Spinner, Robert J.

Snapping elbow is a well‐known condition where elbow flexion and extension elicits a painful, popping sensation. The most frequent etiology is anterior dislocation of the ulnar nerve over the medial epicondyle. Four patients (3 females and 1 male) presented with complaints of a popping sensation in the elbow, pain over the medial aspect of the forearm, and ulnar neuritis. All patients underwent preoperative dynamic ultrasound and surgical exploration of the medial elbow. Intraoperatively, snapping of the MABC over the medial epicondyle was discovered in all four patients. In three patients, there was abnormal displacement of the medial triceps and ulnar nerve: in two of these, both structures dislocated over the medial epicondyle and in one patient both structures subluxated. In each case, the MABC was decompressed (n = 1) and transposed (n = 3), and in three cases, the medial triceps and ulnar nerve were addressed as well. Symptomatic improvement was achieved in all cases. Retrospective review of the ultrasound revealed the snapping MABC, though it was less effective prospectively in the cases when snapping MABC was not suspected. In conclusion, snapping of the MABC broadens the spectrum of disorders that results in snapping elbow. To our knowledge, we are unaware of prior reports of this entity. Clin. Anat. 28:872–877, 2015. © 2015 Wiley Periodicals, Inc.

Based on our experience in treating peripheral non‐neural sheath derived pathology, we have identified a novel pattern of lesion progression along the anatomic course of nerves. This report highlights the existence of a subparaneurial compartment around peripheral nerves. We first applied an anatomic framework to review MR images and intraoperative photographs of patients treated by the senior author in the last 10 years. After identifying a pattern that was consistent with subparaneurial lesion progression, we searched for other examples of cases that might exhibit this pattern. Four examples of subparaneurial pathology were identified, a hemangioma of the ulnar nerve, a ganglion cyst of the common fibular nerve, a lymphoma of the sciatic nerve and a lipoma of the ulnar nerve. All four patients were operated on and had intraoperative photographs; three had high resolution MR imaging. This report highlights the existence of pathology contained within a subparaneurial compartment, outside of the epineurium, that follows the course of the nerve and surrounds it circumferentially. The subparaneurial localization of peripheral nerve lesions has hitherto received little attention. Identification of this new pattern on preoperative MRI may have implications for surgical management. Clin. Anat. 28:925–930, 2015. © 2015 Wiley Periodicals, Inc.

Iatrogenic injury of the spinal accessory nerve (SAN) is a significant reducible risk with any invasive procedure involving the posterior cervical triangle. Most commonly associated with cervical lymph node biopsy, it affects 3–6% of patients and serves as a major cause of avoidable medical malpractice litigation. Medical malpractice cases not only affect the primary surgeon but also may include the repairing surgeon through a shift of blame. For this reason, we discuss the strategies all clinicians may utilize in approaching iatrogenic SAN injuries. By taking basic precautionary measures based on simple application of anatomy in the management of these patients, clinicians may protect themselves from needless malpractice litigation. A thorough knowledge of the anatomy and application in preventative strategies may provide guidance for clinicians in reducing the incidence of iatrogenic injuries, providing effective postinjury management, and ensuring the salvaging surgeon is not at fault if litigation is pursued. Clin. Anat. 28:761–766, 2015. © 2015 Wiley Periodicals, Inc.

OBJECT Despite the growing epidemic of falls, the true incidence of peripheral nerve injuries (PNIs) in this patient population remains largely unknown. METHODS The authors performed a retrospective cohort study of 839,210 fall-injured patients who were registered in the National Trauma Data Bank (NTDB) between 2009 and 2011 and fulfilled the inclusion criteria. Regression techniques were used to investigate the association of demographic and socioeconomic factors with the rate of PNIs in this patient population. The association of age with the incidence of PNIs was also investigated. RESULTS Overall, 3151 fall-injured patients (mean age 39.1 years, 33.3% females) sustained a PNI (0.4% of all falls). The respective incidence of PNIs was 2.7 per 1000 patients for ground-level falls, 4.9 per 1000 patients for multilevel falls, and 4.5 per 1000 patients for falls involving force. This demonstrated a rapid increase in the first 2 decades of life, with a maximum rate of 1.1% of all falls in the 3rd decade, followed by a slower decline and eventual plateau in the 7th decade. In a multivariable analysis, the association of PNIs with age followed a similar pattern with patients 20–29 years of age, demonstrating the highest association (OR 2.34 [95% CI 2.0–2.74] in comparison with the first decade of life). Falls involving force (OR 1.25 [95% CI 1.14–1.37] in comparison with multilevel falls) were associated with a higher incidence of PNIs. On the contrary, female sex (OR 0.87 [95% CI 0.80–0.84]) and ground-level falls (OR 0.79 [95% CI 0.72–0.86]) were associated with a lower rate of PNIs. CONCLUSIONS Utilizing a comprehensive national database, the authors demonstrated that PNIs are more common than previously described in fall-injured patients and identified their age distribution. These injuries are associated with young adults and falls of high kinetic energy.

To satisfy different mechanical requirements in hard and soft tissue replacements, a series of biodegradable and crosslinkable copolymers of poly(propylene fumarate)‐co‐polycaprolactone (PPF‐co‐PCL) are synthesized and employed to fabricate 2D disks and 3D scaffolds via photocrosslinking. Thermal properties such as the glass transition temperature (Tg) and melting temperature (Tm) of the PPF‐co‐PCL networks can be controlled efficiently by varying the PCL composition (φPCL). As a result, their mechanical properties vary significantly from hard and stiff materials to soft and flexible ones with increasing φPCL, making them attractive candidate materials for bone and peripheral nerve regeneration, respectively. Several PPF‐co‐PCL formulations are selected to perform in vitro cell studies using mouse pre‐osteoblastic MC3T3‐E1, rat Schwann cell precursor line (SPL201), and pheochromocytoma (PC12) cells, and in vivo animal testing in the rat femur bone defect model and in the rat sciatic nerve transection model. The formation of new bone in the porous bone scaffolds with a low φPCL and guided axon growth through the nerve conduits with a higher φPCL suggest that crosslinked PPF‐co‐PCLs have appropriate compatibility and functionality. Furthermore, the role of surface stiffness in modulating cellular behavior and functions is verified on the crosslinked PPF‐co‐PCL surfaces without any pretreatments.

ABSTRACTIntroductionNeurolymphomatosis (NL) is a rare disorder characterized by invasion of cranial or peripheral nerves, nerve roots, or plexi, usually by aggressive subtypes of non‐Hodgkin lymphoma (NHL). The most common clinical presentation is that of a painful polyneuropathy or polyradiculopathy, followed by cranial neuropathy and, less frequently, by painless polyneuropathy.MethodsClinical and pathologic findings are reported for 2 NL cases.ResultsThe following 2 patients with NL, with disparate clinical presentations, are presented: a patient with subacute onset, painful, multifocal, mixed axonal and demyelinating radiculoplexus neuropathy due to a large B‐cell NHL, who required 2 targeted fascicular nerve biopsies to demonstrate NL; and a patient with a slowly progressive, length‐dependent axonal polyneuropathy due to a low‐grade B‐cell lymphoproliferative disorder, as shown on a diagnostic sural nerve biopsy.ConclusionsThe cases described illustrate the wide clinical spectrum of NL. Muscle Nerve 52:449–454, 2015

The authors describe the case of an intraneural ganglion cyst involving a cranial nerve (V3), which was found to have a joint connection in support of an articular origin within the cranial nerves. An inferior alveolar intraneural cyst was incidentally discovered on a plain radiograph prior to edentulation. It was resected from within the mandibular canal with no joint connection perceived at surgery. Histologically, the cyst was confirmed to be an intraneural ganglion cyst. Reinterpretation of the preoperative CT scan showed the cyst arising from the temporomandibular joint. This case is consistent with the articular (synovial) theory of intraneural ganglion cysts. An anatomical explanation and potential joint connection are provided for this case as well as several other cases of intraneural cysts in the literature, and thus unifying cranial nerve involvement with accepted concepts of intraneural ganglion cyst formation and propagation.