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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, John C. Wellons III, Jeffrey P. Blount, Paul A. Grabb and W. Jerry Oakes

its segmental nervous innervation originates from here. The perceived shoulder pain could then be due to either stimulation of the supraclavicular nerves of the cervical plexus (C3–4) that innervate the skin over the shoulder or by stimulation of C-5 articular nerves to the shoulder joint, such as from the axillary or suprascapular nerves. Referred pain to the shoulder may result from C-5 radiculopathy (disc prolapse or foraminal stenosis), brachial plexus irritation (cervical rib or scalene entrapment), cervical zygapophysial joint pathology, entrapment of the

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R. Shane Tubbs, John C. Wellons III, Jeffrey P. Blount, Paul A. Grabb and W. Jerry Oakes

its segmental nervous innervation originates from here. The perceived shoulder pain could then be due to either stimulation of the supraclavicular nerves of the cervical plexus (C3–4) that innervate the skin over the shoulder or by stimulation of C-5 articular nerves to the shoulder joint, such as from the axillary or suprascapular nerves. Referred pain to the shoulder may result from C-5 radiculopathy (disc prolapse or foraminal stenosis), brachial plexus irritation (cervical rib or scalene entrapment), cervical zygapophysial joint pathology, entrapment of the

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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, Mohammadali M. Shoja, Leslie Acakpo-Satchivi, John C. Wellons III, Jeffrey P. Blount, W. Jerry Oakes and Bermans J. Iskandar

, and anatomical landmarks, such as the anterior scalene and phrenic nerves and the upper trunks of the brachial plexus, were identified. The triangle of the VA was carefully approached by retracting the SCM muscle medially, and the origin of the VA from the subclavian artery was identified ( Fig. 2 ). The VA was followed superiorly to its entrance into the C-6 transverse foramen. The C1–6 transverse foramina were palpated, and muscles overlying their lateral parts (for example, the anterior scalene and levator scapulae) were dissected using a periosteal dissector. In

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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

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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

T he suprascapular nerve is a branch of the upper trunk of the brachial plexus and is comprised of C-5 and sometimes C-6 ventral root fibers. This nerve travels through the posterior cervical triangle alongside the suprascapular artery and vein in a slightly deeper plane than the posterior belly of the omohyoid muscle as it proceeds toward the medial lip of the suprascapular notch. The suprascapular nerve and vessels become segregated as the nerve continues deep to the suprascapular ligament, and the vessels travel superficial to this band ( Fig. 1 ). In