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Quadratus lumborum block has been shown to provide satisfactory analgesia after caesarean section performed under neuraxial anaesthesia. However, its efficacy has not been demonstrated in patients who have received intrathecal morphine. The aim of this study was to assess the efficacy of quadratus lumborum block as part of a multimodal analgesic regimen including intrathecal morphine. This was a prospective, double-blind, placebo-controlled trial. Participants were randomly allocated to receive bilateral quadratus lumborum block (40 ml levobupivacaine 0.25%) or sham block (control) after undergoing elective caesarean section under spinal anaesthesia. The primary outcome was 24-h morphine consumption measured by patient-controlled analgesia. Secondary outcomes included pain scores and quality of recovery. Data from 86 women were analysed. Median (IQR [range]) 24-h morphine consumption was similar in patients receiving quadratus lumborum block and sham block (12 (8-29 [0-68]) mg vs. 14 (5-25 [0-90]) mg, respectively; p = 0.986). There was a reduction in median (IQR [range]) visual analogue scale pain scores at 6 h with quadratus lumborum block compared with sham block both at rest (6 (0-14 [0-98]) mm vs. 14 (3-23 [0-64]) mm (p = 0.019); and on movement: 23 (10-51 [0-99]) mm vs. 44 (27-61 [2-94]) mm; (p = 0.014)). There was no difference in pain scores at any other time-point up to 48 h. When used in conjunction with intrathecal morphine and spinal anaesthesia, bilateral quadratus lumborum block does not reduce 24-h morphine consumption after caesarean section.

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Los errores innatos del metabolismo comprenden un amplio grupo de patologías, habitualmente con una alta morbimortalidad. Son poco conocidas por parte de la comunidad médica debido a su baja prevalencia, y las dificultades en su diagnóstico y tratamiento hacen que sea imprescindible su manejo en Unidades especializadas. La Unidad de Enfermedades Metabólicas del Hospital Ramón y Cajal fue pionera en el estudio de estos pacientes, y es hoy un referente ¡mundial en la asistencia e investigación en este campo (AU)

Inborn errors of metabolism are an extensive group of diseases that usually have high morbility and mortality. They are little known within the medical community due to their low prevalence, which coupled with the difficulties in their diagnosis and treatment make it indispensable for them to be handled in specialized units. The Metabolic Department of the Ramón y Cajal was a pioneer in the study of these patients and is nowadavs a worldwide recognized center in the treatment and investigation in this field (AU)

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The DEIMOS (Dichroism Experimental Installation for Magneto-Optical Spectroscopy) beamline was part of the second phase of the beamline development at French Synchrotron SOLEIL (Source Optimisée de Lumière à Energie Intermédiaire du LURE) and opened to users in March 2011. It delivers polarized soft x-rays to perform x-ray absorption spectroscopy, x-ray magnetic circular dichroism, and x-ray linear dichroism in the energy range 350-2500 eV. The beamline has been optimized for stability and reproducibility in terms of photon flux and photon energy. The main end-station consists in a cryo-magnet with 2 split coils providing a 7 T magnetic field along the beam or 2 T perpendicular to the beam with a controllable temperature on the sample from 370 K down to 1.5 K.

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Eight sectioned specimens and 8 cadavers were used to evaluate the location of the vertebral artery in the cervicothoracic junction. The results of the measurements showed that there was no significant difference between either sides at the C7-T1 junction in terms of all distances taken. The mean width of the vertebral artery was 2.9 mm at the levels of the C-7 and T-1. The sagittal distance between the vertebral artery and the posterior cortex was 16.8+/-3.0 mm at the C7 and 21.7+/-2.8 mm at T-1. The coronal distance between the vertebral artery and the midline of the vertebra was 17.5+/-1.8 mm at the C7 and 22.3+/-2.9 mm at the T-1. The mean angle between the line connecting the lateral border of the vertebral artery with the posterior midway of the lateral mass and the parasagittal line at C-7 was 14.1+/-6.1 degrees. The mean angle of the vertebral artery with respect to the midline was 22.8+/-6.4 degrees. This study suggests that the vertebral artery has closer anatomic relationship to the C-7 lateral mass. Care should be taken to avoid injury to the vertebral artery if lateral mass screw fixation at the C-7 is intended.

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Seven adult cadaver lumbopelvises were harvested to study the anatomic relationship of the L4 and L5 nerves to S1 dorsal screw placement and the location of the L4, L5, and S1 nerves on plain radiographs. The mean lateral angle of S1 screw trajectory toward the L4 nerve was 31+/-8 degrees, and the mean screw trajectory length was 53+/-8 mm. The mean lateral angle of the screw trajectory toward the L5 nerve was 21+/-8 degrees, and the mean screw trajectory length was 38+/-4 mm. On both inlet and outlet radiographs, the lateral angle of the nerves increased from L4 to S1. The L4 nerve coursed over the middle third of the superior ala in the inlet view and the middle third of the lateral mass in the outlet view. The L5 nerve coursed over the inner third of the superior ala and inner third of the lateral mass. On the lateral view, the mean distances from the sacral promontory to the L4, L5, and S1 nerves along the anterior border of the sacrum were 4+/-7 mm, 12+/-5 mm, and 28+/-8 mm, respectively. This study suggests that S1 sacral screws be directed between 30 degrees and 40 degrees lateral to avoid compromising the lumbosacral trunk and sacroiliac joint.

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Because dimensions of the upper sacral cortexes vary greatly among individuals, preoperative computed tomographic (CT) evaluation of individual sacrum may help surgeons choose sacral screw insertion techniques. Axial CT scans were performed on 40 dry sacrum specimens to quantitatively evaluate the internal structure of the lateral sacral mass in the first and second segments. The results showed that the greatest cortical thickness in the S1 vertebra was found in the anterior cortex (3.4+/-0.9 mm), followed by the anterolateral (3.2+/-1.2 mm), and anteromedial (2.9+/-1 mm). The greatest cortical thickness in the S2 region was noted in the anteromedial cortex (2.4+/-0.5 mm), followed by the anterior and anterolateral (2.2+/-0.9 mm). The mean percentage of the anterior cortex thickness versus the lateral sacral mass depth was 12.8+/-3.7 for S1 and 11.1+/-2.8 for S2. Bicortical screw placement is recommended to achieve stronger fixation, but care should be taken not to violate the vital structures anterior to the sacrum.

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Eight cervical specimens were transversely sectioned with slices approximately 2 mm to 3 mm in thickness to evaluate the anatomic relationship of the spinal nerves to the lateral masses. Results showed that the spinal nerve either does not appear or, when it does, is situated anteromedially to the superior facet on the cross sections through the upper portion of the superior facet. The anterolateral aspect of the superior facet is free from the spinal nerve. Cross sections through the lower pedicle of the vertebra showed that the spinal nerve rested on the transverse process anterolateral to the lateral mass. The mean distances between the posterior midline of the lateral mass and the posterior border of the spinal nerve measured 15 degrees in the lateral direction were 16.1+/-1.7 mm for C3, 16.5+/-1.8 mm for CA, 16.8+/-1.2 mm for C5, 16.3+/-2.0 mm for C6, and 8.5+/-0.9 mm for C7. This study suggests that the anterolateral corner of the superior facet and the anterior aspect of the lateral mass lateral to the origin of the transverse process would be safer zones for screw exit. Attention should therefore be paid to the screw orientation for the Magerl technique and to the screw length for the Roy-Camille technique. Care should be taken to insert the screw into the C7 lateral mass.

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Axial computed tomography scans with a slice thickness of 2 mm taken from 12 cervical spines were used to study the internal structure of the lateral mass. Images representing the middle of zone I (Heller's classification) and the top of zone III were analyzed. The measurement of zone I involved anterior cortex thickness (ACT) while measurements of zone III included ACT, lateral cortex thickness (LCT), posterior cortex thickness (PCT), lateral mass thickness (LMT), and lateral mass width (LMW). The percentage of the ACT and PCT with respect to the LMT (ACT/LMT and PCT/LMT) were calculated. Results showed the average ACT in zone I ranged from 1.6 to 1.8 mm. In zone III, the average LMT and LMW ranged from 8 to 9 mm and 13 to 15 mm, respectively. The smallest LMT was found at C7. The average ACT and PCT for all levels ranged from 1.8 to 2 mm. The ACT with respect to the LMT (ACT/LMT) was approximately 17% to 19% for C3 to C5 and C7, and 15% for C6 separately. The PCT with respect to the LMT (PCT/LMT) was approximately 16% to 18% for C3 to C6, and 20% for C7. These results show the ventral cortex of the lateral mass is relatively thicker and support the concept of bicortical screw purchase.

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Technological advances in the design and manufacture of soft toric contact lenses have made it possible for most astigmatic patients to achieve successful results with current soft lenses, but a small percentage of those patients are wearing them. We present the observations on 21 subjects that requested soft toric lenses in the past year. This lenses (TP 60) offered all the comfort of soft lenses and a good vision correction for astigmatism up to 6 diopters.

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The inflammatory and infectious circumstances involving the orbit are known as 'orbitopathies' Considering the progress of immunology and imagistical investigations, it has been proposed a new classification of these entities. This classification divides the orbithopathies in specific and nonspecific. This paper brings up the case of a 65 year old female patient, showing unilateral proptosis with progressive evolution for about one year. The local examination and paraclinical investigations (computerised tomography and thyroid gland scintigram) sustained the diagnosis of Basedow disease. The ophthalmopathy in Basedow disease is a specific orbital involvement. Considering it's high rate of occurrence among the exophthalmic eyes (10%) it rests a severe disease, with a not yet fully understood physiopathology and a controversial treatment. The basedowian ophthalmopathy is, as well, an autoimmune disease, which requires the presence of T lymphocytes at the level of the orbital tissue. The computerised tomography gives us a direct visualisation of the enlarged muscles in hyperthyroidism (the muscles can increase 8 times their normal size), that is why we have to recommend it every time we are facing a patient with proptosis, especially unilateral.

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Thirty-three cadaveric dissections were performed to identify radial nerve branching patterns to the triceps brachii. Radial innervation of the long head of the triceps originated in the axilla in 88% of the cases and the brachio-axillary angle in 12%. Innervation of the medial head of the triceps originated in the spiral groove in 52% of the cases, the brachio-axillary angle in 39%, and the axilla in 9%. The lateral head was innervated by branches arising in the spiral groove in 70% of the cases, the brachio-axillary angle in 24%, and the axilla in 6%. On average, the radial nerve crossed the midline in the proximal 45% of the arm, 3 cm superior to the level of the deltoid insertion. An intramuscular tendon was present in the medial head of the triceps. The tendon, located medial to the midline of the arm, was seen in all specimens. This tendon serves as an interneural plane with nerve branches descending on either side, but never crossing from one side to the other. Due to the complexity of radial nerve branching, this tendon may be used as a reference plane for longitudinal splitting of the medial head minimizing the risk of nerve damage.

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STUDY DESIGN: This study analyzed anatomic parameters between the midpoint of cervical vertebral lateral masses as seen on the superficial, posterior aspect of the mass and cervical nerve roots. Posterior cervical dissection was performed, with the midpoint of the lateral masses kept intact and the nerve roots exposed. OBJECTIVE: To quantitatively determine the location of the cervical nerve roots and the transverse foramina, indicating vertebral artery placement relative to the posterior aspect of the cervical spine. SUMMARY OF BACKGROUND DATA: Posterior plate-screw fixation of the cervical spine has been widely used to treat unstable fractures of the cervical spine. However, injury to the spinal nerve roots during the procedure remains an important concern. No previous anatomic study regarding the location of the cervical nerve roots relative to the posterior aspect of the cervical spine has been reported. METHODS: Fifteen specimens were obtained for study of the cervical spine. Laminectomy and partial removal of the superior and inferior articular facets then were performed on C2-C3 through C7-T1 to expose the nerve roots and dura. Photographs, containing a reference scale, were taken simultaneously perpendicular to the sagittal and transverse planes of the specimen. Using enlarged versions of the photographs, independent measurements by several observers were taken from the superficial, posterior center of each lateral mass to the nerve root superiorly and inferiorly, and to the lateral limits of the dura. Vertebrae from an additional 20 spines were examined to determine the position of the transverse foramina relative to the lateral mass of the vertebrae. RESULTS: The results showed that for C3-C7, the average distance from the superficial, posterior center of the lateral mass to the nerve root superiorly was 5.7 +/- 1.5 mm. Inferiorly, the average distance was 5.5 +/- 0.8 mm. The average distance from the lateral mass to the spinal cord dura was 9.2 +/- 1.4 mm, and the average medial angle of the nerve root was 76.3 degrees +/- 4.4 degrees. For cervical vertebrae C3-C5, the transverse foramina were situated medial to the posterior center of the lateral mass. At the C6 level, the transverse foramina were situated anterior to the posterior midpoint of the lateral mass. CONCLUSION: This study demonstrates that the posterior midpoint of the lateral mass is a safe point for initiating screw insertion.

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STUDY DESIGN: This study analyzed the anatomic relationships between bony structures and soft tissues of the cervicothoracic junction. OBJECTIVES: To provide composite reference data for intrasegmental and intersegmental gradients of anatomic variation within the cervical-thoracic junction. SUMMARY OF BACKGROUND DATA: Because the risk of soft tissue damage during posterior spinal stabilization, an understanding of bony and soft tissue changes in the cervicothoracic junction is necessary. METHODS: Three-hundred-twenty-four cross-sectional spinal segments from nine spines were analyzed to characterize cervicothoracic junctional anatomy. RESULTS: There were predictable cranial-to-caudal alterations in both bone and soft tissue anatomy of the cervicothoracic junction. Neural and vascular structures directly anterior to the lateral mass or transverse process and lateral to the pedicle tend to decrease in frequency, whereas measured parameters of the vertebrae increase in size from C5-T3, except for pedicle dimensions that tend to increase at the C7-T1 junction. CONCLUSION: The anatomic changes that occur within the cervicothoracic junction are consistent and predictable, and their recognition should lead to a better appreciation of their clinical implications.

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STUDY DESIGN: Linear and angular measurements were performed on 128 vertebrae (16 spines) from C5 to T5. OBJECTIVES: Vertebrae were studied to characterize vertebral shape and size changes in the cervico-thoracic region. SUMMARY OF BACKGROUND DATA: Analysis of vertebral anatomy has been extensive and well characterized. Regions of transitional anatomy necessitate further study due to the often abrupt changes in anatomic relationships. METHODS: Two observers performed linear and angular measurements including pedicle width, height, and length, as well as pedicle-body, pedicle-lamina, lamina-transverse process, and pedicle-lamina angular measurements. Pedicle axis projection on the posterior aspect of the lamina was also calculated. RESULTS: The mean pedicle width ranged from 7.8 mm (T1) to 4.4 mm (T5). The body-pedicle angle decreased > 4 degrees per level in the transverse plane, from 50 degrees (C5) to 11 degrees (T5). The axial projection of the pedicle changed throughout the region (compared with level above) and was significant for T1. CONCLUSIONS: Because of the complexities of the cervico-thoracic junction, additional characterization increases the knowledge of the anatomic relationships in this region.

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One hundred eighty-four cemented primary total articular replacement arthroplasty (TARA) resurfacing total hip procedures were performed by a single surgeon from 1981 to 1985. One hundred seventy-four hips had a mean follow-up period of eight years (range, 3.5-10.4 years). Osteoarthrosis was the predominant diagnosis (79%). Failure was defined as a hip needing additional surgery because of an implant failure and occurred in 13.2% of the patients. No statistically significant difference was found between preoperative etiology, patient gender, or the side of the hip involved between the revised and unrevised patients. The revised group was seven years younger at the time of TARA implantation than the group that was not revised (55.7 versus 65.3 years), with significance to the p < 0.01 level. Survival analysis demonstrated an 87.1% chance of survival at seven years, decreasing to 84.5% at ten years. The cemented TARA hip replacement has a better intermediate-to long-term success than other resurfacing designs reported using cemented fixation. However, this does not compare favorably with the longevity of cemented Charnley total hip replacements reported at similar intervals.

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