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In 1989, we reported our thoughts on the neurophysiological and anatomic aspects of pudendal nerve involvement in certain types of perinal pain. Since that time, the surgical approach has been modified. Here we report our follow-up of 40 patients with 48 operated nerves. Follow-up ranged from 6 months to 7 years and outcome revealed improvement in 67% and no change in 33%. Thus surgery had been useful in two-thirds of the cases; in 44% of the patients, there was either a frank improvement or no change. Early diagnosis appears to be the determining factor in improving results. Operating for the canal syndrome must be performed before lesions to the nervous trunk become too important.

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This observation has been previously reported as a multifocal and recidivant desmoid tumor. The first time, the patient was operated on for a desmoid tumor situated on his left thigh. He was reoperated on fourteen years later for a recurrent tumor implanted on the same place and a new one on the right arm. Recently bilateral pulmonary tumors were discovered. As far as this evolution was concerned, its exceptional pattern induced a new analysis of the microscopic data and the diagnosis of fibrohistiocytic sarcoma was established. This observation suggest to the authors some comments about the difficulty of diagnosis and therapy of such soft tissue tumors.

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Pain is as old as mankind. It has a threshold beyond which nobody can escape it. Pain is a biological and physiological phenomenon, an integrated part of our body and ego. Will all our efforts eventually make it disappear? Is its disappearance desirable? Pain is one of the major expressions of sensation. It is integrated by the central structures and expressed as a behavior of avoidance or attenuation of the effects produced by the cause of pain. The study of this behavior and of the transmission of the pain message corresponds to the study of how to fight against this message, which means that it should logically lead to the treatment of pain.

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After having outlined the theories of cranial osteopathy (SUTHERLAND, KARNI, UPLEDGER, and, more recently, CLAUZADE and DARRAILLANS), the authors refute the latter point by point. "Primary respiration" is in fact a way of thinking, and the various bones making up the calvaria and base of the skull, which are solidly synostosed in the adult, are clearly incapable of the pretended rhythmic displacements "described" by the osteopaths. Moreover, the C.R.L., like any liquid, is incompressible and mildly pulsatile. Conversely, although the brain clearly shows rhythmic pulsations, which every neuro-surgeon notes every day, the latter are exclusively connected to the vascular system.

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The biomechanics-, engineering- and anatomy-oriented authors studied the craniofacial structures emphasizing their perfect adaptation to stresses developing during mastication or related to head statics and motions. For a better understanding of the biomechanics of the basis of the skull and face, attention is consistently drawn to solutions used in state-of-the-art engineering, such as aeronautics, in consideration that such solutions as are chosen by engineers are often--consciously or not--copied from nature.

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The authors studied the strains acting on a normal femur, and on the same femur fitted with an uncemented screwed prosthesis, by means of the method of holographic interferometry. This modern optical method has the advantage of not requiring any preparation of the surfaces or modification of the bone to be studied. It is non-destructive and can be repeated. This study required 40 interferograms for each case, using two or even three views. Comparison of the images obtained showed major modifications: disappearance of the physiologic flexion of the diaphysis, overload of the upper third, and zones of excess constraint.

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Using thick sections of the base of the skull and face their mechanical structure is viewed from the engineering aspect and the anatomic solutions evolved are compared with those selected by Aerospatiale engineers for the concept and development of the Airbus. It is concluded that the anterior and middle cranial fossae, together with the face, constitute an inseparable mechanical assembly each of whose component units participate in the rigidity of the others. Since this mechanical assembly must provide maximal rigidity for minimal weight, this suggests that aeronautical solutions should throw much light on the detail of construction of the skull and face. Indeed, the rigidity and lightness of the latter are obtained by means of solutions familiar in aeronautics: the reliance on thin-shelled beams with a honeycomb filling, the diploe analogous to a preconstrained composite or sandwich structure, a system of frames, struts and stiffeners, and the use of fillets at the sites of junction of struts.

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Technical alternatives in conservative proctocolectomy are presently investigated to improve the functional results of the operation. To avoid 2 difficult steps in the procedure, mucosectomy and transanal manual suturing, is of interest to retain the entire and canal and to reduce anal stretching duration. A new technique of stapled anastomosis is described: after full mobilization and eversion of the rectum, this latter is closed using a linear stapler and cut immediately above the anal canal; a 18 cm long J pouch is constructed and the anastomosis is stapled using the new premium EEA instrument*. Clinical experience begun in 1989 january, concerns 6 patients (2 U.C., 4 polyposis): at this time, 5 of these had their ileostomy closed, functional results being under evaluation. This method allows 1) to retain all the anal canal, 2) to avoid prolonged anal dilatation, 3) to perform a rapid and safe stapled anastomosis.

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Clinical observations in patients suffering from positional perineal pain have led us to performing an anatomical study of the pudendal nerve in order to demonstrate compression of this nerve trunk by elements likely to compress it in the sitting position. Thus we observed that the falciform process of the sacrotuberous ligament may act in this way. Besides helping us to understand the clinical symptoms, this anatomical study allowed choosing the technique we found most appropriate for the anatomical conditions observed out of the various neurophysiological examinations described in the literature. Lastly, we describe the surgical technique that allows releasing the trunk of the pudendal nerve under an operating microscope.

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The authors question whether strengthening beams and spans for the calvarium really exist and, if so, what are their exact anatomic counterparts and their exact function in the resistance of the calvarium. They opine that this function is of secondary importance except for the frontal and internal occipital pillars. The resistance of the calvarium must rather be attributed to its sandwich structure, with local bracing where the constraints are too severe. While they believe in the existence of such braces as the occipital pillars between the calvarium and the endochondral skull base, they prefer the concept of the mastoid pillars. The mastoid process is a structure with a thin shell and alveolar content, which has the advantage of giving the sternocleidomastoid and digastric muscles a bigger area of attachment to a light structure.

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The caudate lobe of the liver is an independent segment straddling the right and left lobes of the liver. It is divided into 2 parts, right and left, indicated externally by the caudate and papillary processes. It is now possible to unvestigate it by ultrasonography and computed tomography, allowing its surgical excision for tumoral disease of the superior biliary confluence.

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The action of the omohyoid muscle on the hemodynamics of the internal jugular vein is controversial. For some authors, contraction of this muscle, by tightening the cervical fascia, promotes jugular venous return. For others, contraction of this muscle compresses the jugular vein in its cervical path. With this latter point in mind, the hemodynamics of the internal jugular vein have been studied in its cervical path by echography in 10 healthy volunteers. One hundred twenty measurements of the venous surface were made at rest, with the mouth open and during deep inspiration. In the last 2 situations, evidence of a significant increase in the venous surface was found above the omohyoid muscle. These data confirm the role of compression of the vein by the omohyoid muscle, leading to modifications in intracerebral venous hemodynamics, which can be affected in yawning.

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The caudal lobe of liver is an independent sector astride the right and left liver regions. It is formed of two parts, right and left, distinguished exteriorly by the caudal and papillary processes, and can now be explored (ultrasound and CT imaging) allowing its surgical removal (tumoral lesion of the superior biliary confluent).

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