Cranial Direction Research Articles

Two-Year Postoperative Upper Airway Cone-Beam Computed Tomographic Outcomes Based on a Verified Upper Airway Analysis Following Bimaxillary Orthognathic Surgery

Upper airway (UA) assessment after orthognathic surgery should rely on a verified method of UA analysis. Therefore, the authors applied a new validated UA evaluation method to determine the effect of bimaxillary surgery (BMS) on UA parameters and hyoid bone and epiglottis displacement evaluated immediately and 2years after surgery. A retrospective cohort study was implemented of patients without obstructive sleep apnea who had undergone BMS for maxillomandibular deficiencies. A new validated UA cone-beam computed tomographic (CBCT) analysis, based on stable anatomic landmarks, was applied to CBCT scans acquired before initiation of treatment (T0), immediately after surgery (T1), and 2years postoperatively (T2). A quality assessment was performed before analysis. The primary predictor variable consisted of time points during treatment (T0, T1 and T2), and UA volumes, cross-sectional area (CSA), and hyoid bone and epiglottis displacement were the outcome variables. Descriptive statistics and t test were performed and the P value was set at .05. Fifty patients (16 men and 34 women) with a mean age of 25.7±8.2years at time of surgery were included. CBCT scans were acquired at T0 (20±9months before surgery), T1 (14±2days after surgery), and T2 (30±6months after surgery). Immediately after surgery (T1 vs T0), BMS resulted in a statistically relevant UA volume increase of 26%. At 2-year follow-up (T2 vs T0), UA volume showed a statistically relevant increase by 20%. CSA increased by approximately 26 and 19% (P<.001) at T1 versus T0 and T2 versus T0, respectively. Two years after surgery, epiglottis displacement was 2mm(P<.001) and hyoid bone displacement was 3mm(P<.001) in a cranial direction and hyoid bone anterior displacement measured 3mm(P<.001). Based on an objective, standardized, and validated CBCT UA analysis, BMS was associated with increased UA volume and CSA measures evaluated immediately and 2years after surgery.

Dispersal Pattern of Injectate After Cervical Epidural Steroid Injection Evaluated With Magnetic Resonance Imaging

Study Design:Prospective, nonrandomized, clinical study.Objective:Epidural steroid injections (ESIs) are an important diagnostic and treatment modality for spine pathology. The success of these injections has been attributed to the anatomic location reached by the injectate. This study evaluates injectate dispersal patterns after cervical interlaminar ESI using magnetic resonance imaging (MRI).Methods:Patients between the ages of 18 and 85 years with cervical radiculopathy were identified. After obtaining consent for study participation, a gadolinium-enhanced cervical ESI was administered via an interlaminar approach under fluoroscopic guidance. Study participants underwent a cervical spine MRI within 15 minutes of administering the injection. Craniocaudal dispersal and the presence or absence of circumferential dispersal was assessed.Results:The injectate dispersed a mean of 8.11 cm in the cranial direction, 6.63 cm in the caudal direction, and 360° circumferentially. No adverse events related to the ESI were reported.Conclusions:Fluoroscopy-guided cervical interlaminar ESI resulted in nearly uniform circumferential dispersal within the epidural space with multilevel migration in the cranial and caudal directions. MRI is a safe and accurate tool to evaluate spinal injectate dispersal.

Improved error detection using a divided treatment plan in volume modulated arc therapy.

We sought to improve error detection ability during volume modulated arc therapy (VMAT) by dividing and evaluating the treatment plan. VMAT involves moving a beam source delivering radiation to tumor tissue through an arc, which significantly decreases treatment time. Treatment planning for VMAT involves many parameters. Quality assurance before treatment is a major focus of research. We used an established VMAT prostate treatment plan and divided it into 12°×30° sections. In all the sections, only image data that generated errors in one segment and those that were integrally acquired were evaluated by a gamma analysis. This was done with five different patient plans. The integrated image data resulting from errors in each section was 100% (tolerance 0.5mm/0.5%) in the gamma analysis result in all image data. Division of the treatment plans produced a shift in the mean value of each gamma analysis in the cranial, left, and ventral directions of 94.59%, 98.83%, 96.58%, and the discrimination ability improved. The error discrimination ability was improved by dividing and verifying the portal imaging.

Cranially migrated lumbar intervertebral disc herniations: A multicenter analysis with long-term outcome.

Objective:Risk factors of cranial migration were investigated in patients with lumbar disc herniation (LDH) that migrated in the cranial direction and the long-term outcomes are discussed in this study.Materials and Methods:Patients who underwent surgery for LDH at four different centers between 2012 and 2017 were studied. Extraligamentous discs were located in the lateral part of the posterior longitudinal ligament (PLL) within the spinal canal of the axial plane, and subligamentous discs were located under the PLL. The extent of cranial migration was calculated as a percentage of the height of the migrated corpus. Based on the extent of cranial migration, partial hemilaminectomy or hemilaminectomy was performed at different rates in each patient and the amount of laminectomy performed was recorded. During surgery, all free fragments were attempted to be removed. The appropriate technique was decided intraoperatively, and the surgery was performed on an individual patient basis.Results:Of 1289 patients who underwent surgery for LDH, 654 (50.73%) had caudal migration, 576 (44.68%) had migration at the level of the disc, and 59 (4.57%) had cranial migration. Analysis of 59 patients with cranial migration according to the localization of the disc fragment revealed that 31 had extraligamentous and 28 had subligamentous fragments (P = 0.024).Conclusions:Extraligamentous intervertebral disc fragments migrate more cranially than subligamentous intervertebral fragments. The anatomy of the PLL that varies along the corpus is the main reason for the weakness of the resistance of the disc material to the dorsolateral region, direction of discrete force vectors, and orientation of the disc fragment due to torsional vertebral movements.

Evaluation of Multi-Slice Spiral Computed Tomography in In vivo Simulation of Individualized Cervical Pedicle Screw Placement at C3-C7 in Chinese Healthy Population.

Background:Cervical pedicle screw fixation through posterior approach has shown greater cervical stability advantage. The cervical pedicle screw fixation technique through posterior approach is demanding. The key to the technique is the choice of point and angle of screw entrance. The angle of screw placement is variable. Morphometric measurements of the cervical pedicle are a prerequisite for individualized screw. CT imaging has become the most reliable and important means to obtain cervical pedicle's measurement data and morphology in vivo. This study explores the feasibility and application of precise in vivo measurements by multi-slice computed tomography (MSCT) for individualized cervical transpedicular screw placement at C3–C7 in Chinese healthy population.Materials and Methods:80 adults who underwent cervical examination by enhanced and nonenhanced computed tomography angiography, respectively, were selected and submitted to bone algorithm reconstruction for slice thickness and interval of 0.75 mm to acquire clear images and detailed bone structures. Simulation of individualized screw placement was performed with a 4.0 mm diameter screw with the help of postprocessing workstation. Pedicle transverse angle (PTA) and sagittal angle (PSA) were measured using the single- and double-line methods (analog nailing, 4.0 mm in diameter) in 160 pairs of C3–C7 pedicles, setting positive and negative values for cranial direction and foot side PSAs, respectively. Comparison of the measured change scope in PTA and PSA between the two methods was carried out; the range was defined as the error range.Results:Significantly, different results (P < 0.05) were obtained between the single- and double-line methods in the error ranges of PTA and PSA in C3–C7 pedicles. Interestingly, the double-line method was better in simulating the actual needs of individualized nailing. The mean values of PTA and PSA were 42.9°, 45.5°, 42.4°, 37.1°, 29.0° and 8.4°, 5.0°, −4.0°, and −7.8°, −8.1°, respectively, with the double-line method.Conclusion:MSCT reconstruction techniques can determine the direction and required parameters for individualized screw placement. In addition, accurate in vivo measurements of PTA and PSA, particularly PSA, provide the orthopedic surgeon with theoretical guidance and reliable basis in screw placement.

First reported adult patient with TARP syndrome: A case report

TARP syndrome (talipes equinovarus, atrial septal defect, Robin sequence, and persistence of the left superior vena cava) is a rare X‐linked syndrome often resulting in pre‐ or post‐natal lethality in affected males. In 2010, RBM10 was identified as the disease‐causing gene, and we describe the first adult patient with TARP syndrome at age 28 years, hereby expanding the phenotypic spectrum. Our patient had Robin sequence, atrial septal defect, intellectual disability, scoliosis, and other findings previously associated with TARP syndrome. In addition, he had a prominent nose and nasal bridge, esotropia, displacement of lacrimal points in the cranial direction, small teeth, and chin dimple, which are the findings that have not previously been associated with TARP syndrome. Our patient was found to carry a hemizygous c.273_283delinsA RBM10 mutation in exon 4, an exon skipped in three of five protein‐coding transcripts, suggesting a possible explanation for our patient surviving to adulthood. Direct sequencing of maternal DNA indicated possible mosaicism, which was confirmed by massive parallel sequencing. One of two sisters were heterozygous for the mutation. Therefore, we recommend sisters of patients with TARP syndrome be carrier tested before family planning regardless of carrier testing results of the mother. Based on our patient and previously reported patients, we suggest TARP syndrome be considered as a possible diagnosis in males with severe or profound intellectual disability combined with septal heart defect, and Robin sequence, micrognathia, or cleft palate.

Complete intracorporeal defect closure using unidirectional barbed suture in laparoscopic incisional hernia repair: Preliminary experience with short-term follow-up.

Surgical techniques to close defects in laparoscopic incisional hernia repair vary across the literature. We herein demonstrate our original and standardized surgical technique for laparoscopic incisional hernia repair with complete intracorporeal defect closure using barbed suture. Complete intracorporeal defect closures were indicated for defects less than or equal to 6 cm in transverse diameter. We performed a defect closure with a running suture using barbed suture in a caudal to cranial direction, with tissue bites and inter-suture spacing of 1 cm each. The hernial sac was incorporated into the suturing to reduce possible dead space. After the procedure, intraperitoneal onlay mesh was placed. Seven patients underwent this procedure. The median total operative time was 188 min, and the median time specifically for defect closure was 25 min. There was no seroma, mesh bulge, persisting pain, or hernia recurrence at follow-up. Our proposed technique is simple and can be safely performed with good short-term outcomes.

The development of the human notochord.

The notochord is a major regulator of embryonic patterning in vertebrates and abnormal notochordal development is associated with a variety of birth defects in man. Proper knowledge of the development of the human notochord, therefore, is important to understand the pathogenesis of these birth defects. Textbook descriptions vary significantly and seem to be derived from both human and animal data whereas the lack of references hampers verification of the presented data. Therefore, a verifiable and comprehensive description of the development of the human notochord is needed. Our analysis and three-dimensional (3D) reconstructions of 27 sectioned human embryos ranging from Carnegie Stage 8 to 15 (17–41 days of development), resulted in a comprehensive and verifiable new model of notochordal development. Subsequent to gastrulation, a transient group of cells briefly persists as the notochordal process which is incorporated into the endodermal roof of the gut while its dorsal side attaches to the developing neural tube. Then, the notochordal process embeds entirely into the endoderm, forming the epithelial notochordal plate, which remains intimately associated with the neural tube. Subsequently, the notochordal cells detach from the endoderm to form the definitive notochord, allowing the paired dorsal aortae to fuse between the notochord and the gut. We show that the formation of the notochordal process and plate proceeds in cranio-caudal direction. Moreover, in contrast to descriptions in the modern textbooks, we report that the formation of the definitive notochord in humans starts in the middle of the embryo, and proceeds in both cranial and caudal directions.

Image-Guided Study of Interfraction and Intrafraction Set-up Variability and Margins in Reverse Semi-Decubitus Breast Radiation Therapy

Reverse semi-decubitus (RSD) technique could reduce cardiac dose during breast radiotherapy for patients unable to tolerate breath hold. This study aimed to report the interfraction and intrafraction set-up variability for RSD technique and to determine an appropriate clinical tumor volume (CTV) to planning target volume (PTV) margin to account for motion and positional uncertainties. Twenty-five consecutive patients were prospectively enrolled in the protocol of RSD breast radiotherapy. The prescribed dose was 40 Gy in 15 fractions delivered by opposed tangential field or volumetric arc therapy with 7-mm PTV margin. The pre- and post-fraction cone-beam CT (CBCT) scans were acquired at fractions 1, 4, 7, 8, 11 and 14. CBCT data were matched to planning CT data using (i) chest wall and (ii) clips. Mean displacement (MD), systematic (Σ), and random (σ) translational errors in 3-dimensions (LR: left-right; AP: anterior-posterior; and CC: cranial-caudal) were analyzed. Positive values for LR, AP, and CC pointed at motion in right, anterior, cranial directions, respectively. Body weight and body mass index (BMI) were recorded to examine predictive factors for set-up variability. The CTV to PTV margins were calculated based on the van-Herk formula (2.5Σ + 0.7σ). A total of 300 CBCT scans were analyzed for 25 patients. The population MD, systematic, and random errors based on each of chest wall and clip matches were shown in the Table 1. The calculated interfraction and intrafraction CTV to PTV margins were 8.8/12.9/11.2 and 8.7/13.5/11.4 mm (LR/AP/CC) for the chest wall and clip matches, respectively. A correlation was observed between interfraction setup variability in the AP direction and body weight (R2 = 0.32; p = 0.004) and BMI (R2 = 0.61; p < 0.001). To calculate the AP margin for patients with heavier body weight and higher BMI, we divided the patients into two groups for each median value. The AP margins were 9.2 and 8.4 mm for patients with lighter body weight, and lower BMI, respectively. The AP margins were 11.6 and 10.9 mm for patients with heavier body weight and higher BMI, respectively. This is the first study to determine the PTV margins for interfraction and intrafraction set-up variability for reverse semi-decubitus breast radiotherapy using pre- and post-fraction CBCT scans. A uniform 7-mm PTV margin is insufficient in the absence of CBCT. Table 1 Mean displacement (MD), systematic (Σ) and random (σ) translational errors, and calculated margins in 3-dimensions for chest wall and clip based cone-beam CT versus planning CT matches in reverse semi-decubitus positions (mm).Abstract 272; TableChest wall matchClip based matchInterfractionIntrafractionInterfractionIntrafractionLRMD0.3-0.20.7-0.2Σ1.90.91.80.9σ1.71.11.61.1Margin5.92.95.73.0APMD-2.3-0.5-1.6-0.6Σ3.30.93.61.0σ1.81.41.61.4Margin9.53.410.13.4CCMD0.80.30.40.3Σ2.51.02.60.9σ2.21.52.11.4Margin7.73.58.13.3 Open table in a new tab

Diagnosis of incarcerated intramesosigmoid hernia aided by multiplanar reconstruction images of multidetector computed tomography: a case report

BackgroundInternal hernia is a rare cause of intestinal obstruction, and sigmoid mesocolon hernia is an extremely rare form of this condition.Among sigmoid mesocolon hernias, intramesosigmoid hernia is the least frequent subtype.We described a case of intramesosigmoid hernia through the orifice on the right leaf of the mesosigmoid with an incarcerated ileum of 6 cm in length without strangulation. This case was diagnosed by multidetector computed tomography with multiplanar reconstruction images and treated without resection of the small intestine in a 52-year-old man with characteristic diagnostic images.Case presentationA 52-year-old man suffering periumbilical cramping pain with sudden onset that had persisted for 1 week without recovery was referred to Fukui Katsuyama General Hospital. Multidetector computed tomography revealed small bowel obstruction, and an incarcerated short intestinal loop was revealed by sagittal slices of the multiplanar reconstruction images of the routine study of the left side of the pelvic space. Sagittal multiplanar reconstruction images also showed narrow belt-shaped fluid retention contacting the tip of the incarcerated short loop toward the cranial direction localized in the mesosigmoid. These findings indicated that the fluid and the herniated small bowel were wrapped together in the mesosigmoid, which was characteristic of intramesosigmoid hernia.The patient underwent laparotomy operation 2 days after admission. The ileum, which was approximately 75 cm proximal to the ileocecal junction and herniated into the mesosigmoid through the right leaf, was released without resection. The orifice located in the central part of the right leaf was oval shaped and measured less than 2 cm in diameter. The left leaf of the mesosigmoid was intact. The orifice of the right lobe was closed by suture. The patient showed an uneventful recovery.ConclusionWe report an extremely rare case of incarcerated intramesosigmoid hernia that was diagnosed by multidetector computed tomography with multiplanar reconstruction images. The finding of narrow belt-shaped fluid retention contacting the tip of the incarcerated short intestinal loop is characteristic of intramesosigmoid hernia and will be useful for conclusively differentiating this disease from transmesosigmoid hernia. Although intramesosigmoid hernia is a rare cause of internal hernia, multidetector computed tomography and multiplanar reconstruction images can provide the characteristic findings and proved useful for the precise preoperative diagnosis and treatment of intramesosigmoid hernia.

Dose variability in different lymph node levels during locoregional breast cancer irradiation: the impact of deep-inspiration breath hold.

Aim of the present analysis was to evaluate the movement and dose variability of the different lymph node levels of node-positive breast cancer patients during adjuvant radiotherapy(RT) with regional nodal irradiation (RNI) in deep-inspiration breath hold (DIBH). Thirty-five consecutive node-positive breast cancer patients treated from October 2016 to February 2018 receiving postoperative RT of the breast or chest wall including RNI of the supra-/infraclavicular lymph node levels (corresponding to levelsIV, III, Rotter LN (interpectoral), and some parts of levelII) were analyzed. To evaluate the lymph node level movement, acenter of volume (COV) was obtained for each lymph node level for free-breathing (FB) and DIBH plans. Geometric shifts and dose differences between FB and DIBH were analyzed. Asignificant movement of the COV in anterior(y) and cranial(z) dimensions was observed for lymph node levelsI-II and Rotter lymph nodes (p < 0.001) due to DIBH. Only minor changes in the lateral dimension (xaxis) were observed, without reaching significance for levelsIII, IV, and internal mammary. There was asignificant difference in the mean dose of levelI (DIBH vs. FB: 38.2 Gy/41.3 Gy, p < 0.001) and levelII (DIBH vs. FB: 45.9 Gy/47.2 Gy, p < 0.001), while there was no significant difference in levelIII (p = 0.298), levelIV (p = 0.476), or internal mammary nodes (p = 0.471). Asignificant movement of the axillary lymph node levels was observed during DIBH in anterior and cranial directions for node-positive breast cancer patients in comparison to FB. The movement leads to asignificant dose reduction in levelI and levelII.

High-Speed Fluoroscopy to Measure Dynamic Spinal Cord Deformation in an In Vivo Rat Model.

Although spinal cord deformation is thought to be a predictor of injury severity, few researchers have investigated dynamic cord deformation, in vivo, during impact. This is needed to establish correlations among impact parameters, internal cord deformation, and histological and functional outcomes. Relying on surface deformations alone may not sufficiently represent spinal cord deformation. The objective of this study was to develop a high-speed fluoroscopic method of tracking the surface and internal cord deformations of rat spinal cord during experimental cord injury. Two radio-opaque beads were injected into the cord at C5/6 in the dorsal and ventral white matter. Four additional beads were glued to the surface of the cord. Dynamic bead displacement was tracked during a dorsal impact (130 mm/sec, 1 mm depth) by high-speed radiographic imaging at 3000 FPS, laterally. The internal spinal cord beads displaced significantly more than the surface beads in the ventral direction (1.1-1.9 times) and more than most surface beads in the cranial direction (1.2-1.5 times). The dorsal beads (internal and surface) displaced more than the ventral beads during all impacts. The bead displacement pattern implies that the spinal cord undergoes complex internal and surface deformations during impact. Residual displacement of the internal beads was significantly greater than that of the surface beads in the cranial-caudal direction but not the dorsoventral direction. Finite element simulation confirmed that the additional bead mass likely had little effect on the internal cord deformations. These results support the merit of this technique for measuring in vivo spinal cord deformation.

Blackburne-Peel ratio predicts patients' outcomes after total knee arthroplasty.

Alterations in patellar height and posterior tibial slope (PTS) are frequently measured radiographic parameters associated with postoperative impairments after total knee arthroplasty (TKA). Few studies correlate the clinical outcome of TKA with the radiological indices. Both the modified Insall-Salvati ratio (mISR) and the Blackburne-Peel ratio (BPR) were hypothesised to correlate with the clinical outcome after TKA. A total of 282 computer navigated primary LCS®-TKAs, implanted in our institution from 2008 to 2012, were included. Data (ROM, FJS-12, WOMAC, and revision surgery) were collected independently and prospectively. Patellar height (mISR, BPR), joint-line position, and PTS were measured on pre- and postoperative radiographs. Bivariate and multiple regression analyses were performed. Mean mISR (1.5-1.4) and BPR (0.8-0.6) decreased from preoperatively to 1year follow-up. Mean joint-line shift in a cranial direction was 2mm after TKA implantation. Analysis of dichotomous variables (presence of PB and PPB or not) only showed significantly lower flexion in patients with PPB (p < 0.001). However, multiple regression revealed that BPR was a significant positive independent predictor for FJS-12 (p = 0.016) and flexion (p < 0.001) at 1year follow-up. Postoperative PTS (p < 0.01) and initial patella height (p < 0.001) were both predictive for BPR at follow-up, while the joint-line height was not. The BPR is a useful and reliable radiographic parameter to predict patient outcomes 1year after primary navigated TKA. Lowering the BPR should be avoided, as this may lead to significant restrictions in terms of ROM and PROMs. Level 3.

F164. Visualization of electrical activities of lumbar nerve root and cauda equina by a magnetospinograph system

Introduction There are many cases of multilevel lumbar spinal stenosis and foraminal stenosis, but there is still no neuroelectrophysiological diagnostic method with a high spatial resolution for these conditions. We have been developing a magnetospinograph system which is a supine position-type biomagnetometer equipped with superconducting quantum interference device (SQUID) fluxmeter. We have reported that magnetospinography could noninvasively evaluate the spinal cord and spinal nerve activity by body surface recordings. Methods We used a newly developed 124-channel SQUID biomagnetospinometer system (Kanazawa Institute of Technology, Japan) with a wide sensor area and a suitable curve for lumber lordosis. Neuromagnetic fields of 32 healthy subjects (64 nerves), 22–58 years of age (mean age 41 years), were measured at the surface of the lower back after electric stimuli of the peroneal nerves at the knees. With the use of a unit gain normalized minimum-norm (UGMN) filter method, which is a spatial filtering technique, the direction and intensity of the current source on each reconstruction point was reconstructed, and the conductive direction, distribution, and temporal change of the current source were visualized. Then, the propagation pathway of the estimated electrical currents was superimposed on lumbar spine X-rays. Results We used a newly developed 124-channel SQUID biomagnetospinometer system (Kanazawa Institute of Technology, Japan) with a wide sensor area and a suitable curve for lumber lordosis. Neuromagnetic fields of 32 healthy subjects (64 nerves), 22–58 years of age (mean age 41 years), were measured at the surface of the lower back after electric stimuli of the peroneal nerves at the knees. With the use of a unit gain normalized minimum-norm (UGMN) filter method, which is a spatial filtering technique, the direction and intensity of the current source on each reconstruction point was reconstructed, and the conductive direction, distribution, and temporal change of the current source were visualized. Then, the propagation pathway of the estimated electrical currents was superimposed on lumbar spine X-rays. For all subjects, we could record the nerve action magnetic fields in the lumbar spine after peroneal nerve stimuli. In 44 nerves (68.8%), we could visualize the estimated electrical currents propagating through the surrounding fifth intervertebral foramina and ascending to the cranial direction in the lumbar canal. The conduction velocity of the current source was 40.3–78.8 m/s (mean 56.5 m/s), as calculated from the peak latency. Conclusion Using the magnetospinograph system, we successfully visualized the propagation of estimated neural electric activities in the lumbar spine after peroneal nerve stimuli. This system holds enormous potential for establishing a non-invasive neuroelectrophysiological diagnostic method for the identification of the disordered site in lumbar spinal nerves.

Formirovanie pozvonochnogo kanala v ehmbriogeneze cheloveka

In the study, 29 totally cleared and double-stained human embryos of 7-12 weeks of gestational age and 33series of histological sections of 7-70 mm CRL human embryos were used. At the 5th week of gestation, the vertebrae are presented by mesenchymal condensations around the notochord. In 7 week embryos, separate centers of chondrification are identified in the vertebral primordia. At the end of the embryonic period (8th week of development) due to the fusion of the centers of chondrification, the vertebral primordia are presented by whole cartilaginous structures having a centrum located in front of the spinal cord and two neural processes that span it from two sides. The body of the future vertebrae is located on the ventral side of the spinal cord, the anteroposterior size of which is approximately twice as large as the similar size of the cartilaginous primordium of vertebral body. The neural processes are directed dorsally and cover only 3/4 of the circumference of the spinal cord from both sides. As a result, the vertebral foramen remains open behind and there is no spinous process. The neural arches of all thoracic and upper lumbar vertebrae fuse in fetuses of the 10th week of gestation. At the 10th week of gestation, the centers of ossification appear in the neural processes of C2-Th8. The primary centers of ossification in the ribs appear from the 8th week of embryogenesis. It is established that the fusion of the neural processes behind the spinal cord begins with the lower cervical - upper thoracic vertebrae and then the process spreads in the cranial and caudal directions. Simultaneously with the fusion of the neural processes, a spinous process of the vertebrae is formed. The formation of the spinal canal is completed in 12-week human fetuses. At all stages of development of the vertebral primordia, their close interaction with the notochord is traced. Notochord plays an important role in the morphogenesis of axial structures. The congenital neural tube defect (anencephaly) is combined with the spina bifida and fusion of adjacent vertebral arches.

Microscope and Fiberscope-assisted Subarachnoid-Subarachnoid (S-S) Bypass: A Novel Surgical Technique to Reestablish Cerebrospinal Fluid Flow in Treating Dorsal Spinal Arachnoid Webs, Diagnosed by Cine-MRI.

A "dorsal spinal arachnoid web" is the thickened arachnoid band on the surface of the spinal cord which disturbs the cerebrospinal fluid (CSF) flow, known as a rare cause of thoracic myelopathy. The ideal treatment is controversial because of the risk of readhesion after simple resection of the web. A subarachnoid-subarachnoid bypass is a method to reestablish CSF flow through a silicon tube between the cranial and caudal subarachnoid space. This method is reported to be useful for traumatic syringomyelia, adhesive arachnoiditis, etc. We applied this technique for arachnoid webs with the assistance of a microscope and fiberscope. After a dura incision, the thickened arachnoid web can be seen fluttering within the CSF flow inside the arachnoid space, which partitions the subarachnoid space into cranial and caudal parts. After opening the subarachnoid space and resection of the web under a microscope, the fiberscope is inserted toward the cranial and caudal directions to check for the presence of another arachnoid web. If another web is found, it is penetrated using a guiding wire. Then, a silicone tube is inserted into the cranial and caudal normal subarachnoid space. In this paper, we would like to introduce this technique.

COMPARISON OF A NEW VERESS NEEDLE ENTRY METHOD AND CLASSIC VERESS NEEDLE ENTRY METHOD IN GYNECOLOGIC LAPAROSCOPY: A PROSPECTIVE RANDOMIZED STUDY

Background: To compare cranial 15º angulation of Veres needle to classic Veress needle entry in closed laparoscopic entry in obese patients.&#x0D; Method: Patients with BMI index&gt;30 were divided into two groups. Initial entry into the abdomen in Group 1 (n=29) was performed with the intraumbilical insertion of Veress needle in 90o angle relative to the horizontal plane. In Group 2 (n=31) the Veress needle was placed intraumbilically in a cranial direction, the tip of the needle towards the thoracic cavity, with an angle of 15o to the horizontal plane. Two groups were compared with respect of the operative outcomes.&#x0D; Results: In Group 2, the mean number of Veress needle entries attempt was significantly lower than Group 1 (p=0.01). Time to insertion of the Veress needle was found to be significantly shorter in Group 2 than in Group 1 (p&lt;0.001). While entry failure occurred in 3 patients in Group 1 (10.3%), no failures were monitored in any patients in Group 2 (p= 0.01). Complication rate was significantly lower in Group 2 than in Group 1 (p= 0.03).&#x0D; Conclusion: Placement of Veress needle intraumbilically in a cranial direction at 15°angle to the horizontal plane increases entry success and reduces complications.

Abstract PD2-06: Preoperative diagnosis of sentinel lymph node metastasis using computed tomography lymphography for early breast cancer patients

Abstract Background: Sentinel lymph nodes (SLN) biopsy has been established as a standard of care in the treatment of early breast cancer. This technique represents a minimally invasive, highly accurate method of axillary staging and is an alternative to conventional axillary lymph node dissection. However, an indication of SLN navigation to metastatic disease may lead to misdiagnosis for staging. Recently, SLN identification using computed tomography lymphography (CTLG) has been reported in Japan. This study investigated the value of CTLG for preoperative prediction of SLN status in early breast cancer patients. Patients and method: Between January 2013 and August 2016, 350 breast cancer patients without clinical evidence of lymph node metastasis were treated. On the day before the operation, CTLG was performed using 64-row multidetector helical CT scanner. Patients were placed in a supine position with their arms positioned in a cranial direction with CT guidelineattached to the skin at the axilla. We performed an intradermal injection in the periareolar area, using 4 ml of iopamidolwith 1 ml of local anesthetic. The contrasted lymph route and SLN were identified in reconstructed three-dimensional imaging. The SLN spot was indicated by CT laser light navigator system. We established typical pattern of the lymphography: stain defect of SLN, stagnation of lymphatic route for preoperative diagnosis of metastatic SLN. SLN biopsy was performed using the fluorescence imaging system, Photpdynamic Eye (pde-neo, Hamamatsu Photonics Co., Japan) referring to the point by axillary compression technique by plastic device. Intraoperative pathological analysis of SLN was examined, and an axillary lymph node dissection was performed in patients with SLN metastasis pathologically. Results: The median age of the 350 patients was 59 (range 28 – 90) years old. One patient was male and others were female. CTLG were safely performed in all patients. CTLG could visualize lymphatic route and accurately identify SLN in 336 (96.0 %) and 343 (98.0 %) cases, respectively. Lymphatic routes of CTLG were completely consistent with those of fluorescence imaging. The mean number of SLN identified by CTLG was 1.1. Fifty of 350 patients had metastatic SLN pathologically, and 11 of them had micrometastases of SLNs. The accuracy for metastatic diagnosis of SLN using CTLG without micrometastasis was 84.1 %, sensitivity was 82.1 % and specificity was 84.3 %. The positive predictive value was 40.5 % and negative predictive value was 97.3 %. There were no complications associated with SLN identification. Conclusion: CTLG in SLN biopsy has some advantages in that this method is simple and quite useful for obtaining accurate anatomic images of the SLN, lymph vessels, and tumor. CTLG could select the candidate with truly node negative cases in early breast cancer patients, because it predicts lymph node metastasis preoperatively from natural status of the lymphographic image. Citation Format: Abe H, Teramoto A, Tanaka M, Yamasaki K, Yoneda K. Preoperative diagnosis of sentinel lymph node metastasis using computed tomography lymphography for early breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-06.

Influence of adequate pelvic floor muscle contraction on the movement of the coccyx during pelvic floor muscle training.

[Purpose] Pelvic floor muscle training is a first-line therapy for female stress urinary incontinence. Previous studies have suggested that the coccyx tip moves ventrally and cranially during pelvic floor muscle contraction. The study aimed to elucidate the influence of adequate pelvic floor muscle contraction on coccyx movement. [Subjects and Methods] Sixty-three females (57 patients with stress urinary incontinence and additional 6 healthy volunteers) were enrolled. Using magnetic resonance imaging, coccyx movement was evaluated during pelvic floor muscle contraction and strain. An adequate contraction was defined as a contraction with good Oxford grading scale [≥3] and without inadequate muscle substitution patterns. [Results] Inadequate muscle substitution patterns were observed in 33 participants (52.4%). No significant difference was observed in the movement of the coccyx tip in the ventrodorsal direction between females with and without inadequate muscle substitution patterns. However, a significant increase in the movement of the coccyx tip in the cranial direction was detected in the group without inadequate muscle substitution patterns. Compared to participants with inadequate pelvic floor muscle contraction, those who had adequate pelvic floor muscle contraction exhibited significantly increased cranial movement of the coccyx. [Conclusion] Adequate pelvic floor muscle contraction can produce cranial movement of the coccyx tip.

Arterial Vascularization of the Base of the Brain in Galea (Galea spixii)

Background: Galea (Galea spixii) are rodents which are especially distributed in the northeastern region of Brazil, and have economic importance as their meat is used as a source of protein by the regional population. Currently, they have received attention from researchers in studies involving their morphology. Thus, seeking to contribute information that supports their sanitary management in addition to the lack of literature on their nervous system, our objective was to describe the arterial vascularization of the base of the brain in this species, in order to identify the arterial pattern and arterial circuit behavior, as well as possible variations in these vessels.Materials, Methods &amp; Results: Brains were obtained from 20 animals (10 males and 10 females) aged between 11 and 12 months, obtained from the Wild Animal Multiplication Center (CEMAS) of the Federal Rural Semi-Arid University (UFERSA), under the approval of CEUA/UFERSA (case number 23.091.000653/2014-26 and opinion number 15/2014), euthanized according to anesthetic protocol recommended for rodents (resolution number 714/2002 of the CFMV/ UFERSA) and preserved frozen in a freezer for an average period of 30 days. The animals were thawed and a longitudinal incision was performed in the thoracic region to allow exposure of the aortic arch. Next, they were cannulated in the cranial direction and injected with Noprene Latex “650” stained with water-based white or red pigment. The animals were subsequently fixed in 3.7% aqueous formaldehyde solution for 48 h, and soon after the brain skull cap was dissected and removed, which was then analyzed, photographed and sketched. Of the 20 animals evaluated, 100% presented vertebrobasilar system responsible for encephalic irrigation of the rostral and caudal regions, and anastomosis of the left internal carotid artery was found in only one case (female) (5%), irrigating the rostral region of the encephalon together with the vertebro-basilar system. In the most frequently found arrangement, the unpaired main arteries present at the base of the brain included: ventral spinal, basilar, medial branch of the rostrais cerebral arteries, medial rostral inter-hemisphere; and the pairs: vertebral, cerebellar caudal, middle cerebellar, trigeminal, rostral cerebellar, rostral tectal, caudal cerebral, pituitary, internal ophthalmic, middle cerebral, rostral cerebral, lateral olfactory bulb and internal ethmoid. Arterial circuit formation was observed as being geometrically similar to a complete, closed and elongated hexagon in the caudal-rostral direction, bypassing the mammillary body, the cinereous tuft and the optic chiasm.Discussion: The study of the nervous system, especially on identification of the arteries responsible for supplying the brain is relevant, especially when it comes to a wild species such as in galea considering that little is known about their morphology, and also because it can be used as a model in clinical and surgical studies related to the nervous system. Based on the analyzed animals, we conclude that the arterial vascularization of the base of the brain in galea is type III, similar to the findings in other species of rodents such as in otters and porcupines; and differing from those described for agoutis and mice-moles. The arterial circuit of galea is complete and closed like those described for the agouti and the European beaver, yet differing from that observed for otters and chinchillas which have an open circuit.