Anatomical terms of location

Use of ‘Low-Risk Ankle Rule’ May Limit X-Rays in Children.

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Using the “low-risk ankle rule” to assess children’s ankle injuries in emergency departments significantly reduces X-ray imaging, according to aCanadian Medical Association Journal study.

Nearly 2200 patients aged 3 to 16 years presented with acute ankle injuries to emergency departments designated as either intervention or control sites. Intervention sites applied the rule, which says that radiography may not be necessary when tenderness and swelling is isolated to the distal fibula and the adjacent lateral ligaments distal to the tibial anterior joint line. At control sites, procedures for ankle injuries were unchanged.

After implementation of the rule, intervention sites saw a 22-percentage-point reduction in weekly ankle radiography, compared with controls. Application of the ankle rule was not associated with an increase in significant fractures being missed or a decrease in physician or patient satisfaction.

The authors conclude: “Widespread implementation of this rule could safely lead to reduction of unnecessary radiography in this radiosensitive population and a more efficient use of healthcare resources.”

Source: CMAJ

Risk factor analysis of the development of new neurological deficits following supplementary motor area resection.

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Clinical article

Abstract

OBJECT

Supplementary motor area (SMA) resection often induces postoperative contralateral hemiparesis or speech disturbance. This study was performed to assess the neurological impairments that often follow SMA resection and to assess the risk factors associated with these postoperative deficits.

METHODS

The records for patients who had undergone SMA resection for pharmacologically intractable epilepsy between 1994 and 2010 were gleaned from an epilepsy surgery database and retrospectively reviewed in this study.

RESULTS

Forty-three patients with pharmacologically intractable epilepsy underwent SMA resection with intraoperative cortical stimulation and mapping while under awake anesthesia. The mean patient age was 31.7 years (range 15–63 years), and the mean duration and frequency of seizures were 10.4 years (range 0.1–30 years) and 14.6 per month (range 0.1–150 per month), respectively. Pathological examination of the brain revealed cortical dysplasia in 18 patients (41.9%), tumors in 16 patients (37.2%), and other lesions in 9 patients (20.9%). The mean duration of the follow-up period was 84.0 months (range 24–169 months). After SMA resection, 23 patients (53.5%) experienced neurological deficits. Three patients (7.0%) experienced permanent deficits, and 20 (46.5%) experienced symptoms that were transient. All permanent deficits involved contralateral weakness, whereas the transient symptoms patients experienced were varied, including contralateral weaknesses in 15, apraxia in 1, sensory disturbances in 1, and dysphasia in 6. Thirteen patients recovered completely within 1 month. Univariate analysis revealed that resection of the SMA proper, a shorter lifetime seizure history (< 10 years), and resection of the cingulate gyrus in addition to the SMA were associated with the development of neurological deficits (p = 0.078, 0.069, and 0.023, respectively). Cingulate gyrus resection was the only risk factor identified on multivariate analysis (p = 0.027, OR 6.530, 95% CI 1.234–34.562).

CONCLUSIONS

Resection of the cingulate gyrus in addition to the SMA was significantly associated with the development of postoperative neurological impairment.

Source: JNS

 

Foramen ovale puncture, lesioning accuracy, and avoiding complications: microsurgical anatomy study with clinical implications.

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Abstract

OBJECT

Foramen ovale (FO) puncture allows for trigeminal neuralgia treatment, FO electrode placement, and selected biopsy studies. The goals of this study were to demonstrate the anatomical basis of complications related to FO puncture, and provide anatomical landmarks for improvement of safety, selective lesioning of the trigeminal nerve (TN), and optimal placement of electrodes.

METHODS

Both sides of 50 dry skulls were studied to obtain the distances from the FO to relevant cranial base references. A total of 36 sides from 18 formalin-fixed specimens were dissected for Meckel cave and TN measurements. The best radiographic projection for FO visualization was assessed in 40 skulls, and the optimal trajectory angles, insertion depths, and topographies of the lesions were evaluated in 17 specimens. In addition, the differences in postoperative pain relief after the radiofrequency procedure among different branches of the TN were statistically assessed in 49 patients to determine if there was any TN branch less efficiently targeted.

RESULTS

Most severe complications during FO puncture are related to incorrect needle placement intracranially or extracranially. The needle should be inserted 25 mm lateral to the oral commissure, forming an approximately 45° angle with the hard palate in the lateral radiographic view, directed 20° medially in the anteroposterior view. Once the needle reaches the FO, it can be advanced by 20 mm, on average, up to the petrous ridge. If the needle/radiofrequency electrode tip remains more than 18 mm away from the midline, injury to the cavernous carotid artery is minimized. Anatomically there is less potential for complications when the needle/radiofrequency electrode is advanced no more than 2 mm away from the clival line in the lateral view, when the needle pierces the medial part of the FO toward the medial part of the trigeminal impression in the petrous ridge, and no more than 4 mm in the lateral part. The 40°/45° inferior transfacial–20° oblique radiographic projection visualized 96.2% of the FOs in dry skulls, and the remainder were not visualized in any other projection of the radiograph. Patients with V1 involvement experienced postoperative pain more frequently than did patients with V2 or V3 involvement. Anatomical targeting of V1 in specimens was more efficiently achieved by inserting the needle in the medial third of the FO; for V2 targeting, in the middle of the FO; and for V3 targeting, in the lateral third of the FO.

CONCLUSIONS

Knowledge of the extracranial and intracranial anatomical relationships of the FO is essential to understanding and avoiding complications during FO puncture. These data suggest that better radiographic visualization of the FO can improve lesioning accuracy depending on the part of the FO to be punctured. The angles and safety distances obtained may help the neurosurgeon minimize complications during FO puncture and TN lesioning.

Source: JNS

 

What’s the Best Route for Subacromial Injections?

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In a randomized trial, lateral and anterior routes were better than posterior.

The subacromial bursa can be injected using anterior, lateral, or posterior approaches. To determine which approach is best, U.S. researchers performed a study in which each of 75 patients with rotator cuff syndrome was randomized to one of these three approaches. A single orthopedist (who traditionally had used the posterior approach) performed all injections, which contained corticosteroid, local anesthetic, and radiopaque contrast medium. After the injections, shoulders were x-rayed to determine whether the contrast was within the bursa.

The proportion of patients whose injections were intrabursal was significantly greater with the lateral and anterior approaches (92% and 84%, respectively) than with the posterior approach (56%). The lower accuracy of the posterior approach was especially striking in women. Pain relief at 1 hour was significantly greater in patients whose injections were intrabursal than in those whose injections were extrabursal.

Comment: A limitation of this study is that a single physician did the injections; nevertheless, the authors discuss anatomic reasons why the posterior route might be the least accurate. I’ve always done subacromial injections via the lateral approach; this study vindicates that practice.

Source: Journal Watch General Medicine

 

 

Can We Predict the Site of Entry Tear by Computed Tomography in Patients With Acute Type A Aortic Dissection?

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In patients with acute type A aortic dissection (AAD), localization of the primary entry tear to be excluded is of major importance for intervention.

Hypothesis:

There are reliable indirect computed tomography (CT) findings to predict the entry site.

Methods:

In 83 patients with type A AAD whose primary entry tears were identified surgically between 2003 and 2009, we retrospectively examined the diagnostic CT scans regarding pericardial effusion, the largest short-axial diameter of the aorta, widths of true and false lumens, and false lumen thrombosis at 6 levels of thoracic aorta from the aortic root to the descending aorta.

Results:

The primary entry sites identified intraoperatively were proximal ascending in 21 patients, middle ascending in 21, distal ascending in 21, arch in 17, and descending or unknown in 16. The multivariate logistic analysis revealed that pericardial effusion (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.2–3.4, P < 0.001) and dilated ascending aorta (OR: 1.6, 95% CI: 1.1–2.4, P = 0.012) were the significant CT findings to predict the entry tear in the ascending aorta. It also revealed that the significant CT finding to predict the entry tear distal to the aortic arch was nonthrombosed false lumen in the descending aorta (OR: 1.2, 95% CI: 1.1–2.1, P = 0.048).

Conclusions:

We can predict the primary entry site by the preoperative CT findings in patients with type A AAD, considering pericardial effusion, aortic diameter, widths of true and false lumens, and false lumen thrombosis at different anatomic levels.

Source: http://onlinelibrary.wiley.com