The lymphatic system of the uterine cervix: towards a more precise definition of the drainage routes.

PURPOSE: Lymph node involvement in cancer of the uterine cervix is a major independent prognostic factor for overall survival. The aim of our study was to examine the lymphatic drainage regions of the different parts of the uterine cervix. METHODS: An anatomical study of fresh cadavers was conducted by injecting patent blue in the anterior or posterior lip of the uterine cervix and dissecting drainage regions. Furthermore, a retrospective radiological and pathological studies were conducted on patients who were treated for early-stage cancer of the uterine cervix with lymph node involvement. Radiological analysis of pre-therapeutic MRIs and/or pathological analysis of surgical specimens showed the precise location of the tumour. A correlation between the anatomy of the primary lesion site and the lymphatic area involved was established. RESULTS: We administered 15 cadaveric injections: 8 in the anterior lip of the uterine cervix and 7 in the posterior one. For 100% of the anterior lip injections, lymphatic drainage was bilateral ileo-obturator (n = 8/8) combined with bilateral parametrial drainage. For the posterior injections, there was never any ileo-obturator drainage, and 6 of the 7 (75%) posterior injections drained in the posterior uterine serosa. Concerning the clinical study, we included 21 patients. We observed a non-significant tendency towards bilateral lymph node involvement when the tumour of the anterior lip. CONCLUSION: Physiological lymphatic drainage of the uterine cervix presents anatomical specificities, depending on the structure studied, anterior or posterior lip of the cervix. Better knowledge of these specificities should allow personalized surgery for each patient.

Total Denervation of the Elbow: Cadaveric Feasibility Study.

PURPOSE: Total elbow arthroplasty for the treatment of patients with severe elbow osteoarthritis is associated with postoperative activity limitations and risk of midterm complications. Elbow denervation could be an attractive therapeutic option for young, active patients. The aim of our study was to assess the feasibility of selective total elbow denervation via 2 anteriorly based approaches. METHODS: Selective total elbow denervation was performed in 14 cadaver elbows by 2 fellowship-trained elbow surgeons. Lateral and medial approaches to the elbow were used. The length of skin incisions and the minimum distance between them were noted. The number of articular branches identified and their respective distances from the lateral or medial epicondyle of the humerus were recorded. RESULTS: The anterolateral and anteromedial approaches allowed for the identification of all mixed and sensory nerves in all 14 cases. The mean number of resultant articular branches per cadaver was 1 for the musculocutaneous nerve, 2 (range, 1-3) for the radial nerve, 1 (range, 1-3) for the posterior cutaneous nerve of the forearm, 2 (range, 1-3) for the ulnar nerve, and 2 (range, 1-3) for the medial antebrachial cutaneous nerve; the collateral ulnar nerve was connected directly to the capsule. The length of the medial and lateral incisions was 15 cm (range, 12-18 cm) and 12 cm (range, 10-16 cm), respectively. The mean minimum distance between the incisions was 7.5 cm (range, 6.7-8.5 cm). CONCLUSIONS: The findings suggest that selective elbow denervation via 2 approaches is feasible. CLINICAL RELEVANCE: Selective elbow denervation via 2 approaches is feasible. Surgeons should target the articular branches of the musculocutaneous, radial, ulnar, and collateral ulnar nerves, posterior cutaneous nerve of the forearm, as well as medial antebrachial cutaneous nerves when carrying out this procedure.

Sensory Innervation of the Hip Joint and Referred Pain: A Systematic Review of the Literature.

OBJECTIVES: The aim of this literature review was to establish consensus with respect to the anatomic features of the articular branches innervating the hip joint and the distribution of sensory receptors within its capsule. METHODS: Five electronic databases were queried, with the search encompassing articles published between January 1945 and June 2019. Twenty-one original articles providing a detailed description of sensory receptors around the hip joint capsule (n=13) and its articular branches (n=8) were reviewed. RESULTS: The superior portions of the anterior capsule and the labrum were found to be the area of densest nociceptive innervation. Similar to the distribution of nociceptors, mechanoreceptor density was found to be higher anteriorly than posteriorly. Hip joint capsular innervation was found to consistently involve the femoral and obturator nerves, which supply the anterior capsule, and the nerve to the quadratus femoris, which supplies the posterior capsule. The femoral, obturator, and superior gluteal nerves supply articular branches to the most nociceptor-rich region of the hip capsule. CONCLUSIONS: The femoral and obturator nerves and the nerve to the quadratus femoris were found to consistently supply articular branches to both the anterior and posterior capsule of the hip joint. The anterior capsule, primarily supplied by the femoral and obturator nerves, and the superior labrum appear to be the primary pain generators of the hip joint, given their higher density of nociceptors and mechanoreceptors. LEVEL OF EVIDENCE: Anatomy study, literature review.

Sensory innervation of the human shoulder joint: the three bridges to break.

BACKGROUND: Painful shoulders create a substantial socioeconomic burden and significant diagnostic challenge for shoulder surgeons. Consensus with respect to the anatomic location of sensory nerve branches is lacking. The aim of this literature review was to establish consensus with respect to the anatomic features of the articular branches (ABs) (1) innervating the shoulder joint and (2) the distribution of sensory receptors about its capsule and bursae. MATERIALS AND METHODS: Four electronic databases were queried, between January 1945 and June 2019. Thirty original articles providing a detailed description of the distribution of sensory receptors about the shoulder joint capsule (13) and its ABs (22) were reviewed. RESULTS: The suprascapular, lateral pectoral, axillary, and lower subscapular nerves were found to provide ABs to the shoulder joint. The highest density of nociceptors was found in the subacromial bursa. The highest density of mechanoreceptors was identified within the insertion of the glenohumeral ligaments. The most frequently identified innervation pattern comprised 3 nerve bridges (consisting of ABs from suprascapular, axillary, and lateral pectoral nerves) connecting the trigger and the identified pain generator areas rich in nociceptors. CONCLUSION: Current literature supports the presence of a common sensory innervation pattern for the human shoulder joint. Anatomic studies have demonstrated that the most common parent nerves supplying ABs to the shoulder joint are the suprascapular, lateral pectoral, and axillary nerves. Further studies are needed to assess both the safety and efficacy of selective denervation of the painful shoulders, while limiting the loss of proprioceptive function.

Sensory innervation of the human elbow joint and surgical considerations.

Based on the currently available literature, total denervation of the elbow joint is considered impossible. However, consensus with respect to the anatomic location of sensory branches is lacking. The aim of this literature review was to establish consensus with respect to the anatomic features of the articular branches innervating the elbow joint, as well as the distribution of sensory receptors about its capsule. Four electronic databases were queried, between January 1945 and June 2019. Twenty-one original articles providing a detailed description of the distribution of sensory receptors about the elbow joint capsule (5) and its articular branches (16) were reviewed. The posterior capsule was found to be primarily innervated by the ulnar and radial nerves via combined articular branches and sensory branches of the medial antebrachial cutaneous nerve. The anterior capsule was found to be primarily innervated by a plexus of articular ramifications from muscular branches of mixed nerves (ulnar, musculocutaneous, radial, and median nerves). A higher density of nociceptors and mechano-receptors was identified within the posterior and anterior capsules, respectively. Thorough denervation, via the technique proposed herein, is likely to be sufficient in eliminating pain from degenerative conditions of the elbow joint.

The specific branches leading to the genioglossus muscle: three-dimensional localisation using skin reference points.

INTRODUCTION: Supra-selective stimulation of the branches destined for the horizontal part of genioglossus muscle (GGh) could be a target of choice in the treatment of mild-to-severe obstructive sleep apnea syndrome. The main aim of our study was to assess a percutaneous method for the three-dimensional localisation of the terminal branches destined to GGh. MATERIALS AND METHODS: Twenty cadaveric hypoglossal nerves were dissected and included in the injection protocol. The distance between the posterior edge of the mandibular symphysis and the hyoid bone on the sagittal midline as the approximated distance of the geniohyoid muscle (dGH) was measured before any dissection. Methylene blue mixed with a thickening agent, was injected. The injection point was defined in relation to dGH, in an orthonormal coordinate system. For each dissection, we recorded the theoretical and the real (X, Y, Z) coordinates of GGh motor points and measured their distance to each other. RESULTS: X was accurately estimated. Y and Z were overestimated by + 5.34 ± 5.21 mm ([Formula: see text]) and + 4.79 ± 3.99 mm ([Formula: see text]) on average, respectively. We found a more significant difference between the theoretical and real Y and Z coordinates in the subgroup BMI < 25 kg/m2 (8.6 ± 4.5 mm and 6.9 ± 2.5 mm, respectively, p = 0.0009), and of Z in subgroup with dGH ≥ 50 mm (6.89 ± 3.26 mm, p = 0.0494). CONCLUSIONS: X can be estimated accurately using the relationship [Formula: see text]. Y seems to be related to BMI and Z may be estimated with the relationship [Formula: see text]. This three-dimensional localisation could be very helpful to facilitate placement of cuff electrodes to manage refractory sleep apnea.

Sensory innervation of the subacromial bursa by the distal suprascapular nerve: a new description of its anatomic distribution.

BACKGROUND: Sensory innervation to the shoulder provided by the distal suprascapular nerve (dSSN) remains the subject of debate. The purpose of this study was to establish consensus with respect to the anatomic features of the sensory branches of the dSSN. The relevant hypothesis was that the dSSN would give off 3 sensory branches providing innervation to the posterior glenohumeral (PGH) capsule, the subacromial bursa, in addition to the coracoclavicular and acromioclavicular ligaments. METHODS: The division, course, and distribution of the sensory branches that originated from the dSSN and innervated structures around the shoulder joint were examined macroscopically by dissecting 37 shoulders of 19 fresh-frozen cadavers aged of 83.0 years (range, 74-98 years). RESULTS: The 37 dSSN provided 1 medial subacromial branch (MSAb), 1 lateral subacromial branch (LSAb), and 1 PGH branch (PGHb) to the shoulder joint. This arrangement allowed for bipolar-MSAb and LSAb-innervation of the subacromial bursa, acromioclavicular (MSAb and LSAb) and coracoclavicular (MSAb) ligaments, as well as the PGH capsule (PGHb). CONCLUSIONS: The dSSN provided 2 subacromial branches and 1 PGHb to the shoulder joint. This arrangement allowed for bipolar-MSAb and LSAb-innervation of the subacromial bursa, acromioclavicular and coracoclavicular ligaments, as well as the PGH capsule.

Distal suprascapular nerve block-do it yourself: cadaveric feasibility study.

BACKGROUND: A bone landmark-based approach (LBA) to the distal suprascapular nerve (dSSN) block is an attractive "low-tech" method available to physicians with no advanced training in regional anesthesia or ultrasound guidance. The primary aim of this study was to validate the feasibility of an LBA to blockade of the dSSN by orthopedic surgeons using anatomic analysis. The secondary aim was to describe the anatomic features of the sensory branches of the dSSN. MATERIALS AND METHODS: An LBA was performed in 15 cadaver shoulders by an orthopedic resident. Then, 10 mL of methylene blue-infused 0.75% ropivacaine was injected around the dSSN; 2.5mL of red latex solution was also injected to identify the position of the needle tip. The division and distribution of the sensory branches that originate from the suprascapular nerve were described. RESULTS: The median distance between the dSSN and the site of injection was 1.5 cm (0-4.5 cm). The most common injection site was at the proximal third of the scapular neck (n = 8). Fifteen dSSNs were stained proximal to the origin of the most proximal sensory branch. All 15 dSSNs gave off 3 sensory branches that innervated the posterior glenohumeral capsule, the subacromial bursa, and the coracoclavicular and acromioclavicular ligaments. CONCLUSIONS: An LBA for anesthetic blockade of the dSSN by an orthopedic surgeon is a simple, reliable, and accurate method. Injection close to the suprascapular notch is recommended to involve the dSSN proximally and its 3 sensory branches.

Assessment of brain midline shift using sonography in neurosurgical ICU patients.

INTRODUCTION: Brain midline shift (MLS) is a life-threatening condition that requires urgent diagnosis and treatment. We aimed to validate bedside assessment of MLS with Transcranial Sonography (TCS) in neurosurgical ICU patients by comparing it to CT. METHODS: In this prospective single centre study, patients who underwent a head CT were included and a concomitant TCS performed. TCS MLS was determined by measuring the difference between the distance from skull to the third ventricle on both sides, using a 2 to 4 MHz probe through the temporal window. CT MLS was measured as the difference between the ideal midline and the septum pellucidum. A significant MLS was defined on head CT as > 0.5 cm. RESULTS: A total of 52 neurosurgical ICU patients were included. The MLS (mean ± SD) was 0.32 ± 0.36 cm using TCS and 0.47 ± 0.67 cm using CT. The Pearson's correlation coefficient (r(2)) between TCS and CT scan was 0.65 (P < 0.001). The bias was 0.09 cm and the limits of agreements were 1.10 and -0.92 cm. The area under the ROC curve for detecting a significant MLS with TCS was 0.86 (95% CI = 0.74 to 0.94), and, using 0.35 cm as a cut-off, the sensitivity was 84.2%, the specificity 84.8% and the positive likelihood ratio was 5.56. CONCLUSIONS: This study suggests that TCS could detect MLS with reasonable accuracy in neurosurgical ICU patients and that it could serve as a bedside tool to facilitate early diagnosis and treatment for patients with a significant intracranial mass effect.

CNS tumor with EP300::BCOR fusion: discussing its prevalence in adult population.

The Central Nervous System (CNS) tumor with BCOR internal tandem duplication (ITD) has recently been added as a novel embryonal histomolecular tumor type to the 2021 World Health Organization (WHO) Classification of CNS Tumors. In addition, other CNS tumors harboring a BCOR/BCORL1 fusion, which are defined by a distinct DNA-methylation profile, have been recently identified in the literature but clinical, radiological and histopathological data remain scarce. Herein, we present two adult cases of CNS tumors with EP300::BCOR fusion. These two cases presented radiological, histopathological, and immunohistochemical homologies with CNS tumors having BCOR ITD in children. To compare these tumors with different BCOR alterations, we performed a literature review with a meta-analysis. CNS tumors with EP300::BCOR fusion seem to be distinct from their BCOR ITD counterparts in terms of age, location, progression-free survival, tumor growth pattern, and immunopositivity for the BCOR protein. CNS tumors from the EP300::BCOR fusion methylation class in adults may be added to the future WHO classification.

The emergence level of the musculocutaneous nerve from the brachial plexus: implications for infraclavicular nerve blocks.

BACKGROUND: In this cadaveric study we assessed the level of the emergence of the musculocutanous nerve (MCN) relative to needle insertion site during infraclavicular block. METHODS: Forty brachial plexi from 20 embalmed adult cadavers were dissected. The MCN was exposed from its origin on the lateral cord to its penetration into the coracobrachialis muscle. The point of emergence of the MCN from the lateral cord relative to a line drawn directly caudad from the anteromedial tip of the coracoid process was measured. A needle was placed predissection using our previously described technique, and the distance from the needletip to the emergence of the MCN was measured. RESULTS: MCN often emerged distal to the coracoid process. At the needle insertion site, 80% of MCN had already emerged from the lateral cord. The distance of emergence ranged from 8.5 cm proximal to 12 cm distal to the coracoid process. CONCLUSION: This anatomical study suggests that MCN may be one of the factors explaining MCN block failure for the single-injection technique of infraclavicular block using lateral needle trajectory.

Subthalamic nucleus stimulation in severe obsessive-compulsive disorder.

BACKGROUND: Severe, refractory obsessive-compulsive disorder (OCD) is a disabling condition. Stimulation of the subthalamic nucleus, a procedure that is already validated for the treatment of movement disorders, has been proposed as a therapeutic option. METHODS: In this 10-month, crossover, double-blind, multicenter study assessing the efficacy and safety of stimulation of the subthalamic nucleus, we randomly assigned eight patients with highly refractory OCD to undergo active stimulation of the subthalamic nucleus followed by sham stimulation and eight to undergo sham stimulation followed by active stimulation. The primary outcome measure was the severity of OCD, as assessed by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), at the end of two 3-month periods. General psychopathologic findings, functioning, and tolerance were assessed with the use of standardized psychiatric scales, the Global Assessment of Functioning (GAF) scale, and neuropsychological tests. RESULTS: After active stimulation of the subthalamic nucleus, the Y-BOCS score (on a scale from 0 to 40, with lower scores indicating less severe symptoms) was significantly lower than the score after sham stimulation (mean [+/-SD], 19+/-8 vs. 28+/-7; P=0.01), and the GAF score (on a scale from 1 to 90, with higher scores indicating higher levels of functioning) was significantly higher (56+/-14 vs. 43+/-8, P=0.005). The ratings of neuropsychological measures, depression, and anxiety were not modified by stimulation. There were 15 serious adverse events overall, including 1 intracerebral hemorrhage and 2 infections; there were also 23 nonserious adverse events. CONCLUSIONS: These preliminary findings suggest that stimulation of the subthalamic nucleus may reduce the symptoms of severe forms of OCD but is associated with a substantial risk of serious adverse events. (ClinicalTrials.gov number, NCT00169377.)

Iron distribution in the lentiform nucleus: A post-mortem MRI and histology study.

Iron plays an important role in many neurobiological processes, especially in the basal ganglia, the brain structures with the highest concentration. Composed of the pallidum and putamen, the lentiform nucleus plays a key role in the basal ganglia circuitry. With MRI advances, iron-based sequences such as R2* and quantitative susceptibility mapping (QSM) are now available for detecting and quantifying iron in different brain structures. Since their validation using classic iron detection techniques (histology or physical techniques), these sequences have attracted growing clinical attention, especially in the field of extrapyramidal syndromes that particularly affect the basal nuclei. Accurate mapping of iron in these nuclei and their connections is needed to gain a better understanding of this specific anatomy, before considering its involvement in the physiopathological processes. We performed R2* and QSM along with Perls histology, to gain new insights into the distribution of iron in the lentiform nucleus and its surrounding structures, based on four specimens obtained from voluntary donors. We found that iron is preferentially distributed in the anterior part of the globus pallidus externus and the posterior part of the putamen. The lateral wall of the putamen is iron-poor, compared with the lateral medullary lamina and intraputaminal fibers. The relevance of perivascular iron concentration, along with pallido- and putaminofugal iron-rich fibers, is discussed.

Transvaginal minimally invasive approach: An update on safety from an anatomical, anatomopathological and clinical point of view.

INTRODUCTION: The aim of this work was to analyze the transvaginal approach in minimally invasive surgery in terms of anatomical, histopathological and functional characteristics, to show the safety of this surgical approach. METHODS: Anatomical study was first conducted by dissection on fresh cadavers of adult women in order to measure the distance between the vaginal incision and the ureters, rectum and hypogastric nerves. In parallel, an anatomopathological study detailed and compared the macroscopic and histological characteristics of the anterior and posterior surfaces of vaginal samples obtained from cadavers and patients in the context of a hysterectomy for benign pathology. Finally, patients who underwent a transvaginal approach nephrectomy or transplantation were retrospectively enrolled for a clinical examination and an evaluation of their sexuality. RESULTS: The anatomical study conducted on seventeen cadavers showed that the posterior vaginal fornix was remote from the major structures of the pelvis such as rectum, ureters, hypogastric plexus, which allowed a safe incision. Mechanical tests further demonstrated that the posterior vaginal fornix was more extensible than the anterior and histological features showed no major vascular or nervous structures. Ten patients were included in the retrospective clinical study. Long-term follow up showed no negative impact on the texture of the vagina or satisfaction from sexual intercourse. CONCLUSIONS: Anatomical, histological and functional data supported that transvaginal approach by posterior vagina fornix incision is a minimally invasive surgery that can be performed safely and effectively by a skilled surgeon in cases with a specific surgical indication for this approach.

The anterior intermeniscal ligament of the knee: an anatomic and MR study.

BACKGROUND: The purposes of this study were to identify the presence of the anterior intermeniscal ligament of the knee (AIL), to study its attachment patterns and relationships to other anatomic structures within the knee and to evaluate the potential association of its rupture with other pathology of the knee. METHODS: Ten human cadaver knees were dissected excluding knees with surgical scars. Fifty-one MR examinations were performed in symptomatic patients. Arthroscopic observations were carried out on ten patients. RESULTS: AIL was found in nine dissected knees with type I insertion in six cases, type II insertion in three cases. The average length was 31.2 mm (25-45 mm). The average distance between AIL and insertion of the anterior cruciate ligament was 12 mm (11-15 mm). Concerning MR study, AIL was found in 34 cases (82.9%). Four (9.75%) ruptures of the AIL were encountered. Where AIL was intact, 14 patients presented meniscal lesions (46.6%). Where AIL was ruptured, three patients presented meniscal lesions (75%). CONCLUSION: The present study demonstrates through anatomical and MR studies that AIL is present in more than 80% of the cases with predominant type I insertion. The association of meniscal and AIL lesions was highlighted demonstrating that AIL is not only an anatomical point of interest but also a clinical and surgical reality.

Matching ex vivo MRI With Iron Histology: Pearls and Pitfalls.

Iron levels in the brain can be estimated using newly developed specific magnetic resonance imaging (MRI) sequences. This technique has several applications, especially in neurodegenerative disorders like Alzheimer's disease or Parkinson's disease. Coupling ex vivo MRI with histology allows neuroscientists to better understand what they see in the images. Iron is one of the most extensively studied elements, both by MRI and using histological or physical techniques. Researchers were initially only able to make visual comparisons between MRI images and different types of iron staining, but the emergence of specific MRI sequences like R2* or quantitative susceptibility mapping meant that quantification became possible, requiring correlations with physical techniques. Today, with advances in MRI and image post-processing, it is possible to look for MRI/histology correlations by matching the two sorts of images. For the result to be acceptable, the choice of methodology is crucial, as there are hidden pitfalls every step of the way. In order to review the advantages and limitations of ex vivo MRI correlation with iron-based histology, we reviewed all the relevant articles dealing with the topic in humans. We provide separate assessments of qualitative and quantitative studies, and after summarizing the significant results, we emphasize all the pitfalls that may be encountered.

Vulvar necrosis after surgical treatment of femoral neck fracture: a case report and investigation of the mechanism of injury.

We report the case of a young patient, presenting with total bilateral vulvar necrosis after reduction of a femoral neck fracture. This report describes the management of this complication, its mechanism of injury and the associated means of prevention. We present an investigation of the vulvar vasculature in order to understand the mechanism of injury.The study of the vulvar vasculature rejects the anatomical hypothesis of selective damage to the internal and external arteries. Instead, it suggests intraoperative impingement of the terminal blood vessels caused by compression against the perineal post prompting discussion on the use of moulded countertraction posts during orthopaedic surgery.

Asymptomatic spherocytosis presenting with spinal cord compression: case report.

Extramedullary hematopoiesis (EMH) is a compensatory mechanism occurring in patients with chronic anemia, which occurs most frequently with thalassemia. The authors report the case of a 57-year-old man, with no history of clinical or hematological disease, presenting with spinal cord compression. Magnetic resonance (MR) imaging demonstrated a homogeneous posterior epidural mass extending from T-3 to T-6. Following decompressive surgery, the patient's symptoms improved. Histological analysis showed features consistent with a diagnosis of EMH. Subsequent workup was remarkable for an asymptomatic spherocytosis without anemia. There was no family history of anemia. An EMH-related presentation of mild spherocytosis has been described in the literature, but its epidural location led to spinal cord compression. The MR imaging features were suggestive of EMH, but in the presence of spinal cord compression and in the absence of a history of chronic anemia, the authors did not believe that nonsurgical management would have been reasonable.

Identification of neuropeptide FF-related peptides in human cerebrospinal fluid by mass spectrometry.

Several neuropeptide FF (NPFF)-related peptides, known as modulators of the opioid system, have been previously characterized in bovine and rodent brain. Reverse-phase high pressure liquid chromatography (HPLC) fractions of a human with normal pressure hydrocephalus cerebrospinal fluid (CSF), co-migrating with NPFF-related synthetic peptides, were characterized by capillary HPLC coupled on-line to nanospray ion trap tandem mass spectrometry. Two peptides present in the pro-NPFF(A) precursor, NPAF (AGEGLNSQFWSLAAPQRF-NH2) and NPSF (SLAAPQRF-NH2), were identified. The monitoring of NPFF-related peptides in human CSF can be helpful to understand their roles in pain sensitivity.