Computed tomography-guided trigeminal tractotomy-nucleotomy in the management of vagoglossopharyngeal and geniculate neuralgias

OBJECTIVE

Vagoglossopharyngeal and geniculate neuralgias are less frequently seen types of cranial neuralgias. Their causes and symptomatology are similar to those of trigeminal neuralgia; however, the complex anatomic relationship between the intermedius, vagal, and glossopharyngeal nerves leads to difficulties in the diagnosis and management of neuralgias originating from these cranial nerves. Numerous procedures have been used to treat intractable neuralgias of the VIIth, IXth, and Xth cranial nerves: 1) extracranial sectioning of the cranial nerves, 2) percutaneous thermal rhizotomy, 3) intracranial glossopharyngeal and vagal rhizotomies, 4) microvascular decompression, and 5) percutaneous trigeminal tractotomy-nucleotomy (TR-NC) or nucleus caudalis dorsal root entry zone operation. We propose that computer-guided TR-NC may be the first-choice operation for patients with glossopharyngeal, vagal, or geniculate neuralgia.

PATIENTS AND METHODS

Nine patients suffering from idiopathic vagoglossopharyngeal neuralgia (six patients) and geniculate neuralgia (three patients) were managed at our clinic. Computed tomography-guided percutaneous trigeminal TR-NC was performed for these nine patients.

RESULTS

Excellent (six patients) or good (three patients) pain control was obtained in each patient. Complications included temporary ataxia in two patients after TR-NC.

CONCLUSION

The risk:benefit ratio should be evaluated individually to select the appropriate treatment procedure for patients with vagoglossopharyngeal and geniculate neuralgias. Computed tomography-guided percutaneous TR-NC is an effective and minimally invasive procedure for such patients.

Accessory extensor carpi radialis muscle and interconnecting muscular bundle

An accessory muscle and a muscular bundle were found and prepared in both forearms of a 55-year-old male cadaver. On the left side, the accessory muscle-originated from the medial aspect of the extensor carpi radialis brevis (ECRB) muscle, coursed downwards, crossed posterior to the tendon of ECRB, passed through the second chamber of the extensor retinaculum and inserted into the base of second metacarpal bone. Additionally, a muscular bundle was observed between the extensor carpi radialis longus (ECRL) and ECRB muscles. On the right side, both ECRL and ECRB had bifid tendons. The long and thin additional tendon of ECRL coursed downwards and joined the accessory tendon of the ECRB before entering the second chamber of the extensor retinaculum and the common tendon inserted into the base of the second metacarpal bone.

An unusual insertion of accessory biceps brachii muscle

In the course of a routine dissection of the anterior region of the arm an accessory muscle was observed in the flexor aspect of the right arm of a 64-year-old male cadaver. This accessory muscle, which was considered to be the third head of the biceps brachii muscle originated from the inserting tendon of the deltoid muscle. The muscle gave rise to three tendons as it approached the cubital fossa. Two of these tendons inserted to the bicipital aponeurosis whereas the third tendon inserted to the ulnar head of the pronator teres muscle. Dissection of the forearm on both sides revealed that the palmaris longus muscles was absent bilaterally. Mechanical effects of the insertion tendons of the accessory head of the biceps brachii on the median nerve, especially during the supination of the forearm, are discussed. For radiodiagnostic procedures, MRI images of the accessory head were obtained in the coronal and axial planes.

Location of the ostia of the renal arteries in the aorta

A total of 30 adult abdominal aorta specimens dissected from cadavers was used in our study. The location of the ostium of the superior mesenteric a. relative to the ostium of the celiac trunk was identified on the aortic wall. Following this, the locations of the ostia of the renal aa. on the internal wall of the abdominal aorta were examined relative to the ostia of the arteries mentioned earlier. The ostium of the superior mesenteric a. was usually localized on the inferior-right side of the ostium of the celiac trunk. The mean value of the distance between the ostia was 17.9 mm. The ostium of the right renal a. was more cranial than the ostium of the left renal a. (53.3%). However, the ostia of both right and left renal aa. were at the same level in three cases (10%). Locations of the ostia of the renal aa. were usually on the lateral and anterolateral regions of the aortic wall. This study was carried out in order to contribute to selective angiography and surgical interventions for the removal and transplantation of organs, particularly of the kidney. Our results are compared with previous similar studies in man.

Endoscopic anatomic distances on the lateral nasal wall

OBJECTIVE

Functional endoscopic sinus surgery has become popularized during the last decade all over the world. Knowledge about the intricate anatomy of the nasal cavity, the ethmoid labyrinth, and related structures is of vital importance for the endoscopic sinus surgeon to avoid probable complications. This study was undertaken to provide a set of reference distances to the endoscopic surgeons.

METHOD

In this surgical anatomic study, the distances of special anatomic landmarks from the anterior nasal spine were measured during the endoscopic dissection. The procedure was performed in 50 cadavers and measurements were done by the use of straight surgical guide under endoscopic vision.

CONCLUSIONS

Optimum attention should be concentrated on vital structures such as optic nerve and internal carotid artery at posterior rhinobasis after approximately 75 mm. Surgical distances of critical anatomic landmarks on the lateral nasal wall from anterior nasal spine should be kept in mind during surgical interventions.

Mitral and aortic valve replacement using fresh unstented pulmonary and aortic homografts

The use of prosthetic valves carries a high incidence of complications including thromboembolism, hemolysis, infection, impaired hemodynamic function and mechanical failure. Unstented homograft valves provide a good quality of life, particularly in terms of a reasonable freedom from these complications. This paper presents the first simultaneous replacement of the mitral and aortic valves using fresh unstented pulmonary and aortic homografts collected from the same donor. We believe that this technique will be especially useful in developing countries facing financial difficulties and problems with patient education.

Accessory muscular bundles arising from biceps femoris muscle

Two kinds of accessory muscle bundles arising from the long head of the biceps femoris muscle were encountered in a 20-year-old Turkish female cadaver during routine dissections. The one occurred on both sides, each arising from the lower portion of the long head of the muscle and passed deep to the fascia of the popliteal fossa to be inserted into the crural fascia. The other one which was observed only on the right side, arose from the upper portion of this head to be inserted into the semitendinosus muscle.

Morphometry of the fibrous ring of the mitral valve

In standard textbooks of anatomy it is generally accepted that the fibrous ring of the mitral valve lies in a single plane throughout its entire circumference. Some authors have stated otherwise, but there are no morphometric studies. 30 formalin-fixed hearts were sectioned to reveal the shape of the fibrous ring of the mitral valve and studied by morphometric, radiographic and histological methods. It was noted that the fibrous ring adopted a horizontal "S" shape around the two commissures and the average distance between the highest and lowest parts of the fibrous ring was found to be 7.1 mm (range 6.2-12.5 mm). Radiographic evaluation revealed that the fibrous ring lies approximately in two planes rather than in one. Histological study showed that the fibrous tissue of the mitral valve is continuous with the aortic fibrous ring, and that a slight but significant thickening marks the insertion of the mitral valve. The mitral valve thus lies in two planes, and it is hoped that this information will contribute to cardiac and valvuloplastic surgery.

Surgical treatment of urethral diverticula in men

Two 21-year-old men were treated for congenital diverticulum at the bulbous portion of the anterior urethra. One of the diverticula contained a stone. Acquired anterior urethral diverticulum with ventral displacement of the penile shaft following repair of hypospadias was treated in a 21-year-old man. Correction of the defect involved ventral paramedian vertical incision, excision of the diverticulum with closure at the urethra, and traction sutures for the ventral penile displacement.

New technique to enlarge the aortic annulus

A new technique is described to enlarge the aortic annulus and the supraaortic area by using the anterior mitral leaflet. This technique is used when it is necessary to replace both the aortic and mitral valves.