in triplet fashion, just above the circumflex scapular artery. All these accessory nerves were supplying upper part of the subscapularis muscle. As per our knowledge, this is a rare variation of brachial plexus. Many variations are encountered in the formation of brachial plexus. The normal and the abnormal origin of nerves are important considering neurotisation surgeries as well as during the infraclavicular nerve block for various axillary and upper limb surgeries. PMID:27790416
Fantry, Amanda; Lareau, Craig; Vopat, Bryan; Blankenhorn, Brad
Management of posterior malleolus fractures continues to be controversial, with respect to both need for fixation and fixation methods. Fixation methods include an open posterior approach to the ankle as well as percutaneous reduction and fixation with or without arthroscopy for visualization of the articular surface. Plain radiographs are unreliable in identifying fracture pattern and intraoperative reduction, making arthroscopy a valuable adjunct to posterior malleolus fracture management. In this article, we report a case of tibialis posterior tendon entrapment within a posterior malleolus fracture, as identified by arthroscopy and managed with open reduction. Tibialis posterior tendon entrapment within a posterior malleolus has not been previously reported. Ankle arthroscopy for posterior malleolus fractures provides an opportunity to identify soft-tissue or tendinous entrapment, articular surface reduction, and articular cartilage injuries unlikely to be identified with fluoroscopy alone and should be considered in reduction and fixation of posterior malleolus fractures.
Chai, Ho Lam; Lui, Tun Hing
Introduction: The posterior portion of the knee joint, which includes the tibial attachment of the posterior cruciate ligament and the posterior horn of the menisci, has been called a “blind spot” because it is difficult to observe this area under arthroscopy through standard anterior portals. Posteromedial, posterolateral, and posterior transseptal portals have been developed for visualization and instrumentation of the posteromedial and posterolateral compartments of the knee joint. Case Report: A 57-year-old man presented of persistent left posterior knee pain for 1 year. Radiographs and magnetic resonance imaging showed posterior knee encapsulated loose bodies. The symptoms did not respond to physiotherapy and analgesics. The loose bodies were removed via posterior knee arthroscopy. The symptoms subsided afterward. Conclusion: Lateral portal of the knee allows establishment of the posterolateral portal under endoscopic visualization, and the loose bodies of the posterior compartment of the knee can be effectively removed via the posterior knee arthroscopy. PMID:28819604
Lui, T H
FHL tendoscopy has been described as minimally invasive method used to create some pathologies or facilitate some surgeries. As we have encountered lateral plantar nerve neurapraxia, we investigate the cause of lateral nerve injury during Zone 2 flexor digitorum longus (FHL) tendoscopy with a cadaveric model. Eight feet of 4 embalmed cadavers were used for this study. Posterior ankle endoscopy (Zone 1 FHL tendoscopy) was performed with posteromedial and posterolateral portals. A 4.0-mm metal rod was inserted into the Zone 2 tendon health through the posteromedial portal. The distance between the posteromedial portal and the posterior tibial nerve was measured with the ankle in neutral position. Then, the shortest distance between the posterior tibial nerve and the rod was measured with the ankle in three positions: 20 degrees plan-tarflexion, neutral, and the 20 degrees dorsiflexion. The average distance between the posterior tibial nerve and the posteromedial portal was 9.3 mm. The average shortest distance between the posterior tibial nerve and the metal rod was 5 mm with the ankle in 20 degrees dorsiflexion. Ankle dorsiflexion brings the posterior tibial nerve in contact with the arthroscope during Zone 2 tendoscopy. In order to avoid potential nerve injury during Zone 2 FHL tendoscopy, ankle dorsiflexion should be avoided.
Tubbs, R Shane; Ajayi, Olaide O; Fries, Fabian N; Spinner, Robert J; Oskouian, Rod J
The anatomy of the accessory nerve has been well described but continued new clinical and anatomical findings exemplify our lack of a full understanding of the course of this nerve. Therefore, this study aimed to expand on our knowledge of the course of the 11th cranial nerve via anatomical dissections. Fifty-six cadavers (112 sides) underwent dissection of the accessory nerve from its cranial and spinal origins to its emergence into the posterior cervical triangle. Immunohistochemistry was performed when appropriate. Our findings included two cases (1.8%) where the nerve was duplicated, one intracranially and one extracranially. One accessory nerve (0.9%) was found to enter its own dural compartment within the jugular foramen. The majority of sides (80%) were found to have a cranial root of the accessory nerve. Thirty-one sides (28%) had connections to cervical dorsal roots medially and three sides (2.7%) laterally. Medial connections were most common with the C1 nerve. Medial components of these dorsal root connections were all sensory in nature. However, lateral components were motor on two sides (1.8%). Nerves traveled anterior to the internal jugular vein on 88% of sides. One (0.9%) left side nerve joined an interneural anastomosis between the dorsal rootlets. Macroganglia were found on the spinal part of the intracranial nerve on 13% of sides. The lesser occipital nerve arose directly from the accessory nerve on two sides (1.8%) and communicated with the accessory nerve on 5.4% of sides. One side (0.9%) was found to communicate with the facial nerve with both nerves innervating the sternocleidomastoid muscle. Additional anatomical knowledge of the variants of the accessory nerve may benefit patient care when this nerve is pathologically involved.
Guerra, Waltraud Kleist-Welch; Schroeder, Henry W S
Peripheral nerve palsy caused by torsional nerve injury is rare. Only a few patients have been reported in the literature. The etiology of this type of nerve lesion is poorly understood. To report on 5 patients presenting with peripheral nerve palsy caused by a torsional nerve injury. Five patients presented with 6 upper peripheral nerve palsy involving the axillary nerve (n = 2), musculocutaneous nerve (n = 2), radial nerve (n = 1), and suprascapular nerve (n = 1). There was no history of trauma in 3 patients, but in the other 2 patients, nerve palsy occurred after a traumatic event. Because of a lack of spontaneous recovery, surgical exploration was performed. Torsion of the whole nerve (n = 5) or only 1 fascicle (n = 1) was found. Epifascicular epineurectomy and detorsion, as well as resection of the torsion site with subsequent primary nerve suture, were performed in 3 lesions. Good to excellent recovery of motor function was achieved in all 5 patients. In the last patient who presented with 2 nerve torsions, the follow-up period after the last surgery is too short to allow evaluation. Although not a frequent event, torsional nerve injury should be taken into consideration when dealing with peripheral nerve injuries. Surgical exploration with detorsion or suture results in good recovery.
Gordon, Lynn K
Optic nerve diseases arise from many different etiologies including inflammatory, neoplastic, genetic, infectious, ischemic, and idiopathic. Understanding some of the characteristics of the most common optic neuropathies along with therapeutic approaches to these diseases is helpful in designing recommendations for individual patients. Although many optic neuropathies have no specific treatment, some do, and it is those potentially treatable or preventable conditions which need to be recognized in order to help patients regain their sight or develop a better understanding of their own prognosis. In this chapter several diseases are discussed including idiopathic intracranial hypertension, optic neuritis, ischemic optic neuropathies, hereditary optic neuropathies, trauma, and primary tumors of the optic nerve. For each condition there is a presentation of the signs and symptoms of the disease, in some conditions the evaluation and diagnostic criteria are highlighted, and where possible, current therapy or past trials are discussed.
Messina, Aurora; Van Zyl, Natasha; Weymouth, Michael; Flood, Stephen; Nunn, Andrew; Cooper, Catherine; Hahn, Jodie; Galea, Mary P.
Loss of hand function after cervical spinal cord injury (SCI) impacts heavily on independence. Multiple nerve transfer surgery has been applied successfully after cervical SCI to restore critical arm and hand functions, and the outcome depends on nerve integrity. Nerve integrity is assessed indirectly using muscle strength testing and intramuscular electromyography, but these measures cannot show the manifestation that SCI has on the peripheral nerves. We directly assessed the morphology of nerves biopsied at the time of surgery, from three patients within 18 months post injury. Our objective was to document their morphologic features. Donor nerves included teres minor, posterior axillary, brachialis, extensor carpi radialis brevis and supinator. Recipient nerves included triceps, posterior interosseus (PIN) and anterior interosseus nerves (AIN). They were fixed in glutaraldehyde, processed and embedded in Araldite Epon for light microscopy. Eighty percent of nerves showed abnormalities. Most common were myelin thickening and folding, demyelination, inflammation and a reduction of large myelinated axon density. Others were a thickened perineurium, oedematous endoneurium and Renaut bodies. Significantly, very thinly myelinated axons and groups of unmyelinated axons were observed indicating regenerative efforts. Abnormalities exist in both donor and recipient nerves and they differ in appearance and aetiology. The abnormalities observed may be preventable or reversible. PMID:27690115
McGee, Corey; O'Brien, Virginia; Van Nortwick, Sara; Adams, Julie; Van Heest, Ann
Hand therapists selectively strengthen the first dorsal interosseus (FDI) to stabilize arthritic joints yet the role of the FDI has not yet been radiographically validated. To determine if FDI contraction reduces radial subluxation (RS) of the thumb metacarpal (MC). Fluoroscopy was used to obtain true anterior-posterior radiographs of non-arthritic CMC joints: 1) at rest, 2) while stressed and 3) while stressed with maximal FDI contraction. Maximal FDI strength during CMC stress and thumb MC RS and trapezial articular width were measured. The ratio of RS to the articular width was calculated. Seventeen participants (5 male, 12 female) participated. Subluxation of a stressed CMC significantly reduced and the subluxation to articular width ratio significantly improved after FDI activation. Contraction of the FDI appears to radiographically reduce subluxation of the healthy thumb CMC joint. Further exploration on the FDI's reducibility and its carry-over effects in arthritic thumbs is needed. 4. Copyright © 2015 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.
Pressure distribution in the humeroradial joint and force transmission to the capitellum during rotation of the forearm: effects of the Sauvé-Kapandji procedure and incision of the interosseous membrane.
Ofuchi, S; Takahashi, K; Yamagata, M; Rokkaku, T; Moriya, H; Hara, T
A biomechanical study was undertaken, using four fresh cadaveric arms, to evaluate the changes in pressure distribution in the humeroradial joint (H-R joint) during rotation of the forearm before and after the Sauvé-Kapandji procedure (S-K procedure) and also after incision of the interosseous membrane (IOM) following the S-K procedure. The pressure distribution was measured with a pressure-sensitive conductive rubber sensor while the forearm was rotated. Force transmitted to the capitellum was calculated from the measured pressure. In the intact specimens, pressure was concentrated on the medial side of the capitellum in pronation and on the posterolateral side in supination. The pattern of change after the S-K procedure and that after incision of the IOM following the S-K procedure were almost the same as that in the intact forearm. Although the force transmitted to the capitellum increased after the S-K procedure, there were no significant differences between the forces before and after the S-K procedure. However, the force increased significantly after incision of the IOM following the S-K procedure when the forearm was supinated more than 35 degrees, and it was concentrated on the posterior side of the capitellum. The IOM seemed to have an important axial load-bearing function in the forearm position supinated more than 35 degrees. The S-K procedure in patients suffering from distal radioulnar joint disorders with IOM injury is likely to induce H-R joint osteoarthritis, so it should be avoided in these patients.
Youssef, A Samy; van Loveren, Harry R
The posterior clinoid process, a bony prominence at the superolateral aspect of the dorsum sellae, has a strategic importance in a transcavernous approach to basilar tip aneurysms. To further optimize this microsurgical technique during posterior clinoidectomy, we performed a cadaveric study of this regional anatomy, describe a technique called dural tailoring, and report initial results in the surgical treatment of upper basilar artery (BA) aneurysm. After 10 adult cadaver heads (silicone-injected) were prepared for dissection, a posterior clinoidectomy with dural tailoring was performed. The dura overlying the upper clivus was coagulated with bipolar electrocoagulation and incised. Stripping dura off the clivus and lateral reflection then exposed the ipsilateral posterior clinoid process and dorsum sellae, thus creating a dural flap. Posterior clinoidectomy with dural tailoring was then used in seven patients with upper BA aneurysms. Our stepwise modification of the posterior clinoidectomy with dural tailoring created a flap that afforded protection of the cavernous sinus and oculomotor nerve. During surgery, there were no recorded intraoperative injuries to neurovascular structures. One patient died postoperatively from morbidity related to severe-grade subarachnoid hemorrhage. Postoperative oculomotor nerve palsy occurred in 3 patients (43%). In all cases, the nerve was anatomically preserved and partial to complete recovery was recorded during the first postoperative year. This technique effectively provided exposure of retrosellar upper basilar aneurysms in seven patients (basilar tip 43% and superior cerebellar artery aneurysms 57%). Outcomes and safety are at least equivalent to or better than basilar aneurysm surgery performed without surgical adjuncts, presumably a less complex subset.
Yahagi, S; Kasai, T
We investigated changes in motor evoked potentials (MEPs) to explain why mental practice can improve motor performance. MEPs were recorded from right and left first dorsal interosseous (FDI) muscles of 9 normal, right-handed subjects during different motor images of index finger movement: (1) rest, (2) flexion, (3) abduction, (4) extension. A paired t test was used to compare differences of stimulus intensities and MEP amplitudes among conditions. MEP amplitudes significantly increased in both FDI muscles during motor images of flexion and abduction but not of extension. Moreover, MEP amplitudes were larger in flexion than in abduction. These differences were proportional to the amount of real EMG discharge of FDI muscle in the selected direction of index finger movement. With regard to right-left differences, MEP amplitudes in the right FDI muscle were larger than those in the left. The primary motor cortex plays a role in the mental representation of motor acts. Furthermore, the amount of corticomotoneuronal cell activity is affected by the different motor images utilizing the same muscle. Right-left difference of MEP amplitude supports the view of left-hemisphere dominance for motor programming as an aspect of normal brain function among right-handers.
Waters, Michael S; Werner, Frederick W; Haddad, Stefanos F; McGrattan, Michael L; Short, Walter H
To determine the relative roles of the dorsal and volar portions of the scapholunate interosseous ligament (SLIL) in the stability of the scaphoid and lunate. Sixteen fresh cadaver wrists were moved through physiological motions using a wrist joint simulator. Electromagnetic sensors measured the motion of the scaphoid and lunate. Data were collected with the wrist intact, after randomly sectioning the dorsal SLIL first (8 wrists) or the volar SLIL first (8 wrists), and after full ligamentous sectioning. Differences in the percent increase in scaphoid flexion or lunate extension were compared using a t test with significance set at P < .05. Sectioning the dorsal SLIL accounted for 37%, 72%, and 68% of the increase in scaphoid flexion in wrist flexion-extension, radioulnar deviation, and dart throw motion as compared with complete SLIL sectioning. Sectioning the volar SLIL accounted for only 7%, 6%, and 14%, respectively. In the same 3 motions, sectioning the dorsal SLIL accounted for 55%, 57%, and 58% of the increase in lunate extension, whereas volar SLIL sectioning accounted for 27%, 28%, and 22%. The dorsal SLIL provides more stability to the scaphoid and lunate in biomechanical testing. The volar SLIL does provide some, although less, stability. Although this study supports the critical importance of dorsal SLIL repairs or reconstructions, it also shows that there may be some value in implementing a volar SLIL repair or reconstruction. Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Wahab, Salima S.; Hettige, Samantha; Mankad, Kshtij
Posterior fossa syndrome (PFS), or cerebellar mutism syndrome (CMS), is a collection of neurological symptoms that occur following surgical resection of a posterior fossa tumour, and is characterised by either a reduction or an absence of speech. Some authors suggest that CM is only one symptom of the CMS complex that also includes ataxia, hypotonia and irritability as well as cranial nerve deficits, neurobehavioral changes and urinary retention or incontinence. It is seen almost exclusively in children. In 1985 Rekate et al. published the first work describing CM as a clinical entity, occurring as a consequence of bilateral cerebellar injury. Other associated symptoms include visual impairment, altered mood, impaired swallowing and significant gross and fine motor deficits. The effects of this can have a devastating impact on both the patient and their carers, posing a significant clinical challenge to neurorehabilitation services. The reported incidence was between 8% and 31% of children undergoing surgery for posterior fossa tumour. The underlying pathologies include vasospasm, oedema, and axonal/neuronal injury. Neuroimaging has contributed to a better understanding of the anatomical location of postoperative injury. There have been a number of suggestions for treatment interventions for PFS. However, apart from some individual reports, there have been no clinical trials indicating possible benefit. Occupational therapy, speech and language therapy, as well as neurocognitive support, contribute to the recovery of these patients. PMID:27942479
Flores, Leandro Pretto
The results of surgical repair of the fibular division of the sciatic nerve have been considered unsatisfactory, especially if grafts are necessary to reconstruct the nerve. To consider the clinical application of the concept of distal nerve transfer for the treatment of high sciatic nerve injuries, this study aimed to determine detailed anatomic data about the possible donor branches from the tibial nerve that are available for reinnervation of the deep fibular nerve at the level of the popliteal fossa. An anatomic study was performed that included the dissection of the popliteal fossa in 12 lower limbs of 6 formalin-fixed adult cadavers. It focused on the detailed anatomy of the tibial nerve and its branches at the level of the proximal leg as well as the anatomy of the common fibular nerve and its largest divisions at the level of the neck of the fibula, i.e., the deep and superficial fibular nerves. The branches of the tibial nerve destined to the lateral and medial head of the gastrocnemius had a mean length of 43 mm and 35 mm, respectively. The branch to the posterior soleus muscle had a mean length of 65 mm. Intraneural dissection of the common fibular nerve, isolating its deep and superficial fibular divisions, was possible to a proximal mean distance of 71 mm. A tensionless direct suture to the deep fibular nerve was made possible by using the nerve to the lateral head of the gastrocnemius and the nerve to the posterior soleus muscle in all specimens. Direct suture of the nerve to the medial head of the gastrocnemius was possible in all cases except 1. The nerve to the lateral and medial heads of the gastrocnemius and the nerve to the posterior soleus muscle can be used as donors to restore function of the deep fibular nerve in cases of high sciatic nerve injury. However, proximal intraneural dissection of the deep fibular division of the common fibular nerve must also be performed. We recommend that the nerve to the posterior soleus muscle should be the
Kim, Yeon Dong; Yu, Jae Yong; Shim, Junho; Heo, Hyun Joo
Background Recently, ultrasound has been commonly used. Ultrasound-guided interscalene brachial plexus block (IBPB) by posterior approach is more commonly used because anterior approach has been reported to have the risk of phrenic nerve injury. However, posterior approach also has the risk of causing nerve injury because there are risks of encountering dorsal scapular nerve (DSN) and long thoracic nerve (LTN). Therefore, the aim of this study was to evaluate the risk of encountering DSN and LTN during ultrasound-guided IBPB by posterior approach. Methods A total of 70 patients who were scheduled for shoulder surgery were enrolled in this study. After deciding insertion site with ultrasound, awake ultrasound-guided IBPB with nerve stimulator by posterior approach was performed. Incidence of muscle twitches (rhomboids, levator scapulae, and serratus anterior muscles) and current intensity immediately before muscle twitches disappeared were recorded. Results Of the total 70 cases, DSN was encountered in 44 cases (62.8%) and LTN was encountered in 15 cases (21.4%). Both nerves were encountered in 10 cases (14.3%). Neither was encountered in 21 cases (30.4%). The average current measured immediately before the disappearance of muscle twitches was 0.44 mA and 0.50 mA at DSN and LTN, respectively. Conclusions Physicians should be cautious on the risk of injury related to the anatomical structures of nerves, including DSN and LTN, during ultrasound-guided IBPB by posterior approach. Nerve stimulator could be another option for a safer intervention. Moreover, if there is a motor response, it is recommended to select another way to secure better safety. PMID:27413483
Approximately 20-25% of all acute strokes occur in the posterior circulation. These strokes can be rather difficult to diagnose because they present in such diverse ways, and can easily be mistaken for more benign entities. A fastidious history, physical exam, high clinical suspicion, and appropriate use of imaging are essential for the emergency physician to properly diagnose and treat these patients. Expert stroke neurologist consultation should be utilized liberally.
Solyga, Volker Moræus; Western, Elin; Solheim, Hanne; Hassel, Bjørnar; Kerty, Emilia
Posterior cortical atrophy is a neurodegenerative condition with atrophy of posterior parts of the cerebral cortex, including the visual cortex and parts of the parietal and temporal cortices. It presents early, in the 50s or 60s, with nonspecific visual disturbances that are often misinterpreted as ophthalmological, which can delay the diagnosis. The purpose of this article is to present current knowledge about symptoms, diagnostics and treatment of this condition. The review is based on a selection of relevant articles in PubMed and on the authors' own experience with the patient group. Posterior cortical atrophy causes gradually increasing impairment in reading, distance judgement, and the ability to perceive complex images. Examination of higher visual functions, neuropsychological testing, and neuroimaging contribute to diagnosis. In the early stages, patients do not have problems with memory or insight, but cognitive impairment and dementia can develop. It is unclear whether the condition is a variant of Alzheimer's disease, or whether it is a separate disease entity. There is no established treatment, but practical measures such as the aid of social care workers, telephones with large keypads, computers with voice recognition software and audiobooks can be useful. Currently available treatment has very limited effect on the disease itself. Nevertheless it is important to identify and diagnose the condition in its early stages in order to be able to offer patients practical assistance in their daily lives.
Brelin, Alaina; Dickens, Jonathan F
Posterior shoulder instability is a relatively uncommon condition, occurring in ∼10% of those with shoulder instability. Because of the rarity of the condition and the lack of knowledge in treatment, it is often misdiagnosed or patients experience a delay in diagnosis. Posterior instability typically affects athletes participating in contact or overhead sports and is usually the result of repetitive microtrauma or blunt force with the shoulder in the provocative position of flexion, adduction, and internal rotation, leading to recurrent subluxation events. Acute traumatic posterior dislocations are rare injuries with an incidence rate of 1.1 per 100,000 person years. This rate is ∼20 times lower than that of anterior shoulder dislocations. Risk factors for recurrent instability are: (1) age below 40 at time of first instability; (2) dislocation during a seizure; (3) a large reverse Hill-Sachs lesion; and (4) glenoid retroversion. A firm understanding of the pathoanatomy, along with pertinent clinical and diagnostic modalities is required to accurately diagnosis and manage this condition.
Barth, William H
Persistent occiput posterior (OP) is associated with increased rates of maternal and newborn morbidity. Its diagnosis by physical examination is challenging but is improved with bedside ultrasonography. Occiput posterior discovered in the active phase or early second stage of labor usually resolves spontaneously. When it does not, prophylactic manual rotation may decrease persistent OP and its associated complications. When delivery is indicated for arrest of descent in the setting of persistent OP, a pragmatic approach is suggested. Suspected fetal macrosomia, a biparietal diameter above the pelvic inlet or a maternal pelvis with android features should prompt cesarean delivery. Nonrotational operative vaginal delivery is appropriate when the maternal pelvis has a narrow anterior segment but ample room posteriorly, like with anthropoid features. When all other conditions are met and the fetal head arrests in an OP position in a patient with gynecoid pelvic features and ample room anteriorly, options include cesarean delivery, nonrotational operative vaginal delivery, and rotational procedures, either manual or with the use of rotational forceps. Recent literature suggests that maternal and fetal outcomes with rotational forceps are better than those reported in older series. Although not without significant challenges, a role remains for teaching and practicing selected rotational forceps operations in contemporary obstetrics.
... polyneuropathy Tibial nerve dysfunction Ulnar nerve dysfunction Any peripheral neuropathy can cause abnormal results. Damage to the spinal ... Herniated disk Lambert-Eaton syndrome Mononeuropathy Multiple ... azotemia Primary amyloidosis Radial nerve dysfunction Sciatica ...
Park, Su Kyeong; Kong, Kyoung Ae; Cha, Eun Shil; Lee, Young Joo; Lee, Gyu Taek; Lee, Won Jin
This study aimed to determine whether occupational exposure to pesticides was associated with decreased nerve conduction studies among farmers. On 2 separate occasions, the authors performed a cross-sectional study of a group of 31 male farmers who periodically applied pesticides. The study included questionnaire interviews and nerve conduction studies on the median, ulnar, posterior tibial, peroneal, and sural nerves. Although all mean values remained within laboratory normal limits, significant differences between the first and second tests were found in sensory conduction velocities on the median and sural nerves, and motor conduction velocities on the posterior tibial nerve. Lifetime days of pesticide application was negatively associated with nerve conduction velocities at most nerves after adjusting for potential confounders. These findings may reflect a link between occupational pesticide exposure and peripheral neurophysiologic abnormality that deserves further evaluation.
Tabachnikova, T V; Serova, N K; Shimansky, V N
Over 200 patients with acoustic neuromas and over 100 patients with posterior cranial fossa meningiomas are annually operated on at the N.N. Burdenko Neurosurgical Institute. Intraoperative monitoring of the facial nerve function is used in most patients with tumors of the posterior cranial fossa to identify the facial nerve in the surgical wound. If the anatomical integrity of the facial nerve in the cranial cavity cannot be retained, facial nerve repair is performed to restore the facial muscle function. Intraoperative electrical stimulation of the facial nerve has a great prognostic significance to evaluate the dynamics of lagophthalmos in the late postoperative period and to select the proper method for lagophthalmos correction. When the facial nerve was reinnervated by the descending branch or trunk of the hypoglossal nerve, sufficient eyelid closure was observed only in 3 patients out of 17.
Tennent, T. D.; Chambler, A. F.; Rossouw, D. J.
Injuries in basketball are usually to the ankles and knees. Dislocation of the hip is usually associated with severe trauma--for example, road traffic accidents. A case is reported here in which a 22 year old club basketball player slipped on landing from a jump shot, forcing him into a side splits position from which he sustained a posterior dislocation of the hip resulting in a sciatic nerve palsy. PMID:9865411
Golshani, Kiarash; Ferrell, Andrew; Zomorodi, Ali; Smith, Tony P.; Britz, Gavin W.
Background: Technical advancements have significantly improved surgical and endovascular treatment of cerebral aneurysms. In this paper, we review the literature with regard to treatment of one of the most common intra-cranial aneurysms encountered by neurosurgeons and interventional radiologists. Conclusions: Anterior clinoidectomy, temporary clipping, adenosine-induced cardiac arrest, and intraoperative angiography are useful adjuncts during surgical clipping of these aneurysms. Coil embolization is also an effective treatment alternative particularly in the elderly population. However, coiled posterior communicating artery aneurysms have a particularly high risk of recurrence and must be followed closely. Posterior communicating artery aneurysms with an elongated fundus, true posterior communicating artery aneurysms, and aneurysms associated with a fetal posterior communicating artery may have better outcome with surgical clipping in terms of completeness of occlusion and preservation of the posterior communicating artery. However, as endovascular technology improves, endovascular treatment of posterior communicating artery aneurysms may become equivalent or preferable in the near future. One in five patients with a posterior communicating artery aneurysm present with occulomotor nerve palsy with or without subarachnoid hemorrhage. Factors associated with a higher likelihood of recovery include time to treatment, partial third nerve deficit, and presence of subarachnoid hemorrhage. Both surgical and endovascular therapy offer a reasonable chance of recovery. Based on level 2 evidence, clipping appears to offer a higher chance of occulomotor nerve palsy recovery; however, coiling will remain as an option particularly in elderly patients or patients with significant comorbidity. PMID:21206898
Kokkalis, Zinon T; Mavrogenis, Andreas F; Ballas, Efstathios G; Papagelopoulos, Panayiotis J; Soucacos, Panayotis N
Nerve wrapping materials have been manufactured to inhibit nerve tissue adhesions and diminish inflammatory and immunologic reactions in nerve surgery. Collagen nerve wrap is a biodegradable type I collagen material that acts as an interface between the nerve and the surrounding tissues. Its main advantage is that it stays in place during the period of tissue healing and is then gradually absorbed once tissue healing is completed. This article presents a surgical technique that used a collagen nerve wrap for the management of median nerve tissue adhesions in 2 patients with advanced carpal tunnel syndrome due to median nerve scarring and adhesions. At last follow-up, both patients had complete resolution with no recurrence of their symptoms. Complications related to the biodegradable material were not observed. Copyright 2015, SLACK Incorporated.
Coulter, Jess M; Warme, Winston J
We report an unusual case of spinal accessory nerve palsy sustained while transporting climbing gear. Spinal accessory nerve injury is commonly a result of iatrogenic surgical trauma during lymph node excision. This particular nerve is less frequently injured by blunt trauma. The case reported here results from compression of the spinal accessory nerve for a sustained period-that is, carrying a load over the shoulder using a single nylon rope for 2.5 hours. This highlights the importance of using proper load-carrying equipment to distribute weight over a greater surface area to avoid nerve compression in the posterior triangle of the neck. The signs and symptoms of spinal accessory nerve palsy and its etiology are discussed. This report is particularly relevant to individuals involved in mountaineering and rock climbing but can be extended to anyone carrying a load with a strap over one shoulder and across the body.
Blatt, F. J.
Summarizes research done on the resting and action potential of nerve impulses, electrical excitation of nerve cells, electrical properties of Nitella, and temperature effects on action potential. (GS)
Blatt, F. J.
Summarizes research done on the resting and action potential of nerve impulses, electrical excitation of nerve cells, electrical properties of Nitella, and temperature effects on action potential. (GS)
van Kampen, Robert J.; Bayne, Christopher O.; Moran, Steven L.
Introduction Most surgical techniques for scapholunate interosseous ligament (SLIL) repair address only the dorsal component of the ligament, potentially leading to high surgical failure rates. We introduce a new technique to reconstruct the volar SLIL using a portion of the long radiolunate ligament (LRL). A biomechanical evaluation was performed to evaluate the rupture strength of this repair, and a subsequent anatomic study was performed to verify that this repair would not compromise the blood supply to either the scaphoid or the lunate. Methods A reconstruction of the volar SLIL was developed utilizing a lunate-based strip of the LRL. Fourteen cadaver arms were injected with red-colored epoxide and latex. The blood supply of the volar wrist capsule was dissected. The vascular supply to the ligaments, scaphoid, and lunate were investigated. The biomechanical strength of this reconstruction was tested on five cadaver arms by potting the scaphoid, lunate, and radius and subjecting the repair to a tensile load using a servohydraulic vertical displacement testing machine. Results In all arms, a branch of the radial artery or radiocarpal arch supplied the radioscapholunate ligament at the medial border of the LRL. The proximal half of the scaphoid was supplied by dorsal branches of the radial artery. In all cases, a vessel entered the lunate on its ulnar volar side, away from the repair. The average strength of the intact LRL strip was 97.4 N, and the average strength of the ligament-suture interface used for the capsulodesis was 43.5 N. Conclusion This volar approach to the SLIL does not compromise the vascularity of the scaphoid or the lunate. This approach allows the possibility of repairing or augmenting the volar SLIL. The strength of this repair appears to be less than the strength of the native SLIL. Further clinical studies are warranted. PMID:26539326
Bhatt, Neel K; Mejias, Christopher; Kallogjeri, Dorina; Gale, Derrick C; Park, Andrea M; Paniello, Randal C
Cranial nerve transection during head and neck surgery is conventionally repaired by microsuture reanastomosis. Laser nerve welding (LNW), using CO2 laser to spot-weld the epineurium of transected nerve endings, has been shown in animal models to be a novel alternative to microsuture repair. This method avoids needle/suture material and minimizes instrumentation of the nerve. We hypothesized that potassium titanyl phosphate (KTP) laser would be superior to CO2 laser in repairing transected nerves. Using a rat posterior tibial nerve injury model, we compared CO2 laser, KTP laser, and microsuture reanastomosis. Animal study. Animals underwent unilateral posterior tibial nerve transection. The injury was repaired by microsuture repair (n = 15), CO2 laser repair (n = 15), or KTP laser repair (n = 15). Weekly walking tracks were performed to measure functional recovery. Nerve segments were harvested for axon counting. At 6 weeks, the KTP LNW had the best functional recovery (92.4 ± 8.6%) compared to microsuture repair (84.5 ± 10.2%, difference 7.9%, 95% confidence interval [CI]: 0.84%-14.96%). CO2 laser repair had a functional recovery of 86.8 ± 11.2%. KTP LNW had better axon recovery compared to transection/repair (difference 530.7 axons, 95% CI: 329.9-731.5). Operative time for the microsuture repair was 18.2 ± 6.8 minutes, compared to 5.8 ± 3.7 minutes for the LNW groups (difference 12.4 minutes, 95% CI: 8.6-16.2 minutes). KTP, CO2 , and microsuture repair all showed good functional recovery following complete transection of the posterior tibial nerve. Following complete nerve transection during head and neck surgery, KTP LNW may be a novel alternative to microsuture repair. NA Laryngoscope, 127:1525-1530, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.
Weijs, Teus J; Ruurda, Jelle P; Luyer, Misha D P; Nieuwenhuijzen, Grard A P; van Hillegersberg, Richard; Bleys, Ronald L A W
Pulmonary complications are frequently observed after transthoracic oesophagectomy. These complications may be reduced by sparing the vagus nerve branches to the lung. However, current descriptions of the regional anatomy are insufficient. Therefore, we aimed to provide a highly detailed description of the course of the pulmonary vagus nerve branches. In six fixed adult human cadavers, bilateral microscopic dissection of the vagus nerve branches to the lungs was performed. The level of branching and the number, calibre and distribution of nerve branches were described. Nerve fibres were identified using neurofilament immunohistochemistry, and the nerve calibre was measured using computerized image analysis. Both lungs were supplied by a predominant posterior and a smaller anterior nerve plexus. The right lung was supplied by 13 (10-18) posterior and 3 (2-3) anterior branches containing 77% (62-100%) and 23% (0-38%) of the lung nerve supply, respectively. The left lung was supplied by a median of 12 (8-13) posterior and 3 (2-4) anterior branches containing 74% (60-84%) and 26% (16-40%) of the left lung nerve supply, respectively. During transthoracic oesophagectomy with en bloc lymphadenectomy and transection of the vagus nerves at the level of the azygos vein, 68-100% of the right lung nerve supply and 86-100% of the inferior left lung lobe nerve supply were severed. When vagotomy was performed distally to the last large pulmonary branch, 0-8% and 0-13% of the nerve branches to the right middle/inferior lobes and left inferior lobe, respectively, were lost. In conclusion, this study provides a detailed description of the extensive pulmonary nerve supply provided by the vagus nerves. During oesophagectomy, extensive mediastinal lymphadenectomy denervates the lung to a great extent; however, this can be prevented by performing the vagotomy distal to the caudalmost large pulmonary branch. Further research is required to determine the feasibility of sparing the
Brachial plexus is complex network of nerves, formed by joining and splitting of ventral rami of spinal nerves C5, C6, C7, C8, and T1 forming trunks, divisions, and cords. The nerves emerging from trunks and cords innervate the upper limb and to some extent pectoral region. Scanty literature describes the variations in the formation of cords and nerves emanating from them. Moreover, the variations of cords of brachial plexus and nerves emanating from them have iatrogenic implications in the upper limb and pectoral region. Hence study has been carried out. Twenty-eight upper limbs and posterior triangles from 14 cadavers fixed in formalin were dissected and rare and new variations of cords were observed. Most common variation consisted of formation of posterior cord by fusion of posterior division of upper and middle trunk and lower trunk continued as medial cord followed by originating of 2 pectoral nerves from anterior divisions of upper and middle trunk. Other variations include anterior division of upper trunk continued as lateral cord and pierced the coracobrachialis, upper and middle trunk fused to form common cord which divided into lateral and posterior cords, upper trunk gave suprascapular nerve and abnormal lateral pectoral nerve and formation of median nerve by 3 roots. These variations were analyzed for diagnostic and clinical significance making the study relevant for surgeons, radiologists in arresting failure patients and anatomists academically in medical education.
Gelman, Joel; Wisenbaugh, Eric S.
Pelvic fracture urethral injuries are typically partial and more often complete disruptions of the most proximal bulbar and distal membranous urethra. Emergency management includes suprapubic tube placement. Subsequent primary realignment to place a urethral catheter remains a controversial topic, but what is not controversial is that when there is the development of a stricture (which is usually obliterative with a distraction defect) after suprapubic tube placement or urethral catheter removal, the standard of care is delayed urethral reconstruction with excision and primary anastomosis. This paper reviews the management of patients who suffer pelvic fracture urethral injuries and the techniques of preoperative urethral imaging and subsequent posterior urethroplasty. PMID:26691883
Feola, Andrew; Raykin, Julia; Mulugeta, Lealem; Gleason, Rudolph; Myers, Jerry G.; Nelson, Emily S.; Samuels, Brian; Ethier, C. Ross
Microgravity experienced during spaceflight affects astronauts in various ways, including weakened muscles and loss of bone density. Recently, visual impairment and intracranial pressure (VIIP) syndrome has become a major concern for space missions lasting longer than 30 days. Astronauts suffering from VIIP syndrome have changes in ocular anatomical and visual impairment that persist after returning to earth. It is hypothesized that a cephalad fluid shift in microgravity may increase the intracranial pressure (ICP), which leads to an altered biomechanical environment of the posterior globe and optic nerve sheath (ONS).Currently, there is a lack of knowledge of how elevated ICP may lead to vision impairment and connective tissue changes in VIIP. Our goal was to develop a finite element model to simulate the acute effects of elevated ICP on the posterior eye and optic nerve sheath. We used a finite element (FE) analysis approach to understand the response of the lamina cribrosa and optic nerve to the elevations in ICP thought to occur in microgravity and to identify which tissue components have the greatest impact on strain experienced by optic nerve head tissues.
Wang, Yan; Brown, Dale P; Duan, Yuanli; Kong, Wei; Watson, Brant D; Goldberg, Jeffrey L
To develop a reliable, reproducible rat model of posterior ischemic optic neuropathy (PION) and study the cellular responses in the optic nerve and retina. Posterior ischemic optic neuropathy was induced in adult rats by photochemically induced ischemia. Retinal and optic nerve vasculature was examined by fluorescein isothiocyanate–dextran extravasation. Tissue sectioning and immunohistochemistry were used to investigate the pathologic changes. Retinal ganglion cell survival at different times after PION induction, with or without neurotrophic application, was quantified by fluorogold retrograde labeling. Optic nerve injury was confirmed after PION induction, including local vascular leakage, optic nerve edema, and cavernous degeneration. Immunostaining data revealed microglial activation and focal loss of astrocytes, with adjacent astrocytic hypertrophy. Up to 23%, 50%, and 70% retinal ganglion cell loss was observed at 1 week, 2 weeks, and 3 weeks, respectively, after injury compared with a sham control group. Experimental treatment by brain-derived neurotrophic factor and ciliary neurotrophic factor remarkably prevented retinal ganglion cell loss in PION rats. At 3 weeks after injury, more than 40% of retinal ganglion cells were saved by the application of neurotrophic factors. Rat PION created by photochemically induced ischemia is a reproducible and reliable animal model for mimicking the key features of human PION. The correspondence between the features of this rat PION model to those of human PION makes it an ideal model to study the pathophysiologic course of the disease, most of which remains to be elucidated. Furthermore, it provides an optimal model for testing therapeutic approaches for optic neuropathies.
Introduction: Sciatic Nerve (SN) is the nerve of the posterior compartment of thigh formed in the pelvis from the ventral rami of the L4 to S3 spinal nerves. It leaves the pelvis via the greater sciatic foramen below piriformis and divides into Common Peroneal Nerve (CPN) and Tibial Nerve (TN) at the level of the upper angle of the popliteal fossa. Higher division of the sciatic nerve is the most common variation where the TN and CPN may leave the pelvis through different routes. Such variation may lead to compression of the nerve and lead to Non-discogenic sciatica. Materials and Methods: Fifty lower limbs were used for the study from Department of Anatomy, J.J.M.M.C Davangere, Karnataka, India. Observation and Results: In our study on 25 cadavers (50 lower limbs), we have observed 4 (8 %) lower limbs high division of sciatic nerve was noted. High division of sciatic nerve in the back of thigh was noted in one specimen (2%), while high division within the pelvis was noted in 3 specimens (6%), while in 46 (92%) it occurred outside the pelvis. Conclusion: Knowledge regarding such variation and differences in the course of SN is important for the surgeons to plan for various surgical interventions pertaining to the gluteal region. The variant anatomy of SN may cause piriformis syndrome and failure of SN block. Hence present study is undertaken to know the level of division, exit, course, relationship to piriformis and variations in the branching pattern of SN. PMID:25302181
Sellards, Robb; Kuebrich, Chris
This article deals with common injuries to the elbow. Elbow anatomy is reviewed. Diagnosis and treatment of pronator syndrome,lateral epicondylitis (tennis elbow), radial tunnel syndrome, posterior interosseous nerve syndrome, medial epicondylitis (golfer's elbow), ulnar collateral ligament injury, cubital tunnel syndrome,posterolateral rotatory instability, distal biceps injuries, tricepstendon injuries, and posterior elbow impingement are discussed.
Crutch, Sebastian J; Lehmann, Manja; Schott, Jonathan M; Rabinovici, Gil D; Rossor, Martin N; Fox, Nick C
Posterior cortical atrophy (PCA) is a neurodegenerative syndrome that is characterized by a progressive decline in visuospatial, visuoperceptual, literacy and praxic skills. The progressive neurodegeneration affecting parietal, occipital and occipito-temporal cortices which underlies PCA is attributable to Alzheimer's disease (AD) in the majority of patients. However, alternative underlying aetiologies including Dementia with Lewy Bodies (DLB), corticobasal degeneration (CBD) and prion disease have also been identified, and not all PCA patients have atrophy on clinical imaging. This heterogeneity has led to diagnostic and terminological inconsistencies, caused difficulty comparing studies from different centres, and limited the generalizability of clinical trials and investigations of factors driving phenotypic variability. Significant challenges remain in identifying the factors associated with both the selective vulnerability of posterior cortical regions and the young age of onset seen in PCA. Greater awareness of the syndrome and agreement over the correspondence between syndrome-and disease-level classifications are required in order to improve diagnostic accuracy, research study design and clinical management. PMID:22265212
... Español Eye Health / Eye Health A-Z Microvascular Cranial Nerve Palsy Sections What Is Microvascular Cranial Nerve Palsy? ... Microvascular Cranial Nerve Palsy Treatment What Is Microvascular Cranial Nerve Palsy? Leer en Español: ¿Qué Es una Parálisis ...
Cavalcanti, Daniel D; Garcia-Gonzalez, Ulises; Agrawal, Abhishek; Tavares, Paulo L M S; Spetzler, Robert F; Preul, Mark C
The lower cranial nerves must be identified to avoid iatrogenic injury during skull base and high cervical approaches. Prompt recognition of these structures using basic landmarks could reduce surgical time and morbidity. The anterior triangle of the neck was dissected in 30 cadaveric head sides. The most superficial segments of the glossopharyngeal, vagus and its superior laryngeal nerves, accessory, and hypoglossal nerves were exposed and designated into smaller anatomic triangles. The midpoint of each nerve segment inside the triangles was correlated to the angle of the mandible (AM), mastoid tip (MT), and bifurcation of the common carotid artery. A triangle bounded by the styloglossus muscle, external carotid artery, and facial artery housed the glossopharyngeal nerve. This nerve segment was 0.06 ± 0.71 cm posterior to the AM and 2.50 ± 0.59 cm inferior to the MT. The vagus nerve ran inside the carotid sheath posterior to internal carotid artery and common carotid artery bifurcation in 48.3% of specimens. A triangle formed by the posterior belly of digastric muscle, sternocleidomastoid muscle, and internal jugular vein housed the accessory nerve, 1.90 ± 0.60 cm posterior to the AM and 2.30 ± 0.57 cm inferior to the MT. A triangle outlined by the posterior belly of digastric muscle, internal jugular vein, and common facial vein housed the hypoglossal nerve, which was 0.82 ± 0.84 cm posterior to the AM and 3.64 ± 0.70 cm inferior to the MT. Comprehensible landmarks can be defined to help expose the lower cranial nerves to avoid injury to this complex region. Copyright © 2010 Elsevier Inc. All rights reserved.
Mangat, K S; Martin, A G; Bache, C E
We compared two management strategies for the perfused but pulseless hand after stabilisation of a Gartland type III supracondylar fracture. We identified 19 patients, of whom 11 were treated conservatively after closed reduction (group 1). Four required secondary exploration, of whom three had median and/or anterior interosseus nerve palsy at presentation. All four were found to have tethering or entrapment of both nerve and vessel at the fracture site. Only two regained patency of the brachial artery, and one patient has a persistent neurological deficit. In six of the eight patients who were explored early (group 2) the vessel was tethered at the fracture site. In group 2 four patients also had a nerve palsy at presentation and were similarly found to have tethering or entrapment of both the nerve and the vessel. The patency of the brachial artery was restored in all six cases and their neurological deficits recovered completely. We would recommend early exploration of a Gartland type III supracondylar fracture in patients who present with a coexisting anterior interosseous or median nerve palsy, as these appear to be strongly predictive of nerve and vessel entrapment.
Moisi, Marc; Fisahn, Christian; Tkachenko, Lara; Jeyamohan, Shiveindra; Reintjes, Stephen; Grunert, Peter; Norvell, Daniel C; Tubbs, R Shane; Page, Jeni; Newell, David W; Nora, Peter; Oskouian, Rod J; Chapman, Jens
OBJECTIVE Posterior atlantoaxial stabilization and fusion using C-1 lateral mass screw fixation has become commonly used in the treatment of instability and for reconstructive indications since its introduction by Goel and Laheri in 1994 and modification by Harms in 2001. Placement of such lateral mass screws can be challenging because of the proximity to the spinal cord, vertebral artery, an extensive venous plexus, and the C-2 nerve root, which overlies the designated starting point on the posterior center of the lateral mass. An alternative posterior access point starting on the posterior arch of C-1 could provide a C-2 nerve root-sparing starting point for screw placement, with the potential benefit of greater directional control and simpler trajectory. The authors present a cadaveric study comparing an alternative strategy (i.e., a C-1 screw with a posterior arch starting point) to the conventional strategy (i.e., using the lower lateral mass entry site), specifically assessing the safety of screw placement to preserve the C-2 nerve root. METHODS Five US-trained spine fellows instrumented 17 fresh human cadaveric heads using the Goel/Harms C-1 lateral mass (GHLM) technique on the left and the posterior arch lateral mass (PALM) technique on the right, under fluoroscopic guidance. After screw placement, a CT scan was obtained on each specimen to assess for radiographic screw placement accuracy. Four faculty spine surgeons, blinded to the surgeon who instrumented the cadaver, independently graded the quality of screw placement using a modified Upendra classification. RESULTS Of the 17 specimens, the C-2 nerve root was anatomically impinged in 13 (76.5%) of the specimens. The GHLM technique was graded Type 1 or 2, which is considered "acceptable," in 12 specimens (70.6%), and graded Type 3 or 4 ("unacceptable") in 5 specimens (29.4%). In contrast, the PALM technique had 17 (100%) of 17 graded Type 1 or 2 (p = 0.015). There were no vertebral artery injuries found
Lartigue, C; Roualdès, G; Muckensturm, B; Mesz, M; Deglaire, B
Dysphagia due to a traumatic lesion of the foramen lacerum posterior is relatively rare. Two cases are described in which swallowing troubles were perceived when the post-traumatic coma improved; these were ascribed to a traumatic lesion of the foramen lacerum posterior injuring the cranial nerves. Treatment involves preventing inhalation and nasogastric feeding whilst starting active and early rehabilitation of swallowing. Recovery is possible in most cases without surgery.
Kudoh, H; Sakai, T; Horiguchi, M
Twenty-four human legs were dissected macroscopically to study the morphological details of the accessory deep peroneal nerve. This nerve arose from the superficial peroneal nerve and descended in the lateral compartment of the leg, deep to peroneus longus along the posterior border of peroneus brevis. Approaching the ankle joint, this nerve passed through the peroneal tunnels to wind around the lateral malleolus; it then crossed beneath the peroneus brevis tendon anteriorly to reach the dorsum of the foot. The accessory deep peroneal nerve was found in every case examined and constantly gave off muscular branches to peroneus brevis and sensory branches to the ankle region. In addition, this nerve occasionally had muscular branches to peroneus longus and extensor digitorum brevis, and sensory branches to the fibula and the foot. The anomalous muscles around the lateral malleolus were also innervated by this nerve. Neither cutaneous branches nor communicating branches with other nerves were found. The present study reveals that the accessory deep peroneal nerve is consistently present and possesses a proper motor and sensory distribution in the lateral region of the leg and ankle. It is not an anomalous nerve as has previously been suggested.
Sanches, Marco Antonio; Ramalho, Gabriel Cardoso; Manzi, Marcello Roberto
Bone resorption of the posterior mandible can result in diminished bone edge and, therefore, the installation of implants in these regions becomes a challenge, especially in the presence of the mandibular canal and its contents, the inferior alveolar nerve. Several treatment alternatives are suggested: the use of short implants, guided bone regeneration, appositional bone grafting, distraction osteogenesis, inclined implants tangential to the mandibular canal, and the lateralization of the inferior alveolar nerve. The aim was to elucidate the success rate of implants in the lateralization technique and in inferior alveolar nerve transposition and to determine the most effective sensory test. We conclude that the success rate is linked to the possibility of installing implants with long bicortical anchor which favors primary stability and biomechanics. PMID:27433360
The keratoprosthesis is the last solution for corneally blind patients that cannot benefit from corneal transplants. Keratoprostheses that have been designed to be affixed anteriorly usually necessitate multi-step surgical procedures and are continuously subjected to the extrusion forces generated by the positive intraocular pressure; therefore, clinical results in patients prove inconsistent. We proposed a novel keratoprosthesis concept that utilizes posterior corneal fixation which `a priori' minimizes the risk of aqueous leakage and expulsion. This prosthesis is implanted in a single procedure thereby reducing the number of surgical complications normally associated with anterior fixation devices. In addition, its novel design makes this keratoprosthesis implantable in phakic eyes. With an average follow-up of 13 months (range 3 to 25 months), our results on 21 cases are encouraging. Half of the keratoprostheses were implanted in severe burn cases, with the remainder in cases of pseudo- pemphigus. Good visual results and cosmetic appearance were obtained in 14 of 21 eyes.
Petrović, Branko; Kostić, Vladimir; Sternić, Nadezda; Kolar, Jovo; Tasić, Nebojsa
Reversible Posterior Leukoencephalopathy Syndrome was introduced into clinical practice in 1996 in order to describe unique syndrome, clinically expressed during hypertensive and uremic encephalopathy, eclampsia and during immunosuppressive therapy . First clinical investigations showed that leucoencephalopathy is major characteristic of the syndrome, but further investigations showed no significant destruction in white cerebral tissue [2, 3, 4]. In majority of cases changes are localise in posterior irrigation area of the brain and in the most severe cases anterior region is also involved. Taking into consideration all above mentioned facts, the suggested term was Posterior Reversible Encephalopathy Syndrome (PRES) for the syndrome clinically expressed by neurological manifestations derived from cortical and subcortical changes localised in posterior regions of cerebral hemispheres, cerebral trunk and cerebellum . Patient, aged 53 years, was re-hospitalized in Cardiovascular Institute "Dediwe" two months after successful aorto-coronary bypass performed in June 2001 due to the chest bone infection. During the treatment of the infection (according to the antibiogram) in September 2001, patient in evening hours developed headache and blurred vision. The recorded blood pressure was 210/120 mmHg so antihypertensive treatment was applied (Nifedipin and Furosemid). After this therapy there was no improvement and intensive headache with fatigue and loss of vision developed. Neurological examination revealed cortical blindness and left hemiparesis. Manitol (20%, 60 ccm every 3 hours) and i.v. Nytroglicerin (high blood pressure). Brain CT revealed oedema of parieto-occipital regions of both hemispheres, more emphasized on the right. (Figure 1a, b, c). There was no sign of focal ischemia even in deeper sections (Figure 1d, e, f). Following three days enormous high blood pressure values were registered. On the fourth day the significant clinical improvement occurred
Ou, Judy I; Wheeler, Sharon M; O'Brien, Joan M
This chapter focuses on the diagnosis and management of choroidal melanoma in light of recent findings from the COMS. Retinoblastoma is emphasized to describe recent trends in primary treatment away from EBRT and toward chemoreduction with local therapy. In addition, vascular and glial tumors of the retina and tumors of the retinal pigment epithelium are described because of the association between these lesions and systemic disease. Recent advances in treatment and genetic testing for these diseases are discussed. Finally, ocular metastasis, intraocular lymphoid tumors, and intraocular leukemia are included because of their importance in determining systemic treatment and prognosis. The chapter gives an overview of important posterior pole tumors and highlights recent developments in the management of each intraocular disease process.
Matsuno, H; Rhoton, A L; Peace, D
The microsurgical anatomy of the posterior fossa cisterns was examined in 15 cadavers using 3X to 40X magnification. Liliequist's membrane was found to split into two arachnoidal sheets as it spreads upward from the dorsum sellae: an upper sheet, called the diencephalic membrane, which attaches to the diencephalon at the posterior edge of the mamillary bodies, and a lower sheet, called the mesencephalic membrane, which attaches along the junction of the midbrain and pons. Several other arachnoidal membranes that separate the cisterns were identified. These include the anterior pontine membrane, which separates the prepontine and cerebellopontine cisterns; the lateral pontomesencephalic membrane, which separates the ambient and cerebellopontine cisterns; the medial pontomedullary membrane, which separates the premedullary and prepontine cisterns; and the lateral pontomedullary membrane, which separates the cerebellopontine and cerebellomedullary cisterns. The three cisterns in which the arachnoid trabeculae and membranes are the most dense and present the greatest obstacle at operation are the interpeduncular and quadrigeminal cisterns and the cisterna magna. Numerous arachnoid membranes were found to intersect the oculomotor nerves. The neural and vascular structures in each cistern are reviewed.
Cooper, D S; Shindo, M; Sinha, U; Hast, M H; Rice, D H
The aim of this research was to investigate the contractile properties of the posterior cricoarytenoid (PCA) muscle. Simultaneous measurements were made of the isometric force, temperature, and electromyographic activity of the dorsal cricoarytenoid muscle of anesthetized dogs during supramaximal stimulation of the recurrent laryngeal nerve for twitch and tetanic contraction. The conduction delay between stimulation of the recurrent nerve at the level of the larynx and the onset of the muscle action potential averaged 2.0 +/- 0.2 milliseconds (ms), and the latent period between the onset of electrical activity of the muscle and the onset of contraction had a mean duration of 3.3 +/- 0.8 ms. The mean of isometric contraction times found was 33.3 +/- 2.0 ms, shorter than most previous studies of canine PCA muscle. Tetanic frequency defined as smooth contraction was higher than previous estimates. Considerations of scaling of physiological time based on animal mass were applied to analysis of the experimental findings to make possible systematic comparison of previous findings across species and animal size.
Bakshi, Jaimanti; Mohammed, Abdul Wadood; Lele, Saudamini; Nada, Ritambra
Ganglioneuromas are benign tumors that arise from the Schwann cells of the autonomic nervous system. They are usually seen in the posterior mediastinum and the paraspinal retroperitoneum in relation to the sympathetic chain. In the head and neck, they are usually related to the cervical sympathetic ganglia or to the ganglion nodosum of the vagus nerve or the hypoglossal nerve. We describe what we believe is the first reported case of multiple ganglioneuromas of the parapharyngeal space in which two separate cranial nerves were involved. The patient was a 10-year-old girl who presented with a 2-year history of a painless and slowly progressive swelling on the left side of her neck and a 1-year history hoarseness. She had no history of relevant trauma or surgery. Intraoperatively, we found two tumors in the left parapharyngeal space-one that had arisen from the hypoglossal nerve and the other from the vagus nerve. Both ganglioneuromas were surgically removed, but the affected nerves had to be sacrificed. Postoperatively, the patient exhibited hypoglossal nerve and vocal fold palsy, but she was asymptomatic. In addition to the case description, we discuss the difficulties we faced during surgical excision.
Nocini, P F; De Santis, D; Fracasso, E; Zanette, G
Inferior alveolar nerve (IAN) transposition surgery may cause some degree of sensory impairment. Accurate and reproducible tests are mandatory to assess IAN conduction capacity following nerve transposition. In this study subjective (heat, pain and tactile-discriminative tests) and objective (electrophysiological) assessments were performed in 10 patients receiving IAN transposition (bilaterally in 8 cases) in order to evaluate any impairment of the involved nerves one year post-operatively. All patients reported a tingling, well-tolerated sensation in the areas supplied by the mental nerve with no anaesthesia or burning paresthesia. Tactile discrimination was affected the most (all but 1 patient). No action potential was recorded in 4 patients' sides (23.5%); 12 sides showed a decreased nerve conduction velocity (NCV) (70.5%) and 1 side normal NCV values (6%). There was no significant difference in NCV decrease between partial and total transposition sides, if examined separately. Nerve conduction findings were related 2-point discrimination scores, but not to changes in pain and heat sensitivity. These findings show that lateral nerve transposition, though resulting in a high percentage of minor IAN injuries, as determined by electrophysiological testing, provides a viable surgical procedure to allow implant placement in the posterior mandible without causing severe sensory complaints. Considering ethical and forensic implications, patients should be fully informed that a certain degree of nerve injury might be expected to occur from the procedure. Electrophysiological evaluation is a reliable way to assess the degree of IAN dysfunction, especially if combined with a clinical examination. Intraoperative monitoring of IAN conduction might help identify the pathogenetic mechanisms of nerve injury and the surgical steps that are most likely to harm nerve integrity.
Li, Xiaoyan; Shin, Henry; Zhou, Ping; Niu, Xun; Liu, Jie; Rymer, William Zev
The objective of this study was to help assess complex neural and muscular changes induced by stroke using power spectral analysis of surface electromyogram (EMG) signals. Fourteen stroke subjects participated in the study. They were instructed to perform isometric voluntary contractions by abducting the index finger. Surface EMG signals were collected from the paretic and contralateral first dorsal interosseous (FDI) muscles with forces ranging from 30% to 70% maximum voluntary contraction (MVC) of the paretic muscle. Power spectral analysis was performed to characterize features of the surface EMG in paretic and contralateral muscles at matched forces. A Linear Mixed Model was applied to identify the spectral changes in the hemiparetic muscle and to examine the relation between spectral parameters and contraction levels. Regression analysis was performed to examine the correlations between spectral characteristics and clinical features. Differences in power spectrum distribution patterns were observed in paretic muscles when compared with their contralateral pairs. Nine subjects showed increased mean power frequency (MPF) in the contralateral side (>15 Hz). No evident spectrum difference was observed in 3 subjects. Only 2 subjects had higher MPF in the paretic muscle than the contralateral muscle. Pooling all subjects' data, there was a significant reduction of MPF in the paretic muscle compared with the contralateral muscle (paretic: 168.7 ± 7.6 Hz, contralateral: 186.1 ± 8.7 Hz, mean ± standard error, F=36.56, p<0.001). Examination of force factor on the surface EMG power spectrum did not confirm a significant correlation between the MPF and contraction force in either hand (F=0.7, p>0.5). There was no correlation between spectrum difference and Fugl-Meyer or Chedoke scores, or ratio of paretic and contralateral MVC (p>0.2). There appears to be complex muscular and neural processes at work post stroke that may impact the surface EMG power spectrum. The
Hassan, Anhar; Leep Hunderfund, Andrea N; Watson, James; Boon, Andrea J; Sorenson, Eric J
Median nerve ultrasound shows increased cross-sectional area (CSA) in carpal tunnel syndrome (CTS) and diabetic peripheral neuropathy (PN). The role of ultrasound in diagnosing CTS superimposed on diabetic PN is unknown. The objective of this study is to evaluate ultrasound for diagnosis of CTS in diabetic PN. Prospective recruitment of diabetics with electrodiagnostically proven PN, subdivided into cases (with CTS) or controls (without CTS). The gold standard for CTS was clinical diagnosis. NCS were correlated with blinded median nerve CSA ultrasound measurements. Eight cases (CTS) and eight controls (no CTS) were recruited. Nerve conduction studies (NCS): Median nerve distal latencies (antidromic sensory; palmar; lumbrical motor; and lumbrical motor to ulnar interosseous difference) were significantly prolonged in CTS cases. No ultrasound measurement (distal median CSA, wrist-forearm ratio, wrist-forearm difference) reached significance to detect CTS. Area under the curve was greatest for lumbrical distal latency by receiver operator characteristic analysis (0.85). In this pilot study, NCS may be superior to ultrasound for identification of superimposed CTS in diabetic PN patients, but larger numbers are needed for confirmation. Copyright © 2012 Wiley Periodicals, Inc., a Wiley company.
Yee, T C; Kalichman, M W
To test the hypothesis that the dose requirement for local anesthetics is changed in aged animals, the effects of two different local anesthetics on nerve conduction block were tested in young and old rats. Young (6 months) and old (27 months) male Fisher-344 rats were anesthetized with intraperitoneal pentobarbital and diazepam. Stimulating electrodes were placed in the sciatic notch and in the ankle and recording electrodes were placed distally in the ipsilateral foot to record evoked electrical activity of the interosseous muscles. Motor nerve conduction velocity was significantly less in old (48.8 +/- 3.9, mean +/- SD m.sec-1) than in young rats (56.4 +/- 10.3 m.sec-1) (P < 0.05). To test the effects of aging on conduction block, equipotent doses of bupivacaine (0.2%), an amide-linked local anesthetic, or procaine (0.6%), an ester-linked local anesthetic, were injected next to exposed sciatic nerves and evoked electrical activity was monitored following repeated stimulation at the sciatic notch. At 10 minutes after injection, bupivacaine produced significantly greater nerve block in old rats (100 +/- 0.0%) than young rats (29.8 +/- 41.6%) (P < 0.01); the difference for procaine (old 67.5 +/- 40.4% vs. young 30.4 +/- 35.3%) was not statistically significant. The lower dose requirement for bupivacaine, and the apparent differences compared to procaine, may have implications for the use of local anesthetics in an aging patient population.
Reinpold, W; Schroeder, A D; Schroeder, M; Berger, C; Rohr, M; Wehrenberg, U
Chronic inguinodynia is one of the most frequent complications after groin herniorrhaphy. We investigated the retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve to prevent direct nerve injury during hernia repairs and to find the most advantageous approach for posterior triple neurectomy. We dissected the inguinal nerves in 30 human anatomic specimens bilaterally. The distances from each nerve and their entry points in the abdominal wall were measured in relation to the posterior superior iliac spine, anterior superior iliac spine, and the midpoint between the two iliac spines on the iliac crest. We evaluated our findings by creating high-resolution summation images. The courses of the iliohypogastric and ilioinguinal nerve are most consistent on the anterior surface of the quadratus lumborum muscle. The genitofemoral nerve always runs on the psoas muscle. The entry points of the nerves in the abdominal wall are located as follows: the iliohypogastric nerve is above the iliac crest and lateral from the anterior superior iliac spine, the ilioinguinal nerve is with great variability, either above or below the iliac crest and lateral from the anterior superior iliac spine, the genital branch is around the internal inguinal ring, the femoral branch is either cranial or caudal to the iliopubic tract, and the lateral femoral cutaneous nerve is either medial or lateral to the anterior superior iliac spine. Nerve injury during inguinal hernia repairs can be avoided by taking the topographic anatomy of the inguinal nerves into consideration. The most advantageous plane to look for the iliohypogastric and ilioinguinal nerve during posterior neurectomy is on the anterior surface of the quadratus lumborum muscle. For the surgical treatment of severe chronic inguinodynia, especially after posterior open or endoscopic mesh repair (TAPP/TEP), the retroperitoneoscopic or open retroperitoneal approach for posterior
Kohli, Ritesh; Singh, Surinder; Gupta, Sahwani K.; Matreja, Prithpal S.
We are reporting a rare case of a schwannoma which originated from the cervical portion of the spinal accessory nerve, which was located in the left posterior triangle of the neck and did not have any neurological deficit, which was diagnosed by the Magnetic Resonance Imaging (MRI) scan and confirmed histopathologically after surgery. PMID:24086895
Vacher, C; Cyna-Gorse, F
Motor innervation of the face depends on the facial nerve for the mobility of the face, on the mandibular nerve, third branch of the trigeminal nerve, which gives the motor innervation of the masticator muscles, and the hypoglossal nerve for the tongue. In case of facial paralysis, the most common palliative surgical techniques are the lengthening temporalis myoplasty (the temporal is innervated by the mandibular nerve) and the hypoglossal-facial anastomosis. The aim of this work is to describe the surgical anatomy of these three nerves and the radiologic anatomy of the facial nerve inside the temporal bone. Then the facial nerve penetrates inside the parotid gland giving a plexus. Four branches of the facial nerve leave the parotid gland: they are called temporal, zygomatic, buccal and marginal which give innervation to the cutaneous muscles of the face. Mandibular nerve gives three branches to the temporal muscles: the anterior, intermediate and posterior deep temporal nerves which penetrate inside the deep aspect of the temporal muscle in front of the infratemporal line. The hypoglossal nerve is only the motor nerve to the tongue. The ansa cervicalis, which is coming from the superficial cervical plexus and joins the hypoglossal nerve in the submandibular area is giving the motor innervation to subhyoid muscles and to the geniohyoid muscle. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
Nakagawa, Yu; Toda, Masahiro; Shibao, Shunsuke; Yoshida, Kazunari
Background: The purpose of this study was to consider the mechanism of isolated oculomotor nerve palsy after minor head trauma. Case Description: We report a rare case of delayed and isolated oculomotor nerve palsy following minor head trauma. A 19-year-old boy complained of double vision 1 day after a minor head trauma. Neuro-ophthalmic examination showed isolated left oculomotor nerve palsy. Computed tomography and magnetic resonance imaging examination revealed no abnormal findings and steroid therapy was administered for a week. Three months after the injury, the ptosis and extraocular movements had fully resolved, although the pupillary light reflex was still abnormal. Conclusions: Delayed and isolated oculomotor nerve palsy may be caused by an injury at the point where the oculomotor nerve runs over the posterior petroclinoid ligament. Because edema of the damaged oculomotor nerve might result in constriction at the point where the nerve pierces the dura of the cavernous sinus, symptoms of oculomotor nerve palsy appeared late after trauma. Steroid treatment reducing edema could be effective for delayed and isolated oculomotor nerve palsy following minor head trauma. PMID:28217399
Xing, Hong-Shun; Wang, Shou-Xian; Wang, Zhe; Cao, Pei-Cheng; Ma, Yong-Qian; Wang, Zeng-Wu
The objective of this study was to summarize the experience about the protection of the facial nerve in surgery for acoustic neuroma surgery with the aim to improve the retention of facial nerve function and the quality of life. Forty-two patients with acoustic neuroma were recruited from the year 2010 to 2013. Using microsurgical techniques, the tumors were resected through the suboccipital approach over the posterior edge of the sigmoid sinus, and intraoperative electrophysiological monitoring of the facial nerve function was performed. The House-Brackmann (H-B) grading was used to evaluate the facial nerve function evaluation postoperatively. Total tumor resection was achieved in 32 cases, and partial resection in 10 cases, without any intraoperative deaths. Also facial nerves were retained in 35 of 42 cases (83.33 %). One week after surgery, the facial nerve H-B grading was grade I in 8 cases, grade II in 15 cases, grade III in 12 cases, grade IV in 6 cases, and grade V in 1 case. The key to improved protection of the facial nerve during acoustic neuroma surgery includes a complete understanding of the anatomy of the cerebellopontine angle, proper use of microsurgical techniques, and intraoperative electrophysiological monitoring of the status of facial nerve functions to avoid damage to the nerves.
Garg, A K; Morales, M J
In the event of moderate to severe mandibular bone resorption posterior to the mental foramen, repositioning of the inferior alveolar nerve provides a greater amount of available bone for implant placement and reduces the risk of nerve injury. While neural paresthesia may initially occur, this altered sensation generally resolves spontaneously. Alveolar nerve repositioning may be possible in cases in which other procedures cannot be performed due to the extent of atrophy of the posterior mandibular alveolar crest. This article presents the surgical technique to achieve this objective.
Dores, Luís Almeida; Simão, Marco Alveirinho; Marques, Marta Canas; Dias, Éscar
Sphenoid sinus disease is particular not only for its clinical presentation, as well as their complications. Although rare, these may present as cranial nerve deficits, so it is important to have a high index of suspicion and be familiar with its diagnosis and management. Symptoms are often nonspecific, but the most common are headache, changes in visual acuity and diplopia due to dysfunction of one or more ocular motor nerves. The authors report a case of a 59 years-old male, who was referred to the ENT emergency department with frontal headaches for one week which had progressively worsened and were associated, since the last 12 hours, with diplopia caused by left third cranial nerve palsy. Neurologic examination was normal aside from the left third cranial nerve palsy. Anterior and posterior rhinoscopy excluded the presence of nasal masses and purulent rhinorrhea. The CT scan revealed a soft tissue component and erosion of the roof of the left sphenoid sinus. Patient was admitted for intravenous antibiotics and steroids treatment without any benefit after 48 hours. He was submitted to endoscopic sinus surgery with resolution of the symptoms 10 days after surgery. The authors present this case for its rarity focusing on the importance of differential diagnosis in patients with headaches and cranial nerves palsies.
Smith, J L; Vuksanovic, M M; Yates, B M; Bienfang, D C
Optic nerve sheath meningiomas, formerly thought to be rare, have been encountered with surprising frequency since the widespread use of computed tomography. Early diagnosis led to an enthusiastic surgical approach to these lesions, but this has been tempered by the realization that even in the best of hands, blindness followed such surgery with distressing frequency. Optic nerve sheath meningiomas may be divided into primary, secondary, and multiple meningioma groups. Five patients with primary optic nerve sheath meningiomas treated with irradiation therapy are presented in this report. Improvement in visual acuity, stabilization to increase in the visual field, and decrease in size to total regression of optociliary veins, have been documented following irradiation therapy of the posterior orbital and intracanalicular portions of the optic nerve in some of these cases. Although each patient must be carefully individualized, there is no question that visual palliation can be achieved in some cases of optic nerve sheath meningioma. Further investigation of this therapeutic modality in selected cases in advised.
... There are many different types of optic nerve disorders, including: Glaucoma is a group of diseases that ... are having vision problems. Tests for optic nerve disorders may include eye exams, ophthalmoscopy (an examination of ...
... Distal median nerve dysfunction is a form of peripheral neuropathy that affects the movement of or sensation in ... and the A.D.A.M. Editorial team. Peripheral Nerve Disorders Read more Latest Health News Read more Health ...
Tcheng, Ping; Supplee, Frank H., Jr.; Prass, Richard L.
Nerve stimulator applies and/or measures precisely controlled force and/or displacement to nerve so response of nerve measured. Consists of three major components connected in tandem: miniature probe with spherical tip; transducer; and actuator. Probe applies force to nerve, transducer measures force and sends feedback signal to control circuitry, and actuator positions force transducer and probe. Separate box houses control circuits and panel. Operator uses panel to select operating mode and parameters. Stimulator used in research to characterize behavior of nerve under various conditions of temperature, anesthesia, ventilation, and prior damage to nerve. Also used clinically to assess damage to nerve from disease or accident and to monitor response of nerve during surgery.
Collins, Kathryn; And Others
Over a two-year period this study evaluated the condition of 65 athletes with nerve injuries. These injuries represent the spectrum of nerve injuries likely to be encountered in sports medicine clinics. (Author/MT)
Collins, Kathryn; And Others
Over a two-year period this study evaluated the condition of 65 athletes with nerve injuries. These injuries represent the spectrum of nerve injuries likely to be encountered in sports medicine clinics. (Author/MT)
Garbino, José Antonio; Heise, Carlos Otto; Marques, Wilson
Leprosy neuropathy is dependent on the patient's immune response and expresses itself as a focal or multifocal neuropathy with asymmetric involvement. Leprosy neuropathy evolves chronically but recurrently develops periods of exacerbation during type 1 or type 2 reactions, leading to acute neuropathy. Nerve enlargement leading to entrapment syndromes is also a common manifestation. Pain may be either of inflammatory or neuropathic origin. A thorough and detailed evaluation is mandatory for adequate patient follow-up, including nerve palpation, pain assessment, graded sensory mapping, muscle power testing, and autonomic evaluation. Nerve conduction studies are a sensitive tool for nerve dysfunction, including new lesions during reaction periods or development of entrapment syndromes. Nerve ultrasonography is also a very promising method for nerve evaluation in leprosy. The authors propose a composite nerve clinical score for nerve function assessment that can be useful for longitudinal evaluation. Copyright © 2016 Elsevier Inc. All rights reserved.
Tcheng, Ping; Supplee, Frank H., Jr.; Prass, Richard L.
Nerve stimulator applies and/or measures precisely controlled force and/or displacement to nerve so response of nerve measured. Consists of three major components connected in tandem: miniature probe with spherical tip; transducer; and actuator. Probe applies force to nerve, transducer measures force and sends feedback signal to control circuitry, and actuator positions force transducer and probe. Separate box houses control circuits and panel. Operator uses panel to select operating mode and parameters. Stimulator used in research to characterize behavior of nerve under various conditions of temperature, anesthesia, ventilation, and prior damage to nerve. Also used clinically to assess damage to nerve from disease or accident and to monitor response of nerve during surgery.
... of the brain to the back). Viewing the Cranial Nerves Twelve pairs of cranial nerves emerge from the ... magnetic resonance imaging (MRI) is often needed. Testing Cranial Nerves Cranial Nerve Number Name Function Test 1st Olfactory ...
Martinez-Pereira, M A; Rickes, E M
In this study, the spinal nerves that constitute the lumbosacral plexus (plexus lumbosacrales) (LSP) and its distribution in Chinchilla lanigera were investigated. Ten chinchillas (6 males and 4 females) were used in this research. The spinal nerves that constitute the LSP were dissected and the distribution of pelvic limb nerves originating from the plexus was examined. The iliohypogastric nerve arose from L1 and L2, giving rise to the cranial and caudal nerves, and the ilioinguinal nerve arose from L3. The other branch of L3 gave rise to the genitofemoral nerve and 1 branch from L4 gave rise to the lateral cutaneous femoral nerve. The trunk formed by the union of L4-5 divided into medial (femoral nerve) and lateral branches (obturator nerve). It was found that the LSP was formed by all the ventral branches of L4 at L6 and S1 at S3. At the caudal part of the plexus, a thick branch, the ischiadic plexus, was formed by contributions from L5-6 and S1. This root gave rise to the nerve branches which were disseminated to the posterior limb (cranial and caudal gluteal nerves, caudal cutaneous femoral nerve and ischiadic nerve). The ischiadic nerve divided into the caudal cutaneous surae, lateral cutaneous surae, common fibular and tibial nerve. The pudendal nerve arose from S1-2 and the other branch of S2 and S3 formed the rectal caudal nerve. The results showed that the origins and distribution of spinal nerves that constitute the LSP of chinchillas were similar to those of a few rodents and other mammals.
Sylvester, Lauren N; Goree, Johnathan H
We present a case of a 68-year-old woman with 6 months of chronic unilateral posterior thigh pain after a total knee arthroplasty. The patient's pain was refractory to various treatments. After appropriate diagnostic tests, a genicular nerve block and subsequent radiofrequency ablation were performed. These procedures provided substantial pain relief of her thigh pain at 3 months follow-up.
Antoniadis, G; Richter, H P; Rath, S; Braun, V; Moese, G
Suprascapular nerve entrapment (SNE) in the suprascapular notch is a rare entity that must be considered in the differential diagnosis of radicular pain, as well as that of shoulder discomfort. Over a period of 10 years (1985-1995), the authors treated 28 cases of SNE in 27 patients by surgical decompression of the nerve. One patient underwent operation bilaterally within 5 years. Five patients presented with a history of trauma to the shoulder region. In three patients, a ganglion cyst was the origin of the nerve lesion. In 16 patients, the nerve problem was primarily related to athletic activities. Eight of these patients were professional volleyball players. In the remaining three patients, there was no relationship between the nerve lesion and trauma or athletic activities. Twenty-one patients (22 cases) complained of pain located over the suprascapular notch. Seventeen patients had paresis and atrophy of both the supraspinatus (SS) and infraspinatus (IS) muscles. In 10 patients only the IS muscle was involved. One patient exhibited a sensory deficit over the posterior portion of the shoulder. Electromyography was performed in all cases. The mean follow-up period in the 25 cases (24 patients) that could be evaluated was 20.8 months (range 3-70 months). Nineteen of 22 cases with preoperative pain could be evaluated. Sixteen of these patients were completely free of pain after surgery and three patients found their pain had improved. Motor function in the SS muscle improved in 86.7% and motor function in the IS muscle in 70.8% of cases. Atrophy of the SS muscle resolved in 80.7% and atrophy of the IS muscle in 50% of cases. Surgical treatment of SNE is indicated after failed conservative treatment and in cases of atrophy of the SS and IS muscles. The authors recommend the posterior approach, which minimizes risks and complications and produces good postoperative results.
Hanson, K.M.; Cunningham, G.S.
The Markov Chain Monte Carlo (MCMC) technique provides a means to generate a random sequence of model realizations that sample the posterior probability distribution of a Bayesian analysis. That sequence may be used to make inferences about the model uncertainties that derive from measurement uncertainties. This paper presents an approach to improving the efficiency of the Metropolis approach to MCMC by incorporating an approximation to the covariance matrix of the posterior distribution. The covariance matrix is approximated using the update formula from the BFGS quasi-Newton optimization algorithm. Examples are given for uncorrelated and correlated multidimensional Gaussian posterior distributions.
Anatomical variations of the recurrent laryngeal nerve (RLN), such as an extralaryngeal terminal bifurcation (ETB), threaten the safety of thyroid surgery. Besides the morphology of the nerve branches, intraoperative evaluation of their functional anatomy may be useful to preserve motor activity. We exposed 67 RLNs in 36 patients. The main trunk, bifurcation point, and terminal branches of bifid nerves were macroscopically determined and exposed during thyroid surgery. The functional anatomy of the nerve branches was evaluated by intraoperative nerve monitoring (IONM). Forty-six RLNs with an ETB were intraoperatively exposed. The bifurcation point was located along the prearterial, arterial, and postarterial segments in 11%, 39%, and 50% of bifid RLNs, respectively. Motor activity was determined in all anterior branches. The functional anatomy of terminal branches detected motor activity in 4 (8.7%) posterior branches of 46 bifid RLNs. The motor activity in posterior branches created a wave amplitude at 25–69% of that in the corresponding anterior branches. The functional anatomy of bifid RLNs demonstrated that anterior branches always contained motor fibres while posterior branches seldom contained motor fibres. The motor activity of the posterior branch was weaker than that of the anterior branch. IONM may help to differentiate between motor and sensory functions of nerve branches. The morphology and functional anatomy of all nerve branches must be preserved to ensure a safer surgery. PMID:27493803
Bro, Søren Pauli; Bille, Jesper; Petersen, Kristian Bruun
30% of the patients presenting with epistaxis at emergency wards and otorhinolaryngeal specialist departments have posterior bleeding. Traditional treatment with packing often leads to initial treatment failure, and many patients experience recurrent bleeding within the following month. Recurrent posterior epistaxis should be treated with local electrocautery or endoscopic ligation of the sphenopalatine artery to reduce patient discomfort, hospital stay, risk of treatment failure and recurrence.
Singh, Shikha; Loh, Hitendra Kumar; Mehta, Vandana; Suri, Rajesh Kumar
Sternocleidomastoid (SCM) and Trapezius (TM) muscle present in the cervical region serves as an important landmark in forming boundaries of posterior triangle of neck. This case reports a continuous muscle sheet obscuring the left posterior triangle in the neck of a 60-year-old Indian male cadaver. An unfamiliar oval gap was observed in its posterosuperior portion. Description of such a variant in anatomical literature is rare and is scarcely reported. An attempt has been made to portray its embryological and phylogenetic basis. In addition authors have endeavoured to discuss its clinical implications. Awareness of such anatomical variations is relevant for the operating surgeons in their endeavour to perform various reconstruction surgeries of head and neck, radiologists while concluding various levels in Computed Tomography (CT) and Magnetic Resonance Images (MRI) of the region and to the anaesthetists in their search for nerves and vessels while attempting various anaesthetic procedures. PMID:28384846
Alvi, Aijaz; Janecka, Ivo P.; Kapadia, Silloo; Johnson, Bruce L.; McVay, William
The length of the optic nerves is a reflection of normal postnatal cranio-orbital development. Unilateral elongation of an optic nerve has been observed in two patients with orbital and skull base neoplasms. In the first case as compared to the patient's opposite, normal optic nerve, an elongated length of the involved optic nerve of 45 mm was present. The involved optic nerve in the second patient was 10 mm longer than the normal opposite optic nerve. The visual and extraocular function was preserved in the second patient. The first patient had only light perception in the affected eye. In this paper, the embryology, anatomy, and physiology of the optic nerve and its mechanisms of stretch and repair are discussed. ImagesFigure 1Figure 2Figure 3Figure 4Figure 5Figure 6Figure 7Figure 8Figure 9Figure 10Figure 11Figure 13 PMID:17170975
Selesnick, S H; Abraham, M T; Carew, J F
Anterior rerouting of the intratemporal facial nerve in the infratemporal fossa approach is employed to access to the jugular bulb, hypotympanum, and lateral skull base, whereas posterior rerouting of the facial nerve, as employed in the transcochlear craniotomy, is most frequently used for surgery of the posterior fossa, cerebellopontine angle, prepontine region, and petrous apex. Facial nerve rerouting may lead to facial paresis or paralysis. This review of the literature is intended to define the physiologic "cost" of these procedures, so that the neurotologic surgeon can determine if the morbidity incurred in these techniques is worth the resultant exposure. Inconsistencies in reporting facial function places into question the validity of some of the cumulative data reported. Postoperatively, grades I-II facial nerve function was seen in 91% of patients undergoing short anterior rerouting, 74% of patients undergoing long anterior rerouting, and 26% of patients undergoing posterior complete rerouting. Although facial nerve rerouting allows unhindered exposure to previously inaccessible regions, it is achieved at the cost of facial nerve function. Facial nerve dysfunction increases with the length of facial nerve rerouted.
Piagkou, Maria; Demesticha, Theano; Piagkos, Giannoulis; Georgios, Androutsos; Panagiotis, Skandalakis
Running through the infratemporal fossa is the lingual nerve (i.e. the third branch of the posterior trunk of the mandibular nerve). Due to its location, there are various anatomic structures that might entrap and potentially compress the lingual nerve. These anatomical sites of entrapment are: (a) the partially or completely ossified pterygospinous or pterygoalar ligaments; (b) the large lamina of the lateral plate of the pterygoid process; and (c) the medial fibers of the anterior region of the lateral pterygoid muscle. Due to the connection between these nerve and anatomic structures, a contraction of the lateral pterygoid muscle, for example, might cause a compression of the lingual nerve. Any variations in the course of the lingual nerve can be of clinical significance to surgeons and neurologists because of the significant complications that might occur. To name a few of such complications, lingual nerve entrapment can lead to: (a) numbness, hypoesthesia or even anesthesia of the tongue's mucous glands; (b) anesthesia and loss of taste in the anterior two-thirds of the tongue; (c) anesthesia of the lingual gums; and (d) pain related to speech articulation disorder. Dentists should, therefore, be alert to possible signs of neurovascular compression in regions where the lingual nerve is distributed. PMID:21404967
Gonçalves da Silva Leite, Janaina; Costa Cavalcante, Maria Luzete; Fechine-Jamacaru, Francisco Vagnaldo; de Lima Pompeu, Margarida Maria; Leite, José Alberto Dias; Nascimento Coelho, Dulce Maria; Rabelo de Freitas, Marcos
Sensory receptors are distributed throughout the oral cavity, pharynx, and larynx. Laryngeal sensitivity is crucial for maintaining safe swallowing, thus avoiding silent aspiration. Morphologic description of different receptor types present in larynx vary because of the study of many different species, from mouse to humans. The most commonly sensory structures described in laryngeal mucosa are free nerve endings, taste buds, muscle spindles, glomerular and corpuscular receptors. This study aimed at describing the morphology and the distribution of nerve endings in premature newborn glottic region. Transversal serial frozen sections of the whole vocal folds of three newborns were analyzed using an immuno-histochemical process with a pan-neuronal marker anti-protein gene product 9.5 (PGP 9.5). Imaging was done using a confocal laser microscope. Nerve fiber density in vocal cord was calculated using panoramic images in software Morphometric Analysis System v1.0. Some sensory structures, i.e. glomerular endings and intraepithelial free nerve endings were found in the vocal cord mucosa. Muscle spindles, complex nerve endings (Meissner-like, spherical, rectangular and growing) spiral-wharves nerve structures were identified in larynx intrinsic muscles. Nervous total mean density in vocal cord was similar in the three newborns, although they had different gestational age. The mean nerve fiber density was higher in the posterior region than anterior region of vocal cord. The present results demonstrate the occurrence of different morphotypes of sensory corpuscles and nerve endings premature newborn glottic region and provide information on their sensory systems.
Sudharshan, S; Ganesh, Sudha K; Biswas, Jyotrimay
Posterior uveitic entities are varied entities that are infective or non-infective in etiology. They can affect the adjacent structures such as the retina, vitreous, optic nerve head and retinal blood vessels. Thorough clinical evaluation gives a clue to the diagnosis while ancillary investigations and laboratory tests assist in confirming the diagnosis. Newer evolving techniques in the investigations and management have increased the diagnostic yield. In case of diagnostic dilemma, intraocular fluid evaluation for polymerase chain testing for the genome and antibody testing against the causative agent provide greater diagnostic ability. PMID:20029144
Gomez-Tames, Jose; Yu, Wenwei
The distance between nerve and stimulation electrode is fundamental for nerve activation in Transcutaneous Electrical Stimulation (TES). However, it is not clear the need to have an approximate representation of the morphology of peripheral nerves in simulation models and its influence in the nerve activation. In this work, depth and curvature of a nerve are investigated around the middle thigh. As preliminary result, the curvature of the nerve helps to reduce the simulation amplitude necessary for nerve activation from far field stimulation.
Kimball, David; Kimball, Heather; Matusz, Petru; Tubbs, R. Shane; Loukas, Marios; Cohen-Gadol, A. Aaron
Objectives The roof of the porus trigeminus, composed of the posterior petroclinoid dural fold, is an important landmark to the skull base surgeon. Ossification of the posterior petroclinoid dural fold is an anatomical variation rarely mentioned in the literature. Such ossification results in the trigeminal nerve traversing a bony foramen as it enters Meckel cave. The authors performed this study to better elucidate this anatomical variation. Design Fifteen adult cadaveric head halves were subjected to dissection of the middle cranial fossa. Microdissection techniques were used to examine the posterior petroclinoid dural folds. Skull base osteology was also studied in 71 dry human skulls with attention paid to the attachment point of the posterior petroclinoid dural folds at the trigeminal protuberances. Setting Cadaver laboratory Main Outcome Measures Measurements were made using a microcaliper. Digital images were made of the dissections. Results Completely ossified posterior petroclinoid folds were present in 20% of the specimens. Of the 142 dry skull sides examined, 9% had large trigeminal protuberances. Conclusions Based on this study, the posterior petroclinoid dural fold may completely ossify in adults that may lead to narrowing of the porus trigeminus and potential compression of the trigeminal nerve at the entrance to Meckel cave. PMID:26225315
Hill, J David; Lovejoy, John F; Kelly, Robert A
Recurrent posterior glenohumeral instability is uncommon and is often misdiagnosed. Damage to the posterior capsule, posteroinferior glenohumeral ligament, and posterior labrum have all been implicated as sources of traumatic posterior instability. We describe a case of traumatic recurrent posterior instability resulting from a posterior Bankart lesion accompanied by posterior humeral avulsion of the glenohumeral ligaments. The Bankart lesion was repaired using a single arthroscopic suture anchor at the glenoid articular margin. The posterior humeral avulsion of the glenohumeral ligaments was addressed with 3 suture anchors placed at the capsular origin at the posterior humeral head. Using these anchors, the posterior capsule was advanced laterally and superiorly for a secure repair. Arthroscopic anatomic reconstruction of both lesions resulted in an excellent clinical outcome.
Bali, Rishi Kumar; Nautiyal, Vijay P; Sharma, Praveen; Sharma, Rohit
The maxillary teeth are supplied by the anterior, middle and posterior superior alveolar nerves. The anterior and middle superior alveolar (AMSA) nerves exit the skull from the infra-orbital foramen, where they can be blocked for procedures on the maxillary anteriors and premolars. Sometimes, the middle superior alveolar nerve has a variant course and is not blocked by the conventional block technique. A new technique has been described for blocking the AMSA nerves, keeping in view the alternate pathway of the middle superior alveolar nerve. PMID:25756021
Moreta, J; Foruria, X; Labayru, F
Sciatic nerve injuries associated with acetabular fractures can be post-traumatic, perioperative or postoperative. Late postoperative injury is very uncommon and can be due to heterotopic ossifications, muscular scarring, or implant migration. A case is presented of a patient with a previous transverse acetabular fracture treated with a reconstruction plate for the posterior column. After 17 years, she presented with progressive pain and motor deficit in the sciatic territory. Radiological and neurophysiological assessments were performed and the patient underwent surgical decompression of the sciatic nerve. A transection of the nerve was observed that was due to extended compression of one of the screws. At 4 years postoperatively, her pain had substantially diminished and the paresthesias in her leg had resolved. However, her motor symptoms did not improve. This case report could be relevant due to this uncommon delayed sciatic nerve injury due to prolonged hardware impingement.
Izumi, T; Kusaka, H; Imai, T
A 26-year-old male patient gradually developed muscular atrophy of the right lower leg over a two-year period. Neurological examination revealed absent Achilles tendon reflex and muscular atrophy of the right lower leg and right hamstring muscles. Conduction velocity of the F waves was delayed in the right posterior tibial nerve. A computerized tomography scan and magnetic resonance imaging revealed a mass lesion along the proximal segment of the right sciatic nerve. Exploration revealed a fusiformly swollen sciatic nerve. Histological examination showed that a swollen segment of the sciatic nerve was filled with onion-bulb formations of perineurial cells, consistent with the diagnosis of localized hypertrophic neuropathy. This condition should be added to several etiologies of monomelic amyotrophy. Electrophysiological studies and neuroimaging techniques were useful in obtaining differential diagnosis.
Satchi, Khami; McNab, Alan A
A 60-year-old woman presented with several years increasing right upper eyelid ptosis. She had undergone surgical decompression of the right trigeminal nerve in the posterior cranial fossa 15 years earlier for trigeminal neuralgia. This left her with permanent numbness in the second and third divisions of the trigeminal nerve. In addition to the ptosis, she was found to have right enophthalmos and a smaller right face. CT scans showed a smaller midfacial skeleton on the right and a depressed orbital floor. The changes were different to those seen in silent sinus syndrome. Photographs taken over many years showed the facial changes were acquired and came on gradually many years after the trigeminal nerve injury. It is possible that trigeminal nerve injury may lead to trophic changes in the facial skeleton, but these have not been previously reported.
Wagenaar, Inge; Brandsma, Wim; Post, Erik; Richardus, Jan Hendrik
The monofilament test (MFT) is a reliable method to assess sensory nerve function in leprosy and other neuropathies. Assessment of the radial cutaneous and sural nerves, in addition to nerves usually tested, can help improve diagnosis and monitoring of nerve function impairment (NFI). To enable the detection of impairments in leprosy patients, it is essential to know the monofilament threshold of these two nerves in normal subjects. The radial cutaneous, sural, ulnar, median and posterior tibial nerves of 245 volunteers were tested. All nerves were tested at three sites on both left and right sides. Normal monofilament thresholds were calculated per test-site and per nerve. We assessed 490 radial cutaneous and 482 sural nerves. The normal monofilament was 2 g (Filament Index Number (FIN) 4.31) for the radial cutaneous and 4 g (FIN 4.56) for the sural nerve, although heavy manual laborers demonstrated a threshold of 10 g (FIN 5.07) for the sural nerve. For median and ulnar nerves, the 200 mg (FIN 3.61) filament was confirmed as normal while the 4 g (FIN 4.56) filament was normal for the posterior tibial. Age and occupation have an effect on the mean touch sensitivity but do not affect the normal threshold for the radial cutaneous and sural nerves. The normal thresholds for the radial cutaneous and sural nerves are determined as the 2 g (FIN 4.31) and the 4 g (FIN 4.56) filaments, respectively. The addition of the radial cutaneous and sural nerve to sensory nerve assessment may improve the diagnosis of patients with impaired sensory nerve function.
Padia, Reema; Smith, Marshall E
Dysphonia secondary to posterior glottic insufficiency (PGI) can be difficult to identify and correct. Inadequate arytenoid approximation from medial arytenoid erosion results in a breathy, soft voice. The anatomical location of the gap is difficult to correct by vocal fold injection laryngoplasty. This study reviews the presentation, evaluation, and treatment for pediatric patients who were identified with PGI. An Institutional Review Board-approved chart review was performed on all patients who were diagnosed with PGI at our institution from 2013 to 2015. We studied the presentation, workup, and treatment for these patients, including laryngoscopy, parent or patient-based voice impairment ratings, and response to treatment. Seven patients were identified. Erosion of the medial arytenoid was identified on microlaryngoscopy for all of these patients. The patients had suboptimal improvement from injection laryngoplasty. Three patients underwent surgical correction with an endoscopic posterior cricoid reduction laryngoplasty (EPCRL) with significant improvement in voice, assessed by perceptual, laryngoscopic, and patient-based measures. The key diagnostic procedures to identify posterior glottic insufficiency include laryngoscopic findings of a posterior glottal gap, microlaryngoscopy with close inspection of the posterior glottis and medial arytenoids, and suboptimal response to injection laryngoplasty. The EPCRL is an effective procedure to treat dysphonia from PGI.
Uluer, Tuğba; Aktekin, Mustafa; Kurtoğlu, Zeliha; Buluklu, Semih; Karşıyaka, Dilan; Can, Erdem
Objectives: To examine the fetal axillary nerve to reveal and compare its morphometric features within the second and third trimester. Methods: This study was conducted at the Anatomy Department, School of Medicine, Mersin University, Mersin, Turkey. Thirty-five fetal shoulders were studied to provide anatomic data and to describe its position with regard to certain landmarks around the shoulder. Results: The shortest distance between the axillary nerve and the glenoid labrum was found 2.27 mm and 2.89 mm in the second and third trimester fetuses, respectively. The shortest distances between the anterior and posterior acromial tips and the axillary nerve were also measured and were used with arm length measurements to define the anterior and posterior indexes. Conclusion: The indexes show that the distance between the axillary nerve and the anterior/posterior acromial tips are approximately one-fourth of the arm length in both the second and third trimester fetuses. The data presented in this study will be of use to surgeons, particularly to pediatric and orthopedic surgeons who will undertake surgical procedures in the axilla and arm in the newborn or early childhood. PMID:26492124
Khairallah, Moncef; Kahloun, Rim; Ben Yahia, Salim; Jelliti, Bechir; Messaoud, Riadh
Emergent and resurgent arthropod vector-borne diseases are major causes of systemic morbidity and death and expanding worldwide. Among them, viral and bacterial agents including West Nile virus, Dengue fever, Chikungunya, Rift Valley fever, and rickettsioses have been recently associated with an array of ocular manifestations. These include anterior uveitis, retinitis, chorioretinitis, retinal vasculitis and optic nerve involvement. Proper clinical diagnosis of any of these infectious diseases is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular involvement. The diagnosis is usually confirmed by the detection of a specific antibody in serum. Ocular involvement associated with emergent infections usually has a self-limited course, but it can result in persistent visual impairment. There is currently no proven specific treatment for arboviral diseases, and therapy is mostly supportive. Vaccination for humans against these viruses is still in the research phase. Doxycycline is the treatment of choice for rickettsial diseases. Prevention, including public measures to reduce the number of mosquitoes and personal protection, remains the mainstay for arthropod vector disease control. Influenza A (H1N1) virus was responsible for a pandemic human influenza in 2009, and was recently associated with various posterior segment changes.
Douglas, Pamela Sylvia
Currently, many clinicians who help with breastfeeding problems are diagnosing "posterior" tongue-tie in infants and performing or referring for frenotomy. In this "Speaking Out" article, I argue that the diagnosis of "posterior" tongue-tie has successfully raised awareness of the importance of impaired tongue function in breastfeeding difficulty. However, the diagnosis of "posterior" tongue-tie also applies a reductionist, medicalized theoretical frame to the complex problem of impaired tongue function, risking unintended outcomes. Impaired tongue function arises out of multiple interacting and co-evolving factors, including the interplay between social behaviors concerning breastfeeding and mother-infant biology. Consideration of theoretical frames is vital if we are to build an evidence base through efficient use of the scarce resources available for clinical breastfeeding research and minimize unintended outcomes.
Sato, Aya; Torii, Tetsuya; Iwahashi, Masakuni; Iramina, Keiji
The purpose of this study is to analyze the inhibition mechanism of magnetic stimulation on motor function. A magnetic stimulator with a flat figure-eight coil was used to stimulate the peripheral nerve of the antebrachium. The intensity of magnetic stimulation was 0.8 T, and the stimulation frequency was 1 Hz. The amplitudes of the motor-evoked potentials (MEPs) at the abductor pollicis brevis muscle and first dorsal interosseous muscle were used to evaluate the effects of magnetic stimulation. The effects of magnetic stimulation were evaluated by analyzing the MEP amplitude before and after magnetic stimulation to the primary motor cortex. The results showed that MEP amplitude after magnetic stimulation compared with before magnetic stimulation decreased. Because there were individual differences in MEP amplitude induced by magnetic stimulation, the MEP amplitude after stimulation was normalized by the amplitude of each participant before stimulation. The MEP amplitude after stimulation decreased by approximately 58% (p < 0.01) on average compared with before stimulation. Previous studies suggested that magnetic stimulation to the primary motor cortex induced an increase or a decrease in MEP amplitude. Furthermore, previous studies have shown that the alteration in MEP amplitude was induced by cortical excitability based on magnetic stimulation. The results of this study showed that MEP amplitude decreased following magnetic stimulation to the peripheral nerve. We suggest that the decrease in MEP amplitude found in this study was obtained via the feedback from a peripheral nerve through an afferent nerve to the brain. This study suggests that peripheral excitement by magnetic stimulation of the peripheral nerve may control the central nervous system via afferent feedback.
Mokarram, Nassir; Dymanus, Kyle; Srinivasan, Akhil; Tipton, John; Chu, Jason; English, Arthur W.; Bellamkonda, Ravi V.
Injuries to the peripheral nervous system are major sources of disability and often result in painful neuropathies or the impairment of muscle movement and/or normal sensations. For gaps smaller than 10 mm in rodents, nearly normal functional recovery can be achieved; for longer gaps, however, there are challenges that have remained insurmountable. The current clinical gold standard used to bridge long, nonhealing nerve gaps, the autologous nerve graft (autograft), has several drawbacks. Despite best efforts, engineering an alternative “nerve bridge” for peripheral nerve repair remains elusive; hence, there is a compelling need to design new approaches that match or exceed the performance of autografts across critically sized nerve gaps. Here an immunomodulatory approach to stimulating nerve repair in a nerve-guidance scaffold was used to explore the regenerative effect of reparative monocyte recruitment. Early modulation of the immune environment at the injury site via fractalkine delivery resulted in a dramatic increase in regeneration as evident from histological and electrophysiological analyses. This study suggests that biasing the infiltrating inflammatory/immune cellular milieu after injury toward a proregenerative population creates a permissive environment for repair. This approach is a shift from the current modes of clinical and laboratory methods for nerve repair, which potentially opens an alternative paradigm to stimulate endogenous peripheral nerve repair. PMID:28611218
Bumbasirevic, Marko; Palibrk, Tomislav; Lesic, Aleksandar; Atkinson, Henry DE
As a result of its proximity to the humeral shaft, as well as its long and tortuous course, the radial nerve is the most frequently injured major nerve in the upper limb, with its close proximity to the bone making it vulnerable when fractures occur. Injury is most frequently sustained during humeral fracture and gunshot injuries, but iatrogenic injuries are not unusual following surgical treatment of various other pathologies. Treatment is usually non-operative, but surgery is sometimes necessary, using a variety of often imaginative procedures. Because radial nerve injuries are the least debilitating of the upper limb nerve injuries, results are usually satisfactory. Conservative treatment certainly has a role, and one of the most important aspects of this treatment is to maintain a full passive range of motion in all the affected joints. Surgical treatment is indicated in cases when nerve transection is obvious, as in open injuries or when there is no clinical improvement after a period of conservative treatment. Different techniques are used including direct suture or nerve grafting, vascularised nerve grafts, direct nerve transfer, tendon transfer, functional muscle transfer or the promising, newer treatment of biological therapy. Cite this article: Bumbasirevic M, Palibrk T, Lesic A, Atkinson HDE. Radial nerve palsy. EFORT Open Rev 2016;1:286-294. DOI: 10.1302/2058-5241.1.000028. PMID:28461960
Li, Qingfu; Peng, Jie
Sensory nerves are a kind of nerve that conduct afferent impulses from the periphery receptors to the central nervous system (CNS) and are able to release neuromediators from the activated peripheral endings. Sensory nerves are particularly important for microcirculatory response, and stimulation of pancreatic sensory nerves releases a variety of neuropeptides such as substance P (SP), calcitonin gene-related peptide (CGRP), etc., leading to neurogenic inflammation characterized as the local vasodilatation and plasma extravasation. Deactivation of sensory nerves often leads to the disturbances of pancreatic microcirculation. Pancreatitis is a common digestive disease that can lead to severe complications and even death if it goes untreated. Experimental studies in animals and tissue analysis in patients with pancreatitis have shown significant changes in sensory nerves supplying the pancreatic gland. Thus making clear the whole mechanism of pancreatitis is essential to treat and cure it. Sensory nerves may have a close correlation with the development of pancreatitis, and knowing more about the role of sensory nerve in pancreatitis is important for the treatment for pancreatitis. This review is aimed to summarize the relationship between sensory nerves and pancreatitis.
Arora, Sumit; Goel, Navneet; Cheema, Gursimrat Singh; Batra, Sumit; Maini, Lalit
The relationship of the radial nerve is described with various osseous landmarks, but such relationships may be disturbed in the setting of humerus shaft fractures. Alternative landmarks would be helpful to more consistently and reliably allow the surgeon to locate the radial nerve during the posterior approach to the arm. We investigated the relationship of the radial nerve with the apex of triceps aponeurosis, and describe a technique to locate the nerve. We performed dissections of 10 cadavers and gathered surgical details of 60 patients (30 patients and 30 control patients) during the posterior approach of the humerus. We measured the distance of the radial nerve from the apex of the triceps aponeurosis along the long axis of the humerus in cadaveric dissections and patients. This distance was correlated with the height and arm length. For all patients, we recorded time until first observation of the radial nerve, blood loss, and postoperative radial nerve function. The mean distance of the radial nerve from the apex of the triceps aponeurosis was 2.5 cm, which correlated with the patients' height and arm length. The mean time until the first observation of the radial nerve from beginning the skin incision was 6 minutes, as compared with 16 minutes in the control group. Mean blood loss was 188 mL and 237 mL, respectively. With the numbers available, we observed no difference in the incidence of patients with postoperative nerve palsy: none in the study group and three in the control group. The apex of the triceps aponeurosis appears to be a useful anatomic landmark for localization of the radial nerve during the posterior approach to the humerus.
Ozaki, Taku; Nakazawa, Mitsuru; Yamashita, Tetsuro; Ishiguro, Sei-Ichi
We developed an inhibitory peptide that specifically acts against mitochondrial μ-calpain (Tat-μCL, 23 amino acid, 2857.37 Da) and protects photoreceptors in retinal dystrophic rats. In the present study, we topically administered Tat-μCL to the eyes of Sprague-Dawley rats for 7 days to determine both the delivery route of the peptide to the posterior segment of the eye and the kinetics after topical application in adult rats. Distribution of the peptide was determined by immunohistochemical analysis, and enzyme-linked immune-absorbent assay was used to quantify the accumulation in the retina. Peptides were prominently detected in both the anterior and posterior segments of the eye at 1 h after the final eye drop application. Immunohistochemically positive reactions were observed in the retina, optic nerve, choroid, sclera and the retrobulbar tissues, even in the posterior portion of the eye. Immunoactivities gradually diminished at 3 and 6 h after the final eye drop. Quantitative estimations of the amount of peptide in the retina were 15.3, 5.8 and 1.0 pg/μg protein at 1, 3 and 6 h after the final instillation, respectively. Current results suggest that while the topically applied Tat-μCL peptide reaches the posterior segment of the retina and the optic nerve, the sufficient concentration (> IC50) is maintained for at least 6 h in the rat retina. Our findings suggest that delivery of topically applied peptide to the posterior segment and optic nerve occurs through the conjunctiva, periocular connective tissue, sclera and optic nerve sheath.
Lemos, Nucelio; Souza, Caroline; Marques, Renato Moretti; Kamergorodsky, Gil; Schor, Eduardo; Girão, Manoel J B C
To demonstrate the laparoscopic neuroanatomy of the autonomic nerves of the pelvis using the laparoscopic neuronavigation technique, as well as the technique for a nerve-sparing radical endometriosis surgery. Step-by-step explanation of the technique using videos and pictures (educational video) to demonstrate the anatomy of the intrapelvic bundles of the autonomic nerve system innervating the bladder, rectum, and pelvic floor. Tertiary referral center. One 37-year-old woman with an infiltrative endometriotic nodule on the anterior third of the left uterosacral ligament and one 34-year-old woman with rectovaginal endometriosis. Exposure and preservation by direct visualization of the hypogastric nerve and the inferior hypogastric plexus. Visual control and identification of the autonomic nerve branches of the posterior pelvis. Exposure and preservation of the hypogastric nerve and the superficial part of the left hypogastric nerve were achieved on the first patient. Nerve roots S2, S3, and S4 were identified on the second patient, allowing for the exposure and preservation of the pelvic splanchnic nerves and the deep portion inferior hypogastric plexus. Radical surgery for endometriosis can induce urinary dysfunction in 2.4%-17.5% of patients owing to lesion of the autonomic nerves. The surgeon's knowledge of the anatomy of these nerves is the main factor for preserving postoperative urinary function. The following nerves are the intrapelvic part of the autonomic nervous system: the hypogastric nerves, which derive from the superior hypogastric plexus and carry the sympathetic signals to the internal urethral and anal sphincters as well as to the pelvic visceral proprioception; and the pelvic splanchnic nerves, which arise from S2 to S4 and carry nociceptive and parasympathetic signals to the bladder, rectum, and the sigmoid and left colons. The hypogastric and pelvic splanchnic nerves merge into the pararectal fossae to form the inferior hypogastric plexus. Most
Knutsen, Elisa J; Calfee, Ryan P
Hand surgeons routinely treat carpal and cubital tunnel syndromes, which are the most common upper extremity nerve compression syndromes. However, more infrequent nerve compression syndromes of the upper extremity may be encountered. Because they are unusual, the diagnosis of these nerve compression syndromes is often missed or delayed. This article reviews the causes, proposed treatments, and surgical outcomes for syndromes involving compression of the posterior interosseous nerve, the superficial branch of the radial nerve, the ulnar nerve at the wrist, and the median nerve proximal to the wrist. Copyright © 2013 Elsevier Inc. All rights reserved.
Ethier, C. R.; Feola, A.; Myers, J. G.; Nelson, E.; Raykin, J.; Samuels, B.
Visual Impairment and Intracranial Pressure (VIIP) syndrome is a concern for long-duration space flight. Current thinking suggests that the ocular changes observed in VIIP syndrome are related to cephalad fluid shifts resulting in altered fluid pressures . In particular, we hypothesize that increased intracranial pressure (ICP) drives connective tissue remodeling of the posterior eye and optic nerve sheath (ONS). We describe here finite element (FE) modeling designed to understand how altered pressures, particularly altered ICP, affect the tissues of the posterior eye and optic nerve sheath (ONS) in VIIP. METHODS: Additional description of the modeling methodology is provided in the companion IWS abstract by Feola et al. In brief, a geometric model of the posterior eye and optic nerve, including the ONS, was created and the effects of fluid pressures on tissue deformations were simulated. We considered three ICP scenarios: an elevated ICP assumed to occur in chronic microgravity, and ICP in the upright and supine positions on earth. Within each scenario we used Latin hypercube sampling (LHS) to consider a range of ICPs, ONH tissue mechanical properties, intraocular pressures (IOPs) and mean arterial pressures (MAPs). The outcome measures were biomechanical strains in the lamina cribrosa, optic nerve and retina; here we focus on peak values of these strains, since elevated strain alters cell phenotype and induce tissue remodeling. In 3D, the strain field can be decomposed into three orthogonal components, denoted as first, second and third principal strains. RESULTS AND CONCLUSIONS: For baseline material properties, increasing ICP from 0 to 20 mmHg significantly changed strains within the posterior eye and ONS (Fig. 1), indicating that elevated ICP affects ocular tissue biomechanics. Notably, strains in the lamina cribrosa and retina became less extreme as ICP increased; however, within the optic nerve, the occurrence of such extreme strains greatly increased as
Girotto, Vittorio; Gonzalez, Michael
Do young children have a basic intuition of posterior probability? Do they update their decisions and judgments in the light of new evidence? We hypothesized that they can do so extensionally, by considering and counting the various ways in which an event may or may not occur. The results reported in this paper showed that from the age of five,…
Girotto, Vittorio; Gonzalez, Michael
Do young children have a basic intuition of posterior probability? Do they update their decisions and judgments in the light of new evidence? We hypothesized that they can do so extensionally, by considering and counting the various ways in which an event may or may not occur. The results reported in this paper showed that from the age of five,…
Agner, Celso; Dujovny, Manuel; Evenhouse, Raymond; Charbel, Fady T.; Sadler, Lewis
Posterior fossa cranioplasty has been suggested for improvement of neurological symptoms following craniectomy. However, there is no particular recommendation in the literature about techniques for prosthesis manufacture and implantation. We report our experience using rapid prototyping technology and stereolithography for pre-surgical implant design and production of cranioplasties. ImagesFigure 1Figure 2Figure 3Figure 4Figure 5 PMID:17171056
Nauta, J M; Timmenga, N M; Cats, H
There are different etiological factors concerning the acute peripheral facial nerve palsy. In the majority of the cases, however, no etiological factor can be found. These cases are called idiopathic facial palsy or Bells palsy. Perhaps local anaesthetics could play a role as an etiological factor. By means of a case-report this form of facial nerve palsy will be discussed.
Basheer, H; Rabia, F; Basheer, H; el-Helw, K
We report four cases of neurofibromas affecting the digital nerves. Diagnosis and management are both difficult and demanding. Excision of the tumour while preserving the nerve was achieved by meticulous dissection in three out of four cases, resulting in normal sensation in two. The risk of recurrence is outweighed by the risk to sensation.
Abejón, David; Pérez-Cajaraville, Juan
Recently, there has been a tremendous evolution in the field of neurostimulation, both from the technological point of view and from development of the new and different indications. In some areas, such as peripheral nerve stimulation, there has been a boom in recent years due to the variations in the surgical technique and the improved results documented by in multiple published papers. All this makes imperative the need to classify and define the different types of stimulation that are used today. The confusion arises when attempting to describe peripheral nerve stimulation and subcutaneous stimulation. Peripheral nerve stimulation, in its pure definition, involves implanting a lead on a nerve, with the aim to produce paresthesia along the entire trajectory of the stimulated nerve. Copyright © 2011 S. Karger AG, Basel.
Mawaddah, Azman; Marina, Mat Baki; Halimuddin, Sawali; Mohd Razif, Mohd Yunus; Abdullah, Sani
Bilateral vocal fold immobility (BVFI) is commonly caused by injury to the recurrent laryngeal nerve (RLN) and leads to stridor and dyspnea of varying onsets. A retrospective study was done at the Department of Otorhinolaryngology of Universiti Kebangsaan Malaysia Medical Centre on laser microsurgical posterior cordectomy for BVFI. The objectives were to identify the average duration of onset of stridor from the time of insult and to evaluate the outcome of laser posterior cordectomy as a surgical option. From 1997 to 2007, a total of 31 patients with BVFI were referred for surgery. Twelve patients had tracheostomy done prior to the procedure, whereas 19 patients were without tracheostomy. Ten patients were successfully decannulated, and only 4 patients had complications related to the procedure. The minimum onset of stridor was 7 months, maximum onset of stridor was 28 years, and the mean onset of stridor was 8.7 years. The commonest complication observed was posterior glottic adhesion following bilateral posterior cordectomy. Laser endolaryngeal posterior cordectomy is an excellent surgical option as it enables successful decannulation or avoidance of tracheostomy in patients with BVFI. The onset of stridor took years after the insult to the recurrent laryngeal nerves. PMID:27660547
Yazawa, Shigenobu; Umesono, Yoshihiko; Hayashi, Tetsutaro; Tarui, Hiroshi; Agata, Kiyokazu
Despite long-standing interest, the molecular mechanisms underlying the establishment of anterior–posterior (AP) polarity remain among the unsolved mysteries in metazoans. In the planarians (a family of flatworms), canonical Wnt/β-catenin signaling is required for posterior specification, as it is in many animals. However, the molecular mechanisms regulating the posterior-specific induction of Wnt genes according to the AP polarity have remained unclear. Here, we demonstrate that Hedgehog (Hh) signaling is responsible for the establishment of AP polarity via its regulation of the transcription of Wnt family genes during planarian regeneration. We found that RNAi gene knockdown of Dugesia japonica patched (Djptc) caused ectopic tail formation in the anterior blastema of body fragments, resulting in bipolar-tails regeneration. In contrast, RNAi of hedgehog (Djhh) and gli (Djgli) caused bipolar-heads regeneration. We show that Patched-mediated Hh signaling was crucial for posterior specification, which is established by regulating the transcription of Wnt genes via downstream Gli activity. Moreover, differentiated cells were responsible for the posterior specification of undifferentiated stem cells through Wnt/β-catenin signaling. Surprisingly, Djhh was expressed in neural cells all along the ventral nerve cords (along the AP axis), but not in the posterior blastema of body fragments, where the expression of Wnt genes was induced for posteriorization. We therefore propose that Hh signals direct head or tail regeneration according to the AP polarity, which is established by Hh signaling activity along the body's preexisting nervous system. PMID:20018728
Zhou, Xiang; He, Bo; Zhu, Zhaowei; He, Xinhua; Zheng, Canbin; Xu, Jian; Jiang, Li; Gu, Liqiang; Zhu, Jiakai; Zhu, Qingtang; Liu, Xiaolin
Acellular nerve grafts are good candidates for nerve repair, but the clinical outcome of grafting is not always satisfactory. We investigated whether etifoxine could enhance nerve regeneration. Seventy-two Sprague-Dawley rats were divided into 3 groups: (1) autograft; (2) acellular nerve graft; and (3) acellular nerve graft plus etifoxine. Histological and electrophysiological examinations were performed to evaluate the efficacy of nerve regeneration. Walking-track analysis was used to examine functional recovery. Quantitative polymerase chain reaction was used to evaluate changes in mRNA level. Etifoxine: (i) increased expression of neurofilaments in regenerated axons; (ii) improved sciatic nerve regeneration measured by histological examination; (iii) increased nerve conduction velocity; (iv) improved walking behavior as measured by footprint analysis; and (v) boosted expression of neurotrophins. These results show that etifoxine can enhance peripheral nerve regeneration across large nerve gaps repaired by acellular nerve grafts by increasing expression of neurotrophins. Copyright © 2013 Wiley Periodicals, Inc.
Miyamoto, Hideaki; Serradori, Thomas; Mikami, Yoji; Selber, Jesse; Santelmo, Nicola; Facca, Sybille; Liverneaux, Philippe
The aim of this study was to report the feasibility of robotic intercostal nerve harvest in a pig model. A surgical robot, the da Vinci Model S system, was installed after the creation of 3 ports in the pig's left chest. The posterior edges of the fourth, fifth, and sixth intercostal nerves were isolated at the level of the anterior axillary line. The anterior edges of the nerves were transected at the rib cartilage zone. Three intercostal nerve harvesting procedures, requiring an average of 33 minutes, were successfully performed in 3 pigs without major complications. The advantages of robotic microsurgery for intercostal nerve harvest include elimination of physiological tremor, free movement of joint-equipped robotic arms, and amplification of the surgeon's hand motion by as much as 5 times. Robot-assisted neurolysis may be clinically useful for intercostal nerve harvest for brachial plexus reconstruction.
Urrets-Zavalia, Julio A; Crim, Nicolas; Esposito, Evangelina; Correa, Leandro; Gonzalez-Castellanos, M Eugenia; Martinez, Dana
Purpose To present a case of a complicated posterior melanocytoma that was successfully treated with intravitreal bevacizumab. Case report A 50-year-old Caucasian man was referred with sudden-onset metamorphopsia and decreased vision in his right eye over the course of the last 2 months. His best-corrected visual acuity was 20/80 and poorer than Jaeger 14 in the right eye, and 20/20 and Jaeger 1 in his left eye. In the right fundus, there was a melanocytic lesion occupying the inferotemporal quadrant of the optic disk, extending to the adjacent choroid inferiorly; optic nerve edema, superotemporal retinal vein dilatation, and subretinal fluid under the macula and nasal half of the posterior pole were observed, and a subretinal choroidal neovascularization complex was observed adjacent to the superotemporal margin of the optic disk, confirmed by fluorescein angiography, surrounded by a dense subretinal hemorrhage. Optical coherence tomography showed retinal edema and detachment of neurosensory retina. The patient was treated with three consecutive doses on a monthly basis of intravitreal 1.25 mg/0.05 mL bevacizumab. Visual acuity recovered rapidly, and at 4 months after treatment, it was 20/20 and Jaeger 1, with complete resolution of macular edema and subretinal fluid and hemorrhage. After 3 years of follow-up, best-corrected visual acuity remained stable, macular area was normal, and there was no evident optic nerve edema, retinal vein caliber and aspect were normal, and there was no significant change of the tumor. Fluorescein angiography only evidenced late staining of choroidal neovascularization scar, and optical coherence tomography showed a normal macular anatomy. Conclusion Intravitreal bevacizumab was effective in the treatment of choroidal neovascularization, optic nerve edema, venous dilatation, and local capillary telangiectasia, complicating an optic disk melanocytoma. PMID:25834382
Lee, Yong Ki; Han, Eun Young; Choi, Sung Wook; Kim, Bo Ryun; Suh, Min Ji
Type 2 superior labral anterior to posterior (SLAP) lesion is a common cause of shoulder pain requiring surgical operation. SLAP tears are often associated with paralabral cysts, but they rarely cause nerve compression. However, we experienced two cases of type 2 SLAP-related paralabral cysts at the spinoglenoid notch which were confirmed as isolated nerve entrapment of the infraspinatus branch of the suprascapular nerve by electrodiagnostic assessment and magnetic resonance imaging. In these pathological conditions, comprehensive electrodiagnostic evaluation is warranted for confirmation of neuropathy, while surgical decompression of the paralabral cyst combined with SLAP repair is recommended.
McQuarrie, I G
In treating the three main surgical problems of peripheral nerves--nerve sheath tumors, entrapment neuropathies, and acute nerve injuries--the overriding consideration is the preservation and restoration of neurologic function. Because of this, certain other principles may need to be compromised. These include achieving a gross total excision of benign tumors, employing conservative therapy as long as a disease process is not clearly progressing, and delaying repair of a nerve transection until the skin wound has healed. Only three pathophysiologic processes need be considered: neurapraxia (focal segmental dymyelination), axonotmesis (wallerian degeneration caused by a lesion that does not disrupt fascicles of nerve fibers), and neurotmesis (wallerian degeneration caused by a lesion that interrupts fascicles). With nerve sheath tumors and entrapment neuropathies, the goal is minimize the extent to which neurapraxia progresses to axonotmesis. The compressive force is relieved without carrying out internal neurolysis, a procedure that is poorly tolerated, presumably because a degree of nerve ischemia exists with any long-standing compression. When the nerve has sustained blunt trauma (through acute compression, percussion, or traction), the result can be a total loss of function and an extensive neuroma-in-continuity (scarring within the nerve). However, the neural pathophysiology may amount to nothing more than axonotmesis. Although this lesion, in time, leads to full and spontaneous recovery, it must be differentiated from the neuroma-in-continuity that contains disrupted fascicles requiring surgery. Finally, with open nerve transection, the priority is to match the fascicles of the proximal stump with those of the distal stump, a goal that is best achieved if primary neurorrhaphy is carried out.
Natori, Yuhei; Yoshizawa, Hidekazu; Mizuno, Hiroshi; Hayashi, Ayato
During surgery, peripheral nerves are often seen to follow unpredictable paths because of previous surgeries and/or compression caused by a tumor. Iatrogenic nerve injury is a serious complication that must be avoided, and preoperative evaluation of nerve paths is important for preventing it. In this study, transcutaneous electrical nerve stimulation (TENS) was used for an in-depth analysis of peripheral nerve paths. This study included 27 patients who underwent the TENS procedure to evaluate the peripheral nerve path (17 males and 10 females; mean age: 59.9 years, range: 18-83 years) of each patient preoperatively. An electrode pen coupled to an electrical nerve stimulator was used for superficial nerve mapping. The TENS procedure was performed on patients' major peripheral nerves that passed close to the surgical field of tumor resection or trauma surgery, and intraoperative damage to those nerves was apprehensive. The paths of the target nerve were detected in most patients preoperatively. The nerve paths of 26 patients were precisely under the markings drawn preoperatively. The nerve path of one patient substantially differed from the preoperative markings with numbness at the surgical region. During surgery, the nerve paths could be accurately mapped preoperatively using the TENS procedure as confirmed by direct visualization of the nerve. This stimulation device is easy to use and offers highly accurate mapping of nerves for surgical planning without major complications. The authors conclude that TENS is a useful tool for noninvasive nerve localization and makes tumor resection a safe and smooth procedure.
O'Shaughnessy, Brian A; Getch, Christopher C; Bendok, Bernard R; Batjer, H Hunt
Intracranial aneurysms arising from the posterior wall of the supraclinoid carotid artery are extremely common lesions. The aneurysm dilation typically occurs in immediate proximity to the origin of the posterior communicating artery and, less commonly, the anterior choroidal artery (AChA). Because of the increasingly widespread use of noninvasive neuroimaging methods to evaluate patients believed to harbor cerebral lesions, many of these carotid artery aneurysms are now documented in their unruptured state, prior to occurrence of subarachnoid hemorrhage. Based on these factors, the management of unruptured posterior carotid artery (PCA) wall aneurysms is an important element of any neurosurgical practice. Despite impressive recent advances in endovascular therapy, the placement of microsurgical clips to exclude aneurysms with preservation of all afferent and efferent vasculature remains the most efficacious and durable therapy. To date, an optimal outcome is only achieved when the neurosurgeon is able to combine systematic preoperative neurovascular assessment with meticulous operative technique. In this report, the authors review their surgical approach to PCA wall aneurysms, which is greatly based on the extensive neurovascular experience of the senior author. Focus is placed on their methods of preoperative evaluation and operative technique, with emphasis on neurovascular anatomy and the significance of oculomotor nerve compression. They conclude by discussing surgery-related complications, with a particular focus on intraoperative rupture of aneurysms and their management, and the postoperative ischemic AChA syndrome.
Triantafyllou, Asterios; Fletcher, David
Normal posterior deep and superficial salivary glands of tongue were examined in male mice by means of light microscopical histochemistry and neurohistology. Both glands showed acini and simple ducts. Demilunes were present in the superficial gland. Disulphides and neutral mucosubstances occurred in acini and demilunes. Tryptophan staining was seen in acini of the deep gland and demilunes, whereas acid mucosubstances were exclusively localised in the superficial gland. Dehydrogenase activities were widespread. Strong esterase activity occurred throughout the parenchyma of the deep gland and in demilunes; it was variably inhibited by E600, apart from acinar apical regions in the deep gland. Lipase was confined to acini of the deep gland and demilunes. Acid phosphatase staining was similarly localised; it was also seen in periluminal ductal rims of the deep gland, in which ouabain-sensitive Na,K-ATPase was localised basolaterally. Staining for alkaline phosphatase decorated occasional myoepithelial-like arrangements and interstitial capillaries. Acetylcholinesterase was associated with nerve fibres embracing glandular parenchyma. Adrenergic fibres were not seen. The results suggest that the acini of the posterior deep lingual gland secrete neutral glycoproteins, whereas the ducts transport ions and absorb luminal material. The posterior superficial lingual gland mainly secretes acid glycoproteins. Both glands produce lingual lipase, receive cholinergic-type innervation and have inconspicuous myoepithelium. Copyright © 2016 Elsevier GmbH. All rights reserved.
Suzuki, M; Harada, Y; Omura, R; Hirakawa, H
The anterior semicircular canals of bull frogs were isolated and the cupula was removed from the crista and the sensory cilia on the crista were depressed toward the canal side by a glass micropipette. Seven points on the crista were selected for stimulation. Decremental time constants of the anterior ampullary nerve action potentials were measured. The longer time constants were measured at the lateral points of stimulation which progressively shortened toward the central point. The overall values of the time constant were significantly shorter than those of the posterior semicircular canal. This indicates that the anterior semicircular canal has a larger number of phasic receptors than the posterior canal.
Downs, J. Crawford
This nontechnical review is focused upon educating the reader on optic nerve head biomechanics in both aging and disease along two main themes: what is known about how mechanical forces and the resulting deformations are distributed in the posterior pole and ONH (biomechanics) and what is known about how the living system responds to those deformations (mechanobiology). We focus on how ONH responds to IOP elevations as a structural system, insofar as the acute mechanical response of the lamina cribrosa is confounded with the responses of the peripapillary sclera, prelaminar neural tissues, and retrolaminar optic nerve. We discuss the biomechanical basis for IOP-driven changes in connective tissues, blood flow, and cellular responses. We use glaucoma as the primary framework to present the important aspects of ONH biomechanics in aging and disease, as ONH biomechanics, aging, and the posterior pole extracellular matrix (ECM) are thought to be centrally involved in glaucoma susceptibility, onset and progression. PMID:25819451
Burstein, Jeffrey; Mastin, Chris; Le, Bach
Injury to the inferior alveolar nerve during implant placement in the posterior atrophic mandible is a rare but serious complication. Although a preoperative computerized tomography scan can help determine the distance from the alveolar ridge to the nerve canal, variables such as magnification errors, ridge anatomy, and operator technique can increase the chance for complications. The routine use of intraoperative periapical radiographs during the drilling sequence is an inexpensive and reliable tool, allowing the operator to confidently adjust the direction and depth of the implant during placement. Most important, it helps avoid the risk of injury to the inferior alveolar nerve in cases in which there is limited vertical alveolar bone. Using this technique for 21 implants placed in the posterior atrophic mandible, with less than 10 mm of vertical bone to the inferior alveolar nerve canal, the authors observed no incidents of postoperative paresthesia.
Hirose, Y; Sagoh, M; Mayanagi, K; Murakami, H
A 47-year-old male presented with abducens nerve palsy due to basilar impression associated with atlanto-occipital assimilation manifesting as slowly progressive bilateral trigeminal neuralgia and diplopia in the right lateral gaze. X-ray and computed tomography of the skull confirmed the diagnosis of basilar impression and atlanto-occipital assimilation, and magnetic resonance imaging disclosed tightness of the posterior cranial fossa. Surgical suboccipital decompression resulted in gradual resolution of the patient's complaints, and no additional symptoms were recognized. Impairment of the sixth cranial nerve is a rare symptom compared to those of the fifth or the eighth cranial nerve in a patient with a craniocervical malformation. However, the present case shows the possibility of cranial nerve dysfunction due to tightness of the posterior cranial fossa, and suggests that surgical treatment for basilar impression with atlanto-occipital assimilation should be considered in patients with uncommon and unusual symptoms.
Andrabi, Syed Mukhtar-Un-Nisar; Alam, Sharique; Zia, Afaf; Khan, Masood Hasan; Kumar, Ashok
Whenever endodontic therapy is performed on mandibular posterior teeth, damage to the inferior alveolar nerve or any of its branches is possible. Acute periapical infection in mandibular posterior teeth may also sometimes disturb the normal functioning of the inferior alveolar nerve. The most common clinical manifestation of these insults is the paresthesia of the inferior alveolar nerve or mental nerve paresthesia. Paresthesia usually manifests as burning, prickling, tingling, numbness, itching or any deviation from normal sensation. Altered sensation and pain in the involved areas may interfere with speaking, eating, drinking, shaving, tooth brushing and other events of social interaction which will have a disturbing impact on the patient. Paresthesia can be short term, long term or even permanent. The duration of the paresthesia depends upon the extent of the nerve damage or persistence of the etiology. Permanent paresthesia is the result of nerve trunk laceration or actual total nerve damage. Paresthesia must be treated as soon as diagnosed to have better treatment outcomes. The present paper describes a case of mental nerve paresthesia arising after the start of the endodontic therapy in left mandibular first molar which was managed successfully by conservative treatment.
Huang, Da-geng; Hao, Ding-jun; Li, Guang-lin; Guo, Hao; Zhang, Yu-chen; He, Bao-rong
The C1 lateral mass screw technique is widely used for atlantoaxial fixation. However, C2 nerve dysfunction may occur as a complication of this procedure, compromising the quality of life of affected patients. This is a review of the topic of C2 nerve dysfunction associated with C1 lateral mass screw fixation and related research developments. The C2 nerve root is located in the space bordered superiorly by the posterior arch of C1 , inferiorly by the C2 lamina, anteriorly by the lateral atlantoaxial joint capsule, and posteriorly by the anterior edge of the ligamentum flavum. Some surgeons suggest cutting the C2 nerve root during C1 lateral mass screw placement, whereas others prefer to preserve it. The incidence, clinical manifestations, causes, management, and prevention of C2 nerve dysfunction associated with C(1) lateral mass screw fixation are reviewed. Sacrifice of the C2 nerve root carries a high risk of postoperative numbness, whereas postoperative nerve dysfunction can occur when it has been preserved. Many surgeons have been working hard on minimizing the risk of postoperative C2 nerve dysfunction associated with C1 lateral mass screw fixation. © 2014 Chinese Orthopaedic Association and Wiley Publishing Asia Pty Ltd.
Alam, Sharique; Zia, Afaf; Khan, Masood Hasan; Kumar, Ashok
Whenever endodontic therapy is performed on mandibular posterior teeth, damage to the inferior alveolar nerve or any of its branches is possible. Acute periapical infection in mandibular posterior teeth may also sometimes disturb the normal functioning of the inferior alveolar nerve. The most common clinical manifestation of these insults is the paresthesia of the inferior alveolar nerve or mental nerve paresthesia. Paresthesia usually manifests as burning, prickling, tingling, numbness, itching or any deviation from normal sensation. Altered sensation and pain in the involved areas may interfere with speaking, eating, drinking, shaving, tooth brushing and other events of social interaction which will have a disturbing impact on the patient. Paresthesia can be short term, long term or even permanent. The duration of the paresthesia depends upon the extent of the nerve damage or persistence of the etiology. Permanent paresthesia is the result of nerve trunk laceration or actual total nerve damage. Paresthesia must be treated as soon as diagnosed to have better treatment outcomes. The present paper describes a case of mental nerve paresthesia arising after the start of the endodontic therapy in left mandibular first molar which was managed successfully by conservative treatment. PMID:25110646
Balaratnasingam, Chandrakumar; Morgan, William H; Johnstone, Victoria; Pandav, Surinder S; Cringle, Stephen J; Yu, Dao-Yi
Intraocular pressure and cerebrospinal fluid (CSF) pressure are important determinants of the trans-laminar pressure gradient which is believed to be important in the pathogenesis of glaucomatous optic nerve degeneration. Computational models and finite element calculations of optic nerve head biomechanics have been previously used to predict pressures and stresses in the human optic nerve. The purpose of this report is to morphometrically compare the optic nerve laminar and pia mater structure between humans and dogs, and to use previously reported tissue pressure measurements in the dog optic nerve to estimate individual-specific human optic nerve pressures and pressure gradients. High resolution light microscopy was used to acquire quantitative histological measurements from sagittal sections taken from the middle of the optic nerve in 34 human cadaveric eyes and 10 dog eyes. Parameters measured included the pre-laminar and lamina cribrosa thickness, distance from posterior boundary of lamina cribrosa to inner limiting membrane (ILM), shortest distance between anterior lamina cribrosa surface and subarachnoid space, shortest distance between ILM and inner surface of pia mater in contact with the subarachnoid space and optic nerve diameter. Pia mater thickness in the proximal 4 mm of post-laminar nerve was also determined. There was no significant difference in lamina cribrosa thickness between dog and human eyes (P = 0.356). The distance between the intraocular and subarachnoid space was greater in dogs (P < 0.001). Pia mater thickness was greatest at the termination of subarachnoid space in both species. In humans, pia mater thickness decreased over the proximal 500 mum to reach a constant value of approximately 60 mum. In dogs this decrease occurred over 1000 mum to reach a constant diameter of approximately 30 mum. Using previous measurements of optic nerve pressures and pressure gradients in dogs we estimate that at an IOP of 15 mmHg and a CSF pressure of 0
Endo, Yoshimi; Miller, Theodore T; Carlson, Erik; Wolfe, Scott W
Spontaneous nerve torsion is a rare cause of nerve palsy. We describe a case of nerve torsion affecting the radial nerve in order to inform radiologists of the existence of this condition and subtle features on cross-sectional imaging that can suggest the diagnosis preoperatively.
Ding, David Y; Gupta, Asheesh; Snir, Nimrod; Wolfson, Theodore; Meislin, Robert J
The long head of the biceps can develop tendonitis and tendinosis, which can lead to pain in the bicipital groove. The use of bicortical button fixation allows for a smaller defect in the humerus compared with tenodesis screws, reducing the risk of fracture. Our objective is to evaluate the exit location of our bicortical button and its relation to relevant posterior nervous structures. We performed anatomic dissection of 6 fresh-frozen cadaveric upper extremities. At the level of the inferior border of the pectoralis major tendon, the musculotendinous junction of the long head of the biceps was identified. At the base of the bicipital groove, a 3.2-mm guidewire was advanced perpendicularly through both the anterior and posterior cortex. Posteriorly, the radial and axillary nerves were carefully dissected. For each dissection, we recorded the closest distance from the posterior cortical hole created by our drill to both the axillary and radial nerves using digital calipers. The mean distance from the axillary nerve to the posterior drill hole was 25.1 mm (95% confidence interval, 21.6 to 28.6 mm). The mean distance from the radial nerve to the posterior drill hole was 30.3 mm (95% confidence interval, 27.2 to 33.4 mm). With placement of the tenodesis at the inferior aspect of the bicipital groove in conjunction with the musculotendinous junction, open subpectoral tenodesis of the long head of the biceps can be performed using bicortical button fixation without risk to the posterior nervous structures. This cadaveric study suggests that posterior proximal humerus nervous structures can be avoided with proper tenodesis placement. Published by Elsevier Inc.
Phillips, Flip; Voshell, Martin G
The study of spatial vision is a long and well traveled road (which, of course, converges to a vanishing point at the horizon). Its various distortions have been widely investigated empirically, and most concentrate, pragmatically, on the space anterior to the observer. The visual world behind the observer has received relatively less attention and it is this perspective the current experiments address. Our results show systematic perceptual distortions in the posterior visual world when viewed statically. Under static viewing conditions, observer's perceptual representation was consistently 'spread' in a hyperbolic fashion. Directions to distant, peripheral locations were consistently overestimated by about 11 degrees from the ground truth and this variability increased as the target was moved toward the center of the observer's back. The perceptual representation of posterior visual space is, no doubt, secondary to the more immediate needs of the anterior visual world. Still, it is important in some domains including certain sports, such as rowing, and in vehicular navigation.
Coert, J Henk
In extensive burns peripheral nerves can be involved. The injury to the nerve can be direct by thermal or electrical burns, but nerves can also be indirectly affected by the systemic reaction that follows the burn. Mediators will be released causing a neuropathy to nerves remote from the involved area. Involved mediators and possible therapeutic options will be discussed. In burned patients nerves can be reconstructed using autologous nerve grafts or nerve conduits. A key factor is an adequate wound debridement and a well-vascularized bed to optimize the outgrowth of the axons. Early free tissue transfers have shown promising results.
Modified skin incision for avoiding the lesser occipital nerve and occipital artery during retrosigmoid craniotomy: potential applications for enhancing operative working distance and angles while minimizing the risk of postoperative neuralgias and intraoperative hemorrhage.
Tubbs, R Shane; Fries, Fabian N; Kulwin, Charles; Mortazavi, Martin M; Loukas, Marios; Cohen-Gadol, Aaron A
Chronic postoperative neuralgias and headache following retrosigmoid craniotomy can be uncomfortable for the patient. We aimed to better elucidate the regional nerve anatomy in an effort to minimize this postoperative complication. Ten adult cadaveric heads (20 sides) were dissected to observe the relationship between the lesser occipital nerve and a traditional linear versus modified U incision during retrosigmoid craniotomy. Additionally, the relationship between these incisions and the occipital artery were observed. The lesser occipital nerve was found to have two types of course. Type I nerves (60%) remained close to the posterior border of the sternocleidomastoid muscle and some crossed anteriorly over the sternocleidomastoid muscle near the mastoid process. Type II nerves (40%) left the posterior border of the sternocleidomastoid muscle and swung medially (up to 4.5cm posterior to the posterior border of the sternocleidomastoid muscle) as they ascended over the occiput. The lesser occipital nerve was near a midpoint of a line between the external occipital protuberance and mastoid process in all specimens with the type II nerve configuration. Based on our findings, the inverted U incision would be less likely to injure the type II nerves but would necessarily cross over type I nerves, especially more cranially on the nerve at the apex of the incision. As the more traditional linear incision would most likely transect the type I nerves and more so near their trunk, the U incision may be the overall better choice in avoiding neural and occipital artery injury during retrosigmoid approaches.
Girard, Michaël J A; Downs, J Crawford; Burgoyne, Claude F; Suh, J-K Francis
The sclera is the white outer shell and principal load-bearing tissue of the eye as it sustains the intraocular pressure. We have hypothesized that the mechanical properties of the posterior sclera play a significant role in and are altered by the development of glaucoma-an ocular disease manifested by structural damage to the optic nerve head. An anisotropic hyperelastic constitutive model is presented to simulate the mechanical behavior of the posterior sclera under acute elevations of intraocular pressure. The constitutive model is derived from fiber-reinforced composite theory, and incorporates stretch-induced stiffening of the reinforcing collagen fibers. Collagen fiber alignment was assumed to be multidirectional at local material points, confined within the plane tangent to the scleral surface, and described by the semicircular von Mises distribution. The introduction of a model parameter, namely, the fiber concentration factor, was used to control collagen fiber alignment along a preferred fiber orientation. To investigate the effects of scleral collagen fiber alignment on the overall behaviors of the posterior sclera and optic nerve head, finite element simulations of an idealized eye were performed. The four output quantities analyzed were the scleral canal expansion, the scleral canal twist, the posterior scleral canal deformation, and the posterior laminar deformation. A circumferential fiber organization in the sclera restrained scleral canal expansion but created posterior laminar deformation, whereas the opposite was observed with a meridional fiber organization. Additionally, the fiber concentration factor acted as an amplifying parameter on the considered outputs. The present model simulation suggests that the posterior sclera has a large impact on the overall behavior of the optic nerve head. It is therefore primordial to provide accurate mechanical properties for this tissue. In a companion paper (Girard, Downs, Bottlang, Burgoyne, and Suh, 2009
Kieser, Jules; Kuzmanovic, Dusan; Payne, Alan; Dennison, John; Herbison, Peter
This study investigated the path of emergence of the mental nerve in a number of human population groups. Skeletal material comprised 117 Negro skulls (53 males), 114 caucasoid skulls (62 males) and 100 pre-contact Maori skulls (70 males). In each case, the path of emergence was classified into posterior, anterior, right-angled or multiple. Those cases with severely resorbed alveolar ridges that made classification difficult were excluded from the study. Additionally, 56 cadaveric mandibles were examined, in which an osteotomy of 1cm was made on either side of the mental foramen to expose the nerve. The most common pattern of emergence in caucasoids and Maoris was a posterior direction (86.7% of caucasoid males, 90.2% of caucasoid females; 85.5% of Maori males, 93.1% of Maori females). In Negroes the most common pattern was a right-angled path of emergence (45.8% of males, 45.0% of females), with this difference between population groups being statistically significant (Pearson's chi(2): males=23.4, females=45-97; P<0.01). Multiple foramina were rare, with the highest incidence being in Maori and Negro males. Cadaveric data supported the findings of the skeletal investigation, with the dominant emergence recorded as posteriorly directed (80.7% of males, 86.6% of females). It was concluded that while the traditionally accepted ontogenetic explanation for the inclination of the mental nerve might be applicable to caucasoids and Maoris, it fails to explain the observed right-angled emergence pattern in Negroes. Hence, the nerve's emergence might be genetically, rather than functionally, determined. The study did not show a measurable anterior loop in the emergence of the mental nerve that would have any significant impact on treatment planning for implants in the anterior mandible.
Kosiyatrakul, Arkaphat; Luenam, Suriya; Phisitkul, Phinit
Tarsal tunnel syndrome, a compressive neuropathy of the tibial nerve or its branches with in the tarsal tunnel, is an uncommon condition. Various etiologies of the syndrome have been described. We report a rare case of tarsal tunnel syndrome associated with a perforating branch from the posterior tibial artery. A 56-year-old woman presented with 1-year history of paresthesia and hypoesthesia in the medial and lateral plantar area of the left foot. Tinel's sign was elicited at the tarsal tunnel. Electrodiagnostic studies confirmed the diagnosis of left tarsal tunnel syndrome. Intraoperatively, the perforating branch from posterior tibial artery which traveled through a split in the tibial nerve was encountered. The patient's symptom improved significantly at 2 years after tarsal tunnel release and vascular ligation. Only a minor degree of paresthesia remains in the forefoot.
Neuropathy - femoral nerve; Femoral neuropathy ... Craig EJ, Clinchot DM. Femoral neuropathy. In: Frontera WR, Silver JK, Rizzo TD Jr, eds. Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and Rehabilitation . 3rd ...
... the wrong times. This damage is called diabetic neuropathy. Over half of people with diabetes get it. ... change positions quickly Your doctor will diagnose diabetic neuropathy with a physical exam and nerve tests. Controlling ...
Degenerative nerve diseases affect many of your body's activities, such as balance, movement, talking, breathing, and heart function. Many of these diseases are genetic. Sometimes the cause is a medical ...
Diabetic neuropathy; Diabetes - neuropathy; Diabetes - peripheral neuropathy ... In people with diabetes, the body's nerves can be damaged by decreased blood flow and a high blood sugar level. This condition is ...
... is commonly injured at the elbow because of elbow fracture or dislocation. The ulnar nerve is near the surface of the body where it crosses the elbow, so prolonged pressure on the elbow or entrapment ...
Howland, Robert H
The vagus nerve is a major component of the autonomic nervous system, has an important role in the regulation of metabolic homeostasis, and plays a key role in the neuroendocrine-immune axis to maintain homeostasis through its afferent and efferent pathways. Vagus nerve stimulation (VNS) refers to any technique that stimulates the vagus nerve, including manual or electrical stimulation. Left cervical VNS is an approved therapy for refractory epilepsy and for treatment resistant depression. Right cervical VNS is effective for treating heart failure in preclinical studies and a phase II clinical trial. The effectiveness of various forms of non-invasive transcutaneous VNS for epilepsy, depression, primary headaches, and other conditions has not been investigated beyond small pilot studies. The relationship between depression, inflammation, metabolic syndrome, and heart disease might be mediated by the vagus nerve. VNS deserves further study for its potentially favorable effects on cardiovascular, cerebrovascular, metabolic, and other physiological biomarkers associated with depression morbidity and mortality.
Howland, Robert H.
The vagus nerve is a major component of the autonomic nervous system, has an important role in the regulation of metabolic homeostasis, and plays a key role in the neuroendocrine-immune axis to maintain homeostasis through its afferent and efferent pathways. Vagus nerve stimulation (VNS) refers to any technique that stimulates the vagus nerve, including manual or electrical stimulation. Left cervical VNS is an approved therapy for refractory epilepsy and for treatment resistant depression. Right cervical VNS is effective for treating heart failure in preclinical studies and a phase II clinical trial. The effectiveness of various forms of non-invasive transcutaneous VNS for epilepsy, depression, primary headaches, and other conditions has not been investigated beyond small pilot studies. The relationship between depression, inflammation, metabolic syndrome, and heart disease might be mediated by the vagus nerve. VNS deserves further study for its potentially favorable effects on cardiovascular, cerebrovascular, metabolic, and other physiological biomarkers associated with depression morbidity and mortality. PMID:24834378
... machines can help monitor and detect loss of optic nerve fibers. The Heidelberg Retina Tomograph (HRT) is a special ... keeping organized, you can establish a routine that works for you. Read more » Are You at Risk ...
... is the nerve that helps control the deltoid muscles of the shoulder and the skin around it. A problem with ... can cause difficulty moving your arm. The deltoid muscle of the shoulder may show signs of muscle atrophy . Tests that ...
Tognù, A; Borghi, B; Gullotta, S; White, P F
The purpose of the case is to report the clinical value of the ultrasound-guided posterior approach to the brachial plexus in the treatment of phantom limb syndrome after an upper extremity amputation. The author experienced ultrasound guidance as sole technique to localize the brachial plexus for the purpose of placing a catheter for continuous infusion of a local anesthetic in a patient where standard landmark-based nerve stimulation for placement of a continuous perineural block was not possible.
complete dependence on nerves. Organ culture of sciatic nerves, combined with an assay for axolotl transferrin developed earlier, allows quantitative study...axonal release of various unknown proteins. Combining this approach with the ELISA for quantitative measurement of axolotl transferrin developed with...light microscope autoradiographic analysis following binding of radiolabelled Tf. Studies of Tf synthesis will employ cDNA probes for axolotl Tf mRNA
Auyong, Thomas G; Le, Anh
Nerve injury associated with dentoalveolar surgery is a complication contributing to the altered sensation of the lower lip, chin, buccal gingivae, and tongue. This surgery-related sensory defect is a morbid postoperative outcome. Several risk factors have been proposed. This article reviews the incidence of trigeminal nerve injury, presurgical risk assessment, classification, and surgical coronectomy versus conventional extraction as an approach to prevent neurosensory damage associated with dentoalveolar surgery. Copyright © 2011. Published by Elsevier Inc.
Lee, Linda N; Lyford-Pike, Sofia; Boahene, Kofi Derek O
Facial nerve trauma can be a devastating injury resulting in functional deficits and psychological distress. Deciding on the optimal course of treatment for patients with traumatic facial nerve injuries can be challenging, as there are many critical factors to be considered for each patient. Choosing from the great array of therapeutic options available can become overwhelming to both patients and physicians, and in this article, the authors present a systematic approach to help organize the physician's thought process.
Nakamura, Keiko; Mori, Fumiaki; Tanji, Kunikazu; Miki, Yasuo; Toyoshima, Yasuko; Kakita, Akiyoshi; Takahashi, Hitoshi; Yamada, Masahito; Wakabayashi, Koichi
Accumulation of phosphorylated α-synuclein in neurons and glial cells is a histological hallmark of Lewy body disease (LBD) and multiple system atrophy (MSA). Recently, filamentous aggregations of phosphorylated α-synuclein have been reported in the cytoplasm of Schwann cells, but not in axons, in the peripheral nervous system in MSA, mainly in the cranial and spinal nerve roots. Here we conducted an immunohistochemical investigation of the cranial and spinal nerves and dorsal root ganglia of patients with LBD. Lewy axons were found in the oculomotor, trigeminal and glossopharyngeal-vagus nerves, but not in the hypoglossal nerve. The glossopharyngeal-vagus nerves were most frequently affected, with involvement in all of 20 subjects. In the spinal nerve roots, Lewy axons were found in all of the cases examined. Lewy axons in the anterior nerves were more frequent and numerous in the thoracic and sacral segments than in the cervical and lumbar segments. On the other hand, axonal lesions in the posterior spinal nerve roots appeared to increase along a cervical-to-sacral gradient. Although Schwann cell cytoplasmic inclusions were found in the spinal nerves, they were only minimal. In the dorsal root ganglia, axonal lesions were seldom evident. These findings indicate that α-synuclein pathology in the peripheral nerves is axonal-predominant in LBD, whereas it is restricted to glial cells in MSA. © 2015 Japanese Society of Neuropathology.
Sanders, I; Mu, L; Wu, B L; Biller, H F
The lateral cricoarytenoid (LCA) muscle is one of the adductors of the vocal cords; however, some investigators believe that the lateral edge of the muscle may be involved in abduction. The possibility of functionally distinct compartments within the LCA was investigated by observing the pattern of the intramuscular nerve supply. This technique has previously clearly demonstrated neural compartments in the posterior cricoarytenoid, thyroarytenoid and cricothyroid muscles. Five adult human larynges were processed by the Sihler's stain which clears all soft tissue while counterstaining the nerves. The results of our study showed that the innervation pattern of the human LCA muscle is composed of a homogenous nerve plexus localized to the middle region of the muscle. This pattern correlates with the location of motor endplates described by prior investigators. The consistent neural pattern suggests that the LCA is composed of a single neuromuscular compartment.
Yuan, Lisi; Prayson, Richard A
We report a 55-year-old woman with optic nerve Aspergillosis. Aspergillus is an ubiquitous airborne saprophytic fungus. Inhaled Aspergillus conidia are normally eliminated in the immunocompetent host by innate immune mechanisms; however, in immunosuppressed patients, they can cause disease. The woman had a past medical history of hypertension and migraines. She presented 1 year prior to death with a new onset headache behind the left eye and later developed blurred vision and scotoma. A left temporal artery biopsy was negative for giant cell arteritis. One month prior to the current admission, she had an MRI showing optic nerve thickening with no other findings. Because of the visual loss and a positive antinuclear antibody test, she was given a trial of high dose steroids and while it significantly improved her headache, her vision did not improve. At autopsy, the left optic nerve at the level of the cavernous sinus and extending into the optic chiasm was enlarged in diameter and there was a 1.3 cm firm nodule surrounding the left optic nerve. Histologically, an abscess surrounded and involved the left optic nerve. Acute angle branching, angioinvasive fungal hyphae were identified on Grocott's methenamine silver stained sections, consistent with Aspergillus spp. No gross or microscopic evidence of systemic vasculitis or infection was identified in the body. The literature on optic nerve Aspergillosis is reviewed.
Hirata, Akira; Masaki, Toshihiro; Motoyoshi, Kazuo; Kamakura, Keiko
Whether nerve growth factor (NGF) promotes peripheral nerve regeneration in vivo, in particular in adults, is controversial. We therefore examined the effect of exogenous NGF on nerve regeneration and the expression of GAP 43 (growth-associated protein 43) in adult rats. NGF was infused intrathecally via an osmotic mini-pump, while control rats received artificial cerebrospinal fluid. Two days after the infusion was initiated, the right sciatic nerves were transected or crushed, and the animals allowed to survive for 3 to 11 days. The right DRG, the right proximal stump of the transected sciatic nerve, and the posterior horn of the spinal cord were examined by Western blotting, immunohistochemistry, and electron microscopy. GAP 43 immunoreactivity in the NGF-treated animals was significantly lower than in the aCSF-treated controls. Electron microscopy showed that the number of myelinated and unmyelinated axons decreased significantly in the NGF-treated rats as compared with the controls. These findings are indicative that exogenous NGF delayed GAP 43 induction and the early phase of peripheral nerve regeneration and supports the hypothesis that the loss of NGF supply from peripheral targets via retrograde transport caused by axotomy serves as a signal for DRG neurons to invoke regenerative responses. NGF administered intrathecally may delay the neurons' perception of the reduction of the endogenous NGF, causing a delay in conversion of DRG neurons from the normal physiological condition to regrowth state.
Bhatt, Neel K; Khan, Taleef R; Mejias, Christopher; Paniello, Randal C
Cranial nerve transection during head and neck surgery is conventionally repaired with microsuture. Previous studies have demonstrated recovery with laser nerve welding (LNW), a novel alternative to microsuture. LNW has been reported to have poorer tensile strength, however. Laser-activated chitosan, an adhesive biopolymer, may promote nerve recovery while enhancing the tensile strength of the repair. Using a rat posterior tibial nerve injury model, we compared four different methods of nerve repair in this pilot study. Animal study. Animals underwent unilateral posterior tibial nerve transection. The injury was repaired by potassium titanyl phosphate (KTP) laser alone (n = 20), KTP + chitosan (n = 12), microsuture + chitosan (n = 12), and chitosan alone (n = 14). Weekly walking tracks were conducted to measure functional recovery (FR). Tensile strength (TS) was measured at 6 weeks. At 6 weeks, KTP laser alone had the best recovery (FR = 93.4% ± 8.3%). Microsuture + chitosan, KTP + chitosan, and chitosan alone all showed good FR (87.4% ± 13.5%, 84.6% ± 13.0%, and 84.1% ± 10.0%, respectively). One-way analysis of variance was performed (F(3,56) = 2.6, P = .061). A TS threshold of 3.8 N was selected as a control mean recovery. Three groups-KTP alone, KTP + chitosan, and microsuture + chitosan-were found to meet threshold 60% (95% confidence interval [CI]: 23.1%-88.3%), 75% (95% CI: 46.8%-91.1%), and 100% (95% CI: 75.8%-100.0%), respectively. In the posterior tibial nerve model, all repair methods promoted nerve recovery. Laser-activated chitosan as a biopolymer anchor provided good TS and appears to be a novel alternative to microsuture. This repair method may have surgical utility following cranial nerve injury during head and neck surgery. NA Laryngoscope, 127:E253-E257, 2017. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.
Singh, Manmohan; Nair, Achuth; Aglyamov, Salavat R.; Wu, Chen; Han, Zhaolong; Lafon, Ericka; Larin, Kirill V.
Recent work has shown that the biomechanical properties of tissues in the posterior eye have are critical for understanding the etiology and progression of ocular diseases. For instance, the primary risk for glaucoma is an elevated intraocular pressure (IOP). Weak tissues will deform under the large pressure, causing damage to vital tissues. In addition, scleral elasticity can influence the shape of the eye-globe, altering the axial length. In this work, we utilize a noncontact form of optical coherence elastography (OCE) to quantify the spatial distribution of biomechanical properties of the optic nerve, its surrounding tissues, and posterior sclera on the exterior of in situ porcine eyes in the whole eyeglobe configuration. The OCE measurements were taken at various IOPs to evaluate the biomechanical properties of the tissues as a function of IOP. The air-pulse induced dynamic response of the tissues was linked to Young's modulus by a simple kinematic equation by quantified the damped natural frequency (DNF). The results show that the posterior sclera is not as stiff as the optic nerve and its surrounding tissues ( 460 Hz and 894 Hz at 10 mmHg IOP, respectively). Moreover, the scleral stiffness was generally unaffected by IOP ( 460 Hz at 10 mmHg IOP as compared to 516 Hz at 20 mmHg), whereas the optic nerve and its surrounding tissues stiffened as IOP was increased ( 894 Hz at 10 mmHg to 1221 Hz at 20 mmHg).
Tucker, John A; Tucker, Sean T
The existence of the posterior commissure (PC) of the human larynx has been disputed (Hirano M, Sato K, et al. The posterior glottis. Trans Am Laryngol Assoc. 1986;107:70-75). "The term posterior commissure has no relevance to anatomical structure. The term commissure means a joining together. The bilateral vocal folds never join at their posterior ends. The posterior aspect of the glottis is a wall. The posterior lateral aspect of the posterior glottis is also the lateral wall of the posterior glottis" (Hirano M, Sato K, et al. The posterior glottis. Trans Am Laryngol Assoc. 1986;107:70-75). This study is intended to clarify the development of anatomical and morphological aspects of the PC in conjunction with a clinical classification of the larynx in sagittal view. This study uses human embryo and fetal laryngeal sections from the Carnegie Collection of Human Embryos (the world standard) and whole organ laryngeal sections from the Tucker Laryngeal Fetal Collection. Correlation of histologic and gross anatomical structure is made with the Hirano et al atlas, the Vidić Photographic Atlas of the Human Body, and the O'Rahilly Embryonic Atlas. Embryologic data clearly describe and illustrate the posterior union of the cricoid cartilage with formation of the PC. The anatomical functional aspects of the posterior lateral cricoid lamina as the supporting buttress of the articulating arytenoid cartilages are illustrated.
Kou, Y H; Jiang, B G
Peripheral nerve defects are still a major challenge in clinical practice, and the most commonly used method of treatment for peripheral nerve defects is nerve transplantation, which has certain limitations and shortcomings, so new repair methods and techniques are needed. The peripheral nerve is elongated in limb lengthening surgery without injury, from which we got inspirations and proposed a new method to repair peripheral nerve defects: peripheral nerve elongation. The peripheral nerve could beelongated by a certain percent, but the physiological change and the maximum elongation range were still unknown. This study discussed the endurance, the physiological and pathological change of peripheral nerve elongation in detail, and got a lot of useful data. First, we developed peripheral nerve extender which could match the slow and even extension of peripheral nerve. Then, our animal experiment result confirmed that the peripheral nerve had better endurance for chronic elongation than that of acute elongation and cleared the extensibility of peripheral nerve and the range of repair for peripheral nerve defects. Our result also revealed the histological basis and changed the rule for pathological physiology of peripheral nerve elongation: the most important structure foundation of peripheral nerve elongation was Fontana band, which was the coiling of nerve fibers under the epineurium, so peripheral nerve could be stretched for 8.5%-10.0% without injury because of the Fontana band. We confirmed that peripheral nerve extending technology could have the same repair effect as traditional nerve transplantation through animal experiments. Finally, we compared the clinical outcomes between nerve elongation and performance of the conventional method in the repair of short-distance transection injuries in human elbows, and the post-operative follow-up results demonstrated that early neurological function recovery was better in the nerve elongation group than in the
Alberio, N; Cultrera, F; Antonelli, V; Servadei, F
This report describes a case of delayed post-traumatic glossopharyngeal and vagus nerves palsy (i.e. dysphonia and swallowing dysfunction). A high resolution CT study of the cranial base detected a fracture rim encroaching on the left jugular foramen. Treatment consisted in supportive measures with incomplete recovery during a one-year follow-up period. Lower cranial nerves palsies after head trauma are rare and, should they occur, a thorough investigation in search of posterior cranial base and cranio-cervical lesions is warranted. The presumptive mechanism in our case is a fracture-related oedema and ischemic damage to the nerves leading to the delayed occurrence of the palsy.
Koukoulias, Nikolaos E; Papastergiou, Stergios G
The authors present a case of calcified posterior cruciate ligament (PCL). A 61-year-old female presented in our department reporting 12 months history of knee pain that was getting worse during the night. The patient was under medication for epileptic seizure, osteoporosis and hyperthyroidism. X-rays demonstrated calcification of the PCL. CT and MRI excluded any other intra-articular and extra-articular pathology. Arthroscopic debridement of the calcium deposits was performed and the symptoms resolved immediately, while the postoperative x-rays were normal. Histological examination confirmed the calcium nature of the lesion. Two years postoperatively the patient remains asymptomatic. PMID:22669889
Mouilhade, F; Oger, P; Roussignol, X; Boisrenoult, P; Sfez, J; Duparc, F
Many techniques for arthroscopic subtalar arthrodesis have been described since 1985. The procedure can be challenging because posterior and anterior portals are used conjointly with distraction. A posterior 2-portal approach was described in 2000. The goal of this study was to evaluate the quality of the freshening that can be achieved in the posterior subtalar joint using this approach. Does a posterior 2-portal approach allow for a complete freshening of the posterior subtalar joint? Freshening was performed through an arthroscopic posterior 2-portal approach on 10 cadavers. The quality of bone freshening and proximity of the neurovascular structures to the posterior portals were subsequently evaluated by dissection. There was one partial laceration of the sural nerve. The posteromedial portal was 6.8mm (95% CI: 4.4 to 9.2) away from the posterior tibial vascular pedicle. The entire talar and calcaneal articular surfaces of the posterior subtalar joint were freshened. In eight of 10 cases (95% CI: 48 to 95%), the posteromedial process of the talus prevented contact between fragments. This study showed that the entire posterior subtalar joint can be freshened through an arthroscopic posterior 2-portal approach with little morbidity. Level IV. Copyright © 2011 Elsevier Masson SAS. All rights reserved.
Fan, Yuan-Yuan; Yu, Dong-Ming; Shi, Yu-Juan; Yan, Jian-Qun; Jiang, En-She
The sensor of the taste is the taste bud. The signals originated from the taste buds are transmitted to the central nervous system through the gustatory taste nerves. The chorda tympani nerve (innervating the taste buds of the anterior tongue) and glossopharyngeal nerve (innervating the taste buds of the posterior tongue) are the two primary gustatory nerves. The injuries of gustatory nerves cause their innervating taste buds atrophy, degenerate and disappear. The related taste function is also impaired. The impaired taste function can be restored after the gustatory nerves regeneration. The rat model of cross-regeneration of gustatory nerves is an important platform for research in the plasticity of the central nervous system. The animal behavioral responses and the electrophysiological properties of the gustatory nerves have changed a lot after the cross-regeneration of the gustatory nerves. The effects of the injury, regeneration and cross-regeneration of the gustatory nerves on the taste function in the animals will be discussed in this review. The prospective studies on the animal model of cross-regeneration of gustatory nerves are also discussed in this review. The study on the injury, regeneration and cross-regeneration of the gustatory nerves not only benefits the understanding of mechanism for neural plasticity in gustatory nervous system, but also will provide theoretical basis and new ideas for seeking methods and techniques to cure dysgeusia.
Kuriyama, Shinichi; Ishikawa, Masahiro; Nakamura, Shinichiro; Furu, Moritoshi; Ito, Hiromu; Matsuda, Shuichi
During cruciate-retaining total knee arthroplasty, surgeons sometimes encounter increased tension of the posterior cruciate ligament. This study investigated the effects of femoral size, posterior tibial slope, and rotational alignment of the femoral and tibial components on forces at the posterior cruciate ligament in cruciate-retaining total knee arthroplasty using a musculoskeletal computer simulation. Forces at the posterior cruciate ligament were assessed with the standard femoral component, as well as with 2-mm upsizing and 2-mm downsizing in the anterior-posterior dimension. These forces were also determined with posterior tibial slope angles of 5°, 7°, and 9°, and lastly, were measured in 5° increments when the femoral (tibial) components were positioned from 5° (15°) of internal rotation to 5° (15°) of external rotation. Forces at the posterior cruciate ligament increased by up to 718N with the standard procedure during squatting. The 2-mm downsizing of the femoral component decreased the force at the posterior cruciate ligament by up to 47%. The 2° increment in posterior tibial slope decreased the force at the posterior cruciate ligament by up to 41%. In addition, posterior cruciate ligament tension increased by 11% during internal rotation of the femoral component, and increased by 18% during external rotation of the tibial component. These findings suggest that accurate sizing and bone preparation are very important to maintain posterior cruciate ligament forces in cruciate-retaining total knee arthroplasty. Care should also be taken regarding malrotation of the femoral and tibial components because this increases posterior cruciate ligament tension. Copyright © 2015 Elsevier Ltd. All rights reserved.
Parot, Catalina; Leclercq, Caroline
The median nerve is responsible for the motor innervation of most of the muscles usually involved in upper limb spasticity. Selective neurectomy is one of the treatments utilized to reduce spasticity. The purpose of this study was to describe the variations of the motor branches of the median nerve in the forearm and draw recommendations for an appropriate planning of selective neurectomy. The median nerve was dissected in the forearm of 20 fresh cadaver upper limbs. Measurements included number, origin, division, and entry point of each motor branch into the muscles. One branch for the pronator teres was the most common pattern. In 9/20 cases, it arose as a common trunk with other branches. A single trunk innervated the flexor carpi radialis with a common origin with other branches in 17/20 cases. Two, three or four branches innervated the flexor digitorum superficialis, the first one frequently through a common trunk with other branches. They were very difficult to identify unless insertions of pronator teres and flexor digitorum superficialis were detached. The flexor digitorum profundus received one to five branches and flexor pollicis longus one to two branches from the anterior interosseous nerve. There is no regular pattern of the motor branches of the median nerve in the forearm. Our findings differ in many points from the classical literature. Because of the frequency of common trunks for different muscles, we recommend the use of peroperative electrical stimulation. Selective neurotomy of flexor digitorum superficialis is technically difficult, because the entry point of some of their terminal branches occurs just below the arch and deep to the muscle belly.
Terzis, Julia K; Kokkalis, Zinon T
In obstetrical brachial plexus palsy, suprascapular nerve reinnervation is a priority. For the most favorable outcomes in shoulder function, it is the authors' policy to also reconstruct the axillary nerve with intraplexus donors to the posterior cord (early cases) or directly with intraplexus or extraplexus motor donors (late cases). Between 1979 and 2003, 80 consecutive patients (82 brachial plexuses) underwent plexus exploration and nerve reconstruction for obstetrical palsy. Axillary nerve reconstruction was performed in 60 plexuses, and evaluation of the results was carried out for 55 patients (56 plexuses) with adequate follow-up (mean follow-up, 6.5 years). Overall, there were good and excellent results (>/=M3+) in 49 of 56 plexuses (87.5 percent) for the deltoid muscle, and the average postoperative muscle grade for the deltoid was 3.89 +/- 0.79. The average shoulder abduction increased from 35 +/- 31 degrees preoperatively to 109 +/- 35 degrees postoperatively (average gain, 74 degrees), and the average external rotation increased from -13 +/- 28 degrees preoperatively to 47 +/- 18 degrees postoperatively (average gain, 60 degrees). The timing of surgery and the type of paralysis significantly influenced the final outcome. Reconstruction of the axillary nerve should always be performed to maximize the final outcome of shoulder function in obstetrical brachial plexus patients. The best results were seen in early cases (=3 months), where the posterior cord was reconstructed from intraplexus donors. In late cases, reconstruction of the axillary nerve directly from the intercostal nerves could be a reliable option.
Yan, Liang; Gao, Rui; Liu, Yang; He, Baorong; Lv, Shemin; Hao, Dingjun
Ossification of the posterior longitudinal ligament (OPLL) is a multi-factorial disease involving an ectopic bone formation of spinal ligaments. It affects 0.8-3.0% aging Asian and 0.1-1.7% aging European Caucasian. The ossified ligament compresses nerve roots in the spinal cord and causes serious neurological problems such as myelopathy and radiculopathy. Research in understanding pathogenesis of OPLL over the past several decades have revealed many genetic and non-genetic factors contributing to the development and progress of OPLL. The characterizations of aberrant signaling of bone morphogenetic protein (BMP) and mitogen-activated protein kinases (MAPK), and the pathological phenotypes of OPLL-derived mesenchymal stem cells (MSCs) have provided new insights on the molecular mechanisms underlying OPLL. This paper reviews the recent progress in understanding the pathophysiology of OPLL and proposes future research directions on OPLL. PMID:28966802
Dos Santos, Manuel Filipe Dias; de Santa Barbara, Rita de Cassia
Congenital encephalocele is a neural tube defect characterized by a sac-like protrusion of the brain, meninges, and other intracranial structures through the skull, which is caused by an embryonic development abnormality. The most common location is at the occipital bone, and its incidence varies according to different world regions. We report a case of an 1-month and 7-day-old male child with a huge interparietal-posterior fontanel meningohydroencephalocele, a rare occurrence. Physical examination and volumetric computed tomography were diagnostic. The encephalocele was surgically resected. Intradural and extradural approaches were performed; the bone defect was not primarily closed. Two days after surgery, the patient developed hydrocephaly requiring ventriculoperitoneal shunting. The surgical treatment of the meningohydroencephalocele of the interparietal-posterior fontanel may be accompanied by technical challenges and followed by complications due to the presence of large blood vessels under the overlying skin. In these cases, huge sacs herniate through large bone defects including meninges, brain, and blood vessels. The latter present communication with the superior sagittal sinus and ventricular system. A favorable surgical outcome generally follows an accurate strategy taking into account individual features of the lesion. PMID:26484324
Opdam, N.J.M.; van de Sande, F.H.; Bronkhorst, E.; Cenci, M.S.; Bottenberg, P.; Pallesen, U.; Gaengler, P.; Lindberg, A.; Huysmans, M.C.D.N.J.M.; van Dijken, J.W.
The aim of this meta-analysis, based on individual participant data from several studies, was to investigate the influence of patient-, materials-, and tooth-related variables on the survival of posterior resin composite restorations. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a search resulting in 12 longitudinal studies of direct posterior resin composite restorations with at least 5 years’ follow-up. Original datasets were still available, including placement/failure/censoring of restorations, restored surfaces, materials used, reasons for clinical failure, and caries-risk status. A database including all restorations was constructed, and a multivariate Cox regression method was used to analyze variables of interest [patient (age; gender; caries-risk status), jaw (upper; lower), number of restored surfaces, resin composite and adhesive materials, and use of glass-ionomer cement as base/liner (present or absent)]. The hazard ratios with respective 95% confidence intervals were determined, and annual failure rates were calculated for subgroups. Of all restorations, 2,816 (2,585 Class II and 231 Class I) were included in the analysis, of which 569 failed during the observation period. Main reasons for failure were caries and fracture. The regression analyses showed a significantly higher risk of failure for restorations in high-caries-risk individuals and those with a higher number of restored surfaces. PMID:25048250
Moriyama, Muka; Cao, Kejia; Ogata, Satoko; Ohno-Matsui, Kyoko
To analyse the characteristics of posterior vortex veins detected in highly myopic eyes by wide-field indocyanine green angiography (ICGA). One hundred and fifty-eight consecutive patients (302 eyes) with high myopia (myopic refractive error >8.0 dioptres (D) or axial length ≥26.5 mm) were studied. Wide-field ICGA was performed with the Spectralis HRA module. Posterior vortex veins were found in 80 eyes (26%). The prevalence of posterior staphyloma was significantly higher in eyes in which posterior vortex vein was detected than in eyes without posterior vortex vein. The posterior vortex veins were classified into five types according to the site of exit from the eye; around the optic nerve in 28%, in the macular area in 17%, along the border of staphyloma in 6%, along the margin of macular atrophy or large peripapillary conus in 21%, and elsewhere in 28%. In one eye, two posterior vortex veins collected the choroidal venous blood from the entire fundus. Wide-field ICGA can analyse the characteristic features of choroidal blood outflow system through posterior vortex veins in highly myopic eyes. They may play an important role as routes of choroidal outflow in highly myopic eyes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
Barham, H P; Collister, P; Eusterman, V D; Terella, A M
Introduction. The mandibular condyle is the most common site of mandibular fracture. Surgical treatment of condylar fractures by open reduction and internal fixation (ORIF) demands direct visualization of the fracture. This project aimed to investigate the anatomic relationship of the tragus to the facial nerve and condylar process. Materials and Methods. Twelve fresh hemicadavers heads were used. An extended retromandibular/preauricular approach was utilized, with the incision being based parallel to the posterior edge of the ramus. Measurements were obtained from the tragus to the facial nerve and condylar process. Results. The temporozygomatic division of the facial nerve was encountered during each approach, crossing the mandible at the condylar neck. The mean tissue depth separating the facial nerve from the condylar neck was 5.5 mm (range: 3.5 mm-7 mm, SD 1.2 mm). The upper division of the facial nerve crossed the posterior border of the condylar process on average 2.31 cm (SD 0.10 cm) anterior to the tragus. Conclusions. This study suggests that the temporozygomatic division of the facial nerve will be encountered in most approaches to the condylar process. As visualization of the relationship of the facial nerve to condyle is often limited, recognition that, on average, 5.5 mm of tissue separates condylar process from nerve should help reduce the incidence of facial nerve injury during this procedure.
Girard, Michaël J A; Downs, J Crawford; Bottlang, Michael; Burgoyne, Claude F; Suh, J-K Francis
The posterior sclera likely plays an important role in the development of glaucoma, and accurate characterization of its mechanical properties is needed to understand its impact on the more delicate optic nerve head--the primary site of damage in the disease. The posterior scleral shells from both eyes of one rhesus monkey were individually mounted on a custom-built pressurization apparatus. Intraocular pressure was incrementally increased from 5 mm Hg to 45 mm Hg, and the 3D displacements were measured using electronic speckle pattern interferometry. Finite element meshes of each posterior scleral shell were reconstructed from data generated by a 3D digitizer arm (shape) and a 20 MHz ultrasound transducer (thickness). An anisotropic hyperelastic constitutive model described in a companion paper (Girard, Downs, Burgoyne, and Suh, 2009, "Peripapillary and Posterior Scleral Mechanics--Part I: Development of an Anisotropic Hyperelastic Constitutive Model," ASME J. Biomech. Eng., 131, p. 051011), which includes stretch-induced stiffening and multidirectional alignment of the collagen fibers, was applied to each reconstructed mesh. Surface node displacements of each model were fitted to the experimental displacements using an inverse finite element method, which estimated a unique set of 13 model parameters. The predictions of the proposed constitutive model matched the 3D experimental displacements well. In both eyes, the tangent modulus increased dramatically with IOP, which indicates that the sclera is mechanically nonlinear. The sclera adjacent to the optic nerve head, known as the peripapillary sclera, was thickest and exhibited the lowest tangent modulus, which might have contributed to the uniform distribution of the structural stiffness for each entire scleral shell. Posterior scleral deformation following acute IOP elevations appears to be nonlinear and governed by the underlying scleral collagen microstructure as predicted by finite element modeling. The
Moore, Amy M.; MacEwan, Matthew; Santosa, Katherine B.; Chenard, Kristofer E.; Ray, Wilson Z.; Hunter, Daniel A.; Mackinnon, Susan E.; Johnson, Philip J.
Background Processed nerve allografts offer a promising alternative to nerve autografts in the surgical management of peripheral nerve injuries where short deficits exist. Methods Three established models of acellular nerve allograft (cold-preserved, detergent-processed, and AxoGen® -processed nerve allografts) were compared to nerve isografts and silicone nerve guidance conduits in a 14 mm rat sciatic nerve defect. Results All acellular nerve grafts were superior to silicone nerve conduits in support of nerve regeneration. Detergent-processed allografts were similar to isografts at 6 weeks post-operatively, while AxoGen®-processed and cold-preserved allografts supported significantly fewer regenerating nerve fibers. Measurement of muscle force confirmed that detergent-processed allografts promoted isograft-equivalent levels of motor recovery 16 weeks post-operatively. All acellular allografts promoted greater amounts of motor recovery compared to silicone conduits. Conclusions These findings provide evidence that differential processing for removal of cellular constituents in preparing acellular nerve allografts affects recovery in vivo. PMID:21660979
Chaudhry, Tahseen; Noor, Saqib; Maher, Ben; Bridger, John
The radial nerve passes around the posterior aspect of the humerus where it is prone to injury in both humeral fractures and surgical exploration of this region. We examined 55 cadaveric limbs to determine whether the exact position of the radial nerve could be reliably predicted on the basis of superficial anatomical markings. We found that when there is considerable variability in the position of the nerve in relation to the lateral epicondyle, the nerve consistently passed adjacent to the lateral border of the triceps aponeurosis at a distance of 22-27 (+/-2) mm. It was never found to be closer than 13 (+/-1) mm to the aponeurosis. The lateral border of the triceps aponeurosis is easy to identify and our findings may help avoid iatrogenic injury to the radial nerve during exploration.
Peltonen, Sirkku; Alanne, Maria; Peltonen, Juha
This review introduces the traditionally defined anatomic compartments of the peripheral nerves based on light and electron microscopic topography and then explores the cellular and the most recent molecular basis of the different barrier functions operative in peripheral nerves. We also elucidate where, and how, the homeostasis of the normal human peripheral nerve is controlled in situ and how claudin-containing tight junctions contribute to the barriers of peripheral nerve. Also, the human timeline of the development of the barriers of the peripheral nerve is depicted. Finally, potential future therapeutic modalities interfering with the barriers of the peripheral nerve are discussed. PMID:24665400
Nair, Akshay Gopinathan; Pathak, Rima S; Iyer, Veena R; Gandhi, Rashmin A
Optic nerve glioma is the most common optic nerve tumour. However, it has an unpredictable natural history. The treatment of optic nerve gliomas has changed considerably over the past few years. Chemotherapy and radiation therapy can now stabilize and in some cases improve the vision of patients with optic nerve gliomas. The treatment of optic nerve glioma requires a multi-disciplinary approach where all treatment options may have to be implemented in a highly individualized manner. The aim of this review article is to present current diagnostic and treatment protocols for optic nerve glioma.
Tawfik, Eman A; Walker, Francis O; Cartwright, Michael S
Ultrasound of cranial nerves is a novel subdomain of neuromuscular ultrasound (NMUS) which may provide additional value in the assessment of cranial nerves in different neuromuscular disorders. Whilst NMUS of peripheral nerves has been studied, NMUS of cranial nerves is considered in its initial stage of research, thus, there is a need to summarize the research results achieved to date. Detailed scanning protocols, which assist in mastery of the techniques, are briefly mentioned in the few reference textbooks available in the field. This review article focuses on ultrasound scanning techniques of the 4 accessible cranial nerves: optic, facial, vagus and spinal accessory nerves. The relevant literatures and potential future applications are discussed.
Kubota, Shinji; Tanabe, Shigeo; Sugawara, Kenichi; Muraoka, Yoshihiro; Itoh, Norihide; Kanada, Yoshikiyo
To develop effective electrical stimulation treatment to reduce spasticity, we examined the optimal stimulus point of the common peroneal nerve. The locations of selective stimulus points for the deep peroneal nerve or superficial peroneal nerve fiber were examined in 25 healthy subjects in both legs (50 legs) using the ratio of the tibialis anterior (TA) to the peroneus longus (PL) M-wave amplitude (TA/PL ratio). In addition, we measured reciprocal Ia inhibition in ten healthy subjects. The amount of inhibition was determined from short-latency suppression of the soleus (Sol) H-reflex by conditioning stimuli to the deep or superficial peroneal nerve. The paired t-test was used for statistical analysis. The mean TA/PL ratio during deep peroneal nerve stimulation was significantly different from superficial peroneal nerve stimulation (p < 0.001). The mean stimulus point for the deep peroneal nerve was located 7 ± 5 mm distal and 3 ± 6 mm anterior from the distal edges of the head of fibula and was markedly different from the stimulus point for the superficial peroneal nerve (20 ± 7 mm distal and 12 ± 8 mm posterior). During deep peroneal nerve stimulation, the mean conditioned H-reflex was depressed to 83.8 ± 10.7% of the unconditioned value of the H-reflex. In contrast, during superficial peroneal nerve stimulation, the mean conditioned H-reflex increased to 105.3 ± 5.2%. These values were significantly different (p < 0.001). In the present study, we revealed a stimulus area of the deep peroneal nerve. Also, we observed the inhibitory effects of stimulation upon the deep peroneal nerve at individual stimulus point. Our results appear to indicate that localized stimulation of the deep peroneal nerve is more useful for the reduction of ankle spasticity. © 2012 International Neuromodulation Society.
Kao, Hsuan-Kai; Lee, Wei-Chun; Yang, Wen-E; Chang, Chia-Hsieh
Closed reduction and percutaneous Kirschner wire fixation are widely recommended for displaced supracondylar humeral fractures. However, the optimal K-wire configuration is still controversial. The purpose of this study was to compare the results of crossed pinning with or without a posterior intrafocal pin in Gartland type III supracondylar humeral fractures. We retrospectively reviewed 93 children who underwent crossed pinning for Gartland type III supracondylar humeral fractures between January 2009 and December 2013. One surgeon preferentially added one posterior intrafocal pin onto the crossed pins in 35 children, and the other surgeons used standard crossed pinning technique in 58 children. Results were assessed by range of elbow motion and radiographic measures including the Baumann angle, the lateral humerocapitellar angle and the position of the anterior humeral line (AHL). The demographic data were comparable between the 2 groups. Children treated with the additional posterior intrafocal pin had greater range of elbow motion (138.7° vs. 133.6°, p=0.01) and had a greater lateral humerocapitellar angle (44.9° vs. 37.8°, p=0.01) measured 3 months postoperatively. The percentage of AHL position in the posterior third was significantly higher in children with the posterior intrafocal pin immediately after fixation (odds ratio [OR]: 6.26) and 3 months later (OR: 2.84). The percentage of AHL position in the anterior third was also significantly lower in children with the posterior intrafocal pin 3 months postoperatively (OR: 0.29). No pin site infection or nerve injury was associated with the additional posterior pin. Adding one posterior intrafocal pin to crossed pinning can facilitate fracture reduction and enhance fixation stability. Better sagittal alignment and elbow motion support this safe and effective technique in treating type III humeral supracondylar fractures. Copyright © 2016 Elsevier Ltd. All rights reserved.
Dieu, Tam; Johnstone, Bruce R; Newgreen, Don F
The unpredictability of a brachial plexus graft, a median nerve repair, or a facial-nerve reconstruction is well known. No matter how precise the technical skills, a perfect recovery from a peripheral-nerve lesion is elusive. To resolve this problem, understanding of the normal development of the peripheral nervous system is needed. Presently, the development of the innervation in the upper limb is complex and not fully understood. However, many of the genes involved in this process are now known, and the link between anatomy and genetics is becoming clearer. This short review aims to acquaint the clinical surgeon with some of the main genes. The principal steps in the establishment of neural circuits will be summarized, in particular, the specification and development of neurons and glia, the pathfinding of cells and axons towards their target, and the downstream molecules that control the circuitry of these neurons.
Prades, J M; Gavid, M; Asanau, A; Timoshenko, A P; Richard, C; Martin, C H
The purpose of the study was to determine the relationships between the extracranial glossopharyngeal (IX) nerve and the muscles of the styloid diaphragm. In humans, the IX nerve is a hidden retrostyloid nerve which plays a critical role notably in swallowing and has to be preserved during infratemporal fossa and parapharyngeal spaces surgical procedures. In ten adult heads from cadavers (20 sides) fixed in formalin, dissection of the extracranial IX nerve was performed under operating microscope with special attention given to the relationships between this nerve and the styloid muscles of the styloid diaphragm. The three styloid muscles delimit three triangular intermuscular intervals which were each thoroughly explored. Different osseous landmarks were investigated for easy nerve location. The styloid process (SP) is the main superior osseous landmark for the three muscles of the styloid diaphragm. The stylohyoid muscle (SHM) is anteromedially located to the posterior belly of the digastric muscle. The styloglossus muscle (SGM) is medial and anterior to the SHM. The stylopharyngeal muscle (SPM) is the most vertical and medial of the three styloid muscles. It courses from the medial surface of the SP in a deep plane hidden between the SHM and the SGM. The extracranial IX nerve turns around the SPM superiorly with a vertical segment posterior to the SPM and inferiorly with a horizontal segment lateral to the SPM. The meeting point of the two segments of the IX nerve is about 10 mm anteriorly located from the transverse process of the atlas. The external carotid artery and some of its branches lie in contact with the lateral side of the IX nerve. Such relationships between the extracranial IX nerve, the styloid muscles and the transverse process of the atlas should be appreciated by clinician who treats patients with stylohyoid complex syndromes and by the surgeon for the parapharyngeal spaces approach.
Bermejo, P.; López, M.; Larraya, I.; Chamorro, J.; Cobo, J. L.; Ordóñez, S.
The innocuous transcutaneous stimulation of nerves supplying the outer ear has been demonstrated to be as effective as the invasive direct stimulation of the vagus nerve for the treatment of some neurological and nonneurological disturbances. Thus, the precise knowledge of external ear innervation is of maximal interest for the design of transcutaneous auricular nerve stimulation devices. We analyzed eleven outer ears, and the innervation was assessed by Masson's trichrome staining, immunohistochemistry, or immunofluorescence (neurofilaments, S100 protein, and myelin-basic protein). In both the cavum conchae and the auditory canal, nerve profiles were identified between the cartilage and the skin and out of the cartilage. The density of nerves and of myelinated nerve fibers was higher out of the cartilage and in the auditory canal with respect to the cavum conchae. Moreover, the nerves were more numerous in the superior and posterior-inferior than in the anterior-inferior segments of the auditory canal. The present study established a precise nerve map of the human cavum conchae and the cartilaginous segment of the auditory canal demonstrating regional differences in the pattern of innervation of the human outer ear. These results may provide additional neuroanatomical basis for the accurate design of auricular transcutaneous nerve stimulation devices. PMID:28396871
Bermejo, P; López, M; Larraya, I; Chamorro, J; Cobo, J L; Ordóñez, S; Vega, J A
The innocuous transcutaneous stimulation of nerves supplying the outer ear has been demonstrated to be as effective as the invasive direct stimulation of the vagus nerve for the treatment of some neurological and nonneurological disturbances. Thus, the precise knowledge of external ear innervation is of maximal interest for the design of transcutaneous auricular nerve stimulation devices. We analyzed eleven outer ears, and the innervation was assessed by Masson's trichrome staining, immunohistochemistry, or immunofluorescence (neurofilaments, S100 protein, and myelin-basic protein). In both the cavum conchae and the auditory canal, nerve profiles were identified between the cartilage and the skin and out of the cartilage. The density of nerves and of myelinated nerve fibers was higher out of the cartilage and in the auditory canal with respect to the cavum conchae. Moreover, the nerves were more numerous in the superior and posterior-inferior than in the anterior-inferior segments of the auditory canal. The present study established a precise nerve map of the human cavum conchae and the cartilaginous segment of the auditory canal demonstrating regional differences in the pattern of innervation of the human outer ear. These results may provide additional neuroanatomical basis for the accurate design of auricular transcutaneous nerve stimulation devices.
Ugrenovic, Sladjana Z; Jovanovic, Ivan D; Kovacevic, Predrag; Petrović, Sladjana; Simic, Tamara
The aim was to investigate the arterial supply of the sciatic, tibial, and common peroneal nerves. Thirty-six lower limbs of 18 human fetuses were studied. The fetuses had been fixed in buffered formalin and the blood vessels injected with barium sulfate. Fetal age ranged from 12 to 28 weeks of gestation. Microdissection of the fetal lower extremities was done under ×5 magnifying lenses. The sciatic nerves of 10 lower extremities were dissected and excised and radiographs taken. The extraneural arterial chain of the sciatic nerve was composed of 2-6 arterial branches of the inferior gluteal artery, the medial circumflex femoral artery, the perforating arteries, and the popliteal artery. The extraneural arterial chain of tibial nerve was composed of 2-5 arteries, which were branches of the popliteal, the peroneal, and the posterior tibial arteries. Radiographs showed the presence of complete intraneural arterial chains in the sciatic and tibial nerves, formed from anastomosing vessels. Dissection showed that, in 97.2% of the specimens, the common peroneal nerve was supplied only by one popliteal artery branch, the presence of which was confirmed radiologically. The sciatic and tibial nerves are supplied by numerous arterial branches of different origins, which provide for collateral circulation. In contrast, the common peroneal nerve is most frequently supplied only by one elongated longitudinal blood vessel, a branch of the popliteal artery. Such a vascular arrangement may make the common peroneal nerve less resistant to stretching and compression. Copyright © 2012 Wiley Periodicals, Inc.
Three systems, two sensory and one protective, are present in the skin of the living Australian lungfish, Neoceratodus forsteri, and in fossil lungfish, and the arrangement and innervation of the sense organs is peculiar to lungfish. Peripheral branches of nerves that innervate the sense organs are slender and unprotected, and form before any skeletal structures appear. When the olfactory capsule develops, it traps some of the anterior branches of cranial nerve V, which emerged from the chondrocranium from the lateral sphenotic foramen. Cranial nerve I innervates the olfactory organ enclosed within the olfactory capsule and cranial nerve II innervates the eye. Cranial nerve V innervates the sense organs of the snout and upper lip, and, in conjunction with nerve IX and X, the sense organs of the posterior and lateral head. Cranial nerve VII is primarily a motor nerve, and a single branch innervates sense organs in the mandible. There are no connections between nerves V and VII, although both emerge from the brain close to each other. The third associated system consists of lymphatic vessels covered by an extracellular matrix of collagen, mineralised as tubules in fossils. Innervation of the sensory organs is separate from the lymphatic system and from the tubule system of fossil lungfish. Copyright © 2016 Elsevier Ltd. All rights reserved.
Shi, J G; Xu, X M; Sun, J C; Wang, Y; Guo, Y F; Yang, H S; Kong, Q J; Yang, Y; Shi, G D; Yuan, W; Jia, L S
Objective: To define a novel disease-lumbosacral nerve bowstring disease, and propose the diagnostic criteria, while capsule surgery was performed and evaluated in the preliminary study. Methods: From June 2016 to December 2016, a total of 30 patients (22 male and 8 female; mean age of 55.1±9.7 years) with lumbosacral nerve bowstring disease were included in Department of Spine Surgery, Changzheng Hospital, the Second Military Medical University.Lumbosacral nerve bowstring disease was defined as axial hypertension of nerve root and spinal cord caused by congenital anomalies, which could be accompanied by other lesions as lumbar disc herniation, spinal cord stenosis or spondylolisthesis, or aggravated by iatrogenic lesions, resulting in neurological symptoms.This phenomenon is similar to a stretched string, the higher tension on each end the louder sound.Meanwhile, the shape of lumbosacral spine looks like a bow, thus, the disease is nominated as lumbosacral nerve bowstring disease.All the patients underwent capsule surgery and filled out Owestry disability index (ODI) and Tempa scale for kinesiophobia (TSK) before and after surgery. Results: The mean surgery time was (155±36) min, (4.3±0.4) segments were performed surgery.The pre-operative VAS, TSK and ODI scores were (7.6±0.8), (52.0±10.3) and (68.4±12.7), respectively.The post-operative VAS, TSK and ODI scores were (3.3±0.4), ( 24.6±5.2) and (32.1±7.4)(P<0.05, respectively), respectively. Conclusion: The definition and diagnostic criteria of lumbosacral nerve bowstring disease was proposed.Capsule surgery was an effective strategy with most patients acquired excellent outcomes as symptoms relieved and quality of life improved.
Chu, Bin; Hu, Shaonan; Chen, Liang; Song, Jie
To investigate the feasibility of the 3rd-6th intercostal nerve transfer to the suprascapular nerve for reconstruction of shoulder abduction. Fifteen thoracic walls (30 sides) were collected from cadavers. The 3rd-6th intercostal nerve length which can be dissected between the midaxillary line and midclavicular the transfer distance between the midaxillary line and midpoint of the clavicular bone (prepared point for neurotization) measured. In 30 sides of specimens, the 3rd and 4th intercostal nerves could be obtained between the midaxillary and midclavicular line, the available length of which was significantly greater than the transfer distance (P < 0.01). Six 5th intercostal nerve and 16 sides of 6th intercostal nerve were covered by the costal cartilage before reaching the midclavicular line. The available length of the 5th intercostal nerve was similar to the transfer distance (P > 0.01), while the available the 6th intercostal nerve was significantly less than transfer distance (P < 0.01). The suprascapular nerve could be dissociated turned to the clavicular bone of more than 2 cm. The whole length of the available 5th intercostal nerve length and length (2 cm) of suprascapular nerve was significantly greater than the transfer distance (P < 0.01), but for the 6th nerve, the whole length was still less than transfer distance (P < 0.01). It could be an alternative method the 3rd, 4th, and 5th intercostal nerve transfer to the suprascapular nerve for reconstruction of shoulder abduction. And 6th intercostal nerve, longer dissociated length may be required for direct coaptation or using a graft for nerve repair.
Fox, Ida K
Hand and upper extremity function is instrumental to basic activities of daily living and level of independence in cervical spinal cord injury (SCI). Nerve transfer surgery is a novel and alternate approach for restoring function in SCI. This article discusses the biologic basis of nerve transfers in SCI, patient evaluation, management, and surgical approaches. Although the application of this technique is not new; recent case reports and case series in the literature have increased interest in this field. The challenges are to improve function, achieve maximal gains in function, avoid complications, and to primum non nocere.
Soldatos, Theodoros; Batra, Kiran; Blitz, Ari M; Chhabra, Avneesh
Imaging evaluation of cranial neuropathies requires thorough knowledge of the anatomic, physiologic, and pathologic features of the cranial nerves, as well as detailed clinical information, which is necessary for tailoring the examinations, locating the abnormalities, and interpreting the imaging findings. This article provides clinical, anatomic, and radiological information on lower (7th to 12th) cranial nerves, along with high-resolution magnetic resonance images as a guide for optimal imaging technique, so as to improve the diagnosis of cranial neuropathy. Copyright © 2014 Elsevier Inc. All rights reserved.
Rubenstein, W.A.; Auh, Y.H.; Zirinsky, K.; Kneeland, J.B.; Whalen, J.P.; Kazam, E.
Intraperitoneal compartments may extend posteriorly to the level of known retroperitoneal structures at several locations within the abdomen. These locations include the posterior subhepatic or hepatorenal space, the splenorenal space, the retropancreatic recess, the paracolic gutters, and the pararectal fossae. Because of their posterior location, fluid collections within these compartments may be mistaken radiologically for retroperitoneal masses. The sectional anatomy of these spaces and particularly their appearance on computed tomographic scans, are illustrated in this paper.
Moser, Brad R
Dancers spend a lot of time in the relevé position in demi-pointe and en pointe in their training and their careers. Pain from both osseous and soft tissue causes may start to occur in the posterior aspect of their ankle. This article reviews the potential causes of posterior ankle impingement in dancers. It will discuss the clinical evaluation of a dancer and the appropriate workup and radiographic studies needed to further evaluate a dancer with suspected posterior ankle impingement.
Sanjay, K Mandal; Partha, P Chakraborty
The posterior/potentially reversible encephalopathy syndrome is a unique syndrome encountered commonly in hypertensive encephalopathy. A 13-year-old boy presented with of intermittent high grade fever, throbbing headache and non-projective vomiting for 5 days. The patient had a blood pressure of 120/80 mmHg but fundoscopy documented grade 3 hypertensive retinopathy. The patient improved symptomatically following conservative management. However, on the 5(th) post-admission day headache reappeared, and blood pressure measured at that time was 240/120 mmHg. Neuroimaging suggested white matter abnormalities. Search for the etiology of secondary hypertension led to the diagnosis of pheochromocytoma. Repeated MRI after successful surgical excision of the tumor patient showed reversal of white matter abnormalities. Reversible leucoencephalopathy due to pheochromocytoma have not been documented in literature previously.
Objective The purpose of this study was to evaluate the outcome of endoscopic decompression surgery for intraforaminal and extraforaminal nerve root compression in the lumbar spine. Methods The records from seventeen consecutive patients treated with endoscopic posterior decompression without fusion for intaforaminal and extraforaminal nerve root compression in the lumbar spine (7 males and 10 females, mean age: 67.9 ± 10.7 years) were retrospectively reviewed. The surgical procedures consisted of lateral or translaminal decompression with or without discectomy. The following items were investigated: 1) the preoperative clinical findings; 2) the radiologic findings including MRI and computed tomography-discography; and 3) the surgical outcome as evaluated using the Japanese Orthopaedic Association scale for lower back pain (JOA score). Results All patients had neurological findings compatible with a radiculopathy, such as muscle weakness and sensory disturbance. MRI demonstrated the obliteration of the normal increased signal intensity fat in the intervertebral foramen. Ten patients out of 14 who underwent computed tomography-discography exhibited disc protrusion or herniation. Selective nerve root block was effective in all patients. During surgery, 12 patients were found to have a protruded disc or herniation that compressed the nerve root. Sixteen patients reported pain relief immediately after surgery. Conclusions Intraforaminal and extraforaminal nerve root compression is a rare but distinct pathological condition causing severe radiculopathy. Endoscopic decompression surgery is considered to be an appropriate and less invasive surgical option. PMID:21439083
Rozand, Vianney; Grosprêtre, Sidney; Stapley, Paul J; Lepers, Romuald
Percutaneous electrical nerve stimulation is a non-invasive method commonly used to evaluate neuromuscular function from brain to muscle (supra-spinal, spinal and peripheral levels). The present protocol describes how this method can be used to stimulate the posterior tibial nerve that activates plantar flexor muscles. Percutaneous electrical nerve stimulation consists of inducing an electrical stimulus to a motor nerve to evoke a muscular response. Direct (M-wave) and/or indirect (H-reflex) electrophysiological responses can be recorded at rest using surface electromyography. Mechanical (twitch torque) responses can be quantified with a force/torque ergometer. M-wave and twitch torque reflect neuromuscular transmission and excitation-contraction coupling, whereas H-reflex provides an index of spinal excitability. EMG activity and mechanical (superimposed twitch) responses can also be recorded during maximal voluntary contractions to evaluate voluntary activation level. Percutaneous nerve stimulation provides an assessment of neuromuscular function in humans, and is highly beneficial especially for studies evaluating neuromuscular plasticity following acute (fatigue) or chronic (training/detraining) exercise.
... of individual nerve fibers and surrounding outer sheath (“insulation”) Figure 2: Nerve repair with realignment of bundles © ... of individual nerve fibers and surrounding outer sheath insulation Figure 2 - Nerve repair with realignment of bundles ...
Branch, Byron C.; Hilton, Donald L.; Watts, Clark
Background: Minimally invasive tubular access for posterior cervical foraminotomy can be an effective and safe technique for decompression of the nerve root utilizing minimally invasive muscle splitting with routine outpatient discharge. This technique has come under scrutiny calling into question the associated learning curve, a subjective limited exposure provided, and an argument that the risks and complications are largely unknown. In response to previously published critiques, this study aims to describe the outcomes and complications associated with this technique in a large patient series. Methods: A retrospective chart review was performed from 1999 to 2013 capturing a single surgeon's experience with the minimally invasive tubular access for posterior cervical foraminotomy technique from a single institution, encompassing 463 patients. Surgical outcome documented at follow-up and complications were obtained from this patient series. Additional variables analyzed include: Hospital length of stay, number of levels operated, targeted root for decompression, side operated, length of surgery, and estimated blood loss. Results: Outpatient discharge was achieved in 91.6% of cases. There were 10 complications (2.2%) among the 463 patients undergoing this technique from 1999 to 2013. Patients were followed for an average of 1 year and 2 months postoperatively. Improvement from the preoperative condition was observed in 98.2% of patients and excellent outcomes with patients reporting complete relief of symptoms with no or mild residual discomfort was seen in 92.2%. Conclusions: Compared with open techniques, minimally invasive tubular access for posterior cervical foraminotomy demonstrates comparable, if not superior, complication rates, and patient outcomes. PMID:26009705
Zeki, S. M.; Dutton, G. N.
Optic nerve hypoplasia (ONH) is characterised by a diminished number of optic nerve fibres in the optic nerve(s) and until recently was thought to be rare. It may be associated with a wide range of other congenital abnormalities. Its pathology, clinical features, and the conditions associated with it are reviewed. Neuroendocrine disorders should be actively sought in any infant or child with bilateral ONH. Early recognition of the disorder may in some cases be life saving. Images PMID:2191713
Williams, Ian D.
This experiment investigated the capability for movement and muscle spindle function at successive stages during the development of ischemic nerve block (INB) by pressure cuff. Two male subjects were observed under six randomly ordered conditions. The duration of index finger oscillation to exhaustion, paced at 1.2Hz., was observed on separate…
axolotl limbs are transected the concentration of transferrin in the distal limb tissue declines rapidly and limb regeneration stops. These results...transferrin binding and expression of the transferrin gene in cells of axolotl peripheral nerve indicate that both uptake and synthesis of this factor occur
Williams, Ian D.
This experiment investigated the capability for movement and muscle spindle function at successive stages during the development of ischemic nerve block (INB) by pressure cuff. Two male subjects were observed under six randomly ordered conditions. The duration of index finger oscillation to exhaustion, paced at 1.2Hz., was observed on separate…
Phair, Alison; Hajibandeh, Shahin; Hajibandeh, Shahab; Kelleher, Damian; Ibrahim, Riza; Antoniou, George A
Popliteal artery aneurysm is an uncommon vascular disease but one that can cause significant morbidity, the most severe being limb loss reported in 20% to 59% of cases. Two approaches to repair are described in the literature, the posterior and the medial; however, the "gold standard" method of repair remains controversial. A systematic review of electronic information sources was undertaken to identify papers comparing outcomes of posterior repair vs medial repair. The methodologic quality of the papers was assessed using the Newcastle-Ottawa Scale. Fixed-effect or random-effects models were applied to synthesize data. The search yielded seven articles eligible for inclusion. The total population comprised 1427 patients; 338 had posterior repair and 1089 had medial repair. There was no difference in the two groups in terms of postoperative nerve damage (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.24-4.2) and 30-day postoperative complications (OR, 0.87; 95% CI, 0.43-1.77). Limb loss at 30 days occurred more frequently in the medial approach group, but the difference was not statistically significant (risk difference [RD], 0.02; 95% CI, -0.04 to 0.00). Thirty-day primary patency was not statistically different between groups (RD, -0.01; 95% CI, -0.04 to 0.02), but the 30-day secondary patency suggested superiority of the posterior approach (RD, 0.05; 95% CI, 0.02-0.07). Long-term primary and secondary patency both favored the posterior approach (OR, 1.61 [95% CI, 1.06-2.43] and OR, 1.73 [95% CI, 0.91-3.30], respectively). Aneurysm exclusion was also superior with the posterior approach (OR, 4.20; 95% CI, 1.40-12.60). The rate of reoperation favored the posterior approach (OR, 0.26; 95% CI, 0.09-0.72). Long-term risk of limb loss favored posterior repair, but no statistically significant difference was found (OR, 0.32; 95% CI, 0.43-1.77). High-level comparative data comparing posterior and medial repair for popliteal artery aneurysms are not available
Matsubayashi, Jun; Tsuchiya, Kuniaki; Shimizu, Soichiro; Kitagawa, Naoyuki; Wakabayashi, Yukari; Kuroda, Masahiko; Sakurai, Michio; Nagao, Toshitaka
Objective To describe a rare autopsy case of posterior spinal artery syndrome with marked swelling of the spinal cord, an unusually subacute onset and short clinical course. Methods Case report. Findings An 84-year-old Japanese woman presented with bilateral muscle weakness of the lower legs and sensory disturbance 1 week after head contusion. Neurological findings worsened gradually. She developed phrenic nerve paralysis and died of respiratory failure 6 weeks after the onset of neurological symptoms. On pathological examination, the spinal cord was markedly swollen in the cervical and upper thoracic segments. Microscopically, there was loss of myelin sheath in the bilateral posterior columns and neuronal loss of the posterior horns in all of the spinal segments. However, findings were unremarkable in the bilateral anterior columns and bilateral anterior horns in most of the spinal segments. Posterior spinal arteries had no stenosis, occlusion, or thrombosis. We considered that pathogenesis was infarction associated with head injury. Conclusion To our knowledge, this is the first report of a case of posterior spinal artery syndrome with a markedly swollen spinal cord and poor prognosis. PMID:23433332
Takizawa, Megumi; Suzuki, Daisuke; Ito, Hajime; Fujimiya, Mineko; Uchiyama, Eiichi
The hip adductor group, innervated predominantly by the obturator nerve, occupies a large volume of the lower limb. However, case reports of patients with obturator nerve palsy or denervation have described no more than minimal gait disturbance. Those facts are surprising, given the architectural characteristics of the hip adductors. Our aim was to investigate which regions of the adductor magnus are innervated by the obturator nerve and by which sciatic nerve and to consider the clinical implications. Twenty-one lower limbs were examined from 21 formalin-fixed cadavers, 18 males and 3 females. The adductor magnus was dissected and was divided into four parts (AM1-AM4) based on the locations of the perforating arteries and the adductor hiatus. AM1 was supplied solely by the obturator nerve. AM2, AM3, and AM4 received innervation from both the posterior branch of the obturator nerve and the tibial nerve portion of the sciatic nerve in 2 (9.5%), 20 (95.2%), and 6 (28.6%) of the cadavers, respectively. The double innervation in more than 90% of the AM3s is especially noteworthy. Generally, AM1-AM3 corresponds to the adductor part, traditionally characterized as innervated by the obturator nerve, and AM4 corresponds to the hamstrings part, innervated by the sciatic nerve. Here, we showed that the sciatic nerve supplies not only the hamstrings part but also the adductor part. These two nerves spread more widely than has generally been believed, which could have practical implications for the assessment and treatment of motor disability. Copyright © 2013 Wiley Periodicals, Inc.
YANG, PINGLIN; HE, XIJING; LI, HAOPENG; ZANG, QUANJIN; WANG, GUOYU
The present study aimed to analyze the indications, feasibility, safety and clinical effects of total spondylectomy and spine reconstruction through posterior or combined anterior-posterior approaches for thoracic lumbar and sacral vertebrae tumors. Between December 2009 and May 2012, 10 patients with thoracic lumbar and sacral vertebrae tumors were retrospectively analyzed. Different surgical indications and approaches were used according to the affected segments, the extent of lesion involvement and the specific pathology results. One-stage posterior or combined anterior-posterior total spondylectomy and reconstruction was used for the treatment of complicated thoracic lumbar and sacral vertebral malignant tumors and invasive benign tumors. The duration of surgery, levels of intraoperative blood loss and transfusions, and the clinical effects were observed. The average surgical duration was 6.8 h (range, 4.8–12 h), with an average blood loss level of 3,200 ml (range, 1,500–10,000 ml) and an average transfusion level of 2,500 ml. During the average 15 months (range, 3–29 months) follow up, two patients succumbed and one patient experienced tumor recurrence. Neither tumor reoccurrence nor metastasis was observed in all other patients. Personalized surgical indications and approaches according to the affected segments, the extent of lesion involvement and the specific pathology results would aid in the reduction of pain, the improvement of nerve function and the reduction of tumor recurrence. PMID:26998076
Prak, Roeland F; Doestzada, Marwah; Thomas, Christine K; Tepper, Marga; Zijdewind, Inge
In able-bodied (AB) individuals, voluntary muscle activation progressively declines during sustained contractions. However, few data are available on voluntary muscle activation during sustained contractions in muscles weakened by spinal cord injury (SCI), where greater force declines may limit task performance. SCI-related impairment of muscle activation complicates interpretation of the interpolated twitch technique commonly used to assess muscle activation. We attempted to estimate and correct for the SCI-related-superimposed twitch. Seventeen participants, both AB and with SCI (American Spinal Injury Association Impairment Scale C/D) produced brief and sustained (2-min) maximal voluntary contractions (MVCs) with the first dorsal interosseous. Force and electromyography were recorded together with superimposed (doublet) twitches. MVCs of participants with SCI were weaker than those of AB participants (20.3 N, SD 7.1 vs. 37.9 N, SD 9.5; P < 0.001); MVC-superimposed twitches were larger in participants with SCI (SCI median 10.1%, range 2.0-63.2%; AB median 4.7%, range 0.0-18.4% rest twitch; P = 0.007). No difference was found after correction for the SCI-related-superimposed twitch (median 6.7%, 0.0-17.5% rest twitch, P = 0.402). Thus during brief contractions, the maximal corticofugal output that participants with SCI could exert was similar to that of AB participants. During the sustained contraction, force decline (SCI, 58.0%, SD 15.1; AB, 57.2% SD 13.3) was similar (P = 0.887) because participants with SCI developed less peripheral (P = 0.048) but more central fatigue than AB participants. The largest change occurred at the start of the sustained contraction when the (corrected) superimposed twitches increased more in participants with SCI (SCI, 16.3% rest twitch, SD 20.8; AB, 2.7%, SD 4.7; P = 0.01). The greater reduction in muscle activation after SCI may relate to a reduced capacity to overcome fast fatigue-related excitability changes at the spinal level.
Miller, Jonathan D; Herda, Trent J; Trevino, Michael A; Sterczala, Adam J; Ciccone, Anthony B
What is the central question of this study? The influences of motor unit recruitment threshold and twitch force potentiation on the changes in firing rates during steady-force muscular contractions are not well understood. What is the main finding and its importance? The behaviour of motor units during steady force was influenced by recruitment threshold, such that firing rates decreased for lower-threshold motor units but increased for higher-threshold motor units. In addition, individuals with greater changes in firing rates possessed greater twitch force potentiation. There are contradictory reports regarding changes in motor unit firing rates during steady-force contractions. Inconsistencies are likely to be the result of previous studies disregarding motor unit recruitment thresholds and not examining firing rates on a subject-by-subject basis. It is hypothesized that firing rates are manipulated by twitch force potentiation during contractions. Therefore, in this study we examined time-related changes in firing rates at steady force in relationship to motor unit recruitment threshold in the first dorsal interosseous and the influence of twitch force potentiation on such changes in young versus aged individuals. Subjects performed a 12 s steady-force contraction at 50% maximal voluntary contraction, with evoked twitches before and after the contraction to quantify potentiation. Firing rates, in relationship to recruitment thresholds, were determined at the beginning, middle and end of the steady force. There were no firing rate changes for aged individuals. For the young, firing rates decreased slightly for lower-threshold motor units but increased for higher-threshold motor units. Twitch force potentiation was greater for young than aged subjects, and changes in firing rates were correlated with twitch force potentiation. Thus, individuals with greater increases in firing rates of higher-threshold motor units and decreases in lower-threshold motor units
Lachman, Nirusha; Acland, Robert D; Rosse, Cornelius
The accessory nerve is conventionally described as having a cranial and spinal root. According to standard descriptions the cranial root (or part) is formed by rootlets that emerge from the medulla between the olive and the inferior cerebellar peduncle. These rootlets are considered to join the spinal root, travel with it briefly, then separate within the jugular foramen to become part of the vagus nerve. In 15 fresh specimens we exposed the posterior cranial fossa with a coronal cut through the foramen magnum and explored the course of each posterior medullary rootlet (PMR) arising from within the retro-olivary groove. We chose the caudal end of the olive as the landmark for the caudal end of the medulla. In all specimens every PMR that did not contribute to the glossopharyngeal nerve joined the vagus nerve at the jugular foramen. The distance between the caudal limit of the olive and the origin of the most caudal PMR that contributed to the vagus nerve ranged from 1-21 mm (mean = 8.8 mm). All rootlets that joined the accessory nerve arose caudal to the olive. The distance from the caudal limit of the olive and the most rostral accessory rootlet ranged from 1-15 mm (mean = 5.4 mm). We were unable to demonstrate any connection between the accessory and vagus nerves within the jugular foramen. Our findings indicate that the accessory nerve has no cranial root; it consists only of the structure hitherto referred to as its spinal root.
Oisi, Yasuhiro; Fujimoto, Satoko; Ota, Kinya G; Kuratani, Shigeru
The vertebrate body is characterized by its dual segmental organization: pharyngeal arches in the head and somites in the trunk. Muscular and nervous system morphologies are also organized following these metameric patterns, with distinct differences between head and trunk; branchiomeric nerves innervating pharyngeal arches are superficial to spinal nerves innervating somite derivatives. Hypobranchial muscles originate from rostral somites and occupy the "neck" at the head-trunk interface. Hypobranchial muscles, unlike ventral trunk muscles in the lateral body wall, develop from myocytes that migrate ventrally to occupy a space that is ventrolateral to the pharynx and unassociated with coelomic cavities. Occipitospinal nerves innervating these muscles also extend ventrally, thereby crossing the vagus nerve laterally. In hagfishes, the basic morphological pattern of vertebrates is obliterated by the extreme caudal shift of the posterior part of the pharynx. The vagus nerve is found unusually medially, and occipitospinal nerves remain unfasciculated, appearing as metameric spinal nerves as in the posterior trunk region. Moreover, the hagfish exhibits an undifferentiated body plan, with the hypobranchial muscles not well dissociated from the abaxial muscles in the trunk. Comparative embryological observation showed that this hagfish-specific morphology is established by secondary modification of the common vertebrate embryonic pattern, and the hypobranchial muscle homologue can be found in the rostral part of the oblique muscle with pars decussata. The morphological pattern of the hagfish represents an extreme case of heterotopy that led to the formation of the typical hypoglossal nerve, and can be regarded as an autapomorphic trait of the hagfish lineage.
Hale, Douglass S; Fenner, Dee
Posterior vaginal wall prolapse is one of the most common prolapses encountered by gynecological surgeons. What appears to be a straightforward condition to diagnose and treat surgically for physicians has proven to be frustratingly unpredictable with regard to symptom relief for patients. Functional disorders such as dyssynergic defecation and constipation are often attributed to posterior vaginal wall prolapse. Little scientific evidence supports this assumption, emphasizing that structure and function are not synonymous when treating posterior vaginal wall prolapse. Rectoceles, enteroceles, sigmoidoceles, peritoneoceles, rectal and intraanal intussusception, rectal prolapse, and descending perineal syndrome are all conditions that have an impact on the posterior vaginal wall. All too often these different anatomic conditions are treated with the same surgical approach, addressing a posterior vaginal wall bulge with a traditional posterior colporrhaphy. Studies that examine the correlation between stage of posterior wall prolapse and patient symptoms have failed to reliably do so. Surgical outcomes measured by prolapse staging appear successful, yet patient expectations are often not met. As increasing attention is being placed on patient satisfaction outcomes concerning surgical treatments, this fact will need to be addressed. Surgeons will have to clearly communicate what can and what cannot be expected with surgical repair of posterior vaginal wall prolapse. Copyright © 2016 Elsevier Inc. All rights reserved.
di Iorgi, Natascia; Secco, Andrea; Napoli, Flavia; Calandra, Erika; Rossi, Andrea; Maghnie, Mohamad
While the molecular mechanisms of anterior pituitary development are now better understood than in the past, both in animals and in humans, little is known about the mechanisms regulating posterior pituitary development. The posterior pituitary gland is formed by the evagination of neural tissue from the floor of the third ventricle. It consists of the distal axons of the hypothalamic magnocellular neurones that shape the neurohypophysis. After its downward migration, it is encapsulated together with the ascending ectodermal cells of Rathke's pouch which form the anterior pituitary. By the end of the first trimester, this development is completed and vasopressin and oxytocin can be detected in neurohypophyseal tissue. Abnormal posterior pituitary migration such as the ectopic posterior pituitary lobe appearing at the level of median eminence or along the pituitary stalk have been reported in idiopathic GH deficiency or in subjects with HESX1, LHX4 and SOX3 gene mutations. Another intriguing feature of abnormal posterior pituitary development involves genetic forms of posterior pituitary neurodegeneration that have been reported in autosomal-dominant central diabetes insipidus and Wolfram disease. Defining the phenotype of the posterior pituitary gland can have significant clinical implications for management and counseling, as well as providing considerable insight into normal and abnormal mechanisms of posterior pituitary development in humans.
Romero, Alicia Del Carmen Becerra; da Silva, Carlos Eduardo; de Aguiar, Paulo Henrique Pires
Background: The diencephalic leaf of the Liliequist's membrane is a continuous structure that should be perforated in the endoscopic third ventriculostomy. Its lateral borders are penetrated by the third cranial nerve and the posterior communicating arteries. The most important complication of endoscopic third ventriculostomy is the vascular injury, such as the posterior communicating artery. The purpose of this study is to measure the distance between posterior communicating arteries located below the third ventricle floor and anterior of the mammillary bodies. Methods: In this observational prospective study 20 fresh brains from cadavers were utilized to measure the distance between the posterior communicating arteries in April 2008 at the Death Check Unit of our Institution. A digital photograph of the posterior communicating arteries was taken and the distance between the arteries was measured. The measurement was analyzed using descriptive statistics. Results: In the descriptive analysis of the 20 specimens, the posterior communicating arteries distance was 9 to 18.9 mm, a mean of 12.5 mm, median of 12.2 mm, standard deviation of 2.3 mm. Conclusion: The detailed knowledge of vascular structures involved in the endoscopic third ventriculostomy as to the posterior communicating arteries distance provides a safe lateral vascular border when performing such procedure. PMID:21748043
Borgeat, Alain; Blumenthal, Stephan; Karovic, Dirk; Delbos, Alain; Vienne, Patrick
Tibial and common peroneal nerves can be blocked by the posterior approach to the popliteal fossa. Techniques using fixed measured distances between knee skin crease and puncture point have been described. We report on an approach that is based on manual identification of the apex of the popliteal fossa. Five-hundred patients undergoing surgery of ankle or foot were prospectively included. The apex of the popliteal fossa (determined by the crossing point of the biceps femoris and the semitendinosus and semimembranosus muscles) was assessed by manual palpation. The puncture point was 0.5 cm below the apex, on the medial side of the biceps femoris muscle. When indicated for postoperative analgesia, a perineural catheter was placed. We assessed success rate, number of attempts, the distance between knee skin crease and the apex of the popliteal fossa, nerve depth, and acute and late complications. Block success rate was 94% and 92% when the block was performed through the needle and the catheter, respectively. Inversion was the motor response with the highest success rate. The first attempt was successful in 97.5% of the patients. Mean depth of the nerve was 4.5 cm (range, 2.0 to 7.0 cm) and mean knee skin crease to apex of popliteal fossa distance was 9 cm (range, 7.0 to 12.0 cm). Nine patients (2%) had acute complications. There were no technical problems associated with the perineural nerve catheter. After 12 weeks, no late complications were observed. The modified posterior anatomical approach for popliteal sciatic nerve block is easy to perform, has a high success rate, and has a low complication rate. The location of the needle insertion point is assessed without any measurement, thus avoiding inaccuracies caused by repeated skin-distance measurements.
Rilo, Benito; da Silva, José Luis; Mora, María Jesús; Cadarso-Suárez, Carmen; Santana, Urbano
This study was designed to characterize masticatory-cycle morphology, and distance of the contact glide in the closing masticatory stroke, in adult subjects with uncorrected unilateral posterior crossbite (UPXB), comparing the results obtained with those obtained in a parallel group of normal subjects. Mandibular movements (masticatory movements and laterality movements with dental contact) were registered using a gnathograph (MK-6I Diagnostic System) during unilateral chewing of a piece of gum. Traces were recorded on the crossbite and non-crossbite sides in the crossbite group, and likewise on both sides in the non-crossbite group. Mean contact glide distance on the crossbite side in the UPXB group was significantly lower than in the control group (p<0.001), and mean contact glide distance on the non-crossbite side in the UPXB group was significantly lower than in the control group (p=0.042). Cycle morphology was abnormal during chewing on the crossbite side, with the frequency distribution of cycle types differing significantly from that for the noncrossbite side and that for the control group (p<0.001). Patients with crossbite showed alterations in both contact glide distances and masticatory cycle morphology. These alterations are probably adaptive responses allowing maintenance of adequate masticatory function despite the crossbite.
Ness, T; Virchow, J C
To demonstrate the difficulties of the differential diagnosis between tuberculosis and sarcoidosis as the cause of posterior uveitis. A 56-year-old woman suffered from bilateral anterior uveitis, snow-ball like infiltrates in the vitreous, and peripheral retinochoroidal granulomas with marked exudation shown in fluorescein angiography. Angiotensin-converting enzyme, as a marker of sarcoidosis, was elevated; the tuberculin test, however, was negative. Chest X-ray revealed an infiltrate and numerous smaller granulomas. The presumptive diagnosis was sarcoidosis. Surprisingly, in the biopsy of the pulmonal lesion tubercle bacilli were detected by Ziehl-Neelsen staining. Thus, a diagnosis of pulmonal and also retinochoroidal tuberculosis was made. After tuberculostatic therapy the choroidal lesions healed off. In a second case, a 30-year-old man suffered from bilateral panuveitis with candle wax exudates near the retinal vessels. Chest X-ray revealed lymphomas in the hilus, and the lymph node biopsy showed granulomas with epitheloid cells, indicating sarcoidosis. Detection of mycobacterium tuberculosis by culture or histological criteria was negative. Only in the PCR was mycobacterium tuberculosis DNA detectable. Tuberculostatic therapy had no benefit. Under therapy with steroids, however, pulmonal and ophthalmologic findings rapidly disappeared. The difficult differential diagnosis between sarcoidosis and tuberculosis cannot always be made by laboratory tests or diagnostic imaging alone. Clinical manifestations, including response to therapy, are essential.
Komesu, Yuko M.; Rogers, Rebecca G.; Kammerer-Doak, Dorothy N.; Barber, Matthew D.; Olsen, Ambre L.
OBJECTIVE The purpose of this study was to determine the effect of posterior repair (PR) on sexual function in patients who have undergone incontinence and/or pelvic reconstructive surgery. STUDY DESIGN A cohort study of women who underwent incontinence and/or prolapse surgery was performed. Participants completed the pelvic organ prolapse urinary incontinence sexual questionnaire (PISQ) before and after the operation. PISQ scores were compared between women who underwent PR and women who did not. RESULTS Of 73 study participants, 30 women underwent PR; 43 women did not (no PR). Although there was no difference in dyspareunia between groups pre-op, dyspareunia prevalence post-op was significantly lower in the no PR group. Preoperative PISQ scores were similar between groups. After the operation, both groups significantly improved their PISQ scores, without a difference between groups. CONCLUSION Although the incidence of dyspareunia differed between PR and no PR groups, overall improvement in sexual function was reflected in improved total PISQ scores that occurred irrespective of PR performance. PMID:17618777
Ramasastry, S S; Schlechter, B; Cohen, M
A high rate of success can be expected in the management of posterior trunk defects with muscle flaps. The surgeon has to adhere closely to the basic reconstructive principles of adequate debridement of all necrotic or devitalized tissues; management of infection with local wound care and appropriate antibiotic therapy; and coverage with well-vascularized tissue to obliterate any residual dead space and to cover bone grafts, orthopedic hardware, and vital structures such as the dura and spinal cord. Flap selection is also of paramount importance for success, and only muscles with appropriate arc of rotation, vascularity (vascular pedicles outside the field of radiation injury, or intact vascularity following previous procedures) and bulk should be used. Adequate flap mobilization to obtain a tension-free closure and judicious use of drains and perioperative antibiotic agents are essential. Occasionally, microvascular free-tissue transfer may be necessary if local flaps are unavailable. The complications of flap reconstruction include partial flap loss, persistent dead space for lack of adequate muscle bulk, and persistent infection. Debridement and re-advancement of the flap is adequate in most cases. If there is significant or total flap loss, however, a second flap reconstruction is often necessary to obliterate the dead space and protect vital structures.
AlDarrab, Abdulrahman; Alrajeh, Mohammed; Alsuhaibani, Adel H
To study the effect of posterior blepharitis on meibomian glands using infrared meibography and to correlate the results with tear film parameters. This is a prospective cohort study. The study included eyes from two groups: 86 eyes of healthy volunteers' eyes and 72 eyes with posterior blepharitis. Participants were examined, and diagnosis of posterior blepharitis was achieved clinically based on signs of posterior blepharitis. Clinical assessment of dryness was performed including slit lamp examination looking for signs of posterior blepharitis, tear breakup time (TBUT), superficial punctate keratopathy (SPK), Schirmer II test (with anesthesia) and meibum score. Non-contact meibography was performed for both upper and lower eyelids using the meibo-grade system which involved distortion of meibomian gland, shortening and dropout. Lid margin abnormalities (Telangiectasia, lid margin swelling and hyperemia) were all significantly higher in the posterior blepharitis group. SPK, meibum score, meibography dropout, distortion, shortening, and total meibography were all significantly higher in the posterior blepharitis group as well as meibum score (P value < 0.001). TBUT was significantly shorter in the posterior blepharitis group (P value < 0.001). There was no significant difference between the two groups in Schirmer's II test. Meibography can be a helpful non-invasive tool for the clinical evaluation of the extent of the anatomical damage in patients having meibomian glands loss due to posterior blepharitis. Knowing the extent of damage in meibomian glands may help in selecting the appropriate treatment modality and expect the response to treatment in patients with posterior blepharitis.
Ellis, Richard F; Hing, Wayne A; McNair, Peter J
Controlled laboratory study using a single-group, within-subjects comparison. To determine whether different types of neural mobilization exercises are associated with differing amounts of longitudinal sciatic nerve excursion measured in vivo at the posterior midthigh region. Recent research focusing on the upper limb of healthy subjects has shown that nerve excursion differs significantly between different types of neural mobilization exercises. This has not been examined in the lower limb. It is important to initially examine the influence of neural mobilization on peripheral nerve excursion in healthy people to identify peripheral nerve excursion impairments under conditions in which nerve excursion may be compromised. High-resolution ultrasound imaging was used to assess sciatic nerve excursion at the posterior midthigh region. Four different neural mobilization exercises were performed in 31 healthy participants. These neural mobilization exercises used combinations of knee extension and cervical spine flexion and extension. Frame-by-frame cross-correlation analysis of the ultrasound images was used to calculate nerve excursion. A repeated-measures analysis of variance and isolated means comparisons were used for data analysis. Different neural mobilization exercises induced significantly different amounts of sciatic nerve excursion at the posterior midthigh region (P<.001). The slider exercise, consisting of the participant performing simultaneous cervical spine and knee extension, resulted in the largest amount of sciatic nerve excursion (mean ± SD, 3.2 ± 2.0 mm). The amount of excursion during the slider exercise was slightly greater (mean ± SD, 2.6 ± 1.5 mm; P = .002) than it was during the tensioner exercise (simultaneous cervical spine flexion and knee extension). The single-joint neck flexion exercise resulted in the least amount of sciatic nerve excursion at the posterior midthigh (mean ± SD, -0.1 ± 0.1 mm), which was significantly smaller than
Ethier, C. R.; Feola, A. J.; Raykin, J.; Mulugeta, L.; Gleason, R.; Myers, J. G.; Nelson, E. S.; Samuels, B.
Purpose: Visual Impairment and Intracranial Pressure (VIIP) syndrome is a new and significant health concern for long-duration space missions. Its etiology is unknown, but is thought to involve elevated intracranial pressure (ICP)that induces connective tissue changes and remodeling in the posterior eye (Alexander et al. 2012). Here we study the acute biomechanical response of the lamina cribrosa (LC) and optic nerve to elevations in ICP utilizing finite element (FE) modeling. Methods: Using the geometry of the posterior eye from previous axisymmetric FE models (Sigal et al. 2004), we added an elongated optic nerve and optic nerve sheath, including the pia and dura. Tissues were modeled as linear elastic solids. Intraocular pressure and central retinal vessel pressures were set at 15 mmHg and 55 mmHg, respectively. ICP varied from 0 mmHg (suitable for standing on earth) to 30 mmHg (representing severe intracranial hypertension, thought to occur in space flight). We focused on strains and deformations in the LC and optic nerve (within 1 mm of the LC) since we hypothesize that they may contribute to vision loss in VIIP. Results: Elevating ICP from 0 to 30 mmHg significantly altered the strain distributions in both the LC and optic nerve (Figure), notably leading to more extreme strain values in both tension and compression. Specifically, the extreme (95th percentile) tensile strains in the LC and optic nerve increased by 2.7- and 3.8-fold, respectively. Similarly, elevation of ICP led to a 2.5- and 3.3-fold increase in extreme (5th percentile) compressive strains in the LC and optic nerve, respectively. Conclusions: The elevated ICP thought to occur during spaceflight leads to large acute changes in the biomechanical environment of the LC and optic nerve, and we hypothesize that such changes can activate mechanosensitive cells and invoke tissue remodeling. These simulations provide a foundation for more comprehensive studies of microgravity effects on human vision, e
Bisaria, K K
In a study of 80 cavernous sinuses in 40 cadavers, the trochlear nerve entered the cavernous sinus in 87.5% of cases before the crossing, in 7.5% at the crossing and in 5.0% after the crossing of the free and the attached margins of the tentorium cerebelli. In 77.5% of specimens the trochlear nerve showed a marked bend with flattening at the site of its entrance into the cavernous sinus. The nerve ran between the superficial and deep layers of dura, partly between them, in the thickness of the deeper layer, or deep to the deep layer but adherent to it. These findings do not conform with the description of its course by other workers in the past. In 72.5% of specimens the size of the trochlear nerve was larger during its course in the cavernous sinuses but in 20.0% of specimens such an increase in thickness was noted even in the posterior cranial fossa. Only in one specimen was the trochlear nerve adherent to the ophthalmic division of the trigeminal nerve. Cases showing the trochlear nerve entering the cavernous sinus after the crossing of the two margins of tentorium cerebelli and the splitting and branching of the trochlear nerve in the cavernous sinus have not hitherto been reported. Images Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 PMID:3248970
Bian, Liu-Guan; Sun, Qing-Fang; Tirakotai, Wuttipong; Zhao, Wei-Guo; Bertalanffy, Helmut; Shen, Jian-Kang
We report a patient with a posterior inferior cerebellar artery (PICA) aneurysm and an incidental facial nerve schwannoma at the cerebellopontine angle (CPA). A 46-year-old woman presented with the sudden onset of a severe headache, nausea, and vomiting. She had no other abnormal neurological symptoms and signs. Computed tomography (CT) showed hemorrhage in the fourth ventricle. Cerebral angiography demonstrated an aneurysm arising from the tonsillomedullary segment of the left PICA. A facial nerve schwannoma was incidentally found as the aneurysm was being clipped. The aneurysm was clipped via a left transcondylar approach. Subsequently, the schwannoma (2 x 3 x 2 mm) was resected from the facial nerve fascicles, and the facial nerve was preserved. Postoperatively, the patient developed mild to moderate dysfunction of the facial nerve (House-Brackmann grade III [H-B III]) but her hearing was intact. Both a facial nerve schwannoma involving the CPA and an aneurysm involving the PICA can be managed through the transcondylar approach. An asymptomatic facial nerve schwannoma can be resected safely with minimal facial nerve dysfunction.
McConaghie, F A; Payne, A P; Kinninmonth, A W G
Acetabular retractors have been implicated in damage to the femoral and obturator nerves during total hip replacement. The aim of this study was to determine the anatomical relationship between retractor placement and these nerves. A posterior approach to the hip was carried out in six fresh cadaveric half pelves. Large Hohmann acetabular retractors were placed anteriorly, over the acetabular lip, and inferiorly, and their relationship to the femoral and obturator nerves was examined. If contact with bone was not maintained during retractor placement, the tip of the anterior retractor had the potential to compress the femoral nerve by passing superficial to the iliopsoas. If pressure was removed from the anterior retractor, the tip pivoted on the anterior acetabular lip, and passed superficial to the iliopsoas, overlying and compressing the femoral nerve, when pressure was reapplied. The inferior retractor pierced the obturator membrane in all specimens medial to the obturator nerve, with subsequent retraction causing the tip to move laterally, making contact with the nerve. Iliopsoas can only offer protection to the femoral nerve if the retractor passes deep to the muscle bulk. The anterior retractor should be reinserted if pressure is removed intra-operatively. Vigorous movement of the inferior retractor should be avoided. Cite this article: Bone Joint Res 2014;3:212-6. ©2014 The British Editorial Society of Bone & Joint Surgery.
Ozdogmus, Omer; Saban, Enis; Ozkan, Mazhar; Yildiz, Sercan Dogukan; Verimli, Ural; Cakmak, Ozgur; Arifoglu, Yasin; Sehirli, Umit
Morphometric measurements of cranial nerves in posterior cranial fossa of fetus cadavers were carried out in an attempt to identify any asymmetry in their openings into the cranium. Twenty-two fetus cadavers (8 females, 14 males) with gestational age ranging between 22 and 38 weeks (mean 30 weeks) were included in this study. The calvaria were removed, the brains were lifted, and the cranial nerves were identified. The distance of each cranial nerve opening to midline and the distances between different cranial nerve openings were measured on the left and right side and compared. The mean clivus length and width were 21.2 ± 4.4 and 13.2 ± 1.5 mm, respectively. The distance of the twelfth cranial nerve opening from midline was shorter on the right side when compared with the left side (6.6 ± 1.1 versus 7.1 ± 0.8 mm, p = 0.038). Openings of other cranial nerves did not show such asymmetry with regard to their distance from midline, and the distances between different cranial nerves were similar on the left and right side. Cranial nerves at petroclival region seem to show minimal asymmetry in fetuses.
Yampolsky, Andrew; Ziccardi, Vincent; Chuang, Sung-Kiang
During trigeminal nerve repair, a gap is sometimes encountered that prevents the tension-free apposition of nerve endings. The use of a processed acellular nerve allograft is a novel technique that shows promise in overcoming this problem. The goal of the present study was to support the slowly evolving body of evidence that acellular processed nerve allografts (Avance; Axogen, Alachua, FL) are a viable alternative to autogenous nerve grafting and the use of conduits for reconstructing defects of the trigeminal nerve. The study design consisted of a retrospective review of the medical records of patients referred to Rutgers School of Dental Medicine for management of trigeminal nerve injuries from July 2008 to August 2014. Sixteen patients met the inclusion criteria for the present study. All patients underwent nerve grafting using a processed nerve allograft. All operations were performed by the same surgeon (V.Z.). Serial neurosensory testing was performed by 1 clinician (V.Z.) in a standardized fashion. The primary outcome variable was the interval to functional sensory recovery as defined by the Medical Research Council Scale. The participants ranged in age from 16 to 62 years (mean 32). Of the 16 patients, 12 were female (75%) and 4 were male (25%), and 3 were smokers (18.75%) and 13 were nonsmokers (81.25%). One half of the patients (n = 8; 50%) underwent surgery on the inferior alveolar nerve, and 8 (50%) underwent surgery on the lingual nerve. The most common mechanism of injury was impacted third molar removal (n = 9; 56.25%) Of the 16 patients, 15 (93.75%) achieved functional sensory recovery during the study period. The results of the present study support the hypothesis that processed nerve allografts are effective in reconstructing small (<2-cm) trigeminal nerve defects. Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
de Sèze, M P; Rezzouk, J; de Sèze, M; Uzel, M; Lavignolle, B; Midy, D; Durandeau, A
Anatomy textbooks say that the motor branch of the long head of the triceps brachii (LHT) arises from the radial nerve. Some clinical observations of traumatic injuries of the axillary nerve with associated paralysis of the LHT have suggested that the motor branch of the LHT may arise from the axillary nerve. This anatomic study was performed, using both cadaver anatomical dissections and a surgical study, to determine the exact origin of the motor branch of the LHT. From the adult cadaver specimens (group I), 20 posterior cords were dissected from 10 subjects (eight embalmed, two fresh) using 3.5x magnification. The axillary nerve was followed from its onset to the posteromedial part of the surgical neck of the humerus and the radial nerve. We looked for the origin of the proximal branch of the LHT by a meticulous double anterior and posterior dissection. From the surgical group (group II), 15 posterior cords were dissected from 15 patients suffering from a C5-C6 injured paralysis, without paralysis of the LHT. During the surgical procedure, we looked for the origins of the motor branch of the LHT with a nerve stimulator. In group I, the motor branch of the LHT arose in 13 cases from the axillary nerve near its origin, in five cases from the terminal division of the posterior cord itself, and in two cases from the posterior cord 10 mm before its terminal division into the radial and axillary nerves. In no case did we find the motor branch of the LHT arising from the radial nerve. In eight cases, we found some accessory branches that arose near the principal branch. In group II, the motor branch of the LHT arose in 11 cases from the axillary nerve near its origin and in four cases from the terminal division of the posterior cord itself. The motor branch of the LHT never originated from the radial nerve. In four cases, we found some accessory branches that arose near the principal branch of the LHT. These results reveal that the motor branch of the LHT seems to
Hager, Shaun; Backus, Timothy Charles; Futterman, Bennett; Solounias, Nikos; Mihlbachler, Matthew C
Students of human anatomy are required to understand the brachial plexus, from the proximal roots extending from spinal nerves C5 through T1, to the distal-most branches that innervate the shoulder and upper limb. However, in human cadaver dissection labs, students are often instructed to dissect the brachial plexus using an antero-axillary approach that incompletely exposes the brachial plexus. This approach readily exposes the distal segments of the brachial plexus but exposure of proximal and posterior segments require extensive dissection of neck and shoulder structures. Therefore, the proximal and posterior segments of the brachial plexus, including the roots, trunks, divisions, posterior cord and proximally branching peripheral nerves often remain unobserved during study of the cadaveric shoulder and brachial plexus. Here we introduce a subscapular approach that exposes the entire brachial plexus, with minimal amount of dissection or destruction of surrounding structures. Lateral retraction of the scapula reveals the entire length of the brachial plexus in the subscapular space, exposing the brachial plexus roots and other proximal segments. Combining the subscapular approach with the traditional antero-axillary approach allows students to observe the cadaveric brachial plexus in its entirety. Exposure of the brachial dissection in the subscapular space requires little time and is easily incorporated into a preexisting anatomy lab curriculum without scheduling additional time for dissection.
Hislop, M; Tierney, P
The management of musculoskeletal conditions makes up a large part of a sports medicine practitioner's practice. A thorough knowledge of anatomy is an essential component of the armament necessary to decipher the large number of potential conditions that may confront these practitioners. To cloud the issue further, anatomical variations may be present, such as supernumerary muscles, thickened fascial bands or variant courses of nerves and blood vessels, which can themselves manifest as acute or chronic conditions that lead to significant morbidity or limitation of activity. There are a number of contentious areas within the literature surrounding the anatomy of the leg, particularly involving the deep posterior compartment. Conditions such as chronic exertional compartment syndrome, tibial periostitis (shin splints), peripheral nerve entrapment and tarsal tunnel syndrome may all be affected by subtle anatomical variations. This paper primarily focuses on the deep posterior compartment of the leg and uses the gross dissection of cadaveric specimens to describe definitively the anatomy of the deep posterior compartment. Variant fascial attachments of flexor digitorum longus are documented and potential clinical sequelae such as chronic exertional compartment syndrome and tarsal tunnel syndrome are discussed.
Lui, Tun Hing
Chronic exertional compartment syndrome is a rare cause of lower leg pain incurred during sports activities and typically affects young athletes who need to return to their activity level as quickly as possible. Nonoperative treatments are often unsuccessful and fasciotomy of the involved compartment is the treatment of choice. Endoscopically assisted release of the anterior and deep compartments is proven to be safe and effective. Endoscopically assisted deep posterior compartment release via an incision 1 to 3 cm behind the medial tibial border has high risk of injury to the great saphenous and perforating veins and the saphenous nerve. The purpose of this Technical Note is to describe the details of endoscopic fasciotomy of the superficial and deep posterior compartments of the leg. The operative field of this approach is away from the saphenous vein and nerve. Moreover, the tibial insertion of the soleus muscle does not need to be released to gain access to the proximal part of the deep posterior compartment.