Lateral Lymph Node Dissection for Locally Advanced Rectal Carcinoma: A Step-by-Step Description of Surgical Anatomical Planes During Cadaveric Dissection and Minimally Invasive Surgery.

PURPOSE: Total mesorectal excision (TME) is accepted as gold standard method in rectal cancer globally. But there is no standard for lateral lymph nodes. Combination of neoadjuvant treatment plus lateral lymph node dissection (LLND) in select patients might be a promising method. Our purpose is to describe the anatomic landmarks of LLND on cadavers and minimally invasive surgery. MATERIALS AND METHODS: Local advanced rectal cancer and lateral lymph node (LLN) metastasis are accepted as an indication of neoadjuvant treatment. LLND was performed according to preoperative imaging after radiochemotherapy. RESULTS: Twenty-eight (10.5%) of 267 patients with rectal cancer who had suspected lateral lymph node metastasis (LLNM) with magnetic resonance imaging (MRI) underwent LLND in addition to TME after neoadjuvant chemoradiotherapy. Eight of them had LLNM. Three patients had bilateral LLND and only 1 had LLNM. The median number of harvested lymph nodes was 6. The rates of LLNM increased with the presence of poor prognosis markers. One regional and 1 distant recurrence were detected in patients who had no LLN metastasis compared with2 regional and 4 distant recurrences in the LLN-positive group. CONCLUSIONS: Local advanced rectal cancer cases may benefit from LLND, but it does not appear to have an effect on overall survival. There is no consensus whether size and/or morphologic criteria in MRI are the ideal guide for LLND.

Correction to: The results of decompression of the musculocutaneous nerve entrapment in children with obstetric brachial plexus palsy.

The original version of this article unfortunately contained an error. Tables and Supplementary are incorrectly processed during production. Given in this article are the correct tables.

The results of decompression of the musculocutaneous nerve entrapment in children with obstetric brachial plexus palsy.

PURPOSE: Elbow flexion is a key indicator of functional recovery in obstetric brachial plexus palsy (OBPP). However, lack of flexion could be a result of an entrapped musculocutaneous nerve during the healing period. The purpose of this study was to investigate the possible compression of the musculocutaneous nerve and outcomes of decompression. METHODS: The study included 11 children aged with a mean age of 10.9 ± 2.7 months (range, 8-16 months) with Narakas 2 involvement OBPP, who had insufficient elbow flexion but had satisfactory shoulder abduction. Prior to surgery, magnetic resonance imaging (MRI) was performed to identify the entrapment. The children were evaluated pre-operatively and at 3 and 12 months postoperatively using the Active Movement Scale and Faradic Excitability Test. The musculocutaneous nerve was explored and decompressed in all the children. Regular physiotherapy and a home exercise programme were prescribed after surgery. RESULTS: The MRI findings were consistent with the surgical exploration in all the infants. Statistical analyses showed that decompression of the musculoskeletal nerve improved active movement scale scores on elbow flexion and faradic excitability test values of biceps brachii within 3 months after surgery. CONCLUSION: Children with delayed elbow flexion and satisfactory shoulder abduction may have an entrapped musculocutaneous nerve in the proximal arm and decompression of the nerve improves elbow function.

Preventing the recurrence of acute anorectal abscesses utilizing a loose seton: a pilot study.

INTRODUCTION: This pilot study aimed to document our results of treating anorectal abscesses with drainage plus loose seton for possible coexisting high fistulas or drainage plus fistulotomy for low tracts at the same operation. METHODS: Drainage plus fistulotomy were performed only in cases with subcutaneous mucosa, intersphincteric, or apparently low transsphincteric fistula tracts. For all other cases with high transsphincteric fistula or those with questionable sphincter involvement, a loose seton was placed through the tract. Drainage only was carried out in 17 patients. RESULTS: Twenty-three patients underwent drainage plus loose seton. Drainage plus fistulotomy were performed in four cases. None of the patients developed recurrent abscess during a follow-up of 12 months. Not surprisingly, the incontinence scores were similar pre and post-operatively (p=0.564). Only minor complications occurred in 4 cases (14.8 percent). Secondary interventions following loose seton were carried out in 13 patients (48.1 percent). At 12 months, drainage only was followed by 10 recurrences (58.8 percent; p<0.0001, compared with concomitant surgery). CONCLUSION: Concomitant loose seton treatment of high fistula tracts associated with anorectal abscess prevents abscess recurrence without significant complications or disturbance of continence. Concomitant fistulotomy for associated low fistulas also aids in the same clinical outcome. Concomitant fistula treatment with the loose seton may suffice in treating the whole disease process in selected cases. Even in patients with high fistula tracts, the loose seton makes fistula surgery simpler with a mature tract. Abscess recurrence is high after drainage only.

Matrix induced autologous chondrocyte implantation in the knee: Comparison between osteochondritis dissecans and osteonecrosis and effect of chondrocyte thickness on prognosis.

OBJECTIVE: The aim of this study was compare the clinical success of treatments for avascular necrosis and osteochondritis dissecans in cases who underwent matrix autologous chondrocyte implantations, and evaluate cartilage thickness on the clinical outcomes after implantation. METHODS: A total of 37 patients (29 men, and 8 women; mean age: 23.8 years (16-38)) were treated prospectively with a two-stage matrix autologous chondrocyte implantation (avascular necrosis, n=21; osteochondritis dissecans, n=18). Clinical improvements and follows-up were assessed based on the patients' International Cartilage Repair Society (ICRS) scores with simultaneous cartilage thickness measurement using short-TI inversion recovery magnetic resonance imaging. The patients were divided into four subgroups based on their clinical scores, as group D <65 points, Group C 65-83 points, Group B 84-90 and Group A ≥90. RESULTS: The mean ICRS score was 28.33±7.14 in the preoperative period in the avascular necrosis group, which increased to 70.88±12.61 at 60 months; while the mean ICRS score increased from 29.75±7.15 preoperatively to 87.58±12.83 at 60 months in the osteochondritis dissecans group. A statistically significant difference in the ICRS scores was noted between the two groups, and also between the ICRS scores and cartilage thicknesses of the subgroups (p<0.05). CONCLUSION: Our study results revealed that greater clinical improvement was achieved in patients with osteochondritis dissecans undergoing matrix autologous chondrocyte implantation than in those with avascular necrosis. In addition, cartilage thickness greater than 3.7 mm following an autologous chondrocyte transplantation showed excellent clinical improvement. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Evaluation of Muscle Injuries in Professional Football Players: Does Coach Replacement Affect the Injury Rate?

OBJECTIVES: To assess the incidence and characteristics of muscle injuries in professional football players and to assess if coach dismissal may be related with muscle injuries within 1-month period from the dismissal. DESIGN: Prospective cohort study during 3 consecutive seasons. SETTING: Turkish Super League football teams. PARTICIPANTS: One hundred eighteen male football players. MAIN OUTCOME MEASURES: Data on time-loss muscle injuries confirmed using magnetic resonance imaging were recorded, including type, body part, duration, and lay-off time, and training session and match exposure times. The muscle injury rate was evaluated at 2 weeks and 30 days after coach dismissal. RESULTS: In total, 124 muscle injuries were recorded, with injury incidences of 2.3 muscle injuries per 1000 hours of exposure overall, 1.2 in training sessions, and 13.6 in matches. Injury time loss ranged from 3 to 67 days (median, 13 days). Eighteen percent of the injuries (n = 23) were recurrent; no association was found between recurrence rate and the player's age or position (P = 0.15, P = 0.27, respectively). Recurrent injuries caused more severe injuries (26.1%, P = 0.02) and longer median lay-off time (P = 0.01). During the study, teams A and B replaced 7 and 3 coaches, respectively. The injury incidence increased to 5.3 per 1000 hours of exposure in the 2 weeks after the coach dismissal, and decreased to 4.5 within 1 month of coach dismissal. CONCLUSION: Given the link between coach dismissal and increased rates of muscle strain injuries, increased attentiveness to preventing muscle injuries during coaching transitions and to the impact of new training regimens is required by trainers and medical teams.

Complementary Specific Pelvic Sequences on Routine Lumbar Magnetic Resonance Imaging Scans: An Imaging-Based Study Focused on Piriformis Syndrome.

AIM: To discuss the rationale and merit of specific pelvic sequences as an adjunct to routine lumbar magnetic resonance imaging (MRI) for early detection of piriformis syndrome (PS) and to disclose its frequency in patients who underwent radiological evaluation. MATERIAL AND METHODS: This retrospective, imaging-based study included all individuals who underwent lumbar MRI and those who were further evaluated with a pelvic MRI, but excluded all high-energy trauma cases. The patients' demographics and radiological features were reviewed using electronic patient records and hospital-based picture image archiving and communication system. RESULTS: Overall, 1321 individuals (659 females; 662 males) underwent lumbar MRI during the study period, and of these, 485 (238 females; 247 males) were further analyzed with a pelvic MRI for differential diagnosis. Forty patients (8.2%) (23 females; 17 males) were diagnosed with PS-all confirmed with MR neurography (MRN). On re-evaluation of all lumbar and pelvic MRIs and MRNs, we realized that adding just three specific pelvic sequences to routine lumbar MRI scans were enough to accurately delineate the piriformis muscle pathologies and sciatic nerve intensities. The calculated frequencies of PS in females, males, and the whole study population within 57 months were 3.49%, 2.57%, and 3.03%, respectively. CONCLUSION: Although PS being a clinical diagnosis, this study indicated that in patients whom PS was not suspected at the initial examination, 8.2% of them were finally diagnosed after MRI evaluations. Performing specific pelvic sequences as an adjunct to routine lumbar MRI can salvage underdiagnosed patients with PS and facilitate early detection of this pathological condition.

Regression of lumbar disc herniation by physiotherapy. Does non-surgical spinal decompression therapy make a difference? Double-blind randomized controlled trial.

BACKGROUND AND OBJECTIVES: The aim of the study determining whether or not Non-invasive Spinal Decompression Therapy (NSDT) was effective in resorption of herniation, increasing disc height in patients with lumbar disc herniation (LHNP). METHODS: A total of twenty patients diagnosed as LHNP and suffering from pain at least 8 weeks were enrolled to the study. Patients were allocated in study (SG) and control groups (CG) randomly. Both groups received combination of electrotherapy, deep friction massage and stabilization exercise for fifteen session. SG received additionally NSDT different from CG. Numeric Anolog Scale, Straight leg raise test, Oswestry Disability Index (ODI) were applied at baseline and after treatment. Disc height and herniation thickness were measured on Magnetic Resonance Imagination which performed at baseline and three months after therapy. RESULTS: Both treatments had positive effect for improving pain, functional restoration and reduction in thickness of herniation. Although reduction of herniation size was higher in SG than CG, no significant differences were found between groups and any superiority to each other (p> 0.05). CONCLUSIONS: This study showed that patients with LHNP received physiotherapy had improvement based on clinical and radiologic evidence. NSDT can be used as assistive agent for other physiotherapy methods in treatment of lumbar disc herniation.

One patient, one bone, and two different tumoral lesions.

In this article, we report a 67-year-old female patient who has two different tumoral lesions located in left humerus with clinical and radiological findings. Previously, the patient was diagnosed as impingement syndrome in shoulder, but, tumoral lesions were detected on the radiograms incidentally during evaluation.

Lumbar Epidural Varicose Vein: Early Neurological Improvement and Late Radiological Full Recovery with Surgery; The Importance of Magnetic Resonance Imaging in Follow-Up.

A lumbar epidural varicose vein is a rare clinical condition that can lead to neurological deficits. 3 types of lumbar epidural varicose veins were described according to the magnetic resonance imaging (MRI) findings: Type 1 is a thrombosed dilated epidural vein, type 2 is a non-thrombosed dilated epidural vein and type 3 is a sub-membraneous epidural hematoma. Enlarged epidural venous plexuses must be decompressed if they have lead to a neurological deficit. Surgical treatment is by excision or disrupting the cyst's integrity. We present a case of lumbar epidural varicose vein that was surgically treated twice and showed no radiological change despite the disruption of integrity with a partial excision. The lesion spontaneously and completely disappeared in the late period. We emphasize the importance of MRI in follow-up.

Comparison of minimally invasive techniques in tongue base surgery in patients with obstructive sleep apnea.

OBJECTIVE: To compare the effectiveness and morbidity of 3 microinvasive tongue base surgical procedures combined with uvulopalatopharyngoplasty (UPPP) in supine-dependent obstructive sleep apnea (OSA) patients. STUDY DESIGN: A prospective, randomized clinical study. SETTING: A tertiary referral center. METHODS: Fifty OSA patients were randomly advised to undergo UPPP combined with low-temperature bipolar radiofrequency (group 1), submucosal minimally invasive lingual excision with radiofrequency (SMILE-R; group 2), or submucosal minimally invasive lingual excision with a harmonic scalpel (SMILE-H; group 3). The Epworth Sleepiness Scale, the visual analog scale (VAS) for snoring, the pre- and postoperative 3-month polysomnography (PSG) findings, and the decrease in tongue volume using magnetic resonance imaging (MRI) were compared. The operation times, the postoperative pain VAS score, the analgesic requirement, and the time in commencing a normal diet were compared in the 3 groups. RESULTS: The decrease in apnea-hypopnea index (AHI) and supine AHI values at the postoperative 3-month time point was significant in group 2 (P < .05). The decrease in tongue volume at the 3-month postoperative time point according to the MRI evaluations was higher in groups 1 and 2 (P < .05). In the subjective comparison of effectiveness, there was no significant difference. The operation time was significantly lower in group 3. In the assessment of postoperative pain, no significant difference was found between the groups. CONCLUSION: When the PSG findings and MRI were evaluated, UPPP + SMILE-R were found to be more effective. No significant difference was found between the 3 techniques when morbidity and complications were compared.

Quantification of the effects of transcutaneous electrical nerve stimulation with functional magnetic resonance imaging: a double-blind randomized placebo-controlled study.

OBJECTIVE: To evaluate the effects of transcutaneous electric nerve stimulation (TENS) by using functional magnetic resonance imaging (fMRI) in patients with carpal tunnel syndrome (CTS). DESIGN: Randomized controlled trial. SETTINGS: University medical center and an outpatient imaging center. PARTICIPANTS: Female patients with CTS (n=20) were randomized into 2 groups receiving either TENS (n=10) or sham TENS (n=10). In both groups, an initial baseline fMRI session was performed via stimulating digits 2, 5, and 3 in turn, 1 scan run for each. TENS versus sham TENS treatment was given, and a repeat imaging was performed starting 20 minutes after the treatment as follows: second finger on the 20th minute, fifth finger on the 25th minute (ulnar nerve innervated control finger), and third finger on the 30th min. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Differences in fMRI activation between the 2 groups were evaluated. RESULTS: Our results demonstrated that 20 to 25 minutes after TENS treatment-but not in the sham TENS group-a significant fMRI signal decrease for digit 2 (post-TENS vs baseline) was observed in the secondary somatosensory regions, ipsilateral primary motor cortex (M1), contralateral supplementary motor cortex (SMA), contralateral parahippocampal gyrus, contralateral lingual gyrus, and bilateral superior temporal gyrus. Measurements on the 25th to 30th minutes for digit 5 were similar between the groups, with presence of activities in areas other than generally activated regions because of painful stimuli. Thirty to 35 minutes after TENS treatment, a significant fMRI signal decrease for digit 3 was detected in the contralateral M1 and contralateral SMA only in the TENS group. CONCLUSIONS: Our findings showed that TENS treatment significantly decreased the pain-related cortical activations caused by stimulation of the median nerve-innervated fingers up to 35 minutes after treatment.

Paget-Schroetter syndrome forerunning the diagnoses of thoracic outlet syndrome and thrombophilia.

Reported here is a 22-year-old professional wrestler who was diagnosed to have Paget-Schroetter syndrome after Greco-Roman wrestling. On substantial neuromuscular examination and laboratory testing, he was found to have also thoracic outlet syndrome and heterozygous mutations for factor V Leiden and methyltetrahydrofolate reductase genes. To the best knowledge of the authors, the concomitance of these pathologies is discussed for the first time in the literature.

Anatomical study of axis for odontoid screw thickness, length, and angle.

Anterior odontoid screw fixation is a safe and effective method for treatment of odontoid fractures. The screw treads should fit into the odontoid medulla, should pass the fracture line, and should pull fractured odontoid tip against body of axis in order to achieve optimum screw placement and treatment. This study has demonstrated optimal anterior odontoid screw thickness, length, and optimal angle for safe and strong anterior odontoid screw placement. Dry bone axis vertebrae were evaluated by direct measurements, X-ray measurements, and computerized tomography (CT) measurements. The screw thickness (inner diameter of the odontoid) was measured as well as screw length (distance between anterior-inferior point body of axis and tip of odontoid), and screw angle (the angle between basis of axis and tip of odontoid). The inner diameter of odontoid bone was measured as 6.5+/-1.9 mm, the screw length was 37.6+/-3.3 mm, and the screw angle was 62.4+/-4.7 on CT. There was no statistical difference between X-ray and CT in the measurements of screw thickness and angle. X-ray and CT measurements are both safe methods to determine the inner odontoid diameter and angle preoperatively. Screw length should be measured on CT only. To provide safe and strong anterior odontoid screw fixation, screw thickness, length, and angle should be known preoperatively, and these can be measured on X-ray and CT.

Magnetic resonance findings of osteitis pubis.

PURPOSE: To determine the correlation of MR findings with clinical features of osteitis pubis and to look for associating injuries complicating chronic cases. MATERIALS AND METHODS: Pelvic MR images of the 22 elite athletes with groin pain were taken. Correlation analysis between the MR findings and clinical properties was carried out. RESULTS: Six of the MR findings had strong correlation with duration of symptoms. Subchondral bone marrow edema, fluid in symphysis pubis joint, and periarticular edema had significant correlation with acuity of the case. On the contrary, subchondral sclerosis, subchondral resorption and bony margin irregularities, and osteophytes correlated with the chronicity of the case. Associated tendon injuries correlated with the duration of symptoms; i.e., all tendon injuries were in chronic cases. CONCLUSION: Subchondral bone marrow edema, fluid in symphysis pubis joint, and periarticular edema are the most reliable MRI findings of osteitis pubis that has a history of less than six months. Subchondral sclerosis, subchondral resorption and bony margin irregularities, and osteophytes (or pubic beaking) are the most reliable MRI findings of the chronic disease that has been present for more than six months. Associated pathologies, especially adductor or other tendon injuries, underlie more than half of the chronic cases of osteitis pubis.

Congenital absence of flexor pollicis longus tendon without associated anomalies of thumb hypoplasia: a case report and review of the literature.

In this paper, we report a case of a 14-year-old girl with congenital aplasia of the flexor pollicis longus tendon who had no other associated anomalies of thumb hypoplasia and no trauma history. Flexor pollicis longus tendon anomalies are rare; several types of this congenital anomaly have been reported in the literature. The diagnosis should be considered if a patient is unable to flex the interphalangeal joint of the thumb. A hypoplastic thumb or an absent interphalangeal joint crease may be a diagnostic feature in such cases. Besides physical examination, we also used direct radiography and magnetic resonance imaging to diagnose this rare congenital anomaly in our patient.

Significance of fibrosis around and/or at external urinary sphincter on pelvic magnetic resonance imaging in patients with postprostatectomy incontinence.

OBJECTIVES: To determine the clinical importance of fibrosis on pelvic magnetic resonance imaging in patients with postprostatectomy incontinence (PPI) due to sphincteric incompetence. METHODS: Urethral and periurethral fibrosis was determined by pelvic magnetic resonance imaging in patients who did (n = 22) or did not (n = 14) have urinary incontinence after transurethral resection, transvesical prostatectomy, or radical retropubic prostatectomy. The relation between fibrosis and the duration of incontinence, pad weight, symptom score, cystoscopy findings, and urodynamic findings was examined. RESULTS: Fibrosis was seen in all patients (22 of 22) in the study group and in 4 of 14 patients in the control group (P <0.001). All the patients with severe fibrosis had undergone radical retropubic prostatectomy (P <0.001). Similar to the etiology for incontinence, no relation was found between the severity of fibrosis and the duration of incontinence, pad weight, symptom score, cystoscopy findings, or urodynamic findings. However, the duration of incontinence was shorter in patients with mild fibrosis, clinically. CONCLUSIONS: The results of our study have shown that the incidence of fibrosis is much greater in patients with PPI than in patients without PPI. Consequently, we believe that fibrosis plays an important role in the development of PPI because it may have a negative effect on external urethral sphincter function.