Anthony V. D'Antoni

Ossification of the suprascapular ligament: A risk factor for suprascapular nerve compression?

Introduction: Entrapment of the suprascapular nerve at the suprascapular notch may be due to an ossified suprascapular ligament. The present study was conducted in order to investigate the incidence of this anomaly and to analyze the resultant bony foramen (foramen scapula) for gross nerve compression. Materials and Methods: We evaluated 104 human scapulae from 52 adult skeletons for the presence of complete ossification of the suprascapular ligament. When an ossified suprascapular ligament was identified, the diameter of the resultant foramen was measured. Also, the suprascapular regions of 50 adult cadavers (100 sides) were dissected. When an ossified suprascapular ligament was identified, the spinati musculature was evaluated for gross atrophy and the diameters of the resultant foramen scapulae and the suprascapular nerve were measured. Immunohistochemical analysis of the nerve was also performed. Results: For dry scapular specimens, 5.7% were found to have an ossified suprascapular ligament. The mean diameter of these resultant foramina was 2.6 mm. For cadavers, an ossified suprascapular ligament was identified in 5% of sides. Sections of the suprascapular nerve at the foramen scapulae ranged from 2 to 2.8 mm in diameter. In all cadaveric samples, the suprascapular nerve was grossly compressed (~10-20%) at this site. All nerves demonstrated histologic signs of neural degeneration distal to the site of compression. The presence of these foramina in male cadavers and on right sides was statistically significant. Conclusions: Based on our study, even in the absence of symptoms, gross compression of the suprascapular nerve exists in cases of an ossified suprascapular ligament. Asymptomatic patients with an ossified suprascapular ligament may warrant additional testing such as electromyography.

Applications of the Mind Map Learning Technique in Chiropractic Education: A Pilot Study and Literature Review

Objective: To present a review of the literature and survey results of student satisfaction after using the mind map learning technique. Methods: Fourteen third-year physical therapy students enrolled in a doctoral neurorehabilitation course were required to create a mind map based upon the lecture presentation and assigned reading for 6 diagnoses. The students were asked to complete a post-course survey to assess their perceptions of the usefulness of the mind map learning technique in improving organization and integration of course material. Results: Although the subject pool was limited to 14 students, 10 out of 14 agreed that the mind map learning technique enabled them to better organize/integrate material presented in the course, while only 2 disagreed. The final 2 students responded neutrally when asked if the mind map learning technique assisted them in organizing/integrating course material. However, these 2 students did agree the technique enabled them to recognize areas in which further study was necessary for them to adequately master the course material. Conclusion: While the data obtained from this limited educational experience offers some support for the use of the mind map learning technique in promoting course material integration and learning in physical therapy education, further work is needed to explore its usefulness in chiropractic education. (J Chiropr Humanit 2006;13:2-11) Key Indexing Terms: Chiropractic; Education, Professional; Learning; ProblemBased Learning

Anatomical study of the third occipital nerve and its potential role in occipital headache/neck pain following midline dissections of the craniocervical junction: Laboratory investigation

OBJECTIVE Occipital neuralgia can be a debilitating disease and may occur following operative procedures near the occipital and nuchal regions. One nerve of this region, the third occipital nerve (TON), has received only scant attention, and its potential contribution to occipital neuralgia has not been appreciated. Therefore, in the present study the authors aimed to detail the anatomy of this nerve and its relationships to midline surgical approaches of the occiput and posterior neck. METHODS Fifteen adult cadavers (30 sides) underwent dissection of the upper cervical and occipital regions. Special attention was given to identifying the course of the TON and its relationship to the soft tissues and other nerves of this region. Once identified superficially, the TON was followed deeply through the nuchal musculature to its origin in the dorsal ramus of C-3. Measurements were made of the length and diameter of the TON. Additionally, the distance from the external occipital protuberance was measured in each specimen. Following dissection of the TON, self-retaining retractors were placed in the midline and opened in standard fashion while observing for excess tension on the TON. RESULTS Articular branches were noted arising from the deep surface of the nerve in 63.3% of sides. The authors found that the TON was, on average, 3 mm lateral to the external occipital protuberance, and small branches were found to cross the midline and communicate with the contralateral TON inferior to the external occipital protuberance in 66.7% of sides. The TON trunk became subcutaneous at a mean of 5 cm inferior to the external occipital protuberance. In all specimens, the cutaneous main trunk of the TON was intimately related to the nuchal ligament. Insertion of self-retaining retractors in the midline placed significant tension on the TON in all specimens, both superficially and more deeply at its adjacent facet joint. CONCLUSIONS Although damage to the TON may often be unavoidable in midline approaches to the craniocervical region, appreciation of its presence and knowledge of its position and relationships may be useful to the neurosurgeon who operates in this region and may assist in decreasing postoperative morbidity.

Cruveilhier plexus: an anatomical study and a potential cause of failed treatments for occipital neuralgia and muscular and facet denervation procedures.

OBJECT The nerves of the posterior neck are often encountered by the neurosurgeon and are sometimes the focus of denervation procedures for muscular, joint, or nervous pathologies. One collection of fibers in this region that has not been previously investigated is the Cruveilhier plexus, interneural connections between the dorsal rami of the upper cervical nerves. METHODS Fifteen adult cadavers (30 sides) were subjected to dissection of the upper cervical and occipital regions with special attention given to identifying potential connections between adjacent extradural dorsal rami of the cervical nerves. When connections were identified, measurements were made and random samples were immunohistochemically stained. RESULTS At least one communicating branch was identified on 86.7% of sides. Sampled nervous loops were composed primarily of sensory fibers, but occasional motor fibers were identified. For C-1, a communicating loop joined the medial branches of C-2 on 65.4% of sides. On 29.4% of sides, this loop pierced the obliquus capitis inferior muscle before joining C-2. On 54% of sides, a communicating loop joined the medial branches of the dorsal rami of C-2 and C-3; and on 15.4% of sides, a communicating loop joined the medial branches of the dorsal rami of C-3 and C-4. No specimen had communicating branches between the dorsal rami of cervical nerves C-5 to C-8. Articular branches arose from the deep surface of the interneural connections as they crossed the adjacent facet joint on 34.6% of sides. Loops giving rise to fibers that terminated into surrounding musculature were seen on 35% of sides. CONCLUSIONS Physical examinations that reveal unexpected results, such as altered sensory dermatome findings, may be attributed to the Cruveilhier plexus. Based on findings in the present study, surgical procedures, such as those aimed at completely denervating the upper posterior cervical musculature, facets, or nerves supplying the skin of the occiput, must also transect the Cruveilhier plexus.

Cryosurgery for the treatment of heel pain.

Background: Although cryosurgery has been used to treat certain conditions, its efficacy for the treatment of heel pain has not been established. The objective of this retrospective case series was to investigate both short- and long-term changes in heel pain after cryosurgery. Materials and Methods: A sample of 137 feet (n = 137) was analyzed over a 24-month period after cryosurgery. The mean age was 56 years and the mean BMI was 33. Subjects in our analysis included only those who had failed 6 months of conservative care prior to cryosurgery. Pain was measured using a Numeric Pain Scale (NPS, zero to 10) at 3 weeks and 24 months. Statistics were calculated using SPSS version 12.0 (Chicago, IL). Results: A total of 106 subjects had successful pain relief and 31 subjects failed to gain relief; the success and failure rates were 77.4% and 22.6%, respectively. Mean pain before cryosurgery was 7.6, after cryosurgery at three weeks was 1.6 (p < 0.0005), and after cryosurgery at 24 months was 1.1 (p < 0.0005). Conclusion: In subjects who achieved successful pain relief, the significantly lower mean pain score at 3 weeks and 24 months, compared to the initial pain score prior to cryosurgery, suggests that cryosurgery was successful in resolving both short- and long-term heel pain.

The transverse occipital ligament: an anatomic, histologic, and radiographic study

BACKGROUND CONTEXT The craniocervical region is an osteoligamentous complex that provides structural stability and movement by means of numerous ligaments. Fundamental knowledge of these ligaments is important for physicians who treat patients with disorders of this region to reduce morbidity and mortality. There is a paucity of data in the literature regarding the morphology, function, and classification of the transverse occipital ligament (TOL). PURPOSE The purpose of this study was to investigate the prevalence, morphology, and variations of the TOL in a large number of adult human cadavers using dissection, histology, and digital radiography. STUDY DESIGN Cadaveric laboratory study. SAMPLE Thirty-two formalin-fixed human adult cadavers were dissected in the study. Fourteen cadavers were found to have a TOL. OUTCOME MEASURES Measurements using a digital caliper, high-resolution digital photography, histologic staining with bright-field microscopy, and digital radiography. METHODS The posterior musculature and related soft tissues were dissected and underlying bony elements removed. The TOL was identified, isolated, measured, and then removed for histologic preparation with hematoxylin and eosin staining. Anteroposterior open-mouth digital radiographs of the upper cervical spine with monofilament attached to the TOL were used to demonstrate its relations to the occiput, atlas, and axis. RESULTS The TOL was present in 14 of 32 (44%) of the dissected cadavers (six male and eight female). Three types of TOLs were identified. Type 1 had bilateral connections to the alar ligaments and had fibers inserting onto the dens. Type 2 also had bilateral connections to the alar ligaments but did not have fibers inserting onto the dens. Type 3 neither had any connections to the alar ligaments nor had fibers that connected to the dens. Male cadavers always had a Type 1 TOL compared with 3 of 8 (38%) female cadavers and this difference was significant (p=.031). The TOL consisted of dense regular connective tissue with parallel arrangements of collagen fibers and interposed fibroblasts. CONCLUSIONS Our data suggest that the TOL is not an anatomic variant and can be classified into three types. Future biomechanical studies can be designed to investigate the function of the TOL, although we hypothesize that it may act as a fulcrum during flexion and extension of the head because it is located between the apical ligament and superior crus of the cruciform ligament. Anteroposterior open-mouth digital radiographs revealed the location of the TOL with respect to the upper two cervical vertebrae. Future research should investigate the radiologic characteristics of the TOL using magnetic resonance imaging.

Anatomic study of the suboccipital artery of Salmon with surgical significance

The anatomy of the muscular branches of the vertebral arteries has clinical relevance during surgical procedures, suboccipital injections, and manual therapies. Each vertebral artery is divided into four segments. Segment V3, found in the suboccipital triangle, courses posteromedially around the lateral mass to lie in a groove on the posterior arch of the atlas, ultimately coursing beneath the posterior atlanto‐occipital membrane to enter the skull. Although not always present, any muscular branch that emanates from this segment to supply the suboccipital muscles is called the suboccipital artery of Salmon. There is a paucity of literature on this artery despite its clinical relevancy. We found the suboccipital artery of Salmon in 10 (67%) of 15 embalmed adult cadavers. This frequency is considerably higher than that in previous reports. Two (20%) of the 10 cadavers demonstrated bilateral and symmetrical suboccipital arteries of Salmon (one artery on each side). Four (40%) of the 10 cadavers had an arrangement of two parallel suboccipital arteries of Salmon on one side, and one on the contralateral side. Three (30%) of the 10 cadavers displayed an asymmetrical unilateral arrangement (only one artery). One (10%) of the 10 cadavers displayed the unique arrangement of three arteries of Salmon on one side and one artery on the contralateral side. This study adds to a limited, but growing, body of knowledge by providing photographic evidence of the course and arrangement of these arteries and, therefore, can be of value to surgeons and other clinicians whose procedures focus on the suboccipital region. Clin. Anat. 23:798–802, 2010.

Symmetric corticospinal excitability and representation of vastus lateralis muscle in right-handed healthy subjects

The purpose of this study was to determine the size and location of the representations of the anterior thigh muscles on the human motor cortex in the dominant and non‐dominant hemispheres. Motor‐evoked potentials (MEPs) induced by transcranial magnetic stimulation were recorded from the right and left vastus lateralis (rVL, lVL) muscles. A total of ten right‐handed healthy volunteers participated in the study. In a single session experiment, we investigated VL muscle corticospinal excitability (motor threshold, MEP size, short interval intracortical inhibition, intracortical facilitation) and cortical representation (map area, volume, and location) in the dominant and non‐dominant hemispheres. The motor threshold, MEPs, and intracortical excitability did not differ significantly between the hemispheres (P > 0.05). Furthermore, no difference between sides was found in the location of VL motor representation (mediolateral and anteroposterior axis) or in map area and volume (P > 0.05). Vastus lateralis muscle corticospinal excitability and cortical map were symmetrical in right‐handed subjects. Future studies on patients with unilateral lower extremity injuries could examine side‐to‐side plastic reorganization in corticomotor output and map location in both hemispheres. Clin. Anat. 27:1053–1057, 2014.

Sciatic Nerve Intercommunications: New Finding

OBJECTIVE Communicating branches between the tibial and common fibular divisions of the sciatic nerve have not been previously described. The aim of our study was to examine such neural connections. MATERIALS AND METHODS Twenty unembalmed adult cadavers underwent dissection of the sciatic nerve. Observations were made for interneural communications between the tibial and common fibular divisions of this nerve. When present, these were measured and classified. RESULTS The majority of sides (75%) had neural communications between the parts of the sciatic nerve in the gluteal/posterior thigh regions before the normal bifurcation of the nerve just above the knee. These connections were always within 20 cm of the greater sciatic notch. Most connections were represented by Testut intercommunicating branches types A (14 sides), F (8 sides), and D (2 sides). Most sides were found to have 1 location for sciatic nerve intercommunications. However, 4 sides (13%) had multiple locations (up to 3) for these intercommunications. The mean length of the communications was 4.1 cm, and the mean diameter was 2.4 mm. No statistically significant difference was found between sides or sexes. CONCLUSIONS To our knowledge, neural interconnections between the divisions of the sciatic nerve in the posterior thigh have not been described in the extant literature. Such data might help explain unusual neurologic examinations and alert the surgeon as to the potential for encountering such connections at operation.

Five Common Clinical Presentations in the Elderly: An Anatomical Review

Elderly patients face distinct health challenges and have an increased demand for specific medical procedures. As the aging population continues to increase, age‐associated conditions such as congestive heart failure, hip fractures, spine degeneration, dementia, and airway compromise will increase in prevalence and procedures to correct these conditions will be increasingly performed. A clear understanding of the clinical anatomy of these diseases and procedures is imperative for anatomists and clinicians alike in order to best treat patients and continue to advance aging research and better teach future medical practitioners about the specific anatomy often involved in this group. The aging process mirrors in a variety of ways the common pathologies of the elderly, but it is key to draw the distinction between normal aging and pathology, particularly for congestive heart failure and dementia, in the clinical setting. This article aims to review the common presentations or procedures of the elderly and how the normal aging process is associated with the anatomy of these conditions or complications. Clin. Anat. 30:168–174, 2017.