PECS II block is associated with lower incidence of chronic pain after breast surgery / 대한통증학회지

BACKGROUND: Breast cancer is complicated by a high incidence of chronic postoperative pain (25%–60%). Regional anesthesia might play an important role in lowering the incidence of chronic pain; however it is not known if the pectoral nerve block (PECS block), which is commonly used for breast surgery, is able to prevent this complication. Our main objective was therefore to detect any association between the PECS block and chronic pain at 3, 6, 9, and 12 months in patients undergoing breast surgery. METHODS: We conducted a prospective, monocentric, observational study. We enrolled 140 consecutive patients undergoing breast surgery and divided them in patients receiving a PECS block and general anesthesia (PECS group) and patients receiving only general anesthesia (GA group). Then we considered both intraoperative variables (intravenous opioids administration), postoperative data (pain suffered by the patients during the first 24 postoperative hours and the need for additional analgesic administration) and development and persistence of chronic pain (at 3, 6, 9, and 12 mo). RESULTS: The PECS group had a lower incidence of chronic pain at 3 months (14.9% vs. 31.8%, P = 0.039), needed less intraoperative opioids (fentanyl 1.61 μg/kg/hr vs. 3.3 μg/kg/hr, P < 0.001) and had less postoperative pain (3 vs. 4, P = 0.017). CONCLUSIONS: The PECS block might play an important role in lowering incidence of chronic pain, but further studies are needed.

Thoracic interfascial nerve block for breast surgery in a pregnant woman: a case report / 대한마취과학회지

Regional anesthesia for non-obstetric surgery in parturients is a method to decrease patient and fetal risk during general anesthesia. Thoracic interfascial nerve block can be used as an analgesic technique for surgical procedures of the thorax. The Pecs II block is an interfascial block that targets not only the medial and lateral pectoral nerves, but also the lateral cutaneous branch of the intercostal nerve. Pecto-intercostal fascial block (PIFB) targets the anterior cutaneous branch of the intercostal nerve. The authors successfully performed a modified Pecs II block and PIFB without complications in a parturient who refused general anesthesia for breast surgery.

Thoracic interfascial nerve block for breast surgery in a pregnant woman: a case report / 대한마취과학회지

Regional anesthesia for non-obstetric surgery in parturients is a method to decrease patient and fetal risk during general anesthesia. Thoracic interfascial nerve block can be used as an analgesic technique for surgical procedures of the thorax. The Pecs II block is an interfascial block that targets not only the medial and lateral pectoral nerves, but also the lateral cutaneous branch of the intercostal nerve. Pecto-intercostal fascial block (PIFB) targets the anterior cutaneous branch of the intercostal nerve. The authors successfully performed a modified Pecs II block and PIFB without complications in a parturient who refused general anesthesia for breast surgery.

Surgical excision of the breast giant fibroadenoma under regional anesthesia by Pecs II and internal intercostal plane block: a case report and brief technical description: a case report / 대한마취과학회지

A 22-years-old female patient at 171 cm and 67 kg visited the Department of Breast Surgery of the hospital with a mass accompanied with pain on the left side breast as chief complaints. Since physical examination revealed a suspected huge mass, breast surgeon decided to perform surgical excision and requested anesthesia to our department. Surgery of breast tumor is often under local anesthesia. However, in case of big size tumor, surgery is usually performed under general anesthesia. The patient feared general anesthesia. Unlike abdominal surgery, there is no need to control visceral pain for breast and anterior thoracic wall surgery. Therefore, we decided to perform resection under regional anesthesia. Herein, we report a successful anesthetic and pain management of the patient undergoing excision of a huge breast fibroadenoma under regional anesthesia using Pecs II and internal intercostal plane block.

Lumbar spinal anesthesia with cervical nociceptive blockade. Critical review of a series of 1, 330 procedures / Raquianestesia lombar com bloqueio nociceptivo cervical. Revisão crítica de uma serie de 1. 330 procedimentos

BACKGROUND AND OBJECTIVES: The manufacture of minimally traumatic needles and synthesis of pharmacological adjuncts with safe and effective action on inhibitory and neuromodulatory synapses distributed along the nociceptive pathways were crucial for a new expansion phase of spinal anesthesia. The objectives of this paper are present our clinical experience with 1330 lumbar spinal anesthesia performed with purposeful nociceptive blockade of the thoracic and cervical spinal nerves corresponding to dermatomes C4 or C3; warn about the method pathophysiological risks, and emphasize preventive standards for the safe application of the technique. CONTENT: Review of the historical background and anatomical spinal anesthesia with cervical levels of analgesia. Description of the technique used in our institution; population anesthetized; and surgery performed with the described method. Critical exposition of the physiological, pathophysiological, and clinical effects occurred and registered during anesthesia-surgery and postoperative period. CONCLUSION: Spinal anesthesia with nociceptive blockade to dermatome C4, or C3, is an effective option for surgery on somatic structures distal to the metamer of the third cervical spinal nerve, lasting no more than four or five hours. The method safety depends on the unrestricted respect for the essential rules of proper anesthesia.

JUSTIFICATIVA E OBJETIVOS: A fabricação de agulhas minimamente traumáticas e a síntese de coadjuvantes farmacológicos com ação efetiva e segura nas sinapses inibitórias e neuromoduladoras distribuídas ao longo das vias nociceptivas foram determinantes para uma nova fase de expansão da anestesia subaracnoidea. Os objetivos deste artigo são: apresentar a experiência clínica dos autores com a realização de 1.330 Raquianestesias lombares com bloqueio nociceptivo proposital dos nervos espinhais torácicos e cervicais até os dermátomos correspondentes a C4 ou C3; alertar sobre os riscos fisiopatológicos do método e enfatizar as normas preventivas para a realização da técnica com segurança. CONTEÚDO: Revisão dos fundamentos históricos e anatomofuncionais da anestesia subaracnoidea com níveis cervicais de analgesia. Descrição da técnica utilizada em nossa instituição; da população anestesiada e das cirurgias realizadas com o método descrito. Exposição crítica dos efeitos fisiológicos, clínicos e fisiopatológicos ocorridos e registrados durante o ato anestésico-cirúrgico e no período pós-operatório. CONCLUSÃO: A Raquianestesia com bloqueio nociceptivo até o dermátomo de C4, ou de C3 é uma opção efetiva para cirurgias sobre estruturas somáticas distais ao metâmero do terceiro nervo espinhal cervical com duração não superior a 4 ou 5 horas. A segurança do método depende do respeito irrestrito às regras essenciais da correta prática anestésica.

Risk of Encountering Dorsal Scapular and Long Thoracic Nerves during Ultrasound-guided Interscalene Brachial Plexus Block with Nerve Stimulator

BACKGROUND: Recently, ultrasound has been commonly used. Ultrasound-guided interscalene brachial plexus block (IBPB) by posterior approach is more commonly used because anterior approach has been reported to have the risk of phrenic nerve injury. However, posterior approach also has the risk of causing nerve injury because there are risks of encountering dorsal scapular nerve (DSN) and long thoracic nerve (LTN). Therefore, the aim of this study was to evaluate the risk of encountering DSN and LTN during ultrasound-guided IBPB by posterior approach. METHODS: A total of 70 patients who were scheduled for shoulder surgery were enrolled in this study. After deciding insertion site with ultrasound, awake ultrasound-guided IBPB with nerve stimulator by posterior approach was performed. Incidence of muscle twitches (rhomboids, levator scapulae, and serratus anterior muscles) and current intensity immediately before muscle twitches disappeared were recorded. RESULTS: Of the total 70 cases, DSN was encountered in 44 cases (62.8%) and LTN was encountered in 15 cases (21.4%). Both nerves were encountered in 10 cases (14.3%). Neither was encountered in 21 cases (30.4%). The average current measured immediately before the disappearance of muscle twitches was 0.44 mA and 0.50 mA at DSN and LTN, respectively. CONCLUSIONS: Physicians should be cautious on the risk of injury related to the anatomical structures of nerves, including DSN and LTN, during ultrasound-guided IBPB by posterior approach. Nerve stimulator could be another option for a safer intervention. Moreover, if there is a motor response, it is recommended to select another way to secure better safety.

Diagnosis and Treatment of Abdominal Cutaneous Nerve Entrapment Syndrome Using Ultrasonography

Abdominal cutaneous nerve entrapment syndrome is one of the abdominal wall-origin pain that develops in anterior cutaneous branches of 7th to 12th thoracic nerves passing through fibrous ring in rectus abdominis. Number of this condition has been misdiagnosed to visceral dysfunctions; therefore, delayed diagnosis leads to waste of cost and time. Injection of local anesthetics is a kind of useful technique for the purpose of the confirmed diagnosis with treatment in abdominal wall pain. Recently, the accuracy and safety of local anesthetics injection to muscle or nerve are significantly improved than the past times since ultrasound has been accepted as a substantial device in clinical area. Here, we report a case of abdominal cutaneous nerve syndrome, treated by ultrasound-guided nerve block accompanied with medical treatment.

Combined Video-Assisted Thoracic Surgery and Posterior Spinal Surgery for the Treatment of Dumbbell Tumor of the First Thoracic Nerve Root

Although several cases of a dumbbell tumor of thoracic nerve roots have been reported, reports on the surgical procedures for a dumbbell tumor of the first thoracic (T1) nerve root are rare. Surgeons should be cautious, especially when performing a surgical procedure for a dumbbell tumor of the T1 nerve root because the tumor is anatomically located adjacent to important organs and because the T1 nerve root composes the lower trunk of the brachial plexus with the eighth cervical nerve root. We present cases with dumbbell tumors of the T1 nerve root that were treated with combined surgical treatment to remove the tumor. We first performed video-assisted thoracic surgery (VATS) to release the organs anteriorly and then performed posterior spinal surgery in the prone position. The combined VATS and posterior spinal surgery may become a standard surgical procedure for the treatment of dumbbell tumors of the T1 nerve root.

Dynamic Stabilization of the Scapula for Serratus Anterior Dysfunction: A Retrospective Study of Functional Outcome and Results

BACKGROUND: Twenty-six patients (12 male and 14 female) with symptomatic scapular winging caused by serratus anterior dysfunction were managed by split pectoralis major tendon transfer (sternal head) with autogenous hamstring tendon augmentation from 1998 to 2006. METHODS: Twenty-five patients showed positive results upon long thoracic nerve palsy on electromyography. The mean duration of symptoms until surgery was 48 months (range, 12-120 months). Four patients had non-traumatic etiologies and 22 patients had traumatic etiologies. On follow-up assessment for functional improvement, a Constant-Murley score was used. Twenty-one patients were completely evaluated, while five patients who had less than 12 months of follow-up were excluded. RESULTS: Pain relief was achieved in 19 of the 21 patients, with 20 patients showing functional improvement. The pain scores improved from 6.0 preoperatively to 1.8 postoperatively. The mean active forward elevation improved from 108degrees (range, 20degrees-165degrees) preoperatively to 151degrees (range, 125degrees-170degrees) postoperatively. The mean Constant-Murley score improved from 57.7 (range, 21-86) preoperatively to 86.9 (range, 42-98) postoperatively. A recurrence developed in one patient. Of the 21 patients, ten had excellent results, six had good results, four had fair results, and one had poor results. CONCLUSIONS: Most patients with severe symptomatic scapular winging showed functional improvement and pain relief with resolution of scapular winging.

Dynamic Stabilization of the Scapula for Serratus Anterior Dysfunction: A Retrospective Study of Functional Outcome and Results

BACKGROUND: Twenty-six patients (12 male and 14 female) with symptomatic scapular winging caused by serratus anterior dysfunction were managed by split pectoralis major tendon transfer (sternal head) with autogenous hamstring tendon augmentation from 1998 to 2006. METHODS: Twenty-five patients showed positive results upon long thoracic nerve palsy on electromyography. The mean duration of symptoms until surgery was 48 months (range, 12-120 months). Four patients had non-traumatic etiologies and 22 patients had traumatic etiologies. On follow-up assessment for functional improvement, a Constant-Murley score was used. Twenty-one patients were completely evaluated, while five patients who had less than 12 months of follow-up were excluded. RESULTS: Pain relief was achieved in 19 of the 21 patients, with 20 patients showing functional improvement. The pain scores improved from 6.0 preoperatively to 1.8 postoperatively. The mean active forward elevation improved from 108degrees (range, 20degrees-165degrees) preoperatively to 151degrees (range, 125degrees-170degrees) postoperatively. The mean Constant-Murley score improved from 57.7 (range, 21-86) preoperatively to 86.9 (range, 42-98) postoperatively. A recurrence developed in one patient. Of the 21 patients, ten had excellent results, six had good results, four had fair results, and one had poor results. CONCLUSIONS: Most patients with severe symptomatic scapular winging showed functional improvement and pain relief with resolution of scapular winging.

Origens e ramificações do plexo braquial no cachorro-do-mato Cerdocyon thous (Linnaeus, 1766) / Origins and ramifications of brachial plexus in the crab-eating-fox Cerdocyon thous (Linnaeus, 1766)

Este estudo teve o objetivo de descrever a origem e ramificação dos nervos de vinte plexos braquiais de cachorro-do-mato (Cerdocyon thous). Dez animais da espécie, obtidos post mortem por atropelamento em rodovias, foram utilizados para o estudo, de acordo com a autorização do IBAMA/SISBIO nº33667-1. Depois de coletados, os cadáveres foram fixados em solução de formaldeído a 50% e conservados por pelo menos 14 dias em solução de formaldeído a 10% antes das dissecções. Após remoção da pele, incisões na musculatura peitoral e afastamento dos membros, acessou-se o espaço axilar e os nervos do plexo tiveram seu trajeto dissecados individualmente até sua inserção muscular. Para melhorar a visualização dos ramos ventrais cervicais e torácicos que originavam cada nervo, removeram-se a musculatura que encobria os forames intervertebrais, os processos transversos e os corpos vertebrais ventralmente, expondo inclusive a medula espinhal. Registros fotográficos e desenhos esquemáticos documentaram a origem e ramificação dos nervos. Os vinte plexos braquiais foram resultantes das conexões entre os ramos ventrais dos três últimos nervos espinhais cervicais (C6, C7 e C8) e do primeiro torácico (T1). Estes ramos derivaram os nervos supra-escapular, subescapular, axilar, musculocutâneo, radial, mediano, ulnar para a musculatura intrínseca e os nervos braquiocefálico, toracodorsal, torácico lateral, torácico longo, peitoral cranial e peitoral caudal para a musculatura extrínseca do membro torácico. Constatou-se que os ramos ventrais de C7 foram os que mais contribuíram na formação de nervos (61,5%), seguido de C8 (55,4%), de T1 (41,2%) e de C6 (30,8%). O teste t de comparação entre as médias, ao nível de significância de 5%, não demonstrou diferenças na origem do plexo quando comparados os antímeros e os sexos. Do total dos 260 nervos dissecados, 68,8% foram originados pela combinação de dois ou três ramos, enquanto apenas 31,2% tiveram formação por um único ramo. A combinação entre C8 e T1 foi a que mais formou nervos para o plexo (23,8%) nesta espécie. Quando comparadas a origem, ramificação e área de inervação do plexo braquial do C. thous com outras espécies domésticas e silvestres, verificou-se maior semelhança com o cão doméstico. Os resultados deste estudo podem embasar o diagnóstico de disfunções neuromusculares, as técnicas de bloqueios anestésicos e análises morfofuncionais comparativas envolvendo esta espécie.

This study aimed to describe the origin and branching of nerves from twenty brachial plexuses of crab-eating foxes (Cerdocyon thous). Ten animals of the species, obtained post mortem from being run over on highways, were used for the study, in accordance with the authorization from IBAMA / SISBIO No. 33667-1. Once collected, the cadavers were fixed in 50% formaldehyde and kept for at least 14 days in a solution of 10% formaldehyde before dissections. After removal of skin, incisions in breast muscles and reflection of thoracic limbs allowed access to axillary space and the nerves could have trajects dissected individually to each muscle insertion. To improve visualization of the cervical and thoracic ventral roots that originated every single nerve, muscles that covered the intervertebral foramina, transverse processes and vertebral bodies were removed ventrally and the spinal cord exposed. Schematic drawings and photographic records documented the origin and branching of nerves. The twenty plexuses were resulted from connections between the ventral branches of the last three cervical spinal nerves (C6, C7 and C8) and first thoracic (T1). These branches derived the nerves suprascapular, subscapular, axillary, musculocutaneous, radial, median and ulnar to the intrinsic muscles and brachiocephalic, thoracodorsal, lateral thoracic, long thoracic, cranial and caudal pectoral nerves to the extrinsic muscles of the thoracic limb. It was found that the ventral rami of C7 were the main contributors in the formation of nerves (61.5%), followed by C8 (55.4%), T1 (41.2%) and C6 (30.8%). The t-test comparison between means at a significance level of 5% showed no differences in the origin of plexus when compared antimeres and sexes. Of the total of 260 dissected nerves, 68.8% originated by the combination of two or three roots, while only 31.2% were formed by a single root. The combination between C8 and T1 was the most frequent origin of nerves to the plexus (23.8%) in this species. Comparing the origin, branching and innervation area of the brachial plexus in C. thous with other domestic and wild species, there was a greater similarity with the domestic dog. These results may give the anatomical basis to diagnosis of neuromuscular disorders, anesthetic blocks techniques and comparative morphofunctional analyzes involving this species.

Lesiones del nervio torácico largo de Bell. Revisión de conceptos terapéuticos / Long thoracic nerve of Bell. Review of therapeutic management

Las lesiones del nervio torácico producen parálisis del serrato anterior y originan una deformidad característica (escápula alata), que genera debilidad y alteraciones importantes en la movilidad del hombro. En esta revisión, se analizan conceptos sobre anatomía, etiología, presentación clínica y alternativas terapéuticas.

The long thoracic nerve injuries are manifested by a characteristic deformity called scapula alata, causing weakness, and impaired shoulder mobility. In this review current concepts of the anatomy, etiology, clinical presentation and therapeutic management are analyzed.

Dismorfia de genitales externos en la población pediátrica / Dysmorphia external genitalia in the pediatric population

El procedimiento estético más común de los genitales femeninos es la reducción de los labios menores (labioplastía). Cada vez son más las niñas y mujeres jóvenes que prestan especial atención a la apariencia estética de sus genitales externos. La causa más común de hipertrofia es probablemente la congénita. Las mujeres afectadas habitualmente sufren vergüenza social y preocupación estética. Existen numerosas técnicas para la corrección quirúrgica en la literatura médica, aunque ningún método es superior a otro. Se presentan dos casos de dismorfia de labios menores en adolescentes. En un caso, de dismorfia congénita, se utilizó la técnica de reducción en ancho y en largo mediante desepitelización y resección en cuña inferior. Esta asociación proporciona un cierre libre de tensión y asegura una vascularización adecuada del borde del colgajo superior, lo que disminuiría el riesgo de dehiscencia de herida. En el otro caso, secuela de trauma, se reimplantó el labio afectado con resección del tercio distal del mismo. En ambas pacientes los resultados estéticos fueron satisfactorios...

The most common cosmetic procedure of the female genitalia is the labia minora reduction (labiaplasty). There are more and more girls and young women, with special attention to the aesthetic appearance of their external genitalia. The most common cause of hypertrophy is likely to congenital. Affected women usually suffer social shame and aesthetic concerns. There are numerous techniques for surgical correction in the medical literature, although no method is superior to another. Two cases of a minor dysmorphic teen lips are presented. In one case, a congenital dysmorphic, we used the reduction technique in width and in length by epithelialization and lower wedge resection. This partnership provides tension-free closure and ensures proper vascularization of the upper edge flap, which would reduce the risk wound dehiscence. In the other case, sequel to trauma, the affected lip were treated with resection of the distal portion. In both patients the aesthetic results were satisfactory...

Multiple unilateral variations in medial and lateral cords of brachial plexus and their branches / 대한해부학회지

During routine dissection of the upper extremity of an adult male cadaver, multiple variations in branches of medial and lateral cords of brachial plexus were encountered. Three unique findings were observed. First, intercordal neural communications between the lateral and medial cords were observed. Second, two lateral pectoral nerves and one medial pectoral nerve were seen to arise from the lateral and medial cord respectively. The musculocutaneous nerve did not pierce the coracobrachialis. Finally, the ulnar nerve arose by two roots from the medial cord. Knowledge of such variations is of interest to anatomists, radiologists, neurologists, anesthesiologists, and surgeons. The aim of our study is to provide additional information about abnormal brachial plexus and its clinical implications.

Traumatismo da medula espinhal em cães e gatos: estudo prospectivo de 57 casos / Spinal cord injuries in dogs and cats: prospective study of 57 cases

O traumatismo da medula espinhal é uma causa comum de disfunção neurológica em cães e gatos. Lesões nestas espécies ocorrem devido a vários tipos de acidentes, podendo ocasionar sequelas que prejudicam o paciente como animais de estimação ou lesões que comprometam a vida. O objetivo principal deste estudo foi a monitoração intensiva de animais com lesão medular atendidos entre 8/2009 e 11/2010 no Hospital Veterinário da Universidade Estadual de Londrina, estudando os fatores epidemiológicos e etiológicos, fatores de risco, segmentos medulares mais afetados, resultados dos tratamentos conservativo ou cirúrgico, relação entre o tempo de atendimento e a recuperação do animal, eficácia e efeitos colaterais do succinato sódico de metilprednisolona, complicações, sequelas e evolução do quadro. Durante este período foram acompanhados 57 animais (48 cães e nove gatos). Observou-se predominância de animais machos (68%) e domiciliados (79%). A principal causa de lesão foi o atropelamento (66%). O tempo entre o trauma e o atendimento foi menos de oito horas em 42% dos casos e mais de um dia em 51%. O segmento medular mais atingido foi o toracolombar (52%). Vinte animais foram submetidos à eutanásia após o atendimento inicial devido ao prognóstico reservado. O tratamento conservativo com repouso e/ou imobilização externa foi realizado em 29 animais e um bom resultado com esta modalidade foi obtida em 72,4% dos casos: houve recuperação funcional total em 17 (58,6%) animais e parcial em quatro (13,8%). Quatro animais não se recuperaram e quatro animais morreram. Oito pacientes foram submetidos ao tratamento cirúrgico, sendo que três animais recuperaram-se, um paciente não apresentou recuperação e quatro morreram ou foram submetidos a eutanásia devido a complicações no trans ou pós-operatório. O tratamento conservativo foi viável, principalmente em cães com lesão medular cervical.

Spinal cord injury is a common cause of neurological dysfunction in dogs and cats. Lesions in these species are due to various types of accident, which can cause sequelae that impair the patient for life as a pet, or cause life-threatening injury. The main purpose of this work was the accompaniment of animals with spinal cord trauma seen from August 2009 to November 2010 at the Veterinary Hospital of Universidade Estadual de Londrina, studying the epidemiology and etiology, risk factors, spinal cord segments most affected, outcome of conservative or surgical treatment, ratio of time of patient care with recovery, efficacy and side effects of neuroprotective drugs, complications, sequels and evolution of patients. During this period we monitored 57 animals (48 dogs and nine cats). We observed a predominance of males (68%) and indoors (79%). The main cause of injury was being hit by a car (66%). The time between injury and first attendance was less than eight hours in 42% of cases and more than a day in 51%. The spinal segment most affected was the thoracolumbar (52%). Twenty animals were euthanized after the initial attendance due to poor prognosis. The conservative treatment such as rest and/or external immobilization was performed on 29 animals, and a good outcome was seen in 72.4% of this patients: total functional recovery was observed in 17 (58.6%) animals and partial functional recovery was seen in four (13.8%). Four animals did not recover, and four animals died. Surgical treatment was performed in eight patients, and three animals recovered, one patient did not recover and four animals died or were subjected to euthanasia due to complications during intraoperative or postoperative period. Conservative treatment was a viable therapy, mainly in dogs with cervical spinal cord trauma.

The existence of axillary arch in human fetus and applied importance and clinical implications in the axillary brachial plexus blocks / La existencia de arco axilar en el feto humano y la importancia aplicadae implicancias clínicas en los bloques de plexo braquial

Axillary arch is the most common muscle variation of axillary fossa that gains importance for regional interventional procedures, screening methods and physical examination. In order to avoid malpractice the variations must be borne in mind. This study has been planned to research the frequency and the features of the axillary arch in human fetus, to mention the potential clinical and functional significance of axillary arch while applying axillary brachial plexus block and reflect on possible complications. Axillary fossa was examined with a stereomicroscope in 20 upper extremities of ten human fetuses. The gestation ages ranged from 16 to 36 weeks. Axillary arch was determined in 2/20 specimen unilaterally. In both specimen, muscular slip detached from latissimus dorsi, passed anterior neurovascular bundle and ended posterior pectoralis major tendon and lateral border of intertubercular groove. In one specimen axillary arch was innervated with medial pectoral nerve whereas the other one did not have a particular innervating nerve branch. The possible effects of axillary arch in the axillary brachial plexus block applications are discussed. Arcus axillaris may have a potential clinical and functional significance with regard the axillary brachial plexus block applications and may have possible effects on failure rate and acute complications. Also, we think that this fetus study which the pure structure of the muscles without any usage effect can be observed will be beneficial regarding this topic.

El arco axilar es la variación muscular más común de la fosa axilar, siendo de importancia para la región en los procedimientos de intervención, los métodos de selección y el examen físico. Con el fin de evitar las negligencias se debe tener en cuenta las variaciones. El objetivo de este estudio fue determinar la frecuencia y las características del arco axilar en el feto humano. Es necesario mencionar la importancia del potencial clínico y funcional del arco axilar en la aplicación de bloqueo axilar del plexo braquial y sus posibles complicaciones. La fosa axilar fue examinada bajo microscopio estereoscópico en 20 miembros superiores de diez fetos humanos. La edad de gestación varió de 16 a 36 semanas. El arco axilar se observó unilateralmente en 2/20 especímenes. En ambos especímenes el músculo cruzó anteriormente el paquete neurovascular y terminó en el tendón del músculo pectoral mayor y en el margen lateral del surco intertubercular. En un especimen el arco axilar se encontraba inervado por el nervio pectoral medial, mientras que en el otro no existía una determinado ramo del nervio. Se discuten los posibles efectos del arco axilar en las aplicaciones de bloqueo axilar del plexo braquial. Puede tener un significado potencial clínico y funcional, en lo que se refiere a la aplicación de bloqueo axilar del plexo braquial y aademás producir efectos de complicaciones agudas.

Back to the debate: sternalis muscle / Volver al debate: músculo esternal

The sternalis muscle (SM) is an anatomical variant found in the anterior thoracic wall. While the attachment sites of SM are generally agreed upon, the innervation and function of this muscle are not well established. Cadaveric and surgical explorations to date report that SM is innervated by either the pectoral nerves or the anterior branches of the intercostal nerves, or a combination of both. Knowledge of SM is relevant to health care providers specialising in imaging and/or surgery of the anterior thoracic wall. This paper aims to raise awareness in the medical community of the clinical relevance of SM through two case reports and a brief literature review.

El músculo esternal (ME) es una variante anatómica en la pared torácica anterior. Mientras que los sitios de fijación del ME estan acordados, la inervación y la función de este músculo no están bien establecida. Exploraciones cadavéricas y quirúrgicas han informado que el ME está inervado por los nervios pectorales o ramos anteriores de los nervios intercostales, o una combinación de ambos. El conocimiento del SE es relevante para los proveedores de atención de salud especializada de imágenes y/o cirugía de la pared torácica anterior. Este documento tiene como objetivo crear conciencia en la comunidad médica de la relevancia clínica de ME a través de dos reportes de caso y una breve revisión bibliográfica.

Neurotization from Two Medial Pectoral Nerves to Musculocutaneous Nerve in a Pediatric Brachial Plexus Injury

Traumatic brachial plexus injuries can be devastating, causing partial to total denervation of the muscles of the upper extremities. Surgical reconstruction can restore motor and/or sensory function following nerve injuries. Direct nerve-to-nerve transfers can provide a closer nerve source to the target muscle, thereby enhancing the quality and rate of recovery. Restoration of elbow flexion is the primary goal for patients with brachial plexus injuries. A 4-year-old right-hand-dominant male sustained a fracture of the left scapula in a car accident. He was treated conservatively. After the accident, he presented with motor weakness of the left upper extremity. Shoulder abduction was grade 3 and elbow flexor was grade 0. Hand function was intact. Nerve conduction studies and an electromyogram were performed, which revealed left lateral and posterior cord brachial plexopathy with axonotmesis. He was admitted to Rehabilitation Medicine and treated. However, marked neurological dysfunction in the left upper extremity was still observed. Six months after trauma, under general anesthesia with the patient in the supine position, the brachial plexus was explored through infraclavicular and supraclavicular incisions. Each terminal branch was confirmed by electrophysiology. Avulsion of the C5 roots and absence of usable stump proximally were confirmed intraoperatively. Under a microscope, neurotization from the musculocutaneous nerve to two medial pectoral nerves was performed with nylon 8-0. Physical treatment and electrostimulation started 2 weeks postoperatively. At a 3-month postoperative visit, evidence of reinnervation of the elbow flexors was observed. At his last follow-up, 2 years following trauma, the patient had recovered Medical Research Council (MRC) grade 4+ elbow flexors. We propose that neurotization from medial pectoral nerves to musculocutaneous nerve can be used successfully to restore elbow flexion in patients with brachial plexus injuries.

Quantification of the Nerve Fiber of the Terminal Branches of the Typical Brachial Plexus / 체질인류학회지

This study was carried out to evaluate the quantity of the nerve fiber of the terminal branches of the typical brachial plexus in the 6 sides of the Korean adults. The dorsal scapular nerve, which is derived from ramus of the brachial plexus, was comprised of C5 and participating nerve fiber was 355+/-180. The long thoracic nerve was composed of C5, C6 and C7, and was mainly originated from C6, and participating nerve fiber was 743+/-346. The nerves, which are branched out from trunk, nerve to subclavius muscle was composed of C5 and participating quantity was 242+/-71. The suprascapular nerve was comprised of C5 and C6, and the nerve fiber was mainly derived from C5 (1,942+/-505). The nerve, which is originated from proximal portion of the cord, the lateral pectoral nerve was constituted of C5, C6 and C7. The main component was C7 as the 2,917+/-785 nerve fiber. The medial pectoral nerve was made with C8 and T1. The main component was C8 as the 964+/-430 nerve fiber. The upper subscapular nerve was derived from C5 and C6. The nerve fiber was 1,179+/-92 in C5, mainly participated. The Lower subscapular nerve was constituted of C5, C6 and C7. C6 was the main component and contributing nerve fiber was 1,070+/-390 in C6, principal component. The thoracodorsal nerve was formed by C6, C7 and C8. The chief component was C7, contributed of 2,335+/-324. The nerves, which are came out from the distal portion of the cord, musculocutaneous nerve was derived from the C5, C6 and C7. The C6 was principal component, and was joined with 4,009+/-1,883. The median nerve was contributed from C5 to T1. The chief component was C7 added with 9,651+/-2,663. The ulnar nerve was composed of C7, C8 and T1. The C8 was the main component comprised of 10,075+/-1,473. The medial brachial and antebrachial cutaneous nerves was constituted of C8 and T1. In the both nerves, the main component was T1 participated with 1,752+/-390, 3,080+/-1,140 respectively. The radial nerve was composed of C5 to T1. The C7 was principal component added with 7,958+/-2,333. The axillary nerve was made up C5 and C6. In the nerve, the both spinal segments were similarly participated to the nerve. This results could be applied for the injuries and neurotization procedure of the terminal nerves of the brachial plexus.

Metal stress-induced arrhythmia and thoracic spinal cord 1-5 nerve remodeling and myocardial electrophysiological remodeling in rats / 中华心血管病杂志

<p><b>OBJECTIVE</b>The study aimed to investigate the relationship between arrhythmia occurrence and nerve remodeling of thoracic spinal cord 1-5 nerves as well as myocardial electrophysiological remodeling in a metal stress rat model.</p><p><b>METHODS</b>Thirty SD rats (weight 180-250 g) were randomly divided into control group (n = 10), stress group (n = 10) and fluoxetine group (n = 10, 10 mg/kg i.p. for 3 weeks). Stress model (given by unpredicted chronic mild stress) was established according to Cronli's protocol. Following parameters were observed:(1) ECG waveform change and arrhythmias;(2) tissue field action potential duration (FAPD) of thoracic spinal cord 1-5 and cardiac tissue mapped by microelectrode arrays (MEA) technique;(3) myocardial growth-associated protein (GAP-43), tyrosine hydroxylase (TH), choline acetyltransferase (CHAT) distribution observed by immunofluorescence and confocal laser scanning microscope (LSCM).</p><p><b>RESULTS</b>Three weeks later: (1) The body weight, food intake, consumption of sugar water, the horizontal and vertical movement score, cleaning action of rats were significantly decreased, and fecal grains significantly increased, P-wave, P-R interval, QRS-wave and Q-T interval were significantly prolonged and heart rate was significantly reduced in stress group compared with control group (all P < 0.05). Incidence of ventricular premature beat was 80% in stress group and 0% in control group (P < 0.05). The FAPD of thoracic spinal cord 1-5 nerves [(144.25 ± 12.63)ms vs (79.56 ± 8.01)ms] and of cardiac tissue [LA(122.43 ± 19.34)ms vs (92.59 ± 7.61)ms, RA(149.89 ± 14.68)ms vs (105.18 ± 15.94)ms, LV(162.62 ± 7.04)ms vs (110.45 ± 6.92)ms, RV(152.21 ± 30.49)ms vs (131.06 ± 12.04)ms] were significantly prolonged, FAPD dispersion (FAPDd) significantly increased [thoracic spinal cord 1-5(13.3 ± 9.11)ms vs (9.36 ± 7.01)ms] in stress group compared with the control group. Disarrangement of myocardial cells, proliferation of collagen fiber, infiltration of neutrophil and lymphocytes in the cardiac tissue were also observed and distribution of GAP-43, TH and CHAT was significantly increased in stress group. (2) All these changes could be partly reversed by the treatment with fluoxetine.</p><p><b>CONCLUSION</b>Metal stress induced cardiac autonomic nerve and myocardial electrophysiological remodeling and ventricular arrhythmia in rats which could be significantly attenuated by fluoxetine in this model.</p>