Ultrasound-guided anterior axilla musculocutaneous nerve block.

PURPOSE: This paper presents a technique of ultrasound-guided localisation and block of the musculocutaneous nerve through the anterior wall of the axilla. MATERIALS AND METHODS: Twenty patients (7 males and 13 females; mean age, 35 years) had axillary nerve block for upper extremity trauma. With the arm adducted, the ultrasound probe was positioned on the anterior axillary wall; the axillary artery, coracobrachialis and pectoralis major muscles and lateral cord of brachial plexus were visualised in cross section. With continuous imaging of the axillary artery in cross section, the ultrasound probe was slowly moved towards the biceps muscle until the musculocutaneous nerve appeared crossing the coracobrachialis muscle. After ultrasound localisation of the musculocutaneous nerve, the arm was abducted and externally rotated, and the nerve was identified with nerve stimulation and blocked. The quality of sensory and motor nerve block, as well as of ultrasound imaging were evaluated. RESULTS: Ultrasound-guided block of the musculocutaneous nerve was excellent and complete in 18 of the 20 patients. In two patients, the musculocutaneous nerve was fused with the median nerve and the nerve block was repeated successfully with the same technique. The quality of ultrasound imaging was excellent in all patients. No patient experienced pain or tourniquet discomfort during surgery, or any other nerve block-related complication. CONCLUSION: The anterior axillary ultrasound view provides for complete nerve block and imaging of the entire course of the musculocutaneous nerve and its relations with adjacent structures with excellent quality.

Corona mortis: anatomical data and clinical considerations.

BACKGROUND: Minimally invasive procedures, such as the TVT-Secur™, have been linked to injury to the corona mortis. Injury during the insertion of the TVT-Secur™ happens due to the vessel's position close to the place of the margin (25-30 mm from the symphysis pubis). AIMS: Systematic description of the aberrant vessel anatomy so as to help gynaecologists determine the risk of peri- and postoperative complications during the TVT-Secur™ and related procedures. METHODS: In a cadaver study, the lesser pelvis of ten female cadavers with venous or arterial coronae mortis was dissected. The origin, diameter and course of the aberrant vessels, as well as the distance from the symphysis pubis, were documented. RESULTS: Arterial coronae mortis were found in eight hemipelvises. All vessels originated from the ipsilateral inferior epigastric artery and all crossed over the superior pubic rami. Average distance from the symphysis pubis was 52.4 mm. Average vessel diameter was 3 mm. Venous coronae mortis were identified in ten hemipelvises. Eight drained into the external iliac and four into the inferior epigastric artery. Nine vessels crossed over the superior pubic rami. Average distance from the symphysis pubis was 46.7 mm. Average vessel diameter was 3.13 mm. CONCLUSION: Although individual variation makes direct contact with the vessel possible, in most cases there is a window of eight millimetres at least between the margin of the TVT-Secur™ and most aberrant veins. Possible aberrant arteries seem to lie even further.

OCT Angiography Study of the Macula in Patients with Diabetic Macular Edema Treated with Intravitreal Aflibercept.

Purpose: To compare foveal avascular zone density (FAZ) in the superficial (SCP) and deep (DCP) capillary plexus and vessel density (VD) in the macula in eyes with diabetic macular edema (DME) treated with intravitreal aflibercept.Methods: Patients with DME were imaged at baseline, and 30 days after the 1st, 2nd and 3rd intravitreal aflibercept injection. Images were analyzed for the FAZ area in the SCP and DCP in each visit and VD.Results: Twenty eyes were enrolled. FAZ was 0.304 ± 0.131 mm2 in the SCP and 0.738 ± 0.5836 mm2 in the DCP at baseline. SCP FAZ was not significantly different whereas, FAZ in the DCP decreased (p = .035) after treatment. VD in the center was 20.62 ± 4.31 at baseline and decreased by 8% (p = .002). Parafoveal VD remained unchanged with treatment.Conclusion: DCP ischemia may improve after aflibercept treatment. Central macular vessel density was found to decrease post-treatment, but the clinical relevance needs further investigation.

Ultrasound anatomy of the cervical paravertebral space: a preliminary study.

PURPOSE: The aim of the study was to examine the ultrasound anatomy of the cervical paravertebral space in order to facilitate the implementation of sonographically guided regional anesthesia techniques for this region. METHODS: Twenty volunteers were recruited, and the anatomic components of the cervical paravertebral space were sonographically examined. The transducer was positioned in the axial and coronal plane at the posterior cervical triangle. The cervical transverse processes with their respective nerve roots, the deep cervical fascia and the paravertebral muscles were identified. RESULTS: There was excellent visualization of the C-3, C-4, C-5, C-6 and C-7 transverse processes in all cases. Excellent visualization of the scalene muscles, vertebral artery and deep cervical fascia was also achieved in all cases. Visualization of the levator of scapula muscle was difficult in 9 and excellent in 11 out of the 20 cases. In all cases, visualization of the C-1, C-2 and C-3 nerve roots was unfeasible. The identification of the C-4 nerve root was excellent in 3, difficult in 6 and unfeasible in 11 out of the 20 cases. The C-5, C-6 and C-7 nerve roots were excellently identified in all cases. The C-8 nerve root was identified only in 8 of the 20 cases. The cervical nerve roots also showed high variation, dividing into more than one branch as they exited the cervical transverse processes. CONCLUSION: Cervical paravertebral anatomy can be depicted with ultrasound imaging techniques. This could be highly clinically significant for the implementation of regional anesthesia techniques.

Rare anatomic variation of left gastric artery and right hepatic artery in a female cadaver.

The present report describes a rare case in which the left gastric artery arises directly from the abdominal aorta and the right hepatic artery from the superior mesenteric artery, as observed during the dissection of a female cadaver. The left gastric artery usually rises as one of the three branches of the celiac trunk, which was originally described by Haller in 1756, whereas the right hepatic artery usually originates from the proper hepatic artery. The knowledge of the typical anatomy of the abdominal arteries, and their variations, is especially important due to the numerous interventions performed in the abdominal area.

Surgical anatomy of the external branch of the superior laryngeal nerve and its clinical significance in head and neck surgery.

Injury of the external branch of the superior laryngeal nerve (EBSLN) increases the morbidity following a variety of neck procedures and can have catastrophic consequences in people who use their voice professionally. Identification and preservation of the EBSLN are thus important in thyroidectomy, parathyroidectomy, carotid endarterectomy, and anterior cervical spine procedures, where the nerve is at risk. There are large variations in the anatomical course of the EBSLN, which makes the intraoperative identification of the nerve challenging. The topographic relationship of the EBSLN to the superior thyroid artery and the upper pole of the thyroid gland are considered by many authors to be the key point for identifying the nerve during surgery of the neck. The classifications by Cernea et al. ([1992a] Head Neck 14:380-383; [1992b] Am. J. Surg. 164:634-639) and by Kierner et al. ([1998] Arch. Otolaryngol. Head Neck Surg. 124:301-303), as well as clinically important connections are discussed in detail. Along with sound anatomical knowledge, neuromonitoring is helpful in identifying the EBSLN during neck procedures. The clinical signs of EBSLN injury include hoarseness, decreased voice projection, decreased pitch range, and fatigue after extensive voice use. Videostroboscopy, electromyography, voice analysis, and electroglottography can provide crucial information on the function of the EBSLN following neck surgery.

Expression of ets-1 is not affected by N-ras or H-ras during oral oncogenesis.

PURPOSE: To determine whether ras-activated cascades lead to activation of ets-1 expression in sequential histological stages of oral oncogenesis in an experimental animal model. METHODS: Thirty-seven Syrian golden hamsters were divided into three experimental groups (A, B, C) and one control group. The hamsters' buccal pouches in experimental groups were treated with 0.5% 9, 10-dimethyl-1, 2-benzanthracene (DMBA) for 14 weeks and were excised at 10, 14, 19 weeks, respectively. The biopsies were classified pathologically (normal mucosa, hyperkeratosis, hyperplasia, dysplasia, early invasion, well and moderately differentiated carcinoma) and studied immunohistochemically. The two-tailed Student's t test was performed for each animal group and for each histological category. RESULTS: The ets-1 expression increased in early stages of oral tumor formation and invasion. The expression of N-ras gradually decreased during oral oncogenesis, as previously observed with H-ras. CONCLUSIONS: Neither N-ras nor H-ras affects ets-1 expression in contrast to other types of cancer in which N-ras and ets-1 are implicated in the same signalling pathway. Therefore, the existing pathway implicating these proteins might be somehow altered in oral cancer. It seems that ets-1 is a good prognostic marker for invasiveness and progression of oral cancer.

The co-expression of c-myc and p53 increases and reaches a plateau early in oral oncogenesis.

BACKGROUND: The balance between cell proliferation and apoptosis plays a significant role in cancer development. The expressions of the p53 and c-myc genes, both strongly related to cell proliferation and apoptosis, were studied in sequential histological grades of oral carcinogenesis in an animal model. MATERIALS AND METHODS: Thirty-seven hamsters were divided into three groups (A,B,C), which were treated with 9,10-dimethyl-1,2-benzanthracene and sacrificed at 10,14 or 19 weeks, respectively, after treatment. The histological status of the oral lesions in the experimental groups corresponded well with tumour advancement (from dysplasia to moderately-differentiated carcinoma). Tumour sections were studied immunohistochemically. RESULTS: The expressions of both p53 and c-myc increased significantly in precancer stages and then reached a plateau. The same pattern was observed in the animal groups with the culmination of expression of both genes in group A. CONCLUSION: The coexpression of p53 and c-myc proteins in the earlier stages of oral oncogenesis may be used for the early detection of premalignant lesions.

Amyand's hernia: a case report.

The presence of vermiform appendix in inguinal hernia is rare and is known as Amyand's hernia. We report an Amyand's hernia, where the appendix was found in a right inguinal hernia in one male cadaver aged ninety two years.

Saphenous and Infrapatellar Nerves at the Adductor Canal: Anatomy and Implications in Regional Anesthesia.

Conflicting data exist regarding the anatomical relationship of the saphenous and infrapatellar nerves at the adductor canal and the location of the superior foramen of the canal. Therefore, the authors performed a cadaveric study to detail the relationship and course of the saphenous and infrapatellar nerves and the level of the superior foramen of the canal. The adductor canal and subsartorial compartment were dissected in 17 human cadavers. The distance between the superior foramen of the canal and the mid-distance (MD) between the base of the patella and the anterior superior iliac crest were measured; the course of the saphenous and infrapatellar nerves and the level of origin of the infrapatellar branch were detailed. In 13 of 17 specimens, the superior foramen of the adductor canal was distal to the MD (mean, 6.5 cm); in the remaining specimens, it was proximal to the MD. In 12 of 17 specimens, the infrapatellar branch exited the canal separately from the saphenous nerve; in the remaining specimens, it originated caudally to the canal. In all dissections, the infrapatellar branch had a constant course in close proximity to the saphenous nerve within the canal and between the sartorious muscle and femoral artery caudally to the canal. Most commonly, the superior foramen of the adductor canal is located caudally to the MD; the infrapatellar branch originates from the saphenous nerve within the canal and has a constant course in close proximity to the saphenous nerve. These observations should be considered for regional anesthesia techniques at the adductor canal.

Anatomy and clinical implications of the ultrasound-guided subsartorial saphenous nerve block.

BACKGROUND: We evaluated the anatomic basis and the clinical results of an ultrasound-guided saphenous nerve block close to the level of the nerve's exit from the inferior foramina of the adductor canal. METHODS: The anatomic study was conducted in 11 knees of formalin-preserved cadavers in which the saphenous nerve was dissected from near its exit from the inferior foramina of the adductor canal. The clinical study was conducted in 23 volunteers. Using a linear probe, the femoral vessels and the sartorius muscle were depicted in short-axis view at the level where the saphenous nerve exits the inferior foramina of the adductor canal. Ten milliliters of 1.5% lidocaine was injected into the compartment structured by the sartorius muscle and the femoral artery. RESULTS: The saphenous nerve was found to exit the adductor canal from its inferior foramina in 9 (81.8%) of 11 and at a more proximal level in 2 (18.2%) of 11 of the anatomic specimens. In a single specimen (9%), the saphenous nerve was formed by the anastomosis of 2 branches. In all the dissections, the saphenous nerve, after exiting the adductor canal, passed between the sartorius muscle and the femoral artery. Of the 23 volunteers, 22 responded with a complete sensory block, whereas a single volunteer demonstrated no sensory blockade. None of the volunteers experienced a motor block of the hip flexors and knee extensors. CONCLUSIONS: Ultrasound-guided injection directly caudally from the inferior foramina of the adductor canal, between the sartorius muscle and the femoral artery, seems to be an effective approach for saphenous nerve block.

Medical students' perceptions on factors influencing a surgical career: the fate of general surgery in Greece.

BACKGROUND: A decline of medical students' interest in a general surgery career is occurring in the Western medical world. We sought data on the mentality of Greek students toward specialty selection, and we determined whether trends indicated a decline in interest for general surgery in Greece. METHODS: A structured questionnaire was distributed to 3 groups of medical students: to pre-4th-year (group 1) surgical clerkship, post-4th-year (group 2) surgical clerkship, and post-6th-year internship students in surgery (group 3). The questions covered a wide spectrum of data including career choices, influential factors, and satisfaction rates on educational and training issues. RESULTS: From a total of 500 distributed questionnaires 363 were returned. Most students (63.1%) indicated preference toward nonsurgical (medical) specialties. Surgical specialties within the 3 groups gathered 19.5% (group 1), 26.5% (group 2) and 31.2% (group 3) preference rates. Among surgical specialties, general surgery was chosen by 29.4% in group 1, 10.0% in group 2, and 17.9% in group 3. The most common criterion for specialty selection was "quality of life" (68.6%) among group 1 students and "patient contact" for group 2 and group 3 students (77.3% and 65.3%, respectively). Among the 96 students who chose surgical specialties, the most common criterion for specialty selection was "scientific challenge" (100%) in group 1 and "patient contact" in groups 2 and 3 (62.5% and 69.2%, respectively). The 3 more frequently chosen factors that influenced the "picture" of surgery positively were attending live surgery cases in the operating room (37.6%), clinical experience (29.6%), and patient care (14.4%), followed by assisting in the operating room (8.8%). CONCLUSION: Our survey suggests a limited interest of Greek medical students for surgical specialties and general surgery in particular. As the medical curriculum is restructured, our data underscore the need for actions by surgical educators and medical school authorities so as to enhance the interest of medical students in general surgery in Greece.

Anatomic variations of the obturator nerve in the inguinal region: implications in conventional and ultrasound regional anesthesia techniques.

BACKGROUND AND OBJECTIVES: This study was conducted to provide a thorough description of the variability in the obturator nerve branching pattern in the inguinal region. METHODS: The anatomic variability of obturator nerve branching among 84 dissected embalmed cadavers was investigated. Ultrasound examination of the inguinal region was undertaken in 20 cases and the location of the obturator nerve was identified. RESULTS: The point of division for the obturator nerve into the anterior and posterior branches was intrapelvic (23.22%), within the obturator canal (51.78%), or in the thigh (25%). Most commonly, the anterior branch was divided among 3 major muscular branches (66.66%) that innervated the adductor longus, adductor brevis, and gracilis muscles. Four, and 2 subdivisions of the anterior branches were observed, in 4.76% and 28.57% of cases, respectively. The posterior branch predominantly separated into 2 divisions (60.11%), which provided innervation to the adductor brevis and adductor magnus muscles. In addition, either 1 (13.69%), 3 (19.04%), or 4 (7.14%) muscular divisions of the posterior branch were observed. The articular branch of the obturator nerve showed 9 different branching patterns, which most frequently arose from the common obturator nerve. The fascias medial to the femoral vessels and deep to the pectineus muscle were clearly visualized (100%) by ultrasound imaging. This region was used as an "imaging" landmark for localization (success rate of 80%) of the common obturator nerve. CONCLUSIONS: High anatomic variability in the obturator nerve's divisions and subdivisions does exist, and explains the difficulty frequently encountered in the application of regional anesthetic techniques.