Popliteal Fossa Anatomy

341800
Nervus Ischıadıcus'un insan fetuslarında mikroanatomik ve topografik olarak araştırılması / Microanatomical structure and topografic anatomy of sciatic nerve in human fetuses
Yazar:ANIL DİDEM AYDIN KABAKÇI
Danışman: PROF. DR. MUSTAFA BÜYÜKMUMCU
Yer Bilgisi: Necmettin Erbakan Üniversitesi / Sağlık Bilimleri Enstitüsü / Anatomi Ana Bilim Dalı
Konu:Anatomi = Anatomy
Dizin:Anatomi = Anatomy ; Fetal gelişim = Fetal development ; Fetüs = Fetus ; Lumbosakral pleksus = Lumbosacral plexus ; Sinir blokajı = Nerve block ; Sinir sıkışma sendromları = Nerve compression syndrome ; Siyatik sinir = Sciatic nerve ; Varyasyon = Variation Onaylandı
Yüksek Lisans
Türkçe
2013
94 s.

N. ischiadicus vücudun en uzun ve kalın siniri olup, fossa poplitea?da n. tibialis ve n. peroneus communis dallarına ayrılır. N. ischiadicus?un gluteal bölgede ve uyluk arka yüzünde seyri esnasında anatomik varyasyonlar görülebilmektedir. Bu anatomik varyasyonların, piriformis sendromu, siyatika, koksidini ve kas atrofisi gibi klinik durumlarda etkisi olabilir. Bu durum, n. ischiadicus ve bu sinirin alt ekstremite de dalların ayrılma yerlerinde cerrahi girişimlerde bulunacak klinisyenler tarafından dikkate alınması gerektirmektedir. Çalışmamızda insan fetuslarında n. ischiadicus?un morfometrik gelişiminin gestasyonel yaşa göre değerlendirilmesi ve bu sinirin seyri boyunca oluşan anatomik varyasyonların cinsiyete ve trimesterlere göre görülme insidanslarının belirlenmesi, n. ischiadicus?un komşu yapılar ile olan ilişkisinin değerlendirilmesi amaçlandı. Bu çalışma, gestasyonel yaşları 9-40. haftalar arasında olan anomalisi olmayan toplam 60 spontan abort fetus üzerinde gerçekleştirildi. Çalışma da n. ischiadicus?un gluteal bölge ve uyluk arka tarafındaki yerleşimi belirlendikten sonra sinir ve sinirin komşu yapıları ile ilgili morfometrik ölçümler gerçekleştirildi. Tüm parametreler için trimesterlere göre ortalamalar tespit edildi ve bütün parametrelerin gestasyonel yaş ile birlikte arttığı belirlendi (p

Microanatomical structure and topografic anatomy of sciatic nerve in human fetuses The longest and thickest nerve of the body, sciatic nerve is divided into tibial and common peroneal nerve in the popliteal fossa. Anatomical variations can be seen during the course of sciatic nerve at the gluteal region and posterior compartment of the thigh. These anatomical variations may contribute to piriformis syndrome, sciatica, coccygodynia and muscle atrrophy. This should be taken into account by clinicians. The aim of this study was to evaluate the morphometric development, the correlation between sciatic nerve and relative structure, determine the incidences of anatomical variations which was to be during the course of this nerve according to gender and trimester. In this study which was carried out on 60 spontaneous abortion human fetuses aged between 9-40 weeks of gestation without anomalies. After the determining the localization of sciatic nerve, morphometric measurements were carried out about sciatic nerve and relative structures. Mean values and standart deviations of all parameters according to trimesters were determined and all parameters were found to be increased with gestational age (p

Fossa, anatomide çukur demektir.  Örneğin medial inguinal fossa direkt inguinal herninin kaynaklandığı bölgedir. Popliteal fossa, dizin arkasındaki çukurluk.

Genel Cerrahide Fossa Örnekleri

Epigastrik fossa:

1. Biri epigastrik bölgededir
2. Diğeri urakusa ait fossadır

İliak fossa (fossa iliaca): İliumun iç yüzeyinin büyük kısmını, özellikle anteriorundaki içbükey (konkav) alan; buraya iliak kas yapışır.

Infraklavikular fossa: Klavikula’nın hemen altındaki üçgen bölge, deltoid ve pectoralis major kaslar arasındadır. Meme kanserinde infraklaviküler fossadaki lenf nodlarının tutlumu en ileri N3b dir. (Her T, N3, M0 Evre IIIC dir)

Supraklaviküler fossa: Klavikülanın hemen üstündeki fossadır. Supraklaviküler fossadaki dolgunluk, üst ekstremite derin ven trombozunun belirtisi olabilir. Özellikle meme ve mide kanserinde lenf nodu metastazının olabildiği bir bölgedir. Mide kanserinde supraklaviküler lenf nodlarına metastaz uzak metastaz sayılır. Meme kanserinde suptaklaviküler fossadaki lenf nodlarının tutlumu en ileri N tutulumudur (N3c). (Her T, N3, M0 Evre IIIC dir)

Iskioektal (iskioanal) fossa: Pelvik diyafram (levator ani) ile cilt arasındaki potansiyel (yağ dokusu ile dolu) boşluk. Anorektal apsenin geliştiği bölgelerden biridir.

Supraveziküler fosssa (fossa suprevesicularis): Mesanin sağ ve solundaki çukur (fossa).

Medial inguinal fossa (fossa inguinalis medialis): Supravezikal ve lateral inguinal fossalar arasındadır. Direkt inguinal herninin çıkış bölgesidir.

Lateral inguinal fossa (fossa inguinalis lateralis): Medial inguinal fossanın dışındadır (En dıştaki inguinal fossadır). İndirekt inguinal herninin çıkış bölgesidir.

 

 

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Discussion

Superficial femoral artery is continued by the popliteal artery which is located in the popliteal fossa, posteriorly. Lower extremity claudication is a common symptom in elderly, which is mainly caused by atherosclerotic diseases. Young and healthy adults with lower extremity claudication are the candidates for the diseases originating from the muscle-fascia, bone-periosteum, nerve or vascular structures.[5,6] Since PAES is mostly found in patients with well-developed muscles, the military surgeons have a great interest on this disorder.[7]

The symptoms of this syndrome may vary individually. The typical signs and symptoms include leg swelling, aching pain, pain at rest, and cramping of the calf. In early stages, the patient may have only a feeling of coldness or transitory cramps; however, in later stages, it may progress to acute ischemia and total occlusion of the artery.[7] External arterial compression may cause chronic arterial micro-injuries and the extremity becomes prone to arteriosclerosis and thrombus formation. Clinical evidences suggest that it is associated with an increased risk of lower extremity ischemia.[8] In this study, 18 patients were in class 2 or 3 with the main complaint of claudication, and three patients presented with acute ischemic leg pain due to acute occlusion of the popliteal artery.

The impingement of popliteal artery in popliteal fossa causes PAES and the classification of PAES is based on the association of the vessel with musculoskeletal structures in the neighborhood.[4] Love and Whelan[9] developed a useful PAES scheme in 1965. In 1970, Insua[10] also classified the most common variations of PAES as four types. Type 1 includes the attachment of medial head of gastrocnemius muscle on the medial condyle of the femur; however the tract of the popliteal artery is abnormal on the medial direction around the muscle belly. In type 2, there is an impingement of the popliteal artery by the aberrant medial head of the gastrocnemius muscle which originates laterally than its natural position. In type 3, the popliteal artery is also entrapped by the aberrant slips of the muscle like in type 2; however, the artery and the muscle are in their natural anatomic positions. Type 4 is comprised of the entrapment of the popliteal artery by the fibrous bands of the popliteus muscle. In 1979, Rich et al.[4] modified the PAES scheme and categorized into six types which has been widely accepted. Of note, if there is any type of impingement of the popliteal vein, it is defined as type 5.[4]

The functional entrapment syndrome is defined as the entrapment caused by the hypertrophic gastrocnemius muscle.[12] Rignault described the functional popliteal impingement as a normal physiological variant of PAES without any musculotendinous anomaly.[12] Rutherford classification was based on the symptoms and clinical presentation at the time of surgery.[4] There is an also classification based on radiological and intraoperative findings developed by Delaney.[13]

The incidence of PAES has not been clearly delineated in the literature. As it is extremely rare, few studies reported that the incidence varied between 0.17% and 3.5%.[14,15]

Although color DUS is the primary imaging tool for the diagnosis of PAES, it lacks to reveal the popliteal fossa anatomy.[16] Conventional angiography and DSA give superior results on arterial anatomy compared to DUS.[17,18] Computed tomography and MRI can show arterial stenosis, poststenotic dilatation, and popliteal fossa anatomy, as well.[16] In our study, conventional angiography was performed in 10 patients. After adapting three-dimensional reconstruction technique, CTA became the main modality diagnostic tool after 2005. In the present study, CTA was performed in eight patients and MRI in four patients.

Furthermore, the management of PAES depends on the disease classification and the extent of the arterial damage. Simple correction of the anatomic abnormality by dividing the appropriate musculotendinous structures may be adequate in patients with type 1 PAES without any irreversible arterial damage. On the other hand, the patients with PAES type 2, 3 and 4 division of any entrapped structure with the combination of vein bypass were performed, as recommended. In two other of type 1 cases, we performed only saphenous vein graft interposition without musculotendinous resection after proper popliteal artery exploration. Management of PAES should be carried out even in asymptomatic patients; thus, preventing serious complications such as aneurysm formation[19] and distal embolization are crucial in healthy lower extremity. A simple myotomy to the medial head of the gastrocnemius muscle is able to restore normal arterial flow. However, depending on the degree of arterial injury, revascularization may be required in patients with advanced disease.

Another controversy is on posterior or medial approach. Several studies suggest that the posterior approach may give a better visual anatomy and better cosmesis and an access to the lesser saphenous vein for graft harvesting in short occlusions.[7] For longer occlusions necessitating longer bypass grafts, the medial approach is often recommended.[7,20-23]

The long-term postoperative care after infrainguinal vein bypass surgery deserves a special interest, as the patient population is mostly young. All patients should be on antiplatelet therapy with low-dose aspirin. However, what remains controversial is still the use of anticoagulants after infrainguinal vein bypass surgery. The Veterans Affairs Cooperative Trial concludes that vein bypass graft patency did not increase by the addition of coumadin to aspirin; however, there was a significant increase in hemorrhagic complications.[24] Therefore, many surgeons use anticoagulation selectively after vein bypass surgery in patients having poor conduit or poor arterial run-off.[25]

Moreover, PAES is a challenging condition not only for the patient, but also for the treating physician. The physician should have a thorough anatomical knowledge to choose the definite diagnosis in the management of the patient. Symptomatic PAES may eventually progresses to the intimal injuries and thrombosis formation, and total occlusion, eventually.[7,11] The patients may apply or may be referred to multiple different disciplines. Of note, time consumption can exacerbate the limb ischemia and the limb loss may even be inevitable over time. Obtaining a long-term patency of the popliteal artery with surgery is critical in young population, particularly. As reported in a study, the pediatrician should look for the presentation of claudication which is a key symptom of PAES.[16] Therefore, it seems to be important not only for the cardiovascular surgeons, but also for the all practitioners to be aware of the lower extremity claudication in patients admitted with various complaints. In our current study, cardiovascular surgeons were the primary treating physicians, whereas the other specialties were confined to the awareness of claudication, which subsequently referred the patients to the cardiovascular surgery clinic.

In conclusion, early suspicion of the disease is solely available with a thorough communication among the physicians. Therefore, an interdisciplinary approach may give these patients improved limb survival with long-standing comfort. We believe that it is critical for the practitioners from different subspecialities to be aware of manifestations of lower extremity claudication, which is a major diagnosis criterion for popliteal artery entrapment syndrome, and refer these patients to the disciplines, where they can receive an appropriate treatment.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.