International consensus for a dissection room quality system (DRQS): A Delphi panel study

Dissection Rooms (DRs) are key facilities that allow teaching and research on human anatomy, where students and researchers work with human bodies to acquire, increase, or create new knowledge. Usually, DRs work with a Body Donation Program (BDP), where living donors bequeath their bodies for use in teaching and research after they expire. Despite DRs being part of universities worldwide, no common guidelines, regulations, or quality management systems (QMS) exist that could be applied to different countries. With that purpose in mind, we aimed to develop a QMS that could be applied to DRs globally, using a Delphi panel to achieve consensus about the items that should constitute the QMS. The panel was constituted by 20 anatomy professors from 20 different countries, and the 167 standards to create the rules or guidelines that constitute the QMS were divided in five categories: direction, body donation, students, instructors, and research. After two rounds of revisions, 150 standards were considered "essential" or "important" by more than 70% of the participants, thus being incorporated to the Dissection Room Quality System (DRQS). The results of this panel represent a minimum list of items of the DRQS for improving the functioning of DRs globally.

An unusual origin of a papillary muscle of the right ventricle

Knowledge of anatomical variations of the heart are important to cardiac surgeons, cardiologists, and radiologist. During routine dissection of a 77-year-old male cadaver, we observed an unusual origin of a papillary muscle of the right ventricle arising from the atrioventricular aspect of the moderator band. This papillary muscle was 6.7mm long and 2.6mm wide. It gave rise to two chordae tendineae: one to the inferior (posterior) papillary muscle of the right ventricle and one directly to the inferior (posterior) leaflet of the tricuspid valve. Variants of the internal anatomy of the heart as exemplified in the present case report should be born in mind during image interpretation and invasive procedures of the right ventricle of the heart.

The petroclinoid ligament: a meta-analysis of its morphometry and prevalence of mineralization with a review of the literature

BACKGROUND

The petroclinoid ligament (PCL) is an important structure in the petroclival region. The anatomy of the PCL and its relationship with the surrounding structure is highly variable. The aim of this study was to estimate the morphometry, prevalence of mineralization, and anatomy of the PCL. To achieve this, the authors carried out a meta-analysis, including all studies that report extractable data on the PCL.

MATERIALS AND METHODS

Major online medical databases such as PubMed, Scopus, ScienceDirect, Web of Science, SciELO, BIOSIS, Current Content Connect, Korean Journal Database, and Russian Citation Index were searched to gather all studies regarding the anatomical characteristics, morphometry, and relationship with the anatomical surroundings of the PCL.

RESULTS

A total of 25 studies were included in this meta-analysis. Data were gathered and analysed in eight categories: (1) mineralization of the PCL, (2) relationship of the abducens nerve with the PCL, (3) relationship of the dorsal meningeal artery with the PCL, (4) shape, number, and continuity of the PCL, (5) PCL anterior attachment, (6) PCL anterior attachment point on bone, (7) PCL posterior attachment point on bone, (8) morphometric features of the PCL.

CONCLUSIONS

In conclusion, the authors of the present study believe that this is the most accurate and up-to-date meta-analysis regarding the morphology and mineralization of the PCL. The data provided by the present study may be a useful tool for surgeons performing neurosurgical procedures, such as endoscopic transnasal surgeries. Detailed anatomical knowledge of the petroclival region can surely prevent surgical complications when operating in this area.

Variations in extra-hepatic biliary tree morphology and morphometry: a narrative review of literature with focus on cystohepatic triangle

The morphometry and morphology of the components of extrahepatic biliary tree show extensive variations. A beforehand recognition of these variations is very crucial to prevent unintended complications while performing surgeries in this region. This study was conducted to analyse the configuration of the extrahepatic biliary tree and its possible variations, as well as measure the components that limit the cystohepatic triangle. Articles were searched in major online indexed databases (Medline and PubMed, Scopus, Embase, CINAHL Plus, Web of Science and Google Scholar) using relevant key words. A total of 73 articles matched the search criteria of which 55 articles were identified for data extraction. The length of left and right hepatic duct in majority of studies was found to be > 10 mm. A wide range of diameters of hepatic ducts were observed between 5 and 43 mm. The average length of cystic duct is around 20 mm. The length and diameter of the common bile duct are 50-150 mm and 3-9 mm, respectively. The most frequently observed pattern of insertion of cystic duct into common hepatic duct is right lateral, rarely anterior, or posterior spiral insertion can present. The results of this study will provide a standard reference range which instead will help to differentiate the normal and pathological conditions.

A Comprehensive study of the Abdominal Ganglia Part 3: An overview of the most commonly observed ganglion patterns, with particular emphasis on inferior mesenteric and gonadal ganglia

INTRODUCTION

Chronic pain from untreatable abdominal cancers or pancreatitis can severely decrease an individual's quality of life due to accompanying neuropathic pain, the most difficult pain mechanism to treat. Current treatment modalities focus on peripheral block or neurolysis procedures of the sympathetic ganglia in an attempt to curb the pain and improve quality of life. Reports indicated that these treatments are ineffective with patients either experiencing no relief or return the pain in a few weeks. The aim of this study was to investigate the location, macro- and microscopic morphology and interconnections of the abdominal ganglia.

METHODS

The abdominal sympathetic ganglia of nine adult cadavers were investigated. The locations, morphology, interconnections and microscopic structure was studied in 108 potential abdominal ganglia. Particular emphasis was placed on direct interconnectivity between the ganglia and histological morphology.

RESULTS

A total of 100 ganglia were confirmed histologically to contain ganglion cells. The number and locations of most of the ganglia identified in our study does not correspond to that described by previous reports. Numerous interconnections between the different ganglia, as well as direct communications with the lumbar sympathetic chain ganglia were observed.

CONCLUSIONS

The interconnections and presence of ganglion cells the nerves connecting the ganglia lead to the belief that the system should be considered as a unit and that pain fibers may be transmitted via alternative previously undiscovered pathways. If the pain treatments are to be reassessed with this information in mind, we believe that greater success could be achieved. This article is protected by copyright. All rights reserved.

Variations of coronary sinus tributaries among patients undergoing cardiac resynchronization therapy

BACKGROUND

In cardiac resynchronization therapy, the coronary venous system is used for left ventricular pacing electrode placement. Despite the well-known anatomy of the coronary sinus and its tributaries, heart failure patients' remodeled and enlarged left ventricles may impede the successful lead placement because of acquired anatomical obstacles.

MATERIALS AND METHODS

Fifty-five patients qualified for cardiac resynchronization therapy treatment (CRT) were divided into ischemic and non-ischemic cardiomyopathy. Forty-four control groups without heart failure underwent dual-source computed tomography (CT). Rendered reconstructions of cardiac coronary systems were compared.

RESULTS

The presence of main tributaries was comparable in all groups. The left marginal vein, small cardiac vein, and oblique vein of the left atrium were present in 63%, 60%, and 51% of the hearts in all the groups. CRT referred CT's had significantly longer distances between posterior and lateral cardiac veins over the left ventricle (p < 0.05), wider angles of tributaries (p = 0.03), and smaller lumen of coronary sinus (p = 0.03). In the non-ischemic group, the posterior interventricular and great cardiac veins are more extensive than in the control group. Age-related analysis of vessel size shows a moderate correlation between age and diminishing mean vessel size in all the groups studied.

CONCLUSIONS

The general structure of the coronary heart system is consistent in patients with and without heart failure. The variance of the general structure, or the presence of adequate veins, is an individual variation. The use of CT and analysis of the coronary veins allow better planning of the CRT-D implantation procedure and may reduce the risk of ineffective left ventricular electrode implantation.

Are the nerves supplying the anterior sacroiliac joint nociceptive?

BACKGROUND

Sacroiliac joint (SIJ) pain is often difficult to diagnose. Moreover, while its anatomical characteristics have been well studied, its innervation and the contributions of particular nerves remain controversial, especially in relation to posterior joint innervation. To our knowledge, previous studies have not investigated the presence of nociceptive fibres in the nerves innervating the anterior SIJ.

MATERIALS AND METHODS

Eight adult cadaveric sides underwent dissection of the anterior SIJ. Adjacent anterior rami were examined for branches to the anterior SIJ. Any branches contributing to the anterior SIJ were measured and then resected. These samples were fixed in formalin and substance P was identified immunohistologically.

RESULTS

On all sides, 1-2 small branches (mean diameter of 0.33 mm) arose from the posterior aspect of the L4 anterior ramus (12.5%), the L5 anterior ramus (62.5%), or simultaneously from both the L4 and L5 anterior rami (25%). These branches had a mean length of 13.5 mm. All histological samples contained nerve tissue. All samples of nerve fibres traveling to the anterior SIJ were positive for diffuse substance P reactivity. There were no histological differences between sides or sex. Each of the branches identified as travelling to the SIJ exhibited similar positivity for substance P.

CONCLUSIONS

This cadaveric study demonstrates that the anterior SIJ nerve fibres carry pain fibres. This new knowledge has application to patients with SIJ syndrome and to its various treatments including interventional approaches to SIJ pain.

"False" foramina and fissures of the skull: a narrative review with clinical implications

"False" foramina and fissures of the skull are described as openings formed between the adjacent edges of two or more bones and not conduits directly through a single bone. Trauma and metabolic disorders appear to affect these foramina and fissures differently when compared to the "true" foramina and fissures. Therefore, the aim of this paper is to provide a narrative review of the current literature about "false" foramina and fissures of the skull and skull base with a focus on their clinical significance.

A systematic classification of the left-sided aortic arch variants based on cadaveric studies' prevalence

INTRODUCTION

Typical branching pattern of the left-sided aortic arch consists of the brachiocephalic trunk (BCT), the left common carotid artery (LCCA) and the left subclavian artery (LSA). Variant patterns have been associated with a broad spectrum of pathologies. The meticulous knowledge of potential aortic arch variants is of utmost importance to radiologists, interventional cardiologists, vascular and thoracic surgeons. The current systematic review collects all aortic arch branching patterns and their frequency as published by various cadaveric studies, calculates prevalence taking into account the gender and the different people background, as well. All extracted variant patterns are classified into types and subtypes according to the number of emerging (major and minor) branches (1, 2, 3, 4 and 5) and to the prevalence they appear. In cases of similar prevalence, total cases were taken into consideration; otherwise the variants were classified under the title "other rare variants".

METHODS

A systematic online search of PubMed and Google books databases was performed only in cadaveric studies.

RESULTS

Twenty studies with typical (78% prevalence) and variable (22%) branching patterns were included. Types 3b, 2b, 4b, 1b and 5b had a prevalence of 81%, of 13%, of 5%, 0% and of 0%, respectively. Common variants were the brachiocephalico-carotid trunk (BCCT, 49% prevalence), the aberrant left vertebral artery (LVA, 41%) and the aberrant right subclavian artery (ARSA, 8%). LVA of aortic origin was detected in 32%, the bicarotid trunk (biCT) in 5% and the bi-BCT trunk in 3%. Thyroidea ima artery, a minor branch emerging from the aortic arch was found in 2%. Coexisted variants were detected in 4% (ARSA with a distinct RCCA and LCCA origin), in 3% (BCCT with a LVA of aortic origin), in 2% (ARSA with a biCT and a vertebrosubclavian trunk).

CONCLUSION

No significant gender or ethnic differences exist among the 5 branching types. The proposed classification scheme aims to become a valuable and easy to use tool in the hands of all physicians involved in diagnosis and treatment of aortic arch pathology. It could be also useful in anatomical education, as well.

Postfixed lumbosacral plexus with split L5 ventral ramus and furcal nerve arising from L5

Variations of the peripheral nerve plexuses are important to those clinicians who diagnose and treat patients with pathology of their parts. During routine dissection, a postfixed lumbosacral plexus with a furcal nerve arising from L5, not L4, was discovered. In addition, the case was found to have a split L5 ventral ramus. Such a variation might become clinically significant during clinical presentations of radiculopathy. With a better understanding of the fucal nerve variation presented here, along with previously documented variations, the diagnostic and treatment procedures for atypical radiculopathy can be refined, reducing the rates of nerve injury and failed back surgery.

Extensive pneumatisation of the sphenoid bone - anatomical investigation of the recesses of the sphenoid sinuses and their clinical importance

BACKGROUND

There is a great variance between the extent of pneumatisation of the sphenoid sinuses that can reach beyond the body of the sphenoid bone. The purpose of this study was to find the frequency prevalence of the recesses of the sphenoid sinuses in Polish adult population.

MATERIALS AND METHODS

296 computed tomography (CT) scans of patients who did not present any pathology in the sphenoid sinuses were evaluated in this retrospective analysis. Spiral CT scanner - Siemens Somatom Sensation 16 - was used to glean the medical images. Standard procedure applied in the option Siemens CARE Dose 4D. No contrast medium was administered.

RESULTS

In the majority of the patients - 93.92%, the pneumatisation of the sphenoid sinuses expanded beyond the body of the sphenoid bone, hence there were recesses of the sinuses present. The most common variant was the prevalence of two recesses - 12.84% of the cases. The frequency prevalence of all the 17 recesses was only 0.34%. Amongst the uneven recesses present, the sphenoidal rostrum's recess (61.15% of the patients) and the inferior clinoid recess (56.42%) were the most common. Amongst the even recesses present, the lateral recess was prevalent in the majority (65.88%), whereas the posterior clinoid process' recess was the least common (9.8%).

CONCLUSIONS

Presence of the recesses might facilitate access to the cranial fossae, hence comprehensive evaluation of the sphenoid sinuses is of immense importance in order to avoid unnecessary drills through the hard bone, that could potentially damage the nearby neurovascular structures.

Ectopic arachnoid granulation involving a rare intracranial venous sinus variant

Arachnoid granulations are hypertrophied arachnoid villi, which extend from the subarachnoid space into the venous system and aid in the passive filtration and reabsorption of cerebrospinal fluid. These macroscopic structures have been described in various locations, with the transverse and sigmoid sinuses seen as normal variants on imaging. Here we present the occurrence of an enlarged arachnoid granulation at the foramen rotundum where a variant intracranial venous sinus was identified during routine dissection. Variations, such as the one described herein, should be recognised by those who operate or interpret images of the skull base.

The triangles of Grynfeltt and Petit and the lumbar tunnel: an anatomo-radiologic study

PURPOSE

Lumbar hernias are protrusions of intra-abdominal contents classically through the superior (Grynfeltt) and inferior (Petit) lumbar triangles. The anatomy of the triangles is variable and quantitative data are few. No radiological data on the anatomy of the triangles are available.

METHODS

Fifty computed tomography angiography of the upper abdomen (M25, F25, mean age 72.5-year-old) were analyzed. The dimensions and the contents of the lumbar triangles were analyzed. The characteristics of the space between the two triangles were also documented.

RESULTS

The superior lumbar triangle showed a mean surface area of 5.10 ± 2.6 cm². In the area of the triangle, the 12th intercostal pedicle and the 1st lumbar branches of the iliolumbar vessels were found in 42 and 46 %, respectively. The inferior lumbar triangle had a mean surface of area 18.7 ± 8.4 cm². In this area, the 2nd, 3rd, and 4th lumbar branches were found in 9, 67, and 8 %, respectively. On oblique coronal images, a direct tunnel between the superior and the inferior lumbar triangles was found, showing an oblique course, with a postero-anterior direction (mean length 36.5 ± 5.8 mm, mean caliber 7.4 ± 3.1 mm).

CONCLUSIONS

Among the anatomical factors of weakening of the abdominal wall, the course of branches of the lumbar vessels was documented not only in the superior but also in the inferior lumbar triangle. A real musculoaponeurotic tunnel between the superior and the inferior lumbar triangles located in the oblique coronal plane was found, that could play a role in the development of incarceration or strangulation of lumbar hernias.

The clinical anatomy of cystic artery variations: a review of over 9800 cases

PURPOSE

While laparoscopic cholecystectomy can be a routine procedure when biliary anatomy is normally located, cystic artery variations can easily disorientate the inexperienced surgeon to the anatomy of the hepatobiliary triangle. This study presents the clinically important anatomical variations of the cystic artery.

METHODS

PubMed, Medline, Cochrane Database of Systematic Reviews, and Google Scholar databases were searched to conduct a review of the existing English literature on the clinically important cystic artery variations. An aberrant vessel was defined as a vessel that originated from an atypical source and/or one that was present in a specimen in addition to the normal vessel.

RESULTS

The cystic artery originated typically from the right hepatic artery (79.02 %) and was found in the hepatobiliary triangle in only 5427 of 6661 (81.5 %) cases. Clinically important cystic artery variations are (1) the cystic artery located anterior to the common hepatic duct or common bile duct found in 485 of 2704 (17.9 %) and 228 of 4202 (5.4 %) of cases, respectively, (2) the cystic artery located inferior to the cystic duct found in 38 of 770 (4.9 %) of cases, (3) short cystic arteries found in 98 of 1037 (9.5 %) cases and (4) multiple cystic arteries found in (8.9 %) of cases.

CONCLUSION

These variations are common in the general population and can lead to inadvertent ligation of biliary ducts or aberrant vessels. Therefore, it is important for the hepatobiliary surgeon to be aware of these vascular anomalies to avoid operative complications.

Meta-analysis of vagus nerve stimulation treatment for epilepsy: correlation between device setting parameters and acute response

BACKGROUND

Vagus nerve stimulation (VNS) is an adjunctive neurophysiological treatment for those patients who have pharmacoresistant or surgically resistant partial onset epilepsy.

OBJECTIVE

The aim of this study is to determine the effects of high and low stimulation paradigms on a responder rate of ≥50 and ≥75% reduction in seizure frequency and associated adverse effects in adults and children.

METHOD

A literature search was performed using Medline, PubMed, EMBASE, and Cochrane library for studies using vagus nerve stimulation published from January 1980 until July 2014 for medically or surgically resistant partial onset seizures, in children and adults. No restrictions on languages were imposed.

DATA COLLECTION AND ANALYSIS

Four authors reviewed and selected studies for inclusion and exclusion. The search identified five randomized control trials that fit with our inclusion criteria. The following outcomes were evaluated: 50% or greater reduction in total seizure frequency, 75% or greater reduction in total seizure frequency, and adverse effects.

RESULTS

Four randomized controlled trials were analyzed in this meta-analysis. Results indicate high stimulation is more effective in adult patients who experienced ≥50 and ≥75% reduction in seizure frequency with a significant difference within both high and low stimulation groups. In children, there was no significant difference between the two groups and patients with ≥50 % reduction in seizures. Adverse effects such as hoarseness and dyspnea were more common in the high stimulation group where the remaining side effects were not statistically different among both groups.

CONCLUSION

High stimulation is more effective than low stimulation in producing a greater reduction in seizure frequency in patients with medically and surgically resistant epilepsy.

Fat herniation through the canal of Schwalbe

The authors report a case of fat herniation through the canal of Schwalbe noted in a female cadaver during abdominopelvic dissection. Perineal hernias are rare hernias, and herniations through the hiatus of Schwalbe represent a rare posterior lateral perineal hernia. While these hernias are extremely rare, anatomists and surgeons should be aware of them, and the clinical significance and manifestations which may occur with these hernias.

A partially ossified falx cerebri

During a routine faculty prosection of the head and neck region of an adult female cadaver, a partial ossification of the falx cerebri was found. Ossification of other dural areas or regions of the body were not found. In addition, the brain and remaining organs appeared to be grossly normal. Reports of partial ossification of the falx cerebri are still rare and while certain pathologies such as nevoid basal cell carcinoma syndrome typically present with ossification of the falx on radiographs, the causal relationship of such an abnormality remains unclear.

Proboscis lateralis

INTRODUCTION

Proboscis lateralis is a rare congenitally acquired facial abnormality characterized by a soft-tissue tube- or trunk-like appendage projecting from the surface of the face, most frequently rooted in the medial canthal region. Proboscis lateralis is generally associated with a wide range of concomitant craniofacial anomalies, giving rise to multiple theories describing the embryological pathogenesis and various classification systems to account for the pathological associations.

RESULTS/CONCLUSION

This paper provides a literature review of the rare manifestations of proboscis lateralis and represents a summary of current literature related to embryological pathogenesis, definitive diagnosis, and surgical management approaches.

A review of the tragal pointer: anatomy and its importance as a landmark in surgical procedures

The tragal pointer has long been used as a surgical landmark for the identification of the facial nerve trunk and the maxillary artery in such procedures as parotidectomy, internal fixation of subcondylar and condylar fractures, mandibular osteotomy, temporomandibular joint arthroplasty, and percutaneous blocks of branches of the trigeminal nerve and pterygopalatine ganglion. Aside from its use as an external landmark, it has also been implicated as a contributor to crease formation in the presence of peripheral arterial disease. This article will review the available literature on the tragal pointer's use as an external landmark.

A review of the T2 segment of the brachial plexus

Although the complex architecture of the brachial plexus (BP) has been described for decades, recent literature still aims to elucidate the variation in nerve root contributions to the BP. Understanding this variability in the nerve morphology of the BP may assist physicians and surgeons in the diagnosis and management of certain clinical conditions that involve the BP, either directly or indirectly due to its close association with neighbouring structures. In this article, we review the current anatomical knowledge of the BP, focusing especially on its T2 contribution, and discuss the causes and consequences of some relevant BP pathologies.

Multiple variations of the hepatobiliary vasculature including a splenomesenteric trunk

Anatomical variations of the origins and branching patterns of the hepatobiliary system may be encountered during both surgical and laparoscopic procedures. We report the rare finding of a splenomesenteric trunk with an absent coeliac trunk in a 74-year-old female cadaver. Due to the absence of the coeliac trunk, the common hepatic artery was found to originate from the splenic artery. Embryological considerations and possible clinical consequences are discussed.

Princeps pollicis artery arising from the superficial palmar arch

We present a 48-year-old male cadaver in which the right superficial palmar arterial arch had no contribution from the radial artery and terminated by giving rise to a common trunk for the princeps pollicis and radialis indicis arteries. The dorsal radial artery of the thumb was absent and no arterial supply was provided by the radial artery. Accordingly, the entire arterial supply to the right thumb was provided by the superficial palmar arterial arch, which was composed solely of the ulnar artery, which received no collateral supply from the radial artery system. Considering that the arterial supply of the thumb in the present case was solely provided by the superficial palmar arch, a potential hazard could exist in the event of traumatic injury to the ulnar artery.

An interrupted inferior vena cava in a situs inversus. Case report and review of the literature

Situs inversus with interrupted inferior vena cava is an uncommon anatomic variant found in the abdominal and thoracic viscera. In this report, we present a 59-year-old woman with this variation, found during gross anatomical dissection. While this type of variation has been variable, in the present case the hepatic veins drained directly into a very short (2.2 cm) inferior vena cava. The infrarenal component of the inferior vena cava was present and drained into the azygos and hemiazygos veins. Clinical considerations of this variant anatomy are of interest, as they may present in patients as pathology on cross sectional imaging.

Variation of the axillary arch muscle with multiple insertions

Axillary arch muscles have been described as having variable and sometimes multiple insertions. We report a 90-year-old female cadaver with an axillary arch muscle that originated from the latissimus dorsi and was inserted into the pectoralis major, pectoralis minor and coracoid process. Recognising that axillary arch muscles can be present in such complex forms is important in clinical practice.

The costoclavicular ligament revisited: a functional and anatomical study

INTRODUCTION

The sternoclavicular joint is of clinical importance. However, there is scant information in the literature regarding one ligament of this area, the costoclavicular ligament (CCL).

MATERIAL AND METHODS

In order to further elucidate this structure, 10 adult formalin-fixed cadavers (17 sides) underwent dissection of the CCL. Once the CCL was identified, measurements were made of its dimensions and observations made of its anatomy. Next, ranges of motion were performed of the upper extremity and the CCL observed for tension or laxity.

RESULTS

Of the 17 sternoclavicular regions examined 16 (94%) were found to possess a CCL. The average medial and lateral lengths, width and thickness were 1, 2, 1.2, 0.340 cm, respectively. The width of the CCL was statistically smaller in women that in men. The majority of ligaments were single structures traveling from the inferior surface of the medial clavicle just lateral and sometimes-fused (12.5%) to the lateral edge of the sternoclavicular joint. These fibers then terminated on the medial end of the first rib and first costal cartilage (75%) or exclusively onto the first costal cartilage (25%). Most ligaments were single and not composed of two parts. Arm abduction resulted in tautness of the ligament and increased as the degree of abduction increased. Internal rotation of the arm translated into medial shift of the clavicle, raising the clavicle away from the first rib creating tension on the CCL. Moderate degrees of external rotation were required before the CCL became taut and even began to pull the first rib laterally. Small amounts of protraction and retraction of the scapula both put the CCL under tension.

CONCLUSIONS

The CCL is a constant structure found just lateral to the sternoclavicular joint. This ligament was a single band in the majority of our specimens and limited most ranges of motion of the proximal upper limb thus stabilizing the sternoclavicular region.

Anatomy of the reflected ligament of the inguinal region

BACKGROUND

There is a paucity in the literature regarding the reflected ligament. Therefore, the present study was performed in order to further elucidate this anatomy.

MATERIAL AND METHODS

Eighteen formalin-fixed adult cadavers (35 sides) underwent dissection of the medial inguinal region. The reflected ligament was observed for and when identified, its dimensions were measured.

RESULTS

83% of sides were found to have a reflected ligament. These were identified in 16 male and 13 female bodies. The size and shape for the reflected ligaments were variable but overall, triangular in nature. In general, the reflected ligament was found to extend from the lacunar and medial inguinal ligaments and extended obliquely toward the midline at an approximate 45 degrees angle to insert near the linea alba. Two ligaments (6.9 %) were identified that interdigitated with the contralateral reflected ligament. The medial and lateral lengths of the ligament had a mean measurement of 2.28 and 2.58 cm. The base of the reflected ligament had a mean of 2.52 cm and the height of this ligament was found to have a mean of 2.56 cm. The mean area of the reflected ligament was calculated as 2.93 cm(2). There was no statistically significant difference between right or left sides or between genders.

CONCLUSIONS

The reflected ligament was identified in the majority of our specimens and this structure usually contributed to the formation of the posteromedial wall of the external inguinal ring. Therefore, this fact should be included in future descriptions of this ligament.

Screening for renal artery stenosis in patients with aorticoiliac occlusive disease

BACKGROUND

The prevalence of atherosclerotic renal artery disease has increased with improved life expectancy. Because renal artery stenosis is a potentially correctable cause of hypertension and ischemic nephropathy, early identification of this entity may lead to proper hypertension control and improved renal function and survival. The aim of this study was to determine the prevalence and patterns of subclinical renal artery stenosis in patients with aorticoiliac atherosclerosis.

PATIENTS AND METHODS

The abdominal angiographies of 44 patients with high-grade aorticoiliac occlusive disease (> 70% stenosis) were reviewed for evidence of renal artery stenosis. This was compared to a group of 20 patients with mild-to-moderate aorticoiliac disease (< 70% stenosis). These patients had no history of renal artery disease or renal failure.

RESULTS

In patients with high-grade aorticoiliac occlusive disease, renal artery stenosis was found in 25 patients (56.8%); 13 with unilateral (29.5%) and 12 (27.3%) with bilateral involvement. A hemodynamically significant stenosis (> 50%) was found in 11 patients (25%), one of whom had bilateral stenosis (2.3%). High-grade renal artery stenosis (> 70%) or complete arterial occlusion was noted on seven sides (7.9%). The most common sites of stenosis were the origin and first centimeter of the renal artery. In patients with mild-to-moderate aorticoiliac disease, renal artery stenosis was found in two patients (10%).

CONCLUSIONS

The present study revealed that subclinical renal artery disease may be present in more than half of the patients with high-grade aorticoiliac atherosclerosis highlighting the need for proper risk stratifications and screening programs. Based on our results, we suggest that examination of the renal arteries in these patients may be necessary in order to delay or prevent complications. Additionally, such information may have important therapeutic implications in planning reconstructive vascular surgeries or percutaneous angioplasties.

Levator claviculae: a case report and review of the literature

The levator claviculae is an uncommon anatomical variant found in the posterior cervical triangle. In this report we present a 78-year-old man with this muscular variation, which was found during gross anatomical dissection. While sites of insertion and origin have been variable, in the present case the muscle originated from the left transverse processes of C3 and C4, and inserted onto the lateral third of the ipsilateral clavicle. Clinical considerations of this variant anatomy are of interest, as they may present in patients as a supraclavicular mass and may also mimic pathology on cross-sectional imaging.

Morphologic variation of the diaphragmatic crura: a correlation with pathologic processes of the esophageal hiatus?

The contributions of muscle fibers from the right and left diaphragmatic crura to the formation of the esophageal hiatus have been documented in several studies, none coming to a complete consensus on the number of anatomic variations or the prevalence of these variations in the human population. These variations may play a role in the pathogenicity of specific diseases that involve the esophageal hiatus, such as hiatal hernias. We examined a total of two hundred adult cadavers during 2000-2007. The variations in the diaphragmatic crura, particularly their muscular contributions to the formation of the esophageal hiatus, were grossly examined and revealed a bilateral occurrence of diaphragmatic crura in all 200 specimens. The results of the various morphological patterns of circumferential muscle fibers forming the esophageal hiatus were classified into six groups. The most common type (Type I, 45%) formed the esophageal hiatus from muscular contributions arising solely from the right crus. In Type II (20%) the esophageal hiatus was formed by muscular contributions from the right and left crura. In Type III (15%), the right and left muscular contributions arose from the right crus with an additional band from the left crus. Type IV (10%) showed that the right and left muscular contributions arose from the right crus, with two additional (anterior and posterior) bands arising from the left crus. Type V (5%) demonstrated the contributions arising solely from the left crus. In Type VI (5%) the right and left contributions originated from the left crus with two additional bands, one from the right crus and one from the left crus. These variations may play a role in the pathogenicity of specific diseases that involve the esophageal hiatus such as hiatal hernia, gastroesophageal reflux disease and Dunbar's syndrome.

An abnormal variation of the brachial plexus with potential clinical significance

In this case of a male adult Caucasian cadaver, variations were noted involving the location of the CS ventral ramus descending anterior and superolateral to the anterior scalene muscle. An unusual communicating branch was discovered that originated from C5 at the midpoint of the anterior scalene muscle, two centimeters proximal to Erb's point, to communicate with C6 and another communicating branch originating from C6 to C7. Awareness of the possibility of this variation is of great importance during certain surgical procedures. Comparison of this case with the literature is discussed.

A case of May-Thurner syndrome

May-Thurner syndrome is a condition that results from narrowing of the left common iliac vein lumen due to pressure from the right common iliac artery as it crosses anterior to it. We describe a very rare case in which a previously asymptomatic patient presented with May-Thurner syndrome.

A review of the distribution of the arterial and venous vasculature of the diaphragm and its clinical relevance

The diaphragm is the major respiratory muscle of the body. As it plays such a vital role, a continuous arterial and venous blood supply is of the utmost importance. It is therefore not surprising to find described in the literature a complex system of anastomoses that contributes to the maintenance of this muscle's life-preserving contraction. Understanding the anatomy of the diaphragm and any divergence in its vasculature is literally vital to humanity. In the light of this, we review the literature on the blood supply to the diaphragm, with specific emphasis on the recent description of the inferior phrenic vessels and the superior phrenic artery, summarize the clinical significance of the diaphragmatic vasculature and suggest future avenues of study to further expand on this current body of knowledge.

Intraluminal septation of the basilar artery: incidence and potential clinical significance

Variations in the cerebrovascular tree can increase surgical or interventional morbidity. To date, only scant comments are to be found in the literature regarding intraluminal variations of the basilar artery. To further elucidate such anatomy, a cadaveric study was performed. One hundred and fifty human brains were evaluated for the present study. The basilar artery was identified in each and sectioned longitudinally to observe for the presence of intraluminal septa. One specimen (0.67%) was identified that harbored an intraluminal septum of the basilar artery. This wall was within the proximal basilar artery and measured 3 mm by 1.5 mm. No specimen was found to have other anomalies of the basilar artery and in the single specimen with an intraluminal septum no signs of intracranial pathology were seen. Although seemingly rare, septation of the basilar artery can be found. Knowledge of such an intraluminal vascular variation may be important during invasive and minimally invasive procedures.

The ansa subclavia: a review of the literature

The ansa subclavia, subclavian loop, Vieussens' ansa or Vieussens' loop is a nerve cord that connects the middle cervical and inferior cervical sympathetic ganglia, forming a loop around the subclavian artery. The structure of the ansa subclavia is evolutionarily conserved from rats, guinea pigs, the porcine species and dogs to humans. A common application in physiological studies is to electrically stimulate the ansa subclavia in animal models as a robust protocol to modulate stimulatory cardiac sympathetic input. Despite a large number of physiological studies utilizing the ansa subclavia, only very brief descriptions have been devoted to it in standard anatomy texts. An extensive search found only one report in the English language literature concerning the anatomy of the ansa subclavia. The aim of this report, therefore, was to provide a comprehensive review of the clinical anatomy of the ansa subclavia and to discuss its potential physiological functions.

The clinical anatomy of the cephalic vein in the deltopectoral triangle

Identification and recognition of the cephalic vein in the deltopectoral triangle is of critical importance when considering emergency catheterization procedures. The aim of our study was to conduct a cadaveric study to access data regarding the topography and the distribution patterns of the cephalic vein as it relates to the deltopectoral triangle. One hundred formalin fixed cadavers were examined. The cephalic vein was found in 95% (190 right and left) specimens, while in the remaining 5% (10) the cephalic vein was absent. In 80% (152) of cases the cephalic vein was found emerging superficially in the lateral portion of the deltopectoral triangle. In 30% (52) of these 152 cases the cephalic vein received one tributary within the deltopectoral triangle, while in 70% (100) of the specimens it received two. In the remaining 20% (38) of cases the cephalic vein was located deep to the deltopectoral fascia and fat and did not emerge through the deltopectoral triangle but was identified medially to the coracobrachialis and inferior to the medial border of the deltoid. In addition, in 4 (0.2%) of the specimens the cephalic vein, after crossing the deltopectoral triangle, ascended anterior and superior to the clavicle to drain into the subclavian vein. In these specimens a collateral branch was observed to communicate between the cephalic and external jugular veins. In 65.2% (124) of the cases the cephalic vein traveled with the deltoid branch of the thoracoacromial trunk. The length of the cephalic vein within the deltopectoral triangle ranged from 3.5 cm to 8.2 cm with a mean of 4.8+/-0.7 cm. The morphometric analysis revealed a mean cephalic vein diameter of 0.8+/-0.1 cm with a range of 0.1 cm to 1.2 cm. The cephalic vein is relatively large and constant, usually allowing for easy cannulation.

Screening for thoracoabdominal aortic aneurysms in patients with aortoiliac atherosclerosis: a preliminary study

Thoracoabdominal aortic aneurysms (TAAs) usually present with rupture and carry a high morbidity and mortality rate. Early detection of TAAs with screening methods and elective surgical repair could potentially diminish these complications. The present study was aimed at screening for TAA in patients with angiography-proven aortoiliac atherosclerosis (n=43). A group of patients without aortoiliac atherosclerosis was used as controls (n=15). Age, sex and aortic diameter at the level of the T12 vertebra were recorded. The subjects were divided into two age categories, the first made up of those aged less than 65 years and the second those aged 65 years or more. A T12 aortic diameter greater than 35 mm was used to indicate TAA. Statistical analyses were performed by independent t-test and general linear model with age category, sex and atherosclerosis as factors. The mean T12 aortic diameters were greater in patients with atherosclerosis than in the control group (25.2+/-5.0 vs. 22.9+/-2.4 mm; p=0.034). Two out of 43 patients (4.7%) with aortoiliac atherosclerosis had TAA, while no one in the control group had TAA. A general linear model showed that the interaction of age category and sex significantly affected the T12 aortic diameter [F (1.49)=4.044, p=0.050]. Post hoc (LSD) tests revealed that male patients aged over 65 had greater T12 aortic diameters than other patients. We conclude that patients with aortoiliac atherosclerosis may be at greater risk for developing TAA. Ageing and male sex may also be associated with thoracoabdominal aortic enlargement.

The venous circle of Trolard

A venous anastomotic network is occasionally found at the base of the brain, which closely resembles the vicinal arterial circle of Willis. When present, this venous polygon is composed of the anterior cerebral and communicating veins, the basal vein of Rosenthal and the posterior communicating and lateral mesencephalic veins. We propose that this anastomotic ring be termed the venous circle of Trolard. This venous circle might cause bleeding with such procedures as an endoscopic third ventriculostomy. We believe that information regarding this venous circle may be useful to neuroradiologists or neurosurgeons operating at the base of the brain (Fig. 1, Ref. 10). Full Text (Free, PDF) www.bmj.sk.

Retained hand function following transection of the ulnar nerve

Generally, complete transection of a peripheral nerve results in cessation of function of the muscles innervated by such a nerve. We report a case of a child with a traumatically transected ulnar nerve who retained complete hand function. The authors believe this retention of hand function was due to a Martin-Grüber anastomosis, which is an interneural communication between the ulnar and median nerve in the forearm. Such neural variations should be considered when evaluating injuries to the nerves of the upper extremity (Fig. 2, Ref. 5).

Popliteal artery aneurysms: a review

Popliteal artery aneurysms (PAAs) are the most common form of peripheral arterial aneurysms. The popliteal artery is the continuation of the femoral artery and represents the major source of blood to the leg. Thrombus formation as a result of PAA may reduce blood flow, leading to limb-threatening ischemia and potential limb amputation. Popliteal artery aneurysms are predominantly seen in males (95-99% of cases), presumably owing to their predisposition for arteriosclerosis, which is also a major factor for PAA predisposition. Additionally, it is not uncommon to see an abdominal aortic aneurysm associated with a PAA (30-50% of cases) or bilateral presentation of PAA (approximately 50% of cases). A consequence of a PAA and thrombus located in the popliteal fossa is an inflammatory reaction, potentially involving adjacent structures in the fossa. This may present clinically as pain in the leg and/or edema. Treatment of PAA involves either a conservative management protocol or a more aggressive intervention such as surgery. Proponents of conservative management will regulate the diameter of the aneurysm by ultrasound, while those in favor of surgical intervention will repair the aneurysm through a number of open surgical methods or by endovascular stent grafting. This review summarizes the historical points related to PAA and analyzes the pertinent anatomical implications, clinical findings and treatment methods for PAA.