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R. Shane Tubbs, Mohammadali M. Shoja, Marios Loukas, W. Jerry Oakes and Aaron Cohen-Gadol

William Henry Battle (1855–1936) practiced medicine in England > 1 century ago and is primarily remembered for his description of ecchymosis over the mastoid, which indicates fracture of the skull base. Although Mr. Battle made many contributions to medicine, almost nothing exists in the literature regarding his life and findings, especially in regard to head injury. The following is a review of Battle's background and his contributions to medicine, specifically his observations associated with basilar skull fractures.

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Ghaffar Shokouhi, John C. Wellons III, W. Jerry Oakes and Aaron A. Cohen-Gadol

Object

Various donor nerves, including the ipsilateral long thoracic nerve (LTN), have been used for brachial plexus neurotization procedures. Neurotization to proximal branches of the brachial plexus using the contralateral long thoracic nerve (LTN) has, to the authors' knowledge, not been previously explored.

Methods

In an attempt to identify an additional nerve donor candidate for proximal brachial plexus neurotization, the authors dissected the LTN in 8 adult human cadavers. The nerve was transected at its distal termination and then passed deep to the clavicle and axillary neurovascular bundle. This passed segment of nerve was then tunneled subcutaneously and contralaterally across the neck to a supra- and infraclavicular exposure of the suprascapular and musculocutaneous nerves. Measurements were made of the length and diameter of the LTN.

Results

All specimens were found to have a LTN that could be brought to the aforementioned contralateral nerves. Neural connections remained tension free with left and right neck rotation of ~ 45°. The mean length of the LTN was 22 cm with a range of 18–27 cm. The overall mean diameter of this nerve was 3.0 mm. No gross evidence of injury to surrounding neurovascular structures was identified in any specimen.

Conclusions

Based on the results of this cadaveric study, the use of the contralateral LTN may be considered for neurotization of the proximal musculocutaneous and suprascapular nerves.

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Mohammad Ardalan and W. Jerry Oakes

The 11th century was culturally and medicinally one of the most exciting periods in the history of Islam. Medicine of this day was influenced by the Greeks, Indians, Persians, Coptics, and Syriacs. One of the most prolific writers of this period was Ibn Jazlah, who resided in Baghdad in the district of Karkh. Ibn Jazlah made many important observations regarding diseases of the brain and spinal cord. These contributions and a review of the life and times of this early Muslim physician are presented.

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Mohammad R. Ardalan, Nihal Apaydin, Candice Myers, Ghaffar Shokouhi and W. Jerry Oakes

Object

The intradural contributions of the C-4 nerve rootlets have not been previously evaluated for their connections to the brachial plexus. The authors undertook a cadaveric study to evaluate the C-4 contributions to the upper trunk of the brachial plexus.

Methods

The posterior cervical triangles from 60 adult cadavers were dissected. All specimens that were found to have extradural C-4 contributions to the upper trunk of the brachial plexus were excluded from further study. In specimens found to have no extradural C-4 contributions to the brachial plexus a C1–T1 laminectomy was performed. Observations were made of any neural communications between adjacent spinal rootlets, specifically between C-4 and C-5.

Results

Nine (15%) of the 60 sides were found to have extradural C-4 contributions to the upper trunk of the brachial plexus. These sides were excluded from further study. No specimen was found to have a postfixed brachial plexus. Of the remaining 51 sides, 11 (21.6%) were found to have intradural neural connections between C-4 and C-5 dorsal rootlets and 1 (1.96%) had a connection between the ventral roots of C-4 and C-5. Communications between these 2 adjacent dorsal cervical cord levels were of 3 types. Type I was a vertical communication between the more horizontally traveling dorsal roots. Type II was a forked communication between adjacent C-4 and C-5 dorsal rootlets. The Type III designation was applied to connections between ventral rootlets. Although communications were slightly more frequent on left sides, this did not reach statistical significance.

Conclusions

In ~ 20% of normally composed brachial plexuses (those with extradural contributions from only C5–T1) we found intradural C4–5 neural connections. Such variations may lead to misinterpretation of spinal levels in pathological conditions of the spinal axis and should be considered in surgical procedures of this region, such as rhizotomy.

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R. Shane Tubbs, William A. Shaffer, Marios Loukas, Mohammadali M. Shoja and W. Jerry Oakes

Object

Injury of the facial nerve with resultant facial muscle paralysis may result in other significant complications such as corneal ulceration. To the authors' knowledge, neurotization to the facial nerve using the long thoracic nerve (LTN), a nerve used previously for neurotization to other branches of the brachial plexus, has not been explored previously.

Methods

In an attempt to identify an additional nerve donor candidate for facial nerve neurotization, 8 adult human cadavers (16 sides) underwent dissection of the LTN, which was passed deep to the clavicle and axillary neurovascular bundle. The facial nerve was localized from the stylomastoid foramen onto the face, and the distal cut end of the previously dissected LTN was tunneled to this location. Measurements were made of the length and diameter of the LTN. Long thoracic nerve innervation to the first and second digitations of the serratus anterior was maintained on all sides.

Results

All specimens were found to have an LTN with more than enough length to be tunneled superiorly, tension-free to the extracranial facial nerve. Connections remained tensionless with left and right head rotation of up to 45°. The mean length of this part of the LTN was 18 cm with a range of 15–22 cm. The overall mean diameter of this nerve was 2.5 mm. No evidence of injury to the surrounding neurovascular structures was identified on gross examination.

Conclusions

To the authors' knowledge, the LTN has not been previously examined as a donor nerve for facial nerve reanimation procedures. Based on the results of this cadaveric study, the use of the LTN may be considered for such surgical maneuvers.

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Ghaffar Shokouhi and W. Jerry Oakes

✓François Magendie lived during a tumultuous period in French history. Although this early medical pioneer made significant contributions to the fields of neuroanatomy, physiology, and pharmacology, little information is found in the non-French literature regarding this significant person in history. Based on this review, one could also consider this trained surgeon as an early pioneer of neurosurgery. For example, he is known to have used Galvanic current to treat various neuralgias, described a technique for extracting cerebrospinal fluid and quantitated and described its characteristics in normal and pathological specimens, and elucidated the functions of the the cranial nerves using vivisection. Additionally, he accurately described the functions of the dorsal and ventral rootlets using vivisection, and realized that the exposed meninges were susceptible to painful stimuli. Our current knowledge is based on the early contributions of scientists such as François Magendie.

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Nihal Apaydin, Mohammad R. Ardalan and W. Jerry Oakes

Object

There is scant and conflicting information in the literature regarding the lateral lacunae, or lateral lakes of Trolard. As these venous structures can be encountered surgically, this study aimed at further elucidating their anatomy, identifying surgical landmarks, and associated quantitation.

Methods

Thirty-five adult cadavers were dissected of lateral lacunae. Following quantitation of the lacunae, these structures were measured, as were the distances from them to the coronal and sagittal sutures.

Results

A mean of 1.9 lacunae were identified on the right sides and 1.4 lacunae on the left sides. Although there tended to be slightly more lacunae on the right sides, this difference did not reach statistical significance (p > 0.05). The average lengths of the lacunae were 3.2 and 2.0 cm for the right and left sides, respectively. The mean widths of these venous lakes were 1.5 cm for the right sides and 0.8 cm for the left sides. Lacunae were variably positioned but tended to cluster near the vertex of the skull. None were identified posterior to the lambdoid sutures, and only 5 were found to lie anterior to the coronal suture, with 4 of these located on right sides (p < 0.05). When lacunae were identified anterior to the coronal suture, they were generally 5–6 cm from this structure. The majority of lacunae could be identified between the coronal and lambdoid sutures and within 3 cm of the midline.

Conclusions

Although the situation varies, lateral lacunae are concentrated posterior to the coronal suture and anterior to the lambdoid sutures. They are most often found within 3 cm of the sagittal suture. These previously unreported data could be useful to the neurosurgeon in planning surgical procedures that traverse the calvaria.

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R. Shane Tubbs, Robert G. Louis Jr., Christopher T. Wartmann, Marios Loukas, Mohammadali M. Shoja, Mohammad R. Ardalan and W. Jerry Oakes

Object

Facial nerve injury with resultant facial muscle paralysis is disfiguring and disabling. To the auhtors' knowledge, neurotization of the facial nerve using a branch of the brachial plexus has not been previously performed.

Methods

In an attempt to identify an additional nerve donor candidate for facial nerve neurotization, 5 fresh adult human cadavers (10 sides) underwent dissection of the suprascapular nerve distal to the suprascapular notch where it was transected. The facial nerve was localized from the stylomastoid foramen onto the face, and the cut end of the suprascapular nerve was tunneled to this location. Measurements were made of the length and diameter of the supra-scapular nerve. In 2 of these specimens prior to transection of the nerve, a nerve-splitting technique was used.

Results

All specimens were found to have a suprascapular nerve with enough length to be tunneled, tension free, superiorly to the extracranial facial nerve. Connections remained tensionless with left and right head rotation of up to 45°. The mean length of this part of the suprascapular nerve was 12.5 cm (range 11.5–14 cm). The mean diameter of this nerve was 3 mm. A nerve-splitting technique was also easily performed. No gross evidence of injury to surrounding neurovascular structures was identified.

Conclusions

To the authors' knowledge, the suprascapular nerve has not been previously explored as a donor nerve for facial nerve reanimation procedures. Based on the results of this cadaveric study, the authors believe that use of the suprascapular nerve may be considered for surgical maneuvers.

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R. Shane Tubbs, Mark Hill, Marios Loukas, Mohammadali M. Shoja and W. Jerry Oakes

Object

Many authors have concluded that the Chiari malformation Type I (CM-I) is due to a smaller than normal posterior cranial fossa. In order to establish this smaller geometry as the cause of hindbrain herniation in a family, the authors of this paper performed volumetric analysis in a family found to have this malformation documented in 4 generations.

Methods

Members from this family found to have a CM-I by imaging underwent volumetric analysis of their posterior cranial fossa using the Cavalieri method.

Results

No member of this family found to have CM-I on preoperative imaging had a posterior fossa that was significantly smaller than that of age-matched controls.

Conclusions

The results of this study demonstrate that not all patients with a CM-I will have a reduced posterior cranial fossa volume. Although the mechanism for the development of hindbrain herniation in this cohort is unknown, this manifestation can be seen in multiple generations of a familial aggregation with normal posterior fossa capacity.

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Robert J. Spinner, Erik H. Middlebrooks, William R. Stetler Jr., Leslie Acakpo-Satchivi, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes

Object

The suprascapular nerve may become entrapped as it travels deep to the suprascapular ligament, necessitating decompression. The present study was performed to verify the feasibility of a minimally invasive, endoscopically assisted technique for decompressing the suprascapular nerve in the supraspinous fossa.

Methods

The authors performed dissection and decompression of the suprascapular ligament using an endoscopically assisted technique via a 3-cm skin incision in 10 adult cadavers (20 sides). Measurements were also made of the depth from the skin to the suprascapular ligament.

Results

A mean depth of 4 cm was necessary to reach the suprascapular ligament from the skin surface. With the authors' approach, no obvious injury occurred to the suprascapular or other vicinal neurovascular structures (such as the spinal accessory nerve and suprascapular vessels).

Conclusions

The results of this cadaveric study demonstrate that access to the suprascapular nerve can be obtained endoscopically via a small suprascapular incision. This approach obviates a large incision, entry into the glenohumeral joint, and reduces the risk of spinal accessory nerve injury in the posterior cervical triangle, or atrophy of the trapezius or supraspinatus muscles from a standard larger dissection. To the authors' knowledge an endoscopically assisted approach to decompressing the suprascapular nerve as it courses deep to the suprascapular ligament has not been reported previously.