Understanding bone safety zones during bone marrow aspiration from the iliac crest: the sector rule.

PURPOSE: Should the trocar suddenly lose contact with bone during bone marrow aspiration, it may result in visceral injury. The anatomy of the ilium and the structures adjacent to the iliac bone were studied to determine the danger of breach by a trocar introduced into the iliac crest. METHODS: The authors followed two series of patients, one series to do measurements of distance and angles of the structures at risk to the iliac bone and the other to evaluate the risk of a trocar being directed outside the iliac wing during bone marrow aspiration. The authors also examined 24 pelvices by computed tomography (CT) scans of mature adults (48 iliac crests). Lines dividing the iliac wing into six equal sectors were used to form sectors (e.g. sector 1 anterior, sector 6 posterior). Vascular or neurological structures were considered at risk if they were accessible to the tip of a 10-cm trocar introduced into the iliac crest with a possible deviation of 20° from the plane of the iliac wing on the three-dimensional reconstruction. The authors tracked bone marrow aspiration of six different surgeons and calculated among 120 patients (480 entry points) the number of times the needle lost contact with bone in each sector of aspiration. RESULTS: The sector system reliably predicted safe and unsafe areas for trocar placement. Among the 480 entry points in the 120 patients, 94 breaches were observed and higher risks were observed in the thinner sectors. The risk was also higher in obese patients and the risk decreased with more experienced surgeons. The trocar could reach the external iliac artery on pelvic CT scans in the four most anterior sectors with a higher frequency in women. Posterior sectors were at risk for sciatic nerve and gluteal vessel damage when the trocar was pushed deeper than 6 cm into the posterior iliac crest. In cadavers, the dissection demonstrated nine vascular or neurological lesions. CONCLUSIONS: Using the sector system, trocars can be directed away from neural and vascular structures and toward zones that are likely to contain larger bone marrow stock.

Intracranial cerebrospinal fluid spaces imaging using a pulse-triggered three-dimensional turbo spin echo MR sequence with variable flip-angle distribution.

OBJECTIVE: To assess the three-dimensional turbo spin echo with variable flip-angle distribution magnetic resonance sequence (SPACE: Sampling Perfection with Application optimised Contrast using different flip-angle Evolution) for the imaging of intracranial cerebrospinal fluid (CSF) spaces. METHODS: We prospectively investigated 18 healthy volunteers and 25 patients, 20 with communicating hydrocephalus (CH), five with non-communicating hydrocephalus (NCH), using the SPACE sequence at 1.5T. Volume rendering views of both intracranial and ventricular CSF were obtained for all patients and volunteers. The subarachnoid CSF distribution was qualitatively evaluated on volume rendering views using a four-point scale. The CSF volumes within total, ventricular and subarachnoid spaces were calculated as well as the ratio between ventricular and subarachnoid CSF volumes. RESULTS: Three different patterns of subarachnoid CSF distribution were observed. In healthy volunteers we found narrowed CSF spaces within the occipital aera. A diffuse narrowing of the subarachnoid CSF spaces was observed in patients with NCH whereas patients with CH exhibited narrowed CSF spaces within the high midline convexity. The ratios between ventricular and subarachnoid CSF volumes were significantly different among the volunteers, patients with CH and patients with NCH. CONCLUSION: The assessment of CSF spaces volume and distribution may help to characterise hydrocephalus.

Rare Case of Dynamic Thoracic Outlet Syndrome Resolved by an Isolated Subclavius Posticus Muscle Resection: A Case Report.

CASE: We reported a dynamic neurogenic left thoracic outlet syndrome (TOS) with a permanent abduction of the fifth left finger. Preoperative magnetic resonance imaging (MRI) assessed the presence of subclavius posticus muscle (SPM). Because of a nonoperative treatment failure, we performed a brachial plexus neurolysis and SPM resection. Immediate postoperative assessment showed an immediate disappearance of the Wartenberg sign. CONCLUSION: SPM constitutes an underestimated cause of TOS. A careful MRI reading is necessary to make correct diagnosis. Nonoperative treatment includes physiotherapy and can be proposed in first instance. When nonoperative treatment fails, brachial plexus exploration with release of the SPM may result in resolution of symptoms.

High-resolution sonographic study of the communicating branch of Berrettini: an anatomical feasibility study.

Sensory changes are common manifestations of nerve complications of carpal tunnel surgery. Division or contusion of a superficial communicating branch between the median nerve and the ulnar nerve, the communicating branch of Berrettini, can explain these symptoms. The aim of this study was to describe the potential value of high-resolution sonography to examine this branch. We conducted a study on eight fresh cadaver hands. An ultrasound assessment of the communicating branch of Berrettini, accompanied by an injection of methylene blue, was performed by a senior radiologist. Subsequent dissections confirmed that the eight guided ultrasound injections allowed the methylene blue to be placed around the origin and termination of the communicating branch of Berrettini. This study extends the limits of ultrasound both in the postoperative diagnosis of potential nerve complications and its possible use in ultrasound-guided carpal tunnel release.

Atypical Localization of Calcific Shoulder Tendinopathy: Humeral Insertion of the Pectoralis Major.

INTRODUCTION: Calcific tendinopathy of the pectoralis major at its humeral insertion is extremely rare. Few cases have been reported in the literature. We reported a unique case of calcification of the pectoralis major insertion site and conducted a review of the existing literature to propose standardized management. CASE PRESENTATION: We reported a case of a 63-year-old lady, right-handed, non-smoker, homemaker without any history of trauma or symptoms suggestive of para-neoplasia syndrome. For 1 month, the patient presented severe, disabling pain of the left shoulder which occurred spontaneously, usually in the morning and after effort. The patient had painful passive terminal adduction and internal rotation. There was no neurovascular deficiency. Magnetic resonance imaging and computed tomography (CT) scan helped diagnose the calcific tendinopathy at the pectoralis major humeral insertion. Non-surgical management was performed, combining physiotherapy and painkillers. Two months' control, CT scan reported complete calcification resorption. The biologic assessment revealed hyperparathyroidism. CONCLUSION: This rare and atypical localization can mislead the surgeon. A biological assessment to research a systemic etiology is mandatory and standardized. A biopsy is not required, radiological examinations are sufficient. Surgical treatment may be proposed in specific cases to shorten the necessary rehabilitation time.

Endoscopic brachial plexus neurolysis in the management of infraclavicular nerve injuries due to glenohumeral dislocation.

INTRODUCTION: Infraclavicular brachial plexus (BP) injury secondary to glenohumeral joint (GHJ) dislocation is a rather common complication, which may be accountable for long-lasting deficits. The purpose of this study was to assess the potential benefits of BP neurolysis in such presentation, using an endoscopic approach. MATERIALS AND METHODS: All patients who underwent endoscopic BP neurolysis in the setting of infraclavicular BP palsy due to GHJ dislocation were included. Preoperative physical examination was conducted to classify the observed motor and sensitive deficits into nerves and/or cord lesions. Six weeks after the trauma, examination was repeated and endoscopic BP neurolysis was elected if no significant improvements were observed. If nerve ruptures and/or severe damages were identified during surgery, nerve reconstructions were conducted within a month; in other cases, follow-up examinations were conducted at 6 weeks, 3 and 6 months to assess the course of postoperative recovery. RESULTS: Eleven patients were included, including 6 men and 5 women, with a mean age of 43 ± 23 years (16;73). Six patients had at least one cord involved, four patients had isolated axillary nerve palsy, and one patient had a complete BP palsy. In 7 patients with cord lesions and/or isolated axillary nerve palsy, at least grade-3 strength, according to the British Medical Research Council grading system, was noted in all affected muscles within 6 weeks following the neurolysis; after 3 months of follow-up, grade-4 strength was observed in all muscles, and all but patients but one had fully recovered within 6 months. In 3 patients with isolated axillary nerve palsy, complete nerve ruptures (n=2) and severe damages (n=1) were identified under scopic magnification; secondary nerve transfers were conducted to reanimate the axillary nerve, and all patients fully recovered within a year. In one patient with complete BP palsy, improvements started after 6 months of follow-up, and full recovery was yielded after 2 years. No intra- and/or postoperative complications were noted. CONCLUSIONS: At the cost of minimal additional morbidity, endoscopic BP neurolysis appears to be a safe and reliable procedure to shorten recovery delays in most patients presenting with BP palsy due to GHJ dislocation.

Ultrasound-Guided Surgery for Carpal Tunnel Syndrome: A New Interventional Procedure.

Carpal tunnel syndrome (CTS) may be treated surgically if medical treatment fails. The classical approach involves release of the flexor retinaculum by endoscopic or open surgery. Meta-analyses have shown that the risk of nerve injury may be higher with endoscopic treatment. The recent contribution of ultrasound to the diagnosis and therapeutic management of CTS opens new perspectives. Ultrasound-guided carpal tunnel release via a minimally invasive approach enables the whole operation to be performed as a percutaneous radiological procedure. The advantages are a smaller incision compared with classical techniques; great safety during the procedure by visualization of anatomic structures, particularly variations in the median nerve; and realization of the procedure under local anesthesia. These advantages lead to a reduction in postsurgical sequelae and more rapid resumption of daily activities and work. Dressings are removed by the third day postsurgery. Recent studies seem to confirm the medical, economic, and aesthetic benefits of this new approach.

High bone mineral density in sickle cell disease: Prevalence and characteristics.

BACKGROUND: Osteosclerosis (OSC) is a rarely studied complication of sickle cell disease (SCD). The objective of our study was to determine the prevalence and characteristics of high bone mineral density (BMD) and its radiological features in adult SCD patients. METHODS: This prospective observational study was conducted from May 2007 to May 2016 in consecutive patients with steady-state SCD at two university hospitals. The BMD of the lumbar spine (L1-L4) and right femoral neck was determined by dual energy X-ray absorptiometry. Clinical, laboratory and radiographic data were recorded. High BMD was defined as a BMD Z-score of at least +2.5 standard deviations at the lumbar spine or hip. The characteristics of the patients with high BMD were compared to those of individuals with low or middle BMD, using multivariate ordinal logistic regression. RESULTS: 135 patients (86 women and 49 men) with a median age of 27 (IQR 23-33) years were included. High BMD was diagnosed in 20 (15%) patients with a median age of 33.5 (IQR 28-45) years. The SCD genotypes of these patients were SS in 11, SC in 5, S/beta+ in 3, and S/beta0 in 1. High BMD patients more frequently harbored the S/beta SCD genotype (21% vs 5% in non-high BMD patients; p=0.047) and were older (p=0.0007). Compared to patients with low or middle BMD, after adjustment for age and SCD genotype, high BMD patients had a higher prevalence of avascular necrosis history (p=0.009), higher BMI (p=0.007), and lower serum resorption marker CTX (p=0.04), bilirubin (p=0.02) and parathyroid hormone levels (p=0.02). There were no differences between groups regarding fracture history, H-shaped vertebrae or other biological variables. CONCLUSION: High-BMD values is a common manifestation in SCD patients, especially in those with the S/beta-thalassemia genotypes. The prevalence of high-BMD in SCD is associated with older age, suggesting that it will be more common in the future because the life span of patients with SCD is increasing thanks to significant progress in SCD treatment.

High-resolution ultrasound in etiological evaluation of ulnar neuropathy at the elbow.

OBJECTIVE: Ulnar neuropathy at the elbow (UNE) involves mechanical compression and irritation of the ulnar nerve (UN) caused by environmental and dynamic abnormalities that can however also be found in asymptomatic patients. Using high-resolution ultrasound, we aimed to assess and compare the relevance of morphological and dynamic variants of the UN and its surrounding structures (UN abnormalities) in symptomatic and asymptomatic patients. METHOD: UN abnormalities in patients with UNE were assessed using high-resolution ultrasound and compared against unaffected arms (patients or healthy volunteers). RESULTS: We studied 234 arms of 117 individuals (89 with UNE and 145 control). Eighty-one percent of the arms with UNE compared to 40% of control (p=0.00001) showed UN abnormalities. While it was dislocated in 49% of arms with UNE compared to in 23% of control (p=0.004). CONCLUSION: The two-fold higher frequency of occurrence of UN abnormalities in arms with UNE indicates their causative or at least contributory role in such neuropathies. High-resolution ultrasound should be part of the initial evaluation of UNE in order to assess the etiology of the conflict.

Percutaneous Ultrasound-Guided Carpal Tunnel Release: Study Upon Clinical Efficacy and Safety.

OBJECTIVES: To evaluate the feasibility and 6 months clinical result of sectioning of the transverse carpal ligament (TCL) and median nerve decompression after ultra-minimally invasive, ultrasound-guided percutaneous carpal tunnel release (PCTR) surgery. METHODS: Consecutive patients with carpal tunnel syndrome were enrolled in this descriptive, open-label study. The procedure was performed in the interventional radiology room. Magnetic resonance imaging was performed at baseline and 1 month. The Boston Carpal Tunnel Questionnaire was administered at baseline, 1, and 6 months. RESULTS: 129 patients were enrolled. Significant decreases in mean symptom severity scores (3.3 ± 0.7 at baseline, 1.7 ± 0.4 at Month 1, 1.3 ± 0.3 at Month 6) and mean functional status scores (2.6 ± 1.1 at baseline, 1.6 ± 0.4 at Month 1, 1.3 ± 0.5 at Month 6) were noted. Magnetic resonance imaging showed a complete section of all TCL and nerve decompression in 100% of patients. No complications were identified. CONCLUSIONS: Ultrasound-guided PCTR was used successfully to section the TCL, decompress the median nerve, and reduce self-reported symptoms.