The Upper Attachment of the Uncinate Process and Anterior Ethmoidal Artery

OBJECTIVE

Variations in the upper attachment of the uncinate process (UP) are important because they can affect frontal sinus drainage and change the morphology. Functional endoscopic sinus surgery (FESS) is the primary technique used to treat chronic medically refractory rhinosinusitis. Uncinectomy is the basis of FESS technique to obtain the best possible result from surgery. The anterior ethmoidal artery (AEA) enters the nasal cavity through the orbital medial wall (lamina papyracea) may also be affected by the upper attachment of the UP. The aim of this study was to investigate a possible link between UP variations and the course of the AEA.

MATERIALS AND METHODS

This retrospective, computed tomography (CT)-based, anatomic study was conducted on 200 healthy adults (100 females and 100 males) by screening bilateral paranasal sinus images. The upper attachment of the UP was classified in 6 types (1-6) based on the Liu classification. The AEA was divided into 4 types (A-D) based on location: anterior to the frontal sinus (A), between the frontal sinus and the middle nasal turbinate (B), and anterior to the posterior ethmoidal cells (C and D). All the CT images were evaluated simultaneously by 2 anatomists and 1 radiologist.

RESULTS

Of the total cases (200 right and 200 left side), 48.8% were type 1 UP attachment, 11.0% type 2, 12% type 3, 9% type 4, 18% type 5, and 1.2% type 6. The AEAs were classified as 12.2% type A, 71.8% type B, 15.2% type C, and 0.8% type D.

CONCLUSION

The course of the AEA through the nasal cavity was observed to shift anteriorly from the ethmoidal bulla to the frontal sinus in patients with UP attached to the lamina papyracea and middle turbinate. Remarkably, the AEA always coursed anterior from the middle nasal turbinate line.

Anatomical Variants of the Uncinate Process: A Challenge in the Endoscopic Surgery of the Nose and Paranasal Sinuses

Importance To identify the anatomical variants of the uncinate process relevant to surgical intervention during the nose and paranasal sinus surgeries. Objective To evaluate the frequency of anatomical variants of the uncinate process in a population of northeast Mexico and compare it with another population. Methods Retrospective study, descriptive and analytical, randomly selected patients with radiological evaluation at Hospital Universitario Dr. José Eleuterio González, Monterrey, Mexico. Images were obtained from the Radiology Department. A total of 149 patients aged from 18 to 79 years with paranasal sinus-CT performed between January 2019 and December 2021 were analyzed. The variables evaluated were uncinate process anatomical variations by age group, radiological classification of the superior attachment of the uncinate process, and morphological variations. Main outcomes and measures The primary study outcome was the determination of the most frequent insertion of uncinate process in the northeast Mexican population. Results The 149 CT scans comprised 71 females with a mean age of 38.28 ± 16.7 years and 78 males, with a mean age of 41.8 ± 15.01 years. The most frequent uncinate process of superior attachment was type one, observed in 57.7% of males (n=45) and 50.7% of females (n=37) (p=0.494). Type one was most observed on the right side (57.7%). Type four was the second most common type, present in 12.8% of males (n=10) and 12.7% of females (n=9) (p=0.82). Conclusion Knowledge about the types of variations in the insertion of the uncinate process is fundamental prior to any endoscopic sinus surgery. The surgeon must be familiar with this detail when approaching patients with sinonasal pathology.

Computed Tomography Osteoabsorptiometry Evaluation of Cervical Endplate Subchondral Bone Mineral Density

STUDY DESIGN

Basic Science.

OBJECTIVE

Poor subchondral bone mineral density (sBMD) has been linked with subsidence of cervical interbody devices or grafts, which are traditionally placed centrally on the endplates. Considering that sBMD reflects long-term stress distributions, we hypothesize that the cervical uncovertebral joints are denser than the central endplate region. This study sought to investigate density distributions using computed tomography osteoabsorptiometry (CT-OAM).

METHODS

Twelve human cervical spines from C3-C7 (60 vertebrae, 120 endplates) were imaged with CT and segmented to create 3D reconstructions. The superior and inferior endplates were isolated, and the sBMD of the whole endplate, endplate center, and uncus was evaluated using CT-OAM. Density distributions were compared across the subaxial cervical spine.

RESULTS

The uncinate region of the inferior and superior endplates was significantly denser than the central endplate across all vertebral levels (P < .01). When comparing sBMD of the whole inferior and superior endplates, the superior endplate was significantly denser than the inferior endplate (P < .0001). However, the inferior uncus was denser than the superior uncus (P = .035). When assessing sBMD by vertebral level, peak densities were observed at C4 and C5, while C7 was, on average, significantly less dense than all other vertebrae.

CONCLUSION

The subchondral bone of the cervical uncovertebral joints is significantly denser than the central endplates. While the superior endplate in its entirety is denser than the inferior endplate, the inverse was true for the uncovertebral joints. This study serves as a basis for future investigations of new implant designs and their implications on subsidence.

Pancreatic morphology/contour variations should be recognized and remembered

Background

Pancreatic contour variations can be detected incidentally on computed tomography (CT). Recognition and remembering of these variations are important in volumetric measurements and surgery as well as in preventing misdiagnosis.

Aim

This study aims to evaluate the morphology/contour variations in the pancreas head-neck, body-tail, and uncinate process with multi-detector CT (MDCT) examinations (triple phase CT abdomen).

Material and Method

Around 1662 adult age (>18 years old) patients were evaluated retrospectively, and after exclusion criteria, 945 patients were included in the study. Aplasia and hypoplasia of the uncinate process were determined, and pancreatic contour variances were categorized according to the Ross et al. and Omeri et al. classifications. Pancreatic head-neck variants were categorized into Type I-anterior, Type II-posterior, and Type III-horizontal variations. Pancreatic body-tail variants were sectioned into Type Ia-anterior protrusion, Type Ib-posterior protrusion, and Types IIa-globular, IIb-lobulated, IIc-tapered, and IId-bifid pancreatic tail.

Results

Of the 945 patients, 481 (50.9%) were female. The mean age was 43.28 ± 10.49 (min. 20-max. 68). In the evaluations made according to the uncinate process morphology variant, hypoplasia was detected in 66 (7%) patients and aplasia in 12 (1.3%) patients. Pancreatic head-neck and body-tail contour variations were observed in 596 (63.1%) patients. The most common head-neck variation was Type II in 233 (24.6%) patients, followed by type III in 96 (10.2%). There were Type Ia in 83 (8.8%) patients and Type Ib in 14 (1.5%) patients. The pancreatic tail configuration was normal in 792 (83.8%) patients; it was Type IIa in 62 (6.6%) patients and IIb in 50 (5.3%) patients. The most common variation was head and tail in 33 (3.5%) patients.

Discussion

Pancreatic variations detected in CT examinations for distinct reasons are not rare; these variations should be recognized and remembered.

An Integrated Analysis Reveals Ciliary Abnormalities in Antrochoanal Polyps

Objective

The mechanisms underlying the antrochoanal polyps (ACPs) remained unclear. We aimed to identify the differentially expressed genes (DEGs) profile, the cilia-related genes expression levels and the morphological characteristics of ciliated cells in patients with ACPs.

Methods

We obtained ACPs biopsy samples from 28 patients and uncinate process from 27 healthy controls. Whole-transcriptome RNA sequencing, immunofluorescence staining, quantitative polymerase chain reaction, and scanning electron microscopy were performed.

Results

3739 DEGs were detected between ACPs and controls, and Gene Ontology analysis on these DEGs implicated cilium assembly, cilium motility, cilia component, cilia function, inflammatory response and immune system process were included in ACPs pathogenesis. Gene set enrichment analysis implicated sets of genes regulated in processes associated with cilium organization, cilium morphogenesis, cilium movement, axoneme assembly, axonemal dynein complex assembly and cell projection assembly. The expression levels of cilia-related genes (FOXJ1, DNAI1, DNAH9, RSPH1, RSPH9 and RSPH4A) were validated by quantitative polymerase chain reaction (Fold change >2, P<0.05) and FOXJ1 was positive correlated with DNAI1, DNAH9, RSPH4, RSPH1, RSPH9, DNAH5, DNALI1 in ACPs (all P < 0.05). Based on our semi-quantitative scoring system, median scores of α-Tubulin, DNAI1 and RSPH4A were significantly higher in ACPs than in controls. In addition, loss of ciliated cells and a shorter cilia pattern were further confirmed by immunofluorescence staining and scanning electron microscopy in ACPs.

Conclusion

The aberrant expression of cilia-related genes and ciliary structural impairment are an important pathological phenomenon in ACPs, and our findings may provide novel insights into understanding the mysterious mechanisms underlying ACPs.

The Échancrure of the Uncovertebral Joint: A Forgotten Structure of the C3-C7 Cervical Vertebral Bodies

Introduction The échancrure (a French term meaning "indentation") of the cervical vertebrae is the poorly defined articular part on the inferolateral aspect of the cervical spine body, which, with the uncinate processes of the associated caudal vertebra, makes up the joints of Luschka (uncovertebral joint). With no known previous studies on the échancrure, the present anatomical study aimed to better elucidate this structure, its prevalence, and its relationships to the adjacent intervertebral foramen and uncinate process. Methods We observed 50 adult cervical spines (100 sides) for the presence of an énchancrure. When an énchancrure was identified, its morphometry was documented and photographed. Measurements included the width and height of the énchancrure. The relationship with the adjacent uncinate process was also studied. Any correlation between the size and shape of the adjacent uncinate process and the énchancrure was recorded. Results Anénchancrure was found at all levels of the cervical vertebrae except at C1 and C7 and was clearly visible on 88% of the sides. The énchancrure, more or less, conformed to the reciprocal shape of the uncinate process, which was found on all sides. The shapes were roughly arched, ovoid, or linear. These structures were always in an anterolateral position on the body of the vertebra and just outside the apophyseal ring. The mean height of the énchancrure was 2.1 mm. The length of the uncinate process correlated positively (r=0.8) to the size of the adjacent énchancrure. The height of the énchancrure was inversely related to the diameter of the adjacent intervertebral foramen. The mean width was 8.3 mm. These structures tended to be largest at C3 and C4 vertebral levels and were smallest at C5 and C6 levels. The énchancrure was most in contact with the uncinate process with lateral flexion of the cervical spine and in specimens with a longer uncinate process, e.g., C6. The énchancrure was also found to be wider in cases of cervical spine degeneration involving the body of the cervical vertebrae. Degeneration of the uncovertebral joint was most often seen at the énchancrure and not at the adjacent uncinate process. Conclusions We found that the énchancrure is found in the majority of cervical spines. These structures tended to be largest at C3 and C4 vertebral levels and were smallest at C5 and C6 levels, and they had more prominence when the adjacent uncinate process was enlarged. The énchancrure should be considered a normal feature of the inferolateral aspect of the cervical vertebrae. Future clinical studies are necessary to better elucidate their functional significance.

Anatomical Changes in a Case with Asymmetrical Bilateral Maxillary Sinus Hypoplasia

Background and Objectives: The maxillary sinus hypoplasia (MSH) is an occasional variation of the maxilla, occurring either unilaterally or bilaterally. Previous studies dealing with MSH have not detailed the consequent anatomical changes of the maxilla and adjacent fossae. Materials and Methods: A 58-year-old female case was scanned in Cone Beam Computed Tomography and found to have asymmetrical bilateral MSH, who was then further evaluated anatomically. Results: The maxillary sinuses were hypoplastic and had mild mucosal thickenings. The orbital floors were curved. The uncinate process and the ethmoidal infundibulum were laterally displaced beneath the orbit floor. On each side, the lateral nasal wall protruded within the respective maxillary bone to reach above the vestibular cortical plate of the alveolar process. This expansion of the lateral nasal walls was limited to the premolar and first molar regions. The inferior turbinates were laterally curved. The perpendicular palatine plate was building a postero-lateral nasal wall in front of the pterygopalatine fossa. Conclusions: The classification systems of MSH should be detailed to indicate whether the normal uncinate process is medial or inferior to the orbit. The lateral expansion of the lateral nasal wall in MSH is limited to the anterior part of that wall. The laterally expanded nasal fossa could reach anterior to the pterygopalatine fossa in MSH. Seemingly, CBCT is a better tool than CT to evaluate the detailed anatomy of the modified anatomical structures in MSH; as such, it could be of help in a surgical approach.

[The investigation of the histological differences between the mucosa on the nasal and sinus sides of uncinate process of chronic rhinosinusitis]

Objective:The aim of this study is to check whether histopathological differences exist between the nasal side and the sinus side of uncinate process of chronic rhinosinusitis and the histopathological basis of nasal polyp was discussed. Methods:The uncinate processes of chronic rhinosinusitis and control subjects were enrolled from October 2016 to April 2017. The following histopathological data were assessed: height of basement membrane, the proportion of glands in the sub-epithelium, the numbers of goblet cells and inflammatory cells. Results:A total of 116 patients were recruited, including 38 chronic rhinosinusitis with nasal polyps（CRSwNP）, 58 chronic rhinosinusitis without nasal polyps（CRSsNP） and 20 controls. There was no significant difference between age and gender distribution（P>0.05）. The basement membrane was significantly thinner on the sinus side of the 3 groups' uncinate processes than on the nasal side except CRSwNP group（P<0.05）. The basement membrane of CRSwNP and CRSsNP was significantly higher than control uncinate processes（P<0.05）. Inflammatory cells number were significantly increased in CRSwNP and CRSsNP than in the control uncinate processes, and the nasal side was obviously more than the sinus side in the CRSwNP and CRSsNP groups（P<0.05）. The number of goblet cells was more on the sinus side of the 3 groups uncinate processes than on the nasal side, that of CRSsNP and control were significant difference between the nasal side and sinus side（P<0.05）. The proportion of glands was larger on the sinus and nasal side of the uncinate processes in CRSwNP and CRSsNP than that of the control uncinate processes（P<0.05）, and the proportion of glands was significantly greater on the nasal side than on the sinus side of the uncinate processes in CRSwNP（P<0.05）. Conclusion:Histopathological differences exist between the nasal side and sinus side of the ups of CRSwNP, CRSsNP and control. The nasal side is more prone to polyps than the sinus side, which may be related to the thickening of basement membrane, the increase of inflammatory cells and gland area, and the decrease of goblet cells.

Efficiency of minimal oblique resection of the uncinate process during an anterior cervical discectomy and fusion

Hypertrophy of the uncinate process (UP) can cause radiculopathy. Minimal UP resection is considered to remove the lesion while minimizing the risk of complications. This study aimed to elucidate the surgical results of minimal oblique resection of the UP. This study is a retrospective review of about sixty segments in 34 patients who underwent anterior cervical discectomy and fusion (ACDF) with minimal oblique uncinectomy between 2016 and 2018. The cross-sectional area of the UP was measured pre- and postoperatively. The interspinous distance, segmental Cobb angle, subsidence, fusion rate, surgical time, estimated blood loss, and postoperative complications were evaluated. The mean resected areas of the UP were 17.4 ± 8.7 mm2 (25.9%) on the right and 17.3 ± 11.2 mm2 (26.2%) on the left. The difference in interspinous distance in flexion-extension was 7.1 ± 3.2 and 1.6 ± 0.6 mm pre- and postoperatively, respectively (P = .000). The fusion rate after ACDF was 91.7% when measured according to segment (55/60) and 91.2% when measured according to patients (31/34). The difference in the segmental Cobb angle in flexion-extension was 8.3 ± 6.2° and 1.9 ± 0.3° pre and postoperatively, respectively (P = .000). Subsidence occurred in 4 (11.8%) patients and 5 (8.3%) segments. The average surgical time per segment was 68.8 ± 9.3 minute, and the estimated blood loss was 48.5 ± 25.0 mL. Postoperative complications comprised 1 case each of neck swelling, wound infection, pneumonia, and gastrointestinal bleeding. Our findings therefore revealed that minimal oblique uncinectomy during an ACDF can maintain the stability of the uncovertebral joint while sufficiently decompressing the neural foramen.

Prevalence of Maxillary Sinus Hypoplasia and Silent Sinus Syndrome: A Radiological Cross-Sectional Retrospective Cohort Study

BACKGROUND

Maxillary sinus hypoplasia (MSH), associated with enophthalmos and hypoglobus in the silent sinus syndrome (SSS), is a poorly studied condition. The real incidence of MSH and SSS in the adult population is not known. Our study aims at estimating the radiological prevalence of MSH and identifying undiagnosed cases of SSS in a retrospective cohort.

METHODS

A cross-sectional retrospective cohort study was performed in adults, without a history of maxillofacial surgery or trauma, undergoing head CT scans. A radiological database of 1012 consecutive scans was reviewed independently by two authors to identify patients with signs of MSH and SSS and associated findings (septal deviation, uncinate deviation, concha bullosa, sinus opacification, bony rarefaction, and pterygopalatine fossa enlargement). The findings of MSH and SSS were compared with radiological reports.

RESULTS

891 eligible CT scans were analyzed. MSH and SSS prevalences were 6.17% (n = 55) and 0,56% (n = 5), respectively. The maxillary sinus was normally or partially ventilated in 96.36% of MSH patients. Lateralization of the uncinate process was detected in about 50% of MSH patients, while a septal deviation towards the affected sinus was detected in 21.82%. In 20% of MSH scans, a concha bullosa was identified. Radiological reports identified a single MSH case.

CONCLUSIONS

Our study confirmed the literature data on MSH prevalence, while it determined a precedently unknown prevalence for SSS, underestimated in the radiology reports. This prevalence needs further confirmation but suggests a routine accurate comparison of both maxillary sinuses in CT scans.

Estimation of the ethmoid roof depth and length of lateral lamella of the cribriform plate, upper attachment of the uncinate process and anterior ethmoid artery in multiplanar reconstructions of Computed Tomography

The aim is to assess the relationship of Anterior Ethmoid Artery with the Upper Attachment of the Uncinate Process and their relation with the Lateral Lamella of the Cribriform Plate in multiplanar reconstructions (i.e. coronal, axial and sagittal) of Computed Tomography. We measured the depth of the olfactory fossa, the length of the LLCP and determined the most superior attachment of the uncinate process, which designates boundaries of the frontal recess anteriorly, laterally and medially [20,22].

METHODS

All CT examinations were performed using the 320-detector Aquilion ONE CT Scanner (Canon Medical Systems, Otawara, Japan). Axial, coronal,sagittal reconstructions were performed by using dedicated workstation software (Vitrea Enterprice Siute, Version 6.7; Vital Images, Minnetonka USA). The Statistica 13 software was used for the analysis, results were considered statistically significant at the level of p&lt;0,05.

RESULTS

The most frequent types of Uncinate Process according to Landsberg- Friedman criteria in group of mens are: type I-30,77%,type II-30,77%, type III-26,92%, type VI-7,69%, type V-3,85%, type IV-0% respectively. In women&apos;s group: type III-44,12%,type II-32,35%, type I-8,82%,type V-8,82%, type IV-5,88%, type VI-0%. The median LLCP length in the anterior-posterior dimension measures 13 mm i. e. Yenigun type II on the both sides. The median value of depth in the superior-inferior dimension of the LLCP in the ethmoid roof is 5 mm i.e. Keros type II on both sides. The mean distance between Anterior Ethmoid Artery and Upper Attachment of the Uncinate Process measures approximately 9,73 mm and 9,16 mm on the right and left side respectively.

CONCLUSIONS

The assessment of the AEA, UAUP and configuration of the anterior skull base on CT multiplanar reconstructions contribute to optimazing the results of frontal sinus surgery.

Effect of Partial Uncinectomy After Balloon Sinuplasty on Maxillary Sinus Irrigant Penetration: A Cadaveric Study

Objective

The uncinate process may play a role in the amount of irrigation penetrance. In this cadaver study, we aimed to investigate if the addition of partial uncinectomy provides better maxillary sinus irrigation penetrance than balloon sinuplasty (BSP) alone.

Study Design

Cadaveric study.

Setting

Simulation laboratory at the Mayo Clinic in Florida.

Methods

Five fresh-frozen human cadaveric heads (10 sides) were used to assess maxillary sinus irrigation penetration after 3 interventions performed sequentially: irrigation penetrance with no intervention, irrigation after BSP, and irrigation after BSP and partial removal of the uncinate. Penetrance was recorded with intrasinus endoscopy and scored by 4 blinded observers using a scale from 0 (no irrigation) to 5 (fully irrigated). The diameter of the maxillary ostium was measured before and after BSP. Internal consistency was evaluated with Cronbach’s alpha.

Results

Mean ostium size increased from 4.1 to 6.8 mm after BSP (P = .013). Cronbach’s alpha was 0.93. The median scores of irrigation penetration after no intervention, BSP, and BSP and partial uncinectomy were 2.5, 3, and 4, respectively. We found a significantly higher penetrance following partial uncinectomy plus BSP versus BSP alone (P = .008). Both interventions had a statistically significant difference in irrigation penetrance as compared with no intervention (P = .0001).

Conclusion

Maxillary sinus irrigation penetration increased from baseline after BSP. The addition of a partial uncinectomy to the balloon dilation of the maxillary sinus was associated with a statistically significant increase in irrigation penetrance scores as compared with BSP alone.

Combination of anterior superior mesenteric vein-first and right posterior superior mesenteric artery-first approaches for uncinate process dissection in minimally invasive pancreaticoduodenectomy

Background

Uncinate process dissection is a key step in minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic and robotic procedures, which increase the intraoperative blood loss and operative time and decrease the R0 resection rate if improperly handled. However, few studies have reported the operative skills in detail.

Methods

We performed uncinate process dissection using a combination of the anterior superior mesenteric vein (SMV)-first approach and the right posterior superior mesenteric artery (SMA)-first approach in MIPD for 138 patients with periampullary tumors between March 2017 and October 2019. The demographic and perioperative data of all the patients were collected to evaluate the efficacy of this method.

Results

All patients underwent an uneventful operation. An assistant incision was performed to separate extensive adhesion between the tumor and the SMV in 3 patients. The combined approach had a notably shorter operation time and resection time, less intraoperative blood loss and a shorter postoperative hospital stay than the traditional approach (P<0.05). There were no significant differences in conversion rate, numbers of harvested lymph node or postoperative complications, including postoperative pancreatic fistula, bile leakage, delayed gastric emptying, postoperative bleeding and reoperation between the two groups (P>0.05). There were no deaths during the perioperative period.

Conclusions

The combination of the anterior SMV-first approach and the right posterior SMA-first approach is a safe and feasible technique for uncinate process dissection in MIPD.

Microanatomical considerations for safe uncinate removal during anterior cervical discectomy and fusion: 10-year experience

Cervical radiculopathy from uncovertebral joint (UVJ) hypertrophy and nerve root compression often occurs anterior and lateral within the cervical intervertebral foramen, presenting a challenge for complete decompression through anterior cervical approaches owing to the intimate association with the vertebral artery and associated venous plexus. Complete uncinatectomy during anterior cervical discectomy and fusion (ACDF) is a controversial topic, many surgeons relying on indirect nerve root decompression from restoration of disc space height. However, in cases of severe UVJ hypertrophy, indirect decompression does not adequately address the underlying pathophysiology of anterolateral foraminal stenosis. Previous reports in the literature have described techniques involving extensive dissection of the cervical transverse process and lateral uncinate process (UP) in order to identify the vertebral artery for safe removal of the UP. Recent anatomical investigations have detailed the microanatomical organization of the fibroligamentous complex surrounding the UP and neurovascular structures. The use of the natural planes formed from the encapsulation of these connective tissue layers provides a safe passage for lateral UP dissection during anterior cervical approaches. This can be performed from within the disc space during ACDF to avoid extensive lateral dissection. In this article, we present our 10-year experience using an anatomy-based microsurgical technique for safe and complete removal of the UP during ACDF for cervical radiculopathy caused by UVJ hypertrophy.

Total uncinectomy of the cervical spine with an osteotome: technical note and intraoperative video

Total uncinate process resection or uncinectomy is often required in the setting of severe foraminal stenosis or cervical kyphosis correction. The proximity of the uncus to the vertebral artery, nerve root, and spinal cord makes this a challenging undertaking. Use of a high-speed burr or ultrasonic bone dissector can be associated with direct injury to the vertebral artery and thermal injury to the surrounding structures. The use of an osteotome is a safe and efficient method of uncinectomy. Here the authors describe their technique, which is illustrated with an intraoperative video.

The Anterior Ethmoidal "Genu": A Newly Appreciated Anatomic Landmark for Endoscopic Sinus Surgery

Human sinonasal anatomy varies widely between patients, challenging surgeons operating in the sinuses. Ethmoid sinus anatomy is so variable it has been referred to as a labyrinth. Accordingly, reliable, consistent anatomic landmarks aid surgeons operating in this region. The goal of this investigation was to explore our observations and hypothesis that the ethmoidal bulla and the uncinate process are not entirely separate structures but rather attach, and the attachment could potentially provide a landmark for surgeons performing ethmoid and frontal recess surgery. Ethmoid sinus anatomy was studied in 57 sinonasal complexes through a variety of methods including gross anatomic dissection, endoscopic dissection and 3D CT stereoscopic imaging. The uncinate process and ethmoidal bulla were noted to fuse at the superior aspect of the hiatus semilunaris in 57/57 cases, forming a genu-like feature in the anterior ethmoid. This consistent anatomic feature related closely to the frontal sinus drainage pathway, which drained medial to it in 44/57 (77%) cases. The anterior ethmoidal "genu" appears to be an excellent anatomic feature that surgeons can use during ethmoid and frontal recess surgery. High resolution 3D stereoscopic CT scan is capable of demonstrating sinonasal anatomy in a detailed fashion previously only achieved by cadaveric dissection. This technology can potentially allow for a virtual dissection of a patient's anatomy prior to surgery and could improve minimally invasive procedures and reduce complications. Clin. Anat. 32:534-540, 2019. © 2019 Wiley Periodicals, Inc.

Computed Tomography Description of the Uncinate Process Angulation in Patients With Cystic Fibrosis and Comparison With Primary Ciliary Dyskinesia, Nasal Polyposis, and Controls

BACKGROUND:

There is a medial bulging of the lateral nasal wall in patients with cystic fibrosis (CF).

AIMS:

Uncinate process (UP) angulation measurements in patients and controls to objectify this bulging.

MATERIALS AND METHODS:

Thirty CF, 17 primary ciliary dyskinesia (PCD), 13 chronic rhinosinusitis with polyps (CRSwp), and 30 controls were included. Angles were measured bilaterally on computed tomography (CT) scans: A, B, C on coronal sections, D and E on axial sections. Angle A was between the UP and the orbit inner wall, whereas the others were between UP and midline.

RESULTS:

There was no significant difference between controls, PCD, and CRSwp. However, CF had 3 statistically different angles with controls, 5 with CRSwp, and 4 with PCD. Angle A average value was 126° (±16°) in patients with CF, 138° (±19°) in controls ( P = .007), 145° (±15°) in PCD ( P = .001), and 138° (±14°) in CRSwp ( P = .001). Angle E average value was 35° (±10°) in patients with CF, 20° (±6°) in controls ( P < .001), 21° (±4°) in PCD ( P < .001), and 22° (±6°) in CRSwp ( P < .001).

CONCLUSION:

Uncinate process's anatomy is only modified in CF: Angle between UP and inner wall of orbit is closed, and angles between UP and midline are opened.

SIGNIFICANCE:

These measures quantify the medial bulging of lateral nasal wall and support nasofibroscopic observations.

[The correlation between the types of the uncinate process superiorattachment and chronic frontal sinusitis without nasal polyps]

Objective:To investigate the correlation between the types of unicate process (UP) superior attachment and the chronic frontal sinusitis without nasal polyps(CFSsNP).Method:The images of 240 sides of frontal recess were evaluated. The types of UP superior attachment was compared between the CFSsNP group and the control group. The correlation between UP the superior attachment and CFSsNP were analyzed. Result:Seven types of UP superior attachment were identified. The most common type in the two study groups was type 1(insertion into the lamina papyracea). The occurrence rate of type 1 of UP superior attachment in the CFSsNP group was significantly higher than that in the control group(59.8% and 36.4%,respectively P<0.01),but type 5(insertion into both the lamina papyracea and the skull base) was significantly less frequent in the CFSsNP group than in the control group(9.8%，28.8%,P<0.01). Logistic regression analysis revealed that the type 1 of UP superior attachment was an independent risk factor for CFSsNP(OR=1.181,P<0.05),and that type 5 of UP superior attachment was a protective factor for CFSsNP(OR=0.391,P<0.05). Conclusion:UP superior attachment varied significantly,with the most common type being type 1; This type is intimately related to CFSsNP.

Microdiscectomy and Foraminotomy in Cervical Spondylotic Myelopathy and Radiculopathy

This study was to assess the efficacy of microdiscectomy, cage fixation, and right tranuncal foramintomy for the patients suffering from right radiulo-myelopathy. Anterior cervical foraminotomy was reported to be an effective option for the treatment of cervical degenerative radiculopathy but with the problem of recurrence. Since Hakuba reported the method of trans-unco-discal approach in 1976, it was designed as keyhole foraminotomy which was called transuncal approach, transpedicular approach or transvertebral approach. In the anterior approach, we usually use the right-sided approach because most of us are right-handed surgeons. We retrospectively investigated our patients who had the right foraminal stenosis causing radiculopathy and were treated with microdiscectomy, cage fixation, and right keyhole transuncal foraminotomy. Since 2011, 23 patients were treated with the manner. All of the 23 patients who had central canal stenosis and among the 23 patients, 8 patients showed only right radiculopathy and 15 patients showed radiculo-myelopathy. In all patients, the radiculopathy disappeared or significantly improved without any complications postoperatively. The average of VAS scores was 7.6 ± 2.2 in preoperative state, 2.8 ± 2.2 at discharge, and 1.1 ± 1.6 in 1 month after surgery. The average of follow-up time was 38.3 months and they had no recurrence of radiculopathy. We showed that this manner is effective and one option for the combined disease of right foraminal and canal stenosis and we believe that this manner is not complex and safe if we can understand the anatomy.

Surgical Anatomy of the Longus Colli Muscle and Uncinate Process in the Cervical Spine

PURPOSE

There have been a few previous reports regarding the distances between the medial borders of the longus colli to expose the disc space. However, to our knowledge, there are no reports concerning longus colli dissection to expose the uncinate processes. This study was undertaken to assess the surgical relationship between the longus colli muscle and the uncinate process in the cervical spine.

MATERIALS AND METHODS

This study included 120 Korean patients randomly selected from 333 who had cervical spine MRIs and CTs from January 2003 to October 2013. They consisted of 60 males and 60 females. Each group was subdivided into six groups by age from 20 to 70 years or more. We measured three parameters on MRIs from C3 to T1: left and right longus colli distance and inter-longus colli distance. We also measured three parameters on CT: left and right uncinate distance and inter-uncinate distance.

RESULTS

The longus colli distances, uncinate distances, and inter-uncinate distances increased from C3 to T1. The inter-longus colli distances increased from C3 to C7. There was no difference in longus colli distances and uncinate distances between males and females. There was no difference in the six parameters for the different age groups.

CONCLUSION

Although approximate guidelines, we recommend the longus colli be dissected approximately 5 mm at C3-5, 6 mm at C5-6, 7 mm at C6-7, and 8 mm at C7-T1 to expose the uncinate process to its lateral edge.

Comparison of Uncinate Process Cancer and Non-Uncinate Process Pancreatic Head Cancer

The special anatomical position accounts for unusual clinicopathological features of uncinate process cancer. This study aimed to compare clinicopathological features of patients with uncinate process cancer to patients with non-uncinate process pancreatic head cancer. Total 160 patients with pancreatic head cancer were enrolled and classified into two groups: uncinate process cancer and non-uncinate process pancreatic head cancer. We found that the ratio of vascular invasion was significantly higher in patients with uncinate process cancer than in patients with non-uncinate process pancreatic head cancer. In addition, the rate of R1 resection was significantly higher in patients with uncinate process cancer. Furthermore, the median disease-free survival (11 months vs. 15 months, p=0.043) and overall survival (15 months vs. 19 months, p=0.036) after R0 resection were lower for uncinate process cancer. Locoregional recurrence was more frequent (p=0.017) and earlier (12 months vs. 36 months; p=0.002) in patients with uncinate process cancer than in patients with non-uncinate process pancreatic head cancer. In conclusion, uncinate process cancer is more likely to invade blood vessel and has worse prognosis due to the earlier and more frequent locoregional recurrence.

Intraductal Papillary Mucinous Neoplasm and Pancreas Divisum: Two Cases

Background: Pancreatic intraductal papillary mucinous neoplasms (IPMNs) are a subset of ductal cell tumors with potential for malignancy. Because it is difficult to predict whether and when they will become malignant, management and resection are widely debated.

Case 1: A 70-year-old male with a 1-year history of epigastric pain was found to have pancreas divisum with a dominant 2.4 cm multicystic uncinate process lesion communicating with the main pancreatic duct and associated uncinate duct dilation.

Case 2: An 83-year-old male with pancreas divisum had a 7.3 cm uncinate cystic lesion with mural nodularity that had increased in size from 2.1 cm in 2008.

Conclusion: Management of patients with IPMNs can be challenging and may require resection to prevent malignant transformation.

Morphometric evaluation of the uncinate process and its importance in surgical approaches to the cervical spine: a cadaveric study

INTRODUCTION

The uncinate process (UP) has an important role because of its relationship with the vertebral artery and spinal roots. Degenerative diseases cause osteophyte formation on the UP, leading to radiculopathy, myelopathy and vertebral vascular insufficiency, which may require surgical management. This study aimed to evaluate the morphometry of this region to shed light on the anatomy of the UP.

METHODS

Morphometric data was obtained from 13 male formaldehyde-fixed cadavers. Direct measurements were obtained using a metal caliper. Computed tomography (CT) morphometry was performed with the cadavers in the supine position.

RESULTS

Direct cadaveric measurements showed that the height of the UP increased from C3 (5.8 ± 1.0 mm) to C7 (6.6 ± 0.5 mm). On CT, the corresponding measurements were 5.9 ± 1.2 mm at C3 and 6.9 ± 0.6 mm at C7. The distance between the left and right apex of the UP from C3 to C7 also increased on both direct cadaveric and CT measurements (C3: 20.8 ± 1.0 mm and C7: 28.1 ± 2.4 mm vs. C3: 23.7 ± 3.4 mm and C7: 29.0 ± 3.0 mm, respectively). On CT, the distance between the UP and superior articular process at the C3 to C7 levels were 9.8 ± 1.7 mm, 7.9 ± 1.8 mm, 7.9 ± 1.6 mm, 7.8 ± 1.3 mm and 8.2 ± 1.7 mm, respectively.

CONCLUSION

Direct cadaveric and CT measurements of the UP are useful for preoperative evaluation of the cervical spine and may lead to better surgical outcomes.

Surgical Anatomy of the Uncinate Process and Transverse Foramen Determined by Computed Tomography

Study Design Computed tomography-based cohort study. Objective Although there are publications concerning the relationship between the vertebral artery and uncinate process, there is no practical guide detailing the dimensions of this region to use during decompression of the intervertebral foramen. The purpose of this study is to determine the anatomic parameters that can be used as a guide for thorough decompression of the intervertebral foramen. Methods Fifty-one patients with three-dimensional computed tomography scans of the cervical spine from 2003 to 2012 were included. On axial views, we measured the distance from the midline to the medial and lateral cortices of the pedicle bilaterally from C3 to C7. On coronal reconstructed views, we measured the minimum height of the uncinate process from the cranial cortex of the pedicle adjacent to the posterior cortex of vertebral body and the maximal height of the uncinate process from the cranial cortex of the pedicle at the midportion of the vertebral body bilaterally from C3 to C7. Results The mean distances from midline to the medial and lateral cortices of the pedicle were 10.1 ± 1.3 mm and 13.9 ± 1.5 mm, respectively. The mean minimum height of the uncinate process from the cranial cortex of the pedicle was 4.6 ± 1.6 mm and the mean maximal height was 6.1 ± 1.7 mm. Conclusions Our results suggest that in most cases, one can thoroughly decompress the intervertebral foramen by removing the uncinate out to 13 mm laterally from the midline and 4 mm above the pedicle without violating the transverse foramen.

Surgical management of adenocarcinoma of the pancreatic uncinate process in a cancer hospital in egypt

INTRODUCTION

Pancreatic carcinoma affecting the uncinate process is a challenging surgical condition. Several considerations affect the management plan, including the need for vascular resection and the ability to achieve a clear margin.

METHODS

The data of 19 patients who had curative resection for pancreatic adenocarcinoma of the uncinate process were reviewed. Operative mortality and morbidity, and disease-free survival (DFS) were calculated.

RESULTS

The study population included 13 male and 6 female patients with a mean age of 55 years. Nine patients (47.4%) had stage I disease, seven patients (36.8%) had stage II disease, and three patients (15.8%) had stage III disease. A total of 12 patients had Whipple procedure and 7 patients had total pancreatectomy. In total, there were 9 R0 and 10 R1 resections. Operative mortality rate was 10.5% (2/19), postoperative leakage rate was 21.1% (4/19), and wound sepsis rate was 21.1%. Median DFS was 19.2 months. Survival was superior in the Whipple procedure group than in the total pancreatectomy group (median survival 19 months vs 4 months, respectively). Vascular resection and retroperitoneal safety margin status did not affect disease relapse.

CONCLUSION

Non-metastatic pancreatic adenocarcinoma of the uncinate process should be offered R0 or R1 resection whenever technically feasible.

Anatomic relationship of nasolacrimal duct and major lateral wall landmarks: cadaveric study with surgical implications

BACKGROUND

Detailed knowledge of the surgical anatomic landmarks of the lateral nasal wall is important for safe and successful endoscopic sinonasal surgery. We sought to determine the relationship of major landmarks to the nasolacrimal duct (NLD).

METHODS

Twenty mid-sagittal head sections of 10 fresh frozen cadavers were studied after removal of the nasal septum. The insertion of the alar cartilage into the maxilla was taken as a fixed point and all measurements were performed in a defined axial plane at the level of the maxillary sinus natural ostium. Two surgeons independently recorded each measurement 3 times with an average of the readings used for statistical analysis.

RESULTS

The overall agreement index was excellent (r = 0.84) between the observers. At the level of maxillary ostium, the mean distance from the alar rim to the NLD was 43.05 ± 4.76 mm on the right and 41.25 ± 4.56 mm on the left. The most anterior projection of the middle turbinate head was noted to be anterior to the NLD in 70% of specimens. In positional relationship, the maxillary line was posterior to the NLD in 55%, whereas the bulla ethmoidalis and the free edge of uncinate process were uniformly posterior to the NLD in all the specimens.

CONCLUSION

This study provides useful anatomic and positional relationships between the NLD and major lateral wall landmarks. Although the maxillary line and the head of the middle turbinate are often considered useful guides to the position of the ipsilateral NLD, their spatial relationship to the NLD is not consistent. These landmarks, therefore, cannot be solely relied upon during surgery to avoid injury to the NLD.

Anatomy and clinical significance of the uncinate process and uncovertebral joint: A comprehensive review

INTRODUCTION

The uncinate process and its associated uncovertebral articulation are features unique to the cervical spine. This review examines the morphology of these unique structures with particular emphasis on the regional anatomy, development and clinical significance.

MATERIALS AND METHODS

Five electronic databases were utilized in the literature search and additional relevant citations were retrieved from the references. A total of 74 citations were included for review.

RESULTS

This literature review found that the uncinate processes and uncovertebral articulations are rudimentary at birth and develop and evolve with age. With degeneration they become clinically apparent with compression of related structures; most importantly affecting the spinal nerve root and vertebral artery. The articulations have also been found to precipitate torticollis when edematous and be acutely damaged in severe head and neck injuries. The uncinate processes are also important in providing stability and guiding the motion of the cervical spine.

CONCLUSION

This review is intended to re-examine an often overlooked region of the cervical spine as not only an interesting anatomical feature but also a clinically relevant one.

Success rate and complications of endonasal dacryocystorhinostomy with unciformectomy

BACKGROUND

Endonasal dacryocystorhinostomy (DCR) has been widely used to treat nasolacrimal duct obstruction. Here, we evaluated the anatomical advantages of the uncinate process as a landmark and to study the effect of unciformectomy on success rate and complications of endonasal DCR .

METHODS

In total, 288 eyes of 265 adult patients who underwent endonasal DCR between January 2003 and February 2010 were reviewed retrospectively. The eyes were classified into two groups, according to whether unciformectomy was performed or not. All surgical procedures and surgical indications were the same except unciformectomy and endonasal DCR was performed by one surgeon. Unciformectomy was performed by resecting the anterior part of uncinate process.

RESULTS

One hundred and eighty-six eyes of 168 patients received endonasal DCR with unciformectomy, and 102 eyes of 97 patients received endonasal DCR alone. The average success rate of endonasal DCR with unciformectomy was 97.8 % and that of endonasal DCR alone was 90.2 %, with statistically significant difference (Student's t-test, p-value < 0.05). There were 14 eyes with post-operative nasolacrimal obstruction, caused by granuloma in five eyes, intranasal synechia in two eyes, membranous obstruction in six eyes, and canalicular stenosis in one eye. There were no serious complications such as orbital fat prolapse, cerebrospinal fluid leak, or delayed hemorrhage.

CONCLUSIONS

Anterior resection of the uncinate process gives improved access to the lacrimal bone by exposing the medial aspect of the lacrimal fossa and forming the precise location of the osteotomy on the lacrimal bone during endonasal DCR. Thus, the uncinate process can be used as an anatomical landmark for endonasal DCR. The unciformian endonasal DCR improves operation success rate by allowing access to the large space of the nasal cavity and reducing the synechiae of the nasal cavity.

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The authors emphasize that late results following surgery for pancreatic cancer can be improved by increasing the rate of R0 resections. Therefore, they propose a new method for pancreatic head resection, which starts with the dissection of the uncinate process and continues in a caudo-cranial direction (retrograde). Thus the superior mesenteric artery comes into view at the beginning, and the peripancreatic tissues can be removed completely along the vessel consequently. This method can potentially decrease the risk of the bleeding and major vessel injury. The authors carried out six pancreatic head resections with the technique mentioned above, and histology revealed R0 resection in all six cases. Non-traditional, retrograde dissection of the pancreatic head is a recommended method which is supported by literature data as well as the authors' own experience.