Surgical anatomy of the axillary nerve within the quadrangular space

2005 ◽  
Vol 102 (5) ◽  
pp. 912-914 ◽  
Author(s):  
R. Shane Tubbs ◽  
Elizabeth C. Tyler-Kabara ◽  
Alan C. Aikens ◽  
Justin P. Martin ◽  
Leslie L. Weed ◽  
...  
Keyword(s):  
Axillary Nerve ◽  
Surgical Anatomy ◽  
Triceps Brachii ◽  
Main Trunk ◽  
Content Type ◽  
Mean Width ◽  
Human Cadavers ◽  
The Mean ◽  
Nerve Muscle ◽  
Fine Print

Object. There is a paucity of literature regarding the surgical anatomy of the quadrangular space (QS), which is a potential site of entrapment for the axillary nerve. Muscle hypertrophy of this geometrical area and fascial bands within it have been implicated in compression of the axillary nerve. Methods. Fifteen human cadavers (30 sides) were dissected for this study. Measurements of the QS and its contents were made. The mean height of this space was 2.5 cm and the mean width 2.5 cm; its mean depth was 1.5 cm. The axillary nerve was always the most superior structure in the space, and in all cases the nerve and artery hugged the surgical neck of the humerus just superior to the origin of the lateral head of the triceps brachii muscle. This arrangement placed the axillary nerve in the upper lateral portion of the QS in all cadaveric specimens. The nerve branched into its muscular components within this space in 10 sides (33%) and posterior to it in 20 sides (66%). The cutaneous component of the axillary nerve branched from the main trunk of the nerve posterior to the QS in all specimens. Fascial bands were found in this space in 27 (90%) of 30 sides. Conclusions. Knowledge of the anatomy of the QS may aid the surgeon who wishes to explore and decompress the axillary nerve within this geometrical confine.

Surgical anatomy of the dorsal scapular nerve

2005 ◽  
Vol 102 (5) ◽  
pp. 910-911 ◽  
Author(s):  
R. Shane Tubbs ◽  
Elizabeth C. Tyler-Kabara ◽  
Alan C. Aikens ◽  
Justin P. Martin ◽  
Leslie L. Weed ◽  
...  
Keyword(s):  
Trapezius Muscle ◽  
Spinal Nerve ◽  
Surgical Anatomy ◽  
Anterior Border ◽  
Content Type ◽  
Levator Scapulae ◽  
Human Cadavers ◽  
Relationship Of ◽  
The Relationship ◽  
Fine Print

Object. There is a paucity of literature regarding the surgical anatomy of the dorsal scapular nerve (DSN). The aim of this study was to elucidate the relationship of this nerve to surrounding anatomical structures. Methods. Ten formalin-fixed human cadavers (20 sides) were dissected, and measurements made between the DSN and related structures. The nerve pierced the middle scalene muscle at a mean distance of 3 cm from its origin from the cervical spine and was more or less centrally located at this exit site. It lay a mean distance of 1.5 cm medial to the vertebral border of the scapula between the serratus posterior superior, posterior scalene, and levator scapulae muscles. It was found to have a mean distance of 2.5 cm medial to the spinal accessory nerve as it traveled on the anterior border of the trapezius muscle. The nerve intertwined the dorsal scapular artery in all specimens and was found along the anterior border of the rhomboid muscles. On 19 sides the DSN originated solely from the C-5 spinal nerve, and on one side it arose from the C-5 and C-6 spinal nerves. Conclusions. Knowledge of the anatomy of the DSN will aid the surgeon who wishes to explore and decompress this structure.

Superficial landmarks for the spinal accessory nerve within the posterior cervical triangle

2005 ◽  
Vol 3 (5) ◽  
pp. 375-378 ◽  
Author(s):  
R. Shane Tubbs ◽  
E. George Salter ◽  
John C. Wellons ◽  
Jeffrey P. Blount ◽  
W. Jerry Oakes
Keyword(s):  
The Body ◽  
Spinal Accessory Nerve ◽  
Accessory Nerve ◽  
Mastoid Process ◽  
Exit Point ◽  
Content Type ◽  
Spinal Accessory ◽  
Mean Width ◽  
The Mean ◽  
Fine Print

Object. The spinal accessory nerve (SAN) within the posterior cervical triangle (PCT) is the most commonly iatrogenically injured nerve in the body. Nevertheless, there is a paucity of published information regarding superficial landmarks for the SAN in this region. Additional identifiable landmarks of this nerve may assist the surgeon in identifying it for repair, use of it in peripheral nerve neurotization, or avoiding it as in proximal brachial plexus repair. The present study was undertaken to provide reliable superficial landmarks for the identification of the SAN within the PCT. Methods. The PCT was dissected in 30 cadaveric sides. Measurements were made between the SAN and surrounding landmarks. The mean distances between the entry site of the SAN into the trapezius and a midpoint of the clavicle, mastoid process, acromion process, and lateral aspect of the sternocleidomastoid (SCM) muscle were 6, 7, 5.5, and 3.5 cm, respectively. The mean distances between the angle of the mandible and the mastoid process and the exit point of the SAN from the posterior border of the SCM muscle were 6 and 5 cm, respectively. The mean width and length of the SAN were 3 and 3.5 cm, respectively. Conclusions. It is the authors' hope that these data will aid those who may need to locate or avoid the SAN while undertaking surgery in the PCT and thus decrease morbidity that may follow manipulation of this region.

Surgical landmarks for the proximal portion of the axillary nerve

2001 ◽  
Vol 95 (6) ◽  
pp. 998-1000 ◽  
Author(s):  
R. Shane Tubbs ◽  
W. Jerry Oakes ◽  
Jeffrey P. Blount ◽  
Scott Elton ◽  
George Salter ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Axillary Artery ◽  
Coracoid Process ◽  
Axillary Nerve ◽  
Proximal Portion ◽  
Anatomical Structures ◽  
Content Type ◽  
Pectoralis Minor ◽  
Human Cadavers ◽  
Fine Print

Object. The proximal segment of the axillary nerve (ANp) is often difficult to identify without extensive dissection deep into the axilla. The present study was performed to find reliable surgical landmarks for this nerve. Methods. Thirty dissections of human cadavers were performed to determine the relationships between the ANp and specific anatomical structures. The authors found that the ANp is consistently located within an anatomical triangle constructed by lines passing between the coracobrachialis and pectoralis minor muscles and the axillary artery. In addition, the ANp was routinely found 4 cm distal to the coracoid process of the scapula. Conclusions. These findings should assist the surgeon in locating the ANp during brachial plexus reconstruction.

Gamma knife radiosurgery in the management of cavernous sinus meningiomas

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 68-73 ◽  
Author(s):  
Pierre-Hugues Roche ◽  
Jean Régis ◽  
Henry Dufour ◽  
Henri-Dominique Fournier ◽  
Christine Delsanti ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Tumor Growth ◽  
Gamma Knife ◽  
Cavernous Sinus ◽  
Gamma Knife Radiosurgery ◽  
Surgical Removal ◽  
Content Type ◽  
Cavernous Sinus Meningioma ◽  
The Mean ◽  
Fine Print

Object. The authors sought to assess the functional tolerance and tumor control rate of cavernous sinus meningiomas treated by gamma knife radiosurgery (GKS). Methods. Between July 1992 and October 1998, 92 patients harboring benign cavernous sinus meningiomas underwent GKS. The present study is concerned with the first 80 consecutive patients (63 women and 17 men). Gamma knife radiosurgery was performed as an alternative to surgical removal in 50 cases and as an adjuvant to microsurgery in 30 cases. The mean patient age was 49 years (range 6–71 years). The mean tumor volume was 5.8 cm3 (range 0.9–18.6 cm3). On magnetic resonance (MR) imaging the tumor was confined in 66 cases and extensive in 14 cases. The mean prescription dose was 28 Gy (range 12–50 Gy), delivered with an average of eight isocenters (range two–18). The median peripheral isodose was 50% (range 30–70%). Patients were evaluated at 6 months, and at 1, 2, 3, 5, and 7 years after GKS. The median follow-up period was 30.5 months (range 12–79 months). Tumor stabilization after GKS was noted in 51 patients, tumor shrinkage in 25 patients, and enlargement in four patients requiring surgical removal in two cases. The 5-year actuarial progression-free survival was 92.8%. No new oculomotor deficit was observed. Among the 54 patients with oculomotor nerve deficits, 15 improved, eight recovered, and one worsened. Among the 13 patients with trigeminal neuralgia, one worsened (contemporary of tumor growing), five remained unchanged, four improved, and three recovered. In a patient with a remnant surrounding the optic nerve and preoperative low vision (3/10) the decision was to treat the lesion and deliberately sacrifice the residual visual acuity. Only one transient unexpected optic neuropathy has been observed. One case of delayed intracavernous carotid artery occlusion occurred 3 months after GKS, without permanent deficit. Another patient presented with partial complex seizures 18 months after GKS. All cases of tumor growth and neurological deficits observed after GKS occurred before the use of GammaPlan. Since the initiation of systematic use of stereotactic MR imaging and computer-assisted modern dose planning, no more side effects or cases of tumor growth have occurred. Conclusions. Gamma knife radiosurgery was found to be an effective low morbidity—related tool for the treatment of cavernous sinus meningioma. In a significant number of patients, oculomotor functional restoration was observed. The treatment appears to be an alternative to surgical removal of confined enclosed cavernous sinus meningioma and should be proposed as an adjuvant to surgery in case of extensive meningiomas.

Gamma knife radiosurgery for craniopharyngiomas

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 47-56 ◽  
Author(s):  
Wen-Yuh Chung ◽  
David Hung-Chi Pan ◽  
Cheng-Ying Shiau ◽  
Wan-Yuo Guo ◽  
Ling-Wei Wang
Keyword(s):  
Clinical Outcome ◽  
Gamma Knife ◽  
Tumor Volume ◽  
Gamma Knife Radiosurgery ◽  
Tumor Control ◽  
Content Type ◽  
Stereotactic Aspiration ◽  
Cystic Component ◽  
The Mean ◽  
Fine Print

Object. The goal of this study was to elucidate the role of gamma knife radiosurgery (GKS) and adjuvant stereotactic procedures by assessing the outcome of 31 consecutive patients harboring craniopharyngiomas treated between March 1993 and December 1999. Methods. There were 31 consecutive patients with craniopharyngiomas: 18 were men and 13 were women. The mean age was 32 years (range 3–69 years). The mean tumor volume was 9 cm3 (range 0.3–28 cm3). The prescription dose to the tumor margin varied from 9.5 to 16 Gy. The visual pathways received 8 Gy or less. Three patients underwent stereotactic aspiration to decompress the cystic component before GKS. The tumor response was classified by percentage reduction of tumor volume as calculated based on magnetic resonance imaging studies. Clinical outcome was evaluated according to improvement and dependence on replacement therapy. An initial postoperative volume increase with enlargement of a cystic component was found in three patients. They were treated by adjuvant stereotactic aspiration and/or Ommaya reservoir implantation. Tumor control was achieved in 87% of patients and 84% had fair to excellent clinical outcome in an average follow-up period of 36 months. Treatment failure due to uncontrolled tumor progression was seen in four patients at 26, 33, 49, and 55 months, respectively, after GKS. Only one patient was found to have a mildly restricted visual field; no additional endocrinological impairment or neurological deterioration could be attributed to the treatment. There was no treatment-related mortality. Conclusions. Multimodality management of patients with craniopharyngiomas seemed to provide a better quality of patient survival and greater long-term tumor control. It is suggested that GKS accompanied by adjuvant stereotactic procedures should be used as an alternative in treating recurrent or residual craniopharyngiomas if further microsurgical excision cannot promise a cure.

Gamma knife radiosurgery for uveal melanomas: an 8-year experience

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 184-188 ◽  
Author(s):  
Gerald Langmann ◽  
Gerhard Pendl ◽  
Georg Papaefthymiou ◽  
Helmuth Guss ◽  
Keyword(s):  
Gamma Knife ◽  
Ciliary Body ◽  
Tumor Regression ◽  
Gamma Knife Radiosurgery ◽  
Neovascular Glaucoma ◽  
Content Type ◽  
Prescription Dose ◽  
The Mean ◽  
Fine Print ◽  
Uveal Melanomas

Object. The authors report their experience using gamma knife radiosurgery (GKS) to treat uveal melanomas. Methods. Between 1992 and 1998, 60 patients were treated with GKS at a prescription dose between 45 Gy and 80 Gy. The mean diameter of the tumor base was 12.2 mm (range 3–22 mm). The mean height of the tumor prominence was 6.7 mm (range 3–12 mm). The eye was immobilized. The follow-up period ranged from 16 to 94 months. Tumor regression was achieved in 56 (93%) of 60 patients. There were four recurrences followed by enucleation. The severe side effect of neovascular glaucoma developed in 21 (35%) patients in a high-dose group with larger tumors and in proximity to the ciliary body. A reduction in the prescription dose to 40 Gy or less and excluding treatment to tumors near the ciliary body decreased the rate of glaucoma without affecting the rate of tumor control. Conclusions. Gamma knife radiosurgery at a prescription dose of 45 Gy or more can achieve tumor regression in 85% of the uveal melanomas treated. Neovascular glaucoma can develop in patients when using this dose in tumors near the ciliary body. It is advised that such tumors be avoided and that the prescription dose be reduced to 40 Gy.

Gamma knife radiosurgery for intracranial metastatic melanoma: a 6-year experience

2002 ◽  
Vol 97 ◽  
pp. 494-498 ◽  
Author(s):  
Jorge Gonzalez-martinez ◽  
Laura Hernandez ◽  
Lucia Zamorano ◽  
Andrew Sloan ◽  
Kenneth Levin ◽  
...  
Keyword(s):  
Prognostic Factors ◽  
Brain Metastases ◽  
Metastatic Melanoma ◽  
Gamma Knife Radiosurgery ◽  
Tumor Control ◽  
Karnofsky Performance Scale ◽  
Content Type ◽  
Significant Difference ◽  
The Mean ◽  
Fine Print

Object. The purpose of this study was to evaluate retrospectively the effectiveness of stereotactic radiosurgery for intracranial metastatic melanoma and to identify prognostic factors related to tumor control and survival that might be helpful in determining appropriate therapy. Methods. Twenty-four patients with intracranial metastases (115 lesions) metastatic from melanoma underwent radiosurgery. In 14 patients (58.3%) whole-brain radiotherapy (WBRT) was performed, and in 12 (50%) chemotherapy was conducted before radiosurgery. The median tumor volume was 4 cm3 (range 1–15 cm3). The mean dose was 16.4 Gy (range 13–20 Gy) prescribed to the 50% isodose at the tumor margin. All cases were categorized according to the Recursive Partitioning Analysis classification for brain metastases. Univariate and multivariate analyses of survival were performed to determine significant prognostic factors affecting survival. The mean survival was 5.5 months after radiosurgery. The analyses revealed no difference in terms of survival between patients who underwent WBRT or chemotherapy and those who did not. A significant difference (p < 0.05) in mean survival was observed between patients receiving immunotherapy or those with a Karnofsky Performance Scale (KPS) score of greater than 90. Conclusions. The treatment with systemic immunotherapy and a KPS score greater than 90 were factors associated with a better prognosis. Radiosurgery for melanoma-related brain metastases appears to be an effective treatment associated with few complications.

Prolonged survival in a subgroup of patients with brain metastases treated by gamma knife surgery

2005 ◽  
Vol 102 (Special_Supplement) ◽  
pp. 262-265
Author(s):  
C. P. Yu ◽  
Joel Y. C. Cheung ◽  
Josie F. K. Chan ◽  
Samuel C. L. Leung ◽  
Robert T. K. Ho
Keyword(s):  
Brain Metastases ◽  
Gamma Knife ◽  
Patient Survival ◽  
Gamma Knife Surgery ◽  
Prolonged Survival ◽  
Organ Involvement ◽  
Lesion Volume ◽  
Content Type ◽  
The Mean ◽  
Fine Print

Object. The authors analyzed the factors involved in determining prolonged survival (≥ 24 months) in patients with brain metastases treated by gamma knife surgery (GKS). Methods. Between 1995 and 2003, a total of 116 patients underwent 167 GKS procedures for brain metastases. There was no special case selection. Smaller and larger lesions were treated with different protocols. The mean patient age was 56.9 years, the mean number of initial lesions was 3.15, and the mean lesion volume was 10.45 cm.3 The mean follow-up time was 9.2 months. The median patient survival was 8.68 months. One-, 2-, 3-, 4-, and 5-year actuarial survival rates were 31.8%, 19.8%, 14.6%, 7.7%, and 6.9%, respectively. Patient age, number of lesions at presentation, and lesion volume had no influence on patient survival. Twenty-three (19.8%) patients survived for 24 months or more. Certain factors were associated with increased survival time. These were stable primary disease (21 of 23 patients), a long latency between diagnosis of the primary tumor and the occurrence of brain metastases (mean 28.4 months, median 16 months), absence of third-organ involvement, and repeated local procedures. Ten patients underwent repeated GKS (mean 3.4 per patient). Seven patients required open surgery for local treatment failures (recurrence or radiation necrosis). Two patients had both. Fifteen patients underwent repeated procedures. Conclusions. Aggressive local therapy with GKS, repeated GKS, and GKS plus surgery can achieve increased survival in a subgroup of patients with stable primary disease, no third-organ involvement, and long primary-brain secondary intervals.

Split spinal cord malformations in children

1998 ◽  
Vol 88 (1) ◽  
pp. 57-65 ◽  
Author(s):  
Yusuf Ersşahin ◽  
Saffet Mutluer ◽  
Sevgül Kocaman ◽  
Eren Demirtasş
Keyword(s):  
Spinal Cord ◽  
Neurological Deficits ◽  
Single Type ◽  
Type I ◽  
Type Ii ◽  
Content Type ◽  
Spinal Lesion ◽  
The Mean ◽  
Fine Print

Object. The authors reviewed and analyzed information on 74 patients with split spinal cord malformations (SSCMs) treated between January 1, 1980 and December 31, 1996 at their institution with the aim of defining and classifying the malformations according to the method of Pang, et al. Methods. Computerized tomography myelography was superior to other radiological tools in defining the type of SSCM. There were 46 girls (62%) and 28 boys (38%) ranging in age from less than 1 day to 12 years (mean 33.08 months). The mean age (43.2 months) of the patients who exhibited neurological deficits and orthopedic deformities was significantly older than those (8.2 months) without deficits (p = 0.003). Fifty-two patients had a single Type I and 18 patients a single Type II SSCM; four patients had composite SSCMs. Sixty-two patients had at least one associated spinal lesion that could lead to spinal cord tethering. After surgery, the majority of the patients remained stable and clinical improvement was observed in 18 patients. Conclusions. The classification of SSCMs proposed by Pang, et al., will eliminate the current chaos in terminology. In all SSCMs, either a rigid or a fibrous septum was found to transfix the spinal cord. There was at least one unrelated lesion that caused tethering of the spinal cord in 85% of the patients. The risk of neurological deficits resulting from SSCMs increases with the age of the patient; therefore, all patients should be surgically treated when diagnosed, especially before the development of orthopedic and neurological manifestations.

Subtle deterioration in shunted childhood hydrocephalus

1986 ◽  
Vol 65 (2) ◽  
pp. 211-216 ◽  
Author(s):  
Arno Fried ◽  
Kenneth Shapiro
Keyword(s):  
Buffering Capacity ◽  
Volume Index ◽  
Shunt Revision ◽  
Pressure Waves ◽  
Ventricular Size ◽  
Csf Shunts ◽  
Content Type ◽  
The Mean ◽  
Childhood Hydrocephalus ◽  
Fine Print

✓ Eighteen hydrocephalic children who presented with subtle deterioration when their shunts malfunctioned were studied during shunt revision by means of the pressure-volume index (PVI) technique. Bolus manipulation of cerebrospinal fluid (CSF) was used to determine the PVI and the resistance to the absorption of CSF (Ro). Ventricular size was moderately to severely enlarged in all the children. Steady-state intracranial pressure (ICP) at the time of shunt revision was 17.5 ± 7.3 mm Hg (range 8 to 35 mm Hg). Pressure waves could not be induced by bolus injections in the 8- to 35-mm Hg range of ICP tested. The mean ± standard deviation (SD) of the predicted normal PVI for this group was 18.5 ± 2.7 ml. The mean ± standard error of the mean of the measured PVI was 35.5 ± 2.1 ml, which represented a 187% ± 33% (± SD) increase in volume-buffering capacity (p < 0.001). The ICP did not fall after bolus injections in three children, so that the Ro could not be measured. In the remaining 15 patients, Ro increased linearly as a function of ICP (r = 0.74, p < 0.001). At ICP's below 20 mm Hg, Ro ranged from 2.0 to 5.0 mm Hg/ml/min, but increased to as high as 21 mm Hg/ml/min when ICP was above 20 mm Hg. This study documents that subtle deterioration in shunted hydrocephalic children is accompanied by abnormally compliant pressure-volume curves. These children develop ventricular enlargement and neurological deterioration without acute episodic pressure waves. The biomechanical profile of this group differs from other children with CSF shunts.

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