Surgical Anatomy of the Supraretinacular Fat Pad: Sensory Innervation and Preservation in Open Carpal Tunnel Release.

BACKGROUND AND OBJECTIVES: Postoperative pain may occur following open carpal tunnel release (OCTR). Various causes have been postulated. During OCTR, adipose tissue located between the palmar aponeurosis and the flexor retinaculum is exposed. It is unknown whether damage to this pad of supraretinacular fat (SRF) might contribute to postoperative palmar pain or tenderness. We studied the sensory innervation of the SRF exposed in OCTR to assess whether SRF damage could potentially generate pain. METHODS: A microanatomic dissection of the innervation and vascular supply of the SRF was performed in 25 embalmed human cadaveric upper limbs. Eight fat pads were removed en bloc for histological evaluation. Three-dimensional reconstructions were made based on immunohistochemically stained sections using computer-assisted microscopy. RESULTS: The SRF is the radial continuation of the hypothenar fat pad that covers the neurovascular bundle in the Guyon canal. The fat pad is richly innervated and contains Pacinian corpuscles. The sensory innervation originates exclusively from the ulnar nerve (palmar branch) and its vascular supply from the ulnar artery. The integrity of the SRF can be preserved by detaching it from the flexor retinaculum in a radial to ulnar fashion. CONCLUSION: The SRF, which is exposed during OCTR, is richly innervated by sensory fibers from the ulnar nerve. It is the radialmost extension of the hypothenar fat pad. In view of its rich innervation, damage to the SRF during OCTR might generate postoperative pain. Preserving its integrity during OCTR is technically possible and even simplifies the procedure. Clinical trials are needed to corroborate whether preservation of the SRF during OCTR indeed makes a clinical difference in postoperative pain generation.

Origin, branching pattern, foraminal and intraspinal distribution of the human lumbar sinuvertebral nerves.

BACKGROUND CONTEXT: The lumbar sinuvertebral nerve (SVN) innervates the outer posterior intervertebral disc (IVD); it is thought to mediate discogenic low-back pain (LBP). Controversy, however, exists on its origins at higher (L1-L2) versus lower (L3-L5) lumbar levels. Additionally, lack of knowledge regarding its foraminal and intraspinal branching patterns and extensions may lead to iatrogenic damage. PURPOSE: To systematically describe the origins of the L2 and L5 SVNs, their morphological variation in the intervertebral foramen (IVF) and intraspinal distribution. STUDY DESIGN: Dissection-based study of 20 SVNs with histological confirmation in five embalmed human cadavers. METHODS: The origin, branching pattern and distribution of the L2 and L5 SVNs was investigated bilaterally in five human cadavers using dorsal and anterolateral dissection approaches. Parameters studied included somatic and/or autonomic SVN root contributions, foraminal SVN morphology and course, diameter, branching point, intraspinal distribution and IVD innervation pattern. Nerve tissue was confirmed by immunostaining for neurofilament and S100 proteins. RESULTS: The SVN and its origins was identified in all except one IVF at L2 and in all foramina at L5. At L2, the SVN arose in nearly 90% of sides from both somatic and autonomic roots and at L5 in 40% of sides. The remaining SVNs were formed by purely autonomic roots. The SVN arose from significantly more roots at L2 than L5 (3.1 ± 0.3 vs. 1.9 ± 0.3, respectively; p=.022). Four different SVN morphologies could be discerned in the L2 IVF: single filament (22%), multiple (parallel or diverging) filament (33%), immediate splitting (22%) and plexiform (22%) types, whereas the L5 SVN consisted of single (90%) and multiple (10%) filament types. SVN filaments were significantly thicker at L2 than L5 (0.48 ± 0.06 mm vs. 0.33 ± 0.02 mm, respectively; p=.043). Ascending SVN filaments coursed roughly parallel to the exiting spinal nerve root trajectory at L2 and L5. Branching of the SVN into ascending and descending branches occurred mostly intraspinal both at L2 and L5. Spinal canal distribution was also similar for L2 and L5 SVNs. Lumbar posterior IVDs were innervated by the descending branch of the parent SVN and ascending branch of the subjacent SVN. CONCLUSIONS: The SVN at L2 originates from both somatic and autonomic roots in 90% of cases and at L5 in 40% of cases. The remaining SVNs are purely autonomic. In the IVF, the L2 SVN is morphologically heterogeneous, but generally consists of numerous filaments, whereas at L5 90% contains a single SVN filament. The L2 SVN is formed by more roots and is thicker than the L5 SVN. Intraspinal SVN distribution is confined to its level of origin; lumbar posterior IVDs are innervated by corresponding and subjacent SVNs (ie, two spinal levels). CLINICAL SIGNIFICANCE: Our findings indicate that L5 discogenic LBP may be mediated both segmentally and nonsegmentally in 40% of cases and nonsegmentally in 60% of cases. Failure of lower lumbar discogenic pain treatment may be the result of only interrupting the nonsegmental pathway, but not the segmental one as well. Relating SVN anatomy to microsurgical spinal approaches may prevent iatrogenic damage to the SVN and the formation of postsurgical back pain.

The Cortisol Response of Male and Female Choroidal Endothelial Cells: Implications for Central Serous Chorioretinopathy.

CONTEXT: Central serous chorioretinopathy (CSC) is a severe ocular disease characterized by fluid accumulation under the retina and abnormalities in the underlying vascular layer, the choroid. CSC has a striking prevalence in males of 80% to 90% of total patients. Corticosteroids are the most pronounced extrinsic risk factor for CSC. Choroidal endothelial cells (CECs) are important for the vascular integrity of the choroid, but the effects of corticosteroid effects in these cells are unknown. OBJECTIVE: We aimed to reveal the potential steroidal contribution to CSC. METHOD: We characterized the expression of the glucocorticoid, mineralocorticoid, and androgen receptor in the human choroid using immunohistochemistry. Using RNA-sequencing, we describe the cortisol response in human CECs derived from 5 male and 5 female postmortem donors. RESULTS: The glucocorticoid receptor was highly expressed in the human choroid, whereas no to minimal expression of the mineralocorticoid and androgen receptors was observed. The extensive transcriptional response to cortisol in human primary cultured CECs showed interindividual differences but very few sex differences. Several highly regulated genes such as ZBTB16 (log2 fold change males 7.9; females 6.2) provide strong links to choroidal vascular regulation. CONCLUSIONS: The glucocorticoid receptor predominantly mediates the response to cortisol in human CECs. Interindividual differences are an important determinant regarding the cortisol response in human cultured CECs, whereas intrinsic sex differences appear less pronounced. The marked response of particular target genes in endothelial cells to cortisol, such as ZBTB16, warrants further investigation into their potential role in the pathophysiology of CSC and other vascular conditions.

Asymmetry and Heterogeneity: Part and Parcel in Cardiac Autonomic Innervation and Function.

The cardiac autonomic nervous system (cANS) regulates cardiac adaptation to different demands. The heart is an asymmetrical organ, and in the selection of adequate treatment of cardiac diseases it may be relevant to take into account that the cANS also has sidedness as well as regional differences in anatomical, functional, and molecular characteristics. The left and right ventricles respond differently to adrenergic stimulation. Isoforms of nitric oxide synthase, which plays an important role in parasympathetic function, are also distributed asymmetrically across the heart. Treatment of cardiac disease heavily relies on affecting left-sided heart targets which are thought to apply to the right ventricle as well. Functional studies of the right ventricle have often been neglected. In addition, many principles have only been investigated in animals and not in humans. Anatomical and functional heterogeneity of the cANS in human tissue or subjects is highly valuable for understanding left- and right-sided cardiac pathology and for identifying novel treatment targets and modalities. Within this perspective, we aim to provide an overview and synthesis of anatomical and functional heterogeneity of the cANS in tissue or subjects, focusing on the human heart.

Long-lasting modulation of synaptic plasticity in rat hippocampus after early-life complex febrile seizures.

A small fraction of children with febrile seizures appears to develop cognitive impairments. Recent studies in a rat model of hyperthermia-induced febrile seizures indicate that prolonged febrile seizures early in life have long-lasting effects on the hippocampus and induce cognitive deficits. However, data on network plasticity and the nature of cognitive deficits are conflicting. We examined three specific measures of hippocampal plasticity in adult rats with a prior history of experimental febrile seizures: (i) activity-dependent synaptic plasticity (long-term potentiation and depression) by electrophysiological recordings of Schaffer collateral/commissural-evoked field excitatory synaptic potentials in CA1 of acute hippocampal slices; (ii) Morris water maze spatial learning and memory; and (iii) hippocampal mossy fiber plasticity by Timm histochemistry and quantification of terminal sprouting in CA3 and the dentate gyrus. We found enhanced hippocampal CA1 long-term potentiation and reduced long-term depression but normal spatial learning and memory in adult rats that were subjected to experimental febrile seizures on postnatal day 10. Furthermore, rats with experimental febrile seizures showed modest but significant sprouting of mossy fiber collaterals into the inner molecular layer of the dentate gyrus in adulthood. We conclude that enhanced CA1 long-term potentiation and mild mossy fiber sprouting occur after experimental febrile seizures, without affecting spatial learning and memory in the Morris water maze. These long-term functional and structural alterations in hippocampal plasticity are likely to play a role in the enhanced seizure susceptibility in this model of prolonged human febrile seizures but do not correlate with overt cognitive deficits.

The Effect of Corticosteroids on Human Choroidal Endothelial Cells: A Model to Study Central Serous Chorioretinopathy.

Purpose: To isolate, culture, and characterize primary human choroidal endothelial cells, and to assess their responsiveness to corticosteroids, in order to enable knowledge gain on the pathogenesis of central serous chorioretinopathy. Methods: Choroidal endothelial cells were isolated from cadaveric human donors. Magnetic-activated cell sorting with anti-human CD31 was performed for choroidal endothelial cell isolation. Primary cultures of purified choroidal endothelial cells were treated with several regimens of corticosteroids and analyzed for effects on primary corticosteroid responsive genes. Results: Isolated choroidal endothelial cell cultures had a cobblestone appearance in monolayer cultures and stained positive for vascular endothelial cadherin. Moreover, on a 3D-Matrigel matrix, these cells formed capillary-like structures, characteristic of in vitro endothelial cells. Primary cultures of purified choroidal endothelial cells treated with several regimens of corticosteroids demonstrated significant transcriptional upregulation of primary corticosteroid responsive genes (FKBP5, PER1, GILZ, and SGK1). Further pharmacologic analysis using specific agonists (dexamethasone, aldosterone) and antagonists (mifepristone, spironolactone) for either the glucocorticoid receptor or the mineralocorticoid receptor showed that this response was exclusively mediated by the glucocorticoid receptor in our model. Conclusions: With this optimized choroidal endothelial cell isolation and culturing protocol, we have established an in vitro model that appears very suitable for research on both central serous chorioretinopathy and other diseases in which corticosteroids and choroidal endothelial cells are involved. Our model proves to be suitable for studying effects mediated through the glucocorticoid receptor. The role of mineralocorticoid receptor-mediated effects needs further research, both in vivo and in cell model development.

Up-regulation of hippocampal metabotropic glutamate receptor 5 in temporal lobe epilepsy patients.

Metabotropic glutamate receptors (mGluRs) are G protein-coupled receptors involved in the regulation of glutamatergic transmission. Recent studies indicate that excitatory group I mGluRs (mGluR1 and mGluR5) contribute to neurotoxicity and hyperexcitability during epileptogenesis. In this study, we examined the distribution of mGluR1alpha and mGluR5 immunoreactivity (IR) in hippocampal resection tissue from pharmaco-resistant temporal lobe epilepsy (TLE) patients. IR was detected with panels of receptor subtype specific antisera in hippocampi from TLE patients without (non-HS group) and with hippocampal sclerosis (HS group) and was compared with that of non-epileptic autopsy controls (control group). By immunohistochemistry and immunoblot analysis, we found a marked increase of mGluR5 IR in hippocampi from the non-HS compared with the control group. High mGluR5 IR was most prominent in the cell bodies and apical dendrites of hippocampal principal neurons and in the dentate gyrus molecular layer. In the HS group, this increase in neuronal mGluR5 IR was even more pronounced, but owing to neuronal loss the number of mGluR5-immunoreactive neurons was reduced compared with the non-HS group. IR for mGluR1alpha was found in the cell bodies of principal neurons in all hippocampal subfields and in stratum oriens and hilar interneurons. No difference in mGluR1alpha IR was observed between neurons in both TLE groups and the control group. However, owing to neuronal loss, the number of mGluR1alpha-positive neurons was markedly reduced in the HS group. The up-regulation of mGluR5 in surviving neurons is probably a consequence rather than a cause of the epileptic seizures and may contribute to the hyperexcitability of the hippocampus in pharmaco-resistant TLE patients. Thus, our data point to a prominent role of mGluR5 in human TLE and indicate mGluR5 signalling as potential target for new anti-epileptic drugs.

In vivo 1H magnetic resonance spectroscopy, T2-weighted and diffusion-weighted MRI during lithium-pilocarpine-induced status epilepticus in the rat.

Temporal lobe epilepsy (TLE) is associated with febrile convulsions and childhood status epilepticus (SE). Since the initial precipitating injury, triggering epileptogenesis, occurs during this SE, we aimed to examine the metabolic and morphological cerebral changes during the acute phase of experimental SE noninvasively. In the rat lithium-pilocarpine model of SE, we performed quantified T(2)- and isotropic-diffusion-weighted (DW) magnetic resonance imaging (MRI) at 3 and 5 h of SE and acquired single-voxel (1)H MR spectra at 2, 4 and 6 h of SE. T(2) was globally decreased, most pronounced in the amygdala (Am) and piriformic cortex (Pi), in which also a significant decrease in apparent diffusion coefficient (ADC) was found. In contrast, ADC values increased transiently in the hippocampus (HC) and thalamus (Th). MR spectra showed a decrease in N-acetylaspartate (NAA) and choline (Cho) and an increase of lactate in a hippocampal voxel. The T(2) decrease, attributed to raised deoxyhemoglobin, and the presence of lactate both indicate a mismatch between oxygen demand and delivery. The ADC decrease, indicative of excitotoxicity, confirms that the amygdala and piriformic cortex are particularly vulnerable to lithium-pilocarpine-induced seizures. The transient ADC increase in the thalamus may reflect the breakdown of the blood-brain barrier (BBB), which is shown to occur in this region at these time points. Neuronal damage and failure of energy-dependent formation of NAA are likely causes of an observed decrease in NAA, while the decrease in Cho is possibly due to depletion of the cholinergic system. This study illustrates that relative hypoxia, excitotoxicity and concomitant neuronal damage associated with SE can be probed noninvasively with MR. These pathological phenomena are the first to contribute to the pathophysiology of spontaneous recurrent seizures in a later stage in this animal model.

Persistent changes in action potential broadening and the slow afterhyperpolarization in rat CA1 pyramidal cells after febrile seizures.

Febrile (fever-induced) seizures (FS) are the most common form of seizures during childhood and have been associated with an increased risk of epilepsy later in life. The relationship of FS to subsequent epilepsy is, however, still controversial. Insights from animal models do indicate that especially complex FS are harmful to the developing brain and contribute to a hyperexcitable state that may persist for life. Here, we determined long-lasting changes in neuronal excitability of rat hippocampal CA1 pyramidal cells after prolonged (complex) FS induced by hyperthermia on postnatal day 10. We show that hyperthermia-induced seizures at postnatal day 10 induce a long-lasting increase in the hyperpolarization-activated current I(h). Furthermore, we show that a reduction in the amount of spike broadening and in the amplitude of the slow afterhyperpolarization following FS are also likely to contribute to the hyperexcitability of the hippocampus long term.

Timing and sequence of differentiation of embryonic rat hepatocytes along the biliary epithelial lineage.

To study the differentiation of hepatocytes along the biliary epithelial lineage in vivo, embryonic day 14 (E14) rat hepatocytes were isolated by differential centrifugation and transplanted as single-cell suspensions into the spleen of adult syngeneic rats. Hepatocytes and cholangiocytes were identified and their maturation characterized by the level of expression of alpha-fetoprotein (AFP), glutamate dehydrogenase (GDH), and carbamoyl phosphate synthetase I (CPS); annexin IV, annexin V, cytokeratin 19 (CK-19), and cystic fibrosis transmembrane conductance regulator (CFTR); and electron microscopy. By correlating morphologic changes with the timing in the expression of these markers, we show that the organization of the transplanted E14 hepatocytes into lobular structures is accompanied by the formation and maturation of bile ducts around these developing lobules. Morphologic differentiation of the emerging bile ducts was accompanied by a gradual loss of hepatocyte markers and a gradual acquisition of cholangiocyte markers, with markers identifying a large-cholangiocyte phenotype appearing latest. Once fully differentiated, the intrasplenic liver lobules developed cholestatic features. The accompanying proliferation of bile ducts was due to cholangiocyte proliferation, but ductular transformation of hepatocytes was also observed. In conclusion, (1) bile duct formation at the interface between hepatocytes and connective tissue is an inherent component of liver development and (2) the susceptibility of developing hepatocytes to bile duct-inducing signals is highest in the fetal liver but that (3) this capacity is not irreversibly lost in otherwise mature hepatocytes.