Unusual array of neural communications in the infratemporal fossa: Useful for skull base surgery.

Variations in the branching pattern of the mandibular nerve frequently accounts for failure to obtain adequate local anesthesia in routine oral and dental procedures, and also for unexpected injury to the nerves during surgery. The knowledge of the neurovascular relationships of the infratemporal region is relevant in odontostomatology practice. In this article we present a rare case of atypical communication between the inferior alveolar nerve and lingual nerve and the mylohyoid and lingual nerves. Further, the clinical implications of these communications on the development of the supplementary innervation and their possible role in anesthesia is discussed in detail. The communication between mylohyoid and lingual nerve was found in this case near the submandibular ganglion after the lingual nerve passes in close relation to third molar tooth, which makes it more susceptible to injury during third molar extractions. The communicating branch between the mylohyoid nerve and lingual nerve may also innervate the tongue, and surgeons should be aware of this variation to avoid post- operative complcations after oral surgeries. Thus the precise anatomy of structures of infratemporal region and its variations may prove beneficial to clinicians, especially to oral and maxillofacial surgeons.

Pronator teres accessorius: A new variant in flexor antebrachial musculature.

Muscles of flexor compartment of forearm have a common origin from medial epicondyle of humerus. Additional bellies of flexor muscles are commonly reported but presence of supernumerary muscles is an infrequent phenomenon. The present study describes an unusual muscle mass in flexor compartment of forearm simulating pronator teres. During routine dissection the upper limb of a 50 years old male cadaver, a supernumerary muscle was found on left side of the upper limb in the flexor compartment. The origin of the muscle was 2cm wide and aponeurotic in nature and attached to an oblique line extending from the inferior surface of the medial epicondyle and the medial surface of the trochlea. It was inserted on an oblique line 2.5cm wide on the radius in area between supinator superiorly and flexor digitorum profundus inferiorly. Existence of accessory muscles, which connect flexor muscles, could be explained embryologically by incomplete cleavage of flexor mass during development. The flexor muscles of the forearm develop from the flexor mass which subsequently divides into two layers: superficial and deep. The deep layer gives rise to flexor digitorum superficialis, flexor digitorum profundus and flexor pollicis longus. These supernumerary muscles are extremely rare entities and probably represent deranged embryological development or the process of atavism in which the anomalous part persist for a longer time in the tree of evolution.

Bilateral clavicular attachment of omohyoid muscle.

Omohyoid muscle present in cervical region is of particular importance to anatomists as it defines anteriorly the carotid triangle and divides the posterior cervical triangle. It has superior and inferior bellies and an intermediate common tendon. Like sternohyoid, sternothyroid and thyrohyoid muscles, omohyoid is also an infrahyoid muscle, but it differs from them in its course. The infrahyoid muscles are formed from a muscle primordium occurring in the anterior cervical area. Anderson (Anderson, 1881) theorized that the superior belly of the omohyoid muscle is a true infrahyoid muscle, whereas the inferior belly most likely shares a common embryology with the subclavius muscle. In the present study, during routine dissection in the neck region of an adult male cadaver of 50 years age, an anomalous origin of inferior belly of omohyoid with absence of intermediate tendon was observed bilaterally. It was arising from clavicle on both sides. Both the muscle bellies were measured from the lateral end of fascial sling. The inferior belly of omohyoid extending from the lateral margin of sling to clavicular surface was measured 3.3cm in length on left side and 3.6cm on right side. The omohyoid is important in neck dissections because it is considered as an ideal landmark for level III and IV lymph node metastases. Knowledge of variations of this muscle is very important for surgeries in neck region because of its close relation to the internal jugular vein and brachial plexus. Its crucial relationship to vascular structures in the neck makes it an important landmark during neck surgeries.

Clinico-embryological submission of an unilateral anomalous presentation of axillary artery.

OBJECTIVES: Descriptions of the variant arterial pattern of upper limb are not exceptional and are therefore frequently reported in anatomy archives. BACKGROUND: A noteworthy deviation from the usual branching pattern was observed unilaterally in a single cadaver. This unique division of axillary artery (AA) was present on the right side in an adult human cadaver of Indian origin. RESULTS: The first part of axillary artery gave off the superior thoracic and thoraco-acromial arteries. Just proximal to the upper border of pectoralis minor the AA was observed to divide into two trunks a medial and a lateral. The lateral trunk continued into the brachium as the usual axillary artery where as the medial trunk displayed the other branches deep and distal to the pectoralis minor muscle. The remarkable feature was the wide caliber of the axillary artery where it bifurcated into two branches. An attempt has been made to dwell upon the embryological basis of the present anomaly. CONCLUSIONS: The relevance of anomalous arterial pattern of upper limb (U.L.) is realized while performing percutaneous arterial venous catheter insertion into subclavian vein via the infraclavicular route. We advocate a meticulous familiarization of the anatomy of axillary artery and its topographical relationship to other neurovascular structures for the operating plastic surgeon, anesthetist and radiologist (Fig. 1, Ref. 12).

Unilateral intercordal neural communication coexistent with variant branching pattern of posterior cord of brachial plexus.

Variant branching pattern of the cords of brachial plexus coupled with erroneous communications has been an area of concern for surgeons opting to explore this region. Anaesthetic blocks and surgical approaches are the highlights of these interventions, where a keen familiarization of the anatomy of this region is mandatory. The present case description reports a unilateral variant branching pattern of the posterior cord coexistent with a neural communication between lateral and medial cords in an adult male cadaver. This intercordal neural communication between lateral and medial cords was oriented obliquely and measured 2.2 cm in length. Furthermore, the posterior cord revealed a variant branching pattern. It branched into three upper subscapular nerves and a common trunk for the thoracodorsal and lower subscapular nerves. The lowest of the three upper subscapular nerves gave a communicating twig to the thoracodorsal nerve. Inspite of uncountable reports on variations ofbrachial plexus, descriptions regarding anomalous branching patterns hold enormous clinical significance for the radiologists, anesthetists and surgeons, besides being of academic interest for the anatomists.

Accessory muscle belly of peroneus tertius in the leg--a rare anatomical variation with clinical relevance--utility in reconstructions.

We report here a rare muscular anomaly of the lower leg in an adult male cadaver observed during routine cadaveric dissection. Peroneus tertius (PT) is peculiar to man, being a hallmark of bipedal locomotion and erect posture. During the course of gross anatomy dissection, a rare finding of accessory belly of PT muscle was discovered. A meticulous dissection was performed and the observations were noted. The PT displayed two distinct bellies of origin. Both the bellies were substantial in size and were eventually fused close to their insertion at the base of the fifth meta-tarsal bone. Innervation of both the bellies was derived from the deep peroneal nerve. Soft tissue defects of the leg may be effectively covered by local muscles in the vicinity of the wounds. PT has been reliably used in the past for local transposition flaps in the lower extremities. The relations of the superficial nerve and the PT during placement of the anterolateral portal in ankle arthroscopy are vital to avoid inadvertent neuromuscular injuries. The presence of two bellies of the PT muscle has been discussed in the comparative perspective. A precise and detailed knowledge of the anatomical details of the crural muscles is important for performing reconstructive surgeries.

Role of antigen-presenting cells in mediating tolerance and autoimmunity.

The mechanisms that determine whether receptor stimulation leads to lymphocyte tolerance versus activation remain poorly understood. We have used rat insulin promoter (RIP)-gp/P14 double-transgenic mice expressing the lymphocytic choriomeningitis virus (LCMV) glycoprotein (gp) on pancreatic beta-islet cells together with T cells expressing an LCMV-gp-specific T cell receptor to assess the requirements for the induction of autoimmunity. Our studies have shown that administration of the gp peptide gp33 leads to the activation of P14-transgenic T cells, as measured by the upregulation of activation markers and the induction of effector cytotoxic activity. This treatment also leads to expansion and deletion of P14 T cells. Despite the induction of cytotoxic T lymphocyte activity, peptide administration is not sufficient to induce diabetes. However, the administration of gp peptide together with an activating anti-CD40 antibody rapidly induces diabetes. These findings suggest that the induction of tolerance versus autoimmunity is determined by resting versus activated antigen-presenting cells.

A rare bimuscular conglomeration gluteopiriformis case report.

The present paper reports a rare anomalous muscle in the gluteal region, which appears to be a conglomeration of gluteus maximus and piriformis muscles. The muscle was proximally attached to the gluteus maximus and distally merged with the piriformis muscle. The innervation of the anomalous muscle was derived from the inferior gluteal nerve. Recognition of such a muscle variant may facilitate early clinical diagnosis and treatment of patients with symptoms of piriformis syndrome or sciatica of unexplained etiology. Contraction of such an anomalous muscle could lead to altered biomechanics of the piriformis and the gluteus maximus. Such a rare muscle, which morphologically resembles the piriformis and developmentally appears to be a part of gluteus maximus could be a challenging puzzle for the present day surgeon and radiologist.

Rectus thoracis bifurcalis: a new variant in the anterior chest wall musculature.

A cadaveric study was undertaken to report the incidence of sternalis muscle in cadavers of Asian origin. A total of 88 cadavers were studied over a period of six years and the sternalis was reported only in a single case and that too unilaterally. The accessory muscle was discovered in the right pectoral region in a 40-year-old male cadaver. The muscle emanated from the external oblique aponeurosis of abdomen confirming its origin from the ventral longitudinal sheet of muscle. The muscle was fleshy throughout its extent except at the ends where they were aponeurotic. At the sternal angle, the muscle displayed "Y" shaped configuration and merged with the respective sternocleidomastoid muscle. The innervation was derived from the third intercostals nerve. We intend to highlight a few points through this study. Firstly, we found a paucity of studies undertaken to describe the incidence of sternalis muscle. Further, the studies present in anatomical archives are mainly case reports. Secondly, this muscle presents itself in varying configurations on radiological studies. The radiologist should acquaint himself with all these presentations, so that he can make accurate diagnosis of a breast mass. Thirdly, this muscle having more morphological relevance may be conveniently utilized for flap procedures of post mastectomy breast reconstruction. Lastly, the presence of this muscle may alter the depth at which the internal mammary lymph nodes are irradiated in case of carcinoma breast. Additionally, it should not be erroneously diagnosed as a mass which recurred on follow up of breast cancer patients. The present investigation endeavors to discuss the anatomical, embryological and clinical relevance of a rare accessory muscle of the anterior chest wall.

Crucial neurovascular structures entrapped in a brachial intramuscular tunnel.

We report a case where the median nerve accompanied by brachial vessels were found to traverse an intra-muscular tunnel within the brachialis muscle, in the floor of the cubital fossa. The muscular tunnel commenced 5 cm proximal to the neck of radius, measured 4.4 cm in length, and was present unilaterally. This unusual tunnel was distally found to blend with the brachial fascia. The present study was planned with an endeavor to elucidate in an improved way the clinical implications of compressed median nerve and brachial vessels. There are several sites where median nerve maybe compressed along its course in the arm and forearm. The relevance of the present documentation lies in the fact that these vital neurovascular structures may be compressed leading to neuropathies and vascular changes.

Clinico-embryological perspective of a rare accessory brachial muscle with possible musculocutaneous nerve compression.

Both brachialis and biceps brachii are primary flexors of the arm and elbow from the biomechanical perspective. Numerous reports exist in anatomical literature regarding accessory heads of biceps brachii, although such accessory bellies in relation to brachialis muscle are less frequently elucidated. We report a unilateral case of a rare accessory muscle interposed between the biceps brachii and brachialis, having the musculocutaneous nerve (MCN) entrapped between the two. Furthermore, the muscle divided into two slips, upper slip was attached to biceps brachii and the other gained insertion to the brachial fascia. Innervation to this accessory muscle was derived from MCN. The embryological basis for such supernumerary muscle is discussed. Additionally, the case is considered under surgical and clinical perspective, highlighting the importance of familiarity with such variations. Anatomical variations of the brachial musculature may cause diagnostic perplexities while interpreting MRI or CT scans.

A new variant in the brachium musculature with reinforced innervation from a median-musculocutaneous nerve communication.

Neural variations of the brachium constitute an important anatomical and clinical entity. Although frequently reported, if accompanied by other anomalies, they deserve special mention in anatomical literature. The goal of this present study is to report a communication between the median (MN) and musculocutaneous nerve (MCN), concomitant with an accessory muscle belly. Interestingly, an important proximal connection between the lateral and medial roots of the MN was also observed. The MCN joined the MN at mid humeral level. The peculiarity of the current report arises due to the presence of a twig passing from the site of communication between the two nerves, to supply the coracobrachialis. Concomitantly, an accessory muscle measuring 5cm in length originating from the short head of biceps brachii, fusing with the coracobrachialis was seen in the mid brachium. The observations of the current study may cause a perplexing situation for anesthetists attempting brachial plexus blocks and for surgeons who operate on this vital anatomical arena.

Unilateral partial ossification of sacrotuberous ligament: anatomico-radiological evaluation and clinical implications.

The present study describes the topography and morphometry of a unilateral ossified sacrotuberous ligament. It aims to discuss its anatomical, radiological and clinical implications. The pudendal nerve, internal pudendal artery, nerve to obturator internus and coccygeal branch of inferior gluteal artery are all-important structures near sacrotuberous ligament. An ossified sacrotuberous ligament may be an important etiological factor in neurovascular compression syndromes and its anatomical knowledge may help in the development of new treatment for this common clinical problem. The ossified sacrotuberous ligament in the present case was 7.6 cm in length and exhibited a characteristic anterior and posterior segment. The base was at the ischial tuberosity and the apex showed numerous small bony protuberances with deep intervening grooves. The ossified STL may be important in differential diagnosis of soft tissue pain and tenderness after trauma. It may be a challenging puzzle for the present day surgeon and radiologist in interpretation of CT-scans and MRI.

Peculiar tendinous origin of the brachialis muscle: anatomic and clinical insight.

The current study seeks to elucidate the presence and potential function of an anomalous tendinous origin of the brachialis muscle. The brachialis muscle originates from the humeral shaft, which is usually muscular, thereby becoming tendo-aponeurotic distally towards its insertion. During routine cadaveric dissection, in a 52-year-old cadaver, the anomalous brachialis muscle originated in the form of a tendon measuring 4.4 cm in length. The tendon was attached to the proximal humeral shaft near the lateral lip of inter-tubercular sulcus. The aponeurotic insertion was as usual, into the ulnar coronoid process. The long tendinous origin of the brachialis muscle as observed in the present study could alter the biomechanics of the muscle. A long tendinous origin of the muscle may predispose to frequent tendinous injuries. There are possibilities of the anomalous tendon being used as a graft in elbow injuries. A comprehensive knowledge of such a rare anatomical variation could prove beneficial in surgical, rehabilitation and radiological field.

Bilateral temporal spinous projections overshadowing the sphenoidal spines: an anatomical and radiological evaluation.

The infratemporal fossa has traditionally been described as a post-maxillary space, which is open below, to the rear and laterally. The most reliable osseous landmarks of the infratemporal and parapharyngeal spaces are the pterygoid and styloid processes and the sphenoidal spine. In the present study the skull exhibited the normal sphenoidal spines along with a prominent spinous projection emanating bilaterally from the tympanic plate of the temporal bone. The objective of the present paper is to report an anatomical and radiological evaluation of the sphenoidal spines coexistent with bilateral temporal spinous projections. Additionally, the topographical relationship of this osseous variation is discussed with particular reference to neurovascular structures. Unduly prominent temporal spinous projections may cause obstruction, thus reducing the operative field. The anatomical variations relating to bony and vascular structures in this region are of paramount importance to neurosurgeons and otorhinolaryngologists.

An asymmetrical inferior articular process of a lumbar vertebra.

The present case report describes the topographical anatomy and radiological study of an asymmetrical inferior articular process of a lumbar vertebra, which was detected during routine osteology teaching of undergraduate medical students. The inferior articular process of the lumbar vertebra on the left side was rudimentary, while that on the right was normal in size. On the left side an additional bony projection was noted anterior to the rudimentary inferior articular process. The difference in height between the inferior articular processes of the two sides may play an important role in the kinematics of the particular joint. The orientation of the facets of the articular processes of the vertebrae are important for axial weight transmission and anomalies involving these can possibly alter the orientation of movements in that particular segment. An asymmetrical inferior articular process may be related to disc prolapse and may be a cause of back pain. In view of the paucity of research reports of anatomicoradiological study of the inferior articular process of a lumbar vertebra in relation to other parts of the vertebra, we, as anatomists, believe that knowledge of anomalies of the inferior articular process may be relevant for academic, anthropological and clinical purposes.

A triplicate obturator foramen.

The obturator foramen is a large opening in the hip bone situated below and anterior to the acetabulum. The obturator foramen is enclosed by the obturator membrane, apart from the part above near the obturator groove, where the obturator vessels and nerve pass through. The present study reports multiple openings in the obturator foramen detected incidentally in a left hip bone specimen and discusses its clinical implications. To the best of our knowledge, the occurrence of multiple openings associated with the obturator foramen is rare and has not been reported in any standard textbook of anatomy or in any research study. Anatomical knowledge of the presence of such anomalies may be clinically important for radiologists interpreting skiagrams and surgeons performing operative procedures in the hip region.

Fluorescence properties of oxidised human plasma low-density lipoproteins.

Appearance of fluorescence emission between 380-550 nm (lambda exc 350-400 nm) in freshly prepared low-density lipoprotein from asymptomatic normolipemic human plasma revealed the presence of in vivo oxidative modification of its protein moiety. Low-density lipoprotein elicited seven fluorophores in three dimensional fluorescence spectrogram. Assignment of fluorescent chemical structures originating from oxidative modification of the protein moiety of low-density lipoprotein has been made with the help of second derivative fluorescence spectroscopy.

Adductor accessorius - an unusual supernumerary adductor muscle of thigh.

The knowledge of variant anatomy of medial compartment of thigh is extremely important in surgical procedures requiring obturator nerve block. The nerve block is also recommended for providing additional analgesia following major knee surgeries and for relieving painful adductor muscle spasm. The interfascial injection technique is commonly followed in ultrasound guided obturator nerve block. For this procedure it is imperative to identify the adductor muscles on sonography to inject the anesthetic solution in the intermuscular fascial planes. The presence of an additional muscle can prove useful in myocutaneous flap surgeries for reconstruction especially of perineum. We hereby report a case of such an anomalous supernumerary adductor muscle present between adductor brevis and proximal part of adductor magnus, in an adult Indian male cadaver, recorded during routine dissection in Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital. The muscle was innervated by the posterior division of obturator nerve. The morphology, embryological basis and clinical aspects are also discussed.

Unusual branching pattern of brachial artery - Embryological basis and clinicoanatomical insight.

Variations in the arterial pattern of upper limb are of colossal importance to the surgeons as they are liable to iatrogenic injuries. During routine dissection for undergraduate medical students, an anomaly of brachial artery was discovered. The brachial artery terminated at higher level into ulnar and radial artery. The common interosseus artery took origin arising from radial artery. The ulnar artery did not give any branches in the forearm. Both radial and ulnar artery displayed a superficial course in the forearm. The anatomical knowledge of these variations may be of great help for the clinicians in planning and conducting flap harvesting during reconstructive surgeries and in arteriography.