Meningo-orbital band detachment: A key step for the extradural exposure of the cavernous sinus and anterior clinoid process

The meningo-orbital band (MOB) is the most superficial dural band that tethers the fronto-temporal dura to the periorbita. It is usually encountered when performing a pterional or fronto-temporo-sphenoidal approach, and it disrupts surgical access to deeper regions.Our objective was to perform a detailed anatomy study and a stepwise method to successfully detach the MOB using cadaveric specimens. We used six formalin‐fixed, silicone‐injected cadaveric heads. On each side, we performed a pterional approach plus mini‐peeling of the anterior third of the middle fossa and/or extradural anterior clinoidectomy. We also applied this technique in three clinical cases to prove its safety and efficacy. The detachment of the MOB consists in four steps, 1) detachment of the temporal and frontal dura, 2) cutting of the MOB, 3) exposure and drilling of the anterior clinoid process, and 4) pealing of the lateral wall of the cavernous sinus. Using clinical cases, we explain how to adapt the technique depending on the localization of the lesion. The detachment of the MOB is the key to safely expose the cavernous sinus and the anterior clinoid process. The authors proposed a step-by-step method for the safe and effective detachment of the MOB. It is recommended, particularly to less experienced neurosurgeons that are starting with skull base surgery, and also to experts that want to expand their knowledge.     

前床突及床突间隙的显微解剖学研究

目的 对前床突及床突间隙进行显微外科解剖学研究，为手术入路提供解剖学基础。方法 利用10例经福尔马林固定的国人成人尸头共20侧，15例头颅干标本共30侧，对前床突及床突间隙相关解剖标志进行了详细地显微解剖、观察、拍摄、测量和统计。结果 床突间隙是磨除前床突后人为形成的锥形腔隙，其容积与前床突及周围组织结构的构成、范围和边缘的大小有关，并影响经该处的显微手术操作。通过它可显露颈内动脉海绵窦段的前升部、前曲部和眼动脉的起点。术中磨除前床突及视柱，应注意其周围重要组织结构的构成。颈内动脉出海绵窦处的远、近环均存在颈内动脉穴。远环硬膜囊内是蛛网膜，而近环内是海绵窦静脉丛。结论 通过床突间隙拓展海绵窦-眶尖区手术入路，为利用颅底间隙进行入路提供了依据．     

前床突的应用解剖学研究

目的为颅底外科提供前床突的解剖学资料。方法取164例（328侧）成人干颅骨和30例（60侧）成人尸头标本,观察和测量前床突及其邻近结构,在形态学上对其进行分类,观察其变异情况。结果国人前床突的外形可分为三边型、四边型、五边型、乳头型、J-型、手指型,其中以三边型最为多见。前床突内侧缘可呈钝角、直角、锐角和弧形。前床突与中床突、后床突可形成骨桥或通过韧带连接。气化前床突占11.7%,气腔可与蝶窦、筛窦相通。结论前床突及其周围结构复杂,且国人前床突具有高度变异性。处理该区域病变术前需行充分影像学检查,了解前床突气化情况;术前、术中密切关注骨桥变异情况。     

Complete recovery of visual loss following surgical treatment of mucopyocele of the anterior clinoid process

A mucocele is a collection of mucus, which is lined by the mucus-secreting epithelium of a paranasal sinus. Paranasal sinus mucoceles occur as a result of inflammation, tumor, trauma or surgical manipulation. The anterior clinoid process may be pneumatized by an extension of the sphenoid paranasal sinus air space during normal development. Mucocele of the anterior clinoid process is rare. We report a patient with mucopyocele of the anterior clinoid process that resulted in rapid monocular visual loss. The left optic canal was exposed extradurally via a supraorbital craniotomy and the mucopyocele was totally excised. The optic canal was decompressed by drilling the superior, lateral and medial rims, to achieve circumferential decompression of the optic nerve. The patient’s vision improved postoperatively.     

Structural approach of human MAO-A using fold recognition (threading) techniques

The major goal of the present work is to further approach the structure of human monoamine oxidase A (MAO-A). A first partial three-dimensional model of human MAO-A has already been established using secondary structure predictions and fold recognition methods [Wouters and Baudoux, 1998]. In this modeled structure, a segment of the sequence (residues 369-393) located near the covalent linkage to the essential flavin cofactor, and potentially involved in the structure of the active site of the protein, could not be modeled. We here propose a possible fold for that segment, based on threading techniques. The identification of regions of the protein potentially involved in its dimerization was also undertaken by studying hydrophobic areas present at the surface of the structure.     

Hamlet as process: a novel approach to using literature in teaching psychiatry

Psychiatrists have made many forays into literature for the purposes of theory building, clinical understanding, and teaching. Given how fascinating and fruitful such inquiries can be, one wonders why they have had a mostly episodic place in teaching. I submit that at least some limitations resulted from an emphasis on what I would loosely call "content" and, related to it, on comprehensive "formulations" of a single literary character. This paper argues instead for a shift in focus onto "process" and situations created by particular interactions between the characters. Rather than pursue "the psychology of the individual characters; what they are like, what makes them what they are, what intentions, often apparently not conscious, seem to motivate their actions and attitudes" (Silberger 1973), I would look instead at what characters do (what they say, what they appear to emote and think) in response to each others' speech and imputed feelings and designs. The give-and-take entailed in the collision of their wishes, needs, and pasts at specific points in the evolution of the plot, and their reciprocal (mis)perceptions and (mis)interpretations, is especially relevant to understanding and teaching what is often thought to be the most complex aspect of being/becoming a psychiatrist, namely, comprehending and managing the emotional valences of the therapist-patient relationship. While such interactions are often explicit in, or can be adduced from, novels, short stories, or poems, the one form to which they are intrinsic is drama.     

扩大中颅底硬膜外入路经岩骨窗切除哑铃型三叉神经鞘瘤

目的 探讨扩大中颅底硬膜外入路经岩骨窗切除哑铃型三叉神经鞘瘤的治疗效果.方法 我科2007 - 2010年应用扩大中颅底硬膜外入路经岩骨窗切除哑铃型三叉神经鞘瘤21例.术前CT及MRI评估位于中、后颅窝肿瘤大小及岩骨侵蚀程度,分为三种类型:Mp型12例,MP型7例及mP型2例.结果 肿瘤全切19例,次全切2例,无手术死亡,术后出现新的暂时性脑神经麻痹4例,1例脑脊液漏,经腰大池引流脑脊液治愈.随访18例,时间6个月-3年(平均22.4个月),2例次全切除肿瘤复发,均位于后颅窝,经乙状窦后入路再次手术治愈.结论 扩大中颅底硬膜外入路经岩骨窗切除哑铃型三叉神经鞘瘤是一种有效的治疗方法,尤其对于肿瘤明显侵蚀破坏岩骨者.然而,如果后颅窝肿瘤部分过大时,该入路显露不足,难以全切肿瘤.     

Sensibility to the unconscious (Balint approach)

The physician-patient relationship is recognized as having an essential role in the process of medical care, providing the context in which caring and healing can occur. Good patient-doctor relationship goes far deeper than the behaviour of physicians, particularly those behaviours recognized in popular culture as acting in a professional manner, being respectful of the patients' circumstances and bedside manner. The therapeutic relationship is a relationship between two persons--on one side is the patient who is psychologically modified in his illness, in regression, with resistance mechanisms, defences, fears and need for gratification, care and also for secondary profit. On the other side is the physician with his authority, knowledge, personality, habits, defences, unconscious of his own pharmacological effect on the patient, as the most potent drug. In the patient-centred medical model, based on contemporary scientific knowledge of disease, the physician has to understand the patient's "world of illness", and to accept the patient as a person with his whole conscious and unconscious reasons for suffering and not only as a"collection of symptoms".     

Mapping the motor point in the human tibialis anterior muscle

ObjectivePercutaneous electrical stimulation of the motor point permits selective activation of a muscle. However, the definition and number of motor points reported for a given muscle varies. Our goal was to address these problems.MethodsThe area, location and number of motor points in human tibialis anterior were examined, using isometric dorsiflexion torque responses to electrical stimuli. Three methods were used: lowest electrical threshold, maximum muscle response, and approximate motor point.ResultsA single motor point was identified in 39/40 subjects regardless of method. The area of the site of lowest electrical threshold was smaller (median, 35 mm²) than those using the maximum muscle response (144 mm²) and approximate motor point (132 mm²). There was substantial, but not significant, between-subject variation in motor point location. Fifty three percent of motor points would have been missed if located only by reference to anatomical landmarks.ConclusionsThese results suggested that the motor point’s location cannot be determined a priori and that the identification method will affect both area and location.SignificanceIf it is important to maximally activate a single muscle in isolation, the motor point is best represented by the site producing a maximal but isolated muscle response at the lowest stimulation intensity.     

A field guide to the anterior olfactory nucleus (cortex)

While portions of the mammalian olfactory system have been studied extensively, the anterior olfactory nucleus (AON) has been relatively ignored. Furthermore, the existing research is dispersed and obscured by many different nomenclatures and approaches. The present review collects and assembles the relatively sparse literature regarding the portion of the brain situated between the olfactory bulb and primary olfactory (piriform) cortex. Included is an overview of the area's organization, the functional, morphological and neurochemical characteristics of its cells and a comprehensive appraisal of its efferent and afferent fiber systems. Available evidence suggests the existence of subdivisions within the AON and demonstrates that the structure influences ongoing activity in many other olfactory areas. We conclude with a discussion of the AON's mysterious but complex role in olfactory information processing.     

A novel retractor for the anterior approach to the cervical spine

Abstract

Various types of retractors have been used in cervical disc operations. The most frequently used type is the Cloward's retractor. Caspar also designed a new retractor for cervical operations. The presented device is a new instrument for simple cervical disc herniation. It provides a significant surgical exposure area under the surgical microscope. When using this retractor, there is no need to use a vertebral spreader because the retractor itself can be used as a vertebral spreader and it is possible to carry out the Smith Robinson type fusion. This retractor has been used for over two hundred cases and there has not been any complication involving the carotid artery, trachea and esophagus. [Neurol Res 1999; 21: 43—44]     

A novel retractor for the anterior approach to the cervical spine

Various types of retractors have been used in cervical disc operations. The most frequently used type is the Cloward's retractor. Caspar also designed a new retractor for cervical operations. The presented device is a new instrument for simple cervical disc herniation. It provides a significant surgical exposure area under the surgical microscope. When using this retractor, there is no need to use a vertebral spreader because the retractor itself can be used as a vertebral spreader and it is possible to carry out the Smith Robinson type fusion. This retractor has been used for over two hundred cases and there has not been any complication involving the carotid artery, trachea and esophagus.     

两种前路减压植骨融合并钛钢板置入内固定治疗相邻两个节段脊髓型颈椎病的比较

【摘要】目的：比较两种不同的颈椎前路减压植骨融合内固定术治疗相邻两个节段脊髓型颈椎病（cervical spondylotic myelopathy,CSM）的临床效果。方法：54例相邻两节段脊髓型颈椎病患者按完全随机设计分为两组。27例采用前路椎间盘切除植骨融合钛板内固定术（anterior cervical discectomy and fusion, ACDF组),27例采用前路椎体次全切除植骨融合钛板内固定术（anterior cervical corpectomy and fusion, ACCF组)。比较两组手术时间、手术失血量、住院时间、融合节段高度和Cobb’s角、神经功能改善率、术后并发症发生率。结果:两组患者各有4例术后因失随访或随访时间不到2年未纳入本组。 ACDF组23例术后随访26～48个月,平均29个月;ACCF组23例术后随访24～53个月,平均31个月。两组住院时间,脊髓功能改善率,手术优良率和有效率差异无显著性（P>0.05）。ACCF组手术时间、术中出血量均高于ACDF组（P<0.05）;ACDF组对融合节段Cobb’s角的改善优于ACCF组（P<0.05）;ACDF组供骨区并发症发生率低于ACCF组,差异有统计学意义（P<0.05）。结论：两种手术方法治疗相邻两个节段脊髓型颈椎病均取得满意的疗效,ACDF术式具有手术时间短,术中出血量少,明显改善融合节段Cobb’S角,椎体骨质保留多,减少供骨区并发症等优点。     

Craniopharyngioma in children Surgical treatment by a transbasal anterior approach

The authors present two cases of giant, ossified, craniopharyngioma in paediatric patients; one was subtotally (more than 90%) and the other, totally resected, both by a transfrontal-nasal approach. The results have been excellent, with total clinical recovery, olfactory function preserved and no cosmetic sequelae. Received: 18 May 1998     

Beneficial effect of eyelid make-up (natural rubber latex) to induce a new fold in the treatment of blepharoptosis in myotonic dystrophy]

Blepharoptosis is one of the troublesome ocular complications of myotonic dystrophy. To correct drooping eyelids for two men with myotonic dystrophy, we used Eye Putti, a cosmetic made of natural rubber latex, which induces a new fold in the upper eyelid. The cosmetic rubber latex dramatically improved the sight of a 59-year-old patient who previously had a great difficulty in looking forward and had to bend his head backward to see an object because of severe blepharoptosis. The other patient aged 54 with moderate ptosis also had satisfactory improvement. Appropriate use did not prevent eye blinking and induce corneal erosion or skin rash. The cosmetic rubber latex was effective to patients who had no residual function of the levator palpebrae and frontal muscles. This daily treatment is simple and safe, therefore may have an advantage over surgical correction of blepharoptosis for patients not only with myotonic dystrophy, but with other neuromuscular disorders including oculopharyngeal muscular dystrophy.