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R. Shane Tubbs, E. George Salter, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes

The dissection of the nerves is a toilsome and difficult matter for many reasons. Consequently, I believe that in regard to the very small nerves, a number of anatomists simply follow what they find to be the likeliest and most reasonable course, that of adopting what others have said without having seen the nerves with their own eyes. Many of them have made unsatisfactory statements about them. Galen ca. AD 160 A lthough much less common than injuries of the brachial plexus, injuries to the lumbar plexus do occur, and the surgeon must be familiar with

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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

I solated axillary nerve injuries make up as many as 6% of all brachial plexus injuries. 21 The axillary nerve, or circumflex nerve, is one of the two terminal branches of the posterior cord of the brachial plexus; the radial nerve is the second. Usually, the axillary nerve contains fibers from C-5 and C-6 ventral rami. This nerve innervates the teres minor and deltoid muscles, skin over the shoulder (upper lateral brachial nerve), and the glenohumeral joint. 22 Traveling posteriorly, the axillary nerve enters and traverses the QS, or foramen of Velpeau. 19

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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

: Photograph depicting the anterior view of a cadaveric specimen. Note the proximal brachial plexus and suprascapular nerve ( left arrowhead of horizontal double arrow ) and the phrenic nerve crossing the anterior scalene muscle ( right arrowhead of horizontal double arrow ). The oblique double arrow marks the cervical plexus (right arrowhead) and DSN exiting the middle scalene muscle (left arrowhead). Right: Line drawing of Fig. 1 left . Note the middle and posterior scalene muscles deep to the dorsal and suprascapular nerves. Also observe the proximal brachial

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R. Shane Tubbs, E. George Salter, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes

cadaveric specimen. a = SCM muscle; b = upper fibers of the trapezius muscle; c = clavicle. Note the SAN (wide arrow) superficial to the levator scapulae muscle and the transverse cervical artery (thin arrow) crossing the brachial plexus and middle scalene muscle. The transverse cervical nerve is seen crossing from posterior to anterior, superficial to the SCM muscle. Fig. 2. Schematic drawing of the left side of the neck. Note the measurements made in this study with ranges and means ± SDs: the distance between the angle (a) of the mandible and the

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R. Shane Tubbs, James W. Custis, E. George Salter, Jeffrey P. Blount, W. Jerry Oakes and John C. Wellons III

T he ulnar nerve, the largest derived from the medial cord of the brachial plexus, leaves the ulnar sulcus posterior to the medial humeral epicondyle and passes between the humeral and ulnar heads of the FCU muscle as the nerve enters the forearm. The two heads of this muscle are often connected by the arcuate ligament (the Osborne ligament) 8 , 17 a tendinous arch that is a continuation of the fibroaponeurotic covering of the epicondylar groove and defines the roof of the cubital tunnel. 12 When important motor nerves are injured, it is advantageous for

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R. Shane Tubbs, James W. Custis, E. George Salter, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes

Object

There are scant data regarding the anterior interosseous nerve (AIN) in the neurosurgical literature. In the current study the authors attempt to provide easily identifiable superficial osseous landmarks for the identification of the AIN.

Methods

The AIN in 20 upper extremities obtained in adult cadaveric specimens was dissected and quantified. Measurements were obtained between the nerve and surrounding superficial osseous landmarks.

The AIN originated from the median nerve at mean distances of 5.4 cm distal to the medial epicondyle of the humerus and 21 cm proximal to the ulnar styloid process. The distance from the origin of the AIN to its branch leading to the flexor pollicis longus muscle and to the point it travels deep to the pronator quadratus (PQ) muscle measured a mean 4 and 14.4 cm, respectively. The mean distance from the AIN branch leading to the flexor pollicis longus muscle to the proximal PQ muscle was 12.1 cm, and the mean distance between this branch and the ulnar styloid process was 7.2 cm. The mean diameter of the AIN was 1.6 mm at the midforearm.

Conclusions

Additional landmarks for identification of the AIN can aid the neurosurgeon in more precisely isolating this nerve and avoiding complications. Furthermore, after quantitation of this nerve, the AIN branches can be easily used for neurotization of the median and ulnar nerves, and with the aid of a transinterosseous membrane tunneling technique, passed to the posterior interosseous nerve.

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R. Shane Tubbs, E. George Salter, James W. Custis, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes

. Results There was no statistically significant difference in the nerve between sexes or sides (p > 0.05). The LTN's length ranged from 23 to 30 cm (mean 27 ± 4.5 cm) and its main trunk diameter from 2.5 to 3.5 mm (mean 3 ± 2.5 mm). Two to three branches were noted to leave the main trunk of this nerve and enter each digitation of the serratus anterior muscle. No pre- or postfixed brachial plexuses were noted. The distance from the angle of the mandible to the most proximal portion of the LTN ranged from 4 to 8.5 cm (mean 6 ± 1.1 cm). The distance from this proximal

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, E. George Salter, W. Jerry Oakes and Jeffrey P. Blount

border of the trapezius muscle, and posterior border of the SCM muscle. Important structures within or adjacent to this geometric region include the spinal accessory nerve, proximal brachial plexus, phrenic nerve, and branches of the thyrocervical trunk (for example, the suprascapular and transverse cervical arteries). There were no injuries to any of these structures during the posterior approach to the vagus nerve in the cervical region; however, special care is necessary to avoid injury to, or excessive retraction on, the spinal accessory nerve, which is found

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R. Shane Tubbs, Charles A. Khoury, E. George Salter, Leslie Acakpo-Satchivi, John C. Wellons III, Jeffrey P. Blount and W. Jerry Oakes

F lexion of the elbow and abduction of the shoulder are essential to the ability to manipulate items and feed oneself. 6 Therefore, restoring these functions after brachial plexus injury is a main goal in neurotization of this area. 5 In cases of isolated musculocutaneous or axillary nerve injury in which a primary reanastomosis is not possible, intersegmental graft or neurotization procedures are performed. As a candidate nerve for grafting or neurotization in these cases the LSN has not been explored specifically ( Fig. 1 ). This branch of the