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BACKGROUND AND OBJECTIVESParavertebral block (PVB) is an established technique for providing anesthesia for breast surgery. The primary objective was to compare anatomical landmark technique (ALT) to the ultrasound-guided (USG) PVB block for providing surgical anesthesia. Secondary objectives included comparison of perioperative analgesia and complications. METHODSThis randomized, controlled, observer-blinded study included 72 females, aged 18 to 65 years, American Society of Anesthesiologists physical status I or II, undergoing elective unilateral breast surgery. Study participants were randomized to the ALT group or USG group. Ipsilateral PVB was performed with the respective technique from T1 to T6. Five milliliters of local anesthetic mixture (0.5% ropivacaine, 5 μg/mL adrenaline, 1 μg/kg clonidine) was administered at each level. Paravertebral catheter was inserted at T4/T3 level. After confirming sensory loss, patients were taken up for surgery with propofol sedation (20–50 μg/kg per minute). RESULTSMore patients in the USG group (34/36 [94.44%]) had a successful block as compared with the ALT group (26/36 [72.22%]) (P = 0.024). Difference in proportion was 18.1 (95% confidence interval, 0.15–36.0) (P = 0.024) after adjustment for age. More dermatomes were blocked in the USG group (P = 0.0018) with less sparing of upper T2 and T3 dermatomes (P = 0.003, P = 0.006, respectively). Median time to first postoperative analgesic requirement was 502.5 minutes (range, 195–1440 minutes) in the USG group versus 377.5 minutes (range, 215–1440 minutes) in the ALT group. Pain at rest and movement 2 and 4 hours postoperatively and number of catheter top-ups in 24 hours postoperatively were lesser in the USG group (P = 0.012). Complications were comparable. CONCLUSIONSUltrasound-guided PVB provided better anesthesia and perioperative analgesia than the landmark technique for breast surgery. CLINICAL TRIAL REGISTRATIONThe trial was registered retrospectively at the Clinical Trial Registry of India, CTRI/2015/05/005774.

ABSTRACT OBJECTIVE: The aim of this randomized clinical trial was to evaluate the dental, dentoalveolar, and skeletal changes occurring right after the rapid maxillary expansion (RME) and slow maxillary expansion (SME) treatment using Haas-type expander. METHODS: All subjects performed cone-beam computed tomography (CBCT) before installation of expanders (T1) and right after screw stabilization (T2). Patients who did not follow the research parameters were excluded. The final sample resulted in 21 patients in RME group (mean age of 8.43 years) and 16 patients in SME group (mean age of 8.70 years). Based on the skewness and kurtosis statistics, the variables were judged to be normally distributed and paired t-test and student t-test were performed at significance level of 5%. RESULTS: Intermolar angle changed significantly due to treatment and RME showed greater buccal tipping than SME. RME showed significant changes in other four measurements due to treatment: maxilla moved forward and mandible showed backward rotation and, at transversal level both skeletal and dentoalveolar showed significant changes due to maxillary expansion. SME showed significant dentoalveolar changes due to maxillary expansion. CONCLUSIONS: Only intermolar angle showed significant difference between the two modalities of maxillary expansion with greater buccal tipping for RME. Also, RME produced skeletal maxillary expansion and SME did not. Both maxillary expansion modalities were efficient to promote transversal gain at dentoalveolar level. Sagittal and vertical measurements did not show differences between groups, but RME promoted a forward movement of the maxilla and backward rotation of the mandible. RESUMO OBJETIVO: o objetivo do presente ensaio clínico randomizado foi avaliar as transformações dentárias, dentoalveolares e ósseas que ocorrem imediatamente após o tratamento com expansão rápida da maxila (ERM) e lenta (ELM) usando expansores do tipo Haas. MÉTODOS: todos os indivíduos foram submetidos a tomografias computadorizadas de feixe cônico (TCFC) antes da colocação dos expansores (T1) e imediatamente após a estabilização do parafuso (T2). Os pacientes que não seguiram os parâmetros da pesquisa foram excluídos. A amostra final constou de 21 pacientes no grupo ERM (idade média de 8,43 anos) e 16 no grupo ELM (idade média de 8,7 anos). Com base em estatística de assimetria e curtose, as variáveis foram consideradas de distribuição normal, e os testes t pareado e t de Student foram realizados, com nível de significância de 5%. RESULTADOS: o ângulo intermolares mudou significativamente devido ao tratamento, e o grupo ERM apresentou maior inclinação vestibular do que o grupo ELM. O grupo ERM mostrou alterações significativas em outras quatro medidas devido ao tratamento: a maxila apresentou deslocamento anterior e a mandíbula, rotação posterior; no nível transversal, houve tanto alterações ósseas quanto dentoalveolares significativas, devido à expansão maxilar. O grupo ELM apresentou alterações significativas devido à expansão maxilar. CONCLUSÕES: apenas o ângulo intermolares apresentou diferença significativa entre as duas modalidades de expansão maxilar, com maior inclinação vestibular no grupo ERM. A ERM resultou, também, em expansão maxilar óssea, ao contrário da ELM. As duas modalidades de expansão maxilar promoveram, de forma eficiente, um ganho transversal em nível dentoalveolar. As medidas sagitais e verticais não apresentaram diferenças entre os grupos, mas a ERM promoveu o deslocamento anterior da maxila e a rotação posterior da mandíbula.

BACKGROUND AND OBJECTIVESWhile existing studies about onabotulinumtoxinA for chronic migraines have focused on injection location and appropriate dosing, little consideration has been given to patient body habitus and its potential impact on efficacy. We hypothesized that with increasing patient body mass index (BMI) there would be more subcutaneous fat separating targeted muscle groups from the skin surface, such that standard 0.5-inch needles used in existing protocols may not allow intramuscular injection. This may have implications for treatment planning. METHODSAnatomically normal computed tomography scans of the head, neck, and face were randomly selected. Subjects were stratified into 4 groups based on BMI, with 30 patients in each group. Four standardized locations were chosen to obtain measurements from the skin surface to the underlying muscle fascia, including (1) frontalis, (2) temporalis, (3) semispinalis capitis, and (4) trapezius. RESULTSMedian depth for the temporalis was 12.65 mm (Q1 = 9.32 mm, Q3 = 15.08 mm) for the BMI greater than 35 kg/m group. Median depth for the semispinalis capitis was 13.77 mm (Q1 = 10.3 mm, Q3 = 15.7 mm) for the BMI 30 to 35 kg/m group, and 14.75 mm (Q1 = 11.00, Q3 = 17.00 mm) for the BMI greater than 35 kg/m group. Median depth for the trapezius was 13.95 mm (Q1 = 10.18 mm, Q3 = 19.00 mm) for the BMI greater than 35 kg/m group. These medians exceeded the length of the standard 0.5-inch (12.-mm) needle used in existing protocols. CONCLUSIONSOur study demonstrates that with increasing BMI there is a greater distance between the skin surface and the muscle fascia of muscles that are targeted for injection in standard chronic migraine botulinum toxin injection protocols. Because of this, patient body habitus may be an important factor in injection technique.

Background and ObjectivesThe erector spinae plane (ESP) and retrolaminar blocks are ultrasound-guided techniques for thoracoabdominal wall analgesia involving injection into the musculofascial plane between the paraspinal back muscles and underlying thoracic vertebrae. The ESP block targets the tips of the transverse processes, whereas the retrolaminar block targets the laminae. We investigated if there were differences in injectate spread between the 2 techniques that would have implications for their clinical effect.MethodsThe blocks were performed in 3 fresh cadavers. The ESP and retrolaminar blocks were performed on opposite sides of each cadaver at the T5 vertebral level. Twenty milliliters of a radiocontrast dye mixture was injected in each block, and injectate spread was assessed by magnetic resonance imaging and anatomical dissection.ResultsBoth blocks exhibited spread to the epidural and neural foraminal spaces over 2 to 5 levels. The ESP block produced additional spread to intercostal spaces over 5 to 9 levels and was associated with a greater extent of craniocaudal spread along the paraspinal muscles.ConclusionsThe clinical effect of ESP and retrolaminar blocks can be explained by epidural and neural foraminal spread of local anesthetic. The ESP block produces additional intercostal spread, which may contribute to more extensive analgesia. The implications of these cadaveric observations require confirmation in clinical studies.

Purpose The anatomical landmark for the anteroposterior (AP) axis of the proximal tibia and its variability was investigated in order to determine whether a certain landmark could be employed as a reference axis for the proximal tibia after the rotating platform mobile bearing and fixed bearing total knee arthroplasties (TKAs). Methods Eighty primary osteoarthritic knees were randomized to undergo either rotating platform mobile bearing (Group A, n  = 40) or fixed bearing (Group B, n  = 40) TKAs, and were followed up for 31 and 30 months, respectively. The AP axes were defined for the distal femur, proximal tibia, ankle, and each TKA component on the reconstructed CT scan and the angles between the distal femoral AP axis and those of each bone or component were estimated. Clinical and radiographic outcomes were evaluated during the follow up. Results A significant difference was seen between the preoperative and postoperative rotational position of the proximal tibia relative to the distal femur following rotating platform mobile bearing TKA ( P  = 0.014) whereas no such difference was seen after fixed bearing TKA. The mean postoperative alignment of the tibia differed between the two groups (Group A:Group B = −2.9:0.2, P  = 0.010) and its variability was significantly greater in group A ( P  < 0.001). There were no differences in the clinical outcomes including range of motion, knee society score, function score, HSS, and WOMAC score as well as the mean postoperative coronal tibiofemoral alignment between the two groups. Conclusion The unpredictable change in the rotational axis of the tibia and its broad variability after rotating platform mobile bearing TKA may provide a warning against the use of a fixed landmark for establishing tibial rotational alignment. Level of evidence Prospective comparative study, Level II.

BACKGROUND AND OBJECTIVESThe knee joint is the most common site of osteoarthritis. While joint replacement is considered an ultimate solution, radiofrequency denervation may be contemplated in some cases. Radiofrequency ablation requires precise localization of the articular branches innervating the joint capsule. The objective of this cadaveric study was to determine the source, course, relationships, and frequency of articular branches innervating the anterior knee joint capsule. METHODSFifteen knees were meticulously dissected. The number and origin of the articular branches were recorded, and their distribution defined by quadrants. Their relationships to anatomical landmarks were identified. RESULTSThe articular branches terminated in 1 of the 4 quadrants with minimal overlap. In all specimens, the superolateral quadrant was innervated by the nerve to vastus lateralis, nerve to vastus intermedius, superior lateral genicular and common fibular nerves; inferolateral by the inferior lateral genicular and recurrent fibular nerves; superomedial by the nerve to vastus medialis, nerve to vastus intermedius and superior medial genicular nerve; and inferomedial by the inferior medial genicular nerve. In 3 specimens, the inferomedial quadrant also received innervation from the infrapatellar branch of saphenous nerve. All articular branches except the nerves to vastus lateralis and medialis course at the periosteal level. CONCLUSIONSThe frequency map of the articular branches provides an anatomical basis for the development of new clinical protocols for knee radiofrequency denervation and perioperative pain management.

Mindboggle (http://mindboggle.info) is an open source brain morphometry platform that takes in preprocessed T1-weighted MRI data and outputs volume, surface, and tabular data containing label, feature, and shape information for further analysis. In this article, we document the software and demonstrate its use in studies of shape variation in healthy and diseased humans. The number of different shape measures and the size of the populations make this the largest and most detailed shape analysis of human brains ever conducted. Brain image morphometry shows great potential for providing much-needed biological markers for diagnosing, tracking, and predicting progression of mental health disorders. Very few software algorithms provide more than measures of volume and cortical thickness, while more subtle shape measures may provide more sensitive and specific biomarkers. Mindboggle computes a variety of (primarily surface-based) shapes: area, volume, thickness, curvature, depth, Laplace-Beltrami spectra, Zernike moments, etc. We evaluate Mindboggle's algorithms using the largest set of manually labeled, publicly available brain images in the world and compare them against state-of-the-art algorithms where they exist. All data, code, and results of these evaluations are publicly available.

Objective To use deep learning to segment the mandible and identify three-dimensional (3D) anatomical landmarks from cone-beam computed tomography (CBCT) images, the planes constructed from the mandibular midline landmarks were compared and analyzed to find the best mandibular midsagittal plane (MMSP). Methods A total of 400 participants were randomly divided into a training group ( n  = 360) and a validation group ( n  = 40). Normal individuals were used as the test group ( n  = 50). The PointRend deep learning mechanism segmented the mandible from CBCT images and accurately identified 27 anatomic landmarks via PoseNet. 3D coordinates of 5 central landmarks and 2 pairs of side landmarks were obtained for the test group. Every 35 combinations of 3 midline landmarks were screened using the template mapping technique. The asymmetry index (AI) was calculated for each of the 35 mirror planes. The template mapping technique plane was used as the reference plane; the top four planes with the smallest AIs were compared through distance, volume difference, and similarity index to find the plane with the fewest errors. Results The mandible was segmented automatically in 10 ± 1.5 s with a 0.98 Dice similarity coefficient. The mean landmark localization error for the 27 landmarks was 1.04 ± 0.28 mm. MMSP should use the plane made by B (supramentale), Gn (gnathion), and F (mandibular foramen). The average AI grade was 1.6 (min–max: 0.59–3.61). There was no significant difference in distance or volume ( P  > 0.05); however, the similarity index was significantly different ( P  < 0.01). Conclusion Deep learning can automatically segment the mandible, identify anatomic landmarks, and address medicinal demands in people without mandibular deformities. The most accurate MMSP was the B-Gn-F plane.

Purpose In spite of technological breakthroughs, the choice of a suitable location for the coronary sinus (CS) lead in biventricular implants is still mostly empiric. The aim of this study was to investigate the utility of a radiological index—the distance between the right ventricular (RV) and CS lead tips on fluoroscopic recordings, measured by means of a new method—as a tool for selecting the most profitable left ventricular (LV) lead position. Methods Forty-nine consecutive patients (36 male, 13female; mean age 63 ± 19 year), in whom the LV electrode was implanted in a lateral/postero-lateral position in the CS, were evaluated immediately after implantation. The fluoroscopic distances between the RV and LV lead tips were calculated off-line in antero-posterior (2DAP) and latero-lateral (2DLL) projections by means of integrated software. Results On 1-year follow-up evaluation, 53 % patients were classed as responders (R) (>15 % reduction in LV end-systolic volume) and 47 % as non-responders (NR). On receiver-operating curve analysis, 2DAP and 2DLL showed cut-off values of 81 mm and 51 mm, respectively. In discriminating between R and NR, 2DAP >81 mm displayed 95 % specificity and 74 % sensitivity, while 2DLL >51 mm displayed 74 % specificity and 92 % sensitivity. On multivariate analysis, the cut-off values of 2DAP and 2DLL were significantly predictive of R to CRT. Conclusions In our single-center prospective experience, RV-LV interlead distance measured by means of a novel method on fluorographic recordings correlated with CRT response. The use of this method as an intra-operative guide to identifying suitable lead placement in the CS needs evaluating on-line and on a large scale.

This paper introduces a Deep Learning (DL) framework to localize landmark coordinates within the semicircular canals in Computed Tomography (CT) scans of the temporal bone. These landmarks can be consistently defined across patients and imaging modalities and as such can serve as a means of forming a common coordinate system. We propose a DL based framework for automating the landmark selection process. We establish the accuracy of the methods using Bone Beam CT scans of the temporal bone of 20 patients and landmarks selected by 3 human experts as the ground truth. We show that the error rates are similar to the levels of variation in landmark selection achieved by human experts. We further validated the method on CT scans from 14 additional patients, demonstrating that the accuracy remains within clinically acceptable parameters.