Clinical anatomy : official journal of the American Association of Clinical Anatomists & the British Association of Clinical Anatomists
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Postoperative atrophy of the deep back muscles may be caused by denervation during a dorsomedian approach to the thoracolumbar spine; ensuing instability of the spine with poor clinical results, perhaps due to such muscle loss, has been observed in 11.7% of cases (Sihvonen et al., 1993, Spine 18:575--581). More specifically, this complication may be caused by damaging the medial branches of the posterior rami of the spinal nerves during lateral retraction of the muscles. To investigate the anatomic topography of the medial branches of the posterior rami of the spinal nerves, 18 carbol-formol-fixed specimens were dissected using an operation microscope; also, 3 fresh cadavers were cut in horizontal and vertical planes with a rotary cryotome to confirm the anatomic topography observed in the fixed specimens. ⋯ When the dorsomedian approach to the thoracolumbar spine is enlarged laterally to the articular processes by retracting the paraspinous muscles, the medial branches of the posterior rami of the spinal nerves are endangered. This may cause postoperative pain as well as dynamic instability beyond the corresponding segments. The results of our anatomic study suggest that the posterior surgical midline approach to the thoracolumbar spine should not be enlarged laterally to the articular processes to prevent injury to the medial branches of the posterior rami of the spinal nerves.
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Clinical Trial
The treatment of subcapital humerus fracture with dynamic helix wire and the risk of concommitant lesion of the axillary nerve.
Displaced subcapital fractures of the humerus represent a therapeutic challenge for the surgeon, all the more so because of their high incidence among osteoporotic patients. Open surgical repair involves increased risk of avascular necrosis of the humeral head, while percutaneous reduction and fixation often fails as a result of loosening pins. As a possible solution, a minimally invasive technique was developed in which a dynamic titanium wire helix is inserted into the medullary space of the diaphysis of the humerus and then rotated proximally into the head fragment. ⋯ An associated anatomical study of 53 human cadavers investigated the position of the main branches of the axillary nerve relative to the surgical placement of the wire helix. In all cases, the distance between the most vulnerable anterior branch of the axillary nerve (ABAN) and the operative site was sufficient, as long as insertion occurs in the distal third of the distance between the head of the humerus and the deltoid tuberosity. Utilization of the titanium helix results in prompt healing of subcapital fractures while offering minimal risk for the elderly osteoporotic patient and does not endanger branches of the axillary nerve.
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This paper by the Educational Affairs Committee of the American Association of Clinical Anatomists (AACA) is a sequel to one published earlier, "A Clinical Anatomy Curriculum for the Medical Student of the 21st Century: Gross Anatomy" (AACA. 1996, Clin Anat. 9:71-99). In that curricular document a number of clinical procedures that apply gross anatomy to current medical practice are cited, including procedures related to the physical examination. ⋯ The AACA Educational Affairs Committee also hopes that the examples presented here will serve as a starting point for incorporating elements of the physical examination within a clinical anatomy curriculum in gross anatomy at the medical school level. This paper focuses on the physical examination of the thorax, abdomen, perineum, and pelvis; a subsequent paper will treat the physical examination of the limbs, back, head, and neck.
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Working with cadavers, whether through active dissection or by examination of prosected specimens, constitutes a potential stressor in medical education although there is no consensus on its effect. Some reports have suggested that it creates such a strongly negative experience that it warrants special curricular attention. ⋯ We found that although a vast majority of students expressed a positive attitude toward the experience, both before and after taking the course, there remains a small percentage of students for whom human dissection may initially be a traumatic experience. We offer explanations for our findings, comments on disparate results from other studies and suggestions for appropriate responses by anatomy faculty, who must address these student needs.
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First-year medical students were surveyed by questionnaire to assess levels of stress and physical symptoms resulting from their experience of the anatomy room. There was a 100% response rate from the 188 students. Most students (95%) found the prospect of their first visit to the anatomy room exciting. ⋯ Our findings support previous studies suggesting that American/Canadian students in particular find anatomy stressful. However, the wisdom of interpreting adverse reactions as symptomatic of post-traumatic stress disorder is questioned. This study shows the anatomy room to be a positive learning experience for the students of the Royal College of Surgeons in Ireland.