Variability in the projection level of the vertebra prominens: a cadaveric study.

The 7th cervical vertebra (C7) is described as having the most prominent spinous process (SP) and is characterized as the "vertebra prominens" (VP) of the cervical spine in anatomy textbooks. The VP is an important anatomical landmark of the neck for clinical examination and therapeutic intervention. The present study identifies the level of the most prominent SP of the cervical and uppermost thoracic vertebrae in a cadaveric cohort. Thirty-nine (23 female and 16 male) cadavers of a mean age of 77.5 years were investigated in a prone position and a certain cervical kyphotic bending. The most prominent SP, at the base of the neck, was palpated and marked with a wedging nail into the SP of the vertebra. The cervical region was dissected, and a blind investigator examined whether the nail was placed into the SP of C7 or the SP of another upper or lower vertebra. In 19 out of 39 cadavers (48.7%), the C7 was identified as the VP (typical anatomy), followed by the C6 (in 14 cadavers, 35.9%), C5 (in 4 cadavers, 10.3%). In 2 cadavers (5.1%) the first thoracic vertebra was identified as having the most prominent SP. Although C7 is described as the VP, in the present study the SP of C7 was the most prominent in less than 50%. The high variable projection level of the most prominent SP of the cervical vertebra holds great clinical significance for spine examination, neck surgery, and spinal anesthesia.

Ganglionic Local Opioid Analgesia at the Superior Cervical Ganglion: MRI-Verified Solution Spread.

INTRODUCTION: Ganglionic local opioid analgesia (GLOA) at the superior cervical ganglion (SCG) is performed for pain control and is known to be an effective procedure. In this study, we evaluated the spread of the injectate in the area of the SCG. Our expectation was that there would be a correlation between the area and volume of the injectate spread and post-procedural outcome measures. METHODS: This was a retrospective blinded review of magnetic resonance imaging (MRI) scans. Assessors evaluated the anatomical area of fluid spread, the furthermost spread from midline, any hampered spread and contact of contrast fluid with other structures. The efficacy of GLOA and complications were estimated. RESULTS: The main solution spread reached from the C1 to C3 vertebrae. The furthest spread in the lateral and sagittal planes was 21.2 and 15.2 mm, respectively. The furthest craniocaudal spread was 63.5 mm. In 53.3% and 33% of interventions, the solution was found in the parapharyngeal space and in its "medial compartment," respectively. A correlation was found between pain relief and both solution spread and volume of solution spread. No hampered spread was recorded. A negative correlation between pain reduction and number of GLOA was observed. Higher pre-procedural pain intensity was correlated with higher pain reduction. We estimated pain relief in 93% of procedures correctly. No correlation between post-procedural Numerical Rating Scale (NRS) scores and different needle approaches was found. CONCLUSION: For the transoral blocking technique, a strict laterodorsal needle direction is recommended to prevent possible block failures. A total volume of 2 ml injected into the parapharyngeal space and its "medial compartment" is recommended. Higher volumes may lead to uncontrolled distribution patterns. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT05257655; date of registration 2022-02-25; patient enrollment date from 2023-01-09 to 2023-08-31.

The injection of low-dose opioids (mainly buprenorphine or sufentanil) to different sympathetic ganglia has been termed "ganglionic local opioid analgesia" (GLOA). This form of therapy has been successfully used for numerous, often protracted diseases that severely impair the patient's quality of life, such as trigeminal neuralgia. For example, as part of a multimodal approach for pain management, GLOA at the superior cervical ganglion should be considered for pain treatment in patients suffering from trigeminal neuralgia with high pre-procedural pain scores.

Continuous Interscalene Brachial Plexus Blocks: An Anatomical Challenge between Scylla and Charybdis?

Brachial plexus blocks at the interscalene level are frequently chosen by physicians and recommended by textbooks for providing regional anesthesia and analgesia to patients scheduled for shoulder surgery. Published data concerning interscalene single-injection or continuous brachial plexus blocks report good analgesic effects. The principle of interscalene catheters is to extend analgesia beyond the duration of the local anesthetic's effect through continuous infusion, as opposed to a single injection. However, in addition to the recognized beneficial effects of interscalene blocks, whether administered as a single injection or through a catheter, there have been reports of consequences ranging from minor side effects to severe, life-threatening complications. Both can be simply explained by direct mispuncture, as well as undesired local anesthetic spread or misplaced catheters. In particular, catheters pose a high risk when advanced or placed uncontrollably, a fact confirmed by reports of fatal outcomes. Secondary catheter dislocations explain side effects or loss of effectiveness that may occur hours or days after the initial correct function has been observed. From an anatomical and physiological perspective, this appears logical: the catheter tip must be placed near the plexus in an anatomically tight and confined space. Thus, the catheter's position may be altered with the movement of the neck or shoulder, e.g., during physiotherapy. The safe use of interscalene catheters is therefore a balance between high analgesia quality and the control of side effects and complications, much like the passage between Scylla and Charybdis. We are convinced that the anatomical basis crucial for the brachial plexus block procedure at the interscalene level is not sufficiently depicted in the common regional anesthesia literature or textbooks. We would like to provide a comprehensive anatomical survey of the lateral neck, with special attention paid to the safe placement of interscalene catheters.

The relationship between the lateral cutaneous antebrachial nerve and the superficial branch of the radial nerve and its impact on regional anesthetic and pain blocks of the thumb; What is more important: Nerves or dermatomes?

BACKGROUND: Innervation of the thumb and radial part of the dorsum of the hand is achieved primarily by the radial nerve, which is usually blocked for hand surgery. Inefficient blocks occur because the lateral antebrachial cutaneous nerve also extends into this area. The question then arises, whether skin innervation and peripheral blocking techniques should be directed at from the innervation by these nerves or more by the dermatome and its spinal segments. METHODS: In 68 human upper limbs embalmed with Thiel's method, the topography of the lateral antebrachial cutaneous nerve (LACN), the superficial branch of the radial nerve (sbRN) and communicating branch (CB) were investigated by meticulous dissection from the cubital fossa to the most distal macroscopically dissectible branch, and the areas reached by these nerves were compared to the described dermatome. RESULTS: In 52.9% of all specimens, the LACN was found proximal to the rascetta, in 35.3% it extended to the base of the thumb, and in 8 cases (11.8%) it extended distally to the base of the thumb. In 50%, the LACN was anterolateral to the brachioradialis muscle, and in 38.2%, strictly lateral. Only in 8 cases (11.8%) the LACN presented itself running more dorsally and laterally. A CB was observed in 28 specimens (41.2%). Both investigated nerves were found to innervate the dermatomes of C6 and C7. CONCLUSIONS: The LACN should be considered for individual targeted blocks for surgical procedures and pain therapy within the wrist and thumb region as all nerves that might contribute to innervation of a targeted dermatome should be blocked.

Ultrasound-Guided Dorsal Penile Nerve Block in Children: An Anatomical-Based Observational Study of a New Anesthesia Technique.

Dorsal penile nerve block stands out as one of the commonly employed regional anesthetic techniques in children. Despite the large body of experience, failure rates are still significant. We included 20 children (median (SD) age of 73 (31) months) scheduled for circumcision without general anesthesia and secondary airway manipulation in a consecutive case series. Under ultrasound guidance and utilizing an in-plane needle guidance technique, the dorsal penile nerve block was administered with slight sedation, and spontaneous respiration was maintained in all cases. To investigate the underlying anatomy for dorsal penile nerve blockade, we dissected three cadavers. The primary study endpoint was the success rate of surgical blockade, meaning that the surgical procedure could be performed without additional general anesthesia and invasive airway management. The secondary endpoint was the requirement of analgesics until discharge from the post-anesthesia care unit. The primary endpoint was successfully met in all patients according to our strict definition without additional general anesthesia or airway manipulation. In addition, no child received analgesics until discharge from the recovery room. The anatomical investigation clarified the specific anatomy as baseline knowledge for an ultrasound-guided dorsal penile nerve blockade and enabled successful performance in 20 consecutive children where penile surgery was possible in light sedation without additional airway manipulation.

Alpha-Ketoglutarate or 5-HMF: Single Compounds Effectively Eliminate Leukemia Cells via Caspase-3 Apoptosis and Antioxidative Pathways.

BACKGROUND: We recently showed that a combined solution containing alpha-ketoglutarate (aKG) and 5-hydroxymethyl-furfural (5-HMF) has a solid antitumoral effect on the Jurkat cell line due to the fact of its antioxidative, caspase-3 and apoptosis activities, but no negative effect on human fibroblasts was obtained. The question arises how the single compounds, aKG and 5-HMF, affect peroxynitrite (ONOO-) and nitration of tyrosine residues, Jurkat cell proliferation and caspase-activated apoptosis. METHODS: The ONOO- luminol-induced chemiluminescence reaction was used to measure the ONOO- scavenging function of aKG or 5-HMF, and their protection against nitration of tyrosine residues on bovine serum albumin was estimated with the ELISA technique. The Jurkat cell line was cultivated in the absence or presence of aKG or 5-HMF solutions between 0 and 3.5 µM aKG or 0 and 4 µM 5-HMF. Jurkat cells were tested for cell proliferation, mitochondrial activity and caspase-activated apoptosis. RESULTS: aKG showed a concentration-dependent reduction in ONOO-, resulting in a 90% elimination of ONOO- using 200 mM aKG. In addition, 20 and 200 mM 5-HMF were able to reduce ONOO- only by 20%, while lower concentrations of 5-HMF remained stable in the presence of ONOO-. Nitration of tyrosine residues was inhibited 4 fold more effectively with 5-HMF compared to aKG measuring the IC50%. Both substances, aKG and 5-HMF, were shown to cause a reduction in Jurkat cell growth that was dependent on the dose and incubation time. The aKG effectively reduced Jurkat cell growth down to 50% after 48 and 72 h of incubation using the highest concentration of 3.5 µM, and 1, 1.6, 2, 3 and 4 µM 5-HMF inhibited any cell growth within (i) 24 h; 1.6, 2, 3 and 4 µM 5-HMF within 48 h (ii); 2, 3 and 4 µM 5-HMF within 72 h (iii). Furthermore, 4 µM was able to eliminate the starting cell number of 20,000 cells after 48 and 72 h down to 11,233 cells. The mitochondrial activity measurements supported the data on aKG or 5-HMF regarding cell growth in Jurkat cells, in both a dose- and incubation-time-dependent manner: the highest concentration of 3.5 µM aKG reduced the mitochondrial activity over 24 h (67.7%), 48 h (57.9%) and 72 h (46.8%) of incubation with Jurkat cells compared to the control incubation without aKG (100%). 5-HMF was more effective compared to aKG; the mitochondrial activity in the presence of 4 µM 5-HMF decreased after 24 h down to 68.4%, after 48 h to 42.9% and after 72 h to 32.0%. Moreover, 1.7 and 3.4 µM aKG had no effect on caspase-3-activated apoptosis (0.58% and 0.56%) in the Jurkat cell line. However, 2 and 4 µM 5-HMF increased the caspase-3-activated apoptosis up to 22.1% and 42.5% compared to the control (2.9%). A combined solution of 1.7 µM aKG + 0.7 µM 5-HMF showed a higher caspase-3-activated apoptosis (15.7%) compared to 1.7 µM aKG or 2 µM 5-HMF alone. In addition, 3.5 µM µg/mL aKG + 1.7 µM 5-HMF induced caspase-activated apoptosis up to 55.6% compared to 4.5% or 35.6% caspase-3 activity using 3.5 µM aKG or 4 µM 5-HMF. CONCLUSION: Both substances showed high antioxidative potential in eliminating either peroxynitrite or nitration of tyrosine residues, which results in a better inhibition of cell growth and mitochondrial activity of 5-HMF compared to aKG. However, caspase-3-activated apoptosis measurements revealed that the combination of both substances synergistically is the most effective compared to single compounds.

Computed Tomography-Guided Coeliac Plexus Neurolysis in Palliative in-Patients with Intra-Abdominal Malignancy: Retrospective Evaluation of Neurolytic Solution Spread as a Predictive Factor.

INTRODUCTION: Computed tomography (CT)-guided coeliac plexus neurolysis (CPN) is considered effective at controlling pain in patients with intra-abdominal malignancies. The primary objective was to correlate pain outcomes with the spread of neurolytic solution in the coeliac area and to evaluate the predictive value for the spread of injectate for pain outcomes and side effects. METHODS: Blinded CT scans were reviewed. The coeliac area was divided into nine quadrants. Assessors evaluated quadrants according to contrast spread, needle tip position, and the contact between the injectate and other organs and plexuses. Efficacy of CPN and complications were estimated. RESULTS: In 54.9% there was complete spread of the neurolytic in the coeliac area with no correlation between pain relief and spread of injectate. In 85% the neurolytic had contact with viscera with no correlation with pain relief or complications. There was no correlation between needle tip position and spread of the neurolytic and contact of the neurolytic with viscera. In 71.6% the injectate was found to have spread into "other" plexuses. In 13.3% hampered spread of the injectate was observed. There was no correlation between patterns of injectate spread and pain relief, pain relief and spread of injectate in any particular quadrants, and expected and documented post-procedural pain scores. CONCLUSIONS: Based on the spread of contrast medium clinicians can neither correctly anticipate the pain relief or post-procedural NRS, nor the duration of pain relief and complications. It is not essential to have the perfect sickle-shaped spread of the injectate for adequate pain control.

CT-guided coeliac plexus neurolysis is considered effective at controlling pain in patients with intra-abdominal malignancies. Based on the spread of contrast medium clinicians can neither correctly anticipate the pain relief or post-procedural NRS, nor the duration of pain relief and complications. It is not essential to have the perfect sickle-shaped spread of the injectate for adequate pain control.

Dorsal minimally invasive plate osteosynthesis of the humerus: Feasibility and risk of nervous injury of a modified technique in an anatomical study.

BACKGROUND: The aim of the study was to design a convenient technique for dorsal minimally invasive plate osteosynthesis (MIPO) of extra-articular fractures of both distal thirds of the humeral shaft as well as to characterise the course and proximity of the radial nerve (RN) and the axillary nerve (AN). METHODS: The collective consisted of 20 upper extremities of human adult body donors. A 3.5 mm Locking Compression Plate (LCP), an extra-articular distal humerus plate was inserted through a MIPO approach including two incisions. The primary incision was performed 5 cm in lenght on the dorsal side of the lateral epicondyle. An additional 5 cm incision was conducted distal to the humeral deltoid muscle insertion and the RN was depicted. The longest suitable plate was advanced under nerve protection starting distally and fixed by locking screws. A third incision with a length of 5 cm was made beginning at the distal border of the deltoid muscle, and a muscle split was performed to dissect the AN. The respective plate holes, where the AN and RN were located and the distances between the nerves were examined. RESULTS: The RN was mostly (30%) localised on holes 6 and 7 (starting distally). The AN laid directly on the plate in 65% and on the most proximal plate hole in 12 cases, but was never situated underneath the plate. The distance between the AN and RN was at mean 93.5 mm. CONCLUSIONS: MIPO via a dorsal method proves to be a noteworthy technique and valuable option as indicated by our results. This 5-5-(5) concept may be performed as a two-incision or three-incision technique for extra-articular fractures of both distal thirds of the humerus.

Anatomical Analysis of the Lateral Femoral Cutaneous Nerve and Its Passage beneath the Inguinal Ligament.

BACKGROUND: Meralgia paraesthetica is a mononeuropathy of the lateral femoral cutaneous nerve. According to the literature, the nerve travels beneath the inguinal ligament 1.3 to 5.1 cm medial to the anterior superior iliac spine. Compression at this site may cause pain and paresthesia. The aim of this study was to provide more accurate measurements to improve the diagnostic and surgical management of meralgia paraesthetica. METHODS: The lateral femoral cutaneous nerve was dissected bilaterally in 50 Thiel-embalmed human cadavers. Measurements were performed with a standard caliper at the superior and inferior margins of the inguinal ligament. The distance from the inner lamina of the anterior superior iliac spine to the medial margin of the lateral femoral cutaneous nerve was measured. Data were collected and statistical analysis was performed with R. RESULTS: Ninety-three lateral femoral cutaneous nerves of 50 cadavers were dissected. In 6 percent of cadavers, the lateral femoral cutaneous nerve could not be found. The mean distance from the inner lamina of the anterior superior iliac spine to the lateral femoral cutaneous nerve's medial border was 2.1 ± 1.3 cm (range, 0.2 to 6.4 cm; 95 percent CI, 1.8 to 2.4 cm) at the superior margin of the inguinal ligament and 1.9 ± 1.4 cm (range, 0.2 to 3.0 cm; 95 percent CI, 1.6 to 2.2 cm) at the inferior border of the inguinal ligament. CONCLUSION: This anatomical study shows that the majority of the lateral femoral cutaneous nerve passes beneath the inguinal ligament in a very narrow area of 0.6 cm.

The influence of dissection on clinical anatomical knowledge for surgical needs.

PURPOSE: Due to the ongoing discussion of the usefulness of dissection on human bodies in medical curricula, we investigated the influence of anatomical knowledge collected in the dissection course and requested for modules of visceral surgery. METHODS: Students attending the dissection course of topographic anatomy had to answer a questionnaire of 22 questions with focus on anatomical knowledge required for visceral surgical modules. Failure was defined as 13 or fewer correct answers, success categorized as high, good or moderate. The same questionnaire was handed out to 245 students prior to the module on visceral surgery. Students provided information on which regions they had dissected during the course or prior to the module. The results were compared to the result of a written Multiple Choice Question (MCQ) exam of the module visceral surgery (n = 160 students) with an unannounced primary focus on anatomy. RESULTS: Students who dissected the truncal regions of the human body succeeded in answering the questionnaire with high success. Students dissecting regions of the Head/Neck or Limbs had a high failure rate, and none of them reached the "high" success level. In the MCQ exam, students dissecting truncal regions had a high success rate, while those who had not dissected or who dissected the Head/Neck or Limbs had a high failure rate. CONCLUSION: Dissections support and improve the required knowledge for surgical modules. For the visceral surgical module, students dissecting the region prior to the module greatly benefited. Therefore, entire human body dissection assumes to be preferable.

CT-Guided Coeliac Plexus Neurolysis in Patients with Intra-Abdominal Malignancy: A Retrospective Evaluation of 52 Palliative In-Patients.

INTRODUCTION: Prevalence rates of chronic abdominal pain (CAP) and breakthrough cancer pain (BTcP) are high in patients with intra-abdominal malignancies. As part of a multimodal approach, CT-guided coeliac plexus blockade (CPB) and CT-guided coeliac plexus neurolysis (CPN) are commonly used pain management strategies. The aim of this study was to evaluate pain outcomes among patients with intra-abdominal malignancies who underwent CPB and/or CPN. METHODS: Patients with intra-abdominal malignancies who underwent CPB and/or CPN for pain control at the general hospital Klagenfurt am Wörthersee from 2010 to 2019 were enrolled. RESULTS: A total of 84 procedures (24 CPB and 60 CPN) were performed on 52 patients; 62% of these patients had pancreatic cancer. CPN led to significant pain reduction and decreased BTcP intensity. Patients receiving repeated CPN showed higher individual pain reduction. Higher pre-procedural pain intensity was correlated with higher pain reduction. No difference in pain reduction in patients receiving a diagnostic CPB prior to CPN compared to patients without a diagnostic CPB was found. Higher pain reduction after CPN led to longer-lasting pain relief. The time frame from diagnosis to CPN was 472 (± 416) days. Patients experienced a mean duration of pain prior to CPN of 330 (± 53) days. The time frame from diagnosis to CPN was shorter in patients with pancreatic cancer compared to other intra-abdominal malignancies. In 58% of patients pain medication was stable or was reduced after CPN; 16% of patients complained about pain during the procedure; no major complications occurred. There was no correlation between median survival after CPN and pain outcomes. CONCLUSIONS: In patients with intra-abdominal malignancy-related CAP, CPN is a safe and effective procedure which can provide long-lasting significant relief of background pain and BTcP. As part of a multimodal approach, CPN should be considered as an earlier option for pain management in these patients.

In patients with intra-abdominal malignancy-related abdominal pain, CT-guided coeliac plexus neurolysis is a safe and effective procedure. It can provide long-lasting significant relief of background pain and breakthrough cancer pain. As part of a multimodal approach, coeliac plexus neurolysis should be considered as an earlier option for pain management in patients with intractable abdominal cancer pain.

Transverse plane ultrasound-guided caudal epidural injections: sonographic anatomy and stepwise technique.

PURPOSE: The present study aims to provide a step-by-step procedural and anatomical familiarization guide for transverse plane ultrasound (US)-guided caudal epidural (CE) injection. METHODS: The study cohort consisted of 23 chronic low back pain patients (23-67 years old) previously unresponsive to conservative management. A transverse plane US-guided CE injection was performed, with each procedure step documenting and emphasizing sonographic anatomy. Several Thiel's method fixed cadaveric specimen dissections were also performed to demonstrate relevant CE injection-related anatomy. RESULTS: The sacral hiatus location can be estimated by visually forming an equilateral triangle between the posterior superior iliac spines and the sacral apex (trigonum sacrale). Follow-up palpation locates the sacral cornua, guiding transducer placement visualizing over the paired cornua 'bull frog's eye's appearance, with the epidural space visualized as a hypoechoic line, between the eyes. Then, 2-3 ml of 1% lidocaine is injected subcutaneously at the mid-point between the sacral cornua and superficial to the posterior sacrococcygeal ligament (SCL). Although keeping the cornua, superficial posterior SCL and epidural space in view, the needle is slowly advanced to the epidural space at around a 20 degree cephalad angle till the tip becomes visible. Expansion of the epidural space is monitored under the transverse sacral ligament as the injectant is slowly introduced. CONCLUSION: The present study demonstrated the anatomical landmarks necessary for the transverse ultrasound caudal epidural technique and that the cornua, superficial posterior SCL, CE space, and other relevant sacral hiatal anatomy are well visualized with this technique.

Revisiting the vascularity of the keratinized gingiva in the maxillary esthetic zone.

BACKGROUND: The active arterial-to-arterial collaterals are a significant factor in the prevention of ischemia and extensive tissue necrosis in the case of arterial blockage of various tissues. The present study investigates the mucogingival vasculature in the maxillary esthetic zone mucosa in human cadavers and functionally evaluates the area, which is supplied by the terminal arterioles, on the individual level. METHODS: In the human cadaver study, macroscopic arterial analyses of the anterior maxillary vestibule in 7 specimens were scrutinized by latex milk injection. The tracks of the mucosal branches in relation to the mucogingival junction were investigated. In the functional study, individual gingival blood flow (GBF) changes were measured by laser speckle contrast imaging (LSCI) in 31 young subjects with healthy gingiva before and during 30-s compressions. This was conducted with a ball-shaped condenser. The data was analyzed by the linear mixed model. RESULTS: The vertically aligned branches of the superior labial artery (SLA) divided into small, slightly deviating sub-branches near the mucogingival junction. These arteries created collateral plexuses and supplied the attached gingiva. The compression of these branches resulted in ischemia coronally with significant individual variation. The ischemia was either apico-mesial, apico-distal, or straight apical to the compression. A significant correlation was found between the ischemic area and the magnitude of the decrease in GBF (r = 0.81, p < 0.001). In males, 77% of the subjects, and 50% of the female subjects had an ischemic response in either region. The horizontal extension of the ischemic area ranged between 0.26 mm and 8.76 mm. Males had significantly higher baseline GBF and larger ischemia than females. At the base of the papilla, significant restoration of GBF was observed during compression in males, but not in females. CONCLUSION: The arcade anastomoses formed by the small arteries in the keratinized gingiva of the upper esthetic zone explain the consequences of vertical incisions. The considerable individual variations in ischemic responses might be the reason for unexpected surgical outcomes in some cases. Furthermore, there is increasing evidence that men have different vascular reactivity and/or regulation of collateral circulation than women, which may affect wound healing.

C5 ventral ramus block for clavicle surgery: How low concerning the volume can we go?

Background and Aims: Clinical case reports mention 3-5 ml of local anesthetic (LA) at the cervical root 5 (C5) for surgical anesthesia essential for clavicle surgeries with reasonable success. A volume of 5 ml LA has been shown to cause hemidiaphragmatic paresis. Material and Methods: We implement the 3-5 ml LA for awake clavicle surgeries along with a supraclavicular nerve (SCN) block with another 2 ml. To understand the spread of injectate, we conducted anatomic macroscopic dissection on Theil based cadavers. Post ultrasound injection of 3 ml of blue latex in one cadaver and green latex in the other, we dissected one cadaver and the other cadaver underwent a cross-section. Results: Dissection confirmed a vertical spread of dye more caudad than cephalad. There was no neuraxial spread visualized in the cross-section. The phrenic nerve (PN) was not stained in both cadavers, but a possibility exists depending on its course. Conclusion: Based on this limited study we recommend a volume of LA of 3 ml at the level of C5 and another 2 ml at the level SCN of LA for clavicle surgeries.

Innervation of the acromioclavicular joint by the suprascapular nerve.

BACKGROUND: The suprascapular nerve is largely responsible for the majority of the sensory innervation of the acromioclavicular joint. In this anatomical study, we describe, in detail, the anatomy of the sensory innervation of the acromioclavicular joint by the branches of the suprascapular nerve. METHODS: Twenty-seven shoulders from 17 cadaveric specimens were carefully dissected to identify the course of the suprascapular nerve, with the main focus being on the sensory innervation of the acromioclavicular joint. Nine specific measurements of the acromioclavicular joint sensory nerves were made of each shoulder in relation to distinct anatomical landmarks to determine the mean location and course of these nerves. RESULTS: In all 27 shoulders (100%), a sensory branch to the acromioclavicular joint with a proximal origin from the suprascapular nerve could be depicted ("first sensory branch"). The mean length of this branch was 4.3 cm (range: 3.3-5.3 cm). In 14 shoulders (52%), a further sensory branch of the suprascapular nerve innervating the posterior acromioclavicular joint capsule could be identified ("second sensory branch"). DISCUSSION: A detailed anatomical description of the sensory innervation of the acromioclavicular joint from suprascapular nerve branches was performed, which can potentially aid in the development of more focused anesthetic blockades and acromioclavicular joint denervation procedures.

Detection of Vascular Pathways of Oral Mucosa Influencing Soft- and Hard Tissue Surgeries by Latex Milk Injection.

In this methodological study, the purpose was to visualize the macroscopic vascular pathway of the oral mucosa. Corpses were injected and fixed with Thiel's solution for embalming to keep the natural color, fresh texture, and elasticity of the tissues. Latex milk injection is a technique used to stain blood vessels. A combination of Thiel's embalming method and latex milk injection allows surgeons to work on a raw specimen and identify the distribution and anastomosis of vessels macroscopically in the oral mucosa for flap/incision design in periodontal and maxillofacial surgeries. The latex milk contains radiopaque material that enables clinicians to visualize the pathway of the blood vessels radiographically. A step-by-step protocol is described for the correct adjustment of Thiel embalming and latex milk injection. The combined application of both methods allows the clinician to understand anatomical structures practically. As a result, proper incisions and flaps can be designed, which prevents neurovascular damage, intraoperative bleeding, and postoperative morbidity during patient surgery.

The superficial anatomical landmarks are not reliable for predicting the recurrent branch of the median nerve.

PURPOSE: The variability of the recurrent branch (RB) of the median nerve lends itself to an increased risk of injury when performing the minimally invasive approach for carpal tunnel release without its direct visualization. This risk is less so when it is released via the more invasive open approach as the RB can be easily identified, but the drawback is that of longer postoperative patient recovery time. Therefore, performing these releases via the less invasive approach should be more favorable for patients providing it could be done safely. Hence with there being a positive link between the hypertrophy of the thenar musculature and the course of RB according to previous studies. METHODS: We dissected 28 hands of 14 donated bodies fixed using Thiel's method to try to demonstrate these findings of the associations among the RB, palmar creases and other superficial anatomical landmarks. Fisher's exact test was conducted to verify the relationship between those structures statistically. RESULTS: Statistically significant links were found between the type of the RB and the type of the palmar creases (p value = 0.0094) and between the RB type and the palmaris longus muscle presence (p value = 0.028). CONCLUSION: It was inferred that palmar creases and other superficial anatomical landmarks listed in the text could not be used to predict the variability of the RB and the choice of mini-invasive approach should not be based on their course.

Accessory flexor carpi ulnaris muscle with associated anterior interosseous artery variation: case report with the definition of a new type and review of concomitant variants.

PURPOSE: Knowledge of accessory flexor carpi ulnaris (AFCU) is not only important for proper orientation in the surgical field but it can be used for tendon transfer as well. AFCU commonly occurs with concomitant variants, and its presence should rise caution in order to prevent iatrogenic injury. METHODS: During a routine dissection for research data collection at the Institute of Anatomy, a AFCU with concomitant variants was observed in a European cadaver fixed with Thiel's method. A thorough review of the literature concerning all the encountered variants was performed. RESULTS: AFCU was found in the right upper limb with its insertion on the flexor retinaculum. Palmaris longus muscle was absent in this limb, and an accessory branch of the anterior interosseous artery coursed over the pronator quadratus muscle to anastomose with the ulnar artery 5 cm proximally to the pisiform. On the left hand, a variable lumbrical of the second finger originating from the flexor retinaculum was found, which was not described in the literature before. CONCLUSIONS: AFCU commonly occurs together with concomitant variants, and special attention is needed when performing surgery on such forearm.

The reverse latissimus dorsi flap: An anatomical study and retrospective analysis of its clinical application.

The segmental paraspinous and intercostal blood vessels form the blood supply and represent the pivot point for the reverse latissimus dorsi flap. Aim of this study was to confirm the exact location of the blood supply and the most caudal pivot point to assess the suitability of the reverse latissimus dorsi flap for pedicled reconstructions of the trunk as well as sacral area. Our study comprised a human cadaver study, where 30 latissimus dorsi flaps were assessed in 15 specimens, and a clinical study with 49 patients who underwent distally based latissimus dorsi flap reconstructions in our division. 74% of all perforators were located in a bilateral 7 cm broad area, which spread from the 6th intercostal space to the subcostal plane. In a second clinical part of this study we evaluated forty-nine patients, who underwent reconstruction with the reverse latissimus dorsi flap. We demonstrated that the pivot point can also be planned below the 12th rib, thus reaching tissue defects in the sacral area. To the best of our knowledge, this is the first study to define a caudal "hotspot" for the safest blood supply of the reverse latissimus dorsi flap.