A Morphometric Study of Typical and Atypical Lumbar Vertebrae in South Indian Population

Introduction:The lumbar vertebrae are affected in conditions such as congenital defects, degenerative diseases, accidents, and cancer metastasis. A thorough knowledge of the morphometry of typical and atypical lumbar vertebrae in adults of South Indian population is needed for lumbar spine surgeries. MaterialsandMethods: Adescriptive study was done on 200 dry lumbar vertebrae, of which 100 were typical and 100 were atypical lumbar vertebrae. The following dimensions of both typical and atypical lumbar vertebrae were measured with digital vernier calipers: anteroposterior and transverse diameters of the body; anterior and posterior body heights; anteroposterior and transverse diameters of vertebral foramen; height, breadth, and width of the laminae; length, height, and width of the pedicles; transverse processes and spinous process; distance between the two superior articular processes; and the distance between the two inferior articular processes. All the measurements were tabulated. The mean and standard deviation were calculated for each of the parameters and the results were statistically analyzed. Results: The anteroposterior and transverse diameters of the body, the height of the laminae on both sides, the length and height of the spinous process, and the distance between the superior articular facets were significantly longer in atypical lumbar vertebrae than that of typical lumbar vertebrae (P < 0.05). There was no significant difference in measurements between both sides. Conclusion: The dimensions of vertebral foramen, transverse processes, spinous processes, and distance between articular processes were different from the dimensions of previous studies. The morphometric data obtained will be useful for orthopedic procedures on the lumbar vertebrae in South Indian population

Assessment of incidence of recurrence and constipation in patients of rectal prolapse undergoing rectal mobilization only with division of lateral stalks

Background: Rectal prolapse is a pelvic floor disorder that can occur in men and women of all ages. It results in pain, bleeding per rectum, seepage, diarrhoea or constipation and a disabled quality of life. With the advent of twentieth century, perineal operative procedures have become more common. Perineal procedures though have lower morbidities but have higher recurrence rate and high incidence of post-operative constipation. Novel abdominal approaches to rectal prolapse repair also became common during the first half of this century. Numerous types of surgical procedures have been attempted. Most techniques developed till now have some advantages and some short comings. CT Speakman and Pollen et al have shown in their studies   that division of lateral ligaments caused new onset constipation and they attributed this effect to denervation of rectum. As the issue of recurrence and post-operative constipation remained unsettled.Methods: This was an observational study to assess the incidence of recurrence and post-operative constipation in patients of rectal prolapse. In well selected patients, we performed complete rectal mobilization with division   of lateral ligaments. We assessed the patients on the basis of Clevland clinical constipation scoring system.Results: Out of 25 patients, 4 patients developed constipation, 2 had mild and 2 had moderate constipation and 2 patients had recurrence. Patients were kept under six monthly follow-up till a period of eighteen months.Conclusions: Only rectal mobilization with division of lateral ligaments can be a good surgical option in patients of rectal prolapse not having severe constipation.

Biometría del músculo grácil: pedículos vasculares e inervación en un grupo de individuos brasileños / Biometric characteristics of the gracilis muscle: vascular pedicles and innervation in a group of Brazilian individuals

El músculo grácil (MG) está ubicado en la cara medial del muslo, medial y posterior al aductor largo en su parte proximal. Se origina a nivel del pubis y se inserta en la cara medial de la tibia, en su parte superior. Como colgajo libre funcional ha sido uno de los injertos más utilizados en reconstrucciones diversas, tales como pene, perineo, vagina, pierna, plexo braquial, parálisis facial, lesiones rectales, entre otras. Basado en lo anterior, el objetivo de este estudio fue complementar la anatomía del MG tanto en sus dimensiones como en sus pedículos vasculares e inervación, estableciendo las relaciones biométricas existentes, contribuyendo a la anatomía quirúrgica, en su uso como injerto. Para ello, se utilizaron 30 miembros inferiores de 20 cadáveres de individuos adultos, brasileños, de sexo masculino, 14 derechos y 16 izquierdos; 17 fijados en formol y 13 en glicerina. Se dividió al muslo en 4 cuartiles enumerados de proximal a distal como C1,C2,C3 y C4. Se contabilizó el número de pedículos y se nombraron como pedículo principal (PP), pedículo menor 1 (Pm1), pedículo menor 2 (Pm2) y pedículo menor 3 (Pm3). La longitud media del GM fue de 42,25 cm ± 2,35 cm y su ancho promedio de 32,90 ± 4,86 mm. Con respecto a los pedículos vasculares se encontró un pedículo en 10/30 casos (33,3 %); un pedículo principal y uno menor en 10/30 (33,3 %); un pedículo principal y dos menores en 8/30 (26,7 %) y un pedículo principal y tres menores en 2/30 (6,7 %). Su inervación siempre procedió del ramo anterior del nervio obturador (RaNO). El punto motor se encontró a una distancia promedio de 7,94 mm proximal al ingreso del pedículo principal en el MG. Los registros biométricos están expresados en tablas. Los resultados obtenidos aportarán al conocimiento anatómico, pudiendo ser utilizados como soporte morfológico a los procedimientos quirúrgicos que involucren al músculo grácil.

The gracilis muscle (GM) is located in the medial aspect of the thigh, medial and posterior to the long adductor in its proximal part. It originates at the pubic level and is inserted in the medial face of the tibia, in its upper part. As a functional free flap, it has been one of the most co mmonly used grafts in various reconstructions, such as penis, perineum, vagina, leg, brachial plexus, facial paralysis, rectal lesions, among others. Based on the above, the objective of this study was to complement the anatomy of the GM both in its dimensions and in its vascular pedicles and innervation, establishing the existing biometric relationships, contributing to the surgical anatomy, in its use as a graft. For this, 30 lower limbs of 20 bodies of adult, Brazilian, male, 14 right and 16 left individuals were used; 17 fixed in formaldehyde and 13 in glycerin. The thigh was divided into 4 quartiles listed from proximal to distal such as C1, C2, C3 and C4. The number of pedicles was counted and they were named as principal pedicle (PP), minor pedicle 1 (mP1), minor pedicle 2 (mP2) and minor pedicle 3 (mP3). The average length of the GM was 42.25 cm ± 2.35 cm and its average width was 32.90 ± 4.86 mm. With respect to vascular pedicles, a pedicle was found in 10/30 cases (33.3 %); one PP and one mP in 10/30 (33.3 %); one PP and two mP in 8/30 (26.7 %) and one PP and three mP in 2/30 (6.7 %). Its innervation always came from the anterior branch of the obturator nerve (aBON). The motor point was found at an average distance of 7.94 mm proximal to the entry of the PP in the GM. Biometric records are expressed in tables. The results obtained will contribute to anatomical knowledge, and can be used as morphological support for surgical procedures that involve the GM.

Seven segmental pedicles at the porta hepatis / Siete pedículos segmentarios en la porta hepatis

SUMMARY: We wanted to know how many segmental portal branches were born from the primary branches of the hepatic portal vein in the porta hepatis, in order to determine the number of portal segments in human liver. We studied 286 human livers, age groups ranging from fetuses to octogenarians, both sexes and all races, using dissection, colored acrylic injection and reconstituted tomographic images. We found the porta hepatis channel formed by each and every portal segment; we found seven segmental terminal pedicles for seven portal segments, three planes of vertical and three planes of horizontal portal fissures. There are seven terminal portal pedicles that are formed in the porta hepatis from the right and left branches of the hepatic portal vein. The only variation was portal branch V emerging from the right branch in 79 % of cases or from the left branch in 21 %. The definition of hepatic portal segment is: Portion of parenchyma irrigated by terminal branches of the portal vein and the hepatic artery proper, isolated from the other segments by planes of portal fissures and forms the parenchymal channel of the porta hepatis where it receives its vascularization. We propose a new and simple portal segmentation based on the previous definition.

RESUMEN: El objetivo de este trabajo consistió en conocer el número de ramas portales segmentarias que nacen de las ramas primarias de la vena porta hepática en la Porta hepatis, con la finalidad de determinar el número de segmentos portales en el hígado humano. Estudiamos 286 hígados, los grupos etarios fueron desde fetos hasta octogenarios, ambos sexos y todas las razas, usamos la disección en fresco, inyección de acrílico coloreado e imágenes tomográficas reconstituidas. El canal de la Porta hepatis estuvo formado por todos y cada uno de los segmentos portales, encontramos siete pedículos terminales segmentarios para siete segmentos portales, el pedículo portal para el segmento V nació de la porta derecha en 79 % de casos y de la porta izquierda en 21 %, encontramos tres planos de fisuras portales verticales y tres horizontales. Existen siete pedículos segmentarios portales terminales que se forman en la Porta hepatis a partir de las ramas derecha e izquierda de la vena porta hepática. La única variación fue que la rama portal para el segmento V nació de la rama derecha en 79 % de casos y de la rama izquierda en 21 %. Concluimos que la definición de segmento portal hepático es: Porción de parénquima irrigado por ramas terminales de la vena porta y la arteria hepática propia, aislada de los otros segmentos por planos de fisuras y que llega a conformar el canal parenquimal de la Porta hepatis donde recibe su vascularización. Proponemos una nueva y sencilla segmentación portal basada en la definición previa.

Origin of left accessory hepatic artery from the left gastric artery.

In recent years there has been an increase in number of transplantation surgeries, especially live donor liver transplantation in the western countries. So, anatomical variations of Hepatobiliary vessels gained special attention from anatomists, Gastroenterological surgeons and Interventional radiologists. We report a case of the accessory hepatic artery that arise from the left gastric artery, entered the liver at an independent site from the portahepatis to supply the left lobe of the liver. Transplantation of such livers with multi vascular pedicles may pose a challenge during anastomosis of these accessory hepatic arteries of the donor liver to the nearby arteries of the recipient.

Estimation of Sex Using Demarking Points from Diameters of Lumbar Pedicles in Adult Nigerians.

Aim: To estimate sex using demarking points and index of sexual dimorphism of horizontal and vertical diameters of lumbar pedicles in male and female Nigerians. Study Design: Retrospective study. Place and Duration of Study: Department of Human Anatomy and Department of Radiology (University of Maiduguri Teaching Hospital), University of Maiduguri, Borno State Nigeria between February 2007 and June 2008. Methodology: Four hundred (400) radiographs of adult Nigerians (200 males and 200 females) were measured. Age range for the individuals was 18-76 years. Radiographs used for this study were obtained from the collection of record unit of the Radiology Department, University of Maiduguri Teaching Hospital (UMTH) in Borno state, Nigeria.Radiographic viewing box, temporary maker, pencil and a meter rule were used for the measurements.The radiographs for males and females were classified separately into six (6) age groups with ten (10) years interval. Vertical and Horizontal diameters of lumbar pedicle were represented on the radiographs by “h” (taken as the maximum dimension of the pedicle between the upper and lower margins of the pedicles) and by “t” (maximum diameter between the medial and lateral aspect of each pedicle). Distance between upper and lower extremities, as well as that between medial and lateral extremities of each pedicle were marked and measured as vertical and horizontal diameters respectively. Results: The result of the present study showed that, the vertical and horizontal diameters of the lumbar pedicles in adult Nigerians were all greater in male than in female counterpart. It was also observed that sexual differences in the two parameters were found to be statistically significant (P<0.001) in both sexes. Index of sexual dimorphism (ISD) was also calculated and it was observed that all parameters were found to be greater than 100; this showed that male had higher values over female counterpart. Demarking points were also calculated for each parameter, the result also showed similar pattern of increase in male parameters over female counterpart. The result also showed age-related significant (P<0.001) variations for the lumbar pedicle diameters, from 18-27 through 38-47 years age groups with a decrease in diameters at the 48-57 through 68-77 years age groups in both sexes. Conclusion: It was observed that the vertical and horizontal diameters were sexually dimorphic; the demarking points of male diameter were all higher than those of the female counterpart. Index of sexual dimorphism also showed that male vertical and horizontal diameters were all greater than female vertical diameter as the index of sexual dimorphism were all greater than 100 from L1 through L5. This study reconfirms the fact that osteometric assessment is highly population- specific. It may be added that more studies are required in the southern part of Nigerian population to give a better picture of the racial variation that exists there and to offer more osteometric standards for assessing sex for the entire country.

Morphometry of pedicle and vertebral body in a Mexican population by CT and fluroscopy / Morfometría del cuerpo vertebral y pedículo en una población mexicana mediante TC y fluoroscopía

It is necessary to have precise anatomical knowledge of lumbar pedicles for the safe placement of screws. There are not reports about the morphometry of lumbar pedicles in a Mexican population exist. A descriptive, observational and cross-sectional study was done in 60 cadavers from the dissection lab of the Human Anatomy Department of the Medicine School. The aim of the study was to quantify the morphometric characteristics of the pedicles of the lumbar spine in a Mexican population. A total of 60 cadavers were evaluated by fluoroscopy and CT from L1 to L5, in the age range of 40 to 78 years. Each vertebral pedicle was measured in the axial, sagittal and coronal planes. The measurements included the minimum pedicle width, the pedicle angle, the distance to anterior cortex, and anteroposterior and interpedicular spinal canal diameters. CT evaluation showed a progressive and gradual increase in the width of the pedicles from L1 (7.81 +/- 1.30 mm) to L5 (14.36 +/- 14.36 mm). A progressive and gradual decrease of pedicle length from L1 (20.92 +/- 2.62 mm) to L5 (17.23 +/- 1.35 mm). When fluoroscopy was used there was the same relationship, but the values were higher than those obtained by CT. The values for widths and lengths are slightly higher in males than in females, but do not reveal any significant difference (p<0.05). The data in this study indicates that pedicle screws (5.5-6.5mm) may be used in the lumbar region.

Es necesario tener un conocimiento anatómico preciso de la morfología de los pedículos en la region lumbar para la colocación segura de tornillos intrapediculares. No existen reportes de la morfometría de los pedículos lumbares en la población Mexicana. Se desarrolló un estudio descriptivo, observacional y transversal en 60 cadaveres en el laboratorio del Departamento de Anatomía Humana de la Facultad de Medicina. El objetivo del estudio fue determinr las características morfométricas de los pedículos de la region lumbar en una muestra de población Mexicana. Se evaluaron las regiones lumbares (L1-L5) de un total de 60 cadaveres por fluroscopía y TC en un rango de edad entre 40 y 78 años. Cada pedículo fue medido en los planos axial, sagital y coronal. La evaluacion por TC muestra un aumento progresivo y gradual de la anchura de los pedículos de L1 (7,81 +/- 1,30 mm) a L5 (14,36 +/- 14,36 mm). También se observó una disminución gradul de la longitud del pedículo de L1 (14,36 +/- 14,36 mm) a L5 (17,23 +/- 1,35 mm). Al realizar las mediciones por fluroscopia se observaron las mismas condiciones, pero los valores fueron proporcionalmente mayores que los obtenidos por TC. La anchura y longitud pedicular fueron ligeramente mayores en hombres que en mujeres, pero no revelan significancia estadística (p<0,05). Los datos obtenidos del estudio indican que los tornillos intrapediculares (5,5- 6,5mm) pueden ser utilizados en la region lumbar.

The Optimal Period of the Pedicles Implantation for the Patent Vasculature in the Prefabricated Periosteofascial Flap through the Vascular Pedicles Transfer

This study was designed to investigate the optimal period of pedicles implantation in the prefabricated periosteofascial flap using a vascular tissue transfer. Flap prefabrication was prepared with a transposition of the central pedicles of right auricle on the calvarium of the New Zealand white rabbit. Thirty flaps were divided into five groups of six flaps, including control group (group I) of the conventional periosteofascial flap based on the right lateral border of parietal bone. The prefabricated flap was elevated as a 2x2cm sized island flap and reposed in place in 1, 2, 3, and 4 weeks after the pedicles transfer in groups II, III, IV, and V, respectively. Five days after flap repositioning, the flap viability and vascularity were evaluated with microangiography and histological study quantitatively. The flap survival was increased in accordance with the implanted period of the pedicle. New vessels developed around the implanted pedicle in the 2nd week, and overall vascularization of the flap was accomplished in the 3rd week. The flap with 4 weeks of implantation period, however, showed the same survival rate as the control group. In conclusion, prefabricated periosteo- fascial flap can be created with a vascular tissue transfer, and the optimal duration of the pedicle implantation is more than 4 weeks to obtain adequate flap survival.

The Sternal Turn Over Procedure with Preservation of the Internal Mammary Vessel and Rectus Abdominis Muscle Pedicles for the Repair of Severe Pectus Excavatum.

Pectus excavatum or funnel chest is one of the most common congenital chest wall deformities. Surgical correction should be considered for all patients with moderate to severe deformities because of the significant cosmetic and psychological improvement, subjective increase in exercise tolerance, documented changes in the cardiac and respiratory status, and prevention of the development of scoliosis after surgical intervention in these patients. The sternal turn over procedure with preserved internal mammary vessels and rectus abdominis muscle pedicles for the corrective repair of severe pectus excavatum, involves resection of the deformed thoracic wall, sternum and ribs, preserving an attachment of the rectus abdominis muscle,and a vascular pedicle of the internal mammary vessel. A short segment resection above the ipsilateralcostal cartilage is mandatory to allow reposition of the vascular pedicle onto the presternal surface after turn over of the sternum. Multiple corrective osteotomy and costoplasty must be completed before refixing the sternum and ribs. The modified sternal turn over procedure restores the sternal blood supply and should be applied to the severe form of pectus excavatum which needs extensive and multiple bony resection. The procedure has been applied to a boy and a girl aged 5 years. At a three year follow up, the results obtained are excellent.

Morphometric Study of the Pedicle of Lumbar and Selected Thoracic Vertebrae for Surgical Spinal Fixation / 대한정형외과학회잡지

The pedicle instrumentation has become a popular way of spinal fixation. Placement of a screw through the pedicle into vertebral body appears to be a very successful way to accomplish spinal fixation. However, the configuration of the pedicle morphometry must be understood. The measurement includes pedicle width, angle of pedicle axis to the transverse plane, ideal screw length, ideal screw entry point and ideal angle. This study was accomplished using computerized axial tomogram(CT) of 704 vertebrae(T10-L5). The results were as follows. 1. Transverse pedicle diameter were narrowest at T10, widest at L5. 2. The pedicle axis is oriented anteromedially at all levels except T11 and T12, then increase from L1 to L5. 3. Screw lengths are fairly constant between all levels, thus the range of screw lengths need is limited. 4. The incidence of pedicle less than 6 mm in the transverse diameter is most common at T10 and followed by levels L1, T12 and L2. Preoperative determination of transpedicular screw diameter and length can be made, by direct measurement from the patient's CT scan.