Epiphora and Hyperlacrimation as Paradoxical Manifestations of Facial Nerve Injury: Mechanistic Insights.

The incidence of facial nerve paralysis is approximately 30 per 100,000 persons annually. Although it is often idiopathic, as in Bell's palsy, it can also result from infections, trauma, or neoplasms. Facial nerve paralysis may present with partial or total facial paresis, lagophthalmos, denervation of the lacrimal gland, and other ocular abnormalities. While dry eye is a commonly expected outcome of facial nerve injury, some patients may paradoxically experience epiphora and hyperlacrimation. In this review, we examine this phenomenon and its mechanisms in facial nerve injury. Several mechanisms have been proposed for epiphora and hyperlacrimation, including aberrant axonal regeneration, which is known to cause crocodile tears syndrome; ocular irritation due to dry eye, resulting in increased reflex lacrimation due to disruption of the tear film; and impaired drainage of tears caused by paralysis of the orbicularis oculi muscle and malposition of the eyelids. Understanding the pathophysiology of these symptoms is crucial in guiding the management of patients with facial nerve injury. Further experimental and clinical studies focusing on the quantification of tear production and localization of nerve damage will help improve our understanding of the neuroanatomical correlates of this paradoxical manifestation.

Nontuberculous Mycobacterial Flexor Tenosynovitis of the Wrist and Hand.

Nontuberculous mycobacteria (NTM) are uncommon causes of cutaneous and musculoskeletal infections. Here, we present an immunocompromised patient with persistent swelling in the left hand, wrist, and distal forearm. MRI findings revealed flexor tenosynovitis with synovial hypertrophy of the left hand and wrist and loculated fluid containing rice bodies along the distal flexor digitorum muscles in the volar aspect of the left wrist. The patient underwent flexor tenosynovectomy, and histological examination of the excised tenosynovium and mass revealed noncaseating granulomas. Mycobacterium intracellulare was identified in microbiological cultures. Antimycobacterial therapy was administered postoperatively to manage the infection. This report underscores the significance of maintaining a high index of suspicion for NTM infection when assessing chronic hand swelling, particularly in individuals with compromised immune systems.

Typical brachial plexus: the legacy of a forgotten anatomist, Abram T. Kerr (1873-1938).

The brachial plexus, a complex network of nerves responsible for innervating the upper limb, exhibits remarkable anatomical variations. This editorial explores the composite drawing of a "typical" brachial plexus portrayed by Abram T. Kerr in 1918. This composite drawing of the typical brachial plexus stands as a critical contribution to the field of anatomy and surgery, and encapsulates the most prevalent patterns of formation, branching, and origins within the brachial plexus, offering a statistical map of its common variants. Kerr portrays the typical brachial plexus as a foundational resource for anatomists and medical professionals seeking to navigate the intricate landscape of this neural structure. It serves as a hypothetical model, reflecting the common arrangement of trunks, cords, and branches, shedding light on the typical composition of the plexus observed in most individuals. Beyond being a visual representation, the 'typical' brachial plexus provides a bridge between theoretical knowledge and practical applications, aiding in the identification of variations and deviations in surgical contexts. This composite drawing enhances our comprehension of the intricate and ever-evolving anatomy of the brachial plexus, reinforcing its role as a fundamental reference point for anatomical studies and clinical practice.

Conservative Management of a Delayed Benign Gastrobronchial Fistula: A 20-Year Follow-up.

We describe a case of gastrobronchial fistula (GBF) following a thoracoabdominal gunshot wound in a previously healthy young man. Despite initial surgery, the patient suffered recurrent hemoptysis, and a GBF was diagnosed 18 months after initial presentation. The patient was treated with oral proton pump inhibitors for a prolonged period with the resolution of the fistula. During a follow-up 20 years later, no recurrence of the fistula was noted. The importance of early diagnosis of such fistulae cannot be overstated. This report provides a testimony to the feasibility of the conservative approaches in managing delayed, benign, and post-traumatic GBF.

Dakin's Solution: "One of the most important and far-reaching contributions to the armamentarium of the surgeons".

Henry Drysdale Dakin is a notable person in the history of surgery, wound care, military medicine and infectious disease control. Dakin is an exemplar scientist who in the midst of war forged an international collaboration with scientists in multiple fields to create and universalize an antiseptic utopia, which saved thousands lives during World War I, remarkably diminished functional disabilities from wounds and continues to be a "far-reaching armamentarium" of the surgeons and wound care specialists around the globe. Dakin investigated over 200 different antiseptic substances to finally conclude that a 0.5% buffered sodium hypochlorite solution satisfies his criteria for an ideal antiseptic. The only potential limitation was that the germicidal property of the solution was short lived, which meant the solution had to be used continuously or repeatedly delivered into wounds. Dakin's solution, still in use by modern wound care specialists around the globe, has laid the foundation for wound care management as we know it today. Nevertheless, Dakin contributed more to science than just his solution. In this article, Dakin's life story, his unique scientific career and his contributions to surgical literature are explored. The article also illustrates how a wartime necessity resulted in a medical discovery that is still in use to date.

Acute Thyroid Storm Following Thymectomy: A Surprising Result of Undiagnosed Graves' Disease.

Postoperative thyroid storm represents a diagnostic dilemma in patients with overlooked hyperthyroid state undergoing a nonthyroid surgery. We report a 30-year-old female with a history of mixed connective tissue disease who presented with an anterior mediastinal mass and underwent a thoracoscopic resection of the mass. On postoperative day 1, she had an acute change in mental status with fever, tachycardia and hypercapnic respiratory failure requiring intubation and mechanical ventilation. An elevated free thyroxine concentration and almost undetectable serum thyroid stimulating hormone suggested thyroid storm as the culprit. The patient was rendered euthyroid after initiation of therapy with propylthiouracil/methimazole, potassium iodide oral solution and systemic steroid. Histopathology of the resected anterior mediastinal mass showed thymic hyperplasia. In retrospect, the patient had hyperthyroid symptoms before surgery, but this diagnosis was overlooked. Non-thyroid surgeries can trigger thyroid storm in the setting of poorly controlled or overlooked hyperthyroidism. Although uncommon, thyroid storm should be considered in differential diagnosis of perioperative tachycardia and respiratory failure. We emphasize on the importance of preoperative thyroid workup in patients with tachycardia, palpitation, labile blood pressure, unexplained weight changes or poorly controlled anxiety. The significance of a proper preoperative assessment cannot be overestimated.

Embryology of the craniocervical junction and posterior cranial fossa, part II: Embryogenesis of the hindbrain.

Although pathology of the hindbrain and its derivatives can have life altering effects on a patient, a comprehensive review on its embryology is difficult to find in the peer-reviewed medical literature. Therefore, this review article, using standard search engines, seemed timely. The embryology of the hindbrain is complex and relies on a unique timing of various neurovascular and bony elements. Derailment of these developmental processes can lead to a wide range of malformations such as the Chiari malformations. Therefore, a good working knowledge of this embryology as outlined in this review of the hindbrain is important for those treating patients with involvement of this region of the central nervous system. Clin. Anat. 31:488-500, 2018. © 2018 Wiley Periodicals, Inc.

Double dermal sinus tracts of the cervical and thoracic regions: a case in a 3-year-old child and review of the literature.

INTRODUCTION: Dermal sinus tracts are rare congenital abnormalities characterized by an epithelium-lined tract that extends from the subcutaneous tissue to the underlying thecal sac or neural tube. These developmental anomalies can present asymptomatically with a cutaneous dimple or with devastating complications including recurrent episodes of meningitis, or neurological complications including paralysis. Dermal sinus tracts generally occur as single lesions, and the presentation of midline double dermal sinus tracts of the cervical and thoracic regions has not been previously described. METHODS: Here, we present the case of a 3-year-old girl suffering from recurrent episodes of myelitis, paraparesis, and intramedullary intradural masses, who was diagnosed with double dermal sinus tracts of the cervical and thoracic regions. We also present a summary of all previous reported cases of multiple dermal sinus tracts. RESULTS: Our patient was successfully treated surgically and is now 2 years status post her last procedure with a significant improvement in her neurologic function and normal muscle strength and tone for her age, and there was no recurrence of her symptoms. CONCLUSIONS: Early treatment with prophylactic surgery should be performed when possible, but removal of these lesions once symptoms have arisen can also lead to success, as in the case presented here. Complete excision and intradural exploration is required to excise the complete tract.

Association of cystathionine beta-synthase polymorphisms and aneurysmal subarachnoid hemorrhage.

OBJECTIVE Cystathionine ß-synthase (CBS) is involved in homocysteine and hydrogen sulfide (H2S) metabolism. Both products have been implicated in the pathophysiology of cerebrovascular diseases. The impact of CBS polymorphisms on aneurysmal subarachnoid hemorrhage (aSAH) and its clinical sequelae is poorly understood. METHODS Blood samples from all patients enrolled in the CARAS (Cerebral Aneurysm Renin Angiotensin System) study were used for genetic evaluation. The CARAS study prospectively enrolled aSAH patients at 2 academic institutions in the United States from 2012 to 2015. Common CBS polymorphisms were detected using 5'exonuclease genotyping assays. Analysis of associations between CBS polymorphisms and aSAH was performed. RESULTS Samples from 149 aSAH patients and 50 controls were available for analysis. In multivariate logistic regression analysis, the insertion allele of the 844ins68 CBS insertion polymorphism showed a dominant effect on aSAH. The GG genotype of the CBS G/A single nucleotide polymorphism (rs234706) was independently associated with unfavorable functional outcome (modified Rankin Scale Score 3-6) at discharge and last follow-up, but not clinical vasospasm or delayed cerebral ischemia (DCI). CONCLUSIONS The insertion allele of the 844ins68 CBS insertion polymorphism was independently associated with aSAH while the GG genotype of rs234706 was associated with an unfavorable outcome both at discharge and last follow-up. Increased CBS activity may exert its neuroprotective effects through alteration of H2S levels, and independent of clinical vasospasm and DCI.

Adult Apical Ligament of the Dens Lacks Notochordal Tissue: Application to Better Understanding the Origins of Skull Base Chordomas.

INTRODUCTION: The apical ligament has long been reported to contain notochord remnants and thus might serve as a site of origin of chordoma formation at the skull base. However, to our knowledge, the histologic study of the apical ligament using histologic staining specific for notochordal tissue has not been previously performed. Therefore the current study was undertaken. METHODS: Fifteen apical ligament samples underwent histologic examination with specific markers for notochordal differentiation. RESULTS: Across all samples, there was no indication of any notochordal remnants. CONCLUSIONS: On the basis of our cadaveric study, the apical ligament does not contain notochord tissue and in adults should not be considered a remnant of this structure. Moreover, it is unlikely that the apical ligament gives rise to chordomas at the craniocervical junction under normal circumstances.

Antifibrinolytic therapy in aneurysmal subarachnoid hemorrhage increases the risk for deep venous thrombosis: A case-control study.

OBJECTIVES: Aneurysm re-rupture is associated with significant morbidity and mortality in aneurysmal subarachnoid hemorrhage (aSAH). While antifibrinolytics reduce aneurysm re-rupture rates, they have been associated with hydrocephalus, delayed cerebral ischemia, and venous thrombosis. We performed a case-control study in patients enrolled in the Cerebral Aneurysm Renin Angiotensin System (CARAS) study to evaluate the impact of short course (<48 h) ɛ-aminocaproic acid (EACA) on deep venous thrombosis (DVT) rates. PATIENTS AND METHODS: A case-control study design was utilized to evaluate the effect of EACA on DVT formation. All cases and controls were obtained from the CARAS study, a prospective, blinded study assessing the association of polymorphisms in the renin angiotensin system and aSAH. RESULTS: One hundred and twenty-eight eligible patients were enrolled in CARAS. Overall, 48 (37.5%) patients were screened for DVT, 57 (44.5%) patients were treated with short course (<48 h) EACA, and 8 (6.3%) patients suffered a re-rupture (4 treated with EACA). Ten patients (7.8%) were diagnosed with DVT as evidenced by Doppler US and represent the cases. Twenty controls without evidence of a DVT matched for age, sex, race, tobacco history, Hunt-Hess score, Fisher grade, body mass index, and length of stay were identified from the remaining pool of 118 patients. EACA was found to significantly increase the risk of DVT formation in patients with aSAH (OR 8.49, CI 1.27-77.1). CONCLUSION: Short course (<48 h) administration of EACA in patients with aneurysmal subarachnoid hemorrhage is associated with an 8.5 times greater risk of DVT formation.

Venous drainage of the spine and spinal cord: a comprehensive review of its history, embryology, anatomy, physiology, and pathology.

Venous drainage of the spine and spinal cord is accomplished through a complex network of venous structures compartmentalized to intrinsic, extrinsic, and extradural systems. As the literature on this topic is scarce, the following review was performed to summarize the available literature into a single coherent format. The medical literature on the spinal venous system was reviewed using online sources as well as historical documents that were not available online in regard to history, embryology, anatomy, and physiology with a particular emphasis on the pathology affecting this system. The spinal venous system is complex and variable. Proper understanding of all aspects is critical for the management of the pathology that results from its failure.

Return to system within 30 days of discharge following pediatric non-shunt surgery.

OBJECT: Hospital readmission after discharge is a commonly used quality measure. In a previous study, the authors had documented the rate of readmission and reoperation after pediatric CSF shunt surgery. This study documents the rate of readmission and reoperation after pediatric neurosurgical procedures excluding those related to CSF shunts. METHODS: Between May 1, 2009, and April 30, 2013, 3098 non-shunt surgeries during 2924 index admissions were performed at a single institution. Demographic, socioeconomic, and clinical characteristics were prospectively collected in the administrative, business, and clinical databases. Clinical events within the 30 days following discharge were reviewed and analyzed. The following events of interest were analyzed for risk factor associations using multivariate logistic regression: return to the emergency department (ED), all-cause readmission, readmission to the neurosurgical service, and reoperation. RESULTS: The number of all-cause readmissions within 30 days of discharge was 304 (10.4%, 304/2924). Admission sources consisted of the ED (n = 173), hospital transfers (n = 47), and others (n = 84). One hundred eighty of the 304 readmissions were associated with an operation, but only 153 were performed by the neurosurgical service (reoperation rate = 5.2%). These procedures included wound revisions (n = 30) and first-time shunt insertions (n = 35). The remaining 124 readmissions were nonsurgical, and only 54 were admitted to the neurosurgical service for issues related to the index non-shunt surgery. Thus, the rate of related readmission was 7.1% ([153 + 54]/2924). A longer length of stay and admission to the neonatal intensive care unit during the index admission were associated with an increased likelihood of return to the ED and readmission. Certain procedures, such as baclofen pump insertion and intracranial pressure monitor placement, were also found to be associated with adverse clinical events in the 30-day period. Lastly, patients were more likely to a undergo reoperation if the index procedure had started after 3 p.m. CONCLUSIONS: The all-cause readmission rate within 30 days of discharge after a pediatric neurosurgical procedure was 10.4%, and the rate of related readmission was 7.1%. Whether these readmissions are preventable and to what extent they are preventable requires further study.

The fibular collateral ligament of the knee: a detailed review.

The fibular collateral ligament (FCL) is one of the larger ligaments of the knee. The FCL, along with the popliteus tendon, arcuate popliteal ligament, and joint capsule, make up the posterolateral corner of the knee. Recently, there has there been an increased awareness and research on the structures of the posterolateral corner of the knee, particularly the FCL. Studying the detailed structure of the FCL may provide a better understanding that can lead to better diagnosis and treatments following injury. Therefore, this article reviews the FCL, which appears to be the primary restraint to varus rotation but is poorly oriented to resist external rotation of the knee.

Anatomic study of the deltoid ligament of the ankle.

BACKGROUND: There is heterogeneity in the literature regarding the anatomy and number of ligamentous bands that form the deltoid ligament (DL). Anatomic knowledge of the DL and its variations are important for surgeons who repair ankle fractures. METHODS: The DL was dissected in 33 ankles from 17 formalin-fixed cadavers (mean age at death, 76.6 years) to examine its morphology. The length, width, and thickness of its constituent bands were recorded with a digital caliper. Descriptive and correlational statistics were used to investigate the relationships between band size, age at death, and sex. A literature review was conducted to compare our data to those of previous studies. RESULTS: The DL has superficial and deep layers with up to 8 different bands. CONCLUSION: The DL stabilizes the medial ankle and should be evaluated in flatfoot deformities and severe ankle fractures. CLINICAL RELEVANCE: Anatomic knowledge of DL variations should aid the surgeon in repairing torn DLs.

Return to system within 30 days of discharge following pediatric shunt surgery.

OBJECT: The rate of readmission after CSF shunt surgery is significant and has caught the attention of purchasers of health care. However, a detailed description of clinical scenarios that lead to readmissions and reoperations after index shunt surgery is lacking in the medical literature. METHODS: This study included 1755 shunt revision and insertion surgeries that were performed at a single institution between May 1, 2009, and April 30, 2013. Demographic, socioeconomic, and clinical characteristics were prospectively collected in the administrative, business, and operating room databases. Clinical events within the 30 days following discharge were reviewed and analyzed. Two events of interest, Emergency Department (ED) utilization and reoperation, were further analyzed for risk factor associations by using multivariate logistic regression. RESULTS: There were 290 readmissions within 30 days of discharge (16.5%). Admission sources included ED (n = 216), hospital transfers (n = 23), and others. Of the 290 readmissions, 184 were associated with an operation, but only 165 of these were performed by the neurosurgical service. These included surgeries for shunt occlusion and externalization (n = 150), wound revision (n = 7), and other neurosurgical procedures that were not shunt related (n = 8). The remaining readmissions (n = 106) were not associated with an operation, and only 59 patients were admitted for issues related to the index shunt surgery. When return to the ED was the dependent variable in a multivariate regression model, patients who returned to the ED were more likely to be from the Atlanta metropolitan area and to be either uninsured or insured with public assistance. When reoperation was the dependent variable, patients whose surgery started after 3 p.m. were more likely to undergo subsequent CSF shunt revision surgery on readmission. CONCLUSIONS: Of the readmissions within 30 days of shunt surgery, 74.5% were related to the index shunt surgery. Whether and to what extent these readmissions are preventable continues to be controversial. Further study is needed to identify modifiable risk factors that may eventually improve patient care.

Arterial supply of the lower cranial nerves: a comprehensive review.

The lower cranial nerves receive their arterial supply from an intricate network of tributaries derived from the external carotid, internal carotid, and vertebrobasilar territories. A contemporary, comprehensive literature review of the vascular supply of the lower cranial nerves was performed. The vascular supply to the trigeminal, facial, vestibulocochlear, glossopharyngeal, vagus, spinal accessory, and hypoglossal nerves are illustrated with a special emphasis on clinical issues. Frequently the external carotid, internal carotid, and vertebrobasilar territories all contribute to the vascular supply of an individual cranial nerve along its course. Understanding of the vasculature of the lower cranial nerves is of great relevance for skull base surgery.

Petrus Camper: A history and overview of the clinical importance of Camper's fascia in surgical anatomy.

Petrus Camper's contributions to modern anatomical science include descriptions of the foot, upper limb, axilla, and inguinal region. His explanation of the etiology of inguinal hernias revolutionized the surgical practice of their repair. Camper's description of abdominal anatomy was an invaluable contribution to the field of abdominal surgery. Current research reviewed in this article shows the importance of understanding the layers of the abdominal wall, notably Camper's fascia, the closure of which has been found to be vital to proper wound healing and patient recovery. This article begins with a biography of Petrus Camper and his research in the inguinal region. It continues with anatomical and histological descriptions of Camper's fascia and finishes with its clinical correlates in surgical practice.

The impact of temporary artery occlusion during intracranial aneurysm surgery on long-term clinical outcome: Part II. The patient who undergoes elective clipping.

BACKGROUND: Temporary artery occlusion (TAO) during intracranial aneurysm surgery is a key element in facilitating aneurysm dissection and clipping. Despite its significance, knowledge of its effects on long-term clinical outcome in patients undergoing elective clipping for unruptured aneurysms is limited. This study evaluated the safety of this technique in this patient population by 1 surgeon. METHODS: Patients managed for an intracranial aneurysm were followed from 2000-2009. This study included a cohort of patients found to have unruptured intracranial aneurysms who underwent TAO during their elective clipping procedure. Potential risk factors to affect outcome were considered. Effects of TAO on long-term clinical outcome were evaluated using the Glasgow Outcome Scale (GOS) obtained retrospectively by analyzing medical records at the last follow-up visit or discharge. Analyses included descriptive statistics, binary logistic regression, and ordinal logistic regression. RESULTS: Inclusion criteria were met by 246 patients (75.2% female, age 54 years±10.9) with electively clipped, unruptured aneurysms. Mean follow-up was 53 months±67.5. Mean temporary artery clipping time was 16.1 minutes±14.7. Of patients, 86% had a good outcome and made a complete recovery at last follow-up (GOS 5); 9% of patients were moderately disabled (GOS 4); 5% of patients were severely disabled (GOS 3), were in a vegetative state (GOS 2), or had died (GOS 1). TAO time had no effects on overall long-term clinical outcomes (P=0.59). Although patients with posterior circulation aneurysms had a worse outcome compared with patients with anterior circulation aneurysms (P=0.008), age (P=0.176) and aneurysm size (P=0.497) were not significantly associated with clinical outcome. CONCLUSIONS: This study did not demonstrate any relationship between limited duration of TAO and clinical outcome. Posterior circulation aneurysms are associated with worse long-term clinical outcomes in patients with electively clipped, unruptured aneurysms.