Pelvic Neuro-Visualization: An Anatomical Illustration of the Autonomic Pelvic Nervous Network in Gynecologic Surgery.

OBJECTIVE: During radical pelvic surgeries fibers of the autonomic pelvic nervous network can be accidentally damaged leading to significant visceral sequelae, which dramatically affect women's quality of life because of urinary, anorectal, and sexual postoperative dysfunctions.1,2 Direct visualization is one way to preserve hypogastric nerves (HNs), pelvic splanchnic nerves (PSNs), and the bladder branches from the inferior hypogastric plexus (IHP). However, the literature lacks critical photos and/or illustrations that are necessary to understand the precise anatomy needed to preserve the pelvic autonomic fibers. DESIGN: Narrated laparoscopic video footage for identifying, dissecting, and preserving the autonomic nerve bundles during pelvic surgery. SETTING: Tertiary level hospital-"IRCCS Istituto Nazionale dei Tumori", Milano, Italy. INTERVENTIONS: Visceral pelvic innervation is established by the superior hypogastric plexus(SHP) located anteriorly to the aortic bifurcation and the median sacral vessels and carries mostly sympathetic fibers. SHP divides in front of the sacrum into the right and left HN. At the level of the paracervix, the HNs join the parasympathetic PSNs coming out from sacral root S2, S3, S4 to form the IHP.2-5 Here, we performed laparoscopic surgery, before "Laparoscopic Approach to Cervical Cancer" trial (LACC) era, identifying key anatomic landmarks useful to highlight the path of the most commonly encountered autonomic pelvic nerves in gynecologic radical surgery: during the narration we describe and illustrate the procedure to identify all autonomic pelvic nerves, the sympathetic fibers, the PSNs, and the bladder branch emerging from the IHP in order to preserve their anatomic and functional integrity. This technique is anatomically and surgically indicated for adequate removal of the parametrical issues and vagina while preserving the total pelvic nervous system. CONCLUSION: Nerve-sparing surgery reduces bowel-, bladder- and sexual- dysfunction without decreasing surgical efficacy.1,2 To accomplish safe and effective surgery, comprehension of the 3 dimensional structure of the vascular and nerve anatomy in the pelvis is essential. This video provides a great resource to educate surgeons, especially the youngest ones, about the retroperitoneal nervous networking: we identified the autonomic nerve pathway from adjacent tissues along the pathway consisting of cardinal, sacro-uterine, rectouterine/vaginal, and vesico-uterine ligaments.

El término glía, una tradición conceptual errada: propuesta de cambio por sinneuronas / The term glia, a wrong conceptual tradition: proposal for change for synneurons

RESUMEN: Desde su descubrimiento, las células no neuronales del sistema nervioso recibieron el nombre de glia, palabra de origen griego que significa unión o pegamento, porque se creía que su función era formar una especie de masilla en la que se encuentran inmersas las neuronas. Desde entonces, mediante nuevas técnicas de tinción, se descubrieron otros tipos celulares que fueron catalogados también como glía, que hasta la fecha siguen siendo consideradas como las células de unión o pegamento del tejido nervioso. El objetivo de este artículo es cuestionar el uso inadecuado del término glía y proponer un nuevo término para designar a las células no neuronales. A pesar del enorme conocimiento que actualmente se tiene de estas células y de la gran variedad de funciones que realizan para mantener el correcto funcionamiento de las neuronas y los circuitos nerviosos, aún se les conserva el nombre de glía, un término errado que desdibuja el verdadero papel que cumplen y su importancia para el sistema nervioso. Por lo anterior, se propone el término "sinneuronas", del prefijo griego syn que significa con o junto con, lo que daría a entender que son células que presentan cercanía estructural y funcional con las neuronas.

SUMMARY: Since their discovery, the non-neuronal cells of the nervous system have been called glia, a word of Greek origin that means union or glue, because it was believed that their function was to form a kind of putty, in which neurons are immersed. Thereafter, new cell types discovered by new staining techniques, were also classified as glia, which to this day are still considered as binding cells or glue of nerve tissue. The objective of this paper is to question the inappropriate use of the term glia and to propose a new term to designate non-neuronal cells. Despite the enormous knowledge that is currently available of these cells and the great variety of functions they perform to maintain the proper functioning of neurons and nerve circuits, they still retain the name of glia, an inappropriate name that blurs the true role they play. Therefore, the term "synneuronas" is proposed, from the Greek prefix syn which means with or together with, what would suggest that they are cells that present structural and functional proximity with to neurons.

Neurovascular and lymphatic vessels distribution in uterine ligaments based on a 3D reconstruction of histological study: to determine the optimal plane for nerve-sparing radical hysterectomy.

OBJECTIVE: To present the distribution of neurovascular and lymphatic vessels in uterine ligaments using 3D models based on the pathological staining of serial 2D sections of postoperative specimens. METHODS: Serial transverse sections of fresh uterine ligaments from a patient with stage IB1 cervical squamous cell carcinoma were studied using the computer-assisted anatomic dissection (CAAD) technique. The sections were stained with hematoxylin and eosin, Weigert elastic fibers, D2-40 and immunostainings (sheep anti-tyrosine hydroxylase and rabbit anti-vasoactive intestinal peptide). The sections were then digitalized, registered and reconstructed three-dimensionally. Then, the 3D models were analyzed and measured. RESULTS: The 3D models of the neurovascular and lymphatic vessels in uterine ligaments were created, depicting their precise location and distribution. The vessels were primarily located in the upper part of the ligaments model, while the pelvic autonomic nerves were primarily in the lower part; the lymphatic vessels were scattered in the uterine ligaments, without obvious regularity. CONCLUSION: CAAD is an effective anatomical method to study the precise distribution of neurovascular and lymphatic vessels in uterine ligaments. It can present detailed anatomical information about female pelvic autonomic innervation and the spatial relationship between nerves and vessels and may provide a better understanding of nerve-sparing radical hysterectomy.

Anatomical considerations for transanal minimal-invasive surgery: the caudal to cephalic approach.

AIM: Nerve-sparing surgery during laparoscopic rectal mobilization is still limited by anatomical constraints such as obesity, the narrowness of the male pelvis, an ultra low rectal cancer or all of these. The transanal approach for total mesorectal excision has overcome the shortcomings of limited access to the rectal 'no-man's land' close to the pelvic floor. The aim of this anatomical study was to define a roadmap of anatomical landmarks for the caudal to cephalic approach so as to standardize nerve-sparing rectal mobilization procedures. METHOD: Macroscopic dissections of the pelvis in a caudal to cephalic direction were performed in eight alcohol-glycerol embalmed cadavers. A roadmap of anatomical landmarks was created at different levels of section to demonstrate the sites of nerve injury. RESULTS: Extrinsic autonomic nerves to the urogenital organs and the internal sphincter muscle are closely adjacent to the lowest portion of the rectum above the pelvic diaphragm. CONCLUSION: This anatomical guide for the pelvic surgeon should facilitate a safe and nerve-sparing dissection of the mesorectal plane with a meticulous overview of the lowest autonomic nerve fibres. New anatomical insights by a 'caudal to cephalic' approach to the 'no-man's land' should help overcome anatomical constraints of a narrow, obese and male pelvis during rectal mobilization procedures.

[A comparative study of the laparoscopic appearance and anatomy of the autonomic nervous in normal males].

OBJECTIVE: To further understand the anatomical basis of pelvic autonomic nerve preservation. METHODS: Autopsy of five adult male donated cadavers was performed. Meanwhile, ten videos of laparoscopic total mesorectal excision for male mid-low rectal cancer admitted from January to June 2012 were observed and studied. Anatomical features of pelvic autonomic nerve were compared between autopsy and laparoscopic appearance. RESULTS: Autopsy observations indicated that:the abdominal aortic plexus was situated upon the sides and front of the aorta, between the origins of the superior and inferior mesenteric arteries. The superior hypogastric plexus was a plexus of nerves situated on the the bifurcation of the abdominal aorta to sacrum; after incision of sacrum fascia was done cling to the sacrum; the pelvic splanchnic nerves and sacral splanchnic nerves were demonstrated; pelvic splanchnic nerves were splanchnic nerves that arised from ventral rami of the second, third, and often the fourth sacral nerves to provide preganglionic parasympathetic innervation to the hindgut;sacral splanchnic nerves providing postganglionic fibers, emerged from the sympathetic trunk, were then joined by the pelvic splanchnic nerves to form the inferior hypogastric plexuses which were placed lateral to the rectum.Laparoscopic observations showed that:abdominal aortic plexus and superior hypogastric plexus were unclear; at the level of sacroiliac joint, the hypogastric nerve began where the superior hypogastric plexus split into a right and left plexus, situated under the loose connective tissue, and continued inferiorly on its corresponding side of the body at the level of the 3rd sacral vertebra;left hypogastric nerve was closed to posterior of mesorectum;denonvilliers fascia was thin, reflective fascial structure, and easily removed together with mesorectum excision because of anterior loose structure. CONCLUSIONS: Ligation of the inferior mesenteric artery at its origin is safe.Excessive dissection of the connective tissue covering the surface of the aorta should be avoided to protect the abdominal aortic plexus.Sharp dissection performed by pursuing the outer surface of the mesorectum maintaining the integrity of mesorectum, could avoid the superior hypogastric plexus and hypogastric nerves injury posteriorly, and protect the inferior hypogastric plexues while cutting lateral ligament laterally. The integrity of Denonvilliers fascia during anterior resection of rectum should be confirmed to avoid urogenitalis aparatus branches damage.

Revisitando a fisiologia do sistema nervoso simpático: o que há de novo? / Facing sympathetic nervous system physiology: what's new?

o sistema nervoso autônomo (SNA), descrito no inicio do século passado, é definido como sendo o sistema de neurônios motores que inervam as glândulas e a musculatura lisa e cardíaca, sendo fundamental para a manutenção do equilibrio organismo, definindo esta situação com o termo "homeostasia", Atualmente, entretanto, reconhece-se que este sistema também apresenta neurônios sensoriais (neurônios aferentes), que transmitem as informações recebidas de receptores sensoriais autonômicos, principalmente viscerais, para o sistema nervoso central. O termo autônomo, hoje consagrado, vem da ideia de que este sistema atuava somente de forma autônoma; no entanto, hoje se admite que a atividade deste sistema é gerada, ou pelo menos supervisionada, pelo sistema nervoso central. A ativação e a desativação tônicas e reflexas de seus dois componentes, simpático e do parassimpático, determinam em condições fisiológicas ajustes do débito cardíaco e da resistência vascular periférica, contribuindo para a estabilização e manutenção da pressão arterial sistêmica durante diferentes situações fisiológicas, ampliando a capacidade de adaptação e sobrevivência do organismo. Neste contexto, o termo disautonomia se refere àquelas condições em que a função autonômica se modificou de maneira a contribuir negativamente para a saúde. Estas mudanças têm sido quantificadas e têm permitido estimar a contribuição da hiperatividade simpática na instalação e na manutenção da doença cardiovascular. Neste artigo, são revisados aspectos anatômicos e funcionais do sistema nervoso simpático e parassimpático, destacando os principais métodos de avaliação do SNA, bem como o papel da hiperatividade simpática como mecanismo desencadeador e de agravamento de disfunções cardiovasculares.

The autonomic nervous system (ANS) described at the beginning of the last century is defined as the system of motor neurons that innervate glands as well as smooth and cardiac musc/es essential for maintaining the body's balance, defining this situation with the term "homeostasis". Current1y, however it is recognized that this system also provides sensory neurons (afferent neurons) that transmit information received from sensory autonomic receptors mainly visceral to the central nervous system. The use of the term autonomic comes from the idea that this system acts only in autonomic way; however, nowadays it is accepted that the activity of this system is generated or at least supervised by the central nervous system. The tonic and reflex acti vation and deacti vation of both of its components, the sympathetic and the parasympathetic system, can determine adjustments in cardiac output and peripheral vascular resistance contributing to the stabilization and maintenance of systemic blood pressure during different physiological situations, expanding the capacity of adaptation and survival of the organismo ln this context, the terrn dysautonomia refers to those conditions in which autonomic function was changed in a way that negatively contribute to health. These changes have been quantified and have alJowed to estimate the contribution of sympathetic hyperactivity in the installation and maintenance of cardiovascular disease. In this manuscript anatomical and functional, sympathetic and parasympathetic nervous system aspects are reviewed, highJighting key evaluation methods of ANS and the role of sympathetic overacti vity as a trigger and as a worsening mechanism that can contribute to cardiovascular dysfunctions.

MRI-based 3D pelvic autonomous innervation: a first step towards image-guided pelvic surgery.

OBJECTIVE: To analyse pelvic autonomous innervation with magnetic resonance imaging (MRI) in comparison with anatomical macroscopic dissection on cadavers. MATERIAL AND METHODS: Pelvic MRI was performed in eight adult human cadavers (five men and three women) using a total of four sequences each: T1, T1 fat saturation, T2, diffusion weighed. Images were analysed with segmentation software in order to extract nervous tissue. Key height points of the pelvis autonomous innervation were located in every specimen. Standardised pelvis dissections were then performed. Distances between the same key points and the three anatomical references forming a coordinate system were measured on MRIs and dissections. Concordance (Lin's concordance correlation coefficient) between MRI and dissection was calculated. RESULTS: MRI acquisition allowed an adequate visualization of the autonomous innervation. Comparison between 3D MRI images and dissection showed concordant pictures. The statistical analysis showed a mean difference of less than 1 cm between MRI and dissection measures and a correct concordance correlation coefficient on at least two coordinates for each point. CONCLUSION: Our acquisition and post-processing method demonstrated that MRI is suitable for detection of autonomous pelvic innervations and can offer a preoperative nerve cartography. KEY POINTS: • Nerve preservation is a hot topic in pelvic surgery • High resolution MRI can show distal peripheral nerves • Anatomo-radiological comparison shows good correlation between MRI and dissection • 3D reconstructions of pelvic innervation were obtained with an original method • This is a first step towards image-guided pelvic surgery.

Anastomoses between lower cranial and upper cervical nerves: a comprehensive review with potential significance during skull base and neck operations, part I: trigeminal, facial, and vestibulocochlear nerves.

Descriptions of the anatomy of the neural communications among the cranial nerves and their branches is lacking in the literature. Knowledge of the possible neural interconnections found among these nerves may prove useful to surgeons who operate in these regions to avoid inadvertent traction or transection. We review the literature regarding the anatomy, function, and clinical implications of the complex neural networks formed by interconnections among the lower cranial and upper cervical nerves. A review of germane anatomic and clinical literature was performed. The review is organized in two parts. Part I concerns the anastomoses between the trigeminal, facial, and vestibulocochlear nerves or their branches with any other nerve trunk or branch in the vicinity. Part II concerns the anastomoses among the glossopharyngeal, vagus, accessory and hypoglossal nerves and their branches or among these nerves and the first four cervical spinal nerves; the contribution of the autonomic nervous system to these neural plexuses is also briefly reviewed. Part I is presented in this article. An extensive anastomotic network exists among the lower cranial nerves. Knowledge of such neural intercommunications is important in diagnosing and treating patients with pathology of the skull base.

A comprehensive review with potential significance during skull base and neck operations, Part II: glossopharyngeal, vagus, accessory, and hypoglossal nerves and cervical spinal nerves 1-4.

Knowledge of the possible neural interconnections found between the lower cranial and upper cervical nerves may prove useful to surgeons who operate on the skull base and upper neck regions in order to avoid inadvertent traction or transection. We review the literature regarding the anatomy, function, and clinical implications of the complex neural networks formed by interconnections between the lower cranial and upper cervical nerves. A review of germane anatomic and clinical literature was performed. The review is organized into two parts. Part I discusses the anastomoses between the trigeminal, facial, and vestibulocochlear nerves or their branches and other nerve trunks or branches in the vicinity. Part II deals with the anastomoses between the glossopharyngeal, vagus, accessory and hypoglossal nerves and their branches or between these nerves and the first four cervical spinal nerves; the contribution of the autonomic nervous system to these neural plexuses is also briefly reviewed. Part II is presented in this article. Extensive and variable neural anastomoses exist between the lower cranial nerves and between the upper cervical nerves in such a way that these nerves with their extra-axial communications can be collectively considered a plexus.

Regional innervation of the heart in the goldfish, Carassius auratus: a confocal microscopy study.

The intracardiac nervous system represents the final common pathway for autonomic control of the vertebrate heart in maintaining cardiovascular homeostasis. In teleost fishes, details of the organization of this system are not well understood. Here we investigated innervation patterns in the heart of the goldfish, a species representative of a large group of cyprinids. We used antibodies against the neuronal markers zn-12, acetylated tubulin, and human neuronal protein C/D, as well as choline acetyltransferase, tyrosine hydroxylase, nitric oxide synthetase, and vasoactive intestinal polypeptide (VIP) to detect neural elements and their transmitter contents in wholemounts and sections of cardiac tissue. All chambers of the heart were innervated by choline acetyltransferase-positive axons, implying cholinergic regulation; and by tyrosine hydroxylase-containing axons, implying adrenergic regulation. The mean total number of intracardiac neurons was 713 ± 78 (SE), nearly half of which were cholinergic. Neuronal somata were mainly located in a ganglionated plexus around the sinoatrial valves. Somata were contacted by cholinergic, adrenergic, nitrergic, and VIP-positive terminals. Putative pacemaker cells, identified by immunoreactivity for hyperpolarization activated, cyclic nucleotide-gated channel 4, were located in the base of the sinoatrial valves, and this region was densely innervated by cholinergic and adrenergic terminals. We have shown that the goldfish heart possesses the necessary neuroanatomical substrate for fine, region-by-region autonomic control of the myocardial effectors that are involved in determining cardiac output.

[Clinical anatomy study on autonomic nerves related to anterior approach lumbar surgery ].

OBJECTIVE: To understand the location characteristics of the lumbosacral autonomic nerve plexus and the morphological changes so as to provide the anatomic theoretical basis for the protection of autonomic nerve during the lower lumbar anterior approach operation. METHODS: A random anatomic investigation was carried out on 19 formalin-treated adult cadavers (15 males and 4 females; aged 44-78 years, mean 64 years). The anterior median line (connection of suprasternal fossa point and the midpoint of the symphysis pubis) was determined, and the characteristics of abdominal aortic plexus (AAP), inferior mesenteric plexus (IMP), and superior hypogastric plexus (SHP) were observed. The relationship between the autonomic nerve and the anterior median line was measured and recorded. RESULTS: APP and IMP were found to be located chiefly in front of the abdominal aorta in a reticular pattern, and the nerve fibers of the two nerve plexuses were more densely at the left side of abdominal aorta than at the right side. Superior hypogastric plexus showed more distinct main vessel variations, including 4 types. The main vessel length of the SHP was (59.38 ± 12.86) mm, and the width was (11.25 ± 2.92) mm. The main vessels of SHP were mainly located at the left side of the ventral median line (10, 52.6%) and anterior lumbar vertebra (13, 68.4%). The main vessels extended down to form the left and right hypogastric nerves. CONCLUSION: It is applicable to expose the nerve from the right side of centrum and move the autonomic nerve and blood vessel as a whole during anterior lower lumbar operation. In this way, the dissection to separate nerve plexus is not needed, thus nerve injury can be avoided to the largest extent.

[Anatomy and physiology of autonomic pelvic innervations].

Autonomic innervation is responsible for the correct function of the organs in the pelvis. Retroperitoneal surgery is associated with trauma of the nerve structures. For this reason a detailed knowledge of topographic anatomy of the pelvis is needed, when surgery for oncological diseases or endometriosis is performed. Faster recovery, decrease of the number of postoperative complications and a better quality of life are the result of the nerve-sparing approach.

Autonomic nervous system control of the cerebral circulation.

The classic view of cerebrovascular physiology has been that blood flow and cerebral metabolism are tightly coupled under the influence of substances, such as H(+), adenosine, nitric oxide, and K(+), which ensure a rapid and matched supply of blood. In part driven by the use of cerebral blood flow measurements in functional brain imaging, it has become clear that astrocytes also play a role in modulating functionally associated changes in cerebral blood flow. The concept of neural control or neurogenically mediated changes in cerebral blood flow is relatively newer, although the presence of such nerves was probably identified anatomically more than 500 years ago. The autonomic innervation of the cranial circulation has both a sympathetic component that arises predominantly from the superior cervical ganglion and a cranial parasympathetic component that traverses the pterygopalatine (sphenopalatine) and otic ganglion. Neuropeptide transmitters such as neuropeptide Y (NPY), vasoactive intestinal polypeptide (VIP), and pituitary adenylate cyclase-activating peptide (PACAP), helodermin, and helospectin have each been identified in components of the system. Clinical problems such as migraine, cluster headache, and stroke likely involve the autonomic innervation of the cerebral circulation in terms of disorder expression and ultimately with an eye to novel therapies.

Colorectal surgery and its impact on male sexual function.

The quality of functional outcome has become increasingly important in view of improvement in prognosis with colorectal cancer patients. Sexual dysfunction remains a common problem after colorectal cancer treatment, despite the good oncologic outcomes achieved by expert surgeons. Although radiotherapy and chemotherapy contribute, surgical nerve damage is the main cause of sexual dysfunction. The autonomic nerves are in close contact with the visceral pelvic fascia that surrounds the mesorectum. The concept of total mesorectal excision (TME) in rectal cancer treatment has led to a substantial improvement of autonomic nerve preservation. In addition, use of laparoscopy has allowed favorable results with regards to sexual function. The present paper describes the anatomy and pathophysiology of autonomic pelvic nerves, prevalence of sexual dysfunction, and the surgical technique of nerve preservation in order to maintain sexual function.

Outcomes following proctectomy.

Rectal resection is the most common treatment of rectal cancer and inflammatory bowel disease. The surgical techniques for removing and reconstructing the rectum have evolved significantly over the past 50 years. Technological advances including retractors, stapling devices, energy delivery systems, and minimally invasive approaches, as well as the nerve-sparing total mesorectal excision, have revolutionized the surgical treatment. Surgical exposure and precise technique affect the ability to preserve the pelvic autonomic nerves, directly influencing postoperative urinary and sexual function. The complex interplay between all these factors demands attention because of the associated short-term and long-term impact on patient quality of life.

Autonomic-somatic communications in the human pelvis: computer-assisted anatomic dissection in male and female fetuses.

Sphincter continence and sexual function require co-ordinated activity of autonomic and somatic neural pathways, which communicate at several levels in the human pelvis. However, classical dissection approaches are only of limited value for the determination and examination of thin nerve fibres belonging to autonomic supralevator and somatic infralevator pathways. In this study, we aimed to identify the location and nature of communications between these two pathways by combining specific neuronal immunohistochemical staining and three-dimensional reconstruction imaging. We studied 14 normal human fetal pelvic specimens (seven male and seven female, 15-31 weeks' gestation) by three-dimensional computer-assisted anatomic dissection (CAAD) with neural, nitrergic and myelin sheath markers. We determined the precise location and distribution of both the supra- and infralevator neural pathways, for which we provide a three-dimensional presentation. We found that the two pathways crossed each other distally in an X-shaped area in two spatial planes. They yielded dual innervation to five targets: the anal sphincter, levator ani muscles, urethral sphincter, corpus spongiosum and perineal muscles, and corpora cavernosa. The two pathways communicated at three levels: proximal supralevator, intermediary intralevator and distal infralevator. The dorsal penis/clitoris nerve (DN) had segmental nitrergic activity. The proximal DN was nNOS-negative, whereas the distal DN was nNOS-positive. Distal communication was found to involve interaction of the autonomic nitrergic cavernous nerves with somatic nitrergic branches of the DN, with nitrergic activity carried in the distal part of the nerve. In conclusion, the pelvic structures responsible for sphincter continence and sexual function receive dual innervation from the autonomic supralevator and the somatic infralevator pathways. These two pathways displayed proximal, intermediate and distal communication. The distal communication between the CN and branches of the DN extended nitrergic activity to the distal part of the cavernous bodies in fetuses of both sexes. These structures are important for erectile function, and care should therefore be taken to conserve this communication during reconstructive surgery.

Anatomy of the cardiac nervous system with clinical and comparative morphological implications.

Unlike autonomic nervous preservation in other surgeries for improving patient quality of life, autonomic cardiac nervous system (ACNS) preservation has been neglected in cardiovascular surgery because of technical difficulties and other unsolved issues. Because such ACNS preservation in cardiovascular surgery is anticipated in the future, detailed anatomical investigation of the human ACNS is required. Therefore, we have conducted morphological studies of the ACNS from macroscopic, clinical, and evolutionary anatomical viewpoints. In this study, I review detailed anatomical studies of the human ACNS together with their clinical implications. In addition, the evolutionary comparative anatomical significance of primate ACNS is also summarized to help understand and translate the findings of functional experiments to humans. These integrated findings will be the subject of a future study unifying molecular embryological and anatomical findings to clarify cardiac functions based on functional animal experiments, clinical applications such as improving surgery techniques and individual order-made surgery in cardiac surgery, and for future evaluation in regenerative medicine.

The contribution(s) of the insula to speech production: a review of the clinical and functional imaging literature.

Skilled spoken language production requires fast and accurate coordination of up to 100 muscles. A long-standing concept--tracing ultimately back to Paul Broca--assumes posterior parts of the inferior frontal gyrus to support the orchestration of the respective movement sequences prior to innervation of the vocal tract. At variance with this tradition, the insula has more recently been declared the relevant "region for coordinating speech articulation", based upon clinico-neuroradiological correlation studies. However, these findings have been criticized on methodological grounds. A survey of the clinical literature (cerebrovascular disorders, brain tumours, stimulation mapping) yields a still inconclusive picture. By contrast, functional imaging studies report more consistently hemodynamic insular responses in association with motor aspects of spoken language. Most noteworthy, a relatively small area at the junction of insular and opercular cortex was found sensitive to the phonetic-linguistic structure of verbal utterances, a strong argument for its engagement in articulatory control processes. Nevertheless, intrasylvian hemodynamic activation does not appear restricted to articulatory processes and might also be engaged in the adjustment of the autonomic system to ventilatory needs during speech production: Whereas the posterior insula could be involved in the cortical representation of respiration-related metabolic (interoceptive) states, the more rostral components, acting upon autonomic functions, might serve as a corollary pathway to "voluntary control of breathing" bound to corticospinal and -bulbar fiber tracts. For example, the insula could participate in the implementation of task-specific autonomic settings such as the maintenance of a state of relative hyperventilation during speech production.

[Pathophysiology of one warm foot. Anatomy of the autonomic nervous system]. / Pathofysiologie van één warme voet. De anatomie van het autonome zenuwstelsel.

A 50-year-old man presented with a persistently warm left foot, which did not perspire. What initially seemed to be an innocent disorder turned out to be a retroperitoneal germ cell tumour situated at Liii-Liv. In most people this location is the site of the lumbar paravertebral ganglia (an important part of the sympathetic nervous system). The fact that these ganglia were affected by the tumour explained the autonomic dysfunction in this case. The patient received curative chemotherapy. Exploration of the symptoms with respect to the pathophysiology and anatomy of the autonomous nervous system might have led to an earlier diagnosis.