Norman Eizenberg

The anatomy of the subscapular-thoracodorsal arterial system: study of 100 cadaver dissections

The results of 100 cadaver dissections of the subscapular-thoracodorsal arterial system are presented. These results confirm the anatomical reliability of the thoracodorsal artery and report the consistent presence of a branch of the thoracodorsal artery to the serratus anterior muscle. The branches to serratus anterior were of sufficient dimensions to support either a latissimus dorsi flap or a serratus anterior flap. A direct cutaneous branch from the thoracodorsal artery to the skin of the axilla was identified in only 47% of the dissections.

The anatomy of the distal vagina: towards unity.

INTRODUCTION Factual presentations of sexual anatomy are required for educational purposes, for clinical and more general communication about sexual matters. To date, unambiguous, accurate and objective images with appropriate labeling to enhance specificity in communication have been lacking. AIM The aim of this presentation is to provide a comprehensive overview of anatomy of the distal vagina. We aim to simplify the anatomy to reduce the confusion of historical descriptions. In doing so, we aim to avoid sacrificing any of the specific detail. This would aid communication between clinicians, researchers, and the nonclinician regarding this anatomy. OUTCOME MEASURES AND METHODS: This article reviews the historical and current anatomical literature. Systematic dissection and photography, histological study, and magnetic resonance imaging have been used as the basis for this presentation. Digital technology has been used to label, color, and highlight photography to provide clarity and permit diagramatization of photography. No distortion has otherwise been used in presenting images from cadavers or anatomical research. RESULTS The anatomy of the distal vagina and surrounding structures is shown and described in detailed. The distal vagina, clitoris, and urethra form an integrated entity covered superficially by the vulval skin and its epithelial features. These parts have a shared vasculature and nerve supply and during sexual stimulation respond as a unit though the responses are not uniform. CONCLUSIONS Significant progress has been made in the field of female sexual anatomy and its pictorial representation. This may facilitate further progress in the related fields of female sexual health and education.

Anatomy of the pudendal nerve and its terminal branches: a cadaver study

Background:  This study documents the anatomy of the pudendal nerve, which has a major role in maintaining faecal continence. Unexpected faecal incontinence can develop following perineal surgery even when the anal sphincters are not damaged. In addition, injury to the pudendal nerve might be encountered during pelvic procedures such as a sacrospinous colpopexy.

The place of anatomy in medical education: AMEE Guide no 41*

This Guide, a combined work by three authors from different countries, provides perspectives into the history of teaching gross anatomy, briefly, from the earliest of times, through to a detailed examination of curricula in both traditional didactic approaches and Problem-Based Learning (PBL) curricula. The delivery of a module within a curriculum in tertiary education is interplay between the content (knowledge and skills) of a subject, the teaching staff involved, the students and their approaches to learning, and the philosophy underpinning the delivery of the learning material. The work is divided into sections that deal with approaches to learning anatomy from the perspective of students, to delivery of the content of the curriculum by lecturers, including the assessment of knowledge, and itemises the topics that could be considered important for an appropriate anatomy module in an integrated course, delivered in a way that emphasises clinical application. The work concludes by looking to the future, and considering what measures may need to be addressed to ensure the continued development of anatomy as a clinically relevant subject in any medical curriculum.

Lengthening of the gastrocnemius-soleus complex: an anatomical and biomechanical study in human cadavers

BACKGROUND Lengthening of the gastrocnemius-soleus complex is frequently performed for equinus deformity. Many techniques have been described, but there is uncertainty regarding the precise details of some surgical procedures. METHODS The surgical anatomy of the gastrocnemius-soleus complex was investigated, and standardized approaches were developed for the procedures described by Baumann, Strayer, Vulpius, Baker, Hoke, and White. The biomechanical characteristics of these six procedures were then compared in three randomized trials involving formaldehyde-preserved human cadaveric lower limbs. After one of the lengthening procedures was performed, a measured dorsiflexion force was applied across the metatarsal heads with use of a torque dynamometer. Lengthening of the gastrocnemius-soleus complex was measured directly, by measuring the gap between the ends of the fascia or tendon. RESULTS The gastrocnemius-soleus musculotendinous unit was subdivided into three zones. In Zone 1, it was possible to lengthen the gastrocnemius-soleus complex in either a selective or a differential manner-i.e., to lengthen the gastrocnemius alone or to lengthen the gastrocnemius and soleus by different amounts. The procedures performed in this zone (Baumann and Strayer procedures) were very stable but were limited with regard to the amount of lengthening achieved. Zone-2 lengthenings of the conjoined gastrocnemius aponeurosis and soleus fascia (Vulpius and Baker procedures) were not selective but were stable and resulted in significantly greater lengthening than Zone-1 procedures (p < 0.001). In Zone 3 (Hoke and White procedures), lengthenings of the Achilles tendon were neither selective nor stable but resulted in significantly greater lengthening than Zone-1 or 2 procedures (p < 0.001). CONCLUSIONS Surgical procedures for the correction of equinus deformity by lengthening of the gastrocnemius-soleus complex vary in terms of selectivity, stability, and range of correction. Procedures for the correction of equinus deformity have different anatomical and biomechanical characteristics. Clinical trials are needed to determine whether these differences are of clinical importance. It may be appropriate for surgeons to select a procedure involving the zone best suited to the clinical needs of a specific patient.

Review article: anatomical considerations for ultrasound guidance for regional anesthesia of the neck and upper limb

PurposeThe purpose of this narrative review is to describe an anatomical approach for residents-in-training and anesthesiologists who are learning techniques of ultrasound-guided regional anesthesia of the neck and upper limbSourcesRelevant articles relating anatomy and anatomical variation to the emerging practice of ultrasound-guided regional anesthesia for the neck and upper limb were sourced via both Medline and PubMed databases. Also, our approach to teaching ultrasound technique has developed from using anatomical resources and cadaveric workshops. This approach emphasizes precise image acquisition, a detailed knowledge of anatomy and anatomical variations, and, importantly, visual interpretation of sonographic landmarks based on pattern recognition when interpreting sonograms.Principal findingsTypical sonographic patterns orient the examiner to nerve position, which is necessary for executing successful regional anesthesia of the neck and upper limb. Only by understanding the typical anatomical arrangement can the examiner then visually interpret any individual anatomical variation that may occur.ConclusionSimple sonographic anatomical patterns can provide a strategy to correctly locate nerves when performing ultrasound-guided cervical and brachial plexus anesthesia.RésuméObjectifL’objectif de ce compte-rendu narratif est de décrire une approche anatomique destinée aux résidents en formation et aux anesthésiologistes qui apprennent les techniques d’anesthésie régionale du cou et des membres supérieurs par échoguidage.SourcesLes articles pertinents traitant de l’anatomie et des variations anatomiques dans la pratique émergente de l’anesthésie régionale du cou et des membres supérieurs par échoguidage ont été tirés des bases de données Medline et PubMed. De plus, notre approche de l’enseignement des techniques échoguidées a évolué grâce au recours à des ressources anatomiques et des ateliers sur des cadavres. Cette approche met l’accent sur l’obtention d’images précises, une connaissance détaillée de l’anatomie et des variations anatomiques et, composante importante, l’interprétation visuelle de points de repères échographiques selon une reconnaissance des configurations lors de l’interprétation des échogrammes.Constatations principalesLes configurations échographiques typiques fournissent des informations à l’examinateur quant à la position des nerfs, ce qui est nécessaire à la réalisation d’une anesthésie régionale du cou et des membres supérieurs réussie. Il faut que l’examinateur comprenne la disposition anatomique typique pour ensuite pouvoir interpréter de façon visuelle les variations anatomiques individuelles potentielles.ConclusionDes configurations anatomiques échographiques simples peuvent constituer une bonne stratégie pour localiser correctement les nerfs lors de la réalisation d’une anesthésie cervicale et du plexus brachial par échoguidage.

Ulnar Artery as a Coronary Bypass Graft

BACKGROUND The ulnar artery has been used as a coronary bypass graft in 8 patients when it was deemed unsafe to harvest the radial artery after evaluation of the arterial circulation in the forearm and hand. METHODS The ulnar artery was removed from the lower three quarters of the forearm, along with its satellite veins. Dissection was commenced distally near the wrist and extended proximally to where the ulnar artery passed between the two heads of origin of the flexor digitorum superficialis. The artery was divided distally above the wrist joint and proximally at a point immediately below the origin of the common interosseus artery. RESULTS Ten ulnar arteries were removed for use as coronary artery bypass grafts; two were rejected, one because of severe calcification and the other because of atherosclerotic occlusion. The remaining eight ulnar arteries were grafted successfully to coronary arteries other than the left anterior descending. No early hand or cardiac complications were observed. CONCLUSIONS The ulnar artery is an alternative coronary artery bypass graft that may be used when the radial artery is dominant and cannot be removed without risk. The ulnar artery is in close proximity to the ulnar nerve and harvesting has the potential to injure the nerve. Therefore, until the use of the ulnar artery has been more fully evaluated it should be used only when other options have been exhausted.

Should there be a national core curriculum for anatomy

Are medical students taught enough anatomy? It is now abundantly clear that there are serious concerns about the level of anatomy taught to medical students. Concerns have been expressed by the students themselves, by those responsible for training procedural specialities and by the community at large. Currently, a sufficient knowledge of Anatomy is assumed by certain medical educationalists. However, Craig et al., in a unique and timely survey detailing issues in teaching anatomy to medical students in Australia and New Zealand, demonstrate convincingly that this is not always the case. Their survey is unique because it sheds light on what is actually taking place at the teaching coal face, and it is timely, given that the theme of the recent annual scientific meeting of the Australian and New Zealand Association of Clinical Anatomists (ANZACA) held at Monash University was anatomy education. The ANZACA meeting included a forum exploring the need for agreed, national core curricula in anatomy for students in professional courses. It is no accident that anatomy education galvanized the establishment of ANZACA in 2004 and that clinical anatomy is the future of anatomy. This is also of direct interest to surgeons with implications for the college and postgraduate surgical training. The findings of a mailed questionnaire sent to all 21 Australian and New Zealand medical schools by staff at the University of Wollongong, Graduate School of Medicine are not altogether surprising, although informative and remindful for they resonate with the concerns previously expressed by contributors to this journal. These were in response to the invited comments made by one of us almost a decade ago lamenting the decline of dissection-based teaching of anatomy in medical curricula. This followed the introduction of graduate medical programmes with shorter courses and a broader mix of students (including some from non-science backgrounds) as well as the adoption of problem-based learning (PBL) to ensure integration and to more adequately deal with the rapid expansion of medical knowledge. The radically changed educational approaches commencing from the mid-1990s resulted in a very significant reduction in total contact teaching time for all preclinical disciplines, especially anatomy, with the consequent loss of cadaver dissection and viva vocé examinations, once the major drivers for learning, teaching and assessing this subject. The ensuing debate as to how, when and what anatomy to teach medical students has generated considerable interest with lively correspondence, often anecdotal, and with little factual information. This is now largely redressed by the findings of the survey by Craig et al. Indeed, despite the use of prosected specimens, models, body painting, innovative computer simulation and radiology imaging, including computerized tomography and ultrasonography, it has to be said that the loss of the opportunity for cadaver dissection was a serious deficit and a concern to many, including the students themselves. The sentiment from both the Craig et al. paper and the ANZACA forum is that anatomy must be reinstated primarily (though not exclusively) as a ‘stand-alone’ subject within the framework of PBL curricula. This could include dissection and not just as an ‘option’. Furthermore, with the dissolution of the Anatomical Society of Australia and New Zealand in 1996 (until resurrected as ANZACA in 2004), the onus seemed to be on the college to set the agenda, to safeguard content and standards and even to fill the gap by providing teachers capable of teaching the subject. What is the state of play now, and what needs to be performed in the short to medium term? These are important considerations in the debate given that many medical students (who are now recent graduates) felt very insecure about their anatomical knowledge, especially those considering future surgical careers; the critical loss of medically qualified teachers from anatomy departments who are capable of teaching clinically relevant anatomy and the alarm this continues to generate in the press. The most important finding of the survey by Craig et al. was the considerable variation in all aspects of the teaching of anatomy throughout Australasian medical schools. Currently, the average time allocated to anatomy according to the survey is 171 h (standard deviation (SD) ~117), mainly delivered in the early years of the course, typically using a combined regional/systemic approach. It seems to us that given a mean contact time of about 170 h throughout the course, if 130 h of that was ‘stand-alone’ anatomy (see Table 1), this would enable time within practical classes to include targeted dissection (and even incorporate the anatomical basis of clinical procedures that can be required of a first port of call doctor). The 40 h not designated as ‘stand alone’ anatomy ideally should be integrated (including within PBL tutorials) and also permeate later years of the course.

Gastrocsoleus recession techniques: an anatomical and biomechanical study in human cadavers

Lengthening of the conjoined tendon of the gastrocnemius aponeurosis and soleus fascia is frequently used in the treatment of equinus deformities in children and adults. The Vulpius procedure as described in most orthopaedic texts is a division of the conjoined tendon in the shape of an inverted V. However, transverse division was also described by Vulpius and Stoffel, and has been reported in some clinical studies. We studied the anatomy and biomechanics of transverse division of the conjoined tendon in 12 human cadavers (24 legs). Transverse division of the conjoined tendon resulted in predictable, controlled lengthening of the gastrocsoleus muscle-tendon unit. The lengthening achieved was dependent both on the level of the cut in the conjoined tendon and division of the midline raphé. Division at a proximal level resulted in a mean lengthening of 15.2 mm (sd 2.0, (12 to 19), which increased to 17.1 mm (sd 1.8, (14 to 20) after division of the midline raphé. Division at a distal level resulted in a mean lengthening of 21.0 mm (sd 2.0, (18 to 25), which increased to 26.4 mm (sd 1.4, (24 to 29) after division of the raphé. These differences were significant (p < 0.001).

A broad perspective on anatomy education: celebrating teaching diversity and innovations.

natomy education is an everevolving field. Innovative Aanatomy teaching practices are actualised by dedicated, professionally qualified academic staff who often devote their entire careers to the education of future clinicians. While traditional approaches to anatomy education focused on surgical training and knowledge-based competency, modern anatomy literacy must be applied to a wide variety of clinical disciplines. Thus current teaching approaches need to reflect this. To this end, modern topographic anatomy is combined with other anatomical sciences (ie, embryology, histology and neuroscience), and taught within integrated medical curricula in the context of clinical medicine, clinical skills, pathology and radiology. As with other pre-clinical and paraclinical fields (including biochemistry, physiology and immunology), there are clear benefits in engaging teaching staff with a variety of qualifications and expertise to maximise the effectiveness of the vertical and horizontal knowledge integration that is essential inmodern medical curricula.