Epidural space "ballooning" during local anaesthetic injection in infants and children: An ultrasound observational study.

BACKGROUND: Infants and children require a larger dose of a local anaesthetic (LA) to establish epidural analgesia than adults, but the reason for this remains unclear. We hypothesised that prominent ventro-dorsal expansion of the epidural space limits cranio-caudal spread of LA in infants. Accordingly, we studied the dimensions of the epidural space with real-time ultrasound (US) before and after epidural injection. METHODS: Ninety-six infants and children aged 0-12 years who underwent abdominal surgery under combined epidural and general anaesthesia were examined in this prospective observational study. Using a micro-convex probe, US recordings of the posterior epidural space were performed while a LA (0.5 ml kg-1 ) was infused at 0.54 ml s-1 . The width in the ventro-dorsal dimension (VDD) of the posterior epidural space before and after injection was recorded; the change in VDD was defined as "ballooning". Correlations between "ballooning" and patient age, body mass index, and volume and rate of LA administration were analysed. RESULTS: "Ballooning" correlated positively but weakly with age (R2  = 0.25; p < .001) and the infused LA volume (R2  = 0.32; p < .001). The "magnitude of ballooning" ("ballooning" per ml of injected LA) correlated negatively but weakly with age (R2  = 0.27; p < .001). CONCLUSIONS: "Magnitude of ballooning" of the epidural space become inconspicuous with growing during epidural injection. This effect may slow the cranio-caudal spread of LA and explain partially why larger volumes of LA are required to effect a block in children.

Through the forest of motor representations.

Following neuroscience, and using different labels, several philosophers have addressed the idea of the presence of a single representational mechanism lying in between (visual) perceptual processes and motor processes involved in different functions and useful for shaping suitable action performances: a motor representation (MR). MRs are the naturalized mental antecedents of action. This paper presents a new, non-monolithic view of MRs, according to which, contrarily to the received view, when looking at in between (visual) perceptual processes and motor processes, we find not only a single representational mechanism with different functions, but an ensemble of different sub-representational phenomena, each of which with a different function. This new view is able to avoid several issues emerging from the literature and to address something the literature is silent about, which however turns out to be crucial for a theory of MRs.

Parietal control of hand movement.

The parietal lobe has been implicated in the sensorimotor control and integration that supports the skillful use of our hands to reach for, grasp, and manipulate objects in the environment. This area is involved in several circuits within the classic subdivisions of the dorsal stream. Recently, the dorsal stream has been further divided into a "dorso-dorsal" and a "ventro-dorsal" streams. The ventro-dorsal stream is regarded as functionally linked to object manipulation. The dorso-dorsal stream is proposed to subserve reaching and online control of actions. Affordances indicate action possibilities characterized by object properties the environment provides. Affordances are likely represented by the dorsal stream. They code structural object properties that can elicit actions. A further subdivision of affordances into "stable" and "variable" allows an understanding of the neuronal mechanisms underlying object manipulation. Whereas stable affordances emerge from slow processing of visual information based on knowledge of object properties from previous experiences and object interaction, variable affordances emerge from fast online processing of visual information during actual object interaction, within a changing environment. The relevance of the dorsal stream subdivisions in this context is that the dorso-dorsal stream is associated with coding of variable affordances, while that of the dorso-ventral stream is implicated in action representations elicited by stable affordances. A greater interaction between these and ventral stream perceptual and semantic representations allows the parietal control of hand movement. An understanding of these networks is likely to underlie recovery from complex deficits described in limb apraxias.

The role of the parietal cortex in sensorimotor transformations and action coding.

The picture of the human cortical motor system has fully changed in the last two decades. In the light of new data, the notion of a motor system devoted solely to action execution, strictly isolated from the sensory system, is not sustainable. There is evidence that parietal areas are strictly connected to frontal areas and these connections build up sensorimotor circuits aimed at interacting with objects in the environment, and at understanding actions. They are known as the canonic neuron system and mirror neuron system, respectively. These circuits are part of the classic dorsal stream. Recently, the dorsal stream has been further divided into a dorsodorsal and a ventrodorsal stream. The ventrodorsal stream is regarded as functionally linked to object awareness for action recognition/organization. The dorsodorsal stream is proposed to subserve online control of actions. Affordances indicate "action possibilities" as characterized by object properties the environment provides to interacting organisms. Affordances may be divided into stable and variable ones. According to this distinction, stable affordances emerge from slow offline processing of visual information based on object knowledge as well as previous experiences in object interaction. In contrast, variable affordances emerge from fast online processing of visual information during actual object interaction and refer to changing or temporary object characteristics, such as orientation in space, size changes, including the update of hand shape for grasping, defining overall the current state of the object. It has been proposed that the dorsodorsal stream codes for variable affordances, while the dorsoventral stream codes for stable affordances.

Impaired Communication Between the Dorsal and Ventral Stream: Indications from Apraxia.

Patients with apraxia perform poorly when demonstrating how an object is used, particularly when pantomiming the action. However, these patients are able to accurately identify, and to pick up and move objects, demonstrating intact ventral and dorsal stream visuomotor processing. Appropriate object manipulation for skilled use is thought to rely on integration of known and visible object properties associated with "ventro-dorsal" stream neural processes. In apraxia, it has been suggested that stored object knowledge from the ventral stream may be less readily available to incorporate into the action plan, leading to an over-reliance on the objects' visual affordances in object-directed motor behavior. The current study examined grasping performance in left hemisphere stroke patients with (N = 3) and without (N = 9) apraxia, and in age-matched healthy control participants (N = 14), where participants repeatedly grasped novel cylindrical objects of varying weight distribution. Across two conditions, object weight distribution was indicated by either a memory-associated cue (object color) or visual-spatial cue (visible dot over the weighted end). Participants were required to incorporate object-weight associations to effectively grasp and balance each object. Control groups appropriately adjusted their grasp according to each object's weight distribution across each condition, whereas throughout the task two of the three apraxic patients performed poorly on both the memory-associated and visual-spatial cue conditions. A third apraxic patient seemed to compensate for these difficulties but still performed differently to control groups. Patients with apraxia performed normally on the neutral control condition when grasping the evenly weighted version. The pattern of behavior in apraxic patients suggests impaired integration of visible and known object properties attributed to the ventro-dorsal stream: in learning to grasp the weighted object accurately, apraxic patients applied neither pure knowledge-based information (the memory-associated condition) nor higher-level information given in the visual-spatial cue condition. Disruption to ventro-dorsal stream predicts that apraxic patients will have difficulty learning to manipulate new objects on the basis of information other than low-level visual cues such as shape and size.

Affordance processing in segregated parieto-frontal dorsal stream sub-pathways.

The concept of affordances indicates "action possibilities" as characterized by object properties the environment provides to interacting organisms. Affordances relate to both perception and action and refer to sensory-motor processes emerging from goal-directed object interaction. In contrast to stable properties, affordances may vary with environmental context. A sub-classification into stable and variable affordances was proposed in the framework of the ROSSI project (Borghi et al., 2010; Borghi and Riggio, 2015, 2009). Here, we present a coordinate-based meta-analysis of functional imaging studies on object interaction targeting consistent anatomical correlates of these different types of affordances. Our review revealed the existence of two parallel (but to some extent overlapping) functional pathways. The network for stable affordances consists of predominantly left inferior parietal and frontal cortices in the ventro-dorsal stream, whereas the network for variable affordances is localized preferentially in the dorso-dorsal stream. This is in line with the proposal of differentiated affordances: stable affordances are characterized by the knowledge of invariant object features, whereas variable affordances underlie adaptation to changing object properties.

A neural network model of causative actions.

A common idea in models of action representation is that actions are represented in terms of their perceptual effects (see e.g., Prinz, 1997; Hommel et al., 2001; Sahin et al., 2007; Umiltà et al., 2008; Hommel, 2013). In this paper we extend existing models of effect-based action representations to account for a novel distinction. Some actions bring about effects that are independent events in their own right: for instance, if John smashes a cup, he brings about the event of the cup smashing. Other actions do not bring about such effects. For instance, if John grabs a cup, this action does not cause the cup to "do" anything: a grab action has well-defined perceptual effects, but these are not registered by the perceptual system that detects independent events involving external objects in the world. In our model, effect-based actions are implemented in several distinct neural circuits, which are organized into a hierarchy based on the complexity of their associated perceptual effects. The circuit at the top of this hierarchy is responsible for actions that bring about independently perceivable events. This circuit receives input from the perceptual module that recognizes arbitrary events taking place in the world, and learns movements that reliably cause such events. We assess our model against existing experimental observations about effect-based motor representations, and make some novel experimental predictions. We also consider the possibility that the "causative actions" circuit in our model can be identified with a motor pathway reported in other work, specializing in "functional" actions on manipulable tools (Bub et al., 2008; Binkofski and Buxbaum, 2013).

Two action systems in the human brain.

The distinction between dorsal and ventral visual processing streams, first proposed by Ungerleider and Mishkin (1982) and later refined by Milner and Goodale (1995) has been elaborated substantially in recent years, spurred by two developments. The first was proposed in large part by Rizzolatti and Matelli (2003) and is a more detailed description of the multiple neural circuits connecting the frontal, temporal, and parietal cortices. Secondly, there are a number of behavioral observations that the classic "two visual systems" hypothesis is unable to accommodate without additional assumptions. The notion that the Dorsal stream is specialized for "where" or "how" actions and the Ventral stream for "What" knowledge cannot account for two prominent disorders of action, limb apraxia and optic ataxia, that represent a double dissociation in terms of the types of actions that are preserved and impaired. A growing body of evidence, instead, suggests that there are at least two distinct Dorsal routes in the human brain, referred to as the "Grasp" and "Use" systems. Both of these may be differentiated from the Ventral route in terms of neuroanatomic localization, representational specificity, and time course of information processing.