Hip Adductor Intramuscular Nerve Distribution Pattern of Children: A Guide for BTX-A Treatment to Muscle Spasticity in Cerebral Palsy

An assessment of the variation of the intramuscular innervation of the gracilis muscle, with the aim of determining its neuromuscular compartments

Some muscles present neuromuscular compartments, one of which is the gracilis muscle. The aim of the present study is to determine the number of compartments present within the gracilis muscle based on its intramuscular innervation patterns; such knowledge could be of value in free functional muscle transfer. The study comprised 72 gracilis muscles (38 women, 34 men), fixed in 10% formalin solution. The muscles were removed and then stained using Sihler's method. When sufficient transparency was achieved, some measurements were made. Three different types of intramuscular innervation were distinguished. Type I (70.8%) was featured by at least one direct proximal nerve branch. Type II (23.6%) presented at least one indirect proximal nerve branch. Type III (5.6%) did not possess any proximal nerve branch. The median of descended nerve branches was five. Considerable anatomical variation is possible within the intramuscular innervation of the gracilis muscle. The muscle presents neuromuscular compartments, but the exact number depends on the type of its intramuscular innervation and the number of the main descendent nerve branches. All three types seem to be appropriate for free functional muscle transfer. Our findings may be of great value for surgeons carrying out complex reconstructions with the use of the gracilis muscle.

Localization of the gracilis muscle motor points - key considerations for botulinum neurotoxin injection and electrical stimulation

INTRODUCTION

Muscle motor points are considered the best sites for electrode positioning in electrical stimulation and, by some researchers, for botulinum neurotoxin injections. The aim of this study is to locate the motor points in the gracilis muscle to improve muscle function maintenance and treatment of spasticity.

MATERIAL AND METHODS

Ninety-three gracilis muscles (49 right, 44 left), fixed in 10% formalin solution, were subjected to the research. All nerve branches running towards the muscle were precisely traced to each motor point. Specific measurements were collected.

RESULTS

The gracilis muscle presents multiple motor points (median of 12), all of which were localized on the deep (lateral) side of the muscle belly. Generally, motor points of this muscle were spread between 15% and 40% of the reference line length.

CONCLUSION

Our findings may help clinicians identify appropriate locations for electrode placement during electrical stimulation of the gracilis muscle; they also deepen our understanding of the correlation between motor points and motor end plates and improve the application of botulinum neurotoxin injections.

Safety and efficacy outcomes after intranasal administration of neural stem cells in cerebral palsy: a randomized phase 1/2 controlled trial

BACKGROUND

Neural stem cells (NSCs) are believed to have the most therapeutic potential for neurological disorders because they can differentiate into various neurons and glial cells. This research evaluated the safety and efficacy of intranasal administration of NSCs in children with cerebral palsy (CP). The functional brain network (FBN) analysis based on electroencephalogram (EEG) and voxel-based morphometry (VBM) analysis based on T1-weighted images were performed to evaluate functional and structural changes in the brain.

METHODS

A total of 25 CP patients aged 3-12 years were randomly assigned to the treatment group (n = 15), which received an intranasal infusion of NSCs loaded with nasal patches and rehabilitation therapy, or the control group (n = 10) received rehabilitation therapy only. The primary endpoints were the safety (assessed by the incidence of adverse events (AEs), laboratory and imaging examinations) and the changes in the Gross Motor Function Measure-88 (GMFM-88), the Activities of Daily Living (ADL) scale, the Sleep Disturbance Scale for Children (SDSC), and some adapted scales. The secondary endpoints were the FBN and VBM analysis.

RESULTS

There were only four AEs happened during the 24-month follow-up period. There was no significant difference in the laboratory examinations before and after treatment, and the magnetic resonance imaging showed no abnormal nasal and intracranial masses. Compared to the control group, patients in the treatment group showed apparent improvements in GMFM-88 and ADL 24 months after treatment. Compared with the baseline, the scale scores of the Fine Motor Function, Sociability, Life Adaptability, Expressive Ability, GMFM-88, and ADL increased significantly in the treatment group 24 months after treatment, while the SDSC score decreased considerably. Compared with baseline, the FBN analysis showed a substantial decrease in brain network energy, and the VBM analysis showed a significant increase in gray matter volume in the treatment group after NSCs treatment.

CONCLUSIONS

Our results showed that intranasal administration of NSCs was well-tolerated and potentially beneficial in children with CP.

TRIAL REGISTRATION

The study was registered in ClinicalTrials.gov (NCT03005249, registered 29 December 2016, https://www.

CLINICALTRIALS

gov/ct2/show/NCT03005249 ) and the Medical Research Registration Information System (CMR-20161129-1003).

A consensus statement on the use of botulinum toxin in pediatric patients

Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.

Morphologic classification and innervation patterns of the pectineus muscle

The purpose of this study was to identify the frequency of pectineal hiatus and of pectineus innervations, including femoral, obturator, and/or accessory obturator nerves. Also, this study sought to detailed intramuscular nervous distributions, with a particular focus on the relationship of nerves in multi-innervated pectineus. One hundred (49 right and 51 left) thighs from 52 cadavers (25 men and 27 women) were dissected. The morphology and innervations of the pectineus were investigated. Modified Sihler's whole-mount nerve-staining method was employed for visualization of the intramuscular nerve-distribution patterns of the pectineus. Variation of the pectineus forming a hiatus was identified in 18% of the specimens. The femoral innervations to the pectineus were identified in all specimens. Additional innervation either by the obturator or the accessory obturator branch to the pectineus was identified in 10% or 2% of specimens, respectively. No case of triple innervation to the pectineus was observed. In cases of dually innervated pectineus, two nerves formed a communication system inside the muscle. Among the three nerves supplying the pectineus, the femoral nerve branched more than the other two nerves and covered the greatest area in the muscle. The pectineal hiatus appears to be a common variation. The femoral nerve branch in a dually innervated pectineus is the dominant nerve component that supplies the muscle when considering frequency, branching pattern, and area, even though cooperation between two nerve components is implied. This study serves to advance the existing anatomical knowledge about the pectineus muscle, which is of clinical value.

Sihler's staining of the cutaneous nerves of the leg and its implications for sensory reconstruction

INTRODUCTION

This study aimed to reveal the entire cutaneous nerve distribution pattern of the leg and provide a morphological basis for sensory reconstruction during skin flap transplantation.

MATERIALS AND METHODS

Twelve adult cadavers were fixed with formalin, and the whole leg skin with subcutaneous fat was removed close to the muscle surface. The cutaneous nerves were visualized using modified Sihler's staining to reveal the distribution and innervation density of the cutaneous nerves.

RESULTS

The saphenous nerve innervated the anterior part, 82.2% of the upper-middle region of the lateral part of the anterolateral leg, and the upper 63.4% of the medial posterior leg. The superficial peroneal nerve innervated 90.1% of the lateral lower one-third of the anterolateral leg. The medial sural cutaneous nerve covered 26.4% of the posterior leg. The lateral sural cutaneous nerve covered 42.3% (approximately 28.6% overlap with the saphenous nerve) of the upper-middle region of the anterolateral and posterolateral leg. The number of branches differed between certain cutaneous nerves in the leg. Communications were observed between the arborizations of the four cutaneous nerves mentioned above. The highest density of primary and secondary nerve branches was observed in the upper one-third of the lateral posterior leg. The upper one-third of the posteromedial leg contained the highest density of intracutaneous nerve branches and highest number of total nerve branches.

CONCLUSIONS

These results may be used to map sensory regions when designing leg skin flaps for reconstruction surgery to obtain improved sensory recovery.

Anatomical variations of the levator palpebrae superioris, including observations on its innervation and intramuscular nerves' distribution pattern

BACKGROUND

The levator palpebrae superioris muscle (LPS) acts as the upper eyelid's major elevator and retractor and is innervated by the oculomotor nerve. The muscle's paralysis is manifested by ptosis.

MATERIAL AND METHODS

70 orbits were dissected. After removing the orbital roof, the LPS' shape and anatomical variations (i.e., the presence of accessory muscular bands or atypical formation of the muscle) were assessed. To visualize the distribution of the oculomotor nerve's intramuscular sub-branches, the isolated levator palpebrae superioris muscles were stained using Sihler's staining technique.

RESULTS

Several LPS anatomical variations were observed in the specimens examined, in seven of which (7/70; 10%) additional delicate muscular slips arose from the LPS' lateral border and reached the lacrimal gland. Histological examination confirmed the presence of striated skeletal muscle fibers in all those cases. In three other specimens (3/70; 4.28%), supernumerary muscular bands ("tensor trochleae") were found that linked the levator with the superior oblique muscle's trochlea. In the next case, the LPS' origin was double and the muscle was bipartite on its proximal half. In most cases (55/70; 78.6%), muscular branches formed a single bundle that wrapped around the superior rectus muscle's medial border to reach the levator's inferior surface. Intramuscular sub-branches were distributed largely within the proximal two-thirds of the LPS and formed an irregular, tree-like pattern. However, thin sub-branches and small retrograde sub-branches extended as far as the muscle's insertion.

CONCLUSIONS

Plastic surgeons and ophthalmologists should be aware of the levator palpebrae superioris muscle's anatomic variations both in planning and conducting surgeries on the upper eyelid.