Branch Of Nerve Research Articles

Assessment of Vidian canal morphology in axial section and its associated structures using cone beam computed tomography: A descriptive study

The Vidian Nerve (VN), a branch of the trigeminal nerve, passes by the Vidian Canal (VC), located at the base of the skull. The VC branches into the greater petrosal nerve and the VN in the pterygopalatine fossa, where the greater petrosal nerve carries parasympathetic fibers to the lacrimal glands and nasal mucosa, and the VN carries sensory fibers from the nasopharynx, nasal cavity, and palate. In this study, 60 subjects of both sexes who underwent cone beam computed tomography (CBCT) were selected by a convenient sampling technique. The data were subjected to statistical analysis following the examination of the various parameters in the axial sections. Among the various morphological characteristics appraised in the axial section, there was no significant sexual dimorphism, except for the angle between the VC and the medial wall of the maxillary sinus, which shows statistical significance. The present study aims to investigate morphometric analysis and its associated structures, offering insightful information about the complex structure of the Vidian canal (VC), which provides adequate knowledge for surgeons to plan with more caution complex skull base procedures, and eventually to lower the therapeutical risks associated with it.

Corneal subepithelial nerve fibers in type 2 diabetes: potential biomarker of diabetic neuropathy

AIM: To observe the changes in corneal subepithelial nerve fibers (CNFs) and Langerhans cells (LCs) in patients with type 2 diabetes using corneal laser confocal microscopy (CLCM). METHODS: A total of 60 patients (64 eyes), including 40 patients with type 2 diabetes (DM group) and 20 subjects without diabetes (control group) were included with CLCM. Neuron J plugin of Image J software were used for quantitative analysis of CNF length (CNFL), CNF density (CNFD), corneal nerve branch fiber density (CNBD), main branch length density, branch length density, corneal nerve fiber tortuosity (NT) score, and LCs density. An independent samples t-test to analyze the variability between the two groups was performed, and Pearson correlation analysis was used to analyze the relationships between CNF and multiple biochemical indicators in the DM group. The predictive power of CNF for type 2 diabetes was assessed using the receiver operating characteristic (ROC) curve. RESULTS: There were significant differences in the CNFL, CNFD, and main branch length density between two groups. The results of Pearson correlation analysis showed a significant negative correlation between CNFD and the duration of diabetes as well as triglyceride levels and total cholesterol, and a significant positive correlation between CNFD and serum albumin. In addition, the NT score showed a positive correlation and urea nitrogen, similar to the positive correlation observed between LC density and glycosylated hemoglobin (HbA1c) levels. CNFD showed the highest area under the curve (AUC of ROC) value, followed by main branch length density and CNFL. The AUC of the ROC curve under the logistic regression model also demonstrated good predictive values. The cut-off values of CNFD, CNFL, and main branch length density for diabetes showed 31.25, 18.85, and 12.56, respectively. CONCLUSION: In patients with type 2 diabetes, there is a notable reduction in both CNFL and CNFD. These measurements can be influenced by various blood biochemical factors. However, the compromised nerve fibers can serve as valuable indicators for predicting the onset of type 2 diabetes and also as biomarkers for detecting diabetic neuropathy and its related complications.

Short-Latency Trigeminocervical Reflex Obtained Without Muscle Activation: Topographic Distribution and Methodological Approach

Purpose: Electrical stimulation of trigeminal nerve branches elicits early and late reflex responses in the cervical muscles, known as the trigeminocervical reflex (TCR). This study aimed to evaluate the neurophysiological aspects, stimulation patterns, and topographic distribution of short-latency TCR components in humans in the absence of voluntary muscle activation. Methods: This prospective observational study included 30 participants. Trigeminocervical reflex responses were simultaneously recorded from the bilateral sternocleidomastoid, trapezius, and splenius capitis muscles (without voluntary muscle activation), after electrical stimulation of the supraorbital and infraorbital nerves. Two different stimulation protocols were evaluated: a 3 Hz stimulation protocol (using averaging) and a single-pulse stimulation protocol. Results: Using a 3 Hz stimulation protocol, short-latency TCR responses were recorded in the sternocleidomastoid, trapezius, and splenius capitis muscles, ipsilateral and/or contralateral, but with variable recordability depending on the recording site. The most reliable response was obtained in ipsilateral sternocleidomastoid muscle. To the best of our knowledge, this is the first study to demonstrate the elicitation of short-latency TCR components in the sternocleidomastoid muscle in the absence of voluntary muscle activation in humans without craniocervical junction disorders or lower brainstem abnormalities. Conclusions: The choice of an appropriate stimulation protocol is particularly relevant for recording short-latency TCR components, considering that the visualization of early or late responses seems to be facilitated by different stimulation methodologies.

Role of Intraoperative Neuromonitoring to Identify External Branch of Superior Laryngeal Nerve During Thyroidectomy

Role of Intraoperative Neuromonitoring to Identify External Branch of Superior Laryngeal Nerve During Thyroidectomy

Fiber anatomy and histological characteristics of the innervation of the triangular fibrocartilage complex.

To evaluate the precise origin of sensory nerves through gross anatomical study of the TFCC, synthesized alongside imaging and histological techniques. Six cadaveric forearm specimens were obtained to map the course and branches of the ulnar nerve through macrodissection. Immunohistochemical staining targeting PGP 9.5 and type IV collagen was performed on frozen TFCC sections to visualize nerve fibers microscopically. Computed tomography, magnetic resonance imaging, and arthrography findings were also reviewed. At the macroscopic level, the articular branches supplying the TFCC originated predominantly from the dorsal branch of the ulnar nerve. Microscopic analysis revealed positive PGP 9.5 expression and discernible neural marker expression, signifying fine nerve fiber ingrowth within the TFCC. Imaging modalities aided the diagnosis of TFCC lesions. The dorsal cutaneous branch of the ulnar nerve, medial cutaneous nerve of the forearm, and volar sensory branch of the ulnar nerve emerged as the principal nerves innervating the TFCC. This study provides anatomical evidence that the TFCC receives innervation from branches of the ulnar nerve and contains sensory nerve fibers. These findings enhance understanding of potential neuropathic pain mechanisms in TFCC injuries and offer insights to guide surgical interventions. Further investigations are warranted to elucidate the clinical implications.

Prevalence and characteristics of facial nerve bifurcation in the mastoid segment: a retrospective analysis using temporal bone CT scans.

To investigate the prevalence and characteristics of bifurcation of the facial nerve (FN) in the mastoid segment using temporal bone CT scans. A total of 970 cases (1931 ears) of temporal bone CT scans were reviewed, including 463 females and 498 males, aged 1 to 95years (interquartile range: 20-69years). CT imaging with multiplanar reconstruction (MPR) was used to identify and evaluate the bifurcation of the FN. Cases showing branching were confirmed by consensus among three physicians. We identified 10 cases (10 ears) with facial nerve branching in the vertical segment, yielding an incidence rate of 0.52% (10/1931 ears). Every cases were unilateral, predominantly on the left side. Age analysis revealed 1 case (0.22%) in individuals under 20years and 9 cases (0.61%) in those over 20years. Bifurcation generally occurred near the middle to lower vertical segment, with the closest proximity to the second genu observed in a 15-year-old patient. Bifurcation of the FN in the mastoid segment, though rare, can be encountered in otologic surgery. Detailed preoperative imaging evaluations are crucial for surgical planning to minimize the risk of nerve damage. Our findings emphasize the importance of recognizing anatomical variations in the FN for improving surgical outcomes and patient safety.

Maximum extension and regression rate of cutaneous sensory block obtained with the external oblique intercostal block or the modified thoracoabdominal nerves block through perichondrial approach in patients undergoing laparoscopic cholecystectomy.

Several studies demonstrate that both external oblique ıntercostal block (EOIB) and modified thoracoabdominal nerves block through perichondrial approach (M-TAPA) contribute to analgesia in the anterior abdomen by targeting the thoracoabdominal nerves through distinct pathways. However, the sensory assessment and dermatomal analysis remain poorly understood. This prospective observational study aimed to determine the sensory assessment and dermatomal regression rate of EOIB and M-TAPA in patients undergoing laparoscopic cholecystectomy. The study included a total of 24 patients, with 12 patients in each group. Blocks were performed bilaterally, administering 25 mL of bupivacaine 0.25% for each side, resulting in a total volume of 50 mL. The anterior abdominal wall was vertically partitioned into the midabdomen, left-lateral abdomen, and right-lateral abdomen, and horizontally divided into the epigastric, umbilical, and hypogastric regions. Sensory block was assessed at the 45th minute with cold stimulus and pinprick. Subsequent evaluations were at intervals of 6, 10, 14, 18, 22, and 24 hours. The blocked area percentile with cold sensation in the anterior abdomen was 43.07% (36.67-55.74) with EOIB, 40.49% (34.05-43.67) with M-TAPA (P=0.3219). When the region above the intertubercular plane was examined with cold sensation, EOIB covered 55.92% (46.75-62.07), and M-TAPA covered 49.60% (40.39-54.03) of the epigastric and umbilical areas. Assessment of the midabdominal portion of the anterior abdomen revealed that the blocked area percentile was statistically significantly higher in the M-TAPA group with both cold sensation and pinprick. At 45 minutes, the percentage of blocked dermatomes was 100% between T7-T8 in the EOIB group and between T7-T10 in the M-TAPA group. Both groups exhibited lower success rates in dermatomes T5 and T12, with no sensory block within the L1 dermatome, and cutaneous dermatomal block status either absent or negligible after 24 hours. All trocar entries were located within the cutaneous sensory block for both blocks, except for trocar C, which was located most laterally. Bilateral EOIB and M-TAPA produce a comparable sensory cutaneous block in the anterior abdomen, particularly in the umbilical and epigastric regions. Additionally, the midabdominal cutaneous blocked area was greater in patients undergoing M-TAPA, suggesting a more consistent distribution along the anterior cutaneous branches of the thoracoabdominal nerves.

Oblique or short incisions reduce the risk of saphenous nerve damage during hamstrings harvesting. A model for mapping nerve pathways at the harvest site.

INTRODUCTIONHamstring autografts are frequently used for ligament reconstruction surgery. Twelve to 84% of patients describe hypo or dysaesthesia secondary to injury of the saphenous nerve or one of its branches after hamstring harvesting. Type of incision (orientation and length) is subject of much debate to limit the risk of nerve damage. A cadaveric study was performed to determine which type of incision limits the risk of injury to the saphenous nerve or one of its branches, based on an anatomic model for mapping nerve pathways at the harvest site. METHODSAn anatomical study was performed on 20 knees from 12 embalmed bodies. Distance between saphenous nerve branches and 4 points of interest along the tibial crest was measured. Based on these measurements, a digital model of the saphenous nerve and its branches was created. A model of three common types of incision (vertical, horizontal and oblique) was overlaid. Each incision was modelled for three lengths (2, 3 and 4cm). Percentage of collision between nerve course model and incision model was then calculated to determine the risk of nerve damage for each type of incision. Based on the nerve course model, a “low collision risk” safe zone was identified. RESULTSNerve damage risk after an oblique incision was significantly lower than for a horizontal or vertical incision, for incision lengths of 3 and 4cm (p<0.05). For a specific incision orientation, the length of the incision did not affect the risk of nerve damage. A trapezoidal space close to the tibial crest and distal to the anterior tibial tuberosity appears to reduce risk of nerve damage. CONCLUSIONThis cadaveric study suggests that during hamstring harvesting, incisions shorter than 2cm reduce the risk of saphenous nerve’s branches injuries. For incisions longer than 2cm, using an oblique incision may reduce the risk compared to vertical or horizontal incisions. LEVEL OF EVIDENCELevel of evidence not applicable: Laboratory experiments

Developmental and physiological impacts of pathogenic human huntingtin protein in the nervous system

Huntington's Disease (HD) is a neurodegenerative disorder, part of the nine identified inherited polyglutamine (polyQ) diseases. Most commonly, HD pathophysiology manifests in middle-aged adults with symptoms including progressive loss of motor control, cognitive decline, and psychiatric disturbances. Associated with the pathophysiology of HD is the formation of insoluble fragments of the huntingtin protein (htt) that tend to aggregate in the nucleus and cytoplasm of neurons. To track both the intracellular progression of the aggregation phenotype as well as the physiological deficits associated with mutant htt, two constructs of human HTT were expressed in the Drosophila melanogaster nervous system with varying polyQ lengths, non-pathogenic-htt (NP-htt) and pathogenic-htt (P-htt), with an N-terminal RFP tag for in vivo visualization. P-htt aggregates accumulate in the ventral nerve cord cell bodies as early as 24 h post hatching and significant aggregates form in the segmental nerve branches at 48 h post hatching. Organelle trafficking up- and downstream of aggregates formed in motor neurons showed severe deficits in trafficking dynamics. To explore putative downstream deficits of htt aggregation, ultrastructural changes of presynaptic motor neurons and muscles were assessed, but no significant effects were observed. However, the force and kinetics of muscle contractions were severely affected in P-htt animals, reminiscent of human chorea. Reduced muscle force production translated to altered locomotory behavior. A novel HD aggregation model was established to track htt aggregation throughout adulthood in the wing, showing similar aggregation patterns with larvae. Expressing P-htt in the adult nervous system resulted in significantly reduced lifespan, which could be partially rescued by feeding flies the mTOR inhibitor rapamycin. These findings advance our understanding of htt aggregate progression as well the downstream physiological impacts on the nervous system and peripheral tissues.

Is the Sublingual Artery a Reliable Alternative for Intraoral Anastomoses in Head and Neck Free-Flap Reconstruction? Anatomical Basis and Preliminary Results

Background/Objectives: Head and neck free-flap reconstructions are often required to treat tumors or extensive post-traumatic jaw defects. The facial artery is the standard receiving vessel for intraoral microvascular anastomoses. However, its use is associated with several disadvantages, such as lesions of buccal nerve branches of the facial nerve or the parotid duct, as well as variability in course and diameter. The aim of this study is to investigate whether branches of the sublingual artery can be considered as an alternative intraoral supply vessel to the facial artery to avoid these drawbacks. Methods: Twelve formalin-fixed cadaveric heads with 24 sides (n = 24) were dissected. The origin, course, branching pattern, and distribution of the sublingual artery were examined. In addition, the diameters of the branches of the sublingual artery were assessed to identify potential supply vessels for anastomoses. Results: In ten of the twenty-four cases (41.7%), the sublingual artery originated from the lingual artery, and in nine cases (37.5%), the lingual artery originated from the facial artery. The main trunk of the sublingual artery was present in the floor of the mouth in all cases (100%), with a diameter of ≥0.9 mm in vitro (1 mm in vivo). In 15 of the 24 half heads (62.5%), branches of the sublingual artery with ≥0.9 mm were identified in this space, with the main branch being considerably stronger. Conclusions: The large diameter of the sublingual artery in the floor of the mandible suggests that this vessel or its branches could be considered as alternative pedicles for intraoral anastomoses in mandibular microvascular free-flap grafts.

The comparison of the efficacy of 3D fast spoiled gradient echo sequence and steady state free precession sequence in imaging vascular compression in patients with trigeminal neuralgia

Aims: Trigeminal neuralgia is a condition characterized by sudden and intense pain in the face, affecting the fifth cranial nerve. While it can occur for various reasons, vascular compression is a well-known cause. Additionally, conditions such as tumors, arachnoid cysts, idiopathic inflammation, damage, or demyelination can result in trigeminal neuralgia, extending to the distal branches of the trigeminal nerve from the pons. We aimed to investigate the diagnostic efectiveness of post-contrast three-dimensional fast spoiled gradient echo images (3D-FSPGR) in addition to steady-state free precession (SSFP) images in the imaging of trigeminal neuralgia. Methods: A total of 33 patients with a preliminary diagnosis of trigeminal neuralgia between May 2022 and October 2023 were investigated and five individuals were excluded. Among the remaining 28 patients, vascular compression was observed in only 14 patients. Trigeminal nerve thickness on both side, the distance between trigeminal nerve and superior cerebellar artery on both side, presence of vascular compression, level of the compression, presence or absence of displacement and atrophy were reported for each sequences. The findings and results were compared using independent sample T-test and paired T-test. Results: The mean age of the patient group was calculated to be 56.29 ± 4.5, while for the control group, it was 52.07 ± 3.09. Trigeminal nerve thickness wasn’t different between patient with or without vascular compression (p=0.874 for right side on SSFP, p=0.804 for left side on SSFP, p=0.667 for right side on 3D-FSPGR and 0.769 for left side on 3D-FSPGR). In 10 patients, unilateral compression of the trigeminal nerve was observed, while in 4 patients, it was bilateral. In the right trigeminal nerve, vascular compression was observed in SSFP images in 5 cases in the transitional zone, 2 cases in the nerve root entry zone, and 1 case distally. In 3D-FSPGR images, it was interpreted as being in the transitional zone in 4 cases, in the NR entry zone in 3 cases, and distally in 1 case. On the other hand, for the left trigeminal nerve, vascular compression was observed in both SSFP and 3D FSGPR images in 5 cases in the nerve root entry zone, 3 cases in the distal zone, and 2 cases in the transitional zone. Conclusion: Both SSFP and 3D-FSPGR images can provide comparable information regarding the spatial relationship between the trigeminal nerve and vascular structures. Contrast enhanced imaging allows us diferentiate the tumoral and infammatory demyelinating processes from vascular compression, we recommended to continue with SSFP images in cases where contrast enhanced 3D FSGPR images are inconclusive.

Identification of peripheral nerve functional fascicles in Sprague-Dawley rats by the carbon quantum dot-Annexin V antibody complex

To explore a method to identify the sensory and motor fascicles of the peripheral nerve to achieve accurate peripheral nerve functional fascicle suture. The peripheral nerve Sunderland V injury model, muscle branch of the femoral nerve and saphenous nerve were established in the bilateral femoral nerves of Sprague-Dawley (SD) rats. The specific samples were grouped as follows: the main trunk of the femoral nerve was exposed bilaterally and cut with microscopic scissors in the main trunk of the femoral nerve to prepare a model of Sunderland V injury in the mixed fascicle of peripheral nerves; the muscle branch of the femoral nerve was exposed bilaterally and cut in the middle section of the muscle branch of the femoral nerve to prepare a model of Sunderland V injury in the motor fascicle of peripheral nerves; the saphenous nerve was exposed bilaterally and cut at 1 cm below the patella to prepare a model of Sunderland V injury to the sensory fascicle of the peripheral nerves. A carbon quantum dot (CD)-annexin V antibody complex was prepared and applied to the distal and proximal nerve stumps of the peripheral nerve Sunderland V injury model groups of SD rats. Under the excitation light source of a 380 nm uv lamp, fluorescence color development was observed under a fluorescence microscope after 5, 10, 15, and 20 min. At 5 min, sections of the bilateral femoral nerve trunk, muscular branches of the femoral nerve, and Sunderland V lesion of the saphenous nerve in SD rats were only dark in color under the microscope, and there was no difference in fluorescence. The intensity of the staining increased significantly for 10–20 min. The sensory fascicles and saphenous nerves of the femoral nerve trunk showed blue fluorescence under the CD-Annexin V antibody complex staining, while the motor fascicles and muscle branches of the femoral nerve trunk showed no fluorescence. Fluorescence intensity gradually decreased after 20 min of staining. There was no significant difference in the staining intensity at 5, 10, 15, and 20 min in each group. Our results suggest that the CD-Annexin antibody complex can be used to identify functional fascicles of peripheral nerves in SD rats.

MRI genicular nerve mapping: a novel approach to sagittal genicular nerve localization

Background and objectivesChronic knee pain, including postarthroplasty knee pain, is a major cause of morbidity. Radiofrequency ablation of genicular nerve branches is a treatment option. The literature to date has...

Short term efficacy of subtalar arthroscopy combined with medial calcaneal-talar joint distraction in minimally invasive treatment of diabetic patients with calcaneal fractures: a retrospective study

BackgroundThe surgical treatment and management of postoperative soft tissue complications in diabetic patients with displaced calcaneal fractures are still controversial. We aimed to evaluate the short-term efficacy of percutaneous minimally invasive screw fixation in treatment of diabetic patients with Sanders II and III calcaneal fractures under subtalar arthroscopy assisted by preoperative musculoskeletal ultrasonic locating lateral calcaneal branch (LCB) of the sural nerve and calcaneal-talar joint distraction device.MethodsThe clinical data of 52 diabetic patients diagnosed with Sanders II or III calcaneal fractures from March 2016 to August 2020 were followed up and analyzed. There were 23 patients of type II and 29 patients of type III, 34 males and 18 females, with a mean age of 61.7 ± 14.5 years (range: 45–72 years). Preoperative musculoskeletal ultrasonography was routinely examined to locate LCB of the sural nerve. During surgery, we performed arthroscopic percutaneous prying reduction screw fixation assisted by medial calcaneal-talar joint distraction. Incision healing, local skin paraesthesia and other conditions were observed regularly at 3 days, 6, 12 months, and the last follow-up after surgery. Also, we measured the length, width, height, Böhler angle, and Gissane angle of the calcaneus on lateral and axial x-rays. Visual analogue pain scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) score and Maryland score were used to evaluate the efficacy.Results52 patients were followed up for 23.7 ± 3.2 months (range: 20–28 months) without incision-related complications. Calcaneal radiographic parameters (length, width, height, Böhler/Gissane angle) were improved after surgery, and the differences were all statistically significant (P<0.05). There was no difference between calcaneal radiographic parameters at 6,12 months and the last follow-up compared with 3 days after surgery without significant loss in overall morphology (P>0.05). Postoperative VAS, AOFAS scores, and Maryland scores were significantly improved compared with those before surgery (P<0.05).ConclusionsPreoperative ultrasonic locating LCB of the sural nerve and arthroscopic percutaneous minimally invasive screw fixation of Sanders II and III calcaneal fractures with the assistance of calcaneal-talar joint distraction have good short-term efficacy and clinical feasibility in diabetic patients.

Normative values and factors affecting saphenous nerve responses in a south Asian population: a cross-sectional neurophysiological study at a tertiary care hospital in Pakistan

BackgroundThe saphenous nerve, a sensory branch of the femoral nerve, is not commonly included in routine lower extremity nerve conduction studies due to a high frequency of non-recordable responses in healthy subjects. However, saphenous nerve conduction studies are sometimes utilized for the diagnostic assessment of isolated lumbosacral plexus, femoral, or saphenous mononeuropathies. Our study aims to determine normative saphenous nerve response values in a healthy Pakistani population and to investigate their associations with patient body mass index, age, and gender.MethodsThis cross-sectional descriptive study was undertaken over a 3‑month period (May to July 2021) at a neurophysiology department of a tertiary care center in Pakistan. Healthy subjects underwent neurological examination, anthropometric measurements, and bilateral SN nerve conduction studies, with recording of peak-latency, peak-to-peak amplitude and conduction velocity. Statistical analyses and linear regression were conducted to evaluate associations between nerve conduction study variables and patient characteristics. Statistical analyses were also run to assess patient characteristics affecting recordability of saphenous nerve responses. A p-value < 0.05 was considered statistically significant.ResultsAmong 117 subjects, 79.5% (n = 93) had recordable saphenous nerve responses. Median peak-latency, amplitude, and conduction velocity were 3.2 (3.0-3.3) m/s, 7.7 (5.8–9.9) uV, and 44.0 (42.0–47.0) m/s, respectively. Bilaterally absent responses were observed in 20.5% (n = 24) of subjects. Obese participants had a significantly higher number of absent saphenous responses (p = 0.033). Females had shorter peak-latency (p = 0.006) and higher conduction velocity (p = 0.012).ConclusionsSaphenous nerve responses can be used to assess unilateral femoral and saphenous nerve pathologies, provided they are recordable on the asymptomatic side for comparison. Absent bilateral saphenous nerve responses should be interpreted with caution given their prevalence in healthy individuals. Patient characteristics should be taken into consideration when interpreting recordable and nonrecordable saphenous nerve responses.

A case-series study of hepatic left lateral segment inversion for surgical field exposure in laparoscopic gastrectomy

PurposeRetraction of the hepatic left lateral segment (HLLS) is a crucial maneuver for surgical field exposure during laparoscopic gastrectomy with systematic lymphadenectomy. Though various methods of retraction are available, there is no perfect solution. Here, we report the results of our initial 42 cases with HLLS inversion method and discuss the feasibility, safety, effectiveness and technical aspects of this method.MethodsThe intraoperative and postoperative short-term outcomes of 42 patients who underwent HLLS inversion during laparoscopic total gastrectomy and proximal gastrectomy in our department September, 2023 to January, 2024 were reviewed. HLLS inversion was performed by mobilizing the HLLS and inverting it to the right supra-hepatic space through an incision at the falciform ligament.Results42 patients underwent HLLS inversion successfully with an average time of 13.9 min. 7 patients needed re-inversion due to slipping back of the HLLS during operation. Optimal exposure of the surgical field was achieved in all patients. No intra-operative complications occurred, except for 1 patient presented with mild intraoperative hepatic hemorrhage requiring electrocoagulation for hemostasis. Alanine aminotransferase and glutamine aminotransferase elevated in some patients on postoperative day 1(POD1), but declined to preoperative levels on the 7th postoperative day. There were no Clavien-Dindo II grade or higher digestive complications after surgery. In 5 patients with preservation the hepatic branch of the vagus nerve, the contractile function of the gall bladder was intact or slightly impaired 2 weeks after operation.ConclusionFor laparoscopic proximal gastrectomy (LPG) and laparoscopic total gastrectomy (LTG), HLLS inversion is a feasible method for optimizing visualization of the surgical field with preservation of the function of the hepatic branch of the vagus nerve. It is safe and acceptable as to the manipulation time. Re-inversion is easy and effective even in case of failure of inversion. HLLS inversion seems to be a promising technique for retraction of the liver during laparoscopic gastrectomy.

Intraparotid Facial Nerve Schwannoma - A Case Report

Abstract Rationale: Intraparotid facial nerve schwannoma (IPFNS) is a rare entity. Diagnosing these tumours is challenging as multiple differential diagnoses exist for swellings in the infraauricular region. Delay in diagnosis can lead to adverse outcomes. Patient Concerns: A 27-year-old female presented with swelling over the left infraauricular region, which concerned her cosmetic appearance. Diagnosis: It was initially misdiagnosed with imaging techniques computerised tomography (CT scan) and fine-needle aspiration cytology, leading to a diagnostic dilemma. Treatment: Superficial parotidectomy was planned and intraoperatively, a cystic lesion was seen adherent to the temporal branch of the facial nerve, which was resected along with the nerve branch. Histopathology confirmed the diagnosis as facial nerve schwannoma. Outcomes: The patient’s cosmetic concern was resolved but there was loss of wrinkles over the ipsilateral forehead region. No recurrence was seen. Take-Away Lessons: IPFNS often causes a diagnostic dilemma and an appropriate and timely diagnosis is required to decrease the morbidity and undertreatment.

Glucose-lowering medication associated with weight loss may limit the progression of diabetic neuropathy in type 2 diabetes.

Obesity is a major risk factor for diabetic peripheral neuropathy (DPN) in type 2 diabetes (T2D). This study investigated the effect of glucose lowering medication associated with weight change on DPN. Participants with T2D were grouped based on whether their glucose lowering medications were associated with weight gain (WG) or weight loss (WL). They underwent clinical, metabolic testing and assessment of neuropathic symptoms, vibration perception threshold (VPT), sudomotor function and corneal confocal microscopy (CCM) at baseline and follow-up between 4 and 7 years. Of 76 participants, 69.7% were on glucose lowering medication associated with WG, and 30.3% were on glucose lowering medication associated with WL. At baseline, participants in the WG group had a significantly longer duration of diabetes (p < .01), higher douleur neuropathique en 4 (DN4) score (p < .0001) and VPT (p = .01) compared with those in the WL group. Over a 56-month period, participants in the WG group showed no significant change in body weight (p = .11), HbA1c (p = .18), triglycerides (p = .42), DN4 (p = .11), VPT (p = .15) or Sudoscan (p = .43), but showed a decline in corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD) and corneal nerve fiber length (CNFL) (p < .0001). Participants in the WL group showed a reduction in weight (p = .01) and triglycerides (p < .05), no change in DN4 (p = .30), VPT (p = .31) or Sudoscan (p = .17) and a decline in the corneal nerve branch density (p < .01). Participants treated with glucose lowering medication associated with weight gain had worse neuropathy and greater loss of corneal nerves during follow-up, compared to patients treated with medication associated with weight loss.

Corneal nerve loss in adolescents with obesity and acanthosis nigricans.

Obesity and related metabolic abnormalities in adults are associated with peripheral neuropathy. Acanthosis nigricans (AN) is associated with insulin resistance, fatty liver, hyperlipidemia and glucose intolerance, all of which are risk factors for neuropathy. The aim of this study was to investigate if obese adolescents with AN have evidence of small nerve fiber damage. Adolescents with obesity with and without AN underwent body composition analysis, assessment of vibration perception threshold (VPT), monofilament sensitivity and corneal confocal microscopy (CCM) to quantify corneal nerve fiber density (CNFD), branch density (CNBD), length (CNFL) and inferior whorl length (IWL). Forty-six participants with obesity with (n = 31) and without (n = 15) AN aged 15(14-17) years were compared to 20 healthy controls aged 13(12-14) years. There was no difference in VPT, monofilament sensitivity and CCM measures between adolescents with obesity and controls. However, adolescents with AN had a significantly higher weight (P = 0.022), fat% (P = 0.029) and fat-muscle ratio (P = 0.012) with a lower CNFD (P = 0.045) compared to those with obesity without AN. Adolescents with obesity and acanthosis nigricans have a higher fat mass and small nerve fibre loss, indicative of a sub-clinical neuropathy.

Predicting thenar motor branch anatomy for a safer carpal tunnel release

PurposeAnatomic variations of the thenar motor branch of the median nerve (TMB) that place the nerve more ulnarly in the palm can increase the risk for iatrogenic injury to the nerve during carpal tunnel release. This study examines the prevalence of an origin of the TMB that is more ulnar than its typical branching from the radial aspect of the median nerve and explores whether the appearance of the palmar intrinsic muscles at surgery can predict an unusual TMB origin prior to visualizing the TMB itself. MethodsA prospective study of patients undergoing carpal tunnel release surgery was undertaken to document the take-off point of the TMB along the circumference of the median nerve and the presence or absence of intrinsic muscle obscuring the distal transverse carpal ligament. ResultsForty-one hands were evaluated. Eleven (26.8 %) demonstrated transverse carpal muscle. The most common origin of the TMB was from the radial aspect of the median nerve (56.1 %). In approximately 20 % of nerves, the TMB originated near its anterior midline. There was a statistically significant relationship between the TMB originating more ulnarly and the presence of transverse carpal muscle. ConclusionsThis study introduces a new classification system for further defining anatomic variations of the TMB. When transverse carpal muscle is absent, the TMB is highly likely to arise from the radial aspect of the median nerve. In the presence of transverse carpal muscle, the origin of the TMB is unpredictable and is significantly more likely to arise from the median nerve more ulnarly than is typically seen. Under these circumstances, attempts should be made to identify the TMB prior to completing ligament division.