Correlation of anorectal symptoms and endoanal ultrasound findings after obstetric anal sphincter injuries (OASIS)

INTRODUCTION

Obstetric anal sphincter injuries (OASIS) predispose to development of anorectal symptoms that affect women's quality of life.

METHODS

A retrospective cohort study was conducted for all women with singleton vaginal deliveries who had a primary OASIS repair and attended the Postpartum Perineal Clinic between July 1st 2017 and December 31st 2020. This study was approved by the Research Ethics Board. The purpose of this study was (1) to determine correlation between endoanal ultrasound (EAUS) findings and anorectal symptoms quantified by the St. Mark's Incontinence Score (SMIS), (2) to determine the incidence of residual anal sphincter defects, and (3) to determine the rate of clinical overdiagnosis of OASIS. Pearson correlation coefficient was used to assess correlation between anorectal symptoms and EAUS findings.

RESULTS

A total of 247 participants with clinical diagnosis of OASIS met the inclusion criteria. A 3rd-degree tear was identified in 126 (51.0%) and 4th-degree tear was identified in 30 (12.1%) participants. In participants with sonographic evidence of OASIS, there was a statistically significant weak positive correlation between the size of residual defect and SMIS for both external anal sphincter (EAS) (r = .3723, p < .0001) and internal anal sphincter (IAS) (r = .3122, p = .0180). Residual defect in the anorectal sphincter of greater than 1 hour (> 30°) in width was present in 64.3% participants with 3rd-degree tear and 86.7% participants with 4th-degree tear. The rate of overdiagnosis was 36.8%.

CONCLUSION

The size of residual defect of EAS and IAS has a weak positive correlation with anorectal symptoms, emphasizing the importance of EAUS for counselling regarding mode of subsequent delivery.

Role of ultrasonography for evaluation of nerve recovery in repaired median nerve lacerations

This study aimed to investigate whether ultrasonographic inspection of the repair site of median nerve lacerations may provide useful evidence about the functional outcome in the affected hand. Forty-three patients with complete transection of the median nerve at the distal forearm were examined at a median of 40.9 months after operation by detailed ultrasonographic imaging and clinical assessment of the affected hand by the Michigan Hand Questionnaire and Rosén-Lundborg Protocol to investigate the quality of nerve healing. The continuity of individual nerve fascicles was assessed and the cross-sectional area of the enlarged nerve at the repair site was measured and compared with the contralateral median nerve at the same level. An enlargement ratio for the repair site of each nerve was calculated and compared with the numeric results obtained from the two clinical tests. A statistically significant reverse correlation was observed between nerve enlargement and the functional results of the repaired nerve.Level of evidence: IV.

Underdiagnosis of internal anal sphincter trauma following vaginal delivery

OBJECTIVE

Damage to the anal sphincter during childbirth remains the leading cause of fecal incontinence in women. Defects in the internal (IAS) or external anal sphincter, alongside symptoms and sphincter tone, will generally dictate the suggested mode of delivery in any successive pregnancy. This study aimed to examine using endoanal ultrasonography the prevalence of IAS damage in women referred with Grade-3a or -3b obstetric anal sphincter injury (OASI) in a tertiary-referral perineal clinic.

METHODS

This was a retrospective observational study of all women referred to a tertiary-referral perineal clinic after primary repair of OASI (Grade 3a-c, 4) diagnosed for the first time following vaginal delivery between January 2016 and December 2019, inclusive. Women were assessed using the Wexner bowel continence questionnaire, digital examination of sphincter tone and endoanal ultrasound. Injuries in each sphincter were classified as a scar (≤ 30°) or defect (> 30-90° or > 90°) on endoanal imaging in the axial plane.

RESULTS

In total, 615 women were referred following primary repair of OASI. Sonographic evidence of damage to the IAS was seen in 9.1% (46/506) of women diagnosed with a Grade-3a/3b injury. In women referred with a Grade-3a/3b tear, symptom scores were statistically higher (P = 0.025) in those with an IAS defect > 30° compared to those with an intact or scarred IAS, although the median score was zero in both groups. The proportion of women in each group with severe symptoms (score > 9) was similar (2.6% vs 6.5%; P = 0.148). Among women referred with a Grade-3a/3b tear, sphincter tone was reduced more frequently in those with a defect of the IAS than in those with an intact or scarred IAS (52.2% vs 11.7%; odds ratio, 8.14 (95% CI, 4.26-15.67); P < 0.001). Regardless of the reason for referral, women with reduced sphincter tone on rectal examination were four times as likely to have had an IAS defect > 30° than were those with normal resting tone (risk ratio, 4.58 (95% CI, 3.25-6.45); P < 0.001).

CONCLUSIONS

One in 11 women diagnosed with a Grade-3a or -3b tear have evidence of damage to their IAS on endoanal ultrasound. Damage to this muscle is linked to fecal incontinence in women and can have a significant impact on the planning of any future deliveries. This study highlights the importance of established perineal clinics with access to ultrasound. Nonetheless, if reduced sphincter tone is felt on rectal examination, a clinician should have a high index of suspicion for an occult IAS injury. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasonographic foetal head circumference and cheek-to-cheek diameter at term as predictors of labour outcomes

BACKGROUND

The clinical uses of ultrasonography have varied and increased over time, especially the ability of ultrasonographic measured parameters to predict the outcomes of labour. The proper understanding of the association between these ultrasonographic parameters, mode of delivery, adverse maternal and foetal outcomes will further improve patient counselling as well as the planning of intrapartum care.

AIM

The study explored the ultrasonographic measurement of foetal head circumference (HC) and cheek-to-cheek diameter (CCD) at term as predictors of labour outcomes.

METHODOLOGY

Eligible pregnant women at term were recruited from the antenatal clinic and had obstetric ultrasound scans done with HC and CCD measured. Maternal and foetal outcomes were measured and included progress in labour, obstetric lacerations, mode of delivery and suspected foetal distress. Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 20.

RESULTS

One hundred and thirty-two patients were recruited into the study. Foetal HC measurements ≥35 cm were closely associated with caesarean delivery odds ratio - 2.40 (95% confidence interval - 1.02-5.66. P = 0.046). Neither CCD nor CCD/HC ratio was predictive of the modes of delivery. The occurrence of perineal lacerations and poor progress of labour were observed more frequently with increasing HC and CCD.

CONCLUSIONS

HC performed well in predicting caesarean delivery as well as perinatal outcomes among parturients. The ultrasonographic measured HC (≥35 cm) is associated with a higher incidence of both obstetric interventions for poor progress of labour and adverse perinatal outcomes in comparison to CCD. The association between HC and labour dystocia was found to be linear. The CCD did not perform well as a predictor of the mode of delivery.

Comparison of Magnetic Resonance Imaging and Ultrasound Evaluations of Zone II Partial Flexor Tendon Lacerations: A Cadaveric Study

OBJECTIVES

Surgical intervention for zone II high-grade partial flexor tendon lacerations is often required when more than half of the tendon width is torn. Reliable noninvasive tests are critical for optimizing clinical decision making. Our team previously investigated the use of ultrasound (US) for identification of high-grade zone II flexor digitorum profundus lacerations. In this study, we compared magnetic resonance imaging (MRI) to US for the evaluation of high-grade partial flexor tendon lacerations in cadaveric specimens.

METHODS

Dissection of 32 digits in 8 fresh-frozen upper extremity cadaveric specimens was performed. The flexor digitorum profundus tendons were randomized into 3 groups: intact, low-grade laceration, and high-grade laceration. A dynamic US examination was performed by a blinded musculoskeletal radiologist. The same specimens underwent hand coil MRI, which was read by the same blinded radiologist. Magnetic resonance imaging test performance metrics were calculated and compared to those computed for the US evaluation.

RESULTS

For US evaluation of high-grade lacerations, the sensitivity and specificity were 0.5 and 1.0, with positive likelihood ratio (LR+) and negative likelihood ratio (LR-) values of ∞ and 0.50, respectively. The sensitivity and specificity for MRI evaluation were 0.2 and 1.0, with LR+ and LR- values of ∞ and 0.80.

CONCLUSIONS

Both US and MRI are adequate at determining the presence of a high-grade laceration. Magnetic resonance imaging was more specific than US in identification of high-grade partial flexor tendon lacerations. Although less specific, US is a reasonable and less-expensive alternative to MRI when evaluating for clinically significant high-grade partial flexor tendon lacerations.

Post-partum pelvic floor dysfunction assessed on 3D rotational ultrasound: a prospective study on women with first- and second-degree perineal tears and episiotomy

Purpose: To evaluate the morphology and biometry of pelvic floor structures 3 months after birth in women experiencing first- or second-degree perineal tears or undergoing episiotomy during labor.Material and methods: Prospective observational study including nulliparous women delivering at term with a clinical diagnosis of first- or second-degree perineal tears after birth or undergoing episiotomy. The role of Kristeller maneuver during labor in affecting pelvic structure and function is also explored. All women underwent 2D trans-perineal and 3D endovaginal or endoanal ultrasound 3 months after birth.Results: 115 women assessed 3 months after delivery were enrolled in the study. Compared with controls, women who experienced first-degree perineal tears had higher bladder neck-symphysis (versus 20.9 ± 4.9 versus 16.1 ± 4.9 mm, p = .017), bladder wall-pubic symphysis (22.4 ± 7.4 versus 14.2 ± 9.5 mm, p = .02) and anorectal angle-symphysis distance (12.5 ± 4.7 versus 9.3 ± 4.3 mm, p = .018). Furthermore, they have thicker internal and external anal sphincter. The incidence of partial right and left pubo-rectalis muscle avulsion was higher in women experiencing first-degree vaginal tear during labor (16.2 versus 0%, p = .004 for both). In women affected by second-degree tears, the occurrence of partial avulsion of the right and left pubo-rectalis muscle was 16.2%, while Oasis was detected in 10.8% of the cases. Women receiving Kristeller maneuver during labor had a higher incidence of either right or left puborectalis muscle avulsion.Conclusion: Women who had either first- and second-degree perineal tears or episiotomy show signs of abnormal pelvic morphometry on 3D rotational ultrasound 3 months after birth.

Comparison of MRI and MRA for the diagnosis of rotator cuff tears: A meta-analysis

BACKGROUND

Numerous quantitatively based studies measuring the accuracy of MRI and MRA for the diagnosis of rotator cuff tears remain inconclusive. In order to compare the accuracy of MRI with MRA in detection of rotator cuff tears a meta-analysis was performed systematically.

METHODS

PubMed/Medline and Embase were utilized to retrieve articles comparing the diagnostic performance of MRI and MRA for use in detecting rotator cuff tears. After screening and diluting out the articles that met inclusion criteria to be used for statistical analysis the pooled evaluation indexes including sensitivity and specificity as well as hierarchical summary receiver operating characteristic (HSROC) curves with 95% confidence interval (CI) were calculated.

RESULTS

Screening determined that 12 studies involving a total of 1030 patients and 1032 shoulders were deemed viable for inclusion in the meta-analysis. The results of the analysis showed that MRA has a higher sensitivity and specificity than MRI for the detection of any tear; similar results were observed in the detection of full-thickness tears. However, for the detection of partial-thickness tear, MRI has similar performance with MRA.

CONCLUSION

MRI is recommended to be a first-choice imaging modality for the detection of rotator cuff tears. Although MRA have a higher sensitivity and specificity, it cannot replace MRI after the comprehensive consideration of accuracy and practicality.

Isolated gallbladder injury from blunt abdominal trauma: A rare co-incidence

Gallbladder injury resulting from blunt abdominal trauma is a rare entity and generally associated with other intra-abdominal injuries. Incidence of isolated gallbladder injury has not been reported yet. The most common mechanism of injury reported is road traffic accident. Diagnosis is usually made on imaging as clinical presentation may vary from no symptoms to peritonitis due to extravasation of bile in the abdominal cavity. Cholecystectomy is the treatment of choice and minimally invasive approach can be considered in haemodynamically stable patients.

Diffusion Tensor Tractrography Visualizes Partial Nerve Laceration Severity as Early as 1 Week After Surgical Repair in a Rat Model Ex Vivo

BACKGROUND

Previous studies in our laboratory have demonstrated that a magnetic resonance imaging method called diffusion tensor imaging (DTI) can differentiate between crush and complete transection peripheral nerve injuries in a rat model ex vivo. DTI measures the directionally dependent effect of tissue barriers on the random diffusion of water molecules. In ordered tissues such as nerves, this information can be used to reconstruct the primary direction of diffusion along fiber tracts, which may provide information on fiber tract continuity after nerve injury and surgical repair.

METHODS

Sprague-Dawley rats were treated with different degrees of partial transection of the sciatic nerve followed by immediate repair and euthanized after 1 week of recovery. Nerves were then harvested, fixed, and scanned with a 7 Tesla magnetic resonance imaging to obtain DTIand fiber tractography in each sample. Additional behavioral (sciatic function index, foot fault asymmetry) and histological (Toluidine blue staining) assessments were performed for validation.

RESULTS

Tractography yielded a visual representation of the degree of injury that correlated with behavioral and histological evaluations.

CONCLUSIONS

DTI tractography is a noninvasive tool that can yield a visual representation of a partial nerve transection as early as 1 week after surgical repair.

INCREASED OASIS INCIDENCE - INDICATOR OF THE QUALITY OF OBSTETRIC CARE?

In the era of new molecular, epigenetic and proteomic discoveries, birth canal injuries seem like outdated discussion. A vast increase in the incidence of obstetric anal sphincter injuries (OASIS) has been recorded in the last two decades despite advantages in modern medicine and new obstetric methods. This increase might be attributed to the new classification of perineal injury but also to the new imaging methods, including endoanal sonography, which earlier identifies injuries that previously were considered to be occult and actually underwent unrecognized, and which should have been recognized immediately postpartum. OASIS are third and fourth degree perineal injuries that occur during delivery. The reported incidence of OASIS varies from 0.1% to 10.9%. It is well known that third and fourth degree perineal injuries occur more often in primiparae, and in cases of macrosomic newborn, dorsoposterior position of fetal head and shoulder dystocia. The protective role of episiotomy is controversial. Birth canal injury during delivery can happen to any parturient woman. It is important for obstetricians to have this in mind at every delivery. Repercussions of OASIS are serious and can persist for life. They include emotional, psychological, social, physical and sexual disturbances. Therefore, it is very important to recognize the risk factors, diagnose the injury on time and treat it properly by a multidisciplinary team. Accordingly, it can be concluded that the increased incidence of OASIS is a result of better recognition of the risk factors, reduced rates of unrecognized sphincter injuries, adoption of the new classification and better postpartum imagining methods for detection of occult injuries.

A pilot study on the effects of direct contact of two different surgical burs on the cadaveric lingual nerve

The lingual guttering technique for third molar surgery carries the risk of injury to the lingual nerve if the surgical bur comes into direct contact with it. This study investigated the extent of nerve injury caused by two different burs, a tungsten carbide bur and the Dentium implant bur; the latter is designed to be soft tissue friendly. This study also examined whether ultrasound and magnetic resonance imaging are able to detect any injury inflicted. This cadaveric research involved subjecting 12 lingual nerves to the drilling effect of two different burs at two different speeds. The amount of damage caused was measured using different imaging modalities to assess their ability to detect the injury inflicted. At high speed, the Dentium bur caused a deeper and wider laceration than the carbide bur. At low speed, the laceration depths and widths caused by the two burs did not differ significantly. Ultrasound scanning was able to detect the nerve laceration at damaged sites observed using optical coherence tomography. Thus, a carbide bur (at low speed) would be preferable for lingual bone guttering, as it causes less laceration to the lingual nerve. In the event of a suspected injury, ultrasound scanning would provide an objective evaluation of the amount of nerve damage in vivo.

Clinical relation among dural adhesion, dural ossification, and dural laceration in the removal of ossification of the ligamentum flavum

BACKGROUND CONTEXT

Dural laceration frequently occurs during surgery in patients with ossification of the ligamentum flavum (OLF), mainly because of dural adhesion (DA) and dural ossification (DO) between the ligamentum flavum and the dura mater. However, the radiological predictive factors of DA in OLF have rarely been reported.

PURPOSE

The objective of this study was to determine the preoperative radiological signs for predicting intraoperative DA in OLF by using preoperative magnetic resonance imaging (MRI) and computed tomography (CT).

STUDY DESIGN

This is a retrospective study.

PATIENT SAMPLE

This study included 182 patients who underwent decompressive laminectomy and OLF removal from 2005 to 2014.

OUTCOME MEASURE

Demographic data, preoperative neurologic status, surgical procedure and results, and intraoperative and postoperative complications were analyzed. Clinical outcome was assessed with the Japanese Orthopaedic Association score.

MATERIALS AND METHODS

Depending on the morphologic appearance of OLF in preoperative radiographs, we aimed to investigate the prevalence of intraoperative DA and DO. We used the following factors of representative classifications: (1) surface appearance, (2) "double-layer" or "tram-track" sign, (3) cross-sectional area of the stenosed level, (4) Sato classification as axial classification, (5) Kuh classification as sagittal classification, and (6) high-signal-intensity change on T₂-weighted MRI.

RESULTS

Intraoperative evidence of DA was observed in 52 patients (29%), and DO was observed in 23 patients (13%). Twenty-seven patients (15%) had dural laceration during surgery. Statistically, DA was closely associated with the non-uniform type of surface appearance (odds ratio 5.396, p=.001) and with the presence of either a double-layer sign or a tram-track sign (odds ratio 11.525, p<.001). In the preoperative CT and MRI, 21 out of 23 patients with DO showed a "double-layer sign" or a "tram-track sign."

CONCLUSIONS

This study identified two predictive factors of DA in OLF, which were the non-uniform surface appearance and the presence of a double-layer sign or a tram-track sign. The presence of DO in OLF was closely associated with a double-layer sign or a tram-track sign in the preoperative radiological images.

Ultrasonographic Evaluation of Zone II Partial Flexor Tendon Lacerations of the Fingers: A Cadaveric Study

OBJECTIVES

Accurate assessment of zone II partial flexor tendon lacerations in the finger is clinically important. Surgical repair is recommended for lacerations of greater than 50% to 60%. Our goal was to evaluate ultrasonographic test characteristics and accuracy in identifying partial flexor tendon lacerations in a cadaveric model.

METHODS

From fresh-frozen above-elbow human cadaveric specimens, 32 flexor digitorum profundus tendons were randomly selected to remain intact or receive low- or high-grade lacerations involving 10% to 40% and 60% to 90% of the radioulnar width within Verdan Zone II, respectively. Static and dynamic ultrasonography using a linear array 14-MHz transducer was performed by a blinded musculoskeletal radiologist. Sensitivities, specificities, and other standard test performance metrics were calculated. Actual and measured percentages of tendon laceration were compared by the paired t test.

RESULTS

After randomization, 24 tendons were lacerated (12 low- and 12 high-grade), whereas 8 remained intact. The sensitivity and specificity in detecting the presence versus absence of a partial laceration were 0.54 and 0.75, respectively, with positive and negative likelihood ratio values of 2.17 and 0.61. For low-grade lacerations, the sensitivity and specificity were 0.25 and 0.85, compared to 0.83 and 0.85 for high-grade lacerations. Ultrasonography underestimated the percentage of tendon involvement by a mean of 18.1% for the study population as a whole (95% confidence interval, 9.0% to 27.2%; P < .001) but accurately determined the extent for correctly diagnosed high-grade lacerations (-6.7%; 95% confidence interval, -18.7% to 5.2%; P = .22).

CONCLUSIONS

Ultrasonography was useful in identifying and characterizing clinically relevant high-grade zone II partial flexor digitorum profundus lacerations in a cadaveric model.

Overdiagnosis and rising rate of obstetric anal sphincter injuries (OASIS): time for reappraisal

OBJECTIVES

To determine the accuracy of clinical diagnosis of obstetric anal sphincter injuries (OASIS) using three-dimensional (3D) endoanal ultrasound (EA-US) and to compare symptoms and anal manometry measurements between women with anal sphincters adequately repaired and those with persistent anal sphincter defects.

METHODS

The EA-US images of women with clinically diagnosed and repaired OASIS, defined as third- or fourth-degree perineal tear, who attended the perineal clinic at Croydon University Hospital over a 10-year period (2003-2013) were reanalyzed by a single expert blind to symptoms and the results of clinical examination. St Mark's Incontinence Scores (SMIS) and anal manometry measurements were obtained and compared between women with an intact anal sphincter and those with an anal sphincter scar and between those with an intact anal sphincter and those with a defect. Anal manometry measurements were compared between women with an external anal sphincter (EAS) defect and those with an internal anal sphincter (IAS) defect.

RESULTS

The images of 908 women were reanalyzed. No evidence of OASIS was found in 64 (7.0%) women, an EAS scar alone was detected in 520 (57.3%) and an anal sphincter defect in 324 (35.7%). Of the 324 women with a defect, 112 had an EAS defect, 90 had an IAS defect and 122 had a combined IAS and EAS defect. SMIS results were significantly higher in women with an anal sphincter defect compared with those with no evidence of OASIS (P = 0.018), but there was no significant difference in scores between women with an intact sphincter and those with an EAS scar only. Women with a defect had a significantly lower maximum resting pressure (median (range), 44 (8-106) vs 55 (29-86) mmHg; P < 0.001) and maximum squeeze pressure (median (range), 74 (23-180) vs 103 (44-185) mmHg; P < 0.001) compared with those in the intact group. Similar, but less marked, differences were observed in women with an EAS scar compared with those who had an intact anal sphincter. The anal length was significantly shorter in women with a defect compared with those in the intact group (median (range), 20 (10-40) vs 25 (10-40) mm; P = 0.003).

CONCLUSIONS

Seven percent of women with a clinical diagnosis of OASIS were wrongly diagnosed. We believe that this rate may differ from that of other units but training methods and competency assessment tools for the diagnosis and repair of OASIS need urgent reappraisal. The role of EA-US in the immediate postpartum period needs further evaluation as the accurate interpretation of the images is dependent on the expertise of the staff involved. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

A Special Tear Pattern of Anterior Horn of the Lateral Meniscus: Macerated Tear

BACKGROUND

We describe a special, interesting phenomenon found in the anterior horn of the lateral meniscus (AHLM): most tear patterns in the AHLM are distinctive, with loose fibers in injured region and circumferential fiber bundles were separated. We name it as macerated tear. The goal of this study was to bring forward a new type of meniscal tear in the AHLM and investigate its clinical value.

MATERIALS AND METHODS

AHLM tears underwent arthroscopic surgery from January 2012 to December 2014 were included. Data regarding the integrity of AHLM were prospectively recorded in a data registry. Tear morphology and treatment received were subsequently extracted by 2 independent reviewers from operative notes and arthroscopic surgical photos.

RESULTS

A total of 60 AHLM tears in 60 patients (mean age 27.1 years) were grouped into horizontal tears (n = 15, 25%), vertical tears (n = 14, 23%), complex tears (n = 6, 10%), and macerated tears (n = 25, 42%). There were 6 patients with AHLM cysts in macerated tear group and one patient in vertical tear group. 60 patients were performed arthroscopic meniscus repairs and were followed-up with averaged 18.7 months. Each group had significant postoperative improvement in Lysholm and IKDC scores (p < 0.05). However, the macerated tear group showed least functional recovery of Lysholm and IKDC scores compared to other groups (p < 0.05). In addition, there were no differences in postoperative range of motion, return to work, or return to sport/other baseline activities between the four groups (p > 0.05).

CONCLUSIONS

This study demonstrated that the macerated tear is common in the tear pattern of AHLM. However, feasibility of the treatment of this type of meniscal tear, especially the meniscus repairs still requires further study.

[Case of Central Venous Catheter Laceration of the Pectoralis Minor Muscle]

A 50's underwent gastrectomy for gastric cancer 4 years before. He had received chemotherapy for para-aortic lymph node metastases. A central venous catheter with a subcutaneous port was implanted via the right subclavian vein, under ultrasonographic guidance, 1 year 3 months earlier. The patient complained of swelling in his right chest during intravenous injection of ramucirumab and paclitaxel via the port. A chest radiograph revealed that a catheter fracture. A CT scan showed that the fractured catheter had lacerated the pectoralis minor muscle and the tip was in the right inferior pulmonary artery. The catheter fragment was removed using a pigtail catheter and a snare catheter via a percutaneous transfemoral approach, without any complication. The catheter was cut at 15.5 cm from the tip. This fracture was thought to be caused by a kink in the pectoralis muscle.

Perineal and vaginal tears are clinical markers for occult levator ani trauma: a retrospective observational study

OBJECTIVES

Levator avulsion has been shown to be associated with anterior and central compartment prolapse and is a risk factor for prolapse recurrence. Diagnosis in the delivery room is usually impossible, as levator avulsion is commonly occult. The objective of this study was to determine if vaginal and major perineal tears are clinical markers of levator trauma as diagnosed by four-dimensional (4D) translabial ultrasound 3-6 months postpartum.

METHODS

This was a retrospective observational study using data obtained in two perinatal trials. A total of 774 women seen, on average, 5 (range, 2.3-22.4) months after their first delivery of a term singleton cephalic baby underwent a standardized interview, clinical assessment and 4D translabial ultrasound examination. Clinical data were obtained from the institutional obstetric database, including information on vaginal and perineal tears. Levator avulsion was diagnosed using tomographic ultrasound, with operators blinded to the clinical data.

RESULTS

Both third- and fourth-degree perineal tears and vaginal sidewall tears were independently associated with levator avulsion (P = 0.004 and P = 0.012, respectively). The odds ratio for avulsion in women suffering from such overt trauma was 3.44 (95% CI, 1.47-8.03) for third-/fourth-degree perineal tears and 3.35 (95% CI, 1.30-8.61) for vaginal sidewall tears.

CONCLUSIONS

Vaginal sidewall and third-/fourth-degree perineal tears were found to be independent clinical indicators of an increased risk of levator trauma, as diagnosed by 4D translabial ultrasound 3-6 months postpartum. Such clinical markers may become useful in the identification of women at high risk of levator trauma and future pelvic floor disorders.

Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth

BACKGROUND

During childbirth, many women sustain trauma to the perineum, which is the area between the vaginal opening and the anus. These tears can involve the perineal skin, the pelvic floor muscles, the external and internal anal sphincter muscles as well as the rectal mucosa (lining of the bowel). When these tears extend beyond the external anal sphincter they are called 'obstetric anal sphincter injuries' (OASIS). When women sustain an OASIS, they are at increased risk of developing anal incontinence either immediately following birth or later in life. Anal incontinence is associated with significant medical, hygiene and social problems. Endoanal ultrasound (EAUS) can be performed with a bedside scanner by inserting a small probe into the anus and the structures of the anal canal and perineum can be reviewed in real-time. We proposed that by examining the perineum with EAUS after the birth of the baby and before the tear has been repaired, there would be an increase in detection of OASIS. This increased detection could lead to improved primary repair of the external and internal anal sphincter resulting in reduced rates of anal incontinence and improved quality of life for women. EAUS may also have a role after perineal repair in the evaluation of residual injury and may help guide a woman's management in subsequent pregnancies and allow for early referral to specialised units, minimising long-term complications.

OBJECTIVES

To evaluate the effectiveness of EAUS in the detection of OASIS following vaginal birth and in reducing the risk of anal sphincter complications related to OASIS.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2015) and reference list of the one retrieved study.

SELECTION CRITERIA

Randomised control trials (RCTs) comparing EAUS versus no ultrasound in women prior to repair of perineal trauma and EAUS performed after perineal repair. RCTs published in abstract form only and trials using a cluster-randomised design were eligible for inclusion, but none were identified.Trials using a cross-over design and quasi-RCTs were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

The two review authors independently assessed the single trial for inclusion and assessed trial quality. Both review authors independently extracted data. Data were checked for accuracy.

MAIN RESULTS

We included one trial that randomised 752 primiparous women with clinically detectable second-degree perineal tears to either further assessment with EAUS prior to perineal repair or standard care. We assessed this trial as being at a low risk of bias. The trial reported women's anal incontinence at three and 12 months as well as their pain scores and quality of life assessment. The trial authors reported outcomes at three months for 719 women (364 in the experimental group, 355 in the control group, 4% loss to follow-up), and an outcome at 12 months for 684 women (342 in the experimental group, 342 in the control group, 9% loss to follow-up). Primary outcomeCompared with clinical examination (routine care), the use of EAUS prior to perineal repair was associated with a reduction in the rate of severe anal incontinence (defined as involuntary loss of faeces or flatus that constitutes social and/or hygiene problems, or as defined by authors), at greater than six months postpartum (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.24 to 0.97, 684 women at the 12-month time point). Secondary outcomes Severe anal incontinence at less than six months was reduced with the use of EAUS prior to repair when compared with clinical examination (routine care) (RR 0.38, 95% CI 0.20 to 0.72, 719 women). However, increased perineal pain at three months was associated with the use of EAUS prior to perineal repair when compared with routine care (RR 5.86, 95% CI 1.74 to 19.72, 684 women). There was no clear difference in the number of women who reported any anal incontinence at either less than six months or equal to or greater than six months (outcomes not prespecified in our published protocol). Similarly, there was no clear difference between groups in terms of faecal incontinence, flatal incontinence, faecal urgency, or maternal quality of life. The study did not report any data on the need for secondary repair of external anal sphincter, dyspareunia, women's satisfaction with care or the planned or actual mode of birth in any subsequent pregnancy. We were unable to assess the detection rates of OASIS with EAUS from the included study because women with clinically-detected OASIS were excluded from randomisation.

AUTHORS' CONCLUSIONS

There is some evidence to suggest that EAUS prior to perineal repair is associated with reduced risk of severe anal incontinence but an increase in the incidence of perineal pain at three months postpartum. However, these results are based on one small study involving 752 women. The study took place in a large teaching hospital with an average to busy labour ward. The trial participants were similar to those found in most large obstetric units in developed countries, thus increasing applicability of the evidence, but were restricted to primiparous women.More research is needed to further evaluate the effectiveness of EAUS in the detection of OASIS following vaginal birth and in reducing the risk of anal sphincter complications related to OASIS. More high-quality RCTs are needed to fully evaluate the intervention before the routine use of EAUS on the labour ward could be supported. It would be particularly useful if future trials could assess detection rates of OASIS with EAUS versus clinical examination alone as this is the basis of the theory for improved outcomes with this intervention. Cost and the training required to implement EAUS should be considered, along with maternal quality of life and individual symptoms experienced by postnatal women . It would also be useful to follow up women after their subsequent vaginal births to determine if subsequent mode of delivery affects long-term outcomes. Future studies in multiparous women may also be useful.

Residual defects of the external anal sphincter following primary repair: an observational study using transperineal ultrasound

OBJECTIVES

Obstetric anal sphincter tears are common and an important factor in the etiology of anal incontinence. The objective of the study was to evaluate the prevalence of residual defects of the external anal sphincter (EAS) after primary repair of obstetric anal sphincter injury using four-dimensional (4D) transperineal ultrasound and to correlate sonographic findings of residual defects and levator avulsion with significant symptoms of anal incontinence, defined as St Mark's fecal incontinence score (SMIS) of ≥ 5.

METHODS

This was a retrospective observational study. One-hundred and forty women were seen after primary repair of obstetric anal sphincter tears in a dedicated perineal clinic at a tertiary hospital in Australia. They all underwent a standardized interview, and physical and 4D transperineal ultrasound examination.

RESULTS

Mean follow-up interval was 1.9 months after delivery. Eighty-nine (64%) women had a 3a/3b tear, 28 (20%) a 3c/4(th) degree tear and 23 (16%) an unclassified 3(rd) degree tear. Thirty-five (25%) patients reported symptoms of anal incontinence. Nine had an SMIS of ≥ 5. A residual defect was found in 56 (40%) cases and levator avulsion in 27 (19%). On multivariate logistic regression, residual defects (P = 0.03; odds ratio (OR) = 6.38; 95% CI, 1.23-33.0) and levator avulsion (P = 0.047; OR = 4.38; 95% CI, 1.02-18.77) were found to be independent risk factors for anal incontinence.

CONCLUSIONS

Residual defects of the EAS were found on transperineal ultrasound in 40% of women after primary repair of obstetric anal sphincter injuries. Although most were asymptomatic, residual anal sphincter defects and levator avulsion were associated with significant symptoms of anal incontinence as quantified using the SMIS.

BWH emergency radiology-surgical correlation: pancreatic laceration

We describe the radiological and intraoperative correlation of pancreatic laceration in a 76-year-old unrestrained motor-vehicle driver following blunt abdominal trauma. The purpose of this article is to emphasize the importance of recognizing pancreatic injuries in trauma patients, as these injuries are rare and can be overlooked on CT.

Differences in muscle activities during shoulder elevation in patients with symptomatic and asymptomatic rotator cuff tears: analysis by positron emission tomography

BACKGROUND

Differences in muscle activity patterns between patients with symptomatic and asymptomatic full-thickness rotator cuff tears have not yet been fully clarified. The purpose of this study was to investigate the muscle activity pattern by use of positron emission tomography (PET) in patients with symptomatic and asymptomatic rotator cuff tears.

METHODS

Ten shoulders of 9 patients with full-thickness rotator cuff tears were divided into 2 groups by a numerical pain rating scale (0-10), symptomatic (≥2) and asymptomatic (0 or 1), with 5 shoulders each. Scaption exercise of bilateral arms (200 repetitions in 10 minutes) with a weight of 0.25 kg each was performed before and after injection of fluorodeoxyglucose. After PET examination, the standardized uptake value of each muscle was calculated to quantify its activity and compared between the two groups.

RESULTS

The activity of the anterior and middle deltoid was significantly decreased in the symptomatic group compared with the asymptomatic group (anterior deltoid, P = .02; middle deltoid, P = .03). In contrast, the activity of the superior trapezius was significantly increased in the symptomatic group compared with the asymptomatic group (P = .02).

CONCLUSION

In patients with a symptomatic tear, the deltoid activity was decreased and the trapezius activity was increased. It is likely that they might have moved the painful glenohumeral joint less and instead moved the painless scapulothoracic joint more during the prescribed exercise. We conclude that patients with painful rotator cuff tears use the parascapular muscles more than those without pain do during arm elevation.

Distal pectoralis major tears: sonographic characterization and potential diagnostic pitfalls

OBJECTIVES

Distinction between musculotendinous tears of the pectoralis major and distal tendon avulsions is important, as the latter typically requires surgical repair. The objective of this study was to characterize the sonographic appearances of surgically proven distal tendon avulsion tears of the pectoralis major.

METHODS

A retrospective search of the radiology database (2001-2011) revealed 22 cases of pectoralis major tears on sonography, of which 9 had surgical correlation. Sonograms were retrospectively characterized by 3 fellowship-trained musculoskeletal radiologists in consensus with respect to the location and size of the fluid collection and the presence of tendon or tendonlike tissue superficial to the biceps brachii tendon.

RESULTS

At surgery, complete distal tendon avulsions or tears of the sternal head of the pectoralis were present in all 9 cases: isolated in 6 and combined with clavicular head tears in 3. The location of the fluid collection was at the musculotendinous junction in 89% (8 of 9) and medial to the biceps brachii tendon in 11% (1 of 9), with a mean largest dimension of 3.8 cm (range, 0.7-6.2 cm). In no case was fluid seen at the humeral attachment of the pectoralis. In 67% (6 of 9), linear thickened hypoechoic tissue was seen superficial to the biceps brachii tendon, which simulated an abnormal but intact tendon, whereas in 33% (3 of 9), a normal distal pectoralis tendon was seen.

CONCLUSIONS

Surgically proven distal pectoralis major tendon avulsions most commonly showed fluid collections at the musculotendinous junction and not at the humeral shaft, with either a normal tendon or hypoechoic tendonlike tissue over the biceps brachii long-head tendon. These findings may potentially cause misdiagnosis of distal tendon avulsions or tears as musculotendinous injuries.

Abdominal injuries related to bicycle accidents in children

PURPOSE

Bicycling is a well-liked sporting activity in which many children participate, and bicycle accidents are one of the most common causes of abdominal injuries in children. We evaluated the characteristics and outcomes of abdominal injuries due to bicycle accidents in children.

PATIENTS AND METHODS

This study was carried out retrospectively on children at the Department of Pediatric Surgery who were hospitalized for abdominal injury due to a bicycle accident, from 2008 to 2012. Abdominal injury-related bicycle accidents were evaluated with respect to patient characteristics, clinical presentation, management strategy, and outcome.

RESULTS

Fifty-nine patients were hospitalized for abdominal injuries related to a bicycle accident. The mean age of the patients was 11.48 ± 3.6 years. Most patients had an imprint of the handlebar edge on their abdomen. The most common abdominal organ injury due to a bicycle accident was laceration of the liver. Most patients were treated conservatively. Surgery was performed in 14 (24.1 %) patients. Hospital stay was 1-68 (mean 4.34 ± 11.6) days.

CONCLUSIONS

Abdominal injuries following a bicycle accident are frequent, serious, and preventable. Most patients were treated conservatively. Bicycle injuries can be prevented.

Anatomic guide and sonography for surgical repair of leg muscle lacerations

BACKGROUND

There were over 110,000 leg laceration cases reported in the United States in 2011. Currently, muscle laceration is repaired by suturing epimysium to epimysium. Tendon-to-tendon repair is stronger, restores the muscle's resting length, and leads to a better functional recovery. Tendons retract into the muscle belly following laceration and surgeons have a difficult time finding them. Many surgeons are unfamiliar with leg muscle anatomy and the fact that the leg muscles have long intramuscular tendons that are not visible in situ. A surgical anatomic guide exists to help surgeons locate forearm tendons; no such guide exists for tendons in the leg.

MATERIALS AND METHODS

The leg tendon ends of 11 cadavers were dissected, measured, and recorded as percentages of leg length. High-frequency ultrasound was used to locate tendon ends in three additional cadavers. These locations were compared with the actual tendon ends located via dissection.

RESULTS

There was little variation in tendon end position within the cadaver group, between men and women or right and left legs. The data are presented as an anatomic guide to inform surgeons of the tendon ends' likely locations in the leg.

CONCLUSION

The location of leg intramuscular tendon ends is predictable and the anatomic guide will help surgeons locate tendon ends and perform tendon-to-tendon repairs. Ultrasound is a potentially effective tool for detection of accurate location of repairable tendon ends in leg muscle lacerations.

Diffuse trauma of the right lobe of the liver successfully treated without resection. Case report

The victim of a motorcycle frontal crash was treated in a high reference teaching hospital for disruption of the right lobe of the liver (IV grade AAST/Moore). Primary packing, secondary biloma and abscess treatment including papillotomy and biliary stent, led, after 8 months, to cicatrisation of a damaged liver parenchyma. In conclusion, the authors stress that such injuries should be treated in highest level reference centres where all modern noninvasive interventional modalities are available, and that surgical resection is not always the operation of best choice.

Incontinence after primary repair of obstetric anal sphincter tears is related to relative length of reconstructed external sphincter: a case-control study

OBJECTIVE

To determine if anatomic primary repair with end-to-end reconstruction of the external anal sphincter (EAS) in its full length combined with separate repair of coexisting internal anal sphincter (IAS) tear, when present, results in less incontinence and better anal sphincter integrity compared with conventional primary end-to-end repair in which the IAS is not actively reconstructed.

METHODS

Women who sustained third- or fourth-degree obstetric tears were included prospectively in the study following anatomic primary repair. Women treated with conventional primary repair prior to the study period comprised the control group. Three-dimensional endoanal ultrasonography (3D-EAUS) images were classified according to the EAUS defect score, and incontinence according to St Mark's score.

RESULTS

Sixty-three women were included in the study group and 61 in the control group, with mean follow-up times of 11 and 21 months, respectively. Among women who had not delivered vaginally prior to the tear, St Mark's score ≥ 3 was reported by 9.6% (5/52) in the study group and 37.5% (15/40) in the control group at follow-up (P = 0.002). The corresponding numbers among women who had previously delivered vaginally were 36.4% (4/11) and 42.9% (9/21), respectively (non-significant). St Mark's score correlated with the EAUS defect score (P = 0.017). An EAS defect exceeding 50% of the sphincter length was significantly less common in the study group, and in a multivariable logistic regression model, mode of repair (anatomic vs conventional) was the only factor explaining the difference in EAS sphincter length between the two groups (P = 0.007).

CONCLUSION

Improved continence status after anatomic primary repair was associated with a better longitudinal reconstruction of the EAS, while the integrity of the IAS did not differ between the groups. Women with a history of vaginal delivery prior to the sphincter tear had an inferior outcome regardless of mode of repair.

Three-dimensional transperineal ultrasound findings associated with anal incontinence after intrapartum sphincter tears in primiparous women

OBJECTIVE

Three-dimensional transperineal sonography (3D-TPS) performed in women following third- or fourth-degree intrapartum tears repaired with the overlapping technique demonstrates characteristic signs. The aim of this study was to investigate the correlation of these signs with clinical complaints of incontinence.

METHODS

This was a prospective observational study. Sixty primiparous women underwent 3D-TPS 3-42 (mean, 10.6) months after surgical repair of third- or fourth-degree postpartum sphincter tears with the overlapping technique and were evaluated for clinical degree of incontinence using the St Mark's Incontinence Score (SMIS) questionnaire. The following signs were assessed on 3D-TPS: interruption of the internal anal sphincter or external anal sphincter, 'half moon' sign, changes in the mucosal folds and thickening of the external anal sphincter in the area of sphincter repair. As a comparison group, 27 primiparous women after normal vaginal delivery, without clinically recognized anal sphincter tears, were evaluated similarly, 3-37 (mean, 9.9) months postpartum.

RESULTS

Abnormal sonographic signs were apparent in 35 (58.3%) of 60 women in the study group, and 39 (65%) of 60 had some clinical complaints of incontinence 3-42 months after delivery, most of a mild degree. Higher SMIS results were found in women of the study group than in those of the comparison group (mean (SD) 2.80 (0.481) vs. 1.15 (0.365); P = 0.018). The rates of incontinence were similar between the women in the study group with normal ultrasound findings and the women in the comparison group (9/25 vs. 10/27; relative risk (RR) = 0.97, 95% CI, 0.47-1.97).

CONCLUSIONS

Sonographic signs of anal sphincter tear and repair had disappeared at follow-up examination in almost half of the patients, and therefore this examination should be deferred from the early postpartum period. A substantial proportion of women report some complaint of incontinence after sphincter repair, most of a slight degree. Such complaints are associated with abnormal 3D-TPS findings at follow up, while in women with a normal 3D-TPS scan the rate of incontinence complaints is similar to that in women after normal delivery.

Iatrogenic tracheal tear

Large post intubation tracheal tears are usually detected intra-operatively due to unstable signs namely impaired ventilation and mediastinal emphysema and often require surgical management. Smaller tracheal tears are often missed during anaesthesia and recognized during the postoperative period. Conservative management should be considered in these latter cases.

Botulinum toxin-assisted endoscopic repair of traumatic vocal fold avulsion

Blunt traumatic laryngeal injury in children often leads to intralaryngeal soft-tissue damage, which can quickly compromise an already small airway. Injuries requiring operative intervention have historically been repaired via open approaches such as thyrotomy and laryngofissure. These approaches carry significant long-term sequelae that can compromise the airway, deglutition, and voice. We describe a safe and effective alternative to open repair that includes the use of a botulinum toxin chemical myotomy to ensure optimal healing. We used this procedure to treat a 13-year-old boy who had experienced a traumatic avulsion of the true vocal folds. Postoperatively, his voice outcome was satisfactory, as evidenced by a marked improvement in his pediatric Voice Handicap Index score. No complication or compromise of the airway or swallowing occurred, and resolution of the botulinum effect was observed by 6 months postoperatively. The endoscopic approach supplemented by botulinum toxin injection avoids scarring and allows for safe postoperative extubation. Compared with open repair, it is associated with a shorter hospital stay and a lower risk of stenosis and fibrosis.

Outcome of primary repair of obstetric anal sphincter injuries (OASIS): does the grade of tear matter?

OBJECTIVES

To assess risk factors and outcome of different grades of obstetric anal sphincter injuries (OASIS) after primary repair, and to assess the relationship between outcome of anal sphincter defects as diagnosed by endoanal ultrasound.

METHODS

We included 531 consecutive women (of which eight were tertiary referrals) who had sustained OASIS, underwent primary sphincter repair and were followed up between July 2002 and July 2008. At follow-up, defecatory symptoms and bowel-related quality of life (QoL) were evaluated and anal manometry and endoanal ultrasound were performed.

RESULTS

The mean time of follow-up was 9 (SD, 5.9) weeks after delivery. Compared with women with a minor (Grade 3a/3b) tear, those with a major (Grade 3c/4) one had a significantly poorer outcome (P < 0.05) with respect to the development of defecatory symptoms and associated QoL as well as anal manometry. Women with major tears were significantly more likely to have an endosonographic isolated internal anal sphincter (IAS) or combined IAS and external anal sphincter (EAS) defect. Combined defects were associated with a higher risk of loose fecal incontinence and lower anal canal pressures. Use of epidural analgesia was the only independent factor predicting a major tear.

CONCLUSIONS

The greater likelihood of endosonographic anal sphincter defects in women with major tears compared with minor tears is the probable cause of the less favorable outcome of primary repair. Endosonographic combined defects are associated with poorer outcome and it is therefore important to identify the full extent of injury at delivery in women who sustain OASIS, and to pay particular attention to repair of IAS defects.

Selective fiberoptic left main-stem intubation to treat bronchial laceration in an extremely low birth weight neonate

A neonate born at 24 weeks gestation developed a right tension pneumothorax that persisted despite the placement of multiple thoracostomy tubes, the use of high-frequency ventilation and postural therapy. On day-of-life 11, bedside bronchoscopy revealed a laceration at the junction of the trachea and right main-stem bronchus. Under fiberoptic guidance the left main-stem bronchus was intubated. Single-lung ventilation then was employed for 24h, after which time the pneumothorax never recurred. We postulate that the diversion of positive-pressure ventilation away from the laceration site allowed the surrounding injury-induced granulation tissue to create a seal and facilitate closure of the defect.

Tracheal laceration associated with cervical spine injury-case report

Mortality as a result of cervical spine injuries is predominantly associated with respiratory complications. Besides atelectasis, pneumonia, or respiratory failure, possible complications also include damage to anatomical structures of the respiratory tract.

CASE REPORT

We present the case of a 44-year-old man who suffered a cervical spine injury with associated tracheal laceration after a fall from a height of about 2 meters. Vertebrae C3, C4, C5 were damaged with anterior dislocation at the C3/C4 level. Because of the development of respiratory failure, the patient was intubated and mechanical ventilation was commenced. In view of a complete and irreversible spinal cord injury, the patient was not qualified for an emergency stabilisation of the vertebral fractures. Surgery was further delayed because of increasing signs of a respiratory infection. On the 12th ICU day, a perforation of the anterior tracheal wall was identified during an elective tracheotomy. Due to the presence of pus at the tracheostomy site and air leakage around the tracheostomy tube cuff, the patient was intubated with a double-lumen endotracheal tube. On the 23th ICU day, acute problems with mechanical ventilation developed due to persisting air leakage around the tube cuff accompanied by signs suggestive of a tracheo-oesophageal fistula. Replacement of the double-lumen tube with a single-lumen one and a bronchoscopy was followed by cardiac arrest. Resuscitation led to the return of circulation over four hours, followed by death of the patient in the setting of increasing shock. The cervical spine injury suffered by the patient can be classified as Magerl's B1.2.3 and additionally as a Category C injury. These are the most severe injuries which may be accompanied by tracheal or oesophageal damage. In such cases, it is advisable to carry out detailed work-up to detect any damage to structures adjacent to the spine, in particular the trachea and oesophagus. Early stabilisation of severe spinal fractures allows for intraoperative assessment of the adjacent structures. A delay in diagnosing damage to the trachea or oesophagus is associated with poorer prognosis and a potential inability to treat the injuries due to developing inflammatory complications.

Evaluation of the risk of intercostal artery laceration during thoracentesis in elderly patients by using 3D-CT angiography

OBJECTIVE

Our study was undertaken to determine the location of the tortuous intercostal artery in elderly patients by using 3D-CT angiography in order to prevent laceration during thoracentesis.

METHODS

We evaluated the data of 3D-CT angiography of the intercostal artery in consecutive patients who had undergone contrast chest CT scan in our hospital from December 2007 to April 2008. We considered the "percent safe space" (the shortest lower rib-to-intercostal artery distance/the upper rib-to-lower rib distance) to be an index of safety that can be used to prevent laceration of the intercostal artery during thoracentesis. We measured this index at 3 points: the total site (5-10 cm lateral to the spine), the lateral site (9-10 cm lateral to the spine), and the medial site (5-6 cm lateral to the spine).

RESULTS

We evaluated 33 cases (25 males and 8 females; mean age, 74.2 years). The mean percent safe space at the total site was 58.6%. The percent safe space at the total site tended to decrease with advancing age, but the correlation was low (p=0.0378, r=-0.3631). The percent safe space at the lateral site (mean, 79.8%) was significantly higher than that at the medial site (61.2%, p<0.0001).

CONCLUSION

We showed that the intercostal artery is tortuous and does not always lie along the inferior edge of the rib and that the percent safe space at the lateral site is significantly higher than that at the medial site in elderly patients.

Iliac artery injury during lumbar microdiscectomy

BACKGROUND

Accidental laceration of major abdominal vessels during lumbar disc surgery is a relatively rare complication that requires rapid diagnosis and management.

CASE REPORT

A 25-yr-old woman, operated on for an L4-L5 disc hernia, developed cardiovascular collapse after disc removal. This was treated with volume replacement and ephedrine, and a postoperative CT scan revealed a large retroperitoneal haematoma. During an immediate laparotomy, a 10 cm laceration of the left iliac artery was repaired and massive blood loss replaced (to lowest haemoglobin concentration during the surgery was 2.1 mmol L(-1)).The patient made a full recovery.

CONCLUSION

In any case of unexpected hypotension during lumbar disc herniation surgery, accidental vascular damage should be suspected and a CT scan performed immediately.

High-flow priapism complicating ischemic priapism following iatrogenic laceration of the dorsal artery during a Winter procedure

We report a case of a patient who developed high-flow priapism following a Winter procedure performed for the treatment of low-flow ischemic priapism. During the creation of bilateral cavernosal-glandular shunts, the tip of the left dorsal artery was accidentally lacerated. A fistula developed through the shunt between the torn artery and the cavernosal sinusoids of the tip of the left corpus cavernosum. Gray-scale and Doppler sonography and angiography allowed diagnosis and guided the therapeutic approach.