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OBJECTIVE Extension fractures in the setting of diffuse idiopathic skeletal hyperostosis (DISH) represent highly unstable injuries. As a result, these fractures are most frequently treated with immediate surgical fixation to limit any potential risk of associated neurological injury. Although this represents the standard of care, patients with significant comorbidities, advanced age, or medical instability may not be surgical candidates. In this paper, the authors evaluated a series of patients with extension DISH fractures who were treated with orthosis alone and evaluated their outcomes. METHODS A retrospective review from 2015 to 2022 was conducted at a large level 1 trauma center. Patients with extension-type DISH fractures without neurological deficits were identified. All patients were treated conservatively with orthosis alone. Baseline patient characteristics and adverse outcomes are reported. RESULTS Twenty-seven patients were identified as presenting with extension fractures associated with DISH without neurological deficit. Of these, 22 patients had complete follow-up on final chart review. Of these 22 patients, 21 (95.5%) were treated successfully with external orthosis. One patient (4.5%) who was noncompliant with the brace had an acute spinal cord injury 1 month after presentation, requiring immediate surgical fixation and decompression. No other complications, including skin breakdown or pressure ulcers related to bracing, were reported. CONCLUSIONS Treatment of extension-type DISH fractures may be a reasonable option for patients who are not candidates for safe surgical intervention; however, a risk of neurological injury secondary to delayed instability remains, particularly if patients are noncompliant with the bracing regimen. This risk should be balanced against the high complication rate and potential mortality associated with surgical intervention in this patient population.

Background Posterior interosseous nerve palsy (PINP) is a disorder caused by damage to the posterior interosseous nerve, resulting in weak extension of the wrist and fingers as well as radial deviation of the wrist. Methods: In this study, a new type of evaluation for PINP was analyzed in hopes of increasing ease of diagnosis and earlier detection of the disorder. The “Window Test” is performed by the examiner laying hands on the ulnar aspect of the patient’s pronated forearm while the latter is trying to extend the wrist. A positive test is observed when a gap (window) appears between the examiner’s forearm and the patient’s hand. Lay people, medical students, residents, and practicing providers were assessed prospectively on their ability to correctly diagnose PINP by observing one hand, both hands, and by using the Window Test. Results: The Window Test was consistently found to be the most effective method of evaluation as it increased the accuracy of diagnoses in all groups surveyed. Additionally, case studies were performed using the Window Test on patients, further demonstrating the efficacy of the test by confirming wrist radial deviation. Conclusion: The Window Test introduces a reference frame, making it easier to assess wrist radial deviation and offering a simple evaluation that can be administered by virtually anyone. These findings indicate that the implementation of the Window Test will increase the accuracy and effectiveness of PINP diagnosis, thus allowing early diagnosis and better management.

Brachial plexus injury (BPI) occurs when the brachial plexus is compressed, stretched, or avulsed. Although rodents are commonly used to study BPI, these models poorly mimic human BPI due to the discrepancy in size. The objective of this study was to compare the brachial plexus between human and Wisconsin Miniature SwineTM (WMSTM ), which are approximately the weight of an average human (68-91 kg), to determine if swine would be a suitable model for studying BPI mechanisms and treatments. To analyze the gross anatomy, WMS brachial plexuses were dissected both anteriorly and posteriorly. For histological analysis, sections from various nerves of human and WMS brachial plexuses were fixed in 2.5% glutaraldehyde, and postfixed with 2% osmium tetroxide. Subsequently paraffin sections were counter-stained with Masson's Trichrome. Gross anatomy revealed that the separation into three trunks and three cords is significantly less developed in the swine than in human. In swine, it takes the form of upper, middle, and lower systems with ventral and dorsal components. Histological evaluation of selected nerves revealed differences in nerve trunk diameters and the number of myelinated axons in the two species. The WMS had significantly fewer myelinated axons than humans in median (p = 0.0049), ulnar (p = 0.0002), and musculocutaneous nerves (p = 0.0454). The higher number of myelinated axons in these nerves for humans is expected because there is a high demand of fine motor and sensory functions in the human hand. Due to the stronger shoulder girdle muscles in WMS, the WMS suprascapular and axillary nerves were larger than in human. Overall, the WMS brachial plexus is similar in size and origin to human making them a very good model to study BPI. Future studies analyzing the effects of BPI in WMS should be conducted.

BACKGROUND Benign eccrine spiradenoma is a rare tumor arising from the sweat glands and is a pathology that is almost never encountered in routine neurosurgical practice. Although this is a rare pathology, it is one that should be included in the differential diagnosis for a patient presenting with a painful, subcutaneous mass, because it can guide further treatment considerations. OBSERVATIONS The authors present a case of benign eccrine spiradenoma that mimicked a nerve sheath tumor in clinical presentation, imaging characteristics, and gross appearance. LESSONS Complete local excision of these lesions is the gold standard treatment, because they are painful, and there are reports of local recurrence and malignant degeneration with incomplete resection. For this reason, neurosurgeons should be sure to include this in the differential diagnosis of a patient with a painful, subcutaneous mass, because it may help to guide management decisions.

To evaluate the effect of intravenous (IV) contrast on sensitivity, specificity, and accuracy of magnetic resonance (MR) neurography of the knee with attention to the common peroneal nerve (CPN) in identifying nerve lesions and active muscle denervation changes. A retrospective search for contrast-enhanced MR neurography cases evaluating the CPN at the knee was performed. Patients with electrodiagnostic testing (EDX) within 3 months of imaging were included and those with relevant prior surgery were excluded. Two radiologists independently reviewed non-contrast sequences and then 4 weeks later evaluated non-contrast and contrast sequences. McNemar’s tests were performed to detect a difference between non-contrast only and combined non-contrast and contrast sequences in identifying nerve lesions and active muscle denervation changes using EDX as the reference standard. Forty-four exams in 42 patients (2 bilateral) were included. Twenty-eight cases had common peroneal neuropathy and 29, 21, and 9 cases had active denervation changes in the anterior, lateral, and posterior compartment/proximal muscles respectively on EDX. Sensitivity, specificity, and accuracy of non-contrast versus combined non-contrast and contrast sequences for common peroneal neuropathy were 50.0%, 56.2%, and 52.3% versus 50.0%, 56.2%, and 52.3% for reader 1 and 57.1%, 50.0%, and 54.5% versus 64.3%, 56.2%, and 61.4% for reader 2. Sensitivity, specificity, and accuracy of non-contrast and combined non-contrast and contrast sequences in identifying active denervation changes for anterior, lateral, and posterior compartment muscles were not significantly different. McNemar’s tests were all negative. IV contrast does not improve the ability of MR neurography to detect CPN lesions or active muscle denervation changes.

Background: Myxofibrosarcoma (MFS) is a rare and locally infiltrative tumor that commonly occurs in extremities in older adults; however, truncal and head and neck cases have been reported. They are characterized by multinodular growth, incomplete fibrous septa, and myxoid stroma. Surgical resection is the mainstay of treatment. Case Description: The authors report a case of a combined, supraclavicular, infraclavicular, transaxillary, and posterior subscapular approaches for resection of giant MFS. Conclusion: The anatomical complexity and rarity of tumors involving the brachial plexus impose many challenges onto surgeons performing surgical resections. Treatment choices and surgical outcomes rely heavily on meticulous multidisciplinary planning, anatomical knowledge, careful dissection, and extent of resection. This case is unique in utilizing four different approaches to the brachial plexus to resect one tumor.

OBJECTIVEIatrogenic nerve injuries are devastating to both the patient and the surgeon. This study focuses on the anatomical relationship of the palmar recurrent branch with the parent median nerve in an attempt to identify higher risk types.METHODSThe palmar recurrent branch was dissected in 75 embalmed cadavers. The median nerve was divided into 4 sections from lateral to medial, defined as zones 1–4. The angle to the axial plane of the median nerve was also measured and classified as 0°, 45°, 60°, and 90°.RESULTSAccessory recurrent branches were found in 36.2% of cases. The recurrent branch originated from zone 1 in 32.42%, zone 2 in 61.54%, zone 3 in 6.04%, and zone 4 in 0%. These are respectively classified as types I, II, III, and IV. The motor branch made an angle with the median nerve of 0° in 17% of cases, 45° in 37.4%, 60° in 26.4%, and 90° in 19.2%. These are respectively classified as types A, B, C, and D.CONCLUSIONSClose attention should be paid to the potential anatomical variabilities when performing nerve surgeries. For the palmar recurrent branch, the more medial the origin and the greater the angle it makes with the median nerve, the more dangerous it is. This classification is helpful in unifying the language and comparing results.

Median nerve anatomy is of great interest to clinicians and scientists given the importance of this nerve and its association with diseases. A rare anatomical variant of the median nerve in the distal forearm and wrist was discovered during a cadaveric dissection. The median nerve was deep to the flexor digitorum superficialis (FDS) in the carpal tunnel. It underwent a 360-degree spin before emerging at the lateral edge of FDS. The recurrent motor branch moved from medial to lateral on the deep surface of the median nerve, as it approached the distal carpal tunnel. This variant doesn't fall into any of Lanz's four groups of median nerve anomalies. We propose a fifth group that involves variations in the course of the median nerve. This report underscores the importance of recognizing variants of the median nerve anatomy in the forearm and wrist during surgical interventions, such as for carpal tunnel syndrome.

Background Intracranial tumor growth associated with pregnancy is not an uncommon phenomenon. Pilocytic astrocytoma is typically considered to be an indolent tumor with little to no risk of progression to higher-grade lesion. We present a rare case of cerebellar pilocytic astrocytoma transformation to hemorrhagic high-grade glioma during pregnancy. Case Description Patient EK was a 32-year-old female with neurofibromatosis type 1 and known cerebellar pilocytic astrocytoma. For nearly a decade before her pregnancy, her cerebellar tumor was stable on imaging. Routine magnetic resonance imaging (MRI) of the head obtained at 20 weeks’ gestation continued to demonstrate tumor stability. At 24 weeks’ gestation, the patient had sudden, severe headaches. MRI of the head showed evidence of significant tumor expansion. The following day, the patient was found unresponsive. Computed tomography of the head demonstrated hemorrhage within the tumor and tonsillar herniation. Her neurologic examination revealed no brainstem reflexes; however, given her age and pregnancy, she underwent emergent decompression and tumor debulking. Unfortunately, she never improved neurologically. Final pathology identified the lesion as high-grade glioma with anaplastic changes and hemorrhagic conversion. Conclusions This is a unique case of indolent cerebellar pilocytic astrocytoma that transformed to high-grade glioma during pregnancy, proven by tumor growth on MRI and anaplasia on pathology. We hypothesize that increased levels of pregnancy hormones (progesterone, vascular endothelial growth factor, placental growth factor, among others) likely contributed to tumor growth. We recommend that all glial tumors be monitored extremely closely throughout pregnancy, and perhaps one should consider surgical treatment (if possible) before patients become pregnant.

Lateral femoral cutaneous neuropathy, also known as meralgia paresthetica, is a pathology commonly encountered by neurosurgeons. Symptoms include numbness, tingling, and burning pain over the anterolateral thigh due to impingement on the lateral femoral cutaneous nerve (LFCN). Surgical treatment has traditionally involved nerve release or neurectomy. LFCN transposition is a relatively new approach that can provide excellent symptomatic relief. In this video, the authors highlight key operative techniques to ensure easy identification, adequate decompression, and transposition of the nerve. Key steps include ultrasound-guided wire localization, superficial decompression, opening of the inguinal ligament, deep decompression, and medial transposition. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID2289

Background: Accessory muscles in the arm are well-known anatomical variants which have been hypothesized as sources of neurovascular compression syndromes. We report a rare presentation of neuropathy secondary to an accessory biceps aponeurosis causing compression of the median nerve in the antecubital fossa. Case Description: A 65-year-old man presented with a 5-year history of numbness and pain associated with arm flexion. Electromyography was normal and exam revealed mild weakness in the median nerve distribution; however, magnetic resonance imaging demonstrated an accessory biceps tendon overlaying the median nerve in the antecubital fossa. The patient underwent surgical decompression of the median nerve with detachment of the accessory tendon resulting in clinical improvement. Conclusion: Anomalous biceps musculature should be considered in the workup and treatment of proximal median neuropathy.

Background: Thoracic outlet syndrome (TOS) is a clinical diagnosis caused by compression of neurovascular structures in the thoracic outlet. There are a variety of structures that cause compression implicated in TOS. TOS patients frequently require surgical decompression. Various structural anomalies encountered during decompression have been reported in the literature. Case Description: We present two females (ages 42 and 45) that each underwent anterior scalenectomy for thoracic outlet decompression through a supraclavicular approach. A supraclavius muscle anomaly was observed in both patients. Analogous to the two reports previously described in the literature, the muscle inserted, along the medial superior undersurface of the clavicle and originated dorsally along the trapezius muscle. This is not to be confused with the subclavius posticus muscle, which originates from the first rib and inserts on the upper border of the scapula. Conclusion: These two cases represent just the third and fourth ever descriptions of a supraclavius muscle anomaly encountered during TOS surgery. Due to the wide variety of anatomical variations encountered during TOS surgery, it is not only crucial for continued reporting of such anatomical variations to be reported in the literature but equally important for clinicians that treat TOS to be aware of such variations.

In skin wound healing the injured tissue goes through a normal progression, inflammation subsides and remodeling occurs. However after spinal cord injury inflammation persists and there is less progression into a regenerative/rebuilding phase. This inflammatory process after spinal cord injury is orchestrated by many cell types and numerous cytokines. Although there are several positive effects of inflammation after spinal cord injury, such as the removal of debris, the substantial upregulation of immune cells has been shown to contribute to neural degeneration. Several chemokines and cytokines including many interleukins are involved in guiding these immune cells to the lesion. While there are many inflammatory cytokines acting on these immune cells after SCI, there are also several anti-inflammatory interleukins that have shown beneficial effects in reducing inflammation. After SCI in a rat model, interleukin-10 and interleukin-19 have been shown to downregulate the synthesis of pro-inflammatory species including interleukin-1β and tumor necrosis factor-α, which resulted in a significant improvement in rat hind limb function. Also, interleukin-4 and interleukin-13 are related anti-inflammatory cytokines that regulate many aspects of inflammation and have also been shown to induce alternative macrophage activation. The differing and complex roles interleukins play, highlight their importance on the inflammation that persists after spinal cord injury. Here we review both the positive effects and negative effects that interleukins have during the multifaceted inflammation process following spinal cord injury.

Background The presence of symptomatic lumbar facet cysts has been associated with segmental instability. Given this association, decompression versus decompression with fusion is a frequently debated topic. Multiple grading scales have been devised to identify patients at high risk for development of cyst recurrence; however, there exists no external evaluation of these scales. Methods A retrospective review of 54 patients undergoing initial treatment for lumbar synovial cysts at a single institution over the past 12 years was conducted. Surgical treatment consisted of decompression with cystectomy without fusion. Patients were assessed and classified according to the NeuroSpine Surgery Research Group (NSURG) and Rosenstock Classification systems. Five neurosurgeons reviewed the preoperative magnetic resonance images, and results were classified. Interrater reliability was assessed using both Gwet’s AC1 coefficient and Krippendorff’s alpha. A 1-way analysis of variance was used to evaluate predictive ability of both classification systems. Results In total, of the 54 patients who underwent decompression, 7 had cyst recurrence. Overall cyst recurrence was most common in NSURG grade 2 cysts (3/12, 25%) followed by grade 1 cysts (4/27, 14.8%). Of the NSURG grade 3 and 4 patients, none had cyst recurrence. In the Rosenstock grades the most common recurrence was in grade 3 cysts (1/4, 25%) followed by grade 1 cysts (5/26, 19.2%). Interrater reliability demonstrated good reproducibility on Gwet’s AC1 and Krippendorff’s alpha on both grading scales. Neither score was predictive of cyst recurrence (P > 0.05). Conclusions The Rosenstock and NeuroSpine scores demonstrate good overall interrater reliability but are inconsistent in their ability to predict recurrence of lumbar facet cysts.

Purpose To evaluate the feasibility and efficacy of ultrasound-guided microwave ablation for the treatment of inguinal neuralgia. Materials and Methods A retrospective review of 12 consecutive ultrasound-guided microwave ablation procedures was performed of 10 consecutive patients (8 men, 2 women; mean age, 41 years [range, 15–64 years]), between August 2012 and August 2016. Inclusion criteria for inguinal neuralgia included clinical diagnosis of chronic inguinal pain (average, 17.3 months [range, 6–46 months]) refractory to conservative treatment and a positive nerve block. Pain response—reduction of pain level and duration and percent pain reduction using a 10-point visual analog scale (VAS) at baseline and up to 12 months after the procedure—was measured. Nine patients had pain after the inguinal hernia repair, and 1 patient had pain from the femoral artery bypass procedure. The microwave ablation procedure targeted the ilioinguinal nerve in 7 cases, the genitofemoral nerve in 4 cases, and the iliohypogastric nerve in 1 case. Results Average baseline VAS pain score was 6.1 (standard deviation, 2.5). Improved pain levels immediately after the procedure and at 1, 6, and 12 months were statistically significant (P = .0037, .0037, .0038, .0058, respectively). Also, 91.7% (11/12) of the procedures resulted in immediate pain relief and at 1 month and 6 months. At 12 months, 83.3% (10/12) of patients had an average of 69% ± 31% pain reduction. Percent maximal pain reduction was 93% ± 14% (60%–100%), and the average duration of clinically significant pain reduction was 10.5 months (range, 0–12 months.). No complications or adverse outcomes occurred. Conclusions Ultrasound-guided microwave ablation is an effective technique for the treatment of inguinal neuralgia after herniorrhaphy.

Rats have been the primary model to study the process and underlying mechanisms of recovery after spinal cord injury. Two weeks after a severe spinal cord contusion, rats can regain weight-bearing abilities without therapeutic interventions, as assessed by the Basso, Beattie and Bresnahan locomotor scale. However, many human patients suffer from permanent loss of motor function following spinal cord injury. While rats are the most understood animal model, major differences in sensorimotor pathways between quadrupeds and bipeds need to be considered. Understanding the major differences between the sensorimotor pathways of rats, non-human primates, and humans is a start to improving targets for treatments of human spinal cord injury. This review will discuss the neuroplasticity of the brain and spinal cord after spinal cord injury in rats, non-human primates, and humans. A brief overview of emerging interventions to induce plasticity in humans with spinal cord injury will also be discussed.

Background: Vascular compression is an extremely rare cause of mononeuropathy and compression of selective tibial nerve branches is an additionally a rare finding and makes diagnosis difficult. Case Description: Here within, we describe the case of a 41-year-old male who presented with isolated mononeuropathy of the medial gastrocnemius (MG) branch of the tibial nerve presented as persistent fasciculations and atrophy. After electromyography and clinical evaluation, surgical exploration was recommended. A vascular bundle was found to be compressing the MG branch of the tibial nerve and thus was ligated to decompress the nerve. Postoperatively, all fasciculations improved and muscle atrophied improved. Conclusion: Vascular compression resulting in mononeuropathy of the peripheral nerves is a rare clinical entity. Clinicians should include these etiologies on their differential when considering surgical exploration of mononeuropathies.

The lumbosacral plexus and its branches extend from the retroperitoneal space to the buttock area, thigh, leg, and foot. Surgical exposures depend on the indication and pathology. Nerve entrapments can require piriformis release in the buttock, fibular nerve decompression at the fibular neck, tibial nerve release under the soleal arch, or tarsal tunnel release at the ankle. Nerve trauma can be treated by direct suturing if it can be performed without tension, grafting including autograft or allograft, or nerve transfer. Common nerve sheath tumors including neurofibroma and schwannoma can be encountered sporadically or as part of neurofibromatosis 1, neurofibromatosis 2, or schwannomatosis. Complications depend on the approach but in general terms include wound infection, hematoma, or nerve injury. The latter can cause pain, paralysis, or loss of sensation. Retroperitoneal approaches have the added risk of bowel perforation and ureteric or vascular injuries.

Background: Brachial plexus injury (BPI) occurs when the brachial plexus is compressed, stretched, or avulsed. Although rodents are commonly used to study BPI, these models poorly mimic human BPI due to the discrepancy in size. The objective of this study was to compare the brachial plexus between human and Wisconsin Miniature SwineTM (WMSTM), which are approximately the weight of an average human (68–91 kg), to determine if swine would be a suitable model for studying BPI mechanisms and treatments. Methods: To analyze the gross anatomy, WMS brachial plexi were dissected both anteriorly and posteriorly. For histological analysis, sections from various nerves of human and WMS brachial plexi were fixed in 2.5% glutaraldehyde and then myelinated axons were labeled using 2% osmium tetroxide before being counter-stained with Masson’s Trichrome. Results: Gross anatomy revealed that the separation into 3 trunks and 3 cords is significantly less developed in the swine than in human. In swine, it takes the form of upper, middle, and lower systems with ventral and dorsal components. Histological results showed that despite the similarity in body size between the miniature swine model and humans, there was some discrepancy in nerve size and the number of the myelinated axons. The WMS had significantly fewer myelinated axons than humans in median (p = 0.0009), ulnar (p = 0.0001), and musculocutaneous nerves (p = 0.0451). The higher number of myelinated axons in these nerves for humans is expected, because there is a high demand of fine motor function in the human hand, with more motor units. Due to the stronger shoulder girdle muscles in WMS, the WMS suprascapular nerves were larger than in human. Conclusion: Overall, the WMS brachial plexus is similar in size and origin to human making them an excellent model to study BPI. Future studies analyzing the effects of BPI in WMS should be conducted.

Chronic groin pain can be due to a variety of causes and is the most common complication of inguinal hernia repair surgery. The etiology of pain after inguinal hernia repair surgery is often multifactorial though injury to or scarring around the nerves in the operative region, namely the ilioinguinal nerve, genital branch of the genitofemoral nerve, and the iliohypogastric nerve, is thought to be a key factor in causing chronic post-operative hernia pain or inguinal neuralgia. Inguinal neuralgia is difficult to treat and requires a multidisciplinary approach. Radiologists play a key role in the management of these patients by providing accurate image-guided injections to alleviate patient symptoms and identify the pain generator. Recently, ultrasound-guided microwave ablation has emerged as a safe technique, capable of providing durable pain relief in the majority of patients with this difficult to treat condition. The objectives of this paper are to review the complex nerve anatomy of the groin, discuss diagnostic ultrasound-guided nerve injection and patient selection for nerve ablation, and illustrate the microwave ablation technique used at our institution.

Spinal cord injury (SCI) is a devastating condition affecting 270,000 people in the United States. The use of growth factors is a potential treatment for reducing secondary damage, promoting axon growth, and restoring some of the lost function post-SCI. Glial cell line-derived neurotrophic factor (GDNF) is an important growth factor, because it can affect both neurons and support cells. Here, we give an in-depth review of the previously published literature where GDNF was used to treat SCI. The effects of GDNF have been shown to decrease lesion size, improve allodynia, and regenerate axons in the central nervous system and peripheral nervous system. GDNF is necessary for early development, and lack of GDNF can lead to abnormal development of the autonomic nervous system or death. Exogenous administration of GDNF either before or immediately after SCI is most effective. Even though GDNF can be directly administered, genetically modified cells are often used as a delivery vehicle. Several different types of genetically modified cells have been used with varying success. Although GDNF is effective when used alone, it has been shown to be more effective when used in combination with other neurotrophic factors. Overall, GDNF significantly improved functional recovery, increased the number of sprouting neurons, reduced lesion size at the injury site, and had minimal adverse effects.

Meralgia paresthetica causes pain in the anterolateral thigh. Most surgical procedures involve nerve transection or decompression. We conducted a cadaveric study to determine the feasibility of lateral femoral cutaneous nerve (LFCN) transposition. In three cadavers, the LFCN was exposed in the thigh and retroperitoneum. The two layers of the LFCN canal superficial and deep to the nerve were opened. The nerve was then mobilized medially away from the ASIS, by cutting the septum medial to sartorius. It was possible to mobilize the nerve for 2 cm medial to the ASIS. The nerve acquired a much straighter course with less tension. A new technique of LFCN transposition is presented here as an anatomical feasibility study. The surgical technique is based on the new understanding of the LFCN canal. Clin. Anat. 30:409-412, 2017. © 2017 Wiley Periodicals, Inc.

OBJECTIVE Meralgia paresthetica causes dysesthesias and burning in the anterolateral thigh. Surgical treatment includes nerve transection or decompression. Finding the nerve in surgery is very challenging. The author conducted a cadaveric study to better understand the variations in the anatomy of the lateral femoral cutaneous nerve (LFCN). METHODS Twenty embalmed cadavers were used for this study. The author studied the LFCN's relationship to different fascial planes, and the distance from the anterior superior iliac spine (ASIS). RESULTS A complete fascial canal was found to surround the nerve completely in all specimens. The canal starts at the inguinal ligament proximally and follows the nerve beyond its terminal branches. The nerve could be anywhere from 6.5 cm medial to the ASIS to 6 cm lateral to the ASIS. In the latter case, the nerve may lodge in a groove in the iliac crest. Other anatomical variations found were the LFCN arising from the femoral nerve, and a duplicated nerve. A thick nerve was found in 1 case in which it was riding over the ASIS. CONCLUSIONS The variability in the course of the LFCN can create difficulty in surgical exposure. The newly defined LFCN canal renders exposure even more challenging. This calls for high-resolution pre- or intraoperative imaging for better localization of the nerve.

Thoracic outlet syndrome (TOS) is caused by compression of the brachial plexus and/or subclavian vessels as they pass through the cervicothoracobrachial region, exiting the chest. There are three main types of TOS: neurogenic TOS, arterial TOS, and venous TOS. Neurogenic TOS accounts for approximately 95% of all cases, and it is usually caused by physical trauma (posttraumatic etiology), chronic repetitive motion (functional etiology), or bone or muscle anomalies (congenital etiology). We present two cases in which neurogenic TOS was elicited by vascular compression of the inferior portion of the brachial plexus.

Crucifixion was a widely used form of execution for capital crimes in antiquity. Civilizations and empires perfected the technique, leading to centuries of discussions, controversies, and questions, many of which concerned the death of Jesus Christ. To this day, much remains to be discovered in both religious and scientific realms. However, the aim of this study is to discuss such facts as are known from the medical perspectives of clinical anatomists. Nails/spikes were driven through the hands/wrists and feet of five adult cadavers, and the cadavers were then dissected to observe the anatomical structures that had been injured or placed at risk for injury. While many historical and archeological facts remain to be discovered, we hope that this cadaveric study will enhance our modern understanding of ancient practices from a medical and anatomical perspective. Clin. Anat. 32:12-21, 2019. © 2019 Wiley Periodicals, Inc.

Nerve stimulation is a reversible technique that is used successfully for the treatment of traumatic neuropathic pain, complex regional pain syndrome, and craniofacial neuropathic pain. Nerve field stimulation targets painful regions rather than a single nerve and has expanded indications, including axial low back pain. Appropriate patient education and motivation are crucial prior to surgery. Ongoing research is necessary to provide high-level evidence for the use of nerve stimulation. Most electrodes are primarily designed for spinal cord stimulation, hence the need to develop nerve electrodes dedicated for nerve stimulation.

Intractable pain from malignancy or other causes can be debilitating. When medical management fails, surgical treatment can be considered. Different techniques of surgical lesioning are presented here.

The gold standard for treating peripheral nerve injuries that have large nerve gaps where the nerves cannot be directly sutured back together because it creates tension on the nerve, is to incorporate an autologous nerve graft. However, even with the incorporation of a nerve graft, generally patients only regain a small portion of function in limbs affected by the injury. Although, there has been some promising results using growth factors to induce more axon growth through the nerve graft, many of these previous therapies are limited in their ability to release growth factors in a sustained manner and tailor them to a desired time frame. The ideal drug delivery platform would deliver growth factors at therapeutic levels for enough time to grow axons the entire length of the nerve graft. We hypothesized that mineral coated microparticles (MCMs) would bind, stabilize and release biologically active glial cell-derived neurotrophic factor (GDNF) and nerve growth factor (NGF) in a sustained manner. Therefore, the objective of this study was to test the ability of MCMs releasing growth factors at the distal end of a 10 mm sciatic nerve graft, to induce axon growth through the nerve graft and restore hind limb function. After sciatic nerve grafting in Lewis rats, the hind limb function was tested weekly by measuring the angle of the ankle at toe lift-off while walking down a track. Twelve weeks after grafting, the grafts were harvested and myelinated axons were analyzed proximal to the graft, in the center of the graft, and distal to the graft. Under physiological conditions in vitro, the MCMs delivered a burst release of NGF and GDNF for 3 days followed by a sustained release for at least 22 days. In vivo, MCMs releasing NGF and GDNF at the distal end of sciatic nerve grafts resulted in significantly more myelinated axons extending distal to the graft when compared to rats that received nerve grafts without growth factor treatment. The rats with nerve grafts incorporated with MCMs releasing NGF and GDNF also showed significant improvement in hind limb function starting at 7 weeks postoperatively and continuing through 12 weeks postoperatively when compared to rats that received nerve grafts without growth factor treatment. In conclusion, MCMs released biologically active NGF and GDNF in a sustained manner, which significantly enhanced axon growth resulting in a significant improvement of hind limb function in rats. The animal experiments were approved by University of Wisconsin-Madison Animal Care and Use Committee (ACUC, protocol# M5958) on January 3, 2018.

Autologous peripheral nerve grafts are commonly used clinically as a treatment for peripheral nerve injuries. However, in research using an autologous graft is not always feasible due to loss of function, which in many cases is assessed to determine the efficacy of the peripheral nerve graft. In addition, using allografts for research require the use of an immunosuppressant, which creates unwanted side effects and another variable within the experiment that can affect regeneration. The objective of this study was to analyze graft rejection in peripheral nerve grafts and the effects of cyclosporine A (CSA) on axonal regeneration.Peripheral nerve grafts in inbred Lewis rats were compared with Sprague-Dawley (SD) rats to assess graft rejection, CSA side effects, immune responses, and regenerative capability. Macrophages and CD8+ cells were labeled to determine graft rejection, and neurofilaments were labeled to determine axonal regeneration.SD rats without CSA had significantly more macrophages and CD8+ cells compared to Lewis autografts, Lewis isografts, and SD allografts treated with CSA. Lewis autografts, Lewis isografts, and SD autografts had significantly more regenerated axons than SD rat allografts. Moreover, allografts in immunosuppressed SD rats had significantly less axons than Lewis rat autograft and isografts.Autografts have long been the gold standard for treating major nerve injuries and these data suggest that even though CSA is effective at reducing graft rejection, axon regeneration is still superior in autografts versus immunosuppressed allografts.