Nicolas Leboucq

Anatomic study using three-dimensional computed tomographic scan measurement for truncal maxillary nerve blocks via the suprazygomatic route in infants.

A maxillary nerve block using external anatomic landmarks is a safe regional anesthesia for adults. However, the classic approach to the nerve may be difficult in infants. To use this block in infants, we describe the anatomical landmarks needed to reach the foramen rotundum area using the suprazygomatic route. Computed tomographic scans of 55 infants (mean age, 8.5 months; range, 1 week to 16 months) without any malformation were retrospectively evaluated using multimodal and multiplanar software. For each side, the distances and angles from the skin to the greater wing of the sphenoid and to the foramen rotundum area (representing the maxillary nerve) were measured in the axial and oblique planes. The distances from the skin at the frontozygomatic angle to the greater wing of the sphenoid in the axial plane and the foramen rotundum area in the oblique plane are 24.1 mm ± 2.7 and 47.4 mm ± 4.1, respectively. From the skin landmark, the direction of the trajectory was oriented 19.3 ± 5.3 and 8.7 ± 2.9 degrees forward. These distances and angles must be slightly adapted for infants younger than 6 months, although none of these parameters were correlated with age during the period studied. This anatomic study based on computed tomographic scan information may be useful for clinical application of the truncal maxillary nerve block in infants using the suprazygomatic route.

Classification and pathogenic models of unintentional postural cranial deformities in infants: plagiocephalies and brachycephalies.

Unintentional postural deformities of the skull have increased in a pseudoepidemic manner in the last 15 years. Although dorsal decubitus and prenatal risk factors can play a role in the genesis of such deformities, we think that a crucial determinant is a postnatal defect of cervical mobility responsible for the infants posture (ie, positional preference) when supine. Indeed, muscular factors, which limit the range of head and neck movements, have been underestimated in the genesis of skull deformities. Here, we have retrospectively analyzed data from 181 infants with unintentional skull deformities and propose a classification of these deformities into 3 types based on their pathogenic model and clinical appearance: fronto-occipital plagiocephalies due to severe muscle hypertonia in which the myogenic component is the first implicated, occipital plagiocephalies with muscle imbalance due to neurogenic muscle hypertonia, and posterior brachycephalies with neurogenic muscle hypertonia of the suboccipital muscles due to trauma to the occipitovertebral junction. Future studies on the size and density of specific muscles or group of muscles should help us to better understand their involvement in the pathogenesis of postural deformities. Our findings also highlight the importance of carefully assessing cervical mobility during the first week of life to detect possible limitations and to prescribe (if needed) an adapted rehabilitation. Rehabilitation should be associated with postural measures put in place when infants sleep supine to prevent the appearance of skull deformations.