Celiac Artery Dissection in a Young Smoker.

Isolated dissection of the celiac artery (IDCA) is a rare phenomenon with unclear pathogenesis. Although several risk factors have been attributed, it is essential for clinicians to maintain this diagnosis in the list of differentials to ensure prompt implementation of diagnostic and treatment modalities. We present the case of a 37-year-old smoking male who presented with upper abdominal pain radiating to the left upper quadrant with associated nausea/vomiting, diaphoresis, and diarrhea.

Transclival Venous Circulation: Anatomic Study.

INTRODUCTION: The clivus is a small, central area of the basal cranium with limited surgical access and high morbidity associated with pathologies of its surrounding structures. Therefore thorough knowledge and understanding of the anatomy in this region are crucial for the success of treatments and interpretation of imaging. As to our knowledge, there is no extant cadaveric examination of the transclival veins, so the present study was performed. METHODS: Fifteen lightly embalmed adult heads underwent blue latex injection of the left and right internal jugular veins. Special attention was given to the presence or absence of transclival vessels. When transclival veins were identified, their intracranial source, point of penetration of the clivus and anterior connections were documented. RESULTS: Ten (66.7%) specimens were found to have transclival veins. These connected the basilar venous plexus to the retropharyngeal venous plexus on all specimens. Eight of the 10 specimens had multiple transclival veins, and 2 had only 1 vessel. The majority of the transclival veins were found penetrating the clivus at its lower one third. However, 2 specimens also had transclival veins that pierced the clivus at its upper one third. CONCLUSIONS: An improved understanding of the skull base and its venous drainage can assist clinicians and surgeons in better understanding normal, pathologic, and variant anatomy in this region.

The Alar Ligaments: A Cadaveric and Radiologic Comparison Study.

OBJECTIVE: A precise anatomical description of the alar ligaments is important to better understand their biomechanical and pathologic implications. Although there are several studies regarding their anatomy, the literature is inconsistent. To our knowledge, there are no reports that compare cadaveric morphologic findings with computed tomography (CT) images of the alar ligaments. METHODS: Eight sides from 4 fresh-frozen cadaveric specimens were used in this study. After routine dissection of the craniocervical junction, the alar ligaments were exposed. We carried out measurements of the alar ligaments, their position within the craniovertebral junction, and their relation to the dens and adjacent structures. Fine-cut CT of the specimens was performed, and the measurements were later compared with the original cadaveric dissections. RESULTS: Alar ligaments were attached to the upper half of the lateral surface of the dens and ran laterally to its insertion just medial to the occipital condyle. The ligaments were found to have an ovoid cross-sectional area with a nearly horizontal caudocranial trajectory and comparable diameters in both anteroposterior and superoinferior directions between the CT and cadaveric measurements. CONCLUSIONS: There were small but not statistically significant differences in the measurements between the cadaver specimens and the CT images. There was however, a strong correlation between the proximal and distal insertions, as well as the orientation of the fibers, that suggests CT images can be an appropriate approach to the study of the anatomical and 3-dimensional features of the alar ligaments.

Potential Mechanism for Some Postoperative C5 Palsies: An Anatomical Study.

STUDY DESIGN: Anatomical Study. OBJECTIVE: Determine if shoulder depression (eg, taping the shoulders) might result in C5 nerve traction and subsequent injury. SUMMARY OF BACKGROUND DATA: Postoperative C5 nerve palsy is a recognized entity that is still often enigmatic. Inferior shoulder depression is usually employed to assist with surgical visualization during cervical spine procedures. METHODS: In the supine position, 10 adult fresh frozen human cadavers underwent dissection of the spinal cord and its adjacent dorsal, ventral roots, and spinal nerves from C4 to T1. In the supine position, the head was rotated ipsilaterally, contralaterally, and in lateral flexion. The shoulder was elevated, retracted, protracted, and depressed all with direct observation of nerve roots, intradural ventral/dorsal rootlets, or the spinal cord. The effects of these movements upon the cervical nerve rootlets were measured. RESULTS: The greatest displacement of nervous tissue was generated by shoulder depression and occurred primarily at the intradural rootlet level. The nerve rootlets that underwent the greatest average displacement were found at C5, with a decreasing gradient to C7 and no gross motion at C8 or T1. With maximal shoulder depression, C5-C7 rootlet tension produced cord movement to the ipsilateral side, touching the dura mater covering the lateral vertebral column with the C5 nerve root moving farthest. CONCLUSION: Shoulder depression is often used during cervical spine surgery. In cadavers, shoulder depression causes significant tension and displacement of the C5 nerve rootlets, and in the extreme, cord displacement to the ipsilateral side. This could be a mechanism for injury, putting patients at greater risk for postoperative C5 palsy. LEVEL OF EVIDENCE: 5.

Anatomical Study and Comprehensive Review of the Incisivus Labii Superioris Muscle: Application to Lip and Cosmetic Surgery.

Objectives The incisivus labii superioris muscle, which originates from the floor of the incisive fossa of the maxilla, has previously been described, it is not well understood. The purpose of this study was to investigate the incisivus labii superioris muscle with detailed dissection. Methods Twenty-six halves from thirteen fresh frozen cadaveric Caucasian heads were used in this study. First, the incisivus labii superioris muscle was dissected to reveal its origin and insertion, and its relationship to other mimetic muscles. Secondly, the distance from the midline to the innermost part of the bony attachment of the muscle was measured. The literature describing the incisivus labii superioris muscle was reviewed. Results The incisivus labii superioris muscle consisted of two parts, inferior and superior. The former merged into the orbicularis oris and the latter into the nasalis. The mean distance from the midline to the innermost part of the bony attachment of the incisivus labii superioris muscle was 4.8 ± 1.7 mm on the right side and 4.9 ±1.7 mm on the left. Conclusions The results of the present study suggest that the inferior part of the incisivus labii superioris should be considered as an accessory muscle of the orbicularis oris complex, and the superior part is the nasalis muscle.

Neuroleukemiosis: Two Case Reports.

Extramedullary tumors composed of myeloblasts or monoblasts can present in various locations. Patients with a history of acute myeloid leukemia (AML) can present with neuropathic pain and no evidence of relapse of their leukemia. Neuroleukemiosis is a form of extramedullary tumor present in the peripheral nervous systems (PNS) of leukemia patients. We report two AML patients who were in remission and later presented with neurological symptoms due to neuroleukemiosis with negative bone marrow biopsies.

Anatomy of Alar Ligament Part I: Morphometrics and Variants.

OBJECTIVE: The alar ligaments are among the primary ligamentous structures contributing to craniovertebral stability. The purpose of this study is to clarify the morphology of the alar ligament using fresh cadaveric specimens. METHODS: Twenty-two fresh, frozen cadaveric alar ligaments were used in this study. The occiput, C1, and C2 were removed en bloc from each specimen, and various measurements and observations including variations were documented. RESULTS: The angle formed by both alar ligaments was measured in a neutral position (149 ± 24.19 degrees), as well as during forced flexion (134.18 ± 27.08 degrees) and extension (163.81 ± 24.54 degrees). CONCLUSIONS: The current cadaveric evaluation offers an interesting window into better understanding the anatomy of the alar ligaments.

A Rare Case of Double-Headed Psoas Minor Muscle with Review of its Known Variants.

Variations of the muscles of humans are important to remember for those who interpret imaging and for those who operate near these anomalies. Herein, we describe a rare two-headed psoas minor muscle found incidentally during dissection of the posterior abdominal wall. This case is presented with a detailed review of all known variations of the minor psoas and is analyzed through a literature review.

Pineal Gland Agenesis: Review and Case Illustration.

Agenesis of the pineal gland has rarely been reported in the medical literature. Herein, we report a cadaveric specimen found to have agenesis of the pineal gland. The remaining gross examination of the brain was normal. A review of the literature was performed on this unusual finding.

Extreme aplasia cutis congenita involving the skull.

Aplasia cutis congenita (ACC) is a rare congenital malformation of primarily the skin; it is most commonly seen on the scalp but can occur anywhere on the body. The exact etiology is still unclear but there are many suggested causes. Classification systems have been proposed to help categorize patients and assist with treatment. Treatment options are controversial and range from conservative to surgical interventions. We report an extreme case of ACC that included a significant part of the skull. We discuss this case and review salient literature. Although such cases of ACC with bony involvement are rare, this aspect of the pathology should be kept in mind when treating or imaging such patients.

Lateral Transpsoas Approach to the Lumbar Spine and Relationship of the Ureter: Anatomic Study with Application to Minimizing Complications.

BACKGROUND: Complications from lateral lumbar interbody fusion procedures range from neurologic deficits to organ and blood vessel injuries. Injury to the ureter has been reported though uncommon. The present study was performed to elucidate the anatomic relationship of the ureter to this surgical approach. METHODS: Eight adult cadavers (16 sides) were placed in the full lateral position, and the distal ureter was cannulated with a metal wire that was passed up to the kidney. Fluoroscopy was used to establish the position of the ureter in relation to the bony anatomy in this region. RESULTS: In the lumbar region, there was a posterior to anterior course of the left and right ureter. From the direct lateral position, the ureter was found to lie at or posterior to the anterior edge of the lumbar vertebral bodies. On 87.5% of sides, the ureter was on average 2.5 cm posterior to the anterior border of the vertebral bodies at L2, 3 cm posterior at L3, 1.0 cm posterior at L4, and on the margin of the anterior vertebral bodies at L5. In general, the ureter, from a lateral perspective, crossed the posterior third of the upper lumbar vertebrae, approached the middle third at L3, and reached the anterior third at L4/L5 before descending into the pelvis. CONCLUSIONS: Owing to the proximity of the ureter to the lumbar vertebral bodies, it is imperative to verify that this structure is not in the surgical trajectory during lateral lumbar interbody fusion procedures if injury is to be avoided.

Relationship of the Median and Radial Nerves at the Elbow: Application to Avoiding Injury During Venipuncture or Other Invasive Procedures of the Cubital Fossa.

INTRODUCTION: The median and radial nerves are two important neural structures found in the cubital fossa. The trajectory and landmarks used to identify their location are important when procedures are done in this area. METHODS AND MATERIALS: Ten fresh-frozen cadavers were dissected (20 upper limbs) and measurements were taken from the medial epicondyle to the median and radial nerves as well as to the lateral epicondyle of each limb. RESULTS: The distance between the medial epicondyle and the median nerve was found to be three centimeters with a range of 2.1 to four centimeters and the distance from the medial epicondyle to the radial nerve had a mean distance of 5.5 cm and a range of 3.8 to seven centimeters. DISCUSSION: Damage to the median or radial nerves can lead to major complications including loss of extension, flexion, and sensation in the forearm and hand. Other studies have tried to identify the course of these nerves in order to prevent their injury during procedures. CONCLUSION: After identifying the medial epicondyle, using the results we obtained, physicians may have a better understanding of where the median and radial nerves lie within the cubital fossa when performing procedures in this area.

Junctional neural tube defect in a newborn: report of a fourth case.

INTRODUCTION: A discontinuous, functionally disconnected spinal cord is an extremely rare finding, with only three known reports in the literature. Titled junctional neural tube defect (JNTD), this newly reported dysraphism is believed to arise from a developmental error occurring during junctional neurulation, a transitory stage of development marked by the end of primary neurulation and the beginning of secondary neurulation. Herein, we report a newborn case of JNTD. CASE REPORT: We report a newborn boy born with anorectal atresia. Physical examination revealed normal movement in the upper and lower extremities. Imaging revealed distal sacral agenesis and a spinal cord that was discontinuous at the thoracolumbar junction. Three vertebral segments inferiorly, at the L2 vertebral level, the distal end of the spinal cord (i.e., conus medullaris) were visualized. No signs of a tethered cord were identified. CONCLUSIONS: Characterized by an error in junctional neurulation in which the primary and secondary NT fail to integrate appropriately, JNTD has been recently classified. We believe the current patient to represent only the fourth reported case of JNTD in the literature.

Misdiagnosed syrinx in a patient with neuroschisis and Klippel-Feil syndrome: case report.

INTRODUCTION: Patients with Klippel-Feil syndrome can present with a myriad of symptoms and imaging findings. Herein, we present a case of Klippel-Feil syndrome that was initially misdiagnosed with syringomyelia. We review this case and discuss the imaging findings. CONCLUSIONS: Neuoroschisis should be suspected in patients with Klippel-Feil syndrome and differentiated from syringomyelia.

New supplemental landmark for the greater palatine foramen as found deep to soft tissue: application for the greater palatine nerve block.

PURPOSE: Many researches have investigated the morphology of the greater palatine foramina using dry skulls and cone-beam computed tomography. In most studies, some structures in the hard tissue have been measured and statistically analyzed. However, none of the studies has analyzed this foramen in regard to its location with overlying soft tissues, which is so clinically relevant. Therefore, this study was performed to provide the knowledge about relationship between the greater palatine foramen and foveola palatina for a better understanding of dental procedures such as greater palatine nerve block. METHODS: Thirty sides, from fifteen fresh cadaveric heads, were used in this study. The specimens were derived from eight males and seven females. A 27-gauge needle was inserted into the fossa, which was palpated at the edge of a dental mirror at a 45° angle to the occlusal plane and parallel to the sagittal plane. The anteroposterior distance, which was parallel to the midline, between the penetration site and foveola palatina was measured. RESULTS: All the penetrations advanced to the greater palatine foramen. The distances ranged from 2.0 to 8.3 mm on right sides, and 1.1 to 8.2 mm on left sides, respectively. CONCLUSION: The results of this study could help dentists identify the correct location of the greater palatine foramen with a supplemental landmark.

Simultaneous lateral ponticle with facet-like depression and epitransverse process of the atlas.

The lateral ponticle and epitransverse process are rare anatomical variations found on the atlas vertebra of the cervical spine. When a lateral ponticle occurs, an abnormal bony bridge extends from the superior articular facet to the transverse process. This bony bridge bisects the transverse foramen wherein the vertebral artery normally lies. In this case report, we describe a C1 specimen from an adult male with a lateral ponticle on the right side and an epitransverse process on the left side. Additionally, an articular facet-like structure was also found on the lateral ponticle's surface. Relevant literature regarding the lateral ponticle across age groups, sex, race, and species is also reviewed. We postulate that genesis of the lateral ponticle of the atlas occurs in utero, specifically during the lateral ossification of the ventral sclerotomes. To our knowledge, an articular facet-like structure on such a ponticle has not been reported previously. Moreover, simultaneous occurrence of a lateral ponticle and contralateral epitransverse process has, to our knowledge, not been reported before.

The Clinical anatomy of the physical examination of the abdomen: A comprehensive review.

Physical examination of the abdomen is an essential skill. Knowledge of its clinical anatomy and application is vital for making diagnoses. Misinterpretation of anatomy during examination can have serious consequences. This review addresses understanding of the anatomy, methodology, and complications of abdominal physical examination. It includes particular reference to modern technology and investigations. Physical examination is performed for diagnostic purposes. However, the art of physical examination is declining as more and more clinicians rely on newer technology. This can have regrettable consequences: negligence, waste of time and resources, and deterioration of clinical skills. With a sound knowledge of clinical anatomy, and realization of the importance of physical examination of the abdomen, clinician, and patients alike can benefit. Clin. Anat. 30:352-356, 2017. © 2017 Wiley Periodicals, Inc.

Auscultation of the heart: The Basics with Anatomical Correlation.

Proficiency in heart auscultation continues to be important even in an era of modern technology. However, many physicians and health care providers are uncomfortable and often inaccurate in their ability to identify normal and abnormal heart sounds. The following review was performed to provide a basis that health care providers can use to strengthen their understanding and improve their techniques when auscultating the human heart. Clin. Anat. 30:58-60, 2017. © 2016 Wiley Periodicals, Inc.

A Previously Unreported Variant of a Thoracic Vertebra.

Pathology associated with anomalous transverse processes is uncommon and usually involves elongated C7 transverse processes in the so-called cervical rib syndrome. We report a single adult thoracic vertebra found to have duplicated transverse processes on the left side. We believe this to be the first report of a duplicated transverse process in man. The clinician and anatomist who view osteological material or imaging should consider this an extremely rare anatomical variation of the thoracic spine.