Suprascapular nerve block for postoperative pain relief in arthroscopic shoulder surgery: a new modality?

Arthroscopic shoulder surgery has a 45% incidence of severe postoperative pain. Opiates and interscalene nerve blocks have a high incidence of side effects, and intraarticular local anesthetic has been shown to be ineffective when used for postoperative pain relief. The suprascapular nerve supplies 70% of the sensory nerve supply to the shoulder joint, and local anesthetic block of this nerve is effective in certain shoulder pain disorders. To determine the efficacy of a suprascapular nerve block, subcutaneous saline was compared with a suprascapular nerve block using 10mL of 0.5% bupivacaine with 1:200,000 epinephrine before general anesthesia was induced. In the immediate postoperative period, a 51% reduction in demand and a 31% reduction in consumption of morphine delivered by a patient-controlled analgesic system was demonstrated. There was more than fivefold reduction in the incidence of nausea, as well as reduced visual analog and verbal pain scores for patients who received a suprascapular nerve block. The duration of hospital stay was reduced by 24% in the suprascapular nerve block group. A 24-h phone call interview revealed a 40% reduction in analgesic consumption and a reduction in verbal pain scores at rest and on abduction. There were no complications from the suprascapular nerve block. This study demonstrates that a suprascapular nerve block for pain relief in arthroscopic shoulder surgery is an effective and safe modality of postoperative pain relief.     

Suprascapular neuropathy after distal clavicle excision

Two cases of suprascapular neuropathy after excision of the distal clavicle are reported. Both patients were treated successfully with neurolysis of the suprascapular nerve starting at the upper trunk of the brachial plexus. Anatomic dissections revealed that the suprascapular nerve is quite close (<1.4 cm) to the posterior aspect of the distal clavicle, within 2 to 3 cm of the acromioclavicular joint. To avoid the complication of suprascapular neuropathy that could be associated with this close relationship, it is recommended that no more than 1 cm of the distal clavicle be removed posteriorly. It is also recommended that minimal periosteal elevation should be performed on the posteroinferior border of the distal clavicle.     

Anatomy and histological characteristics of the spinoglenoid ligament

The spinoglenoid (inferior transverse scapular) ligament, when present, is located at the spinoglenoid notch. The ligament originates on the spine of the scapula and inserts on the superior margin of the glenoid neck. Because of discrepancies in the literature, we sought to determine its prevalence and to define its histological characteristics. We dissected 112 shoulders of seventy-six cadavera and classified the ligament as absent or an insubstantial structure, a thin fibrous band (type I), or a distinct ligament (type II). We found no distinct ligamentous structure in twenty-two shoulders (20 percent), a type-I ligament in sixty-eight shoulders (61 percent), and a type-II ligament in twenty-two shoulders (20 percent). Overall, ninety (80 percent) of the shoulders had a fibrous band of tissue that, together with the spine of the scapula, formed a narrow fibro-osseous tunnel through which the suprascapular nerve traveled. The bone-spinoglenoid ligament-bone complexes from three specimens were analyzed histologically. There were two type-I ligaments and one type-II ligament; all three ligaments were composed of collagen fibers. One type-I ligament and the type-II ligament demonstrated Sharpey fibers at their origin on the spine of the scapula. The other type-I ligament attached to the spine of the scapula through the periosteum. All three ligaments inserted into the periosteum of the glenoid neck.     

Damage to the inguino-femoral nerves in the treatment of hernias. An anatomical hazard of traditional and laparoscopic techniques

Laparoscopic techniques currently constitute an alternative proposed for the repair of hernias of the inguinofemoral region. Nerve injuries have led some teams to recommend technical principles based on the anatomical relations of these nerves with the subperitoneal fascia transversalis and inguinal fossae. An anatomical study consisting of dissection of nonembalmed cadavres, allowed, after evisceration, dissection of the lumbar plexus and its terminal branches, particularly those supplying the inguinofemoral region: iliohypogastric and ilio-inguinal nerves, the genitofemoral nerve, the femoral nerve and the lateral cutaneous nerve of the thigh. Via transperitoneal laparoscopy, the posterior surface of the anterior abdominal wall is centered on the deep inguinal ring, containing testicular vessels and the vas deferens. This deep inguinal ring receives the genitofemoral nerve. Medially, the anterior parietal peritoneum describes three folds formed by the outline of the epigastric artery, umbilical artery and urachus on the midline. The outline of Hesselbach's ligament separates the deep inguinal ring from Hesselbach's triangle, the zone of weakness of direct inguinal hernia. The iliac psoas muscle pass laterally underneath the inguinal ligament, while the external iliac vessels, subsequently becoming the femoral vessels, are located medially. Pectineal ligament lies on the posterior surface of the femoral ring between the umbilical artery and the epigastric artery. Installation of an abdominal wall prosthesis, either transperitoneally or retroperitoneally, must be centered on the deep inguinal ring, and its solid sutures are located medially to the pectineal ligament and anterior abdominal wall. On the other hand, the nerves at risk of being damaged are situated laterally: the ilio-inguinal and ilio-hypogastric nerves in the plane between external oblique and internal oblique above the anterior superior iliac spine, lateral cutaneous nerve of the thigh under the inguinal ligament close to the anterior superior iliac spine, genitofemoral nerve with the spermatic cord in the deep inguinal ring and femoral nerve underneath the inguinal ligament with the psoas muscle lateral to the external iliac artery. No stapling must be performed under the plane of the inguinal ligament to avoid damage to the femoral vessels and lateral to the deep inguinal ring to avoid nerve damage.     

Case presentation: leukemia in a child

Palsy of the suprascapular nerve may be easily overlooked in the differential diagnosis of the painful shoulder. Although the diagnosis is well documented in the literature, opinion is still divided regarding its etiology and treatment. This case report offers an example of successful nonoperative management of a suprascapular nerve palsy which followed an acute episode of muscular stress in a young male athlete.     

The petrolingual ligament: the anatomy and surgical exposure of the posterolateral landmark of the cavernous sinus

The petrolingual ligament is the posteroinferior attachment of the lateral wall of the cavernous sinus, where the internal carotid artery enters the cavernous sinus. The petrous segment of the internal carotid artery finishes and the cavernous segment begins at the superior margin of this ligament. The ligament is surgically important due to its identification as a landmark for dissection of the internal carotid artery during the approaches to posterolateral intracavernous and extracavernous lesions. It can be well exposed after mobilization of the gasserian ganglion, or after the trigeminal root and ganglion have been split along the junction of V2 and V3 (the transtrigeminal approach). The petrolingual ligament was studied in five cadaveric head specimens from ten sides. The size of the ligament was measured, and its anatomical, clinical and surgical importance is discussed.     

Is it possible to choose the safest contrast media through the results of clinical studies?

We describe a method of exposing the whole length of the axillary and suprascapular nerves through a sabre-cut incision. The coracoid process is osteotomised and part of trapezius is detached from its insertions. The posterior deltoid is freed from its scapular origin to expose infraspinatus. We have used this approach to explore combined injuries of the axillary and suprascapular nerves with good results, and no serious complications. Its success depends on a meticulous surgical technique.     

Temperature dependence on the recovery of electrical activities in brain slice during incubation

Four cases of suprascapular neuropathy treated by nonoperative means have been presented. Complete recovery occurred in all four. The anatomy of the suprascapular nerve and probable mechanisms of injury secondary to traction have been discussed. The importance of electromyography in diagnosis has been stressed. Longer periods of nonoperative treatment are recommended here than by previous authors. Since the lesion is felt not to be an entrapment phenomenon but, rather, a traction injury, operative treatment should consist of release of the nerve at the notch to reduce the possibility of further traction injury, and a neurolysis should be done as well.     

Morphology of the male accessory organs of reproduction of immature fallow deer (Dama dama L.) with particular reference to puberty and antler development

Cutting the suspensory ligament reduced the ovarian content of norepinephrine (NE) to less than half that of controls and only a few blood vessels had perivascular fibers and an occasional nerve remained in the interstitial gland. Cutting the ovarian plexus had a less drastic, but similar effect on the ovarian content of NE and on the pattern of ovarian adrenergic nerves. Cutting both the suspensory ligament and ovarian plexus eliminated visualization of ovarian adrenergic nerves, but some ovarian NE was still measurable. Fluorescence and electron microscopic studies of the suspensory ligament revealed a large adrenergic nerve embedded in smooth muscle of the ligament. The nerve was also acetylcholinesterase-positive. Cutting the celiac plexus or incising a small nerve lateral to the plexus and medial to the origin of the suspensory ligament, had the same effect on the ovarian adrenergic nerves as cutting the suspensory ligament. It is concluded that the extrinsic adrenergic nerves to the rat ovary reach the organ by two routes: one via the nerve in the suspensory ligament (superior ovarian nerve), and one via the traditionally described ovarian plexus along the ovarian artery.     

Pterional craniotomy via a transcavernous approach for the treatment of low-lying distal basilar artery aneurysms

OBJECT: The author describes a surgical procedure in which pterional craniotomy is performed via a transcavernous approach to treat low-lying distal basilar artery (BA) aneurysm. This intradural procedure is compared with the extradural procedure described by Dolene, et al. METHODS: The addition of a transcavernous exposure to the standard pterional intradural transsylvian approach allows a lower exposure of the distal BA behind the dorsum sellae. The technical steps involved in this procedure are as follows: 1) removal of the anterior clinoid process: 2) entry into the cavernous sinus medial to the third nerve; 3) packing of the venous channels of the cavernous sinus lying between the carotid artery and the pituitary gland to open this space; 4) removal of the posterior clinoid process and the portion of the dorsum sellae that is exposed from within the cavernous sinus; and 5) removal of the exposed dura mater to obtain additional exposure of the peri-mesencephalic cistern. Eight cases of aneurysms of the distal BA are presented to illustrate how this approach can help in their surgical treatment. CONCLUSIONS: Using the standard pterional approach, these distal BA aneurysms were found to be either too low relative to the posterior clinoid process for adequate exposure or there was insufficient room for temporary clipping of the BA proximal to the lesion. The addition of a transcavernous exposure eliminated these technical problems and aneurysm clipping could be accomplished in each case.     

Using monoclonal antibodies to characterize a sequential epitope on the group I allergen of Bermuda grass pollen

We measured the incidence of cuff retear and injury to the suprascapular nerve after mobilization and repair of a massive rotator cuff tear. Of one hundred four rotator cuff repairs performed over a 5-year period, 10 patients (7 men and 3 women, age range 22 to 68 years) had primary repairs of massive rotator cuff tears requiring cuff mobilization and an acromioplasty as their only procedure. These patients were evaluated at a mean of 2.5 years (range 2.0 to 3.0 years) after surgery. At follow-up electromyographic examination confirmed that 1 of the 10 patients had an iatrogenic suprascapular nerve injury, whereas ultrasound evaluation revealed that 2 of 10 repairs failed. Pain relief was achieved in the eight patients with intact repairs and not in the two with recurrent tears. All patients had some limitation of active motion or strength, especially in external rotation. Thus 7 of 10 patients had neither evidence of nerve injury nor recurrent rotator cuff tears yet still showed limited active motion or weakness. It appears that operative injury to the suprascapular nerve during cuff mobilization can occur, but other factors such as inadequate cuff muscle function are more frequently responsible for the poor functional outcomes seen after successful repairs of massive rotator cuff tears.     

The TMJ-ear connection

This article documents the existence of three structures that traverse through the petrotympanic fissure. These structures are the mandibular malleolar ligament, the chorda tympani nerve and the anterior tympanic artery. The mandibular malleolar ligament or the disk-malleolar ligament originates on the anterior process of the mallous. It traverses through the petro-tympanic fissure and attaches to the posterior portion of the capsule and disk of the temporomandibular joint. The chorda tympani nerve supplies sensory feeling to the posterior two thirds of the tongue. The anterior tympanic artery supplies blood to the area of the tympanic membrane. Clinical experience with implants that impinge or cover ear problems and other symptoms. Removal of these implants and placements with devices that do not cover these structures often relieve these symptoms.     

The pial ligaments of the anterior spinal artery and their stretch receptors. A spinal cord distraction-sensing system?

The pial sheath of the anterior spinal artery displays a system of ligaments that course along the ventral surfaces of the anterior spinal artery and its medullary feeder arteries on the lower half of the spinal cord. Frequently, discrete ligamentous straps extend from these anterior spinal artery ligaments to the sheath of an anterior spinal nerve root to reinforce the general cauda equina pial connections to this system. Microscopy of ligament sections revealed that numerous Golgi-type neurofascicular receptors were oriented longitudinally among the ligament fascicles and associated with well-myelinated nerves. As this type of mechanoreceptor has been known only in association with stretch reflex mediation in the musculoskeletal system, it appeared likely that these anterior spinal artery ligaments and their homologous type of receptors may be implicated in sensing distraction of the thoracolumbar spinal cord and protectively modifying the actions of the involved spinal musculature.     

Suprascapular nerve block for persistent rotator cuff lesions

The suprascapular nerve supplies sensory nerves to the posterosuperior aspect of the shoulder, including major portions of the rotator cuff. Suprascapular nerve block using steroid/bupivacaine is temporarily effective in reducing pain in rotator cuff tendinitis and tears, improving movement range in tendinitis and is possible in an outpatient setting with little or no complication risk.     

The proximal sesamoid bone of the horse; vascular and neurologic characteristics

Sesamoiditis is characterized clinically by repeated lameness and radiologically by changes in the proximal sesamoid bones. This thesis, which was defended in June 1997, investigated two characteristics of sesamoiditis, namely the arterial blood supply and the innervation of the proximal sesamoid bones, in order to gain more insight into the etiopathogenesis of sesamoiditis. Experiments with patient material showed that the proximal sesamoid bones have an enormous arterial reserve, due in part to the formation of an arterial shift. Moreover, the sesamoid bones have their own sensory innervation, provided by a branch of the medial and lateral palmar nerve. This branch is called the sesamoid nerve in this article. A special technique was developed to anaesthetize this nerve and can be used for further differentiation of pastern lameness. That the sesamoid bones are sensitive to pain was demonstrated by detection of the so-called nociceptive neuropeptides, substance P and calcitonin gene-related peptide, which are specifically involved in pain sensation. However, the adjacent ligament appear to be even more sensitive. The etiopathogenesis of sesamoiditis is discussed, as are a number of clinical implications of pain in the sesamoid bones. A number of potential future developments are mentioned.     

Suprascapular nerve entrapment in a basketball player

A basketball player was shown to have a suprascapular nerve lesion without any history of shoulder girdle trauma. This acute neuropathy, never previously described in basketball players, is a result of repeated micro-trauma, due to nerve traction over the coracoid notch during violent movement ("dunking" most probably). Clinically, he was unable to abduct his arm and had some difficulty in external rotation. He developed atrophy in both the supra- and the infraspinatus muscles. Nerve conduction latency to the supraspinatus muscle was 8.0 ms, and to the infraspinatus, 8.5 ms. The compound muscle action potential registered in the supraspinatus was 1.224 mV, and in the infraspinatus, 1.237 mV. After 3 weeks of inactivity, recovery was spontaneous and practically complete.     

Extra-hippocampal lesions and alteration of didactic knowledge (semantic explicit memory)

The acetabular labrum appears as a bundle of distinctly circular lined up collagenous fibers. It surrounds the limbus tangentially and is separated from the cartilagenous covered facies lunata through a thin gap (fissure) except of a small zone in the craniocaudal part. The labrum is strongly fixed with the transverse acetabular ligament. A vascular anastomotic ring surrounds the capsular attachment. It derives its blood supply especially from the superior gluteal vessels, the obturator artery and one ascending branch of the medial femoral circumflex artery. The innervation of the acetabular labrum is coming from a branch of the nerve to the quadratus femoris muscle and from the obturator nerve. There are all types of mechanoreceptors in the labrum. The acetabular labrum is able to exert a high tensional force on the rim of the acetabulum. This plays a very important role in view of the physiological, load depending incongruity of the articulating parts of the hip-joint.