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Acute injury of the trigeminal nerve or its branches can result in posttraumatic trigeminal neuropathy (PTTN). Affected patients suffer from chronic debilitating symptoms long after they have recovered from the inciting trauma. Symptoms vary but usually consist of paresthesia, allodynia, dysesthesia, hyperalgesia, or a combination of these symptoms. PTTN of the trigeminal nerve can result from a variety of traumas, including iatrogenic injury from various dental and maxillofacial procedures. Treatments include medications, pulsed radiofrequency modulation, and microsurgical repair. Although trigeminal nerve stimulation has been reported for trigeminal neuropathy, V3 implantation is often avoided because of an elevated migration risk secondary to mandibular motion, and lingual nerve implantation has not been documented. Here, the authors report on a patient who suffered from refractory PTTN despite multiple alternative treatments. He elected to undergo novel placement of a lingual nerve stimulator for neuromodulation therapy. To the best of the authors’ knowledge, this is the first documented case of lingual nerve stimulator implantation for lingual neuropathy, a technique for potentially reducing the risk of electrode migration.

BackgroundFollowing mild traumatic brain injury (mTBI) compromised white matter structural integrity can result in alterations in functional connectivity of large-scale brain networks and may manifest in functional deficit including cognitive dysfunction. Advanced magnetic resonance neuroimaging techniques, specifically diffusion tensor imaging (DTI) and resting state functional magnetic resonance imaging (rs-fMRI), have demonstrated an increased sensitivity for detecting microstructural changes associated with mTBI. Identification of novel imaging biomarkers can facilitate early detection of these changes for effective treatment. In this study, we hypothesize that feature selection combining both structural and functional connectivity increases classification accuracy.Methods16 subjects with mTBI and 20 healthy controls underwent both DTI and resting state functional imaging. Structural connectivity matrices were generated from white matter tractography from DTI sequences. Functional connectivity was measured through pairwise correlations of rs-fMRI between brain regions. Features from both DTI and rs-fMRI were selected by identifying five brain regions with the largest group differences and were used to classify the generated functional and structural connectivity matrices, respectively. Classification was performed using linear support vector machines and validated with leave-one-out cross validation.ResultsGroup comparisons revealed increased functional connectivity in the temporal lobe and cerebellum as well as decreased structural connectivity in the temporal lobe. After training on structural connections only, a maximum classification accuracy of 78% was achieved when structural connections were selected based on their corresponding functional connectivity group differences. After training on functional connections only, a maximum classification accuracy of 69% was achieved when functional connections were selected based on their structural connectivity group differences. After training on both structural and functional connections, a maximum classification accuracy of 69% was achieved when connections were selected based on their structural connectivity.ConclusionsOur multimodal approach to ROI selection achieves at highest, a classification accuracy of 78%. Our results also implicate the temporal lobe in the pathophysiology of mTBI. Our findings suggest that white matter tractography can serve as a robust biomarker for mTBI when used in tandem with resting state functional connectivity.

Tentorial dural arteriovenous fistulas have an increased risk of rupture and hemorrhage, and therefore require urgent treatment to occlude the fistula and proximal venous drainage. This is usually accomplished via endovascular treatment. We present a case of a Cognard grade IV dural arteriovenous fistula that presented as trigeminal neuralgia. This video showcases the angiographic vascular composition of the lesion with main feeders coming from the middle meningeal artery and the tentorial artery of Bernasconi and Cassinari. Details, benefits, and risks of the procedure were thoroughly discussed with the patient and consent was obtained prior to the procedure. We performed endovascular Onyx embolization through a distal branch of the right middle meningeal artery. We were able to successfully occlude the lesion using Onyx embolization and the patient had significant improvement of her pretreatment trigeminal neuralgia.

The lingual nerve is a branch of the posterior trunk of the mandibular nerve. It provides sensation and taste to the ipsilateral anterior two-thirds of the tongue. Posttraumatic neuropathy of the lingual nerve can be chronic and debilitating long after the inciting trauma. In this operative video, the authors describe a novel technique for the treatment of lingual nerve neuropathy with neuromodulation. They present a case of a 69-year-old female with posttraumatic lingual nerve neuropathy after left molar extraction. The patient reported 95% symptom improvement after the procedure. This video demonstrates the feasibility of lingual nerve neuromodulation.The video can be found here: https://youtu.be/l-CKP8-8eqk

Anterior ankle impingement (AAI) results from repetitive microtrauma leading to pain and decreased dorsiflexion due to spur formation and synovial hypertrophy. Information about the prevalence of anterior spur formation in a large population, and the individual contributions of the talus and tibia to osseous impingement, is limited. A total of 670 ankle specimens from 344 individuals (n = 111 females, n = 233 males) aged 20 to 40 years at the time of death were examined. Matching tibia and talus were opposed and any spurring causing impingement was recorded. Spur locations were measured and ratios calculated to allow for inter-specimen comparison between: (1) medial-to-lateral and anterior-to-posterior spur location versus dimensions of talar neck width, and (2) medial-to-lateral spur location to dimensions of distal anterior tibial width. Differences in spur prevalence in relation to sex, race, height and age were identified by univariant and multivariable statistical analyses. Bony impingement was observed in 21% (n = 72) of specimens, with bilateral involvement in 8% (n = 27). For ankles with AAI, spurs were seen on the talus only in 61%, on the tibia only in 14%, and on both the tibia and talus in 26%. Spurs were significantly more prevalent in males (P = 0.001) and with increasing specimen age (P = 0.002). There were no significant differences related to specimen height or race. Spurs were predominately located on the anterolateral talus (78%) and the anterolateral portion of the distal tibial margin (80%). AAI was present in 21% of young osseous specimens and was significantly more prevalent in males and with increasing specimen age. Clin. Anat. 31:1144-1150, 2018. © 2018 Wiley Periodicals, Inc.

A great variety of anomalies of hand extensor musculature have been described over the last century and a half, beginning with Wood (1864) [15–19]. Hand extensor anomalies have been observed in cadaveric cases, during hand surgeries, and through imaging. The continued identification of these anomalies is important in academic studies to examine limb function and characteristics of human development. In addition, reporting limb anomalies is important not only in the clinical diagnosis and treatment of limb dysfunction and injury, but also for awareness in human anatomical and functional variation. In this case study, we present cadaveric cases of muscular anomalies in the third and fourth extensor compartments of the wrist and anomalous tendons that were observed and identified by students during dissection in a graduate human gross anatomy course. Bilateral anomalies were observed in the extensors of the thumb and index finger in the hands of a 103-year-old female cadaver, and a unilateral anomaly was observed in an 85-year-old female cadaver. Dissection and isolation of the anomalies showed some similarity of the anomalies between the two cadavers, in that the anomalies presented associations between the individual extensors in the third and fourth extensor compartments. Further, the cadavers were received in sequential order through the Body Donation Program at Case Western Reserve University School of Medicine and were investigated for a familial link.