Unusual array of neural communications in the infratemporal fossa: Useful for skull base surgery.

Variations in the branching pattern of the mandibular nerve frequently accounts for failure to obtain adequate local anesthesia in routine oral and dental procedures, and also for unexpected injury to the nerves during surgery. The knowledge of the neurovascular relationships of the infratemporal region is relevant in odontostomatology practice. In this article we present a rare case of atypical communication between the inferior alveolar nerve and lingual nerve and the mylohyoid and lingual nerves. Further, the clinical implications of these communications on the development of the supplementary innervation and their possible role in anesthesia is discussed in detail. The communication between mylohyoid and lingual nerve was found in this case near the submandibular ganglion after the lingual nerve passes in close relation to third molar tooth, which makes it more susceptible to injury during third molar extractions. The communicating branch between the mylohyoid nerve and lingual nerve may also innervate the tongue, and surgeons should be aware of this variation to avoid post- operative complcations after oral surgeries. Thus the precise anatomy of structures of infratemporal region and its variations may prove beneficial to clinicians, especially to oral and maxillofacial surgeons.

Pronator teres accessorius: A new variant in flexor antebrachial musculature.

Muscles of flexor compartment of forearm have a common origin from medial epicondyle of humerus. Additional bellies of flexor muscles are commonly reported but presence of supernumerary muscles is an infrequent phenomenon. The present study describes an unusual muscle mass in flexor compartment of forearm simulating pronator teres. During routine dissection the upper limb of a 50 years old male cadaver, a supernumerary muscle was found on left side of the upper limb in the flexor compartment. The origin of the muscle was 2cm wide and aponeurotic in nature and attached to an oblique line extending from the inferior surface of the medial epicondyle and the medial surface of the trochlea. It was inserted on an oblique line 2.5cm wide on the radius in area between supinator superiorly and flexor digitorum profundus inferiorly. Existence of accessory muscles, which connect flexor muscles, could be explained embryologically by incomplete cleavage of flexor mass during development. The flexor muscles of the forearm develop from the flexor mass which subsequently divides into two layers: superficial and deep. The deep layer gives rise to flexor digitorum superficialis, flexor digitorum profundus and flexor pollicis longus. These supernumerary muscles are extremely rare entities and probably represent deranged embryological development or the process of atavism in which the anomalous part persist for a longer time in the tree of evolution.

Bilateral clavicular attachment of omohyoid muscle.

Omohyoid muscle present in cervical region is of particular importance to anatomists as it defines anteriorly the carotid triangle and divides the posterior cervical triangle. It has superior and inferior bellies and an intermediate common tendon. Like sternohyoid, sternothyroid and thyrohyoid muscles, omohyoid is also an infrahyoid muscle, but it differs from them in its course. The infrahyoid muscles are formed from a muscle primordium occurring in the anterior cervical area. Anderson (Anderson, 1881) theorized that the superior belly of the omohyoid muscle is a true infrahyoid muscle, whereas the inferior belly most likely shares a common embryology with the subclavius muscle. In the present study, during routine dissection in the neck region of an adult male cadaver of 50 years age, an anomalous origin of inferior belly of omohyoid with absence of intermediate tendon was observed bilaterally. It was arising from clavicle on both sides. Both the muscle bellies were measured from the lateral end of fascial sling. The inferior belly of omohyoid extending from the lateral margin of sling to clavicular surface was measured 3.3cm in length on left side and 3.6cm on right side. The omohyoid is important in neck dissections because it is considered as an ideal landmark for level III and IV lymph node metastases. Knowledge of variations of this muscle is very important for surgeries in neck region because of its close relation to the internal jugular vein and brachial plexus. Its crucial relationship to vascular structures in the neck makes it an important landmark during neck surgeries.

Clinico-embryological submission of an unilateral anomalous presentation of axillary artery.

OBJECTIVES: Descriptions of the variant arterial pattern of upper limb are not exceptional and are therefore frequently reported in anatomy archives. BACKGROUND: A noteworthy deviation from the usual branching pattern was observed unilaterally in a single cadaver. This unique division of axillary artery (AA) was present on the right side in an adult human cadaver of Indian origin. RESULTS: The first part of axillary artery gave off the superior thoracic and thoraco-acromial arteries. Just proximal to the upper border of pectoralis minor the AA was observed to divide into two trunks a medial and a lateral. The lateral trunk continued into the brachium as the usual axillary artery where as the medial trunk displayed the other branches deep and distal to the pectoralis minor muscle. The remarkable feature was the wide caliber of the axillary artery where it bifurcated into two branches. An attempt has been made to dwell upon the embryological basis of the present anomaly. CONCLUSIONS: The relevance of anomalous arterial pattern of upper limb (U.L.) is realized while performing percutaneous arterial venous catheter insertion into subclavian vein via the infraclavicular route. We advocate a meticulous familiarization of the anatomy of axillary artery and its topographical relationship to other neurovascular structures for the operating plastic surgeon, anesthetist and radiologist (Fig. 1, Ref. 12).

Unilateral intercordal neural communication coexistent with variant branching pattern of posterior cord of brachial plexus.

Variant branching pattern of the cords of brachial plexus coupled with erroneous communications has been an area of concern for surgeons opting to explore this region. Anaesthetic blocks and surgical approaches are the highlights of these interventions, where a keen familiarization of the anatomy of this region is mandatory. The present case description reports a unilateral variant branching pattern of the posterior cord coexistent with a neural communication between lateral and medial cords in an adult male cadaver. This intercordal neural communication between lateral and medial cords was oriented obliquely and measured 2.2 cm in length. Furthermore, the posterior cord revealed a variant branching pattern. It branched into three upper subscapular nerves and a common trunk for the thoracodorsal and lower subscapular nerves. The lowest of the three upper subscapular nerves gave a communicating twig to the thoracodorsal nerve. Inspite of uncountable reports on variations ofbrachial plexus, descriptions regarding anomalous branching patterns hold enormous clinical significance for the radiologists, anesthetists and surgeons, besides being of academic interest for the anatomists.

Accessory muscle belly of peroneus tertius in the leg--a rare anatomical variation with clinical relevance--utility in reconstructions.

We report here a rare muscular anomaly of the lower leg in an adult male cadaver observed during routine cadaveric dissection. Peroneus tertius (PT) is peculiar to man, being a hallmark of bipedal locomotion and erect posture. During the course of gross anatomy dissection, a rare finding of accessory belly of PT muscle was discovered. A meticulous dissection was performed and the observations were noted. The PT displayed two distinct bellies of origin. Both the bellies were substantial in size and were eventually fused close to their insertion at the base of the fifth meta-tarsal bone. Innervation of both the bellies was derived from the deep peroneal nerve. Soft tissue defects of the leg may be effectively covered by local muscles in the vicinity of the wounds. PT has been reliably used in the past for local transposition flaps in the lower extremities. The relations of the superficial nerve and the PT during placement of the anterolateral portal in ankle arthroscopy are vital to avoid inadvertent neuromuscular injuries. The presence of two bellies of the PT muscle has been discussed in the comparative perspective. A precise and detailed knowledge of the anatomical details of the crural muscles is important for performing reconstructive surgeries.

A rare bimuscular conglomeration gluteopiriformis case report.

The present paper reports a rare anomalous muscle in the gluteal region, which appears to be a conglomeration of gluteus maximus and piriformis muscles. The muscle was proximally attached to the gluteus maximus and distally merged with the piriformis muscle. The innervation of the anomalous muscle was derived from the inferior gluteal nerve. Recognition of such a muscle variant may facilitate early clinical diagnosis and treatment of patients with symptoms of piriformis syndrome or sciatica of unexplained etiology. Contraction of such an anomalous muscle could lead to altered biomechanics of the piriformis and the gluteus maximus. Such a rare muscle, which morphologically resembles the piriformis and developmentally appears to be a part of gluteus maximus could be a challenging puzzle for the present day surgeon and radiologist.

Rectus thoracis bifurcalis: a new variant in the anterior chest wall musculature.

A cadaveric study was undertaken to report the incidence of sternalis muscle in cadavers of Asian origin. A total of 88 cadavers were studied over a period of six years and the sternalis was reported only in a single case and that too unilaterally. The accessory muscle was discovered in the right pectoral region in a 40-year-old male cadaver. The muscle emanated from the external oblique aponeurosis of abdomen confirming its origin from the ventral longitudinal sheet of muscle. The muscle was fleshy throughout its extent except at the ends where they were aponeurotic. At the sternal angle, the muscle displayed "Y" shaped configuration and merged with the respective sternocleidomastoid muscle. The innervation was derived from the third intercostals nerve. We intend to highlight a few points through this study. Firstly, we found a paucity of studies undertaken to describe the incidence of sternalis muscle. Further, the studies present in anatomical archives are mainly case reports. Secondly, this muscle presents itself in varying configurations on radiological studies. The radiologist should acquaint himself with all these presentations, so that he can make accurate diagnosis of a breast mass. Thirdly, this muscle having more morphological relevance may be conveniently utilized for flap procedures of post mastectomy breast reconstruction. Lastly, the presence of this muscle may alter the depth at which the internal mammary lymph nodes are irradiated in case of carcinoma breast. Additionally, it should not be erroneously diagnosed as a mass which recurred on follow up of breast cancer patients. The present investigation endeavors to discuss the anatomical, embryological and clinical relevance of a rare accessory muscle of the anterior chest wall.

Crucial neurovascular structures entrapped in a brachial intramuscular tunnel.

We report a case where the median nerve accompanied by brachial vessels were found to traverse an intra-muscular tunnel within the brachialis muscle, in the floor of the cubital fossa. The muscular tunnel commenced 5 cm proximal to the neck of radius, measured 4.4 cm in length, and was present unilaterally. This unusual tunnel was distally found to blend with the brachial fascia. The present study was planned with an endeavor to elucidate in an improved way the clinical implications of compressed median nerve and brachial vessels. There are several sites where median nerve maybe compressed along its course in the arm and forearm. The relevance of the present documentation lies in the fact that these vital neurovascular structures may be compressed leading to neuropathies and vascular changes.

Clinico-embryological perspective of a rare accessory brachial muscle with possible musculocutaneous nerve compression.

Both brachialis and biceps brachii are primary flexors of the arm and elbow from the biomechanical perspective. Numerous reports exist in anatomical literature regarding accessory heads of biceps brachii, although such accessory bellies in relation to brachialis muscle are less frequently elucidated. We report a unilateral case of a rare accessory muscle interposed between the biceps brachii and brachialis, having the musculocutaneous nerve (MCN) entrapped between the two. Furthermore, the muscle divided into two slips, upper slip was attached to biceps brachii and the other gained insertion to the brachial fascia. Innervation to this accessory muscle was derived from MCN. The embryological basis for such supernumerary muscle is discussed. Additionally, the case is considered under surgical and clinical perspective, highlighting the importance of familiarity with such variations. Anatomical variations of the brachial musculature may cause diagnostic perplexities while interpreting MRI or CT scans.

Unilateral partial ossification of sacrotuberous ligament: anatomico-radiological evaluation and clinical implications.

The present study describes the topography and morphometry of a unilateral ossified sacrotuberous ligament. It aims to discuss its anatomical, radiological and clinical implications. The pudendal nerve, internal pudendal artery, nerve to obturator internus and coccygeal branch of inferior gluteal artery are all-important structures near sacrotuberous ligament. An ossified sacrotuberous ligament may be an important etiological factor in neurovascular compression syndromes and its anatomical knowledge may help in the development of new treatment for this common clinical problem. The ossified sacrotuberous ligament in the present case was 7.6 cm in length and exhibited a characteristic anterior and posterior segment. The base was at the ischial tuberosity and the apex showed numerous small bony protuberances with deep intervening grooves. The ossified STL may be important in differential diagnosis of soft tissue pain and tenderness after trauma. It may be a challenging puzzle for the present day surgeon and radiologist in interpretation of CT-scans and MRI.

Peculiar tendinous origin of the brachialis muscle: anatomic and clinical insight.

The current study seeks to elucidate the presence and potential function of an anomalous tendinous origin of the brachialis muscle. The brachialis muscle originates from the humeral shaft, which is usually muscular, thereby becoming tendo-aponeurotic distally towards its insertion. During routine cadaveric dissection, in a 52-year-old cadaver, the anomalous brachialis muscle originated in the form of a tendon measuring 4.4 cm in length. The tendon was attached to the proximal humeral shaft near the lateral lip of inter-tubercular sulcus. The aponeurotic insertion was as usual, into the ulnar coronoid process. The long tendinous origin of the brachialis muscle as observed in the present study could alter the biomechanics of the muscle. A long tendinous origin of the muscle may predispose to frequent tendinous injuries. There are possibilities of the anomalous tendon being used as a graft in elbow injuries. A comprehensive knowledge of such a rare anatomical variation could prove beneficial in surgical, rehabilitation and radiological field.

Bilateral temporal spinous projections overshadowing the sphenoidal spines: an anatomical and radiological evaluation.

The infratemporal fossa has traditionally been described as a post-maxillary space, which is open below, to the rear and laterally. The most reliable osseous landmarks of the infratemporal and parapharyngeal spaces are the pterygoid and styloid processes and the sphenoidal spine. In the present study the skull exhibited the normal sphenoidal spines along with a prominent spinous projection emanating bilaterally from the tympanic plate of the temporal bone. The objective of the present paper is to report an anatomical and radiological evaluation of the sphenoidal spines coexistent with bilateral temporal spinous projections. Additionally, the topographical relationship of this osseous variation is discussed with particular reference to neurovascular structures. Unduly prominent temporal spinous projections may cause obstruction, thus reducing the operative field. The anatomical variations relating to bony and vascular structures in this region are of paramount importance to neurosurgeons and otorhinolaryngologists.

Unusual branching pattern of brachial artery - Embryological basis and clinicoanatomical insight.

Variations in the arterial pattern of upper limb are of colossal importance to the surgeons as they are liable to iatrogenic injuries. During routine dissection for undergraduate medical students, an anomaly of brachial artery was discovered. The brachial artery terminated at higher level into ulnar and radial artery. The common interosseus artery took origin arising from radial artery. The ulnar artery did not give any branches in the forearm. Both radial and ulnar artery displayed a superficial course in the forearm. The anatomical knowledge of these variations may be of great help for the clinicians in planning and conducting flap harvesting during reconstructive surgeries and in arteriography.

Adductor accessorius - an unusual supernumerary adductor muscle of thigh.

The knowledge of variant anatomy of medial compartment of thigh is extremely important in surgical procedures requiring obturator nerve block. The nerve block is also recommended for providing additional analgesia following major knee surgeries and for relieving painful adductor muscle spasm. The interfascial injection technique is commonly followed in ultrasound guided obturator nerve block. For this procedure it is imperative to identify the adductor muscles on sonography to inject the anesthetic solution in the intermuscular fascial planes. The presence of an additional muscle can prove useful in myocutaneous flap surgeries for reconstruction especially of perineum. We hereby report a case of such an anomalous supernumerary adductor muscle present between adductor brevis and proximal part of adductor magnus, in an adult Indian male cadaver, recorded during routine dissection in Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital. The muscle was innervated by the posterior division of obturator nerve. The morphology, embryological basis and clinical aspects are also discussed.

Rare atypical vascular pattern of subscapular artery: Anatomico-clinical insight.

BACKGROUND AND OBJECTIVE: The use of muscles of scapular region in transposition and reparative surgery has made the anatomical knowledge of axillary artery and its branches imperative. The subscapular arterial tree is frequently used as a source of microvascular grafts to replace damaged or diseased portion of arteries especially in upper and lower limbs. This investigation is aimed to study the variation in branching pattern of the third part of axillary artery. MATERIALS AND METHODS: Routine educational cadaveric dissection of a young adult Indian male cadaver. RESULTS: The present article highlights a rare variation of the subscapular artery and its branches. The subscapular artery displayed a unique pattern of trifurcation. Its branches were seen supplying serratus anterior, subscapularis, latissimus dorsi and teres major muscles. CONCLUSIONS: The study focuses on a new variation of the subscapular artery which could prove useful for interventional radiologists and surgeons in reconstructive surgeries.

Closed mitral valvotomy for mitral restenosis: experience in 113 consecutive cases.

The costs of heart operations and the problems related to anticoagulation after prosthetic valve replacement are among the limitations faced by patients in nonindustrialized countries with mitral stenosis caused by chronic rheumatic heart disease. The young age at which these patients are seen also compels the surgeon to preserve the native valve. The least costly and optimal way to achieve this objective is by closed mitral valvotomy. After closed mitral valvotomy, mitral restenosis is commonly encountered. We report here our 10-year experience with operation on 113 consecutive patients with mitral restenosis. Closed transventricular revalvotomy was performed with Tubbs dilator in 105 of 113 patients. Mean age was 343 years, with a male to female ratio of 1:1.5. Most patients were in New York Heart Association functional classes III and IV (74.3% and 19.4%, respectively). Mean interval between first and second valvotomy was 9.4 years, Hospital mortality rate was 2.8%, trivial postoperative mitral regurgitation occurred in 16.1%, and moderately severe regurgitation occurred in 1.9%. Early postoperative systemic embolism occurred in 3.8% of the cases. Moderate to excellent symptomatic improvement was noted in 89.4% of the cases and poor results were seen in 10.2%. Late follow-up of 76 patients ranged from 2 to 10 years (mean 3.8 years), with 39.4% patients in New York Heart Association class I and 50% in class II. Close mitral revalvotomy is thus an economical, simple, and safe palliative procedure that carries good long-term results.

Complete congenital sternal cleft in an adult: repair by autogenous tissues.

We are reporting here a rare case of congenital complete sternal cleft in an adult of 25 years of age, with absent anterior pericardium and "diastasis recti." Successful surgical repair was achieved along with the preservation of the already existing anatomic and mechanical sanctity of thoracic cage, sternal reconstruction, and protection of the underlying heart and great vessels with a good cosmetic result using autogenous tissue i.e., iliac bone and "V-Y" myoplasty of pectoralis major muscles with their functional preservation and correction of associated anomalies.

Traumatic subarachnoid-pleural fistula.

BACKGROUND: Traumatic subarachnoid-pleural fistula is a very uncommon but important condition. Only 21 cases have been reported so far in the world literature. METHODS: We encountered 2 cases of subarachnoid-pleural fistula, both in pediatric patients presenting without any neurologic deficit. Whereas our first patient presented with recurrent, rapidly filling clear pleural effusions with an obscure cause, posing a diagnostic problem for the pediatricians, the second patient had trauma to the pleura and dura mater by the sharp edge of Kirschner wire, with impending risk of injury to spinal cord and infection. RESULTS: Surgical intervention was undertaken after we had a strong suspicion of subarachnoid-pleural fistula in both cases. A subarachnoid-pleural fistula was found at the level of the eleventh thoracic vertebra in the first patient and at the level of the eighth thoracic vertebra in the second patient. Autogenous tissues (mediastinal pleural flap and hammered intercostal muscle covered with methylcellulose) were used to repair the fistula. The subarachnoid space was decompressed with a lumbar drain in the second patient. CONCLUSIONS: The diagnosis of subarachnoid-pleural fistula is difficult when it is not associated with any neurologic deficit. We found that a high degree of suspicion and early surgical intervention to repair the fistula are rewarding.

Repair of parachute mitral valve with multiple ventricular septal defects: a case report and literature review.

A case of parachute mitral valve (PMV) associated with multiple muscular ventricular septal defects (VSDs) is reported in a 16-year-old girl who presented with dyspnea and a cardiac murmur. In addition, there were deformities of the right ear lobe and kyphoscoliosis of the thoracolumbar spine since birth. A preoperative diagnosis was made using two-dimensional and Doppler echocardiography, cardiac catheterization and angiocardiography. PMV was found to be stenotic and mildly regurgitant. At surgery, mitral valvuloplasty, preservation of the native valve apparatus and Dacron patch closure of multiple muscular VSDs was achieved. The latest available case reports in the literature pertaining to PMV and associated deformities have been reviewed.