Standring Gray's Anatomy E-Book

The Anatomical Basis of Clinical Practice
41. Auflage 2015
ISBN: 978-0-7020-6851-5
Verlag: Elsevier HealthScience EN
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)

E-Book, Englisch, 1592 Seiten

Reihe: Grays Anatomy

In 1858, Drs. Henry Gray and Henry Vandyke Carter created a book for their surgical colleagues that established an enduring standard among anatomical texts. After more than 150 years of continuous publication, Gray's Anatomy remains the definitive, comprehensive reference on the subject, offering ready access to the information you need to ensure safe, effective practice.

This 41st edition has been meticulously revised and updated throughout, reflecting the very latest understanding of clinical anatomy from field leaders around the world. The book's traditional lavish art programme and clear text have been further honed and enhanced, while major advances in imaging techniques and the new insights they bring are fully captured in new state-of-the-art X-ray, CT, MR, and ultrasonic images.

• Presents the most detailed and dependable coverage of anatomy available anywhere.
• Regional organization collects all relevant material on each body area together in one place, making access to core information easier for clinical readers.
• Anatomical information is matched with key clinical information where relevant.
• Numerous clinical discussions emphasize considerations that may affect medical care.

• Each chapter has been edited by experts in their field, ensuring access to the very latest evidence-based information on that topic.
• More than 1,000 completely new photographs, including an extensive electronic collection of the latest X-ray, CT, MR, and histological images.
• Carefully selected electronic enhancements include additional text, tables, illustrations, labelled imaging and videos - as well as 24 specially invited 'Commentaries' on new and emerging topics related to anatomy.

Autoren/Hrsg.

Standring, Susan

Leseproben

Preface Commentary

The continuing relevance of anatomy in current surgical practice and research

R Shane Tubbs

When our anatomy forebears embarked on the uncharted study of the human body, they did so without reference. Their focus was to chart and map the body simply to learn and describe intricacies never chronicled before. The anatomical ‘map’ we use today came about thanks to figures such as da Vinci, Vesalius, Cheselden and, more recently, Henry Gray. On the shoulders of these giants, we see farther than our predecessors. In The Metalogicon, published in 1159, John Salisbury recognized the profound observation of French philosopher Bernard of Chartres, who declared that ‘...we are like dwarfs on the shoulders of giants, so that we can see more than they, and things at a greater distance, not by virtue of any sharpness of sight on our part, or any physical distinction, but because we are carried high and raised up by their giant size’. So, with the gross anatomy of man presumed, by many scholars, to have been described and understood long ago, how does the modern anatomist bring relevance to the continued study of morphology? Is there any uncharted territory for the modern anatomist to plot in order to sustain our field of study and for it to continue to be perceived as relevant to an educational world, and to medical and dental curricula in which the time allotted to anatomical study has significantly waned? Simply put, yes. Henry Gray, based on the title of his original text, Anatomy, Descriptive and Surgical, knew very well that there was a need to refocus the lenses of teaching and research in the anatomical sciences, and to expand and explore their surgical relevance. Our gross anatomical map of the human body must continue to be updated and legends must continue to be placed on that map to incorporate modern advances in technology. New methods of surgery, such as laparoscopy and endoscopy, as well as the use of the surgical microscope, offer the opportunity to view the human form in a different light and in greater surgical detail than ever before. If anything, the relevance of anatomy in surgery is more important now than at any other time in the past. The modern surgeon must take what is learned macroscopically, in the dissection room, and apply this knowledge to structures seen under magnification and through instruments that provide a surgical field that is, at times, just millimetres in diameter. Therefore, attention to anatomical detail is of vital importance as references and anatomical landmarks are minimized in the surgical theatre of the new millennium.

As mentioned before, early anatomists dissected with curiosity about the unknown and gained knowledge that would become a prerequisite for proper surgical manœuvres. Today, as anatomists, our anatomical knowledge should create in us a curiosity about what we can do with the knowledge that we have gained. The ability to apply that knowledge offers an opportunity to be an integral part of the ever-progressing field of surgery. For example, today, surgical problems are often the impetus for dissection studies, which can influence the way in which surgery is performed and, moreover, can sway the way in which anatomy is taught (e.g. redefining a focus in condensed curricula and with decreased work hours for house officers). Surgically, dissection studies have allowed us to manipulate known human anatomy and to solve, for example, complex neurological problems. As an illustration of the surgical relevance of modern-day anatomical studies for neurological pathologies, we have conducted, in my laboratory, cadaveric feasibility studies that suggested that the phrenic nerve could be reinnervated in high quadriplegic patients who are ventilator-dependent (a morbid condition with an associated high mortality rate) by using the intact, adjacent accessory nerve (i.e. neurotization) (Tubbs et al 2008a) (Fig. 1.6.1). The theory behind this investigation was that the functioning accessory nerve would be used to form a new circuit between it and the dysfunctional phrenic nerve, and that this would allow recovery of diaphragm function. For this technique, a longitudinal incision was made along the lower half of the posterior border of sternocleidomastoid. Dissection was then performed in order to identify both the accessory nerve at this level, at its entrance into trapezius, and the phrenic nerve crossing anterior to scalenus anterior. The medial half of the accessory nerve was then split away from its lateral half and transected at its entrance into muscle. This distally disconnected medial half of the nerve was then swung medially to the phrenic nerve, which had been transected proximally. The two nerves were then sutured together without tension. This ‘rearranging’ of human anatomy has now been employed clinically with success. Yang et al (2011) used our study results to treat a 44-year-old man with complete spinal cord injury at the C2 level. Clinically, left diaphragm activity was decreased and the right diaphragm was completely paralysed. Four weeks after surgery, training of the synchronous activities of trapezius and inspiration was conducted. Six months after surgery, motion was observed in the previously paralysed right diaphragm. Evaluation of lung function indicated improvements in vital capacity and tidal volume. The patient was able to sit in a wheelchair and conduct activities without assisted ventilation 12?months after surgery. For the surgeon, such manipulation of anatomy requires a comprehensive understanding not only of normal anatomy but also of what might occur functionally by rewiring such nerves. For example, patients undergoing this surgery will initially need to think of moving their trapezius to activate their diaphragm. With time, this will not be the case. Similar illustrations of the plasticity of the brain have been seen in patients undergoing hypoglossal to facial nerve neurotization procedures; these patients at first need to think of moving their tongue in order for their facial muscles to contract.

Fig. 1.6.1A schematic representation of the anatomically defined technique of using the accessory nerve for neurotization of the phrenic nerve with application to patients with high cervical quadriplegia who are ventilator-dependent. With nerve regrowth, axons from the intact and functioning accessory nerve travel into the phrenic nerve to reinnervate this nerve and restore diaphragmatic function. In this example, only one-half of the accessory nerve is used in order to maintain some function of trapezius.(Drawn by Mr David Fisher.)

Rewiring of nerves has been addressed in other studies. Thus, we have shown, first in a cadaveric study (Hansasuta et al 2001) and then clinically (Wellons et al 2009), that the medial pectoral nerve can be sectioned near its entrance into the deep surface of pectoralis major and swung round and sewn into the musculocutaneous nerve (Fig. 1.6.2). If this procedure is successful, axonal regrowth from the medial pectoral nerve into the musculocutaneous nerve (about 1?mm/day) will re-establish function in the anterior arm muscles; the loss of clinically significant function of the dually innervated pectoralis major is minimal and the functional gain of having the anterior arm muscles work is significant (Wellons et al 2009). Being able to bring the hand to the mouth and feed oneself is a task that most take for granted. In children with birth-related injuries to the upper brachial plexus (i.e. Erb's palsy), this movement is often the difference between waiting to be fed or feeding oneself. This method has been used at our institution for over 15?years with an 80% success rate, where success is measured as the patient regaining function of arm flexion.

Fig. 1.6.2The neurotization of the musculocutaneous nerve with the medial pectoral nerve (inset). Similar to the example illustrated in Figure 1.6.1, such a method of nerve repair is employed in the hope that a patient with an upper brachial plexus injury and anterior arm muscles that are dysfunctional can regain function by regrowth of axons from the intact medial pectoral nerve into and along the musculocutaneous nerve.(Drawn by Mr David Fisher.)

Another example of what we have termed ‘reverse translational research in anatomy’ (i.e. from the bed to the bench and back) is the location of new anatomical diversionary sites (in this case, the medullary cavity of the ilium) that could be used in patients with cerebrospinal fluid absorption problems (i.e. hydrocephalus) and in whom the traditionally used receptacles for absorbing this diverted cerebrospinal fluid (e.g. peritoneal and pleural cavities, heart) are not options, as a consequence of e.g. malabsorption or local infection (Tubbs et al 2015) (Fig. 1.6.3). This alternative site has, for the first time, just been used and with success (unpublished data). Although not proven clinically, an earlier study in primates showed that the manubrium of the sternum could also be used as a distal receptacle for cerebrospinal fluid collection (Tubbs et al 2011). After tubing was tunnelled from the cannulated ventricle, the distal tubing was inserted subcutaneously into the superior aspect of the midline manubrium, where a small hole had been drilled. Up to 50?ml of saline per hour could be infused into the primate sternum without vital sign changes. This study, and...