The most commonly injured nerves at surgery: A comprehensive review.

Iatrogenic nerve injury during surgery is a major source of concern for both patients and surgeons. This study aimed to identify the nerves most commonly injured during surgery, along with the commonly associated operative procedures. A literature search was conducted using the PubMed database to identify nerves commonly injured during surgery, along with the surgical procedure associated with the injury. The following 11 nerves, ranked in order with their associated surgical procedures, were found to be the most commonly injured: (a) intercostobrachial nerve in axillary lymph node dissections and transaxillary breast augmentations, (b) vestibulocochlear nerve in cerebellopontine tumor resections and vestibular schwannoma removals, c) facial nerve in surgeries of the inner ear and cheek region, (d) long thoracic nerve in axillary lymph node dissections, (e) spinal accessory nerve in surgeries of the posterior triangle of the neck and cervical lymph node biopsies, (f) recurrent laryngeal nerve in thyroid surgeries, (g) genitofemoral nerve in inguinal hernia and varicocele surgeries, (h) sciatic nerve in acetabular fracture repairs and osteotomies, (i) median nerve in carpal tunnel release surgeries, (j) common fibular nerve in varicose vein and short saphenous vein surgeries, and (k) ulnar nerve in supracondylar fracture surgeries. Although the root cause of iatrogenic nerve injury differs for each nerve, there are four unifying factors that could potentially decrease this risk for all peripheral nerves. These four influencing factors include knowledge of potential anatomical variations, visual identification of at-risk nerves during the procedure, intraoperative nerve monitoring, and expertise of the surgeon.

The inferior intercavernous sinus: An anatomical study with application to trans-sphenoidal approaches to the pituitary gland.

OBJECTIVES: The inferior intercavernous sinus is located below the pituitary gland in the sella turcica. Its presence has been controversial among anatomists because it is not always found on radiological imaging or during cadaveric dissections; however, it is becoming a better-known structure in the neurosurgical and radiological fields, specifically with respect to transsphenoidal surgery. Therefore, the present study was performed to better elucidate this structure at the skull base. PATIENTS AND METHODS: Fifty adult, latex injected cadavers underwent dissection. The presence or absence of the inferior cavernous sinus was evaluated and when present, measurements of its width and length were made. Its connections with other intradural venous sinuses were also documented. RESULTS: An inferior intercavernous sinus was identified in 26 % of specimens. In all specimens, it communicated with the left and right cavernous sinus. The average width and length were 3 mm and 9.5 mm, respectively. In the sagittal plane, the inferior intercavernous sinus was positioned anteriorly in 31 %, at the nadir of the sella turcica in 38 %, and slightly posterior to the nadir of the sella turcica in 31 %. In two specimens (15.4 %), the sinus was plexiform in its shape. In one specimen a diploic vein connected the basilar venous plexus to the inferior intercavernous sinus on its deep surface. CONCLUSION: An improved understanding of the variable anatomy of the inferior intercavernous sinus is important in pathological, surgical, and radiological cases.

Anatomic Study of the Bifurcation of the Obturator Nerve: Application to More Precise Surgical/Procedural Localization.

BACKGROUND: This anatomic study aimed to more precisely locate the bifurcation of the obturator nerve in relationship to the obturator foramen. Such information might improve outcomes in neurotization or other procedures necessitating exposure of the obturator nerve and could increase success rates for obturator nerve blockade. METHODS: Fourteen sides from fresh-frozen cadaveric specimens were used in this study. Dissection of the obturator nerve was performed, and its bifurcation into anterior and posterior branches was documented and classified. Measurements of these branches were also performed. Bifurcations of the obturator nerve were classified as type I when proximal to the obturator foramen, type II when inside the obturator foramen, and type III when distal to the obturator foramen. RESULTS: Type I, type II, and type III obturator nerve bifurcations were observed in 14.3%, 64.3%, and 21.4% of sides, respectively. In type I nerves, the mean distance from the bifurcation of the obturator nerve to the obturator foramen was 15.8 mm, and in type II nerves the mean was 14.0 mm. The mean diameter of the main trunk, anterior branch, and posterior branch was 3.74 mm, 2.64 mm, and 2.28 mm, respectively. CONCLUSIONS: Bifurcation of the obturator nerve can occur proximally, distally, or inside the obturator foramen. Therefore using imaging modalities such as ultrasound is strongly recommended for identifying the main trunk or anterior and posterior branches of the obturator nerve before surgery or other procedures aimed at this nerve due to such anatomic variations.

The evolution of transgender surgery.

An estimated 1.4% of the population worldwide has been diagnosed with Gender Dysphoria, as defined by the Diagnostic and Statistical Manual of Mental Disorders. Gender reassignment, which holistically encompasses psychotherapy, hormonal therapy and genital and nongenital surgeries, is considered the most effective treatment for transgender nonconforming patients afflicted with gender dysphoria. Little research is currently available identifying the psychosocial needs of the transgender population and their access to preventative and primary care during this transitioning process. This article presents an overview of the evolution and current approaches to genital surgical procedures available for both male-to-female, as well as female-to-male gender-affirmation surgeries. Clin. Anat. 31:878-886, 2018. © 2018 Wiley Periodicals, Inc.

Ultrasound-guided central venous catheterization: A review of the relevant anatomy, technique, complications, and anatomical variations.

Central venous catheterization is a commonly used and important intervention. Despite its regular use it is still associated with a high incidence of complications especially infection and catheter tip embolization. Addition of ultrasound guidance to the technique has shown great improvement to the time and number of attempts for successful catheterization. The preference of vein depends greatly on the situation; subclavian vein is the preferred method overall but internal jugular vein is preferred in patients undergoing cardiac or thoracic surgery. This is especially true for pediatric patients in whom femoral vein catheterization is still preferred despite it carrying a higher risk than other locales. Addition of ultrasound guidance greatly reduces the incidence of arterial puncture and subsequent hematoma formation regardless of location. This is because it allows for visualization of anatomical variation prior to intervention and continual visualization of the needle during the placement. It is noteworthy however, that addition of ultrasound does not prevent complications such as catheter tip embolization as this may occur even with perfect placement. The value of ultrasound usage is undisputable since all studies assessing the difference between it and landmark based methods showed preferable outcome. Reduction of time and number of attempts is sufficient argument to make ultrasound guidance standard practice. Clin. Anat. 30:237-250, 2017. © 2017 Wiley Periodicals, Inc.

Occipital neuralgia: anatomic considerations.

Occipital neuralgia is a debilitating disorder first described in 1821 as recurrent headaches localized in the occipital region. Other symptoms that have been associated with this condition include paroxysmal burning and aching pain in the distribution of the greater, lesser, or third occipital nerves. Several etiologies have been identified in the cause of occipital neuralgia and include, but are not limited to, trauma, fibrositis, myositis, fracture of the atlas, and compression of the C-2 nerve root, C1-2 arthrosis syndrome, atlantoaxial lateral mass osteoarthritis, hypertrophic cervical pachymeningitis, cervical cord tumor, Chiari malformation, and neurosyphilis. The management of occipital neuralgia can include conservative approaches and/or surgical interventions. Occipital neuralgia is a multifactorial problem where multiple anatomic areas/structures may be involved with this pathology. A review of these etiologies may provide guidance in better understanding occipital neuralgia.

Genitofemoral neuralgia: a review.

Genitofemoral neuralgia is a cause of neuropathic pain that is often debilitating in nature. It is characterized by chronic neuropathic groin pain that is localized along the distribution of the genitofemoral nerve. The symptoms include groin pain, paresthesias, and burning sensation spreading from the lower abdomen to the medial aspect of the thigh. It may present with scrotal pain in male, while females experience symptoms radiating to the labia majora and mons pubis. Genitofemoral neuropathy has been attributed to iatrogenic nerve injury occurring during inguinal and femoral herniorrhaphy, with cases developing after both open and laparoscopic techniques. Diagnosis of genitofemoral neuralgia can be challenging, due to the overlap in sensory distribution the nerve shares with the ilioinguinal and iliohypogastric nerve. Differential nerve blocks are recommended in effort to differentiate the nerves when patients present with lower abdominal and groin pain. Once a diagnosis has been made, there exist several treatment options for genitofemoral neuralgia ranging from medical management, non-invasive injections, and surgery. Literature has also brought light to radiofrequency ablation and cryoablation performed under ultrasound guidance as emerging treatments. The aim of the current article is to review the anatomy, diagnostic techniques, and treatment options for patients with genitofemoral neuralgia.

Histologic and immunohistochemical analysis of the antiatherogenic effects of myocardial bridging in the adult human heart.

BACKGROUND: Myocardial bridging is a common anatomic variation of the human heart in which an epicardial coronary artery takes an intramural course within the myocardium. Studies have proposed that myocardial bridges offer a "protective effect" from atherosclerosis within the involved coronary artery. METHODS: We examined 250 formalin-fixed human hearts with gross dissection and histologic and immunohistochemical techniques. The bridged arteries were divided into premyocardial, myocardial, and postmyocardial segments. Atherogenic activity was assessed by comparing proliferative activity (Ki-67), smooth muscle α-actin, and macrophages. In addition, atherosclerotic lesions were carefully categorized according to the Stary classification. RESULTS: The presence of myocardial bridges was confirmed in 92 hearts (36.8%). The most common location of a myocardial bridge was over the anterior interventricular artery in 38 (41.3%) hearts. Overall, the bridged segments demonstrated weaker Ki-67 activity, a decreased number of smooth muscle cells and macrophages, and lower modal Stary classifications for atherosclerosis severity as compared to pre- and postbridge segments of the same coronary artery. CONCLUSION: Atherosclerotic lesions in vessel sections deep to the myocardial bridges were found to be less developed in contrast to the pre- and postbridge segments of the same coronary arteries. Although the precise mechanism of atherogenic protection is unknown, it has been proposed that compression by the contracting myocardium stimulates the release of anticoagulant and growth factors, which could have a synergistic effect in protecting the endothelium from denudation, inflammation, and resultant atherosclerosis.

The twisted colon: a review of sigmoid volvulus.

Sigmoid volvulus (SV) is the third leading cause of colon obstruction in adults. In infants and children, it is exceedingly rare with only sporadic cases reported so far. SVs from secondary causes, with congenital megacolon being the most important, are nevertheless more common in young people. The etiology of this disorder is not completely understood. It is known to occur in the setting of redundant sigmoid loop, which rotates around its narrow and elongated mesentery. Although the latter occurs in the setting of constipation, a congenitally elongated colon, and other predisposing factors, there is no consensus on the precipitating factor leading to SV formation. The symptoms are suggestive of small bowel obstruction, but the presentations can be acute or indolent. Plain abdominal radiography is used to diagnose SV in most cases with computed tomography scan or magnetic resonance imaging as the confirmatory tests when necessary. After it has been untwisted, the definitive and standard therapy for SV is sigmoid resection and primary anastomosis. The nonresective alternatives have also been widely used with mixed success, but a large, randomized controlled trial is needed to compare their efficacy with resection and primary anastomosis. Laparoscopic surgery in SV management is unwarranted and costly. Complications of SV include hemorrhagic infarction, perforation, septic shock, and death. The mortality data from SV vary, but the latest literature cites an overall range of 14 to 45 per cent.

A review of subclavian steal syndrome with clinical correlation.

Subclavian 'steal' phenomenon is a function of the proximal subclavian artery (SA) steno-occlusive disease, with subsequent retrograde blood flow in the ipsilateral vertebral artery (VA). The symptoms from the compromised vertebrobasilar and brachial blood flows constitute the subclavian steal syndrome (SSS), and include paroxysmal vertigo, drop attacks and/or arm claudication. Once thought to be rare, the emergence of new imaging techniques has drastically improved its diagnosis and prevalence. The syndrome, however, remains characteristically asymptomatic and solely poses no serious danger to the brain. Recent studies have shown a linear correlation between increasing arm blood pressure difference with the occurrence of symptoms. Atherosclerosis of the SA remains the most common cause. Doppler ultrasound is a useful screening tool, but the diagnosis must be confirmed by CT or MR angiography. Conservative treatment is the initial best therapy for this syndrome, with surgery reserved for refractory symptomatic cases. Percutaneous angioplasty and stenting, rather than bypass grafts of the subclavian artery, is the widely favored surgical approach. Nevertheless, large, prospective, randomized, controlled trials are needed to compare the long-term patency rates between the endovascular and open surgical techniques.

Medial plica syndrome: a review of the literature.

Knee pain is a very common complaint seen in the clinical setting. A torn medial meniscus, osteochondral defects, inflammation, or an irritated medial plica are some of the most common causes of medial knee pain. Plicae are synovial invaginations that are believed to be remnants of the embryological development of the knee. They have a potential to become inflamed and symptomatic. Diagnosis of medial plica syndrome involves physical exam and imaging studies, but the current gold standard is arthroscopy and therefore a definitive diagnosis cannot be made until surgery. As such, medial plicae are the most commonly missed diagnoses in the knee as it is purely a clinical diagnosis. Medial plica syndrome can be treated with physiotherapy, corticosteroid injections, or surgery. Overall, good outcomes have been seen following diagnosis and treatment of medial plica syndrome, with patients returning to their preferred levels of activity. This article reviews the topic of medial plica syndrome.

Cardiomyopathy in the mouse model of Duchenne muscular dystrophy caused by disordered secretion of vascular endothelial growth factor.

BACKGROUND: Duchenne muscular dystrophy (DMD) is a genetic neuromuscular disorder that affects skeletal muscles and cardiac muscle tissue. In some cases, myocardial injury secondary to hypoxia can lead to dilative cardiomyopathy (DCM). A genetic defect in the dystrophin gene may increase the susceptibility of myocardium to hypoxia. Available data suggest that this may be caused by impaired secretion of NO, which is bound with secretion of VEGF-A. MATERIAL/METHODS: Male mice C57BI/10ScSn mdx (animal model of DMD) and healthy mice C57BI/10ScSn were exposed to hypobaric hypoxia in low-pressure chambers. Their hearts were harvested immediately after and 1, 3, 7, and 21 days after exposure to hypoxia. Normobaric mice were used as controls. The expression of VEGF-A in myocardium and cardiac vessel walls was evaluated using immunohistochemistry, Western blotting, and in situ hybridization. RESULTS: VEGF-A expression in myocardium and vessel walls of healthy mice peaked 24 hours after exposure to hypoxia. The expression of VEGF-A in vessel walls was similar in dystrophic and healthy mice; however, VEGF-A expression in the myocardium of dystrophic mice was impaired, peaking around day 7. In the heart, the total level of VEGF depends on VEGF expression in myocardium, not in vessel endothelium, and our research demonstrates that the expression of VEGF is dystrophin-dependent. CONCLUSIONS: Disordered secretion of VEGF-A in hypoxic myocardium caused the total level of this factor to be impaired in the heart. This factor, which in normal situations protect against hypoxia, promotes the gradual progression of cardiomyopathy.

A review of the thoracic splanchnic nerves and celiac ganglia.

Anatomical variation of the thoracic splanchnic nerves is as diverse as any structure in the body. Thoracic splanchnic nerves are derived from medial branches of the lower seven thoracic sympathetic ganglia, with the greater splanchnic nerve comprising the more cranial contributions, the lesser the middle branches, and the least splanchnic nerve usually T11 and/or T12. Much of the early anatomical research of the thoracic splanchnic nerves revolved around elucidating the nerve root level contributing to each of these nerves. The celiac plexus is a major interchange for autonomic fibers, receiving many of the thoracic splanchnic nerve fibers as they course toward the organs of the abdomen. The location of the celiac ganglia are usually described in relation to surrounding structures, and also show variation in size and general morphology. Clinically, the thoracic splanchnic nerves and celiac ganglia play a major role in pain management for upper abdominal disorders, particularly chronic pancreatitis and pancreatic cancer. Splanchnicectomy has been a treatment option since Mallet-Guy became a major proponent of the procedure in the 1940s. Splanchnic nerve dissection and thermocoagulation are two common derivatives of splanchnicectomy that are commonly used today. Celiac plexus block is also a treatment option to compliment splanchnicectomy in pain management. Endoscopic ultrasonography (EUS)-guided celiac injection and percutaneous methods of celiac plexus block have been heavily studied and are two important methods used today. For both splanchnicectomies and celiac plexus block, the innovation of ultrasonographic imaging technology has improved efficacy and accuracy of these procedures and continues to make pain management for these diseases more successful.

The description of vascular variations in three-dimensional space: a novel method of spatial cerebral arteries evaluation.

BACKGROUND: Anatomical and clinical descriptions of variations in arteries are based solely on anatomical terminology. New diagnostic techniques depend on terms such as the anterior, posterior, superior, inferior, medial, and lateral location of arteries and their branches or bifurcations, trifurcations, and fenestrations. However, these methods may be obsolete and such a simplistic approach is inadequate, especially for procedures that require precise morphological and morphometrical descriptions in 3D space. This is critical for neruonavigational surgery and interventional vascular radiology. MATERIAL/METHODS: This paper presents a new system for the accurate location and description of structural variations in vessels which is based on the alpha, beta, and gamma direction cosines. The algorithm can be summarized in the following steps: acquisition of the point coordinates in 3D space, interpolation, recovery of the 3D point coordinates, and calculation of the interpolated trajectory. RESULTS: New parameters (cos alpha, beta, and gamma, the tortuous index TI, and the deviation index DI) were calculated for the spatial description of vessels. CONCLUSIONS: By using this new method, new vascular descriptive methods have been proposed. It is possible that new categories as well as vessel variations may be found. The curvature and tortuosity of the vascular segments can also be considered more effective when incorporated into the description of vessels, especially in cases where pathologies such as tumors have altered the vessel in some way.

Structural and functional characteristic of a model for deep-seated lacunar infarct in rats.

Deep-brain lacunar infarct represents a significant clinical problem as it produces severe symptoms highly resistant to rehabilitation. The limited area of necrosis may facilitate neurorepair via the action of various novel neuroprotective strategies including cell-based therapies. The lesion was induced by stereotactic injection of ouabain into adult rat brains. Subsequent behavioral testing involved beam walking task, rotarod, visual discrimination task and apomorphine rotation. For morphological and topographical analysis brain slices were stained with H-E and evaluated under light microscopy. Lesion size was measured in absolute terms and in relation to the whole brain volume. Immunohistochemical analysis for the co-localization of BrdU with specific cell-type markers (PSA-NCAM, NG2, beta-tubulin III, GFAP, ED1) have has been performed, to determine the fate of newly generated cells with emphasis on evidence of neurogenesis. The lesion involved the basal ganglia, basal forebrain nuclei, internal capsule and striatum (just 1-2% of total brain volume). Significant and relatively stable behavioral deficits were observed up to 30 days. Furthermore, large numbers of cells are seen to be newly generated in response to injury with a significant proportion of these being present on account of neurogenesis.

The clinical relevance of coeliac trunk variations.

The coeliac trunk is a surgically significant artery originating from the abdominal aorta and supplying the supracolic organs. Branches of this arterial trunk supply the primary organs of the abdomen and divert a significant volume of blood from the abdominal aorta. Past research has shown that the anatomy of the coeliac trunk is not identical for all human beings and that about 15% of the population displays significant variations from the typical branching pattern. Data derived from earlier research has been consolidated to give an account of the major variations found in the anatomy of the coeliac trunk and to put forward some theories for the cause of such variation. It is crucial to achieve full comprehension of these topics as knowledge of these variations is indispensable in operative and diagnostic procedures within the abdomen. Without understanding of the arterial architecture and knowledge of the variation characterising the patient in this critical region surgery may entail a considerable risk of an error being committed that may occasionally lead to lethal complications.

[Transplantation of islets of langerhans--alternative or solution in type 1 diabetes treatment?]. / Przeszczep wysp trzustkowych langerhansa--alternatywa czy rozwiazanie w leczeniu cukrzycy typu 1?

Diabetes mellitus is severe disease caused by partial or total lack of insulin leading to microangiopathy. Methods of treatment used today do not protect patients from the complications of disease. The proposed alternative of the treatment is transplantation of the pancreas islets. Till June 2003, 705 transplantation were performed worldwide. Allotransplant trials were described so far, while xenotransplants may appear as an alternative using alien species donors. Immune incompatibility of a human and animals is a major problem in the method, which can be solved by the use of genetically modified animals. In vitro genetic modifications of the pancreatic islets were already undertaken. New perspective arose with the development of the "stem cells" technology--differentiation of the primary cells into the Langerhans islets cells. Contemporary data show positive value of the method and give new perspective in the treatment of diabetes mellitus with respect to its rising morbidity.