A new anatomical variation of the musculocutaneous and the median nerve anastomosis

Variations of the brachial plexus and its terminal branches are not uncommon.Therein, the anatomical variations of the musculocutaneous and the median nerve are classified into 5 types, while the communicating branches between the musculocutaneous and the median nerve are classified into 3 types, depending on their position related to the coracobrachial muscle. The case reviewed in this paper presents a variation similar to that of the second variety, but is significantly different due to the appearance of the proximal musculocutaneous nerve and its communicating branching, the site rising from the communicating branch (through the coracobrachial), and important clinical implications of this new variation. Despite the communicating branch being located in the upper third of the upper arm, it should not be considered as being a double lateral root of the median nerve

Significance of anatomical variations of the lateral circumflex femoral artery for the tensor fasciae latae flapping

The tensor fasciae latae (TFL) muscle is commonly used in plastic and reconstructive surgery as a transpositional or a free flap, in order to repair different kinds of defects. In most cases its vascularisation is provided by an ascending branch of lateral circumflex femoral artery (LCFA), which gives different numbers of branches and enters the TFL muscle in different manners. The represented study deals with the arterial vascularisation of the TFL muscle: the entrance of the vascular stalk branches; variations of the LCFA bifurcation’s angle; and the skin area of vascularisation. The study was performed on both lower limbs of a 100 foetal and 10 adult cadavers. The LCFA was injected with micropaque solution, afterwards fixed and preserved in 10% formalin solution. Microdissection was performed under magnifying glass and surgical microscope. Analysis of adult cadavers was performed to determine the skin area vascularised by perforating blood vessels from the TFL muscle, by injecting methylene-blue dye into the artery, prior to which all branches of the LCFA, besides the ascending branch, were ligated. The research of a 100 foetal cadavers showed that the LCFA with its ascending branch ensured the blood supply to the muscle. In 85% it gave two branches, the ascending and the descending one, with the angle of bifurcation circa 90o in 73% of cases. The ascending branch can give 0 or more terminal branches, or even form an arterial net. Skin area affected with dye ranged from 18 × 22 cm to 23 × 28 cm and is in positive correlation with the LCFA length and diameter. The understanding of the presented variations have an exceptional significance in planning and applying the TFL flap, especially free flap, in successful repairing and covering the defects, as well as in preventing postoperative complications

Bilateral anatomic variation in the relation of the upper trunk of the brachial plexus to the anterior scalene muscle

The brachial plexus represents a field of many anatomical variations with impor- tant clinical implications, especially in the diagnosis and treatment of the thoracic outlet syndrome (TOS). The case described in this paper presented a novel bilateral variation in the relation of the upper trunk of the brachial plexus to the anterior scalene muscle. The ventral rami of the C5 and C6 spinal nerves perforated the anterior scalene muscle simultaneously through a common opening, and joined to form the upper trunk. Previous literature reports described variations of the brachial plexus and the scalene muscles, as well as the embryological basis for their presence. The case reported herein helps to improve the comprehension of the TOS, as well as the diagnostic and therapeutical approach to this syndrome

Morphometric characteristics of the optic canal and the optic nerve

Background: The optic nerve (ON), a major component of the visual system, is divided into four segments: the intrabulbar (IB), the intraorbital (IO), the intraca- nalicular (ICn) and the intracranial (ICr). The ICr ends with the two nerves partially decussating in the optic chiasm (OCh). The purpose of this study is to provide a detailed description of the dimensions of the OC (the diameter and the surface area of its foramina and the central segment, as well as the length of the OC and the thickness of its walls) as well as the ON (the length of the ON segments, the diameter of the ICn segment of the ON, the angle of decussation in the OCh, as well as the distance between the two ON at the cranial foramen of the OC).  Materials and methods: The acquired data was then used to estimate the volu- me of the OC and the ICn segment of the ON. The morphometric research was performed on 25 cadavers (17 male and 8 female) and 30 skulls.  Results: The surface area of the central segment of the OC was significantly smaller than the cranial foramen (p = 0.02) and the orbital foramen (p = 0.009). The inferior wall of the OC was significantly shorter than the other OC walls (p < 0.0001). The IO segment of the ON was the longest, where the difference to the ICn and ICr was statistically significant (p < 0.0001). The surface area of the ON at the cranial foramen was significantly larger than the surface area at the central segment of the OC (p = 0.02) and orbital foramen (p < 0.0001). The difference between the surface areas of the ON at the orbital foramen and the central segment of the OC was also statistically significant (p = 0.01). The estimated volume of the OC was calculated to be 190.72 mm3, and the volume of the ICn segment of the ON was estimated to be 50.25 mm3.  Conclusions: It is absolutely crucial to open the central segment of the OC when decompressing the ON, due to the narrowing of the OC in this segment.

The development of the UK National Institute of Health and Care Excellence evidence-based clinical guidelines on motor neurone disease.

The care of people with motor neuron disease/amyotrophic lateral sclerosis is often complex and involves a wide multidisciplinary team approach. The National Institute for Health and Care Excellence (NICE) in the UK has produced an evidence based guideline for the management of patients. This has made recommendations, based on clear evidence or consensus discussion. The evidence is often limited and areas for further research are suggested

Acceptance and Commitment Therapy for people living with motor neuron disease: an uncontrolled feasibility study

Background: Motor neuron disease (MND) is a fatal, progressive neurodegenerative disease that causes progressive weakening and wasting of limb, bulbar, thoracic and abdominal muscles. Clear evidence-based guidance on how psychological distress should be managed in people living with MND (plwMND) is lacking. Acceptance and Commitment Therapy (ACT) is a form of psychological therapy that may be particularly suitable for this population. However, to the authors' knowledge, no study to date has evaluated ACT for plwMND. Consequently, the primary aim of this uncontrolled feasibility study was to examine the feasibility and acceptability of ACT for improving the psychological health of plwMND. Methods: PlwMND aged ≥ 18 years were recruited from 10 UK MND Care Centres/Clinics. Participants received up to 8 one-to-one ACT sessions, developed specifically for plwMND, plus usual care. Co-primary feasibility and acceptability outcomes were uptake (≥ 80% of the target sample [N = 28] recruited) and initial engagement with the intervention (≥ 70% completing ≥ 2 sessions). Secondary outcomes included measures of quality of life, anxiety, depression, disease-related functioning, health status and psychological flexibility in plwMND and quality of life and burden in caregivers. Outcomes were assessed at baseline and 6 months. Results: Both a priori indicators of success were met: 29 plwMND (104%) were recruited and 76% (22/29) attended ≥ 2 sessions. Attrition at 6-months was higher than anticipated (8/29, 28%), but only two dropouts were due to lack of acceptability of the intervention. Acceptability was further supported by good satisfaction with therapy and session attendance. Data were possibly suggestive of small improvements in anxiety and psychological quality of life from baseline to 6 months in plwMND, despite a small but expected deterioration in disease-related functioning and health status. Conclusions: There was good evidence of acceptability and feasibility. Limitations included the lack of a control group and small sample size, which complicate interpretation of findings. A fully powered RCT to evaluate the clinical and cost-effectiveness of ACT for plwMND is underway

A proposed staging system for amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis is a neurodegenerative disorder characterized by progressive loss of upper and lower motor neurons, with a median survival of 2–3 years. Although various phenotypic and research diagnostic classification systems exist and several prognostic models have been generated, there is no staging system. Staging criteria for amyotrophic lateral sclerosis would help to provide a universal and objective measure of disease progression with benefits for patient care, resource allocation, research classifications and clinical trial design. We therefore sought to define easily identified clinical milestones that could be shown to occur at specific points in the disease course, reflect disease progression and impact prognosis and treatment. A tertiary referral centre clinical database was analysed, consisting of 1471 patients with amyotrophic lateral sclerosis seen between 1993 and 2007. Milestones were defined as symptom onset (functional involvement by weakness, wasting, spasticity, dysarthria or dysphagia of one central nervous system region defined as bulbar, upper limb, lower limb or diaphragmatic), diagnosis, functional involvement of a second region, functional involvement of a third region, needing gastrostomy and non-invasive ventilation. Milestone timings were standardized as proportions of time elapsed through the disease course using information from patients who had died by dividing time to a milestone by disease duration. Milestones occurred at predictable proportions of the disease course. Diagnosis occurred at 35% through the disease course, involvement of a second region at 38%, a third region at 61%, need for gastrostomy at 77% and need for non-invasive ventilation at 80%. We therefore propose a simple staging system for amyotrophic lateral sclerosis. Stage 1: symptom onset (involvement of first region); Stage 2A: diagnosis; Stage 2B: involvement of second region; Stage 3: involvement of third region; Stage 4A: need for gastrostomy; and Stage 4B: need for non-invasive ventilation. Validation of this staging system will require further studies in other populations, in population registers and in other clinic databases. The standardized times to milestones may well vary between different studies and populations, although the stages themselves and their meanings are likely to remain unchanged