Posteroinferior Region Research Articles

Clinical Case Report: Use of Essential Oils in Chronic Dermal Wound

Currently, there is a trend towards adopting treatments with more natural alternative products over synthetic ones. Essential oils are known for their numerous medicinal properties (from physical to emotional issues) and have been used by the population for millennia. They contain volatile compounds that have therapeutic properties. Their complex chemical composition provides plants with adaptive advantages in their environment and can be used as important active principles in products intended for human treatment. Essential oils also have antioxidant properties, preventing cellular damage and premature aging (such as lemon, lavender, and sweet orange essential oils, for example). Regarding antimicrobial properties, various essential oils have shown activity against bacteria, fungi, and viruses. For example, tea tree oil has been effective against various bacteria and fungi, including methicillin-resistant Staphylococcus aureus (MRSA) and Candida albicans. Additionally, essential oils are widely used for analgesic purposes, such as peppermint, lavender, eucalyptus, and clove, or essential oils that can reduce anxiety, improve mood, and promote relaxation like lavender, sweet orange, bergamot, and ylang-ylang. Another interesting oil is used in important ingredients in incenses and perfumes, the extract from gum resins obtained from the Burseraceae family trees (Boswellia sp.) that have anti-inflammatory and antineoplastic effects. Chemical components like linalool, linalyl acetate, terpinen-4-ol, 1,8 cineole, pinenes, γ-terpinene, borneol, limonene, α-thujene, and menthol are some of the main components found in various essential oils. The most abundant phenol in oregano essential oil is a potent antibacterial agent. The aim was to report an individual clinical case, in home care, requested by a physical educator, of a female patient, leucoderma, 74 years old, residing in the State of São Paulo, presenting a chronic wound in the posteroinferior region of the right leg that was not responding to conventional methods (antibiotics, anti-inflammatories, analgesics, in addition to laser therapy) for more than two months. She also faced respiratory problems, sleep difficulties, mild depression, and reduced mobility. She reported being a controlled diabetic, hypertensive, and having occupational asthma. As a requested choice, aromatherapy was the sought treatment, and a protocol was established considering both physical and emotional aspects, recommending topical and aromatic use of essential oils of oregano, lavender, tea tree, frankincense, in addition to fractionated coconut and rosehip vegetable oils as diluents. After 47 days, the wound had healed, and the patient showed optimism and improved sleep quality. Aromatherapy offers a holistic and gentle approach to treating various conditions, and this case is an inspiring example of how essential oils can make a difference in people's lives. However, more clinical studies with a larger population are necessary to investigate the treatment's efficacy and safety.

Cholesteatoma of the External Auditory Canal a Rare Pathology: Case Report

Introduction: Cholesteatoma of the external auditory canal (ECA) is a rare nosological entity, it is characterized by the invasion of squamous tissue in an area of the external auditory canal (EAC), generally in the posteroinferior region, which is accompanied by bone erosion [1]. Clinical case: 30-year-old female patient with no known pathological history who presented with a 7-day history of clinical symptoms characterized by left ear otalgia associated with foul-smelling otorrhea and temperature rises at the beginning of the condition, receiving antibiotic treatment with amoxicillin (for 7 days). Without improvement, later it is associated with intense headache at the occipital level, nausea, vomiting and dizziness. Discussion: The percentage of men and women is similar in adulthood. The most frequent location is posteroinferior and in most cases the origin is primary. Otalgia and otorrhea were the main symptoms. In general, treatment is conservative, but a surgical approach was necessary in a third of patients through analoplasty or mastoidectomy, depending on the extent of the lesions [2]. Conclusion: Although we do not know the pathogenic mechanisms responsible for the formation and development of CCAE, the inclusion of keratin between the epithelium and the bone, with the participation of the periosteum, seem to be the triggers of the process. The diagnosis is clinical and its extent determines the use of local or surgical treatment, which is usually resolving [4].

Cavernous Malformations: What They Have Taught Us.

Cavernous Malformations: What They Have Taught Us.

Anatomic, qualitative, and quantitative evaluation of the variants of the infratentorial supracerebellar approach to the posteroinferior thalamus.

The posteroinferior region of the thalamus is formed by the pulvinar, and it is surgically accessed through the infratentorial supracerebellar approach, between the midline and the retromastoid region. This study aimed to compare the paramedian, lateral, extreme lateral, and contralateral paramedian corridors with the posteroinferior thalamus through a suboccipital craniotomy and an infratentorial supracerebellar access. Ten cadavers were studied, and the microsurgical dissections were accompanied by the measurement of the variables using a neuronavigation system. Statistical analysis was performed using analysis of variance (ANOVA). The distance between the access midpoint at the cranial surface and pulvinar varied between 53.3 and 53.9mm, the contralateral access being an exception (59.9mm). The vertical angle ranged from 20.6° in the contralateral access to 23.5° in the lateral access. There was a gradual increase in the horizontal angle between the paramedian (17.4°), lateral (31.3°), and extreme lateral (43.7°) accesses. But, this angle in the contralateral access was 14.6°, similar to that of the paramedian access. The exposed area of the thalamus was 125.1mm2 in the paramedian access, 141.8mm2 in the lateral access, and 165.9mm2 in the extreme lateral access, which was similar to that of the contralateral access (164.9mm2). The horizontal view angle increased with lateralization of the access, which facilitated microscopic visualization. With regard to the exposure of the microsurgical anatomy, the extreme lateral and contralateral accesses circumvent the neural and vascular obstacles at the midline, allowing a larger area of anatomical exposure.

Biomechanical analysis of proximal tibia bone grafting and the effect of the size of osteotomy using a validated finite element model.

Harvesting bone graft from the proximal tibia is gaining popularity, with lower complication rates and adequate quantity of cancellous bone. The amount of harvested bone is dependent on the size of the cortical window introduced via osteotomy onto the proximal tibia, and its mechanical strength after surgery could be compromised. The aim of the study was to investigate the proximal tibia's mechanical stability after bone harvesting and the effect of varying window sizes using a validated finite element model. Two cadaveric tibiae were tested with bone strains measured for different circular cortical window diameters (10-25mm). Sixteen finite element models of the intact and harvested tibia were simulated and validated with experimental data. The experimental and predicted max/min principal bone strains were fitted into regression models and showed good correlations. It was predicted the maximum principal bone stresses were greatest and concentrated at postero-inferior and antero-superior regions of the cortical window. A stress line progressed from the edge of the window to the posterior side of the tibia, which became more prominent with the increase of size of the cortical window. It was found that large circular osteotomies for bone harvesting at the proximal tibia induced stress concentrations and stress lines which could lead to eventual failure. Graphical abstract The formation of a stress line in the harvested tibia initiated from the postero-inferior edge of the window and progressed to the medial side. The stress line became more prominent with the increase of the size of the cortical window from 10 to 25mm in diameter.

Unipolar electrogram-guided radiofrequency catheter ablation in paroxysmal atrial fibrillation: electrogram patterns and outcomes.

Transmural lesions (TLs) are the crucial point for radiofrequency catheter ablation (RFCA) in atrial fibrillation (AF) patients. Previous studies have reported that complete positive unipolar electrogram (UP-EGM) after ablation is associated with transmural lesions. However, UP-EGM patterns may differ in different regions of continuous circular lesions (CCLs) around the pulmonary vein ostia after ablation. We aimed to analyze the different UP-EGM patterns in different CCL regions after ablation and the effectiveness of UP-EGM guided RFCA in paroxysmal atrial fibrillation (PAF). A total of 43 patients with PAF (aged 59 ± 11years; 65% male) were consecutively included. Pulmonary vein isolation was achieved by contiguous point-by-point RFCA. UP-EGM was recorded by the ablation catheter. Both CCLs were divided into six regions. Two points were randomly chosen from each region to analyze UP-EGM type after ablation. All the patients were followed for atrial arrhythmias recurrence. All pulmonary veins were isolated with complete bidirectional block. A total of 1032 RFCA points with complete positive UP-EGM were collected. UP-EGM morphology after ablation was divided into four different types defined as R, rR', Rr', and M. M patterns mostly appeared in anterosuperior (65%) and roof (49%) regions of left CCLs. In the remaining regions, the percentage of non-M patterns (R, rR', and Rr') ranged from 63% in posteroinferior regions of right CCLs to 88% in anteroinferior regions of right CCLs. After a mean follow-up time of 19months, 37 (86%) patients remained in sinus rhythm. Most (72%) UP-EGM types after ablation are non-M patterns. Pulmonary vein isolation guided by UP-EGM with a complete positive pattern in PAF patients is reliable.

Trabecular bone patterning in the hominoid distal femur.

BackgroundIn addition to external bone shape and cortical bone thickness and distribution, the distribution and orientation of internal trabecular bone across individuals and species has yielded important functional information on how bone adapts in response to load. In particular, trabecular bone analysis has played a key role in studies of human and nonhuman primate locomotion and has shown that species with different locomotor repertoires display distinct trabecular architecture in various regions of the skeleton. In this study, we analyse trabecular structure throughout the distal femur of extant hominoids and test for differences due to locomotor loading regime.MethodsMicro-computed tomography scans of Homo sapiens (n = 11), Pan troglodytes (n = 18), Gorilla gorilla (n = 14) and Pongo sp. (n = 7) were used to investigate trabecular structure throughout the distal epiphysis of the femur. We predicted that bone volume fraction (BV/TV) in the medial and lateral condyles in Homo would be distally concentrated and more anisotropic due to a habitual extended knee posture at the point of peak ground reaction force during bipedal locomotion, whereas great apes would show more posteriorly concentrated BV/TV and greater isotropy due to a flexed knee posture and more variable hindlimb use during locomotion.ResultsResults indicate some significant differences between taxa, with the most prominent being higher BV/TV in the posterosuperior region of the condyles in Pan and higher BV/TV and anisotropy in the posteroinferior region in Homo. Furthermore, trabecular number, spacing and thickness differ significantly, mainly separating Gorilla from the other apes.DiscussionThe trabecular architecture of the distal femur holds a functional signal linked to habitual behaviour; however, there was more similarity across taxa and greater intraspecific variability than expected. Specifically, there was a large degree of overlap in trabecular structure across the sample, and Homo was not as distinct as predicted. Nonetheless, this study offers a comparative sample of trabecular structure in the hominoid distal femur and can contribute to future studies of locomotion in extinct taxa.

Stereotactic radiosurgery for medically refractory multiple sclerosis-related tremor.

OBJECTIVE Multiple sclerosis (MS) is a neurodegenerative disease that can lead to severe intention tremor in some patients. In several case reports, conventional radiotherapy has been reported to possibly exacerbate MS. Radiosurgery dramatically limits normal tissue irradiation to potentially avoid such a problem. Gamma Knife thalamotomy (GKT) has been established as a minimally invasive technique that is effective in treating essential tremor and Parkinson's disease-related tremor. The goal in this study was to analyze the outcomes of GKT in patients suffering from medically refractory MS-related tremor. METHODS The authors retrospectively studied the outcomes of 15 patients (mean age 46.5 years) who had undergone GKT over a 15-year period (1998-2012). Fourteen patients underwent GKT at a median maximum dose of 140 Gy (range 130-150 Gy) using a single 4-mm isocenter. One patient underwent GKT at a dose of 140 Gy delivered via two 4-mm isocenters (3 mm apart). The posteroinferior region of the nucleus ventralis intermedius (VIM) was the target for all GKTs. The Fahn-Tolosa-Marin clinical tremor rating scale was used to evaluate tremor, handwriting, drawing, and drinking. The median time to the last follow-up was 39 months. RESULTS After GKT, 13 patients experienced tremor improvement on the side contralateral to surgery. Four patients noted tremor arrest at a median of 4.5 months post-GKT. Seven patients had excellent tremor improvement and 6 had good tremor improvement. Four patients noted excellent functional improvement, 8 noted good functional improvement, and 1 noted satisfactory functional improvement. Three patients experienced diminished tremor relief at a median of 18 months after radiosurgery. Two patients experienced temporary adverse radiation effects. Another patient developed a large thalamic cyst 60 months after GKT, which was successfully managed with Ommaya reservoir placement. CONCLUSIONS Gamma Knife thalamotomy was found to be a minimally invasive and beneficial procedure for medically refractory MS tremor.

Modeling Urinary Dysfunction After External Beam Radiation Therapy of the Prostate Using Bladder Dose-Surface Maps: Evidence of Spatially Variable Response of the Bladder Surface

We assessed the association of the spatial distribution of dose to the bladder surface, described using dose-surface maps, with the risk of urinary dysfunction. The bladder dose-surface maps of 754 participants from the TROG 03.04-RADAR trial were generated from the volumetric data by virtually cutting the bladder at the sagittal slice, intersecting the bladder center-of-mass through to the bladder posterior and projecting the dose information on a 2-dimensional plane. Pixelwise dose comparisons were performed between patients with and without symptoms (dysuria, hematuria, incontinence, and an International Prostate Symptom Score increase of ≥10 [ΔIPSS10]). The results with and without permutation-based multiple-comparison adjustments are reported. The pixelwise multivariate analysis findings (peak-event model for dysuria, hematuria, and ΔIPSS10; event-count model for incontinence), with adjustments for clinical factors, are also reported. The associations of the spatially specific dose measures to urinary dysfunction were dependent on the presence of specific symptoms. The doses received by the anteroinferior and, to lesser extent, posterosuperior surface of the bladder had the strongest relationship with the incidence of dysuria, hematuria, and ΔIPSS10, both with and without adjustment for clinical factors. For the doses to the posteroinferior region corresponding to the area of the trigone, the only symptom with significance was incontinence. A spatially variable response of the bladder surface to the dose was found for symptoms of urinary dysfunction. Limiting the dose extending anteriorly might help reduce the risk of urinary dysfunction.

Association of P53 Protein Overexpression with Clinicopathological Features of Oral Squamous Cell Carcinoma Patients in Bali

Background: Oral cancer was a major health problem with a high incidence rate worldwide. Oral Squamous Cell Carcinoma (OSCC) in Bali, ranked as the second most common cancer after cervix carcinoma. Our understanding of OSCC hasn’t yielded a satisfactory clinical outcome; therefore, further studies about the role of biomolecular markers in OSCC are still needed. One of the biomolecular markers for prognosis and predictor for OSCC that has been a topic of research to date is p53. Method: This is a cross-sectional analytical study of 36 samples to determine the correlation between p53 overexpression with age group, tumor location, tumor stage, and tumor grade in OSCC patients. Data was processed descriptive and analytical using Chi-Square/Fisher 's Exact Test methods with a significance value of p <0.05 was considered significant. Results: From the 36 samples collected, the mean age was 55,19±14,712 years, 19 samples (52.8%) were women, 21 samples (58,3%) were ?60 years, 24 samples (66,7%) had OSCC on the postero inferior region, 19 samples (52,8%) were in high stage group, 22 samples (61,1%) had high grade OSCC, and 22 samples (61,1%) showed high p53 overexpression. There were significant differences in proportion between OSCC grade with p53 expression (Chi-square test p=0,013; r=0,416; OR=6,12 CI=95%) and between OSCC N stage with p53 expression (Fisher's Exact Test p=0,024; r=0,396; OR=6,33 CI=95%). Conclusion: There were significant differences in the proportion between OSCC grade and N stage with p53 expression. Therefore, p53 overexpression can be used as a prognostic indicator and predictor of lymph node involvement in OSCC.

Bedside Lung Ultrasound During Acute Chest Syndrome in Sickle Cell Disease.

Lung ultrasound (LU) is increasingly used to assess pleural and lung disease in intensive care unit (ICU) and emergency unit at the bedside. We assessed the performance of bedside chest radiograph (CR) and LU during severe acute chest syndrome (ACS), using computed tomography (CT) as the reference standard.We prospectively explored 44 ACS episodes (in 41 patients) admitted to the medical ICU. Three imaging findings were evaluated (consolidation, ground-glass opacities, and pleural effusion). A score was used to quantify and compare loss of lung aeration with each technique and assess its association with outcome.A total number of 496, 507, and 519 lung regions could be assessed by CT scan, bedside CR, and bedside LU, respectively. Consolidations were the most common pattern and prevailed in lung bases (especially postero-inferior regions). The agreement with CT scan patterns was significantly higher for LU as compared to CR (κ coefficients of 0.45 ± 0.03 vs 0.30 ± 0.03, P < 0.01 for the parenchyma, and 0.73 ± 0.08 vs 0.06 ± 0.09, P < 0.001 for pleural effusion). The Bland and Altman analysis showed a nonfixed bias of −1.0 (P = 0.12) between LU score and CT score whereas CR score underestimated CT score with a fixed bias of −5.8 (P < 0.001). The specificity for the detection of consolidated regions or pleural effusion (using CT scan as the reference standard) was high for LU and CR, whereas the sensitivity was high for LU but low for CR. As compared to others, ACS patients with an LU score above the median value of 11 had a larger volume of transfused and exsanguinated blood, greater oxygen requirements, more need for mechanical ventilation, and a longer ICU length of stay.LU outperformed CR for the diagnosis of consolidations and pleural effusion during ACS. Higher values of LU score identified patients at risk of worse outcome.

Accuracy of 3D dual echo steady state (DESS) MR arthrography to quantify acetabular cartilage thickness.

To deploy and quantify the accuracy of 3D dual echo steady state (DESS) MR arthrography with hip traction to image acetabular cartilage. Clinical magnetic resonance imaging (MRI) sequences used to image hip cartilage often have reduced out-of-plane resolution and may lack adequate signal-to-noise to image cartilage. Saline was injected into four cadaver hips placed under traction. 3D DESS MRI scans were obtained before and after cores of cartilage were harvested from the acetabulum; the two MRIs were spatially aligned to reference core positions. The thickness of cartilage cores was measured under microscopy to serve as the reference standard. 3D reconstructions of cartilage and subchondral bone were generated using automatic and semiautomatic image segmentation. Cartilage thickness estimated from the 3D reconstructions was compared to physical measurements using Bland-Altman plots. As revealed by the automatic segmentation mask, saline imbibed the joint space throughout the articulating surface, with the exception of the posteroinferior region in two hips. Locations where air bubbles were introduced and regions of suspected low density bone disrupted an otherwise smooth automatic segmentation mask. Automatic and semiautomatic segmentation yielded a bias ± repeatability coefficient (95% limits of agreement) of 0.10 ± 0.51 mm (-0.41 to 0.61 mm) and 0.06 ± 0.43 mm (-0.37 to 0.49 mm), respectively. Cartilage thickness can be estimated to within ∼0.5 mm of the physical value with 95% confidence using 3D reconstructions of 3D DESS MR arthrography images. Manual correction of the automatic segmentation mask may improve reconstruction accuracy.

Lateral extent and ventral laminar attachments of the lumbar ligamentum flavum: cadaveric study

Background contextCadaveric descriptions of the deep layer of the lumbar ligamentum flavum (LF), extending between contiguous borders of adjacent laminae and into the lateral spinal canal region are limited. PurposeTo provide detailed descriptions of the lumbar LF. Study designCadaveric dissection. MethodsThe deep ligamentum flava of 14 formalin-fixed human cadaver lumbar spines (140 levels) were examined to assess their laminar attachments and lateral extents in relation to the intervertebral foramen. ResultsThe variable attachment of the deep layer of the LF with respect to the cephalad and caudad laminae was identified and described. At each successive caudal level of the lumbar spine, the deep layer appeared to become a more prominent feature of the posterior vertebral column, lining more of the laminae to which it is attached and encroaching further into the posteroinferior region of the intervertebral foramen at its lateral margins. ConclusionsWe describe our observations of the deep LF in the human lumbar spine. These observations have clinical relevance for the interpretation of radiologic imaging and the performance of adequate decompression in the setting of spinal stenosis.

Malignant Peripheral Nerve Sheath Tumor in Neurofibromatosis Type 1

A young adult man with neurofibromatosis type 1 (NF1) presented with a several-month history of an increasingly painful mass in the posteroinferior region of the right thigh. Imaging studies (Figure) showed a relatively well-circumscribed mass, 15 cm in length and 7 cm in diameter, arising on a background of very extensive involvement of the peripheral nervous system by plexiform neurofibromas. A biopsy specimen of the mass showed a high-grade (World Health Organization grade IV) malignant peripheral nerve sheath tumor (MPNST). An above-knee amputation was subsequently performed and the MPNST (Figure, inset A) was found to arise in continuity with one of the many preexisting low-grade (World Health Organization grade I) plexiform neurofibromas (Figure, inset B shows an example of such in the leg). For approximately 3.5 years following surgery and radiotherapy, there was no evidence of local tumor recurrence. The patient then was seen with a large left-sided retroperitoneal mass that was histopathologically confirmed to also be an MPNST, possibly a metastasis from the original thigh tumor but more likely a de novo primary tumor. He subsequently underwent several major debulking surgeries, radiotherapy, and rounds of chemotherapy, including palliative doxorubicin, for increasingly disseminated metastatic disease. He died approximately 7 years after his initial presentation.

Understanding the Pincer - The Importance of Reference Plane Orientation on Acetabular Rim Evaluation

Objectives:Femoroacetabular impingement (FAI) is a common cause of young adult hip pain. FAI can result from an acetabular-sided bony lesion, or “pincer” lesion. A pincer lesion is defined as an area of linear contact between the acetabular rim and the femoral head-neck junction due to general or focal acetabular overcoverage. Three dimensional (3D) analysis of the acetabular rim morphology is essential to understand etiology and aciculate diagnosis of the of the pincer type FAI. A few studies have measured 3D geometry of the acetabular rim; in which the acetabular rim is described as a deviation from a reference plane. Therefore, the definition of the reference plane is critical to determine the acetabular rim geometry. The purpose of this study was to use 3D Computed Tomography (CT) modeling to evaluate the impact of varied acetabular orientation reference planes on the interpretation of acetabular rim abnormalities, with the goal to determine the ideal reference plane for future study use.Methods:3D CT modeling was performed on five hip joints of patients who underwent hip arthroscopy with acetabular trimming for a presumed pincer lesion. These models were exported into point-cloud models. An acetabular 3D model was automatically created within 10 mm from the femoral head surface (Fig. 1A, B). The acetabular articular surface and rim were separated with a threshold of 5 mm, which provided an acetabular rim model with a band width of 5 mm (Fig. 1C). A local coordinate system was defined with the acetabular notch midpoint being 6 o’clock. A best-fit plane of the acetabular rim was determined by the least square method using two different acetabular rim models: 1) a model excluding the acetabular notch (plane A) and 2) a model excluding the acetabular notch and superior region from 10:30 to 3:00 (3:00 being anterior) (plane B). The acetabular rim model was transformed into a cylindrical coordinate system with an axis determined by a normal vector of the plane. The final acetabular rim model consisting of 120 points with 3° increments was created by searching the outermost points of the rim. The acetabular center was determined using best-fit sphere of the articular surface model. A reference plane including the center point was determined with orientations determined by normal vectors of the acetabular rim planes (Fig. 1C, yellow line). The 3D geometry of the rim was described by subtended angles from the normal vector of the reference plane.Results:Three distinct peaks were noted at anteroinferior (AI), anterosuperior (AP) and posteroinferior (PI) regions (Fig. 2 A, B). While the AI and PI peaks measured with the plane A were higher than that measured with plane B, the AP peak measured with plane A was lower than that measured with plane B (Fig. 2C). The angle between the normal vectors of plane A and B was 13.7±3.5°.Conclusion:The findings demonstrate that the orientation of the reference plane is critical to the 3D measurement of the acetabular rim. Since bony prominence in the anterosuperior region has been considered as the pathogenesis of the impingement, the reference plane including this region may cause underestimation of the bony lesion. An appropriate determination of the reference plane is crucial for evaluation of the bony lesion in the pincer FAI patient.

Multidirectional instability of the shoulder: rotator interval dimension and capsular laxity evaluation using MR arthrography

To compare the rotator interval and capsular dimension as measured on MR arthrography between patients with clinically diagnosed multidirectional instability (MDI) and control subjects with no instability. We retrospectively reviewed a consecutive series of 658 shoulders that had undergone MR arthrography between 2006 and 2010. Of these, 97 shoulders were included in the present study. These shoulders were divided into two groups according to the clinically established diagnoses. The MDI group comprised 47 shoulders with atraumatic multidirectional shoulder instability, and the control group comprised 50 shoulders with no instability. Two independent observers measured the width and depth of the rotator interval, and the capsular dimensions at the anterior, anteroinferior, inferior, posteroinferior, and posterior regions in the two groups using MR arthrography. The rotator interval width and depth were significantly greater in the MDI group (width, observer 1, 17.7 mm, observer 2, 17.9 mm; depth, observer 1, 8.9 mm, observer 2, 8.8 mm) than in the control group (width, observer 1, 14.3 mm, observer 2, 14.5 mm; depth, observer 1, 5.9 mm, observer 2, 6.2 mm) (p < .001). The capsular dimensions at the inferior and posteroinferior regions were significantly larger in the MDI group (inferior, observer 1, 27.9 mm, observer 2, 27.8 mm; posteroinferior, observer 1, 27.0 mm, observer 2, 27.1 mm) than in the control group (inferior, observer 1, 25.7 mm, observer 2, 25.3 mm; posteroinferior, observer 1, 23.3 mm, observer 2, 23.6 mm) (p < .05). A width greater than 15.2 mm or a depth greater than 6.4 mm of the rotator interval, suggesting MDI, had sensitivities of 81 and 92 % for observer 1, and 79 and 94 % for observer 2, and specificities of 66 and 72 % for observer 1, and 62 and 66 % for observer 2, respectively. Measurements of the rotator interval and the size of the distended inferior and posteroinferior joint capsule on MR arthrography are greater in shoulders with clinical MDI than in stable shoulders.

Contact Pressure in the Facet Joint During Sagittal Bending of the Cadaveric Cervical Spine

The facet joint contributes to the normal biomechanical function of the spine by transmitting loads and limiting motions via articular contact. However, little is known about the contact pressure response for this joint. Such information can provide a quantitative measure of the facet joint's local environment. The objective of this study was to measure facet pressure during physiologic bending in the cervical spine, using a joint capsule-sparing technique. Flexion and extension bending moments were applied to six human cadaveric cervical spines. Global motions (C2-T1) were defined using infra-red cameras to track markers on each vertebra. Contact pressure in the C5-C6 facet was also measured using a tip-mounted pressure transducer inserted into the joint space through a hole in the postero-inferior region of the C5 lateral mass. Facet contact pressure increased by 67.6 ± 26.9 kPa under a 2.4 Nm extension moment and decreased by 10.3 ± 9.7 kPa under a 2.7 Nm flexion moment. The mean rotation of the overall cervical specimen motion segments was 9.6 ± 0.8° and was 1.6 ± 0.7° for the C5-C6 joint, respectively, for extension. The change in pressure during extension was linearly related to both the change in moment (51.4 ± 42.6 kPa/Nm) and the change in C5-C6 angle (18.0 ± 108.9 kPa/deg). Contact pressure in the inferior region of the cervical facet joint increases during extension as the articular surfaces come in contact, and decreases in flexion as the joint opens, similar to reports in the lumbar spine despite the difference in facet orientation in those spinal regions. Joint contact pressure is linearly related to both sagittal moment and spinal rotation. Cartilage degeneration and the presence of meniscoids may account for the variation in the pressure profiles measured during physiologic sagittal bending. This study shows that cervical facet contact pressure can be directly measured with minimal disruption to the joint and is the first to provide local pressure values for the cervical joint in a cadaveric model.

Noncontact Mapping Guided Ablation of Atrioventricular Nodal Reentrant Tachycardia in a Patient with Persistent Left Superior Vena Cava

We described a successful slow-pathway (SP) ablation in a 30-year-old woman with persistent left superior vena cava (PLSVC) guided by 3-dimensional noncontact-mapping (NCM) system. She presented with frequent episodes of poorly tolerated paroxysmal supraventricular tachycardia. The course of the CS catheter was unusual, and the presence of PLSVC with right superior vena cava atresia was documented by venography. The baseline electrophysiologic study indicated the presence of common type AV nodal reentrant tachycardia (AVNRT). By anatomical approach, SP ablation was initially performed in the posteroinferior region of Koch triangle near the CS ostium, but AVNRT was still inducible. In order to avoid extensive ablation and the risk of AV node injury, we introduced a multielectrode array catheter for a NCM approach. We determined the earliest atrial activation area of the retrograde conduction using ventricular extrastimulation. To locate the SP, a right ventricle extrastimulus pacing with S1S1 interval 500 ms, and S1S2 interval started from 450 ms with a 10 ms decrement. In this way, the retrograde slow and fast pathway can be identified from the earliest atrial activation with a rS pattern on the virtual electrograms. Successful ablation was achieved at the site of retrograde SP with an accelerated junctional rhythm observed during RF application. After slow pathway ablation, dual AV nodal physiology disappeared, and AVNRT became non-inducible.

Regional variations of vertebral trabecular bone microstructure with age and gender

The vertebral trabecular bone has a complex three-dimensional (3D) microstructure, with inhomogeneous morphology. A thorough understanding of regional variations in the microstructural properties is crucial for evaluating age- and gender-related bone loss of the vertebra, and may help us to gain more insight into the mechanism of the occurrence of vertebral osteoporosis and the related fracture risks. The aim of this study was to identify regional differences in 3D microstructure of vertebral trabecular bone with age and gender, using micro-computed tomography (micro-CT) and scanning electron microscopy (SEM). We used 56 fourth lumbar vertebral bodies from 28 women and men (57-98 years of age) cadaver donors. The subjects were chosen to give an even age and gender distribution. Both women and men were divided into three age groups, 62-, 77- and 92-year-old groups. Five cubic specimens were prepared from anterosuperior, anteroinferior, central, posterosuperior and posteroinferior regions at sagittal section. Bone specimens were examined by using micro-CT and SEM. Reduced bone volume (BV/TV), trabecular number (Tb.N) and connectivity density (Conn.D), and increased structure model index (SMI) were found between ages 62 and 77 years, and between ages 77 and 92 years. As compared with women, men had higher Tb.N in the 77-year-old group and higher Conn.D in the 62- and 77-year-old groups. The central and anterosuperior regions had lower BV/TV and Conn.D than their corresponding posteroinferior region. Increased resorbing surfaces, perforated or disconnected trabeculae and microcallus formations were found with age. Vertebral trabeculae are microstructurally heterogeneous. Decreases in BV/TV and Conn.D with age are similar in women and men. Significant differences between women and men are observed at some microstructural parameters. Age-related vertebral trabecular bone loss may be caused by increased activity of resorption. These findings illustrate potential mechanisms underlying vertebral fractures.

A permanent junctional reciprocating tachycardia with an atypically located accessory pathway successfully ablated from within the middle cardiac vein

Permanent form of junctional reciprocating tachycardia (PJRT) is an uncommon form of atrioventricular re-entrant tachycardia due to an accessory pathway characterized by slow and decremental retrograde conduction. The majority of accessory pathways in PJRT are localized in the posteroseptal zone. Despite the high success rate, failure may occur during endocardial radiofrequency catheter ablation due to epicardial insertion of the accessory pathway. We report a case of PJRT in a 25-year-old man in whom the accessory pathway was located epicardially in the posteroinferior region and ablated from within the middle cardiac vein by radiofrequency catheter ablation.