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  • By Author: Tyler-Kabara, Elizabeth C. x
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  • By Author: Oakes, W. Jerry x
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Jeffrey P. Blount, R. Shane Tubbs, Mamehri Okor, Elizabeth C. Tyler-Kabara, John C. Wellons III, Paul A. Grabb and W. Jerry Oakes

Object

The authors describe the technique of transecting the spinal cord in children born with myelomeningocele who have undergone multiple detherings and are functionally paraplegic.

Methods

The authors' technique involves identifying the neural placode and sectioning the normal spinal cord just superior to this site. No postoperative complications have been identified in 14 patients undergoing this procedure over an 11-year period. No patient at last follow up was found to have symptoms referable to a tethered spinal cord. The advantage of this procedure is to excise the normally pia-coated cord, which is unlikely to retether compared with the neural placode, which is often covered with scar tissue and does not have a well-formed pial surface—hence, predisposing it to frequent dorsal adhesions.

Conclusions

The authors believe that this technique is of benefit in a small, carefully selected group of myelodys-plastic patients with repetitive tethering of the spinal cord.

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R. Shane Tubbs, Elizabeth C. Tyler-Kabara, Alan C. Aikens, Justin P. Martin, Leslie L. Weed, E. George Salter and W. Jerry Oakes

Object. There is a paucity of literature regarding the surgical anatomy of the quadrangular space (QS), which is a potential site of entrapment for the axillary nerve. Muscle hypertrophy of this geometrical area and fascial bands within it have been implicated in compression of the axillary nerve.

Methods. Fifteen human cadavers (30 sides) were dissected for this study. Measurements of the QS and its contents were made. The mean height of this space was 2.5 cm and the mean width 2.5 cm; its mean depth was 1.5 cm. The axillary nerve was always the most superior structure in the space, and in all cases the nerve and artery hugged the surgical neck of the humerus just superior to the origin of the lateral head of the triceps brachii muscle. This arrangement placed the axillary nerve in the upper lateral portion of the QS in all cadaveric specimens. The nerve branched into its muscular components within this space in 10 sides (33%) and posterior to it in 20 sides (66%). The cutaneous component of the axillary nerve branched from the main trunk of the nerve posterior to the QS in all specimens. Fascial bands were found in this space in 27 (90%) of 30 sides.

Conclusions. Knowledge of the anatomy of the QS may aid the surgeon who wishes to explore and decompress the axillary nerve within this geometrical confine.

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R. Shane Tubbs, Elizabeth C. Tyler-Kabara, Alan C. Aikens, Justin P. Martin, Leslie L. Weed, E. George Salter and W. Jerry Oakes

Object. There is a paucity of literature regarding the surgical anatomy of the dorsal scapular nerve (DSN). The aim of this study was to elucidate the relationship of this nerve to surrounding anatomical structures.

Methods. Ten formalin-fixed human cadavers (20 sides) were dissected, and measurements made between the DSN and related structures. The nerve pierced the middle scalene muscle at a mean distance of 3 cm from its origin from the cervical spine and was more or less centrally located at this exit site. It lay a mean distance of 1.5 cm medial to the vertebral border of the scapula between the serratus posterior superior, posterior scalene, and levator scapulae muscles. It was found to have a mean distance of 2.5 cm medial to the spinal accessory nerve as it traveled on the anterior border of the trapezius muscle. The nerve intertwined the dorsal scapular artery in all specimens and was found along the anterior border of the rhomboid muscles. On 19 sides the DSN originated solely from the C-5 spinal nerve, and on one side it arose from the C-5 and C-6 spinal nerves.

Conclusions. Knowledge of the anatomy of the DSN will aid the surgeon who wishes to explore and decompress this structure.

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R. Shane Tubbs, Elizabeth C. Tyler-Kabara, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes

✓The authors present three cases of infants born with myelodysplasia. Each infant underwent closure of a myelomeningocele and within 2 to 4 days placement of a ventriculoperitoneal (VP) shunt. In each case, on opening the peritoneal cavity, the authors observed egress of a dark or creamy dark fluid. None of the patients had a history of abdominal birth trauma. The decision was made to continue the procedures and send samples of the unusual fluids to the laboratory for culture and analysis. The cultures proved to be nondiagnostic and the characteristics of the fluid samples were most consistent with those of blood-tinged chyle. The authors hypothesize that, occasionally, the mechanical tautness that is created with repair of myelomeningoceles is sufficient to rupture small lymphatic vessels and accompanying blood vessels of the abdomen. An alternative hypothesis is that abdominal compression due to closure of the myelomeningocele may temporarily compress the liver, leading to raised intraportal pressures and resulting in weeping of chyle from the gastrointestinal tract. This abnormal fluid accumulation did not lead to chronic ascites, VP shunt infection, or dysfunction at long-term follow-up examination and abdominal visceral function has not been an issue.