Nerve Trunk Research Articles

P211 BLEEDING AND THROMBOSIS: A MULTIDISCIPLINARY SLALOM

Abstract GG is a 75 kg and 75 years old smoker man with metabolic syndrome, potus, OSAS and LBBB. In 1/2022 the echo imaging showed EF 35%, high dissincrony and PVCs so a myocardial SPECT had been recommended but not carried out by the patient. In 6/2022 new exertional dyspnea, orthopnea and peripheral oedema lead the patient to the Emergency Department: the ECG indicated new onset AF 75 bpm, at laboratory tests creatinine 1.8 mg/dL and NTproBNP 6200 pg/ml and echocardiography confirmed hypokinetic cardiopathy with EF 35%, mild–moderate mitral and tricuspidal regurgitation with pulmonary hypertension and vascular congestion. Admitted for heart failure and new onset AF, diuretic and levosimendan ev, MRA, BB and LMWH started with benefit. At the end of inotropic therapy, ARNI, SGLT2 and inhaled cortisone began. Myocardial SPECT proved moderate fixed inferior wall hypoperfusion. Hospitalization was complicated by ecchymoses and hematomas of abdomen superficial soft tissues during LMWH and proximal saphenous vein and III middle left thigh thrombophlebitis, so apixaban 5mg BID and elastic stockings started with resolution. The onset of paresthesias, pain and left leg progressive hyposthenia led to diagnosis of a partial hematoma of the ilio–psoas muscle resulting in a complete left femoral nerve lesion and severe obturator nerve and left lumbosacral trunk suffering plus further right iliac and rectus abdominis muscles hematomas. Discontinued apixaban, after 72 hours the hematoma was surgically removed without complications and fast recovery thanks to FKT. 9 days later left leg DVT recurrence was observed: in absence of absolute contraindications to anticoagulant therapy and blood count stability, without evident new bleedings, heparin infusion was set with maintenance of the aPTT values at the lower therapeutic range limits. One week later radiological imaging demonstrated reduction of left retroperitoneal hematoma so dabigatran 150 mg BID was initiated. Control echo showed EF 42%, mild MR and TR. Regular the subsequent rehabilitation course: the patient was discharged with dabigatran 110 mg twice daily to limit long–term bleeding risk. The thrombotic/bleeding risks require a complex therapeutic modulation in a multidisciplinary teamwork.

Drop-off in axonal regeneration along the length of a cross-face nerve graft: An experimental study in rats.

The average nerve graft length utilized in cross-face nerve grafting for reconstruction of facial nerve palsy is 20-22 cm. While the graft length is thought to be one of the greatest determinants of muscle strength, the mechanism through which this happens remains unknown. We studied changes in axonal regeneration along the length of a 2 cm cross-face nerve graft in a rat model. The hypothesis was that axon count would decrease along the length of the graft. A 2 cm nerve graft (sciatic nerve) was used as a cross-face nerve graft in 16 adult female, 210-250 g, Sprague Dawley rats. Thirteen weeks later, 5 mm nerve biopsies were taken at four sites: the facial nerve trunk (control), proximal graft, midpoint of graft (1 cm distal to coaptation) and distal graft (2 cm distal to coaptation). Retrograde nerve labeling with FluoroGold was performed at the biopsied nerve site and the facial motor nucleus was taken 1 week later. Microscopic imaging and manual counting of axons and labeled motor nuclei was performed. Retrograde-labeled motor neuron counts were decreased at the midway point of the graft compared to the facial trunk (1517 ± 335 axons, Δ% = 92.5, p = .01) and even further decreased at the distal end of the graft (269 ± 293 axons, Δ% = 175.5, p = .006). Analysis of the nerve biopsies demonstrated no significant differences in myelinated axon count between the nerve trunk and over the length of the nerve graft (range 6207-7179 axons, Δ% = 14.5, p = .07). In a rat model, the number of regenerating motor neurons drops off along the length of the graft and axon count is preserved due to axon sprouting. How this pattern correlates to ultimate muscle strength remains unknown, but this study provides insight into why shorter grafts may afford better outcomes.

Hypoglossal nerve trunk stimulation: electromyography findings during drug-induced sleep endoscopy: a case report

BackgroundLiterature has demonstrated hypoglossal nerve stimulation to be a safe and effective treatment for patients with obstructive sleep apnea nonadherent to positive airway pressure therapy. However, the recommended criteria for patient selection are still unable to identify all the unresponsive patients, highlighting the need for improved understanding about hypoglossal nerve stimulation for obstructive sleep apnea.Case presentationA 48-year-old Caucasian male patient with obstructive sleep apnea had been successfully treated with electrical stimulation of the hypoglossal nerve trunk, documented by level 1 polysomnography data. However, due to snoring complaints, he underwent postoperation drug-induced sleep endoscopy for evaluation of electrode activation during upper airway collapse, aiming to improve electrostimulation parameters. Concurrent surface electromyography of the suprahyoid muscles and masseter was obtained. Activation of electrodes 2, 3, and 6 promoted upper airway opening most strongly at the velopharynx and tongue base during drug-induced sleep endoscopy. The same channels also significantly increased the electrical activity on suprahyoid muscles bilaterally, but predominantly on the stimulated side (right). The masseters also presented a considerable asymmetry in electrical potential on the right side (> 55%).ConclusionBeyond the genioglossus muscle, our findings demonstrate recruitment of other muscles during hypoglossal nerve stimulation, which may be attributed to the electrical stimulation of the nerve trunk. This data provides new insights on how stimulation of the hypoglossal nerve trunk may contribute to obstructive sleep apnea treatment.

Особливості маніфестації неврологічних симптомів гострих полінейропатій та їх диференційна діагностика в дітей при коронавірусній хворобі (COVID-19)

The relevance of the problem of diagnosis and treatment of polyneuropathy in children is due to the diverse clinical manifestations of this pathology, which are often acute and can lead to severe, life-threatening complications. Guillain-Barré syndrome (GBS) refers to acute or subacute, often post-infectious, immune-mediated polyneuropathies accompanied by axonal damage to nerve trunks and peripheral nerves. The present study is devoted to the assessment of neurological symptoms in the acute course of GBS, including its differential diagnosis with musculoskeletal lesions in coronavirus disease (COVID-19) in childhood. Purpose - to determine the features of the debut and characterize the neurological symptoms of acute polyneuropathies in children, including GBS in COVID-19. Materials and methods. We examined 10 children with confirmed GBS. Clinical-anamnestic, general clinical, clinical-neurological, clinical-instrumental and clinical-laboratory methods of examination were used. Results. In 1 of the examined patients aged 6 years, GBS developed in the acute period of COVID-19 and manifested as acute flaccid paresis in the distal, and after 4 days - severe weakness of the thigh muscles in combination with leg pain. In 8 of the examined patients, the debut of GBS occurred within 7-21 days after an acute respiratory viral infection. Of these, 6 children had the acute phase of COVID-19 14-21 days before the onset of GBS, which was confirmed by the results of an oropharyngeal PCR-test. The acute phase of COVID-19 in these patients was manifested by fever up to 38.0º, ague, hyposmia, lasting from 3 to 5 days. Severe pain in the legs was noted in all patients with GBS. The absence of elevated levels of creatine phosphokinase, alanine aminotransferase, aspartate aminotransferase according to biochemical blood tests in patients and the absence of myoglobin in the urine excluded rhabdomyolysis of skeletal muscles. Electroneuromyography (ENMG) confirmed the neural type of lesion in the legs. Conclusions. In most patients, the debut of GBS occurred 3 weeks after the acute phase of COVID-19. Pain syndrome and symmetrical flaccid paresis were the leading symptoms of the course of GBS in children. Reduced excitation conduction velocity along the motor fibres of the tibial and peroneal nerves, according to the results of ENMG, allowed confirming the diagnosis of GBS. Differential diagnosis of GBS with musculoskeletal lesions, in particular, the exclusion of the diagnosis of rhabdomyolysis in COVID-19 in children, allowed for timely prescription of adequate therapy. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Development of the aganglionic colon following surgical rescue in a cell therapy model of Hirschsprung disease in rat.

Patients with Hirschsprung disease lack enteric ganglia in the distal colon and propulsion of colorectal content is substantially impaired. Proposed stem cell therapies to replace neurons require surgical bypass of the aganglionic bowel during re-colonization, but there is inadequate knowledge of the consequences of bypass. We performed bypass surgery in Ednrb-/- Hirschsprung rat pups. Surgically rescued rats failed to thrive, an outcome reversed by supplying electrolyte- and glucose-enriched drinking water. Histologically, the bypassed colon had normal structure, but grew substantially less in diameter than the functional region proximal to the bypass. Extrinsic sympathetic and spinal afferent neurons projected to their normal targets, including arteries and the circular muscle, in aganglionic regions. However, although axons of intrinsic excitatory and inhibitory neurons grew into the aganglionic region, their normally dense innervation of circular muscle was not restored. Large nerve trunks that contained tyrosine hydroxylase (TH)-, calcitonin gene-related peptide (CGRP, encoded by Calca or Calcb)-, neuronal nitric oxide synthase (nNOS or NOS1)-, vasoactive intestinal peptide (VIP)- and tachykinin (encoded by Tac1)-immunoreactive axons occurred in the distal aganglionic region. We conclude that the rescued Ednrb-/- rat provides a good model for the development of cell therapies for the treatment of Hirschsprung disease.

Analysis of side effects of cryoneurolysis for the treatment of spasticity.

To report side effects from clinical studies on ultrasound-guided percutaneous cryoneurolysis for spasticity. Patients were prospectively enrolled in three studies at a single institution. Cryoneurolysis was performed to primarily motor nerve branches (medial and lateral pectoral, musculocutaneous, radial, median, ulnar, tibial, obturator) and mixed motor sensory nerve trunks (median, ulnar, suprascapular, radial, and tibial). Cryoneurolysis was performed for 277 nerves (99 mixed motor sensory), on 113 patients (59F, 54 M, average age 54.4 years). One patient had a local skin infection, two patients had bruising or swelling; all resolved within one month. 9 reported nerve pain or dysesthesia (two motor, seven mixed motor sensory nerves). Four received no treatment, four oral or topical medications, two perineural injections, one botulinum toxin. Three patients' symptoms remained until three months, one had numbness at six. One patient had botulinum toxin injections for cramping. All had at minimum three months follow-up; seven withdrew (x̄ = 5.4 months), four passed away. None of these eleven reported side effects. 96.75% of nerve treatments had no pain or dysesthesias beyond treatment. Few had pain or numbness beyond three months. Cryoneurolysis has potential to be a safe spasticity treatment with manageable side effects.

Predicting postoperative facial nerve paralysis by using intraoperative nerve monitoring during parotid surgery.

To investigate a method for predicting postoperative facial nerve paralysis (POFNP) during parotid surgery using intraoperative nerve monitoring (IONM). We assessed prediction for POFNP by using IONM, comparing between stimulation in the facial nerve trunk and each branch by using facial nerve monitoring. The amplitude response ratio (ARR) was calculated for the trunk/periphery. In addition, we then examined the correlation between ARR and time to recovery of paralyzed branches. 372 branches of 93 patients did not develop POFNP and were classified as group A. Among 20 patients who developed POFNP, 51 branches without POFNP were classified as group B, and 29 branches with POFNP were classified as group C. The ARR was approximately 1 in group A and B. but less than 0.5 in all branches in Group C. When the cut off value of ARR was set at 0.55, the sensitivity, specificity, and accuracy of POFNP diagnosis by ARR were 96.5%, 93.1%, and 96.8%, respectively. Using IONM during parotid surgery enables easy prediction of POFNP.

Cubital tunnel syndrome of the ulnar nerve caused by an epineural ganglion cyst: a case report and review of the literature

BackgroundThe ulnar nerve has a long and complex anatomical course, originating from the brachial neural plexus in the neck with nerve trunk formation at the posterior neck triangle, and on to the axilla. This intricate anatomical pathway renders the nerve susceptible to compression, direct injury, and traction throughout its course. Compression of the ulnar nerve is the second most common compression neuropathy of the median nerve adjacent to the wrist joint, after carpal tunnel syndrome.Case presentationA 45-year-old Sudanese housewife complained of progressive right forearm and hand muscle wasting, pain, and neuropathic symptoms. She was diagnosed with right-sided cubital tunnel syndrome. The diagnosis was derived intraoperatively from a nerve conduction study suggesting the level of conduction block and recommending decompression. Magnetic resonance imaging was not done preoperatively due to financial limitations. An epineural ganglion (15 × 20 mm2) compressing and flattening the ulnar nerve was diagnosed intraoperatively. Surgical decompression of the ulnar nerve and removal of the epineural ganglion achieved a remarkable postoperative result and pleasing outcome.ConclusionSurgical management is the cornerstone of treatment for compressive neuropathy and ranges from simple nerve decompression to complex neurolysis procedures and nerve transposition to adjust the anatomical course of the nerve.

A revamped MIC-McKeown operation without removing azygos vein arch, bronchial artery and vagus nerve trunk

BackgroundThe purpose of this study was to investigate the effect of our revamped MIE-McKeown operation on postoperative gastrointestinal function recovery.MethodsThis revamped MIE-McKeown operation without removing azygos vein arch, bronchial artery and vagus nerve trunk and with the tubular stomach buried throughout esophageal bed and azygos arch, has been implemented from July 2020 to July 2021 by the same medical team of Gaozhou People's Hospital thoracic surgery for 13 times. Preoperative clinical data, main intraoperative indicators and postoperative complications were observed.ResultsAll patients had esophageal malignant tumors at the level of middle and lower thoracic non-azygous venous arch, with preoperative clinical stage CT1-2N0M0 stage i-ii. V-vst test was performed on the 7th postoperative day, and 10 patients were found to have no loss of safety/efficacy. There were 2 cases with impaired efficacy and no impaired safety, 1 case with impaired safety. There were 1 cases of pulmonary infection, 1 cases of anastomotic fistula combined with pleural and gastric fistula, 2 cases of hoarseness, 2 cases of arrhythmia, 10 cases of swallowing function were grade i, 2 cases of swallowing function were grade iii, 1 case of swallowing function was grade iv in watian drinking water test one month after operation.ConclusionsMerit of this revamped MIE-McKeown operation is well preserving the integrity of azygos arch of vagus nerve and bronchial artery, and it is technically safe and feasible. No postoperative mechanical obstruction of thoracostomach, huge thoracostomach and gastrointestinal dysfunction occurs.

Cholinergic collaterals arising from noradrenergic sympathetic neurons in mice.

The sympathetic nervous system vitally regulates autonomic functions, including cardiac activity. Postganglionic neurons of the sympathetic chain ganglia relay signals from the central nervous system to autonomic peripheral targets. Disrupting this flow of information often dysregulates organ function and leads to poor health outcomes. Despite the importance of these sympathetic neurons, fundamental aspects of the neurocircuitry within peripheral ganglia remain poorly understood. Conventionally, simple monosynaptic cholinergic pathways from preganglionic neurons are thought to activate postganglionic sympathetic neurons. However, early studies suggested more complex neurocircuits may be present within sympathetic ganglia. The present study recorded synaptic responses in sympathetic stellate ganglia neurons following electrical activation of the pre- and postganglionic nerve trunks and used genetic strategies to assess the presence of collateral projections between postganglionic neurons of the stellate ganglia. Orthograde activation of the preganglionic nerve trunk, T-2, uncovered high jitter synaptic latencies consistent with polysynaptic connections. Pharmacological inhibition of nicotinic acetylcholine receptors with hexamethonium blocked all synaptic events. To confirm that high jitter, polysynaptic events were due to the presence of cholinergic collaterals from postganglionic neurons within the stellate ganglion, we knocked out choline acetyltransferase in adult noradrenergic neurons. This genetic knockout eliminated orthograde high jitter synaptic events and EPSCs evoked by retrograde activation. These findings suggest that cholinergic collateral projections arise from noradrenergic neurons within sympathetic ganglia. Identifying the contributions of collateral excitation to normal physiology and pathophysiology is an important area of future study and may offer novel therapeutic targets for the treatment of autonomic imbalance. KEY POINTS: Electrical stimulation of a preganglionic nerve trunk evoked fast synaptic transmission in stellate ganglion neurons with low and high jitter latencies. Retrograde stimulation of a postganglionic nerve trunk evoked direct, all-or-none action currents and delayed nicotinic EPSCs indistinguishable from orthogradely-evoked EPSCs in stellate neurons. Nicotinic acetylcholine receptor blockade prevented all spontaneous and evoked synaptic activity. Knockout of acetylcholine production in noradrenergic neurons eliminated all retrogradely-evoked EPSCs but did not change retrograde action currents, indicating that noradrenergic neurons have cholinergic collaterals connecting neurons within the stellate ganglion.

Chronic pain and local pain in usually painless conditions including neuroma may be due to compressive proximal neural lesion.

It has been unexplained why chronic pain does not invariably accompany chronic pain-prone disorders. This question-driven, hypothesis-based article suggests that the reason may be varying occurrence of concomitant peripheral compressive proximal neural lesion (cPNL), e.g., radiculopathy and entrapment plexopathies. Transition of acute to chronic pain may involve development or aggravation of cPNL. Nociceptive hypersensitivity induced and/or maintained by cPNL may be responsible for all types of general chronic pain as well as for pain in isolated tissue conditions that are usually painless, e.g., neuroma, scar, and Dupuytren's fibromatosis. Compressive PNL induces focal neuroinflammation, which can maintain dorsal root ganglion neuron (DRGn) hyperexcitability (i.e., peripheral sensitization) and thus fuel central sensitization (i.e., hyperexcitability of central nociceptive pathways) and a vicious cycle of chronic pain. DRGn hyperexcitability and cPNL may reciprocally maintain each other, because cPNL can result from reflexive myospasm-induced myofascial tension, muscle weakness, and consequent muscle imbalance- and/or pain-provoked compensatory overuse. Because of pain and motor fiber damage, cPNL can worsen the causative musculoskeletal dysfunction, which further accounts for the reciprocity between the latter two factors. Sensitization increases nerve vulnerability and thus catalyzes this cycle. Because of these mechanisms and relatively greater number of neurons involved, cPNL is more likely to maintain DRGn hyperexcitability in comparison to distal neural and non-neural lesions. Compressive PNL is associated with restricted neural mobility. Intermittent (dynamic) nature of cPNL may be essential in chronic pain, because healed (i.e., fibrotic) lesions are physiologically silent and, consequently, cannot provide nociceptive input. Not all patients may be equally susceptible to develop cPNL, because occurrence of cPNL may vary as vary patients' predisposition to musculoskeletal impairment. Sensitization is accompanied by pressure pain threshold decrease and consequent mechanical allodynia and hyperalgesia, which can cause unusual local pain via natural pressure exerted by space occupying lesions or by their examination. Worsening of local pain is similarly explainable. Neuroma pain may be due to cPNL-induced axonal mechanical sensitivity and hypersensitivity of the nociceptive nervi nervorum of the nerve trunk and its stump. Intermittence and symptomatic complexity of cPNL may be the cause of frequent misdiagnosis of chronic pain.

The use of prostaglandin applied in Bai Hui Acupoint on mare reproductive efficiency

SummaryProstaglandin F2α (PGF2α) is one of the most frequently used drugs for pharmacologic manipulation of the oestrous cycle in mares. Among its roles, PGF2α induces luteolysis, leading to an early oestrus return, which reduces the dioestrous phase and the inter‐ovulatory intervals. Interestingly, mares are more sensitive to PGF2α than other domestic species, hence lower doses are used; even so, the side effects are still adverse and inconvenient for animals and breeders. Recent studies of acupuncture, a traditional Chinese medicine technique, have been performed as an alternative to decrease the PGF2α dose for mares. The efficacy described of applying lower doses of PGF2α at specific acupoints is similar to that obtained with the regular dose. Therefore, the objective of this study was to analyse the reproductive performance and characteristics of oestrus in embryo recipient and donor mares using different doses at the Bai Hui—an acupoint located on the dorsal midline, also known as ‘the point of one hundred meetings’, as its region of effect encompasses many nerve trunks, nerve endings and vascular networks—a useful veterinary acupuncture treatment for ovarian disorders. For this study, 76 Quarter Horse mares were randomly assigned to three experimental groups: Control (CTR)—Intramuscular (IM) administration of 5 mg PGF2α; Bai Hui 5 mg (BH5)—application of 5 mg at the Bai Hui acupoint; and Bai Hui 2.5 mg (BH2.5)—application of 2.5 mg at the Bai Hui acupoint. In the results, there were no differences regarding uterine oedema, pregnancy rate or body condition score among the groups. However, oestrous expression was lower (p < 0.001) in both BH groups compared with CTR. Lastly, the interval between application and ovulation was shorter in BH5 compared with CTR (p = 0.042). The results indicate BH5 and BH2.5 as viable alternatives to the IM administration.

Corneal deposits and nerve alterations in Bietti Corneoretinal Crystalline Dystrophy imaged using in vivo confocal microscopy.

To evaluate the imaging features of corneal deposits and nerve alterations in Chinese patients with Bietti Corneoretinal Crystalline Dystrophy (BCD) using in vivo confocal microscopy (IVCM). Twenty patients with BCD and 20 age- and sex-matched healthy controls were enrolled in this retrospective, observational study. Corneal deposits and sub-basal nerve plexus (SNP) were observed by IVCM. Parameters of SNP including total nerve density/number, main nerve trunk density/number, and branch nerve density/number were analyzed by Neuron J. Corneal deposits were observed in both eyes of all patients by IVCM. These crystals appeared as dot-shaped, needle-shaped, and rod-shaped hyperreflective bodies and were located not only in the sub-epithelium and stroma of cornea, but in endothelium which were not reported before. There was a decrease of total nerve density (P < 0.001), main nerve trunk density (P = 0.007), and branch nerve density (P = 0.001), in BCD compared to controls. The number of total nerves/frame (P = 0.001), main nerve trunks/frame (P = 0.005), and branch nerves/frame (P = 0.006) in BCD were lower than controls. New findings in locations of corneal crystals by IVCM expand the phenotype spectrum of BCD. Corneal deposits may be useful for diagnosis of BCD, especially ones without retinal deposits. Corneal nerve parameters were reduced in BCD, which may provide new insights to be further explored to contribute to our understanding of BCD. IVCM is a promising tool to evaluate corneal deposits and nerve alterations in BCD.

Innervation of the heart: Anatomical study with application to better understanding pathologies of the cardiac autonomics.

Current advances in management of the cardiac neuroaxis in different cardiovascular diseases require a deeper knowledge of cardiac neuroanatomy. The aim of the study was to increase knowledge of the human fetal extrinsic cardiac nervous system. We achieved this by systematizing the origin and formation of the cardiac nerves, branches, and ganglia and their sympathetic/parasympathetic connections. Thirty human fetuses (60 sides) were subjected to detailed sub-macroscopic dissection of the cervical and thoracic regions. Cardiac accessory ganglia lying on a cardiac nerve or in conjunction with two or more (up to four) nerves before entering the mediastinal cardiac plexus were observed in 13 sides. Except for the superior cardiac nerve, the sympathetic cardiac nerves were individually variable and inconstant. In contrast, the cardiac branches of the vagus nerve appeared grossly more constant and invariable, although the individual cardiac branches varied in number and position of origin. Each cervical cardiac nerve or cardiac branch of the vagus nerve could be singular or multiple (up to six) and originated from the sympathetic trunk or the vagus nerve by one, two, or three roots. Sympathetic nerves arose from the cervical-thoracic ganglia or the interganglionic segment of the sympathetic trunk. Connections were found outside the cardiac plexus. Some cardiac nerves were connected to non-cardiac nerves, while others were connected to each other. Common sympathetic/parasympathetic cardiac nerve trunks were more frequent on right (70%) versus left sides (20%). The origin, frequency, and connections of the cardiac nerves and branches are highly variable in the fetus. Detailed knowledge of the normal neuroanatomy of the heart could be useful during cardiac neuromodulation procedures and in better understanding nervous pathologies of the heart.

Recommendations for Ultrasound Guidance for Diagnostic Nerve Blocks for Spasticity. What Are the Benefits?

The diagnostic nerve block (DNB) for spasticity is the percutaneous application of an anesthetic to an individual peripheral nerve trunk (mixed motor sensory nerve), nerve branch to a muscle or an intramuscular branch. The DNB causes a temporary paralysis to assess the contribution of muscle(s) on the spastic pattern and may unmask a fully or partially increased joint range of motion. The anesthetic literature supports the use of ultrasound (US) guidance to improve nerve blocks for sensory targets. This communication summarizes the potential advantages that support the use of US to improve DNB technique. Nerves are much smaller than muscle targets and have various known innervation patterns. US allows for rapid localization of the target before injection, particularly in complex anatomy patterns. The nerve trunks are typically found adjacent to or encapsulating blood vessels, which can be quickly identified with or without color Doppler, allowing the clinician to scan from the vessels to the target and avoid intravascular injection. Lower stimulation levels can be used as the targeted muscle(s) can be seen stimulating rather than only on the surface. A shorter needle insertion time and lower stimulation levels should cause less discomfort to the patient. Smaller volumes of anesthetic may be used as the fluid is seen reaching its target and cessation of stimulation is observed. Further study is needed to identify evidence supporting US utilization with electrical stimulation in DNBs for spasticity management, as US use during nerve blocks for perineurial anesthesia has demonstrated improved patient safety and procedural efficiency.

Anatomical Pitfalls of Excision of Deep Endometriosis Nodules of the Sciatic Nerve: A three-dimensional Reconstruction and Surgical Educational Video

To highlight the anatomical keys to safely performing an excision of deep endometriosis nodules of the sciatic nerve DESIGN: We present a didactic video combining an anatomical three-dimensional reconstruction of the pelvis using the Anatomage table and a surgical dissection video of the removal of deep endometriosis nodules of the left sciatic nerve [1]. The patient's approval was obtained. The patient consented that this surgical video be used for publication. Tertiary referral center. To reach this specific area, we must localize precise anatomical pitfalls [2,3]. Taking the external iliac vessels as an anatomical plane of reference, we can divide anatomical structures into lateral and medial. During the first step of the procedure, we open the latero-pelvic peritoneum covering the external iliac artery. This step allows the identification of the lateral anatomic keys. Lateral anatomic keys are represented by: (1) the genito-femoral nerve, an element which is superficially situated between the psoas muscle and external iliac artery, and (2) the obturator nerve (Video Still 1), which is deep and is located within the ilio-lumbar fossa. To enter it, a dissection between the psoas muscle and external iliac artery and vein must be performed. At this point, particular attention must be paid to the obturator artery that runs below the obturator nerve. In this fossa, the lumbosacral trunk is easily identified just below the obturator nerve; it lies at this level on the iliac bone. Then the opening of the posterior leaf of the broad ligament is realized. Therefore, we access the medial anatomic keys: (1) the ureter, and (2) the umbilico-artery trunk with the umbilical and uterine artery. In the opening of the posterior leaf, we can find the obturator nerve and lumbosacral trunk again. Finally, following the umbilical artery (that is the first branch of the internal iliac artery), we discover the internal iliac artery and vein. A very careful dissection of these vessels must be done to avoid big hemorrhages, which can be life-threatening [4-6]. In the plane below the internal iliac artery and vein, we access the sacral roots S1, S2, and S3 (Video Still 2), which join the lumbosacral trunk (lying on the piriformis muscle) to form the ischiatic nerve [7]. At this level, the ischiatic nerve exits through the infra-piriform foramen behind the ischiatic spine and sacrospinous ligament toward the gluteal area in an oblique way [8]. Two other elements may be seen: the pudendal nerve exiting the pelvis behind the sacrospinous ligament in a craniocaudal way and the posterior femoral cutaneous nerve. During this dissection, the autonomous system must be spared as usual to avoid functional sequelae. Removal of deep endometriosis nodules of sciatic nerves is a challenging procedure. Because few surgeries are specifically dedicated to the sciatic area, the specific anatomy of the region is poorly taught and known. However, pelvic anatomical knowledge is indispensable to the safe removal of nodules of sciatic nerves. The main advantage of this anatomical 3D reconstruction is the possibility of visualizing the deep pelvic anatomy in a laparoscopic position. Surgeons must be aware of both somatic and autonomous pelvic nerve anatomy within the retroperitoneal spaces and the great vessels surrounding them.

Intraneral perineurioma in children and adolescents

Intraneral perineurioma (IP) is a rare and little-studied benign neoplasm of peripheral nerves in children and young adults. The clinical picture is usually a slowly progressive mononeuropathy, but plexuses with a predominance of motor deficits may also be involved. The sciatic nerve and its branches are most often affected. It is difficult to diagnose and requires a large amount of research to identify and confirm the diagnosis. Today, non-invasive neuroimaging methods such as magnetic resonance imaging (MRI) of nerve trunks and ultrasound of peripheral nerves are widely used for diagnosis, which are and allow getting ahead of the size and location of the neoplasm. MRI and ultrasound of the peripheral nerves reveal a focal fusiform enlargement of the nerve within one segment of the limb with an increase in the intensity of the MR signal from the IP. These neoplasms are considered rare, but recent advances in MRI and ultrasound diagnostics allow them to be detected at an early stage. MRI also helps distinguish IP from other peripheral nerve neoplasms. Confirmation of the diagnosis is based on histological examination of the altered nerve trunk. To date, there is no generally accepted strategy for the management of IP patients. Both conservative and surgical treatments are used. Neurolysis and nerve decompression improve neurological deficits in half of IP patients. IP does not recur after surgical treatment and does not become malignant during long-term follow-up of the patient.

Pathological changes in the nervous structures of the aortic wall tissue adjacent to an unstable atherosclerotic plaque

To study of nerve structures in the aortic wall in atherosclerosis using a complex of immunohistochemical markers. The objects of the study were excised fragments of the wall of the thoracic and abdominal aorta along with visually determined unstable atherosclerotic plaques. To study nerve structures on paraffin sections, immunohistochemical reactions were performed for the PGP 9.5 protein, tyrosine hydroxylase, and synaptophysin. It has been established that pronounced pathological changes are observed in the nervous structures of the aortic wall near unstable atherosclerotic plaques. Reactive, dystrophic, and severe degenerative changes in neurocytes, nerve fibers, and glial cells are described in the elements of the nervous apparatus of the adventitia (microganglia, nerve trunks, and nerve plexuses). It was found that only sympathetic neurons and their postganglionic fibers remain in the intramural ganglia, while the structures of the parasympathetic nervous apparatus undergo degeneration. Destruction of perivascular nerve plexuses and vasa vasorum in the adventitia, as well as degeneration of varicose axons of the main terminal synaptic plexus at the border of adventitia and superficial smooth muscle layer of the media were demonstrated. It is assumed that the presence of inflammatory infiltrates in the adventitia and intima, denervation and death of vasa vasorum can serve as factors determining the development of the atherosclerotic process.

Malignant peripheral nerve sheath tumor mimicking breast cancer: a case report

Background: Malignant peripheral nerve sheath tumor (MPNST) is a rare variety of soft 10-tissue sarcoma of ectomesenchymal origin. It represents approximately 10% of all soft tissue sarcomas. Though these tumors due to their Schwann cell origin may occur anywhere near a nerve trunk, breast is a rare site of its occurrence. This is a rare case of MPNST arising in the breast and not associated with neurofibromatosis type 1. Case Presentation: A 22-year-old female presented with a large painless breast lump for 5 months, which was clinically suspected to be a Carcinoma. No confirmatory results were 18 obtained with fine needle aspiration biopsy , core biopsy, and magnetic resonance imaging. Wide local excision was done. Histopathology and immunohistochemistry confirmed MPNST. Furthermore, she underwent adjuvant radiation to her breast. Conclusion: The unusual location and size of the tumor make our study noteworthy. Owing to the infrequent occurrence of the tumor, there are no definite guidelines for its management. We recommend wide local excision with postop radiotherapy as the optimum treatment for this condition.

Гистологические особенности ряда органов куньих и их патологические изменения при неэкссудативном перитоните

The article presents the histological features of some organs of weasel family. Also described the pathological changes during nonexudative form of peritonitis of weasel family. The studies were carried out at the Department of General Pathology named after V. M. Koropov of Moscow State Academy of Veterinary Medicine and Biotechnology – MBA named after K. I. Scriabin. The objects of investigation were predatory animals weasel family both healthy and with sings of peritonitis. There are 21 sables, 11 mink cellular content and 15 domestic ferrets. In the study complex methodological approach was used, including classical anatomical preparation, post mortem and histological examination. It has been established, that abdominal wall weasel has three puffs. There are muscle layer, a layer of dense connective tissue and serous membrane. The muscle layer is showing striated muscle tissue with endomysium layers. In the endomysia of muscle febers of abdominal wall of the weasel there are mast cell. Serous membrane is represented by mesothelium, which has typical structure of single – layered squamous epithelium. Large oil seal showing of fat cells with connective tissue layers, including lymphatic capillaries, vessels and nerve trunks. In a large oil seal single mast cell concentrated around the vessels and in the connective tissue of the omentum observed clusters of mast cells. Essential features of the structural organization of the stomach walls and intestinal canal are not found, but revealed a large number of goblet cells in the mucous membrane of the colon and small intestine and mycocytes in mucous membrane of stomach. The liver has a typical structure, lobilarity is weakly expressed. Liver beams are shortned, hepatocytes fit snugly together, sinusoid capillaries are broad. In morphological organization of organs of immune defense weasel significant features are not found. In the spleen was observed a lot of white pulp. In the cortical layer of lymph node was founded a large number of follicles. Thymus has sings age involution. Kidney and lungs weasel has not significant features. Predatory animals weasel family had predominantly nonexudative form of peritonitis. Under the nonexudative peritonitis form was observed sings of acute inflammation of many organs like as system inflammatory response syndrom.