Pediatric glossopharyngeal neuralgia: a comprehensive review.

INTRODUCTION: Debilitating facial pain can seriously affect an individual's daily living. Given that the pathophysiology behind neuropathic and myofascial pain is not fully understood, when chronic facial pain goes undiagnosed, it has been proposed that one of the two is the likely cause. Since their discovery, glossopharyngeal neuralgia (GN) and Eagle's syndrome have been considered mostly conditions afflicting the adult population. However, when pediatric patients present with symptoms resembling GN or Eagle's syndrome, physicians are less apt to include these as a differential diagnosis simply due to the low prevalence and incidence in the pediatric population. MATERIALS AND METHODS: A literature review was performed with the aim to better understand the history of reported cases and to provide a comprehensive report of the anatomical variations that lead to these two conditions as well as the way these variations dictated medical and surgical management. Articles were obtained through Google Scholar and PubMed. Search criteria included key phrases such as pediatric glossopharyngeal neuralgia and pediatric Eagle syndrome. These key phrases were searched independently. PubMed was searched primarily then cross-referenced articles were found via Google Scholar. Results from non-English articles were excluded. RESULTS: A total of 58 articles were reviewed. Most of the articles focused on adult glossopharyngeal neuralgia, and the majority was comprised of case reports. When searched via PubMed, a total of 16 articles and 2 articles returned for glossopharyngeal neuralgia and Eagle's syndrome, respectively. After criteria selection and cross-referencing, a total of seven articles were found with respect to pediatric glossopharyngeal neuralgia. CONCLUSIONS: While they are rare conditions, there are multiple etiologies that lead to the debilitating symptoms of GN and Eagle's syndrome. The clinical anatomy proved notable as multiple causes of GN and Eagle's syndrome are due to variation in the anatomy of the neurovascular structures surrounding the glossopharyngeal nerve, an elongated styloid process, a calcified stylohyoid ligament as well as a calcified stylomandibular ligament. Due to the success of different treatment modalities, the treatment of choice is dependent on clinical judgment.

Revisiting the genital and femoral branches of the genitofemoral nerve: Suggestion for a more accurate terminology.

The genitofemoral nerve is a branch of the lumbar plexus originating from the ventral rami of the first and second lumbar spinal nerves. During routine dissections of this nerve, we have occasionally observed that the genital branch of the genitofemoral nerve gave rise to the femoral branch, and the femoral branch of the genitofemoral nerve gave rise to the genital branch. Therefore, this study aimed to investigate the aforementioned distributions of the genitofemoral nerve in a large number of cadaveric specimens. Twenty-four sides from fourteen fresh-frozen cadavers derived from nine males and five females were used in this study. For proximal branches of the genitofemoral nerve, that is, as they first arise from the genitofemoral nerve, the terms "medial branch" and "lateral branch" were used. For the final distribution, the terms "genital branch" and "femoral branch" were used. On eight sides (33.3%) with nine branches, one or two branch(s) from either the medial or lateral branch became coursed as the femoral or genital branches (five became femoral and four became genital branches). Our study revealed that the distribution of the genitofemoral nerve is more complicated than previously described. The "medial branch" and "lateral branch" that we have used in the present study for describing the proximal branches of the genitofemoral nerve are more practical terms to describe the genitofemoral nerve. Clin. Anat. 32:458-463, 2019. © 2019 Wiley Periodicals, Inc.

The majority of piriformis muscles are innervated by the superior gluteal nerve.

The piriformis muscle is clinically implicated in pain disorders, posterior approaches for total hip arthroplasty, and iatrogenic injury to the muscle and the surrounding nerves. The piriformis muscle has been said to receive innervation from L5 to S3 ventral rami with most sources using S1 and S2 ventral rami as the most common innervation this muscle. However, descriptions of the nerve in the literature are vague. Therefore, the aim of this study was to clarify the anatomy of the nerve supply to the piriformis muscle. Twenty sides from ten fresh-frozen cadavers were studied. Specifically, via anterior dissection of the sacral plexus, branches to the piriformis were identified. Once identified, the nerves to the piriformis muscle were traced proximally to clarify their origin. Nerves supplying the piriformis muscle existed on all sides. On 80% of sides, the piriformis was innervated by two to three nerves. The origin of these nerves was from the superior gluteal nerve on 14 sides (70%), inferior gluteal nerve on one side (5%), L5 ventral ramus on one side (5%), S1 ventral ramus on 17 sides (85%), and S2 ventral ramus on 14 sides (70%), respectively. The most common nerve branches to the piriformis are from the superior gluteal nerve, and the ventral rami of S1 and S2. Based on our study, a single "nerve to piriformis" does not exist in the majority of specimens thus this term should be abandoned. Clin. Anat. 32:282-286, 2019. © 2018 Wiley Periodicals, Inc.

Mechanical relationship of filum terminale externum and filum terminale internum: is it possible to detether the spinal cord extradurally?

INTRODUCTION: Intradural transection of the filum terminale (FTI) is often used to treat tethered cord syndrome. Recently, some have proposed that the extradural part of the filum terminale (FTE) can be sectioned with equal results but with fewer complications. Therefore, the present cadaveric study aimed to evaluate the anatomical foundation of such procedures. METHODS: A posterior lumbosacral approach was performed on five fresh-frozen cadaveric specimens to expose both the FTI and FTE. Tension was then applied to the FTE and observations and measurements made of any movement of the FTI. Other morphological measurements (e.g., length, diameter) of the FTI and FTE were also made. RESULTS: Although very minimal movement of the FTI was seen in the majority of specimens following tension on the FTE, no specimen was found to have more cranial movement of the conus medullaris or cauda equina. The mean length and diameter of the FTI was 52.2 and 0.38 mm, respectively. The mean length and diameter of the FTE was 77 and 0.60 mm, respectively. The force necessary to move the FTI with tension applied to the FTE had a mean of 0.03 N. The average distance that the FTI moved with distal FTE tension was 1.33 mm. All specimens had a thecal sac that terminated at the S2 vertebral level. And no specimen had a low-lying conus medullaris, cutaneous stigmata of occult spinal dysraphism, or grossly visible adipose tissue in either the FTI or FTE. CONCLUSIONS: Based on our studies, tension placed on the FTE has very little effect on the FTI and no obvious effect on the conus medullaris or cauda equina. Therefore, isolated transection of the FTE for a patient with tethered cord syndrome is unlikely to have significant effect. To our knowledge, this is the first study to quantitate the distal forces needed on the FTE to move the FTI.

The clinical anatomy of fibromyalgia.

Fibromyalgia is a disorder characterized by pain and a spectrum of psychological comorbidities, rendering treatment difficult, and often a financial burden. Findings regarding diagnosis, prevalence, comorbidities, and potential pathophysiological links are discussed herein. Fibromyalgia is a complex disorder and there are specific criteria that patients must meet for diagnosis, including scores on fibromyalgia questionnaires, commonalities of age, gender, menopause status, sleep disturbances, and mood symptoms. The close relationship between fibromyalgia and other chronic disorders should alert the physician to explore for comorbid illnesses. In this review of the clinical anatomy of fibromyalgia, we review new studies that could be significant for the current use of clinical interventions for patients with symptoms. Using standard search engines, the clinical anatomy of fibromyalgia is investigated and many related studies are mentioned herein. Fibromyalgia is considered a prototypical central chronic pain syndrome and is associated with widespread pain that fluctuates spontaneously. There is also substantial lifetime psychiatric comorbidity in individuals with fibromyalgia, resulting in a low health-related quality of life. These results have important clinical and theoretical implications, including the possibility that fibromyalgia could share underlying pathophysiological links with some psychiatric disorders. This reveals that patients with fibromyalgia have findings compatible with tissue injury pain, the pain mechanisms involving both the primary afferent neuron and the nociceptive systems in the central nervous system. (1) There is a relationship between fibromyalgia and chronic disorders. This should alert the physician to explore for comorbid illnesses. (2) There is substantial lifetime psychiatric comorbidity resulting in a low health-related quality of life. (3) Patients with fibromyalgia have findings compatible with tissue injury pain Clin. Anat. 31:387-391, 2018. © 2018 Wiley Periodicals, Inc.

The inferior gluteal nerve often has a cutaneous branch: A discovery with application to hip surgery and targeting gluteal pain syndromes.

The inferior gluteal nerve has been traditionally described as a solely motor branch innervating the gluteus maximus. However, during routine dissection of the gluteal region, a cutaneous branch of the inferior gluteal nerve was identified. As the gluteal region is vulnerable to the development of pressure ulcers and iatrogenic injury with for example, surgical approaches and injection therapies, a comprehensive understanding of its cutaneous innervation is important. Therefore, the aim of this study was to elucidate the anatomy of this cutaneous branch of the inferior gluteal nerve in a series of cadavers. Twelve sides from six fresh-frozen cadaveric specimens were dissected. When a cutaneous branch was identified piercing the gluteus maximus, its origin from the inferior gluteal nerve was verified and the diameter and length of it measured. Additionally, for localization, the distance from the midline to the exit point of the cutaneous branch from the gluteus maximus was measured. One to two cutaneous branches were identified as arising from the inferior gluteal nerve on nine sides (75%). The branch(es) were usually located in the lower outer quadrant of the gluteus maximus. These branches had a mean distance of 12.5 cm from the midline. Their mean diameter and length was 0.7 mm and 28.6 cm, respectively. On all sides with a cutaneous branch of the inferior gluteal nerve, the skin over the posterior aspect of the greater trochanter was innervated by superior and inferior cluneal nerves and supplemented by cutaneous branch(es) of the inferior gluteal nerve. Side or sex was not a predictor of the presence of a cutaneous branch of the inferior gluteal nerve. To our knowledge, a cutaneous branch derived from the inferior gluteal nerve has not been previously described. Based on our cadaveric findings, the majority of individuals will have the area of skin over the greater trochanter innervated by this nerve. Therefore, surgeons and pain specialists should be aware of its presence and might develop surgical procedures that help avoid it or develop technical advances that target it for various pain syndromes in this area. We propose naming these cutaneous branches the lateral cluneal nerves, which would necessitate renaming the middle cluneal nerves to medial cluneal nerves. Clin. Anat. 31:937-941, 2018. © 2018 Wiley Periodicals, Inc.

Trauma Functioning and Well-Being in Children Who Receive Mental Health Aid after Natural Disaster or War.

Background: There is worldwide consensus that providing secondary prevention to promote resilience and prevent mental health concerns after a disaster is important. However, data supporting this kind of intervention is largely lacking. The current study evaluates the effectiveness of OperationSAFE, an early intervention for children after community-wide trauma. Methods: Secondary data analyses of data collected during 158 OperationSAFE camps (a five day camp with a curriculum focused on coping with stressors) in five countries and ten disasters between 2015 and 2020 were performed. Data on child trauma-related functioning/well-being were collected by an OperationSAFE in-house developed symptom checklist and completed by counselors about children on the first and last day of the 5-day camp. Results: A total of 16,768 children participated in the camps (mean age 9.4 ± 2.36; 50% male). Trauma-related functioning/well-being improved from day 1 to day 5 (b = 8.44 ± 0.04; p < 0.0001). Older children improved more (b = 0.22 ± 0.01; p < 0.0001). Children in man-made ongoing trauma (war/refugees) situations responded stronger than those after natural disasters (b = 2.24 ± 0.05; p < 0.0001). Negligible effects for gender and the number of days between a traumatic event and the start of camp were found. Conclusions: This is the first study to show in a large and diverse sample that secondary prevention to promote resilience and prevent mental health concerns after a disaster for children is associated with improvements in trauma-related functioning/well-being. Delaying delivery of the intervention did not affect outcomes. Given the uncontrolled nature of the study and lack of long-term outcomes, more studies are needed to corroborate the current findings.

Design and testing of a prototype foot orthosis that uses the principle of granular jamming.

STUDY DESIGN: A mechanical testing protocol was used to compare the material properties of commercially available foams with that of a newly designed granular jamming orthosis prototypes. BACKGROUND: Foot orthoses have an inherent limitation of predetermined mechanical material properties coupled with a fixed orthotic interface shape that cannot be readily changed. OBJECTIVES: To develop and test a novel orthotic insole design concept that incorporates principles of granular jamming. METHODS: Granular media were used in combination with vacuum pressure to create a variable stiffness granular foot orthosis. Four types of granular media (rice, poppy seeds, micropolystyrene, and polystyrene beads) were tested in different prototype configurations varying in volume fill and particulate size. Stress-strain curves were obtained from uniaxial compression tests to characterize granular foot orthosis prototypes in comparison with commercial orthotic foams. RESULTS: Increasing vacuum pressure increased prototype stiffness for most configurations. A single granular jamming orthosis could exhibit energy absorption values that spanned the entire commercial foam performance range, and in some cases extended far beyond the upper values of the tested foams. CONCLUSION: The results suggest that granular jamming principles can provide clinicians the capability for rapid selection of mechanical properties over a wide range of orthosis stiffnesses. Importantly, patients could don the orthosis because the clinician makes real-time assessments and adjustments in the clinic.

Discovery of a new ligament of the lumbar spine: the midline interlaminar ligament.

BACKGROUND: The ligaments of the lumbar spine are integral to structural integrity and have been well-studied. However, during the routine dissection of the lumbar spine, we identified to our knowledge, a previously undescribed midline ligament near the ligamenta flava but distinctly separate. PURPOSE: The purpose of this study was to investigate the morphology of this ligament termed by us the midline interlaminar ligament. STUDY DESIGN: Cadaveric study. METHODS: Thirty-four lumbar vertebral levels from 10 fresh frozen adult cadavers were dissected. The ligamenta flava were dissected anteriorly. The junction between the right and left ligamenta flava was observed and the presence and morphometrics of the median interlaminar ligament (MIL) were recorded. Random ligaments underwent tensile strength testing. Metal wires were also placed on the ligaments and fluoroscopy performed. RESULTS: Twenty-six out of 34 (76.5%) lumbar levels were found to have a MIL traveling on the internal aspect of the most medial aspect of the laminae and positioned slightly anterior to the plane of the ligamenta flava. The mean length and width of the MIL were 9.03±4.29 mm and 4.94±1.56 mm, respectively. The mean force necessary until failure for the MIL was 12.3N. CONCLUSIONS: Based on our findings, a distinct MIL was identified in the lumbar spine at the majority of lumbar levels. CLINICAL SIGNIFICANCE: The MIL might have clinical significance and potential biomechanical importance. Further studies are now necessary to better elucidate this anatomical structure.

Case Report of a Pelvic Crossed Fused Renal Ectopic Kidney.

Herein we present a case of a horseshoe kidney with crossed fused renal ectopia. Both of these pathologies are congenital anomalies; however, to date, there are few cases that present with both. In this case, discovered during routine dissection, the fused kidney was mostly left-sided and very low in the pelvis. No renal artery arose from the right wall of the abdominal aorta, and the right renal vein drained into the lower part of the inferior vena cava (IVC) where the right and left common iliac veins joined. It is essential for clinicians and surgeons to understand these types of congenital anomalies, as they could impact patient care.

Anatomic Study of Superior Cluneal Nerves: Revisiting the Contribution of Lumbar Spinal Nerves.

OBJECTIVE: Superior cluneal nerve (SCN) entrapment neuropathy can result in low back pain and thus be confused with other pathologies (e.g., lumbar disk disease). Therefore we performed cadaveric dissection of the SCN to better understand its anatomy and segmental origin. METHODS: Twenty sides from 10 Caucasian fresh frozen cadavers (6 females and 4 males) were used in this study. The diameter of the SCN, distance between the exit point of the SCN from the thoracolumbar fascia and midline, and distance between the exit point of the SCN from the thoracolumbar fascia and the posterior superior iliac spine to the medial and lateral SCN were measured. The segmental origins of the SCNs were verified. RESULTS: Seventy-five percent of the dorsal rami of L1, 90% of L2, 95% of L3, 45% of L4, and 10% of L5 contributed to the SCN. The SCN was formed by 3 vertebral levels in 55% and by 4 vertebral levels in 30%. Three SCNs pierced the thoracolumbar fascia in 45%. CONCLUSIONS: The origin of the SCN, which has been described in the textbook and literature for a long time, should be reconsidered on the basis of our study results.

Anatomical and Biomechanical Study of the Lumbar Interspinous Ligament.

OBJECTIVE: The lumbar interspinous ligaments (ISLs) are thin and short fibers connecting adjacent spinous processes. However, their morphology is variably described and their biomechanics are not well understood. Therefore, the purpose of this study was to assess the anatomy and biomechanics of the lumbar ISL. MATERIALS AND METHODS: Five fresh frozen cadaveric specimens were dissected posteriorly to reveal and study the lumbar ISL. Measurements of the ligaments included the anterior vertical height (length A), the posterior vertical height (length P), and the length (length H) at each lumbar level. Next, 17 lumbar vertebral levels from 6 cadaveric specimens were used for tensile strength testing. The ISLs were subjected to vertically controlled increasing manual tension. The force necessary to disrupt the ISL was recorded. RESULTS: All the ISLs ran horizontally in an anterior-posterior direction with a slight curve. The average of length A, length P, and length H on the right sides was 9.82, 9.57, and 20.12 mm, respectively. The average of length A, length P, and length H on the left sides was 11.56, 12.01, and 21.42 mm, respectively. The mean tensile strength of the ISL was 162.33 (N) at L1/2, 85.67 (N) at L2/3, and 79 (N) at L3/4. There was a significant difference in the tensile force between L1/2 and L2/3 and L1/2 and L3/4 (P < 0.05). The ligaments became weaker with a descent along the lumbar levels. CONCLUSION: The results of this study might help surgeons understand pathology/trauma of the lumbar vertebral region.

Anatomic Study of the Superior Cluneal Nerve and Its Related Groove on the Iliac Crest.

OBJECTIVE: Superior cluneal nerve entrapment neuropathy is one cause of low back pain often referred to as "pseudo sciatica." Studies have found that the superior cluneal nerve can arise variably from T11 to L5. The osteofibrous tunnels formed by a groove on the iliac crest might compress the superior cluneal nerve. Therefore, the purpose of this study was to investigate the origin of the superior cluneal nerve and its course through such bony grooves. METHODS: Twenty sides from 10 fresh frozen Caucasian cadavers were used in this study. Once both the superior cluneal nerve and its groove were identified, the distance from the groove to the posterior superior iliac spine and midline was measured. RESULTS: A total of 12 grooves were identified in 11 of 20 sides (55%). On 10 sides, the nerve running on the groove was the medial branch of the superior cluneal nerve. The mean distance from the bony groove to the posterior superior iliac spine and midline was 45.2 ± 11.2 mm and 65.3 ± 8.2 mm, respectively. CONCLUSIONS: These results could help identify such bony grooves and better understand low back pain and its related anatomy.

Anatomic Study of Superior Cluneal Nerves: Application to Low Back Pain and Surgical Approaches to Lumbar Vertebrae.

OBJECTIVE: The aim of this study was to investigate the anatomy of the superior cluneal nerves more proximal to the posterior layer of the thoracolumbar fascia. METHODS: Twelve sides of 6 fresh-frozen cadavers were used. The age at death ranged from 54 to 88 years. After a transverse skin incision 10 mm above the iliac crest, the superior cluneal nerves were detected by blunt dissection and traced back to the dorsal root ganglia. The diameter of the nerves from L1 to L3 was measured. Also, the relationship to the erector spinae muscle and dorsal ramus was recorded. RESULTS: The mean diameters of the origin of the L1, L2, and L3 were 1.71 ± 0.29 mm, 1.73 ± 0.40 mm, and 1.52 ± 0.55 mm, respectively. On 7 sides (58.3%) for L1, seven sides (58.3%) for L2, and 10 sides (83.3%) for L3, the nerves pierced the iliocostalis muscle. One side (8.3%) for L2 and one (8.3%) for L3 had no cutaneous branch. CONCLUSIONS: The results of this study could help to elucidate the anatomy of the superior cluneal nerves and help avoid complications during surgical approaches to the lumbar spine.

Anatomical Study of the Posterior Ascending Artery: Application to C2 Pedicle Screw Placement.

OBJECTIVE: Anatomy of the posterior ascending artery (PAA) has been well documented. The PAA forms an apical arcade, which supplies the small branches to the tip of the dens. However, morphometrics of this artery such as diameter and distance from the midline, which could be applied to the diagnosis and surgical procedure, are scant. We aimed to investigate the anatomy of the PAA in order to apply our findings to surgical procedures such as C2 pedicle screw placement. METHODS: Ten sides from 5 Caucasian cadaveric heads in which red latex was injected were used. The origin of the PAA, diameter of the PAA and apical arcade, and the distance from midline were recorded. RESULTS: Diameters of the PAA and apical arcade were approximately 1 mm and 0.7 mm, respectively. Distance from the midline to the PAA was approximately 7 mm. In 1 specimen, the os odontoideum was observed on top of the dens. CONCLUSIONS: The result of this study could provide anatomic knowledge, which is important for C2 pedicle screw placement to the spine surgeon.

Pseudoaneurysm of Posterior Ascending Branch of Vertebral Artery: Previously Unreported Case.

BACKGROUND: Pseudoaneurysms are less common than true aneurysms. Herein, we present a rare case of a mass of the right posterior ascending artery. CASE DESCRIPTION: This was identified during routine dissection of an adult female cadaver. Histology demonstrated that the mass was a pseudoaneurysm. The mass was located posterior to the right alar ligament superior to the right portion of the transverse ligament and measured 7.37 mm and 2.97 mm. CONCLUSIONS: To our knowledge, such a case has not previously been reported. Epidural masses anterior to the cervical dura mater at the craniocervical junction should consider such a pathology in the differential diagnosis.

A Median Artery of the Corpus Callosum.

The anterior communicating artery is one of the main components of the vascular network that delivers blood to the brain. Therefore, a good understanding of the normal anatomy and its variations is important to neurologists, neurosurgeons, and other health care providers dealing with the central nervous system. Here, we present a case of a median artery of the corpus callosum found in a cadaver, with consideration of cerebral hemodynamics implications.

The Conchal Vascular Foramen of the Posterior Auricular Artery: Application to Conchal Cartilage Grafting.

The posterior auricular artery (PAA), a branch of the external carotid artery, gives rise to a conchal network formed by PAA perforators through the conchal floor of the auricle. However, this branch and its entrance (foramen) to the anterior concha, is rarely illustrated in the literature and has not been studied in detail. Therefore, we aimed to investigate the morphology of the perforating artery (PA) and its vascular foramen (VF). Ten sides from five formalin-fixed frozen Caucasian cadaveric heads were used. The number, diameter of the VF, diameter of the perforating artery (PA), shape of the VF (circular or oval), distance from the middle of the tragus and origin of the artery were documented. The number of VF ranged from 1 to 2; one was seen on 90% of the sides and two were seen on 10% of the sides. The VF was oval in 36% of the sides and circular in the remaining 64%. The mean diameter of the long and short axes of the VF, and PA was 2.0±1.4 mm, 1.3±0.9 mm, and 0.7±0.4 mm, respectively. Diameter of the PA was 1.0 mm or greater in 18% of the sides. The mean distance from the middle of the tragus to the VF was 10.7±2.6 mm. The perforating artery of the concha originated from the posterior auricular artery on all 11 sides.

First Report of a Bifid Mandibular Canal Containing a Large Vein Draining into the Anterior Jugular Vein.

The bifid mandibular canal (BMC) is an anatomical variant of the mandible that is often observed on cone-beam computed tomographic images. We identified a BMC during routine cadaveric dissection. The upper mandibular canal contained the inferior alveolar nerve and artery, and the lower mandibular canal contained a large inferior alveolar vein. This latter vein left the mandible through a lateral lingual foramen and joined the anterior jugular vein. Additionally, this vein gave rise to small tributaries to the mental foramen and anterior surface of the mandible from the second mandibular canal. To our knowledge, this is the first report illustrating the contents of a BMC and drainage of a vein into the large anterior jugular vein.

May-Thurner Syndrome Variant Identified in a Cadaver: First Reported Case.

May-Thurner syndrome (MTS) is defined as the compression of the left common iliac vein by the right common iliac artery. Herein, we describe an unusual case of a male cadaver with right-sided compression of the inferior vena cava and the left and right common iliac veins by the right common iliac artery. This is an unusual variant of this syndrome and the first known case report. We suggest this variant be termed MTS type II due to the additional compression of the inferior vena cava.