Anatomical Variations Research Articles

Potential anatomical triggers for plan adaptation of cervical cancer external beam radiotherapy.

This study aimed to identify potential anatomical variation triggers using magnetic resonance imaging for plan adaption of cervical cancer patients to ensure dose requirements were met over an external beam radiotherapy course. Magnetic resonance images (MRIs) acquired before and during treatment were rigidly registered to a pre-treatment computerised tomography (CT) image for 11 retrospective cervix cancer datasets. Target volumes (TVs) and organs at risk (OARs) were delineated on both MRIs and propagated onto the CT. Treatment plans were generated based on the pre-treatment contours and applied to the mid-treatment contours. Anatomical and dosimetric changes between each timepoint were assessed. The anatomical changes included the change in centroid position and volume size. Dosimetric changes included the V30Gy and V40Gy for the OARs, and V95%, V100%, D95% and D98% for the TVs. Correlation with dosimetric and anatomical changes were assessed to determine potential replan triggers. Changes in the bowel volume and position in the superior-inferior direction, and the high-risk CTV anterior posterior position were highly correlated with a change in dose to the bowel and target, respectively. Hence changes in bowel and high-risk CTV could be used as a potential replan triggers.

Ultrasonographic Anatomical Changes in the Nasal Vasculature after Rhinoplasty: Analysis of a Series of Cases

It is known that surgical procedures can change the vascularization of the face, and these changes can be related in the course and depth of vessels, increasing the risk for complications with injectable products. The goal of this work is to objectively demonstrate the course and variation of these vascular structures through Doppler ultra-sonographic monitoring. In this research 9 patients were studied, of which 7 completed the study. The presurgical ultrasound study detected anatomical variations like agenesy of the angular artery and dorsal nasal artery in 11.12% of tha patients. The post surgical evaluation detected 85.71% of vascular changes mainly in the nasal arteries. This findings confirm the importance of practicing ultrasonographis evaluation in patients with rhinoplasty, previous to practicing new filler injections in the face.

The Great Saphenous Vein Proximal Part: Branches, Anatomical Variations, and Their Implications for Clinical Practice and Venous Reflux Surgery.

The anatomical variations in the lower limb veins play a critical role in venous reflux surgeries. This study presents an analysis of the great saphenous vein (GSV) proximal part's anatomical peculiarities, with 257 patients included, who were operated for venous reflux. This study highlighted a progressive increase in the GSV diameter in conjunction with the complexity of the anatomical variations, ranging from no tributaries to more than five tributaries, an anterior accessory GSV, or venous aneurysms. Statistical analysis evidenced this expansion to be significantly correlated with the variations. Additionally, the progression of the chronic venous disease (CVD) stages was notably more prevalent in the complex anatomical variations, suggesting a nuanced interplay between the GSV anatomy and CVD severity. Conclusively, our research articulates the paramount importance of recognizing GSV anatomical variations in optimizing surgical outcomes for CVD patients. These insights not only pave the way for enhanced diagnostic accuracy but also support the strategic framework within which surgical and interventional treatments are devised, advocating for personalized approaches to venous reflux surgery.

The Synergy of Cadaver-Based and Virtual Education: Comparing Learning Outcomes in a Physician Assistant Clinical Anatomy Course

Introduction During the COVID-19 pandemic, nearly all educational content at Tufts University School of Medicine was transformed to virtual formats, including anatomy dissection labs. This study compares face-to-face cadaveric to virtual anatomy instruction and quantifies the utility of cadaver-based laboratory. Methods In 2019, Physician Assistant students completed traditional Clinical Anatomy I and Clinical Anatomy II courses with content delivered via face-to-face lectures, cadaveric-based anatomy laboratories, and case-based workshops. In 2020, students took a traditional Clinical Anatomy I course and a virtual Clinical Anatomy II course (hybrid curriculum). Virtual anatomy course content was delivered via Zoom-based lectures, anatomy laboratories using virtual 3D anatomical models and cadaveric dissection images, and Zoom case-based workshops. In Fall 2020, the traditional and hybrid cohorts were asked to complete surveys to evaluate the utility of the pedagogical approaches used during their respective courses. Examinations were compared to evaluate the impact of pedagogical approaches on learning. Results Students who experienced the virtual format scored significantly higher on the extremities examination and final grade (P = .006; P = .03) than did students with the traditional experience. Thirty-one hybrid (63% response rate) and 31 traditional students (62% response rate) completed their surveys. The traditional cohort agreed/strongly agreed their cadaver-based laboratory experience contributed to the development of their professionalism (82.1%). Most (71%) of the hybrid students agree/strongly agree that a cadaveric laboratory experience will lead to longer retention of anatomy and give them an appreciation of anatomical variation (93.1%), but 68% also felt some structures visualized with virtual tools would not be possible in a cadaver. Discussion Cadaver-based laboratories play an important role and are valued by students for anatomy learning, professional development, and understanding anatomical variation. Our data indicate that adding virtual components to cadaver-based laboratories offers a synergistic learning experience.

Persistent lateral elbow pain from overlooked posterolateral impingement of the elbow: a literature review and guidance for treatment.

Posterolateral impingement is sometimes diagnosed as a cause of refractory elbow pain, often after other treatments have been tried for common conditions such as lateral epicondylitis (tennis elbow) or subtly different conditions common in throwing athletes, such as valgus extension overload syndrome. Arthroscopic surgical treatment is effective when targeting abnormal anatomy such as plical folds. Partial excision of the olecranon must be undertaken with caution because it can lead to instability. This systematic review of the current literature uses a narrative synthesis to identify anatomical morphological variations of the olecranon, humeral and capitellar geometry, and overloading of the lateral part of the elbow as causative factors for this condition and discusses how arthroscopic techniques can resolve symptoms. Further understanding of the static and dynamic anatomy of the lateral part of the elbow will help to develop future treatment and preventive strategies.

BERTOLOTTI'S SYNDROME: DIAGNOSIS AND TREATMENT

IntroductionLumbosacral transitional vertebrae (LSTV) are increasingly recognized as a common anatomical variant and is the most common congenital anomaly of the lumbosacral spine. Patients can have symptomatic LSTV, known as Bertolotti's Syndrome, where transitional anatomy can cause back, L5 distribution leg, hip, and groin pain. We propose an outline for diagnosis and treatment of Bertolotti's Syndrome.MethodsWe retrospectively reviewed over 500 patients presenting to the primary author with low back, buttock, hip, groin and/or leg pain from April 2009 through April 2024. Patients with radiographic findings of an LSTV and clinical presentation underwent diagnostic injections to confirm diagnosis of Bertolotti's syndrome. Treatment was determined based on patient's LSTV classification. 157 patients with confirmed Bertolotti's syndrome underwent surgical treatment.ResultsOver 500 patients presented with an appropriate clinical presentation and radiographic findings of an LSTV. Diagnostic injections were targeted into the transitional anatomy confirming the LSTV as the primary pain generator to make the diagnosis of Bertolotti's syndrome. The decision in the type of surgical intervention, resection or fusion, was made based on patient's LSTV anatomy. 157 patients with confirmed Bertolotti's Syndrome underwent surgical treatment (121 fusions (77%), 36 resections (23%)). The classification system and surgical outcomes, in part, have been previously published in World Neurosurgery.ConclusionWe have outlined the best practice of diagnosis and treatment selection for Bertolotti's syndrome. We have shown significant improvement in outcomes based on this method. We hope to aid in both patient education and provide an outline on how clinicians can become knowledgeable on Bertolotti's syndrome.Conflicts of interestNo conflicts of interestSources of fundingNo funding obtained

A rare presentation of an accessory mitral valve chordae.

The mitral subvalvular apparatus can exhibit complex and unique anatomical variations. Accessory mitral valve chordae (AMVC) typically present as additional thin strands in the left ventricle. Their appearance in the atrium is rare. In the clinical case described, the AMVC was an incidental and intriguing finding during a routine transthoracic echocardiography.

Automatic Segmentation of Mediastinal Lymph Nodes and Blood Vessels in Endobronchial Ultrasound (EBUS) Images Using Deep Learning.

Endobronchial ultrasound (EBUS) is used in the minimally invasive sampling of thoracic lymph nodes. In lung cancer staging, the accurate assessment of mediastinal structures is essential but challenged by variations in anatomy, image quality, and operator-dependent image interpretation. This study aimed to automatically detect and segment mediastinal lymph nodes and blood vessels employing a novel U-Net architecture-based approach in EBUS images. A total of 1161 EBUS images from 40 patients were annotated. For training and validation, 882 images from 30 patients and 145 images from 5 patients were utilized. A separate set of 134 images was reserved for testing. For lymph node and blood vessel segmentation, the mean ± standard deviation (SD) values of the Dice similarity coefficient were 0.71 ± 0.35 and 0.76 ± 0.38, those of the precision were 0.69 ± 0.36 and 0.82 ± 0.22, those of the sensitivity were 0.71 ± 0.38 and 0.80 ± 0.25, those of the specificity were 0.98 ± 0.02 and 0.99 ± 0.01, and those of the F1 score were 0.85 ± 0.16 and 0.81 ± 0.21, respectively. The average processing and segmentation run-time per image was 55 ± 1 ms (mean ± SD). The new U-Net architecture-based approach (EBUS-AI) could automatically detect and segment mediastinal lymph nodes and blood vessels in EBUS images. The method performed well and was feasible and fast, enabling real-time automatic labeling.

Study of Anatomical Variation of Intrahepatic Biliary Tree by Magnetic Resonance Cholangiopancreatography in Patients Attending Tertiary Hospital of Eastern Nepal

Background: There are several variations in the complex anatomy of intrahepatic bile ducts. Magnetic resonance cholangiopancreatographyis a safer imaging modality that effectively shows these variations, aiding in surgical planning and preventing iatrogenic injuries. This study aims to evaluate these anatomical variations using magnetic resonance cholangiopancreatography. Materials and Methods: This cross-sectional prospective study was performed in the Radiology Department of Nobel Medical College for one year using a convenient sampling technique. A total of 165 cases meeting the inclusion criteriawere selected and magnetic resonance cholangiopancreatography was performed to evaluate the anatomical variations. Results: The mean age of patients was 34.32±10.22 years out of which 51.5%were male and 48.5%were female. The branching pattern of right hepatic duct was typical in 66.7% of cases. The right posterior sectoral duct joining left hepatic duct was the most common variation seen in 15.2%. Right posterior sectoral duct joining the common bile duct was present in 6.7%. 6.1% of cases had unclassified variation whereas a trifurcation pattern was found in 5.5%. Left hepatic duct showed the typical branching pattern in 70.9% of cases. Segment II duct draining into the common trunk of segments III and IV was seen in 20%. Triconfluence among segments II, III, and IV was seen in 8.5% and 0.6% of cases had unclassified variation. Conclusion: This study revealed wide variation in branching patterns of intrahepatic biliary ducts. The typical branching pattern of right and left hepatic ducts were seen in majority of cases.

Multi-institutional experimental validation of online adaptive proton therapy workflows

Objective. To experimentally validate two online adaptive proton therapy (APT) workflows using Gafchromic EBT3 films and optically stimulated luminescent dosimeters (OSLDs) in an anthropomorphic head-and-neck phantom. Approach. A three-field proton plan was optimized on the planning CT of the head-and-neck phantom with 2.0 Gy(RBE) per fraction prescribed to the clinical target volume. Four fractions were simulated by varying the internal anatomy of the phantom. Three distinct methods were delivered: daily APT researched by the Paul Scherrer Institute (DAPTPSI), online adaptation researched by the Massachusetts General Hospital (OAMGH), and a non-adaptive (NA) workflow. All methods were implemented and measured at PSI. DAPTPSI performed full online replanning based on analytical dose calculation, optimizing to the same objectives as the initial treatment plan. OAMGH performed Monte-Carlo-based online plan adaptation by only changing the fluences of a subset of proton beamlets, mimicking the planned dose distribution. NA delivered the initial plan with a couch-shift correction based on in-room imaging. For all 12 deliveries, two films and two sets of OSLDs were placed at different locations in the phantom. Main results. Both adaptive methods showed improved dosimetric results compared to NA. For film measurements in the presence of anatomical variations, the [min-max] gamma pass rates (3%/3 mm) between measured and clinically approved doses were [91.5%–96.1%], [94.0%–95.8%], and [67.2%–93.1%] for DAPTPSI, OAMGH, and NA, respectively. The OSLDs confirmed the dose calculations in terms of absolute dosimetry. Between the two adaptive workflows, OAMGH showed improved target coverage, while DAPTPSI showed improved normal tissue sparing, particularly relevant for the brainstem. Significance. This is the first multi-institutional study to experimentally validate two different concepts with respect to online APT workflows. It highlights their respective dosimetric advantages, particularly in managing interfractional variations in patient anatomy that cannot be addressed by non-adaptive methods, such as internal anatomy changes.

Morphological variation of the soleus muscle: Determining general patterns and characteristics of the connective tissue architecture

BackgroundThe tendons within the soleus muscle are commonly utilized to delineate location of injury for soleus muscle strains. Strains within the soleus frequently involve the myotendinous (MTJ) or myofascial (MFJ) junctions, although spatial relationship between these tendinous structures are not well understood. This study aimed to structurally identify the MTJs and MFJs within the soleus as a starting point to understanding the distribution of connective tissue for further anatomical classification. MethodsForty (n = 40) soleus muscles, representing left and right sides from twenty (n = 20) formalin-embalmed cadavers (average age 78 years old; 10 males, 10 females) were dissected in-situ to analyze the distribution and orientation of the MTJs and MFJs within classified morphological variants. Muscles were cut in cross-section at three measured locations, proximal, middle, and distal, which allowed for analyzation of tendons through the course of the muscle. Additionally, anterior surfaces of morphological variants were visualized and reconstructed in three dimensions using a handheld blue light 3D scanner. ResultsThe study revealed five morphological variants. Bipennate-Midline (n = 25), Bipennate-Medial Deviation (n = 6), Bipennate-Lateral Deviation (n = 3), Unipennate (n = 3), and Hypopennate (n = 3). Muscles included an anterior aponeurosis that was split into medial and lateral components, with each side made up of interconnections between the MTJ and MJF. The average width of the medial aponeurosis was greatest in the middle location, while the average lateral aponeurotic width decreased from proximal to distal. Regression analysis at the middle location revealed that 65 % of the change in width of the medial aponeuroses is due to the width of the medial MFJ. ConclusionsProximal-to-distal interconnections between the lateral and medial anterior aponeuroses and their corresponding MTJs and MFJs likely play a role in soleus injury patterns, especially in morphological variants. Awareness of anatomical variations in the location and orientation of these tendinous relationships is crucial for understanding lesions on diagnostic imaging.

A computerized tomography-based study of anatomical variations of the ethmoidal uncinate process

Background: The uncinate process is very relevant with respect to the ventilation and drainage of the frontal, maxillary and anterior ethmoid sinuses in the osteomeatal complex. Aims and Objectives: The study was conducted with the aim to examine and assess various patterns of upper attachment of the ethmoidal uncinate process. The secondary objective of the study was to study the incidence of pneumatization of the uncinate process. Materials and Methods: With the objective to study the various patterns of upper attachment of the uncinate process, the study was conducted at the Department of Ear, Nose, and Throat (ENT) Head and Neck Surgery, at Government Medical College, Doda, J and K, India. The period of study was from November 2020 up to November 2021. The study involved 100 patients who had presented to the ENT outpatient with nasal and or sinus-related complaints. Results: The study included 58 males and 42 females. Among the various patterns, it was the type-2 pattern of the uncinate attachment that was the most prevalent (42%). This was followed by a type-1 pattern (attached to the lamina papyracea) (16%) and then a type-6 pattern (14%). Type-3 in 4%, type-4 in 3%, and type-5 in 7%. In 14% of the cases, there was no upper attachment of the uncinate process. The pneumatization of the uncinate process was noted among 42 of the uncinate processes that we studied. The pneumatization was unilateral in 41% and bilateral in 59% of the uncinate process. The patients with a pneumatized uncinate process had more severe clinical presentation. Conclusions: A thorough computerized tomography scan assessment of the attachments of the uncinate process and its variations aids in minimizing damage to the related landmarks during the surgery and helps minimizing the chances of iatrogenic trauma to the nasolacrimal duct, medial orbital wall, and other surrounding structures. It can also assist in figuring out the likely cause of refractory sinusitis.

Shoeshine maneuver for cystic duct dissection: a simple technique to make Calot-triangle dissection smooth.

Laparoscopic cholecystectomy, introduced in 1985 by Prof. Dr. Erich Mühe, has become the gold standard for treating chronic symptomatic calculous cholecystopathy and acute cholecystitis, with an estimated 750,000 procedures performed annually in the United States of America. The risk of iatrogenic bile duct injury persists, ranging from 0.2 to 1.3%. Risk factors include male gender, obesity, acute cholecystitis, previous hepatobiliary surgery, and anatomical variations in Calot's triangle. Strategies to mitigate bile duct injury include the Critical View of Safety and fundus-first dissection, along with intraoperative cholangiography and alternative approaches like subtotal cholecystectomy. This paper introduces the shoeshine technique, a maneuver designed to achieve atraumatic exposure of anatomical structures, local hemostatic control, and ease of infundibulum mobilization. This technique involves the use of a blunt dissection tool and gauze to create traction and enhance visibility in Calot's triangle, particularly beneficial in cases of severe inflammation. Steps include using the critical view of safety and Rouviere's sulcus line for orientation, followed by careful dissection and traction with gauze to maintain stability and reduce the risk of instrument slippage. The technique, routinely used by the authors in over 2000 cases, has shown to enhance patient safety and reduce bile duct injury risks. The shoeshine technique represents a simple and easy way to apply maneuver that can help surgeon during laparoscopic cholecystectomies exposing the hepatocystic area and promote blunt dissection.

The Importance of Topographical Recognition of Pulmonary Arteries in Diagnostics and Treatment of CTEPH, Based on an Analysis of a Dissected Case Model-A Pilot Study.

Knowledge of the anatomy of pulmonary arteries is essential in many invasive procedures concerning pulmonary circulation. In the diagnosis and treatment of chronic thromboembolic pulmonary hypertension (CTEPH), two-dimensional (2D) pulmonary angiography is used. Recognizing the topographic course of the pulmonary arteries and understanding the status in three dimensions (3D) is paramount. This study aimed to evaluate and describe the branching variant of pulmonary arteries in a single case, as well as morphological parameters of the segmental arteries, like length, diameter and branching angles. One pair of embalmed human cadaver lungs was dissected by a scalpel and surgical forceps and was measured up to the subsegmental arteries. The diameters (ranging from 3.04 to 9.29 mm) and lengths (ranging from 9.09 to 53.91 mm) of the pulmonary segmental arteries varied. The proximal branching angles were wide and close to perpendicular, while distally, the angles between the segmental and subsegmental arteries were narrower (30-45°). Upon evaluating the branching, rare variations were identified and delineated, notably in the lower lobes of both lungs. Utilizing knowledge and data in clinical settings is instrumental for effectively diagnosing and treating CTEPH. Further research is required to explore the complications in invasive procedures related to various anatomical variations.

Deciphering nasal septum deviation: Computed tomography insights into age and gender trends for optimized clinical care

Background: Deviation of the nasal septum (DNS) is defined as any deviation of the septum from the midline and is one of the most common variations of the sinonasal anatomy. Aims and Objectives: The purpose of this study was to observe the prevalence of DNS and its relation with age, gender, and sidedness. Materials and Methods: Sinonasal computed tomographic images of 100 subjects obtained from the Department of Radiodiagnosis, King George’s Medical University, Lucknow, UP, in the period August 2013–July 2014 were analyzed to determine the prevalence of DNS and its relation with age, gender, and sidedness. Results: Of a total of 100 subjects, normal midline nasal septum was seen in 27 subjects whereas 73 subjects (73%) displayed a deviation in its position. The prevalence of nasal septal deviation (NSD) was significantly higher in females (84.21%) as compared to males (66.13%) (P=0.048). We also compared the prevalence of NSD in different age groups and found it to be higher in subjects aged >46 years (83.33%) as compared to other age groups but this difference was not found to be statistically significant (P=0.619). Conclusion: Nasal septu the septum toward the right. No correlation between age intervals and prevalence of DNS was found.

Centripetal endoscopic sinus surgery in rhinogenic headache

ObjectivesThe aim of this manuscript is to analyse a diagnostic protocol to select correctly patients with Rhinogenic Headache Contact Point (RH) and to investigate the effect of surgical treatment and medical therapy in pain relief. MethodsA prospective no-randomized study selected adult patients with headache and nasal alteration at CT exam or endoscopic vision with positive response to test with nasal spray with corticosteroids and antihistamine or/and local anesthesia test to the contact points. MIDAS score, intensity score, daily duration of symptoms, frequency of headache in the last month were collected in patients who performed surgery and in patients who performed medical therapy. ResultsFollowing the inclusion, 415 patients were selected for this study. 302 patients performed nasal surgery (septoplasty, turbinoplasty and/or endoscopic surgery with centripetal technique), 113 performed medical therapy. There was a statistically significant improvement in MIDAS score, intensity score, daily duration of symptoms, frequency of headache in the last month in patients who performed surgery and in patients who performed medical therapy. Regarding the comparison between patients who performed surgery (Group A) and patients who performed only medical therapy for RH (Group B), better outcomes were obtained by Group A. Considering the daily life handicap index, the lowest handicap was obtained in Group A. ConclusionThis study demonstrates that surgery, using in some cases centripetal technique, gives an improvement statistically significant than medical therapy in RH. The use of nasal spray with corticosteroids and with anti-histamine is a good method in the diagnosis of RH, especially in patients with anatomical variants such as concha bullosa, agger nasi cells and Haller cells.

Sinonasal Anatomic Variations in the Adult Population: CT Examination of 1200 Patients.

The nasal cavity and paranasal sinuses are one of the most frequently anatomically varied regions. Their size and shape vary from person to person, and ethnic origin may have a role in this variety. Recognizing this variations is so important for ear nose throat (ENT) specialists because they predispose to sinonasal pathologies and affect the complication rate and success of endoscopic sinus surgery. This study aimed to determine the frequency of sinonasal anatomic variations on paranasal sinus computed tomography (CT) in the Turkish population. Patients who had undergone paranasal sinus CT with any complaints between 2013 and 2020 and aged over 18 years were included in the study. A total of 1209 patients who had undergone paranasal sinus CT were examined for coronal, axial, and sagittal plans retrospectively by two ENT professionals, and anatomical variations were evaluated. To assign the frequency of anatomic variations in a healthy population, patients who had previously undergone paranasal sinus and nasal surgery, who had nasal polyposis, and for whom CT evaluation was not possible due to intense sinusitis were excluded from the study. Among 1209 patients, 644 were male and 565 were female. The mean age of the patients was 33.7 years. The most common sinonasal anatomical variations were nasal septal deviation and agger nasi cells, while the least common variation is the supreme turbinate. No variation was found in 48 (3.9%) CTs. Almost all patients had at least one sinonasal anatomical variation. These variations should be known by the professionals who have interest in sinonasal disease and surgery.

A Computed Tomography (CT)-Based Observational Study of Anatomical Variations in the Sphenoid Sinus: Implications for Surgical Planning and Patient Outcomes.

The sphenoid sinus (SS), a paired paranasal sinus located within the sphenoid bone, is crucial in various physiological and pathological processes. Its anatomical variations are of significant interest in clinical practice, particularly in otolaryngology, neurosurgery, and radiology. This study aims to determine the anatomical variations of the SS and related structures using computed tomography (CT). An observational study was conducted at a tertiary care center. The study included 300 patients aged 7-70 who underwent CT brain scans. Exclusions included prior sinonasal surgeries, tumors, nasal polyposis, recurrent pituitary lesions, head trauma, and past orbital or cranial surgeries.Three-dimensional reconstructions assessed SS dimensions, pneumatization types, and variations in the internal carotid artery and optic nerve. A study on the types of SSs revealed that the reseller type is the most common, accounting for 45% of cases (135 instances). The sellar type accounts for 36% (110 instances), while the conchal type is the least common, observed in 18.33% of cases (55 instances). A significant association between the SS type and variations between neurovascular structures was seen, which was confirmed using chi-square tests. There was a statistically significant relationship between carotid artery variations and SS,with the normal course being predominant at 200individuals (73.33%). Approximately 40 cases(13.33%) present with dehiscence through the sinus, while 30 individuals (10%) show close proximity. Other, less common variations are observed in 10 patients (3.33%). Optic nerve variationsdisplayed distinct frequencies, with the normal course prevailing in 250 cases (83.33%). Approximately 30cases (10%) exhibit close proximity to surrounding structures, while 15 cases (5%) present with dehiscence through the sinus. Other less common optic nerve variations are observed in five patients (1.67%). Comprehensive knowledge of SS anatomy through CT scans is essential for enhancing surgical outcomes and ensuring patient safety.

Bilateral Variations of Pronator Teres in the Upper Limb.

During clinical practice, physicians need to have a sound knowledge of vascular and nerve variations in the body. Patients presenting with various clinical signs and symptoms need to be thoroughly investigated with anatomic variations in mind to prevent misdiagnosis. Most nerve variations are related to their formation or their course and are frequently associated with the variability of structures that surround them. These structures most commonly include blood vessels, ligaments, and muscles. Such variations should be foremost in a physician's mind when analyzing clinical symptoms. This will aid in accurate diagnosis, and if surgical intervention is warranted, such awareness would minimize intraoperative errors. This article discusses a variation in the pronator teres muscle, the branching pattern of the brachial artery, and the median nerve. During the dissection of 11 cadaveric specimens within the Geisinger Commonwealth School of Medicine, an elderly female cadaver exhibited bilateral variations in the pronator teres muscle, which originated from the mid-humerus, instead of the medial epicondyle. Careful dissection revealed associated neurovascular variations in the arm, elbow, and forearm in relation to the muscle. The pronator teres muscles in the remaining 10 cadavers in the lab were examined for variations and their lengths were measured and compared with the cadaver under study. Unlike the normal origin at the medial epicondyle as described in textbooks, it was observed that the humeral heads of the pronator teres muscle originated at mid-humerus level bilaterally,associated with the passage of the median nerve and ulnar artery posterior to it. This muscle was 19 cm in length bilaterally, approximately 5.5 cm longer than the average lengths of pronator teres measured bilaterally in the other cadavers. The abnormally high origin of this muscle was associated with the finding of a median nerve coursing posterior to it to the forearm, failing to appear in the antecubital fossa. Although the ulnar head appeared normal, there were bilateral variations in the median nerve during its passage between the two heads of the pronator teres at the proximal forearmas it proceeded to the deeper compartment of the forearm. The brachial artery was observed to divide into radial and ulnar arteries at the mid-humerus level. The radial artery replaced the brachial artery in the antecubital fossa and the ulnar artery accompanied the median nerve posterior to pronator teres into the forearm. Such variations observed bilaterally have not yet been reported in the literature. Knowledge of these variations in the origin of pronator teres muscle, the absence of specific neurovascular structures as expected within the cubital fossa, and the awareness of early bifurcation and variation in their course can be very profound for physicians, as this region is often involved in the creation of arterio-venous fistulas for medical procedures, surgical treatment options for supracondylar and radial head fractures, and to differentiate median nerve compression in pronator teres syndrome versus carpal tunnel syndrome.

Unveiling Morphological Diversity: An Anatomical Investigation of the Foramen Transversarium in the Cervical Vertebrae.

This study aimed to investigate the morphological variations in the foramen transversarium of the cervical vertebrae and their clinical implications. Understanding these variations is crucial for accurate diagnosis, treatment planning, and surgical procedures involving the cervical spine. This descriptive cross-sectional study was conducted at the AIl India Institute of Medical Sciences, Bibinagar, India, and involved 150 dry cervical vertebrae specimens. Measurements of the anteroposterior and transverse dimensions, as well as anatomical variations such as accessory foramina and bilateral symmetry, were recorded using vernier calipers. Out of 150 vertebrae, 149 had foramina on both sides, while one had a single foramen on the right. The anteroposterior diameter ranged from 1.0 to 10.0 mm on the right (mean: 5.13 ± 1.25 mm) and 2.0 to 8.5 mm on the left (mean: 5.08 ± 1.11 mm). The transverse diameter ranged from 2.0 to 9.0 mm on the right (mean: 5.54 ± 1.06 mm) and 2.0 to 8.0 mm on the left (mean: 5.42 ± 1.07 mm). Statistical analysis indicated symmetry in morphological dimensions. The morphological variations included unilateral and bilateral accessory foramina, incomplete accessory foramina, and asymmetrical foramina. Circular shapes were predominant (76% on the right, 75% on the left), with other shapes, such as oval and irregular shapes, being less common. These findings enhance the understanding of cervical spine anatomy, aiding in the interpretation of radiographic images and the planning of surgical procedures. This research highlights the need for precise anatomical knowledge to improve patient outcomes in cervical spine-related interventions.