Posterior Extension Research Articles

Mediastinal goiter: a comprehensive study of 60 consecutive cases with special emphasis on identifying predictors of malignancy and sternotomy

BackgroundWe describe the clinical characteristics of patients with mediastinal goiter and our principles in surgical management of this pathology; we also identify the predictive factors of malignancy, sternotomy, and posterior mediastinal extension. MethodsWe conducted a retrospective chart review of 60 patients with mediastinal goiter who underwent surgical intervention. ResultsMajor perioperative complications were recurrent laryngeal nerve sacrifice (3.3%) and vagus nerve sacrifice (1.7%). A total of 12.7% of cases were malignant. The presence of dysphonia increased the likelihood of malignancy (P = .02), and malignancy was associated with a significant increase in sternotomy (P = .04) and nerve sacrifice (P < .001) during surgery. A history of thyroidectomy was a predictive factor for extension of the tumor to the posterior mediastinum (P = .02). ConclusionsPresenting with dysphonia is a predictor of malignancy that necessitates careful surgical planning because malignancy is associated with an increase in nerve injury and sternotomy during surgery.

Juvenile Nasopharyngeal Angiofibromas: Does an External Approach Still Make Sense?

Objective: Endoscopic removal has recently become the standard procedure in the case of small juvenile angiofibromas. However, large lesions encroaching the skull base remain a challenge. The aim of this work is to define extensions which at present cannot be addressed reasonably endoscopically. Method: Retrospective review based on cases treated from 2000 to 2010. Ratio of endoscopically treated patients has been analyzed together with staging and topographic description of these lesions. Results: Fifty-nine patients were treated from 2000 to 2010, of whom 31 were treated endoscopically. Ratio of endoscopic procedures raises from 37% (n = 10) for the 2000 to 2005 period to 84% (n = 26) for the 2006 to 2010 period. This trend, analyzed according to the staging following Radkowski, is not related to earlier diagnosis of smaller tumors, since ratio of stage IIIA is similar. Indeed, development of approaches to pterygopalatine fossa, infratemporal fossa, temporal fossa, inferior orbital fissure, orbital apex, and even cavernous sinus allowed control of deep and far-seated lesions. Conclusion: Refinement of hemostasis techniques and 4-hands surgery (Castelnuovo) allows the treatment of lateral-seated tumors, even if large. Posterior extensions may be reached through a transpterygoid approach. Only lesions which engulf the ICA or the optic nerve need further evaluation to choose between open approach or incomplete, subtotal removal.

Planar cell movements and oriented cell division during early primitive streak formation in the mammalian embryo

Formation of the mammalian primitive streak appears to rely on cell proliferation to a minor extent only, but compensating cell movements have not yet been directly observed. This study analyses individual cell migration and proliferation simultaneously, using multiphoton and differential interference contrast time-lapse microscopy of late pregastrulation rabbit blastocysts. Epiblast cells in the posterior gastrula extension area accumulated medially and displayed complex planar movements including U-turns and a novel type of processional cell movement. In the same area metaphase plates tended to be aligned parallel to the anterior-posterior axis, and statistical analysis showed that rotations of metaphase plates causing preferred orientation were near-complete 8 min before anaphase onset; in some cases, rotations were strikingly rapid, achieving up to 45° per min. The mammalian primitive streak appears to be formed initially with its typically minimal anteroposterior elongation by a combination of oriented cell divisions with dedicated planar cell movements.

Percutaneous Vertebroplasty for Pain Management in Spinal Metastasis with Epidural Involvement

Percutaneous vertebroplasty (PVP) has been widely used for the treatment of painful malignant lesions of the spine. Spinal metastasis with epidural involvement, with or without symptoms of neurologic compression, is regarded by some authors as a contraindication or relative contraindication to the procedure. To evaluate safety and effectiveness of PVP in pain management of spinal metastasis with epidural involvement, we retrospectively analyzed PVP in 32 patients with metastatic disease, who presented with at least one vertebral lesion with destruction of the posterior vertebral body wall or epidural extension of tumor. Among these patients, nine had signs of spinal cord or cauda equina compression. Procedural safety was evaluated by any post-procedure adverse events. The PVP analgesic efficacy was evaluated by follow-up neurological examination. Pain intensity was scored on a visual analog scale scored from 0 (no pain) to 10 (maximum pain intensity). The effective pain relief was defined as at least 50% improvement in pain score as compared with pre- procedure baseline. Follow-up assessments were performed at 1 day; 1 week; 1, 3, and 6 months after the procedure. Fifty-three vertebrae in 32 patients were treated in this group. Analgesic efficacy in survival patients was rated at 97% (31/32) at 1day and 1 week, 86.7% (26/30) at 1 month, 82.3% (24/29) at 3 months, and 76.9% (20/26) at 6 months after procedure. Leakage of PMMA was detected in 64% (33/53) treated vertebrae. No systemic complications were observed in all treated patients.

Posterior cranial fossa extension of congenital cholesteatoma in children : report of two cases

Posterior cranial fossa extension of congenital cholesteatoma in children : report of two cases

Sutureless Sacrocolpopexy with Absorbable and Nonabsorbable Tacks for Mesh Fixation

Abstract Introduction: Sacrocolpopexy is the gold standard for high-stage pelvic organ prolapse and has attained this reputation from many successful years in achieving optimal success and duration of surgical results. Reducing the time and potential difficulties with this procedure would be a useful venture for the surgeon. We describe in this video our approach to the utilization of absorbable and nonabsorbable tacks for fixation of both anterior and posterior polypropylene mesh extensions to both the vaginal walls and sacrum. Methods: Between January 2008 and September 2009, 62 patients underwent sacrocolpopexy with absorbable and nonabsorbable tacks (Absorbatack and Protack; Covidien, Mansfield, MA) for repair of stage 2 or more pelvic organ prolapse of at least two pelvic compartments. All surgeries included a tension-free vaginal tape obturator or tension-free vaginal tape Secur (Gynecare, Southfield, NJ) for potential stress urinary incontinence (not demonstrated in video). The absorbable tacks (va...

Vertebral Collapse Caused by Bone Metastasis

A 70-year-old woman with multiple sclerosis was hospitalized with diarrhea, fever 38.3°C, and severe midthoracic back pain for 1 week. The patient was paraplegic with complete paralysis and loss of sensation in both legs and lower abdomen. She was diagnosed with a hypernephroma of the right kidney in 1997, for which a nephrectomy was performed. She refused further follow-up. On computed tomography scan, invasion of several thoracic vertebrae (Th 4, Th 5, Th 6, and partial Th 7) was seen with a 90° angulation of the proximal dorsal pillar compared with the distal pillar (Figure 1A and B). An extraaxial posterior extension was observed. The lesion was biopsied, performed under echographic control, showing a well-differentiated renal cell metastasis. The bone fragments, anterior of the vertebrae, are believed to be parts of the adjacent ribs (Figure 1B). Intravenous morphine was administered to help her cope with the pain. The patient died 10 days after computed tomography scan images were taken. *Department of Radiotherapy, Ghent University Hospital; †Department of Gastro-Enterology, Digestive Oncology, AZ Oudenaarde; and ‡Department of Radiology, AZ Oudenaarde, Belgium. Disclosure: The authors declare no conflicts of interest. Address for correspondence: Dieter Berwouts, Department of Radiotherapy, Ghent University Hospital, De pintelaan 185 Ghent, Belgium. E-mail: dieter.berwouts@ugent.be Copyright © 2011 by the International Association for the Study of Lung Cancer ISSN: 1556-0864/11/0604-0823

Diagnostic Algorithm for a Validated Displacement Grading of Pediatric Supracondylar Fractures

The first AO comprehensive pediatric long bone fracture classification system has been established following a structured path of development and validation with experienced pediatric surgeons. A follow-up series of agreement studies was applied to specify and evaluate a grading system for displacement of pediatric supracondylar fractures. An iterative process comprising an international group of 5 experienced pediatric surgeons (Phase 1) followed by a pragmatic multicenter agreement study involving 26 raters (Phase 2) was used. The last evaluations were conducted on a consecutive collection of 154 supracondylar fractures documented by standard anteroposterior and lateral radiographs. Fractures were classified according to 1 of 4 grades: I=incomplete fracture with no or minimal displacement; II=Incomplete fracture with continuity of the posterior (extension fracture) or anterior cortex (flexion fracture); III=lack of bone continuity (broken cortex), but still some contact between the fracture planes; IV=complete fracture with no bone continuity (broken cortex), and no contact between the fracture planes. A diagnostic algorithm to support the practical application of the grading system in a clinical setting, as well as an aid using a circle placed over the capitellum was proposed. The overall κ coefficients were 0.68 and 0.61 in the Phase 1 and Phase 2 studies, respectively. In the Phase 1 study, fracture grades I, II, III, and IV were classified with median accuracies of 91%, 82%, 83%, and 99.5%, respectively. Similar median accuracies of 86% (Grade I), 73% (Grade II), 83% (Grade III), and 92% were reported for the Phase 2 study. Reliability was high in distinguishing complete, unstable fractures from stable injuries [ie, κ coefficients of 0.84 (Phase 1) and 0.83 (Phase 2) were calculated]; in Phase 2, surgeons' accuracies in classifying complete fractures were all above 85%. With clear and unambiguous definition, this new grading system for supracondylar fracture displacement has proved to be sufficiently reliable and accurate when applied by pediatric surgeons in the framework of clinical routine as well as research. Diagnostic study, Level II.

Comparison of overjet among 3 arch types in normal occlusion

The purposes of this study were to examine the amounts of overjet in the anterior and posterior segments of 3 arch forms by using facial axis points on 3-dimensional virtual models and to verify the minimum posterior extension required for classification of the arch form in normal occlusions. Facial axis points were digitized on 97 virtual models with normal occlusion, classified into 20 tapered, 25 ovoid, and 52 square arch forms. Intercanine and intermolar arch widths and depths were measured. The best-fitting curves were created, and overjet was measured at each facial axis point. Two-way analysis of variance (ANOVA) was performed to assess the relationship between arch form and overjet in different areas. The minimum posterior extension to determine arch type was analyzed with the chi-square test. Subjects with a tapered arch form had larger overjet compared with those with ovoid and square forms, except at the central incisor. A significant difference in overjet among different areas was found in subjects with a square arch form (P<0.0001). No significant difference (P = 0.864) was found among the first and second premolar and the first molar groups for classifying arch-form types. A significant difference was found in anterior and posterior overjet according to arch types. The extension to the first premolar was sufficient to classify arch form type. It might be beneficial to consider more coordinated preformed superelastic archwires according to variations in overjet of different arch types.

Inflammatory Pseudotumor of the Kidney

Inflammatory pseudotumor of the kidney is a rare benign condition with unknown etiology that can mimic malignancy. We report a case of inflammatory pseudotumor of the kidney. A 59-year-old male patient was admitted with a complaint of right flank pain and hematuria. Ultrasonography and magnetic resonance imaging of the patient revealed a 9 cm × 10 cm mass originating from the renal parenchyma with posterior extension. Operative findings revealed a mass adhering to the psoas muscle. Histopathologic examination demonstrated spindle-shaped fibroblast cells accompanying inflammatory cells. The pathological diagnosis was renal inflammatory pseudotumor. Repeated US and computed tomography revealed complete remission.

Posterior Palatal Seal: A Literature Review

ABSTRACT Complete dentures may suffer from a lack of proper border extension, but most important of all is the posterior palatal extension on maxillary complete dentures. The posterior border terminates on a surface that is movable in varying degrees and not at a turn of tissue as are the other denture borders. Locating and designing of posterior palatal seal after thorough understanding of the anatomic and physiological boundaries of this dynamic region greatly enhances border seal and increases maxillary complete denture retention. The diagnostic evaluation and placement of posterior seal are often given only minor attention in complete denture construction. This article reviews the importance of the posterior palatal seal with regard to its anatomy, location, design and placement.

The Electrophysiological Characteristics of Slow/Fast Atrioventricular Nodal Reentrant Tachycardia with Left Posterior Nodal Extension

Introduction: In some slow/fast AVNRT patients, the left posterior nodal extension (LPNE) may form a part of antegrade slow pathway (SP) and ablation in the CS is necessary to eliminate the tachycardia. Methods and Results: We investigated electrophysiological properties of antegrade SP in 62 consecutive slow/fast AVNRT patients. In 10 patients (16.1%), ablation in the CS was necessary to eliminate the tachycardia (CS group), whereas ablation only at the conventional SP area was effective in other patients (83.9%, SP group). In CS group, AVNRT were induced with second AH jump-up phenomenon (N=6) and atrial double response (N=4) whereas, AVNRT were induced with single jump-up phenomenon in all of SP group patients. During AVNRT, there were no significant differences in tachycardia cycle length, AH and HA interval between the two groups. AH interval just before tachycardia induction (AH-t) was significantly longer in CS group than SP group (482±103 vs. 310±57 ms, p<0.01). An AH-t of 375 ms led to a sensitivity of 80% and a specificity of 84% for supposing that antegrade SP locates in CS. Conclusion: In slow/fast AVNRT patients, the long AH-t suggests that the LPNE participates the tachycardia initiation and ablation in the CS can eliminate the tachycardia.

Two Cases of Enlarged Zuckerkandl's Tubercle of the Thyroid Displacing the Recurrent Laryngeal Nerve Laterally

The thyroid has many anatomic variations. Zuckerkandl's tubercle (ZT) is the posterior extension of lateral lobes. ZT has a relation with the recurrent laryngeal nerve (RLN). RLN lateral to ZT is an uncommon occurrence. This paper presents two cases of this uncommon situation. A 60-year-old female patient with large multinodular goiter was treated with total thyroidectomy. A 69-year-old male patient with follicular neoplasm was treated with total lobectomy. The inferior thyroid arteries and the recurrent laryngeal nerves were identified with usual lateral approach. A left ZT was found in case 1 and a right ZT in case 2. Distal parts of the RLNs were displaced laterally by enlarged ZTs in both cases. Grade 3 ZTs composed of thyroid tissue were placed between the trachea and the RLNs. The ZT is a common anatomic feature of the thyroid. Close relation of the tubercle with the RLN is an important surgical entity. The enlarged ZT seldom pushes the nerve laterally. The knowledge of the anatomy of ZT and its relation with the RLN including all variations is mandatory for safe thyroid operations.

The anatomy of the basal turtle Eileanchelys waldmani from the Middle Jurassic of the Isle of Skye, Scotland

ABSTRACTThe stem turtle Eileanchelys waldmani is known from the Bathonian deposits of the Kilmaluag Formation, Isle of Skye, Scotland. A description of all the currently available material, including several skulls and shells, is provided herein. Eileanchelys waldmani is characterised by a mosaic of plesiomorphic and derived features. The former include a flat vomer, a reduced posterior extension of the pterygoid, the absence of flooring of the cavum acustico-jugulare, the absence of proper recessus scalae tympani, wide vertebral scales, a vertebral 3–4 sulcus on neural 6, a pair of mesoplastra meeting medially, and platycoelous cervical vertebrae. Derived features include a prefrontal–vomer contact, an elongate postorbital skull, a well-developed antrum postoticum, and a slender processus interfenestralis of the opisthotic. Eileanchelys waldmani also possesses unique features such as a possible ninth neural or supernumerary suprapygal of unusual shape, as well as a broad first suprapygal that contacts the peripherals laterally. Additionally, E. waldmani documents the evolution of the vomer and basicranium from basalmost turtles to the crown-group.

An Unexpected Abnormality on the EEG

An Unexpected Abnormality on the EEG

The hilum overlay sign in a child

A 9-month-old girl presented with a 1-month history of coughing. A chest X-ray (CXR) was performed, and the antero-posterior view demonstrated the hilum overlay sign. Furthermore, there was absence of the azygo-oesophageal line and bilateral paraspinal lines. The lateral CXR revealed a posterior mediastinal mass. Subsequently, a computed tomogram of the chest confirmed a posterior mediastinal mass, with calcifications and intraspinal extension consistent with neuroblastoma. Histological analysis confirmed this mass as a neuroblastoma.

Osteology of some catfishes of the genus Glyptothorax (Teleostei: Siluriformes) of northeastern India

The morphology of the premaxilla, dentary, Weberian lamina, infraorbital series, vomer and frontal bones were observed in eight species of Glyptothorax of northeastern India. In G. botius, G. granulus, G. manipurensis, G. ngapang, G. striatus and G. ventrolineatus, the premaxilla consists only of proximal and distal tooth plates, the anterior portion of the dentary is slender and its dorsal surface bears villiform teeth, the lateral extension of posterior portion of Weberian lamina terminates at the level of the lateral margin of its anterior portion, and the frontal has a shallow orbital notch. In G. cavia and G. chindwinica, the premaxilla consists of proximal, distal and posterior elements on the roof of the oral cavity; the anterior portion of the dentary bears posterior extension of dentary tooth-plate; the lateral extension of the posterior portion of Weberian lamina extends almost to the distal tip of the fifth parapophysis; there are nine or ten infraorbital bones with a longer and broader body of the lacrimal; greatly enlarged vomerine head; and frontal bears a deep orbital notch. The jaw structure of G. burmanicus is discussed.

Laparoscopic sacral colpoperineopexy: abdominal versus abdominal–vaginal posterior graft attachment

Laparoscopic sacral colpoperineopexy (LSCP) involves posterior graft extension to the perineum for improved posterior support. The objective of this study was to determine whether posterior measurements differed between those that had graft extension done abdominally (A-LSCP) or abdomino-vaginally (AV-LSCP). This was a retrospective cohort study of patients that underwent A-LSCP (n = 17) and AV-LSCP (n = 51). Pre-, peri-, and postoperative variables were compared using Student's t, Fisher's exact, and analysis of covariance tests. Follow-up was 6 to 12 months. There were no differences between A-LSCP and AV-LSCP for any vaginal measurements or stage of prolapse (P > 0.05). Although not statistically different, A-LSCP patients had lower rates of mesh erosion and dyspareunia (P > 0.05). AV-LSCP patients had fewer prolapse symptoms (P = 0.01), but both groups had similar surgical satisfaction (P= 0.8). A-LSCP and AV-LSCP had comparable effects on posterior vaginal measurements; however, mesh erosion and subjective outcomes differed between the two approaches.

Reply to Atoui and de Varennes

We read with great interest the review article ‘Chronic ischaemic mitral regurgitation — current treatment results and new mechanism-based surgical approaches’ by Bouma and colleagues in a past issue of this journal [1]. Management of severe ischaemic mitral regurgitation remains challenging with disappointing long-term surgical results. Furthermore, despite the increasing popularity of valve repair, its longterm durability in chronic ischaemic mitral regurgitation continues to be uncertain. In this article, the authors worked in an excellentmanner to review the different mechanisms of ischaemic mitral regurgitation, and to describe the variety of surgical approaches used to deal with this entity. To address leaflet tethering commonly observed in these patients, our group had recently reported the midterm results of posterior leaflet extension with a bovine pericardium, coupled with remodelling annuloplasty [2]. After extending the posterior leaflet height by about 1 cm from the medial half of P2 to the end of P3 in 44 consecutive patients with type IIIb ischaemic mitral regurgitation, the observed actuarial freedom from recurrent mitral regurgitation was 90% at 2 years. This also correlated with 90% of patients remaining in the New York Heart Association class I at 2 years. We believe that this is a relatively easy technique, safely reproduced, which can lead to good midterm results. Longer follow-up is necessary to assess the competency of the mitral valve and confirm the effectiveness of this approach.

The parabasisphenoid complex in Mesozoic turtles and the evolution of the testudinate basicranium

During the early development of turtles and other amniotes, the parabasisphenoid, or basisphenoid s.l., is formed by at least two centers of ossification: the endochondral basisphenoid s.s. and the dermal parasphenoid. This fusion is usually so dramatic that the two elements cannot be distinguished from each other in the adult stage. Here, we describe the basicranium of two species of Mesozoic turtles from Europe, Plesiochelys etalloni and Pleurosternon bullockii , partly using micro-CT (computer tomography) scans, and show that in both taxa para- and basisphenoid remain distinguishable throughout life. We also identify the extent that each of the two elements has contributed to the formation of the braincase floor. Because the structure of the parabasisphenoid determines the course of the internal carotid artery into the skull, our findings allow us to discuss the early evolution of the carotid pattern and the turtle basicranium in new detail. By surveying the main patterns of carotid circulation in extinct and extant turtles, we bring new evidence to the idea that it was largely the ossification of the parasphenoid that, along with the closure of the interpterygoid vacuity and the posterior extension of the pterygoids, shaped the internal carotid patterns as seen in modern turtles.