Flávia Akamatsu

Trigger Points: An Anatomical Substratum

This study aimed to bring the trapezius muscle knowledge of the locations where the accessory nerve branches enter the muscle belly to reach the motor endplates and find myofascial trigger points (MTrPs). Although anatomoclinical correlations represent a major feature of MTrP, no previous reports describing the distribution of the accessory nerve branches and their anatomical relationship with MTrP are found in the literature. Both trapezius muscles from twelve adult cadavers were carefully dissected by the authors (anatomy professors and medical graduate students) to observe the exact point where the branches of the spinal accessory nerve entered the muscle belly. Dissection was performed through stratigraphic layers to preserve the motor innervation of the trapezius muscle, which is located deep in the muscle. Seven points are described, four of which are motor points: in all cases, these locations corresponded to clinically described MTrPs. The four points were common in these twelve cadavers. This type of clinical correlation between spinal accessory nerve branching and MTrP is useful to achieve a better understanding of the anatomical correlation of MTrP and the physiopathology of these disorders and may provide a scientific basis for their treatment, rendering useful additional information to therapists to achieve better diagnoses and improve therapeutic approaches.

Unusual Relationship between the Piriform Muscle and Sciatic, Inferior Gluteal and Posterior Femoral Cutaneous Nerves

El sindrome del musculo piriforme se ha reconocido cada vez mas como una causa de dolor en los miembros inferiores. Tension excesiva o variaciones anatomicas del nervio y del musculo piriforme se cree son las causas subyacentes de pinzamiento del nervio isquiatico. Se presenta una variacion no descrita anteriormente. Durante una diseccion de rutina en un cadaver de sexo masculino, se observo una division mas alta del nervio isquiatico y la presencia de un musculo piriforme accesorio. El nervio isquiatico se dividia bajo el musculo piriforme y el nervio fibular comun pasaba sobre el musculo piriforme accesorio. Por otra parte, el nervio tibial cruzaba entre los musculos piriforme accesorio y gemelo superior. Ademas, ambos nervios se comunicaban con un ramo lateral bajo el margen inferior del musculo piriforme accesorio y el nervio gluteo inferior se originaba desde el nervio fibular. Variaciones anatomicas y relaciones entre el musculo piriforme y nervio isquiatico pueden estar presentes hasta en el 17% de la poblacion. Seis variaciones diferentes se han descrito en este articulo y ninguna es similar a nuestra descripcion. A pesar del completo entendimiento de la fisiopatologia del sindrome del musculo piriforme, aun queda por esclarecer y conocer las posibles variaciones anatomicas que pueden ser utiles tanto para su diagnostico como para el tratamiento adecuado.

A Rare Pattern of Brachial Artery Variation: Case Report

A diferencia del sistema venoso, las variaciones en la anatomia arterial son menos frecuentes y la mayoria afecta a las arterias viscerales. En los miembros, las variaciones de la arteria braquial son las mas informadas y por lo menos seis diferentes patrones han sido descritos. La variacion mas comun es de la arteria braquial superficial que esta superficialmente al nervio mediano. Mucho menos frecuente es el origen alto de la arteria braquial radial (la arteria braquiorradial) o la existencia de una arteria braquial doble (arteria braquial accesoria). Presentamos un patron de variacion no descrito de la arteria braquial observado durante la diseccion del miembro superior derecho de un cadaver en un hombre de 60 anos de edad. Encontramos la bifurcacion de la arteria braquial en la porcion medial del brazo, pasando posterior al nervio mediano. Luego, esta rama medial se redirecciona lateralmente y cruza nuevamente al nervio mediano, esta vez, anterior a el, hasta alcanzar la region lateral del brazo. A nivel de la flexura del codo, la rama medial origina la arteria radial. La rama lateral de la arteria braquial se mantiene lateral al nervio mediano y continua como arteria ulnar y origina la arteria interosea comun.

Lymph drainage of the upper limb and mammary region to the axilla: anatomical study in stillborns

PurposeWe studied the lymphatic drainage of the upper limb and mammary region directing to the axilla to investigate whether independent pathways can be observed or whether anastomoses and shared drainage occur between them. This analysis aimed to assess the safety of axillary reverse mapping (ARM) in breast cancer treatment and to understand the development of lymphedema after sentinel lymph node biopsy (SLNB) alone.MethodsSeven unfixed stillborn fetuses were injected with a modified Gerota mass in the peri-areolar area, palm and dorsum of the hands, formalin fixed, and then submerged in 10% hydrogen peroxide solution. Microsurgical dissection was then performed on the subcutaneous cellular tissue of the upper limb, axillary region, and anterior thorax to expose the lymphatic vessels and lymph nodes.ResultsThe dye injected into the upper limb reached either the lateral axillary group, known to be exclusively responsible for upper limb drainage, or the anterior group, which is typically related to breast drainage. There was great proximity among the pathways and lymph nodes. Communicating lymphatic vessels among these groups of lymph nodes were also found in all studied cases.DiscussionLymphedema remains a challenging morbidity in breast cancer treatment. ARM and SLNB aim to avoid unnecessary damage to the lymphatic drainage of the upper limb. However, our anatomical study suggests that ARM may have potential oncological risks because preserved lymph nodes may harbor malignant cells due their proximity, overlapping drainage pathways, and connecting lymph vessels among lymph nodes.

Anatomy of the Lymphatic Drainage of the Upper Limb and Breast and its Role in Lymphedema Prevention after Breast Cancer Treatment

El tratamiento quirurgico del cancer de mama ha mejorado a lo largo de los anos con el fin de ofrecer resultados oncologicamente mas seguros y eficaces con menor impacto estetico y menos secuelas. El linfedema del miembro superior es todavia un resultado iatrogenico de gran incidencia y morbilidad despues de este tratamiento. La posible existencia de vias linfaticas de mama y de los miembros superiores independientes se ha convertido en un tema central de muchas investigaciones para lograr minimizar su ocurrencia. Esta revision tiene como objetivo comparar las vias linfaticas en la axila descritas en los libros de anatomia tradicionales con articulos recientemente publicados sobre Mapeo Reverso Axilar (MRA). Con este fin, se realizo un cuadro comparativo con las descripciones y un diagrama de flujo de las anastomosis entre los nodos, ademas de un dibujo analitico de las areas drenadas estadisticamente mas mencionadas. Se observo que existe una gran variabilidad en las descripciones sobre el drenaje y las anastomosis entre los nodos linfaticos, por lo que la descripcion universal no deberia ser considerada un consenso debido a que tambien presenta posibles variaciones anatomicas. Por otra parte, los resultados producidos por los estudios recientes muestran posibles anastomosis entre las vias y los nodos linfaticos, sin embargo, no se han tomado en consideracion cuando se propuso inicialmente el MRA. Por lo tanto, la reseccion axilar con la preservacion de la parte posterior y los nodos linfaticos axilares laterales es teoricamente posible para evitar el linfedema del miembro superior, pero el desarrollo de una descripcion universal actualizada, que incluya todas las posibles variaciones anatomicas, proporcionara un tratamiento mas seguro y eficaz.

Experimental model of Achilles tendon injury in rats

PURPOSE To describe an effective experimental model to study the Achilles tendon healing. METHODS Forty male Rattus norvegicus albinus, Wistar lineage adult male weighing 250 to 300g were used for this experiment and thirty were surgically submitted to bilateral partial transverse section of the Achilles tendon. The right tendon was treated with radio waves (RF) whereas the left tendon served as control. On the third postoperative day, the rats were divided into four experimental groups consisting of ten rats each which were treated with monopolar RF adjusted to 650 kHz and 2w, for two minutes twice a week and a group of normal animals without any intervention, until they were sacrificed on the 7th, 14th and 28th days, respectively. Tendons were weighed and collagen quantification was evaluated by hydroxyprolin content. RESULTS Significant reduction in collagen content on day 7, 14 and 28 was related to control experiment to normal tendon (7 days, p<0.01; 14 e 28 days, p<0.05). CONCLUSION The experimental model has been effective and available to be used to study Achilles tendon healing.

Anatomical Basis of the Myofascial Trigger Points of the Trapezius Muscle

El objetivo de este estudio fue correlacionar los sitios de entrada de los ramos del nervio accesorio en el musculo trapecio con placas motoras y los puntos de gatillo miofasciales. A pesar de las correlaciones anatomoclinicas se constituyeren en la principal caracteristica de los puntos de gatillo, no hay informes en la literatura describiendo sobre la distribucion de los ramos del nervio accesorio y su relacion anatomica con los puntos de gatillo. Ambos musculos trapecio de doce cadaveres adultos fueron disecados por los autores (profesores de anatomia y estudiantes de postgrado en Medicina) para observar el punto exacto donde los ramos del nervio accesorio espinal penetraban en el vientre muscular. La diseccion se llevo a cabo respetando las capas estratigraficas para preservar la inervacion del musculo ubicada profundamente a este. Ocho puntos fueron identificados: En todos los casos correspondieron a la descripcion clinica de los puntos gatillo miofasciales y eran comunes a todos los cadaveres. Esta correlacion anatomoclinica entre la ramificacion del nervio espinal accesorio y los puntos de gatillo miofascial es util para una mejor comprension de la fisiopatologia de los puntos gatillo y puede proporcionar una base para un abordaje diagnostico y terapeutico racional para estos trastornos.

Aneurysm of the Fibular Vein: A Case Report

BACKGROUND Aneurysms of the deep veins of the lower limbs are rare and often asymptomatic. Although natural history is unclear, these aneurysms have been associated with deep venous thrombosis and fatal pulmonary embolism events. To our knowledge, this case represents the fifth patient with isolated aneurysm of a calf vein described in the literature and the second one affecting the fibular vein. METHODS We report the case of a 20-year-old white man with an aneurysm of the fibular vein that we believe is the second case in the literature RESULTS: After evaluation and diagnosis, the aneurysm was resected with full recovery of the patient. CONCLUSIONS Treatment of this unusual condition seems to be mandatory for major thromboembolic events can be as high as 71% with 2 deaths, according to a review of 24 patients with popliteal vein aneurysms. Unlike proximal veins, where reconstruction is advisable, calf vein aneurysms can be safely managed by simple excision and ligature. In our patient, aneurysm resection eliminated symptoms, and good result was maintained in long follow-up.

Anatomical Basis of the Myofascial Trigger Points of the Gluteus Maximus Muscle

Myofascial pain syndrome is characterized by pain and limited range of motion in joints and caused by muscular contracture related to dysfunctional motor end plates and myofascial trigger points (MTrPs). We aimed to observe the anatomical correlation between the clinically described MTrPs and the entry point of the branches of the inferior gluteal nerve into the gluteus maximus muscle. We dissected twenty gluteus maximus muscles from 10 human adult cadavers (5 males and 5 females). We measured the muscles and compiled the distribution of the nerve branches into each of the quadrants of the muscle. Statistical analysis was performed by using Students t-test and Kruskal-Wallis tests. Although no difference was observed either for muscle measurements or for distribution of nerve branching among the subjects, the topography of MTrPs matched the anatomical location of the entry points into the muscle. Thus, anatomical substract of the MTrPs may be useful for a better understanding of the physiopathology of these disorders and provide basis for their surgical and clinical treatment.

Prognostic impact of the lymph node metastatic ratio on 5-year survival of patients with rectal cancer not submitted to preoperative chemoradiation

Metastases linfonodais representam um dos principais fatores prognosticos no câncer colorretal. A resseccao linfonodal inadequada relaciona-se a menor sobrevida. A proporcao entre linfonodos metastaticos (PLM) vem sendo utilizada como fator prognostico em doentes com câncer de colon. Poucos estudos avaliaram o impacto da PLM na sobrevida de doentes com câncer retal. OBJETIVO: Avaliar o impacto da PLM na sobrevida de doentes com câncer de reto nao submetidos a quimioradioterapia pre-operatoria. METODOS: Foram incluidos 90 doentes com adenocarcinoma retal excluindo-se tumores de colon, tumores sincronicos, câncer colorretal hereditario e aqueles submetidos a tratamento radioquimioterapico pre-operatorio. Os doentes foram divididos em tres grupos segundo a PLM: PLM-0, sem linfonodos comprometidos; PLM-1, 1 a 20% dos linfonodos comprometidos; e PLM-2, mais de 21% dos linfonodos comprometidos. A identificacao do ponto de corte da amostra selecionada foi obtida a partir da curva de caracteristicas de operacao do receptor (curva ROC). A sobrevida foi avaliada pelo teste de Kaplan-Meier, a diferenca entre os grupos pelo teste de Cox-Mantel e a correlacao entre as variaveis pelo teste de Pearson, adotando-se um nivel de significância de 5% (p<0,05). RESULTADOS: A sobrevida em cinco anos relacionou-se a classificacao de Dukes, TNM, numero de linfonodos metastaticos e PLM. Houve diferenca na sobrevida ao compararem-se as diferentes classes de PLM. Doentes classificados como PLM-0 apresentaram sobrevida de 85%, enquanto os pertencentes as classes PLM-1 e PLM-2, de 73 e 19%, respectivamente (p=0,0001). CONCLUSAO: Os resultados encontrados mostraram que a PLM tem impacto na sobrevida de doentes com câncer de reto nao submetidos a neoadjuvância.</