Dorsal Nerve Research Articles

(265) The Surgical Anatomy of Clitoral Innervation: A Review of the Current Medical Literature

Abstract Introduction The clitoris is a crucial structure for sexual arousal and orgasm in people with gynecological anatomy. Despite its functional importance, the innervation of the clitoris has historically been understudied. The innervation of the clitoris includes somatic afferents of the dorsal nerve of the clitoris, a branch of the pudendal nerve and sacral plexus, and autonomic afferents of the cavernous nerve, a branch of the inferior hypogastric plexus. Although we have identified these structures, there remains a paucity of research on surgical techniques to avoid clitoral innervation during pelvic surgery, despite the importance of these nerves in gynecological sexual function. Objective This paper aims to summarize the current literature on clitoral innervation with special attention paid to the anatomical locations of nervous structures within the pelvis to inform future pelvic surgeons and reduce sexual side effects related to clitoral nerve damage. Methods We performed a PubMed search from inception through June 14, 2023 utilizing the Medical Subject Headings (MeSH) search terms “(clitor*)) AND (innerv* OR nerv*) AND (surg*)” and imported this search into Covidence software. Included in the literature search were observational studies, clinical trials, review articles, correspondence, and communications, and only articles in English were included. Results An initial abstract screen of 200 articles resulted in 87 articles that were fully screened and 53 articles that were utilized as within the scope of this paper. 45 papers discussed the dorsal nerve of the clitoris, while 15 papers explored autonomic afferents via the cavernous nerve. Fourteen papers discussed both somatic and autonomic innervation to the clitoris. The anatomical location of the dorsal nerve of the clitoris has been tracked in 29 papers, most of which utilize cadaver dissection, with at least six anatomic variations identified. The cavernous nerve’s exact location, however, has not been traced as extensively as has the location of the dorsal nerve of the clitoris, perhaps due to its smaller diameter and shorter length. Additional innervation to the clitoris was proposed in 12 studies as well. Many studies suggested that commonly performed procedures, including midurethral sling placement for stress urinary incontinence, labiaplasty, clitoral hood reduction, clitoroplasty, and urogenital sinus repair may interfere with clitoral innervation if not otherwise modified. Two studies discussed sensory mapping techniques prior to pelvic surgery to account for anatomic variation in clitoral innervation. Conclusions The clitoris is a vastly innervated structure with both somatic and autonomic afferents whose locations and anatomic variations should be considered when performing pelvic surgery. Failure to consider not only the dorsal nerve of the clitoris but the cavernous nerve as well may have consequences that negatively impact clitoral sensitivity, engorgement and erection, orgasmic ability, and overall sexual function. Disclosure No.

(387) Clinical Experience with Malleable Penile Implantation for Salvaging Inflatable Implant Infection

Abstract Introduction Antibiotic irrigation for treating prostheses is commonly believed to be a proper administration for those whose penile implant contracts with infection. However, there is no standard procedure for the irrigation period. Objective As a result, we encounter patients whose sinusoids were ruined from irrigation attempts for over three months. We sought to report an experience of salvaging penile implantation. Methods From 2010 to 2022, eight patients requested salvage penile implantation for treating unsuccessful inflatable implantation elsewhere. They report repeated antibiotic rescuing and wound debridement from 50 to 121 days of hospitalization. The diameter of the glans penis is measured and recorded in mm. Pelvic X-rays were made while the penis was downward and upward. One 44-year-old patient received no further salvaging penile implant because the corporeal sinusoid had too hardly fused to allow the contrast medium injection. The remaining seven received malleable types of penile implants ambulatory under acupuncture-assisted local anesthesia with which a cavernosal block must be performed in addition to a proximal dorsal nerve block, crural block, and peri penile infiltration. In addition, the novel method of glans enhancement was performed unexceptionally. The approach was longitudinal pubic (n=3) and circumferential (n=2). The pain level was assessed on the acupoint needle location or penis property. It was recorded on blood loss amount and operation times. A 32 to 35 ligation was performed at the retro-coronal venous plexus, which is readily identified by glans milking manipulation. A 5cm coroporotomy was made along the 11 or 1 o'clock position of the corpora cavernosa. To minimize the sinusoidal compression, corporal dilatation was made along the dorsal and medial directions distally and dorsolateral proximally. Neither electrocautery nor a suction apparatus was used because of minimal blood loss from manual compression. The water-tight suture was made to the tunic wound, closed continuously with 6-0 nylon with intermittent enhanced suture per centimeter. The overlying fascia layers and skin were finally closed with 6-zero chromic layer by layer. All patients received postoperative pelvic X-rays evidencing the appropriate housing of the cylinder. Sexual satisfaction was followed up yearly by the INTERNET. Results The operation time was 2.5 to 4.5 hours, and the blood loss was negligible. The pain level was more substantial at the arm acupoint at 71.4% (5/7). It was 11 to 61 months from the first and salvaging prosthesis implantation. The diameter of the glans increased from 26.0±2.3 mm to 35.3±2.2 mm. Four patients report couple satisfaction, whereas the remaining one feels male self-esteemed and female acceptable. All patients reported partial sinusoidal erection and no soft glans syndrome eventually. Conclusions A malleable penile prosthesis is beneficial for salvaging inflatable prosthesis infection. An anatomy-based corporeal dilation seems a proper way to minimize sinusoidal compression, although a larger sample size and longer follow-up are mandatory. The glans enhancement was unexceptionally attainable. Disclosure No.

Comparison of Neurovascular Structures at Risk During Ankle Arthroscopy: A Cadaveric Study.

Arthroscopy has become increasingly common for diagnosis and treatment of ankle joint pathology. The four most common portals used for ankle arthroscopy are the anteromedial, anterolateral, posteromedial, and posterolateral. Anatomy of neurovascular structures along the ankle can significantly vary. The distance of neurovascular structures was compared with anatomical landmarks of ankle arthroscopic portals to verify safe zones for scope insertion. Twenty-six fresh frozen cadavers were used, with dissection of standard anatomical landmarks and neurovascular structures. Portals were made and verified with a 2.7-mm arthroscope. Significant differences were found in mean distances between anatomical landmarks except for the peroneus tertius tendon to the intermediate dorsal cutaneous nerve (P = .181; all others, P < .0001). In quantifying a scope space, the anteromedial and anterolateral portals had the largest margin of error at 0.82 cm and 1.04 cm, respectively. The saphenous nerve and vein were an average of 1.39 cm and 1.23 cm, respectively, from the anteromedial portal. The peroneus tertius tendon was an average of 0.23 cm from the intermediate dorsal cutaneous nerve. The tibialis anterior tendon was an average of 1.10 cm lateral to the medial gutter; the peroneus tertius tendon, 1.31 cm medial to the lateral gutter; and the Achilles tendon, 0.94 and 0.73 cm from the medial and lateral gutters, respectively. Among common ankle arthroscopic approaches, the anterolateral portal features the highest anatomic variability. These data support the standard protocol of beginning with the anteromedial portal to facilitate visualization of lateral-sided anatomy before anterolateral portal placement.

Ultrasound-guided injection of the ankle joint: cadaveric investigation of the anterolateral approach.

Injection of the tibiotalar (TT) joint is commonly performed in clinical practice under ultrasound (US) guidance using an anteromedial approach. However, in some patients, this approach may be technically challenging due to post-traumatic and/or degenerative bony changes. Therefore, the aim of this cadaveric investigation was to demonstrate the feasibility of the ultrasound-guided (USG) injection of the ankle joint via the anterolateral sulcus (ALS) by confirming the dye placement/distribution inside the articular space. Likewise, the safety of the procedure has also been evaluated by measuring the distance between the needle and the intermediate dorsal cutaneous nerve of the foot. A descriptive laboratory study with eight embalmed cadaveric ankles using the Fix for Life (F4L) method was performed at the setting of an academic institution. The interventional technique and the related anatomical findings were illustrated. During the injection, the needle was advanced into the TT joint through the ALS under US guidance, i.e., in-plane anterior-to-posterior approach. With the objective to confirm its correct placement, the needle was kept in situ and-to demonstrate the location of the dye inside the articular space-all eight ankles were injected with 3 mL of green color dye. Thereafter, a layer-by-layer anatomical dissection was performed on all four cadavers. The position of the needle's tip within the ALS was confirmed in all specimens. Accurate placement of the dye inside the articular space of the ankle was confirmed in seven of the eight cadaveric ankles, with 87.5% of accuracy. Herewith, unintentional spilling of the dye within the superficial soft tissues was reported in two of the eight ankles (25.0%). The mean distance between the needle and the intermediate dorsal cutaneous nerve of the foot, measured in all eight procedures, was 3 cm. USG injection of the ALS using the in-plane, anterior-to-posterior approach can accurately place the injectate inside the articular space. This cadaveric investigation described the accuracy and potential pitfalls of USG injection of the ankle via the anterolateral approach which represents an alternative technique in patients with reduced accessibility of the anteromedial recess due to degenerative and/or post-traumatic bony changes.

ScRNA-seq analysis of cells comprising the amphioxus notochord

Cephalochordates occupy a key phylogenetic position for deciphering the origin and evolution of chordates, since they diverged earlier than urochordates and vertebrates. The notochord is the most prominent feature of chordates. The amphioxus notochord features coin-shaped cells bearing myofibrils. Notochord-derived hedgehog signaling contributes to patterning of the dorsal nerve cord, as in vertebrates. However, properties of constituent notochord cells remain unknown at the single-cell level. We examined these properties using Iso-seq analysis, single-cell RNA-seq analysis, and in situ hybridization (ISH). Gene expression profiles broadly categorize notochordal cells into myofibrillar cells and non-myofibrillar cells. Myofibrillar cells occupy most of the central portion of the notochord, and some cells extend the notochordal horn to both sides of the ventral nerve cord. Some notochord myofibrillar genes are not expressed in myotomes, suggesting an occurrence of myofibrillar genes that are preferentially expressed in notochord. On the other hand, non-myofibrillar cells contain dorsal, lateral, and ventral Müller cells, and all three express both hedgehog and Brachyury. This was confirmed by ISH, although expression of hedgehog in ventral Müller cells was minimal. In addition, dorsal Müller cells express neural transmission-related genes, suggesting an interaction with nerve cord. Lateral Müller cells express hedgehog and other signaling-related genes, suggesting an interaction with myotomes positioned lateral to the notochord. Ventral Müller cells also expressed genes for FGF- and EGF-related signaling, which may be associated with development of endoderm, ventral to the notochord. Lateral Müller cells were intermediate between dorsal/ventral Müller cells. Since vertebrate notochord contributes to patterning and differentiation of ectoderm (nerve cord), mesoderm (somite), and endoderm, this investigation provides evidence that an ancestral or original form of vertebrate notochord is present in extant cephalochordates.

Schwannoma of the Nose at the Keystone Area in Relation to the Dorsal Nasal Nerve.

Schwannoma of the Nose at the Keystone Area in Relation to the Dorsal Nasal Nerve.

Analgesia for Infant Circumcision: Eutectic Mixture of Local Anesthetic (EMLA) Cream versus Dorsal Penile Nerve Block using Bupivacaine

Context: Circumcision is a painful procedure; thus, analgesia for neonatal circumcision is advocated for every male infant, and its use is considered essential by the American Academy of Pediatrics. Aim: This study aimed to compare the analgesic, hemodynamic effects, and complications of an eutectic mixture of a local anesthetic cream versus dorsal penile nerve block using bupivacaine for infants coming for circumcision. Materials and Methods: This was a prospective randomized interventional study involving 64 infants scheduled for circumcision at the Jos University Teaching Hospital. Infants were randomized into one of two groups through allocation concealment technique. Group I received dorsal penile nerve block with plain bupivacaine 0.5 mL/kg of 0.25%, while group II received 1 g of an eutectic mixture of a local anesthetic cream (EMLA). Circumcision started 5 minutes after penile block for group I and 1 hour after EMLA cream application for group II. Pain levels using CRIES scale, hemodynamic parameters, duration of surgery, and postoperative complications were noted and documented. Data were analyzed using SPSS version 23. A P value of less the 0.05 was considered statistically significant. Results: The study groups were comparable in demographic characteristics (P = 0.054). Less infants had CRIES scores of &gt;4 in the DPNB group up to 2 hours postoperative period. Hemodynamic parameters were within normal ranges but higher in the EMLA group. No complication was noted in both study groups. Conclusion: Dorsal penile nerve block with bupivacaine provided better analgesia in infants undergoing circumcision than EMLA.

Evolving types of pudendal neuromodulation for lower urinary tract dysfunction.

Sacral neuromodulation and posterior tibial nerve stimulation for lower urinary tract dysfunction (LUTD) and overactive bladder yield good and reliable results. However, neuromodulation research is continuously evolving because there is still need for more patient-friendly treatment options in the therapeutic management of LUTD. Pudendal neuromodulation (PNM) has been emerging as a promising alternative treatment option for the last few decades. The aim of this study is to review the current state of the art of PNM. A wide literature search was conducted in the field of PNM using Medline through the PubMed database and Elsevier using the Scopus database; a critical review of the results was then carried out. PNM has been studied in its various possible aspects: percutaneous PNM, transrectal/transvaginal PNM, and both percutaneous and transcutaneous dorsal genital nerve stimulation. Each technique was found to result in promising improvements in different clinical outcomes, with some trials reporting even better results than sacral neuromodulation. As a result of a comparison between the various PNM techniques with both sacral neuromodulation and posterior tibial nerve stimulation, we think that PNM should be seen as seriously promising, and we believe it will expand the treatment options for overactive bladder. Even though several studies accordingly showed PNM to be safe and effective, a systematic review and meta-analysis were not feasible. PNM in its various techniques is a promising treatment for LUTD. Nevertheless, further research is needed to include it in treatment algorithms.

Acute suppression of lower limb spasm by sacral afferent stimulation for people with spinal cord injury: A pilot study.

Lower limb spasm and spasticity may develop following spinal cord injury (SCI), causing hyper-excitability and increased tone, which can impact function and quality of life. Pharmaceutical interventions for spasticity may cause unwanted side effects such as drowsiness and weakness. Invasive and non-invasive electrical stimulation has been shown to reduce spasticity without these side effects. The aim of this study was to investigate the effect of sacral afferent stimulation (SAS), through surface electrical stimulation of the dorsal genital nerve (N=7), and through implanted electrodes on the sacral afferent nerve roots, on lower limb spasm and spasticity (N=2). Provoked spasms were interrupted with conditional SAS, where stimulation commenced following a provoked spasm, or unconditional stimulation, which was applied continuously. Conditionally and unconditionally applied SAS was shown to suppress acute provoked spasms in people with SCI. There was a statistically significant reduction in area under the curve of quadriceps electromyography during acute spasm with SAS compared to a control spasm. These results show that SAS may provide a safe, low-cost method of reducing acute spasm and spasticity in people living with SCI. SAS through implanted electrodes may also provide an additional function to sacral nerve stimulation devices.

A Rare Cause of Winged Scapula in Two Male Adolescents: Dorsal Scapular Nerve Neuropathy

A Rare Cause of Winged Scapula in Two Male Adolescents: Dorsal Scapular Nerve Neuropathy

Evaluation of the efficacy of pulsed radiofrequency therapy in patients with lumbosacral radicular pain: An analysis of single-center data.

Lumbosacral radicular pain (LRP) is one of the most common causes of neuropathic pain. This pain often arises from inflammation in the dorsal root ganglia (DRG) or spinal nerves. Despite various treatment modalities, success rates are not very high in chronic LRP cases. Pulsed radiofrequency (PRF) therapy, frequently applied to the DRG, is widely used, but its effectiveness is often questioned in various studies. The primary aim of our study is to evaluate the effectiveness of PRF treatment in 154 patients. Patients with LRP for longer than 3 months, treated with PRF, were included in this study. To assess the efficacy of PRF treatment, numerical rating scale (NRS) scores were evaluated at the 4th-week and 6th-month follow-ups. The NRS scores were significantly lower at the 4th-week and 6th-month follow-ups compared to pre-treatment levels (p<0.001). However, there was no significant difference between the mean NRS scores at the 4th week and 6th month. Success in interventional pain procedures is often considered as at least a 50% reduction in pain scores. The success rate for PRF treatment for LRP in the literature varies between 30% and 60%, which is similar to our findings at the 4th week and 6th month. PRF treatment is widely used due to its low side-effect profile and cost-effectiveness in the long term. There is no fully standardized practice regarding procedural aspects, such as the duration of the application, and prospective studies with larger participation are needed.

Minimally invasive subtalar joint and talonavicular joint preparation for hindfoot arthrodesis: A Cadaveric study evaluating structures at risk

Minimally invasive surgery (MIS) is growing in popularity due to smaller incisions, faster recovery times with less post-operative pain, and measurable decreases in morbidity. Our center performed an MIS hindfoot joint preparation about the talonavicular and subtalar joints and defined structures at risk in order to make this procedure more reproducible. Using ten fresh frozen cadaver limbs, we created a medial and lateral portal for talonavicular joint (TN) access, and an additional portal for subtalar joint (STJ) access to prepare the subtalar joint. After denuding the aforementioned joints of cartilage, the specimens were dissected to identify nearby anatomical structures. We documented the position of the peroneal sheath and sural nerve relative to the STJ portal, and the position of the dorsalis pedis artery (DP), medial dorsal cutaneous nerve (MDCN), extensor hallucis longus (EHL), extensor digitorum longus (EDL), tibialis anterior (TA), and tibialis posterior (TP) tendons relative to the TN portals. The average distance of the sural nerve and the peroneal sheath from the STJ portal was 34.21 mm and 14.12 mm respectively. The average distance of the DP, MDCN, and deep peroneal nerve from the medial and lateral TN portals were 13.31 mm, 11.54 mm, and 17.14 respectively. No neurovascular structures were transected throughout joint preparation. To our knowledge this is the first study looking into structures at risk for this specific procedure.

Ultrasound-Guided Dorsal Penile Nerve Block in Children: An Anatomical-Based Observational Study of a New Anesthesia Technique.

Dorsal penile nerve block stands out as one of the commonly employed regional anesthetic techniques in children. Despite the large body of experience, failure rates are still significant. We included 20 children (median (SD) age of 73 (31) months) scheduled for circumcision without general anesthesia and secondary airway manipulation in a consecutive case series. Under ultrasound guidance and utilizing an in-plane needle guidance technique, the dorsal penile nerve block was administered with slight sedation, and spontaneous respiration was maintained in all cases. To investigate the underlying anatomy for dorsal penile nerve blockade, we dissected three cadavers. The primary study endpoint was the success rate of surgical blockade, meaning that the surgical procedure could be performed without additional general anesthesia and invasive airway management. The secondary endpoint was the requirement of analgesics until discharge from the post-anesthesia care unit. The primary endpoint was successfully met in all patients according to our strict definition without additional general anesthesia or airway manipulation. In addition, no child received analgesics until discharge from the recovery room. The anatomical investigation clarified the specific anatomy as baseline knowledge for an ultrasound-guided dorsal penile nerve blockade and enabled successful performance in 20 consecutive children where penile surgery was possible in light sedation without additional airway manipulation.

Pediatric ultrasound-guided dorsal penile nerve block and sedation in spontaneous breathing: a prospective observational study.

Worldwide, one of the most common surgical procedures in the pediatric population is circumcision. There is no consent on the best anesthesiologic approach. This study aimed to investigate ultrasound-guided dorsal penile nerve block (DPNB) plus sedation in spontaneous breathing as a time-saving, safe, effective, and opioid-sparing technique. The primary outcome was the assessment of the time from the end of surgery and the discharge to the post-anesthesia care unit. Secondary outcomes were to evaluate the cumulative dosages of opioids, differences in pain levels between the two groups, and complications at the awakening, 4 h and 72 h after surgery, respectively. This was a prospective study with a retrospective control group, approved by the Friuli-Venezia Giulia Ethics Committee. Children in the intervention group received an ultrasound-guided DPNB under sedation and spontaneous breathing. With the probe positioned transversally at the base of the penis using an in-plane approach with a modified technique, local anesthetic was injected under the deep fascia of the penis. We recruited 70 children who underwent circumcision at the University Hospital of Udine, Italy, from 1 January 2016 to 1 October 2021: 35 children in the ultrasound-guided DPNB group and 35 children in the control group. Children who received ultrasound-guided DPNB had a statistically significant lower time to discharge from the operating room, did not require mechanical ventilation, maintained spontaneous breathing at all times, received fewer opioids, had lower mean intraoperative arterial pressures, and lower pain levels immediately after surgery. Ultrasound-guided DPNB associated with sedation and spontaneous breathing is a time-saving, opioid-sparing, safe, and effective strategy for the management of intraoperative and postoperative pain in children undergoing circumcision.Clinical trial registration: ClinicalTrial.gov (NCT04475458, 17 July 2020).

A novel nerve block technique for nail surgery.

In pediatric patients, nail unit anesthesia is frequently required for procedures including matrixectomy or nail avulsion. However, nail unit anesthesia is very painful and requires a significant amount of time to take complete effect, causing a great deal of distress for most pediatric patients. By targeting the palmar and dorsal digital nerves in the distal part of the fingers, our method enables fast, simple, and less painful anesthesia.

Efficacy of adjuvant dexmedetomidine on penile block for pediatric hypospadias repair

The management of postoperative pain, particularly in younger children, presents a challenge due to their limited ability to articulate the intensity of pain, lower pain threshold, and restricted availability of approved analgesics for pediatric use. Peripheral nerve blocks may be favored over neuraxial blocks because they allow quicker mobilization after surgery. The present study aims to investigate the potential impact of adding dexmedetomidine to a local anesthetic (bupivacaine) on the analgesic efficacy in dorsal penile nerve block in hypospadias repair surgery. In this prospective double-blinded clinical trial, 50 children aged between 6 months and 6 years old undergoing hypospadias repair surgery participated. Analgesia was administered through a dorsal penile nerve block (DPNB) at the end of surgery. Participants were divided into two groups; one received bupivacaine alone, and the other received dexmedetomidine and bupivacaine in DPNB. Pain and sedation levels were assessed with FLACC score and MOAA/S score, respectively, at 0,1,2 and 4h after surgery. Vital signs and adverse effects were also recorded, including hemodynamic changes, nausea, and vomiting. There was no statistically significant difference in demographic variables. As illustrated in Figure, the median of FLACC score in group BD was significantly lower compared to group B at every measured time point. MOAA/S score was significantly lower in group BD than in group B (p<0.001), indicating a higher sedation level. None of the participants in either group experienced any adverse effect except for vomiting, which was not statistically significant (8% in group B vs. 4% in group BD, p>0.999). Several studies have documented the supplementary analgesic properties of dexmedetomidine when used in conjunction with local anesthetic during various surgical procedures and nerve blocks. The present study provides evidence for the additional analgesic efficacy of dexmedetomidine and bupivacaine in the context of dorsal penile nerve block during hypospadias repair surgery while not yielding any significant adverse outcomes. Although the patients in our study were monitored for 4h in the postanesthesia care unit (PACU), conducting a more comprehensive assessment of patients is advisable. The findings of our study indicate that incorporating dexmedetomidine alongside bupivacaine in dorsal penile nerve block during hypospadias repair surgery may lead to enhanced management of postoperative pain. The lack of adverse effects implies it may be a potentially safe supplementary pain reliever for surgical procedures.

Intraoperative Monitoring of the External Urethral Sphincter Reflex: A Novel Adjunct to Bulbocavernosus Reflex Neuromonitoring for Protecting the Sacral Neural Pathways Responsible for Urination, Defecation and Sexual Function.

Intraoperative bulbocavernosus reflex neuromonitoring has been utilized to protect bowel, bladder, and sexual function, providing a continuous functional assessment of the somatic sacral nervous system during surgeries where it is at risk. Bulbocavernosus reflex data may also provide additional functional insight, including an evaluation for spinal shock, distinguishing upper versus lower motor neuron injury (conus vs. cauda syndromes) and prognosis for postoperative bowel and bladder function. Continuous intraoperative bulbocavernosus reflex monitoring has been utilized to provide the surgeon with an ongoing functional assessment of the anatomical elements involved in the S2-S4 mediated reflex arc including the conus, cauda equina and pudendal nerves. Intraoperative bulbocavernosus reflex monitoring typically includes the electrical activation of the dorsal nerves of the genitals to initiate the afferent component of the reflex, followed by recording the resulting muscle response using needle electromyography recordings from the external anal sphincter. Herein we describe a complementary and novel technique that includes recording electromyography responses from the external urethral sphincter to monitor the external urethral sphincter reflex. Specialized foley catheters embedded with recording electrodes have recently become commercially available that provide the ability to perform intraoperative external urethral sphincter muscle recordings. We describe technical details and the potential utility of incorporating external urethral sphincter reflex recordings into existing sacral neuromonitoring paradigms to provide redundant yet complementary data streams. We present two illustrative neurosurgical oncology cases to demonstrate the utility of the external urethral sphincter reflex technique in the setting of the necessary surgical sacrifice of sacral nerve roots.

Abstract 18058: Dorsal Root Ganglion Nerve Block Causing Reverse Takotsubo Cardiomyopathy

A 65-years-old female presents to the emergency room after C2 dorsal root ganglion nerve block for cervicogenic headaches, where intraoperatively she became hypotensive and unresponsive with sinus tachycardia to the 140s. She required brief intubation and intravenous vasopressors for resuscitation and was quickly extubated with complete neurologic recovery within hours of presentation. Her vital signs were within normal limits. She had no clinical signs of heart failure on exam. Laboratory values were within normal limits except for elevated hs- troponin which peaked at 1136ng/L. Her EKG showed nonspecific ST changes and T-wave inversion in the high lateral leads. She underwent transthoracic echocardiogram and was found to have basal to mid inferior wall and inferoseptum akinesis with reduced left ventricular ejection fraction of 35-40%. She was initially asymptomatic, but six hours after presentation developed radiating left arm pain then crushing chest and throat pain, with an uptrend in her troponins to 6539, without dynamic EKG changes. She was urgently taken to the cath lab and was found to have clean coronaries, and ventriculography was performed with findings consistent with reverse takotsubo. She was started on low dose beta blockers and ARBs with complete resolution of symptoms. Reverse takotsubo is a rare variant of takotsubo cardiomyopathy, where basal and midventricular segments of the left ventricle are akinetic, with the majority of patients recovering systolic function within months. This condition is frequently triggered by an intense trigger. To our knowledge, this is the first described case of a high-cervical nerve block precipitating takotsubo.

Characterisation and Regeneration of Diopatra claparedii Nervous System

Diopatra claparedii has the potential to serve as an animal model for Neurodegenerative Disease (ND) studies due to its complete nervous system and regenerative ability. However, the characteristics of the nervous system in intact D. claparedii and during the regeneration process are still unknown. In this study, the intact samples were fixed with Hematoxylin and Eosin (H&amp;E) staining for characterisation. Amputated samples were let to regenerate for 60 days with a 20-day interval before histology assessment. The major findings suggested that the intact D. claparedii’s nervous system is built by an anterior dorsal brain and ventral nerve cord, which is segmentally ganglionated. Histology also revealed that the nervous system of regenerated samples on day 60 differs morphologically in terms of brain size. The presence of the brain and ventral nerve cord validates that D. claparedii’s nervous system resembles the nervous system organisation in humans. Thus, it is potentially suitable for further investigation of neurodegenerative studies.

Utilizing an ultrasound guided 5-in-1 trigger point and hydrodissection technique for interscapular mid-thoracic myofascial pain: A retrospective review

Poor posture can lead to excessive strain of the neck and upper back musculature, leading to irritation of the dorsal scapular nerve (DSN) and spinal accessory nerve (SAN). A 5-in-1 trigger point technique has been described that specifically target trapezius, rhomboids, levator scapulae, SAN and DSN in a single percutaneous injection. We modified the technique to include hydrodissecting the DSN and SAN to provide further pain relief from possible nerve entrapments. Our retrospective review revealed that the modified 5-in-1 technique is a safe and effective way to address medial periscapular pain, often seen with anterior head carriage and upper crossed syndrome. Patients who received the modified 5-in-1 technique had statistically significant pain relief, allowing them to participate in rehabilitation programs.