Triangle Approach Research Articles

Kambin Triangle Versus the Supraneural Approach for the Treatment of Lumbar Radicular Pain

The aim of this study was to conduct a randomized, blinded, prospective outcome study on the short-term benefits of the Kambin triangle vs. the supraneural approach for the treatment of lumbar radicular pain. Subjects with lumbar radicular pain (n = 100) were randomly assigned to undergo transforaminal epidural steroid injection using either the Kambin triangle approach or the supraneural approach. Primary outcomes were measured with a verbal numeric pain scale and the Oswestry Disability Index, and the results at 2 and 12 wks after the procedure were compared between the groups. Secondary outcomes included patient satisfaction and the incidence of complications during the transforaminal epidural steroid injection procedure. For both groups, the verbal numeric pain scale and Oswestry Disability Index scores improved 2 wks after the injections, and this improvement was maintained through the 12-wk follow-up. The verbal numeric pain scale, Oswestry Disability Index, and effectiveness scores were not significantly different between groups. Neural contact occurred in nine cases with the supraneural approach; no patients experienced neural contact with the Kambin triangle approach. The Kambin triangle approach can be used instead of the supraneural approach in cases where it is difficult to place the needle at the anterior epidural space.

43 The Usefulness of New Triangle Approach for Needle Insertion in Ultrasonography Guided Internal Jugular Venous Catheterization

Study Objectives: Catheterization of the internal jugular vein by ultrasonography guidance is an essential procedure in emergency department. Most performers have been usually catheterized by identifying catheter tip after determination of needle insertion site on the basis of their experiences. For decreasing the number of needle insertion trial, we mathematically designed new standardized approach (called triangle approach) which determines the site and the angle of a needle insertion during ultrasonography guided internal jugular venous catheterization.

Injectate Volumes Needed to Reach Specific Landmarks and Contrast Pattern in Kambin's Triangle Approach with Spinal Stenosis

ObjectiveTo identify the volumes of contrast material needed to reach the specific landmarks and contrast pattern during Kambin's triangle approach (KB-A) in lumbar spinal stenosis.MethodSixty patients undergoing KB-A were investigated. Fifty-six patients were included in this study. KB-A were performed with the use of contrast-enhanced fluoroscopic visualization. After confirming the appropriate spinal needle position, a slow injection of up to 5.0 ml of nonionic contrast material was carried out. Under intermittent fluoroscopic guidance, contrast volumes were recorded as flow reached specific anatomic landmarks: ipsilateral inferior or superior neural foramen.ResultsAfter 2.0 ml of contrast was injected, 93.2% of KB-A cases spread to the medial aspect of the inferior pedicle of the corresponding level of injection and 86.3% of KB-A spread to the medial aspect of the superior pedicle of the corresponding level of injection. After 3 ml of contrast was injected, 95.3% of KB-A spread to cover both the medial aspect of the inferior pedicle and the superior pedicle of the corresponding level of injection. A volume of 2 ml of injectate reaches the anterior epidural space 100% of the time.ConclusionThis study demonstrates injectate volumes needed to reach the specific anatomic landmarks in KB-A. A volume of 3.0 ml of injectate reaches both the medial aspect of theinferior pedicle and the superior pedicle 94.6% of the time. Therefore, Interventionalists may consider a 1-level instead of a 2-level injection for patients with a bleeding risk or for 2 level central pathology.

The posterior cervical triangle approach for high carotid artery exposure in carotid endarterectomy

A new approach in carotid endarterectomy (CEA) was developed for high carotid artery lesions. With the authors' use of the posterior cervical triangle approach, 20 patients with a high carotid artery lesion were successfully treated with CEA. Accessory nerve palsy in 1 patient and hoarseness in 4 patients were encountered postoperatively as transient complications. There were no permanent procedure-related complications. Although this method has some risks, it is a useful method in CEA for high carotid artery lesions.

Direct Consumer Access to Physical Therapy in Michigan: Challenges to Policy Adoption

Background. Michigan is 1 of only 4 states that require a physician referral or prescription before a consumer can receive treatment from a physical therapist.Objective. The purpose of the present analysis was to examine why the most recent attempts to pass direct access legislation in Michigan failed.Methods. The Policy Analysis Triangle approach, which considers the relevant actors, processes, and context in which a policy must be considered, was used to analyze legislative efforts to attain direct access in Michigan during the 2001–2002, 2003–2004, and 2005–2006 legislative sessions. Data sources included Michigan House and Senate legislative analyses, literature review, stakeholder position statements, political action committee contributions, and expert opinion.Results. Three successive direct access legislative attempts failed despite an increasing body of evidence supporting direct access and an increasing number of states allowing direct access. Proponents represented a relatively small number of individuals with limited political influence. Opponents represented a larger number of individuals who were able to exert greater political influence through large political action committee contributions and through physician legislators in positions of power who had influence over the bills' dispositions.Conclusions. Several prominent contextual and process-related barriers to policy adoption must be overcome in future attempts at direct access based on the findings from this analysis: (1) a limited constituency supporting direct access with regard to number of individuals and their political influence, (2) a perception that only the physician can independently diagnose and treat patient problems, and (3) legislators in positions of power who oppose a bill [corrected].

Optimized mobile phase for CEC of acetylsalicylic acid and its impurities using a methacrylate‐based monolithic column

In the past few years, monolithic methacrylate-based columns have attracted some attention in separation science. The mobile-phase optimization on these columns for drug analysis has not yet been thoroughly examined. This paper evaluates the separation of acetylsalicylic acid and its impurities as a case study. First, the best pH was determined as 2.3. Methacrylate-based phases can be employed at such pH because they remain charged, necessary to generate electro-osmotic flow. Then, a suitable solvent strength was determined. Trifluoroacetic acid (0.1%) was added to the mobile phase to improve peak shapes. The optimal organic modifier composition was then determined, using isoeluotropic mobile phases, based on the theory of Snyder's solvent triangle. Quadratic models were built to predict the retention of the compounds at all mobile-phase compositions within the triangle. The predictions were tested and found appropriate. Eventually, a baseline separation of acetylsalicylic acid and its impurities was not obtained. However, it could be concluded that one can optimize the mobile phase on methacrylate-based monolithic columns in CEC using Snyder's solvent triangle approach.

Kambin's Triangle Approach of Lumbar Transforaminal Epidural Injection with Spinal Stenosis

ObjectiveTo compare the short-term effect and advantage of transforaminal epidural steroid injection (TFESI) performed using the Kambin's triangle and subpedicular approaches.MethodForty-two patients with radicular pain from lumbar spinal stenosis were enrolled. Subjects were randomly assigned to one of two groups. All procedures were performed using C-arm KMC 950. The frequency of complications during the procedure and the effect of TFESI at 2 and 4 weeks after the procedure between the two groups were compared. Short-term outcomes were measured using a visual numeric scale (VNS) and a five-grade scale. Multiple logistic regression analyses were performed to evaluate the relationship between possible outcome predictors (Kambin's triangle or subpedicular approach, age, duration of symptoms and sex) and the therapeutic effect.ResultsVNS was improved 2 weeks after the injection and continued to improve until 4 weeks in both groups. There were no statistical differences in changes of VNS, effectiveness and contrast spread pattern between these two groups. No correlation was found between the other variables tested and therapeutic effect. Spinal nerve pricking occurred in five cases of the subpedicular and in none of the cases of the Kambin's triangle approach (p<0.05).ConclusionThe Kambin's triangle approach is as efficacious as the subpedicular approach for short-term effect and offers considerable advantages (i.e., less spinal nerve pricking during procedure). The Kambin's triangle approach maybe an alternative method for transforaminal epidural steroid injection in cases where needle tip positioning in the anterior epidural space is difficult.

Critical view of safety during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has a 0.3% to 0.5% morbidity rate due to major biliary injuries. The majority of surgeons have routinely performed the so-called "infundibular" technique for gallbladder hilar dissection since the introduction of laparoscopy in the early nineties. The "critical view of safety" approach has only been recently discussed in controlled studies. It is characterized by a blunt dissection of the upper part of Calot's space, which does not usually contain arterial or biliary anomalies and is therefore ideal for a safe dissection, even in less experienced hands. We applied and compared the critical view of safety triangle approach with the infundibular approach in a retrospective cohort study. We divided 174 patients into 2 groups, with a similar case-mix (cholelithiasis, chronic cholecystitis, and acute cholecystitis). Results of operations performed by a young surgeon using critical view of safety dissection were compared to results of the infundibular approach performed by an experienced surgeon. Outcome values and operative times were examined with univariate analysis (Student t test). No difference occurred in terms of morbidity (even though comparison for biliary injuries is inconclusive because of insufficient power) and outcome; significant differences were found in operative time, favoring the critical view of safety approach in every stage of gallbladder disease, with minor significance for acute cases. We suggest this technique as the gold standard for resident teaching, because it has a similar rate of biliary and hemorrhagic complications but has a shorter operative time, builds self-confidence, and is a simple standardized method both for complicated and uncomplicated gallbladder lithiasis.

Revision of Vagal Nerve Stimulator Electrodes Through a Posterior Cervical Triangle Approach: Technical Note

We describe an approach to vagal nerve stimulator (VNS) lead replacement through the posterior cervical triangle. Scar around the structures of the carotid sheath is avoided and new leads are placed on a pristine section of the vagus nerve proximal to the original site. Skin incision from the implantation surgery is incorporated and extended to allow access to the posterior border of the sternocleidomastoid muscle (SCM). Dissection proceeds along the posterior border of the SCM. The SCM and jugular vein are retracted anterior to expose a fresh segment of the vagal nerve immediately superficial to the carotid artery and proximal to the original electrode site. Once the nerve is adequately exposed, electrode placement proceeds in the standard fashion. Dysfunctional electrodes are left in place, and the lead wire is cut as near the electrodes as can be easily accessed. Three patients have undergone lead revision with this approach. Lead placement was successful and free from complications in all cases. The posterior cervical triangle approach provides a virgin dissection plane for VNS revision.

Auricular reconstruction with the use of a modified rhomboid flap

Sir, We describe a simple, safe one-stage procedure for reconstruction of marginal helical defects. Auricular reconstruction after trauma, burn or local excision of tumours has been a common challenge in plastic surgery. Apart from functional importance, the ear also has great aesthetic value, because it frames the face and provides symmetry. A common defect on the ear is partial loss of the helical margin with or without a cartilage defect. Keeping general principles in mind, one can consider various surgical options, based on a reconstructive triangle approach. One effective solution is the use of the rhomboid flap [1]. The skin defect over the superior part of the ear can be covered by a superiorly based random pattern post-auricular flap designed on the non-hair bearing area, this has the advantage of having the same skin colour as the original auricular skin (Figs. 1, 2, 3 and 4). Although the dimensions and shape of both defect and flap are precise, they are variables in planning, namely which of four potential flaps should be used, and the axis around which the excisional rhomboid is be drawn. It is possible to manipulate these variables in such a way that closure of the secondary defect makes use of the laxity of the skin present (use of Dufourmental instead of Limberg flap). A further advantage of this flap is that the donor site scarring comes to lie behind the ear and is, therefore, inconspicuous. The anterior edge of the flap can be cut along the retroauricular sulcus. The greater skin mobility on the post-auricular surface, coupled with the fact that ear tolerates being set back closer to the head, increases the role of this flap considerably. There is some loss of the curve of the helical margin, but patients tend to be in an older age group and thus the result can be acceptable. For small defects, a simple transposition flap that is designed as a formal rhomboid flap is a useful option (Figs. 5, 6). In this situation, Fortier-Riberdy et al. gave some useful tips [2]:

Solving the ordered one-median problem in the plane

In this paper, we propose a general approach solution method for the single facility ordered median problem in the plane. All types of weights (non-negative, non-positive, and mixed) are considered. The big triangle small triangle approach is used for the solution. Rigorous and heuristic algorithms are proposed and extensively tested on eight different problems with excellent results.

The excision and reconstruction technique of atlantoaxial tumors.

Objective To summarize the techniques for atlantoaxial tumors exposure and radical excision, and to evaluate the clinical effects of internal fixation by special formed titanium mesh in upper cervical spine stability reconstruction after atlantoaxial tumors resection. Methods From Mar. 2005 to Aug. 2007, 6 patients (3 males, 3 famales)with atlantoaxial tumors were treated in our hospital, including 4 cases with chordoma,1 case with bone giant cell tumor, 1 case with bone fibrous hyperplasia. Vertebral body and lateral mass or posterior structure were involved in these 6 patients. All the paitents underwent total vertebra resection according to free operating principle by anterior submandibular carotid triangle approach firstly and posterior occipito-cervical approach secondly, and were fixed internally by special formed titanium mesh anteriorly and occipito-cervieal fixation posteriorly, Halo-vest fixed externally. All patients were fol-lowed up for 6-16 months. Results One case underwent C12 resection, 2 cases for C23, 3 cases for C2. Op-eration time was 7.2 hours in average, bleeding volume was 2400 ml in average. Local pain and neurological symptoms of all patients were improved or resolved. No complications of blood vessel and nerve injury. Tu-mor focus recurred in 1 case with chordoma 1 year after operation. All patients had good head position and occipito-cervical stability, no internal fixation failure happened. Conclusion Tumor resection beyond the capsule of lesion according to free operating principle can obtain good clinical results. Internal fixa-tion by special formed titanium mesh with occipito-cervical fixation and Halo-vest external fixation assisted, can improve safety in operation, reestablish stability effectively after tumor resction in the upper cervical spine, and provide immediate stabilization, which has the advantages in easy manipulation, early function ex-ercises, is a good method for stability reconstruction of upper cervical spine. Key words: Atlas; Axis; Neoplasms; Treatment ouwome

Selective denervation of the levator scapulae muscle: an amendment to the Bertrand procedure for the treatment of spasmodic torticollis

The purpose of this cadaveric study was to explore a modification to the Bertrand procedure for the treatment of spasmodic torticollis, namely the denervation of the levator scapulae (LS) muscle for laterocollis. The authors performed a series of 9 cadaveric dissections. Five were done to identify the anterior innervation of the LS, and the remaining 4 were to identify the tendinous insertions of the LS onto the lateral masses of the cervical spine via a posterior approach. The nerve supply to the LS from the anterior divisions of the C-3 and C-4 nerve roots and the contribution from the dorsal scapular nerve were identified over the anterior surface of the muscle. The C-3 and C-4 nerve root branches were situated within 2 cm of each other and inferior to the punctum nervosum. The dorsal scapular contribution was clearly identified in 2 cadavers. Selective denervation of this muscle is possible through the same posterior triangle incision used for denervating the sternocleidomastoid muscle of its accessory nerve branches. This approach will be helpful in patients with laterocollis contralateral to the direction of chin turning. The authors compare this approach to the posterior approach for sectioning the insertions of the LS muscle onto the C1-4 posterior tubercles. The latter approach is appropriate for ipsilateral laterocollis. The posterior triangle approach for denervating the LS muscle is a safe and easy addition to the Bertrand procedure and can be helpful in selected cases of torticollis with a laterocollis component.

Guidance of the Microanatomical Landmarks in Expanded Anteromedial Triangle Approach at Intradural Transcavernous Surgery

Guidance of the Microanatomical Landmarks in Expanded Anteromedial Triangle Approach at Intradural Transcavernous Surgery

MODEL STRATEGIC PLACES TRIANGLE UNTUK PENGEMBANGAN KAWASAN PARIWISATA

This research conducts on analysis of changes in the external environment of tourist destination especially for Kota Batu Malang District (East Java Province). The result of mapping analysis of the external environment shows factors that influence the condition, such as technological changes, the changes on regulation policy, socio-cultural changes, economical changes, and market changes. The analysis of internal environment of tourist destination in Kota Batu Malang results some influencing factors, namely a) nearness to Surabaya as the centre of government and economy, b) bureaucratic government system, c) the growth of industrial and tourism sector after agriculture. The use of Strategic Place Triangle approach and SWOT analysis results Positioning, Differentiation, and Brand of Kota Batu Malang tourism area. The Positioning of Kota Batu Malang tourism area is Bali of East Java that still holds religious values and local culture. The Differentiation is one-stop-shopping services, endless tourism enchantment, natural beauty, welcoming people, fame and enchant. The Brand of Kota Batu Malang tourism area is Enchantment of Kota Batu Malang Tourism.

Guidance of the Microanatomical Landmarks in Expanded Anteromedial Triangle Approach at Intradural Transcavernous Surgery

Guidance of the Microanatomical Landmarks in Expanded Anteromedial Triangle Approach at Intradural Transcavernous Surgery

Microendoscopic Discectomy for the Far Lateral Lumbar Disc Herniation by the Extraforaminal Triangle Approach

Microendoscopic Discectomy for the Far Lateral Lumbar Disc Herniation by the Extraforaminal Triangle Approach

GLOBAL FITS TO THE CABIBBO–KOBAYASHI–MASKAWA MATRIX: UNITARITY CONDITION METHOD VERSUS STANDARD UNITARITY TRIANGLES APPROACH

The aim of the paper is to make a comparison between the unitarity condition method and the standard version of the unitarity triangle approach by using as parameters four independent moduli |Uij|. This choice is motivated by the measurability property and leads to a simple criterion for the separation of unistochastic matrices from the double stochastic ones, whose fulfillment is the key point of any global fit for the CKM entries. In our formulation both the methods are exact, do not depend on any assumption as the smallness of some parameter and both can be used to global fits in the quark and fermion sectors. Monte Carlo simulations show that the separation criterion puts very strong conditions requiring a fine tuning of all the CKM matrix elements.

Model‐based evaluation of methods to determine C:N and N:P regeneration ratios from dissolved nutrients

Four indirect methods to determine carbon and nutrient regeneration ratios in the ocean are applied to results from a physical‐biogeochemical model with prescribed element ratios for organic matter (de‐)composition. The aim is to test whether these methods are suitable to reproduce Corg:N:P element ratios of organic matter remineralization, which in contrast to the real ocean are exactly known in the model framework. The model experiment is carried out using the classical C:N:P Redfield ratio of 106:16:1 for production and decomposition of organic material under preindustrial atmospheric pCO2. Two methods rely on predefined end member values, while the others do not. The first method is a simple linear regression of two parameters, neglecting mixing effects, and yields remineralization signals biased by isopycnal tracer gradients induced by contributions of different water masses. The second method is based on multiple linear regression of three parameters, includes mixing of three, but not‐prescribed end members. It can, in part, reproduce the prescribed remineralization ratios. However, considerable bias appears as a result of water mass mixing. The third method considers isopycnal mixing of three prescribed end member water masses by using temperature/salinity as conservative tracers on the two density surfaces σΘ = 26.8 and σΘ = 27.2. On the basis of a mixing triangle approach, the method is able to reproduce the regeneration rates best in the low latitudes, where the integrated signal of remineralization is high. The fourth method uses the full set of available parameters to derive mixing fractions and remineralization and is applied to the density range from σΘ = 26.8 to σΘ = 27.2, yielding the best reproduction of prescribed remineralization ratios. As expected, results from the last two methods are sensitive to the choice of end member concentrations. In general, best agreement between modeled and reconstructed ratios is found between 20°N and 20°S and deviations occur toward the outcrop regions, which we account to the low amount of remineralized material together with uncertainties in prescribed end member values. Our investigation shows how apparent variability of remineralization ratios can be generated through methodological shortcomings only.

The Big Triangle Small Triangle Method for the Solution of Nonconvex Facility Location Problems

In this paper we propose to modify the big square small square global optimization search in the plane with a big triangle small triangle approach. The triangulation of the feasible region is obtained by using Voronoi diagrams. The resulting algorithm was tested on the obnoxious facility location and the attraction-repulsion Weber problems with excellent results.