Course Of Nerve Research Articles

Effectiveness of Sciatic Nerve Gliding with Hip Abductor Muscle Strengthening in Software Professionals Suffering from Piriformis Syndrome

Background: Piriformis syndrome is a neuromuscular disorder where the sciatic nerve is compressed or irritated by the inflammation of piriformis muscle representing pain, tingling and numbness in the buttock region and in the course of sciatic nerve. Piriformis syndrome can be painful, but it is very rarely alarming and needs surgical interventions. It can be managed effectively by conservative means such as NSAIDS, analgesics and physiotherapy interventions like stretching, electro therapeutic modalities, myofascial release, thermo therapies, etc. The purpose of this study is to compare the effect of sciatic nerve gliding exercise with hip abductor strengthening exercises versus piriformis stretching exercises in software professionals who are sitting for prolong hours in office and diagnosed with piriformis syndrome. Materials & Methods: 30 patients with piriformis syndrome, reporting at the OPD of Physiotherapy Department were evaluated according to the inclusion and exclusion criteria and were divided into Group A (experimental) N=15, Group B (control) N=15 randomly. Their baseline data with respect to age, sex, pain in VAS, hip internal rotation range by goniometer, and disability evaluation by MODQ were taken on day 1 of the treatment and day 15 of the treatment. Data analysis was done by Mann Whitney ‘u’ test for subjective data and unpaired ‘t’ test for objective data analysis with 95%confidence interval. Results: The patients treated with sciatic nerve sliding exercise and abductor strengthening (Group A) showed statistically significant decrease in pain (p=0.00), increase in range of motion for hip internal rotation (p=0.00) and decrease in disability level according to MODQ (p=0.00) after 15 days of interventions as compared to Group B who were treated by piriformis stretching exercises. Conclusion: This study has shown significant improvement in the experimental group (group A) in respect to pain relief, hip internal rotation range of motion, and .......

Double-Flap Elevation From the Ipsilateral Lower Extremity: The Anterior Approach to Fibula Osteo-Cutaneous Flap Elevation.

The free fibular flap has been elevated by a "lateral approach" from the posterior edge of the peroneal muscle for more than 40 years. However, in this approach, the surgical view is limited because flap elevation in mandibular reconstruction is performed simultaneously with tumor resection in the supine position, even when using positioning pillows. We herein propose an "anterior approach" as a new surgical method. We retrospectively investigated free fibular flap surgeries performed using the anterior approach, which consists of three anterior approaches, over a seven-year period. First, to avoid the course of the superficial peroneal nerve, the crural fascia was incised 1-2 cm posterior to the anterior edge of the peroneal muscle. The anterior edge of the peroneus muscle is detached from the anterior intermuscular septum. After performing osteotomies distal and proximal to the fibula, the interosseous membrane was incised from the anterior view. Pulling out the fibula to the anterior space between the anterior intermuscular septum and the peroneal muscle made the surgical field shallow. No postoperative superficial or deep peroneal nerve palsies were found in the 55 patients. Only one tourniquet was used in 31 of the 55 cases (56.4%), with an average of 95 min. Twenty-four patients (43.6%) required a second tourniquet 38 min after an interval. Only one tourniquet was used in 25 of the 30 (83.3%) cases in the last 3 years. Moreover, double flaps were used in 21 cases (38.2%), all of which involved ipsilateral ALT flaps. In 18 cases, double-flap elevation and prefabrication were successfully finished before the completion of tumor resection by otorhinolaryngologists.

Comparative Analysis of Patients Undergoing Microvascular Decompression for Trigeminal Neuralgia Caused by Solely Arterial or Solely Venous Compression

Trigeminal neuralgia (TN) due to venous compression is far less common than that due to arterial compression, and its pathogenesis is less clear. We investigated the clinical and imaging features of TN caused by solely venous compression by measuring the morphologies of the posterior cranial fossa (PCF) and the trigeminal nerve. We retrospectively reviewed records of TN patients who underwent microvascular decompression at our institution and extracted cases with solely arterial or solely venous compression. Preoperative magnetic resonance imaging was used to find the length (Y), width (X), height (Z), and volume (V) of the PCF, the angle between the trigeminal nerve and pons, and the distance between Meckel's cave and the root entry zone of the trigeminal nerve. Of 152 patients, 24 had TN caused solely by venous compression. The value of Y was significantly smaller in the venous group than the arterial group (P < 0.01). The trigeminal nerve and pons was significantly smaller in the venous group (P < 0.01). We hypothesized that TN patients with solely venous compression had a characteristic PCF morphology with a short anteroposterior diameter (Y), such that age-related changes in brain morphology could alter the course of the trigeminal nerve and cause compression by a vein. The morphological features of the PCF differed between patients with TN of venous and those with TN of arterial etiology. Age-related changes in brain morphology and changes of course of the trigeminal nerve may also add to the possibility of developing TN, especially of venous etiology.

Biopsy of the facial nerve in slow-onset facial palsy

IntroductionPrimary squamous cell carcinoma of the parotid gland typically presents as a palpable, often painless mass. Peripheral facial palsy as the only sign of malignant neoplasia is rare. In these cases, the diagnosis is regularly confirmed by radiological imaging followed by surgical exploration and biopsy. However, if there is no detection of malignant lesions and no evidence of a tumor, the reluctance to take a biopsy of an unremarkable nerve can lead to misdiagnoses.Case reportA 40-year-old female patient without medical history presented to our clinic with a complete right-sided peripheral facial palsy that had slowly progressed for 2.5 years. All other otorhinolaryngological examination findings were within normal limits. Magnetic resonance imaging examination of the head and neck and 18-fluorodeoxyglucose positron emission tomography showed unremarkable results. We proceeded with surgical exploration, which revealed no evidence of a tumor and an externally completely unremarkable facial nerve. A biopsy from the main trunk area of the nerve revealed an infiltration by a squamous cell carcinoma. Total parotidectomy with resection and reconstruction of the facial nerve and neck dissection was performed. Considering the absence of a primary tumor and other tumor formations the diagnosis of a completely regressive primary squamous cell carcinoma of the parotid gland was confirmed.ConclusionIn conclusion, in the case of slow-onset peripheral facial palsy that persists without signs of recovery, a gadolinium-enhanced MRI should be performed. If imaging is unremarkable and there is no primary tumor detection along the course of the facial nerve, a surgical exploration with biopsy of the facial nerve is necessary.

Laryngeal nerves in the cadaveric neck and its relevance to neck surgery- A descriptive study

Background Because of its close relationship with vessels that supply the thyroid gland, it is necessary to understand and document the course of the laryngeal nerves to prevent accidental damage. Otherwise it can lead to weakness in vocal cord function if ligated along with the arteries during thyroidectomy or other surgical procedures. The aim of our study was to examine and document the origin, relationship, and branching patterns of the laryngeal nerves on the side of the neck. Method The present cross sectional anatomical study was conducted on 64 dissected necks of formalin-fixed cadavers that were utilized for undergraduate teaching purposes. Different parameters were measured in the neck along with the relationship between the laryngeal nerves and their accompanying arteries. Results We observed usual and unusual course of laryngeal nerves along with some variations. Some of the novel findings were an internal laryngeal nerve piercing the thyroid cartilage lamina and an external laryngeal nerve communicating with the superior cervical ganglion. Conclusion The present study observed anatomical variations in the course of the laryngeal nerves, which are relevant for clinical practice. The potential risks of damage to these laryngeal nerves during various surgical procedures make it necessary to review and compile its relationship with the surrounding structures.

Preoperative visualization of the greater occipital nerve with magnetic resonance imaging in candidates for occipital nerve decompression for headaches

Occipital nerve decompression is effective in reducing headache symptoms in select patients with migraine and occipital neuralgia. Eligibility for surgery relies on subjective symptoms and responses to nerve blocks and Onabotulinum toxin A (Botox) injections. No validated objective method exists for detecting occipital headache pathologies. The purpose of the study is to explore the potential of high-resolution Magnetic Resolution Imaging (MRI) in identifying greater occipital nerve (GON) pathologies in chronic headache patients. The MRI protocol included three sequences targeting fat-suppressed fluid-sensitive T2-weighted signals. Visualization of the GON involved generating 2-D image slices with sequential rotation to track the nerve course. Twelve patients underwent pre-surgical MRI assessment. MRI identified four main pathologies that were validated against intra-operative examination: GON entanglement by the occipital artery, increased nerve thickness and hyperintensity suggesting inflammation compared to the non-symptomatic contralateral side, early GON branching with rejoining at a distal point, and a connection between the GON and the lesser occipital nerve. MRI possesses the ability to visualize the GON and identify suspected trigger points associated with headache symptoms. This case series highlights MRI's potential to provide objective evidence of nerve pathology. Further research is warranted to establish MRI as a gold standard for diagnosing extracranial contributors in headaches.

WALANT office based endoscopic cubital tunnel release

Background: Cubital tunnel syndrome is a common condition caused by compression of the ulnar nerve around the medial elbow. Surgical treatment usually involves open in situ ulnar nerve decompression unless ulnar nerve instability is noted. Endoscopic techniques for cubital tunnel release have been developed and implemented with excellent patient and surgeon satisfaction. Endoscopic cubital tunnel release can be performed in an office based procedure room under wide awake local anesthesia no tourniquet principles. We present our setup and technique for performing an endoscopic cubital tunnel release procedure in an office based setting under local anesthesia. Methods: Local anesthesia is injected along the course of the ulnar nerve on the medial arm and forearm extending 10 cm proximal and distal to the medial epicondyle. After allowing approximately 30 min for appropriate vasoconstriction, the patient is placed in a supine position with the arm abducted and externally rotated position. The endoscopic cubital tunnel release is then performed. Discussion: Our described technique eliminates the need for placement of a prophylactic tourniquet and thereby the need for the procedure to be performed within an OR setting. It also utilizes a single-stage anesthetic administration, which facilitates ease of completion and performance in an office based setting. There is a significant cost savings when endoscopic cubital tunnel release is performed in an office-based procedure room compared to in the operating room. Conclusions: Office-based endoscopic cubital tunnel release can be safely performed utilizing WALANT techniques, leading to high patient satisfaction and decreased overall cost of care. Level of Evidence: Therapeutic IV

CT and MR Imaging Findings of Lingual Nerve Perineural Spread

Retrograde perineural spread is a well-described entity involving many major nerves, including the inferior alveolar, facial, and branches of the trigeminal nerves. However, isolated perineural spread along the lingual nerve has not been well-described in the literature and is often overlooked. Lingual nerve perineural spread is a potential pathway of recurrent floor of the mouth cancers, which are often clinically occult. This article describes the CT and MR imaging findings of lingual nerve perineural spread characterized by thickening and enhancement along the course of the lingual nerve, which extends from the lateral floor of the mouth (between the mylohyoid and hyoglossus muscles), proximally along the medial aspect of the mandibular ramus to the main trunk of mandibular nerve. We also identify 5 unique anatomic “anchor points” that represent imaging landmarks that help radiologists diagnose patients with potential lingual nerve involvement and assist radiation oncologists in contouring the lingual nerve pathway and planning initial treatment in patients with high risk of perineural spread.Learning Objective: To describe the CT and MR imaging findings of lingual nerve perineural spread and provide imaging landmarks that help the neuroradiologist identify lingual nerve involvement and assist radiation oncologists in planning the initial treatment in patients with a high risk of lingual nerve perineural spread

Single-Center Experience in Microsurgical Resection of Acoustic Neurinomas and the Benefit of Microscope-Based Augmented Reality.

Background and Objectives: Microsurgical resection with intraoperative neuromonitoring is the gold standard for acoustic neurinomas (ANs) which are classified as T3 or T4 tumors according to the Hannover Classification. Microscope-based augmented reality (AR) can be beneficial in cerebellopontine angle and lateral skull base surgery, since these are small areas packed with anatomical structures and the use of this technology enables automatic 3D building of a model without the need for a surgeon to mentally perform this task of transferring 2D images seen on the microscope into imaginary 3D images, which then reduces the possibility of error and provides better orientation in the operative field. Materials and Methods: All patients who underwent surgery for resection of ANs in our department were included in this study. Clinical outcomes in terms of postoperative neurological deficits and complications were evaluated, as well as neuroradiological outcomes for tumor remnants and recurrence. Results: A total of 43 consecutive patients (25 female, median age 60.5 ± 16 years) who underwent resection of ANs via retrosigmoid osteoclastic craniotomy with the use of intraoperative neuromonitoring (22 right-sided, 14 giant tumors, 10 cystic, 7 with hydrocephalus) by a single surgeon were included in this study, with a median follow up of 41.2 ± 32.2 months. A total of 18 patients underwent subtotal resection, 1 patient partial resection and 24 patients gross total resection. A total of 27 patients underwent resection in sitting position and the rest in semi-sitting position. Out of 37 patients who had no facial nerve deficit prior to surgery, 19 patients were intact following surgery, 7 patients had House Brackmann (HB) Grade II paresis, 3 patients HB III, 7 patients HB IV and 1 patient HB V. Wound healing deficit with cerebrospinal fluid (CSF) leak occurred in 8 patients (18.6%). Operative time was 317.3 ± 99 min. One patient which had recurrence and one further patient with partial resection underwent radiotherapy following surgery. A total of 16 patients (37.2%) underwent resection using fiducial-based navigation and microscope-based AR, all in sitting position. Segmented objects of interest in AR were the sigmoid and transverse sinus, tumor outline, cranial nerves (CN) VII, VIII and V, petrous vein, cochlea and semicircular canals and brain stem. Operative time and clinical outcome did not differ between the AR and the non-AR group. However, use of AR improved orientation in the operative field for craniotomy planning and microsurgical resection by identification of important neurovascular structures. Conclusions: The single-center experience of resection of ANs showed a high rate of gross total (GTR) and subtotal resection (STR) with low recurrence. Use of AR improves intraoperative orientation and facilitates craniotomy planning and AN resection through early improved identification of important anatomical relations to structures of the inner auditory canal, venous sinuses, petrous vein, brain stem and the course of cranial nerves.

Unilateral optic nerve aplasia associated with microphthalmia: a rare cadaveric report

This case report describes the anatomical presentation of the anomalous optic nerve (cranial nerve II). Cranial nerve II developmental anomalies encompass both optic nerve hypoplasia and aplasia. While most studies on optic nerve anomalies rely on radiological imaging, anatomical presentation and nerve course are rarely described. The current case reveals a complete absence of the right optic nerve and its connection to the optic chiasma, resembling radiological presentation of optic nerve aplasia. In addition, the right-sided bony orbit and eyeball were smaller than the left, accompanied by a poorly developed cornea and iris with a calcified mass, resembling clinical presentation of microphthalmia. Having a thorough understanding of the gross anatomical presentation and course of optic nerve anomalies can facilitate precise diagnosis and management of visual impairments associated with these anomalies. Furthermore, such knowledge can provide valuable insights into the actual prevalence of optic nerve aplasia and further substantiate the literature.

PAROTID TUMORS; PRESENTATION, SURGICAL MANAGEMENT AND COMPLICATIONS

Background: The parotid gland is the most common salivary gland affected by tumors, 80% of them affects the parotid glands and 80% affects the superficial lobe. Pleomorphic adenoma is the commonest salivary tumor. Other types of tumors occur less frequently. Most tumors are diagnosed with ultrasound; MRI shows more anatomical details. Superficial parotidectomy is done for benign tumors, more extensive resection is done for malignant tumors. Results: This a cross sectional study which included 69 patients who underwent various types of parotid surgeries over a period of 4 years. The mean age of our patients was 45.29 years, and 52.2% were males. The tumor was present in the right parotid gland in 49.3%, in the left side in 43.5%, and was bilateral in 2.9%. The mean duration of symptoms was 29.67 months, all patients were sent for ultrasound and 42 patients were sent for the FNAC, 91.3% of patients underwent superficial parotidectomy. Pleomorphic adenoma was the commonest type of tumors which was diagnosed in 69.6%, followed by Warthin’s tumors in 13%, Non-Hodgkin's lymphoma in 4.3%, and the rest comprises some rare types of tumors. Complications were reported in 30.43% of patients and the commonest complications were transient facial nerve weakness followed by salivary leak (11.6 and 8.7 %) respectively. Conclusion: Parotid tumors are rare types of tumors and pleomorphic adenoma is the commonest type, identifying the anatomy during surgery especially the course of the facial nerve is the most important step, complications are common but fortunately most are transient.

Effectiveness of Dry Needling versus Cupping Therapy for Pain in Piriformis Syndrome

Background: Piriformis syndrome is characterized by discomfort in the buttocks and throughout the course of the sciatic nerve. Dry needling modulates pain perception, disrupts pain signaling pathways, and induces local tissue responses. Cupping therapy facilitates localized blood flow, lymphatic drainage, and tissue oxygenation to alleviate muscular tension and improve circulation. Both interventions have shown promise in improving symptoms of piriformis syndrome. Objective: The purpose of this study was to evaluate the efficacy of dry needling versus cupping therapy in managing piriformis pain syndrome. Methods: This experimental study was conducted at Chaudhary Muhammad Akram Teaching and Research Hospital, Lahore, from October 2023 to May 2024. Eighty participants diagnosed with piriformis syndrome, aged between 18 and 65 years, were randomly assigned to one of two groups: Group A (dry needling) and Group B (cupping therapy). Exclusion criteria included pregnancy and previous surgical interventions for piriformis syndrome. Both groups received their respective treatments three times a week for six weeks. Pain intensity was measured using the Visual Analogue Scale (VAS), disability was assessed with the Oswestry Disability Index (ODI), and quality of life was evaluated using a standardized questionnaire. Data were analyzed using SPSS version 25, with paired sample t-tests used for within-group comparisons and independent sample t-tests for between-group comparisons. Statistical significance was set at p &lt; 0.05. Results: In the dry needling group, the mean VAS score decreased from 6.216 ± 1.931 to 3.432 ± 0.987 (p &lt; 0.001), while the cupping therapy group saw a reduction from 6.108 ± 2.195 to 4.189 ± 1.697 (p &lt; 0.001). The mean ODI score in the dry needling group decreased from 27.432 ± 7.617 to 10.054 ± 3.036 (p &lt; 0.001), and in the cupping therapy group from 26.270 ± 7.209 to 12.918 ± 7.495 (p &lt; 0.001). Quality of life scores improved significantly in both groups, with the dry needling group showing a mean reduction from 12.702 ± 3.673 to 7.270 ± 1.627 (p &lt; 0.001), and the cupping therapy group from 13.027 ± 3.523 to 8.270 ± 1.609 (p &lt; 0.001). Conclusion: Both dry needling and cupping therapy are effective interventions for managing piriformis pain syndrome, with dry needling showing greater improvements in pain reduction, disability reduction, and quality of life. These findings support the use of dry needling as a preferred therapeutic option for piriformis syndrome.

Developing a production workflow for 3D-printed temporal bone surgical simulators

Introduction3D-printed temporal bone models enable the training and rehearsal of complex otological procedures. To date, there has been no consolidation of the literature regarding the developmental process of 3D-printed temporal bone models. A brief review of the current literature shows that many of the key surgical landmarks of the temporal bone are poorly represented in models. This study aims to propose a novel design and production workflow to produce high-fidelity 3D-printed temporal bone models for surgical simulation.MethodsDevelopmental phases for data extraction, 3D segmentation and Computer Aided Design (CAD), and fabrication are outlined. The design and fabrication considerations for key anatomical regions, such as the mastoid air cells and course of the facial nerve, are expounded on with the associated strategy and design methods employed. To validate the model, radiological measurements were compared and a senior otolaryngologist performed various surgical procedures on the model.ResultsMeasurements between the original scans and scans of the model demonstrate sub-millimetre accuracy of the model. Assessment by the senior otologist found that the model was satisfactory in simulating multiple surgical procedures.ConclusionThis study offers a systematic method for creating accurate 3D-printed temporal bone models for surgical training. Results show high accuracy and effectiveness in simulating surgical procedures, promising improved training and patient outcomes.

Cochlear implantation through retro-facial approach with congenital microtia malformation with facial nerve deformity: a case report

The difficulty of cochlear implantation in patients with congenital microtia is usually increased due to the vague anatomical marks and facial nerve malformation. The common types of facial nerve malformation include facial nerve bony cover loss, aberrant position, and bifurcation malformation. Bifurcation malformation may obscure the oval window, press against stapes, and bifurcate in the vestibular window while obscuring the round window. It is important to correctly identify the facial nerve and choose a reasonable surgical approach to avoid postoperative complications. This article describes a case of profound sensorineural hearing loss due to facial nerve malformation in our institution. The patient underwent cochlear implantation through the retro-facial approach. There was no facial nerve injury or dysfunction symptoms such as facial paralysis and hemifacial spasm 2 years after the operation, and the cochlear implant works well. The score of the categories of the auditory performance（CAP） questionnaire was 7, and the score of the speech intelligibility rating（SIR） questionnaire was 4. When the round window cannot be exposed through the facial recess approach during surgery, the retro-facial approach is a feasible method. To avoid facial nerve injury, a thin-section CT of the temporal bone should be performed before the middle and inner ear surgery for patients with facial nerve malformation, and the intraoperative facial nerve monitor should be used to clarify the course of the facial nerve to avoid injury.

Effects of Neurodynamics Along With Conventional Exercises on Sciatica Patients: A Single-Blinded Randomized Clinical Trial.

Introduction Sciatica refers to a pain that travels along the course of the sciatic nerve. Patients also often experience paresthesia along with the pain in thighs, which may further radiate to the legs. Most commonly, compression of the lumbosacral nerve root is the cause of this syndrome. Neurodynamics and conventional exercises are considered effective treatment procedures for sciatica. This study aims to find out the efficacy of neurodynamics along with conventional exercises and conventional exercises alone. Methods A total of 58 patients with sciatica aged between 30 and 60 years of both genders were included in the study and randomly divided into a neurodynamic group (n=29) and a conventional group (n=29). Pre-test data were collected before the interventions, and post-test data were collected on the 14th day. The 101 numeric pain rating scale (NPRS) was used to measure data of sciatic pain, the patient-specific functional scale (PSFS) was used to measure the health-related quality of life (HRQL), and a surface electromyography (EMG) biofeedback instrument was used to measure the peak and average muscle activation of the biceps femoris muscle. Results The pre-post data analysis of the neurodynamics and conventional group showed significant (p<0.05) improvement in 101 NPRS, PSFS, and peak EMG values. Insignificant (p>0.05) improvements were seen in average EMG values in the conventional group, and significant (p<0.05) improvement were seen in the neurodynamic group. Between-group analysis showed insignificant (p>0.05) differences in 101 NPRS as well as peak and average EMG values and showed significant (p<0.05) differences in PSFS values. Conclusion Neurodynamics with conventional exercises can help in reducing pain, improving muscle activation of the biceps femoris, and elevating the HRQL of the patient.

Abstract 1085: Vagal Nerve Schwannoma Presenting As A Syncope In A Young Patient

Introduction: Vagal schwannomas are rare, benign masses that usually develop in the cervical region but can arise anywhere along the vagus nerve. Patients may be asymptomatic; however, in most cases, patients present in their third to sixth decades, with neck swelling, hoarseness or cough. Herein, we discuss a case report of a 26-year-old male who presented after an abrupt syncopal episode with sinus bradycardia and was diagnosed with vagal schwannoma. Case Presentation: A 26-year-old male with a past medical history of bipolar disorder was brought to the hospital after an abrupt syncopal episode while driving. He denied any palpitations or prodromal symptoms prior to loss of consciousness. Inpatient cardiac monitoring revealed persistent sinus bradycardia, without high degree AV block. Treadmill EKG stress test confirmed chronotropic competence. CT head did not reveal other etiology of syncope. CT chest revealed a 2.4 x 2.0 cm left superior mediastinal mass. Cardiothoracic surgery was consulted for concern of thoracic outlet mass/mediastinal mass. Robotic-assisted left thoracoscopy was performed for mediastinal mass excision, which revealed a left vagus nerve schwannoma on frozen section. Discussion: Most vagus nerve schwannomas have been found to arise within the cervical course of the vagus nerve. Intrathoracic vagal schwannomas are rare. These tumors are usually asymptomatic, however varied symptoms such as pain, dysphagia and shortness of breath have been reported. In this case presented, the tumor possibly contributed to the heightened vagal tone and neurogenic syncope (with vasovagal syncope). It is also notable that our patient's resting heart rate normalized following excision of the mass. Of note, with a high reported incidence of peri-perioperative vocal cord paralysis, surgical excision remains a challenging mainstay of treatment in symptomatic patients. Conclusion: Vagal neoplasms should be hence considered as a differential diagnosis in patients with otherwise unexplained bradycardia with history of syncope. Reference: Neurocardiogenic syncope; Carol Chen-Scarabelli, cardiovascular nurse practitioner and Tiziano M Scarabelli, associate professor of internal medicine. BMJ 2004 Aug 7; 329 (7461):336-341.

Mentalis nerve branches supplying the lower lip revisited: a study of human fetuses and donated elderly cadavers.

Little information is known about the mentalis nerve course from the lower lip approximation margin (free margin) to the upper lip. Likewise, no difference in nerve distribution has been observed between the cutaneous and mucosal parts of the lip. Therefore, this study reexamined mentalis nerve morphology. For macroscopic observations, three fresh cadavers were dissected (one male and two females; aged 78-93). We also evaluated histological sections obtained from five donated elderly cadavers (two males and three females, aged 82-96 years) and 15 human fetuses (11-40 weeks or crown-rump length 80-372mm). Immunohistochemical analysis for S100 protein and tyrosine hydroxylase was performed. In both fetuses and adult cadavers, one to three nerve branches ran upward in the submucosal tissue from the mental foramen. Near the free margin of the lip, some branches passed through the orbicularis oris muscle layer toward the lip skin, whereas others followed a reversed J-shaped course along the free margin. Nerve twigs ran in parallel beneath the mucosa, whereas wavy nerve twigs attached to the basal lamina of the lip epidermis. The difference in nerve endings abruptly occurred at the skin-mucosal junction. Tyrosine hydroxylase-positive sympathetic nerve twigs surrounded arteries and formed a branch composed of S100-negative unmyelinated fibers. The lower lip skin was innervated by a perforating branch passing through the orbicularis oris muscle, that was different from the lip mucosa. A sudden change in the nerve ending configuration at the mucocutaneous junction seemed to develop postnatally.

A rare case with atypical findings: schwannoma of the radial nerve

A 53-year-old male complained of weakness in the dorsum of the 5-4-3rd fingers of the right hand. The musculus extensor digitorum communis was heavy and the musculus extensor indices proprius was light involved in the needle electroneuromyography study. Radial nerve ultrasonography showed a mass(schwannoma) which located on the radial nerve course after the lateral epicondyle at the elbow level. In conclusion, we should consider radial nerve schwannoma in patients with radial nerve injury and when there is an atypical involvement of the muscles innervated by the radial nerve, we should utilize ultrasonography for evaluation.

A direct saphenous nerve block in TKA: A surgeon friendly technique! Cadaveric study

IntroductionEffective management of postoperative pain in total knee arthroplasty (TKA) poses a significant challenge for surgeons. Achieving rapid recovery without pain and promoting early ambulation in immediate and early postoperative periods are essential for patient satisfaction. There are many pain management protocols including nerve blocks. Nerve blocks procedures were done using USG and anaesthetist dependent. This cadaveric study aimed to define the VMO (Vastus medialis obliquus) triangle to target the ‘safe zone’ of the saphenous nerve during TKA: A surgeon's friendly technique. Methods12 formalin-fixed embalmed cadaveric lower limbs were dissected to explore anatomy, trajectory, the relation of saphenous nerve and measured the distances from the nearby palpable bony landmarks. ResultsThe average distance to target the saphenous nerve i.e target point from midpoint of superior pole of the patella was 10.6cm, the average angle to target the saphenous nerve is the angle between the line joining the medial epicondyle to the midpoint of the superior pole of the patella is found to be 64.2°. The average distance from midpoint of superior pole patella to medial epicondyle is found to be 8.1cm. Therefore, triangle so formed using these three points (1. Medial epicondyle, 2. The midpoint of superior pole of the patella, 3. Target point of the saphenous nerve) is called a VMO triangle. ConclusionsThe saphenous nerve course, relations, and the distances from intraoperative bony landmarks for the VMO triangle during TKA which is a reproducible triangle so may be useful for arthroplasty surgeons to achieve successful saphenous nerve block and to avoid related complications during total knee arthroplasty (TKA).

Transorbital approach to the cavernous sinus: an anatomical study of the related cranial nerves.

The cavernous sinus (CS) is a demanding surgical territory, given its deep location and the involvement of multiple neurovascular structures. Subjected to recurrent discussion on the optimal surgical access, the endoscopic transorbital approach has been recently proposed as a feasible route for selected lesions in the lateral CS. Still, for this technique to safely evolve and consolidate, a comprehensive anatomical description of involved cranial nerves, dural ligaments, and arterial relations is needed. Detailed anatomical description of the CS, the course of III, IV, VI, and V cranial nerves, and C3-C7 segments of the carotid artery, all described from the ventrolateral endoscopic transorbital perspective. Five embalmed human cadaveric heads (10 sides) were dissected. An endoscopic transorbital approach with lateral orbital rim removal, anterior clinoidectomy, and petrosectomy was performed. The course of the upper cranial nerves was followed from their apparent origin in the brainstem, through the middle fossa or cavernous sinus, and up to their entrance to the orbit. Neuronavigation was used to follow the course of the nerves and to measure their length of surgical exposure. The transorbital approach allowed us to visualize the lateral wall of the CS, with cranial nerves III, IV, V1-3, and VI. Anterior clinoidectomy and opening of the frontal dura and the oculomotor triangle revealed the complete course of the III nerve, an average of 37 (±2) mm in length. Opening the trigeminal pore and cutting the tentorium permitted to follow the IV nerve from its course around the cerebral peduncle up to the orbit, an average of 54 (±4) mm. Opening the infratrochlear triangle revealed the VI nerve intracavernously and under Gruber's ligament, and the extended petrosectomy allowed us to see its cisternal portion (27 ± 6 mm). The trigeminal root was completely visible and so were its three branches (46 ± 2, 34 ± 3, and 31 ± 1 mm, respectively). Comprehensive anatomic knowledge and extensive surgical expertise are required when addressing the CS. The transorbital corridor exposes most of the cisternal and the complete cavernous course of involved cranial nerves. This anatomical article helps understanding relations of neural, vascular, and dural structures involved in the CS approach, essential to culminating the learning process of transorbital surgery.