Anomalous plantar intrinsic foot muscle attaching to the medial longitudinal arch: possible mechanism for medial nerve entrapment: a case report

Background Muscular variations are potentially symptomatic and may complicate imaging interpretation. Intrinsic foot musculature and extrinsic tendon insertion variations are common. Distinct supernumerary muscles are rare. We report a novel anomalous intrinsic foot muscle on the medial longitudinal arch. Case presentation An accessory muscle was encountered on the medial arch of the right foot of a 78-year-old white male cadaver, between layers two and three of the foot intrinsics. It did not appear to be a slip or variant of a known foot muscle. This muscle consisted of two slips that ran transversely on the plantar aspect of the medial arch, crossing the medial transverse tarsal joint and attaching to the tuberosity of the navicular, the short and long plantar ligaments, and spring ligament. Conclusions The medial plantar vessels and nerve passed from deep to superficial between the two slips, and this suggests a possible location for medial nerve entrapment.

Evaluation of nerve capture using classical landmarks for genicular nerve radiofrequency ablation: 3D cadaveric study

Background and objectivesRadiofrequency (RF) denervation of the superolateral genicular nerve (SLGN), superomedial genicular nerve (SMGN) and inferomedial genicular nerve (IMGN) is commonly used to manage chronic knee joint pain. However, knowledge of articular branches captured, using classical landmarking techniques, remains unclear. In order to enhance and propose new RF procedures that conceivably capture a greater number of articular branches, more detailed cadaveric investigation is required. The objectives were to (1) determine which articular branches are captured or spared using classical landmarking techniques, and (2) evaluate the anatomical feasibility of classical landmarking techniques using three-dimensional (3D) modeling technology.MethodsUltrasound-guided classical superolateral/superomedial/inferomedial landmarking techniques were used to position RF cannulae in five specimens. The articular branches, bony and soft tissue landmarks, and cannula tip position, were meticulously dissected, digitized and modeled in 3D. Simulated lesions were positioned at the cannula tip, on the 3D models, to determine which articular branches were captured or spared. Capture rates of articular branches were compared.ResultsIn all specimens, classical superolateral/superomedial techniques captured the transverse deep branches of SLGN and SMGN, and articular branches of lateral and medial nerve to vastus intermedius, while sparing distal branches of SLGN/SMGN. The inferomedial technique captured anterior branches of IMGN while sparing the posterior and inferior branches.ConclusionsThis study provides anatomical evidence supporting the effectiveness of classical landmarking for genicular nerve ablation; however, each technique resulted in sparing of articular branches. The extensive innervation of the knee joint suggests the use of supplementary landmarks to improve capture rates and potentially patient outcomes.

Osteopathic correction in complex treatment of carpal tunnel syndrome with complicated closed forearm fractures

A clinical case, described in this study, demonstrates a successful combined treatment of posttraumatic neuropathy of the medial and radial nerves in a patient after the closed comminuted fracture of the distal metaepiphysis of the left radial bone with a fragment displacement. One of the most serious complications of such injuries is the development of carpal tunnel syndrome [1]. Osteopathic physicians were involved in the process of treatment and rehabilitation. According to the data of various authors [1, 2], it is necessary to use complex surgical aids such as decompression of the medial nerve by dissecting the carpal ligament with the scar, as well as nerve transposition if the conservative methods are not effective. Unfortunately, surgical treatment does not always lead to a positive result [4]. Invalidization of patients is significant — 5–7%. It is known that early complex pathogenetic treatment allows to fight against the developing carpal tunnel syndrome in patients with severe bone trauma much more successfully. In order to prevent scar changes of the carpal ligament and maintain adequate trophicity in the injured limb, it is necessary to implement measures aimed at stabilizing microcirculatory disorders in the distal parts of the injured forearm as soon as possible. In order to make the treatment of this pathology even more effective, an integrated approach to solving this complex and socially significant problem is needed, as well as the search for new advanced and relatively safe treatment tactics, these include osteopathic correction too.

A Survey of the Median Nerve Elasticity after Volar Locking Plate Fixation Using Ultrasound Elastography

Introduction Median nerve disorder is one of the complications after surgery using volar locking plate (VLP) for distal radius fracture (DRF). In this study, elasticity of the median nerve was quantified using ultrasound elastography (EG) (real-time tissue EG) and compared between the operation and healthy sides in patients after surgery for DRF using VLP. Materials and Methods The subjects of this study were 28 patients (4 males and 24 females; mean age: 58.5 years) who could be followed up for more than 6 months after surgery for DRF and were able to be examined by EG. We evaluated median nerve elasticities on the operation and healthy sides using EG on the final follow-up. Results The median nerve strain ratios were 3.97 ± 2.99 on the operation side and 3.91 ± 1.51 on the healthy side, showing no significant difference in elasticity of the median nerve between the operation and healthy sides. Conclusion Median nerve disorder, which is a complication after surgery with VLP, can be objectively detected using EG capable of evaluating median nerve elasticity externally to detect medial nerve degeneration while degeneration of the median nerve. Thus, EG may be used as a useful diagnostic tool to prevent complications and decide on appropriate timing of VLP extraction.

Feasibility of sagittal T2 mapping of the median nerve in patients with carpal tunnel syndrome

Purpose: To evaluate patients with carpal tunnel syndrome (CTS) by using 3-Tesla magnetic resonance imaging (MRI) sagittal T2 mapping of the median nerve for localization of abnormal regions. Material and Methods: Nine hands of seven patients with CTS and five hands of five healthy volunteers were evaluated using sagittal T2 mapping and axial spoiled gradient-echo (SPGR) images. Three regions of interest (ROIs) at the carpal tunnel (ROI-1 to ROI-3) and one control ROI distal to the carpal tunnel (ROIC) were defined on the median nerve and T2-ratios at ROI-1 to ROI-3 relative to ROI-C were calculated. The flattening ratio (F-ratio; width/height of the median nerve) was also calculated from the axial SPGR images. Results: On sagittal T2 mapping, the medial nerve of normal volunteers showed constant T2 values at all ROIs. In the patients with CTS, there was large variation in T2 among the ROIs and the region of highest T2 value varied among the patients. T2-ratios at ROI-2 and -3 and the F-ratios along all carpal tunnel levels were significantly higher in the patients with CTS than in the normal volunteers. A significant correlation was found between terminal latency and T2-ratio at ROI-2 but not between terminal latency and F-ratio. Conclusion: Sagittal T2 mapping was feasible for the localization of abnormal T2 regions of the median nerve in patients with CTS.

Formation, trajectory and distribution variants of the median nerve of the fetus

Our study was performed by dissection on a number of 54 nervous trunks of the median nerve of the fetus. We found that the median nerve is always formed from two roots, their joining being at different levels of the upper limb, between the axilla and the elbow. The axilla nerve trunk was formed at the level of the axillary region, in 38.89% of the cases, in 22.22% of the cases the union was made at the middle part of the arm, and in 38.89% of the cases in the elbow. The lateral root of the medial nerve was formed in 55.56% of cases from a single nerve fascicle, in 44.44% of cases consisting of two nerve fascicles. The medial root was formed in 61.11% of cases from a single nerve fascicle, in 38.89% of the cases being made up of two nerve fascicles. In 27.78% of cases, the medial root passed behind the axillary artery. Regarding the volume of the two roots, we found that in 44.44% of the cases, the lateral root was more voluminous, in 27.78% of cases, the median root was larger and in 27.78% of cases, the two roots were approximately equal. We have encountered situations where a ramification for the forearms muscles emerged from the lateral root. Occasionally, a ram for the brachial muscle was detached from the medial root, and from the lateral root a ram for the biceps muscle, both muscles receiving branches also from the musculocutaneous nerve. We have encountered a single case where the median nerve inches the anterior muscles of the arm, missing the musculocutaneous nerve. In cases of low joining of the roots, we have encountered cases where a lateral root formed a ram for forearm muscles. The anastomoses between the two median nerve roots can sometimes be located just above their union or anterior to the lower portion of the axillary artery. In one case, we encountered between the two roots, above their union, the existence of three oblique anastomoses, the two upper ones from the lateral to the medial root, and the third from the medial root to the lateral root. Common are anastomoses between the roots of the roots and the root on the opposite side. The most common are the anastomosis between the medial fascicle of the lateral root and the medial root of the median nerve. In one case, we encountered a double overlap between the musculocutaneous nerve and the lateral nerve root. In one case, we encountered a strong anastomosis between the medial nerve fascicle of the medial root and the radial nerve. Common and at all levels of the upper limb are the anastomoses between the median and ulnar nerves. In the case of a low union of the two median roots, we encountered anastomoses between a root of the root and the ulnar nerve, or between a root and the ulnar nerve. I encountered a single case with an anastomosis, Martin- Gruber, which was previously passing through the ulnar and interos-like arteries and from which the anterior forearm muscles were detached.

Abnormal origin of posterior circumflex humeral artery and subscapular artery: case report and review of the literature

The subscapular, anterior circumflex, and posterior circumflex arteries arise from the third part of the axillary artery. During dissection of the right upper limb of the cadaver of a 70-year-old male, a common trunk was observed arising from the third part of the axillary artery which, after traveling for 0.5 cm, bifurcated into subscapular and posterior circumflex humeral arteries. The common trunk was crossed anteriorly by the radial nerve. The medial nerve was formed by medial and lateral roots on the medial side of the third part of the axillary artery, remaining medial to the brachial artery up to the cubital fossa and then following its usual course thereafter. Awareness of the vascular variations observed in the present case is important when conducting surgical procedures in the axilla, for radiologists interpreting angiographs, and for anatomy-pathologists studying rare findings.

Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: Injection therapies, low-back pain, and lumbar fusion

The medical literature continues to fail to support the use of lumbar epidural injections for long-term relief of chronic back pain without radiculopathy. There is limited support for the use of lumbar epidural injections for shortterm relief in selected patients with chronic back pain. Lumbar intraarticular facet injections are not recommended for the treatment of chronic lower-back pain. The literature does suggest the use of lumbar medial nerve blocks for short-term relief of facet-mediated chronic lower-back pain without radiculopathy. Lumbar medial nerve ablation is suggested for 3–6 months of relief for chronic lower-back pain without radiculopathy. Diagnostic medial nerve blocks by the double-injection technique with an 80% improvement threshold are an option to predict a favorable response to medial nerve ablation for facet-mediated chronic lower-back pain without radiculopathy, but there is no evidence to support the use of diagnostic medial nerve blocks to predict the outcomes in these same patients with lumbar fusion. There is insufficient evidence to support or refute the use of trigger point injections for chronic lowerback pain without radiculopathy.