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Lian P, Chen H, Wang W, Zhu C, Tu Q, Ma X, Xia H, Yi H. Evaluation of the Anatomical Reference Point in Posterior Minimally Invasive Atlantoaxial Spine Surgery: A Cadaveric Anatomical Study. Orthop Surg 2024; 16:943-952. [PMID: 38433589 PMCID: PMC10984822 DOI: 10.1111/os.14023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 01/27/2024] [Accepted: 02/06/2024] [Indexed: 03/05/2024] Open
Abstract
OBJECTIVE Minimally invasive atlantoaxial surgery offers the benefits of reduced trauma and quicker recovery. Previous studies have focused on feasibility and technical aspects, but the lack of comprehensive safety information has limited its availability and widespread use. This study proposes to define the feasibility and range of surgical safety using the intersection of the greater occipital nerve and the inferior border of the inferior cephalic oblique as a reference point. METHODS Dissection was performed on 10 fresh cadavers to define the anatomical reference point as the intersection of the greater occipital nerve and the inferior border of the inferior cephalic oblique muscle. The study aimed to analyze the safety range of minimally invasive atlantoaxial fusion surgery by measuring the distance between the anatomical reference point and the transverse foramen of the axis, the distance between the anatomical reference point and the superior border of the posterior arch of the atlas, and the distance between the anatomical reference point and the spinal canal. Measurements were compared using Student's t test. RESULTS The point where the occipital greater nerve intersects with the inferior border of the inferior cephalic oblique muscle was defined as the anatomical marker for minimally invasive posterior atlantoaxial surgery. The distance between this anatomical marker and the transverse foramen of the axis was measured to be 9.32 ± 2.04 mm. Additionally, the distance to the superior border of the posterior arch of the atlas was found to be 21.29 ± 1.93 mm, and the distance to the spinal canal was measured to be 11.53 ± 2.18 mm. These measurement results can aid surgeons in protecting the vertebral artery and dura mater during minimally invasive posterior atlantoaxial surgery. CONCLUSIONS The intersection of the greater occipital nerve with the inferior border of the inferior cephalic oblique muscle is a safe and reliable anatomical landmark in minimally invasive posterior atlantoaxial surgery.
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Affiliation(s)
- Peirong Lian
- The First School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
- Department of OrthopaedicPeople's Liberation Army General Hospital of Southern Theatre CommandGuangzhouChina
| | - Hu Chen
- The First School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
- Department of OrthopaedicPeople's Liberation Army General Hospital of Southern Theatre CommandGuangzhouChina
| | - Wanshun Wang
- The Second Clinical Medical CollegeGuangzhou University of Chinese MedicineGuangzhouChina
| | - Changrong Zhu
- The First School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
- Department of OrthopaedicPeople's Liberation Army General Hospital of Southern Theatre CommandGuangzhouChina
| | - Qiang Tu
- The First School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
- Department of OrthopaedicPeople's Liberation Army General Hospital of Southern Theatre CommandGuangzhouChina
| | - Xiangyang Ma
- The First School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
- Department of OrthopaedicPeople's Liberation Army General Hospital of Southern Theatre CommandGuangzhouChina
| | - Hong Xia
- The First School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
- Department of OrthopaedicPeople's Liberation Army General Hospital of Southern Theatre CommandGuangzhouChina
| | - Honglei Yi
- The First School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
- Department of OrthopaedicPeople's Liberation Army General Hospital of Southern Theatre CommandGuangzhouChina
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Saglam L, Gayretli O, Coskun O, Kale A. Morphological features of the greater occipital nerve and its possible importance for interventional procedures. J Anat 2024; 244:312-324. [PMID: 37777340 PMCID: PMC10780152 DOI: 10.1111/joa.13959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 10/02/2023] Open
Abstract
Being one of the most prevalent neurological symptoms, headaches are burdensome and costly. Blocks and decompression surgeries of the greater occipital nerve (GON) have been frequently used for migraine, cervicogenic headache, and occipital neuralgia which are classified under headache by International Headache Society. Knowledge of complex anatomy of GON is crucial for its decompression surgery and block. This study was performed to elucidate anatomical features of this nerve in detail. Forty-one cadavers were dissected bilaterally. According to its morphological features, GON was classified into four main types that included 18 subtypes. Moreover, potential compression points of the nerve were defined. The number of branches of the GON up to semispinalis capitis muscle and the number of its branches that were sent to this muscle were recorded. The most common variant was that the GON pierced the aponeurosis of the trapezius muscle, curved around the lower edge of the obliquus capitis inferior muscle, and was loosely attached to the obliquus capitis inferior muscle (Type 2; 61 sides, 74.4%). In the subtypes, the most common form was Type 2-A (44 sides, 53.6%), in which the GON pierced the aponeurosis of each of the trapezius muscle and fibers of semispinalis muscle at one point and there was a single crossing of the GON and occipital artery. Six potential compression points of the GON were detected. The first point was where the nerve crossed the lower border of the obliquus capitis inferior muscle. The second and third points were at its piercing of the semispinalis capitis muscle and the muscle fibers/aponeurosis of the trapezius, respectively. Fourth, fifth, and sixth compression points of GON were located where the GON and occipital artery crossed each other for the first, second, and third times, respectively. On 69 sides, 1-4 branches of the GON up to the semispinalis capitis muscle were observed (median = 1), while 1-4 branches of GON were sent to the semispinalis capitis muscle on 67 sides (median = 1). The novel anatomical findings described in this study may play a significant role in increasing the success rate of invasive interventions related with the GON.
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Affiliation(s)
- Latif Saglam
- Department of Anatomy, Istanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - Ozcan Gayretli
- Department of Anatomy, Istanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - Osman Coskun
- Department of Anatomy, Istanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - Aysin Kale
- Department of Anatomy, Istanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
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Perreault T, Arendt-Nielson L, Fernández-de-las-Peñas C, Dommerholt J, Herrero P, Hubbard R. Intramuscular Electrical Stimulation for the Treatment of Trigger Points in Patients with Chronic Migraine: A Protocol for a Pilot Study Using a Single-Case Experimental Design. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1380. [PMID: 37629671 PMCID: PMC10456716 DOI: 10.3390/medicina59081380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 07/25/2023] [Accepted: 07/25/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Trigger points (TrPs) are prevalent in patients with migraine headaches. Needling interventions targeting TrPs in migraine patients may reduce the intensity and frequency of headaches, yet systematic reviews reveal a lack of robust evidence. Intramuscular electrical stimulation (IMES) is a modality that delivers electrical current into muscles and TrPs, with recent studies suggesting it may amplify the therapeutic effects of dry needling peripherally and centrally. This could be advantageous for patients with migraine and symptomatic TrPs. Materials and Methods: This study will implement a multiple baseline single-case experimental design (SCED). In a clinical setting, a SCED study lends itself to conducting research with only a few patients that each serve as their own controls. In this SCED study, four participants with chronic migraine will be enrolled in a non-concurrent manner and randomized to one of four baseline measurement periods (4, 5, 6 or 7 weeks), leading to four potentially different start dates for each participant in the intervention phase. During the intervention phase, patients will receive five sessions of dry needling with IMES, one session per week for five weeks. The primary outcome measure will be headache frequency, i.e., the reduction in the number of headache days over a one-month period using electronic headache diary data from the Migraine Buddy smartphone application. Secondary outcome measures will be changes in mean migraine pain intensity using a numeric pain rating scale (NPRS), migraine disability using the Migraine Disability Assessment Test (MIDAS), the Headache Impact Test (HIT-6), and changes in selected cervical musculoskeletal impairments including pressure pain thresholds (PPTs) over TrPs, the craniocervical flexion test (CCFT), and cervical active range of motion (AROM). Primary and secondary outcome measures will be analyzed separately using both visual and statistical analyses. Results: Actively recruiting participants. This project was approved by the Mass General Brigham Institutional Review Board (protocol #2023P000931) and is registered with ClinicalTrials.gov (NCT05893914). Conclusions: This study will seek to determine the effects of a five-week intervention period of IMES to TrPs in the posterior cervical muscles of subjects with chronic migraine.
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Affiliation(s)
- Thomas Perreault
- Department of Physical Therapy, Wentworth Douglass Hospital, Dover, NH 03820, USA;
| | - Lars Arendt-Nielson
- Center for Neuroplasticity and Pain, SMI, School of Medicine, Aalborg University, DK-9220 Aalborg, Denmark; (L.A.-N.); (C.F.-d.-l.-P.)
- Department of Gastroenterology & Hepatology, Mech-Sense, Clinical Institute, Aalborg University Hospital, DK-9000 Aalborg, Denmark
- Steno Diabetes Center North Denmark, Clinical Institute, Aalborg University Hospital, DK-9000 Aalborg, Denmark
| | - César Fernández-de-las-Peñas
- Center for Neuroplasticity and Pain, SMI, School of Medicine, Aalborg University, DK-9220 Aalborg, Denmark; (L.A.-N.); (C.F.-d.-l.-P.)
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28922 Madrid, Spain
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia-Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, 28922 Madrid, Spain
| | - Jan Dommerholt
- Myopain Seminars, Bethesda, MD 20814, USA;
- Department of Physical Therapy and Rehabilitation Science, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
| | - Pablo Herrero
- IIS Aragon, Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, 50009 Zaragoza, Spain;
| | - Ryan Hubbard
- Department of Physical Therapy, Wentworth Douglass Hospital, Dover, NH 03820, USA;
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Abstract
BACKGROUND Occipital neuralgia is a well-defined type of headache, and its treatment algorithm is still debated across medical specialties. From the analysis of the literature, it appears that surgical decompression of the occipital nerves is the most effective invasive approach to improve the quality of life of patients with occipital neuralgia refractory to medications. The authors describe here a minimally invasive nerve- and muscle-sparing technique to decompress the occipital nerves. METHODS The results in terms of reduction of migraine days per month, use of medications, pain evaluation, and decrease in Migraine Headache Index were analyzed by means of a retrospective chart review of 87 patients who underwent nerve- and muscle-sparing surgical decompression of the greater and lesser monolateral or bilateral occipital nerves in their institution and were followed up for at least 12 months. The surgical technique is described in detail. RESULTS Surgical decompression significantly reduced occipital neuralgia burden (at least 50% improvement) in 91% of patients, with 45% reporting a complete remission of occipital pain. Days with pain per month decreased by 80%, chronic background pain intensity decreased by 81%, and pain intensity during crisis decreased by 76%. Accordingly, drug use dropped by approximately 70%. Only minor complications were reported in four patients. CONCLUSIONS The described technique could contribute to and further support surgical decompression as the first option among the invasive approaches to treat occipital neuralgia. Results corroborate previous findings, adding a less-invasive, nerve- and muscle-sparing approach. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Kelly BN, Faulkner HR, Smith BL, Korotkin JE, Lanahan CR, Brown C, Gadd MA, Specht MC, Hughes KS, Oseni TS, Colwell AS, Coopey SB. Nipple-Sparing Mastectomy versus Skin-Sparing Mastectomy: Does Saving the Nipple Impact Short- and Long-Term Patient Satisfaction? Ann Surg Oncol 2021; 29:1033-1040. [PMID: 34498158 DOI: 10.1245/s10434-021-10767-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is an oncologically safe alternative to skin-sparing mastectomy (SSM). This study evaluated whether NSM patients were more satisfied than SSM patients in short- and long-term follow-up. METHODS Women who underwent NSM or SSM between 2009 and 2019 completed a postoperative BREAST-Q survey at least 1 year after surgery and patient characteristics were compared. Patient satisfaction at 1-5 years and 6-10 years after NSM and SSM were analyzed. RESULTS Overall, 431 patients were included; 247 had NSM and 184 had SSM 1-10 years prior to BREAST-Q survey completion. SSM patients were older, had higher body mass index (BMI), larger breast weight, and more hypertension than NSM patients, but oncologic treatments were similar between groups. BREAST-Q Psychosocial Well-Being and Sexual Well-Being scores were significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort; however, scores attenuated in the 6-10 years cohort. Satisfaction with breasts was nearly significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort (p = 0.056), but no different in the 6-10 years cohort. Receipt of adjuvant chemotherapy, receipt of postmastectomy radiation therapy, and BMI ≥30 were independent risk factors for dissatisfaction with breasts. CONCLUSIONS Women who are not candidates for NSM should be reassured that long-term qualify of life is not significantly different between SSM and NSM. Dissatisfaction with reconstructed breasts is linked with other factors (besides the nipple), which patients should be made aware of at the time of surgical decision making.
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Affiliation(s)
- Bridget N Kelly
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Heather R Faulkner
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Barbara L Smith
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jenna E Korotkin
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Conor R Lanahan
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Carson Brown
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Michele A Gadd
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle C Specht
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin S Hughes
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - T Salewa Oseni
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Amy S Colwell
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Suzanne B Coopey
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA.
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Peripheral Occipital Nerve Decompression Surgery in Migraine Headache. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3019. [PMID: 33173659 PMCID: PMC7647655 DOI: 10.1097/gox.0000000000003019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 06/08/2020] [Indexed: 01/20/2023]
Abstract
Migraine headache in the occipital region is characterized by a recurrent pain of moderate to severe intensity. However, the diagnosis can be difficult because of the multitude of symptoms overlapping with similar disorders and a pathophysiology that is not well-understood. For this reason, the medical management is often complex and ineffective.
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