Cureus. 2018 Jan 29;10(1):e2122. doi: 10.7759/cureus.2122.

Yilmaz E, Iwanaga J, Moisi M, Blecher R, Abdul-Jabbar A, Tawfik T, Oskouian RJ, Tubbs RS.

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Abstract

Introduction
 The extreme lateral interbody fusion technique (XLIF) is a modification of the retroperitoneal approach to the lumbar spine. This is a minimally invasive technique allowing direct access to the disc space without peritoneal or posterior paraspinal musculature damage. Nevertheless, the retroperitoneal part of the colon can be injured in this operative technique. To our knowledge, a study analyzing the anatomical considerations of the extreme lateral interbody fusion technique with regards to potential colon injuries has not been previously performed. Therefore, the aim of this study was to evaluate the potential risk of colon injuries during the extreme lateral approach to the lumbar spine. Materials and Methods
 The extreme lateral approach to the lumbar spine was performed on four fresh-frozen cadaveric sides. K-wires were placed into the intervertebral discs and positioned at L1/L2, L2/L3, L3/L4, and L4/L5 levels. Next, the distances from the wires to the most posterior aspect of the adjacent ascending or descending colon were measured.
 Results
 The mean distance from the intervertebral disc space to the ascending or descending colon was 23.2 mm at the L2/L3 level, 29.5 mm at the L3/L4 level, and 40.3 mm at the L4/L5 level. The L1/L2 level was above the colon on both sides.
 Conclusion
 Our study quantified the relationship of the retroperitoneal colon during an extreme lateral interbody fusion approach. Our results, as well as previously described cases of bowel perforations, suggest a greater risk for colon injuries at the L2/3 and L3/4 levels.​​​​​​​.

KEYWORDS:

colon injuries; extreme lateral inter body fusion; spine surgery; xlif

Figure 1

Labeled anteroposterior radiograph of the lumbar spine showing the placement of the wires which were used for the measurements.

Figure 2

Labeled lateral radiograph of the lumbar spine showing the placement of the wires which were used for the measurements.

Figure 3

Lateral view showing the wire placement into the intervertebral disc spaces.

Figure 4

Posterior view of the retroperitoneal dissection.

Cureus. 2018 Jan 28;10(1):e2120. doi: 10.7759/cureus.2120.

Iwanaga J, Tubbs RS.

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Abstract

The superior alveolar nerves course lateral to the maxillary sinus and the greater palatine nerve travels through the hard palate. This difficult three-dimensional anatomy has led some dentists and oral surgeons to a critical misunderstanding in developing the anterior and middle superior alveolar (AMSA) nerve block and the palatal approach anterior superior alveolar (P-ASA) nerve block. In this review, the anatomy of the posterior, middle and anterior superior alveolar nerves, greater palatine nerve, and nasopalatine nerve are revisited in order to clarify the anatomy of these blocks so that the perpetuated anatomical misunderstanding is rectified. We conclude that the AMSA and P-ASA nerve blockades, as currently described, are not based on accurate anatomy.

KEYWORDS:

anatomy; innervation; local anesthesia; maxillary nerve; nerve block; tooth

Figure 1

The PSA, MSA and ASA as depicted by Friedman and Hochman (1998) as if they innervate the teeth through the hard palate. The ASA is drawn as if it is the terminal branch of the infraorbital nerve.

ASA: Anterior superior alveolar branch of the infraorbital nerve; MSA: Middle superior alveolar branch of the infraorbital nerve; PSA: Posterior superior alveolar branch of the maxillary nerve.

Figure 2

The proposed drawing of the P-ASA by Friedman and Hochman (1999).

P-ASA: Palatal approach anterior superior alveolar.

Figure 3

Neither AMSA nor P-ASA nerve blockade is close to the main nerve trunk of the superior alveolar nerves. (A) Relationship of the superior alveolar nerves and GPN. (B) Relationship of the superior alveolar nerves and NPN.

AMSA: Anterior and middle superior alveolar; ASA: Anterior superior alveolar branch of the infraorbital nerve; GPN: Greater palatine nerve; ION: Infraorbital nerve; MSA: Middle superior alveolar branch of the infraorbital nerve; NPN: Nasopalatine nerve; PSA: Posterior superior alveolar branch of the maxillary nerve.

Cureus. 2018 Jan 12;10(1):e2055. doi: 10.7759/cureus.2055.

Schmidt CK, Khalid S, Loukas M, Tubbs RS.

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Abstract

Anxiety disorders are among the most prevalent psychological issues worldwide, displaying the youngest age of onset and greatest chronicity of any mood or substance abuse disorder. Given the high social and economic cost imposed by these disorders, developing effective treatments is of the utmost importance. Anxiety disorders manifest in a variety of symptomatic phenotypes and are highly comorbid with other psychological diseases such as depression. These facts have made unraveling the complex underlying neural circuity an ever-present challenge for researchers. We offer a brief review on the neuroanatomy of anxiety disorders and discuss several currently available therapeutic options.

KEYWORDS:

anxiety disorders; functional imaging; neuroanatomy

Cureus. 2018 Jan 9;10(1):e2045. doi: 10.7759/cureus.2045.

Choi PJ, Iwanaga J, Tubbs RS, Yilmaz E.

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Abstract

Owing to its rarity, rhabdomyosarcoma of the head and neck (HNRMS) has seldom been discussed in the literature. As most of the data is based only on the retrospective experiences of tertiary healthcare centers, there are difficulties in formulating a standard treatment protocol. Moreover, the disease is poorly understood at its pathological, genetic, and molecular levels. For instance, 20% of all histological assessment is inaccurate; even an experienced pathologist can confuse rhabdomyosarcoma (RMS) with neuroblastoma, Ewing's sarcoma, and lymphoma. RMS can occur sporadically or in association with genetic syndromes associated with predisposition to other cancers such as Li-Fraumeni syndrome and neurofibromatosis type 1 (von Recklinghausen disease). Such associations have a potential role in future gene therapies but are yet to be fully confirmed. Currently, chemotherapies are ineffective in advanced or metastatic disease and there is lack of targeted chemotherapy or biological therapy against RMS. Also, reported uses of chemotherapy for RMS have not produced reasonable responses in all cases. Despite numerous molecular and biological studies during the past three decades, the chemotherapeutic regimen remains unchanged. This vincristine, actinomycin, cyclophosphamide (VAC) regime, described in Kilman, et al. (1973) and Koop, et al. (1963), has achieved limited success in controlling the progression of RMS. Thus, the pathogenesis of RMS remains poorly understood despite extensive modern trials and more than 30 years of studies exploring the chemotherapeutic options. This suggests a need to explore surgical options for managing the disease. Surgery is the single most critical therapy for pediatric HNRMS. However, very few studies have explored the surgical management of pediatric HNRMS and there is no standard surgical protocol. The aim of this review is to explore and address such issues in the hope of maximizing the number of options available for young patients with HNRMS.

KEYWORDS:

adolescence; childhood; endoscopic; head and neck; microsurgery; parameningeal; reconstruction; rhabdomyosarcoma; skull base surgery; soft tissue sarcoma

Figure 1

The chronology of chemotherapeutic and biological regimens for pediatric RMS

RMS; rhabdomyosarcoma, VAC; vincristine/actinomycin/cyclophosphamide, IRSG; Intergroup RMS Study Group, COG; Children’s Oncology Group, NCI; National Cancer Institute

Figure 2

A summary of surgical interventions for pediatric HNRMS

HNRMS; rhabdomyosarcoma of the head and neck, MIER; minimally invasive endoscopic resection

Cureus. 2018 Jan 7;10(1):e2035. doi: 10.7759/cureus.2035.

Simonds E, Wilson C, Iwanaga J, Laws T, Holley G, Oskouian RJ, Tubbs RS.

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Abstract

Medical imaging techniques have led to great advances in clinical anatomy and forensic pathology. New and emerging technologies allow healthcare professionals to view and understand the human body from different perspectives. This gives way to new and improved interventions, treatment plans, and an overall understanding of the human body. Herein, we present a comprehensive review of the various medical imaging equipment used in cadaveric studies along with their individual strengths and limitations.

KEYWORDS:

anatomy; cadaver; computed tomography; endoscopy; magnetic resonance imaging; ultrasound

Figure 1

C-Arm

Figure 2

Micro-CT

Anat Sci Int. 2018 Jan;93(1):108-113. doi: 10.1007/s12565-016-0381-7. Epub 2016 Nov 9.

D'Antoni AV, Collin PG, Graham RA, Kennedy HM, Ndjatou T, Perez P, Tubbs RS, Loukas M, Kozlowski PB Mtui EP.

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Abstract

The lateral costotransverse ligament, a short band that stabilizes the costovertebral joint, is found in close proximity to the dorsal root ganglion. This ligament is an important surgical landmark during tumor resections or nerve blocks in the paravertebral space. The purpose of this study was to quantitatively and qualitatively describe the morphology of the lateral costotransverse ligament and its relation to the dorsal root ganglion at all levels of the thoracic spine. The thoracic spines of eight embalmed cadavers were dissected bilaterally. The length, width, and thickness of the ligament were measured. The distance from the inferolateral aspect of the ligament to the lateral aspect of the dorsal root ganglion was also measured. Three bilateral groups of lateral costotransverse ligaments, top (on ribs 1-2), middle (on ribs 3-10), and bottom (on ribs 11-12), were compared based on anatomic distinctions between the costotransverse joints, which can influence ligament morphology. Among the three groups, the differences between the length, width, and thickness were not statistically significant. However, the distance from the lateral costotransverse ligament to the dorsal root ganglion differed significantly (P = 0.000), with the middle group having the longest distance, and the bottom group having the shortest distance. This finding can help clinicians and surgeons avoid iatrogenic injuries of neural structures during thoracic spine surgery, or when performing nerve blocks in the paravertebral space.

KEYWORDS:

Dorsal root ganglion; Ligaments; Neurosurgery; Ribs; Thoracic vertebrae

Clin Anat. 2018 Jan;31(1):4-5. doi: 10.1002/ca.22994. Epub 2017 Oct 27.

Tomaszewski KA, Henry BM, Pękala PA, Standring S, Tubbs RS.

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Comment on

• Development of the Anatomical Quality Assurance (AQUA) checklist: Guidelines for reporting original anatomical studies. [Clin Anat. 2017]

J Craniomaxillofac Surg. 2018 Jan;46(1):63-66. doi: 10.1016/j.jcms.2017.07.005. Epub 2017 Jul 25.

Paglio AE, Bradley AP, Tubbs RS, Loukas M, Kozlowski PB, Dilandro AC, Sakamoto Y, Iwanaga J, Schmidt C, D'Antoni AV.

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Abstract

PURPOSE:

To study the morphology of temporomandibular joint (TMJ) elements and examine the feasibility of a novel biofidelic articular disc casting technique.

METHODS:

18 formalin-fixed cadavers (77.8% female, 22.2% male) with mean (SD) death age of 71.9 (13.7) years were used for this study. In each specimen the masseter muscle, mandibular ramus, and articular disc were dissected bilaterally and measured for length, width, and thickness. All anatomic measurements were made using a digital slide caliper (Hawk Inc., Cleveland, OH). Further, a novel method for the creation of biofidelic articular disc models was established through trial and error. Models were measured for accuracy against their biological counterparts.

RESULTS:

Left articular disc length and thickness were inversely correlated (r = -0.58, p < 0.049). Direct correlations existed between right disc and ramus thickness (r = 0.56, p < 0.039), masseter length and thickness (r = 0.59, p < 0.009), and masseter width and thickness (r = 0.66, p < 0.003). Comparison of the model measurements with their biological counterparts found no significant differences.

DISCUSSION:

These observed correlations between elements of the TMJ hold relevance for oral-maxillofacial surgeons and researchers examining disorders of the TMJ. Additionally, our casting technique proved accurate in modeling human articular discs.

Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

KEYWORDS:

Articular disc; Joint disorder; Plastic casts; Temporomandibular joint; Temporomandibular joint disorder

Oper Neurosurg (Hagerstown). 2018 Jan 1;14(1):51-57. doi: 10.1093/ons/opx080.

Tubbs RS, Demerdash A, Loukas M, Curé J, Oskouian RJ, Ansari S, Cohen-Gadol AA.

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Abstract

BACKGROUND:

Descriptions of intracranial extensions of vertebral venous plexuses are lacking.

OBJECTIVE:

To identify vertebral venous plexuses at the craniocervical junction in cadavers and describe them.

METHODS:

The authors dissected 15 ink-injected, formalin-fixed, adult cadaveric heads and measured cranial extensions of the spinal venous plexuses.

RESULTS:

All specimens had vertebral venous plexuses at the craniocervical junction composed of multiple interwoven vessels concentrated anteriorly (anterior vertebral plexuses), posteriorly (posterior vertebral venous plexuses), and laterally (lateral vertebral venous plexuses). Veins making up the plexus tended to be largest for the anterior internal vertebral venous plexus. On 33%, a previously unnamed lateral internal vertebral venous plexus was identified that connected to the lateral marginal sinus. The anterior external vertebral venous plexus connected to the basilar venous plexus via transclival emissary veins in 13%; remaining veins connected either intracranially via small perforating branches through the anterior atlanto-occipital membrane (33%) or had no direct gross connections inside the cranium (53%). The anterior internal vertebral plexus, which traveled between layers of the posterior longitudinal ligament, connected to the anterior half of the marginal sinus in 33% and anterolateral parts of the marginal sinus in 20%. The posterior internal venous plexus connected to the posterior aspect of the marginal sinus on 80% and into the occipital sinus in 13.3%. The posterior external venous plexus connected to veins of the hypoglossal canal in 20% and into the posterior aspect of the marginal sinus in 13.3%.

CONCLUSION:

Knowledge of these connections is useful to neurosurgeons and interventional radiologists.

Copyright © 2017 by the Congress of Neurological Surgeons

KEYWORDS:

Anatomy; Dural venous sinus; Foramen magnum; Neurosurgery; Posterior fossa; Spine; Veins

Surg Radiol Anat. 2018 Jan;40(1):109-110. doi: 10.1007/s00276-017-1932-x. Epub 2017 Sep 30.

Macchi V, Porzionato A, Morra A, Picardi EEE, Stecco C, Loukas M, Tubbs RS, De Caro R.

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Comment on

• Anatomical topography of the inferior lumbar triangle for transversus abdominis block. [Surg Radiol Anat. 2018]

World Neurosurg. 2018 Jan;109:e382-e388. doi: 10.1016/j.wneu.2017.09.188. Epub 2017 Oct 5.

Fisahn C, Schmidt C, Rustagi T, Moisi M, Iwanaga J, Norvell DC, Tubbs RS, Schildhauer TA, Chapman JR.

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Abstract

INTRODUCTION:

Standalone cages have gained popularity because of their ease of implantation, reduced operating time, and lower profile compared with traditional plate and cage systems. The aim of this study was to compare the risk of chronic dysphagia between those who undergwent anterior cervical discectomy and fusion (ACDF) with traditional plating techniques and those who underwent standalone procedures.

MATERIAL AND METHODS:

Between 2014 and 2015, we identified 377 consecutive patients who met the study criteria (standalone, n = 211; plate-cage, n = 166). Patient-specific characteristics and surgical characteristics were collected preoperatively. In addition, the Dysphagia Disability Index (DDI) was collected 2 years postoperatively by telephone interview.

RESULTS:

Among the patients who underwent a standalone procedure, 84% (n = 177) were available for their 2-year follow-up visit in comparison with 75% (n = 124) for plate-cage procedures. There was no statistically significant difference in postoperative DDI scores between the 2 groups, controlling for prior surgery and smoking. However, the strongest risk factors for higher DDI scores were prior cervical surgery (mean 6.0 points higher) and smoking (mean 6.2 points higher). Twenty-seven patients (8.9%) experienced chronic dysphagia. The risk was higher in the plate-cage group (n = 15, 12.1%) than in the standalone group (n = 12, 6.7%), but this difference did not reach statistical significance.

CONCLUSION:

Despite similar mean DDI scores, patients who undergo anterior cervical discectomy with a plate-cage may be at a higher risk for chronic dysphagia than are those with a standalone approach, but further studies with larger sample sizes are necessary to establish this relationship with greater confidence.

Copyright © 2017 Elsevier Inc. All rights reserved.

KEYWORDS:

Anterior cervical discectomy and fusion; Dysphagia; Plate and interbody; Spine; Standalone

World Neurosurg. 2018 Jan;109:40-46. doi: 10.1016/j.wneu.2017.09.059. Epub 2017 Sep 20.

Mortazavi MM, Hassanzadeh T, Khalili K, Suriya SS, Taqi MA, Fard SA, Tubbs RS.

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Abstract

BACKGROUND:

Various techniques have been used for wrap-clipping a ruptured, fusiform intracranial aneurysm; however, there is no available literature on use of the falx cerebri for wrap-clipping. We present a review of the literature, with an illustrative case, of a ruptured fusiform pericallosal artery aneurysm firmly attached to the lower edge of the falx cerebri and not amenable to endovascular intervention.

METHODS:

Although the firm attachment between the inferior falx and the fusiform aneurysm was maintained, a section of the lower thinner part of the falx cerebri firmly attached to the aneurysm was dissected and wrapped around the fusiform aneurysm, and then stabilized with a fenestrated clip. We chose a segment slightly longer than the length of the fusiform aneurysm to avoid pre- and post-wrap-clipping stenosis.

RESULTS:

Postprocedure, except for a small area of numbness on the left distal anterolateral left leg, the patient was neurologically intact and remained neurologically intact at a 12-month follow-up.

CONCLUSIONS:

An inferior thin segment of the falx cerebri can be used for wrap-clipping of ruptured fusiform anterior cerebral artery aneurysms. Furthermore, the inferior falx can be wrapped around the attached fusiform anterior cerebral artery aneurysm without compromising flow, offering a safe solution in these unusually complex cases.

Copyright © 2017 Elsevier Inc. All rights reserved.

KEYWORDS:

Falx cerebri; Falxuplication; Fusiform aneurysm; Wrap-clipping

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Clin Anat . 2018 Mar;31(2):202-215. doi: 10.1002/ca.22939. Epub 2017 Dec 4.

Mohammadali M Shoja, Jaspreet Johal, W Jerry Oakes,  R Shane Tubbs

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Abstract

Although the Chiari malformations are well-studied and described developmental anomalies, there remains some incongruity in regards to their underlying etiologies. A number of theories have been proposed with the purpose of accounting for the embryology and pathogenesis of the Chiari I and II malformations and their associated complications and clinical syndromes. The present review aims to review the pertinent literature for all of the main theories that have been proposed, and outline their validity and relevance to our contemporary understanding of these anomalies. Clin. Anat. 31:202-215, 2018. © 2017 Wiley Periodicals, Inc.

Keywords: Arnold-Chiari malformation; cerebrospinal fluid pressure; etiology; hydrocephalus; mechanism; syringomyelia.

Cureus. 2019 Apr 9;11(4):e4422. doi: 10.7759/cureus.4422. Review.

Lachkar S, Dols MM, Ishak B, Iwanaga J, Tubbs RS.

Clin Neurol Neurosurg. 2019 Aug;183:105391. doi: 10.1016/j.clineuro.2019.105391. Epub 2019 Jun 20.

Ishak B, Steil M, Arroteia IF, Unterberg AW, Kiening KL

Clin Anat. 2020 Jan;33(1):34-40. doi: 10.1002/ca.23437. Epub 2019 Aug 9.

Iwanaga J, Ishak B, Saga T, Singla A, Impastato D, Chapman JR, Oskouian RJ, David G, Porzionato A, Reina MA, Macchi V, de Caro R, Tubbs RS.

Spine J. 2019 Dec 9. pii: S1529-9430(19)31115-5. doi: 10.1016/j.spinee.2019.12.003. [Epub ahead of print]

Simonds E, Iwanaga J, Ishak B, Reina MA, Oskouian RJ, Tubbs RS.

World Neurosurg. 2020 Jan 10. pii: S1878-8750(20)30015-2. doi: 10.1016/j.wneu.2020.01.008. [Epub ahead of print]

Iwanaga J, Warner T, Scullen TA, von Glinski A, Ishak B, Bui CJ, Dumont AS, Tubbs RS.

World Neurosurg. 2020 Jan 22. pii: S1878-8750(20)30109-1. doi: 10.1016/j.wneu.2020.01.091. [Epub ahead of print]

von Glinski A1, Yilmaz E2, Ishak B3, Haymann E3, Ramey W4, Jack A4, Iwanaga J5, Oskouian RJ4, Tubbs RS6, Chapman J4.

Spine (Phila Pa 1976). 2020 Jan 15;45(2):109-115. doi: 10.1097/BRS.0000000000003184.

Ishak B1,2, Abdul-Jabbar A1, Singla A1, Yilmaz E1, von Glinski A1, Ramey WL1, Blecher R3, Tymchak Z1, Oskouian R1, Chapman JR1.

Abstract

STUDY DESIGN: 

Retrospective study.

OBJECTIVE: 

To determine incidence, risk factors, complications, and early postoperative outcome in patients with intraoperative ischemic stroke during elective spine surgery.

SUMMARY OF BACKGROUND DATA: 

Overall, stroke is the fifth leading cause of death in the United States and the second leading cause of death worldwide. It can be a catastrophic event and the main cause of neurological disability in adults.

METHODS: 

A retrospective review of the electronic medical records of patients who underwent elective spine surgery between January 2016 and November 2018 at a larger tertiary referral center was conducted. Patients with infection and neoplastic disease were excluded. Patient demographics, pre- and postoperative neurological status, surgical treatment, surgical time, blood loss, intraoperative abnormalities, risk factors, history of stroke, medical treatment, diagnostics, hospital stay, complications, and mortality were collected.

RESULTS: 

Out of 5029 surgically treated patients receiving elective spine surgery, a total of seven patients (0.15%) were identified who developed an ischemic stroke during the surgical procedure. Patients were predominantly females (n = 6). Ischemic pontine stroke occurred in two patients. Further distributions of ischemic stroke were: left caudate nucleus, left posterior inferior cerebellar artery, left external capsule, left middle cerebral artery, and acute ischemic supratentorial spots. The main risk factors identified for intraoperative ischemic stroke include hypertension, diabetes, smoking, dyslipidemia, and possibly major intraoperative CSF leak. Three patients (43%) had neurological deficits which did not improve during hospital stay. Two patients recovered fully and two patients died. Therefore, in-hospital mortality rate of this subset of patients was 29%.

CONCLUSION: 

With the increase of spinal procedures, it is important to identify patients at risk for having an ischemic stroke and to optimize their comorbidities preoperatively. Patients with intraoperative ischemic stroke carry a higher risk for morbidity and mortality during the index hospitalization.