Effects of Stellate Ganglion Block Through Different Approaches Under Guidance of Ultrasound

ObjectiveThis study aimed to investigate the effects of stellate ganglion block (SGB) through different approaches under guidance of ultrasound.MethodsA total of 130 patients undergoing SGB in our hospital between February 2019 and February 2020 were enrolled as the research subjects. According to the random number table method, these subjects were divided into two groups: a modified 6th cervical vertebra (C6) group (n = 65) and a 7th cervical vertebra (C7) group (n = 65). Under the guidance of ultrasound, the subjects in the modified C6 group were punctured at the level of the C6 transverse process, and the subjects in the C7 group were punctured at the level of the C7 transverse process. The operation duration, number of puncture angle adjustments, block effects, and adverse reactions for SGB were compared between the two groups.ResultsThe modified C6 group showed shorter SGB operation duration and a lower number of puncture angle adjustments than the C7 group, and the differences were statistically significant (P < 0.05). Horner Syndrome occurred in both groups after SGB. The incidence of adverse reactions in the modified C6 group was 4.62%, comprising 1 case of hoarseness and 2 cases of slowed pulse, while that in the C7 group was 6.15%, with 1 case of hoarseness and 3 cases of slowed pulse; the difference between the two groups was not statistically significant (P > 0.05).ConclusionThe operation duration for modified SGB guided by ultrasound puncturing at the C6 transverse process is shorter and requires fewer puncture angle adjustments than puncturing at the C7 transverse process; however, there is no significant difference between the incidence of adverse reactions or the blocking effects of the two methods.

Brachial plexus tuberculosis: A unique neurological variant of a common clinical disease

Isolated primary tuberculous involvement of the brachial plexus has not been reported in the past. Here, we report the case of a 29-year-old male who developed neck pain and radiculopathy for 3 months. Weakness in the left shoulder-elbow (2/5 MRC grade) and wrist (4/5 MRC grade) was present with numbness to pain and temperature along the C4–C5 dermatome. Magnetic resonance imaging (MRI) revealed a T2 hyperintense heterogeneously contrast-enhancing lesion involving the upper trunk of the brachial plexus. Under suspicion of malignancy, surgical exploration was undertaken. Intraoperatively, pus was noticed with unhealthy granulation tissue extending along the left-sided C4–5 lamina and transverse process. The frozen section suggested granulomatous infection and histopathology confirmed tuberculosis (TB). After 18 months of antituberculous treatment, the patient gradually recovered complete strength in the left upper limb. Follow-up brachial plexus MRI showed near-complete resolution of the lesion. We describe a unique case of a young patient clinically suggestive of the rapid progressive lesion (mimicking malignancy) affecting brachial plexus, turning out as TB on histopathology.

Unilateral Biportal Endoscopy for Decompression of Extraforaminal Stenosis at the Lumbosacral Junction: Surgical Techniques and Clinical Outcomes

Objective: The aims of this study were to describe the unilateral biportal endoscopic (UBE) technique for decompression of extraforaminal stenosis at L5–S1 and evaluate 1-year clinical outcomes. Especially, we evaluated compression factors of extraforaminal stenosis at L5–S1 and described the surgical technique for decompression in detail.Methods: Thirty-five patients who underwent UBE decompression for extraforaminal stenosis at L5–S1 between March 2018 and February 2019 were enrolled. Clinical results were analyzed using the MacNab criteria, the visual analogue scale (VAS) for back and leg pain, and the Oswestry Disability Index (ODI). Compression factors evaluated pseudoarthrosis within the transverse process of L5 and ala of sacrum, disc bulging with or without osteophytes, and the thickened lumbosacral and extraforaminal ligament.Results: The mean back VAS was 3.7 ± 1.8 before surgery, which dropped to 2.3 ± 0.8 at 1-year postoperative follow-up (p < 0.001). There was a significant drop in postoperative mean VAS for leg pain from 7.2 ± 1.1 to 2.3 ± 1.2 at 1 year (p < 0.001). The ODI was 61.5 before surgery and 28.6 (p < 0.001). Pseudoarthrosis between the transverse process and the ala was noted in all cases (35 of 35, 100%). Pure disc bulging was seen in 12 patients (34.3%), and disc bulging with osteophytes was demonstrated in 23 patients. The thickened lumbosacral and extraforaminal ligament were identified in 19 cases (51.4%). No complications occurred in any of the patients.Conclusion: In the current study, good surgical outcomes without complications were achieved after UBE decompression for extraforaminal stenosis at L5–S1.

Vertebral Anatomic Variations in Thoroughbred Racehorses in Trinidad

Reports of the occurrence of lumbar vertebrae variants in horses in Trinidad are rare in the literatures. Parts of the skeletons of two horses of unknown age and sex that died in a horse farm in Trinidad and Tobago were brought to the Anatomy laboratory. It was reported that specimens of fused left transverse processes of the 5th and 6th lumbar vertebrae and a blunted left transverse process of the 6th lumbar vertebra in thoroughbred racehorses in Trinidad.

New anomalies and pathologies in the caudal region of the lizard’s axial skeleton

Currently, more than 58 skeletal anomalies and pathologies are known in the recent Squamata reptiles. In this paper, eight pathologies of a complex nature are described in Agamidae and Lacertidae: Paralaudakia caucasia (Eichwald, 1831) and Lacerta agilis Linnaeus, 1758. Description of tail pathologies was carried out based on the analysis of X-ray images and on the results of computer microtomography. In the specimen of P. caucasia (ЗИН 19116.1) complete ablation of the caudal vertebra was revealed, which provoked the detachment of chevron and the proliferation of soft tissues. In some Agamidae, after pseudoautotomy, partial ablation of the caudal vertebra occurs to promote wound healing. Complete ablation of the distal caudal vertebra has not been previously reported in literature. In females of L. agilis, deformation of the right transverse process of the vertebra with “false bifurcation” without the formation of a cartilaginous tube (VOLSU 98.2), scoliosis, hematoma and callus on the cartilaginous tube were noted, as well as the absence of an autotomy plane in the postpygal vertebra (ZIN 31549). An unusual pathology in L. agilis (ZIN 31549) is the absence of an autotomy plane in the postpigal vertebra and of its anterior neural spine. The loss of the plane of autotomy during ontogeny is characteristic of some Iguanidae, but it has not been previously noted in Lacertidae. The described cases of anomalies expand the spectrum of known pathologies in reptiles.

An Osteological Study of Anatomical Variations of Foramen Transversarium of Cervical Vertebrae and its Clinical Implications

Background: In cervical vertebrae, the costal and transverse elements are connected to each other around the foramen transversarium of the transverse process. The adult cervical vertebrae are characterized by the presence of Foramen Transversarium (FT) in transverse process. These transverse foramina are found to have variations in size, shape and numbers and may be absent, incomplete or duplicate, which may lead to various symptoms. Aim: To study the anatomical variations of cervical vertebrae. Materials and methods: The present observational study was performed on 182 dry human cervical vertebrae of unknown sex and age. Intact cervical vertebrae without any degenerative or traumatic disorders were included in this study. Deformed and damaged vertebrae were excluded from the study Results: Out of these 364 foramen transversarium, 98 (27%) foramen transversarium were of type-I. Type -I was the most common presentation in the present study. Type -II foramen transversarium were seen in 33 (09%) foramen transversarium. Out of 364 foramen transversarium 88 (24%) foramen transversarium were of type-III. Type-IV foramen transversarium were seen in 62 (17%) foramen transversarium. Type-V foramen transversarium were seen on 83 (23%) foramen transversarium. Out of 182 vertebrae 40 (22%) showed complete double foramen transversarium. Incomplete double foramen transversarium were seen in 24 (13%) of vertebrae. One side complete & other side incomplete foramen transversarium were seen in 04 (02%) vertebrae. Conclusion: Knowledge of such variations is important for Physicians, Neurologists Otorhinolaryngologists, radiologists and Orthopedicians. Presence of accessory foramen transversarium especially of incomplete variety, the second part of vertebral artery may be dislodged and prone to get damaged easily during posterior cervical injuries. It helps in radiological imaging, neurological diagnosis and complex surgical procedures in the cervical area. KEY WORDS: Cervical Vertebrae, Foramen transversarium, Accessory Foramen Transversarium.

Surgical anatomy of minimally invasive lateral approaches to the thoracolumbar junction

OBJECTIVE The thoracolumbar (TL) junction spanning T11 to L2 is difficult to access because of the convergence of multiple anatomical structures and tissue planes. Earlier studies have described different approaches and anatomical structures relevant to the TL junction. This anatomical study aims to build a conceptual framework for selecting and executing a minimally invasive lateral approach to the spine for interbody fusion at any level of the TL junction with appropriate adjustments for local anatomical variations. METHODS The authors reviewed anatomical dissections from 9 fresh-frozen cadaveric specimens as well as clinical case examples to denote key anatomical relationships and considerations for approach selection. RESULTS The retroperitoneal and retropleural spaces reside within the same extracoelomic cavity and are separated from each other by the lateral attachments of the diaphragm to the rib and the L1 transverse process. If the lateral diaphragmatic attachments are dissected and the diaphragm is retracted anteriorly, the retroperitoneal and retropleural spaces will be in direct continuity, allowing full access to the TL junction. The T12–L2 disc spaces can be reached by a conventional lateral retroperitoneal exposure with the rostral displacement of the 11th and 12th ribs. With caudally displaced ribs, or to expose T12–L1 disc spaces, the diaphragm can be freed from its lateral attachments to perform a retrodiaphragmatic approach. The T11–12 disc space can be accessed purely through a retropleural approach without significant mobilization of the diaphragm. CONCLUSIONS The entirety of the TL junction can be accessed through a minimally invasive extracoelomic approach, with or without manipulation of the diaphragm. Approach selection is determined by the region of interest, degree of diaphragmatic mobilization required, and rib anatomy.

Morphometric Analysis of V2 Segment of Vertebral Artery in Patients with Symptomatic Neck Pain in South Indian Population – A CT Angiography Based Study

Objectives: The morphometric changes in the vertebral artery are essential for various interventions. Inadequate details about it can lead to risk of vertebral artery injury and other complications. This study explains the normal anatomical course of V2 segment of vertebral artery which is more prone for iatrogenic injury. Materials and Method: 25 adult patients with symptomatic neck pain were involved in the study. Various measurements were made from seventh cervical vertebra (C7) to the third cervical vertebra (C3) that included Distance from midline to VA, Distance from medial margin of Longus Colli to VA, Perpendicular distance from anterior margin of transverse process to center of VA, Horizontal distance from anterior tubercle to VA, sagittal and coronal diameter of the transverse foramen and vertebral artery. Result: Distance from midline, Distance from medial margin of Longus Colli, Perpendicular distance from anterior margin of transverse process to center of VA and Horizontal distance from anterior tubercle were increased towards right compared to left side. The sagittal and coronal diameter of the transverse foramen and vertebral artery decreased from C6 to C3 vertebra. Vertebral artery dominance was seen on left side in all cases. Conclusion: Preoperative assessment by computed tomography angiography helps to know the course of the vertebral artery, understand its patterns and assess various abnormalities thereby aids in preventing complications in future surgeries.