CADAVERIC STUDY OF KATIKTARUN MARMA WITH DETAILED DESCRIPTION OF ITS LOCATION AND AGHAT LAKSHANS

Marma Science is one of the most distinctive concepts of Ayurveda. There are 107 marma sites in the body, and they are the conglomeration of muscles, veins, ligaments, bones, and joints. This peculiarity makes Marmamarma a somewhat vulnerable point, and any injury can lead to disability, dysfunction and demise. The cause of the damage can either be traumatic or iatrogenic; therefore, it becomes a necessity to rule out the exact location of the marma and anatomical structure responsible for the traumatic effects. Katiktarun being a Prishthagata marma, is prone to get injured during significant surgeries of the gluteal region and spine. Its injury can lead to delayed death. The aim of this study revolves around the anatomical entity responsible for delayed death caused by katiktarun injury. By identifying the location and structure involved in the marma, it might be possible to repair the structure and deferment the delayed end. Based on Ayurvedic literature and cadaveric observations, the superior margin of the sciatic notch (suprapiriform foraman) is considered as the position of Katiktarun Marma, whereas the neurovasculature associated with suprapiriform foramen is the causative structure of marma trauma symptoms.

Leftward deviation of the primary septum or dividing left atrial shelf?

Isolated leftward prolapse or deviation of the primary atrial septum is a rare CHD that can mimic abnormal pulmonary venous return at first sight. We present a case of a newborn infant, referred for surgical correction of totally anomalous pulmonary venous return into the right atrium, with the peri-operative finding of a leftward deviation of the superior margin of the primary atrial septum. The distinction with a dividing atrial shelf could not be confirmed with certainty. Fifty-three similar cases from the literature are incorporated. A detailed review of the current account on atrial septation is studied. The embryological and clinical features of a dividing partition of the left atrium are discussed.

Morphological Classification of Arch of Frohse and Its Implication in Compression of Deep Branch of Radial Nerve

BACKGROUND Arcade of Frohse (AF) is a tendinous superior margin of superficial layer of supinator muscle which was first described by Frohse and Frankel in 1908. Since then it has been studied by many authors and held accountable as one of the essential components for compression of deep branch of radial nerve (DBRN) which leads to radial tunnel syndrome. Considering AF as an important element of compression, we made an attempt to classify it on the basis of its shape and to find out if any particular shape has a predominant role in compression of the nerve. We also observed the structure of superior and inferior margin of the supinator muscle. METHODS This study was conducted among 80 (70 males and 10 females) formalin fixed upper limbs present in the Department of Anatomy. The limbs were maintained in supine with slightly flexed position and dissection was performed to expose the supinator muscle. The proximal and distal borders of supinator muscles were examined meticulously with the help of magnified lens. The morphometric measurements were taken with the help of a digital caliper. RESULTS The FA is classified into four categories as loop, high arc, low arch and linear shaped. The most frequent shape observed was arch shaped (high and low arch) about 66%, followed by loop shaped (30%) and least was linear shaped (2.5%). On the basis of structure, the proximal and distal margin of supinator muscle was reported to be tendinous in majority of the cases. The distance of the AF from the fixed reproducible anatomical landmark like inter epicondylar line (IEL) was measured and the average distance found was 3.36 cm. CONCLUSIONS Knowledge of different shapes would aid surgeons and radiologists for better approach towards diagnosis and management of supinator syndrome. The morphometric finding can be useful for surgeons to locate the superior margin of supinator (AF) in surgical procedures for decompression of DBRN in supinator syndrome. KEY WORDS Arcade of Frohse, Inter Epicondylar Line, Supinator Muscle, Deep Branch of Radial Nerve and Radial Tunnel Syndrome

Anatomic Measurements of Distances from Lateral Surface of Cranium to Cochlea in Congenital Aural Atresia and Stenosis Patients

<b><i>Introduction:</i></b> Studies have shown that higher response levels can be obtained when the bone conduction stimulation position is closer to the cochlea. However, the morphological characteristics of round window niche and posterior tympanum in congenital aural atresia (CAA) and stenosis (CAS) patients were different from the normal. These affected the position of the cochlea at the cranial base. It was still unknown whether the distances from the cranium of CAA and CAS patients to the cochlea were the same as those of normal patients or not. <b><i>Objective:</i></b> To measure distances from various points on the lateral surface of the cranium to the cochlea and the cranium thickness on these points among a CAA group, CAS group and normal control group, which may provide valuable information for the better position of bone conduction stimulation. <b><i>Methods:</i></b> CT images of CAA, CAS patients and these patients’ healthy sides were analyzed. Firstly, the Frankfurt horizontal plane (Pfrkt) was established. Secondly, a model of part of the cranium was three-dimensionally reconstructed. Then, the Pfrkt plane was rotated down 20, 30 and 40° according to the superior margin of the external auditory canal. At every angle, points 25, 30, 35 and 40 mm away from the superior margin of the external auditory canal were marked out on the surface of the model and recorded as P₂₀A, P₃₀A, P₄₀A, P₂₀B, etc. The spatial distances between the cranium and ipsilateral cochlea were defined as lengths of points on the surface of the model to the cochlea apex (CA), cochlear base (CB) and modiolus midpoint (MM), respectively, recorded as P₂₀A/CA, P₂₀A/CB, P₂₀A/MM, P₃₀A/CA, etc. <b><i>Results and Conclusions:</i></b> In all groups, the length of P₂₀D/CA was the shortest compared to P₃₀D/CA and P₄₀D/CA (<i>p</i> &#x3c; 0.05). The P₂₀A/CB and P₂₀A/MM were also the shortest (<i>p</i> &#x3c; 0.05). When the Pfrkt plane was rotated down 30 and 40°, the results were the same as at 20° (<i>p</i> &#x3c; 0.05). However, P₂₀D, P₃₀D and P₄₀D were almost on the mastoid air cells. We suggest that the bone conduction stimulation position is placed closer to the ear, while avoiding the mastoid air cells in the CAA and CAS patients.

Spontaneous pneumomediastinum in accidental chlorine gas inhalational injury: case report and review of literature

A young man presented in emergency department with shortness of breath and cough after accidental inhalation of chlorine gas. Initial presentation was unremarkable; therefore, he was kept under observation for 8 hours and was later discharged. After 5 hours, the patient presented again in emergency department with sudden-onset shortness of breath and chest discomfort. On examination, subcutaneous crepitation around the neck and chest was found. Chest and neck X-ray revealed subcutaneous emphysema and pneumomediastinum. CT neck and chest was done, which revealed subcutaneous emphysema and pneumomediastinum and a linear air density in close approximation to right posterolateral wall of trachea at the level of superior margin of sternum was reported. These findings raised the possibility of tracheal injury which was later confirmed by fiberoptic laryngoscopy. The patient was intubated due to hypercapnic respiratory failure resulting from hypoventilation and respiratory distress. Bilateral chest tube insertion was done due to worsening subcutaneous emphysema, high ventilator parameters and prevention of progression to pneumothorax. He was extubated after 5 days; bilateral chest tubes were removed before discharge and underwent uneventful recovery.

Primary Adrenal Malignant Rhabdoid Tumor in a 14-Year-Old Female: A Case Report and Literature Review

Malignant rhabdoid tumor (MRT) is a rare, SWItch/sucrose nonfermentable-related matrix-associated actin-dependent regulator of chromatin subfamily B member 1 ( SMARCB1)-deficient, aggressive tumor, occurring predominantly in children below 3 years of age. Primary adrenal MRT is extremely rare, with only 3 cases reported in the literature. A previously healthy 14-year-old female presented with left upper quadrant/epigastric abdominal pain. Imaging studies revealed an 8.0 × 8.0 × 6.5 cm, heterogeneous, partially enhancing mass along the superior margin of the left kidney encasing the adrenal gland. Surgical resection of the tumor revealed a hypercellular heterogeneous neoplasm arising from the adrenal gland. It was composed predominantly of primitive small round blue cells with focal true rosettes and areas of vague glandular epithelial differentiation and chondroid differentiation. Classic rhabdoid-type cytoplasmic inclusions were focally present. Mitoses, tumor necrosis, and hemorrhage were readily seen. Tumor cells showed complete loss of SMARCB1 (INI1) nuclear staining, demonstrated strong, and diffuse positivity for glypican 3, patchy positivity for CD99, cytokeratin, Sal-like protein 4, Lin-28 homolog A, epithelial membrane antigen, and S100. Molecular studies revealed biallelic frameshift mutations in the SMARCB1 gene (c.673delG and c.683dupT) without pathogenic copy number aberrations. The histologic, immunohistochemical, and molecular findings support a diagnosis of MRT. The unusual age, location, and mutations of this case expand the clinicopathologic and molecular spectrum of MRT.

Spleen-preserving surgical treatment of splenic artery aneurysm secondary to chronic pancreatitis and primary biliary cholangitis

Introduction. Splenic artery aneurysm (SAA) represents the third cause of abdominal aneurysms, just after abdominal aorta and iliac arteries aneurysms, with overall prevalence of 1%. Pancreatitis has been linked with pseudoaneurysm formation of SA due to destruction of arterial wall by pancreatic enzymes, however true SAA associated with pancreatitis hasn?t been described yet. We are presenting the first case of true SAA in a patient with chronic pancreatitis and primary biliary cholangitis successfully treated by surgical excision, direct arterial reconstruction and spleen preservation. Case outline. A 74-years-old male patient was admitted for multidetector computed tomography (MDCT) angiography due to suspected SAA and renal artery aneurysm (RAA). He was previously treated for chronic pancreatitis and primary biliary cholangitis. Upon admission, CT arteriography showed SAA 32 mm in diameter and RAA 12 mm with SAA being in direct contact with superior margin of the pancreas. Surgical treatment of SAA was indicated while RAA was treated conservatively. Intraoperatively, SAA adherent to the superior margin of pancreas was noted, followed by complete exclusion of the aneurysm and end-to-end splenic artery anastomosis. Histopathology showed atherosclerotic degeneration of arterial wall with all three layers presenting as true aneurysm. Two years after the surgery control CT angiography showed regular postoperative findings without further progression of RAA. Conclusion. This is the first case to describe a true SAA aneurysm originated on the field of previous episodes of chronic pancreatitis and primary biliary cholangitis. Surgical treatment including aneurysm resection and direct arterial reconstruction with spleen preservation showed satisfactory results.

Morphological and Morphometric Study of Pterion in Adult Dry Human Skulls

Introduction: Pterion is significant bony landmark because it commonly lies near the anterior branch of middle meningeal artery as well as Broca’s Area. The aim is to study the types of pterion and measure the distance from various bony landmarks on skull to the midpoint of pterion. Subjects and Methods: This study was performed on 70 adult dry human skulls of unknown age and sex. Types and location of pterion was observed bilaterally. Measurements were taken in millimeter using digital Vernier caliper from midpoint of pterion to i) fronto-zygomatic suture ii) middle of zygomatic arch iii) tip of mastoid process iv) glabella v) antero-superior margin of external acoustic meatus vi) Asterion. Results: We observed five types of pterion: spheno-parietal, fronto-temporal, stellate, epipteric and atypical. Among the skulls studied the most common type was sphenoparietal bilaterally. The mean of distances from midpoint of pterion to fronto-zygomatic suture was, 31.68 5.58 mm and 31.18 5.82 mm; to the middle of zygomatic arch was 38.87 3.63 mm and 37.84 3.99 mm; to asterion was 83.55 7.22 mm and 85.53 6.88 mm; to external acoustic meatus it was 51.70 3.20 mm and 51.37 3.39mm; to glabella it was 77.24 6.93 mm and 76.44 6.83 mm; to tip of mastoid process it was 80.77 6.10mm on the right side and 79.59 5.70 mm on the left side. Conclusion: Pterion is the most commonly used surface landmark. Findings of present study regarding classification of pterion will be helpful for neurosurgeons, radiologists, anthropologists and forensic pathologists.

Morphological and Functional Outcomes >13 Years After Achilles Tendon Rupture Treated Operatively and Non-operatively

Objectives: In patients >13yrs after treatment for acute Achilles tendon rupture (AATR), 1) investigate side-to-side differences in MRI-defined morphological changes in the Achilles tendon and surrounding calf musculature, 2) investigate side-to-side differences in single-limb functional tasks, and 3) compare patients who received operative vs non-operative treatment. Methods: 28 patients (11 operative, 17 non-operative) from a previous randomized trial returned 15±1 years post-AATR for testing (age: 57±7 years; BMI: 30±5 kg/m2). Patients underwent bilateral 3T MRI (MAGNETOM Prisma, Siemens) including sagittal and axial T1 and T2-weighted turbo spin echo (TSE), axial T1-weighted inversion recovery, and sagittal T2-weighted 3D isotropic TSE sequences. The maximum anteroposterior Achilles tendon diameter (MAD) and cross-sectional area (CSA), distance from the MAD to the superior margin of the calcaneus, tendon length, gastrocnemius and soleus CSA, and calf circumference were measured using distance and area software tools (Figure 1; AGFA Healthcare). Functional measures included single-legged heel-rise repetitions and maximum vertical jump height. All outcomes were compared between limbs and between groups. Results: Overall, there were significant side-to-side differences in most MRI and functional measures, with the injured limb Achilles tendon typically wider and thicker (MAD often twice as large), calf musculature CSA smaller, number of heel raises lower, and vertical jump height lower (Table 1). The only differences between treatment groups was in MAD and the distance from the MAD to the superior margin of the calcaneus, with a greater side-to-side difference for patients treated operatively (Table 1). Conclusion: Substantial side-to-side differences in tendon diameter, thickness, muscle bulk and functional performance persist beyond a decade after treatment for AATR. There were no differences favoring operative treatment over non-operative treatment.

A new anatomic zone division within the human cervical spinal canal

Background: Anatomic details are important for identifying the origin and anatomic basis of symptoms in patients with cervical spondylosis. However, very little quantitative data has been reported. In an effort to provide an anatomic basis for the examination of cervical spondylosis mechanisms, we characterized the morphologic features of cervical spinal nerve rootlets and defined different zones of the human cervical spinal canal.Methods: In 10 cadaveric cervical cords from C2 to T1, we defined three zones bilaterally from the midline (zones I-III) and two zones from cranial to caudal (zones P and IP) on the coronal plane within the cervical spinal canal. We measured each anatomic zone, including 1) horizontal widths of zones I, II and III; 2) the length of the cervical spinal segment at the ventral rootlets (LV); 3) the pedicle height (zone P) and interpedicle height (zone IP); and 4) the distance between the superior margin of the pedicle and the exit of the uppermost ventral nerve rootlet (PN). Results: The horizontal widths of zone I tended to decrease gradually from C4 to C8 (p=0.98). The width of zone II at C4 was significantly less than that at other levels (p=0.008). The width of zone III increased from C4 to C8 and was significantly greater at C7 and C8 than at C4, C5, and C6 (p=0.032). Pedical and interpedical heights were not significantly different at different levels (p=0.365 and 0.240, respectively). LV values at C4 and C8 were smaller than those at C5, C6, and C7 (p=0.001). At C4, the uppermost ventral rootlet was at approximately the same height as the C3 pedicle, whereas at C8, the uppermost ventral rootlet was at the same level as the inferior part of the C6 pedicle. Ventral intradural intersegmental connections were found in three of 20 (15%) intersegments (two specimens).Conclusions: These anatomic zones may be useful for diagnosing cervical spondylosis and guiding anterior decompression surgery.