-
The Journal of Hand Surgery Jun 2024Patients with brachial plexus birth injury with limited intraplexal donors require the use of extraplexal donors. Concern regarding the potential for respiratory...
PURPOSE
Patients with brachial plexus birth injury with limited intraplexal donors require the use of extraplexal donors. Concern regarding the potential for respiratory problems resulting from the harvest of intercostal nerves or the phrenic nerve suggests the need for other options. Transfer of the spinal accessory nerve (SAN) is one option for restoring elbow flexion in adult patients; however, there are few reports of the results of this transfer in brachial plexus birth injury. This study aimed to report the result of SAN transfer to the musculocutaneous nerve (MCN) in brachial plexus birth injury.
METHODS
Patients who had undergone SAN to MCN nerve transfer were included in this study. Patients were classified according to Narakas classification. The chart was reviewed for the time for recovery of elbow flexion according to the Active Movement Scale (AMS).
RESULTS
Eleven patients underwent SAN to MCN transfers with interpositional sural nerve grafts. Mean birthweight was 4,070 grams (range: 3,300-4,670). Mean time to operation was 6.5 months (range: 4-10). Of the 11 patients, two were of Narakas type 3, whereas the others were of type 4. One patient did not recover elbow flexion and underwent later tendon transfer, whereas the other 10 patients reached AMS grade M6 recovery. The median time for AMS grade M1 elbow flexion recovery was eight months (interquartile range: 6.2-8.8) and for AMS grade M5 was 26 months (interquartile range: 14.2-36.5).
CONCLUSIONS
Spinal accessory nerve to MCN transfer with an interposition nerve graft is a viable option for restoring elbow flexion. However, long-term outcomes of this procedure have yet to be fully demonstrated.
TYPE OF STUDY/LEVEL OF EVIDENCE
Case series IV.
PubMed: 38934988
DOI: 10.1016/j.jhsa.2024.04.017 -
Diagnostics (Basel, Switzerland) Jun 2024During routine dissections of cadavers as part of the medical curriculum, we identified a rare unilateral variation in the brachial plexus on the right side of a female...
During routine dissections of cadavers as part of the medical curriculum, we identified a rare unilateral variation in the brachial plexus on the right side of a female body donor. This variation consisted of four unusual changes to the regular pattering of nerve bundles and the dorsal scapular artery permeating the complex neural network. The variation included contributions of root C4 to the plexus by a root C4/C5 anastomosis, a rare fusion of the superior and middle trunks to a 'superomiddle' trunk, a preliminary, proximal branching of the suprascapular nerve off the C5 root. We further observed an accessory 'medial anterior division' branching off the fused upper and middle trunks merging with the anterior division of the inferior trunk forming the medial cord. The latter event potentially introduced nerve fibers from C5 to C7, which are absent in common patterns. We aim to relate these observations to previous categorizations and quantifications of brachial plexus patterns. We believe that the combination of different variations in this case resulted in a unique pattern. Since this observation was made in the dissection class, we further aim to raise awareness among medical students and anatomical instructors for the likelihood of variations to textbook patterns. This will hopefully foster an appreciation of uniqueness and individuality in the interaction with future patients demonstrating that proper preparation prior to surgical interventions is always a necessary prerequisite.
PubMed: 38928654
DOI: 10.3390/diagnostics14121239 -
Journal of Voice : Official Journal of... Jun 2024To investigate the clinical characteristics and prognosis of herpes zoster laryngitis with vocal fold immobility.
OBJECTIVE
To investigate the clinical characteristics and prognosis of herpes zoster laryngitis with vocal fold immobility.
STUDY DESIGN
Retrospective study.
METHODS
Clinical characteristics, laryngeal signs on strobolaryngoscopy, imaging examination findings, and outcomes of patients were analyzed retrospectively.
RESULTS
This study included 17 patients (11 males [64.7%] and six females [35.3%]), with a mean age of 63.3 ± 6.7 years. The primary symptoms were hoarseness (94.1%), dysphagia (76.5%), pharyngalgia on one side (76.5%), and aspiration (70.6%). No patient had skin herpes of the head and neck. The duration of symptoms was 5-30 days (median: 10 days). Twelve patients (70.6%) were in an immunocompromised state before the disease. Strobolaryngoscopy showed congestion and swelling of the mucosa on one side of the larynx, with whitish eruptions on the supraglottic mucosa and ipsilateral vocal fold immobility. Five patients (29.4%) exhibited signs of ipsilateral accessory nerve injury. The imaging examination showed supraglottic inflammatory changes in 12 patients (70.6%). Among the 14 patients whose treatment could be clearly described, only one patient received antiviral treatment, whereas others received neurotrophic and symptomatic treatment. Notably, all patients demonstrated good outcomes because their symptoms eventually returned to normal.
CONCLUSION
Herpes zoster laryngitis is caused by varicella-zoster virus infection of the vagus nerve. It is characterized by laryngeal herpetic changes on one side and unilateral vocal fold immobility. The inducement of the disease tends to be associated with the abnormal immune state of patients. It can be easily misdiagnosed because of the absence of skin herpetic changes. Regardless of antiviral therapy, patients generally exhibit a favorable outcome.
PubMed: 38906743
DOI: 10.1016/j.jvoice.2024.05.020 -
JBJS Essential Surgical Techniques 2024A number of techniques have been described to enter the capsule and gain access to the hip joint during hip arthroscopy. Among these, the interportal and T-capsulotomies...
BACKGROUND
A number of techniques have been described to enter the capsule and gain access to the hip joint during hip arthroscopy. Among these, the interportal and T-capsulotomies are the most commonly utilized; however, these approaches transect the iliofemoral ligament, which normally resists anterior subluxation and stabilizes extension. Thus, these approaches may introduce capsuloligamentous instability and have been associated with complications such as dislocation, postoperative pain, microinstability, seroma, and heterotopic ossification. Although prior literature has demonstrated durable mid-term results for patients undergoing capsulotomies with capsular closure, avoidance of iatrogenic injury to the hip capsule altogether is preferable. Thus, the puncture capsulotomy technique we present is minimally invasive, preserves the biomechanics of the hip joint and capsule without disrupting the iliofemoral ligament, and allows for appropriate visualization of the joint through placement of multiple small portals.
DESCRIPTION
Following induction of anesthesia and with the patient supine on a hip traction table, the nonoperative leg is positioned at 45° abduction with support of a well-padded perineal post, and the operative hip is placed into valgus against the post. Intra-articular fluid distention with normal saline solution is utilized to achieve approximately 9 mm of inferior migration of the femoral head and decrease risk of iatrogenic nerve injury. Then, under fluoroscopic guidance, an anterolateral portal is created 1 cm anterior and 1 cm superior to the greater trochanter at an approximately 15° to 20° angle. Second, via arthroscopic visualization, the anterior portal is created 1 cm distal and 1 cm lateral to the intersection of a vertical line drawn at the anterior superior iliac spine and a horizontal line at the level of the anterolateral portal. Third, equidistant between the anterior and anterolateral portals, the mid-anterior portal is created distally. Finally, at one-third of the distance between the anterior superior iliac spine and the anterolateral portal, the Dienst portal is created. Thus, these 4 portals form a quadrilateral arrangement through which puncture capsulotomy can be performed.
ALTERNATIVES
Alternative approaches to the hip capsule include interportal and T-capsulotomies, with or without capsular closure. Although the most frequently utilized, these approaches transect the iliofemoral ligament and thus may introduce capsuloligamentous instability.
RATIONALE
The puncture capsulotomy technique has the advantage of maintaining the integrity of the capsule through the placement of 4 small portals. The technique does not transect the iliofemoral ligament and thus does not introduce capsuloligamentous instability. Furthermore, although good mid-term outcomes have been reported with capsular closure, the present technique avoids creating unnecessary injury to the capsule and complications of an unrepaired capsule or, conversely, of plication.
EXPECTED OUTCOMES
Patients who underwent the puncture capsulotomy technique showed significant improvements in multiple functional outcome scores at a mean follow-up of 30.4 months, including the International Hip Outcome Tool (iHOT-33) (39.6 preoperatively to 76.1 postoperatively), Hip Outcome Score-Activities of Daily Living subscale (HOS-ADL) (70.0 to 89.3), HOS Sport-Specific Subscale (HOS-SSS) (41.8 to 75.7), and modified Harris hip score (mHHS) (60.1 to 84.9). At 2 years postoperatively with respect to iHOT-33, 81.0% of patients achieved the minimal clinically important difference, 62.0% achieved the patient acceptable symptom state, and 58.9% achieved substantial clinical benefit. In addition, mean visual analog scale pain scores improved significantly over the follow-up period (6.3 to 2.2; p < 0.001). Finally, there were zero occurrences of infection, osteonecrosis of the femoral head, dislocation or instability, or femoral neck fracture in patients treated with puncture capsulotomy.
IMPORTANT TIPS
Anterolateral portal placement should be performed using the intra-articular fluid distention technique with fluoroscopy to avoid risk of iatrogenic labral damage and distraction-induced neurapraxia. Subsequent portals must then be placed under direct arthroscopic visualization.On establishment of the anterolateral portal, the scope should be switched to the anterior portal to ensure that the anterolateral portal has not been placed through the labrum and to adjust its placement to better access pathology. This portal, as well as all others, may be subsequently modified by adjusting the angle of the cannula, without making a new skin incision.If a cam lesion is located more anteromedially or posterolaterally, an additional accessory portal may be made distal or proximal to the anterolateral portal, respectively, in order to enhance visualization.Intermittent traction is utilized throughout the surgery. No traction is utilized during preparing and draping, suture tensioning and tie-down, and femoroplasty, with minimal traction during acetabuloplasty; these precautions serve to prevent iatrogenic superficial peroneal nerve injury.There can be a steep learning curve for this technique. In particular, greater surgical experience is required to perform adequate femoral osteoplasty for large cam lesions with this approach.Instrument maneuverability and visualization can be somewhat constrained with this approach.It is more difficult to perform certain procedures with this technique, including segmental and circumferential labral reconstructions, particularly with remote grafts.
ACRONYMS AND ABBREVIATIONS
iHOT-33 = International Hip Outcome Tool-33HOS-ADL = Hip Outcome Score-Activities of Daily Living subscaleHOS-SSS = Hip Outcome Score-Sport-Specific SubscaleAP = anteroposteriorMRA = magnetic resonance arthrogramMRI = magnetic resonance imagingCT = computed tomographyASIS = anterior superior iliac spinemHHS = modified Harris hip score.
PubMed: 38903605
DOI: 10.2106/JBJS.ST.23.00061 -
Surgical and Radiologic Anatomy : SRA Jun 2024Ossification of the mamillo-accessory ligament (MAL) results in the formation of a mamillo-accessory foramen (MAF), which is associated with aging. The MAL tethers the...
PURPOSE
Ossification of the mamillo-accessory ligament (MAL) results in the formation of a mamillo-accessory foramen (MAF), which is associated with aging. The MAL tethers the medial branches of the lumbar dorsal rami to the lumbar vertebrae. A MAL ossified at the lumbar vertebrae can cause low back pain by compressing the medial branch of a dorsal ramus. Age ranges related to ossification of the MAL have not been reported in previous studies. The objective of the present study was to determine the prevalence of ossification of the MAL in the lumbar column and its relationship to aging, and to measure the newly formed MAF at each level of the lumbar vertebrae.
METHODS
This study examined 935 dried lumbar vertebrae from 187 donors at Khon Kaen University, Thailand, consisting of 93 females and 94 males. The research focused on ossification patterns of the MAL, categorizing them into three patterns.
RESULTS
We found that over 50% of ossified MAL occurred in the 30-45-year-old range and the frequency increased with age. The prevalence of ossified lumbar MAL was 72.73%, especially in L5 on the left side in females (76.92%). The width of the MAF did not differ significantly between the sexes, but it was greater on the left side (2.46 ± 1.08; n = 76) than the right (2.05 ± 0.95; n = 72) (p = 0.016).
CONCLUSION
Ossification of the MAL into the MAF progresses with age, leading to low back pain from nerve compression. Physicians should be aware of the MAF during anesthesia block to treat low back pain.
PubMed: 38900204
DOI: 10.1007/s00276-024-03412-y -
Journal of Otolaryngology - Head & Neck... 2024Neck dissections (ND) are a routine procedure in head and neck oncology. Given the postoperative functional impact that some patients experience, it is imperative to...
BACKGROUND
Neck dissections (ND) are a routine procedure in head and neck oncology. Given the postoperative functional impact that some patients experience, it is imperative to identify and track quality of life (QoL) symptomatology to tailor each patient's therapeutic needs. To date, there is no validated French-Canadian questionnaire for this patient-population. We therefore sought to translate and validate the Neck Dissection Impairment Index (NDII) in Canadian French.
METHODS
A 3-phased approach was used. Phase 1: The NDII was translated from English to Canadian French using a "forward and backward" translational technique following international guidelines. Phase 2: A cognitive debriefing session was held with 10 Canadian French-speaking otolaryngology patients to evaluate understandability and acceptability. Phase 3: The final version was administered prospectively to 30 patients with prior history of ND and 30 control patients. These patients were asked to complete the questionnaire 2 weeks after their first response. Test-retest reliability was calculated with Spearman's correlation. Internal consistency was elicited using Cronbach's alpha.
RESULTS
NDII was successfully translated and validated to Canadian French. Cronbach's alpha revealed high internal consistency (0.92, lower 95% confidence limit 0.89). The correlation for test-retest validity were strong or very strong (0.61-0.91).
CONCLUSION
NDII is an internationally recognized QoL tool for the identification of ND-related impairments. This validated Canadian French version will allow clinicians to adequately assess the surgery-related QoL effect of neck surgery in the French-speaking population, while allowing French institutions to conduct and/or participate in multisite clinical trials requiring the NDII as an outcome measure.
Topics: Humans; Quality of Life; Neck Dissection; Female; Male; Middle Aged; Canada; Surveys and Questionnaires; Translations; Head and Neck Neoplasms; Reproducibility of Results; Aged; Adult; Prospective Studies; Surgical Oncology
PubMed: 38899627
DOI: 10.1177/19160216241263852 -
Indian Journal of Otolaryngology and... Jun 2024In our study, thirty one neck dissections in thirty patients were performed as a part of their treatment for head and neck cancers over a period of one year. In this...
In our study, thirty one neck dissections in thirty patients were performed as a part of their treatment for head and neck cancers over a period of one year. In this study, we aimed to report anatomical variations of the spinal accessory nerve (SAN) encountered during neck dissection with respect to important reference points and structures in the neck and correlate them with the length of the neck and height of patient. We preserved SAN in all the neck dissections and studied its course and branching in relation to internal jugular vein (IJV), sternocleidomastoid (SCM) muscle, greater auricular point (GAP), mastoid process, clavicle, angle of mandible, length of the neck and height of the patient. In 67.7% patients, the SAN was ventral to the IJV at the level of posterior belly of digastric muscle and in 32.3%, it was dorsal to the vein. In all the cases, SAN was found cephalic to the GAP at the posterior border of the SCM muscle with a mean distance of 1.72 ± 0.54 cm (range 0.90-3.06 cm). The distance between the tip of mastoid process and the point of emergence of the SAN from the posterior border of SCM (Exit Point length) was found to be nearly constant with a mean of 6.35 ± 0.63 cm (range 5.03-8.13 cm). We also found that there is a positive correlation between various parameters and the length of the neck and height of patients. Distance of exit point of SAN from the clavicle, however, is least helpful. We infer that the GAP is one of the most reliable landmarks for the localization of the SAN, followed by distance of exit point from mastoid process and angle of mandible. Also, surgeon should be aware of the variations regarding relationship to internal jugular vein and branching pattern of the nerve. The exit point should be sought for relatively inferiorly in longer necks and taller patients. SAN has great variations and thorough knowledge of these helps to prevent debilitating sequelae and medicolegal repercussions of shoulder syndrome.
PubMed: 38883541
DOI: 10.1007/s12070-023-04468-9 -
Zhurnal Voprosy Neirokhirurgii Imeni N.... 2024Meningiomas arising from accessory nerve sheath without dural attachment are rare. To date, only 5 cases are described in the literature. A 53-year-old male presented... (Review)
Review
Meningiomas arising from accessory nerve sheath without dural attachment are rare. To date, only 5 cases are described in the literature. A 53-year-old male presented with long history of occipital pain and headaches. Magnetic resonance imaging revealed a small intradural extramedullary contrast enhanced tumor at the level of foramen magnum. The patient underwent microsurgical resection through minimally invasive midline suboccipital approach. According to intraoperative findings, cystic tumor arose from the left accessory nerve without dural attachment. Gross total resection was achieved without damage to the nerve. Histological analysis revealed angiomatous meningioma. Postoperative period was uneventful without new neurological symptoms. Meningiomas can rarely arise from accessory nerve sheath and mimic schwannoma. These tumors may be totally resected without damage to accessory nerve using minimally invasive surgical approaches.
Topics: Humans; Male; Meningioma; Middle Aged; Meningeal Neoplasms; Magnetic Resonance Imaging; Cranial Nerve Neoplasms
PubMed: 38881021
DOI: 10.17116/neiro20248803190 -
Surgical and Radiologic Anatomy : SRA Jun 2024Our study aims to investigate three parts of the intracranial cavity, their distances to essential anatomical landmarks, and the correlations between these distances...
PURPOSE
Our study aims to investigate three parts of the intracranial cavity, their distances to essential anatomical landmarks, and the correlations between these distances with sex, laterality, and surgical significance.
METHODS
The cranial nerve foraminae and essential surgical landmarks of each fossa were investigated bilaterally in 30 adult formalin-fixed cadaveric heads. Measurements, including lengths, depths, diameters, and horizontal distances to each other, to the midline of the skull, and to the outer lateral margin of the skull, were recorded on both sides.
RESULTS
The optic canal (OC) depth, internal auditory meatus (IAM) width, CNVII and CNIX diameters, and accessory hypoglossal canal (HC) distance were significantly greater on the left side (p < 0.05). CNVI length, CNV diameter, CNXI length, and the distances of the HC and accessory HC from the skull were significantly greater on the right side (p < 0.05). In males, correlations were found between the length of the left CNVIII and the right IAM diameter (r = 0.864, p = 0.001), right CNVIII length (r = 0.709, p = 0.022), right accessory HC length (r = 0.847, p = 0.016), and right-sided skull distance (r = 0.829, p = 0.042). In females, correlations were noted between IAM depth and length, right IAM location relative to the skull, left CNIX and CNX lengths, left CNXII length, left accessory HC location relative to the skull, and accessory HC length.
CONCLUSIONS
The findings of the current study indicate inherent asymmetry, sexual dimorphism, and variability in certain cranial nerves among cadaveric heads, which could have implications for surgical procedures, neuroanatomical studies, and clinical assessments. The study revealed side disparities and correlations within cranial fossa formations and essential surgical landmarks in both genders.
PubMed: 38858315
DOI: 10.1007/s00276-024-03408-8 -
Journal of Minimally Invasive Gynecology Jun 2024
PubMed: 38851628
DOI: 10.1016/j.jmig.2024.06.001