Endoscopic anatomy of the cerebellopontine angle: a study in cadaver brains.

The increasing trend toward performing minimally invasive neurosurgery may benefit from recent progress in using neuroendoscopic techniques to reduce trauma in patients who have undergone operations. Arterial and venous vessels, especially loops, may compress the central segment and cause hyperactive dysfunction of the nerves. Relationships of the anterior inferior cerebellar artery to the facial and vestibulocochlear nerves and the anterior inferior, and superior cerebellar arteries to the trigeminal nerve were studied. The authors report findings from an endoscopic study performed in cadaver heads via the retrosigmoid and retrolabyrinthine approaches. Arteries and veins were colored by injection of red and blue silicon rubber. The cerebellopontine angle (CPA) was examined using 2.7-mm and 4-mm-diameter rigid endoscopes at viewing angles of 0s degrees , 30s degrees , and 70s degrees . Well-known structures could be identified endoscopically without prior dissection, and the entire CPA could be explored. However, with a retrosigmoid or a retrolabyrinthine approach, the cerebellum had to be retracted to some extent to view the CPA. Moreover, wide dural exposure was required to maneuver the endoscope freely in the CPA. Use of the rigid fiberoptic endoscope is not yet superior to standard surgical techniques for approaching and exploring the CPA.

[Primary bilateral tubular adenocarcinoma with antecedents of invasive galactophoric carcinoma of the breast. Apropos of a case; review of the literature]. / Adéno-carcinome tubaire primitif bilatéral avec antécédents de carcinome galactophorique invasif du sein. A propos d'une observation, revue de la littérature.

The authors report a case of primary bilateral adenocarcinoma of the fallopian tube in a woman with invasive ductal carcinoma of the breast in her antecedents. The tubal carcinoma was in situ or invasive and appeared as a bilateral hydrosalpinx, fact which often happens in the literature. Gross examination showed a tumoral mass of about 2 cm diameter at the fimbriated end of the right tube, the diagnostic of bilaterality requiring serial cuts on the left tube. The electron microscopic study showed ciliated differentiation in the neoplastic cells, bearing out the primitive nature of the proliferation.

[Anterolateral hysteropexy via abdominal approach. Results and indications. Apropos of a series of 92 patients]. / L'hystéropexie antéro-latérale par voie abdominale. Résultats et indications. A propos d'une série de quatre-vingt-douze patients.

Of the possible surgical techniques for the treatment of genito-urinary prolapses, abdominal suspension is reserved for young patients in whom retention of sexual function is desirable. Fixation to the sacral promontory is the reference method but has some contraindications. Anterolateral suspension of the uterine isthmus to the anterior superior iliac spines by a strip of non-absorbable mesh, as described by Kapandji, is then a good alternative. We report our results with this technique over an 8-year period in 92 patients. Mean follow-up was 5 years. There was no intraoperative mortality nor major complications. Anatomical results were satisfactory in 87% of cases at 5 years, with however 4 reoperations for total recurrent prolapse, of which one was posterior. Functional results showed two cases of deep dyspareunia and 12% post-operative stress urinary incontinence, of gradual onset. In conclusion, anterolateral hysteropexy associated with removal of the pouch of Douglas is a reliable procedure with no particular danger. It can be a good alternative to fixation to the sacram promontory when the latter is contraindicated or dangerous.

[Malignant degeneration in testicular feminization. Apropos of a case]. / Dégénérescence maligne du testicule féminisant. A propos d'un cas.

The authors describe the main therapeutic features found in a case of testicular feminisation that became malignant. Bilateral gonadal ablation should be carried out after puberty for fear of malignancy. When cancer occurs treatment is best decided on the grounds of extension to the lymph nodes and the histological findings in the tumour. Where there is no extension to the lymph nodes, surgery should be carried out on the gonads with radiotherapy to the lymph nodes. If the tumour is not clearly a seminoma the lymph nodes should be removed before radiotherapy is started.

[Malignant hypercalcemia after treatment of breast cancer]. / Hypercalcémie maligne après traitement d'un cancer du sein.

A premenopausal woman developed hypercalcemia 30 months after treatment for infiltrating breast cancer. After bone metastases had been excluded, primary hyper parathyroidism was suspected. A parathyroid adenoma was removed and histologically confirmed. Hypercalcemia persisted, associated with low plasma phosphate and severely depressed plasma parathormone (PTH) levels. Further investigations showed liver metastases from the primary breast cancer and also secretion of a PTH-like substance. Anti-tumoral treatment was effective on the liver metastases and also normalized calcemia and the PTH-like substance, demonstrating the existence of a paraneoplastic syndrome related to the secretion of a PTH-like substance by disseminated liver metastases of primary breast cancer.

[Utilization of thermosettable compounds in anatomic research]. / Utilisation des thermodurcissables en recherche anatomique.

The authors described a method of vascular injection with a coloured silicon rubber. The injected material was a biocomponent silicon elastomer, with ambiant temperature room vulcanizing. It was supple, easily dissequable and diffuse well into all small caliber vessels. The soft pressure injection did not cause neither material collection by vessels rupture nor anatomic structure distortion. This material could constitute an excellent alternative to coloured latex injection.

[Phlebology and gynecology]. / Phlébologie et gynécologie.

The authors give the pattern of several situations where are added phlebological and gynecological diseases. They summarize the several treatments and the practical uses for this. Medicolegal viewpoints are also taken in account.

PIP: 3 areas in which gynecological factors affect phlebology and especially the venous system of the lower extremities are discussed. The presence of small or moderate varices does not contraindicate use of oral contraceptives (OCs), but venous tonics or even anticoagulants should be administered under specific circumstances in women with a tendency toward thrombosis. OCs should be avoided in women with significant venous lesions. If OCs are imperative, the varices should be treated before OC administration is initiated. Women whose syndrome of venous stasis worsens during menstruation or OC use should be carefully examined for gynecological lesions. If no lesions are found and treated, the OCs should be replaced by a nonhormonal method of contraception or the cause of the venous insufficiency should be further explored. OCs should be temporarily suspended for women undergoing sclerotic treatment of their varicosities. Alternatively, limited interventions such as ambulatory phlebectomies under heparin therapy can be substituted, but in these cases stripping should be avoided because of the danger of deep venous thrombosis. The practitioner contemplating treatment of varicosities in women using OCs should bear in mind the possibility of a malpractice charge if phlebitis should develop. The appearance of varices of varicosities accompanied by a peripheral venous stasis syndrome can be 1 of the 1st signs of pregnancy. Such varices in pregnant women represent small exteriorizations of enormous venous dilatations in the pelvis. They are almost never hemorrhagic during delivery and regress rapidly in the postpartum. Their thrombosis, however, can be very grave when it does occur. Varices of pregnancy which do not regress within 3 months' postpartum will be permanent. Different interventions are necessary in the case of preexisting significant varicosities or complicated varicosities during pregnancy. The usual treatments combine support and heparin therapy. The presence of varices does not absolutely contraindicate gynecological interventions. But OCs are formally contraindicated in the case of women with histories of deep phlebitis with sequelae.

Relationships of the palmar cutaneous branch of the median nerve: a morphometric study.

Treatment of carpal tunnel syndrome consists in decompression of the median nerve by section of the flexor retinaculum. Usually, this surgery improves the disease with disappearance of the symptoms. However, some painful sequelae may remain such as painful discharges, paresthesiae or permanent anesthesia of the base of the thumb or of the scar related to an injury of the palmar cutaneous branch of the median nerve (PCBm). This study was performed to define the accurate emergence and the anatomic characteristics of this nerve in relation to stable landmarks. Moreover, it assessed the importance of the visual identification of the branch during section of the flexor retinaculum. Thirty-five hands were dissected under macroscopic examination and under magnification of the thinnest branches. Measurements were performed with a caliper and the forearm in supination. Determination of the bistyloid line showed variability in the location of the distal wrist crease. Thus, it could not be used as a landmark to locate the PCBm. The palmar cutaneous branch is the distal collateral branch of the median nerve in the forearm. It emerges on its radial side, on average 44.3 mm before the bistyloid line. It courses in line with the third finger and perforates the antebrachial aponeurosis about 5.7 mm from the bistyloid line. This emergence can be located in the palm, where it can be injured if the incision is performed in line with the third finger. The PCBm usually ends in the palm by division into two or three branches. The lateral branch supplies the skin of the thenar eminence while the medial, usually shorter branch supplies the midline part of the palm. This study has shown the importance of performing the cutaneous incision in line with the fourth finger to avoid injury to the PCBm.

Anatomic basis for use of a gracilis muscle flap.

The aim of this study was to specify certain anatomic features of the gracilis m. with a view to the use of muscular or myocutaneous flaps. It was based on dissection of 84 gracilis muscles in 42 subjects as well as selective injection of the main pedicle of 20 muscles. This established the following points: 1) The arterial supply is abundant, consisting of several pedicles reaching the muscle on its deep aspect. The main neurovascular pedicle arises from the deep vessels of the thigh, via either the a. of the adductors (73%), the medial circumflex a. (19.2%) or as a double supply from both arteries (7.7%); 2) The cutaneous vascularisation over the gracilis m., derived from the solitary main pedicle, is inconstant. In 20 injections, it was satisfactory in 11 cases, poor in 5 and absent in 4; 3) The distal tendon of the gracilis m. is closely related to the posterior branch of the saphenous n. to the leg, which it crosses in an elongated X; 4) A simple method of calculation based on the distance between the upper border of the pubis and the medial femoral epicondyle allows quite precise determination of the point of entry of the main pedicle into the gracilis m. 5) Complete dissection of the main pedicle adds to the available length of the muscle flap.

Hypercalcemia and breast cancer related to parathormone-like secretion by liver metastases.

A premenopausal woman developed hypercalcemia 30 months after treatment for infiltrating breast cancer. After bone metastases had been excluded, primary hyperparathyroidism was suspected. A parathyroid adenoma was removed and histologically confirmed. Hypercalcemia, associated with low plasma phosphate and severely depressed plasma parathormone (PTH) levels, persisted. Further investigations showed liver metastases from the primary breast cancer and also secretion of a PTH-like substance. Antitumoral treatment was effective on the liver metastases and also normalized calcemia and the PTH-like substance, demonstrating the existence of a paraneoplastic syndrome related to the secretion of a PTH-like substance by disseminated liver metastases of primary breast cancer.

[Gracilis muscle in man]. / Muscle gracile chez l'homme.

This study is based upon the dissection of 84 gracilis muscles in 42 cadavers. It allowed to emphasize the following features: 1-The proximal insertion of the muscle is a strong tendinous lamina arising from the anterior aspect of the pubis and from the ischio-pubic branch; the distal insertion to the tibia is common to both the gracilis and the semi-tendinous muscles. 2-The distal tendon of the gracilis is tightly connected to the posterior branch of the internal saphenous nerve which crosses the muscle behind the medial femoral condyle. 3-The arterial supply (52 dissections) appears to be very rich, consisting in various pedicles entering the muscle by is lateral side. The main neurovascular bundle is issued from the profound vessels of the thigh, coming either from the adductors artery (73%), either from the medial circumflex artery (19.2%), either from both networks (7.7%). The site of penetration of the vessels in the muscle is remarkably constant. The remaining pedicles (2 to 4, one of which is quite constant at the musculotendinous junction) arise from the muscular branches of the femoral artery. 4-There is a good correlation between the measured length of the muscle and the distance between the superior aspect of the pubic arch and the medial epicondyle. A 0.37 corrective factor applied to this latter distance allows to determine the exact sit of penetration of the main neurovascular bundle in the muscle.

Vertebral pedicle anatomy in relation to pedicle screw fixation: a cadaver study.

New techniques to stabilize and correct the thoracic and lumbar spine have been developed in recent years. In view of the wide variety and complexity of fixation devices, the optimum configuration of spinal instrumentation systems needs to be defined. Linear and angular measurements of both vertebral pedicles were made in ten complete thoracic and lumbar cadaveric spines using callipers and a goniometer. The vertical interpedicular distance gradually increased along the spine up to L5. The transverse interpedicular distance was larger at both ends of the spine. Pedicular height gradually increased from T1 to L5, plateauing between T3 and T9, being widest at the thoracolumbar junction. Pedicular width was greatest at the three junctional regions of the spine. The sagittal pedicular angle decreased along the length of the spine to zero at L5. The transverse pedicular angle decreased from T1 to T12 and then increased to L5. Of the pedicular measurements only width limits the diameter of fixation screws. The vertical interpedicular distance determines the distance between the holes of plates, while the length of the transfixator is related to the transverse interpedicular distance. The pedicular angles enable triangulation of screws and determine the stability of the fixation.

Functional anatomy of the medial ligamentous complex of the elbow. Its role in anterior posterior instability.

The question remains unanswered regarding the role of repair of medial ligament injuries associated with subluxation of the elbow and non-reconstructable radial head fracture and whether or not this will decrease the risk of chronic instability and cubitus valgus. The goal of this study was to define the role of the medial ligamentous complex of the elbow in elbow instability and to describe the anatomy of the complex in 35 fresh-frozen cadaver elbows. We documented medial ligamentous complex anatomy and compared our results to those in the literature. 25 elbows were dissected in order to describe the different bundles of the medial ligament complex and to precise the positions of the elbow that placed each in tension; section of the different ligamentous bundles was done to study the role of each in elbow stability. 10 other elbows were dissected and used for the ligamentous section studies which were performed subcutaneously. We found two bundles at the level of the anterior portion and termed them superficial and deep. Section of the anterior bundle lead to posterior subluxation of the elbow at 30-100 degrees flexion in both supination and pronation. Posterior subluxation was obtained after an anterior capsulotomy; medial epicondylectomy did not compromise the stability of the elbow after a complete section of the insertion of the deep fibers of the anterior bundle. Elements thus required for stability of the elbow are integrity of the articular surface of the humerus and the ulna, and the anterior bundle of the medial ligamentous complex.

Pubourethral ligaments in women: anatomical and clinical aspects.

The anatomy and histological structure of the proximal (PPUL), distal (DPUL) and intermediate (IPUL) pubourethral ligaments in women was examined to improve the understanding of their roles in female urethral physiology. An anatomical study of the pelvis was carried out in 10 adult female cadavers (60-102 years), the pelvis being removed and frozen prior to dissection. The pubourethral ligaments (PUL) were dissected in sagittal sections in seven specimens and in a frontal section in one specimen; the remaining two pelves were dissected using a hypogastric approach. The location, insertion, direction and histological structure of the ligamentous structures were studied. The PUL were identified in all 10 dissections, being paired, symmetrical, pearly-white, fibrous and resistant to stretching. The bony (parietal) insertion was variable on the posterior surface of the pubis, while the visceral insertion was located on the dorsal aspect of the proximal third of the urethra and neck of the bladder for the PPUL and on the distal third of the urethra for the DPUL. Histologically, the ligaments were composed of dense collagen fibres and bundles of axially orientated smooth muscle fibres. The PPUL was closely associated with the sphincter urogenitalis muscle, whereas the DPUL appeared to reinforce the role of the compressor urethra. It is suggested that the PUL plays an effective role in passive and active suspension of the urethra. The pubourethral ligaments are a constant anatomical entity which should be spared in urethral surgery in women in order to ensure an intact urogenital sphincter.

[The gastro-phrenic ligament]. / Contribution à l'etude du ligament gastro-phrenique.

The present study was carried out in order to investigate if 1) the gastrophrenic ligament was involved in gastric stabilization, 2) the surface of this ligament might be influenced by fundus distension induced by the first deglutition of the newborn. In a series of 23 subjects (15 adults, 8 foetuses) the surface of the gastrophrenic ligament was expressed in % of the postero-inferior surface of the stomach. The gastrophrenic ligament consisted of loose areolar tissue and its surface was rather small (5,89% +/- 3,8 in adults; 4,3% +/- 1,5 in the foetus). These facts led us to conclude that this ligament did not play a very important role in gastric stabilization. Furthermore the difference between adults and foetuses was not statistically significant; so the surface of the ligament could not have been changed at birth.

[The Stein-Leventhal syndrome. Clinical, biological and anatomic study of 6 cases in adolescent girls (author's transl)]. / Etude clinique, biologique, anatomique de 6 syndromes de Stein Leventhal de l'adolescente.

Clinical, biological and anatomic studies were performed in 6 adolescent girls with the Stein-Leventhal syndrome. The rare occurrence of this syndrome in pediatrics is emphasized. The main clinical signs consist of obesity, hirsutism and menstrual irregularities. Basic LH and plasma testosterone are useful diagnostic means, as well as -- in children -- the suppression-stimulation and LH-RH tests. However, coelioscopy is necessary to allow a correct diagnosis. Histological examination might not be absolutely necessary since a large biopsy could be responsible for untimely ovulation. Estrogens and anti-androgens are the only logical treatment at the time of puberty.

Microsurgical anatomy of the internal vertebral venous plexuses.

Few studies have been done about the venous vascularization of the spine since neuroradiologic studies in the 1960s and 70s. The aim of this study was to clarify the topography of the internal vertebral venous plexuses in relation to the posterior longitudinal ligament and the dura. The relationships of the vv. were studied at different levels of the spine. The internal vertebral venous system of seven cadavers was injected with a blue bicomponent silicon rubber. It consisted with an anterior and a posterior venous plexus. At the cervical level, the anterior longitudinal vv. are located in a dehiscence of the periosteal layer, in the lateral part of the spinal canal. At each level, they joined the contralateral one at the midline by a retrocorporeal v. located behind the posterior longitudinal ligament. No vv. were found in the epidural space. There was a major development of the retrocorporeal v. of the axis, but it did not receive any venous drainage from the vertebral body. At the thoracic and lumbar levels, the anterior venous plexuses remain within a dehiscence of the periosteal layer, which is thinner. The retrocorporeal vv. become pre-ligamentous. We did not find any posterior venous plexuses at the cervical level, but they were evident at the thoracic level and became more voluminous and sinusoidal in the lumbar region.

Contribution to the study of the tributaries and the termination of the external jugular vein.

The dissection of 100 external jugular veins in 50 cadavers was the object of this anatomic study. A certain number of notions concerning the afferent veins, the mode of termination and the valvular system of this vessel were defined. 1) Afferent veins. Along its pathway toward the deep venous system, the external jugular vein successively received: the transverse cervical vein in 88 cases (88%), usually opposite the intersection of the external jugular vein with the dorsal border of the sterno- cleidomastoid muscle; the suprascapular vein in 47 cases (47%); the anterior jugular vein in 46 cases (46%); the cervical vein or anastomosis with the latter in 13 cases (13%). 2) Mode of termination. Forty-three subjects presented a symmetric mechanism. 100 anastomoses can be classed into three types: in 60 cases (60%), the external jugular vein flowed into the jugulo-subclavian venous confluence; in 36 cases (36%), in to the subclavian vein at a distance from its junction with the internal jugular vein; in 4 cases (4%) in to the trunk of the internal jugular vein. 3) Study of the valves. There were studied in 25 subjects (50 external jugular veins). The valves were found in the ostial and paraostial position in 49 out of 50 veins.