Inferior Trunk Research Articles

Acute Effect of Whole-Body Vibration on Trunk Endurance and Balance in Obese Female Students: Randomized Controlled Trial.

Background and Objectives: Compared to other subjects, obese people have inferior trunk muscle endurance and balance. A modern method of neuro-muscular training called whole body vibration (WBV) may improve trunk muscle endurance and balance. This study evaluates the impact of a 4-week WBV program on trunk endurance and balance in obese female students. Materials and Methods: Sixty participants from 18 to 25 years of age and with BMI values ≥ 30 were randomly distributed into two equal groups: Group A (WBV group), who received 4 min of WBV, and Group B (sham WBV group), who received WBV with a turn-off device. The training was conducted two days/week for six weeks. Trunk endurance was evaluated using the Sorensen Test (ST) and Trunk Flexor Endurance Test (TFET). The Single-Leg Test (SLT) was used to assess static balance, while the Biodex Stability System measured dynamic balance. Results: The current study demonstrated no significant differences (p > 0.05) in pre-treatment variables between Groups A and B. Post-treatment, Group A showed a significantly higher duration of the Sorensen test, TFET and SLS than Group B (p < 0.001). Moreover, Group A showed significantly lower dynamic balance (p < 0.001) than Group B. Conclusions: WBV has a short-term effect on trunk endurance and balance in obese female students. WBV can be added to the rehabilitation program for obese subjects with deficits in trunk endurance and balance.

Epithelioid Angiosarcoma: A Diagnostic Dilemma with Clinically and Histopathologically Overlapping Features

Cutaneous angiosarcoma is a rare malignancy of endothelial cell origin that commonly presents in the head and neck region of elderly individuals and is known for high rates of lymph node metastasis and mortality. There is significant variability in the histopathologic features, and immunohistochemistry is necessary to help differentiate epithelioid angiosarcoma from lesions it may clinically mimic. Here, we report a rare case of poorly differentiated epithelioid angiosarcoma on the trunk initially diagnosed as poorly differentiated squamous cell carcinoma (SCC) on shave biopsy. A 56-year-old man presented for a full-body skin examination significant for a 5.6 x 2.8 mm brown-black macule on the left superomedial posterior trunk and a 5.0 x 2.7 mm pink, ulcerated papule on the right inferior posterior trunk. On histopathology, one lesion was found to be melanoma in situ, and the other showed ulcerated and infiltrative, poorly differentiated SCC. Post-excision histologic analysis of the right inferior back lesion revealed tumor cells immunoreactive to vimentin, ERG, and CD31 (PECAM-1). These findings suggested that the lesion previously diagnosed as SCC was an invasive, poorly differentiated epithelioid angiosarcoma. The patient underwent 40 sessions of radiotherapy. Epithelioid angiosarcoma occurring outside of the conventional epidemiologic profile is believed to portend higher mortality rates. This case highlights the importance of thorough clinical evaluation and appropriate histopathologic diagnosis of an aggressive neoplasm unlikely to present in this location. Further studies are required to explore potential risk factors, effective treatments, and long-term outcomes in patients with epithelioid angiosarcoma.

Different anatomical variations in the anterior segment of the right upper lung

During a routine physical examination three years ago, a 47-year-old woman received a diagnosis of a nodule in her right upper lung. Since then, she has been regularly attending outpatient clinic appointments for follow-up. Over time, the nodule has shown gradual growth, leading to a suspicion of lung cancer. Through the use of enhanced CT imaging, a three-dimensional reconstruction was performed to examine the bronchi and blood vessels in the patient’s chest. This reconstruction revealed several variations in the anatomy of the anterior segment of the right upper lobe. Specifically, the anterior segmental bronchus (B3) was found to have originated from the right middle lung bronchus. Additionally, the medial subsegmental artery of the anterior segmental artery (A3b) and the medial segmental artery (A5) were observed to share a common trunk. As for the lateral subsegmental artery of the anterior segmental artery (A3a), it was found to have originated from the right inferior pulmonary trunk. Furthermore, the apical subsegmental artery of the apical segmental artery (A1a) and the posterior segmental artery (A2) were found to have a shared trunk.

408 Nerve to Subclavius for Neurotization Procedures: An Anatomical Feasibility Study

INTRODUCTION: Injuries to the inferior trunk (IT) of the brachial plexus and its components can be debilitating. As such injuries are prioritized by surgeons during repair, an additional nerve transfer is considered. METHODS: 13 adult cadavers (26 sides) underwent dissection of the nerve to subclavius and proximal brachial plexus. Once the nerve was isolated from origin to termination, the C8 and T1 roots and IT were identified. The distal end of the nerve to subclavius was transected and swung to these roots and the IT. Once the nerves to subclavius were transposed and in a tension-free manner, the length of excess nerve following being brought to each of these nerves was measured. RESULTS: A nerve to subclavius originated from the superior trunk and traveled anterior to the middle and inferior trunks on all sides. The mean diameter of the nerve to subclavius was 0.8 mm and the mean length was 57 mm. After cutting the nerve to subclavius at its entrance into the subclavius muscle, the distal nerve could be transferred tension free to the IT of the brachial plexus and T1 ventral ramus on all sides. The distal nerve to subclavius reached the T1 ventral ramus with an average of 18 mm of additional length and to the C8 ventral ramus with an average of 19 mm. The nerve also could be transferred to the IT of the brachial plexus with an average of 20 mm of additional length. The nerve to subclavius was found to have approximately 3,000 axons. CONCLUSIONS: To our knowledge, use of the nerve to subclavius has previously not been used for nerve transfer procedures. Based on our cadaveric study, this often-overlooked nerve can be easily transposed to other regional nerves such as the IT of the brachial plexus.

Further investigation of the lateral approach for the resection of Knosp grade 4 pituitary adenomas in endoscopic endonasal surgery.

The authors performed a further in-depth study of the lateral compartment of the cavernous sinus (LCCS) by the endoscopic endonasal approach to improve the safety and efficacy of the lateral approach for the removal of Knosp grade 4 pituitary adenomas (KG4PAs). Twenty-three cadaveric specimens were used for endoscopic endonasal dissection, and the LCCS was exposed to observe the neurovascular and fibrous structures within. A subclassification of the lateral approach based on further knowledge of the LCCS was proposed and used to resect 86 KG4PAs, and the surgical outcomes of these cases were reviewed. Type A KG4PAs represent tumor that was mainly distributed in the posterosuperior and superolateral compartments, type B KG4PAs represent tumor that was mainly distributed in the anteroinferior compartments, and type AB KG4PAs represent tumor that extended into each compartment with characteristics of types 4A and 4B. The authors identified multiple fibers that anchored the horizontal segment of the internal carotid artery (ICA) to the abducens nerve. The fibers, the sympathetic nerve, and the inferior lateral trunk form a partition-like structure in the LCCS named the abducens nerve-ICA complex (AIC), and the LCCS can be divided into the superolateral and inferolateral compartments by the AIC. Accordingly, the lateral approach was subclassified into the lateral superior (LS) approach and the anterior inferior (AI) approach. The LS approach was mainly used to resect type A KG4PAs, whereas the AI approach was used to resect type B KG4PAs, and a combination of the two was used to resect type AB KG4PAs. The gross-total, subtotal, and partial resection rates were 81.4%, 12.8%, and 5.8%, respectively. The numbers of cases of postoperative transient cranial nerve palsy, postoperative permanent cranial nerve palsy, ICA injury, and CSF leakage were 6 (6.9%), 2 (2.3%), 1 (1.2%), and 1 (1.2%), respectively. This study revealed that the LCCS is divided by the AIC into the superolateral and inferolateral compartments, avoiding the misconception that the LCCS has vertical communication. Therefore, the lateral approach was subclassified into the LS approach and the AI approach for the resection of KG4PAs, which allowed a high gross-total resection rate with acceptable safety in the surgical treatment of KG4PAs.

Anatomical variations and coding of the intra-trunk pathways in the thoracodorsal nerve

Aim. To study anatomical variations of the intra–trunk pathways in the thoracodorsal nerve bundles and to develop a system for their coding.Materials and methods. After fixation in a 2% solution of acetic acid using the MBS-10 stereomicroscope, we performed macro- and microscopic intra-trunk dissection of thoracodorsal nerve bundles in 121 specimens obtained from 105 corpses of males and females who died at the age of 40–97 years. Using the obtained findings, we compiled a database in the MS Excel 12.0 software and determined the number of anatomical variations in absolute and relative (% from 121 specimens) units.Results. The study revealed that the thoracodorsal nerve is a mixed nerve, which consists of 1 motor and 1– 3 sensory bundles that variously pass through the spinal nerves, trunks, and the axillary nerve with the formation of 20 intra-trunk pathways. In 77% of cases, sensory bundles arising from the thoracodorsal nerve pass through the posterior bundle, the posterior division, the middle trunk, and the C7 spinal nerve or the inferior trunk and the C8 spinal nerve. In 22% of cases, the thoracodorsal nerve has one or, rarely, two duplicate sensory pathways besides the main one. In 93% of cases, the motor bundle to the thoracodorsal nerve passes through the C7 spinal nerve and the middle trunk, the posterior division, and the posterior bundle. Coding the anatomical variations of the intra-trunk pathways in the direction of sensory bundle «posterior bundle → posterior division → trunk → spinal nerve; motor bundle ← posterior bundle ← posterior division ← trunk ← spinal nerve allows to briefly yet clearly and fully display the morphological diversity of the nerve anatomy.Conclusion. The identified anatomical variations of the intra-trunk pathways can be useful in the diagnosis of injuries and diseases. They expand indications for the use of spinal nerves, trunks of the brachial plexus, and the thoracodorsal nerve in reconstructive surgery.

Anatomical distribution and clinical significance of middle cerebral artery M2 segment vessel occlusions and its cortical branches in acute ischaemic stroke patients

BackgroundCharacterisation of anatomical distribution and the clinical impact of middle cerebral artery M2 (MCA-M2) segment occlusion and its subsequent cortical branches (CBs) in acute ischaemic stroke patients (AIS).MethodsRetrospective, monocentric study...

Study of Microsurgical Anatomy of Middle Cerebral Artery in Human Cadaveric Brain

ABSTRACT Background: Micro-dissection of cadaver specimens is the base, on which our knowledge of the intricate anatomy of the human brain. Microsurgical anatomy of middle cerebral artery (MCA) is of particulate interest to neurosurgeons as it is the largest and most complex arterial system of the brain. Although various studies have been done on MCA, no such study has been done taking into consideration large sample size of the Indian population. This study will be advantageous in improving knowledge of MCA and its variations. This will prove useful for neurosurgeons in performing microsurgeries. Objective: A study of the microsurgical anatomy of the MCA in human cadaveric brain; comparison of the findings with the existing studies and implication of these finding in micro-neurosurgical procedures. Materials and Methods: Sixteen formalin-fixed cadaveric brains, that is, 32 vessels from its origin from the internal cerebral artery to M1 segment with respect to diameter, length and branching pattern were studied under high magnification (operating microscope) and the data compared with literature. Results: The mean length of M1 was 24.1 ± 11 mm with the outer diameter of 3.1 ± 08 mm. An average number of perforators pre-bifurcation was 7 and post-bifurcation was 3. The pattern of branching of the main trunk was bifurcation (70%), trifurcation (20%) and tetrafurcation (10%), and amongst this, inferior trunk dominance was seen in 70%. An average number of early cortical branch was 3. Conclusion: The knowledge of anatomy of MCA and its variations is important for neurosurgical residents’ training and neurosurgeons dealing with MCA aneurysm management or bypass surgeries.

Morphometric Analysis of the Ophthalmic and Central Retinal Arteries via the Endoscopic Endonasal Trans-ethmoidal Approach: Surgical Relevance of Vascular Components Within the Medial Intraconal Zones

The endoscopic endonasal approach (EEA) offers a minimally invasive route to treat medial intraconal space (MIS) lesions. Understanding the configuration of the ophthalmic artery (OphA) and the central retinal artery (CRA) is crucial. An EEA to the MIS was performed on 30 orbits. The description of the intraorbital part of the OphA was divided into 3 segments and classified as type 1 and type 2 and the MIS was divided into three surgical zones (A, B, C). The CRA's origin, course, and point of penetration (PP) were analyzed. The relationship between the position of the CRA in the MIS and the OphA type was analyzed. The OphA type 2 was present in 20% of specimens. The site of origin of the CRA from the OphA was found on the medial surface in type 1 and on the lateral surface of type 2. The point of penetrationof the central retinal arterywas found in 87% of the specimens on the inferomedial surface, just anterior to the inferior muscular trunk, at an average distance of 9.5mm±1 from the globe and 17mm±1.5 from the AZ. The presence of the CRA in Zone C was associated only with OphA type1. OphA type 2 is a common finding and can compromise the feasibility of an EEA to the MIS. A detailed preoperative analysis of the OphA and CRA should be conducted prior to approaching the MIS due to the implications of the anatomical variations that can compromise safe intraconal maneuverability during an EEA.

3D-electroanatomical mapping of the left atrium and catheter-based pulmonary vein isolation in pigs: A practical guide.

To propose a standardized workflow for 3D-electroanatomical mapping guided pulmonary vein isolation in pigs. Danish female landrace pigs were anaesthetized. Ultrasound-guided puncture of both femoral veins was performed and arterial access for blood pressure measurement established. Fluoroscopy- and intracardiac ultrasound-guided passage of the patent foramen ovale or transseptal puncture was performed. Then, 3D-electroanatomical mapping of the left atrium was conducted using a high-density mapping catheter. After mapping all pulmonary veins, an irrigated radiofrequency ablation catheter was used to perform ostial ablation to achieve electrical pulmonary vein isolation. Entrance- and exit-block were confirmed and re-assessed after a 20-min waiting period. Lastly, animals were sacrificed to perform left atrial anatomical gross examination. We present data from 11 consecutive pigs undergoing pulmonary vein isolation. Passage of the fossa ovalis or transseptal puncture was uneventful and successful in all animals. Within the inferior pulmonary trunk 2-4 individual veins as well as 1-2 additional left and right pulmonary veins could be cannulated. Electrical isolation by point-by-point ablation of all targeted veins was successful. However, pitfalls including phrenic nerve capture during ablation, ventricular arrhythmias during antral isolation close to the mitral valve annulus and difficulties in accessing right pulmonary veins were encountered. Fluoroscopy- and intracardiac ultrasound-guided transseptal puncture, high-density electroanatomical mapping of all pulmonary veins and complete electrical pulmonary vein isolation can be achieved reproducibly and safely in pigs when using current technologies and a step-by-step approach.

Pulsed field ablation in common inferior pulmonary trunk

Pulsed field ablation in common inferior pulmonary trunk

Immersive Surgical Anatomy of the Far-Lateral Approach.

The far-lateral (FL) approach is a classic neurosurgical technique that enables access to the craniocervical junction, which includes the lower clivus, the anterior foramen magnum, and the first two cervical vertebrae. The FL approach also provides access to the inferior cranial nerves (i.e., CN IX, CN X, CN XI, and CN XII), distal portions of the vertebral artery (VA), and inferior basilar trunk. Recent advances in three-dimensional (3D) technology as well as dissections allow for a better understanding of the spatial relationships between anatomical landmarks and neurovascular structures encountered during neurosurgical procedures. This study aims to create a collection of volumetric models (VMs) obtained from cadaveric dissections that depict the FL approach's relevant anatomy and surgical techniques. We describe the relevant multilayer anatomy involved in the FL approach and discuss modifications of this approach as well. Five embalmed heads and two dry skulls were used to record and simulate the FL approach. Relevant steps and anatomy of the FL approach were recorded using 3D scanning technology (e.g., photogrammetry and structured light scanning) to construct high-resolution VMs. Images and VMs were generated to demonstrate major anatomical landmarks for the FL approach. The interactive models allow for clear visualization of the surgical anatomy and windows in 3D and extended reality, rendering a closer look at the nuances of the topography experienced in the laboratory. VMs can be valuable resources for surgical planning and anatomical education by accurately depicting important landmarks.

Postoperative Residual Coronal Decompensation Inhibits Self-image Improvement in Adolescent Patients with Idiopathic Scoliosis.

Retrospective cohort study. This study aimed to evaluate the relationship between C7 plumb line (C7PL) decompensation and the Scoliosis Research Society (SRS) 22-item patient questionnaire scores, including those related to self-image, preoperatively and 2 years after surgery. In the surgical treatment of adolescent idiopathic scoliosis (AIS), inferior trunk balance caused by C7PL decompensation can negatively affect patients' quality of life. However, there are few reports in the literature that describe or clarify how postoperative trunk imbalance affects each SRS-22 domain, including self-image domain scores. A total of 120 patients with AIS who underwent posterior spinal fusion from August 2006 to March 2017 at our facility and were followed up for 2 years or more were included. Radiological parameters were measured on whole-spine anteroposterior and lateral radiographs. Revised SRS-22 (SRS-22r) values were also recorded. Coronal trunk imbalance was defined as a deviation of ≥2.0 cm between the C7PL and the central sacral vertical line. Patients with and without coronal trunk imbalance at 2 years after surgery were defined as D (+) (decompensation type) and D (-), respectively. Mean SRS-22r values, including function, pain, self-image, mental health, and subtotal were compared between the D (+) and D (-) groups. Logistic regression analysis was performed to detect the preoperative factors related to D (+) using predictors, including curve type, maximum Cobb angle, and coronal trunk imbalance. At 2 years after surgery, the D (+) group had a significantly lower self-image in the domain of SRS-22r scores compared with the D (-) group. Preoperative coronal trunk imbalance was significantly related to D (+) but not to significant changes in the postoperative SRS-22 score in any of the SRS-22 domains. Postoperative C7PL deviation lowers the self-image in patients with AIS. Patients with preoperative coronal trunk imbalance were significantly more likely to be D (+).

Does the Stent Retriever Placement in the Division of Middle Cerebral Artery Affect the Recanalization Success in M1 Occlusions?

The location of arterial occlusions can be predictive in the prognosis and endovascular treatment of acute stroke patients. We aimed to determine if the location of the stent retriever being on the superior or inferior division of the middle cerebral artery has an effect on the success and clinical outcomes of recanalization in middle cerebral artery M1 occlusion. Data were generated for the period from May 2015 to January 2019. Divisions of middle cerebral artery were assigned to the 2 groups as superior and inferior divisions according to the anatomical classification. The dominant trunk of the artery was assessed on the last angiogram image. We eventually included 81/90 patients (mean age: 62 ± 13.5; 63% [51/81] female; mean National Institutes of Health Stroke Scale rating: 16.3 ± 3.6) treated with thrombectomy. The branches of the middle cerebral artery were as follows: 40 (49.4%) co-dominant, 22 (27.2%) inferior, and 19 (23.5%) superior division dominant. The stent retriever was placed in the dominant trunk in 22/41(53.7%) cases at first pass. When stent retriever was placed in the dominant middle cerebral artery trunk, the rate of successful recanalization was very high with the first pass of thrombectomy (P < .001). Stent retriever placement within the superior or inferior middle cerebral artery trunk does not have an effect on the success rate of recanalization; however, its placement in the dominant trunk can increase the chance of complete recanalization to be early.

Thoracic outlet decompression surgery for Gilliatt-Sumner hand as a presentation of neurogenic thoracic outlet syndrome

BackgroundChronic compression of the inferior trunk of the brachial plexus can result in severe pain and progressive atrophy and weakness of the musculature of the forearm and hand, known as Gilliatt-Sumner hand (GSH). The objective of treatment for these patients is to stop further atrophy and pain. Restoration of motor function has been thought to be seldom achieved. The aim of the present contemporary case series was to describe the diagnosis, treatment, and outcomes of surgery for GSH. MethodsAll patients referred between January 2017 and May 2021 with visible signs of a GSH were included. Visible GSH signs were defined as muscle atrophy of the abductor digiti minimi, abductor pollicis brevis, and/or interosseous musculature. All the patients had undergone additional electrodiagnostic (ED) assessments and high-resolution ultrasound (HRUS) studies. All the patients with a diagnosis of GSH had undergone thoracic outlet decompression (TOD) surgery using a transaxillary or supraclavicular approach. The outcomes were measured using the thoracic outlet syndrome disability scale, cervical brachial symptom questionnaire, and disability of the arm, shoulder, and hand scale scores and patient-reported outcomes of motor function, measured using a numerical rating scale (NRS). The standardized elevated arm stress test (sEAST) was used to assess the patients’ motor function before and after TOD surgery. ResultsA total of 20 patients had been referred to our center with visible signs of a GSH. The clinical examination showed atrophy of the abductor digiti minimi, abductor pollicis brevis, and interosseous musculature in all 20 patients. The ED assessments showed plexopathy of the lower brachial plexus in all the patients. HRUS showed an indented inferior trunk of the brachial plexus (so-called wedge-sickle sign) in 18 patients (90%). Of the 20 patients, 17 had undergone TOD surgery (15 transaxillary TOD and 2 supraclavicular TOD). Three patients had refrained from surgery. The median follow-up interval was 15.0 months (interquartile range, 14.0 months). The thoracic outlet syndrome disability scale score had improved significantly (preoperatively: mean, 6.31; 95% confidence interval [CI], 5.49-7.13; postoperatively: mean, 4.25; 95% CI, 2.80-5.70; P = .026). The same improvement was seen for the cervical brachial symptom questionnaire scores (preoperatively: mean, 77.75; 95% CI, 66.63-88.87; postoperatively: mean, 42.65; 95% CI, 24.77-60.77; P = .001) and disability of the arm, shoulder, and hand scale scores (preoperatively: mean, 59.13; 95% CI, 51.49-66.77; postoperatively: mean, 40.96; 95% CI, 24.41-57.51; P = .032). The NRS score for muscle weakness and sEAST score showed no statistically significant differences before and after TOD for the whole group (mean preoperative NRS score for muscle weakness, 6.22; 95% CI, 4.31-8.14; mean postoperative NRS score for muscle weakness, 5.11; 95% CI, 3.25-6.97; P = .269). However, four patients (23.52%) had reported a ≥50% decrease in the NRS score for muscle weakness and a minimum increase of 20% in the total and average force using the sEAST. The NRS for numbness showed a statistically significant decrease for the whole group (preoperatively: mean, 5.67; 95% CI, 4.18-7.16; postoperatively: mean, 3.33; 95% CI, 1.37-5.29; P = .029). ConclusionsA combination of physical examination, ED assessments, and HRUS studies can differentiate GSH in the differential diagnosis. HRUS appears to have an advantage over ED studies in confirming GSH by visualization of compression of the brachial plexus. TOD surgery will stop the progressive muscle atrophy and significantly reduce neurogenic thoracic outlet syndrome complaints, and, in some patients, motor function will recover.

Landmark Guided Lower Interscalene Block as a Rescue Approach in a Case of Elusive Supraclavicular Block for Elbow Surgery

Dear Editor, Our case was an 18 yrs/m, weighing 54 kg without co morbidities presented with pain in right elbow and was posted for screw fixation of fracture capitulum. His routine blood work and airway examination were normal to undergo the surgery under supraclavicular block (SCB). On arrival, patient’s PR was 84/min, BP- 118/72 mm Hg, SpO2- 98% on room air. For right sided SCB, patient was placed supine, head turned to left side with shoulder depressed and needle was inserted lateral to subclavian artery pulsation just above the clavicle, posterolaterally. There was inadvertent puncture of subclavian artery each time, despite using standard techniques. Hence we decided to abandon standard SCB and proceed with lower interscalene block (LISB).Using modified Winnie’s approach interscalene groove was palpated and needle was inserted 2-3 cm below the classical interscalene block (ISB) site. Paresthesia was attained over whole upper limb and then Inj. Lignocaine + Adrenaline (2%) 10 ml along with inj. Bupivacaine 0.5% 10 ml was injected after repeated negative aspirations. A satisfactory sensory and motor blockade was obtained after 15 minutes of injection. Throughout the procedure, patient was continuously monitored and surgery was completed within 1.5h without any adverse event. The patient was shifted to ward. The block weaned off in 6 hrs and his vitals were stable throughout his course of stay in the hospital. Traditionally, the subclavian artery is an important relation of the brachial plexus for landmark guided SCB. However, anatomical variation may be present in as much as 50% of the population. [1] T1 nerve root supplies skin both above and below the elbow. Some authors have suggested a combined ISB + axillary block to get profound anaesthesia for elbow surgery. [2,3] Axillary nerve block was not contemplated in our case as optimal arm positioning was precluded due to severe pain at elbow. The advantages of LISB over SCB and ISB or ISB + axillary block are that it significantly reduces the risk of pneumothorax , inadvertent arterial puncture, ulnar sparing (as lower trunks of brachial plexus are more superficial in LISB) and avoids multiple injections. LISB also provides adequate anaesthesia and analgesia to whole upper limb which could be due to the relative proximity of the inferior trunks to the other components of brachial plexus as they become tightly bundled between the clavicle and first rib at this level.[2] Performing an LISB is easier due to its accessibility and shallow location of the brachial plexus, which may be favourable to those who disfavour or may not be comfortable with the supraclavicular approach. [4] Our case exemplifies that in those centres where ultrasound machine is unavailable and access to the brachial plexus for SCB by landmark technique remains elusive despite troubleshooting, lower interscalene block can be safely used to provide similar quality and extent of surgical anaesthesia.

Microsurgical Anatomy of Middle Cerebral Artery in Northwest Indian Population: A Cadaveric Brain Dissection Study.

Background:Microsurgical anatomy of the Middle Cerebral Artery (MCA) of the Northwest Indian population has not been described to date. A study of cadaveric brains will add to the existing knowledge of brain vessels.Objective:To study and compare the microsurgical anatomy of MCA in Northwest Indian Population with that of the available literature.Methods and Material:15 Formalin Fixed Cadaveric brains, that is 30 vessels from its origin from Internal Cerebral Artery to M5 segment with respect to diameter, length and branching pattern were studied under high magnification (operating microscope) and the data compared with literature.Results:The main trunk of MCA was 16±3 mm long with no significant differences between both sides. Its outer diameter was 3±0.1 mm. Among the early branches 58% were destined to the temporal lobe. Distance between the origin of the early branch from MCA origin was 4±2mm on the right side and 4.5±2.5 mm on the left side. The most consistent perforating branch group was the intermediate group. The pattern of branching of the main trunk was bifurcation (73%), single trunk (10%) and trifurcation (10%). Within the bifurcation group, inferior trunk dominance was seen in 50%. Amongst the cortical branches diameter of the angular artery was largest and the temporo-polar was smallest. No significant difference in the data as compared to literature.Conclusions:The knowledge of anatomy of MCA and its variations are important for neurosurgical residents' training and neurosurgeons dealing with MCA aneurysm management or bypass surgeries.

Prognostic Value of the Distribution of Lymph Node Metastasis in Locally Advanced Rectal Cancer After Neoadjuvant Chemoradiotherapy

Background: The objective of this study is to assess the prognostic value of lymph node metastasis distribution (LND) in locally advanced rectal cancer (LARC) after neoadjuvant chemoradiotherapy (nCRT).Methods: This study included 179 patients with pathological stage III LARC who underwent nCRT followed by radical surgery. LND was classified into three groups: LND1, lymph node metastasis at the mesorectum (140/179, 78.2%); LND2, lymph node metastasis along the inferior mesenteric artery trunk nodes (26/179, 14.5%); LND3, lymph node metastasis at the origin of the IMA (13/179, 7.3%). Clinicopathologic characteristics were analyzed to identify independent prognostic factors.Result: LND showed better stratification for 3-year DFS (LND1 66.8, LND2 50, and LND3 15.4%, P < 0.01) compared to the ypN (3-year DFS: N1 59.9 and N2 60.3%, P = 0.34) and ypTNM (3-year DFS: IIIA 68.6%, IIIB 57.5%, and IIIC 53.5, P = 0.19) staging systems. Similar results were found for 3-year LRFS and DMFS. According to multivariate survival analysis, LND was shown to be an independent prognostic factor for DFS, LRFS, and DMFS in patients with positive lymph nodes (P < 0.01, in all cases).Conclusion: LND is an independent prognostic factor in stage III rectal cancer after nCRT. LND can be used as a supplementary indicator for the ypTNM staging system in patients with LARC after nCRT.

Dual laryngeal reinnervation in bilateral vocal fold paralysis: anatomical pitfalls.

Bilateral laryngeal reinnervation can be a promising procedure for reanimation of laryngeal muscles, but currently not yet standardized. Besides patient conditions some intraoperative anatomical pitfalls need to be solved. Twelve human head and neck specimens (24 sides) have been studied using microdissection and histological serial sections of the nerves. The surgical anatomy of the dual reinnervation procedure according to JP Marie was investigated notably the branching pattern of the phrenic nerve (PN), the Ansa cervicalis (AC) and the recurrent laryngeal nerve (RLN). Despite variations of the AC, a prominent inferior common trunk for sterno-hyoid and sterno-thyroid muscles can be used in more than 90% of the specimens. If the AC is missing because of previous surgery, the tiny nerve of the thyro-hyoid muscle can be used preferred. The PN display a double roots pattern from C3 to C4 cervical plexus in 50% of the specimens. A single root pattern can be found and an end-to-lateral neurorraphy can be used. Intra-laryngeal nerves pattern of the RLN display tiny collaterals which cannot be selected for abduction-adduction activity. Direct implantation of the Y-shape great auricular nerve within the posterior crico-arytenoid muscles can be a reliable method leading to challenging mechanical and functional conditions. Several anatomical pitfalls, including intra-operative choices and variants of the donor nerves, but also the challenging intra-laryngeal dissection of the inferior laryngeal nerve need to be solved. A successful laryngeal reinnervation still needs further studies for a simplified procedure.

Constructing an Individualized Middle Cerebral Artery Model Using 3D Printing and Hydrogel for Bypass Training.

The importance and complexity of cerebral bypass surgery (CBS) highlight the necessity for intense and dedicated training. Several available training models are yet to satisfy this need. In this technical note, we share the steps to construct a digital imaging and communications in medicine (DICOM)-based middle cerebral artery (MCA) model that is anatomically accurate, resembles handling properties of living tissue, and enables trainers to observe the cerebrovascular anatomy, improve and maintain microsurgical dexterity, and train in the essential steps of CBS.The internal and external molds were created from the geometry of DICOM-based MCA using Fusion 360 software (Autodesk, San Rafael, USA). They were then three-dimension (3D) printed using a polylactic acid filament. The 15% w/v solution of polyvinyl alcohol (PVA) was prepared and injected between the molds. Using five freeze-thaw cycles the solution was converted to tissue-mimicking cryo-gel. The model was then placed in a chloroform bath until the internal mold dissolved. To evaluate the accuracy of the MCA model, selected characteristics were measured and compared with the MCA mesh.The DICOM-based MCA model was produced using 3D printing that was available in the lab and the overall cost was less than $5 per model. The external mold required six and a half hours to be 3D printed, while the internal mold only required 23 minutes. Overall, the time required to 3D print the DICOM-based MCA model was just short of seven hours. The greatest statistically significant difference between the virtual MCA model and the DICOM-based MCA model was found in the length of the pre-bifurcation part of the M1 segment and the total length of the superior bifurcation trunk of M1 and superior branch of M2. The smallest statistically significant difference was found at the diameter of the inferior post-bifurcation trunk of the M1 segment and the diameter at the origin of the artery.This technical report aims to show the construction of a CBS training system involving the DICOM-based MCA model that demonstrates the shape of the vascular tree, resembles the handling/suturing properties of living tissue, and helps set up a homemade training station. We believe that our DICOM-based MCA model can serve as a valuable resource for CBS training throughout the world due to its cost-effectiveness and straightforward construction steps. Moreover, once the DICOM-based MCA model is used with our training station, it may offer an option for trainers to gain and maintain CBS skills despite limitations on time, cost, and space.This work was presented in February 2019 at the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Cerebrovascular Section Annual Meeting held in Honolulu, Hawaii.