Impairment of accessory nerves around major pelvic ganglion leading to overflow urinary incontinence in rats.

AIMS: To investigate the relationship between lower urinary tract function and the accessory nerve (ACN) arising from the major pelvic ganglion (MPG). METHODS: Ten-week-old male Wistar/ST rats were randomly divided into eight groups according to the type of treatment (sham or bilateral accessory nerve injury [BACNI]) and the duration of observation (3 days, 1 week, 2 weeks, or 4 weeks: Sham-3d, Sham-1w, Sham-2w, Sham-4w, BACNI-3d, BACNI-1w, BACNI-2ws, and BACNI-4w. BACNI was induced in the following manner: the ACN was crushed for 1 min (2 mm away from the MPG) using reverse-action tweezers. The same procedure was performed on both sides. On the last day of each observation period, the bladder function was measured by awake cystometry, and histological evaluation was performed. RESULTS: All rats in the Sham groups micturated normally. In the BACNI-3d and BACNI-1w groups, all rats showed symptoms of overflow urinary incontinence (OUI). This OUI improved gradually over time. The bladder's size in the BACNI group was significantly larger than that in the Sham group (p < .01). In addition, fibrosis was observed in the subserosa of the bladder of rats in BACNI groups. CONCLUSION: The BACNI model rats exhibited OUI, suggesting that ACN is involved in the lower urinary tract function. It might be possible that ACN controls the function of either the bladder, the urethra, or both.

Correlates of Fatigability in Patients With Spinal Muscular Atrophy.

OBJECTIVE: To determine the associations between fatigability and muscle strength, motor function, neuromuscular junction (NMJ) function, and perceived fatigue in spinal muscular atrophy (SMA), we assessed 61 patients with SMA. METHODS: Fatigability was defined as the inability to continue a 20-minute submaximal repetitive task of either walking or proximal or distal arm function and expressed as drop-out on the Endurance Shuttle Test Combined Score (ESTCS). We assessed muscle strength with the Medical Research Council (MRC) sum score, motor function with the Hammersmith Functional Motor Scale Expanded (HFMSE) and Motor Function Measure (MFM), NMJ function with repetitive nerve stimulation of the accessory and ulnar nerve, and perceived fatigue with the PROMIS Fatigue Short Form questionnaire in 61 children and adults with SMA types 2-4. We applied Cox regression analysis to explore the associations between fatigability and these factors. RESULTS: The hazard of drop-out on the ESTCS decreased 0.8%, 2%, and 1.3% for each point increase in the MRC sum score, the HFMSE score, and the MFM percentual score, respectively. However, we observed prominent fatigability with preserved muscle function and vice versa in 13%-16% of patients. We did not find an association between NMJ dysfunction of the accessory (p = 0.37) and ulnar nerve (p = 0.063) and fatigability, which could be due to a large number of missing values. Perceived fatigue in SMA was comparable to reference values and was not associated with fatigability (p = 0.52). CONCLUSION: Fatigability in SMA is associated with, yet not equivalent to, muscle strength and motor function.

Myelin protein zero gene dose dependent axonal ion-channel dysfunction in a family with Charcot-Marie-Tooth disease.

OBJECTIVE: The myelin impairment in demyelinating Charcot-Marie-Tooth (CMT) disease leads to various degrees of axonal degeneration, the ultimate cause of disability. We aimed to assess the pathophysiological changes in axonal function related to the neuropathy severity in hypo-/demyelinating CMT patients associated with myelin protein zero gene (MPZ) deficiency. METHODS: We investigated four family members (two parents and two sons) harboring a frameshift mutation (c.306delA, p.Asp104ThrfsTer14) in the MPZ gene, predicted to result in a nonfunctional P0, by conventional conduction studies and multiple measures of motor axon excitability. In addition to the conventional excitability studies of the median nerve at the wrist, we tested the spinal accessory nerves. Control measures were obtained from 14 healthy volunteers. RESULTS: The heterozygous parents (aged 56 and 63) had a mild CMT1B whereas their two homozygous sons (aged 31 and 39 years) had a severe Dejerine-Sottas disease phenotype. The spinal accessory nerve excitability could be measured in all patients. The sons showed reduced deviations during depolarizing threshold electrotonus and other depolarizing features which were not apparent in the accessory and median nerve studies of the parents. Mathematical modeling indicated impairment in voltage-gated sodium channels. This interpretation was supported by comparative modeling of excitability measurements in MPZ deficient mice. CONCLUSION: Our data suggest that axonal depolarization in the context of abnormal voltage-gated sodium channels precedes axonal degeneration in severely hypo-/demyelinating CMT as previously reported in the mouse models. SIGNIFICANCE: Measures of the accessory nerve excitability could provide pathophysiological markers of neurotoxicity in severe demyelinating neuropathies.

Sensitivity and specificity of repetitive nerve stimulation with lower cutoffs for abnormal decrement in myasthenia gravis.

INTRODUCTION: The sensitivity of repetitive nerve stimulation (RNS) in myasthenia gravis (MG) is dependent on the cutoff for abnormal decrement. METHODS: RNS data of adults with and without MG from 2014 to 2017 were reviewed retrospectively. The maximum reliable RNS amplitude/area decrement before and after exercise from facial, spinal accessory (SA), ulnar, and fibular nerves was recorded. Sensitivity/specificity using 5%, 7%, and 10% cutoffs were calculated. RESULTS: Seventy-nine of 141 patients had MG (46 generalized, 21 ocular, 12 bulbar). A total of 608 unique RNS recordings were analyzed. Overall RNS sensitivity/specificity at ≥5%, ≥7%, and ≥10% amplitude cutoffs were as follows: SA, 65.6%/86.3%, 49.2%/94.1%, and 29.5%/96.1%; facial, 51.0%/82.5%, 43.1%/95.0%, and 37.3%/100%; ulnar, 43.6%/100%, 41.0%/100%, and 41.0%/100%; and fibular, 52.6%/89.5%, 42.1%/94.7%, and 42.1%/100%. DISCUSSION: Lowering amplitude cutoff from 10% to 7% increased or maintained sensitivity with little loss in specificity. Post-exercise and area analysis resulted in increased sensitivity in some circumstances.

Successful emergency pain control for acute pancreatitis with ultrasound guided erector spinae plane blocks.

Pain control for patients in the Emergency Department (ED) with acute pancreatitis (AP) can be difficult and is often limited to intravenous opioids. The acute side effects from opioids are well known and their use in the treatment of AP is associated with prolonged length of hospitalization. Additionally, up to 10% of patients hospitalized for acute pancreatitis are still receiving opioids 6 months after discharge. Ultrasound-guided regional anesthesia by emergency physicians has increasingly proven to be an integral part of a multi-modal opioid sparing pain control strategy for patients in the ED. The ultrasound guided erector spinae plane block may be an ideal adjunct or alternative to opioids for analgesia from AP in the ED. The erector spinae plane block has already been successfully utilized by emergency physicians for pain control from rib fractures, herpes zoster, and more recently, acute appendicitis A lower thoracic erector spinae plane block targets sympathetic nerve fibers in addition to the dorsal and ventral rami via local anesthetic spread to the paravertebral space to provide both visceral and somatic analgesia. Herein, we present the first reported case of acute pancreatitis pain successfully managed by emergency physicians with the ESPB.

Optimal reference electrode placement for accessory and axillary nerve conduction studies.

BACKGROUND: Various techniques are described for proximal motor nerve conduction studies (NCSs). We investigated alternative reference electrode (E2) locations for accessory and axillary NCSs. METHODS: Multi-channel recordings were made from trapezius or deltoid referred to different sites, and from those sites referred to a remote electrode. Responses were compared using grouped statistics, and correlation analysis. RESULTS: For accessory NCSs, all belly:E2 montages showed comparable responses but axillary NCSs were more variable. Low amplitude contamination was seen at the sternum and contralateral acromion but greater distortion using other potential E2 sites. In both accessory and axillary studies, the ipsilateral acromion showed moderate activity, which correlated with the belly:remote response. CONCLUSIONS: Variation in E2 electrode sites may significantly distort the measured compound muscle action potential (CMAP). For accessory and axillary NCS, a sternal reference has favorable characteristics. Other sites, such as ipsilateral acromion or deltoid insertion, may not yield a representative CMAP.

Electromyographic evaluation of the facial and motor donor nerves before facial reanimation surgery in Moebius syndrome.

BACKGROUND: Moebius syndrome is a clinical entity characterized by bilateral facial and abducens nerve palsies; other cranial nerver might be affected as well. So far, no studies have reported the electromyographic responses of the facial musculature in this group of patients. OBJECTIVE: The objective of our study is to describe the electromyographic responses of the facial muscle and the main donor nerves for facial reanimation in patients with Moebius syndrome. METHOD: We analyzed electromyographies from the facial, hypoglossal, masseterine (trigeminal) and accessory nerves from patients with Moebius syndrome treated between 2010 and 2016. Results are presented as percentages and central tendency measures. RESULTS: 24 patients were included, mean age 11.79 ± 9.39 years. The facial nerve showed complete unilateral recruitment in 4 patients, partial bilaterally in 11, 7 showed no activity bilaterally and two had unilateral inactivity. The masseterine was normal in 14 patients, had partial recruitment bilaterally in 4 and unilaterally in 4 cases. The accessory nerve was normal in 20 patients, showed partial recruitment bilaterally in 3 and unilaterally in 1 patients. The hypoglossal was normal in 22 patients, and altered in 2 cases. CONCLUSION: Patients with Moebius syndrome show several degrees of alteration in electromyographic evaluation of the facial nerve. Electromyography is a useful tool in evaluating potential motor donor nerves for facial reanimation surgery.

ANTECEDENTES: El síndrome de Moebius es una entidad clínica caracterizada por parálisis bilateral congénita del nervio facial y el abducens. Adicionalmente se pueden encontrar afectados otros pares craneales. Actualmente no existen estudios que reporten la respuesta electromiográfica de la musculatura facial en esta población. OBJETIVO: Describir la respuesta electromiográfica de la musculatura facial y de los principales nervios donadores para reconstrucción facial dinámica en pacientes con síndrome de Moebius. MÉTODO: Se analizaron electromiografías de los nervios facial, hipogloso, maseterino (trigémino) y accesorio en pacientes con síndrome de Moebius atendidos entre 2010 y 2016. Los resultados se presentan en porcentajes y medidas de tendencia central y de dispersión. RESULTADOS: Se incluyeron 24 pacientes, con una edad promedio de 11.79 ± 9.39 años. El nervio facial presentó reclutamiento unilateral completo en 4 pacientes, parcial bilateral en 11 pacientes, en 7 pacientes ausencia de reclutamiento bilateral e inactividad unilateral en 2 pacientes. El maseterino tuvo reclutamiento completo en 14 pacientes, parcial bilateral en 4 pacientes y parcial unilateral en 4 pacientes. El nervio accesorio mostró reclutamiento completo en 20 pacientes, parcial bilateral en 3 pacientes y parcial unilateral en 1 paciente. El hipogloso mostró actividad normal en 22 pacientes, parcial bilateral en 1 paciente y parcial unilateral en 1 paciente. CONCLUSIÓN: Los pacientes con síndrome de Moebius presentan alteraciones en los registros electromiográficos del nervio facial. La electromiografía permite identificar los nervios donadores para realizar la reconstrucción dinámica.

Unsafe workout: a weak and painful shoulder in a professional volleyball player.

A 29-year-old professional volleyball player started complaining of a dull ache in the right lateral base of the neck. This pain arose during a preseasonal athletic training intense session. After 3 days, he presented deficiency of right scapula adduction, limitation of scapula elevation, right shoulder weakness and local mild pain. He had asymmetrical neckline with drooping of the affected shoulder, lateral displacement and minimal winging of the right scapula. After 1 week, hypothrophy of superior trapezius appeared. An electromyography of right upper limb showed a denervation in the upper, middle and lower components of the right trapezius muscle, due to axonotmesis of spinal accessory nerve (SAN). A subsequent MRI was consistent with muscular suffering caused by early denervation. This case shows idiopathic SAN palsy, likely secondary to an inappropriate use of a weight-lifting machine, where the athlete recovered after an adequate rest and rehabilitation period.

Study on Electrophysiological Findings of Guillain Barre Syndrome Patients Attending the Department of Neurology in BSMMU.

Incidence and predominant subtype of Guillain Barre Syndrome (GBS) differ geographically. Electrophysiology has an important role in the early diagnosis and prediction of the prognosis. This study conducted to determine the predominant subtype of Guillain Barre Syndrome in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh and to compare the nerve conduction study finding between the axonal and demyelinating form of GBS. To analyze the nerve conduction study findings of Guillain Barre Syndrome patients attending the department of Neurology in BSMMU. This observational, descriptive and cross sectional study was carried out in the department of Neurology, BSMMU, Dhaka from July 2014 to June 2016. Considering the inclusion and exclusion criteria, 50 patients recruited as the study population. Then after performing the nerve conduction study, patients classified into three groups: acute inflammatory demyelinating polyneuropathy (AIDP), acute motor axonal neuropathy (AMAN), acute motor and sensory axonal neuropathy (AMSAN). Among the 50 patients that are finally included in the study; about 50%, 42%, 8% had the AIDP, AMAN and AMSAN variety of GBS respectively. Out of all patients, 64% were male and 34% were female. GBS was seen in a wide range of age (18-75 years). In AIDP, maximum clustering of the cases was seen in the elderly population and in the AMAN it was seen in the younger age group. Cerebrospinal fluid (CSF) analysis did not show any significant difference between the AIDP and AMAN variant of GBS. Distal latency prolonged in at least one nerve in all patients with AIDP. In axonal form of GBS (AMAN and AMSAN), the compound muscle action potential (CMAP) amplitude was 80% of the lower limit of the normal in at least two motor nerves. Prolonged F wave latency by >80% of the upper limit of the normal was seen in 40% of the AIDP patients. According to the nerve conduction study, finding- acute inflammatory demyelinating polyneuropathy (AIDP) is the predominant subtype. Although the electrophysiology and the CSF analysis are the important tools for the diagnosis of GBS, classification should not be making based on a distinct finding alone. If all the NCS parameters in multiple nerves tested after one week and within four weeks of onset of symptoms, definite diagnosis is possible in almost all the patients of Guillain Barre Syndrome.

Cervical Vestibular Evoked Myogenic Potentials (cVEMPs) Evoked by Air-Conducted Stimuli in Patients with Functional Neck Dissection.

OBJECTIVE: Cervical vestibular-evoked myogenic potentials (cVEMPs) are short-latency vestibulocollic reflexes. The damage on any point of the vestibulocollic reflex pathway could affect the cVEMPs. Whether neck dissection has an effect on the sacculocollic pathway, and consequently on cVEMPs, remains unexplored. The aim of this study was to evaluate the cVEMP findings in patients with functional neck dissection without vestibular symptoms. PATIENTS AND METHODS: This cross-sectional study design, 20 patients who had undergone unilateral neck dissection with sparing of the accessory nerve, SCM and internal jugular vein, were included. The response rates (%), cVEMPs parameters such as the prestimulus background EMG [Root mean square (RMS)] activity (µV), P13 and N23 peak latencies (ms), interpeak (N23-P13) interval (ms), scale and non-scale interpeak (N23-P13) amplitudes (µV) were compared between the groups. Amplitude asymmetry ratio (AAR) was calculated. RESULTS: Twenty patients (14 males and 6 females), age was between 38 and 79 years were included in the study. All of the patients had clear cVEMPs on the NOS, whereas 18/20 (90%) patients had on the NDS. P13 and N23 peak latency of the NDS were found to be significantly longer than the NOS (P = 0.01). There was no significant difference in N23-P13 interpeak interval between two sides (P > 0.05). There was a negative correlation between P13 peak latency and post-operative time (P = 0.042; R = ­0.484). Scale and non-scale N23-P13 interpeak amplitudes of the NDS were found to be significantly lower than the NOS (P = 0.03). Mean AAR was found as 0.28 ± 0.16 (0.08-0.76). Seven patients (35%) had abnormal amplitude asymmetry. RMS values, were statistically and significantly lower in NDS compared to NOS (P = 0.01). However, no correlation was observed between the RMS values and peak latency and peak amplitude values (P > 0.05). CONCLUSIONS: cVEMP testing is an easy-to-apply, non-invasive, painless, and recordable test that can be used for evaluations of SAN and SCM function for patients undergoing neck dissection. After neck dissection, VEMP abnormalities can be detected. However, further studies are needed to indicate whether these abnormalities originate within the vestibular system and are due to pathologies originating from the SANs and SCMs. In addition, preoperative and postoperative studies are needed to better guide the clinical application of cVEMP testing.

Vernet syndrome resulting from varicella zoster virus infection-a very rare clinical presentation of a common viral infection.

Vernet syndrome is a unilateral palsy of glossopharyngeal, vagus, and accessory nerves. Varicella zoster virus (VZV) infection has rarely been described as a possible cause. A 76-year-old man presented with 1-week-long symptoms of dysphonia, dysphagia, and weakness of the right shoulder elevation, accompanied by a mild right temporal parietal headache with radiation to the ipsilateral ear. Physical examination showed signs compatible with a right XI, X, and XI cranial nerves involvement and also several vesicular lesions in the right ear's concha. He had a personal history of poliomyelitis and chickenpox. Laringoscopy demonstrated right vocal cord palsy. Brain MRI showed thickening and enhancement of right lower cranial nerves and an enhancing nodular lesion in the ipsilateral jugular foramen, in T1 weighted images with gadolinium. Cerebrospinal fluid (CSF) analysis disclosed a mild lymphocytic pleocytosis and absence of VZV-DNA by PCR analysis. Serum VZV IgM and IgG antibodies were positive. The patient had a noticeable clinical improvement after initiation of acyclovir and prednisolone therapy. The presentation of a VZV infection with isolated IX, X, and XI cranial nerves palsy is extremely rare. In our case, the diagnosis of Vernet syndrome as a result of VZV infection was made essentially from clinical findings and supported by analytical and imaging data.

Single-incision Eden-Lange procedure in trapezius muscle paralysis: A report of 11 cases.

OBJECTIVE: The aim of this study was to evaluate the outcome of single-incision Eden-Lange procedure in trapezius muscle paralysis. METHODS: The medical records of 11 patients (3 females and 8 males); mean age: 41 (25-59) years with trapezius muscle paralysis who underwent Eden-Lange procedure in our Center, between February 2009 and April 2013, were retrospectively analyzed. The clinical outcomes were evaluated with the American Shoulder and Elbow Surgeons Shoulder (ASES) score and visual analogue scale (VAS). RESULTS: The mean duration of symptoms before surgery was 10.18 months. The average duration of follow-up was 33.5 (24-48) months. The mean VAS score improved from 7.8 to 1.6 points (p < 0.05). The total ASES improved from 32.8 to 82.1 points (p < 0.05). The mean range of motion in forward elevation and abduction increased significantly from 121.80 to 154.40 (p < 0.05) and 80.00 to 148.18° (p < 0.05), respectively. CONCLUSION: Single incision Eden-Lange procedure appears to be a safe and effective treatment option for the patients with trapezius muscle paralysis. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Electrophysiology of Cranial Nerve Testing: Spinal Accessory and Hypoglossal Nerves.

Multiple techniques have been developed for the electrodiagnostic evaluation of cranial nerves XI and XII. Each of these carries both benefits and limitations, with more techniques and data being available in the literature for spinal accessory than hypoglossal nerve evaluation. Spinal accessory and hypoglossal neuropathy are relatively uncommon cranial mononeuropathies that may be evaluated in the outpatient electrodiagnostic laboratory setting. A review of available literature using PubMed was conducted regarding electrodiagnostic technique in the evaluation of spinal accessory and hypoglossal nerves searching for both routine nerve conduction studies and repetitive nerve conduction studies. The review provided herein provides a resource by which clinical neurophysiologists may develop and implement clinical and research protocols for the evaluation of both of these lower cranial nerves in the outpatient setting.

The impact on post-operative shoulder function of intraoperative nerve monitoring of cranial nerve XI during modified radical neck dissection.

Intraoperative monitoring of the cranial nerve XI (CN XI) may decrease shoulder disability following modified radical neck dissection. Prospective study was designed comparing results of Constant Shoulder Score (CSS), Shoulder Pain and Disability Index (SPADI) and EMG score of the trapezius muscle (mT) before and after surgery. One side of the neck was monitored during surgery with intraoperative nerve monitor. EMG scores of the mT 6 months postoperatively were statistically better on monitored as compared to the non-monitored side of the neck (p = 0.041), while the differences of the CSS and SPADI were not statistically significant. Patients with better EMG scores of the mT at 6 weeks recuperated better and with smaller decrease of the CSS. Intraoperative monitoring is beneficial at the beginning of the surgeon's learning curve and in the process of familiarizing with anatomical variation of the CN XI.

Complete Spinal Accessory Nerve Palsy From Carrying Climbing Gear.

We report an unusual case of spinal accessory nerve palsy sustained while transporting climbing gear. Spinal accessory nerve injury is commonly a result of iatrogenic surgical trauma during lymph node excision. This particular nerve is less frequently injured by blunt trauma. The case reported here results from compression of the spinal accessory nerve for a sustained period-that is, carrying a load over the shoulder using a single nylon rope for 2.5 hours. This highlights the importance of using proper load-carrying equipment to distribute weight over a greater surface area to avoid nerve compression in the posterior triangle of the neck. The signs and symptoms of spinal accessory nerve palsy and its etiology are discussed. This report is particularly relevant to individuals involved in mountaineering and rock climbing but can be extended to anyone carrying a load with a strap over one shoulder and across the body.

Postoperative shoulder function after different types of neck dissection in head and neck cancer.

Reported complications of neck dissection surgery have included decreases in shoulder muscle power and range of motion, drooping shoulder, and shoulder pain. We conducted a cross-sectional study to assess postoperative shoulder function following three different types of neck dissection surgery that were performed at Aga Khan University Hospital and to determine how various treatment factors and patient characteristics affected postoperative shoulder function. Our study population included 70 patients--51 men and 19 women, aged 18 to 70 years (mean: 48.6 ± 11.6)--who had undergone a total of 92 neck dissections (22 patients underwent bilateral procedures). Patients were assessed by physical examination and questionnaire responses. The physical examination included objective assessments of shoulder muscle power against resistance, active range of motion, maximum possible forward flexion, the length of time needed to repeat active shoulder flexion 5 times, and shoulder abduction. The questionnaire covered shoulder mobility during activities of daily living, the results of physiotherapy (and exercise), postoperative radiation status, and shoulder pain. Of the 92 neck dissections, 17 were selective (18.5%), 64 were modified radical (69.6%), and 11 were radical (12.0%). We found that patients who had undergone a nerve-sparing procedure (i.e., selective neck dissection or a modified radical neck dissection) exhibited significantly better shoulder function than did patients who had undergone radical neck dissections (p < 0.01). In addition, increasing age (p < 0.001) and a history of diabetes (p = 0.003) were associated with worse shoulder function, and postoperative physiotherapy was associated with better shoulder function (p = 0.002). Neither sex, weight, the side of the neck operated on (left or right), the administration of postoperative radiation, the length of time between surgery and shoulder function assessment, comorbidities such as hypertension and ischemic heart disease, nor the status of the level V lymph nodes had any statistically significant association with shoulder function.

Spinal to accessory nerve transfer in traumatic brachial plexus palsy: is body mass index a predictor of outcome?

INTRODUCTION: Several factors that affect functional recovery after surgery in severe brachial plexus lesions have been identified, i.e., time to surgery and presence of root avulsions. The body mass index (BMI) of the patient could be one of these possible factors. The objective of the present paper is to systematically study the relationship between BMI and the outcome of abduction following spinal accessory to suprascapular nerve transfer. METHODS: We retrospectively studied 18 cases that followed these inclusion criteria: (1) Male patients with a spinal accessory to suprascapular nerve transfer as the only procedure for shoulder function reanimation; (2) at least C5-C6 root avulsion; (3) interval between trauma and surgery less than 12 months; (4) follow-up was at least 2 years; (5) no concomitant injury of the shoulder girdle. Pearson correlation analysis and linear regression was performed for BMI versus shoulder abduction. RESULTS: The mean range of post-operative abduction obtained across the entire series was 49.7° (SD ± 30.2). Statistical evaluation revealed a significant, negative moderately strong correlation between BMI and post-operative range of shoulder abduction (r = -0.48, p = 0.04). Upon simple linear regression, time to surgery (p = 0.04) was the only statistically significant predictor of abduction range negatively correlated. CONCLUSIONS: Analysis of this series suggests that a high BMI of patients undergoing brachial plexus surgery is a negative predictor of outcome, albeit less important than others like time from trauma to surgery. Nevertheless, the BMI of patients should be taken into consideration when planning surgical strategies for reconstruction.

The posterior cervical triangle approach for high carotid artery exposure in carotid endarterectomy.

A new approach in carotid endarterectomy (CEA) was developed for high carotid artery lesions. With the authors' use of the posterior cervical triangle approach, 20 patients with a high carotid artery lesion were successfully treated with CEA. Accessory nerve palsy in 1 patient and hoarseness in 4 patients were encountered postoperatively as transient complications. There were no permanent procedure-related complications. Although this method has some risks, it is a useful method in CEA for high carotid artery lesions.

Scapular winging: an update.

Scapular winging is a rare disorder often caused by neuromuscular imbalance in the scapulothoracic stabilizer muscles. Lesions of the long thoracic nerve and spinal accessory nerves are the most common cause. Numerous underlying etiologies have been described. Patients report diffuse neck, shoulder girdle, and upper back pain, which may be debilitating, associated with abduction and overhead activities. Accurate diagnosis and detection depend on appreciation of the scapulothoracic anatomy and a comprehensive physical examination. Although most cases resolve nonsurgically, surgical treatment of scapular winging has been met with success.